COY0026

Written evidence submitted by Peymane Adab

Summary

• The Government childhood obesity plan includes several actions related to the role of schools in promoting healthy eating and physical activity.
• Evidence from three major high quality research studies in the UK, evaluating different school programmes targeting diet and physical activity behaviours in children, suggest these programme are not effective in preventing childhood obesity.
• Schools are one of several layers of influence on children’s behaviour. Any programmes offered in schools should therefore be part of a wider set of co-ordinating activities targeting other determinants of behaviour. These include the family, media, food industry and community leisure and food providers.
• Support for further research is essential to ensure that “common sense” obesity prevention activities and programmes are having the desired impact at a reasonable cost.

1. This statement is based on my involvement in completed and ongoing research in childhood obesity prevention over the last 12 years, including one of the largest UK trials of childhood obesity prevention through schools1. 

Background

2. The greatest increase in obesity occurs during childhood, with a doubling of rates during the primary school years. Social and ethnic inequalities in obesity rates also emerge during this period2.
3. Previous evidence suggested that schools may be a key setting for obesity prevention. The Government’s plan for action includes several measures targeting schools. These include support for regular provision of daily physical activity, investment in high quality sport and physical activity programmes and active travel, introduction of a voluntary school healthy rating scheme and improving school food provision.

WAVES study (Effectiveness of a childhood obesity prevention programme delivered through schools, targeting 6 and 7 year olds)

4. The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study, funded by NIHR, evaluated a programme of activities aimed at increasing physical activity and promoting healthier eating habits in children1. This had been developed in conjunction with school staff, parents, children and community members3 and had been shown to be promising in a previous small pilot study4, funded by NPRI.
5. The 12-month programme was skills based and included activities that were promising based on previous research, and which community consultation suggested were feasible to deliver by school staff and acceptable to a wide range of children.  Components included:
• working with schools to incorporate a daily additional 30 minutes of physical activity within the school day,
• termly cooking skills workshops where parents were invited to practice cooking a healthy meal (breakfast, lunch and dinner) with their child in school
• a 6-week programme in conjunction with a local football club (Aston Villa). This included two visits to the club where children participated in interactive healthy eating and physical activity programmes inspired by sporting heroes, and weekly “challenges” where they pledged to make a healthy lifestyle change
• providing parents with information about local family physical activity opportunities

6. We recruited around 1500 children (aged 5-6 years) of diverse social and ethnic backgrounds, from 54 West Midlands schools. We measured their height, weight wellbeing, diet and physical activity levels at the start and then again after 15 and 30 months. Schools were randomly assigned to either deliver the WAVES programme or to continue their usual activities. We looked at how schools delivered the programme and interviewed those involved to learn about their experiences.

Key findings:

• After 15 and 30 months children generally gained more excess weight, and there was no significant difference in weight status or other measures in children who were in the schools with or without the programme.
• This finding was the same in children from all social and ethnic backgrounds, and did not differ based on the child’s initial weight status.
• There were some schools where children did not gain as much excess weight as others, but there were no consistent patterns to confidently relate this to the programme.
• Interviews with parents, teachers and children in the schools that had received the programme suggested they enjoyed it and some reported changes to their behaviour5,6.
• Schools struggled to deliver the programme fully, particularly the physical activity component, due to academic and time pressures and lack of local structural and national policy support.
• Teachers and parents highlighted the importance of influences from the family, wider community, peers, the media and food industry on children’s behaviour. They also discussed the need for activities outside of school to maintain healthy behaviours and sustain these for longer.

Interpretation

7. There are several reasons why this programme which was rigorously developed and had been shown to be promising in earlier studies was not successful in preventing excess weight gain.
• The programme may have lacked intensity. However, even within a supportive study setting schools struggled to deliver, suggesting that more intense programmes are unlikely to be successful without extensive resources and structural support.
• The type of programme or focus may not have been the most ideal. This is discussed below within the context of other research.
• Other layers of influence outweigh school efforts in determining children’s behaviour, suggesting that school programmes need to be delivered within a wider system context. This was an overwhelming message from the interviews we conducted with teachers and parents in relation to the study.
• We may have missed a small important effect because of technical aspects related to interpreting any research study. This can be considered within context of other studies.

