Health Education

Emerald Article: Childhood obesity prevention and physical activity in schools Fiona Davidson

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To cite this document: Fiona Davidson, (2007),"Childhood obesity prevention and physical activity in schools", Health Education, Vol. 107 Iss: 4 pp. 377 - 395 Permanent link to this document: http://dx.doi.org/10.1108/09654280710759287 Downloaded on: 28-04-2012 References: This document contains references to 95 other documents To copy this document: permissions@emeraldinsight.com This document has been downloaded 5951 times.

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Childhood obesity prevention and physical activity in schools

Fiona Davidson
Derbyshire County Primary Care Trust, Belper, UK
Abstract
Purpose The aim of this literature review is to summarise and synthesise the research base concerning childhood obesity and physical activity, particularly in relation to teachers and schools and within a policy context of the UK. The review investigates childhood obesity, physical activity, physical education, the role of teachers, the role of schools and physical activity in the classroom. Design/methodology/approach A literature review was undertaken involving selection of primary research and other systematic reviews. A computer search was performed using a combination of keywords including: obesity, prevention, intervention, preventive, teachers, schools, healthy schools, role models, physical activity, physical education, active school, active classroom. The review also includes samples of media coverage of the issue. Findings This review highlights the complex and ambiguous nature of the evidence in relation to this important contemporary issue. Originality/value A limited understanding of childhood obesity is evident from the review and this precludes denitive conclusions in relation to almost all aspects of the agenda. More quality research is needed in almost all areas of the topic, including areas such as the engagement of schools and teachers. Keywords Schools, Obesity, Exercise, Teachers, United Kingdom Paper type Literature review

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Received September 2006 Accepted January 2007

Introduction This literature review will consider childhood obesity, physical activity, physical education (PE), the role of teachers, the role of schools and physical activity in the classroom. It will also consider the current policy context of childhood obesity and physical activity in England specically. The review in each area is not exhaustive, because each area has been reviewed in more depth in numerous other reports. Neither is the review itself exhaustive, with areas such as eating habits, family, home environment, parenting behaviours, media inuence in children, TV viewing and many more not being covered. Instead, the goal is to provide an overview of the topic with a particular focus on the role of schools and teachers. Physical activity and healthy eating are often identied as the key features in relation to the prevention of childhood obesity (British Medical Association, 2005; Armstrong, 2004; Deckelbaum and Williams, 2001), and therefore considerable action is being taken by top-level policy makers in these areas; for example changes have been made to the National Healthy Schools Programme to make physical activity and healthy eating compulsory components of the programme (Department of Health, 2005) and strict new standards for school food and school meals come into force over the next 12 months. However, this use of schools as a site for health promotion (Whitelaw et al., 2001) has failed to recognise the role of teachers despite their key status in relation to health promotion programmes in schools (Yager and ODea, 2005; Viig and Wold, 2005; Fairclough and Stratton, 2005).

Health Education Vol. 107 No. 4, 2007 pp. 377-395 q Emerald Group Publishing Limited 0965-4283 DOI 10.1108/09654280710759287

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Physical activity in school is not a new area for research, but much has focused either on physical education (Fairclough and Stratton, 2005; Fairclough et al., 2002; Gard and Wright, 2001; Cale, 2000; Biddle, 1991) and/or childrens use of social time in break (recess) and lunchtimes (Ridgers et al., 2005; Guinhouya et al., 2005). One element of physical activity in school that has been little researched is the integration of physical activity into classroom lessons despite often being proposed as part of a whole school approach to physical activity (Fox et al., 2004; World Health Organisation, 1998; Cale, 1997). The development of the active classroom is a particular area that teachers could have a signicant inuence in developing and potentially impact on the physical activity levels of children. Obesity There is a vast amount of literature on the topic of obesity, and recent years have seen a proliferation of areas of specialisation within the eld. It has been suggested that the current state of knowledge available about obesity is an incomplete jigsaw, with the pieces slowly coming together over time as new research is undertaken (Gard and Wright, 2005). The widely held understandings of the obesity epidemic can be demonstrated by the Chief Medical Ofcers Report (Department of Health, 2004a). He suggests that there has been a decrease in physical activity as a part of daily routines, that there are fewer manual jobs, and that shopping, housework and other activities have become less active. The reduction in activity levels of children in the course of their daily lives is claimed to have contributed to the levels of obesity. The media coverage of the issue may be accused of exaggerating and sensationalising the topic, creating an orthodoxy and contributing to the perceived credibility of knowledge on the subject:
The evidence for the increase in obesity is now so compelling, so incontrovertible, that it has almost lost its power to shock. Instead, every new piece of medical evidence seems to act as an anaesthetic on a jaded public and is lost in a few sensational headlines and soon forgotten (Crace, 2002).

