My article published in the magazine of ScHARR (school of health and related research), University of Sheffield.

An Evaluation of School- based Health Promotion Strategies to Reduce Obesity

Obesity:

It is a disorder in which excess body fat has accumulated to an extent that health may be adversely affected.

Obesity is most commonly defined by the clinicians in terms of body mass index (BMI), calculated as follows

Weight in kilograms = BMI

Height in metres²

A desirable BMI is considered to be in region 20-25. Anything above this is defined as overweight and a BMI over 30 is defined as obese.

Facts and Figures:

About 2/3^rd of population of England is overweight or obese. Obesity has grown by almost 400% in the last 25 years and on present trend will soon surpass smoking as the biggest cause of premature loss of life.

Health Problems Associated with Obesity:

Obesity is a major risk factor for diabetes, dyslipidemia, gall bladder diseases and breathlessness. It is a moderate factor for coronary diseases, hypertension, gout, osteoarthritis and to a lesser degree responsible for cancer (of breast, endometrium and colon), reproductive hormone abnormalities, and low back pain etc.

Obesity is also related to psychological and social problems. Rates of anxiety and depression are 3-4 times higher among obese people.

Even job market is anti-obese. Studies show that the obese people are less likely to be hired than the thin people even with the identical qualifications.

Link between Obesity and Mortality:

Obesity significantly increases the risk of mortality at any given age. Evidence suggests that for young adults, in general, risk of mortality for someone with BMI 30 is about 50% higher than that someone with healthy BMI (between 20- 25). The effect of overweight on mortality persists into the ninth decade of life. 8.7% of deaths in the UK result from excess weight, the highest percentage in EU.

 A report has concluded that 23.6% of British children under four are over weight compared to 14.7% ten years earlier.

Causes:

The prime underlying cause is simple, imbalance in energy intake and energy output. Here the main contributors are the modern sedentary life as well as the highly palatable and prepared foods.

Fifth of boys and girls undertake less than 30 minutes physical activity a day mainly because of T.V. viewing and automation.

In mid 1980s, 2/3^rd of children aged between five and ten walked to school and more than 6% of 11-16 years old cycled to school. By late 1990s, this had fallen to just over half of children (5- 10 years) walking to school and less than 2% of pupils (11-16 years) cycling.

British children eat fewer than half the recommended portions of fruits and vegetables a day and majority has intakes of saturated fat, sugar and salt which exceed the maximum adult recommendation.

Why Target Schools?

As the prediction for adult obesity from childhood measures is poor, a population approach should have more effect at the public health than targeting children who are already obese.

Within the UK, estimates of obesity range from 6% in preschool to 17% by age 15.

Current School Based Health Promotion Strategies to Reduce Obesity

To encourage healthy food quite a few steps are being taken.

National Fruit Scheme and Five a day health promotion programme have been introduced in schools.

The children should have sound knowledge about what is meant by healthy food. Hence food technology which also teaches about nutritional and ingredients content is offered in every primary school and in 90% of secondary schools in England.

Vending machines in schools, offering high caloric drinks and fat and starch rich food, have been blamed for unhealthy eating habits. Lately vending machines are being trialled in some schools to sell healthy food.

School meals these days have guidance regarding nutrient recommendations.

Measures to inculcate sports and exercise culture in schools have been introduced ranging from investment by the top most authority to schemes by concerned departments.

National Healthy Schools Standard encourages schools to provide pupils with a minimum of two hours of physical activity. The standard also encourages school travel and healthy eating.

In 2002, Prime Minister announced investment of 4.59 million pounds to deliver a national strategy of physical education, school sports and club links.

Both the department for culture, media and sport as well as the department for education and skills has a target that 75% of school children should undertake two hours of high quality physical education and school sport each week by 2006.

To achieve this, government is developing school sport partnerships which comprise a specialist sports college, eight secondary schools and 45 primary or special schools in an area.

Some 581 million pounds are being invested in England by the New Opportunities Fund with an aim of improving and increasing sports facilities at school.

Overweight and obesity are now so commonplace amongst children that even parents are failing to notice when their own children become overweight and obese! In a survey of 300 British families, 33% of mothers and 57% fathers described their children as ‘normal’ when in fact they were obese. Therefore it has been suggested by the House of Commons report on obesity that all school children are weighed and measured once a year and their BMI results sent to their parents together with, if appropriate, advice on how to modify diet and exercise pattern.

To encourage walking/cycling to schools and make it safer, the department for education and employment and department of environment, transport and regions jointly produced a guideline ‘A safer journey to school’.

This guidance advises local authorities, schools and parents to walk and cycle and also includes measures to calm road traffic, enhance foot paths and cycle lanes.

Foundations Underlying These Strategies

Studies:

Quite a few studies both British as well as from outside support these strategies.

Let us have a look at a few of them.

Evaluation of implementation and effect of the primary school based intervention to reduce risk factors of obesity.

Ten schools in Leeds were selected and children (8-10 years old) were targeted. The programme team included a dietician, community paediatrician, a health promotion specialist, a psychologist, an obesity physician and a nutritional epidemiologist.

