Environment and policy interventions to prevent obesity in children
Environment and policy interventions to prevent obesity in children
Abstract and Keywords
This chapter presents environmental and policy interventions which have demonstrated an impact on a measure of body weight or been successful in improving eating or physical activity behaviours among children aged 2 to 18. It presents the types of macro- and micro-environmental and policy interventions that have been conducted, what areas seem promising, and where major gaps exist. The chapter discusses various interventions to prevent childhood obesity from around the world, community approaches, and approaches that suggest environmental changes including physics, economic, and political environments. The chapter also puts forward a discussion of interventions that target policy changes such as policy that address laws and regulations as well as formal and informal rules.
The purpose of this chapter is to present environmental and policy interventions which have demonstrated an impact on a measure of body weight or been successful in improving eating or physical activity behaviours among children aged 2 to 18. It is beyond the scope of this chapter to present a systematic review of this topic or to evaluate the quality of evidence presented. The goal is to educate the reader about the types of macro- and micro-environment and policy interventions that have been conducted, what areas seem promising, and where major gaps exist. We discuss various interventions to prevent childhood obesity from around the world, community approaches and approaches that suggest environmental changes including the physical, economic, and political environments. We also present a discussion of interventions that target policy changes such as policy that addresses laws and regulations as well as formal and informal rules. The successful multi-component interventions that are discussed in this chapter represent viable starting points to address childhood obesity prevention.
The precipitous rise in obesity worldwide requires population-based approaches to effectively combat this serious, debilitating, and costly health problem. Children are the priority group for population approaches to obesity because of the difficulties in treating obesity in adults. Thus far, however, interventions to prevent childhood obesity have been minimally successful (Brown & Summerbell, 2009; Doak et al., 2006; Flodmark et al., 2006; Kamath et al., 2008; Sharma, 2006; Summerbell et al., 2005; van Sluijs et al., 2007). Community approaches, especially those that include environmental and policy changes, appear to be warranted (French, 2005; Kirk et al., 2009; Swinburn & Egger, 2002); and they are one of the most frequently proposed strategies for the prevention of childhood obesity (Kirk et al., 2009). Although environmental and policy interventions into childhood obesity are limited, particularly due to a lack of longitudinal research and other methodological limitations, there is a general consensus that addressing environmental factors and policy is critical.
Defining environment and policy
In the health literature, the term environment is defined in many ways, but often refers very broadly to the space surrounding a person and includes elaboration in relation to obesity (Sallis & Owen, 2002; Swinburn et al., 1999). The environment is conceptualized as consisting of two ‘sizes’: the microenvironment that refers to settings that individuals interact with, such as homes (p.322) and schools, and the macro-environment which refers to sectors that influence micro-environments, such as government, education, and the food industry. Swinburn et al. further describe four ‘types’ of environments, including the physical environment which refers to ‘what is available’ (i.e., stores, recreational facilities, information on diet), the economic environment which refers to costs, the political environment which refers to laws, regulations, and formal and informal policies, and the sociocultural environment which refers to attitudes, beliefs, and values (Swinburn et al., 1999).
For intervention approaches, environmental interventions can be conceptualized as interventions that do not require the individual to select himself into the intervention (French & Stables, 2003). Environmental approaches may be more effective than individual-level behaviour change strategies because they do not require a voluntary effort by individual participants (Stokols, 1996). Furthermore, environmental approaches may reach larger audiences (Wechsler et al., 2000). For example, using the school environment to promote physical activity and healthy eating can reach populations that are harder to reach with individual-level strategies (Galbally, 1997), and it can be more sustainable (Swinburn et al., 1999) and cost-effective (Schmid et al., 1995; Swinburn et al., 1999).
