School And Obesity

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Author(s):

	Wendy Van Lippevelde
	Zakstraat 9, 9300 Aalst East-Flanders, Belgium Mobile phone: +32 (0) 486 155580 / Email: Wendy.VanLippevelde@ugent.be
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	Caroline Braet
	Caroline Braet, Ph.D., is a professor in the Department of Developmental, Personality, and Social Psychology at Ghent University in Belgium.
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Introduction 

For understanding and forcing back obesity in youth, focusing on the context of children’s and adolescents’ health behaviours is warranted. From a socioecological perspective, the school context is one of the most important environments to tackle for preventing and decreasing overweight and obesity in youth (Langford et al., 2015). This chapter summarizes some important challenges. First, this chapter will describe how children and adolescents’ weight issues might be related to school performance, and put an emphasis on the detrimental consequences of weight stigma. Second, we will elaborate on the socioecological perspective on obesity, and the importance of the school context in tackling overweight and obesity in youth. Third, this chapter focuses on the possibilities of obesity prevention strategies. To conclude, light is shed on the school-parent partnership in obesity prevention and what future research should focus on towards achieving it.  

The negative consequences of childhood obesity in a school context: academic performance and stigma 

Besides the well-known negative biopsychosocial consequences of childhood obesity (WHO, 2020), one often neglected is the impact on academic performance within the school context. A lot of uncertainties remain about the exact relationship between weight problems and academic performance in youth, merely because of a lack of empirically sound longitudinal studies as well as a large heterogeneity in both age and conceptualizing performance (Santana et al., 2017).  

Nonetheless, it could be hypothesized that stigmatization, more than scholastic capability, plays a crucial role in the association between obesity and academic performance (Langford et al., 2022). After all, although a few studies report lower executive functioning in you with obesity – an important process regarding academic performance – (e.g. Naets et al., 2020), no consistent evidence associates obesity to scholastic abilities in children or adolescents (Afzal & Gortmaker, 2015). The connection between stigmatization and academic performance, however, is well established. Lessard et al. (2021) found that in adolescents with high body weight, especially those who experience weight-biased victimization (i.e. mainly mistreatment from peers), had lower grades. The study of Livermore and colleagues (2020) showed that children with obesity tend to label their school performance as low to mediocre in comparison to peers and that the perception of “deviating from the right weight” can predict lower academic success. Monzonis-Carda and colleagues (2021) demonstrated that weight status can affect the association between depressive feelings – also an important factor to consider in paediatric obesity (Van Vlierberghe et al., 2009) – de  and low academic performance in adolescents. The presence of stigmatisation cannot be underestimated. Youth with weight problems are at great risk of being stigmatized (Fields et al., 2021; Gmeiner & Warschburger, 2020; Puhl et al., 2018), mainly because obesity is mistakenly perceived as a result of controllable unhealthy choices instead of the result of the complex interplay between biopsychological factors (Haqq et al., 2021). Based on the perspectives of Cooley’s looking glass self (Cooley, 2017) and Goffman’s social stigma (Goffman, 2009), the stigmatization of obesity can create a climate of negative social feedback – either real or perceived – that can fester low academic performance because of its connection with low self-efficacy, emotional and behavioural problems (Crosnoe, 2007; Haqq et al., 2021; Palad et al., 2019; Puhl & King, 2013).  

The school environment is an important context in which stigmatization can occur (Lessard et al., 2021; Nutter et al., 2019), as well as in which several determinants of health behaviour can be tackled to curb childhood obesity. Health behaviour models and frameworks such as Social Ecological models (McLeroy et al., 1988; Sallis et al., 2015; Stokols, 1992) and the Environmental Research framework for weight Gain (EnRG) (Kremers et al., 2006) highlight the importance of environmental influences on health. These models are crucial for understanding today’s “obesity epidemic”,  as the contribution of the obesogenic environment in that epidemic is of major significance (Hill et al., 2003; Organization, 2003; Rendina et al., 2019). Therefore, the following section focuses on the influence of the school environment on childhood obesity. 

