What Are the Best Practices in Nutrition Education for Elementary Students? A Review of Reviews
Tasha Cahill
Department of Nutrition & Dietetics, University of North Dakota
N&D 594 Research Methods
Instructor Dr. Nathaniel Johnson
Most children spend the majority of their waking hours at school. This means that schools are responsible for much of the student’s health and wellness, including nutrition. Afterall, healthy habits begin at a young age, and helping children develop these habits should be a priority of all teachers. However, the teacher must understand what the best practices and approaches are for helping their students acquire the knowledge and skills necessary to be successful in their nutritional choices. It is the goal of this review to analyze the evidence-based approaches to nutrition education in elementary schools and decern what elements will lead to the most successful programs.
Background
Without proper nutritional education, children are not developing nor building healthy habits. Good nutrition is crucial to healthy growth and development of a child. Good nutrition in childhood is also essential for their future management of food choices and intake as adults (Rasheed, 2023). Schools play a principal role in shaping children’s food choices and future health (Perera, et al., 2015). “Children should be enabled to make conscious and healthy dietary decisions so they can live healthy lives” (Rasheed, 2023), with schools being the primary place in which these choices take place.
However, not all schools are able to deliver nutrition education to their students or devote adequate time and resources to this topic. Especially in the United States, rates of nutrition education in elementary schools have been dropping since the No Child Left Behind act began in 2001 (Perera, et al., 2015). One reason this has occurred is that teachers choose to spend less classroom time on topics that are not present on the state-wide tests (Perera, et al., 2015, p. 2226-2227).
Many schools around the world are still working toward integrating nutrition education, mostly with programs outside of the classroom like gardening clubs, after-school cooking classes, and food provisions (i.e. free lunch programs) (Kelly & Nash) 2021. There are many more present options available for schools to include students in nutrition education. Through teacher-delivered programs, nutrition education enrichment programs, and volunteer community programs, any school can organize the inclusion of health and wellness to their standards.
Knowing what these programs should require to be successful for the students is the first step in developing or finding the most effective interventions. There is evidence to support many approaches to nutrition education as over 30 years of research has been published and analyzed by nutrition professionals (Kelly & Nash, 2021). Using the most recent systematic reviews on the effectiveness of nutrition education interventions in elementary schools, this review will discover the best practices in nutrition education for students in that age group.
Methods
This review was focused on retrieving systematic reviews of nutrition education programs in elementary schools. Four databases were used for this search: PubMed, CINAHL, Google Scholar, and ScienceDirect. Search terms included were “nutrition education” OR “nutrition literacy” OR “nutrition lessons” AND “best practices” OR implementation” OR “intervention” AND “elementary school” OR “primary school” OR “ages 5 to 12” AND “systematic review.”
Exclusion criteria included articles which focused on body weight (including BMI), specific conditions (such as diabetes or hypertension), or on physical activity alone. Articles which did not address the effectiveness of the studies were also excluded.
Inclusion requirements were systematic or scoping reviews on studies completed in elementary schools with a primary focus on nutrition education. These articles must be written in English with full text available. Some reviews included ages before five years old and after twelve years old; however, they remained in this review if most participating students were within the required age ranges and the authors specifically addressed the effectiveness of programs for the elementary school ages.
Results
A total of nine reviews were found which satisfied the stated requirements. Among the nine systematic reviews there were a total of 288 articles. After removing all duplicated, 164 unique articles remained. This has been determined to have no effect on the overall outcome of this review because the authors of each systematic review had unique perspectives regarding the educational outcomes and findings in their studies.
Of the 164 included reviews, six continents were representative (excluding Antarctica since there are no elementary schools located on that continent), with Africa being the least represented (less than 5%) and Europe being the most (40%). Most common countries in which these studies were performed were the United States, United Kingdom, and Australia. The prevalence of these countries can be accounted for by the requirement that each study is written in English.
