School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

May combine two claims.

The review found low-quality evidence for physical activity duration, with intervention ranges of 3 to 158 minutes and control ranges of 3 to 143 minutes across 23 studies and 15743 participants.

“Physical activity duration (minutes engaged in physical activity) [follow-up: end of intervention to 4 years] Intervention: 3 to 158 Control: 3 to 143 15743 (23) ⊕⊕⊝⊝ low a”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims. The quote only partly states this claim.

The review found low-quality evidence for body mass index, with intervention ranges of 11.3 to 26.0 kg/m2 and control ranges of 12.0 to 26.1 kg/m2 across 27,567 participants.

“Body mass index (BMI) (kg/m 2 ) [follow-up: end of intervention to 4 years] Intervention: 11.3 to 26.0 Control: 12.0 to 26.1 27,567”

May combine two claims.

The review found low-quality evidence for physical activity rates, with intervention ranges of 53 to 92 and control ranges of 44 to 91 across 5 studies and 4123 participants.

“Physical activity rates (% of participants physically active) [follow-up: end of intervention to 1 year] Intervention: 53 to 92 Control: 44 to 91 4123 (5) ⊕⊕⊝⊝ low a”

May combine two claims.

The review found low-quality evidence for television viewing, with intervention group ranges of 85 to 285 minutes and control group ranges of 89 to 288 minutes across 16 studies and 9372 participants.

“Television viewing (minutes spent watching TV) [follow-up: end of intervention to 4 years] Intervention: 85 to 285 Control: 89 to 288 9372 (16) ⊕⊕⊝⊝ low a”

May combine two claims.

The review found low-quality evidence for mean systolic/diastolic blood pressure, with intervention ranges of 96 to 138/50 to 73 mm Hg and control ranges of 97 to 139/50 to 76 mm Hg across 16 studies and 13,739 participants.

“Mean systolic / diastolic blood pressure (mm Hg) [follow-up: end of intervention to 4 years] Intervention: 96 to 138 / 50 to 73 Control: 97 to 139 / 50 to 76 13,739 (16) ⊕⊕⊝⊝ low a”

May combine two claims.

The update's new trials did not substantively change the original review's findings or its recommendations for school-based physical activity and fitness promotion.

“While addition of these new studies contributed further to the evidence-base, they did not substantively alter the findings of the original review or change recommendations made for promoting physical activity and fitness in children and adolescents within the school system.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The majority of studies evaluated outcomes immediately following the intervention (n = 34), with one study evaluating outcomes two weeks post intervention.

“The majority of studies evaluated outcomes immediately following the intervention (n = 34), with one study evaluating outcomes two weeks post intervention”

Probably not a substantial claim: may not pass S3 (load-bearing).

The update includes 14 of the original 26 studies.

“Therefore, this update includes 14 of the original 26 studies”

May combine two claims.

The update includes 44 studies (14 from the original review and 30 from the update) and represents complete data for 36,593 study participants.

“This update includes 44 studies (14 from the original review and 30 from the update), and represents complete data for 36,593 study participants.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Even BMI, measured most consistently, differed in the amount of clothing worn by participants.

“Even BMI, which was measured most consistently across studies, differed in terms of the amount of clothing worn by participants.”

May combine two claims.

The most common reasons original studies were judged not relevant were that relevant outcome data for children and adolescents aged 6 to 18 were not reported, and the intervention was not normally performed by public health professionals.

“The most common reasons studies were judged as not relevant were data on relevant outcomes for children and adolescents (aged 6 to 18 years) were not reported, and the intervention was not an intervention normally performed by public health professionals.”

May combine two claims.

When new inclusion and exclusion criteria were applied, 12 of the original 26 studies were excluded: nine because they were not RCTs, one because the sample included only overweight or obese children, and two because the intervention was shorter than 12 weeks.

“12 of the original 26 studies were excluded: nine because they were not RCTs”

• Also stated in: § R E S U L T S Description of studies · plain

  “one was excluded because the study sample included overweight or obese children only”

• Also stated in: § R E S U L T S Description of studies · plain

  “two others were excluded because the intervention was shorter than 12 weeks”

Probably not a substantial claim: may not pass S3 (load-bearing).

Fifteen studies focused primarily on grade school programs that included some parental involvement.

“A number of studies (n = 15) focused primarily on grade school programs that included some parental involvement”

Probably not a substantial claim: may not pass S3 (load-bearing).

The majority of studies distributed printed or audio-visual educational materials primarily to students, sometimes to parents.

“The majority of studies also distributed printed or audio-visual educational materials primarily to students, but sometimes to parents as well”

Probably not a substantial claim: may not pass S3 (load-bearing).

The original review identified 13,841 records related to physical activity interventions with children and adolescents.

“A total of 13,841 records related to physical activity interventions with children and adolescents were identified in the original review.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In some studies, control schools received other physical activity promotion interventions or standard PE curriculum.

“However, in some studies the control schools received other physical activity promotion interventions provided through other health organizations or venues or standard PE curriculum.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Community-based interventions were used in conjunction with school-based interventions in about half of the studies.

“Communitybased interventions, such as training sessions and workshops for parents and parent involvement in home-based physical activities (homework), were used in conjunction with school-based interventions in about half of the studies.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The majority of children were between nine and 11 years of age at baseline.

“The majority of children were between nine to 11 years of age at baseline.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Of 302 studies assessed for eligibility in the original review, 26 were included.