The programme designed to take place over one academic year targeted the whole school community including parents, teachers and other staff. The team provided training for teachers and some resources.

Questionnaires were administered to all school staff and parents. The questionnaire asked for views about importance of education on nutrition and physical activity, and whether school should share responsibility with parents. Parents were also asked about changes they would like to see in schools and information they would like to receive.

An overwhelming majority answered questions in affirmative agreeing that schools play a major role in promoting health of children and schools should have a food policy and should also encourage physical activity.

Responses from these questionnaires were used by schools to develop school action plans. The progress was very satisfactory. 89% of points in school action plans were implemented. There were positive changes in class room health education, physical education programme and school food service. Participant children recalled activities in which they had been involved. They also scored higher than those who had not yet received programme in terms of knowledge of healthy eating, physical activity and links between diet and health including obesity.

Discussion:

 This study clearly shows that school is an important site for influencing children in their life style. And it also emphasizes involvement of parents in this “Behaviour Change Model”.

However, an RCT of primary school based intervention to reduce risk factors for obesity also involving same schools in Leeds at the same time didn’t ‘apparently’ yield very encouraging results.

634 children aged 7-11 years were selected. Intervention included teacher training, modification of school meals, and the development of school action plans targeting the curriculum, physical education, tuck shops, and playground activities.
Results: Vegetable consumption by 24 hour recall was higher in children in the intervention group than the control group. Surprisingly, fruit consumption was less in the intervention group.  There was no difference in body mass index, other psychological measures, or dieting behaviour between the groups. There were higher levels of self reported behaviour change and knowledge among children who had received the intervention.

Conclusion:

 Although it was successful in producing changes at school level, the programme had little effect on children's behaviour other than a modest increase in consumption of vegetables. Still, it can’t be termed as a failure as it did bring about a change in ethos of schools and attitudes of children. Agreed, not much change was seen in BMI of children. Perhaps one year is too short a period for effecting reduction in BMI especially in the growing age of children.

Let us also review a pilot school programme aimed at prevention of obesity in children carried out in Oxford.

Children aged 5-7 years were randomly allocated to four groups, three interventions and one control.

Intervention:

 ‘Be Smart’ lasted for four school terms (in 14 months).

It was based on Social Learning Theory and incorporated following elements: Providing opportunity to taste healthy foods and undertake non-competitive physical activity, providing incentives to reinforce messages e.g. verbal praise and small prizes, developing practical skills and thus self-confidence in desired behaviour and working with parents to overcome barriers to desired health behaviour.

The Groups:

Nutrition group: Had concepts clarified about healthy food and then fruits and vegetable promoted.

Physical activity group: Physical activity programme was designed followed by reduction in TV viewing.

Combined nutrition and physical activity group: Received half of nutrition and half of physical activity programme each term.

Control Group:

Results: Nutrition knowledge as well as physical activity in school increased. But no effect on physical activity observed outside school. There was significant increase in consumption of vegetables and fruits. Anthropometric measures did not show much change, apparently due to small duration of study.

Conclusion:

The study demonstrated potential of school as suitable setting for promotion of healthy life in children, through a behavioural change. This study provides all the three Es i.e. empowerment, environment and encouragement. Further improvements can be made e.g. with parents’ involvement and continuing messaging with incorporation of healthy life message in curriculum.

A somewhat similar school study in Singapore with some additional elements proved highly successful in reducing prevalence of obesity both among primary and secondary students. These additional elements included integration of nutrition education into formal school curriculum and provision of water coolers to encourage students to drink plain water. Special attention was paid to overweight students through specific physical education programmes.

The school’s contribution regarding physical activity and healthy food should extend to holidays also. Camps may be conducted during holidays by a school or a number of schools. This exercise has proven to be successful in a study done in Massachusetts, USA.

No health promotion strategy can be termed as comprehensive unless it incorporated essential values.

The current school based strategy provides empowerment to school children as school meals have guidance regarding nutrient requirements which should make children aware of distinction between healthy and unhealthy foods. Likewise food technology is offered as a subject at primary as well as secondary level.

Suggestion has also been made that all school children should be weighed and measured once a year and their BMI results sent to their parents together with, if appropriate, advice on how to modify diet and exercise.

Provision of fruit scheme and five-a-day health promotion scheme should help to reduce inequities by providing equal access to healthy food and physical activity to students from all social groups.

Similarly, Prime Minister’s massive investment plan to deliver a national strategy for physical education, school sport and club links should help children from schools in deprived areas to avail grounds, gymnasiums etc of clubs.

Obese children sometimes feel themselves to be marginalized as they find it difficult to participate in competitive sport. Hence suggestions have been made to include wide range of physical activities so that obese children can also take part in disciplines where they feel comfortable.

Strengths and Limitations of Present Strategy

Consumption of five portions daily of fresh fruit or vegetable definitely appears beneficial though it is difficult to see precisely how this will help tackle obesity, unless it is assumed that consuming more fruits and vegetables will displace calories from other sources.

