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<b>SCHOOL- BASED UNIVERSAL PREVENTION PROGRAMS </b>

<b>FOR PEDIATRIC OBESITY: STATE OF THE LITERATURE, </b>

<b>FUTURE DIRECTIONS, AND POLICY IMPLICATIONS</b>

Tran Thanh Nam, Assoc.Prof.PhD1
<b>Abstract: Pediatric obesity is a growing public health concern. To date there </b>

has been limited success with childhood obesity prevention and interventions.
This may be due in part, to the challenge of reaching and engaging partners
in preventions and interventions. Among partners, schools provide an ideal
place to provide preventive health services. The goal of the current paper is
to discuss the roles of schools in preventing pediatric obesity and overweight.
Specifically, the current paper will discuss the rationale for targeting schools
for prevention efforts, results of school-based research and education
programs, areas for further research, and policy implications of the research
findings which can be applied for Vietnam.

<b>Keywords: pediatric obesity; school-based prevention programs; literature </b>

review; policy implication

<b>1. Introduction</b>

Pediatric obesity is a growing public health concern. In 1974, roughly five
percent of youth were considered obese; in 2002, roughly 15 percent of youth were
considered obese (CDC; 2005). Although there are many explanations for why
children are becoming more obese, it is clear that interventions and policies are
needed to address this issue. Childhood overweight is such a widespread problem
that the World Health Organization suggests that preventive public health policies
are needed to effectively address this problem (James & Kerr, 2005; WHO, 1997).

Schools provide an ideal place to provide preventive health services. Thus, the
goal of the current paper is to discuss the roles of schools in preventing pediatric
1 University of Education – Vietnam National University, Hanoi;

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obesity and overweight. Specifically, the current paper will discuss the rationale for
targeting schools for prevention efforts, results of school-based research programs,
areas for further research, and policy implications of the research findings.

<b>2. Childhood obesity in Vietnam</b>

Childhood obesity is a rising health concern in Vietnam, however, research
in this area is not extensive. Obesity is a risk factor for the onset of diseases such
as type II diabetes, cardiovascular diseases, stroke and other metabolic disorders.
Childhood obesity is equally concerning, where excessive fat mass can affect many
of the body’s systems from an early age. Children who are obese are at greater
risk of being obese as adults. In terms of quality of life, obese children can find
movement and breathing difficult and uncomfortable. They also tend to be less
self-confident with their appearance.

According to Thanh CTY, Khan NC, Dat DT, 2004, in 1995, the prevalence
of childhood obesity among primary school children in Ho Chi Minh City was
1.4% according to the CDC definition of obesity (BMI >95th percentile).5,6
Then, prevalence rose to 10.4% during 2002-2003, 16.3% in 2007,7 and 20.8%
in 2008-2009 (International Obesity Task Force definition of overweight and
obesity). Similarly, the figure was 10.4% in Hai Phong City (2000), 5.8% in Nha
Trang (2001), and 10.4% in Buon Ma Thuot (2004) (Thanh CTY, Khan NC, Dat
DT, 2004). In 2012, a survey on over 3,000 children at primary schools in Hanoi
showed that 23.4% of them were overweight and 17.3% were obese. Another
survey conducted in 2013 on 2,375 children aged 4-9 years at kindergartens and
primary schools in the city’s Hoan Kiem district, Hanoi, Vietnam indicated that the

overweight and obese rate was 39.9%; more boys were obese than girls. Among
over 150 overweighed and obese children, 15.3% of them have high cholesterol
levels. As much as 82.7% of those children were physically inactive for over 120
minutes per day, while 18.7% consumed more calories than recommendations. In
Ho Chi Minh City, within seven years from 2002 to 2009, the rate of overweight
and obese grade-schoolers increased by three to four times. Head of the department
Tran Dac Phu said the heath sector should build a proper strategy to prevent obesity
among children and implement effectively the national strategy of preventing
non-communicable diseases in 2015-2025 (Vietnam: Childhood obesity on the rise;
2016, Jul 26)

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<b>3. Targeting Schools </b>

School-based interventions and policies provide a natural setting for the
prevention and intervention of pediatric overweight and obesity. Schools provide
an established institution with corresponding infrastructure that will capture the
target population. About 95% of youth attend school (Story, Kaphingst, & French,
2006) and there are a variety of way in which schools can impact children’s
weight and health status including promoting “good nutrition, physical activity,
and healthy weights among children through healthful school meals and foods,
physical education programs and recess, classroom health education, and school
health services” (Story et al., 2006), p. 110).

