Tackling obesity through school-based interventions

Abstract

A raft of school-based obesity programmes have been developed over recent years. Dr Geraldine Hutchinson shares some of the findings of a new study looking at the types of programmes and their effects.

Full text

Tackling childhood obesity within schools: A review of
interventions
Research report
LITERATURE REVIEW
Janet Wordley and Professor Rachael Dixey

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Contents:
• Introduction
• RQ1:Whatisthecontextofchildhoodobesityinternationally?
1. Introduction: Obesity – the ‘global epidemic’
2. Health consequences of obesity
3. Factors affecting and influencing childhood obesity prevalence
3.1. Environmental risk factors associated with childhood obesity
a. Dietary related risk factors
i. Maternal weight status and dietary intake through pregnancy
ii. Infant feeding: breast v bottle
iii. Soft drinks and snack foods
iv. Eating patterns
v. Increased portion sizes
b. Physical activity related risk factors
3.2. Changing societal structures in transition countries
3.3. Socio-cultural risk factors associated with obesity
a. Ethnicity and culture
b. Socio-economic status
c. Social and cultural norms and behaviours
d. Family lifestyle
4. Summary

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• RQ2:Whatisitfeasibleforschoolstoachieveinmanagingtheissueof 
 childhoodobesity?
SectionOne:Nutritionbasedprogrammesandinitiatives
1.1. Classroom based – education only
1.2. Nutritional education and dietary behaviour change
1.3. The school food environment.
a. Breakfast clubs
b. Food availability and food promotion
c. Fruit tuck shops
d. Free fruit in schools
e. A whole school approach to healthier diet
1.4. Summary of nutrition-focused initiatives
SectionTwo:Physicalactivityinterventions
2.1. Classroom based
2.2. Multi-component- classroom based and PE
2.3. Interventions to increase physical activity focusing on environmental changes
a. Playground markings
b. Walking buses
c. Community partnerships
2.4. Summary of physical activity focused school-based programmes
SectionThree:Multi-componentinterventions
3.1. Nutrition education and physical activity
a. In school
b. Outside lesson times
3.2. Summary of multi-component interventions

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SectionFour:Lessonslearntfrompreviousschool-basedinterventions
(nutrition,physicalactivityandmulti-componentprogrammes)
4.1. Programme type
4.2. Information Provision v Behavioural Approach
4.3. Target group
4.4. Targeting parents
4.5. Community involvement
4.6. Engaging with schools
a. School structure and organisation
b. Teacher training
c. Attitudes, behaviours, norms and knowledge of staff
d. A Child-centred approach – attitudes, norms, knowledge of children
4.6. Research concerns – implementing and evaluating interventions
a. Experimental design
b. Duration
c. Intensity
d. Long-term follow-up
e. Outcome measures
f. Process evaluation
g. Fidelity
h. Theoretical framework
• OverallConclusion

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Figures:
Figure 1: Increasing overweight in children around the world (Foresight,
2007, p25)
Figure 2: Prevalence of overweight and obesity among school-age
children in global regions. Overweight and obesity defined by IOTF
criteria. Children aged 5–17 years. Based on surveys in different years
after 1990. Source: IOTF
Figure 3: Prevalence of obesity among children aged under 5 years.
Obesity in under fives according to WHO standardized cut-offs (Z > 2.0).
Based on surveys in different years. Source: de Onis & Blossner, (2000)

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Tacklingchildhoodobesitywithinschools:A
reviewofinterventions.
JanetWordleyandProfessorRachaelDixey,
LeedsMetropolitanUniversity,UK.
The aim of this review is to address two questions to enable the UAE education sector and policy
makers to think about how they could incorporate schools-based inter ventions into the wider strategy
to tackle childhood obesity. The questions are:
1. What is the context of childhood obesity internationally?
2. What is it feasible for schools to achieve in managing the issue of childhood obesity?
Introduction:
Involving schools in tackling obesity would seem a logical and useful way forward. However, school-based
work can be seen against a backdrop where:
“Hundreds of interventions to the combat obesity epidemic are currently being introduced worldwide, but
there are significant gaps in the evidence base for such interventions and few have been evaluated in a
way that enables any definitive conclusion to be drawn about their effectiveness.” (Thirlaway and Upton
2009 p82)
There are no simple ways forward, and there is no consensus among the public health community about
the best ways to tackle the obesity epidemic. This review will introduce promising interventions, and
also try to make sense of some of the issues in evaluating interventions to tackle obesity within schools.
The lessons for the UAE are not spelt out, as this will be left to educationalists and policy makers within
co untr y.

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RQ1Provideanoutlineofthecontextofchildhoodobesityinternationally
1.Introduction:Obesity–the‘globalepidemic’
The increase in the prevalence of obesity during the last two or three decades has arisen so rapidly that
the World Health Organisation (WHO) has described it as a ‘global epidemic’ (WHO, 1997). There has
been a major shift from it primarily being a public health concern of the most affluent societies to now
being seen in less industrialised countries and in particular, those undergoing economic transition, such
as the Gulf states (Seidell, 2000; Prentice, 2006; Candib, 2007). Current figures suggest that 250 million
people worldwide are obese and by 2025 this is estimated to rise to 300 million (WHO, 1997).
The rapid global increase in obesity of recent years includes children of all ages (Gortmaker et al, 1987;
Troiano et al, 1995).
Figure1:Increasingoverweightinchildrenaroundtheworld(Foresight,2007,p25)
Lobstein et al (2004) estimate that worldwide there were 155 million overweight school children with a
further 30-45 million that were obese.

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Figure2:Prevalenceofoverweightandobesityamongschool-agechildreninglobalregions.
OverweightandobesitydefinedbyIOTFcriteria.Childrenaged5 –17years.Basedonsurveys
indifferentyearsafter1990.Source:IOTF
Additional data highlights increasing prevalence of obesity in preschool children (under 5’s).
Figure3:Prevalenceofobesityamongchildrenagedunder5years.Obesityinunderfives
accordingtoWHOstandardizedcut-offs(Z>2.0).Basedonsurveysindifferentyears.Source:
deOnis&Blossner,(2000)

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The Gulf States have not escaped the trends of rising obesity. Bagchi (2008) concludes for the EMRO
region of the WHO that overweight and obesity are increasing dramatically, with particularly high rates
in UAE, Kuwait, Egypt, Saudi Arabia, Jordan and Bahrain. In the UAE, Al-Haddad et al (2000), in a study
carried out in Ras Al-Khaimah, found 9.3% of girls and 8.5% of boys aged 6-16 were overweight and 7.9%
of both sexes were obese. Their earlier study carried out in 1998-99 (Al-Haddad et al 2005) showed that in
6-7 year olds, 18.9% of girls and 10.8% of boys were overweight, and 7.8% of girls and 5.6% of boys were
obese. Similar prevalence rates can be seen in other Gulf states, with slightly higher rates in Qatar ( Qotba
and Al-Isa 2002, Bener (2004), Kuwait (Sorkou et al 2003, Al-Isa and Moussa 2000) and Saudi Arabia
(Al-Nuaimi et al 1996, El-Hazmi and Warsy 2002, Abalkhail et al 2002). These studies show a higher rate
amongst girls, and among older children.
2.Healthconsequencesofobesity
The public health concern about these high prevalence figures across all age-groups relate largely to the
health impacts of obesity. Evidence shows that obesity is associated with a wide range of health problems
such as diabetes, certain cancers, hypertension and cardiovascular problems (WHO 2000; 2003; Visccher
& Seidell, 2001).
The increasing prevalence in children raises concern about the creation of a growing health and economic
burden for the next generation particularly as there is evidence that obesity in childhood persists into
adulthood (Serdula et al, 1993; Freedman et al, 2001, Guo et al, 1994, Parsons et al, 1999). Research into
cardiovascular risk factors has predicted increased adult cardiovascular morbidity and mortality due to
childhood obesity (Reilly et al, 2003; Singh et al, 2008). Evidence links childhood obesity with increase risk
for metabolic syndrome in adulthood (Vanhala et al, 1998).
However, there is need for prevention, as obese children already suffer. The most common consequences
of obesity in childhood are psychosocial (Dietz, 1998; Strauss, 2000; Reilly et al, 2003) with obese children
being stigmatised (Latner & Stunkard, 2003; Cramer & Steinwert, 1998). Cardiovascular risk factors are
seen frequently in obese children (WHO, 19981; Freedman et al, 1999; Reilly et al, 2003; Berenson et al,
1992). Other consequences of childhood obesity are earlier onset of puberty (Lee et al, 2007), childhood
asthma (Reilly et al, 2003), gastro-oesophageal reflux; sleep apnoea and orthopaedic conditions (WHO,
19981; Sokol, 2000). Time off school directly or indirectly due to a child’s obesity could negatively impact
on their educational attainment, affecting job choice and consequently income (Morris, 2006; Erikkson et
al, 2003).
In addition to the health consequences, disease-treatment as a consequence of obesity is expensive and
the direct and indirect economic costs to countries as obesity prevalence rises will continue to increase
(WHO, 2000, Mazzocchi et al, 2009). Developing countries with fewer health resources will find these
costs particularly difficult to meet.

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3.Factorsaffectingandinfluencingchildhoodobesityprevalence
Any attempt to prevent obesity requires an understanding of its causes. An incontestable fact is that
obesity occurs due to an excess of energy intake over expenditure over a prolonged period of time.
Genetics can also greatly affect predisposition to obesity. Twin, sibling and family studies show that
individuals with a family history of obesity are more likely to become obese themselves (Allison et al, 1999;
Whitaker et al, 1997; Lake et al, 1997; Stunkard et al, 1986; Bouchard & Tremblay, 1997; Perusse et al,
1999). Genetic disorders such as Prader-Willi, Bardet-Biedl, Cohen and Alstrom syndromes (Holm et al,
1993; Katsanis et al, 2001; Farooqui & O’Rahilly, 2000) account for a small fraction of obesity cases.
However, the rapidity of the world-wide increase in obesity, together with the lack of uniformity in its
prevalence, both at a country level and with-in population sub-groups, has highlighted that socio-
environmental factors are the key cause of the current obesity epidemic causing ‘obesogenic’ (i.e. obesity
promoting) environments (Swinburn et al, 1999). An environment’s ‘obesogenicity’ has been defined as
‘the sum of influences that the surroundings, opportunities or conditions of life have on promoting obesity
in individuals or populations (Swinburn & Egger, 2002, p 292). Factors that contribute to the development
of such obesogenic environments will therefore be discussed in detail.
3.1.Environmentalriskfactorsassociatedwithchildhoodobesity
a.Dietaryfactors
As dietary factors relate to the ‘energy-in’ side of the energy balance equation, they are essential potential
childhood obesity risk factors.
i.Maternalweightstatusanddietaryintakethroughpregnancy
Understanding childhood obesity starts while the child is still in the womb. Studies have shown a direct
relationship between maternal obesity, increased infant birth weight and later obesity in the child (Whitaker
& Dietz, 1999).
In increasingly obesogenic environments, maternal over-nutrition and resulting insulin resistance is
becoming more commonplace and has resulted in heavier babies (Nanan, 2002; Dyck et al, 2001; Dabelea
et al, 2000; Silverman et al, 1998; Srinivasan et al, 2003). Furthermore a positive relationship has also been
reported between insulin content of the amniotic fluid and the child’s BMI in adolescence (Silverman et al,
1998; Srinivasan et al, 2003).
Conversely however, other studies (Whitaker & Dietz, 1998; Strauss, 1997; Ozanne et al, 2004; Vajnik,
2004) have reported the relationship between poor intrauterine growth and later obesity in childhood.
Mothers enduring the Dutch famine showed that maternal under-nutrition results in permanent
physiological changes in their infants which predisposed them to obesity (Ravelli et al, 1976). Infants
born with low birth weights and who then become obese in later childhood have been found to be more
susceptible to coronary heart disease and type 2 diabetes than other obese people (Barker et al, 2002).

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Smoking during pregnancy is associated with low birth weight and there is a reported link between
maternal smoking and subsequent adiposity in their children (Power & Jeffries, 2002; Toschke et al, 2002).
In a study by von Kries et al (1999) the relationship between mothers’ smoking levels during pregnancy
and prevalence of overweight and obesity in their children at 5-7 years was independent of mothers’ social
class, mothers’ weight or birth weight of their child. Additionally their findings suggested that there was
no influence on child adiposity from mothers continuing to smoke after birth, suggesting that it was the
intrauterine environment created that influenced later obesity. Similar findings were reported by Al Mamun
et al (2006) who found adolescents of mothers who smoked during pregnancy were more likely to be
overweight and obese than those whose mothers had stopped or never smoked.
Low birth weight has also been linked to the development of stunting in early childhood (short height for
age) and abdominal obesity later in life. Globally, one third of children under 5 (270 million) in developing
and transitional countries are affected by stunting (UNICEF, 2001). Some studies show a relationship
between stunting early in childhood and overweight in later childhood (Sawaya et al, 1995; Steyn et al,
1998). Longitudinal studies have reported children with severe stunting in early childhood have increased
risk of developing abdominal obesity in later childhood and adulthood but are not considered obese by
Western standards (Walker et al, 2002; Schroeder et al, 1999). However studies report that due to this
predisposition to central obesity, these children have increased risk of insulin resistance (Boule et al, 2003).
It therefore appears that what happens in the mother’s womb has major consequences on the child’s
subsequent weight. Both heavier and lighter infants are more at risk of later obesity than are infants born
at normal weight. In an increasing obesogenic environment, physiological changes triggered by the
intrauterine environment could further increase the risk of obesity. For example, de Graft & Aikens (2005)
suggest that the increasing prevalence of glucose intolerance, diabetes and hypertension in Cambodia is
directly due to deprivation suffered there due to civil conflict.
Where there is high prevalence of low birth weight, public health supplementary feeding programmes
are common, but evidence suggests that these could encourage rapid weight gain in early infancy.
Studies have shown however, that no improvement in length for age status in stunted children will occur
if nutritional improvement comes after the child is 24-36 months (Uauy & Kain, 2002). Consequently
supplementary feeding could induce development of obesity in both the low birth weight infant and the
stunted infant, particularly as most PEM prevention programmes provide energy and protein but are often
deficient in micronutrients which would support linear growth (Uauy et al, 2001).
ii.Infantfeeding:breastvbottle
Numerous studies have reported that breast fed infants are less likely to develop childhood obesity
compared to bottle-fed (von Kries et al, 1999; Gillman et al, 2001; Armstrong & Reilly, 2002) and can
protect children at risk of type 2 diabetes from developing it during adolescence (Young et al, 2002).
Bergmann et al (2003) in a longitudinal study found bottle-fed babies had increased risk of being obese
at 2 years, and this relationship persisted even when controlling for SES and mothers’ BMI and smoking
behaviour.
Breast-feeding duration is also important. Baker et al (2004) reported that weaning before 16 weeks
significantly increased weight gain in the first year. Sloan et al (2007) found that Infants weaned earlier than
4 months were heavier at 7 and 14 months, and gained more weight between 8 weeks and 14 months,
even after breastfeeding was controlled for.