“Of these, 302 studies were assessed for eligibility, and 26 were deemed of sufficient quality to be included in the original review.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The most common reasons update studies were judged not relevant were that the design was not an RCT, relevant outcome data for children and adolescents aged 6 to 18 were not reported, or the intervention was not school based.

“The most common reasons studies were judged as not relevant were: the design was not an RCT; data on relevant outcomes for children and adolescents (aged 6 to 18 years) were not reported; or the intervention was not school based.”

Probably not a substantial claim: may not pass S3 (load-bearing).

All studies included a control group representing either a school or group of schools from a different community, city, or state that did not receive the school-based intervention.

“All studies included a control group that represented either a school or group of schools from a different community, city, or state that did not receive the school-based intervention.”

May combine two claims.

Of 285 unique studies assessed for eligibility in the update, 30 met all relevance criteria and were included.

“Of these, 285 unique studies were assessed for eligibility.Of the 285 unique studies, 30 met all relevance criteria and were included in this update”

Probably not a substantial claim: may not pass S3 (load-bearing).

The majority of included studies were conducted in the US (24), Australia (5), Belgium (3), China (2), and Greece (1).

“The majority of studies were conducted in the US (24), Australia (5), Belgium (3), China (2), and Greece (1).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Almost all studies implemented curricula focused on increasing time spent in physical activity and increasing knowledge about the benefits of an active lifestyle.

“For example, almost all studies implemented curricula focused on increasing time spent in physical activity and on increasing knowledge about the benefits of an active lifestyle.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The update search from July 2007 to October 2011 identified 2,378 records related to physical activity interventions with children and adolescents.

“In addition, the search strategy for this update from July 2007 to October 2011 identified 2378 records related to physical activity interventions with children and adolescents.”

May combine two claims.

Physical health measures were generally more objective than behavioral measures, but there were still significant differences in how data were collected.

“While the data collection procedures for the physical health measures (blood pressure, cholesterol, BMI, pulse, and maximal oxygen uptake (VO 2 max)) were generally more objective than the behavioral measures, there were still significant differences in how the data were collected.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

All but 11 studies involved children 12 years of age and under at baseline, and three of those included participants who were 16 years at baseline.

“All but 11 studies involved children 12 years of age and under at baseline, three of which included participants who were 16 years at baseline.”

Probably not a substantial claim: may not pass S3 (load-bearing).

None of the projects used the same combination of interventions with the same intensity, making each project unique.

“Further, although all of the projects were primarily school-based, none of the projects used the same combination of interventions with the same intensity, making each project unique.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Several theoretical models were used to develop interventions, although in several studies it was unclear if a theoretical model had been used.

“Several theoretical models were used to develop the physical activity interventions, although in several studies it was unclear if a theoretical model had been used.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The three most common intervention providers across the 44 included studies were classroom teachers (n = 28), members of the research team (n = 13), and PE teachers (n = 9).

“The three most common intervention providers across the 44 included studies were classroom teachers (n = 28), members of the research team (n = 13), and PE teachers (n = 9).”

Probably not a substantial claim: may not pass S3 (load-bearing).

About a quarter of studies involved school-based activities other than school curricula.

“About a quarter of the studies involved school-based activities other than school curricula”

May combine two claims.

Intervention duration varied from a minimum of 12 weeks to six years, with six studies reporting intervention periods of three years or greater.

“The duration of the interventions varied greatly from a minimum of 12 weeks to six years, with six studies reporting intervention periods of three years or greater”

May combine two claims.

The most commonly used theories were social cognitive theory and the health-belief model, while self-determination theory, PRECEDE, social learning theory, and the transtheoretical model were used to a lesser extent.

“The most commonly used theories were social cognitive theory and the health-belief model while self-determination theory, PRECEDE, social learning theory, and the transtheoretical model were used to a lesser extent.”

May combine two claims.

Colin-Ramirez 2010 and Dishman 2004 did not show a trend toward a positive effect, and data to assess this were not available for Petchers 1988.

“The results reported by Colin-Ramirez 2010 and Dishman 2004 did not illustrate a trend toward a positive effect, and data to make this assessment were not available for Petchers 1988.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In total, the update includes 23 studies reporting the impact of school-based physical activity interventions on physical activity duration.

“In total this update includes 23 studies reporting the impact of school-based physical activity interventions on physical activity duration.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Most duration studies measured impact immediately post intervention, while one measured at two weeks, one at five months, one at six months, one at nine months, one at 12 months, and one at four years.

“Most studies measured impact on physical activity duration immediately post intervention, while one study measured impact at two weeks post intervention, one at five months, one at six months, one at nine months, one at 12 months, and one at four years.”

Probably not a substantial claim: may not pass S3 (load-bearing).

For cholesterol, about half the studies used nonfasting blood samples and half used fasting blood samples.

“For cholesterol, while the procedures for taking a blood sample and analyzing the sample were similar, about half the studies used nonfasting blood samples and the other half used fasting blood samples.”

May combine two claims.

Interventions across all physical activity rate studies sought to increase MVPA in children during school hours, and all but one included changes to the curriculum.

“Interventions across all studies sought to increase MVPA in children during school hours, and all but one study (Verstraete 2006) included changes to the curriculum.”

May combine two claims.

Haerens 2006 reported a statistically significant effect overall, but subgroup analysis showed a significant effect for boys only.

“However, while Haerens 2006 reported a statistically significant effect overall, further subgroup analysis demonstrated a significant effect for boys only.”

May combine two claims.

