In Europe, close to one in four school children is overweight, with numbers rapidly increasing. Similar trends are observed worldwide. There is a growing concern about the rising prevalence rates of obesity among the general population, and specifically for our younger generation. The prevention of obesity is regarded as a major public health concern both at the international and at the national level; and an integrated approach is required to halt and reverse this trend. In most policy documents on obesity (such as the 2005 European Union Green Paper on the prevention of overweight¹ and the WHO paper on the challenge of obesity in the European region²) the focus is on children and young people. Schools are regarded as a key setting for health promoting interventions, and can contribute to the improvement of children’s health by promoting healthy eating and physical activity, by providing a suitable environment which encourages their participation and by developing their skills.

This chapter describes the role schools can play in the prevention of obesity. Since the early 1990s, school health promotion has strongly evolved. Several reviews have demonstrated the effectiveness of this approach. It is now also clear that when dealing with the prevention of obesity in schools, it is not only the promotion of healthy eating and physical activity that should be included, but also aspects of mental health promotion (such as self-esteem, body image, dieting, eating disorders). But schools cannot, and do not have to, do it all on their own, since they are part of a broader community. The health-promoting school approach offers a rich body of evidence indicating that healthy students learn better and that improving knowledge, competencies and health status of children will improve learning outcomes.³ Some successful and promising examples of dealing with obesity prevention via the school setting are described here.

So far, there is a lack of long-term evidence of effective and comprehensive approaches for the issue of obesity prevention in the school setting. A recent review on school-based obesity interventions by Shaya⁴ concluded that no persistence of positive results in reducing obesity in school-age children has been observed. However, the review by Stewart-Brown⁵ demonstrated that effective programs on school health promotion in general adopted whole-school approaches. It is clear that action against obesity should be part of overall strategies on promoting healthy lifestyles.

The period that children spend in schools, usually from age 4 through to adolescence (16–18 years) is very important for their mental and physical development. The school historically and still today is seen by many as a site for health messages and activities.³

During the period of industrialization in the mid-nineteenth century, churches and charities in Europe started schools in order to support the social development of children and to care for them when both parents were working in cities. Rules for healthy living were taught at school, including proper hygiene measures, regular eating, enough physical activity and sufficient sleep. From the beginning of the twentieth century, health education in schools was introduced mainly by the medical profession because of the spread of infectious diseases and the role prevention could play. Medical care was provided through special school doctors and nurses, later also dental care, by specialized school dentists. Added to this was the introduction of school meals and physical education in schools, for example, in the UK, at the turn of the twentieth century.

During this time, in public health there was a shift from communicable to non-communicable diseases, and the recognition that good health is related to lifestyle. There has been a dramatic shift in morbidity and mortality, from infectious diseases to lifestyle-related causes such as cardiovascular diseases and cancers; and an increase in the prevalence of mental health problems. From the 1960s, this was recognized by a change in health education in schools, towards trying to influence health behaviors of children, mainly by providing information about risks related to specific diseases. However, it became clear that knowledge itself was insufficient to change an individual’s lifestyle.

The last two decades have seen a shift towards the more holistic and ecological approach of health promotion. Based on the Ottawa charter,⁶ it became clear that promoting health in a school setting should include teaching in the classroom (or “health education”), but also take the school environment and ethos into account, as well as considering links with the wider community. The charter states that health promotion is a process concerned with enabling people to gain more control over their own health and over their environment. This multi-faceted approach has strongly influenced the health-promoting schools concept, which has implied a shift in dominant paradigms over the years. This in turn had a great impact on the introduction of new health promotion programs and interventions for schools on healthy eating and physical activity (see Box 30.1).

Eating habits and diet have a significant influence on the health and well-being of children. More specifically, the overall health and nutrition of the child is recognized as one of the factors that influence academic performance, among other factors such as gender, ethnicity, quality of school and school experience, and socio-economic status.⁴ Past studies have focused on the effects of a lack of nutrients or malnutrition on decreased school attendance and performance. A number of studies have demonstrated the positive effects of breakfast on school performance, but there are gaps in the literature about the long-term effects. A recent study in Canada⁸ examined the impact of the quality of the whole diet, not just certain nutrients or meals on academic performance. Components of a high quality diet were defined as a high consumption of fruit and vegetables and a moderate fat intake. This was one of the first studies of this kind and it demonstrated that children with overall healthy diets performed better in school than children with unhealthy diets. Therefore, enhanced learning can be regarded as an additional benefit of a healthy diet in childhood. Key messages for school-based programs and policies are the importance of promoting dietary adequacy and variety, increased fruit and vegetable intake and a moderate consumption of dietary fat (see Box 30.1).⁴