Findings in context:

8. At least two other recent large, well conducted school based studies targeting diet and physical activity in children in the UK have had similar findings. One evaluated a curricular educational programme in primary schools7, which had been shown to be promising in preventing obesity in the US, whilst the other assessed an interactive healthy behaviour change programme based on a drama framework, with support from school staff and families8.  Although most schools were able to deliver these programmes well, neither study showed any evidence of preventing excess weight gain in children.
9. Whilst UK studies have not been successful, this may not apply to other settings. We are currently evaluating a programme developed in a similar way to the WAVES study in Chinese schools9. Early unpublished findings suggest that this programme has been successful in preventing excess weight gain in children. This may be because China is at an earlier stage of the obesity epidemic, or because of differences in structural and local government support for such programmes compared to the UK setting.
10. Ongoing research is evaluating other school based programmes which may influence behaviour through other pathways. There is much interest in the UK around the Daily Mile (incorporation of a daily 15-minute outdoors exercise programme for all children), which is also mentioned in the Government’s plan for action. Whilst the WAVES study included a similar component, focus on a simple single behaviour and normalising this through the whole school approach may be effective. Among other groups, we are currently evaluating the effects of the Daily Mile10.
11. Other research includes evaluation of alteration of school architecture or school policies related to diet or physical activity. However these studies will be more difficult to interpret as any benefits are unlikely to be directly attributed to the programmes.

Implications:

12. There is consistent evidence from UK studies that although subgroups of children may have some benefits, school delivered diet and physical activity programmes are unlikely to prevent childhood obesity.
13. Such programmes are important for delivery of knowledge and skills to support healthy lifestyles and to support school efforts for wider education. However, to impact on obesity, it is likely that we need structural and policy support and for programmes to be embedded within a wider systems approach.
14. Support for further research is needed to evaluate other programmes and activities to ensure seemingly good ideas do indeed have measureable effects on obesity prevention at a reasonable cost.

April 2018

References:

1)      Effectiveness of a childhood obesity prevention programme delivered through schools, targeting 6 and 7 year olds: cluster randomised controlled trial (WAVES study). Adab P, Pallan MJ, Lancashire ER, Hemming K, Frew E, Cheng KK et al. BMJ 2018;360:k211

2)      Are school physical activity characteristics associated with weight status in primary school children? A multilevel cross-sectional analysis of routine surveillance data. M Pallan, P Adab, A Sitch, P Aveyard. Arch. Dis. Child. 2014; 99: 135 - 141. [Table 1]

3)      Development of a childhood obesity prevention programme with a focus on UK South Asian communities M Pallan, J Parry, K K Cheng, Adab P. Preventive Medicine, 2013 DOI:10.1016/j.ypmed.2013.08.025

4)      Preventing childhood obesity, phase II feasibility study focusing on South Asians: BEACHeS. Adab P, Pallan M, Cade J, Ekelund U, Barrett T, Daley A, Deeks J, Duda J, Gill P, Parry J, Bhopal R, Cheng KK. BMJ Open , vol 4, no. 4, e004579., 10.1136/bmjopen-2013-004579 2014.

5)      Teacher experiences of delivering an obesity prevention programme (The WAVES study intervention) in a primary school setting. Griffin TL, Clarke JL, Lancashire ER,  Pallan MJ,  Passmore S,  Adab P. Health Education Journal, Nov 2014; 10.1177/0017896914556907

6)      Parent and child perceptions of school-based obesity prevention in England: a qualitative study. Clarke J, Griffin TL,  Lancashire E, Adab P*, Parry JM, Pallan M. BMC Public Health, 2015; 15: 1224. doi:  10.1186/s12889-015-2567-7

7)      Effect of intervention aimed at increasing physical activity, reducing sedentary behaviour, and increasing fruit and vegetable consumption in children: active for Life Year 5 (AFLY5) school based cluster randomised controlled trial. RR Kipping, LD Howe, R Jago,  et al. BMJ, 348 (2014), p. g3256

8)      Effectiveness of the Healthy Lifestyles Programme (HeLP) to prevent obesity in UK primary-school children: a cluster randomised controlled trial. J Lloyd, S Creanor, S Logan et al. Lancet Child Adolesc Health 2018;2(1):35-45 http://dx.doi.org/10.1016/S2352-4642(17)30151-7

9)      Cluster-randomised controlled trial to assess the effectiveness and cost-effectiveness of an obesity prevention programme for Chinese primary school-aged children: the CHIRPY DRAGON study protocol. Li Bai, Liu WJ, Adab P*, Pallan MJ, Hemming K, Frew E, Lin R, Martin J, Liu W, Cheng KK. BMJ Open 2017;7:e018415. doi: 10.1136/bmjopen-2017-018415

10)  A cluster randomised controlled trial evaluating the effectiveness and cost-effectiveness of the daily mile on childhood obesity and wellbeing; the Birmingham daily mile protocol. Breheny K, Adab P, Passmore S, Martin J, Lancashire ER, Hemming K, Frew E. BMC Public Health. 2018;18(1):126. doi: 10.1186/s12889-017-5019-8

Other references:

• Obesity prevention in English primary schools: headteacher perspectives. Clarke J, Pallan M, Lancashire E, Adab P. Health Promotion International 2015. DOI:10.1093/heapro/dav113
• The views of stakeholders on the role of the primary school in preventing childhood obesity: a qualitative systematic review. J Clarke, B Fletcher, E Lancashire, M Pallan, Adab P. Obesity Reviews DOI:10.1111/obr.12058