Food and Nutrition Education against Overweight in School-age Children: A Scoping Review of progress in Spanish-speaking Countries

: Background: School-aged children may benefit from education interventions focused on healthy eating and physical activity to improve their quality of life. Objective: To review the available scientific evidence on food and nutrition education (FNE) in Spanish-speaking countries for the prevention of excess weight in school-aged children (6-12 y). Methods: Relevant evidence was searched between April and August 2021. The searches were conducted using MEDLINE, Google Scholar, and SciELO. The primary search for articles focused on the experience of FNE interventions in Spanish-speaking countries. Results: Overall, 518 articles were found and 33 studies were eligible for data extraction. Forty two percent of the studies had a focus on FNE and 64 percent were focused on describing the eating habits of schoolchildren. Nutritional assessments (anthropometric) were found frequently with 91 percent and 30 percent of the studies focused on physical activity. All interventions focused on preventing or reducing overweight and obesity in school-age children. Educational, cognitive, dietary and physical activity practices were described, being educational the most frequent intervention. Conclusion: Interventions reported positive effects of FNE interventions to improve knowledge and practices of healthy lifestyles in school-age against overweight and obesity in schools. The results can contribute to the implementation of nutritional interventions within the school curriculum, with the help of ministries such as ministries of education, health, social development or agriculture to achieve a positive impact on the learning of healthy lifestyles in school-age children. Finally, the evidence shows that comprehensive FNE interventions such as physical activity, participation of parents, teachers, community environment, and transformation of healthy schools, cause positive effects on nutritional status, improve knowledge, and contribute to chronic non- communicable disease prevention.


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The term overweight is used to refer to an excessive increase in body fat that poses 18 health risks [1]. The increase in overweight and obesity in school-age children (6-12 years) 19 is worrying, due to its increase in recent years both in emerging and developing economies. 20 Globally, 340 million children and adolescents are overweight [1]. Latin America and 21 the Caribbean and other Spanish-speaking countries faces serious challenges to reduce 22 overweight in schoolchildren, where the problem reaches up to 40 percent of school-age 23 children [2].
Many countries are moving through the nutrition transition with increased urbaniza-26 tion, a growing economy, and changing food environments. As a result, negative changes 27 in eating habits and a predominantly sedentary lifestyle are becoming the primary causes 28 of overweight in the population [3]. Furthermore, the changing food environment, contam-29 inated by advertising, promotion, and sponsorship of ultra-processed products and sugary 30 drinks, directly influences the adoption of inappropriate food practices [4]. 31 32 Customized food and nutrition education (FNE) is one intervention modality that may 33 benefit for school-age children to learn about proper eating habits and healthy lifestyles [5]. 34 School-age children may benefit from educational interventions on health and nutrition to 35 change and improve lifestyles. In school settings, children are a captive audience ready 36 to gain new information and skills that they may not be able to learn at home or in their 37 communities. Children must acquire knowledge around healthy eating at an early age 38 to give them the cognitive tools needed to prevent or treat overweight and obesity [6]. 39 Therefore, it is necessary to involve all actors at all levels, i.e. school, community, and 40 home. Thus, teachers are important agents to promote the health and nutrition habits of 41 school-age children in schools so that they can transfer competencies and skills on healthy 42 eating habits when they leave the school setting and enter adulthood [7].

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The literature suggests that a lack of knowledge, together with an unfavorable attitude 45 about healthy eating habits and an obesogenic environment, among other factors, affects the 46 dietary habits of school-age children with health consequences [8]. It is during childhood 47 that most people solidify their nutrition behaviors and lifestyle habits [9]. Children may 48 grow up with inadequate eating habits if they never learned it at an early age [2].