Policies may be defined as ‘laws, regulations, formal and informal rules and understandings that are adopted on a collective basis to guide individual and collective behavior’ (Wallack, 1990). It is important to note that the differences between policies and environmental changes are not always clear, as policies can be used to implement environmental change. For example, a community might pass a regulation (policy) that requires new housing developments to have sidewalks, and, as a result, residents of this neighbourhood begin to walk more than they had previously because the sidewalks (environment) connect to destinations such as stores or parks. Thus, a policy created an environmental intervention and a behaviour change.
For this chapter, we have chosen to use the definition of environment put forth by Swinburn et al. because it applies specifically to the problem of obesity and is often used when addressing childhood obesity. We have, however, chosen to narrow our focus to only three of the four ‘types’ of environments, including the physical, economic, and political environments. We will not address the socio-cultural environment because measuring and intervening into this aspect of the environment is difficult and complex (Swinburn et al., 1999). Also, interventions addressing this aspect of the environment are limited and not well evaluated. With regard to the political environment or policy, we have chosen to use a general definition of policy that addresses laws and regulations as well as formal and informal rules.
Interventions to change the food environment
Free fruit and vegetable programme
A number of studies have observed that offering free fruit and vegetable provisions to school children has short-term effectiveness and/or modest results (Bere et al., 2005; Bere et al., 2007; Davis et al., 2009; Fogarty et al., 2007; Ransley et al., 2007; Van Cauwenberghe et al., 2010; Wells & Nelson, 2005). Most of these studies have been conducted in Europe and are part of a national initiative to increase fruit and vegetable consumption (de Sa & Lock, 2008; Van Cauwenberghe et al., 2010). Only one study (Bere et al., 2005) showed a sustained effect on children’s fruit and vegetable intake (Bere et al., 2007). In general, when these programmes end, intake returns to pre-intervention levels. It probably will be necessary to conduct cost-effectiveness studies to assess the potential of these programmes to contribute to improvements in future health status (de Sa & Lock, 2008).
Eating breakfast has been associated with lower obesity levels in children and adolescents (Gleason & Dodd, 2009; Szajewska & Ruszczynski, 2010; Timlin et al., 2008). A limited number of studies have evaluated the impact of breakfast provision on weight status in children and youth. In a pilot study conducted in Norway, one class of 10th grade students was offered a free breakfast for 4 months, whereas a second class served as control (Ask et al., 2006). Healthier dietary profiles and reduced weight gain were observed for students in the intervention group. In a larger, cluster randomized, controlled trial conducted in low-income areas across England, Shemilt and colleagues found mixed results: some positive changes in student behaviour (school attendance, eating fruits and vegetables), but difficulties in implementation (Shemilt et al., 2004).
In addition to breakfast offerings, interventions have been developed to modify the a la carte offerings within schools. Significant changes in ounces of water, sweetened beverages, and regular chips sold, as well as significant reduction in kilocalorie density per item sold were observed in a non-randomized study in six middle schools in three states (Hartstein et al., 2008). In a similar vein, Schwartz and colleagues conducted a quasi-experimental study over 2 years in three middle schools (versus three comparison schools) to assess the impact of implementing snack guidelines for foods sold at school during the school day (cafeteria a la carte, vending, and fundraisers) (Schwartz et al., 2009). Sweetened beverage intake increased in the comparison schools, but decreased in intervention schools during Year Two. Similarly, water and 100% fruit juice increased in intervention schools in Year Two but not in comparison schools. More healthy snacks were consumed by intervention students in the second year of the intervention, whereas comparison schools remained the same. Data suggest that modifications in snack offerings in schools are feasible and result in encouraging changes to children’s snack intake.