The systematic reviews offered many unique insights into what evidence supports the best practices in a nutrition education program for elementary school students. However, the focus on this review was to find common elements that support the effectiveness of the interventions, providing evidence-based practice in childhood nutrition education. (See Table 1 for select details from the included systematic review articles.)
Within the nine systematic reviews three approaches were most addressed as being effective for nutrition education: (1) experiential learning, (2) curriculum and cross-curriculum, and (3) parental involvement. Also, theory has been shown to play a role in the function and overall outcomes of many studies discussed in the systematic reviews. Lastly, other approaches which have been identified as secondary factors with limitations are also discussed.
Experiential Learning
Most (n=7) of the review articles support experiential learning as being a fundamentally important part of a successful nutrition education program for elementary school students. Experiential learning is the process of developing knowledge through action and reflection. Examples of this approach include cooking classes, food tasting, grocery shopping, and nutrition label reading and deciphering. This style of learning is highly effective because it relates directly to the individual by allowing the learner to initiate, be engaged, form personal experiences, and take risks (The Association for Experiential Education). This approach to learning is widely supported through evidence as the most effective for nutrition education for elementary students.
The work of Charlton, et al. (2020) focused primarily on nutrition education programs that utilized experiential learning. They highlight characteristics of a successful experiential program, which includes frequent exposure, parental involvement, age appropriateness, multiple components, and the involvement of extra personnel from outside the school. Many of these concepts will be further discussed in this review. As Charlton, et al. describes: “Experiential intervention which include multiple experiences and exposures were able to show increases in children’s willingness to taste unfamiliar foods, their cooking and food preparation skills, as well as increased preference, knowledge and consumption of healthier foods” (2020, p. 4656).
Murimi, et al. (2018) studied nutrition education programs from preschool through high school, highlighting important differences required for success in elementary school aged children. The greatest differences were the cognitive abilities of children in that age group and how experiential learning with age-appropriate activities were the most successful (p. 576). Murimi, et al. (2018) reflect upon their predecessors, Dudley, et al. who found “experiential learning approaches had the greatest effect” when discussing their systematic review and meta-analysis in 2015 (p. 23). Murimi, et al. expanded upon the work of Dudley, et al. finding “all elementary school interventions that met their stated objectives applied interactive education and hands-on experiences” (2018, p. 576).
The research by Peralta, et al. (2016) demonstrated experiential learning is an evidence-based strategy (along with curriculum and cross-curriculum). Cotton, et al (2020) found 21 studies using experiential learning (along with curriculum and game-based learning) which all increased the average fruit and vegetable intake of students to some extent, proving to be effective. Collado-Soler, et al (2023) and Omidvar, et al (2022) agree that experiential learning, when combined with curriculum, is the most effective educational approach (p. 13, and p. 2119, respectively).
These highlights from the systematic review articles demonstrate the wide evidence that supports the use of experiential learning for nutrition education interventions. It is important to note that most of the mentioned articles (n=5) include curriculum or cross-curriculum along with experiential learning. This would suggest that experiential learning is effective, but those results can be enhanced when combined with curriculum focused interventions.
Curriculum and Cross-curriculum
The second most (n=7) supported approach in a successful nutrition education program is the use of curriculum and cross-curriculum. Curriculum describes what is intentionally taught, and cross-curriculum describes combining relevant aspects of other subject matter into the learning session. An example is designing a lesson for kindergarten students about choosing healthy produce through selecting a colorful plate (curriculum) and having the students count how many colors they see on a sample plate (cross-curriculum). In this example, the intentional lesson is focused on healthy food choices and the addition of relevant mathematical concepts helps support both current nutrition lesson and previous counting lessons.
