Multi-component school-based obesity prevention interventions

Multi-component school-based obesity prevention interventions involve educational, environmental, and behavioral activities and typically address both physical activity and nutrition before, during, or after school. Multi-component school-based interventions typically include healthy living and nutrition education classes, enhanced physical education and increased physical activity opportunities, school-wide promotion of healthy food options and food environment improvements, capacity building and professional support for teachers and staff, and family education and support. Specific components vary by program (Cochrane-Waters 2011*, AHA-Mozaffarian 2012).

Expected Beneficial Outcomes (Rated)

  • Increased physical activity

  • Improved weight status

  • Improved dietary habits

Other Potential Beneficial Outcomes

  • Reduced obesity rates

Evidence of Effectiveness

There is strong evidence that multi-component school-based obesity prevention programs increase physical activity (Nixon 2012Cochrane-Dobbins 2013*Demetriou 2012*), and improve dietary habits (Kropski 2008Van Cauwenberghe 2012Cawley 2011*). Such programs also improve weight status when implemented with high intensity and for long durations (Bleich 2018*, Shirley 2015*, AHA-Mozaffarian 2012, Khambalia 2012*Cochrane-Waters 2011*Katz 2008*). However, there is significant variability in program design and effect (Brown 2009Harris 2009aCG-Obesity). Additional evidence is needed to confirm long-term effects.

In general, multi-component school-based obesity prevention programs are more successful than single component programs (Shirley 2015*, Cochrane-Waters 2011*Katz 2008*Khambalia 2012*Van Cauwenberghe 2012Dunton 2010*Townsend 2011*). Multi-component school-based obesity prevention programs that include both a nutrition and physical activity focus appear more effective than one-sided programs (Shirley 2015*, De Bourdeaudhuij 2011*). Such programs can also reduce blood pressure more effectively than single-focus interventions (Cai 2014). Specific components of school-based obesity prevention programs may be more effective for some age groups than others (Dunton 2010*).

Multi-component school-based interventions with durations of a year or more, high levels of intensity, and parent and community involvement have the greatest effects on weight-related outcomes (Bleich 2018*, Shirley 2015*, Guerra 2014*). Such interventions may also be more effective among children and adolescents who are overweight or obese (Guerra 2014*). Multi-component school-based obesity prevention programs’ effects on body mass index (BMI) outcomes vary based largely on program duration and intensity. Many programs demonstrate significant positive effects (Bleich 2018*, Murray 2017*, Cochrane-Waters 2011*Kropski 2008Brown 2009), others show no significant effect (Amini 2015, Cochrane-Dobbins 2013*Brown 2009Harris 2009a), and, in rare instances, programs demonstrate negative effects (Demetriou 2012*). The effect on weight outcomes of multi-component interventions that focus on physical activity also depends on the duration and intensity of the intervention (Russ 2015a*, Cai 2014, Sun 2013*). Improvements to the school food environment, implemented as part of multi-component nutrition education interventions, have been shown to reduce or maintain the rate of overweight or obese children (CG-Obesity). In some cases, school-based multi-component interventions appear to work better for girls than boys (Yildirum 2011).

School-based physical activity interventions, as part of an obesity prevention program, can benefit executive functions of children who are overweight or obese (Martin 2018). School-based dietary components of multi-component interventions may also benefit general school achievement for obese children (Martin 2018). Multi-component interventions with a specific focus on self-esteem can improve self-esteem for overweight or obese adolescents; interventions without such a focus improve weight status but not self-esteem (Murray 2017*).

Multi-component school-based interventions can improve weight outcomes for African-American children and youth, especially when programs address both physical activity and nutrition and have a long duration (Robinson 2014). Such interventions appear to be most successful when they are designed as joint parent-youth interventions, include supportive relationships between African-American mentors and youth, emphasize healthy activities that youth enjoy, and are culturally-adapted (Lofton 2016). Targeted multi-component obesity prevention interventions may also benefit Latino children who are overweight or obese (Holub 2014*).

Surveys suggest that obesity prevention programs are not associated with increases in unhealthy weight control behaviors such as fasting. Programs that specifically include the topic of eating disorders in their curricula are associated with a reduction in the percent of students reporting using unhealthy or extreme weight control behaviors (Larson 2017*).

Impact on Disparities

No impact on disparities likely

Implementation Examples

Multi-component school-based obesity prevention programs that include health education classes, enhanced physical education, and promotion of healthy food options are used in all 50 states. Physical Activity and Teenage Health program (Child Trends-PATH 2009); Sports, Play and Active Recreation for Kids program (SPARK); and the Eat Well and Keep Moving program (Eat Well and Keep Moving) are three examples. The 5-2-1-0 childhood obesity prevention program is another example of a multi-component intervention for improving diet, increasing physical activity, and reducing screen time; the program is often implemented in school and community settings and encourages developing daily habits that include 5 servings of fruits and vegetables, 2 hours or less of screen time, 1 hour or more of physical activity, 0 sugary drinks, and increased water consumption. The 5-2-1-0 program started in Maine (MMC-5210), and has expanded to cities and states across the country, including Florida (FL DOH-5210); New Hampshire (FHC-5210); Baton Rouge, LA (MHCI-5210 plus 10); Chesterfield County, VA (COACH-5210 everyday); and Palo Alto, CA (PAMF-5210 resources).

