School-based multi-component healthy lifestyle interventions
School-based multi-component healthy lifestyle interventions combine educational, environmental, and behavioral activities that support positive changes for physical activity, dietary, and mental health habits in school settings. Evidence-based interventions focus on modifiable health behaviors that improve a person’s biomarkers (blood sugar, lipids, blood pressure, etc.) and reduce their risk factors for negative health outcomes such as cardiovascular disease1, 2, 3. Interventions are done in schools, led by trained professionals and involve in-person meetings, with opportunities for counseling, coaching, and support. Multi-component healthy lifestyle interventions frequently include nutrition education, aerobic or strength training exercise sessions, training in behavioral techniques, and specific dietary prescriptions4. Experts suggest programs focus on health behavior changes and biomarker outcomes and stop emphasizing weight or body mass index (BMI) measures, which are not accurate measures of health1.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased physical activity
Improved dietary habits
What does the research say about effectiveness?
Experts suggest school-based multi-component healthy lifestyle interventions can improve health outcomes and healthy behaviors among students3, 5, 6, 7, 8. Overall, there is strong evidence that multi-component healthy lifestyle interventions improve health outcomes and healthy behaviors3, 5, 6, 7, 8. Evidence shows that school-based interventions that focus on weight and weight outcomes do not typically lead to long-term improvements in health outcomes for students2, 5, 8, 9, 10, 11, 12, and instead often cause negative outcomes2, 5, 8, 11, 12.
Improving health. School-based healthy lifestyle interventions increase physical activity levels, improve diet quality (e.g. increasing fruit and vegetable intake, decreasing unhealthy food consumption) and improve nutrition knowledge3, 6, 13, 14, 15. Increasing these healthy lifestyle habits improves cardiorespiratory fitness (i.e., how well systems in the body work together to supply oxygen during physical activity) and cardiometabolic health (i.e., heart health and metabolic health, or how well the body processes energy), which reduces conditions associated with increased mortality risks, such as insulin sensitivity, cardiovascular disease, inflammation, and more5, 7, 8, 11, 12. Evidence shows cardiorespiratory fitness and cardiometabolic health have stronger associations with mortality risk than weight and body mass index (BMI)5, 8, 11, 12. Positive changes in modifiable behaviors (e.g., regular physical activity and improved diet quality) consistently predict lower mortality and morbidity and reliably improve cardiometabolic markers across all weight categories1, 5, 8, 11, 16, 17. Compared to weight-loss focused interventions, weight-neutral programs have better physiological (blood pressure, lipids), psychological (self-esteem, depression), and behavioral (diet quality, reduced disordered eating, physical activity) outcomes, as well as lower dropout rates18.
Negative effects from focusing on weight alone. Research has identified components of health that are most important to measure to predict an individual’s risk of mortality, chronic disease, cardiovascular disease, and other leading causes of death and disability. However, weight-focused research and healthcare practice have largely relied solely on weight and BMI as a proxy for health, despite studies consistently showing they are poor predictors of mortality and disease risk5, 12. BMI fails to capture body composition, fitness, biomarkers, or lifestyle factors, and legitimizes blaming and stigmatizing patients higher on the weight spectrum2. Furthermore, intentional weight loss is only inconsistently linked with meaningful health gains; experts suggest it does not meet the evidence standard to inform health policy1, 18. Interventions focused on weight loss appear ineffective for long-term healthy changes and are more likely to lead to weight regain and weight cycling, which are associated with adverse health outcomes, decreases in well-being, increases in unhealthy behaviors, and damage to patients’ relationships with their health and their health care providers2. Weight-focused interventions reinforce the cycle between weight stigma and weight gain18, 19, which is correlated with elevated ambulatory blood pressure, unhealthy weight control and binge eating behaviors, bulimic symptoms, negative body image, low self-esteem, and depression among children and adolescents. Further, interventions focused on weight outcomes ignore the fact that weight is more strongly shaped by genetic and macrosocial factors than by personal choice alone18, 19, 20.
Best practices. The education system plays a powerful role in shaping beliefs about nutrition, weight, and bodies. Schools adopting comprehensive, weight-inclusive health curricula can help educators teach about eating-disorder prevention and weight-based bullying and help prevent such behaviors21. School-based healthy lifestyle interventions are effective when they are delivered by trained nutrition and exercise professionals6, 21. Collaboration with peers, support from principals, state-level policies, professional development and curricular materials are all essential to successful health and nutrition education in schools21. Nutrition education materials included in school-based healthy lifestyle interventions should be tailored to the developmental stage of the students22. School-based healthy lifestyle interventions are more effective with multiple components, especially when they include parent and family engagement efforts23. Interventions that include relevant and culturally adapted components have been shown to be most effective for people of color24.