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Ong et al (2006) showed that bottle-feeding and early weaning had a potential synergistic negative effect,
reporting that formula-fed infants weaned before 4 months had higher energy consumptions and this
determined their weight gain.
iii.Softdrinksandsnackfoods
Studies have shown that globally, soft drinks are a major contributor of calories in the diets of children of
all ages (Popkin & Nielsen, 2003). Whilst quantity consumed appears to increase with age, findings from
more industrialised countries show they are fast becoming the largest single source of non-milk extrinsic
sugar within even very young children’s diets (Gregory et al, 2000; Webb et al, 2006; Fox et al, 2006).
A recent systematic review, (Brown et al, 2007) found strong evidence that increased consumption
of sugary drinks increases the risk of overweight and obesity. Similarly Bray et al (2004) found a link
between obesity and intake of the high-fructose corn syrup, the caloric sweetener used in soft drinks.
It has been hypothesised that high intake of sugar sweetened drinks promotes weight gain due to their
high glycaemic index or because regulations of calories after ingestion of a liquid is less complete than
after a solid (Ludwig et al, 2001). Hawkes’ review (2005) shows how the leading soft drink and fast food
companies are targeting rapidly developing economies, and especially children and young people. Soft
drink consumption in less developed countries is outpacing that of countries such as the USA (Gelhar and
Regmi 2005).
Globally, ‘fast foods’ are becoming universal. These foods can be described as ‘energy-dense’, giving
a measure of how much energy the food contains per unit weight of food. Higher fat foods will have the
highest energy density but lower nutrient density. Energy-dense, nutrient-poor foods tend to be high in fat
and refined sugar and low in vitamins and minerals. A study conducted in the UK, (Prentice & Jebb, 2003)
analysed a variety of fast foods and reported that their energy density (by weight) was greater than other
foods in a typical Briton’s diet and their energy-density was over twice that of foods recommended for a
healthy diet. Bowman et al (2004) reported that children’s diets were less healthy on the days when they
ate fast foods. Levels of fat and energy density were higher and fruit and vegetable intakes were lower.
Energy-dense foods tend not to be entirely satisfying and are often eaten as a regular addition to the
diet rather than an occasional treat (Astrup, 1996). Whilst direct evidence is lacking that increased
consumption of fast foods leads to overweight and obesity, evidence from epidemiological studies has
shown that even if the total energy intake is similar or even reduced, weight gain is associated with
a higher proportion of fat (Hill & Prentice, 1995; Canoy & Buchan, 2007). This evidence together with
evidence from higher-income countries showing that children’s intake of fast food has increased by 300%
over 2 decades (St-Onge et al, 2003) highlights increased consumption of fast foods as a childhood
obesity risk factor.
iii.Eatingpatterns
Eating patterns in higher-income countries have shifted from the traditional three meals a day culture
to more frequent, less well-defined ‘grazing’ (Nicklas et al, 2001), with an increase in the number and
variety of readily available inexpensive highly palatable foods, resulting in more frequent opportunities for
consuming large quantities of food (Hill & Peters, 1998). Snacking behaviours have particularly increased
in adolescents and young adults (Jahns et al, 2001; Zizza et al, 2001). In the US the average snack size
consumed by young adults has increased significantly and compared to eating occasions classified as
‘non-snacks’, the nutrient contribution of snacks had increased in energy density and proportion of energy
from fat (Popkin, 2005).

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There is some evidence that skipping breakfast can increase a child’s risk of developing obesity (Wolfe et
al, 1994; Siega-Riz et al, 1998). However due to the cross-sectional nature of these studies it is unclear
whether skipping breakfast resulted in obesity or whether those children who were obese skipped
breakfast as a weight-loss method. Two prospective studies report that children and adolescents who
skipped breakfast had larger increases in weight gain and were significantly more likely to become
overweight (Berkey et al, 2004; Barton et al, 2005). This relationship seems to be dependent on ethnic
group: in a prospective cohort study investigating dietary intake of African American and white young
adults, Lewis et al (1997) showed that white adults who skipped breakfast were more likely to become
overweight than those who did not, even after adjustment for baseline BMI. The relationship was not
significant for African-Americans, suggesting that skipping breakfast may be an obesity risk factor only for
some sub-groups.
iv.Increasedportionsizes
Increases to the standard portions of various foods have occurred in most higher-income countries
(Young & Nestle, 2002; Ello-Martin et al, 2005). Although younger children have the innate ability to rely
on their internal cues to regulate food intake (Rolls et al, 2000), it appears that this mechanism can be
overridden by environmental and social factors. Indeed, studies with children aged 4 and over have found
that they tended to eat more even when not hungry (Rolls et al, 2000; Fisher et al, 2003). Within the
current obesogenic environment, it is becoming more likely that children will consume more calories than
they require. For instance, a meal of a double cheeseburger, fries, soft drink and dessert could provide
2200kcal (Ebbling et al, 2001).
b.Physicalactivityrelatedriskfactors
Weight gain is a result of an energy imbalance between energy out and energy in, and as physical activity
levels relate to an individual’s energy output, they are an obesity risk factor. However, it has proved difficult
to demonstrate this association in order to provide guidance for obesity prevention:
i.Activitylevels
Some cross-sectional studies from higher-income countries have suggested that children who are obese
spend less time doing moderate and vigorous physical activity than do non-obese children (Trost et
al, 2001; Anderson et al, 1998; Kimm et al, 2005). However, others have found no relationship (Nader
et al, 1999; Story et al, 2003). Some studies report gender differences: Berkey et al (2000) reported
physical activity was protective of further weight gain in females but Gordon-Larsen et al (2002) found this
protective effect was only present for males. A systematic review exploring the relationship of physical
activity on subsequent fatness in childhood found evidence roughly divided into having a protective effect
or having no effect (Parsons et al, 1999).
Data from the UK and US exploring physical activity levels in the 1980s and 1990s suggested a decrease
in walking and cycling and increased use of the car as the transport method of choice to get to school
(DiGuiseppi et al, 1997; US Department of Transportation, 1997). Cross sectional studies from the UK
(Armstrong et al, 1990; Riddoch et al, 1991) and a longitudinal one from the Netherlands (Kemper et al,
1999) both reported that physical activity during adolescence decreases considerably. As some studies
have given evidence that physical activity behaviours track into adulthood (Raitakari et al, 1994), declining
activity levels in adolescence could have negative implications for physical activity in later life. Bleich et al,
(2008) in a major study of the role of energy-out/energy-in conclude that although rates of physical activity
have declined, the magnitude of the obesity epidemic is best explained by increased calorie intake. This
issue remains controversial.

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ii.Sedentar ybehaviours
Being sedentary encompasses a range of activities (e.g. reading, listening to music, doing homework), but
most studies exploring its effect have looked at the relationship between TV viewing and increased risk of
obesity.
A popular theory is that TV viewing displaces physical activity and therefore contributes to the prevalence
of obesity (Dietz & Gortmaker, 1985). A UK study (Robinson, 1999) reported that over one year, adiposity
had increased in children continuing to watch television at their normal levels, compared to those who
had decreased their viewing by 40%. Cross-sectional and prospective studies conducted in a variety of
countries have found a close relationship between amount of television watched and obesity prevalence
(Dietz & Gortmaker, 1985; Wake et al, 2003; Hernandez et al, 1999; Ruangdaraganon et al, 2002; Krassas
et al, 2001; Hanley et al, 2000). Gortmaker et al (1996) found children watching more than 5 hours a day
were 5 times more likely to be overweight than those watching less than 2 hours daily; at the end of the 4
year study period this relationship was still there even when key variables were controlled for.
Wiecha et al (2001) reported that televisions in bedrooms increased a child’s viewing time by an average of
38 minutes a day; additional sets within the household increased viewing by 7 minutes each and children
in families where family dinners were rare had increased viewing times of 33 minutes. In families where
parents did not limit or control a child’s viewing, television viewing times were increased by 29 minutes.
Another hypothesis is that TV viewing provides an environment for frequent snacking, pre-prepared meals
as well as increased exposure to adverts for high fat, salt and sugar (HFSS) foods (Dietz & Gortmaker,
1985). Borzekowski & Robinson (2001) showed that exposure to a 30 second commercial increased the
likelihood that 3-5 year olds would later select an advertised food when presented with options. While
this research shows that adverts have an effect on children’s preferences, it only becomes a potential
obesity risk factor when it affects their dietary intakes. A study in Australia (Wake et al, 2003) showed
that children’s television viewing ceased to have an effect on their BMI after adjusting for food intake and
general activity level therefore suggesting that television viewing as an obesity risk factor is mediated
through both hypotheses suggested above.
3.2.Changingsocietalstructuresintransitioncountries
The studies discussed above explored environmental risk factors in Western countries. There has been
a marked shift in dietary patterns and related disease patterns in less industrialised countries over recent
years (Kim et al, 2000; Monteiro et al, 1995; Popkin, 1994; 1998; World Cancer Research Fund, 1997).
These changes have included an increase in fat and non-milk extrinsic sugars and a decrease in cereals.
The emerging food system in these countries is based on an industrialised approach to agriculture,
providing food regardless of season and supplying highly processed outputs. The consequences have
been variable. Whilst food availability may have improved, under-nutrition in the poorer sub-groups of the
population has not been solved and the quality of the diet in the affluent groups has decreased (Tansey &
Worsley, 1995). There is also increasing evidence that these dietary shifts to a more ‘Westernised’ diet are
accelerating such that health-related diseases associated with an energy-dense diet (and indeed low levels
of physical activity) are increasingly seen amongst the poorest groups (Popkin, 2001; Monteiro et al, 2000).
The nutritional transition and its accompanying restructuring of economies has resulted in shifts within
the labour force to occupations requiring increasingly more sedentary work (Popkin, 2001), alongside
fewer opportunities outside the work-place for leisure activities and sport. There has also been a marked
increase in the number of households owning a television or computer.

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The shift in the labour force has been accompanied by increased urbanisation: globally, the numbers of
people living in urban dwellings has increased from 16.7% in 1950 to 37% in 1994 with predictions of a rise
to 57% by 2025 (UN, 1995). In light of evidence of an association between urban residence and obesity
(Monteiro et al, 1995), this is a concern.
Longitudinal studies in these countries have given evidence that this societal shift has caused dietary and
physical activity shifts and consequently has impacted on BMI which have progressively increased (Bray &
Popkin, 1998; Paeratakul et al, 1998).
3.3.Socio-culturalriskfactorsassociatedwithobesity
Understanding why people adopt the dietary and physical activity behaviours they do requires an
understanding of social relationships and culture (Lake & Townshend, 2006).
a.Ethnicityandculture
Much of the data exploring the influence of cultural factors on body weight has been conducted in the
USA. Prevalence data indicates higher rates of overweight and obesity amongst African-Americans than
Causasians or Hispanics and lower rates in the Asian population (Matthews et al, 2001; Gordon-Larsen et
al, 2002; Ogden et al, 2002). It is unclear from the prevalence data whether differences in obesity between
different ethnic groups are primarily due to ethnicity or biological factors. A UK study reported South-East
Asian children had higher insulin levels than Caucasian ones and they also showed a stronger relationship
between raised insulin concentration and adiposity (Whincup et al, 2002). Other studies have found that
certain ethnic populations have predispositions to visceral fat deposition, which is directly related to insulin
resistance and development of diabetes (Yajnik, 2004). For instance, Native Americans and Canadians,
Maori, Asian Pacific Islanders and other ethnic groups have higher prevalence of insulin resistance and are
more likely to develop diabetes than White Caucasian populations (Genties et al, 2007; Riddell et al, 2007;
Zimmet et al, 1997).
However, it is unclear just how important biological factors are in contributing to ethnic group differences.
Results from ‘acculturation’ studies which investigate the changing weight status of immigrant groups,
suggest that environmental as well as culturally determined social norms and behaviours play a role
in obesity predisposition. For instance, Brussaard et al (2001) found children of Turkish and Moroccan
immigrants in Holland more at risk of overweight than Dutch children. Lauderdale & Rathouz (2000) found
a positive relationship between risk of overweight and length of duration in the US for Asian immigrants.
Ball & Kenardy (2002) reported similar findings for female immigrants to Australia. Evidence also suggests
that the second generation within immigrant families may fair much worse and be at higher risk of obesity
and related disorders than their parents, as a result of adopting the dietary behaviours of the country
rather than eating their traditional diet which historically may have contained more nutrients and less
energy (Landman et al, 2001; Popkin, 1998).
b.Socio-economicstatus
Socio-economic status (SES) includes a range of indicators such as income, parental education and
occupation. Evidence suggests that adults and children from low socioeconomic backgrounds in Western
societies have increased risk of developing obesity than those with higher SES. This trend is repeated
in middle-income countries such as Thailand and Tunisia (Popkin and Ng 2006). Additionally, an inverse

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relationship has been reported between childhood SES and obesity later in adult life (Ball & Crawford,
2005; Parsons et al, 1999). These results suggest that adult obesity does not lead to low SES but rather
low SES early in a child’s life contributes to their later obesity. Similar conclusions were drawn by Hardy
et al (2000), exploring whether an individual’s SES was mediated through their level of education. However
both factors were independently associated with adult BMI again suggesting that it is factors within the
physical and social environment resulting in low SES early in a child’s life that have a more important effect
on their subsequent weight status.
Data from transition countries indicate that the association between a child’s SES and the patterns of
obesity are more complex. In China, Wang et al (2000) reported that children from urbanised, affluent
families had higher prevalence of obesity than those from more disadvantaged backgrounds. Whereas
in Brazil, women in the lowest socio-economic group show the highest prevalence of both obesity and
underweight (Caballero, 2005). Other countries are showing similar patterns. For instance in Madagascar,
childhood obesity has risen from 1.6% in 1992 to 6.2% in 2004 yet there are still around 36% underweight
and roughly half were stunted (IRINnews, 2009). Underweight is a feature of Gulf States, with high rates in
Qatar foe example (Qotba and Al-Isa 2002).
In some developing and transition countries it is common to find cases of under and over-nutrition within
the same household (Benjelloun, 2002). In Asia, this coexistence is estimated at 15% of households
(Popkin et al, 2001). More recent research quoted by Popkin (2001) found 44%, 23% and 57% of
households in Brazil, China and Russia respectively had an underweight and an overweight member. One
explanation could be that whilst cheap, energy dense and nutrient poor food has adverse effects on the
growth of the child, it causes weight increase in the adult (Caballero, 2005).
It is clear from the studies discussed that in both industrialised and transition countries socio-economic
status is an important risk factor in development of obesity.
c.Socialandculturalnormsandbehaviours
Different socio-cultural groups have different patterns of diet and physical activity. In Western countries
those from low SES reportedly have high fat diets, eat fast food more frequently and consume fruit and
vegetables less frequently than those from higher SES (Giskes et al, 2002; Mishra et al, 2002; French et
al, 2001). They are less likely to participate in sport and physical activity (Britton et al, 2000; Crespo et al,
1999).
Adults living with a partner have higher fruit and vegetable consumption than single, divorced or widowed
adults (Billson et al, 1999; Shahar et al, 2001). Dietary guidelines are more closely adhered to in women
with children, but (Roos et al, 1998) motherhood is linked with lower physical activity (Sallis & Owen, 1999;
Trost et al, 2002). In terms of ethnicity, evidence suggests that groups other than white Caucasians adhere
less closely to dietary guidelines (Patterson et al, 1995). These groups have also been reported as being
less physically active (Trost et al, 2002; Crespo et al, 2000).
Better nutritional knowledge is related to better diet (Wardle et al, 2000) and studies have shown an
association between higher SES and better nutritional knowledge (Parmenter et al, 2000; Buttriss, 1997;
Crawford & Baghurst, 1990). However, nutritional knowledge per se does not necessarily translate into
more healthful behaviours. For instance, in a study of European 14,331 adults, almost 80% reported
difficulty trying to eat a healthier diet despite understanding key messages (Kearney & McElhone, 1999).
The main barriers were time (e.g. irregular working hours and busy lifestyles) and taste (giving up liked
foods). Other barriers included willpower, price, preferences of others and not wanting to change.