Food technology subject which teaches about the nutritional content of food is offered in every primary school and in 90% of secondary schools however only about 16% of GCSE students opt for food technology.

School meals have guidance regarding nutrient recommendations.

But there is an appalling difference in placement of nutrient guidelines within Scotland’s standards and England’s guidance. In case of Scotland, nutrient requirements are present in the first section and they also emphasise that their achievement is essential.

While the nutrient requirements in England’s guidelines are not only placed at the end but message is also only advisory.

National Healthy Schools Standard encourages schools to arrange a minimum of two hours of physical activity within and outside the national curriculum.

But there is no method of compelling schools to meet this standard. In addition, obese children frequently opt out of it.

While many schools lack resources to provide this structured activity.

More contribution of parents in this whole exercise: Chairman of Health development agency said that the parents can make a huge impact on rising levels of childhood obesity by changing whole family’s approach to diet and physical activity by avoiding couch potato life styles.

The Role of Broader Environment

Obesity in school going children is an important issue and is affected by local, national and even international decisions and policies.

House of Commons, 2003 report on obesity demands joined up action by no fewer than six government departments.

Department of health: Main responsibility as obesity is a public health issue.

Department of culture, media and sport: For promoting sports and physical activity.

Department for education and skills: To ensure that children get adequate physical education at schools and have access to food at schools.

Department for transport: For making ‘healthy’ transport policies to encourage cycling and walking.

Department of environment, food and rural affairs: For farming and produce of healthy food.

Department of trade and industry: For food manufacturing and retail industry.

Apart from these six, Office of deputy prime minister: Responsible for promoting urban spaces in which people can pursue healthy travel and recreational activities.

Increased incidence of childhood obesity has a lot to do with societal changes seen in last few decades in terms of increasing popularity of high energy dense foods, soft drinks, convenience foods etc. Britain is now consuming highest no of ready meals in Europe.

There is a need for proper public health campaign similar to one aimed at stopping people from smoking. Since the demise of Health Education Authority, no single body has held strategic responsibility for public health education campaigns.

Public health campaign should be directed to highlight nutritional and life style patterns leading to weight gain and also links between obesity and diseases.

People and parents need to know how to identify healthy foods and how to prepare them to check increasing reliance on ready-prepared meals which require minimal cooking skills.

One can’t expect a child to exercise self-control against a stream of socially endorsed stimuli designed to encourage consumption of excess food calories. In food industry’s advertisement campaign, 95% of their products are ones that increase weight.

British children eat fewer than half the recommended portions of fruits and vegetables a day and a vast majority has intakes of saturated fat, sugar and salt which exceed the maximum adult recommendation.

This calls for action on advertising ban of some sort at least during children’s TV slots like some other countries.

Because of absence of legislation, food labelling is often completely absent from foods and if present, they are difficult to interpret.

Then there is wrong and misleading labelling.

Food industry should be committed to improve overall balance of diet including fat and sugar in food and there is an NHS plan in this regard.

Food pricing is a major factor in the choice of food especially for low income families. This calls for increasing price of unhealthy food and lowering price of healthy food. WHO’s draft strategy on diet and physical activity suggested that the member states consider taxes to send health enhancing price signals to consumers.

BMJ claimed that a fat tax could present 1,000 premature deaths from heart diseases only every year in the UK.

It is a complex issue as the industry and trade laws are involved.

Linking the European agricultural policies CAP to work in concert with the public health policy has failed so far but efforts should be made to subsidize healthy food farming.

The super markets must commit to phase out price promotions favouring unhealthy food.

In Scotland, standards on nutrient recommendation bar the provision of fizzy drinks as part of school meal in primary schools. Crisps, as part of a combination meal deal or packed lunch may only be offered twice per week. Contrarily, in England’s guidance on nutrient recommendations, there is nothing of above.

Two hours of physical activity in schools is below the EU average which is three hours (also recommended by the European Heart Network).

Ofsted inspection criteria of school’s performance should be extended to include school’s achievement in encouraging and sustaining physical activity.

As parents’ example is always a good influence on children so parents should adopt physical culture as a part of their routine life. For that, grounds, gymnasia etc should be provided in living areas.

Walking routes and cycling tracks should be improved to be easily and safely connected to schools. More traffic-calming and traffic- restraining measured should be introduced. Every transport minister since 1996 has promised a national walking strategy but failed.

Conclusion

Obesity is a growing menace in UK. Schools provide a fine target for prevention as well as early treatment. Strategy is based on healthy food and increased physical activity. For this, national food fruit scheme and five a day health promotion programme as well as two hours of physical activity schedule has been introduced in the school.

Further measures suggested include the public health campaign and restriction of advertisement of unhealthy food in media.

In schools, vending machines selling unhealthy should be banned (as it has been done in some countries like Singapore) and food technology presently an optional subject must be made compulsory. While carrying out physical activity in schools should be part of the criterion to judge a school’s performance.

Walking/cycling friendly policy is needed. Parents’ involvement is essential.