Evidence suggests diet and activity behaviors adopted in childhood track throughout life and the potential cumulative effects of small but sustainable changes offer long-term benefits for individuals, communities, and populations9, 15. Sustainable health improvement depends on reshaping sociopolitical conditions—access to nutritious food, respectful healthcare, safe environments, social support—rather than pursuing largely futile and potentially harmful weight-loss targets18. This highlights the need to go beyond individual-level behavior change and implement upstream interventions that support individuals and families by changing the environment to make consuming a healthy diet and being physically active easier9, 25.
How could this strategy advance health equity? This strategy is rated potential for mixed impact on disparities: suggested by expert opinion.
The effects of school-based healthy lifestyle interventions on disparities in health outcomes for students higher on the weight spectrum, students of color, and students from families with low incomes are unclear. There are over 100 interconnected factors that influence weight, including macroeconomic drivers, biological factors, food supply and production, weight stigma and discrimination, media, health care, built environment, transport and recreation, technology, early life experiences and education. These factors act differently in different people9. More evidence is needed to understand intervention effects on the health disparities experienced by weight status, income, race/ethnicity, and gender19.
Evidence shows weight-neutral healthy lifestyle interventions are effective at improving physiological health outcomes, as well as mental and physical health behaviors (e.g. self-care practices, therapy, physical activity levels, diet quality) and such interventions have the potential to reduce health disparities2, 18. However, weight-focused interventions have the potential to increase disparities in health outcomes for students higher on the weight spectrum, as this approach ignores the powerful genetic, socioecological, and economic forces—like food access, safe recreation spaces, stress, and socioeconomic status—that limit individuals’ ability to live a healthy lifestyle or control their weight18, 19. By centering weight loss as both possible and necessary for everyone, it fuels anti-fat bias and stigma, creating health disparities and undermining public health and clinical efforts18, 19. Anti-fat bias and stigma is prevalent in health care, schools, social media and other spaces, leading to negative relationships, and decreasing students’ motivations to practice healthy lifestyle behaviors2, 18, 20. Weight stigma goes beyond the classroom, negatively affecting a student’s health, including increasing risks of depression, low self-esteem, poor body image, and more2, 18, 20.
Socioeconomic inequities are associated with increased risk of having a higher weight status in the U.S.9, 28. Families and communities with lower incomes may find it impossible to purchase high-quality nutrient-dense foods such as fresh fruits and vegetables with limited budgets and/or access to such foods. Instead, refined grains and added sugars, fats, and preservatives are generally inexpensive and readily available in lower-income communities2. Furthermore, lower-income neighborhoods have fewer physical activity resources, such as parks, green spaces, bike paths, and recreational facilities when compared to higher income neighborhoods. Crime, traffic, and unsafe playground equipment are also barriers to physical activity in lower-income communities2. Experts suggest that primary prevention efforts that start early in childhood, include parental involvement, and improve dietary quality, increase physical activity levels and reduce sedentary behaviors may be most effective for reducing health inequities by socioeconomic status28.
Students of color are more likely to be higher on the weight spectrum than students who are white19. Many systemic factors influence weight status and the ability to adopt and maintain healthy lifestyle habits, for example, racism, sexism, ableism, and more18. Systemic factors also include income status and residential neighborhood location, since having a low income and living in a neighborhood with fewer physical activity resources, unsafe physical environments, and lack of access to affordable healthy food options greatly increases the likelihood of people being higher on the weight spectrum2. Available evidence that includes international studies suggests school-based multi-component healthy lifestyle interventions are effective at improving diet (both increasing healthy food consumption and decreasing consumption of unhealthy snack foods and sugar-sweetened beverages), increasing physical activity, and decreasing sedentary time (including reducing screen time) among adolescents from ethnic and racial minority backgrounds14, 15, 29.
Women are particularly impacted by weight-focused interventions and weight stigma, with disadvantages for women higher on the weight spectrum appearing in employment, education, leadership, romantic relationships, and the media18. They are more likely to experience weight stigma as children and adolescents, which increases their risks of unhealthy weight control and binge eating behaviors, bulimic symptoms, negative body image, low self-esteem, and depression1, 2. Weight-neutral healthy lifestyle interventions that include clear causal information that emphasizes how hard it is to control weight and adopt a health-focused model that focuses on sustainable modifiable behavioral changes have the potential to help reduce gender disparities in health outcomes19.
What is the relevant historical background?