As of 2014, 35 states, Washington DC, and Puerto Rico have legislation that supports school-focused policies for healthy eating and physical activity, including many components of successful multi-component obesity prevention interventions (NCSL Winterfeld 2014a).

Implementation Resources

AFHG-Schools - Alliance for a Healthier Generation (AFHG). Schools.

CDC-Nutrition policies 2010 - Division of Nutrition, Physical Activity, and Obesity (DNPAO). DNPAO state program highlights: Applying nutrition policies in child care, school, and worksite settings. Atlanta: Centers for Disease Control and Prevention (CDC); 2010.

CDC-School-based obesity prevention - National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Division of Adolescent and School Health (DASH). School-based obesity prevention strategies for state policymakers. Atlanta: Centers for Disease Control and Prevention (CDC).

ChangeLab-PTA OPR - ChangeLab Solutions. Model state parent teacher association (PTA) childhood obesity prevention resolution (OPR): A framework for PTAs.

CI-WOTN - Community Initiatives (CI). The Weight of the Nation (WOTN).

Citations - Evidence

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Nixon 2012 - Nixon CA, Moore HJ, Douthwaite W, et al. Identifying effective behavioural models and behaviour change strategies underpinning preschool- and school-based obesity prevention interventions aimed at 4-6-year-olds: A systematic review. Obesity Reviews. 2012;13(Suppl 1):106-17.

Cochrane-Dobbins 2013* - Dobbins M, Husson H, DeCorby K, LaRocca RL. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database of Systematic Reviews. 2013;(2):CD007651.

Demetriou 2012* - Demetriou Y, Höner O. Physical activity interventions in the school setting: A systematic review. Psychology of Sport and Exercise. 2012;13(2):186-96.

Kropski 2008 - Kropski JA, Keckley PH, Jensen GL. School-based obesity prevention programs: An evidence-based review. Obesity. 2008;16(5):1009-18.

Van Cauwenberghe 2012 - Van Cauwenberghe E, Maes L, Spittaels H, et al. Effectiveness of school-based interventions in Europe to promote healthy nutrition in children and adolescents: Systematic review of published and “grey” literature. British Journal of Nutrition. 2010;103(6):781-97.

Cawley 2011* - Cawley J, Cisek-Gillman L, Roberts R, et al. Effect of HealthCorps, a high school peer mentoring program, on youth diet and physical activity. Childhood Obesity. 2011;7(5):364–71.

Bleich 2018* - Bleich SN, Vercammen KA, Zatz LY, et al. Interventions to prevent global childhood overweight and obesity: A systematic review. The Lancet Diabetes & Endocrinology. 2018;6(4):332-346.

Shirley 2015* - Shirley K, Rutfield R, Hall N, et al. Combinations of obesity prevention strategies in US elementary schools: A critical review. The Journal of Primary Prevention. 2015;36(1):1-20.

AHA-Mozaffarian 2012 - Mozaffarian D, Afshin A, Benowitz NL, et al. Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association (AHA). Circulation. 2012;126(12):1514–63.

Khambalia 2012* - Khambalia AZ, Dickinson S, Hardy LL, Gill T, Baur LA. A synthesis of existing systematic reviews and meta-analyses of school-based behavioural interventions for controlling and preventing obesity. Obesity Reviews. 2012;13(3):214-33.

Cochrane-Waters 2011* - Waters E, de Silva-Sanigorski A, Burford BJ, et al. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews. 2011;(12):CD001871.

Katz 2008* - Katz D, O’Connell M, Njike V, Yeh M-C, Nawaz H. Strategies for the prevention and control of obesity in the school setting: Systematic review and meta-analysis. International Journal of Obesity. 2008;32(12):1780-9.

Brown 2009 - Brown T, Summerbell C. Systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity: An update to the obesity guidance produced by the National Institute for Health and Clinical Excellence. Obesity Reviews. 2009;10(1):110-41.

Harris 2009a - Harris KC, Kuramoto LK, Schulzer M, Retallack JE. Effect of school-based physical activity interventions on body mass index in children: A meta-analysis. Canadian Medical Association Journal. 2009;180(7):719–26.

CG-Obesity - The Guide to Community Preventive Services (The Community Guide). Obesity.

Dunton 2010* - Dunton GF, Durand CP, Riggs NR, Pentz MA. School-based obesity-prevention programs. In: Bagchi D, ed. Global perspectives on childhood obesity: Current status, consequences, and prevention. Waltham: Academic Press; 2010:319–31.

