Introduction

Top Abstract Introduction Participants and methods Results Discussion References

The prevalence of childhood obesity is increasing throughout the world.¹ Within the United Kingdom, estimates of obesity range from 6% in preschool children² to 17% by age 15. ^{3 4} Because obesity may track into adulthood⁵ and adult obesity is difficult to treat, prevention strategies are best targeted at children. ^{4 6 7}

Most obesity interventions have taken place in clinical settings. However, schools also provide an opportunity for preventing and treating obesity. ^{4 8 9} Most school based approaches have targeted obese children, with most success in primary school aged children.¹⁰ An alternative strategy is to implement a primary intervention health promotion programme aimed at all pupils. Again, these initiatives have had some success in the United States,⁸ although more specific interventions targeted at the different factors influencing children's eating and physical activity behaviours (classroom education, food service, parents) may be needed.⁹

Despite major resources being deployed towards encouraging health promotion in schools in the United Kingdom, no rigorously designed intervention studies of programmes targeting obesity have taken place.¹¹ Health promotion programmes are unlikely to be successful if the programme is of poor quality or has not been efficiently implemented.¹² This paper describes and evaluates the implementation of a health promotion programme in primary schools to prevent risk factors for obesity. The outcome measures relating to weight, diet, and activity, which we evaluated by a randomised controlled trial, are reported separately.¹³

	Participants and methods

Top Abstract Introduction Participants and methods Results Discussion References

Intervention programme
The active programme promoting lifestyle education in school (APPLES) was designed as a multidisciplinary, multiagency programme using a population approach that was underpinned by the Health Promoting Schools philosophy.¹⁴ This philosophy aims to link the school with family and community and focuses on the whole school ethos, including its policies, management style, and attitudes of staff, so that consistent health messages are given and received.

Participants
Ten state primary schools in Leeds were enrolled into the project as described in the accompanying article.¹³ Sociodemographic measures suggested that they were somewhat advantaged schools, with 1-42% of children from ethnic minorities and 7-29% entitled to free school meals (compared with 11% and 25% for Leeds children as a whole).

Design and development of intervention
To inform the design and development of the intervention, questionnaires were administered to all school staff, including secretarial and catering staff, and parents of year 4 and 5 pupils. The questionnaire asked for views about the importance of education on nutrition and physical activity and whose responsibility that should be. In addition, parents were asked about changes they would like to see in school and information they would like to receive. The responses from these questionnaires were used by schools to develop the school action plans. The progress towards these targets was monitored by regular staff meetings and surveys of packed lunches, breaktime snacks, and playground activities

Focus groups
To determine the effect on children's levels of knowledge and attitudes towards healthy living, we held focus groups in schools at the end of the first year. Details are available in the accompanying paper.¹⁴

	Results

Top Abstract Introduction Participants and methods Results Discussion References

We received questionnaires from 124 school staff before the intervention (62 teachers, 13 non-teaching assistants, 23 special needs assistants, 17 catering staff, and 9 administrative staff). The questionnaire administered by pupil post was completed by 410 (64%) of parents; response rates ranged from 39% to 85% between schools. Table 1 shows the responses of parents and staff to questions relating to the importance and relative responsibility of home and school in engendering a healthy lifestyle in children. Table 2 shows the changes in the school environment that parents hoped to see and the information they felt would be useful. Feedback to the questionnaire and changes within the school were circulated to parents during the year.

Response rates
Table 3 shows that data were available for over 90% of pupils for most measures, indicating excellent participation in the programme by schools and staff. Response rates for the three day diet and activity diaries were satisfactory and indicated a good level of commitment by both children and parents.

Support and training
Nineteen out of 20 teachers attended the training sessions. In anonymous questionnaires at the end of the intervention, all reported that they found the training useful, that the resources were useful and they would continue to use them, that support during the project was good, and that they had an increased awareness of healthy eating and physical activity among pupils.

School action plans
All schools elected to incorporate nutrition education into the curriculum, with additional sessions supplied by the project manager (table 5). They also included a "fit is fun" programme in physical education lessons and undertook to improve their health resources. In total, there were 85 action points with six to 14 points per school plan; 76 (89%) of these points were successfully achieved. Reasons for not achieving action points included shortage of time, staff sickness, and impending inspection by government teaching standards officers.

School meals
Given the emphasis on healthy eating, school meals were an important aspect of the assessment. Positive changes were seen in all schools (table 6).

Focus groups
Compared with other children, children who had received the intervention showed greater understanding of the health benefits of diet and physical activity; sophistication of ideas and vocabulary expressed; willingness and confidence to share their ideas as well as basic knowledge. They also reported behaviour changes and were more able to recollect topics learnt and activities in school linked to diet and physical activity.

	Discussion

Top Abstract Introduction Participants and methods Results Discussion References

The evaluation of the implementation of this programme to reduce risk factors for obesity in children shows that the project was successful. Parents and school staff clearly felt that school was an important site for influencing children in their lifestyle and were supportive. The response rates for questionnaires were high, reflecting the children's and staff's eagerness to participate and commitment to the project. The schools were ready to accept support and input at both the school and classroom level.

The results also show that the programme had a noticeable effect in the schools. Eighty nine per cent of the action points in the school action plans were implemented, and there were positive changes in classroom health education, the physical education programme, and the school food service.⁹ School meals were also improved.

The focus groups supported the sense that the programme had had an effect at school. The children who had participated in the project readily and enthusiastically recalled the activities in which they had been involved. These children also scored higher than did children who had not yet received the programme in terms of knowledge of healthy eating, physical activity, and links between diet and health including obesity. They also attained higher scores for self reported behaviour change.

Ways to tackle obesity
Schools provide an excellent opportunity for preventing and treating obesity.^7-9 They offer continual regular contact with children and opportunities for nutrition education and promotion of physical activity both within the formal curriculum and informally through a supportive environment such as healthy school meals and breaktime snacks.