However, Gard and Wright (2005) suggest that the current state of knowledge is confused and replete (p. 3) and based upon misleading assumptions. The basis for this opinion will be demonstrated throughout this review. Part of the problem in nding causational explanations for obesity is the difculty in measuring many of the possible determinants. Energy input and energy expenditure are notoriously difcult to measure, and many researchers have relied upon self-report data to determine these variables and therefore are subject to response bias, particularly with children. The Department of Health (2004b) in its Choosing Health white paper uses the Health Survey for England (HSE) 2002 to identify the rise in childhood obesity in children aged 2 to 10. The rise is stated as 9.6 per cent to 15.5 per cent from 1995 to 2002. However, the Social Issues Research Centre (2005), using the data from the Health Survey for England 2003, suggest that there has been no statistically signicant increase in the average weight of children over nearly a decade, and they say that this can be taken as evidence that there is no epidemic, as this would have impacted on average weights. The recent update of the childrens overweight and obesity trend tables using the HSE 2004 data led to headlines such as Child obesity doubles in decade (BBC News, 2006). The updated tables (Health and Social Care Information

Centre, 2006) indicate a rise to 14.3 per cent in 2004 for children aged 2-10, which is lower than the 2002 gure of 15.5 per cent. The headline grabbing statistics were in relation to young people aged 11-15, where the rise has been from 14.5 per cent to 25.5 per cent from 1995 to 2004. What is clear however, from all of these reports, is that the general trend in body mass index (BMI) of children is upwards but the rate of acceleration is open to debate. The denitions of overweight and obesity in children and young people are undertaken for the purpose of predicting health risks and for population comparisons. There are two main methods of dening childhood obesity. The rst is a national standard based on UK reference curves from 1990. The other is an international standard based on height/weight distributions across six countries (Social Issues Research Centre, 2005). Both of these methods use BMI as a measure but differ in their cut-off points. BMI is dened as weight (kg)/height squared (m2). The use of BMI in itself is not accepted as the most accurate method of measuring obesity in children (Lobstein et al., 2004). There are other anthropometric measures such as weight, weight for height ratio, waist circumference, waist to hip ratio and skin fold thickness that have their own strengths and weaknesses related to validity, practicality and the ability to dene different categories. There are also other methods such as underwater weighing and magnetic resonance imaging (MRI), which, while providing greater accuracy, are impracticable for large numbers (Lobstein et al., 2004). Despite its lack of sensitivity for people who are particularly short, tall or have an unusual body fat distribution, BMI is recognised as the method that will be used to determine the baseline data for the childhood obesity Public Service Agreement (PSA) (Department of Health, 2006). As well as the concerns already highlighted, the measurement of energy expenditure, food intake, and physical activity are also difcult, especially with children (Goran, 1998). Measurement issues have certainly contributed towards the lack of certainty in relation to many aspects of childhood obesity. In order for fat to be stored there needs be an imbalance in energy intake compared with energy expenditure (Fox, 2004). This simplication of the cause of obesity results in what had been described as a body as machine concept (Gard and Wright, 2005), with the only determinant of obesity being the relationship between energy input and energy expenditure. However this is a simplistic view of a very complicated phenomenon, as the aetiology of obesity is multidimensional (Goran et al., 1999). Factors also considered to be involved in obesity are genetic, environmental, metabolic, behavioural and perinatal (Ebbeling et al., 2002). Lobstein et al. (2004) suggest that between 60 and 85 per cent of the variation in obesity could be caused by genetic predisposition towards obesity, with Gard and Wright (2005) even suggesting between 50 and 90 per cent. Jotangia et al. (2005), in their report for the National Centre for Social Research, also use the HSE data. They consider further factors in relation to the trends in childhood obesity such as social, demographic and behavioural factors. They found that: . In 2002 and 2003 signicantly more children from manual households were obese compared to non-manual households. . There was a clear association between the prevalence of obesity among children and area deprivation.

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There was a relationship between childhood obesity prevalence and household income. Levels of obesity were lowest among managerial or professional households and highest among semi-routine and routine households. A clear relationship between parental BMI status and rates of obesity among children was evident. In households where both parents were classed as obese or overweight, 19.8 per cent of children were obese. This is compared with just 6.7 per cent of children in households where neither parent was obese or overweight. There was a tendency for obesity rates to rise as childrens level of physical activity fell.

