Last week there was a lot of news and online activity around the story of “school anti-obesity plans don’t work” [i]with lots of people asking ‘well, what now?’
Too often governments look to school education programmes to solve so many of our social, health and environmental challenges. What do we do when we discover the evidence is that they don’t work?
First of all we shouldn’t be surprised. We attach great importance to early influence through primary and secondary education, but we also know that an over-reliance on educational messages without structural changes to the environment around us will have limited impact. The changes we need are most likely to be achieved by regulatory and fiscal measures. We cannot expect classrooms of children suddenly to rebel against a celebrity’s endorsement of a junk food product just because a health professional stood up in a classroom for a few weeks and told them how important it was that they ate their veg! An oversimplification? - yes, but currently the odds are stacked against all of us making the healthy choice. Educational messages on their own can’t cut through that.
Secondly this isn’t news; a similar finding was made in Scotland in 2013. After the Obesity Route Map’s publication in 2010, a programme of Child Healthy Weight measures was rolled out across Scotland with the purpose of achieving 14,910 completed child healthy weight interventions over three years. The target was exceeded but childhood overweight and obesity rates did not change. So what did we learn? Be clear about the aim and be careful with the target. In the rush to engage with as many children as possible most Health Boards rolled out school-based interventions as opposed to one-to-one, or small group interventions. A review of the programme concluded that the model of delivery was dominated by school-based interventions – which, while offering greater coverage, have more limited impact than group and one-to-one interventions. The review also concluded that if the aim was to reduce child overweight and obesity in Scotland by bringing about notable behaviour change, then we need to think again about the delivery model.
The recent BBC news coverage referred to the results of the WAVES study[ii], also this month findings from HeLP [iii]were released. Both were school-based interventions. The conclusions of both were that the programmes had not been effective in affecting BMI and that such interventions needed be part of a wider co-ordinated, whole systems approach.
So should we stop school education programmes? No. Absolutely not. Engaging directly has an important role to play, especially in childhood when habits are forming, but we need to think about the learning objective, content, focus and their role within a range of much wider actions to tackle obesity.
Amsterdam is the first area in the world to see a reduction in childhood obesity rates, and schools played an important part in that. What is different about their schools programme? The outcome is actual behaviour change. They don’t just pass on healthy eating messages but support schools to deliver and implement change by creating an environment in which it is easy to be healthy. For a school that has received JumpIn status the only snack allowed at morning break is fruit, the only drinks allowed in school are water and milk, every child’s birthday is celebrated with a healthy snack, and clear guidance is issued on packed lunches. Treats are allowed but each school has a clear policy on what events/festivals/celebrations are marked with treats, agreed with parents and pupils. Yes, this involves rules, but the programme is delivered through partnership working and a will to change, and it is making a difference. This work is supported by other changes in communities and other structural changes within the municipality’s control such as the installation of a network of water fountains.
We also need to accept that schools cannot tackle obesity on their own. We need to change the environment around us so that it is easier for children and adults to make the healthy choice. Children in Amsterdam are not only encouraged to drink tap water but also are given water bottles and it is easy to find water fountains at school and on the streets. In Scotland, children may hear a healthy eating message but then they watch TV and are bombarded with slick, enticing fast food ads or go into school dinners to be offered chocolate cake or stop in at a shop and can buy 2 chocolate bars for pennies more than a single bar. It is a struggle to remember the healthy eating message, never mind act on it.
Perhaps last week’s story should be framed differently as:
'Effective schools programmes must be part of the solution but they are only likely to work if they are accompanied by structural changes to the environment around us'.