Setting: School

School-based nutrition education programs alone are not cost effective for preventing childhood obesity: a microsimulation study

This study aims to estimate the societal costs and potential for cost-effectiveness of 3 nutrition education curricula frequently implemented in United States public schools for childhood obesity prevention.

Kenney EL, Poole MK, McCulloch SM, Barrett JL, Tucker K, Ward ZJ, Gortmaker SL. School-based nutrition education programs alone are not cost effective for preventing childhood obesity: a microsimulation study. Am J Clin Nutr. 2025 Jan;121(1):167-173. doi: 10.1016/j.ajcnut.2024.11.006. Epub 2024 Nov 12.

Abstract

Background

Although interventions to change nutrition policies, systems, and environments (PSE) for children are generally cost effective for preventing childhood obesity, existing evidence suggests that nutrition education curricula, without accompanying PSE changes, are more commonly implemented.

Objectives

This study aimed to estimate the societal costs and potential for cost-effectiveness of 3 nutrition education curricula frequently implemented in United States public schools for childhood obesity prevention.

Methods

In 2021, we searched for nutrition education curricula in the Supplemental Nutrition Assistance Program (SNAP)-Ed Toolkit, a catalog of interventions for obesity prevention coordinated by the federal government. Standard costing methodologies estimated the societal costs from 2023 to 2032 of nationwide implementation of each identified curriculum. Using the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model, which projects the costs, health care costs saved, and cases of obesity prevented for childhood obesity prevention interventions, we conducted threshold analyses for each curriculum, estimating the cost per quality-adjusted life-year for a range of hypothetical effects on child BMI to determine how large of an effect each curriculum would need to have to meet a cost-effectiveness threshold of $150,000 per quality-adjusted life-year.

Results

Three nutrition education curricula without PSE were identified from SNAP-Ed; none had evidence of an impact on obesity risk. From 2023 to 2032, the estimated implementation costs of the curricula nationwide ranged from $1.80 billion (95% upper interval: $1.79, $1.82 billion) to $3.48 billion (95% upper interval: $3.44, $3.51 billion). Each curriculum would have to reduce average child BMI by 0.10 kg/m2 or more—an effect size that has not been reported by any of the 3 curricula, or by more comprehensive existing prevention programs—to be considered cost effective at this threshold.

Conclusions
SNAP-Ed–endorsed nutrition education curricula alone are unlikely to be cost effective for preventing childhood obesity. Continued efforts to implement interventions with strong evidence for effectiveness, including PSE approaches, are needed.

Keywords
childhood obesity; nutrition educationl schools; prevention; cost-effectiveness analysis; threshold analysis


Funding

This study was supported by Healthy Eating Research, a national program of the Robert Wood Johnson Foundation (2833590), The JPB
Foundation, the National Heart, Lung, and Blood Institute (NHLBI) (5T32HL098048, R01HL146625, and 1F31HL162250), the National
Institute of Diabetes and Digestive and Kidney Diseases (K01DK125278), and the Centers for Disease Control and Prevention (U48DP006376). The content is solely the responsibility of the authors and does not necessarily represent the official views of these agencies.

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Strategy Reports: Promoting Physical Activity in Schools

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose. These strategy reports describe the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for effective strategies to improve child health in schools. This information can help inform decision-making around promoting healthy weight and can be useful for planning and prioritization purposes.

Strategy Report: Active Physical Education (Active PE)
Active PE is a policy that requires that 50% of time provided in physical education classes for grades K-8 be spent in moderate-to-vigorous physical activity. Physical education teachers are trained to promote physical activity during PE classes using the SPARK or CATCH curricula.

Strategy Report: Active Recess
Active Recess is a program to increase physical activity during elementary school recess with structured activities, playground markings, and/or portable play equipment. This program is implemented in elementary schools to promote physical activity during recess.

Strategy Report: Active School Day
Policy requiring schools to provide opportunities for students to participate in physical activity during the school day for at least 30 minutes a day or 150 minutes a week.

Strategy Report: Movement Breaks in the Classroom
Movement Breaks in the Classroom is a strategy to promote physical activity during the school day by incorporating five-to-10-minute movement breaks in K-5 public elementary school classrooms.


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Explore and compare these strategies and more using the CHOICES National Action Kit 2.0!

Strategy Profiles: Promoting Physical Activity in Schools

The information in these resources is intended only to provide educational information. These profiles describe the estimated benefits, activities, resources, and leadership needed to implement strategies to improve child health in schools. This information can be useful for planning and prioritization purposes.

Strategy Profile: Active Physical Education (Active PE)
Active PE is a policy that requires that 50% of time provided in physical education classes for grades K-8 be spent in moderate-to-vigorous physical activity. Physical education teachers are trained to promote physical activity during PE classes using the SPARK or CATCH curricula.