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Therefore, understanding how effective the implementation of FNE in schools has 51 been important for developing future interventions aiming to improve healthy eating habits 52 and lifestyles of school-aged children [8]. Likewise, understanding how the participation 53 of parents, teachers and the entire educational community may influence child diets may 54 inform future interventions, in consideration physical environments where dietary prac-55 tices are carried out [10,11]. Given the rising number of interventions targeting overweight 56 and obesity among school-aged children, we conducted this review to summarize the 57 available evidence of FNE for the prevention of overweight in school-age children (6-12 58 years of age). We sought to answer the following two research questions during this review: 59 60 Research question 1: What are the types of FNE intervention approaches being used 61 to improve nutrition outcomes among school-aged children?  Our search included all studies that were observational, descriptive, analytical, cross-80 sectional, cohort studies, cases and controls studies, pre-post-interventions, quasi-experimental81 intervention designs, with or without a control group, and randomized and double blind-82 trials. For the selection of studies, a search was conducted using MEDLINE PubMed, 83 Google Scholar, and SciELO. Descriptive keywords such as: "food and nutrition education", 84 "nutrition education", "knowledge", "loss weight", "school age", "behavior", "eating habits", 85 "physical activity", and "cognitive" were used.

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Titles and abstracts of initially identified articles were screened. Eligible studies were 88 reviewed in full text and each article was checked for inclusion criteria to be selected for 89 data extraction. The information that was extracted included: authors, year of publication, 90 place of execution of the study, objectives, sample size, description of the intervention, 91 summary of results, and conclusions.   Table 1 shows the summary of available evidence from the selected studies on FNE 101 against overweight in school-age children. Five hundred and eighteen studies were initially 102 identified being 402 articles excluded because they were not related to the research objec-103 tives, leaving a total of 116 articles. Seventy-one studies were excluded due to duplication. 104 Twelve articles were excluded because were made in non-Spanish-speaking countries. A 105 total of 33 studies were included for the final extraction of information ( Figure 1).

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Most of the FNE studies intervened through evaluations of eating habits in 63 percent 108 (21/33), followed by educational programs (42 percent (14/33) of the studies). Nutritional 109 assessments (anthropometric) were included in 91 percent (30/33) and 30 percent (10/33) of 110 the studies included physical activity as an outcome. The identified FNE interventions were 111 focused on both physical activity programs and educational activities for schoolchildren. 112 Compared to other study designs, the intervention studies had a focus on preventing and 113 reducing overweight or obesity in participants.

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In the transformation of healthy schools, the FNE intervention was carried out with 116 the school-age children, teachers, and administrative personnel of the schools to achieve 117 changes at the level of the physical structure and the environment, to support the measures 118 of prevention of overweight. In these, they managed to improve the school environment 119 through illustrative posters with health messages or advice throughout the school. In oth-120 ers, they painted the stairs and corridors of the schools to promote physical activity among 121 students. They also focused on improving school canteens, that is, having better options 122 in the food supply, above all suspending the sales of processed foods and sugary drinks, 123 and thus providing and encouraging students to prefer healthy foods, as also reported 124 elsewhere [44,45]. On the other hand, concerning counseling on physical activity and nutrition after 127 school, the interventions consisted of motivating school-age children, parents, or people 128 responsible for children to lead healthy lifestyles after finishing the school day or on hol-129 idays. The main focus for this strategy was motivation to stimulate the will to a healthy 130 lifestyle change. Organized educational sessions were carried out providing support to 131 parents in terms of healthy eating, self-efficacy to change specific behaviors, and taking 132 care of the practice of physical activity for the child. Games were also played to overcome 133 different barriers that children could present and thus remain constantly active, avoiding a 134 sedentary lifestyle in school-age children, as also reported by Annesi

