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NIHR Signal A school-based lifestyle intervention didn’t help children avoid unhealthy weight gain

Published on 13 February 2018

doi: 10.3310/signal-000553

The Healthy Lifestyle Programme delivered to 9-10-year-old school children did not reduce their weight over the course of two years. Around a third remained overweight or obese, the same as in schools that followed the standard syllabus.

This trial, funded by the NIHR, assigned schools across Devon to follow a lifestyle programme in Year five. The comprehensive curriculum included drama and activity workshops, personal goal setting and parental involvement.

Children made better food choices, but this did not affect weight outcomes. It was almost certain the programme wouldn’t give value for money.

Programmes addressing the wider school environment or delivered at the community or population level may have greater scope for preventing obesity.

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Why was this study needed?

The Health Survey for England 2016 showed that 28% of children aged 2-15 are overweight or obese. Less than a quarter achieve recommended physical activity levels. Obesity-related illness costs the NHS around £6 billion each year, with £350 million in social care expenditure.

Child obesity is influenced by many factors including diet, exercise, family and socioeconomic background. Obese children are more likely to become obese adults and develop cardiovascular and metabolic problems like diabetes. Children from areas of socioeconomic deprivation are at highest risk.

The school environment seems the ideal setting for obesity prevention. It provides the organisational and social structure with which to educate a large number of children from across the socioeconomic spectrum. Extensive trials of school-based interventions have been conducted to date, which varies considerably in their delivery format and effects on weight and behaviour change. Furthermore, the majority come from the US.

The Healthy Lifestyle Programme (HeLP) took 10 years to develop an intervention that could be feasible and acceptable to schools, children and families and address some of the shortcomings of previous research. Learning from the previous research, these researchers wanted to pragmatically test the intervention in a large number of schools.

What did this study do?

This cluster randomised controlled trial allocated 32 primary schools in Devon to follow HeLP or the standard school syllabus. HeLP targeted children aged 9-10 years and was conducted in four phases, starting in the spring term of Year five.

Phase one aimed to create a “supportive context” establishing relationships and raising awareness of healthy lifestyles in a positive way. Phase two and three in the summer term involved an intensive healthy lifestyles week followed by personal goal setting with parental support. Final phase four in the autumn reinforced the messages learnt. 

The delivery format varied from assemblies to activity workshops and drama groups. Sessions were provided by HeLP coordinators with assistance from teachers and other personnel (e.g. actors and sportspersons).

A total of 1,324 children participated, and 94% had a follow-up for two years.

What did it find?

  • HeLP had no effect on the main outcome of body mass index (BMI) at 24 months (mean difference [MD] between groups -0.02 kg/m2, 95% confidence interval [CI] -0.09 to +0.05).
  • Neither was there any effect on body measures of waist circumference or percentage body fat at 18 to 24 months, or the proportion who were overweight or obese (31% of the intervention group vs 27% of controls).
  • There was no effect on reported levels of physical activity, though children who received HeLP consumed fewer energy-dense snacks (MD -0.47, 95% CI -0.84 to -0.11) and “unhealthy” foods (MD -0.64, 95% CI -1.17 to -0.11) on weekdays. There was no difference on weekends.
  • Analysis of the child-completed My Lifestyle Questionnaire indicated that improved knowledge, confidence and motivation, and family approval might have been behind these dietary changes.
  • The intervention was estimated to cost £214 per child. This was mainly attributed to costs of the various personnel, their training and travel. With no weight-related effects, nor reduction in obesity-related illness (such as diabetes or cardiovascular disease), it seemed clear the programme would not be cost-effective.

What does current guidance say on this issue?

NICE has public health guidance on planning and commissioning lifestyle weight management services for overweight and obese young people. Programmes should focus on core components of diet and health eating, increasing physical activity and decreasing sedentary time and behaviour change of the person and their close family. A tailored plan is advised to meet needs of the individual. Multidisciplinary team input may include such things as motivational techniques and positive parenting skills training.

NICE recommends that school nurses and those involved in delivering the National Child Measurement Programme (BMI is measured in Reception and Year six) raise awareness of lifestyle weight management.

What are the implications?

This was a carefully designed and implemented real-life test of the programme. Children completed the programme in sufficient numbers to detect a meaningful difference in outcomes if one existed. The results seem clear – it does not work.

That is not to say that other obesity prevention interventions can’t work or aren’t needed. HeLP targeted a single school year. The schools were representative of the average sociodemographic spread across England but did not have the same ethnic diversity. 