Modifying food pricing
French and colleagues conducted two studies to assess the impact of lowered prices of foods with higher nutrition value. The CHIPS study (Changing Individuals’ Purchase of Snacks) investigated price reductions and point-of-purchase promotion on the sale of snacks at 12 secondary schools in Minnesota (French et al., 2001). Prices of low-fat snack foods in vending machines in each of the schools were reduced by 10%, 25%, and 50% and sales in these items increased by 9%, 39%, and 93%, respectively. Where there were 25% and 50% price reductions, low-fat snack sales volume increased significantly. A second study looked at the impact of reducing prices for fresh fruit and vegetables purchased at two high school cafeterias (French et al., 1997). Prices for fresh fruit and baby carrots were reduced by 50%, and fruit sales increased from 14 to 63 items per week. Baby carrot sales doubled from 37 to 77 packets per week. When the sale period ended, sales returned to baseline levels.
Efforts to increase the availability of fresh, local products, especially fruits and vegetables, have led to the establishment of farmer’s markets and community gardens in many neighbourhoods (Twiss et al., 2003; Wakefield et al., 2007). Few studies have attempted to assess the impact of this change to the school environment, but two reviews recently examined the impact of school gardens (Ozer, 2007; Robinson-O'Brien et al., 2009). Most of the studies reviewed were small in size, non-randomized, and had limited outcome measures. In spite of the modest results to date, school gardens may increase fruit and vegetable intake by affecting children’s willingness to (p.324) try new foods and increasing their preferences for fruits and vegetables (Robinson-O'Brien et al., 2009). However, additional studies are needed in this area (Ozer, 2007; Robinson-O'Brien et al., 2009).
Interventions to change the physical activity environment
Additional activity opportunities
Availability and accessibility of opportunities can increase children’s physical activity and energy expenditure, and possibly affect body weight. Most interventions that investigate the benefit of additional activity opportunities have done so in multi-component programmes (see later). However, one area that has been studied separately is activity breaks during academic classes. The Take 10! Program is a series of classroom activities appropriate for use either as a break from class work or as an active reinforcement for class content (e.g., math or language studies) that has resulted in measurable increases in physical activity across three different grades (1st, 3nd, and 5th). Another programme, ‘Energizers’, was tested by Mahar and colleagues (Mahar et al., 2006), who found that students in the intervention group took significantly more in-school steps than control-group students.
Enhanced equipment or physical facilities
Within schools, several environmental interventions have been enacted to improve physical activity among students. A number have focused on redesign of playgrounds, specifically playground marking, and a few have considered the importance of enhanced equipment. In a small study of movable play equipment in one preschool, Hannon and Brown found that children’s physical activity over 5 days increased (over the preceding week) when the children were led through a daily obstacle course with study-provided equipment (Hannon & Brown, 2008). However, it is not known whether these changes resulted from the new equipment or the novel configuration (the obstacle course) that occurred daily. A number of interventions have added colourful markings to elementary school playgrounds, and then assessed changes in children’s physical activity (Cardon et al., 2009; Loucaides et al., 2009; Ridgers et al., 2007; Stratton & Mullan, 2005; Willenberg et al., 2009). Most of these are small studies with short implementation periods. Their positive results suggest that modifications to play areas may enhance children’s activity. However, more work is needed, perhaps in combination with other environmental modifications such as provision of play equipment.
Obtaining access to existing play facilities can be a barrier to children’s activity. Researchers tested the effect of providing a safe play space on physical activity levels of inner-city children (Farley et al., 2007). In one of two matched neighbourhoods, a schoolyard was opened for use, and attendants provided supervision. Play yard use was assessed over 2 years by direct observation. Activity levels in the intervention neighbourhood were 84% higher than in the control neighbourhood, with reported decreases in TV, movie, DVD, and other video use on the weekends. More research is needed to understand the benefits of improved access to facilities along with supervision for active play.
Multi-component interventions at schools
In addition to single environment interventions, multi-component interventions added an environmental component to a larger intervention, although they did not necessarily evaluate the environmental component separately.