Verstraete 2006 reported a statistically significant difference in MVPA among intervention children compared with control (P < 0.01), although no effect size or 95% CI was provided.

“Verstraete 2006, who measured MVPA using accelerometers, also reported a statistically significant difference in moderate to vigorous physical activity (MVPA) among children in the intervention group compared to those in the control group (P < 0.01), although an effect size and 95% CI were not provided.”

May combine two claims.

For all but one study, allocation to treatment or intervention groups occurred at one point in time after study recruitment, and was unknown in one other.

“For all but one study, allocation to treatment or intervention groups occurred at one point in time a er study recruitment, and was unknown in one other.”

May combine two claims.

In three of the four studies reporting a positive effect on systolic blood pressure, the intervention was provided by research staff, and it was not stated in the fourth.

“In three of the four studies reporting a positive effect the intervention was provided by members of the research staff (Angelopoulos 2009;Ewart 1998;Reed 2008), and was not stated in the fourth study (Bayne-Smith 2004).”

May combine two claims.

Two physical activity rate studies reported statistically significant positive effects (Simon 2004; Verstraete 2006), and three did not (Colin-Ramirez 2010; Dishman 2004; Petchers 1988).

“Two of the studies reported statistically significant positive effects on physical activity rates of children (Simon 2004;Verstraete 2006), and three did not report statistically significant effects (Colin-Ramirez 2010;Dishman 2004;Petchers 1988).”

May combine two claims.

Overall, eight of 32 studies reported statistically significant positive effects on BMI in favor of the intervention, while one study reported a statistically significant effect in favor of the control group (Weeks 2008).

“Overall eight of the 32 studies reported statistically significant positive effects on BMI in favor of the intervention (Angelopoulos 2009;Barbeau 2007;Burke 1998;Haerens 2006;Kriemler 2010;Li 2010;Robinson 1999;Salmon 2008), while one study reported a statistically significant effect in favor of the control group (Weeks 2008).”

May combine two claims.

Confounders were adequately controlled in over 50% of studies, although for some studies important confounders such as socioeconomic status and parental education were not accounted for.

“For the most part, confounders were adequately controlled in over 50% of studies although for some studies important confounders such as socioeconomic status and parental education were not accounted for.”

May combine two claims.

Among the two physical activity rate studies with significant positive effects, intervention duration ranged from three months to four school years; among those with no effect, duration ranged from one school year to 12 months.

“Of the two studies reporting statistically significant positive effects the intervention ranged from three months (Verstraete 2006) to four school years (Simon 2004), while for those reporting no effect the intervention ranged from one school year to 12 months.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The sample size of duration studies ranged from 33 to 4019 participants.

“The sample size of the studies ranged from 33 participants to 4019.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Two original review studies and six update studies measured duration of physical activity using accelerometers, although the majority relied on self-report.

“Two studies in the original review (Ewart 1998;Stone 2003), and six in the update measured duration of physical activity using accelerometers”

• Also stated in: § Duration of physical activity · plain

  “although the majority still relied on self report.”

May combine two claims.

Studies were found to be free of selective reporting; however, because many did not have published protocols, it is impossible to know for certain if all outcomes were reported.

“Studies were also found to be free of selective reporting; however, because many of these studies did not have published protocols it is impossible to know for certain if all outcomes were reported on.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Specific behavior outcomes included physical activity rates (five studies), duration of physical activity (23 studies), and time spent watching television (16 studies).

“Specific outcomes related to behavior included: physical activity rates (five studies), duration of physical activity (23 studies), and time spent watching television (16 studies).”

May combine two claims.

In the remaining studies, it was either unclear whether methods were valid and reliable or methods subject to bias were used.

“In the remaining studies it was either unclear whether methods were valid and reliable or methods were used that were subject to bias.”

May combine two claims.

Of three duration studies evaluating impact on adolescent girls, one reported a statistically significant positive effect (Ewart 1998) and two did not (Bayne-Smith 2004; Neumark-Sztainer 2010).

“One of three studies evaluating impact on adolescent girls reported a statistically significant positive effect (Ewart 1998) and two did not (Bayne-Smith 2004;Neumark-Sztainer 2010).”

May combine two claims.

In very few cases were measures taken to account for clustering effects within schools, and just over a third of studies (n = 16) reported conducting an ITT analysis.

“Furthermore, in very few cases were measures taken to account for clustering effects within schools and only just over a third of studies (n = 16) reported that they conducted an ITT analysis.”

May combine two claims.

The intervention provider in the majority of duration studies was classroom teachers; other providers included PE teachers, research workers, peers, and physical activity instructors.

“The intervention provider in the majority of studies was classroom teachers; however, other intervention providers included PE teachers, research workers, peers, and physical activity instructors.”

May combine two claims.

The magnitude of effect across duration studies reporting statistically significant effects varied from just under five minutes to 45 minutes more per week of MVPA, with CIs from 1.4 minutes to approximately 90 minutes more per week.

“The magnitude of effect varied across studies reporting statistically significant effects from just under five min to 45 min more per week of MVPA, and the CIs ranged from as little as 1.4 min to approximately 90 min more per week of MVPA.”

May combine two claims.

All but one physical activity rate study evaluated impact immediately following the intervention, while Colin-Ramirez 2010 evaluated impact one year post intervention.

“All but one study evaluated impact on physical activity rates immediately following the intervention, while Colin-Ramirez 2010, evaluated impact one year post intervention.”

May combine two claims.

