***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Pathways , a multisite school-based study aim ed at promoting healthful eating and increasing physical activity , was a r and omized field trial including 1704 American Indian third to fifth grade students from 41 schools ( 21 intervention , 20 controls ) in seven American Indian communities . METHODS The intervention schools received four integrated components : a classroom curriculum , food service , physical activity , and family modules . The curriculum and family components were based on Social Learning Theory , American Indian concepts , and results from formative research . Process evaluation data were collected from teachers ( n=235 ) , students ( n=585 ) , and families .  Knowledge , Attitudes , and Behavior Question naire data were collected from 1150 students including both intervention and controls . RESULTS There were significant increases in knowledge and cultural identity in children in intervention compared to control schools with a significant retention of knowledge over the 3 years , based on the results of repeating the third and fourth grade test items in the fifth grade . Family members participated in Family Events and take-home activities , with fewer participating each year . CONCLUSION A culturally appropriate school intervention can promote positive changes in knowledge , cultural identity , and self-reported healthful eating and physical activity in American Indian children and environmental change in school food service Background Obesity has become a global public health problem , which also affects children . It has been proposed that the educational interventions during childhood could be a key strategy in the prevention of obesity . Objective To evaluate the efficacy of an intervention on food habits and physical activity in school children . Methods A 2-year cluster-r and omised prospect i ve study with two parallel arms was used to evaluate an intervention programme in children in their first year of primary schooling ( 5–6 years of age ) in schools in the city of Granollers . The intervention consisted of the promotion of healthy eating habits and physical activity by means of the educational methodology Investigation , Vision , Action and Change ( IVAC ) . At the beginning and at the end of the study ( 2006 and 2008 ) the weight and height of each child was measured in situ , while the families were given a self-report physical activity question naire and the Krece Plus quick test . Results Two years after the beginning of the study , the body mass index of the children in the control group was 0.89 kg/m2 higher than that of the intervention schools . The intervention reduced by 62 % the prevalence of overweight children . Similarly , the proportion of children that ate a second piece of fruit and took part in an after-school physical activity increased in the intervention group . In the control group , the weekly consumption of fish was reduced . Conclusions The educational intervention in healthy eating habits and physical activity in the school could contribute to lessen the current increase in child obesity Aims This study assessed the efficacy of a school-based healthy lifestyle intervention ( Sport for LIFE ) for increasing physical activity , decreasing sedentary behaviour , reducing screen time behaviour , encouraging healthy attitudes and behaviour to nutrition , and reducing body mass index ( BMI ) in 8–9-year-old primary school children from lower socioeconomic background s in Northern Irel and . Methods A non-r and omised controlled trial of 416 children from 24 schools took part . Schools were r and omly assigned to one of two groups , an intervention or control group with 12 schools in each group . The intervention group received a 12-week school-based programme based on social cognitive theory . At baseline and follow-up , groups completed question naires assessing physical activity , screen time behaviour and dietary patterns . On each occasion anthropometric assessment  s of height and weight were taken . Physical activity and sedentary behaviour were measured by accelerometry . Results Significant effects were observed for vigorous , moderate and light activity for the intervention group at follow-up . Sedentary behaviour was significantly reduced for the intervention group but not for the control group . No significant effects of the intervention on BMI , screen time behaviour or attitudes to nutrition , with the exception of non-core foods , were shown . Conclusions The programme was effective in increasing physical activity and reducing sedentary behaviour , however no significant changes in screen time behaviour and attitude to nutrition , with the exception of non-core foods , were observed . Future research ideas are offered for tackling low levels of physical activity in children Aims : To estimate the impact of school fruit tuck shops on  children ’s consumption of fruit and sweet and savoury snacks . Design : Cluster r and omised effectiveness trial with school as the unit of r and omisation . Setting : 43 primary schools in deprived