Physical activity has a long tradition in schools, and the importance of having enough physical exercise and participating in sport has been acknowledged since the nineteenth century. Nowadays, physical education is included in the curriculum in primary and secondary schools, and attention is given throughout the school program for promoting physical activity and sports. The school offers a wide range of options for increasing physical activity for school-aged children, not only through the curriculum (physical education, integration with science and other subjects), but also by offering after-school programs and supporting initiatives for safe walking and cycling to school, as well as using the school as a community resource for physical activity. Schools often have a wide range of facilities available, including a gym and outside play area, which can also be used by the local community. Many studies have been carried out to demonstrate the link between physical activity and academic performance, although there is a shortage of prospective, controlled research in this connection. Retrospective studies found a weak or no relationship between this connection; prospective studies suggested concentration increases for a brief time after physical activity or that there is an increased rate of learning per unit of school time, but that these effects are not sufficient to increase academic performance.⁹

Since obesity is now recognized as one of the major public health threats, increased attention has been given to developing integrated programs for schools. When dealing with the issue of obesity in a school setting the two issues of healthy eating and physical activity are usually addressed. The focus in these programs is on “energy balance”. We now know that the most effective way is to integrate these issues into more coordinated programs that promote healthy lifestyles and that are incorporated into the health-promoting school approach.⁵

The importance of education for health outcomes and of health for learning outcomes is well established.¹⁰ When health education became a topic in schools in the Western world during the nineteenth century, the focus was narrow, relating to the individual, and covering moral and physical issues, including hygiene, the prevention of infectious diseases and incorporating strict warnings, for example, on the dangers of using alcohol. The methods used for health education were based on the transmission of knowledge.

The health promoting school approach incorporates the following principles:³

• Health has physical, mental, social and emotional dimensions.
  
• Providing information does not necessarily improve student’s health outcomes.
  
• More active involvement of learners promotes behavioral change.
  
• Individual behavior is influenced by social factors such as peer pressure.
  
• Physical and socio-cultural environments, including the school environments, influence individual and community well-being.

In Europe, the health-promoting school approach was introduced in 1992 and has since developed, supported by the European Network for Health Promoting School s (ENHPS) and now the Schools for Health in Europe network (SHE network). Forty-three countries in the European region are now members of this network. The basic values underpinning the health promoting school approach are:

• equity
  
• active participation of students
  
• development of students’ action competence
  
• importance of the social and physical environment of the school
  
• integration of health promotion policies as part of school development.

In 1997, the first European conference on school health promotion resulted in the identification of ten principles for school health promotion,¹¹ including democracy, equity, empowerment and partnership. In this network it was recognized that health and education are closely linked. Health status is related to access to schools as well as the ability to learn. There is a lot of evidence indicating that healthy students learn better and that improving the knowledge, competencies and health status of children will improve learning outcomes.³ Also, schools that use the health promoting school approach improve at a faster rate than schools that do not use this approach. Effects have been demonstrated in improving learning environments, student concentration and performance, staff health and well-being, and better student achievements.¹²

Many studies have been carried out to investigate the effectiveness of the whole school approach. Overall, it can be concluded that the school health promotion programs that were effective in changing young people’s health or health-related behavior were likely to be complex, multi-factorial and involve activity in more than one domain (curriculum, school environment and community). Also, programs that are intensive and implemented over a long period of time are more effective than programs of short duration and low intensity. Finally, school health promotion can be effective, particularly in improving mental health and in promoting healthy eating and physical activity.⁵

Recent evidence³ makes clear that a whole school approach, which encourages and recognizes student participation and which addresses the building and maintenance of a caring school social environment, may be the most effective way to achieve both health and educational outcomes. Important influences that build health protective factors and reduce risk-taking behavior, are: the way a school is managed; how the school encourages student participation in shaping policies, practices and procedures; how teachers relate to and treat students; and how the school engages with its local community and parents in partnership work.

The supporting role of the school management is recognized as an important factor to start the process of introducing and implementing the health-promoting school approach.

Below is a selection of effective or promising initiatives to tackle obesity through the school setting based on the health-promoting school approach.