Strategy Profile: Active Recess
Active Recess is a program to increase physical activity during elementary school recess with structured activities, playground markings, and/or portable play equipment. This program is implemented in elementary schools to promote physical activity during recess.

Strategy Profile: Active School Day
Policy requiring schools to provide opportunities for students to participate in physical activity during the school day for at least 30 minutes a day or 150 minutes a week.

Strategy Profile: Movement Breaks in the Classroom
Movement Breaks in the Classroom is a strategy to promote physical activity during the school day by incorporating five-to-10-minute movement breaks in K-5 public elementary school classrooms.

Strategy Profile: Safe Routes to School
Safe Routes to School is a program that supports the use of physically active modes of transportation to and from school, and aims to help children in grades K-8 safely walk and bicycle to school through infrastructure improvements, education, enforcement, and promotional activities.


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Explore and compare these strategies and more using the CHOICES National Action Kit 2.0!

Exploring the Cost-Effectiveness of Strategies to Improve Child Health in Massachusetts

The information in this brief is intended only to provide educational information.

The CHOICES Project at the Harvard T.H. Chan School of Public Health, the Massachusetts Department of Public Health (MDPH), and the Massachusetts Department of Elementary and Secondary Education (DESE) worked together as part of the Massachusetts-CHOICES Project, a training, technical assistance, and modeling initiative, to develop a playbook of strategies to promote healthy weight and advance health equity in addition to studying how cost-effectiveness metrics are used by partners throughout the state.

Methods & Strategies Modeled

CHOICES cost-effectiveness analysis examines: How many and what types of people would be affected by the policy or program? What the effect of the policy or program would be on health? What will be the implementation costs and the potential health care cost savings? How could the policy or program reduce health disparities and improve health equity?

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics.

Using CHOICES cost-effectiveness analysis and local data, the MDPH and DESE team worked with CHOICES to create a virtual population that mirrors the current population of Massachusetts. Then, the teams examined the expected costs, health outcomes, impacts on health equity, and health care costs saved if the following strategies were implemented in Massachusetts over a 10-year timeframe (2020-2029):

Movement Breaks in the Classroom
Water Dispensers in Schools

Movement Breaks in the Classroom

Movement breaks in the classroom is a strategy to promote physical activity during the school day by incorporating five-to-10-minute movement breaks in K-5 public elementary school classrooms. To implement this evidence-based strategy,1 the Massachusetts Departments of Public Health and Elementary and Secondary Education would collaborate to connect school districts to the School Wellness Coaching Program. This program helps school districts integrate movement breaks into their local wellness policies and meet state and federal physical activity recommendations.

Teachers in K-5 classrooms would receive training, technical assistance, and materials to support implementation. School wellness champions could also elect to be trained. This strategy aligns with the School Wellness Coaching Program2 and the Whole School, Whole Community, Whole Child initiative to create school environments that prioritize students’ health, well-being, and ability to learn.

Implementing movement breaks in the classroom is an investment in the future. By the end of 2029: 31,600 children would be reached over 10 years; 25 additional minutes of moderate-to-vigorous physical activity per student per school week; $5.72 per child per year.

Additional Key Findings

If movement breaks were incorporated into classrooms in Massachusetts, it is likely to be cost-effective at commonly accepted thresholds3 based on net cost per population health improvement related to excess weight ($66,200 per quality-adjusted life year gained).

By training and equipping over 200 teachers and other school staff to incorporate movement breaks in the classroom, this strategy could help Massachusetts public schools cultivate a positive school climate and improve social emotional learning.4 Additionally, movement breaks allow students an opportunity for a “brain break” to refocus, reconnect and bring their attention back to their academic work.

To learn more about this strategy, read the research brief.

  • Good N, Bolton AA, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Massachusetts: Movement Breaks in the Classroom {Issue Brief}. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; June 2023.
References

1.The Community Preventive Services Task Force. Physical Activity: Classroom-based Physical Activity Break Interventions. The Community Guide; 2021. Accessed Jun 20, 2023. https://www.thecommunityguide.org/pages/tffrs-physical-activity-classroom-based-physical-activity-break-interventions.html
2.School Wellness Initiative for Thriving Community Health (SWITCH). Initiatives: Massachusetts School Wellness Coaching Program. Published 2022. Accessed Oct 5, 2022. https://massschoolwellness.org/initiatives
3.Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. DOI: 10.1056/NEJMp1405158. PMID: 25162885.
4.Centers for Disease Control and Prevention. School-Based Physical Activity Improves the Social and Emotional Climate for Learning. CDC Healthy Schools. Published 2021. Accessed March 9, 2022. https://www.cdc.gov/healthyschools/school_based_pa_se_sel.htm