Peralta, et al. (2016) analyzed 13 articles which utilized cross-curriculum in their scoping review (p. 341). Their stance is that cross-curriculum, when combined with experiential learning, was the strongest evidence-based approaches (p. 342). They further explained that the use of cross-curriculum may help teachers balance time in the classroom between standard lessons and nutrition focused lessons, helping students stay engaged with academic subjects throughout the day (p. 342). Roseman, et al. (2020) concurs, finding that most interventions involved integrating nutrition education into the curriculum of the classroom (p. 817).
In the systematic review and meta-analysis done by Dudley, et al. (2015) ten studies were found to utilize cross-curriculum with results proving to be highly effective (p. 22). Furthermore, they found that both cross-curriculum and quality curriculum were effective interventions for improving fruit and vegetable consumption for elementary school aged children in the conclusion (p. 23).
Omidvar, et al. performed a systematic review focused on the effects of school-based programs on Food and Nutrition Literacy (FNLIT) for elementary aged students (2016). In their work the most effective programs included integrating existing curriculum in the classroom (p. 2118). In their conclusion, they recommend future programs include experiential learning with existing curriculum (cross-curriculum) to improve the student’s functional skills and critical skills in FNLIT (p. 2119).
In Charlton, et al. (2020), which focused primarily on experiential learning, showed curriculum to be a regular theme among their findings. They concluded, “It has been established that experiential learning accompanied with cross-curriculum interventions is most beneficial and effective at producing knowledge and behavior change in young children” (Charlton, et al., 2020, p. 4656). Ideas repeatedly reflected throughout this review.
When examining curriculum and classroom-based approaches to nutrition education, teachers should be considered for their role in supporting or delivering these programs. Peralta, et al. (2016) found deficiencies in resources being directed toward classroom teachers to deliver nutrition education (p. 342). They recommend more support for teachers to help deliver effective lessons with confidence and appropriate resources (p. 342-343). Wang and Stewart (2012) also addressed the need for teachers to be more supported in their resources, adding that proper nutrition education for teachers is required for high-quality programs to exist in the classroom (p. 1098). Teachers must be provided the proper support and materials to deliver effective nutrition lessons in the classroom.
The use of curriculum and cross-curriculum in nutrition education is effective and found throughout the systematic reviews included in this review. Cross-curriculum is especially important as it strengthens understanding of nutrition through academic learning. To increase the quality of nutrition curriculum, teachers must be supported and provided with adequate knowledge and resources.
Parental Involvement
The third most prominent (n=7) aspect of a successful nutrition education program is parental involvement. “Parental involvement in child nutrition education leads to positive change in children’s nutrition-related habits” (Roseman, et al., 2020, p. 814) because parents are the primary role models and “gate keepers” for their children’s diets, purchasing and preparing the majority of the foods consumed by the family (Dixon et al., 2020, p. 2). It is crucial to consider the importance of parental involvement in nutrition education in elementary schools because children at these ages are less likely to make independent decisions on diet and nutrition-related activities. Parental involvement can take many forms, making it more variable than the previous approaches so far discussed.
“Parents and caregivers have an important role to play” (Cotton, et al., 2020, p. 101178) when it comes to supporting the nutrition and education of their children. In the work of Dudley, et al. (2015), they found that parental involvement was a dominant approach in effective nutrition education programs (p. 20). Peralta, et al. (2016) found 15 out of 32 studies used parental involvement, suggesting it was an important part of those studies’ success, but it needed to be studied more (p. 342).
Wang & Stewart (2012), who focused primarily on the Healthy-Promoting Schools (HPS) program, found that parental involvement primarily took place through materials being sent to the home such as pamphlets, newsletters, and homework assignments. Roseman, et al. (2020) agreed that home involvement through written materials was a common practice; however, they found that most interventions engaged parents equally at home and through the school (p. 814). Activities like healthy tailgate parties, parent education evenings events, and family nutrition poster presentations were common approaches discussed by Roseman, et al. (2020, p. 814).