Examples of the confused state of the evidence on obesity are provided almost on a daily basis as research in a myriad of areas is being undertaken, some in areas that have not been investigated before. A recent research publication (Burdette et al., 2006) has thrown into doubt another element of the evidence around obesity that focussed on breastfeeding as a protective factor against obesity in later life. Another group have studied food practices in schools and have found that for each food practice (fund raising using food for example bake sales food used as incentives by teachers, vending machines, etc.) the average BMI of the students increased by 10 per cent (Kubik et al., 2005). Energy intake is fully related to nutritional consumption but energy expenditure is dependant on several different aspects. There are considered to be three components of total daily energy expenditure (TDEE): (1) basal metabolic rate (BMR); (2) thermic effect of food (TEF); and (3) activity thermogenesis (AT). AT has two elements: (1) energy expenditure of exercise; and (2) non-exercise activity thermogenesis (NEAT) (Levine et al., 2006). Levine et al. (2006) believe that for most people it is the NEAT element of the intake/expenditure equation that accounts for most of the variability in TDEE. Nutritional intake and energy expenditure are claimed to be the two most modiable elements of the obesity equation (Anderson, 2000) and as a result are the elements given the most consideration when discussing prevention or treatment of obesity. This body as machine theoretical proposition of some researchers is best demonstrated by Hill et al. (2003), who propose a potential solution to the obesity problem. They suggest the notion of the energy gap, which is the required difference in energy expenditure against energy input that will redress the energy balance. They calculate that this energy gap could be 50 kcal/day and if an intervention could reduce the positive energy balance by this amount, this could offset weight gain in about 90 per cent of the population. They further contend that weight gain in the population could be eliminated completely by increasing energy expenditure by 100 kcal/day. This is the equivalent of a 15-20 minute walk, or one mile per day. The idea that a small increase in energy expenditure could solve the obesity problem is directly linked to the converse theory by Ebbeling et al. (2002) that any

activity that raises energy intake or reduces energy expenditure even slightly will cause obesity over a long period. Hill and Trowbridge (1998) also concur that a very small imbalance of energy over time can cause obesity. Recent press coverage has also focussed on this element of obesity research suggesting that children who drink a can of sugary drink a day may put on up to a stone in weight in a year (Lister, 2006). There appears to be a lack of certainty about any aspect of childhood obesity from causes and prevalence to treatment and prevention. Despite this absence, the discourse surrounding childhood obesity predominantly continues as if that certainty exists. Schools We live in what has been called an obesogenic environment (obesity-promoting) (Doak et al., 2006) and our culture (in the UK and the USA) is considered to be one that encourages energy consumption and discourages energy expenditure by promoting a reliance on convenience (Hill et al., 2003; Ebbeling et al., 2002). Schools could also be considered obesogenic environments themselves, with signicant amounts of time spent sitting still, and limited time for physical activity. Stewart et al. (2004) believe that school structures and the push for improvements in test scores introduce barriers to physical activity promotion. Lowden et al. (2001) state that it is the nature of schoolwork itself that means that pupils are sedentary for much of the school day. Schools are often suggested as an appropriate setting for obesity prevention programmes or interventions to take place (Fox et al., 2004; World Health Organisation, 1998; Cale, 1997). This appears to be a logical suggestion due to most of the target population attending school, the cost effectiveness (Hill and Trowbridge, 1998), and this approach to prevention could also avoid potential stigmatisation of obese children (Ebbeling et al., 2002). Steinbeck (2001) also suggests that early intervention for obesity may have more impact on children due to their potential for growth, that they are still learning lifestyle behaviours and that they may be more exible than adults to change their behaviour. Lobstein et al. (2004) argue that:
. . . genetic studies suggest that most children are at risk of weight gain, and that strategies to prevent obesity in a child population such as encouraging healthful diets and plentiful physical activity will benet the health of all children, whether at risk from obesity or not (p. 7).

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However, the effectiveness of initiatives to prevent obesity or encourage physical activity in schools is unclear and will be discussed in more detail later in this review. Physical activity The governments growing concern about childhood obesity has helped to create greater interest and discourse in physical activity and its contribution to health (Fox, 2004). Laventure (2000) suggests that physical activity and exercise are now accepted as important contributors to public and national health. Sparling et al. (2000) commented that when all the relevant research is considered, it is evident that there is a clear dose-response relationship between activity levels and disease prevention. While the positive benets of physical activity could be considered as accepted knowledge (British Medical Association, 2005; Armstrong, 2004; Deckelbaum and Williams, 2001; Biddle et al., 1998), others contend that knowledge in this area,

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particularly in relation to children, is once again partial and often contradictory (Flegal, 1999; Gard and Wright, 2001). Gard and Wright (2001) suggest that:
While it is probable that some level of physical activity has some health benets for some people, there is little else that we can say with any certainty in this area (p. 547; emphasis added).

