Previously in this series of articles we discussed key messages for the primary prevention of childhood obesity, and how the age, gender and ethnicity of the target children affect outcome. Now we examine the influence of the setting on programme success.
Different settings such as the home, school, clubs etc. all have their own defined structures and provide accessible channels and mechanisms for reaching specific populations. However people do not live in just one setting, their lives span many areas and so interventions involving more than one setting are likely to be more effective than those that focus on only one.1
The school-based approach
The vast majority of obesity prevention studies aimed specifically at children have been based in schools. The benefits of using the school setting are numerous:
• It reaches the majority of children in a population
• Children spend a considerable amount of time at school
• It is possible to incorporate health and lifestyle education into an existing curriculum
• It is an opportunity to offer a health supporting environment by providing healthy food choices and improved access to sports and other active pastimes
• The school can act as a hub for community activities and involvement
Although some successful school-based programmes have confined themselves solely to the school environment, for example Dwyer et al focused on incorporating extra fitness training during lesson time, most have also aimed to influence health behaviour such as eating habits and leisure activities, out of school hours.2 Approximately half the studies have done this purely by educating the children at school 3,4 and leaving it up to the children to act on this knowledge at home and at play, while the other half have actively involved parents 5,6 and/or engaged the wider community in some way.7
Home and Family
There is currently little evidence supporting the importance of the family and home environment in obesity prevention programmes 1,8 but this is mainly because parental involvement differs widely from one study to the next and is difficult to compare. However there is evidence that using parents as agents of change is more effective in managing childhood overweight than a child-only approach.9 The extensive Pathways study 10 with American Indian children reported that ‘involving the family more’ was one of the main lessons learned, and that successful child obesity prevention programmes will need to address environmental and socioeconomic factors that go beyond the school setting. Expert reviews recommend that future interventions need to address the psychological and environmental influences of the home through the education and active involvement of parents.1,8 In particular, recent studies show that watching TV may influence the risk that children have of developing metabolic diseases and cardiovascular diseases in later life, independent of their level of activity.11 Thus, some experts highlight the necessity of targeting excess TV viewing in parallel with encouraging physical activity : new strategies are required in this field, in which parents may have an important role to play.12
Involving the whole community
The development of environments conducive to increasing activity levels and encouraging healthy eating is also vital. Environmental strategies need to build community ownership and commitment by engaging local stakeholders. This way it is possible to incorporate public values and needs, build trust and co-operation, reduce conflict and enhance the quality of decisions. Two small towns in Northern France, Fleurbaix and Laventie, attempted this whole community approach and undertook health coaching for 3,000 of their population, adults and children.13 Following an interview, personal advice relating to diet and activity (also smoking for the adults) was given. Feedback on their progress towards weight, blood pressure and other health goals was given in ‘personal health passports’. The whole community accepted this programme and this was achieved by involving community leaders and organisations at all levels. The success of this study, in terms of weight and other health parameters, is not yet known.
In summary
Based on current evidence, schools provide a good setting for the primary prevention of child obesity.1,8 The lack of evidence relating to the home as a setting for obesity prevention is largely due to problems with access but parents and caregivers cannot be ignored as an important resource for helping children change eating, exercise and TV watching habits. Similarly few studies have been specifically set in the community but programmes where community support and commitment have been achieved like the French ICAPS (Intervention centred on adolescents’ physical activity and sedentary behaviour) 7 and Fleurbaix/Laventie 13 studies are extremely promising. School-based studies which actively encourage parental involvement and seek out community support would appear to be the way forward.
References
1. Flynn MAT (2006) Reducing obesity and related chronic disease risk in children and youth: a syntheses of evidence with best practice recommendations. Obesity Reviews 7 (suppl 1): 7-66
2. Dwyer T et al. (1983) An investigation of the effects of daily physical activity on the health of primary school students in South Australia. International Journal of Epidemiology 12: 308-313
3. Gortmaker SL et al. (1999) Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Archives of Pediatric Adolescent Medicine 153:409-418
4. James J et al. (2004) Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. British Medical Journal 328: 1237
5. Manios Y et al. (1999) Evaluation of a health and nutrition education program in primary school children in Crete over a three-year period. Preventative Medicine 28:149-159
6. Webber LS et al. (1996) Cardiovascular risk factors among children after a 2_ year intervention – the Catch study. Preventative Medicine 25:432-441
7. Simon C et al. (2004) Intervention centred on adolescents’ physical activity and sedentary behaviour (ICAPS): concept and 6-month results. International Journal of Obesity 28( Suppl 3): S96- 8)
8. Doak CM, Visscher TLS, Renders CM & Siedell JC (2006) The prevention of overweight and obesity in children and adolescents: a review of interventions and programmes. Obesity Reviews 7: 111-136
9. Golan M et al. (1998) Role of behaviour modification in the treatment of childhood obesity with the parents as the exclusive agents of change. International Journal of Obesity and Related Metabolic Disorders 22:1217-1224
10. Caballero B et al (2003) Pathways: a school-based randomised controlled trial for the prevention of obesity in American Indian schoolchildren The American Journal of Clinical Nutrition 78:1030-1038
11. Ekelund U, Brage S, Froberg K, Harro M, Anderssen SA, et al. (2006) TV viewing and physical activity are independently associated with metabolic risk in children: The European youth heart study. PLoS Med 3(12): e488.
FOOD TODAY 03/2007
.jpg)