The school environment and childhood obesity 

Since the 1970s, the obesogenic environment has been recognized as an important factor in explaining the presence and increase of obesity, and several models were created to conceptualize this ecological perspective (Cabrera, 2024; Jia, 2021). For example, the ecological model of Bronfenbrenner (Bronfenbrenner, 1992) focused on several systems or “layers” surrounding the child with obesity (i.e. the micro, meso, exo and macrosystem). Later, Swinburn and colleagues (Swinburn et al., 1999) developed the ANGELO- (ANalysis Grid for Environments Linked to Obesity) – framework, and included four distinct types of environments that combine these layers and identify important social determinants of health behaviour and obesity. The (1) physical determinant refers to the availability of (un)healthy food and opportunities to be physically active, the (2) economic determinant refers to the cost of health behaviours and the promotion of (un)healthy products via marketing, the (3) political determinant refers to health rules, laws and political ideologies, and (4) the socio-cultural determinant refers to social norms, expectations and influence on health behaviour (Swinburn et al., 1999). The ANGELO framework can be complemented with individual health behaviour models (Figure 1), including an individual’s (1) physical and psychosocial capability and (2) reflective and automatic motivation.  This framework has been used frequently to identify and change determinants to curb childhood obesity (Cabrera, 2024; Jackson et al., 2021). The systematic review of Jackson and colleagues (Jackson et al., 2021) found that worldwide, most guidelines to prevent childhood obesity consistent with the ANGELO model are well-aligned with research evidence, most frequently in the physical (e.g. limiting sedentary behaviour or engaging children in active play) and socio-cultural environment (e.g. promoting the benefits of physical activity or educating parents about proper sleep).  

Figure 1: Behaviour Wheel (Flanders Institute for Healthy Living, 2020) 

Especially through a socioecological perspective, schools are recognized as one of the most important contexts in which these determinants cultivate. The food environment and physical activity are very important in supporting or discouraging health behaviours. 

First, Harrison and Jones (2012) conducted a systematic review investigating associations between the physical school environment and diet, physical activity, and adiposity and found evidence for the influence of the physical school food environment on children’s and adolescents’ food consumption (Harrison & Jones, 2012). According to the authors, the availability and accessibility of unhealthy foods (i.e., sugar-sweetened drinks; low nutrient energy dense snacks; unhealthy la carte lunch programs) from school canteens and vending machines contribute to a higher consumption of unhealthy foods, a lower intake of fruit, vegetables and milk products and greater odds of obesity. Ohri-Vachaspati and colleagues (Ohri-Vachaspati et al., 2023) concluded that an unhealthy food environment of the school and its surrounding community is associated with a higher number of children suffering from obesity, and contributes to an increase in obesity rates over time. 

Next, Ferreira et al. (2005) showed in their review that school-related PA policies (i.e. time allowed from free play; time spent outdoors; and number of field trips) were associated with differences in children’s weight.  de Souza et al. (2024) identified a significant relationship between children’s weight and the amount and intensity of physical education classes, break duration and the availability of indoor sport courts. Especially adolescents are at risk, as physical activity tends to decrease in comparison to primary schools (Li et al., 2024).  

Of course, it needs to be acknowledged that schools are imbedded into broader macro-environmental settings including communities, health systems, governments and food industries (Bronfenbrenner, 1992; Cabrera, 2024; Swinburn et al., 1999). Nonetheless, schools are an important context factor in the life of children and adolescents, and obesity prevention at this level is an important pathway to curb the obesity epidemic. 

Obesity prevention in the school environment 

Given the importance of the school context and that children and adolescents spend a lot of time there, schools also have a large responsibility in health promotion (i.e. health education lessons, the creation of a PA promoting playground; provision of healthy school meals) (Dietz & Baur, 2022; Story et al., 2006). The WHO started a Global School Health Initiative in 1995 to facilitate health promotion via the implementation of health promoting schools (HPS), aiming at schools that continuously foster health behaviour in children as well as in personnel (WHO, 2021). Although most studies investigating the effectiveness of HPS in the past were of rather low quality (McHugh et al., 2020), we can state that nutrition promotion programs using the HPS approach remain promising in improving dietary behaviours (McHugh et al., 2020).  

There seems to be a lot of variety between the strategies schools adopt to install healthy lifestyle habits in order to prevent obesity (Smit et al., 2023), in terms of single or multicomponent strategies (i.e. nutrition education only or combined with other interventions) and outcome (i.e. intake, physical activity, weight status, etc.). That is at least one of the reasons why recent meta-analyses were not able to show robust effects, such as in studies of Smit and colleagues (2023), Nury et al. (2022) and Sal and Bektas (2022) finding no long-term effects of primary and secondary school-based obesity prevention strategies on weight. Nonetheless, school-based obesity prevention remains a cost-effective strategy (Ananthapavan et al., 2020; Xu et al., 2020) as a lot of studies found that well-designed and well-implemented school-based interventions have positive effects. For example, Nury et al. (2022) did show a moderate improvement in fruit and vegetable intake after preferably multicomponent nutritional interventions. The systematic review of Pineda et al. (2021)  showed significant effects on weight status and fruit consumption of interventions changing the food environment within and around schools. The multicomponent “Health Buddies” program in Canada of Nickel and colleagues (2021) was effective in reducing weight circumference, dietary intake, healthy living knowledge and self-efficacy. On a long term, Bere et al. (2014) showed that offering free fruit in primary schools in Norway was related to a decrease in weight status 4 years later. Jurić et al. (2023) implemented a real-world population-scaled physical activity intervention at schools (adding weekly physical education lessons) for children between 6 and 14 years old in Slovenia, and found  significant effects on weight status after 3 and 5 years. Nonetheless, several well-designed studies fail to find substantial improvements, such as that of Lloyd et al (2018) in the UK  finding no effects on body weight and circumference or dietary intake. Pineda et al. (2021) formulated some lessons learned and advised (1) to use clear and precise dietary guidelines and standards according to the most recent scientific insights, (2) to monitor interventions and pay attention to implementation barriers and facilitators, (3) to realize that fruit intake might be easier to change than vegetable intake, and (4) to properly address social inequalities.  