Negative views of fatness, weight, and body size have existed for several centuries. In the U.S. weight stigma and fatphobia are rooted in racism against people who are Black30. Beginning in the 1700s, colonists who were white used body size and weight as yet another measure to draw distinctions between themselves and the peoples they enslaved and colonized30. This led to the establishment of a cultural ideal of thinness and the use of body size and shape as social and cultural standards to judge people and their status (i.e. enslaved, socioeconomic status, immigrants)31. The rise of eugenics, a form of scientific racism, in the 19th and 20th century co-opted these cultural norms by adapting the Quetelet Index (originally developed in the early 1800s to help study population characteristics based on measurements of a small population of European white men) to establish what an “ideal” and “healthy” height and weight was31. Its proponents claimed that the differences between people who were white and those from other races and ethnicities showed there was a racial propensity to thinness or fatness, and people who were not white were less healthy and physically inferior31.
Health insurance companies, one of the fastest growing industries at the time, chose to incorporate these beliefs in their coverage decision-making by using the index to develop a standardized height and weight table31, effectively placing a white standard on the bodies of people of all races31. This continued even after the medical community directly acknowledged that race is not biological after the devastation of the Holocaust31.
Beginning in the 1950s, these standards also began to be adopted in medicine. They adapted the Quetelet Index as the standard for doctors to use in assessing “healthy weight,” and changed the name to Body Mass Index (BMI)31. By the 1970s, BMI became the norm in medical practice and the research that informed these “universal” standards continued to exclude women, people of color, and people with low incomes, further entrenching racism and discrimination in health care30. In essence, doctors who worked for insurance companies created medical guidelines that were not evidence-based and only served to intensify the tacit whiteness of medical standards in the U.S.31. The values for BMI used to determine what is a “healthy weight” still meant most people, especially women of color, were defined as overweight and thus “unhealthy,” triggering initiatives to “fix” their bodies31. The standards for what qualifies as a healthy BMI have been revised several times, with each iteration leading to more and more people being defined as unhealthy31. These systematic efforts fuel weight stigma and weight-centric messaging that permeate schools, workplaces, healthcare, and media, harming mental health, educational and economic outcomes, and doctor–patient relationships19. For example, experts highlight the correlation between “BMI report cards” some school districts send to families and increases in weight status as promoting weight stigma19.
Inspired by civil rights and social justice movements, community leaders and experts started to push back against these sociopolitical constructs of health and weight that are rooted in racism, sexism, and other discriminatory frameworks30. Over time these movements have led to new frameworks that rely on measures and healthy lifestyle habits that not only are more indicative of health but also help dismantle the various -isms related to weight (i.e. racism, sexism, sizeism, ableism)18.
There are several other contextual factors that influence health in the U.S. Throughout U.S. history, discriminatory housing, lending, and exclusionary zoning policies entrenched racial residential segregation and concentrated poverty32, 33. This systemic disinvestment and exclusion by both government and private entities created and maintains community environments with limited resources, deteriorating infrastructure, hazardous industries and waste disposal sites, and many other factors that lead to poorer health outcomes for people of color and people with low incomes34, 35, 36, 37. Communities shaped by discriminatory policies are often areas that have limited access to healthy and affordable food, formerly known as food deserts38, 39. Individuals who live in these communities face higher food costs, fewer store options, and must travel further to purchase healthy food than those who live in well-resourced communities38. Residents also have increased exposure to high calorie foods that have little nutritional value, which often leads to worse health outcomes39. Many rural areas also lack access to fresh and affordable food, even in areas where farming is an important part of the local economy40. Experts recommend continuing to recognize that a patient’s context likely matters the most for health, such as their food environment, socioeconomic status, medical comorbidities, and social support, as well as practical factors41.
Equity Considerations
- Are schools in your community aware of weight-inclusive practices that can foster trust and engagement in a mutually beneficial relationship centered on health? Are healthcare and public health institutions aware of weight-inclusive practices? Do they have the necessary resources and information to shift their focus from weight-centric care to health-focused care that uses neutral language and emphasizes behaviors over body size? What trainings or resources could help institutions improve their understanding and support teaching and practice?
- What weight-inclusive programs are available in your schools? In neighborhoods with low incomes? Or for racially/ethnically diverse communities? Are they accessible and affordable?
- How can school leaders, community leaders, and public health professionals tailor their communication and efforts to shift their focus from weight-centric to weight-inclusive practices? What efforts can they support to increase access to healthy nutrient-rich foods, opportunities for physical activity, and mental health support and counseling?
Implementation Examples
There are an increasing number of resources available to support shifting from weight-centric approaches to weight-inclusive approaches in programs and policies. Health at Every Size works to support providers so their practice is based on weight inclusivity, health enhancement, respectful care, eating for wellbeing, and life-enhancing movement all to support building healthy habits versus fixating on weight26. Educators have a demonstrated interest in implementing weight-inclusive approaches, however there are few available resources for curricular content, and the lack of state-level policy support challenges their ability to do so21.