Water Dispensers in Schools

This strategy applies an equity lens to increasing water access by installing touchless water dispensers on or near school cafeteria lunch lines in K-8 Massachusetts public schools with identified needs. Priority schools would be those with elevated concentrations of lead in drinking water documented via state lead testing programs1 and located in cities and towns with Environmental Justice designation based on the community’s share of households with lower incomes, limited English proficiency, or individuals identifying as Black, Indigenous, or people of color.2

Better drinking water access in schools has been shown to increase water intake and may help promote a healthy weight.3 The Massachusetts Departments of Public Health and Elementary and Secondary Education would provide outreach to school districts to encourage the installation of water dispensers through existing relationships.

The installation of touchless water dispensers in schools in Massachusetts is an investment in a more equitable future. By the end of 2029: 265,000 students would be reached with improved access to safe drinking water in schools over 10 years; 129,000 Black and Hispanic/Latinx students would be reached with improved access to safe drinking water in schools over 10 years; $9 per student per year.

Additional Key Findings

If water dispensers were installed in K-8 public schools in Massachusetts, it is likely to be cost-effective at commonly accepted thresholds4 based on net cost per population health improvement related to excess weight, at a cost of $72,700 per quality-adjusted life year gained.

Additionally, this strategy would prioritize installing water dispensers in schools that identify elevated concentrations of lead in their drinking water and in school districts located in communities meeting criteria for Environmental Justice designation.2 Fifty percent of the students that would gain access to improved drinking water would be Black and Hispanic/Latinx, a higher proportion than the state’s student population overall.5

To learn more about this strategy, read the research brief.

  • McCulloch SM, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Massachusetts: Water Dispensers in Schools {Issue Brief}. The CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; June 2023.
References

1. MA Executive Office of Energy and Environmental Affairs. Lead and Copper in School Drinking Water Sampling Results. Accessed December 5, 2022. https://www.mass.gov/service-details/lead-and-copper-in-school-drinking-water-sampling-results
2. MA Executive Office of Energy and Environmental Affairs. Environmental Justice Populations in Massachusetts. Accessed April 7, 2023. https://www.mass.gov/info-details/environmental-justice-populations-in-massachusetts
3. Schwartz AE, Leardo M, Aneja S, Elbel B. Effect of a School-Based Water Intervention on Child Body Mass Index and Obesity. JAMA Pediatr. 2016; 170(3):220-226. doi:10.1001/jamapediatrics.2015.3778.
4. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. doi: 10.1056/NEJMp1405158. PMID: 25162885.
5. Massachusetts Department of Elementary and Secondary Education. 2022-23 Enrollment By Race/Gender Report (District). Updated December 1, 2022. Accessed April 7, 2023. https://profiles.doe.mass.edu/statereport/enrollmentbyracegender.aspx


The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This document was developed at the Harvard T.H. Chan School of Public Health through the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This document is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

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Explore and compare these strategies and more using the CHOICES National Action Kit 2.0!

Strategy Report: Active School Day

School children stretching up at lesson

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose.

Overview

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics. This strategy report describes the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for an effective strategy to improve child health. This information can help inform decision-making around promoting healthy weight. To explore and compare additional strategies, visit the CHOICES National Action Kit 2.0.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu with any accessibility questions.

Suggested Citation

CHOICES National Action Kit: Active School Day Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2023.

Acknowledgments

We thank the following members of the CHOICES Project team for their contributions: Molly Garrone, Dar Alon, Stella Zhu, Shilpi Agarwal, Ana Paula Bonner Septien, Jenny Reiner, Matt Lee, Zach Ward.

Funding

This work is supported by the National Institutes of Health (R01HL146625), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders. The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose

For further information, contact choicesproject@hsph.harvard.edu

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Strategy Report: Movement Breaks in the Classroom

Teacher leading a movement break in the classroom with young kids

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose.

Overview

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics. This strategy report describes the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for an effective strategy to improve child health. This information can help inform decision-making around promoting healthy weight. To explore and compare additional strategies, visit the CHOICES National Action Kit 2.0.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu with any accessibility questions.

Suggested Citation

CHOICES National Action Kit: Movement Breaks in the Classroom Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2023.

Acknowledgments

We thank the following members of the CHOICES Project team for their contributions: Molly Garrone, Amy Bolton, Shilpi Agarwal, Ana Paula Bonner Septien, Stephanie McCulloch, Jenny Reiner, Matt Lee, Zach Ward.

Funding

This work is supported by the National Institutes of Health (R01HL146625), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders. The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose

For further information, contact choicesproject@hsph.harvard.edu

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Strategy Report: Active Physical Education

A diverse group of children playing basketball.