Despite the promise that the school environment has a positive impact on
student weight and general health, many of the practices that commonly occur
in school settings can actually have a negative impact on student weight. One
commonly cited concern is the availability of a la carte, food courts and vending
machine items (Kubik, Lytle, & Story, 2005) that sell non-nutritious foods and
sweetened beverages. Many school districts have signed contacts with fast food
and beverage distributors as a source of revenue to supplement shrinking budgets

(Story et al., 2006). Another practice that is likely to have an impact on children’s
weight status is the lack of adequate physical activity through structured physical
education classes or unstructured play periods such as recess. Some investigators
have suggested that the No Child Left Behind Act of 2001 forces schools to cut out
non-academic subjects such as health and physical education classes so that they
can focus more on the academic subjects that are being tested (Story et al., 2006;
Wiecha et al., 2004).

However, despite the trend towards policies and practices that are inconsistent
with a health promotion message, these policies and practices could be modified or
reversed to bring them more in line with a healthy weight message. For example,
many schools provide meals for students through the Federal School Lunch
Program that are in competition with the high-fat, low-nutrient foods that are
typically offered by for-profit companies (Story et al., 2006). The infrastructure
for having an impact on children’s health is present, but needs to be modified to
take full advantage of its influence. Thus, since schools are already providing these
services, it is easier to help them provide the most appropriate services rather than
starting from the beginning and developing infrastructure.

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overweight children who are not able to enroll in medical center based intervention
programs and those who are at risk for becoming overweight in the future (Ells,
Campbell, Lidstone, Kelly, Lange, & Summerbell, 2005). Second, universal
prevention programs in schools will potentially be able to modify factors promoting
obesity on both environmental and individual levels. An environment that is
reinforces healthy weight messages is more likely to support students’ efforts than
one that contains influences that are inconsistent with health promotion and obesity
reduction. Finally, school-based programs allow students to participate in activities
with their peers and have the potential to provide peer-group reinforcement and
decrease the stigma associated with participating in such a prevention program and
improve outcomes.

<b>4. Research on School-based Prevention Programs</b>

Several review papers have highlighted the current state of the research on
prevention programs in schools. A recent conceptual paper reports that of eight
recent school-based prevention programs, one was targeted towards improving
health, two were targeted towards increasing physical activity, and five consisted of
multiple components (Ells et al., 2005). Reductions in weight as well as sedentary
time were found for the health promotion and multiple component programs though
there were no effects for the physical activity programs. Unfortunately, the original
research articles that were summarized in this paper are not widely available and
thus it was not possible for the author of the current paper to review these studies
for more specific details.

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The school-based obesity prevention literature is balanced out by several
well-designed programs of research in this area. One prevention in German schools
contained eight hours of education about lifestyle choices including eating fruits
and vegetables, reducing the consumption of high-fat foods, increasing physical
activity to one hour per day and decreasing television watching to one hour per day.
At the three-month follow-up, children in the control schools had increases in their
fat mass while children in the prevention schools did not (Muller, Asbeck, Mast,
Lagnase, & Grund, 2001). The results of this study suggest that a minimal amount
of education can have an impact on the body mass of students.

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that are taught in different subject areas with classroom teachers who volunteered
to participate in the study (Spiegel & Foulk, 2006). The modules were designed to
be integrated into core classroom curricular activities. In addition, participants in
the prevention group exercised with a 10-minute exercise video each day. Those
in the intervention group decreased their BMI by 2% and there were significantly
less children in the intervention group classified as overweight or as being at risk

for overweight. Although both groups increased their consumption of fruits and
vegetables, the intervention group had a greater increase. The intervention group
also showed a significantly greater increase in physical activity both at school
and outside of school. This study is notable in that the educational component
is incorporated into multiple subject areas which reinforces the messages learned
across contexts as well as being consistent with educational goals.

In summary, school-based prevention efforts are likely to be effective in
reducing obesity and improving other health-related behaviors such as decreased
television viewing and healthier food choices. The results of a recent
meta-analysis summarizes the effectiveness of school-based interventions reported the
<i>effect size to be .50, a medium effect according to Cohen’s d (Haddock, Shadish, </i>
Klesges, & Stein, 1994). The meta-analysis also shows that parent participation at
the medium level resulted in a large effect size while other levels of participation
were associated with medium effect sizes. Despite the promising results of these
prevention programs, further research is needed.

<b>5. Future Directions</b>

Several steps need to be taken in order to ensure that universal prevention
programs for children are effective. First, more studies should be conducted to
determine the effectiveness of a wide-range of prevention programs. Current
prevention programs have mostly been tested in middle-school aged student
without corresponding efforts at examining these programs in elementary and
high school students. Elementary and high school students are likely to benefit
from preventions as well and it is important to ensure that the programs are
developmentally appropriate and are acceptable within the unique environment of
each type of educational setting. Research efforts should also focus on determining
the ages at which particular kinds of prevention efforts are most effective.