Lytle and colleagues conducted a randomized controlled trial (RCT) in 16 Minnesota middle schools to study the effects of an educational and environmental intervention. The TEENS study was designed to increase the availability of fruits, vegetables, and lower fat foods in homes and schools (Lytle et al., 2006). In addition to educational modules and family newsletters, this intervention made changes to the school food environment to increase the number of healthful a la carte and school lunch line options. Results showed that intervention schools offered and sold a higher proportion of healthier foods a la carte; no effects were seen for fruit and vegetables sales as part of the regular lunch meal pattern.
A comprehensive policy intervention conducted in Philadelphia area schools (Foster et al., 2008) included a local community-based food organization and a community task force to implement healthy eating guidelines suggested by the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention, 1996). This randomized control trial was implemented in diverse schools and targeted policy and environment changes to the food environment, along with nutrition education programmes. Although some consideration of physical activity in the schools was included, it was a secondary focus and not prominent in the intervention. After 2 years, BMI-z scores improved, demonstrating that positive changes in obesity can occur in schools with high enrollments of at-risk children by using community planning and implementing school-level policy changes.
Physical activity-only interventions
An example of a multi-component physical activity intervention developed for middle school girls is the Trial of Activity in Adolescent Girls, or TAAG. This large, multi-centre RCT involved 36 middle schools from six different states. In its implementation phase, TAAG focused on modifying physical education and health education to promote physical activity and to encourage community partners to increase activity offerings during and after school. In its maintenance phase, Program Champions were employed to direct the intervention and continue to coordinate community support (Webber et al., 2008). As a result of the Program Champion-directed intervention, girls in intervention schools were more physically active than girls in control schools (about 80 kcal per week).
The Lifestyle Education for Activity Program, or LEAP, successfully used the Program Champion model, along with a school-wide planning team, to implement components of the Coordinated School Health Program (Marx & Wooley, 1998). Components included the physical education and health education programmes, staff wellness programmes, school environment, and community and families activities (Pate et al., 2005; Ward et al., 2006). This programme resulted in higher prevalence of physical activity in girls in the intervention group compared to those in control group; however, there was no effect on BMI.
JUMP-in was a comprehensive, theory-based intervention conducted in Amsterdam that included environmental changes designed to increase physical activity in early adolescent students (Jurg et al., 2006). Along with educational activities conducted during school, additional school sports activities, parent information, and periodic parent–child activities at local sports clubs were provided. JUMP-in increased physical activity participation; intervention children in Grade 6 maintained their pre-intervention activity levels, whereas activity levels of children in the control group decreased.
ICAPS (Intervention Centered on Adolescents’ Physical activity and Sedentary behaviour) was a multi-component intervention implemented in eight middle schools in France (Simon et al., 2004; Simon et al., 2006). The intervention aimed to change knowledge, attitudes, and motivation, (p.326) to increase social support, and to provide environmental, structural, and institutional support for physical activity. Environmental and policy changes included providing new opportunities for physical activity during and after school, and requesting that policy makers provide a supportive environment for physical activity. ICAPS resulted in a significant increase in youth engaged in supervised physical activity outside of physical education, and a signification reduction in time spent engaged in sedentary activities.
Nutrition- and physical activity-related interventions
An early multi-component intervention trial to address diet and physical activity was the CATCH (Child and Adolescent Trial for Cardiovascular Health) trial (Luepker et al., 1996). Along with educational programming and parent education, CATCH included a comprehensive component to improve the nutritional quality of meals provided through the US School Breakfast and Lunch Programs. Although no change in BMI was observed, significant alteration occurred in meals (lower fat and sodium content) following the intervention.
New Zealand’s APPLE intervention was designed to increase physical activity and intake of fruit and vegetables, and reduce the intake of sugary drinks in elementary students in one intervention community with four schools, compared to a comparison community with three schools (Taylor et al., 2008; Taylor et al., 2007). The 2-year intervention used Community Activity Coordinators at each school to increase non-curricular activity at recess, lunchtime, and after school. In addition to educational sessions, other activities included classroom activity breaks, increased availability of sports equipment for free play, increased filtered water, and free fruit. Children in intervention schools had increased physical activity, less sedentary time, and lower BMI- Z scores compared to control schools.