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It is essential to recognise that food and its meaning are culturally derived. Evidence of obesity prevalence
differences between sub-groups within affluent populations implicates cultural behaviours and traditions
as mediators of the effects of the obesogenic environment on obesity (WHO, 2000). For example, cultural
differences exist in how an obese body shape is perceived. In societies where famine and deprivation have
been common, positive connotations may be connected to obese individuals (Sobal & Stunkard, 1989;
Gremillion, 2005). Obesity is related to power, wealth and status, - a fat baby is a healthy one and losing
weight is contrary to the social construction of health and what is considered attractive (Gremillion, 2005).
In the US African Americans and to a lesser extent Hispanic populations consider an obese body-shape to
be acceptable (Lynch et al, 2007; Bennett & Wollin, 2006; Davidson & Knafl, 2006; Becker et al, 1999).
Additionally, cultural differences exist in the values and beliefs people hold about diet and healthy lifestyle.
The same populations revering an obese body shape also do not understand the idea of engaging in
physical activity as a leisure time pursuit. In contrast, Nordic populations are positive towards fitness and
spend considerable amounts of their leisure time in vigorous activities (WHO, 2000).
d.Familylifestyle
Whilst parental obesity may convey some degree of genetic predisposition to the development of obesity
in the child, the impact of the home environment and parental influence on their child’s diet should not be
overlooked as a potential risk factor in the development of obesity (Wardle, 2007). Evidence shows that
early exposure to an obesity-promoting family environment (i.e. low activity and poor dietary patterns) has
negative effects on a child’s subsequent BMI trajectory (Davison & Birch, 2002; Davison et al, 2005) and
more child resistance to healthy eating (Hughes et al, 2005).
A Danish study gave evidence that the quality of the home environment in terms of levels of parental
support and parental neglect was an important risk factor in childhood obesity (Lissau & Sorensen, 1994).
Other studies have shown similar results (Klesges et al, 1992; French et al, 1996; Johnson et al, 2002).
Parents have the opportunity to be good role models of healthy eating behaviours and the power of social
learning and role modelling should not be underestimated. Harper and Sanders (1975) found mothers’
eating had a particularly powerful influence in shaping young children’s (1-4 year olds) food preferences:
children were more likely to imitate them and put food in their mouths than with other carers. In terms
of obesity development, studies have shown that parents providing energy-dense foods to their child
and additionally modelling the eating of such foods in front of their child enhance their child’s innate
preferences for such foods (Jansen & Tenney, 2001; Cutting et al, 1999; Lee et al, 2001).
Parents’ role modelling also influences their child’s physical activity behaviours. A systematic review (van
Sluijs et al, 2007) found strong evidence that including parents in physical activity interventions targeting
adolescents increased their physical activity. Due to a lack of rigorous studies there was less conclusive
evidence that this was the case for younger children. Kohl & Hobbs (1998) suggest that parents have a key
role for encouraging physical activity either directly by providing a supportive environment encouraging
exercise or indirectly, through modelling a physically active lifestyle, or a combination of the two. Moore et
al (1991) and Trost et al (2003) found that active parents tend to have active children.
4.Summary
Given the increasing evidence for the impact of environmental factors on the development of obesity, it is
clear that focusing solely on the individual at risk of obesity, without consideration for their environment,

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17
both physical and socio-cultural, is unlikely to be successful. Furthermore it could be considered unethical
to subject people and especially children to obesity ‘treatments’ rather than tackling the environmental
causes. Genetic studies have shown that within the current obesogenic environment, the majority of
children are at risk of excessive weight gain (Allison et al, 1999; McDermott et al, 1998; Popkin & Udry,
1998). Targeting those individuals most at risk might ensure investment of limited resources into the most
appropriate service but it would also greatly contribute to the stigma which has been shown to exist in
regard to how overweight and obese people are viewed (Latner & Stunkard, 2003; Cramer & Steinwert,
1998). It is therefore more realistic to suggest a focus on prevention of obesity for the whole population.
Furthermore, prevention requires an holistic approach, at a variety of levels, including local and individual,
national and international, requiring integrated working between a range of sectors including government
(local and national), education, social and welfare services, environment and planning, transport, food
production and media.
RQ2whatisitfeasibleforschoolstoachieveinmanagingtheissueof
childhoodobesity?
There has been increased recognition for evidence-based school-based obesity prevention, as reflected
in the numerous school-based programmes developed over recent years (e.g. Warren et al, 2003; Sahota
et al, 2001). However, these programmes have differed greatly in terms of design, duration, focus and
results gained. How programme effectiveness has been defined has also differed greatly between studies,
with some interventions targeting reduction in BMI and others focusing on increasing knowledge and
awareness. Still others have concentrated on establishing behaviour change. These differences make
comparison difficult and the numerous reviews that have been conducted to establish evidence-based
approaches for obesity prevention (for instance, Doak et all, 2006; Summerbell et al, 2005; Sharma et al,
2006; Campbell et al, 2002; Brown & Summerbell, 2008; Flynn et al, 2006; NICE, 2006; Kahn et al, 2002;
Budd & Volpe, 2006) have utilised such different parameters to define success that the health practitioner
is presented with a range of differing recommendations for future programmes. Indeed, there appears to
be no consensus from reviews as to what components future interventions should include to be effective.
Additionally these previous reviews often set strict parameters for the inclusion of studies (e.g. RCT
design and anthropometric outcome measures) which has resulted in a dearth of evidence from which to
draw. Indeed as Summerbell et al (2005) stated ‘at a time in which we see obesity prevention nominated
as a public health priority, we have only a limited number of studies from which to examine findings’
(Summerbell et al, 2005, p 18).
Paradoxically, when there is a need for evidence-based recommendations and guidance to inform policy
and future initiatives, very little is known about what components of interventions are effective. Whilst
there is recognition of the important role schools can play in obesity prevention work and there have
been many school-based initiatives developed, the lack of definitive evidence makes recommendations
difficult. This makes writing this literature review difficult. Whilst the majority of studies reviewed are based
in the US and other industrialised countries (see Doak et all, 2006; Summerbell et al, 2005; Sharma et
al, 2006; Campbell et al, 2002; Brown & Summerbell, 2008; Flynn et al, 2006), the lack of consensus for
defining effectiveness makes it difficult to make recommendations to other countries such as the UAE. It is
therefore proposed that examples of what has been conducted in schools will be outlined and described.
This review is in three sections. Section one will outline nutrition-focused programmes and initiatives,
section two will concentrate on those initiatives and strategies aimed at increasing children’s physical
activity and section three will describe those programmes that have taken a multi-component approach,

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targeting both nutrition and physical activity within the school environment. Discussion will focus on who
the audience was, channels used to reach the target population, outcome measures utilised and how
effectiveness was measured. As far as is possible, this review will conclude with recommendations for
future work, drawing on those made by the various reviewers in the literature. Discussion here will focus on
specific barriers found to effective implementation and in supporting long term behaviour change.
SectionOne:Nutritionbasedprogrammesandinitiatives
Schools provide a valuable opportunity to influence children’s dietary habits. The taught curriculum offers
a means of embedding nutritional education and with the majority of children and staff eating at least one
meal within the setting of the school, gives an ideal opportunity to make the food environment healthier.
Examples will be given of nutrition-focused interventions targeting different aspects of the school
environment. Successful components and recommendations from the various reviews and study authors
themselves will be integrated.
1.1.Classroombased–educationonly
Schools have the potential to reach large numbers of children for education about healthy diet. Studies
have shown that modern play-based methods can be utilised effectively to convey nutrition education and
facilitate learning, giving a fun alternative to simply giving children advice or prohibitions about what they
shouldn’t eat (Bartfay & Bartfay, 1994; Corbett & Lee, 1992; Amaro et al, 2006; Baranowski et al, 2003).
For instance, Amaro et al (2006) devised ‘Kaledo’, a board game aimed at 11-14 year olds in schools in
Naples, Italy. Players had to match differences between total energy intake (with nutrition cards) and total
energy output (with activity cards). At the end of their 24 week study Amaro et al (2006) reported that
intervention children showed a significant increase in their nutritional knowledge (p<0.05) compared to
control children. No significant differences were seen in BMI in either the control or intervention groups and
no difference was reported between the groups. The authors did report a significant increase in vegetable
intake in the intervention children but limitations with the methods used and randomisation procedure
within the study cast doubt on these findings. However, another study evaluating the effectiveness of a
10 session multi-media game ‘Squire’s Quest’ aimed at 9-10 year olds and which incorporated behaviour
change techniques as well as nutritional knowledge, (Baranowski et al, 2003; Cullen et al, 2005) reported
dietary behaviour changes in intervention children at lunch times and snack times when in school such as
increased fruit and vegetable consumption. Therefore it would appear that dietary changes occurred in
eating occasions over which the children had more control.
In summary, whilst educational games can be effective in promoting increases in nutritional knowledge,
it is less clear whether they are effective at promoting dietary behaviour change. Games incorporating
behaviour change techniques have shown that dietary behaviour changes can occur whilst eating at
school. It is less clear whether they have impact on dietary behaviour at home.
Other classroom-based nutrition education interventions focused on the reduction of carbonated drink
consumption. James et al (2004; 2007) reported on an English longitudinal study for 7-10 year old children.
One hour education sessions each term encouraged children not to drink carbonated drinks and to
switch to water and diluted fruit juice. They reported that 12 months after the intervention had finished the
percentage of overweight and obese children in the control group had increased by 7.5% compared to
intervention children where a decrease of 0.2% was reported. However, this difference did not remain after
an additional 2 years follow-up indicating that the intervention had no longer-term effects and suggesting

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that such interventions need to be maintained for long periods. Whilst there is evidence in the literature
of the association between carbonated drinks and obesity (Ebbling et al, 2006; Tam et al, 2006; Smith
West et al, 2006; Rush et al, 2006; Mrdjenovic & Levitsky, 2003; Vartanian et al, 2007), no measures
of children’s intake of carbonated drinks were reported in the study, therefore it is unclear whether the
intervention was effective in its aim of decreasing consumption of carbonated drinks. Additionally, no
measures were made of children’s dietary intake or physical activity levels, so simply concluding weight
changes is problematic.
In their review of nutrition education interventions, Thirlaway & Upton (2009) concluded that “despite
considerable efforts over a number of years, there is limited evidence to suggest that educational
approaches to dietary change (that is providing basic information about what constitutes a ‘healthy’ diet)
alter children’s eating habits.” (Thirlaway and Upton, 2009, p79). Two points can be made here; Firstly,
because there is limited evidence of effectiveness may not necessarily mean that interventions are not
effective (but rather that effective ways of evaluating have not been found). Secondly, that whilst there
are some promising nutrition education interventions within schools, these need to be underpinned with
relevant theory such as Social Cognitive Theory (Bandura, 1986; SCT) if behaviour change is to occur
(Lytle & Achtenberg, 1995).
1.2.Nutritionaleducationanddietarybehaviourchange
interventions incorporating educational components with active learning techniques and practical
strategies underpinned by appropriate behaviour change theories will be discussed below:
In a pilot study in Michigan, US, Fahlman et al (2008), evaluated the impact of a nutrition education
curriculum based on SCT on 11-14 year old children’s nutritional knowledge, efficacy expectations and
eating behaviours. Lessons included giving knowledge of the 5 food groups, balanced eating based on
these groups, reading food labels, surviving fast food restaurants and school cafeterias as well as teaching
skills such as dietary self-evaluation, peer role-modelling, interpretation skills, and goal setting. Lessons
were one hour long, taught by classroom teachers who had received 8 hours of in-service training.
Despite being a short-term study (10 weeks) results indicated that by post-programme intervention
children had not only increased their nutritional knowledge but had also improved their eating behaviours
and increased in their efficacy expectations. They were significantly more likely to eat fruit and vegetables
and less likely to eat junk food compared to the control group.
In another study aimed at 7-9 year olds, Raby Powers et al (2005) reported significant improvements in
intervention children’s dietary behaviours (p< 0.001) and nutritional knowledge (p< 0.001) than in control
children by post programme. The 6 week nutrition-focussed intervention was based on SCT and taught
skills to select healthy foods at home and school, provided hands-on learning opportunities, provided role
models as well as nutritional education on concepts like the 5 food groups and balanced eating.
Whilst both these studies utilised self-report measures and thus caution should be taken when assessing
results, of note was that improvements seen in intervention children’s dietary behaviours (namely increases
in dairy foods and fruit and vegetable), occurred during lunchtime. No school food modification occurred
and both control and intervention children attended the same schools. Therefore such a nutrition
education curriculum positively affected intervention children’s dietary behaviours when presented with
a choice. In addition both programmes reported children had changed their dietary behaviours at home
as a result of the intervention. Both therefore gave evidence that primary school children’s dietary habits
can be positively influenced by such nutrition-focused curricula that incorporate behaviour change
techniques, and such programmes could be successfully incorporated into wider school multi-component
interventions.

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An innovative approach to supporting children’s dietary behaviour change was the development of
an interactive multimedia CD ROM, designed to promote nutrition education in 12 year old secondary
school children in the UK (Livingstone et al, 2002). The ‘Dish it Up!’ tool was based on SCT and promoted
autonomy and self-esteem related to healthy eating as well as teaching decision-making skills. The
programme guided pupils through a virtual school day and covered a range of issues relating to balanced
diet. A key component was self-evaluation and monitoring of set goals. Intervention pupils showed
statistically significant improvements in their nutritional knowledge by post-programme compared to
controls (p<0.0005) and they also reported significant increases in frequency of consumption of fruit,
pasta, yogurt, breakfast cereals (more than normal) and sweets (less than normal). However, findings
were limited by the non-validated tools used to evaluate the intervention and no differences in nutritional
attitudes were reported.
All nutrition-focused interventions discussed so far have been implemented by classroom teachers. The
Food Dude Programme from the UK, designed for 4-11 year olds took a different approach using peer
educators to encourage children to eat more fruit and vegetables. It is a good example of the incorporation
of SCT theory into such interventions, as it built in peer modelling and rewards. ‘Food Dudes’ are role
models who gain superpowers when they eat fruit and vegetables. Children are encouraged to try fruit
and vegetables repeatedly and the idea is that they come to see themselves as fruit and vegetable
eaters within a strongly supportive school ethos. Initial evaluation showed that fruit and vegetable eating
increased to a statistically significant extent (Lowe et al 2001, 2002) and Lowe et al (2007) show that not
only have the effects persisted 15 months after the programme ended, but also that fruit and vegetable
consumption went up at home, and children were also eating a wider range than just that given on the
programme.
Whilst nutrition-focused studies incorporating behaviour change techniques have shown positive effects
on children’s nutritional knowledge and eating behaviours, it is possible that the effects would be more
potent if implemented in tandem with interventions targeting the wider school food environment. Indeed,
it has increasingly been recognised that the wider school food environment will have an influence, either
positive or negative on a child’s dietary habits and behaviours (USDA, 1999).
1.3.Theschoolfoodenvironment.
There have been several studies solely targeting the ‘school food environment’. Examples that will be given
include: breakfast clubs, strategies that increase availability or promotion of healthier options at lunchtime
and snack time, free fruit schemes, school meal standards. These studies have not included a classroom
based education or behaviour change component.
a.Breakfastclubs
These consist of before-school provision of breakfast to children arriving early to school. They originated
in the US in 1966 when federal funding was given to schools to ensure they provided breakfast to low
income children (US Department of Agriculture, 1999). Other countries such as Australia (Shaw, 1998) and
the UK (Smith & Barker, 1997) have since taken them up.
It has been suggested that breakfast clubs can improve children’s nutrition (Hanes et al, 1984; Nicklas et
al, 1993) as well as their educational attainment and psychosocial functioning (Murphy et al, 1998; Pollitt
& Matthews, 1998). Additional evidence has suggested that providing breakfast also improves children’s
school attendance and punctuality (Simpson, 2001; Harrop & Palmer, 2002). Studies exploring these
issues have found conflicting results:

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In a pilot study lasting 4 months in Norway, Ask et al (2006) reported on the impact of a healthy breakfast
on the school performance of 15-16 year olds. Breakfast was served when the adolescents arrived at
school but they could decide whether they had it. The authors reported that at 4 months students’ BMI in
the control group had increased significantly but not in the intervention group. However, whilst the healthy
eating index (gained from a food frequency questionnaire) of intervention children had increased by 4
months, this was only significant for boys (p<0.01).
The study has several limitations, such as being of short duration with a small sample size and not taking
an objective measure of students’ behaviour and performance. Instead the measure used was based
on the students’ self assessment of their own behaviour. There was also a lack of teacher input into the
evaluation to give a more balanced view regarding behaviour and performance. Additionally, the school
chosen had a history of anti-social behaviour potentially biasing results. No evaluation was made of
students’ opinions about the breakfast and teachers did not attend the breakfast, giving very little support
to the project.
In another study, Shemilt et al (2004) evaluated the impact of breakfast provision on children’s health,
educational and social behaviours. The study was conducted in 30 primary and secondary schools in
the UK with a total sample size of 6076 (200 from each school). Results at 3 months indicated that those
children eating breakfast showed improved concentration and fewer reported skipping classes within
the last month. Results at 1 year showed whilst a higher proportion of primary aged children attending
breakfast clubs reported eating fruit for their breakfast, there were also a higher proportion of primary
aged children attending breakfast clubs having borderline or abnormal conduct and total difficulties
scores. In the secondary school children at 1 year, a higher proportion of breakfast club attenders had
higher prosocial scores than non-attenders. Across the entire sample, fewer breakfast attenders reported
skipping 1 or more days of school within the last month than did control children. Yet again however, the
study showed methodological limitations, but the results indicated that breakfast club provision had both
positive and negative impacts on children’s nutritional, educational and psychosocial behaviours.
Thus there is inconclusive evidence that breakfast clubs have an impact on students’ school attendance,
performance, eating behaviours or BMI. However, evidence from studies conducted in the 80’s and 90’s
in the US indicated that breakfast clubs had the potential to improve children’s dietary intakes (Hanes et al,
1984; Nicklas et al, 1993). Whilst more robust studies are required to evaluate their effectiveness, breakfast
clubs may provide a means of positively influencing children’s diet within the school environment.
b.Foodavailabilityandfoodpromotion
Mazzocchi et al (2009, p145) state that, ‘there is limited information’ about the role of consumption of
foods in school (both vended and provided) on obesity rates.
Evidence from a cross-sectional study investigating the relationship between school lunches and vending
machine options and adolescents’ dietary intakes (Kubik et al, 2003) indicated that when students are
provided with a greater availability of higher fat foods, their intakes of more healthful foods was lower.
Thus the study demonstrated that the food choices available within the school have significant effects
on students’ dietary intakes. Restricting vending machines has a significant effect on consumption and
obesity; Anderson & Butcher et al (2004) demonstrated that a 10% increase in the proportion of schools
making ‘junk’ food available translated into a 1% increase in students’ BMI, and where the child had an
obese parent, this increased to 2%.