Public health approaches that target the wider environment, the community, workplaces, and older children, may be more beneficial. The researchers themselves suggest that children of this age have limited ability to affect their diet and levels of physical activity and interventions targeting older children or families might have better success.

Citation and Funding

Wyatt K, Lloyd J, Creanor S, et al. Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost-effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children. Public Health Res. 2018;6(1).

This project was funded by the National Institute for Health Research Public Health Research Programme (project number 10/3010/01).

Bibliography

NHS Digital. Health Survey for England. London: NHS Digital; 2016.

NICE. Weight management: lifestyle services for overweight or obese children and young people. PH47. London: National Institute for Health and Care Excellence; updated March 2017.

Merton Council. Tackling Childhood Obesity Together. Annual Report of the Director of Public Health 2016-17. Merton: Merton Council; 2016-17.

Why was this study needed?

The Health Survey for England 2016 showed that 28% of children aged 2-15 are overweight or obese. Less than a quarter achieve recommended physical activity levels. Obesity-related illness costs the NHS around £6 billion each year, with £350 million in social care expenditure.

Child obesity is influenced by many factors including diet, exercise, family and socioeconomic background. Obese children are more likely to become obese adults and develop cardiovascular and metabolic problems like diabetes. Children from areas of socioeconomic deprivation are at highest risk.

The school environment seems the ideal setting for obesity prevention. It provides the organisational and social structure with which to educate a large number of children from across the socioeconomic spectrum. Extensive trials of school-based interventions have been conducted to date, which varies considerably in their delivery format and effects on weight and behaviour change. Furthermore, the majority come from the US.

The Healthy Lifestyle Programme (HeLP) took 10 years to develop an intervention that could be feasible and acceptable to schools, children and families and address some of the shortcomings of previous research. Learning from the previous research, these researchers wanted to pragmatically test the intervention in a large number of schools.

What did this study do?

This cluster randomised controlled trial allocated 32 primary schools in Devon to follow HeLP or the standard school syllabus. HeLP targeted children aged 9-10 years and was conducted in four phases, starting in the spring term of Year five.

Phase one aimed to create a “supportive context” establishing relationships and raising awareness of healthy lifestyles in a positive way. Phase two and three in the summer term involved an intensive healthy lifestyles week followed by personal goal setting with parental support. Final phase four in the autumn reinforced the messages learnt. 

The delivery format varied from assemblies to activity workshops and drama groups. Sessions were provided by HeLP coordinators with assistance from teachers and other personnel (e.g. actors and sportspersons).

A total of 1,324 children participated, and 94% had a follow-up for two years.

What did it find?

  • HeLP had no effect on the main outcome of body mass index (BMI) at 24 months (mean difference [MD] between groups -0.02 kg/m2, 95% confidence interval [CI] -0.09 to +0.05).
  • Neither was there any effect on body measures of waist circumference or percentage body fat at 18 to 24 months, or the proportion who were overweight or obese (31% of the intervention group vs 27% of controls).
  • There was no effect on reported levels of physical activity, though children who received HeLP consumed fewer energy-dense snacks (MD -0.47, 95% CI -0.84 to -0.11) and “unhealthy” foods (MD -0.64, 95% CI -1.17 to -0.11) on weekdays. There was no difference on weekends.
  • Analysis of the child-completed My Lifestyle Questionnaire indicated that improved knowledge, confidence and motivation, and family approval might have been behind these dietary changes.
  • The intervention was estimated to cost £214 per child. This was mainly attributed to costs of the various personnel, their training and travel. With no weight-related effects, nor reduction in obesity-related illness (such as diabetes or cardiovascular disease), it seemed clear the programme would not be cost-effective.

What does current guidance say on this issue?

NICE has public health guidance on planning and commissioning lifestyle weight management services for overweight and obese young people. Programmes should focus on core components of diet and health eating, increasing physical activity and decreasing sedentary time and behaviour change of the person and their close family. A tailored plan is advised to meet needs of the individual. Multidisciplinary team input may include such things as motivational techniques and positive parenting skills training.

NICE recommends that school nurses and those involved in delivering the National Child Measurement Programme (BMI is measured in Reception and Year six) raise awareness of lifestyle weight management.

What are the implications?

This was a carefully designed and implemented real-life test of the programme. Children completed the programme in sufficient numbers to detect a meaningful difference in outcomes if one existed. The results seem clear – it does not work.

That is not to say that other obesity prevention interventions can’t work or aren’t needed. HeLP targeted a single school year. The schools were representative of the average sociodemographic spread across England but did not have the same ethnic diversity. 