In the discussion of Charlton, et al. (2020), parental involvement is undoubtedly an important factor in effective programs, but they found limited information on how best to engage parents (p. 4657). Whereas Murimi, et al. (2018) found that the most successful programs engage parents face-to-face and identify specific topics (p. 571). Half of the successful interventions engaged parents on a face-to-face basis instead of simply sending information to parents” (Murimi, et al., 2018, p. 571).
Involving parents in children’s nutrition education is an important part to ensure positive nutritional behaviors for the students and their families. There is some debate as to the best approaches to engage parents, with some systematic reviews claiming in-person involvement is best. Nevertheless, the consensus among the research is that parental involvement is as essential to a successful nutrition education program as the experiential activities and curriculum. Finding the right way to engage parents will be at the discretion of the program designer, and involve consideration to the available resources, social environment factors, and context of the lesson.
Theory
When determining the best approaches for nutrition education interventions, theory provides a guide for program developers to connect determinants to desired results (Contento & Koch, 2021, p. 76-77). The most common theories used in the nine systematic reviews were Social Cognitive Theory and Theory of Planned Behavior.
Theory is regularly discussed among the review authors. Dudley, et al. (2015) describes how quality interventions based on theory are capable of achieving improvements (p. 22). In this review 49 studies are included and 26 (53%) use behavioral change theories, leading to some confidence in theory to achieve desired results. Charlton, et al. (2020) agrees: “successful intervention guided by a behavior change theory tended to be the most impactful in terms of creating changes in both school environment and children’s behaviors” (p. 4656). And Omidvar, et al. (2022) analyzes the characteristics of their review and finds that theory-based interventions improve FNLIT (p. 2105). These authors found the use of theory being important to the success of the interventions they reviewed.
Murimi, et al. (2018) acknowledges the importance of theory in the success of a program, but states that most of the interventions in their review were not guided by theory, only informed by theory (p. 578). The difference being that interventions will use “specific constructs in the methodology, intervention, and assessment” when they are theory-driven studies, whereas others may only use constructs of the theory somewhere within the study (p. 575). Murimi, et al. (2018) demonstrates the importance of using theory to fully guide a successful intervention.
Theory gives program designers and teachers the proper framework for how the lesson will accomplish its goals. The systematic reviews have included theories as part of their analysis because it makes a difference in the overall outcomes of the program’s success. The proper use of theory can help inform on what approaches will be best for the intervention. “When applied to nutrition education, theory predicts and explains behavior or behavior change” (Contento & Koch, 2021, p. 81). Theory is the backbone of nutrition education because it is required for writing meaningful curriculum.
Other approaches
Many other approaches were discussed within the systematic reviews. Some agreement between the review authors are notable inclusions to this research, and are (1) environment, (2) game-based learning, and (3) program duration. These three additional approaches are worth mentioning because they were common features of the studies being reviewed. There are limitations to including these approaches, making their inclusion into an evidence-based nutrition program secondary to those previously discussed.
Environment
The use of environment in the classroom and school can greatly impact educational program outcomes. An environment supportive of good nutrition will include positive nutrition modeling, easier access to healthy foods, supportive media exposure which promotes healthy choices, and policies that make healthy choices the desired behavior. Due to the time spent at school, the environment there can greatly impact children’s behaviors; therefore, supportive environments can enable children to make healthy choices (Wang & Stewart, 2012, p. 1083). Collado-Soler, et al. (2023) agrees, stating that school environments (along with parental involvement) is important for the success of any program. Murimi, et al. (2018) and Roseman, et al. (2020) agree that environment is a necessary element to a successful nutrition education program for elementary students. Changes in the school environment require policy changes and school-wide staff dedication, creating some barriers to applying this element to it’s fullest potential.