Only one of 10 studies reported a statistically significant positive effect on mean blood cholesterol (Walter 1988), and in that study only schools in the intervention group from a higher socioeconomic status reported a significant positive effect.

“Only one of the 10 studies reported a statistically significant positive effect on mean blood cholesterol (Walter 1988), and in that study only schools in the intervention group from a higher socioeconomic status reported a statistically significant positive effect.”

May combine two claims.

Among the two duration studies including both grade school and secondary school children, one did not report statistically significant effects (Lubans 2009), while the second reported a statistically significant effect in favor of the control group (Weeks 2008).

“Among the two studies including both grade school and secondary school children, one did not report statistically significant effects (Lubans 2009), while the second reported a statistically significant effect in favor of the control group (Weeks 2008).”

May combine two claims.

In four of the studies reporting a statistically significant positive effect on BMI, the intervention providers were classroom teachers, while in two studies PE teachers were primarily responsible.

“In four of the studies reporting a statistically significant positive effect the intervention providers were classroom teachers (Barbeau 2007;Burke 1998;Haerens 2006;Robinson 1999), while in two studies PE teachers were primarily responsible for implementing the intervention (Kriemler 2010;Salmon 2008).”

May combine two claims.

Simon 2004 reported a statistically significant increase in physical activity rates in the intervention group compared with control (P < 0.0001), with intervention children almost three times more likely to be physically active outside school (OR 2.74; 95% CI 2.01 to 3.75).

“Simon 2004 reported a statistically significant increase in physical activity rates in those exposed to the intervention compared to those in the control group (P < 0.0001), and found that intervention group children were almost three times more likely to be physically active outside of school compared to controls (OR 2.74).The 95% CI ranged from 2.01 to 3.75.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The sample sizes of the five physical activity rate studies ranged from 235 to 2111 participants.

“The sample sizes of the five studies ranged from 235 to 2111 participants.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In total, the update includes five studies evaluating the impact of school-based physical activity interventions on physical activity rates.

“In total, this update includes five studies evaluating the impact of school-based physical activity interventions on physical activity rates.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Intervention providers varied widely, including research staff, teachers, PE teachers, nutritionists, and peers.

“Intervention providers also varied widely from research staff, to teachers, to physical education (PE) teachers, nutritionists, and peers.”

May combine two claims. The quote only partly states this claim.

Seven of the 16 studies found statistically significant positive effects on television viewing, and one found a statistically significant effect favoring the control group.

“In total seven studies reported statistically significant positive effects on time spent watching television (Burke 1998;Gentile 2009;Jones 2008;Robinson 1999;Simon 2004;Singh 2009;Webber 2008), and one reported a statistically significant effect in favor of the control group (Salmon 2008).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The majority of duration studies reported results for a mixed sample of boys and girls combined, two reported results for boys and girls separately, and three included girls only.

“The majority of studies reported results for a mixed sample of boys and girls combined, two reported results for boys and girls separately, and three included girls only.”

May combine two claims.

The remaining 12 studies did not report statistically significant effects on diastolic blood pressure, and no studies showed a trend toward a positive effect.

“The remaining 12 studies did not report statistically significant effects on mean diastolic blood pressure, and no studies showed a trend toward a positive effect.”

May combine two claims.

All physical activity rate studies reported results for a mixed sample of boys and girls combined, except Dishman 2004, which included girls only.

“All studies reported results for a mixed sample of boys and girls combined, except for Dishman 2004, who included girls only.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

For VO2 max, half of the six studies measured blood gases following exertion, while the other half used pulse rate recovery as a proxy.

“Finally, for the six studies measuring VO 2 max half measured blood gases following exertion, while the other half used pulse rate recovery as a proxy for maximal oxygen uptake.”

May combine two claims.

In some duration studies, intervention participants engaged in MVPA longer than control participants at follow-up; in others, intervention participants had a smaller decrease in duration compared with controls.

“In some studies participants in the intervention group engaged in MVPA longer than control group participants at follow-up, while in other studies, those in the intervention group had a smaller decrease in duration of physical activity in comparison to control group participants.”

May combine two claims.

Another limitation was unit of allocation errors; in some studies allocation was by institution or classroom but assessment occurred at the individual level.

“Another limitation of this literature was unit of allocation errors.In some of the studies allocation was o en by institution (e.g.school) or classroom, but assessment occurred at the level of the individual.”

May combine two claims.

One of the two physical activity rate studies with significant positive effects used accelerometers to measure physical activity, while all other studies used self-report.

“One of the two studies reporting a statistically significant positive effect used accelerometers to measure physical activity rates (Verstraete 2006), while all other studies used self-report.”

May combine two claims.

The intervention in all duration studies reporting statistically significant effects included changes to school curricula, and in many studies printed educational materials.

“The intervention in all studies reporting statistically significant effects included changes to school curricula, and in many studies printed educational materials.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Of the five physical activity rate studies, four focused on grade school children only, and one reported on grade school and secondary school students.

“Of these, four studies focused on grade school children only”

• Also stated in: § Physical activity rates · plain

  “and one reported on grade school and secondary school students”

May combine two claims.

All eight studies reporting statistically significant positive effects on BMI used printed education materials, three included community-based strategies, and three included education sessions.

“All studies used printed education materials, while three studies included community-based strategies (Burke 1998;Haerens 2006;Kriemler 2010), and three included education sessions (Burke 1998;Kriemler 2010;Salmon 2008).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Of the 23 duration studies, 17 reported results for grade school children only, two included grade school and secondary school students, and three reported results for adolescents only.