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In recognition of the contribution of school meals on children’s diets, many countries across the world
have developed school meal guidelines. Japan, which has enforced standards for school meals since
1954, and an emphasis on traditional foods within schools, has one of the lowest rates of obesity in the
world (Dalmeny et al, 2004). Current school food standards in the UK are considered some of the most
detailed in the developed world (Harper & Wells, 2007). By September 2008 primary schools had to meet
the standards and secondary schools, special schools and pupil referral units had to meet nutrient-based
standards by September 2009. In each school the board of governors is legally responsible for ensuring
food and nutrient-based standards are met and schools must present evidence during Ofsted inspections
that they are meeting the standards. Additionally, take up figures for school lunches are included in set of
National Indicators used to report on performance (Communities and Local Government, 2007). No impact
measures have yet been used as it is early in the implementation of the standards. However, longitudinal
studies have demonstrated that food environment modification can improve children’s dietary intakes by
supporting them to make healthier food choices:
For instance, a 2 year study conducted in the US (French et al, 2004) investigated the impact on
adolescents’ dietary intakes of an environmental intervention to increase sale of lower-fat foods (5g or
less per serving) at lunchtime in secondary schools. Schools involved in the project set themselves goals
to increase their availability of lower-fat foods by 30% with the ultimate goal being to increase availability
by 50%, using peer promotion of lower-fat foods. Promotional activities run by students included taste
tests, food choice self-assessments and media campaigns. After one year sales of lower fat foods had
significantly increased by 10% in intervention schools but had decreased by 2.8% in controls. By the end
of the intervention, intervention schools reported sales increased by 51% but the decrease in sales seen in
control schools continued, dropping to 5%. In terms of peer promotions, 49 occurred in year one and 127
in year 2. Students in intervention schools reported being significantly more likely to see media promotions
than students in control schools.
Perry et al (2004) conducted a similar study aimed at 7-9 year olds in elementary schools in the US to
achieve increased fruit and vegetable consumption of children in intervention schools after 2 years by
modifying the school lunch menus. School catering staff received 1 day of training and twice yearly
meetings were conducted with food service managers. Intervention schools set themselves goals to offer
at least one more serving of fruit or vegetable a day. Staff were encouraged to make fruit and vegetable
options more attractive and to encourage children. Lunchtime observations showed significantly higher
intakes of fruit by children in intervention schools with the magnitude of the difference being 0.14 to 0.17
servings. No significant increases were seen for vegetable or fruit juice intakes.
Therefore findings discussed above suggest that modifying the lunchtime choices available to children
can improve their dietary intakes even without curriculum modification. It has been argued in the US that
providing school lunches contributes to obesity, as children who consume the provided lunch take in 40-
120 more calories per day at lunch compared with those who take a packed lunch from home (Whitmore
Schanzenbach, 2005, cited in Mazzocchi et al 2009). However, the school lunch is an important part of
the diet especially for lower income families, and if healthy lunches were provided, could greatly improve
overall diet.
c.Fruittuckshops
A study in the UK (Moore, 2001) evaluated the effect of fruit tuck shops on 9-11 year old children’s fruit
consumption. The study ran over one academic year and fruit sales increased over the autumn and spring
terms but declined during the summer term; intake in intervention schools only equated to 0.06 fruits

Tackling Childhood obesity within schools: A review of
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per pupil per day. However, statistically significant increases were reported in the proportion of children
reporting that they used the tuck shops (p= 0.002) and that they ate fruit at school (p = 0.005). Whilst fruit
consumption increased in intervention schools, the increase was not consistent across the school year,
perhaps indicating the novelty value of the tuck shops declined. Additional promotional activities are
required in parallel with such interventions. Another school-based programme evaluating the effectiveness
of healthier food kiosks (Kain et al, 2004) reported they were not effective due to lack of regulation and lack
of revenue available to schools to support them.
d.Freefruitinschools
In the UK the ‘National Fruit Scheme’ was implemented between 2000 and 2002 with the aim that by
2004, every primary school child in the UK would receive a piece of free fruit daily whilst at school (Wells &
Nelson, 2005). Findings showed significant differences between fruit consumption in intervention children
(117g per day) and control children (67 g per day) (p<0.0001).
In another study evaluating the effect of free fruit on 11-12 year old children’s fruit consumption in Norway,
Bere et al (2001) reported significant improvements in fruit consumption (p<0.001) in intervention schools
compared to controls after a year.
Thus it appears that providing free fruit at school could improve children’s fruit consumption at school.
However, additional work is required to understand whether eating fruit in school caused children to
compensate by not eating as much fruit at home. This lack of information should not discourage schools
from adopting such a scheme; the evaluation from the ‘National Fruit Scheme’ highlighted other benefits
such as it providing a social time and a time for learning, giving support to teaching and learning about
healthy eating.
e.Awholeschoolapproachtohealthierdiet
Studies have demonstrated that implementing environmental changes within a wider school and family-
based nutrition-focused programme, (Perry et al, 1998) can increase the strength of interventions (for
example, Perry et al, 1998; Birnbaum et al, 2002). Examples are given below:
The GIMME 5 project (O’Neil et al, 2002; Baranowski et al, 2000), a 4 year dietary intervention for 14-15
year olds in schools in New Orleans, USA, aimed to increase students’ fruit and vegetable intakes to 5
or more a day. It consisted of a school media-marketing campaign to promote positive attitudes towards
fruit and vegetable consumption; a series of workshops incorporating a range of learning strategies
based on the Stages of Change model; an environmental intervention targeting school meals and a
parental component including brochures, newsletters and homework assignments for the parent and
child to complete together, all designed to support parents in healthy eating at home. In addition parents
received ‘point of purchase’ education which was conducted at grocery stores most frequented by
parents. Parents were provided with suggestions for selecting, storing and preparing inexpensive fruit
and vegetables. They were also given videos to watch at home containing information supporting the
GIMME 5 curriculum. Lessons were delivered by a trained class teacher. Results showed that intervention
students’ knowledge increased significantly from baseline (p<0.0001) and when compared to control
students’ (p<0.05). Intervention students’ daily intakes of fruit and vegetables had significantly increased by
14% between baseline and post-programme compared to the control (p<0.001). However no statistically
significant differences were reported in students’ psychosocial variables and no differences were reported
between intervention and control schools in terms of the number of servings of fruit and vegetables in the
school lunch.

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This study included a process evaluation and findings indicated why results were not more promising. For
instance, only 47% of curriculum activities were implemented and out of approximately 120 participating
students per school the mean attendance at ‘point of purchase’ events was reported at 13.9 (sd = 9.4;
range 1-30) and mean number of adults was 7.9 (sd = 4.9, range 1 to 18). Only 65% of parents receiving a
video said they had watched it. It is unclear whether behaviour change would have been more pronounced
had implementation been conducted more rigorously and both students and parents received a more
intensive intervention.
The 5-a-day Power Plus Program (Perry et al, 1998) was conducted in elementary schools in Minnesota.
It aimed to increase fruit and vegetable consumption of 9-10 year olds. The intervention consisted of 4
components: a) a curriculum underpinned by SCT b) parental involvement and education c) food service
modification and d) involvement from industry. The curriculum was taught by classroom teachers who
had attended a one day training. Two classroom curricula were developed, aimed at fourth and fifth grade
students. Lessons were 40 to 45 minutes long, implemented twice a week and incorporated learning
activities such as skill building and problem solving, snack preparation, taste testing and stories. Teams
were devised and competitions were organized for eating fruit and vegetables during lunchtime. Students
achieving the goal of eating two or more servings of fruit and vegetables daily at lunchtime were awarded
incentives. Fourth grade children’s parents received five home packs over the course of the programme
with activities to do with their child, information about the curriculum content, tips for encouraging their
child to eat fruit and vegetable at home and a snack recipe. Fifth grade parents received four snack packs
which involved children and parents making a snack at home together. Catering staff were encouraged to
promote fruit and vegetable at point of purchase, enhance the attractiveness of how fruit and vegetable
were served to children, increase the variety served and provide additional fruit when baked desserts were
offered. Local industries provided fruit and vegetables. Results showed significantly increased lunchtime
fruit consumption and combined fruit and vegetable consumption in intervention children, lunchtime
vegetable consumption in girls and daily fruit consumption as well as proportion of total daily calories from
fruit and vegetables. Results varied by ethnicity with trends being more favourable in Asians and African-
Americans than in Hispanics and no changes were reported in white children.
Process results reported that teacher training was attended by 100% of teachers and 78%-85% of
curriculum activities were implemented by teachers in lessons. However, 68% of parents participated in at
least one home activity each year and a high adherence was reported for the school lunch component.
This study showed that such a programme was feasible to run in US urban public schools with a multi-
ethnic populations and a key strength of the study was its process evaluation finding. The programme was
implemented to a high degree in intervention schools and the authors consider their success was due to
the strong teacher training component and the frequent communication between the intervention staff and
the school throughout the programme. However, results indicated that whilst the programme was effective
in increasing children’s fruit and vegetable intakes at lunchtimes, it was not effective in achieving increases
in their consumption across the whole day. The disappointing family participation could explain this lack of
influence. Only 50% of families returned cards from completed homework assignments. Clearly more work
is needed to involve families and thus positively influence the home.
1.4.Summaryofnutrition-focusedinitiatives
It is difficult to draw conclusions from the array of school-based nutrition focused interventions conducted
globally, as they vary in size, duration, focus of main outcomes, age group and ethnic grouping. Whilst
some contain an education component only, others have targeted food in schools and still others have

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integrated a whole school approach. A large number have targeted changes in food choice and dietary
behaviour as the main outcome measure. Several have included a measure of body fatness and others
have concentrated on changes within the food environment itself. Whilst the results show positive changes
occurring in children’s food choices and dietary behaviours, the extent of success on body fatness is less
clear (Resnicow & Robinson, 1997).
SectionTwo:Physicalactivityinterventions
Physical Education classes are often an integral part of the school curriculum, and school playgrounds,
playing fields, gym and sports equipment feature in most schools. The school day is organised around
breaks and lunch times, providing ideal opportunities to promote physical activity. It is not surprising that
they are a common focus for interventions aimed at children (Cale & Harris, 2005).
The following section will give examples of interventions focusing on reducing sedentary behaviours, multi-
component interventions combining an active PE component with an education component and multi-
component interventions combing PE with a classroom-based curriculum of behaviour modification.
2.1.Classroombased
In a small-scale study in California, Robinson (1999) evaluated the impact of a classroom-based
intervention on primary school-aged children’s media use (TV, videotape and video game use). Lessons
were 30-50 minutes long and taught by the regular classroom teacher. The 18 lessons were based on
SCT and encouraged children to self-monitor and self-report their TV viewing with the aim of motivating
them to want to reduce viewing time. Further lessons challenged children to have a TV and video game-
free 10 day period. After this children set themselves goals to achieve a 7 hour a week budget, and lesson
content encouraged them to become ‘intelligent viewers’, by being more selective in what they watched
and how they used their time. At the end of the 18 weeks statistically significant decreases were reported
in intervention children’s measures of body fatness (including BMI, triceps skinfold thickness, waist
circumference and waist-to-hip ratio). Additionally intervention children reported statistically significant
decreases in TV viewing compared to controls (p<0.001) as well as in number of meals eaten in front of the
TV (p<0.02).
In contrast, results from a similar intervention incorporating similar components and also based on
SCT, ‘Switch Off-Get Active’, (Harrison et al, 2006) reported no statistically significant changes between
intervention and control groups for BMI. However, significant differences were reported in physical activity
between intervention and control groups with intervention children showing greater activity (p<0.05) and
self-efficacy for physical activity (p<0.05) than controls which was not seen in Robinson’s (1999) study.
However, results relied on self-report and thus caution is needed in concluding that there is a simple
relationship between increased physical activity and decreased screen time. Additionally, whilst the study
indicated a co-existence of lower MVPA, aerobic fitness and self efficacy in being able to do physical
activity in those children reporting high screen times, it would be too simplistic to suggest high screen
times displace physical activity: it could be that they serve as a marker of children with low self-efficacy for
physical activity and thus predict their lower physical activity levels.
These studies show that classroom based studies aimed at decreasing TV viewing have mixed effects on
children’s weight status and such short-term studies make it unlikely that behaviour-change is maintained

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in the longer-term. Additionally, Harrison et al (2006) concluded that behaviour-change techniques taught
within the classroom may not be sufficient on their own to have major impact on children’s screen times.
Furthermore, whilst such interventions have shown promise in affecting children’s TV viewing behaviours, it
should be remembered that TV viewing is not the only sedentary behaviour that children do (e.g. reading,
painting, doing homework) and sedentary delivery of such health-related concepts can have little impact
on children’s physical activity levels, particularly in the longer-term.
Simon et al (2006) conducted a classroom-based study for 11-12 year olds in schools in France, aimed
to change children’s attitudes towards physical activity, through an educational intervention, giving
knowledge about physical activity. In addition children were given increased access to activities and more
opportunities to partake in physical activity at breaks, lunchtimes and after school. Thus whilst classroom-
based, the programme sought to make the school environment more supportive. Results at 6 months
showed those children in intervention schools not partaking in physical activity at school had reduced
significantly (p<0.0004) compared to controls and the proportion spending more than 3 hours in sedentary
activity had also significantly decreased compared to controls (p<0.0004).
Such a programme could be useful in schools without regularly scheduled PE classes as it provides
children with daily opportunities to be active in a non-competitive, non-structured way whilst also providing
an educational component through the curriculum to motivate children to be more active.
2.2 .Multi-component-classroombasedandPE
Some interventions have included PE sessions (either
adding a new curriculum into existing PE classes or adding new PE classes into the existing curriculum) as
well as a classroom-based component.
In some, the classroom-based component was education focussed, giving children information about the
benefits of increasing their physical activity.
For instance, Flores (1995) reported on ‘Dance for Health’, an aerobic dance programme aimed at 10-13
year old African American and Hispanic children in Palo Alta, USA. The 12 week programme included
twice weekly dance focused PE sessions and a supporting health education component of 25 lessons
covering nutrition, exercise, obesity, smoking prevention, substance abuse, stress management and peer
pressure. Significant reductions in BMI were reported between intervention and control girls, but there
were no significant reductions for boys. Intervention girls’ fitness increased significantly whilst intervention
boys’ fitness increased but not significantly. By choosing dance, the intervention ensured all students,
whatever size and shape or of whatever skill could participate in non-competitive physical activity. Schools
did not require specialist equipment and the choice of popular music ensured its appeal. However,
its effectiveness with girls and not boys indicates the need to explore more thoroughly how to tailor
interventions to be gender-sensitive.
In another study, Pangrazi et al (2003) devised an intervention (PLAY) aimed at 9-10 year olds in Arizona,
USA with the focus of promoting 30-60 minutes of moderate to vigorous physical activity daily. The
intervention comprised a PE component, integration of 15 minute activity breaks into lessons and a
classroom-based curriculum promoting the importance of physical activity and encouraging children to
set goals to increase their physical activity. The first week included promotion of play behaviour followed
by 3 weeks of teacher-led activities highlighting games suitable for outside school. The last remaining