Game-Based Learning
Of the 164 articles included throughout the systematic reviews, 33 (20%) included game-based learning. Examples of this approach are board games, crossword puzzles, and card games. This approach is discussed in Cotton, et al. (2020), Dudley, et al. (2015), as Peralta, et al. (2016) as an effective inclusion into a nutrition education program. Collado-Soler, et al. (2023) how important it is to use games to keep learning session fun and interactive (p. 14). However fun game-based learning can be, it can be difficult to obtain the appropriate materials and dedicate the classroom time to less academic activities.
Program Duration
All but one (Peralta, et al., 2016) systematic review commented on duration of nutrition education interventions. Collado-Soler, et al. (2023) having mostly effective studies with higher durations, found a study with the lowest duration (5 weeks) having only “slightly higher effects” (p.11). Murimi, et al. (2018) discusses the minimal duration should be six months or more (p. 572). Whereas Charlton, et al. (2020) quoted an article stating a one year minimum (p. 4658). Roseman, et al. (2020) claims duration is not as important as total educational hours, stating a minimum of 50 hours over an intervention (p. 815). The costs associated with longer-term interventions can become overwhelming, making shorter terms more ideal for certain schools. The total duration of a nutrition education program will depend largely on resources, but any term intervention would be beneficial over none at all.
Discussion
For a successful nutrition education program to affect positive changes onto elementary school children it should have the following five elements: (1) use experiential learning, (2) use curriculum and incorporate cross-curriculum, (3) participate in parental involvement that includes in-person contact, (4) is theory driven, (5) incorporates other approaches when appropriate. These elements work together to provide nutrition educators with the foundation to deliver successful lessons to their students.
An example program which satisfies this list of desired elements can be delivered to fourth grade students (ages 9 to 10 years), focused on addressing a deficiency in nutrition label literacy. The intervention will be driven by the Social Cognitive Theory which addresses the use of an individual’s skills to direct change and depends largely on self-efficacy (Contento & Koch, 2021, p. 138-138). The curriculum will be reading and interpreting nutrition labels, with an objective to successfully read common food labels by the end of the lesson. The lesson materials will be a collection of empty food containers with nutrition labels clearly visible. The lesson plan will be to instruct on the main parts of the nutrition label, then have the students break into groups to collect and examine the labels for themselves. Photos of the lesson can be shared with parents electronically, or parent volunteers can also be present to supervise and assist in the group activity.
In this example, group work is both experiential learning and within the scope of the theory. The teacher can introduce cross-curriculum by having the student groups arrange the food labels by specific attributes (mathematics) or write a journal entry explaining which foods they would prefer and why (language arts). Use of other approaches is possible in this example through introducing games, working toward environmental changes with the school staff, and extending the lessons throughout multiple months.
This example program is one possibility inspired by this review and the work completed by the systematic review authors. There are many possibilities for developing great nutrition interventions that will enhance the health and happiness of students. Using these five program elements will help ensure a successful intervention.
Future research into the best practices in nutrition education should focus on studying the exact elements used in nutrition education studies with well described interventions. Knowing what and how is being taught in the studied interventions can further inform on the development of optimal nutrition lessons plans.
Limitations
Due to the nature of this research, most of the findings throughout the systematic reviews were qualitative and interpretive. Many review authors reported issues in analyzing and comparing the effectiveness of all studies due to the different metrics used and qualitative data collected, while others were able to find some common statistical findings. Nevertheless, the overall outcomes of these reviews were generalized to some extent. This review focused on the overall findings of the review authors which is evidenced by the included studies. Therefore, the information presents some bias.
Conclusion
This review collected and analyzed the most recent systematic reviews on the effectiveness of nutrition education approaches in elementary schools. The findings suggest the following five elements will lead to a successful education intervention: (1) use experiential learning, (2) use curriculum and incorporate cross-curriculum, (3) participate in parental involvement that includes in-person contact, (4) is theory driven, (5) incorporates other approaches when appropriate. This information can be used for both designing and researching the best program for each teacher, school, or school district.