areas in south Wales and south-west Engl and with a range of school food policies . Intervention : Schools operated fruit tuck shops throughout one academic year . Control schools did not do so . Measures : Repeated cross-sections of children aged 9–11 years completed a  computerised 24-hour recall question naire  at baseline ( n = 1902 ) and at 1-year follow-up ( n = 1924 ) , when a brief question naire was also completed ( n = 1976 ) . Results : Approximately 70 000 fruits were sold in the 23 intervention schools over the year , equivalent to 0.06 fruits per student per day . Children in intervention schools were more likely to report eating fruit as a snack at school ‘ often ’ ( OR 1.49 , 95 % CI 1.15 to 1.95 ) . There were no significant differences in children ’s intake of fruit or other snacks . There was a significant interaction ( p<0.02 ) between the intervention group and school food policy : where students were only allowed to bring fruit to school , fruit consumption was 0.37 portions per day ( 0.11 to 0.64 ) higher in intervention schools , compared to 0.14 portions ( −0.30 to 0.58 ) where no food was allowed and −0.13 portions ( −0.33 to 0.07 ) where there were no restrictions . Conclusions : In isolation , fruit tuck shops were not effective in changing children ’s snacking behaviour in schools . However , the results suggest that fruit tuck shops had a greater impact when reinforced by school policies restricting the types of foods students were allowed to bring to school Background Many unhealthy dietary and physical activity habits that foster the development of obesity are established by the age of five . Presently , approximately 70 percent of children in the United States are currently enrolled in early childcare facilities , making this an ideal setting to implement and evaluate childhood obesity prevention efforts . We describe here the methods for conducting an obesity prevention r and omized trial in the child care setting . Methods / design A r and omized , controlled obesity prevention trial is currently being conducted over a three year period ( 2010-present ) . The sample consists of 28 low-income , ethnically diverse child care centers with 1105 children ( sample is 60 % Hispanic , 15 % Haitian , 12 % Black , 2 % non-Hispanic White and 71 % of caregivers were born outside of the US ) . The purpose is to test the efficacy of a parent and teacher role-modeling intervention on children ’s nutrition and physical activity behaviors . . The Healthy Caregivers-Healthy Children ( HC2 ) intervention arm schools received a combination of ( 1 ) implementing a daily curricula for teachers/parents ( the nutritional gatekeepers ) ; ( 2 ) implementing a daily curricula for children ; ( 3 ) technical assistance with meal and snack menu modifications such as including more fresh and less canned produce ; and ( 4 ) creation of a center policy for dietary requirements for meals and snacks , physical activity and screen time . Control arm schools received an attention control safety curriculum . Major outcome measures include pre-post changes in child body mass index percentile and z score , fruit and vegetable and other nutritious food intake , amount of physical activity , and parental nutrition and physical activity knowledge , attitudes , and beliefs , defined by intentions and behaviors . All measures were administered at the beginning and end of the school year for year one and year two of the study for a total of 4 longitudinal time points for assessment . Discussion Although few attempts have been made to prevent obesity during the first years of life , this period may represent the best opportunity for obesity prevention . Findings from this investigation will inform both the fields of childhood obesity prevention and early childhood research about the effects of an obesity prevention program housed in the childcare setting .Trial registration Trial registration number : Background Free school breakfast programmes ( SBPs ) exist in a number of high-income countries , but their effects on educational outcomes have rarely been evaluated in r and omised controlled trials . Methods A 1-year stepped-wedge , cluster r and omised controlled trial was undertaken in 14 New Zeal and schools in low socioeconomic re source areas . Participants were 424 children , mean age 9±2 years , 53 % female . The intervention was a free daily SBP . The primary outcome was children 's school attendance . Secondary outcomes were academic achievement , self-reported grade s , sense of belonging at school , behaviour , short-term hunger , breakfast habits and food security . Results There was no statistically significant effect of the breakfast programme on children 's school attendance . The odds of children achieving an attendance rate < 95 % was 0.76 ( 95 % CI 0.56 to 1.02 ) during the intervention phase and 0.93 ( 95 % CI 0.67 to 1.31 ) during the control phase , giving an OR of 0.81 ( 95 % CI 0.59 to 1.11 ) , p=0.19 . There was a significant decrease in children 's self-reported short-term hunger during the intervention phase compared with the control phase , demonstrated by an increase of 8.6 units on the Freddy satiety scale ( 95 % CI 3.4 to 13.7 , p=0.001 ) . There were no effects of the intervention on any other outcome . Conclusions A free SBP did not have a significant effect on children 's school attendance or academic achievement but had significant positive effects on children 's short-term satiety ratings . More frequent programme attendance may be required to influence school attendance and academic achievement . Trial registration Australian New Zeal and Clinical Trials Registry (ANZCTR)—ACTRN12609000854235 This study reports the effect of the Fruits and Vegetables Make the Marks intervention , a school-based fruit and vegetable intervention consisting of a home economics classroom component and parental involvement and encouraged participation in the Norwegian School Fruit Programme , all delivered during the school year of 2001 - 02 . Nine r and omly chosen schools received the intervention and 10 schools served as control schools . Participating pupils completed question naires at baseline ( September 2001 ) , at Follow-up 1 ( May-June 2002 ) and at Follow-up 2 ( May 2003 ) . A total of 369 pupils ( 69 % ; mean age , 11.3 years at baseline ) participated in all three surveys . No effect of the intervention was found for intake of fruit and vegetables eaten at school or all day , neither at Follow-up 1 nor at Follow-up 2 . On analysing the effects on potential mediators , significant differences between intervention and control groups were found for Awareness of the five-a-day recommendations only . The intervention programme was rated as very good by the teachers , and the pupils reported that they enjoyed it . However , the intervention failed to change fruit and vegetable intake , probably because it did not succeed in changing the pupils ' preferences for or the accessibility of fruit and vegetables -- the two strongest correlates of children 's fruit and vegetable intake OBJECTIVE To assess the impact of a school-based nutrition education intervention aim ed at increasing the consumption of fruits and vegetables . DESIGN The intervention programme increased the provision of fruits and vegetables in schools and provided a range of point-of-purchase marketing material s , newsletters for children and parents , and teacher information . Curriculum material s at age 6 - 7 and 10 - 11 years were also developed and utilised . Evaluation was undertaken with groups of younger ( aged 6 - 7 years ) and older ( aged 10 - 11 years ) children . Methods included 3-day dietary records with interview and cognitive and attitudinal measures at baseline , with follow-up at 9 months , in intervention and control schools . SETTING The work was undertaken in primary schools in Dundee , Scotl and . SUBJECTS Subjects comprised 511 children in two intervention schools with a further 464 children from two schools acting as controls . RESULTS Children ( n=64 ) in the intervention schools had an average increase in fruit intake ( 133+/-1.9 to 183+/-17.0 g day(-1 ) ) that was significantly ( P<0.05 ) greater than the increase ( 100+/-11.7 to 107+/-14.2 g day(-1 ) ) estimated in children ( n=65 ) in control schools . No other changes in food or nutrient intake were detected . Increases in scores for variables relating to knowledge about fruits and vegetables and subjective norms were also greater in the intervention than in the control group , although taste preferences for fruits and vegetables were unchanged . CONCLUSIONS It is concluded that a whole school approach to increasing intakes of fruits and vegetables has a modest but significant effect on cognitive and attitudinal variables and on fruit intake Background Current academic literature suggests that school gardening programmes can provide an interactive environment with the potential to change  children ’s fruit and vegetable intake . This is the first cluster r and omised controlled trial ( RCT ) design ed to evaluate whether a school gardening programme can have an effect on  children ’s fruit and vegetable intake .  Methods The trial included children from 23 schools ; these schools were r and omised into two groups , one to receive the Royal Horticultural Society (RHS)-led intervention and the other to receive the less involved Teacher-led intervention . A 24-hour food diary ( CADET ) was used to collect baseline and follow-up dietary intake 18 months apart . Question naires 
    Output:
    
The family-based programs which provided simple positive dietary advice to parents and regular follow-up reduced fat intake significantly .
School and family-based studies , if design ed and implemented well , increased F&V intake , particularly fruit .
Effective school-based programs have incorporated role-models including peers , teachers and heroic figures , rewards and increased access to healthy foods .
School nutrition programs in disadvantaged communities were as effective as programs in other communities .
Conclusions Family and school nutrition programs can improve dietary intake , however evidence of the long-term sustainability of these impacts is limited .