We examined evidence regarding the influence of school physical environment on healthy-eating outcomes. We applied a systems perspective to examine multiple disciplines’ theoretical frameworks and used a mixed-methods systematic narrative review method, considering both qualitative and quantitative sources (published through March 2014) for inclusion. We developed a causal loop diagram from 102 sources identified. We found evidence of the influence of many aspects of a school’s physical environment on healthy-eating outcomes. The causal loop diagram highlights multilevel and interrelated factors and elucidates the specific roles of design and architecture in encouraging healthy eating within schools. Our review highlighted the gaps in current evidence and identified areas of research needed to refine and expand school architecture and design strategies for addressing healthy eating. Children’s and adolescent’s diets have deteriorated in nutritional quality over the past 3 decades, contributing to increased rates of childhood obesity. 1,2 The proportion of children’s total energy intake from sugar-sweetened beverages has doubled, and their fruit and vegetable consumption has significantly decreased. 3,4 Schools have substantial opportunities to address healthy eating because of their role in education and socialization and because they are a major source of food access, contributing up to 50% of many students’ daily energy intake. 5 However, in isolation, school-based nutrition education has not been proven to be consistently effective. This knowledge has driven interest and investment in development of new intervention strategies, including multifaceted approaches to creating school environments conducive to healthy eating. 6,7 An emerging area of investigation is the role of a school facility’s physical design (e.g., siting, architecture, landscape features) as a mediator of healthy-eating behaviors and attitudes among children. 7 Recently, interdisciplinary teams have begun to consider the potential of whole-building design to integrate multiple objectives throughout an entire built project to achieve optimum performance. 8 In a similar fashion, Huang et al. used a systems-based approach and translated theory, research, and practice-based evidence into the Healthy Eating Design Guidelines (HEDGs) for School Architecture. (A description of the collaborative process and items included in the initial version of the HEDGs was published previously. 9 ) The HEDGs describe 10 spatial domains, each with a design-oriented objective and corresponding physical environment strategies ( Table 1 ). These strategies incorporate a systems perspective, taking into account the interactions between spaces throughout the whole school building and its occupants as a system to facilitate and encourage healthy-eating practices and behaviors. TABLE 1— Healthy Eating Design Guideline Domains, Objectives, and Design Strategies Domain Objective Sample Strategies Commercial kitchen Design an open commercial kitchen to facilitate the procurement, preparation, and storage of fresh, organic, whole foods that are prepared in a manner to preserve nutritional value. Provide kitchen equipment such as ovens, tilt skillets, and steamers that allow for a variety of cooking methods for fresh foods. Provide sufficient counter or work space for processing of fresh foods. Teaching kitchen Design complementary hands-on teaching kitchen areas for students and extracurricular organization use. Provide areas conducive to teaching, presentation, and demonstration cooking. Create teaching kitchen as a hands-on learning environment with equipment that is safe and accessible to children. Serving Design cafeteria to function efficiently to maximize dining time for students, while effectively encouraging the selection and enjoyment of healthy foods and beverages. Provide space for healthy grab-and-go meal options in the snack or express line. Provide space for multiple healthy choices in each food category (celery and carrots). Position salad bars away from walls for 360° circulation. Dining Reconceive dining areas as places of enjoyment and relaxation, configured to fully support healthy food initiatives. Design dining areas to recognized national standard for seating capacity, to avoid overcrowding. Create a variety of seating options and social arrangements, recognizing that not all students will be comfortable in a given configuration. Aesthetics of healthy food environments Design spaces to provide a relaxing atmosphere conducive to the enjoyment of food and social interaction. Incorporate appealing colors and lighting. Feature fresh, preserved, or prepared food in public spaces. Educational signage, wayfinding, and marketing Deploy graphic design and signage elements throughout the school environment to reinforce the healthy-eating message. Provide educational (nutritional) information on food choices. Highlight information on seasonal fresh foods i
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