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example for a program that could be easily adapted into a universal program.
Carrel, Clark, Peterson, Nemeth, Sullivan, and Allen (2005) selected children with
BMI’s greater than the 95th_{percentile and randomly assigned them to standard}

gym classes or lifestyle fitness classes. The lifestyle fitness classes were designed
to maximize the amount of physical movement engaged in during each class and
make fitness and nutrition more appealing to children by being ore fun. Both
groups had classes for 45 minutes five times every two weeks during the
school-year. Compared to the standard gym class group, the lifestyle fitness group had
significantly greater decreases in body fat and significantly better cardiovascular
fitness. In addition, post-intervention, the lifestyle fitness group had significantly
better fasting levels than they had at baseline while there were no changes in the
standard gym class group; however, there were no significant between-group
differences post-treatment.

Third, more research should focus on understanding the moderators of
prevention effects. Several moderators of treatment have been identified including
gender and race (e.g., Gortmaker et al., 1999). While researchers have speculated
as to why these interventions have differential effects across populations, it will be
important to go back to the basic literature to determine what might be accounting
for these differences and how to address these issues in future intervention studies.

Fourth, researchers should focus on developing universal prevention programs
that are easily implemented and sustainable after a research team has developed the
program. Schools provide an excellent opportunity for making changes in practices
and policies that are likely to impact students’ weight. However, few prevention
programs have examined the effectiveness of preventions that are as simple as
removing vending machines from schools or limiting the type of food that is used
as rewards in schools, both practices that are associated with increased BMI in
students (Kubik et al., 2005). Although many communities have already begun

adapting their policies and practices to address the pediatric obesity epidemic, no
research has determined the efficacy of these efforts using rigorous methodologies.
Researchers will need to partner with states and with local school districts to assist
in the study design and collect appropriate data. Researchers will need to educate
policy makers and school officials about the scientific method and the benefits of
assessing outcomes through multiple methods. Educators and policy makers will
need to educate researchers about the particular demands of the state, community,
and school to ensure that research projects are meeting the needs of the participants
and stakeholders as well.

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weight status with respect to feeding, parental food habits, children’s exposure
to particular types of food and nutrition knowledge, and physical and sedentary
behaviors (Ells et al., 2005). Thus, it makes sense that interventions and policies
that support families in their efforts to produce healthy children would be more
effective than efforts that focus solely on children in schools. Few studies have
examined the inclusion of parents as a component of a universal prevention, but
results from weight-loss treatment studies show that parents have the ability to
influence children’s dietary habits, but found no impact of parental inclusion on
children’s weight loss (Ells et al., 2005). Although the role of parents will vary
throughout development, parents might be encouraged to eat meals with their
children in elementary school, come to the school themselves for parent classes on
nutrition, exercise, and health, and participate in physical activities at the school
during the school day or after hours and on weekends (Story et al., 2006).

<b>6. Policy Implications</b>

States have begun to address the pediatric obesity epidemic. Current policies that
are being introduced by states include a re-emphasis on nutrition and physical education
through curricular means, changing the school environments to be more consistent with
messages of health and well-being, and restricting access to vending machines and

changing the type of food that is offered through them (Rosenthal & Chang, 2004). A
smaller number of states are focused on educating education departments about weight
and working with community groups (Rosenthal & Chang, 2004).

It is commendable that legislation is being passed to help reduce the pediatric
obesity, but it is important that policies be firmly grounded in empirical evidence.
At this point, there is not sufficient evidence to support changes to current school
policies (Katz et al., 2005). However, there are several areas of policy that suggest
priorities for high-quality prevention research. Observational studies suggest that
adding one hour of physical education class per week will decrease BMI in students,
particularly females (Datar & Sturm, 2004). Research also suggests that limiting
access to food and beverages and reducing the amount of food used as rewards in
classrooms can decrease BMI (Kubik et al., 2005). Thus, these practices should
be tested to determine whether the additional physical education and reduced
opportunity to consume food and beverage are causally related to obesity.

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as the Department of Education, Department of Health and Human Services,
Department of Agriculture, and the National Institutes of Health.

<b>7. Conclusion</b>

In summary, pediatric obesity is a health concern that will be best addressed
through multiple levels of prevention and intervention. One promising venue for
universal prevention efforts are public and private schools. Research has shown
school-based preventions can be effective in reducing overweight and obesity in
youth, but fewer studies have examined universal prevention programs in schools.
More research is needed to determine which policies should be implemented
or modified to reduce the prevalence and incidence of pediatric obesity and the
lifetime health consequences that are associated with it.

<b>References.</b>

1. Austin, S. B., Field, A. E., Wiecha, J., Peterson, K. E., & Gortmaker, S. L.
(2005). The impact of a school-based obesity prevention trial on disordered
weight-control behaviors in early adolescent girls. Archives of Pediatric and
Adolescent Medicine, 159, 225-230.