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While one may agree with the sentiment of this statement in that there is uncertainty about accurate and appropriate levels of physical activity for disease prevention, and there should be some caution particularly when discussing population level interventions or recommendations, the evidence available does suggest an inverse relationship between physical activity and disease. However until unequivocal evidence exists of that relationship, there will always be dissenting voices. In 1998 a consensus statement regarding the recommendations for health-enhancing physical activity for children and young people was written (Biddle et al., 1998; see Table I). A more recent attempt to provide evidence-based recommendations for physical activity for young people in the US was published in 2005 (Strong et al., 2005). The work involved an expert panel evaluating the available evidence. Despite the availability of a greater body of research this groups recommendations mirrored those of Biddle et al. (1998). The 1998 consensus guidelines are referred to frequently by major organisations and government departments such as the Department of Health (2004a), the World Health Organisation (2000) and the British Heart Foundation (2004). All of the above use the consensus statement to outline the current recommendations for physical activity levels for children (while some worryingly ignore the second part of the principle recommendation regarding children who are currently inactive). These documents will guide and support a generation of professionals working with children and will direct interventions into schools and communities on this basis. However, Armstrong (2004), referring to the guidelines above, states that:
. . . this type of guideline-approach tends to reinforce the concept of an activity threshold for health promotion. Strong epidemiological or experimental evidence in support of either threshold or a specic set of recommendations as being optimal for the promotion of young peoples health and well being is not available (p. 334).

Fox et al. (2004) also raise concerns about the consensus statement of physical activity requirements. Their article sites recent research that indicates that most children (70 per cent of boys and 65 per cent of girls) are currently achieving these recommended levels of physical activity. They go onto question either the validity of the evidence used to determine the recommendations or the recommendations themselves on this basis. However, the British Medical Association (2005) suggest that approximately 33
Principal recommendations All young people should participate in physical activity of at least moderate intensity for one hour per day Young people who currently do little activity should participate in physical activity of at least moderate intensity for at least half an hour per day Subsidiary recommendations At least twice a week, some of these activities should help to enhance and maintain muscular strength, exibility and bone health Source: Biddle et al. (1998)

Table I. The recommendations for young people and physical activity

per cent of children aged two to 11 are not sufciently active to meet the consensus statement requirements and that it is possible that the increasing levels of obesity are as a result of this group of inactive children. It appears that the BMA results reasonably match those that Fox et al. (2004) quote, and as such could support the fact that it is the group of inactive children that should be of most concern. The physical activity recommendations seem to have become accepted knowledge and have not being questioned or challenged, despite their age, ambiguity and questionable validity. If we add to this the equivocal evidence of the relationship between physical activity and health, we are placed in a quandary. In the absence of any other advice or support, is it not useful to have some form of baseline, that seems to make intuitive sense, or are we simply perpetuating an approach that requires more critical engagement? Physical education (PE) The World Health Organisation (2000) identies PE as the main vehicle for delivery of physical activity in school. The British Heart Foundation (2004) agree that PE is a perfect opportunity for vigorous activity but also state that PE takes up approximately 1 per cent of a childs waking time and therefore cannot have the signicant impact suggested by WHO. According to Gard and Wright (2001), PE is now considered by many experts to be one of the key sites in which the claimed obesity epidemic can be resisted. Physical education does provide a context within which children and young people experience regular and structured physical activity. However, the benets of this are debated. A shared Public Service Agreement (PSA) between the Department for Education and Skills (DfES) and the Department for Culture Media and Sport (DCMS) is linked to the number of hours of PE schools should be providing. As stated within the Department of Health Choosing Health (2004b) White Paper:
To increase the percentage of schoolchildren spending a minimum of two hours each week on high-quality PE and school sport within and beyond the curriculum (p. 23).

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This two-hours-a-week target is seen as contributing towards the seven hours a week of physical activity recommendation that was presented by Biddle et al. (1998). However, while two hours of timetabled PE may be offered by many schools, the actual amount of physical activity within those lessons can be considerably less. Time is taken up in lessons for changing, essential non-active elements of the lesson (instructional and organisational time) and undertaking analysis and evaluation tasks that are required within the national curriculum. Fox et al. (2004) refer to a study that determined that a 40-minute PE lesson resulted in, on average, only eight minutes of moderate or vigorous physical activity (MVPA). Fairclough and Stratton (2005) also studied the amount of MVPA and vigorous physical activity (VPA) undertaken in PE lessons in Years 7, 8 and 9. In their study pupils averaged 18 minutes of MVPA and they concluded that the pupils attained insufcient amounts of VPA to impact on cardiorespiratory tness but PE can contribute to overall daily physical activity targets when combined with other forms of physical activity. However, Gard and Wright (2005) contend that:
No link between school physical education and either the long-term health, body weight or physical activity levels has ever been established (p. 4).

