Chapter 1: 1.0 Introduction

1.1 Background of the Study

Childhood obesity has become a global health concern over the last two decades. With chronic diseases being one of the leading causes of mortality and morbidity in most countries, with expected increase in the next couple of years, health organisations all over the world are raising an alert on these rates (Waters, et al., 2011). Childhood obesity has been associated with a variety of chronic diseases when victims become adults, including type II diabetes, cancers, cardiovascular diseases, dyslipidaemia, and hypertension, which reduce life expectancy as a result of a compromised quality of life (Verstraeten, et al., 2012). Additionally, childhood obesity has been found to play a great role in leading to poor self-image, social stigmatisation, and psychological problems once victims grow into adulthood (Mond, et al., 2011). Therefore, research on obesity and its management has not just been on fighting childhood obesity as a single disease but focusing on fighting it in unison with an aim of preventing and treating other chronic diseases related to it (Dietz, et al., 2015).

The World Health Organisation, through its recent reports, has reiterated that obesity is indeed a major health concern in the 21st century (WHO, 2016b). A recent report released by WHO recorded that the number of children (aged less than 18 years) who are overweight or obese is 170 million (WHO 2016a). The same report posits that the upper-middle-income countries have a higher prevalence rate when compared to other middle-income countries. While high-income countries recorded a relatively lower prevalence growth rate as compared to middle-income and low-income countries, the rates of obesity are still high across the globe (Wang & Lobstein, 2006; Verstraeten, et al., 2012; WHO, 2016a).

The U.K. has not been an exception in a world where most children end up eating unhealthy diets and becoming overweight. With 31.2% 2-15 year-olds being either overweight or obese, the rates of obesity in the U.K is worrying (National Obesity Observatory, 2016). 14.2% and 19.1% of children aged between 10-11 years were found to be overweight and obese respectively (National Obesity Observatory, 2016). The same report from the National Child Measurement Programme (NCMP) 2014/15 indicates that for children in reception, 12.8% were overweight and 9.1% obese (National Obesity Observatory, 2016). In a bid to ensure that children get educated on social and health issues like obesity, the U.K. offers free education to children in the 3-18 years age group (Lavelle, Pell, & Mackay, 2012). As such, it has become possible to provide a platform to provide school-based intervention to help reduce cases of obesity even for those from economically challenged backgrounds. Schools have been shown to be useful tools in helping reduce cases of childhood obesity (Sallis, et al., 2012). Their role has been overly valuable in creating policies that encourage healthy eating habits, physical exercises, and education on obesity (Sallis, et al., 2012). Thus, it is imperative to discuss various interventions aimed at providing students (children and adolescents) a platform of reducing obesity in a school set-up.

1.2 Aims and Objectives

            1.2.1 Aims

The aim of this study is to determine the extent to which school-based interventions have been effective in helping reduce obesity among children and adolescents. The study assesses the effectiveness of using diet education and physical activity in schools as interventions to help mitigate the escalating rates of obesity among children and adolescents. Therefore, the researcher focuses on developing mechanisms aimed at helping children live healthy lives through knowledge on healthy lifestyles.

            1.2.2 Objectives:

In order to meet the aim of this study, the objectives of this research are as follows:

1. To determine the effect of education on diet interventions in schools in helping manage the prevalence of obesity among children less than 18 years of age.
2. To investigate the effect of physical activity interventions in schools in helping manage the prevalence of obesity among children less than 18 years of age.

• To assess the combined effects of physical activities and education on diet interventions in schools in helping manage the prevalence of obesity among children less than 18 years of age.

1.3 Overview of the Review

Therefore, to meet the aims and objectives of this paper, the researcher first reviews previous research and available material on childhood obesity. Previous research is essential in developing ground on what has already been achieved in the management and prevention of childhood obesity, which links well with adult obesity. Therefore, the literature review section gives this study a platform to introduce an updated systematic review. Secondly, the researcher addresses methods used in achieving the aims and objectives of this study. The methodology section includes issues on how the researcher searched for sources, their inclusion and exclusion criteria, eligibility of the resources used, databases used, and how researchers ensured that the best quality articles formed the basis of this paper. The adequate research gave room to the results section, which presents the studies that the researcher selected. In addition, this section provides the characteristics of articles used to help actualise this study. Of great importance is the discussion section, which emanates from the results and methods section. The discussion chapter identifies key issues that relate to the objectives of this study as presented in different sources that the researcher settled on. Further, the section helps throw new light on what other researchers had already established as presented in the literature review and introduction chapter. Finally, the conclusion chapter sums up important revelations in this study and highlights new areas that other researchers can focus on.