In Belgium, Haerens and colleagues implemented a randomized controlled trial in middle schools that involved environmental changes, personal computer-tailored feedback, and parental involvement (Haerens et al., 2006). Intervention activities included increased activity time (in-class, lunch, after school) and provision of sports equipment to each school for non-instructional use. Schools also were asked to provide fruit and water for free or reduced prices. BMI and BMI z-scores increased less in girls in intervention schools (with parental support) than in the control or intervention-alone group. Also, positive intervention effects were observed for physical activity in boys and girls and for fat intake in girls (Haerens et al., 2006).
Another multi-component RCT intervention that included a significant environmental component was the Middle School Physical Activity and Nutrition Study or M-SPAN. Middle schools in California received new physical activity equipment, provided more teacher supervision and additional activities, and made changes to the school food services (lower-fat vendor items promoted with social marketing). Again, a significant interaction for gender was seen in these results: improvements in BMI and physical activity were observed, but only for boys.
Guidelines for school programmes to promote healthy eating and physical activity have been established by such groups as the US Centers for Disease Control and Prevention (Coordinated School Health Program, 2010) and the World Health Organization (Global School Health Initiative, 2010). These programmes encourage coordination among all facets of the school programme in order to impact child health. Few evaluations of the impact of these all-school approaches on preventing obesity have been conducted. A study from Nova Scotia compared differences in prevalence of overweight and obesity in schools that reported either: no nutrition programme, a nutrition programme, or participation in a coordinating school health programme (Veugelers & Fitzgerald, 2005). Risk of overweight/obesity was significantly less in the schools participating in a coordinated programme, even when controlling for a number of school level factors, including income, education, and geographic area.
(p.327) A similar programme was conducted in British Columbia. Action Schools! BC – Healthy Eating was a policy intervention to change offerings and teacher practices to promote fruit and vegetable consumption (Day et al., 2008; Naylor et al., 2008; Reed et al., 2008). School health teams (called Action Teams) were used to affect policies and practices at the school level across six areas, including school environment, physical education, extra-curricular activities, school spirit, family and community involvement, and classroom activity breaks. The programme was implemented in five schools, and the results compared with matched controls over a 16-month period. Fruit, fruit/vegetable servings, and the number of fruits/vegetables ‘tried’ increased in intervention schools, as did physical fitness. Physical activity (step counts) increased in boys only. The authors note that although many positive changes occurred, implementation was uneven and often challenging and additional studies are needed (Day et al., 2008).
Multi-component neighbourhood or community interventions
Few interventions targeting childcare exist and even fewer addressed the comprehensive aspects of healthy weight environment (Hesketh & Campbell, 2010). One of the few programmes to target childcare is the NAP SACC programme – Nutrition and Physical Activity Self-Assessment for Child Care (Ward et al., 2008). This programme uses staff self-assessment, followed by selection of target areas for change. Although the NAP SACC evaluation study did not measure child behaviour, the intervention resulted in measurable changes in the nutrition and physical activity environments. Although the changes observed in this randomized control trial were modest, NAP SACC has good acceptability by centre staffs and has been found easy to disseminate (Drummond et al., 2009).
Food provisions at local stores may impact what children consume and create increased risks for obesity. In the first study of neighbourhood food stores and children’s dietary intake, Gittelsohn and colleagues implemented a store-level intervention in Hawaii (Gittelsohn et al., 2010). Five food stores in two communities were selected as implementation sites and two others in similar areas served as control sites. The intervention targeted changing to healthier beverages, healthier children’s snacks, healthier condiments (e.g., ‘lite’ mayonnaise), and healthier meals. Stores were also provided point-of-purchase educational displays and promotions. Although parents were the targets of the intervention, as they generally control home food purchases, children significantly increased their Healthy Eating Index scores after the nearly year-long intervention.