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This is not to suggest that PE is not an important element of a childs education, but the idea that PE is the solution to the childhood obesity problem does not appear to be sustainable in the face of the evidence available. Its place as even a signicant contributor is a supposition that is also contested (Biddle et al., 1998; Corbin and Pangrazi, 1998) particularly with the current conguration of the national curriculum and its focus on traditional sports and activities that have little relevance to life-long physical activity. Health Promoting Schools The WHO developed the concept of the Health Promoting School in 1993. It is essentially a framework of school based health promotion emphasising the whole school approach (WSA). Lobstein et al. (2004) suggests that schools need to consider health-promoting policies on nutrition and physical activity, ethos, supportive environment, and cultural norms, skills and practices that are conducive to health promotion. This WSA to promoting physical activity and obesity prevention is also advocated by others in the eld (Fox et al., 2004; Okely and Booth, 1998; and Cale, 1997). In a recent Department of Health (2006) document regarding measuring childhood obesity it was suggested that a healthy school should be addressing the health needs of its pupils and as such should include work to prevent or deal with actual weight issues. While the government would like every school to be working towards National Healthy School Status by 2009, and as such all schools will have such actions in place, schools have had, up until recently, no statutory responsibility to undertake this kind of work. The recent Education and Inspections Act (2006), however, places a statutory obligation on schools to help improve pupils health and well-being as well as their academic attainment. Also, possibly as a result of the new Ofsted inspection framework (Ofsted, 2005a), there appears to be an increased enthusiasm from schools to work towards National Healthy School Status (see Policy context below). Active school The active school concept is illustrative of the settings-based approach to health promotion (Whitelaw et al., 2001). Cale (1997) is a supporter of the active school concept and suggests that an active school should demonstrate a commitment to physical activity through a number of strategies. Fox et al. (2004) also support this idea of the whole school approach to physical activity:
. . . school physical activity promotion needs to change from a restrictive, one-dimensional focus on traditional curricular sport and physical education to a model in which the culture and policy of the school is child centred and health-and-activity driven (p. 346).

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Cale (1997) suggests that there are seven headings under which the avenues available for promoting physical activity can be categorised. These are: (1) policy; (2) the curriculum; (3) the informal curriculum; (4) ethos; (5) community links; (6) the environment; and (7) care and support.

These can also be seen as the key areas through which a school would also become a health-promoting school and can demonstrate the whole school approach. Active classroom One element of physical activity in school that has been little researched is the integration of physical activity into classroom lessons. The development of the active classroom is a particular area that teachers could have a signicant inuence on and potentially impact on the physical activity levels of children. Within texts on active schools, the development of active lessons is cited as one of the elements or strategies that would contribute towards an active school (Fox et al., 2004; Cale, 1997), but no further information is offered. However, the use of movement in the classroom is a concept that has been considered by some authors but not in relation to physical activity, energy expenditure or obesity prevention. Jensen (2000) is one such author who advocates short bursts of physical activity in lessons to increase what he calls implicit learning which he denes as learning that takes place outside of our conscious awareness. He claims that activity that is planned into every hour that learners are learning, and that lasts for approximately ten minutes will help learners to sustain their learning. He also suggests several reasons why regular physical activity and movement in lessons is benecial and even suggests an optimal amount of time for students to spend in recess. However, he cites references from as far back as 1959 to demonstrate the evidential basis for his statements and does not offer a balanced view of the contested evidence around physical activity effecting cognitive performance. Jensen (2000) also links movement methodology to educational kinesiology or brain gym, where directed exercises such as the cross crawl are used with pupils. This link between movement in the classroom and brain based approaches to learning is one that is popular amongst several authors, such as Blaydes (2004), Smith (2002), Jensen (2000) and Hannaford (1995). Despite the lack of evidence to support these approaches, many of these authors have written books to share their theories about movement/activity and its effects on the brain and provide little but anecdotal evidence to support their claims. Another approach linking movement in the classroom to learning is as part of a learning styles framework. It is not within the scope of this review to undertake a full critique or in-depth explanation of learning styles; therefore, I will focus on the most relevant to this review and to teachers. The latest DfES documents, in particular the National Strategy documents (Department for Education and Skills, 2003, 2004), include reference to individualised learning which stem from Howard Gardners work on multiple intelligences (Gardner, 1983). Teachers are being encouraged to use visual, auditory or kinaesthetic teaching activities in their lessons. In brief, this means to include teaching activities that will appeal to learners who prefer the visual, auditory or kinaesthetic (VAK) approaches to learning. The link to this review is the kinaesthetic intelligence. In relation to learning activities, this kinaesthetic approach may vary from a card-sorting activity to a full body movement activity. These kinaesthetic learning activities (KLAs) have been taken on board by Begel et al. (2004) within the eld of computer sciences. They dene KLAs as:
Any activity which physically engages students in the learning process (p. 1).

