## 4 Discussion
### Intervention Characteristics and Effectiveness  
The analysis revealed that ten out of twelve studies demonstrated statistically significant improvements in at least one cardiometabolic biomarker [40; 41; 42; 43; 44; 45; 46; 47; 48; 50], while two studies [49; 51] showed favorable trends without reaching statistical significance. Programs with higher frequency and longer duration consistently produced larger improvements in biomarkers [41; 42; 43; 47; 50]. Those interventions that would work best included being done daily or almost daily, including structured physical activity components, involving thorough nutritional education, and being integrated into curricula at school and not solely performed as extracurricular activities. This supports the premise that continuous support and a positive environment are needed for sustainable behavioral modification [12; 13]. Current meta-analyses have also reinforced that interventions of longer durations and increased intensities yield better results in terms of significant improvement in the status of children's physical and mental well-being [4; 28; 54]. The level of intensity and organization of intervention components varied appreciably between the studies, with some using formalized exercise programs [41; 43; 47; 50], while others promoted overall physical activity through educational programs [42; 46; 51]. Interestingly, several interventions without formally programmed exercise protocols showed substantial improvements in lipid profiles when the educational components were comprehensive and of longer duration [42; 46]. Specifically, [PERSON] et al. [42] achieved significant reductions in total cholesterol and LDL through a two-year classroom-based healthy eating curriculum, while [PERSON] et al. [46] demonstrated similar lipid improvements through school-wide nutritional education integrated into weekly curriculum sessions. The nutritional components included education regarding the Mediterranean diet [19] and culturally adapted healthy eating programs [41; 44; 48], with more specific dietary advice linked to improved consistency of biomarker changes. Family participation has been pinpointed as a key determinant of successful outcomes, as shown by the results of [PERSON] et al. [41], [PERSON] et al. [47], [PERSON] et al. [40], [PERSON] et al. [44], [PERSON] et al. [42] and [PERSON] et al. [51], where family-based promotions of physical activity led to significant improvements in cardiometabolic biomarkers, anthropometrics and healthy habits. This finding resonates with ecological models of health behavior, which stress the importance of engaging multiple levels of influence in order to achieve optimal health outcomes in children [4; 55]. A systematic review of intervention studies on lifestyle changes among ethnic minority groups showed that family participation strongly increases intervention effectiveness, especially for cardio-metabolic outcomes [56]. The gamification approach used by [PERSON] et al. [48] demonstrated that novel and interactive intervention designs can increase participant engagement and produce significant reductions in systolic blood pressure, thereby underlining that intervention development must address developmental appropriateness and acceptability in children. Notably, interventions targeting children with overweight or obesity, as evidenced by the study by [PERSON] et al. [50], showed substantially larger changes across multiple biomarkers when compared with samples from the general population. This study demonstrated significant improvements in blood pressure (SBP: \(-6.0\) mmHg, DBP: \(-4.0\) mmHg), anthropometrics, dietary intake and healthy habits, representing some of the largest effect sizes observed across all included studies. The finding is important in that it suggests both that general prevention is important but that targeted interventions in children at high risk can have greater physiological benefits and are perhaps a more efficient allocation of resources.