Chapter 2: Literature Review

Obesity and overweightedness describe excess adiposity than the set or allowed limits as measured by the body mass index (BMI) (Khambalia, et al., 2012). While BMI remains a primary body fat measure, researchers (Brambilla, et al., 2013; Burkhauser & Cawley, 2009) have suggested the use of waist circumference-to-height ratio and other techniques for children and adolescents. However, even with other techniques, different methods used to measure obesity in children have attested to the fact that indeed, obesity is a major health concern in the 21st century (WHO, 2016b; Verstraeten, et al., 2012). Puhl and Heuer (2009) posit that most obese children end up becoming obese even in their adult life with an inherent risk of associated chronic conditions. The high prevalence of cancer, diabetes, hypertension, and other related diseases remains the primary driving factor in managing obesity at a younger age (Verstraeten, et al., 2012; Neef, et al. 2013). Moreover, Harrist, et al. (2016) assert that with stereotypes against overweight and obese children, such as the belief that obese children are lethargic and unhygienic, socially incompetent, and unsuccessful as academics, psychological consequences of obesity have been critically evaluated. Most obese children tend to develop a negative self-image, which further makes the stereotypes labelled against them seem true (Sahoo, et al., 2015). Therefore, Latzer and Stein (2013) posit that the fight against obesity has primarily been one against a wide range of diseases and not just a move to discourage unhealthy eating among children and adults.

In a bid to manage obesity, treatments have spanned around non-pharmacological and pharmacological treatment (Luttikhuis, et al., 2009; Ijäs, et al. 2015). However, Luttikhuis, et al., (2009) and Person, et al. (2015) illustrate that while the use of surgical interventions and drugs has commonly been used in helping patients, adults and children alike, most of the focus through health organizations, governments, community, family, and individual interventions has taken the non-pharmacological route. According to De Araujo, et al. (2012), campaigns to modify shared environments, discourage consumption of high-energy foods, and increase physical activity have been intensified in most settings. Mühlig and Wabitsch (2015) also assert that change of diet behaviour and physical activities, among other non-pharmacological treatment options have been considered more effective than pharamological methods and to have gained a significant acceptance level across different platforms than the use of surgical options, especially among children.

As reported by the World Health Organisation (2016b) report on managing obesity, the fight against obesity should start at a young age. The report suggests that to manage obesity, parents, health care givers, schools, and other stakeholders should work to support a fight that starts at an early stage of a child’s development. WHO (2016b) reports that it is vital to promote early childhood diet and physical activity management to achieve fundamental goals of handling childhood obesity and related chronic ailments. Thus, this report further supports the use of non-pharmacological treatment in the management of obesity.

According to Lavelle, et al. (2012), the fact that children and adolescents spend a great percentage of their lives in schools, especially with a rising case of boarding schools makes school-based interventions a major factor to consider in the fight against obesity. Besides, the authors illustrate that schools reflect the second home for most students, making their role in helping deal with childhood obesity and other health conditions crucial. A meta-analysis by Suarez, et al. (2009) found that school-based interventions such as social support, physical activity, and diet are effective in managing obesity. Luttikhuis, Zenzen, and Kridli also noted the mentioned interventions to have a significant effect in helping reduce levels of obesity in a school set-up. Katz, et al. (2008) showed that BMI decreased by a significant level with the use of physical activity and nutrition interventions. However, Suarez, et al. (2009) noted that compared to control groups, intervention groups did not exhibit a reduction in BMI. Van Cauwenberghe, et al. (2010) reiterates that school-based interventions remain one of the best interventions, especially with possibilities of increasing fitness, out of school activities, and school-based diet check. The authors noted that 47-65% of the studies they reviewed, including grey literature, were effective, despite not considering assessments and observations outside schools. The difficulty to integrate external assessment in school-interventions has seen Khambalia, et al. (2012) and Verroti, et al. (2014) opine that parents should also help in ensuring that school-based interventions are successful.

While studies on school-based interventions have laid a focus on the overall effectiveness of associated interventions, limited research, and in particular systematic reviews have been done to establish the success of individual interventions. In addition, combination of different interventions is not extensively covered. Therefore, there is a need to compare effectiveness of education on diet and physical activity, which are the main school-based interventions, and their individual effectiveness in dealing with childhood obesity. By laying a major focus on updated literature, this study helps show the strides made in management of obesity in school setups.