“Of these, 17 studies reported results for grade school children only”

• Also stated in: § Duration of physical activity · plain

  “two included grade school and secondary school students”

• Also stated in: § Duration of physical activity · plain

  “and three reported results for adolescents only”

May combine two claims.

Many studies attempted to evaluate intervention integrity, and some conducted process evaluations in addition to evaluating effectiveness.

“Finally, many studies attempted to evaluate the extent to which the intervention was implemented as intended (intervention integrity), and some conducted process evaluations in addition to evaluating intervention effectiveness.”

May combine two claims.

School curriculum was a component in all studies reporting statistically significant effects on television viewing, with printed education materials, education sessions, and community-based strategies implemented in almost all such studies.

“School curriculum was a component in all studies reporting statistically significant effects, with printed education materials, education sessions, and community-based strategies being implemented in almost all studies reporting statistically significant effects.”

May combine two claims.

Among grade-school-only duration studies, 12 reported statistically significant positive effects, two of which used accelerometers.

“Among the studies evaluating duration of physical activity among grade school children only, 12 studies reported statistically significant positive effects”

• Also stated in: § Duration of physical activity · plain

  “two of which measured duration of physical activity with accelerometers.”

May combine two claims. The quote only partly states this claim.

Blood pressure measures were least consistent, varying between manual mercury sphygmomanometer and electronic Dinamap, timing 5 to 15 minutes after active periods, and averaging of three or five measures.

“Blood pressure measures were least consistent where in some studies blood pressure was taken manually using a mercury sphygmomanometer, and in others electronically using a Dinamap machine.”

• Also stated in: § Figure 3. (Continued) · plain

  “the timing of when blood pressure was measured differed significantly across studies with timing varying between 5 and 15 min following active periods during school hours.”

• Also stated in: § Figure 3. (Continued) · plain

  “in some studies the average of three measures taken one minute apart were used, in others five measures were averaged, and in others the second and third of three measures were averaged.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Specific physical health outcomes included mean systolic blood pressure (16 studies), mean diastolic blood pressure (16 studies), blood cholesterol level (10 studies), BMI (32 studies), VO2 max (six studies), and pulse rate (six studies).

“Specific outcomes of physical health status included: mean systolic blood pressure (16 studies), mean diastolic blood pressure (16 studies), blood cholesterol level (10 studies), BMI (32 studies), VO 2 max (six studies), and pulse rate (six studies).”

May combine two claims.

Studies not reporting a significant effect on systolic blood pressure used similar combinations of interventions but tended to use classroom and PE teachers more often and were implemented for longer periods compared with studies reporting significant positive effects.

“Generally, the studies not reporting a statistically significant effect on mean systolic blood pressure used similar combinations of interventions, but tended to use classroom Cochrane Database of Systematic Reviews and PE teachers more o en, and tended to be implemented for longer periods of time, in comparison to studies reporting statistically significant positive effects.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In this update, 16 studies evaluated the impact of school-based physical activity interventions on television viewing.

“In total this update includes 16 studies evaluating the impact of school-based physical activity interventions on television viewing.”

May combine two claims.

There is also some limited evidence in this update that positive effects are maintained in the longer term (six months to four years), although only a small number of studies measured outcomes beyond the end of the intervention.

“There is also some limited evidence in this update that these positive effects are maintained in the longer term, (i.e. six months to four years), although only a small number of studies measured outcomes beyond the end of the intervention.”

May combine two claims.

In this review there is some limited evidence to suggest that school-based physical activity interventions may have a positive effect on physical activity rates in children, meaning there was some limited evidence that school-based interventions were effective in increasing the proportion of children who engaged in MVPA during school hours.

“Also, in this review there is some limited evidence to suggest that school-based physical activity interventions may have a positive effect on physical activity rates in children, meaning there was some limited evidence to suggest that school-based interventions were effective in increasing the proportion of children who engaged in MVPA during school hours.”

May combine two claims.

For duration of physical activity, 14 of 23 studies showed a positive effect, and 5 of those used an accelerometer to measure duration.

“For this outcome, 14 of 23 studies demonstrated a positive effect, and of those five studies measured duration of physical activity with an accelerometer.”

May combine two claims.

At this time there is some limited evidence to suggest that school-based physical activity interventions have a small to moderate impact on behavioral outcomes related to physical activity as well as on one physical health status measure.

“At this time there is some limited evidence to suggest that schoolbased physical activity interventions have a small to moderate impact on behavioral outcomes related to physical activity as well as on one physical health status measure.”

May combine two claims.

Studies reporting a positive effect on VO2max made changes to the school curriculum, two also included printed education materials, and one included education sessions.

“Studies reporting a positive effect made changes to the school curriculum, two also included printed education materials, and one included education sessions.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Generally, the results of this update are for the most part unchanged from those reported in the original review, with two exceptions.

“Generally the results of this update are for the most part unchanged from those reported in the original review with two exceptions.”

May combine two claims.

There is only limited evidence that boys and girls respond differently to school-based interventions as well as different components of interventions from the studies included in this review.

“There is only limited evidence that boys and girls respond differently to school-based interventions as well as different components of interventions from the studies included in this review.”

May combine two claims.

The results illustrate a positive improvement in VO2max across studies ranging from 1.6 to 3.7 mL/kg per min, while a fourth study reported a lower heart rate by 4 beats/min after strenuous exercise following the intervention.