References
The Association for Experiential Education. (2023). What is experiential education?. What is Experiential Education – Association for Experiential Education. https://www.aee.org/what-is-experiential-education
Dixon, H., Scully, M., Gascoyne, C., & Wakefield, M. (2020). Can counter-advertising diminish persuasive effects of conventional and pseudo-healthy unhealthy food product advertising on parents?: An experimental study. BMC Public Health, 20(1). https://doi.org/10.1186/s12889-020-09881-1
Contento, I. R., & Koch, P. A. (2021). Nutrition education: Linking research, theory, and Practice. Jones & Bartlett.
Cotton, W., Dudley, D., Peralta, L., & Werkhoven, T. (2020). The effect of teacher-delivered nutrition education programs on elementary-aged students: An updated systematic review and meta-analysis. Preventive Medicine Reports, 20, 101178–101284. https://doi.org/10.1016/j.pmedr.2020.101178
Cotton, W., Dudley, D., Peralta, L., & Werkhoven, T. (2020). The effect of teacher-delivered nutrition education programs on elementary-aged students: An updated systematic review and meta-analysis. Preventive Medicine Reports, 20, 101178–101284. https://doi.org/10.1016/j.pmedr.2020.101178
Perera, T., Frei, S., Frei, B., Wong, S. S., & Bobe, G. (2015). Improving Nutrition Education in U.S. Elementary Schools: Challenges and Opportunities. Journal of Education and Practice, 6(30), 2222–1735. https://eric.ed.gov/?id=EJ1081364
Rasheed, M. (2023). Promoting nutritional education in primary school children. British Journal of Nursing, 32(8), 14–18. https://doi.org/10.12968/bjon.2023.32.8.s14
Peralta, L. R., Dudley, D. A., & Cotton, W. G. (2016). Teaching healthy eating to elementary school students: A scoping review of nutrition education resources. Journal of School Health, 86(5), 334–345. https://doi.org/10.1111/josh.12382
Kelly, R. K., & Nash, R. (2021). Food literacy interventions in elementary schools: A systematic scoping review*. Journal of School Health, 91(8), 660–669. https://doi.org/10.1111/josh.13053
Dudley, D. A., Cotton, W. G., & Peralta, L. R. (2015). Teaching approaches and strategies that promote healthy eating in primary school children: A systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity, 12(1). https://doi.org/10.1186/s12966-015-0182-8
Wang, D., & Stewart, D. (2012). The implementation and effectiveness of school-based nutrition promotion programmes using a health-promoting schools approach: A systematic review. Public Health Nutrition, 16(6), 1082–1100. https://doi.org/10.1017/s1368980012003497
Charlton, K., Comerford, T., Deavin, N., & Walton, K. (2020). Characteristics of successful primary school-based experiential nutrition programmes: A Systematic Literature Review. Public Health Nutrition, 24(14), 4642–4662. https://doi.org/10.1017/s1368980020004024
Murimi, M. W., Moyeda-Carabaza, A. F., Nguyen, B., Saha, S., Amin, R., & Njike, V. (2018). Factors that contribute to effective nutrition education interventions in children: A systematic review. Nutrition Reviews, 76(8), 553–580. https://doi.org/10.1093/nutrit/nuy020
Omidvar, N., Doustmohammadian, A., Shakibazadeh, E., Clark, C. C., Kasaii, M. S., & Hajigholam-Saryazdi, M. (2022). Effects of school-based interventions on Food and Nutrition Literacy (FNLIT) in primary-school-age children: A systematic review. British Journal of Nutrition, 129(12), 2102–2121. https://doi.org/10.1017/s0007114522002811
Collado-Soler, R., Alférez-Pastor, M., Torres, F. L., Trigueros, R., Aguilar-Parra, J. M., & Navarro, N. (2023). A systematic review of healthy nutrition intervention programs in kindergarten and primary education. Nutrients, 15(15), 1–19. https://doi.org/10.3390/nu15030541
Table 1: Details of the Article Included in this Review.