2. Caballero, B., Clay, T., Davis, S. M., Ethelbah, B., Rock, B. H., Lohman,
T. et al. (2003). Pathways: A school-based, randomized controlled trial for
the prevention of obesity in American Indian schoolchildren. The American
Journal of Clinical Nutrition, 78, 1030-1038.

3. Carrel, A. L., Clark, R., Peterson, S. E., Nemeth, B. A., Sullivan, J., & Allen, D.
B. (2005). Improvment of fitness, body composition, and insulin sensitivity in
overweight children in a school-based exercise program. Archives of Pediatric
and Adolescent Medicine, 159, 963-968.

4. Datar, A., & Sturm, R. (2004). Physical Education in Elementary School and
Body Mass Index: Evidence from the Early Childhood Longitudinal Study.
American Journal of Public Health, 94, 1501-1506.

5. Donnelly, J. E., Jacobsen, D.J., Whatley, J.E., Hill, J.O., Swift, L.L.,
Cherrington, A., et al. (1996). Nutrition and physical activity program to
attenuate obesity and promote physical and metabolic fitness in elementary
school children. Obesity Research, 4, 229-243.

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7. Gortmaker, S. L., Peterson, K., Wiecha, J., Sobol, A. M., Dixit, S., Fox, M. K. et
al. (1999). Reducing obesity via a school-based interdisciplinary intervention
among youth. Archives of Pediatric and Adolescent Medicine, 153, 409-418.
8. Haddock, C. K., Shadish, W.R., Klesges, R.C., & Stein, R.J. (1994). Treatments for

childhood and adolescent obesity. Annals of Behavioral Medicine, 16, 235-244.
9. James, J., & Kerr, D. (2005). Prevention of childhood obesity by reducing soft

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10. Katz, D. L., O’Connell, M., Yeh, M.-C., Nawaz, H., Njike, V., Anderson,
L. M. et al. (2005). Public Health Strategies for Preventing and Controlling
Overweight and Obesity in School and Worksite Settings. Atlanta, GA: Centers
for Disease Control and Prevention.

11. Kubik, M. Y., Lytle, L. A., & Story, M. (2005). Schoolwide food practices
are associated with Body Mass Index in middle school students. Archives of
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12. Rosenthal, J., & Chang, D. (2004). State Approaches to Childhood Obesity: A
Snapshot of Promising Practices and Lessons Learned. Portland, ME: National
Academy for State Health Policy.

13. Spiegel, S. A., & Foulk, D. (2006). Reducing overweight through a
multidisciplinary school-based intervention. Obesity, 14, 88-96.

14. Story, M. (1999). School-based approaches for preventing and treating obesity.
International Journal of Obesity, Supp 2, S43-S51.

15. Story, M., Kaphingst, K. M., & French, S. (2006). The role of schools in
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16. Thanh CTY, Khan NC, Dat DT (2004). Childhood overweight and obesity
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Nutr Sci. 2006; 2: 49-53.

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/>

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<b>CÁC CHƯƠNG TRÌNH PHỊNG NGỪA BÉO PHÌ TRÊN </b>

<b>CƠ SỞ TRƯỜNG HỌC: TỔNG QUAN, HƯỚNG </b>

<b>NGHIÊN CỨU VÀ CÁC HÀM Ý CHÍNH SÁCH</b>

PGS.TS.Trần Thành Nam1

<i><b>Tóm tắt: Béo phì ở trẻ em là một vấn đề y tế ngày càng được sự quan tâm </b></i>

của cộng đồng. Cho đến nay, những thành tích trong cơng cuộc phịng chống
và can thiệp béo phì ở trẻ cịn nhiều hạn chế. Nguyên nhân có thể do những
khó khăn trong việc tiếp cận và lôi kéo các bên cùng góp tay tham gia cơng
cuộc phịng chống và can thiệp béo phì. Theo chúng tơi thấy trường học là
một nơi lý tưởng để cung cấp các dịch vụ y tế dự phịng. Vì vậy, bài báo này
sẽ thảo luận về vai trò của nhà trường trong việc ngăn ngừa chứng béo phì
ở trẻ. Cụ thể hơn, bài viết sẽ bàn luận về những lý do lựa chọn trường học
trong cơng tác phịng ngừa; kết quả của một số chương trình giáo dục phịng
chống dựa trên cơ sở trường học; nhứng lĩnh vực cần tiếp tục nghiên cứu
và những hàm ý chính sách từ kết quả nghiên cứu đi trước có thể áp dụng
cho Việt Nam

<i><b>Từ khóa: Béo phì ở trẻ em; chương trình phịng ngừa trên cơ sở trường học; </b></i>

điểm luận tài liệu; hàm ý chính sách.

1 Trưởng Khoa Các Khoa học Giáo dục;

Trường Đại học Giáo dục – Đại học Quốc Gia Hà Nội;
Email: ;

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