1. Introduction
Childhood obesity is a global issue, and an increasing number of children are becoming overweight and obese. There are approximately 216 million children worldwide who are classed as overweight. All countries are seeing a rise in childhood obesity including low- and middle-income settings. (1) There is also an economic burden; the NHS spent £5.1 billion on illnesses attributed to obesity in 201415. (2)
Obese children are more likely to develop cardiovascular disease and low self-esteem which can affect their productivity. This can lead to poorer employment prospects in the future. (1,3) Furthermore, obese children are more likely to stay obese as they become adults. (4)
The National Child Measurement Programme, (NCMP) 201920 recorded that obesity prevalence among children in reception has increased from 9.7% in 2018-19 to 9.9% in 2019-20. (5) Also, obesity prevalence among children in Year 6 has increased from 20.2% in 2018-19 to 21% in 2019-20. (5)
A socioeconomic gradient exists, where individuals living in the most deprived areas suffer from the worst health, compared to those living in wealthier areas. These inequalities exist because of interactions between access to work, outdoor spaces, education, and exposure to hazards in and out of work. Inequalities affect how individuals can deal with these and become healthier (6) These socioeconomic inequalities start in young children and increase throughout life. (7) This is highest among children who live in the most deprived areas. These children are twice as likely to become obese compared to their wealthier counterparts. (5)
Bristol has some of the most deprived areas including Hartcliffe, Whitchurch Park, and Knowle West. (8) The NCMP recorded childhood obesity rates in Hartcliffe as an increase from 28.6% in 201617 to 32.4% in 2018-19, and in Whitchurch Park, the increase was from 24.8% in 201617 to 28.6% in 201819. (5,9) These obesity rates are some of the highest in Bristol and occur in some of the most deprived areas of the city. (8,9) In addition, 21% of children in Bristol live in income-deprived families. (8) The levels of childhood obesity in Bristol are statistically similar to average; one-fifth of children in reception were classed as overweight or obese, and one-third of Year 6 children were overweight or obese. (9,10)
In Hartcliffe and Withywood, only 45.7% of people living here are physically active. Furthermore, only 27.5% of people play sports once a week compared to the Bristol average of 41% (11) In addition, life expectancy in Hartcliffe is lower than the Bristol average. (4)
The Childhood Obesity Plan 2016 identified key actions in reducing obesity which were sugar and calorie reduction, advertising and promotion, and local areas and schools. (12) Therefore, this healthcare promotion program will use interventions that build on schools and local areas, with a focus on children in reception. (7)
2. Interventions
Dahlgren and Whitehead define the structural determinants of health that lead to inequalities as the environment we are born into, grow, and experience. The greatest level of change can be achieved by changing policy or legislation, followed by strengthening communities, and finally individual behavior change. (13) The following program uses a settings approach and is targeted at children who have a low socioeconomic status. (8,14)
This program aims to reduce childhood obesity by increasing physical activity in schools. Goisis et al. proposed that childhood obesity can be reduced by targeted interventions in young children and by addressing multiple risk factors. (7) There is evidence to suggest that interventions to increase physical activity combined with those to improve diet were the most effective at reducing BMI in children aged 0 to 5 years. In contrast, those interventions targeting physical activity alone were more effective in children aged between 6 to 12 years. (15) This program will focus initially on increasing physical activity.