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8 weeks of the programme encouraged children to engage in self-directed activity and goal setting to
achieve 30 minutes of activity a day. Whilst no statistically significant differences in BMI were reported
between intervention and control groups, girls were significantly more active when the PLAY (classroom-
based component) was delivered with PE. Boys showed no statistically significant differences between
intervention and control. This study again highlights the need for gender to be taken into account.
There are examples of programmes that have been specifically developed to target girls or boys. These
have focused more on behaviour change techniques and promotion of self-efficacy and self-esteem
related to physical activity.
For instance, the ‘New Moves’ study (Neumark-Sztainer et al, 2003) targeted 14-16 year old girls who
were either overweight or at risk of becoming so, in secondary schools in Minnesota, USA and was
underpinned by SCT and Stages of Change. The focus was on promoting life-long physical activity within
a supportive, non-competitive environment, suitable for girls with a variety of shapes, sizes and skill level.
The main component was a physical activity programme offered 4 times a week. The support curriculum
offered on alternate weeks focused on behavioural techniques such as skill building and increasing
self-efficacy related to diet and exercise. It gave nutritional guidance, emphasising balanced eating, and
encouraging girls to avoid dieting. A key component was the link with the community with one of the four
PE sessions each week being run by a guest instructor, aiming to give the girls a range of role models as
well as alert them to the possibilities for physical activity in the community. The intervention included a
parental component aimed at increasing parental support for their child, including postcards sent home
related to physical activity, nutrition and social support. Results indicated that support from parents, peers
and teachers was positively associated with increased physical activity. Additional findings indicated that
girls watching more TV had higher BMI’s and time constraints were inversely associated with physical
activity. Results showed no statistically significant differences between intervention and control schools for
girls’ dietary and physical activity behaviours, psychosocial variables (e.g. self efficacy, self-worth, self-
acceptance), or BMI. This lack of significant findings indicates the need for a more intensive and longer
intervention. However, the rigorous process evaluation gave evidence that such a programme was feasible
and effective in engaging adolescent girls with low levels of physical activity. High program satisfaction was
reported from participants, parents and staff. By incorporating the programme into the existing school
day, girls who would perhaps not seek other means of being active after school were given the opportunity
to be active and to actually enjoy the experience. The program was sustained by all intervention schools
after the study was completed and links with the community were continued.
Another intervention aimed at girls was LEAP (Dishman et al, 2004), targeting 12-14 year old girls with the
aim of enhancing their self-efficacy and behavioural skills related to physical activity, and underpinned by
SCT. A series of classroom-based sessions were delivered within the normal curriculum and integrated
into health education, biology and family and consumer science classes. These classes aimed to support
girls in practicing self regulatory behaviours such as goal setting, time management, identifying and
overcoming barriers and self-reinforcement. In addition the inter vention integrated a physical activity
component into normal PE classes. These classes aimed to enhance girls’ physical activity levels by giving
them positive experiences of physical activity and give opportunities to develop skills to adopt a physically
active lifestyle outside school. The intervention was run by specialists, possibly limiting its sustainability.
However, its strength was that teachers in intervention schools were involved in the development of the
subsequent intervention and their views were sought about what was feasible. By reporting the fidelity
of each school’s implementation of the programme, results showed that some schools implemented
the programme better than others. This highlights which schools need additional support to implement
programmes more effectively in future. Like the New Moves study, this study also had direct effects on

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girls’ self-efficacy, goal setting and physical activity suggesting that self-efficacy and satisfaction had a
synchronous relationship with physical activity. These studies (New Moves and LEAP) therefore show
promise in being able to reach adolescent girls with low physical activity levels. Mixed PE classes (boys
and girls together) present girls with a myriad of concerns and single sex lessons are better for girls. (Taylor
et al, 1999).
Other multi-component physical activity focused programmes targeting both boys and girls have also
incorporated behaviour change techniques. For instance, SPARK targeted 9-10 year old girls and boys
in 6 schools in California (Sallis et al, 1997). The intervention comprised a PE programme and classroom-
based self-management component. PE classes were scheduled 3 times a week for 30 minutes in
two parts: health-fitness activities (such as aerobic dance, skipping, jogging) and skill-fitness activities
(including basketball and football). The self-management component taught children behaviour change
techniques such as self-management, goal setting and problem solving. The aim was to help children
transfer skills learnt in school to physical activity outside school. Monthly homework assignments were
devised to include parents although these were not evaluated. In addition, the study compared the effect
of the intervention being teacher-led to being specialist-led. At 2 years, results showed that children in
specialist and teacher-led classes spent more time per week being active compared to control (p<0.001).
Teacher-led classes had comparable effects to specialist-led classes and thus were sustainable. Results
also showed that the programme increased intervention children’s physical activity levels whilst in school
but had no effect on their out of school levels. Whilst studies (both nutrition focused and physical activity
focused) have highlighted that teaching children behaviour change techniques can help them improve
their health behaviours whilst at school, it is less clear whether these skills can be implemented effectively
at home. In addition, there were gender differences reported in this study. Ironically, it was girls again that
showed greater improvements in abdominal strength and endurance (p<0.001) and cardio-respiratory
endurance (p<0.001) than controls. Thus whilst the programme was aimed at both boys and girls, taking
these findings together with the previously discussed studies suggests that gender differences are a key
consideration when designing physical activity components for future interventions.
2.3.Interventionstoincreasephysicalactivityfocusingonenvironmentalchanges
The majority of interventions targeting physical activity have been integrated into PE lessons. Very few have
considered the aspects of the school environment (Weschler et al, 2000).
a.Playgroundmarkings
In a small-scale study in the UK, Stratton (2000) explored the effect of changing playground markings on
activity levels of 5-7 year olds during break times. Children in the intervention school designed a series
of markings which were then painted onto the playground. Results showed the marking significantly
improved activity levels in intervention children compared to controls. Additionally, increasing the
availability of balls, skipping ropes etc. and increasing length of break-times influenced children’s
activity behaviours. However, the short duration of the study (20 days) limits the impact of the findings.
Additionally, the results are a combination of increasing the length of playtime, incorporating playground
marking and making play equipment more available therefore it is unclear which factor had the most effect.
However, the study does show that in schools where physical activity is low, adding such components to
playtime can positively influence children’s activity levels and such measures are affordable and easy to
implement in most schools.

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b.Walkingbuses
Walking school buses are groups of children that walk to and from school chaperoned by responsible
adults, usually a group of parents. Children can join the route at various points and those living off the
route can be brought by parents to join the ‘bus’ as it passes. They originated in Australia as a practical
solution to traffic congestion, physical activity promotion, levels of pollution and reliance on cars (Engwicht,
1993). They are included here within a discussion of physical activity interventions because their primary
goal is to allow children actively and safely to commute to school.
Whilst walking buses have been set up in a number of countries, studies evaluating their effectiveness are
limited and have shown varying results (Jago & Baranowski, 2004; Davison et al, 2008; Lee et al, 2008).
In a UK study, Rowland et al (2003) reported no change in the method of transport to and from schools
between intervention and control schools. However, the input of the school travel coordinator assisting
the schools in implementing the scheme was limited (16 hours over the school year). In contrast other
studies reported significant effects. For instance, McKee et al (2007) reported significant increases in
the mean distances walked by intervention children compared to control children in their Scottish study
and Mendoza et al (2009) reported significant increases after one year in the number of intervention
children who walked to school compared to controls. Mendoza et al (2009) reported that the school travel
coordinator spent 10-15 hours per week throughout the entire evaluation in intervention schools ensuring
systematic implementation and maintenance of the scheme.
It appears that walking buses may improve the numbers of children walking to school, thus increasing
the amount of physical activity achieved in a day. Sufficient input is required from a coordinator in order to
ensure proper implementation and maintenance of sustainable and effective schemes.
c.Communitypartnerships
The ICAPS study (Simon et al, 2006) is a multi-level program run in schools aimed at improving
adolescents’ physical activity. As well as an educational component run in schools to increase
adolescents’ knowledge and skills about physical activity, the intervention promotes new physical activity
opportunities in lunch and break times and after school. The entire focus is to develop lifelong active
behaviours. The educational component explores physical activity opportunities in everyday life and
promotes such things as active commuting and taking the stairs. Physical activity is also encouraged in
each class (active breaks). The new opportunities presented by the programme aim to overcome such
obstacles as poor accessibility to facilities, unsafe areas, inappropriate opening times, lack of transport
and facilities being too expensive. Guest instructors provide adolescents with opportunities within school
to participate in informal games or aerobics and dance and the emphasis is on being non-competitive
and open to all. Sporting events and bicycle and on-foot school transfers are also organised. Community
representatives met to change the local environment to make it more supportive. Initiatives have included
low cost or free entry to swimming pools and sports clubs and free transportation. Planning for cycle lanes
has also been initiated. The local media were approached to emphasise the community involvement and
promote the initiatives.
Results after the first 6 months of the project showed that adolescents in the intervention schools had
increased their physical activity. The proportion not performing in supervised physical activity at school
reduced significantly (p<0.0004) as did the proportion of those spending more than 3 hours a day in
sedentary activity (p<0.0004). Again gender effects were reported with more girls participating than boys
(p<0.05). However, parental participation was low, particularly in low socioeconomic groups (25% to 40%)

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despite parents stating their interest in the project. The study shows that school-based PE programmes
have the potential to form community links in order to influence positively the wider environment in terms
of physical activity opportunities for adolescents. Such a programme may be less effective with younger
children who have less autonomy when out of school.
2.4.Summar yofphysicalactivityfocusedschool-basedprogrammes
Whilst the studies discussed above show promise in suppor ting children in increasing their physical
activity, the fact that some added additional sessions on top of the children’s normal PE classes (e.g.
Flores et al, 1995; Neumark-Sztainer et al, 2003; Sallis et al, 1997) raises questions about whether they are
practical to implement and consequently whether they are sustainable. Findings have also highlighted that
there are gender differences in how physical activity is perceived and what activities are appealing.
SectionThree:Multi-componentinterventions
There has been a wide range of multi-component interventions developed for schools focusing on
nutrition and physical activity. Some simply focus on educational and informational approaches whilst
others incorporate behaviour change techniques. Still others intervene in the school environment such
as providing healthier school meals or increasing opportunities to be more physically active. The wide
range prevents accurate comparison. This section will simply show-case particular approaches and
programmes.
3.1.Nutritioneducationandphysicalactivity
a.Inschool
A multi-component intervention aimed at 5-7 year olds was conducted in Germany by Muller et al
(2001). The intervention aimed to develop knowledge, self-monitoring, increase children’s elf-esteem
and build autonomy. It focused on increasing children’s fruit and vegetable consumption, reducing their
fat consumption and increasing their physical activity to at least 1 hour a day and decreasing their TV
viewing to less than 1 hour. Intervention schools received 8 hours of nutrition education including ‘active
breaks’. A novel component was the home-based element which included 3 to 5 hours of home visits
for obese children and/or those with obese parents. Family counselling encouraged families to assess
personal preferences of family members and considered family structure, organisation and lifestyle (diet
and activity) of family members. A 6 month structured sports programme was also offered to overweight
children. Short-term effects at 3 months indicated increased nutritional knowledge, increases in physical
activity daily and decrease in TV viewing (p<0.05) in intervention schools. At 1 year, triceps skinfold
thickness increased significantly less than in control children (p<0.01) and % fat mass also increased
significantly less (p<0.05). Whilst the programme showed effectiveness in the short-term it was unclear
how sustainable the intervention would be. Teachers were trained by specialists and co-ran the nutrition
classes but no details of how frequently this training was or how teachers were assessed was given.
Additionally, it is unclear what effect the specialist programmes had on the obese children’s self-esteem or
perception of social inclusion.
Another programme for which this concern could be raised is a primar y school based intervention
developed in Beijing (Jiang et al, 2006). The intervention included nutritional lectures to parents and gave
families educational materials for use at home. Classroom lessons were given to children with additional
lessons for those who were overweight and obese. Parents of overweight and obese children attended

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extra meetings once a semester. Whilst Jiang et al (2006) reported the prevalence of overweight and
obesity reduced significantly in intervention children (p,0.01) as well as significant differences in BMI
between intervention and control schools, no evaluation was made of outcomes such as child self-esteem
or self efficacy or the extent to which obese children felt socially excluded. Indeed, a systematic review
of school-based interventions in China, (Li et al, 2008) highlighted that discrimination of overweight and
obese children was a major factor in all Chinese school-based studies included in the review. In order
to explore such issues, one multi-component intervention targeting 7-11 year olds in the UK, aimed at
improving diet and physical activity behaviours (Sahota et al, 2001) incorporated outcome measures such
as global self-worth, dietary restraint, body shape preference and self-perception as well as the more
common measures of dietary intake and physical activity behaviours. Results showed that global self-
worth scores were higher in the obese children in the intervention group compared to obese controls.
Thus the programme was successful at changing children’s attitudes and did not do harm. It would be
sensible for future programmes to incorporate such measures to explore whether some children are
negatively affected.
A US intervention aimed at 9-11 year olds incorporated a wellness and PE intervention into various
classes including wellness, nutrition, language, art, maths and PE (Spiegel & Foulk, 2006). The curriculum
was implemented through the school year, taking into account individual schools’ schedules. It was
underpinned by the Theory of Reasoned Action and aimed to build students’ academic skills whilst
also developing their health attitudes and behavioural intent, with the longer term aim of affecting their
behaviour. Activities involved students exploring their own attitudes and intentions, collecting, reporting
and analysing information about their own health such as measuring their own height and weight using
tape measures and scales. Physical activity modules encouraged students to devise ways of incorporating
physical activity into their daily lives and the nutrition module focused on learning about balanced eating
and then comparing their beliefs with their own food intakes. The curriculum also included practicing
how students could take home information and skills, to become health advocates in their families. The
curriculum activities included reading, writing and reflection skills as well as being a health promotion
intervention. Classes finished with 10 minutes of aerobics each day. At 6 months significant decreases
in development of overweight were reported in intervention children and a 2% reduction in numbers of
intervention children being overweight was seen. Increases in fruit and vegetable consumption were
reported in both groups but were noticeably higher in the intervention group. Children in the intervention
group reported increases in their physical activity levels at home and at school. However no objective
measures of physical activity were taken and similar multi-component interventions with such measures
have reported no significant increases in physical activity levels (e,g, Gortmaker et al, 1999; Manios et al,
1998; 1999; 2002; Kafatos et al, 2007). It has been suggested that the effectiveness of the physical activity
component of such interventions is hindered by the minimal PE classes and limited after-school provision.
However, the fact that the programme was designed to be incorporated into the existing curriculum in a
range of subjects and promoted academic skills may make it more appealing for schools to adopt, rather
than them perceiving it as an additional programme to somehow be slotted into the academic curriculum.
Spiegel & Foulk’s (2006) programme was of short duration and whilst classroom teachers delivered the
programme, no assessment of teacher training or teacher effectiveness was conducted or indeed whether
teachers implemented all components of the programme. This was the case in similar multi-component
interventions implemented by classroom teachers (e.g. Gortmaker et al, 1999; Manios et al, 1998; 1999;
2002; Kafatos et al, 2007). In addition, in order to be effective at improving children’s health behaviours,
programme effectiveness is not just dependent on intensity but also on teachers’ ability and enthusiasm
for the programme (Bush et al, 1989; Resnicow et al, 1992). Other evidence indicates that in terms of
encouraging adolescents to increase their physical activity levels, unsupportive teachers are a key barrier

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(Mason, 1994; Mulvihill et al, 2000; Orme, 1991; Sports Council for Wales, 1994). Thus future programmes
would benefit from integrating teacher evaluation into their studies not only to assess their level of expertise
but also their views and attitudes.
Other multi-component school-based interventions have included additional components within the wider
school environment than just nutrition and physical activity class-room based curricula.
For instance, the CATCH (Luepker et al, 1996) intervention including nutrition curriculum, enhanced
physical education and school-food modification plus family education, aimed primarily at prevention of
cardiovascular disease, was one of the first and largest multi-component school-based programmes
developed. Like other multi-component interventions the classroom programme was implemented
by teachers and involved skills development related to eating habits and physical activity. Additionally,
the PE component sought to increase the amount of moderate and vigorous physical activity (MVPA)
during PE. Other components included a family-based intervention and food modification. At the end
of 3 years the physical activity intensity of PE classes in intervention schools had increased significantly
compared to control (p<0.02) and significantly more daily vigorous activity was reported by intervention
than controls (58.6 mins vs 46.5 mins, p<0.003). Intervention children’s self reported energy intake from
fat in intervention children significantly reduced (32.7% to 30.3%) compared to control children (32.6%
to 32.2%) (p<0.001) and dietary knowledge, dietary intentions and self-reported food choice changes
were significantly greater for intervention children than controls. Thus the program was effective but
as found in other interventions, whilst a high degree of compliance was reported by PE and classroom
teachers implementing the programme, showing that it was compatible to needs and structure of schools,
implementation was limited by costs, staff time and competing classroom instructional requirements.
In addition staff training time was limited, compromising effectiveness and intensity. The family-based
component comprised 19 activity packs sent home over the 3 years, with the child to be completed with
the parent. These complemented the curriculum content, with rewards given to children who completed
them. In addition family fun nights were run consisting of dance performed by the children for their parents,
distribution of recipes and games and food booths giving away healthy snacks. Family fun nights had
more than 70% parental attendance; however a comparison between schools receiving the curriculum
and those receiving it plus the family component found little benefit was gained by adding the family
component. These findings suggest that the family component of such programmes need to be more
intensive and extensive.
The food modification component aimed to reduce total fat of school meals to 30% total energy,
saturated fat to 10% total energy, and sodium to 600-1000mg per serving whilst maintaining nutrient
content and child participation. Caterers received a training day at the beginning of each school year and
monthly follow-up visits from intervention staff as well as booster sessions provided them with additional
information, added motivation and support for planning menus. Schools were also given a wide variety
of promotional materials to help them encourage students to eat the modified menus. Results showed a
significantly greater mean reduction in % calories from total fat (p<0.001), and saturated fat (p<0.003) in
the intervention schools compared to controls. In addition whilst the sodium content increased in both
intervention and controls, the increase was significantly lower in intervention schools (p = 0.034). No
significant changes were reported for carbohydrate, protein, fibre, calcium, iron, vitamin A and C and the
mean total calories (683kcal) in intervention schools remained above one-third of the RDA’s for the age
group. Thus the food modification component was successful in meeting its goals and this was achieved
in a wide variety of schools representing a range of food services and diverse student populations. Whilst
there was a high degree of compliance in implementation of CATCH by food service staff, the ability