Experts highlight the need for increased education for all on obesity’s complex etiology and clear causal information emphasizing low personal controllability, adoption of a health-focused and weight-inclusive care model, as well as mixed-method interventions combining multiple approaches to improve healthy habits19. Additionally, experts highlight the need for public health programs and policies, as well as campaigns, to shift from their focus on weight-centric metrics and language to ones that are weight-inclusive to reduce weight stigma and promote health-enhancing behaviors1.
Social media is another source that can both alleviate and exacerbate weight bias and stigma, in part because of the ability of users to remain anonymous and free of consequences for harmful behavior27. It can be a positive agent of change, allowing movements like Body Positivity, the Fatosphere, and Health at Every Size to create more inclusive space online that counter negative stereotypes27. Experts highlight the need for public policy development supported by public health professionals, parents, educators, and policymakers to minimize the detrimental effects of social media27. For example, enacting legislation that makes weight-based discrimination illegal, like Michigan and Washington have done1, 27. A key intermediate alternative to legislation is industry self-regulation and accountability, including updating community guidelines outlined by social media platforms and training machine learning algorithms to detect potentially discriminatory content27.
Implementation Resources
‡ Resources with a focus on equity.
AFHG-Schools - Alliance for a Healthier Generation (AFHG). Schools.
ASDAH-HAES‡ - The Association for Size Diversity and Health (ASDAH). (2024). Health at Every Size (HAES). Retrieved October 23, 2025.
Talumaa 2022 - Talumaa, B., Brown, A., Batterham, R. L., & Kalea, A. Z. (2022). Effective strategies in ending weight stigma in healthcare. Obesity Reviews, 23(10), e13494.
NYS DOH-EWPH - New York State Department of Health (NYS DOH). Eat well play hard (EWPH).
ChangeLab-Healthy communities toolkit - ChangeLab Solutions. How to create and implement healthy general plans: A toolkit for building healthy, vibrant communities.
ChangeLab-Planning guide - ChangeLab Solutions. A roadmap for healthier general plans: A guide & infographic about the planning process.
CI-WOTN - Community Initiatives (CI). The Weight of the Nation (WOTN).
Footnotes
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1 Hunger 2020 - Hunger, J. M., Smith, J. P., & Tomiyama, A. J. (2020). An evidence‐based rationale for adopting weight‐inclusive health policy. Social Issues and Policy Review, 14(1), 73–107.
2 Tylka 2014 - Tylka, T. L., Annunziato, R. A., Burgard, D., Daníelsdóttir, S., Shuman, E., Davis, C., & Calogero, R. M. (2014). The weight-inclusive versus weight-normative approach to health: Evaluating the evidence for prioritizing well-being over weight loss. Journal of Obesity, 2014, 1–18.
3 USPSTF-O’Connor 2020 - O’Connor, E. A., Evans, C. V., Rushkin, M. C., Redmond, N., & Lin, J. S. (2020). Behavioral counseling to promote a healthy diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA, 324(20), 2076.
4 CG-Obesity - The Guide to Community Preventive Services (The Community Guide). Obesity.
5 Weeldreyer 2025 - Weeldreyer, N. R., De Guzman, J. C., Paterson, C., Allen, J. D., Gaesser, G. A., & Angadi, S. S. (2025). Cardiorespiratory fitness, body mass index and mortality: A systematic review and meta-analysis. British Journal of Sports Medicine, 59(5), 339–346.
6 Nitschke 2022 - Nitschke, E., Gottesman, K., Hamlett, P., Mattar, L., Robinson, J., Tovar, A., & Rozga, M. (2022). Impact of nutrition and physical activity interventions provided by nutrition and exercise practitioners for the adult general population: A systematic review and meta-analysis. Nutrients, 14(9), 1729.
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17 Unick 2013 - Unick, J. L., Beavers, D., Bond, D. S., Clark, J. M., Jakicic, J. M., Kitabchi, A. E., Knowler, W. C., Wadden, T. A., Wagenknecht, L. E., & Wing, R. R. (2013). The long-term effectiveness of a lifestyle intervention in severely obese individuals. The American Journal of Medicine, 126(3), 236-242.e2.
18 Calogero 2019 - Calogero, R. M., Tylka, T. L., Mensinger, J. L., Meadows, A., & Daníelsdóttir, S. (2019). Recognizing the fundamental right to be fat: A weight-inclusive approach to size acceptance and healing from sizeism. Women & Therapy, 42(1–2), 22–44.
19 Talumaa 2022 - Talumaa, B., Brown, A., Batterham, R. L., & Kalea, A. Z. (2022). Effective strategies in ending weight stigma in healthcare. Obesity Reviews, 23(10), e13494.
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