Chapter 3: Methodology

The researcher conducted a systematic review to evaluate the effectiveness of school-based programs in the prevention and management of childhood obesity. In particular, the focus of this study was on physical activities and education on nutrition in schools as the main interventions. This study used the Cochrane handbook as the base for the exclusion and inclusion of the reviewed studies, and analytical methods to help avoid any biassed post hoc decisions before conducting the review. The review follows a formal guideline for systematic reviews as provided in the Cochrane Handbook (Higgins, Green, & Cochrane Collaboration, 2008). Furthermore, this study was categorical on ensuring that any data chosen was first critically analysed with regards to the period of randomised control trials, with studies showing short-term and long-term follow-ups. Thus, the studies used provided a picture of inclusivism. Randomised trials provide an opportunity to test applied interventions despite their low level of contribution in explaining why and how some factors affect behaviour and health.

3.1 Sources of Information

The study used computerised electronic searches to get articles from different databases, including Science Direct, CINAHL, PubMed, and Cochrane Library, from 2005 to 2016 using the PICO framework (Population, Intervention, Comparison, and Outcome). The researcher then read abstracts and the full articles before making a selection of the relevant materials needed in the study. Additionally, reference lists of these studies were analysed to help come up with other sources that would help increase the credibility of the systematic review. To gain more knowledge from vague literature, the researcher used professional networking sites and Google scholar to get other materials. However, the researcher did not use grey literature since the sources presented by the methods mentioned above were already enough to help meet the objectives of this study.

3.2 Inclusion and Exclusion Criteria

This study included studies that used randomised controlled trials, cluster-randomised controlled trials, or quasi-randomised controlled trials in obesity treatment (Madigan, et al., 2014). The researcher decided to use randomised trials since randomness enabled a researcher to get a better picture of the population behaviour and any errors the primary researchers might have made in choosing samples that suited their study objectives (Domanski & McKinlay, 2009). The treatments selected in all cases included school-based interventions that indirectly or directly used dietary and physical activity approaches. The researcher decided to only use research written in English that focussed on children (under 18 years of age) to avoid difficulties in translations.

Intervention programmes that do not apply diet and physical activity interventions within school frameworks were excluded from the search since they did not form a focus for this study. Besides, non-randomized trials, qualitative studies, literature reviews, and community-based programs were also excluded on the basis that they were not consistent with the guidelines of this study.

3.3 Key Words

The study used terms relating to adolescents and children (for instance, student, adolescent, schoolchild, and child) in AND/OR/NOT- combinations with those that relate to energy, including diet, food, nutrition, sport, exercise, and physical activity. However, key terms included children, childhood, school-intervention, obesity, treatment, and prevention.

3.4 Quality Appraisal Tool

This systematic review made use of a CASP, Critical Appraisal Skills Programme tool in assessing the quality of the studies presented (CASP, 2013). CASP is used to avoid project biasness by evaluating methods used in a research work to ensure it is of the highest quality. The study assessed the quality of randomised controlled trials to help manage the bias risk during the trial. Failure to make appropriate methodological analysis may pose a threat to the overall results of the study, making it the major risk in this study. Thus, a critical review of methodologies used and eligibility of the study was done to prevent erroneous conclusions since it did not involve any experiment or quantitative study under the researcher’s full control.

3.5 Data Extraction and Filtering

The study sourced data from the full text, abstract, and titles of all primary sources used. Only information that was relevant to the research topic and objectives was used in the study. To ensure that all the necessary data was collected, the study adopted an extraction form utilised in the Centre for Reviews and Dissemination (CRD) (2009) publication.

3.6 Statistical Analysis

A critical discussion of the studies used in this review was made to ascertain their aims, methodologies, and results based on the objectives of this study. The researcher created arguments supporting the objectives of this study while looking at the findings of the reviewed research. To establish if a particular school-based intervention was effective, the researcher analysed the conclusions made by various researchers on that intervention. The researcher did not base the study on calculations but depended on descriptive statistics.

3.7 Ethical or Confidentiality Issues

The most significant ethical concern was to acknowledge the inputs of different researchers. All information not from the researcher was cited accordingly. The researcher did not ask for consent from participants since they already provided their consent during the primary researches included in the review. Nevertheless, the researcher ensured that since studies used in the review involved studies whose participants who were not in a position to provide their informed consent, the primary researchers had already asked for the informed consent from the children’s parents and respective school administrations. The researcher used studies that were readily available and followed all copyright issues identified by the publisher. Additionally, the study was not human centred; thus, it did not require approval from IRB.

3.8 Data Synthesis

The study used descriptive data synthesis while assessing different interventions used by researchers. Additionally, different interventions were grouped together to help compare researchers who found the interventions effective and those who did not. Through this approach, the researcher aimed to create a platform that allowed for data integration from different sources and develop an argumentative systematic review.