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of schools to reach intervention objectives varied. The degree of implementation of the food service
component was determined by differences in food service operations, food purchasing and associated
barriers. For instance, schools in Texas all had on-site food preparation and came from a single school-
district. This facilitated support given by policy makers to modify food purchasing, and on-site facilities
meant a greater number of goals could be achieved. In contrast schools in California had meals provided
from a central kitchen and this precluded implementation of any of the intervention goals.
The availability of CATCH curriculum materials has resulted in its wide dissemination and use in other
elementar y schools across several states in the US and tailoring of the programme to other target
populations and school systems. For instance, Coleman et al (2005) reported on the adaptation of
CATCH for low income schools with Hispanic children. Results indicated that whilst the proportion of
overweight girls in both control and intervention schools increased, the increase in intervention schools
was significantly lower.
Whilst many school-based programmes cite using SCT as the theoretical framework and tend to target
children’s self efficacy, outcome expectancies and behavioural capability of knowledge and skills, Sallis et
al (2003) took a novel approach and devised a multi-component intervention based on social marketing.
The aim was to increase children’s total energy expenditure from physical activity and decrease the
number of grams of saturated fat purchased. The intervention targeted 10-14 year olds in San Diego.
Physical activity was increased by changing lesson structure, incorporating activity into classes and
improving teachers’ instructional skills as well as increasing the availability of equipment during breaks and
lunchtimes and provision of organised activities. The nutritional component included changes in school
food provision (lunches and vending machines). Catering staff received 11 hours of training and action
plans were devised to reduce fat content of foods and increase numbers of lower fat options. Students
were set goals to bring more lower-fat alternatives into school in their packed lunches. An additional novel
aim was to create a supporting policy change within the school. Student health committees were set up
and parental education was delivered through existing communication channels such as newsletters, and
PTA meetings. At the end of the 2 year intervention, intervention boys’ BMI had significantly decreased
(p=0.044) but no change was seen in girls. Boys’ MVPA increase significantly (p=0.001) but again no
effect was seen in girls. Findings also indicated similar barriers cited in previous studies; that is that some
schools found it difficult to increase the availability of physical education throughout the school day due
to lack of volunteers to run sessions and there were substantial financial barriers to schools increasing the
amount of lower-fat options on their menus. Some districts also were provided with meals from a central
food system which eliminated the amount of control over food preparation and choice that schools had.
In addition there was a requirement for food services to be self-supporting and therefore schools were
reluctant to serve new menus with lower fat and perishable items such as fruit and vegetables when there
had been no demand for such items and no time in which to promote and encourage them. Also there
was often no appropriate place for promotional materials to be displayed. The study shows that whilst
targeting the school environment appears feasible and to some extent achievable, considerable barriers
exist. More understanding of school systems and structures and policies underpinning these is required.
Yet again, gender differences appeared, highlighting the need for more exploration about what girls and
boys benefit from and what appeals to them.
b.Outsidelessontimes
Whilst schools have been used as a setting for nutrition and physical activity interventions, with increasing
focus on meeting educational and academic standards, there is not always sufficient time to incorporate
health promotion efforts. There is a need to be innovative and utilise non-curriculum time such as

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lunchtimes, break times and after school. Teachers are under considerable pressure to deliver the
standard curriculum and presenting them with an additional programme to implement may not be feasible
or practical.
A study that sought to reduce teachers’ work-load was ‘Be Smart’ (Warren et al, 2003), a UK based
multi-component programme for 5-7 year olds. The intervention was delivered in lunch-time clubs and
aimed to increase children’s outcome expectancies and expectations of physical activity and nutrition
behaviours. Additionally it provided opportunities for children to taste healthy foods, develop practical skills
in order to build their self-efficacy. Furthermore there was a parental component although details were
poor and authors reported difficulty in engaging them. Significant improvements after 20 weeks were seen
in nutritional knowledge (p<0.01) in all children but particularly in those getting both nutrition and physical
activity components (p<0.0001). Significant improvements in fruit consumption (p<0.01) and vegetable
intake (p<0.05) were seen in all children but changes in fruit intake were particularly significant in those
children getting just the nutrition component (p<0.05) and the control (p<0.05). No significant differences
in BMI were reported. Whilst the intervention was a pilot and depended on specialists to deliver it, teachers
expressed interest in incorporating the intervention into the curriculum. Thus the programme showed
promise for the future. However, if schools wanted to keep such a programme integrated into lunchtimes,
a more sustainable means of delivering it needs to be found as reliance on specialists may not be practical
in the longer term.
A novel way of not directly increasing teachers’ workload yet delivering a multi-component intervention
aimed at improving healthy eating and physical activity in 5-12 year olds was devised by Taylor et al (2007)
in New Zealand. The intervention was delivered by appointed community activity coordinators whose role
was to increase the variety and opportunities for physical activity beyond normal provision within school
hours. This included increasing non-curricular activities at breaks, lunchtimes and after-school, as well as
weekends focusing more on lifestyle-based activities rather than organised sports. Additionally, schools
were given money to purchase sports equipment although no details were reported on how schools spent
this money. Nutrition-based components focused on reducing sugary drink intake and increasing fruit
and vegetables. This component did incorporate a curriculum into existing science-lessons although it
was unclear who delivered these and how these were incorporated. Additionally an interactive card game
was developed which involved children completing specific nutrition or physical activity –related tasks
with friends and family. Results at the end of 2 years showed significantly lower BMI z-scores and waist
circumference for intervention children. Intervention children consumed fewer carbonated drinks than
controls and ate more fruit (p<0.01). Physical activity was significantly higher in intervention children at 1
year although no effects were reported for reductions in TV viewing times. A lack of process evaluation
meant that it was unclear how the intervention was perceived by schools and how the community activity
coordinators were assessed.
Schools must also be culturally inclusive and therefore there is less opportunity to tailor interventions to
specific ethnic groups. The GEMS intervention which targeted African American girls specifically, (Story
et al, 2003) was implemented after-school and aimed to increase 8-10 year old girls’ physical activity
and improve their eating. The 12 week intervention took the format of ‘club meetings’ held twice a week.
Intervention content was based on SCT and focused on behaviour change, incorporating physical
activity and nutrition components. Goals were to increase girls’ participation in PE, decrease their time
watching TV, decrease consumption of high fat foods and sweetened beverages, adopt healthy eating
practices such as portion size awareness and increase their consumption of fruit and vegetables. The
family component was designed to reinforce these messages and provide a supportive environment at
home. It consisted of weekly family take-home packets, family events and phone calls home by GEMS

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staff to encourage parents and check progress. The intervention was culturally appropriate and aimed
at low-income African-Americans. Results at 12 weeks showed BMI did not differ between groups but
were in the hypothesised direction. Intervention girls had significantly higher scores on the healthy choice
behavioural intentions (p= 0.001), dietary knowledge (p = 0.001) and preference for physical activity (p =
0.04) compared to control girls. Parents of intervention girls reported significantly less availability of high fat
foods (p=0.001) and lower energy intake from fat in their own diets (p = 0.03) compared to control parents.
A key strength was the process evaluation which demonstrated the programme was well-attended and
well-received by girls and parents. Parental participation was high because the girls were excited about
the events and wanted their parents to attend. All parents said they would recommend it to other parents
and the majority of parents wished the programme had been longer. Other studies have explored the
feasibility of implementing nutrition and/or physical activity programmes in channels such as Girl and Boy
Scouts. The rationale behind this is that such an international movement reaches large numbers of boys
and girls and earning of badges provides a useful mechanism through which to promote learning and
behaviour change. Examples of such programmes include the development of the 5 a Day Badge for Girl
(Cullen et al, 1998) and Boy Scouts (Baranowski et al’s, 2002). The programme was underpinned by SCT
and aimed to increase children’s consumption of fruit and vegetables. The programme included self-
monitoring, goal setting, problem solving and reward activities and aimed to increase children’s skills at
asking for fruit and vegetables at home and being able to prepare simple snacks and meals incorporating
fruit and vegetables. In their study of African-American Boy Scouts, Baranowski et al (2002) reported that
the intervention resulted in a difference of 0.8 daily servings of fruit and vegetables between control and
intervention boys after only 8 weekly troop meetings. However, yet again authors highlighted difficulties in
engaging with parents reporting poor attendance at parents’ meetings. They also reported that leaders at
all levels of the Scouting movement stated their difficulty in engaging with parents, suggesting that parental
involvement is not just a problem for school-based programmes.
3.2.Summaryofmulti-componentinterventions
Programmes targeting nutrition and physical activity have also included food service modification, forging
of community links and a family-based component. Whilst positive results have been reported as a result
of food modification programmes, there is less evidence that such schemes influence children’s dietary
behaviours at home. Additionally, whilst targeting the home environment is recognised as important, there
appears to be no difference in effectiveness between those programmes that have included a family-
based component and those that have not (Kropski et al, 2008). Indeed many studies reported their
difficulty in engaging with families.
SectionFour:Lessonslearntfromschool-basedinterventions(nutrition,
physicalactivityandmulti-componentprogrammes)
This review began by outlining the paradoxical situation that exists in terms of obesity prevention
research in the school setting. Whilst there is clearly a need for obesity prevention to stem the tide of
increasing childhood obesity prevalence, the range of school-based programmes and initiatives that exist
currently makes recommendations difficult. An additional difficulty encountered whilst conducting this
literature review was the dearth of information given by authors about their intervention components and
their content, and the lack of process evaluation meant it was unclear how the programme had been
implemented or received by teachers, children and parents. Indeed, whilst it is important that programmes
implemented are effective in terms of targeting obesity risk factors and changing behaviours, it is also
imperative that they are easily integrated into existing school systems, that they are cost effective and
sustainable. With these considerations in mind, the following section will outline issues that future initiatives
need to address.

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4.1.Programmetype
A range of programmes has been outlined in this review. The most common physical activity focused
programmes and those that have been most effective have involved lengthening the existing time of
PE lessons or adding new lessons (Cale & Harris, 2006). However, schools are faced with the difficulty
of implementing these programmes due to the pressures of utilising curriculum time for core subjects
rather than PE (Kahn et al, 2002). Another concern is that a PE lesson will comprise of other non-active
elements such as changing. Indeed Fox et al (2004) describe a study of a 40 minute PE lesson where on
average only 8 minutes were taken up with moderate or vigorous physical activity. In addition, Biddle et
al (2004) question the wisdom of developing structured activity programmes. They argue that whilst the
aim of such interventions is often cited as teaching children about integrating physical activity as a normal
part of their lives, adult physical activity is often more unstructured. Sallis et al (1992) hold a similar view
stating that programmes encouraging activity across the lifespan should focus on skills development ‘that
promote generalisation and maintenance of physical activity during youth and adolescence and enhance
the probability of carryover to adulthood’ (Sallis et al, 1992, pS255). Despite these recommendations
there have been very few physical activity interventions targeting schools or indeed, taken a non-
competitive approach. Interventions that stand out include Pangrazi et al (2003) where 15 min activity
breaks encouraged children in movement of any sort rather than specific or high intensity and New Moves
(Neumark-Sztainer et al, 2003) deliberately emphasised exercise for all shapes, sizes and skills levels.
Davison (2005) urges researchers to develop the concept of the ‘active classroom’ where physical activity
can be incorporated into lessons.
In terms of nutrition-focused initiatives, Contento (1995) highlighted that integration of nutritional education
into the curriculum was a key to success, and other authors came to the same conclusion. For instance,
whilst effort has been spent in devising interactive and fun teaching materials and tools, often involving
multi-media and CD ROMS and incorporating behaviour change techniques,(Amaro et al, 2006;
Baranowski et al, 2003), Livingstone et al (2002) found that to have longer-term use the place of such tools
within the existing curriculum needed identifying. Increasing fruit and vegetable intake and decreasing
sweetened beverages appear to be the most commonly promoted messages by interventions (e.g.
Reynolds et al, 2000; Baranowski et al, 2000; Perry et al, 1998; James et al, 2004; 2007) and reviewers
have urged researchers to promote these in future despite limited understanding of how much change
in these variables needs to occur to result in significant weight loss (Baraonowski et al, 2002; Sharma,
2006). However, schools have an obligation not just to promote simplistic nutritional messages. Clearly
nutrition education should not just provide information but needs to provide opportunities to develop skills
and behaviours related to areas such as food selection, storage, and preparation as well as consider the
social and cultural aspects of food (Dixey et al, 1999). Several programmes have incorporated nutritional
elements into lessons other than those immediately thought of. For instance Perez-Rodrigo et al (1997)
integrated their curriculum into maths and language lessons and components of the ‘Eat Well Keep
Moving’ programme (Gortmaker et al, 1999) were integrated into maths, science, language, arts and social
studies.
Whilst some interventions targeted only one dimension such as reducing carbonated drinks (James et al,
2004; 2007) or reducing TV viewing (Robinson, 1999), others were multi-faceted, aimed at both nutrition
and physical activity behaviours (Manios et al, 1998; 1999; Gortmaker et al, 1999; Muller et al, 2001). Still
others targeted specific components of the environment such as school meals (French et al, 2004; Perry
et al, 2004) or playground markings (Stratton, 2000). However, it cannot be concluded whether single-
component programmes are more effective than multi-component ones. From an entirely pragmatic point
of view it seems sensible to consider future interventions which incorporate all the issues discussed above
and take a ‘whole-school’ approach to obesity prevention.

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Additionally, whilst multi-component interventions have been developed, their focus is still largely on
targeting individual behaviour change and if the environment has been targeted it is from the perspective
of supporting this behaviour change, rather than considering for the longer-term how whole school policies
or the school environment can be changed to promote a healthy school setting. Whilst environmental
strategies have been explored, looking at school meal and snack provision, the environment in terms of
physical activity at school has rarely been explored. As Cale & Harris (2006) state ‘it is logical to assume
that interventions are likely to be most successful if they target the same behaviour across a number
of levels’ (Cale & Harris, 2006, p 329). This concept is emphasised in the Health Promoting School
philosophy (WHO Euro-EC-CE, 1993) where equal importance given to the taught curriculum, the whole
school ethos and the family and community with the aim of coordinating messages that the children
receive.
4.2.Informationprovisionvbehaviouralapproach
The number of studies combining information-giving approaches with behaviour-change techniques is
increasing. Indeed, in their review of interventions aimed at increasing physical activity, Kahn et al (2002)
identified 13 studies that evaluated the effectiveness of classroom-based health education focusing on
information provision and 9 of these were implemented before 1990. Instead, more recent studies have
comprehended that increased knowledge does not necessarily translate into behaviour change and have
targeted behaviour change through the curriculum (for example Warren et al, (2003) focused on increasing
children’s outcome expectancies and expectations related to nutrition and physical activity behaviours;
Muller et al, (2001) incorporated self monitoring components and sought to increase children’s self esteem
and autonomy at making healthier choices related to nutrition and physical activity; Neumark Sztainer et al,
(2003) focused on skill building and increasing self efficacy).
4.3.Targetgroup
There have been more programmes targeting the primary-school age group to date than those targeting
older children (Sharma, 2006; Cale & Harris, 2006). As it is at this age that dietary and physical activity
behaviours are formed, Sharma (2006) considers it entirely appropriate that interventions target primary
school in order to support children in forming lasting healthy behaviours. One element identified by Lytle
& Achterberg (1995) for successful nutrition-focused school-based interventions were primar y school
interventions with a family component. However, Baranowski et al (2002) consider the most effective
interventions in terms of reduction seen in BMI have been in older children, and they suggest that this
could be due to the target population being more mature and/or having more control over their own
dietary and physical activity behaviours and choices. Other researchers have reached this conclusion
(Kropski et al, 2008; Budd & Volpe, 2006). However, recommendations such as this are based on limited
evidence and whilst there is recognition that interventions must be age-appropriate (Lytle & Achterberg,
1995) no research has outlined how developmental differences can be tailored for, and what approaches
might be more suited to different ages and stages of development. Additionally, Cale & Harris (2006)
hypothesise that the large number of primary-school based programmes may reflect the greater degree of
flexibility within the primary-school curriculum and the more holistic approach to health education. There is
clearly a need to work with school principals and staff when considering the feasibility of integrating such
programmes into the existing school curriculum.