Schools are at the heart of communities and have the potential to become positive centers for health. (16) This program consists of multiple levels for behavior change aimed at the population, community, and individual. These have been proven to be effective if combined. (4,17) The theory draws upon the Behaviour Change Wheel which informs health promotion interventions. (18)
Stakeholders will need to be engaged and motivated to implement the program. The stakeholders involved in this program are children in reception, families, and primary schools in Hartcliffe and Withywood. (19)
The objectives are for primary schools to ensure children receive a minimum of 60 minutes of physical activity during the school day. This will be supported by schools redesigning playgrounds to facilitate creative play for children in and around the school. Finally, schools will need to convey to children the importance of physical activity through lesson times. This can be achieved through PE lessons where play and teamwork are encouraged between older and younger children in the school, thus, creating positive peer pressure. (20)
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The intended outcomes of this multi-level approach are to increase physical activity in reception children, and therefore reduce BMI. (14) This is important in Bristol which, has a high population of children under the age of 5 living in areas of deprivation. (4) The goal of this program is for children to be receiving a minimum of 60 minutes of moderate to vigorous physical activity every day. (21)
i. Population-level change
This intervention focuses on policy change which exists on the outer circle of the Behaviour Change Wheel. Interventions aimed at the population by informing policy can have the biggest impact on behavior change as they target upstream factors. (14) Additionally, evidence has shown that changes in policy can result in behavior change at all levels; individual, community, and population. (17)
The government currently provides funding for all primary schools to ensure adequate levels of physical activity are provided during school time. At present, the requirement is a minimum of 30 minutes. (22) NICE guidelines state that children should be getting at least 60 minutes of physical activity daily. (23) However, given that levels of childhood obesity are increasing, the minimum level of physical activity provided by schools should be set at 60 minutes. (5) At present only 17.5% of children meet the minimum of 60 minutes of exercise per day. Furthermore, most of these children are from deprived areas. (16) Primary schools are important in addressing this issue as it has been shown that rates of obesity doubled in children aged between 5 and 11 years old. (24)
By creating this policy, schools will be responsible for children's physical activity, and ensure it is incorporated into other lesson times as well as PE (21,25) The Chief Medical Officers have recommended that schools prioritize physical activity for all children to ensure they achieve 60 minutes per day. (3)
It has been shown by the active mile' program that primary schools can be highly effective at increasing levels of physical activity in all children. This program had children running a mile each day. Teachers had flexibility in when the mile was taken, and the school had a route mapped out for children and staff to follow. This was successful in ensuring that children were getting a minimum of 60 minutes of exercise daily. (16,24)
ii. Community-level change
Schools are well placed for improving health, with good facilities for physical activity such as playgrounds and green spaces. Furthermore, children have access to these spaces daily. (26) An example of an intervention carried out by a primary school was to change the playground layout to make it more engaging for students. This led to a 20% increase in community activity and a 36% increase in physical activity across the school'.(16) Furthermore, studies have shown that strengthening communities by using school-based interventions has been effective in reducing childhood obesity. (14) This satisfies Chief Medical Officers' recommendation on ensuring that play areas for children are built, looked after, and safe to use. (3)
In Hartcliffe and Withywood there are no outdoor spaces for organized sports, and only one school field is available for hire outside of school hours. Furthermore, there is only one children's play park in Hengrove. (27) This follows the trend where areas of deprivation have fewer green spaces and safe outdoor areas. Access to outdoor spaces has been shown to reduce obesity by increasing physical activity. (24) Therefore, an intervention to redesign and open school playgrounds to the community will significantly benefit the children attending the school, and those living nearby. This adheres to NICE guidance recommendations to ensure schools make their facilities available outside of school hours for the community. (16)
Schools will need to nominate a coordinator and engage the local community. Families and schools must work together as both have a responsibility for ensuring children stay healthy. The primary spaces fund is available for schools to help with set-up costs, but the school can also encourage parents to join the project and help design the new playground. (16,26) This new outdoor space can be utilized by the local community outside of school hours. For example, by families before and after school or community clubs in need of outdoor space. Thus, this will increase the number of acceptable outdoor spaces in Hartcliffe and Withywood and will overcome the barriers faced by many parents who cannot find local, safe spaces for their children to play in. (28)
iii. Individual Level
Individual-level interventions are the least effective at bringing about behavior change. Therefore, it is more effective to combine these with interventions that target the community and the obesogenic environment. (13)
Teaching children in schools about healthy lifestyles should begin in young children to enable them to carry these behaviors through to adolescence and adulthood. As shown by the evidence, obesity increases during primary school years. (5)
An example of a successful school-based intervention aimed at individuals was the food dudes program. This was carried out initially in a group of 450 children who were taught about different fruit and vegetables, they were then encouraged to eat more healthy foods by 'Food dudes' and rewarded for trying new foods. The food dudes' were cartoon characters who were portrayed as positive older role models. The program was successful in increasing the fruit and vegetable intake of children, and this behavior was sustained in schools and at home. (20) The program has since been tested on thousands of children and has been shown to be highly effective in promoting healthy eating. It also showed that positive outcomes can be achieved by creating an environment that is supportive and offers rewards to children. Children look to copy older children so they can be like them. (20)
To promote physical activity in children, a similar model can be applied in schools where older children are seen to be active and taking part in games. Teachers can use this positive peer pressure to show children the variety of physical activities that can take place inside and outside of schools. This model of mentorship is supported by studies on changing individual-level behavior and has proven to be successful in preventing weight gain in children. (14)
Primary schools can look to hold joint PE lessons with older children and encourage them to work together as a team. The seafood dudes program identified that children are more likely to respond to older role models if they are part of a group. Furthermore, children responded well to the program as the food dudes' were heavily branded. Schools can become a brand by utilizing the school logo on PE kits and choosing a school mascot as a friendly figure that children can respond to.
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