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose.

Overview

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics. This strategy report describes the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for an effective strategy to improve child health. This information can help inform decision-making around promoting healthy weight. To explore and compare additional strategies, visit the CHOICES National Action Kit 2.0.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu with any accessibility questions.

Suggested Citation

CHOICES National Action Kit: Active Physical Education Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2023.

Acknowledgments

We thank the following members of the CHOICES Project team for their contributions: Molly Garrone, Dar Alon, Stella Zhu, Shilpi Agarwal, Ana Paula Bonner Septien, Jenny Reiner, Matt Lee, Zach Ward.

Funding

This work is supported by the National Institutes of Health (R01HL146625), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders. The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose

For further information, contact choicesproject@hsph.harvard.edu

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Strategy Report: Active Recess

Children running outside during recess at school

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose.

Overview

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics. This strategy report describes the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for an effective strategy to improve child health. This information can help inform decision-making around promoting healthy weight. To explore and compare additional strategies, visit the CHOICES National Action Kit 2.0.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu with any accessibility questions.

Suggested Citation

CHOICES National Action Kit: Active Recess Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; November 2023.

Acknowledgments

We thank the following members of the CHOICES Project team for their contributions: Molly Garrone, Dar Alon, Stella Zhu, Shilpi Agarwal, Ana Paula Bonner Septien, Jenny Reiner, Matt Lee, Zach Ward.

Funding

This work is supported by the National Institutes of Health (R01HL146625), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders. The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose

For further information, contact choicesproject@hsph.harvard.edu

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Strategy Report: Promoting Water Consumption in Schools

Water dispenser in a school

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose.

Overview

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics. This strategy report describes the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for an effective strategy to improve child health. This information can help inform decision-making around promoting healthy weight. To explore and compare additional strategies, visit the CHOICES National Action Kit 2.0.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu with any accessibility questions.

Suggested Citation

CHOICES National Action Kit: Promoting Water Consumption in Schools Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; November 2023.

Acknowledgments

We thank the following members of the CHOICES Project team for their contributions: Molly Garrone, Dar Alon, Stella Zhu, Shilpi Agarwal, Amy Bolton, Jenny Reiner, Matt Lee, Zach Ward.

Funding

This work is supported by the National Institutes of Health (R01HL146625), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders. The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose

For further information, contact choicesproject@hsph.harvard.edu

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Strategy Profile: Active School Day

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

  • Policy requiring schools to provide opportunities for students to participate in physical activity during the school day for at least 30 minutes a day or 150 minutes a week.

What population benefits?

Children in grades K-8 (ages 5-14).

What are the estimated benefits?

Relative to not implementing the strategy
Increase students’ moderate-to-vigorous physical activity levels and, in turn, promote healthy weight.

What activities and resources are needed?

Activities Resources Who Leads?
Coordinate and support implementation of the active school day policy • Time for school health and wellness staff (Director, Assistant Director, Physical Education Director, Coordinators, and business office staff) to provide support School district
Train Wellness Champions, physical education teachers, and lunch monitors in physical activity promotion • Time for training consultant to train physical education teachers, Wellness Champions, and lunch monitors
• Time for Wellness Champions to attend trainings on policy and implementation strategies (either recess or movement breaks in the classroom)
• Time for physical education teachers to attend training on quality PE strategies
• Time for lunch monitors to attend trainings on recess strategies (in schools implementing recess strategies)
• Travel costs for lunch monitors to attend trainings
• Cost of space rental, food, and promotional flyers for trainings
School district
Develop and maintain materials to support implementation • Cost to develop an online portal or printed materials to support implementation
• Cost to maintain the online portal or replace printed materials in subsequent years
School
Implement strategies that promote physical activity in schools • Time for Wellness Champions and instructional coaches to lead implementation of strategies promoting physical activity
• Time for Wellness Champions and school principals to review performance on strategy implementation
School district
Purchase equipment and materials for a more active school day • Cost of equipment and curricula for promoting physical activity in physical education and in recess or the classroom School district

FOR ADDITIONAL INFORMATION

Cradock AL, Barrett JL, Kenney EL, Giles CM, Ward ZJ, Long MW, Resch SC, Pipito AA, Wei ER, Gortmaker SL. Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood. Prev Med. 2017 Feb;95 Suppl: S17-S27. doi: 10.1016/j.ypmed.2016.10.017. Supplemental Appendix with strategy details available at: https://ars.els-cdn.com/content/image/1- s2.0-S0091743516303395-mmc1.docx


Suggested Citation

CHOICES Strategy Profile: Active School Day. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2023.

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

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