Food and fitness implementation plan (Wales)

The Food and Fitness Implementation Plan¹³ in Wales was developed following the work of a Task Group and consultation with a wide audience including children and young people. Healthy schools were seen as a key component of work to improve nutrition and levels of physical activity. As part of their work, schools are required to consider these issues and to develop a whole school food and fitness policy. The plan looks specifically at the food and drink consumed throughout the whole school day, which has led to the development of a related strategy, called Appetite for Life.^14,15

The importance of developing high quality physical education and practical cookery skills is also reinforced. Some examples of work here include the provision of a mobile cooking classroom—the Cooking Bus. The Cooking Bus visits primary schools in the most deprived areas of Wales and provides practical cooking lessons to pupils, as well as running a teacher training session and providing a session for parents of young children. This is supported by a change in the curriculum from September 2008, which makes it compulsory for pupils aged 7–13 to learn about food. They will have opportunities to practise, safely and hygienically, a broad range of practical food preparation and cooking tasks and to consider current healthy eating messages and nutritional needs. With regard to physical activity there is support via the Physical Education and School Sport program to develop the physical education curriculum, and this is complemented by out-of-school activities.¹⁶ Food and fitness programs in the community, plus training of key workers and evaluation complete the plan.

Growing Through Adolescence (Scotland)

The WHO resource Growing Through Adolescence, developed by NHS Health Scotland,¹⁷ combines nutrition and physical activity within the context of energy balance. This teacher training pack also makes the link with the issue of mental health. There is evidence that increasing numbers of young people are unhappy with their body size and shape and are more frequently becoming involved in dieting and unhealthy eating patterns. The resource explores the biological, social and emotional issues around health using a participative training approach and it aims to enable teachers to be confident with these issues in the classroom and in the health promoting school.

Planet Health (United States)

“Planet Health” is a school-based program on obesity prevention developed in the United States for middle school students (age group 11–14 years). Planet Health helps academic, physical education and health education teachers to guide middle school students in the following areas:

• learning about nutrition and physical activity while building skills in language arts, maths, science and social studies;
  
• understanding how health behaviors are interrelated;
  
• choosing healthy foods, increasing physical activity, and limiting TV and other screen time.

Gortmaker¹⁸ demonstrated that Planet Health prevents obesity in girls, reduces television viewing in girls and boys, increases fruit and vegetable consumption in girls, and prevents disordered eating behaviors in girls. There is a similar program for upper elementary schools (ages 9–12 years) called “Eat well and keep moving”.

Toolkit for overweight prevention in schools (the Netherlands)

In the Netherlands, a toolkit has been developed for schools on preventing overweight.¹⁹ It provides an overview of available programs on healthy eating and physical activity for primary and secondary schools that have been developed at a national and regional level. It also describes strategies to deal with the issue as part of a health-promoting school approach. The toolkit has been developed for regional professionals as guidance for supporting their schools.

The nutrition-friendly school initiative (WHO)

In 2007, the WHO initiated the global nutrition-friendly school initiative, a school-based program to tackle undernutrition and overweight.²⁰ It is a standardized framework that serves as a tool for developing a school environment which promotes the nutritional well-being of school-aged children. The initiative is designed to be easily integrated into existing school programs or to be implemented on its own where there are no ongoing programs. The WHO initiative provides suggestions at both a national and a school level on how to implement the nutrition friendly school programs. At the school level, practical guidelines are given for developing a food and nutrition policy for schools, including: assembling a core action group; developing an action plan; evaluating the plan, and; incorporating changes into school policy. Box 30.2 shows the five elements of the nutrition friendly school initiative.

Since obesity is now recognized as one of the major public health threats, increased attention has been given to developing integrated programs for schools. We now know that the most effective way is to integrate these issues into more coordinated programs that promote healthy lifestyles, and that are incorporated into the health promoting school approach.

Although there has been a lack of effective and comprehensive school-wide approaches for obesity prevention in the school setting, some promising examples are now available. The review by Stewart-Brown⁵ demonstrated that effective programs on obesity prevention adopted whole-school approaches.

Initiatives and new programs on preventing obesity in schools are currently developing in most countries throughout the world. But a more systematic approach on the international and national level is needed, making use of the knowledge that is already available within the health-promoting school approach. Exchange of experiences, research, evaluation and implementation and sharing of good practice is needed.