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4.4.Targetingparents
Whilst school-based programmes have often been successful in improving children’s dietary and physical
activity behaviours whilst in school, there is less evidence to show that it improves these behaviours
outside school (Stone et al, 1998; Lytle et al, 2002; Lytle & Achterberg, 1995). Indeed, Wechsler et al
(2000) consider it unrealistic to expect schools to facilitate changes in children’s behaviours without the
support from families. However, whilst several interventions have tried to incorporate a family component,
few have shown added effectiveness from doing so (Baranowski et al, 1997). For instance whilst Hopper
et al (1992) reported that a school-based nutrition-focused intervention significantly increased at-
home dietary and nutritional knowledge, no correlation could be demonstrated between this increased
knowledge and more positive domestic dietary habits and behaviours. Often authors stated that it was
not practical to run an entire parental intervention in parallel (Perry et al, 1998) and therefore take-home
packs were usually utilised (Perry et al, 1998; Reynolds et al, 2000; O’Neil et al, 2002; Baranowski et al,
2000; Sallis et al, 1997). Several programmes reported their difficulty in engaging with parents, reporting
poor attendance at parents’ meetings (O’Neil et al, 2002; Baranowski et al, 2000; Warren et al, 2003) or
return of homework assignments (Reynolds et al, 2000). Salmon et al (2005) reported that the majority of
parents were unaware of intervention aims and the majority of children lacked support in their behaviour-
change attempts at home. Others have reported good attendance for those families who participated, yet
these families represented only a small percentage of the families who could potentially have got involved
(Nader et al, 1992). It seems ironic that whilst young people associate home with healthy foods and family
members are often used as sources of nutritional information (Ross, 1995; Watt & Sheiham, 1996; Watt &
Sheiham, 1997), it continues to be a problem for interventions in how to engage with families effectively.
However, very few explored parents’ perceptions of the programme and how useful they found the take-
home packs. Indeed, Baranowski et al (1998) stated that GIMME 5 would have worked better if it had been
explored how families could be better supported and engaged with, and if factors affecting food choice
had been integrated into programme activities.
4.5.Communit yinvolvement
Very few interventions have included community involvement and it is unclear whether incorporating
these components increased intervention effectiveness. However, as schools only have limited time
within a school day and stretched resources to tackle obesity prevention, it seems prudent to work
with representatives from industry and the wider community to tackle the issue. For example in the 5
a day Power Plus programme (Perry et al, 1998; Story et al, 2000), local fruit and vegetable producers
provided produce for classroom taste testing as well as snack packs that children took home and were
able to contribute to expanding the food choices given at lunchtimes. In addition they did a 30 minute
presentation to intervention children on fruit and vegetables.
Despite evidence in the literature that a key barrier to young people choosing healthier foods is their
perceived lack of convenience and poor food labelling (Shepherd et al, 2006) very few school-based
interventions have incorporated such wider aspects of eating behaviour into their programmes. One such
initiative (the Minnesota Heart Health Program, (Kelder et al, 1995) integrated a school-based behavioural
education programme alongside community-wide health promotion strategies. The community
component included nutritional labelling in local restaurants and supermarkets, and mass media education
via local television, radio and newspapers. Such an approach resulted in modest but lasting improvements
in adolescents’ knowledge and choices. In terms of encouraging physical activity outside of school, only
one study was found (Simon et al, 2006) that aimed to address children’s barriers such as lack of money,
lack of transport and lack of provision of acceptable activities (Rees et al, 2006).

Tackling Childhood obesity within schools: A review of
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Future interventions would benefit from forging more community links to encourage increased physical
activity and improved dietary habits out of school (Lytle et al, 2002).
4.6.Engagingwithschools
Whilst school-based interventions have varied considerably it is also clear that schools and education
systems differ greatly between and within countries. However, for any initiative to be implemented
effectively, the school culture needs to be targeted for change including all stakeholders - students,
families, staff, administrators, principals as well as the location and surrounding area and any external
political influences. Before a programme can be implemented it is important to have full understanding
of how these stakeholders are involved, their interrelated roles and how these can be influenced. In other
words, school-based initiatives need basing on a thorough needs assessment of the current situation
(Ford et al, 2007; Summerbell et al, 2005; Parcel et al, 2003; Lytle et al, 2002; Sharma, 2006) and building
relationships with and involving key stakeholders is a key step in the process (Summerbell et al, 2005).
Several factors need consideration:
a.Schoolstructureandorganisation
Before intervening in the school environment it is important that a full understanding is gained of the
barriers and challenges facing schools in terms of implementing sustainable programmes targeting healthy
eating and exercise behaviours.
Ford et al (2007) describe schools as ‘political, complex, interactive, evolving environments’ (Ford et al,
2007, p359).
In terms of physical activity programmes, financial constraints and budget cuts have been correlated with
reduction in the availability of extra-curricular sports programs and a lack of facilities (Shaya et al, 2008). In
reviewing the effectiveness of PE intervention incorporated into the normal PE curriculum, Almond & Harris
(1998) concluded that those showing positive effects involved programmes including additional PE time,
but they questioned the sustainability of such programmes in light of school structures and timetables. For
dietary focused programmes, challenges include school meal provision. In countries with an absence of
healthy meal guidelines, it is often the case that schools on limited budgets will opt for ‘fast-food’ cafeteria-
style menus. In an intervention evaluating the effectiveness of fruit tuck shops, Moore (2001) reported that
schools funded these themselves and whilst the initiative was received positively by the schools involved,
the study has importance in highlighting that for schools with limited budgets, such schemes may be the
first to suffer.
Additionally, whilst the opportunity presented by schools for obesity prevention work has been widely
recognized, it is clear that such schemes present a considerable burden to school administrators in terms
of planning and budgeting. Indeed, in their evaluation of a programme to increase students’ fruit and
vegetable consumption, Anderson et al (2000) reported that schools found enlisting the help and support
of the school administrators invaluable for the smooth running of the programme.
A key to successful implementation is the support of the school principal. In a study of school principals,
Price et al (1987) reported that they were unsuppor tive of obesity prevention work. It is logical to predict
that a lack of support from such a key figure will prevent effective implementation of any programme.
Indeed, in their ‘New Moves’ intervention, Neumark-Sztainer et al (2003) consider a strength of their
programme was the strong support generated from PE teachers and principals in the participating
schools, including their decision to apply for funds to continue the intervention after the study was
completed.

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There is also a burden to teachers in terms of training to deliver the programme and then in implementing
the programme. A range of ways of decreasing teacher burden have been explored including utilizing the
lunchtime (Warren et al, 2003) or after-school (Story et al, 2003) slot in which to implement programmes.
Another novel way of decreasing teacher workload was the use of community representatives to come into
school and plan initiatives at lunchtimes and break times (Taylor et al, 2007).
Whilst school based interventions have targeted students’ dietar y and physical activity behaviours in
numerous ways as outlined above, the majority did not make use of the school nurse. Indeed, the role of
the school nurse in obesity prevention still remains relatively undefined: Survey data from the US on their
School Health Policies and Programs Study (SHPPS), highlighted that whilst health services within school
were delivered by the nurses, relatively few of these services were aimed at obesity prevention (Brener et
al, 2001). A review of progress of the SHPPS in 2007 still found this to be the case (Brener et al, 2007). In
there review, Bindler & Bruya (2007) found a dearth of evidence of school based health programmes run
by school nurses in the US and UK. Indeed, the current role of the school nurse in the US and UK appears
limited to school-based height and weight screening which is reported to parents (ION, 2004; NCMP,
2005).
However, studies exploring nurses’ perceptions have reported that the majority support the use of school
health services to provide obesity prevention services (Price et al, 1987; Stang et al, 1997; Moyers et al,
2005; Kubik et al, 2007). A study in the US (Moyers et al, 2005) explored the perceptions of school nurses
with regard to obesity in school children. Their results showed that whilst nurses supported the use of
school health services for obesity prevention work, they found counselling for obesity difficult, particularly
when parental support was lacking. They also stated they felt unconfident in their counselling skills and
only provided counselling and referral to obese children when parents had asked for help. A later study
also showed that school nurses in the US were supportive of obesity prevention services however,
this support increased as nurses’ perceived support from school staff and other health care providers
increased. These studies also bring to light the fact that in the current obesity crisis, the expertise of
school nurses is not being fully utilised.
b.Teachertraining
In terms of curriculum-based programmes, several programmes to date have utilised the existing
classroom teacher to deliver the intervention (Sahota et al, 2001; Manios et al, 1998; 1999; 2002; Muller
et al, 2001; Gortmaker et al, 1999; Sharma, 2006) whereas others used specialist staff (Salmon et al,
2005; Dishman et al, 2004; Lazaar et al, 2007).Sharma (2006) considers having a multi-disciplinary
team of health professionals supporting such health promotion initiatives is advantageous. However this
approach may not be feasible, practical or sustainable. Indeed reviewers have recommended addressing
sustainability by incorporating staff training whilst also targeting behaviour change (Sharma, 2006;
Summerbell et al, 2005; Brown & Summerbell, 2008).
Studies incorporating teacher training tended to report giving one day of training to staff (e.g. O’Neil et
al, 2002; Baranowski et al, 2000), Perez-Rodrigo, Fahlman et al (2008), yet no assessment of whether
this was adequate was conducted and no measure was incorporated into such interventions to measure
teachers’ capability. Indeed, research suggests teachers often complain about lack of information,
training or materials they are given for such programmes (Dixey et al, 1999). For instance, Price et al
(1990) reported that primary school teachers did not feel capable or competent enough to deliver physical
activity programmes aimed to reduce obesity. They went further to state that they felt under-trained to
help prevent obesity. This need from teachers was also highlighted in recent joint report on a consultation

Tackling Childhood obesity within schools: A review of
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with teachers from The Audit Commission, The Healthcare Commision and The National Audit Office in
the UK (2006). Teachers asked for more support and guidance about advising children who were obese
or at risk of becoming so and wanted more support on what advice to give to parents. Therefore future
programmes would benefit from more intensive teacher training.
However, implementation of curricula depends on factors other than the degree of teacher training.
For instance, characteristics of the teacher, the materials, degree of support provided by specialists
all influence the degree of implementation of a programme or curriculum (Tones et al, 1997). Kealey
et al (2000) suggest that teacher training itself should be considered as a behaviour change process,
incorporating motivational components which could help support the teacher to consider how
they implement such a curriculum into their existing classes. Other issues regarding programme
implementation are influenced by wider factors within the school environment and will be considered in the
next section.
c.Attitudes,behaviours,normsandknowledgeofstaf f
There has been concern expressed that promoting obesity prevention work in schools could have
potentially detrimental effects (Garner, 1985). For instance there is potential for such programmes to
stigmatise overweight children and introduce children to the concerns of weight control, fear of food,
negative body image and labelling. Yager & O’Dea (2005) highlight the considerable potential that teachers’
attitudes towards obesity may be transferred through modelling to the children they teach. Evidence
suggests that prejudiced viewpoints about obese children exist amongst teachers (Neumark-Sztainer et
al, 1999; Schwartz & Brownell, 2004; Puhl & Brownell, 2001) but to what extent is unknown. However, as
Davidson (2005) advises ‘before we can begin to reduce the negative stereotyping of obese children there
may be a need to help teachers face their own bias’ (Davidson, 2005, p 387).
d.AChild-centredapproach–attitudes,norms,knowledgeofchildren
Only a few school-based studies were based on an initial pilot study or needs assessment to ensure
the subsequent intervention was tailored to the child population it was aimed at or that the intervention
components were relevant and of interest to children. Studies have found that children were more positive
when their views were sought (Woolfe & Stockley, 2005) and children more engaged with the programme
were more likely to get their parents involved (Neumark-Sztainer et al, 2003). However, in general basing
the study on a needs assessment was rarely done. In a systematic review of physical activity interventions
outside school, Brunton et al (2005) reported that whilst children and parents had clear views about
factors that helped or hindered children’s physical activity levels, these views had rarely been sought and
nor did they inform the development of physical activity interventions.
Additionally, several studies have found favourable outcomes for either girls or boys but not both (e.g.
effect for girls: Perry et al, 1998; Flores, 1995 – Dance for Health; Gortmaker et al, 1999 – Planet Health;
effective for boys: Sallis et al, 2003), suggesting that messages were more accessible or appealing to
specific genders. However, no details of children’s needs or perceptions, makes it difficult to understand
why such differences in outcomes arose. Reviewers suggest that programmes should be focused on
specific target groups so that programme design and content can be ensured to address their specific
needs (e.g. Cale & Harris, 2008; Doak et al, 2006; Kropski et al, 2008; Brown & Summerbell, 2008). It
is clear that girls’ and boys’ perceptions and needs differ. One example of tailoring specifically to girls

Tackling Childhood obesity within schools: A review of
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42
is the GEMS after-school programme designed in a ‘club format’ for overweight African-American girls.
Whilst no significant differences were reported in BMI at 12 weeks, other outcome measures showed
favourably in intervention girls and parents were complementary of the programme and would promote
it to others. Whilst no firm conclusions can be made about how girls and boys’ dietary behaviours can
be more effectively and differentially targeted, reviewers have concluded that in terms of physical activity
programmes, girls may respond better to classroom instruction based on social learning whilst boys may
be more influenced by structural and environmental changes that encourage increased physical activity
(Kropski et al, 2008; Budd & Volpe, 2006;
In the UK, key motivators for healthy eating for children and adolescent boys were sports, being strong
and achieving better performance, whereas for girls the emphasis was personal appearance. Food choice
factors included taste, availability of ready to eat food, appealing packaging and perceived filling quality
(Urbick et al, 1999). Studies have also shown that barriers to children taking part in physical activity include
cost, distance and availability (Mulvihill, 2000) for structured activities and threat of crime and intimidation
from older children as well as perceived lack of safety of the play areas available (Davis & Jones, 1996).
Other studies have specifically targeted population sub-groups and have tailored components accordingly.
For instance, Perez-Rodrigo & Aranceta (1997) developed a nutrition education programme for schools in a
deprived area of Bilbao, Spain which had a high proportion of Gypsy children. Educational methods were
culturally appropriate as the community participated in designing them, and included drawing, craft work
and puppet shows. However, no study has assessed weight reduction or behaviour change in relation to
ethnicity or socio-economic status (Brown & Summerbell, 2008).
An additional concern is how obesity prevention is perceived by those already obese or overweight. For
instance, Curtis (2008) reported on results from a qualitative study with young people. It highlighted that
issues targeted by the National Healthy School Programme (HSP) in the UK such as physical activity and
healthy eating, implemented as part of a wider aim to promote social inclusion, actually reinforced obese
and overweight children’s feelings of vulnerability to bullying and contributed to their social exclusion.
She highlights that future health initiatives within schools should be sensitive to, and tailor programmes
for, vulnerable groups of children such as the obese and overweight. Haines et al (2007) go further
and suggest that such programmes should incorporate strategies that improve children’s body image.
Although some programmes reviewed appear successful at reducing prevalence of overweight and
report significant reductions in BMI, it is unclear whether the overweight and obese children involved felt
marginalised and vulnerable (see Jiang et al, 2007).
4.6.Researchconcerns–implementingandevaluatinginterventions
a.Experimentaldesign
The majority of school-based studies used random assignment experimental designs (Dishman et al,
2004; Salmon et al, 2005; Robinson, 1999; Jiang et al, 2007; Caballero et al, 2003; Luepker et al, 1996;
Manios et al, 1998; 1999; 2002) though some were quasi-experimental (SPARK; Sallis et al, .Kain et al,
2004; Gortmaker et al, 1998; Donnelly, 1996). The process of stratification and randomisation also varied
widely between interventions and there were often methodological limitations. For instance, whilst most
studies using such designs tended to randomise schools, some studies randomised by class (e.g. Flores
(1995); James et al (2004;2007); Ask et al, 2006; Amaro et al, 2006) thus risking contamination between
intervention and control groups. Woolfe & Stockley (2005) in their review of 5 school-based nutrition-
focused interventions give some recommendations for such studies. They suggest that the curriculum