Of course it should be noted that children also spend a significant amount of their time at home with their parents, and it is likely that engaging parents and focusing on these parenting practices in obesity prevention interventions will enhance the long-term impact and sustainability of obesity prevention efforts (Okely & Hammersley, 2018). Consequently, parents should be actively involved in obesity prevention efforts too. In the following section, an overview of the current knowledge is provided concerning parental involvement in school- based obesity prevention including evidence about effectiveness of parental involvement, used strategies to involve parents and target parenting practices, and characteristics of participating parents in school- based obesity prevention. 

The role of parents in school-based obesity prevention 

The Lancet stated that partnerships between schools and families at home can be the missing piece in obesity prevention (Okely & Hammersley, 2018), as parents are equally indispensable when curbing obesity in youth (Aleid et al., 2024). Unfortunately, two problems arise.  

First, methodologically sound research anno 2024 on specific parental involvement in obesity prevention is rather scarce, as most studies and reviews (e.g. Nury et al., 2022; Peters et al., 2009; Sal & Bektas, 2022; Smit et al., 2023) do not differentiate between parental and school involvement and do not examine the specific added value of parental influence (Kovács et al., 2022). Most efforts to involve parents are part of more comprehensive interventions (Hingle et al., 2010). The umbrella review of Tomayko et al (2021) incorporated systematic reviews and meta-analyses of interventions (both preventive as curative) that described parental involvement and found 14 studies ranging from high to low quality. They concluded that including a parent component can be beneficial, but defining parental involvement remains challenging and further research on the specific added value is crucial. One exception, the study of Lippevelde and colleagues (2012), investigated the added value of the parental component in obesity prevention. Not surprising, only five studies could be extracted and because the identified studies had inconsistent findings, this review could not provide conclusive evidence about the specific contribution of parental involvement to the effectiveness of school-based obesity prevention (Van Lippevelde et al., 2012).  

Second, earlier studies emphasized the attrition challenge; e.g. the difficulty to involve parents adequately in school-based interventions (Gentile et al., 2009; Posey-Maddox & Haley-Lock, 2020). Parental adherence remains an issue, but cannot be blamed to unwillingness and is rather explained by factors such as readiness to make behavioural and parenting changes (Schmied et al., 2023). One of the important factors to evolve towards parental engagement in schools is parental attitude and self-efficacy (Goodall & Montgomery, 2023). Clarke et al. (2015) qualitatively investigated parent perceptions of school-based obesity prevention in the UK. Parents acknowledged the importance of school-based interventions, but they felt that parents remain the main ones responsible for their children’s healthy lifestyle and simultaneously faced several barriers (e.g. time, financial means) delivering that responsibility (Clarke et al., 2015). Some parents were also worried about whether the time invested in health promotion at school might interfere with the time spent on education, and they were also concerned about whether a focus on healthy habits might induce eating disordered ways of thinking (Clarke et al., 2015). The authors advice to educating and empowering parents, supported by the school. Van Lippevelde and colleagues (Van Lippevelde et al., 2011) also investigated strategies to increase involvement of parents parents in school-based obesity prevention. They conducted focus group research in four European countries with parents of 10- to 12-year-olds to get more insight into parents’ perspectives about parental involvement in school- based obesity prevention. In line with the study Clarke et al. (2015), parents considered it to be mainly their own responsibility to provide healthy food and to prevent sedentary behaviour, but this study did show that parents think that schools are equally responsible in terms of promoting physical activity. The parents in the study mentioned interactive and practical activities together with their child as the best way to be involved in school-based interventions, such as cooking, food tasting, and nutrition workshops, walking or cycling tours, sport initiations together with their child. Activities should be cheap, on a convenient moment, focused on their children and not on themselves, not lecturing nor theoretical, and at school or home.  

Across all aforementioned studies, authors highlighted that it is difficult to determine whether or not parental involvement positively impacts on outcomes and to identify which strategies to engage parents were most effective. This is due to the heterogeneity in study design, study quality, outcome variables and measurements used to assess outcomes, and the poor description of intervention fidelity, dose, and exposure. Consequently, future research should try to solve this lack of clarity about the importance and effectiveness of parental involvement in obesity prevention by designing studies in such a way that it will be possible to extract the added value of the parental component. However, alternative strategies and channels to effectively target the home environment and parenting practices also need to be explored, i.e., community-based interventions.   

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