“The results illustrate a positive improvement in VO 2 max across studies ranging from 1.6 to 3.7 mL/ kg per min, while a fourth study reported a lower heart rate by 4 beats/min a er strenuous exercise following the intervention.”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based). May combine two claims.

In Bush 1989, total serum cholesterol differed significantly between groups during intervention years 1 and 2 but not in years 3 and 4.

“During intervention (year 1) 187 189 P < 0.02 During intervention (year 2) 189 189 P = 0.418 During intervention (year 3) 171 167 P = 0.432 Bush 1989 End of intervention (year 4) 431 boys and girls 177 180 P = 0.348”

• cites Bush 1989 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

In Martinez 2008, systolic blood pressure at the end of the 9-month intervention did not differ significantly between groups (102 vs 103 mmHg; P = 0.96; mean difference 0.1, 95% CI -1.7 to 1.8).

“Martinez 2008 Girls End of intervention (9 months) 1044 boys and girls 102 103 P = 0.96 0.1 (95% CI -1.7 to 1.8)”

• cites Martinez 2008 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

In Luepker 1996, systolic blood pressure at the end of intervention year 3 did not differ significantly between groups (114 vs 114 mmHg; P = 0.71).

“Luepker 1996 End of intervention (year 3) 4019 boys and girls 114 114 P = 0.71”

• cites Luepker 1996 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

This scope limitation led to the exclusion of 12 of the 26 studies that had been included in the original review.

“This resulted in 12 of the 26 studies included in the original review being excluded in this update.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The 2011 update did not alter the conclusions and recommendations of the original review.

“This update has not impacted the conclusions and recommendations from the original review.”

May combine two claims.

Applying the new relevance criteria led to the exclusion of 12 studies from the original review in the update: 9 were not RCTs, 2 had interventions shorter than 12 weeks, and 1 included only overweight or obese children.

“This resulted in 12 studies from the original review being excluded from the update: 9 because they were not RCTs”

• Also stated in: § Cochrane Database of Systematic Reviews · plain

  “2 because the intervention was shorter than twelve weeks (Eliakim 1996; Fardy 1996); and 1 because the study sample included overweight or obese children only (Carrel 2005a)”

Probably not a substantial claim: may not pass S3 (load-bearing).

It is hard to increase children's activity because many influences-personal, institutional, community, policy, and environmental-shape their behavior.

“Increasing physical activity among children and adolescents is difficult as behavior is influenced by several factors including: personal factors; institutional, community, and public policy; and the physical environment (CIHR 2004).”

• cites CIHR 2004Not checked yet

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May combine two claims.

Even though PE is usually part of the curriculum, it may be scheduled rarely and students are often not very active during it.

“Although most schools require PE as part of their curriculum, PE classes may occur infrequently and children are o en relatively inactive in them (McKenzie 1995;Pate 2006;Simons-Morton 1990;Simons-Morton 1994).”

• cites McKenzie 1995 sourceNot checked yet

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• cites Pate 2006 sourceNot checked yet

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• cites Simons-Morton 1990 sourceNot checked yet

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May combine two claims.

Programs in schools can address children regardless of future chronic disease risk and can raise both knowledge and behavior that support healthier living.

“School-based interventions can target simultaneously, children both at risk and not at risk for future chronic diseases, and can increase both knowledge and behavior conducive to healthier lifestyles.”

May combine two claims.

School-based activity promotion may lower population chronic disease because children spend many waking hours at or going to school and in many countries attend until adolescence.

“Given school-aged children spend a significant amount of their wakeful hours either in transit to or in the school setting, and that in many countries, all children attend school until they reach adolescence, school-based physical activity promotion interventions have potential to reduce population-wide chronic diseases.”

May combine two claims.

Although schools by themselves cannot eliminate inactivity, they can serve as the main community resource for helping students meet recommended activity levels.

“While the schools alone cannot solve the problem of inactivity, they do have the potential to become the central element in a community that ensures students participate in the recommended amount of time engaged in physical activity (Koplan 2005;Pate 2006).”

• cites Koplan 2005Not checked yet

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• cites Pate 2006 sourceNot checked yet

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May combine two claims.

School programs reach children across risk levels, including those lacking play space, and can reduce stigma for those at risk.

“Schools provide benefit to children from all risk groups (Harrell 1996;WHO 2004a), particularly those with limited or no access to play areas (McKenzie 1996); and avoids stigmatization of at-risk children (Harrell 1998).”

• cites Harrell 1996 sourceNot checked yet

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• cites WHO 2004aNot checked yet

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• cites McKenzie 1996Not checked yet

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May combine two claims.

School-based activity has been linked indirectly with academic outcomes such as reduced dropout, improved conduct, self-esteem, engagement, and attention.

“Physical activity in schools has also been shown to be indirectly associated with academic achievement including lower drop-out rates, better classroom behavior, self-esteem and engagement in school, and on-task behavior (Mahar 2006;Trudeau 2008).”

• cites Mahar 2006 sourceNot checked yet

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• cites Trudeau 2008 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Younger children are generally more active than older children and adolescents.

“older children and adolescents less active than younger children”

• cites Adams 1995Not checked yet

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• cites CDC 1997Not checked yet

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• cites Kelder 1995bNot checked yet

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May combine two claims.

Schools are a particularly suitable setting for population-wide activity programs, since no other institution reaches children as strongly during their first 20 years.

“The school setting is an ideal environment for population-based physical activity interventions as no other institution has as much influence on children during their first two decades of life (Story 2009).”