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Begel et al. (2004) identied that within their eld of computer science education students are rarely energised or employ a variety of learning styles within classes.

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They use KLAs to demonstrate concepts within computer science in a physically active way using some or all of the students. However, they do state that KLAs can be difcult to manage, may not always be socially appropriate and the students simply may not understand the concept behind the KLA. Despite the lack of evidence to suggest that linking instructional approaches to students learning styles has any effect on their learning (Klein, 2003; Stahl, 1999), or the effectiveness of brain gym, I hypothesise that these are the two most common ways in which teachers use physical activity in the classroom. Research by Dr James Levine at the Mayo Clinic in Minnesota has recently been reported in the press (Henry and Day, 2006). The article suggests that chair-free classrooms will soon be introduced into Britain as Dr Levines study has found that this could lead to weight loss. Researchers used a specially adapted classroom with lean and move bays, and pupils spent an average of ve hours a day standing, burning three times as many calories as they would if they sat down. The results of this study have yet to be published, but will certainly provide an interesting perspective on the active classroom. If we relate the active classroom concept to Levine et al.s (2006) denition of non-exercise activity thermogenesis (NEAT see earlier) that is the energy expenditure of physical activities other than sporting-like exercise it is clear that movement, or even simply standing, in the classroom will increase students NEAT and as a result could impact on their total daily energy expenditure (TDEE see earlier) and presumably their BMI. The school then becomes a NEAT-promoting environment rather than an obesogenic environment. Whilst I cannot envisage widespread use of the standing classroom approach in the near future, the principle of increasing pupils energy expenditure through the use of physical activity in the classroom is an idea that could be investigated more thoroughly. Teachers As previously mentioned, schools are considered to be ideal places for obesity prevention and physical activity promotion work to be undertaken. However, this approach has failed to engage specically with teachers even though they are considered to be fundamental agents (Yager and ODea, 2005; Viig and Wold, 2005). One series of studies, examining the perceptions of a variety of school personnel (nurses, principals, teachers and parents) towards obesity, has been undertaken (Price et al., 1987b, 1990, 1992). In the study concentrating on teachers (Price et al., 1990), elementary school physical education teachers were used as the sample. It was found that this group of teachers did not feel competent to offer activity programmes that aimed to contribute to weight loss. As these were specialist PE teachers and most primary school teachers in England have very little PE training it could be suggested that teachers here would also feel that they lack the skills and knowledge to undertake this kind of work. It was also found that the respondents from the nurses (Price et al., 1987b) and teachers studies believed that schools were not doing enough to prevent childhood obesity and that they were not trained sufciently to help prevent obesity. The study of the school principals (Price et al., 1987a) also highlighted an important factor for consideration, which was that most principals were not supportive of obesity prevention activities being undertaken in school. Having support from the