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or programme that the control group are getting should be considered and indeed reported and that
by using different geographical locations for intervention and control schools, contamination could be
avoided.
b.Duration
School-based studies have varied in their length with the majority being implemented across one
academic school year, but no pattern has been determined between length of programme and its success
(Sharma, 2006). Thus there have been several short-term studies lasting less than 6 months that have
shown statistically significant reductions in diastolic blood pressure, increasing physical activity and
reducing tricep skinfolds of intervention participants (Wilson et al, 2005; Harrell et al, 1996; Rodgers et al,
2001; Robinson, 1999) whilst others of longer duration have shown no such positive effects (James et al,
2004; 2007; Simon et al, 2006; Caballero et al, 2003). Additionally, some studies have highlighted positive
changes in children’s food choices, dietary and physical activity behaviours, yet this has not translated
into improvement in anthropometric measurements (Resnicow & Robinson, 1997; Kropski et al, 2008)
due to the short duration of the study. Whilst it is logical to assume that studies must be of long enough
duration to enable an impact to be seen, very little can be concluded as to the optimal length of such
initiatives. Indeed current recommendations that currently are related to the practicalities of the length
of programmes. For instance, Wolfe & Stockley (2005) suggest that duration of the study is important
to consider for interventions into the food environment, as food availability changes across the year, as
do eating patterns. They therefore suggest that baseline and follow-up measures for nutrition-focused
interventions should be done at similar times of the year.
c.Intensity
Programmes vary considerably in terms of their intensity. Manios et al’s (1999) programme exceeded the
40 to 50 hours of annual instruction recommended by Contento et al (1992) and stated the intensity of
their programme as a key factor to its effectiveness. However, Baranowski et al (2002) reporting on their
5 a Day Boy Scout badge reported significant results after only 8 weeks of input. It is unclear what the
optimum intensity of such programmes should be and it is obvious that there are many other factors that
impact on programme effectiveness other than intensity. To be implemented effectively, intensity of such
programmes needs to be considered in the context of the school structure and timetable.
d.Long-termfollow-up
Follow-up has only been carried out in a number of studies and longer-term effects of such programmes
have rarely been conducted. One study that had a 3 year follow-up was the CATCH intervention which
showed that children’s dietary and physical activity related behavioural changes that occurred during
primary school had persisted into early adolescence; however no significant changes were seen in
physiological outcomes such as serum cholesterol (Resnicow et al, 1998; Nader et al, 1999). Other
studies with longer-term follow up include Nicklas et al’s (1998) which reported a 14% increase in daily
fruit and vegetables in high school children but found that this effect had disappeared at 3 years follow-
up. James et al (2004; 2007) reported the significant differences seen at 12 months between groups
for % overweight and obese were no longer evident at 3 years. Whilst these short-term impacts of the
programme on behaviour change are encouraging, it is not surprising given the short-term nature of
many of the programmes reviewed that no significant changes have been reported in some studies for
outcomes such as BMI (Kropski et al, 2008) or that there is no evidence of maintenance of behaviour
change in the longer-term. Perez-Rodrigo & Aranceta (2001) recommend that more long-term studies

Tackling Childhood obesity within schools: A review of
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need conducting to assess which behaviour changes are enduring and which are more transitory. Other
reviewers recommend future programmes should have long term follow-up (Flodmark et al, 2006; Kropski
et al, 2008). The lack of longer-term behaviour change shown in current studies does not mean that
school-based programmes are ineffective or should not be commissioned. It simply gives more evidence
that interventions are required at all ecological levels both inside school and in the wider environment if
positive health behaviours are to become enduring and maintained into adulthood.
e.Outcomemeasures
The diversity in assessment approaches seen in the studies reviewed makes comparison across studies
problematic, resulting in recommendations being difficult. Quantitative measures such as BMI’s and
other anthropometric measures are still considered by reviewers to be the most desirable measures of
intervention effectiveness on reducing childhood obesity (Shaya et al, 2008; Sharma, 2006).
In terms of outcome measures for physical activity interventions, Stone et al (1998) found that most
school-based physical activity interventions measured knowledge, attitudes, physical activity behaviours
and most identified increasing physical fitness as the primary outcome of the study. However, the
use of such outcome measures has raised controversy particularly in regard to whether they cause
embarrassment for the less fit or active children (Rowland, 1995; Corbin et al, 1995; Docherty & Bell,
1990). Cale & Harris (2006) therefore recommend that physical activity interventions should be inclusive
and reflect the target populations’ activity needs, interests and preferences. Their focus should be on
a range of non-competitive and unstructured lifestyle activities and thus outcome measures should be
tailored accordingly. They suggest including behavioural, affective and cognitive outcomes.
A range of methods has been utilised to measure children’s dietary habits but often these have included
food frequency questionnaires, food records or repeated 24 hour dietary recalls (Perez-Rodrigo &
Aranceta, 2001). Researchers have been plagued for years on how to measure accurately an individuals’
food intake (Bingham, 1991; Nelson, 2003; Thompson & Subar, 2001; McPherson et al, 2000). These
arguments will not be elaborated on here; it is sufficient to state that in general there is always the potential
for participants to over-report what they perceive as ‘healthy’ foods and under report less healthy ones
(Wrieden et al, 2003) as people want to be seen eating a healthier diet than they actually are. When
reporting for others such as parents reporting their child’s diet, over-reporting is still present (Reilly et al,
2001). However Woolfe & Stockley (2005) suggest the following: if the study is a single-blind one (where
participants don’t know that the researchers are evaluating dietary behaviour), giving them some tool to
measure food intake will invalidate this. If the aim is to focus on specific foods such as fruit and vegetables,
it might be possible. However, they advise researchers to consider any changes in single food items in the
context of the wider diet. Indeed, most dietar y-focused interventions targeted specific messages such as
increasing fruit and vegetables without considering whether children were compensating for this increase
in school by decreasing their intake when at home. Indeed, whilst Baranowski et al (2002) recommend
researchers to promote increasing fruit and vegetables they suggest fur ther work is required to assess
whether such messages are having a detrimental effect on other areas of the diet such as decreasing milk
intake by increasing water.
Other outcome measures included in studies have been psychosocial such as self efficacy (Neumark-
Sztainer et al, 2003; Salmon et al, 2005; Simon et al, 2006), body image (Neumark-Sztainer et al, 2003;
Sahota et al, 2001) social support (Salmon et al, 2005; Simon et al, 2006) and global self worth (Sahota et
al, 2001).

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When choosing appropriate outcome measures it is important to consider both qualitative and quantitative
dimensions of evaluation, particularly in complex multi-component initiatives. Such programmes have
incorporated a range of methods. For instance, studies utilising lunchtime observations reported significant
increases in fruit and vegetable consumption (Kelder et al, 1995, Minnesota Heart Health; Luepker et al,
1996; Nader et al, 1999, CATCH; Perry et al, 1998, 5 a day Power Plus; Gortmaker et al, 1999, Eat Well
and keep Moving) and observations during PE have reported significant increases in children’s physical
activity (Gortmaker et al, 1999, Planet Health; Gortmaker et al, 1999, Eat Well and Keep Moving; Manios
et al, 1999). As qualitative and quantitative results are treated differently, juxtaposing the two methods
generates insights so creating a bigger picture. The result is ‘investigative strategies that offer evidence to
inform judgements, not techniques that provide guaranteed truth or completeness’ (Hammersley, 2005,
p 12). This is similar to Tones’ (1997) term ‘judicial review’ which he compares to the situation of a jury
making a decision despite there not being 100% proof available.
In addition it is important to consider a combination of self reported and objective measures. Whilst self-
report is really the only feasible way of assessing participants’ and stakeholders’ views, attitudes, beliefs
and knowledge, the way they are implemented can subject the results to bias. For instance, people may
answer questions in a way perceived to be socially acceptable. In order to reduce such bias Baranowski
et al (1999) suggested collecting data on different days, separated by enough time that single personal
events which might affect a participant’s answers, have passed with them being unlikely to remember
their responses from the first data collection. They also suggested that assessment should be made of
which variables are more likely to be enduring and slow to change and which variables might show quicker
changes. Data collection could be organised around this. Diaries kept by participants to record feelings or
beliefs could be converted into variables and data collection could be done outside the group setting of
the programme, perhaps reducing the social approval bias when in the group setting. Individuals could be
interviewed separately to understand more fully how their beliefs and behaviours changed throughout the
intervention. Alternatively, both objective and subjective measures could be utilised. For instance, Salmon
et al (2005) utilised accelerometers and fitness tests such as 20 m shuttle runs as well as self-reported
questionnaires to assess the degree of participants’ physical activity in their ‘Switch Play’ intervention.
f.Processevaluation
A growing number of studies are utilising process evaluation as part of their evaluation measures and
reviewers have been urging researchers for years to incorporate such measures. In the GIMME 5 project
(Davis et al, 2000) the process evaluation included: extent of implementation, fidelity to programme,
reach, use of materials, mediators such as teacher training, curriculum delivery, parental involvement,
participation in family activities, attendance at evening activities, availability and accessibility of healthy
foods at home. Another example was the ‘5 a day power plus’ programme (Perry et al, 1998) where
process evaluation of the changes implemented to the school meals included exploration of service
changes, staff views, industry support and identification of any external factors that had affected
implementation. Process evaluations can also help to clarify which are weaker components or why
performance varies by demographics or declines over time. For instance, in the High 5 programme,
Reynolds et al (2000) used focus groups, classroom observations and checklists to explore factors
affecting attendance and obstacles to dietary change.
Whilst studies begin to incorporate such evaluation, process measures continue to be missing or
incomplete in most school-based studies. Indeed, Baranowski et al (2002) comment that the lack of
process evaluation within studies is what makes comparison difficult because researchers cannot assess
which components were effective or not. With such limited details about intervention protocols and

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course components, replicability is difficult and without such information as could be provided by process
evaluation, previous studies provide little guidance for researchers contemplating future initiatives.
g.Fidelity
It has already been discussed previously that to implement a programme effectively better teacher
training is needed. This is particularly important from a research point of view when exploring which
components of a programme are the most effective. No accurate measure of this can be made unless
all components are implemented in the intended manner and fidelity is checked. Indeed Baranowski et
al (2002) recommend future research considers better methods for training teachers in implementing the
experimental curriculum. In the studies explored and reviews consulted, variable implementation was often
reported (For example Reynolds et al, 2000 – ‘High five’)
h.Theoreticalframework
There is increasing recognition that behaviour-change interventions need to be underpinned with
appropriate psychological theories of behaviour change (Campbell et al, 2000; Michie & Abraham, 2004;
Michie et al, 2008; 2009; Baranowski, 2006). Although rigorous evaluation of processes, impacts and
outcomes is important, if no attempt is made to uncover why behaviour change occurred or did not
occur, full understanding of the process cannot be elicited. Yet the number of studies underpinned with
appropriate behaviour-change theory are limited. The majority choosing a theory chose SCT (e.g. Warren
et al, 2003; Manios et al, Robinson et al, 1999, Caballero et al, 2003; Dishman et al, 2004; Harrison et
al, 2006; Gortmaker et al, 1999). Key theoretical constructs used included social learning, skills building,
role modelling, goal setting and self-evaluation and self-monitoring. However, as Baranowski et al (2002)
state, nothing is known about how children usually utilise these skills and that procedures integrated
into interventions is rather ad hoc. Whilst theory may have been chosen, it was often used to chose
the strategies used rather than understand the behaviour change going on. Indeed, in his review of
international school-based studies targeting obesity prevention, Sharma (2006) stated that the apparent
advantage of having a behavioural theory underpinning an intervention was not evident, making it clear
that the use of theory in interventions is not being properly applied. Underpinning interventions with
appropriate theor y is widely recommended from reviews of school-based studies (Lytle et al, 2002; Lytle &
Achterberg, 1995; Brown & Summerbell, 2008; Summerbell et al, 2005).
4.7.Summary
This review began by advocating a public health approach to childhood obesity prevention. This approach
recognises that preventive strategies need to include universal, strategic and targeted initiatives and that
programmes need to exist at all socio-ecological levels. For children, school is just one environment in
which they can be reached and influenced.
The review of effective interventions found a variety of programme and initiatives with a range of
effectiveness. Of particular note was that school-based programmes have the potential to influence
children’s health behaviours whilst in school but are less effective in influencing these behaviours once
at home. No intervention to date has found an effective means of engaging with families. Additionally,
whilst some interventions targeting single factors such as TV viewing or nutrition education have proved
effective in the short term, there are now more and more multi-component interventions emerging which

Tackling Childhood obesity within schools: A review of
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47
target a range of influences within the school environment such as nutrition education, behaviour change
techniques, food service provision and PE classes both within the curriculum and after school. Such a
whole school approach subscribes to the settings approach which has become popular within health
promotion and which recognises that valuable opportunities exist in such settings to influence health
issues such as obesity through policy measures and education. Some school-based initiatives discussed
have been due to Government policy. For instance, in the UK the National School Meals Programme gives
dietary guidelines for school lunches provided in UK schools.
One issue highlighted clearly in reviews of school-based interventions and reflected in the studies
discussed in this review is the large number of initiatives being developed in the US, UK and other
Westernised countries. Whilst programmes exist that have targeted specific sub-groups within the
population (e.g. African Americans – e.g. Story et al, 2003; American Indians – e.g. Caballero et al, 2003)
and whilst programmes are emerging from countries that have undergone rapid economic transition
in recent years, these tend to be small-scale pilot projects (Doak, 2002) or are plagued by a range of
methodological limitations (Li et al, 2008). However, a large number of these countries undergoing rapid
economic transition have focused on their school lunch provision. For instance, in South Korea the Korean
Food and Drug Administration (KFDA) recently developed a national strategy aimed at improving the
food safety and nutrition, focusing particularly on children (Park, 2008). One of their aims by 2010 is to
designate Green Food Zones around schools where junk food cannot be sold and ensure the quality of
food provided by the school lunch program. In Brazil, the Government recently included in their National
School Meals programme, the requirement that 70% of foods used were minimally processed ones and
in Chile the requirement that more fruit and vegetables are included in school meals has been set (Doak,
2002).
Several of these countries have adopted the ‘Healthy Schools’ initiative which is underpinned by the Health
Promoting Schools philosophy. For instance, as part of the national health promotion campaign, ‘Vida
Chile’, Chile has started up a ‘healthy schools’ programme in more than 1000 schools which includes
a nutritional curriculum, increases the number of hours devoted to physical activity and a community
component devised to include participation from parents and teachers (Doak, 2002; Muzzo et al, 2004).
In South Africa too, the ‘healthy schools’ initiative has included a focus on obesity and nutrition-related
chronic disease prevention (Doak, 2002).
Other ‘economic transition’ countries have recognised the need for obesity prevention initiatives in the
school environment and are in the process of ensuring that policies related to school initiatives and
programmes are being delivered effectively. For instance, in Mexico whilst the Ministry of Education
implemented a nationwide primary school-based programme which included 2 30-50 minute sessions
of PE a week and a nutrition education programme promoting healthy diet, evaluative research showed
that the programme was not being delivered as designed in many schools (Joint U.S.-Mexico Workshop
on Preventing Obesity in Children and Youth of Mexican Origin, 2007; Doak, 2002). It is hoped that
the results of the evaluation will facilitate identification of the elements in the school environment that
provide opportunities for success. Thailand is exploring the effectiveness of school-based strategies,
and evaluative research has been done in regional primary and secondary schools where programmes
targeting physical activity and healthy diet have been developed (Banchonhattakit et al, 2009).

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OverallConclusions
There is no evidence to indicate that the UAE has a worse obesity epidemic than comparable countries.
However, most countries in the same position are taking steps to consider how to tackle this epidemic,
and to involve schools in those attempts. We remind the reader of the point made above - there appears to
be no consensus from reviews as to what components future interventions should include to be effective.
This rather pessimistic view suggests that caution is required, rather than that no action should be taken at
all! The message is that there are some effective school-based ways to address those factors known to be
implicated in the development of obesity, viz. healthy eating and exercise promotion. These interventions
must go beyond merely telling children about eating and exercise, and need to be based on social
cognitive theories and developmental principles; they must also alter the broader school environment such
as the catering arrangements or playground facilities, and must also extend beyond the school walls into
the communities and homes where children live.
Schools alone will not solve the problem of obesity, and interventions within the education sector must
be complemented by broader governmental actions to institute some of the other interventions known
to help, such as promotion of breastfeeding, reform of welfare schemes such that poorer families have
adequate diets, regulation of the food and drinks industries and the advertising associated with them,
encouragement of active lifestyles, and so on. There is a need for schemes which help those already
overweight and obese, including children, whilst promoting approaches which do not stigmatise these
groups. It is also necessary to be mindful that whole-population approaches might not be suitable in a
situation where some children are underweight and/or stunted and where some children are not at risk at
becoming overweight.

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