A schoolchild stands in a canteen

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In theory, tackling obesity in children seems obvious: teach them to eat healthier and exercise more. But, in practice, children can't make healthy choices if they don't have environments around them that support those choices. Today’s food environments constantly push them towards consuming cheap unhealthy foods. The result is a public health crisis. 

Today, one in three children in England is overweight or obese by the time they finish primary school. Over their lifetime, this could cost the NHS an estimated £74 billion and the economy £405 billion. But it’s not just wealthier countries that are affected: worldwide, an estimated 340 million young people aged five to 19 are overweight or obese. Unless these grim statistics can be reversed, rising numbers of young people will be at greater risk of preventable illnesses, including cardiovascular disease, type 2 diabetes, and cancer. 

Schools are where children spend most of their time and eat more than a third of their meals and snacks, making them a crucial setting for interventions that foster healthier food environments by shaping the choices available and the options they choose. A range of interventions are increasingly being implemented within and around schools, but their impact on childhood obesity has been unclear.  

Reducing BMI and encouraging smarter food choices 

With that in mind, our recently published research examined ways in which interventions designed to modify the built environment, food choice architecture (i.e. availability and presentation of foods) and direct food provision within and around schools may contribute to healthy food choices and prevent obesity. Based on our analysis of 100 studies in 27 countries, we found that more than half (51 per cent) of interventions reduced body mass index (BMI) or were effective at encouraging students to make smarter food choices.  

Some of the most effective food policies include:  

  • providing clear dietary guidelines on the type of foods permitted or banned in canteens 
  • regulating portion sizes 
  • making healthy meals and snacks more visible 
  • using professional chefs to improve the taste and healthiness of school meals 
  • reducing sugar consumption 
  • providing water instead of sugary drinks 

All these interventions had a significant and meaningful impact on reducing BMI or increasing fruit intake. Enlisting the support of teachers, catering staff and parents, and addressing physical activity and social inequalities, also contributed to healthier weight.  

But only a quarter of these potential solutions were able to deliver sustained improvements. Part of the problem is interventions are often part of short-term scientific studies or government programmes that are difficult to sustain when they are discontinued. 

On top of this, our research showed schools are surrounded by competing obesogenic environments. Every day, the route to and from school is shaping children’s behaviour and making it much harder for them to be a healthy weight. Whether it’s being bombarded by junk food adverts, public spaces dominated by fast-food outlets, or the normalisation of oversized portions, children are constantly being pushed to make unhealthy choices.  

Making healthy eating the easy choice 

To tackle childhood obesity, we need to create school food environments that make healthy and sustainably produced food the most accessible, affordable and desirable choice for millions of children. This will be no small feat. It will require incentives and strong regulation as well as health marketing.  

Multifactorial aspects of the environment within and around schools should be targeted with proven interventions to encourage healthier behaviours – from implementing school meal nutrition standards (e.g. requiring specific amounts of fruit/vegetables, reducing sugar consumption, replacing refined carbohydrates with whole grains) and removing vending machines, to regulating the number of fast-food outlets and their opening times in school areas. The importance of culture and location should not be underestimated. In order to be successful, interventions need to be tailored to local areas and needs. 

But it’s not just about providing healthy, affordable food: we also must make sure the quality, attractiveness and taste are interesting to children so they can really engage with these types of foods rather than unhealthy foods that are marketed as cool and attractive. It’s about flipping children’s perception; with healthy options becoming the easy choice.  

To support these choices, the global food industry must be forced to reformulate and promote healthier versions of foods. Reducing salt, sugar and saturated fat across the board would improve the diet of entire populations and reduce health inequalities. We also need greater restrictions on unhealthy food advertising, with a focus on digital food environments, where there is currently no regulation. Children are particularly influenced by how a product looks, and clearer nutrition labelling (such as the black octagon warning symbols in Chile) and limiting packaging offer big opportunities for health promotion and reducing the carbon footprint.  

Ultimately, however, long-lasting reforms will require serious policy action to support healthy food systems from production to consumption, as well as food environments. Only then will we see a shift in consumption away from unhealthy and unsustainable products and reduce the staggering costs of a lifetime of chronic disease and environmental damage.  

This article draws on findings from "Improving the School Food Environment for the Prevention of Childhood Obesity: What Works and What Doesn't" by Elisa Pineda, Josefina Bascunan and Franco Sassi, published in Obesity Reviews.

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Main image: SDI Productions / E+ via Getty Images.

Elisa Pineda

About Elisa Pineda

Research Fellow
Dr Pineda is a research associate at Imperial's Centre for Health Economics & Policy Innovation and School of Public Health. She holds a doctorate in Epidemiology & Public Health Nutrition. Her current research focuses on the food environment and the prevention of non-communicable diseases.
Among other projects, she is involved in the Science & Technology in Childhood Obesity Policy Project and the NIHR Global Health Research Unit in Cardiovascular Disease & Diabetes among South Asians.

You can find the author's full profile, including publications, at their Imperial Professional Web Page