• cites Story 2009Not checked yet

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May combine two claims.

Several troubling trends in schools coincide with rising obesity: less active commuting, shorter recess, and fewer students enrolled in PE.

“Worrisome trends in the school setting are occurring concurrently with the increasing prevalence of obesity including a decline in physically active transport to and from school, recess duration, and enrolment in PE classes (Pate 2006).”

• cites Pate 2006 sourceNot checked yet

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May combine two claims.

Signs of coronary disease, namely fatty streaks in the coronary arteries, have been detected in overweight teenagers and in autopsies of children.

“atherosclerotic fatty streaks in the coronary arteries, indicative of coronary heart disease, have been found in overweight adolescents (Haque 2008), and postmortem in children (Berenson 1992).”

• cites Haque 2008Not checked yet

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• cites Berenson 1992 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Disagreements in risk of bias assessment were resolved through discussion until consensus was reached.

“Disagreements were resolved through discussion until consensus was reached.”

Classified as probably not a substantial claim. May combine two claims.

Eligible programs had to be public-health relevant rather than physician- or clinic-run, feasible for local public health staff, school-based, and intended to raise activity and fitness.

“The intervention had to be relevant to public health practice (meaning the focus was on health promotion from an individual or population-wide perspective, was not physician or clinic based)”

• Also stated in: § Types of studies · plain

  “the intervention was implemented in a school setting and was aimed at increasing physical activity and fitness in children and adolescents.”

Classified as probably not a substantial claim.

A narrative summary was used because the studies differed greatly in participants, programs, and outcome measures.

“The results were summarized narratively due to wide variations in the populations, interventions evaluated, and outcomes measured.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Studies focused only on subgroups such as obese or inactive children were excluded from the update, which removed a few studies from the original review.

“Studies not aimed at the general population (e.g.studies including obese children only, or only low-active children) were excluded from this update.Again this resulted in a small number of studies included in the original review being excluded in the update.”

May combine two claims.

It remained uncertain from those reviews how much the school context mattered for effectiveness and how much activity by itself improved outcomes like blood pressure, lipids, weight, and fitness.

“In both reviews it is unclear what specific contribution the school setting had on intervention effectiveness as well as the individual contribution of physical activity on improved health status measures, such as blood pressure, blood lipids, weight, and fitness measures.”

• cites Summerbell 2005 sourceNot checked yet

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• cites Thomas 2004aNot checked yet

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Classified as probably not a substantial claim. May combine two claims.

Although the authors recognize that post hoc questions may be biased, they considered the revised eligibility criteria necessary to secure the strongest evidence for their research question.

“The review authors are aware that post hoc questions are susceptible to bias (Higgins 2011); however, in light of the growing body of literature on the effectiveness of school-based physical activity promotion interventions, we believe the changes in inclusion and exclusion criteria were necessary to ensure the most rigorous evidence answering our research question was included in this update.”

• cites Higgins 2011Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The update set a minimum intervention length of 12 weeks, removing some shorter studies that had been in the original review.

“Studies had to have at a minimum an intervention duration of at least 12 weeks otherwise they were excluded from the update.Again this resulted is some studies included in the original review being excluded from the update.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Data were extracted only for outcomes for which some degree of reliability and validity was demonstrated.

“The reliability and validity of all data collection measures were also assessed and data extracted only for those outcomes for which some degree of reliability and validity was demonstrated.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Any disagreements were resolved by discussion to consensus.

“Where discrepancies existed, discussion occurred until consensus was reached.”

Classified as probably not a substantial claim.

For this update, eligible studies were restricted to randomized trials whose intervention ran for 12 weeks or longer.

“Furthermore, in this update we included data only from randomized controlled trials (RCTs) with a minimum intervention duration of 12 weeks.”

Classified as probably not a substantial claim. May combine two claims.

When students learn about activity and get opportunities to be active at school, they are expected to form healthier habits that could persist into adult life.

“and by providing students with both knowledge and the opportunity to be more active during the school day, children will develop healthier behaviors that may track in adulthood.”

May combine two claims.

Because interventions, populations, and outcomes varied, statistical combination across studies was inappropriate, so results were synthesized narratively.

“Variation in the interventions, populations, and outcomes measured made it inappropriate to combine the results statistically across studies, therefore the results are synthesized narratively.”

Probably not a substantial claim: may not pass S3 (load-bearing).

For the update, all studies from the original review and all newly identified studies were assessed independently for risk of bias by two of three review authors.

“For the update all studies from the original review as well as studies identified for this update were assessed independently for risk of bias by two of three review authors (MD, RL, KD).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Risk of bias judgments were made separately for seven domains.

“Critical assessments were made separately for each of seven domains with judgments of low risk of bias, high risk of bias, and unclear risk of bias”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Additional studies were sought by examining bibliographies of included papers and reviews and by asking experts and original authors.

“We identified additional studies by searching the reference lists of included studies and (systematic) reviews, meta-analyses, and health technology assessment reports.”

• Also stated in: § Contacting experts · plain

  “Experts in the field of physical activity promotion in children and adolescents were contacted with a view to seeking additional references.”

Probably not a substantial claim: may not pass S3 (load-bearing).

For the update, three review authors independently extracted population and intervention characteristics for all new studies using standard data extraction templates.

“For this update three review authors (MD, RL, KD) independently abstracted relevant population and intervention characteristics for all new studies using standard data extraction templates”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Relevance screening and data extraction were done by two reviewers working independently with standardized instruments.