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The FNE interventions were beneficial in improving knowledge and lifestyle practices 138 in school-age children. However, very few achieved positive changes in nutritional status 139 [17,19]. This was regardless of the type of intervention and the time duration of the interven-140 tions. The educational interventions to promote healthy eating were carried out to increase 141 knowledge on healthy eating habits in which FNE sessions were constructed using differ-142 ent didactic materials such as talks, workshops, visits to the food market, videos, games, etc.  . At the end of the intervention, the school-age children were able to 156 increase their knowledge of healthy eating and physical activity in a higher proportion than 157 children with normal weight. They were evaluated using instruments designed for each 158 topic to assess the level of learning acquired from healthy eating and physical activity after 159 the intervention. Authors showed that FNE has a significant effect in improving healthy 160 behaviors in school-age children. Martínez Trescastro (2016) in Spain evaluated 28 school-age children in the context 163 of an FNE intervention [8]. Their results were positive responses in the students since 164 more than 70 percent acquired knowledge of healthy eating and healthy lifestyle practices. 165 After two years, the consumption of industrialized products was reduced and fruits were 166 the most consumed food. They concluded that the FNE intervention produces significant 167 changes, improving knowledge and increasing the consumption of healthy foods [8].

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Regarding eating habits, the identified interventions applied different tools to know 170 the eating behaviors in school children, they used food frequency questionnaires, 24-hour 171 dietary recalls, child-eating behavior questionnaires, and facial hedonic scales to know 172 acceptance of the school lunch. Some of the characteristics that could be observed in the 173 eating behaviors in the school-age children in the studies, is that the diet is usually varied 174 and this depends on the sociodemographic characteristics of the children. For example, 175 children from rural areas tend to consume traditional foods typical of their culture, and 176 children from urban areas have access to processed foods, sugary drinks, or fast food. It 177 should be noted that the evaluated dietary patterns included assessing the habit of having 178 breakfast, lunch, and dinner [28,37]. González-González et al., (2016) in a study carried out in Spain with 1142 school-age 181 children, to assess the eating patterns in elementary school, a questionnaire was applied 182 to investigate and fully understand the schoolchild's diet [28]. The result was that food 183 preference is an important factor in children when choosing a specific food. In addition, it 184 was found that cereals were the most consumed food (92.8 percent). Vegetable consump-185 tion was low (35.4 percent). It should be noted that adequate nutrition is essential for the 186 intellectual development of school-age children since it avoids the risks of suffering from 187 Regarding the nutritional evaluations, weight, height, body mass index (BMI), waist 190 index, hip index, and skinfolds were measured in several interventions. The nutritional 191 status of the participants was determined to classify them as having overweight, obesity, or 192 normal weight according to the child growth standards of the World Health Organization 193 [47]. Nutritional assessments are included as an important dimension of the evaluation 194 of FNE interventions. Several articles report the results of knowledge of nutrition, as well 195 as food intake and nutritional status in the FNE intervention periods in schools. One of 196 them is the study carried out by Aparco et al., (2017) in Peru [12]. The objective of the 197 intervention was to determine the impact of an FNE program in school-age children from 198 first to fourth grade on BMI, knowledge of nutrition, and eating patterns. The results found 199 in the 696 school-age children revealed that the intervention carried out in the first year 200 showed a positive impact on the improvement of knowledge in nutrition (OR: 1,46; 95 201 percent: CI: 1,17-1,81), the implementation also improved the eating pattern in all food 202 groups except vegetable. However, this intervention failed to reduce the BMI Z-score [12]. 203

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Another study carried out in Mexico aimed to know the effect that an FNE program 205 in schools has on the eating habits and nutritional status of school-age children [22]. The 206 intervention was carried out in 35 children for 9 months. The results detailed that the 207 school-age children positively improved their eating pattern, especially the consumption of 208 sugary drinks was reduced at the end of the intervention. However, in the anthropometric 209 characteristics, an increase in height, body weight, and waist circumference was observed, 210 the BMI was maintained during the intervention [22].

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A study carried out in Spain on an FNE program evaluated 79 school-age children 213 aged 6 to 8 years intending to improve their nutritional status and eating habits. The 214 intervention did not show statistically significant associations. However, for the body mass 215 index variable after the intervention, the levels of normal weight, overweight, and obesity 216 improved. Concerning eating habits, the need to improve the diet in school-age children 217 was demonstrated, since an impoverished consumption of food groups was found. This 218 intervention shows that it is important to implement FNE programs in schools to improve 219 knowledge and practices of a healthy lifestyle from an early age to achieve optimal growth 220 and development [29].  To determine the quality of the quality of the dietary pattern and the practice of physical activity in primary and secondary and secondary schoolchildren in Galicia and its relationship with sex, educational stage and adiposity and the degree of adiposity, in order to assess the need to reinforce the to assess the need to reinforce the current intervention strategies for the strategies for the promotion of healthy lifestyles.