Shape-Up Sommerville is an example of an orchestrated community intervention to prevent weight gain in young children in grades 1–3 (Economos et al., 2007). This non-randomized controlled trial was conducted in an urban area and involved three culturally diverse cities from one state. A community participation process was used to address all aspects of the children’s school day, including before school (breakfast programme, active school travel), during school (staff development, food service, curriculum, enhanced recess, wellness policies), afterschool (programmes, school travel), home (parent education, events), and community (advisory council, champions, wellness campaigns, and more). Engagement of multiple environments to make policy changes, coupled with education and promotion, were effective in changing BMI z-scores in the intervention communities (compared with control communities). Albeit challenging, community interventions hold the promise of rich rewards.
Healthy Living Cambridge Kids was a community intervention in Cambridge, Massachusetts, that used Community-based Participatory Research (CBPR) methods (Chomitz et al., 2010). This single group study was conducted over 3 years and was a joint project of a local obesity task force, a health institute, and department of public health. Engaging such community organizations as city officials, school personnel, health professionals, and gardening advocates allowed for activation (p.328) of multiple channels of influence. Results were encouraging: obesity among all race/ethnicity groups declined, although the changes were modest. This approach shows promise for creating sustainable changes in the environment that will affect children’s energy balance.
There is universal agreement that researchers must do more to prevent childhood obesity, but international efforts to date have had limited success. In this chapter, we were limited in our ability to conduct a systematic review of environmental and policy interventions because of the broad scope of the topic and the small number of relevant studies within it. However, from the studies we examined, it appears that study quality (lack of control groups, non-random designs, brief intervention period) in nutrition- and physical activity-targeted interventions has been modest at best. Some of the multi-component studies were RCTs, but these studies included other strategies, such as educational programming and promotions, and the environmental component was not evaluated separately.
Previous reviews have noted the limited numbers of environmental and policy interventions in the literature and suggest more studies are needed. In this chapter, we presented an array of different environmental approaches including improving access to healthy foods and increasing physical activity opportunities. These are important and necessary modifications of environment and/or policy. However, it is through multi-component interventions that these modifications might be most effective. Addressing only one issue, such as how to provide more fruits and vegetables or more healthy snacks, might solve one barrier, but getting children to eat more healthy foods and having an impact on child weight are issues that still need solutions. We presented several examples of multi-component interventions that showed positive effects on children’s weight, diet, and/or physical activity levels. These interventions ranged from decreasing the fat content of school lunch and improving the physical education programme to mobilizing community partners to address obesity prevention of children in neighbourhoods.
Most successful interventions were implemented in school settings, so we can continue to use that common approach. These studies demonstrate that only healthy foods should be provided at schools, and children deserve access to opportunities, equipment, and spaces for activity. Policy interventions that affect environmental changes seem to make these enhancements successful. In the United States, Canada, and Europe, the concept of coordinated school health programmes has been part of a number of successful school-based, multi-component interventions. School planning teams, wellness councils, programme champions, and community outreach are common themes in these successful efforts. Ideally, we would prefer both ‘top down’ and ‘bottom up’ approaches that include committed policy makers and energetic community action teams, but these rarely occur synchronously (Swinburn & de Silva-Sanigorski, 2010).
Indeed, successful interventions for obesity prevention require a combination of approaches – educational, behavioural, and environmental/policy changes along with a change in the culture of how we approach food, physical activity, health, and economics (Huang & Story, 2010). Thus, though the need to prevent obesity in children remains great, the successful multi-component interventions that have been discussed in this chapter represent viable starting points to address obesity prevention. Although we should continue to evaluate individual environmental strategies, we should look for effective strategies that can be integrated into multi-component approaches. Moreover, instead of developing new interventions, we should look to successful, existing intervention models or approaches that can be easily replicated, adapted, or developed further as a starting point.
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