principal/head teacher in relation to educational change/innovation may play a signicant part in its success or otherwise (Fullan, 2001; Hall and Hord, 2001). Fox et al. (2004) suggest that teachers may lack the necessary skills to work effectively with the increasing levels of overweight and obese children, and Yager and ODea (2005) highlight the need for teachers to have developed appropriate attitudes towards obesity for prevention programmes to be effective. The World Health Organisation (1998) also suggest that teachers (and other school staff) will need training to encourage students to engage in physical activity. Yager and ODea (2005) advocate training for pre-service and practising teachers in relation to nutrition, obesity and preventative techniques. One other study that did consider teachers attitudes towards obesity (Neumark-Sztainer et al., 1999) found biases including beliefs that obese persons are untidy, more emotional, less likely to be successful and have more family problems. In addition, 43 per cent of teachers strongly agreed that most people feel uncomfortable when they associate with obese people and 28 per cent agreed that one of the worst things that can happen to a person would be for him/her to become obese. In a study undertaken on health professionals who specialize in obesity (Schwartz et al., 2003), it was found that despite the participants having a clear understanding that obesity is caused by genetic and environmental factors as well as being a function of individual behaviour, they associated obesity with laziness, stupidity and worthlessness, demonstrating a signicant anti-fat bias. If these attitudes are prevalent in staff who are knowledgeable about obesity, it may be that similar attitudes may be found within a school context. Several authors suggest that there is a strong anti-fat bias in many institutions, including schools (Schwartz and Brownell, 2004; Puhl and Brownell, 2001). How widespread anti-fat bias and negative attitudes towards obesity are amongst teachers is unknown, and it is recognised that the research in this area needs to be strengthened (Puhl and Brownell, 2001). Negative attitudes amongst teachers can have serious consequences as they may perpetuate these negative attitudes by passing them onto children and young people (ODea and Abraham, 2001). Before we can begin to reduce the negative stereotyping of obese children there may be a need to help teachers face their own bias. The focus instead should be on helping children maintain a healthy lifestyle (Schwartz and Puhl, 2003). All of the cases above highlight the need for teacher training to be an essential part of any intervention in relation to obesity prevention in school. A recent report prepared jointly by The Audit Commission, The Healthcare Commission and The National Audit Ofce (2006) included the results from consultation with teachers. Teachers in their report asked for better support and guidance, particularly around information and advice for children who were obese or at risk of becoming obese, and also information and advice for parents. In relation to attitudes towards physical activity there is less literature. Almost all has focussed on PE specialists (Guan et al., 2005; Green and Thurston, 2002, Kulinna and Silverman, 2000; Cale, 2000). Fairclough and Stratton (2005) suggest that physical educators are some of the most important people in relation to encouraging young people to achieve their PA targets. Cale (2000) studied the attitudes of some PE heads of department in relation to physical activity promotion. She found that some had very limited view and understanding of physical activity and most related physical activity within their school to sport.

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These research results highlight the need for further investigation in the area of teachers knowledge, attitudes and understanding of both obesity issues and physical activity. This should determine the level of need for further training or support. Teachers as role models The idea of a teacher acting as a role model in relation to obesity prevention and physical activity has the potential to be a very contentious issue particularly in relation to modelling health behaviours. Within the National Healthy Schools Programme the whole school approach can be interpreted as including staff as role-models or exemplars to ensure that pupils are receiving consistent messages through the formal and hidden curriculum (Gordon and Turner, 2001). The issue was rst included in the original World Health Organisation (1993) dening criteria for a Health Promoting School. The recent changes to the NHSS include a criterion that asks schools to encourage staff to engage in physical activity (Department of Health, 2005a). It is not clear if this is linked to the idea of role-modelling or for the health and well-being of the school staff, but there is no similar requirement in the healthy eating theme. Gordon and Turner (2001) found in their study of staff as exemplars that pupils did not tend to use school staff as the reference group that would inuence their own lifestyle choices. The key feature that did inuence pupils was the staff-pupil relationships as the teachers behaviours in this instance impacted on the pupils directly. This notion of positive relationships and communication as a key part of the schools ethos is in accordance with the health promoting schools model. The potential for teachers to transfer their (potentially negative) attitudes towards obesity to children through modelling is a possibility, and one that teachers have little control over (Yager and ODea, 2005). Vicarious learning through the hidden curriculum is an opportunity for the perpetuation of the thin ideal amongst children. Interventions There have been a myriad of school-based obesity prevention programmes used in schools (e.g. Stewart et al., 2004; Warren et al., 2003; Sahota et al., 2001a, b; see also Table II). However, the results of these and other programmes have shown a range of results, making it difcult to establish which strategies or combination of strategies will be effective. Effectiveness itself also varies between programmes/interventions as some programmes are designed to reduce BMI or other anthropometric measures, while others are designed to increase knowledge and awareness, or to establish long-term patterns of behaviour. There have also been several reviews that attempt to establish evidence-based approaches for obesity prevention in children (Doak et al., 2006; Summerbell et al., 2005; Public Health Research, Education and Development Program, 2001). Many, of these, however, have had very strict parameters for their reviews (e.g. randomised control trial approach and anthropometric outcome measures). A summary of the key recommendations from the reviews and other readings are found in Table II. Some aspects of health care clearly lend themselves towards randomised controlled trials and evidence of success of health care treatments are provided for clinicians within the health service in the form of the Cochrane Collaboration. One of the most recent British reviews of obesity prevention in children (Summerbell et al., 2005) was also undertaken as a part of the Cochrane Collaboration. It states that:

388

Study Flodmark et al. (2006)