Townsend 2011* - Townsend N, Murphy S, Moore L. The more schools do to promote healthy eating, the healthier the dietary choices by students. Journal of Epidemiology & Community Health. 2011;65(10):889–95.

De Bourdeaudhuij 2011* - De Bourdeaudhuij I, Van Cauwenberghe E, Spittaels H, et al. School-based interventions promoting both physical activity and healthy eating in Europe: A systematic review within the HOPE project. Obesity Reviews. 2011;12(3):205-16.

Cai 2014 - Cai L, Wu Y, Wilson RF, et al. Effect of childhood obesity prevention programs on blood pressure: A systematic review and meta-analysis. Circulation. 2014;129(18):1832-1839.

Guerra 2014* - Guerra PH, Nobre MRC, da Silveira JAC, Taddei JAAC. School-based physical activity and nutritional education interventions on body mass index: A meta-analysis of randomised community trials - Project PANE. Preventive Medicine. 2014;61:81-89.

Murray 2017* - Murray M, Dordevic AL, Bonham MP. Systematic review and meta-analysis: The impact of multicomponent weight management interventions on self-esteem in overweight and obese adolescents. Journal of Pediatric Psychology. 2017;42(4):379-394.

Amini 2015 - Amini M, Djazayery A, Majdzadeh R, Taghdisi MH, Jazayeri S. Effect of school-based interventions to control childhood obesity: A review of reviews. International Journal of Preventive Medicine. 2015;6(1):68.

Russ 2015a* - Russ LB, Webster CA, Beets MW, Phillips DS. Systematic review and meta-analysis of multi-component interventions through schools to increase physical activity. Journal of Physical Activity and Health. 2015;12(10):1436-1446.

Sun 2013* - Sun C, Pezic A, Tikellis G, et al. Effects of school-based interventions for direct delivery of physical activity on fitness and cardiometabolic markers in children and adolescents: A systematic review of randomized controlled trials. Obesity Reviews. 2013;14(10):818-838.

Yildirum 2011 - Yildirim M, van Stralen MM, Chinapaw MJM, et al. For whom and under what circumstances do school-based energy balance behavior interventions work? Systematic review on moderators. International Journal of Pediatric Obesity. 2011;6(Suppl 3):e46-e57.

Martin 2018 - Martin A, Booth JN, Laird Y, et al. Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight. Cochrane Database of Systematic Reviews. 2018;(3):CD009728.

Robinson 2014 - Robinson LE, Webster EK, Whitt-Glover MC, Ceaser TG, Alhassan S. Effectiveness of pre-school- and school-based interventions to impact weight-related behaviours in African American children and youth: A literature review. Obesity Reviews. 2014;15(S4):5-25.

Lofton 2016 - Lofton S, Julion WA, McNaughton DB, Bergren MD, Keim KS. A systematic review of literature on culturally adapted obesity prevention interventions for African American youth. The Journal of School Nursing. 2016;32(1):32-46.

Holub 2014* - Holub CK, Lobelo F, Mehta SM, et al. School-wide programs aimed at obesity among Latino youth in the United States: A review of the evidence. Journal of School Health. 2014;84(4):239-246.

Larson 2017* - Larson N, Davey CS, Caspi CE, Kubik MY, Nanney MS. School-based obesity-prevention policies and practices and weight-control behaviors among adolescents. Journal of the Academy of Nutrition and Dietetics. 2017;117(2):204-213.

Citations - Implementation Examples

* Journal subscription may be required for access.

Child Trends-PATH 2009 - Child Trends. Physical activity and teenage health (PATH) program. 2009.

SPARK - Sports, Play and Active Recreation for Kids (SPARK). Countering childhood obesity since 1989.

Eat Well and Keep Moving - Eat Well & Keep Moving. An interdisciplinary curriculum for teaching upper elementary school nutrition and physical activity.

MMC-5210 - Maine Medical Center (MMC), Healthy Maine Partnerships (HMP). 5-2-1-0 Let's go!

FL DOH-5210 - Florida Department of Health (FL DOH), FloridaHealth Lee County. The 5-2-1-0 plan for a healthier active lifestyle.

FHC-5210 - Foundation for Healthy Communities (FHC). 5-2-1-0 Healthy NH.

MHCI-5210 plus 10 - Mayor's Healthy City Initiative (MHCI). Healthy Baton Rouge: 5-2-1-0+10: Numbers for your children's health!

COACH-5210 everyday - Chesterfield County's Coalition for Active Children (COACH). 5-2-1-0 Everyday!

PAMF-5210 resources - Sutter Health Palo Alto Medical Foundation (PAMF). 5-2-1-0 Resources.

NCSL Winterfeld 2014a - Winterfeld A. State actions to reduce and prevent childhood obesity in schools and communities: Summary and analysis of trends in legislation. National Conference of State Legislators (NCSL); 2014.

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