“Standardized tools were used by two independent reviewers to assess each study for relevance and for data extraction.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Searches covered multiple databases from 1985 through July 2007 for the original review and from July 2007 through October 2011 for the update.

“For the original review the following databases were searched from 1985 to July 2007: MEDLINE, BIOSIS, CINAHL, EMBASE, SPORTDiscus, PsycINFO, Sociological Abstracts and the Cochrane Central Register of Controlled Trials (CENTRAL).For the updated review, the same databases were searched again to capture studies published between July 2007 to October 2011.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Risk of bias was evaluated for every study using the Cochrane Handbook's guidance.

“In addition, each study was assessed for risk of bias as specified in the Cochrane Handbook for Systematic Reviews of Interventions.”

May combine two claims.

Both prior reviews covered complex programs that addressed diet and activity at the same time and were delivered in several settings, including schools, communities, and public places.

“In both the Summerbell 2005 and Thomas 2004a reviews, interventions were multifaceted, meaning the interventions targeted multiple behaviors including diet and physical activity simultaneously, and that they were implemented congruently in multiple settings such as the community, schools, and public places.”

• cites Summerbell 2005 sourceNot checked yet

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• cites Thomas 2004aNot checked yet

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May combine two claims.

One prior review, Summerbell 2005, looked at obesity prevention programs for children; another, Thomas 2004a, evaluated approaches to healthy weight promotion in young people.

“For example, Summerbell 2005 explored the impact of interventions to prevent obesity in children, and Thomas 2004a assessed the impact of strategies to promote healthy body weight in children and adolescents.”

• cites Summerbell 2005 sourceNot checked yet

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• cites Thomas 2004aNot checked yet

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Classified as probably not a substantial claim. May combine two claims.

Eligible participants were school students aged 6-18, including healthy, overweight, and obese children; studies treating a specific serious illness or comorbidity with activity were excluded.

“Studies that included school-attending children and adolescents between the ages of 6 to 18 years were included in this review.This included all otherwise healthy children and adolescents whether they were overweight, obese, or not.We excluded studies where participants received a physical activity intervention as part of a treatment regimen for a specific critical illness or comorbidity (e.g.di”

Classified as probably not a substantial claim.

For the update, eligibility was narrowed to randomized trials, so some non-randomized studies from the original review were dropped.

“the inclusion/exclusion criteria were modified to include only those studies that were RCTs.This change in inclusion criterion resulted in a number of non-RCTs included in the original review being excluded from the update.”

Classified as probably not a substantial claim.

Studies were not eligible if all intervention activities took place outside school.

“We excluded studies when the intervention was conducted entirely outside of the school setting (e.g.community setting, public place, recreation facility, physician office, camp setting).”

Probably not a substantial claim: may not pass S3 (load-bearing).

It is possible that some duration studies with smaller sample sizes were underpowered to detect statistically significant changes in physical activity duration.

“However, it is possible that some studies with smaller sample sizes were underpowered to detect statistically significant changes in physical activity duration.”

The quote only partly states this claim.

All 16 studies measuring television viewing used self-report.

“All studies measured television viewing through self-report.”

Classified as probably not a substantial claim.

It is questionable whether the observed reductions in television viewing would result in reduced risk for chronic diseases.

“drawing into question whether these reductions would result in reduced risk for the development of chronic diseases.”

May combine two claims.

Almost all recent reviews show that school-based physical activity interventions increase children's and adolescents' time in MVPA, and in some cases this translates into improved fitness measures.

“Almost all recent reviews illustrate that school-based physical activity interventions do result in children and adolescents spending more time engaged in MVPA and in some instances this translates into improved fitness measures.”

May combine two claims.

Lack of change in leisure-time physical activity or fitness has been attributed most often to inadequate dose, poor compliance, inattention to multiple risk factors and overly simplistic interventions, methodological errors in fitness measurement, and failure to control confounders.

“Lack of change in leisure time physical activity or physical fitness, in turn, has been attributed most o en to issues of: a) inadequate dose (Tolfrey 2000); b) poor compliance (Baranowski 1990); c) inattention to the multiplicity of risk factors for physical inactivity and subsequent overly simplistic, unidimensional interventions;”

• Also stated in: § Potential biases in the review process · plain

  “d) methodologic errors in measuring fitness (e.g.assessing heart rate only a er, as opposed to during, activity); and e) a failure to control for potentially confounding variables (Tolfrey 2000).”

• cites Tolfrey 2000 sourceNot checked yet

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• cites Baranowski 1990 sourceNot checked yet

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May combine two claims.

The results must be interpreted cautiously and likely overestimate the true treatment effect.

“As such the results must be interpreted cautiously and likely overestimate the true treatment effect.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the Angelopoulos 2009 trial, allocation was concealed because all participants were allocated at a single point after recruitment, so group assignment was unknown at recruitment.

“Comment: criterion not applicable because all participants were allocated at 1 point in time following recruitment, so at time of recruitment allocation was not known”

May combine two claims.

This represents an important risk of bias for this literature and likely resulted in either overestimating the treatment effect or finding a statistically significant positive effect where one did not exist.

“This represents an important risk of bias for this literature and likely resulted in either overestimating the treatment effect or finding a statistically significant positive effect where one did not exist.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Hillsdon 2005 reported similar results among adults for physical activity promotion interventions.

“An additional review by Hillsdon 2005 also reported similar results among adults for interventions to promote physical activity.”