Recommendations Should be long term Should be large scale Should be throughout society Should be enhanced by mass media Should be enhanced by political action Should include health promotion messages that are tailored appropriately according to ethnicity, age or gender Should be evaluated and published Should impact on both school and home settings Should include stakeholders (families, school environments and others) in the decision-making Should consider the issues impacting on sustainability and environmental change whilst simultaneously addressing behaviour change Should consider the climate of the organisation in relation to sustainability Should be exible and responsive to social and cultural environments Should have active involvement by community members Should be theoretically strong Should have long intervention periods Should include printed materials for children and parents Should focus on fostering positive attitudes toward physical activity Should encourage staff to act as role models Should encourage a family/school alliance

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Doak et al. (2006) Spiegel and Foulk (2006) Summerbell et al. (2005)

Parcel et al. (2003) Lytle et al. (2002)

Public Health Research, Education and Development Program (2001) Steinbeck (2001)

Table II. The role of interventions

This review highlights a paradoxical situation. At a time in which we see obesity prevention nominated as a public health priority, we have only a limited number of studies from which to examine ndings (p. 18).

This highlights the difculty for health practitioners who are encouraged to work in an evidence-based way (Duffy, 2000) but the evidence is not available. Flodmark et al. (2006) suggest that the results of their review, which highlighted the fact that many interventions did not report positive outcomes, could be interpreted to mean that programmes directed only to schools struggle to demonstrate effectiveness. Reasons for these failures may include that interventions have been too short, have only impacted on the school environment and disregarded the impact of the family and home, failure to clearly identify target behaviours for change, poor implementation and difculties in measuring. ODea (2003) has concerns that some obesity prevention programmes, along with programmes designed to prevent body image problems and eating disorders, can be potentially harmful; others have warned that some approaches can do more harm than good in school-based settings (Garner, 1985). These concerns include: . introducing young people to concerns about weight control; . negative focus of food messages contributing to fear of food; . transference of poor body image from educators to pupils; . stigmatisation of pupils whose body weight is outside the normal range; and . labelling of pupils as overweight, obese, lazy.

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ODea (2003) suggests that teachers involved in this type of work need the opportunity to examine their own needs as well as those of their pupils further demonstrating the need for training. Policy context Choosing Health (Department of Health, 2004b) was the rst policy document that demonstrated the governments intentions in relation to childhood obesity. It established a joint PSA between the Department of Health, the Department for Education and Skills and the Department for Culture Media and Sport:
To halt, by 2010, the year on year rise in obesity among children under 11 (p. 43).

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The initiatives that would help to deliver this target included the National Healthy Schools Programme and the PE and School Sport Club Links strategy. Currently, we are two years into a six-year strategy (outlined in Choosing Health) to halt the rising levels of childhood obesity and baseline assessment at a local level have just been established. As part of this target, a baseline assessment of obesity levels of children in primary schools was required from every primary care trust (PCT) in the country. Each PCT was asked to weigh and measure every reception and Year 6 pupil in their area. This took place in the summer of 2006 (in most PCTs) and will provide local authority and country-wide data on childhood obesity levels. The Ofsted framework for school inspections (Ofsted, 2005a) has also changed, with inspectors now looking at the schools contribution to childrens health and well-being, as well as their academic achievement. Schools have to provide evidence about:
To what extent do learners adopt healthy lifestyles?
. .

whether learners take adequate physical exercise, and eat and drink healthily learners growing understanding of how to live a healthy lifestyle (Ofsted, 2005b, p. 9).

There has been a renewed enthusiasm from schools towards the National Healthy Schools Programme, and it is possible that the more direct link between Ofsted and the programme has created that enthusiasm. Within the delivery plan that followed Choosing Health, Choosing Activity A Physical Activity Action Plan under the stated goal of encouraging activity in schools has as an action point continuing professional development programmes that will provide teachers with the knowledge, skills and understanding to recognise and support children who may be at risk from obesity. This commitment to continuing professional development (CPD) for teachers is an interesting and positive feature of the Choosing Health documentation. However, exactly how this CPD opportunity will be made available has yet to be decided and may yet fall at the door of either the local healthy schools programmes or within the role of the school nurse. Summary What this review highlights is the lack of denitive evidence in many aspects of obesity prevention work, particularly in the area of schools and their contribution to this issue this at a time when schools are being placed under increasing pressure to deal with such issues. Further research needs to take place before the pieces of the puzzle start to come together into a cohesive picture. This survey of the literature

indicates that little research has been undertaken to determine teachers knowledge, skills and attitudes, and subsequently their training and resource needs around childhood obesity and/or physical activity.
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