Public health approaches that target the wider environment, the community, workplaces, and older children, may be more beneficial. The researchers themselves suggest that children of this age have limited ability to affect their diet and levels of physical activity and interventions targeting older children or families might have better success.

Citation and Funding

Wyatt K, Lloyd J, Creanor S, et al. Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost-effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children. Public Health Res. 2018;6(1).

This project was funded by the National Institute for Health Research Public Health Research Programme (project number 10/3010/01).

Bibliography

NHS Digital. Health Survey for England. London: NHS Digital; 2016.

NICE. Weight management: lifestyle services for overweight or obese children and young people. PH47. London: National Institute for Health and Care Excellence; updated March 2017.

Merton Council. Tackling Childhood Obesity Together. Annual Report of the Director of Public Health 2016-17. Merton: Merton Council; 2016-17.

Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children

Published on 19 January 2018

Wyatt K, Lloyd J, Creanor S, Green C, Dean S G, Hillsdon M, Abraham C, Tomlinson R, Pearson V, Taylor R S, Ryan E, Streeter A, McHugh C, Hurst A, Price L, Crathorne L, Krägeloh C, Siegert R & Logan S.

Public Health Research Volume 6 Issue 1 , 2018

Background Approximately one-third of children in England leave primary school overweight or obese. There is little evidence of effective obesity prevention programmes for children in this age group. Objective To determine the effectiveness and cost-effectiveness of a school-based healthy lifestyles programme in preventing obesity in children aged 9–10 years. Design A cluster randomised controlled trial with an economic and process evaluation. Setting Thirty-two primary schools in south-west England. Participants Children in Year 5 (aged 9–10 years) at recruitment and in Year 7 (aged 11–12 years) at 24 months’ post-baseline follow-up. Intervention The Healthy Lifestyles Programme (HeLP) ran during the spring and summer terms of Year 5 into the autumn term of Year 6 and included four phases: (1) building a receptive environment, (2) a drama-based healthy lifestyles week, (3) one-to-one goal setting and (4) reinforcement activities. Main outcome measures The primary outcome measure was body mass index (BMI) standard deviation score (SDS) at 24 months post baseline measures (12 months post intervention). The secondary outcomes comprised waist circumference SDS, percentage body fat SDS, proportion of children overweight and obese at 18 and 24 months, accelerometer-assessed physical activity and food intake at 18 months, and cost-effectiveness. Results We recruited 32 schools and 1324 children. We had a rate of 94% follow-up for the primary outcome. No difference in BMI SDS was found at 24 months [mean difference –0.02, 95% confidence interval (CI) –0.09 to 0.05] or at 18 months (mean difference –0.02, 95% CI –0.08 to 0.05) between children in the intervention schools and children in the control schools. No difference was found between the intervention and control groups in waist circumference SDS, percentage body fat SDS or physical activity levels. Self-reported dietary behaviours showed that, at 18 months, children in the intervention schools consumed fewer energy-dense snacks and had fewer negative food markers than children in the control schools. The intervention effect on negative food markers was fully mediated by ‘knowledge’ and three composite variables: ‘confidence and motivation’, ‘family approval/behaviours and child attitudes’ and ‘behaviours and strategies’. The intervention effect on energy-dense snacks was partially mediated by ‘knowledge’ and the same composite variables apart from ‘behaviours and strategies’. The cost of implementing the intervention was approximately £210 per child. The intervention was not cost-effective compared with control. The programme was delivered with high fidelity, and it engaged children, schools and families across the socioeconomic spectrum. Limitations The rate of response to the parent questionnaire in the process evaluation was low. Although the schools in the HeLP study included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, the number of children for whom English was an additional language was considerably lower than the national average. Conclusions HeLP is not effective or cost-effective in preventing overweight or obesity in children aged 9–10 years. Future work Our very high levels of follow-up and fidelity of intervention delivery lead us to conclude that it is unlikely that school-based programmes targeting a single age group can ever be sufficiently intense to affect weight status. New approaches are needed that affect the school, the family and the wider environment to prevent childhood obesity. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

Expert commentary

This study is a timely reminder that we must continue to support action outside of the school gates to help children and their families eat healthily and get active.

Schools play an important role in educating children on healthier lifestyle behaviours. However, we should remember that schools are just one part of a broader local community.

We know some local councils are also working with their communities and local businesses to improve the food on offer in shops, around schools and on their high streets - only by working together will we tackle public health issues like obesity.  

Jamie Blackshaw, Team Leader: Obesity & Healthy Weight, Health Improvement, Public Health England