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Overall, the results found in this review, most of the interventions in FNE improve 224 knowledge after the implementation of the programs, which shows a positive response. The 225 FNE interventions are positive, since they guide healthy lifestyles, modify eating behaviors 226 and learn practices or knowledge in food and nutrition. In addition, the evaluated studies 227 of interventions that involve more than one aspect studied, such as FNE, increased physi-228 cal activity, participation of parents, teachers, and transformation of healthy schools and 229 community environments, cause positive physical changes by improving nutritional status 230 and knowledge. It is necessary to continue implementing FNE programs to contribute to 231 the health of school-age children and improve their lifestyles. The results of the present review are consistent with other available reviews. For 234 example, a review conducted in Brazil using 13 articles published between 2000 and 2011 235 showed that FNE improves the knowledge of nutrition and food choices of school-age 236 children [48]. However, the studies that involved anthropometric measurements did not 237 have changes in their nutritional status [48,49]. Despite this, working in schools to achieve 238 positive changes in children's health and that prevention remains the first step in combat-239 ing overweight and obesity. The results on the FNE in the present review are similar to 240 a review performed in Spain based on 17 articles [50]. Primary prevention interventions 241 were shown to positively influence healthy lifestyles, compared to other interventions that 242 are capable of reducing weight in school-age children [50]. Another review carried out 243 in Peru on the effectiveness of an educational intervention to promote healthy eating in 244 school-age children evaluated 10 articles [51]. They reported that FNE interventions have a 245 high probability of improving knowledge about healthy lifestyles in children [51]. It seems 246 that educational interventions have a greater impact on knowledge and attitude towards 247 healthy eating. Therefore, surveillance systems in schools must incorporate a variety of 248 indicators and not just anthropometric markers.

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The duration of the interventions is fundamental to achieve success in an FNE in-251 tervention. If a study fails to show changes, for example, in the weight of school-age 252 children, it may be that this intervention was carried out in a short period and does not 253 necessarily reflect problems with the effectiveness of the FNE intervention. Long-term 254 interventions are associated with higher changes in the lifestyles of school-age children, 255 including nutritional status [12,19,52,53]. It is essential to extend the time frame of FNE 256 interventions to achieve stronger and more sustainable changes over time. In addition, 257 FNE must have a comprehensive approach, considering the environment and all actors in 258 schools such as parents, teachers, and the community.  Figure 2 shows a proposed conceptual framework for the implementation of FNE 261 against overweight and obesity in schools. The results can contribute to the implementation 262 of nutritional interventions within the school curriculum, with the help of ministries such 263 as ministries of education, health, social development or agriculture to achieve a positive 264 impact on the learning of healthy lifestyles in school-age children. Finally, the evidence 265 shows that comprehensive FNE interventions such as physical activity, participation of 266 parents, teachers, community environment, and transformation of healthy schools, cause 267 positive effects on nutritional status, improve knowledge, and contribute to chronic non-268 communicable disease prevention.

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The findings of this review should be analyzed considering some limitations. A limi-271 tation of this study was that a systematic review and meta-analysis were not performed 272 to research statistical conclusions. One strength of this review was the compilation of 273 high quality articles across country contexts to understand the range of FNE intervention 274 modalities being used in school programs. Interventions from an early age have been 275 shown to have a positive effect on increasing knowledge and improving lifestyle.

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In conclusion, FNE interventions come in many varieties regardless of context. How-279 ever, they all have several common attributes for addressing the nutrition of school-aged 280 children. Understanding the relative impacts of different types of FNE interventions on 281 child health and nutrition, by context, may be important follow-up work to inform policy 282 and programming investment for countries wishing to achieve improved population-level 283 health and nutrition.