4.0 Results

As highlighted in Figure 1, the initial search for this study yielded 716 articles from different databases specified in the methods section. After screening the titles, 155 studies met the requirements for the study. Further screening of abstracts reduced the studies to 22. Finally, a focus on the full texts reduced the studies to 10 as some did not have control groups, used different research designs from those outlined for this review, and failed to meet the CASP standards through questions asked in the study. Characteristics of articles used

Table 1. Characteristics of Studies Included in the Review

4.1 Participants

            4.1.1. Age and Gender

All studies included in this research had data for both females and males. The mean age of participants in various studies was six years. Only one study was inclusive of 6-18 year old children (Jiang, et al. 2007). Five studies (Grydeland, et al. 2013; Kipping, et al., 2014; Sichieri, et al., 2009; Li, et al., 2010; Rush, et al., 2012) had participants aged 12 or less than 12 years. Four studies (Carell, et al. 2005; Vissers, et al., 2008; Francis, et al., 2010; Van Nasser, et al., 2014) had participants with ages above 12.

4.2 Interventions

Two studies (Li, et al., 2010; Carell, et al. 2005) focused only on physical activity interventions while other two studies (Grydeland, et al. 2013; Sichieri, et al., 2009) focused on diet-based education interventions. The other six studies (Vissers, et al., 2008; Francis, et al., 2010; Van Nasser, et al., 2014; Jiang, et al. 2007; Kipping, et al., 2014; Rush, et al., 2012) used multi-disciplinary interventions involving both education on diet and increasing physical activity among children.

4.3 Outcomes

Six studies (Vissers, et al., 2008; Francis, et al., 2010; Van Nasser, et al., 2014; Jiang, et al. 2007; Grydeland, et al. 2013; Sichieri, et al., 2009; Li, et al., 2010) identified BMI as the outcome measure. Five studies (Carell, et al. 2005; Vissers, et al., 2008; Van Nasser, et al., 2014; Jiang, et al. 2007; Li, et al., 2010; Rush, et al., 2012) identified prevalence of obesity, body weight, or body fat percentage as potential outcomes. On the other hand, one study (Kipping, et al., 2014) was focused on preventing obesity and did not have body weight or BMI as potential outcomes; the study had rate of physical activity and diet management as potential outcomes.

4.4 Quality Appraisal

The researcher assessed the methodological quality of studies using the CASP tool (CASP, 2013). The model was effective in helping reduce the overall number of studies that would letter be included in the research. Among the core limitations noted on most studies was that there was lack of process valuation (n=15), no proper description of the number of dropouts of participants across different periods in intervention (n=13), no report on integrity (n=30), unblinded assessors (n=28), and unclear methods of randomization (n=8). In addition, four studies reported that students in the control and intervention groups were contaminated since they used the same school set-ups. For studies included in this report, Carrel, et al., (2005) had the lowest CASP score of six out of ten, which is attributed to weak data collection methods, delayed follow-ups, and a small number of participants.

4.5 Post Treatment Outcome

Six studies (Carell, et al. 2005; Vissers, et al., 2008; Jiang, et al. 2007; Li, et al., 2010; Rush, et al., 2012) reported reduced body fat and obesity prevalence. Grydeland, et al., (2013) showed a decrease in BMI only in girls with no overall effect on BMI. Five studies (Francis, et al., 2010; Vissers, et al., 2008; Jiang, et al. 2007; Sichieri, et al., 2009; Li, et al., 2010) showed a decrease in BMI.

All studies (Li, et al., 2010; Carell, et al. 2005) that focused only on physical activity interventions were significant in helping reduce obesity prevalence. For studies that only focused on diet-based education interventions (Grydeland, et al. 2013; Sichieri, et al., 2009), only Sichieri, et al., (2009) was effective as an intervention in helping reduce childhood obesity while Grydeland, et al. (2013) was only effective for girls. Four studies (Vissers, et al., 2008; Francis, et al., 2010; Jiang, et al. 2007; Rush, et al., 2012) that used multi-disciplinary interventions involving both education on diet and increasing physical activity among children showed significance of these interventions in helping prevent and manage obesity among children. Kipping, et al. (2014) and Van Nasser, et al., (2014) were not effective in helping prevent and reduce obesity respectively.

4.6 Post Treatment Outcome

Therefore, the study showed that physical activity, as a school-based intervention was effective in helping manage childhood obesity. Studies that used this intervention reported reduced BMI, prevalence of obesity, and reduction in weight among participants. Further, the effectiveness of this intervention was pronounced among studies that used longer intervention periods. Similarly, diet interventions through education on behaviour change and diet management was also effective in helping reduce obesity. The review established that like in the case of physical activities, the success of diet education largely depended on the period of intervention with longer period of more than six months being more effective compared to shorter periods. A combination of the two interventions, physical activity and education on diet change, were seen as more effective in managing childhood obesity as opposed to the use of only one intervention.

5.0 Discussion

Childhood obesity remains a major health threat in the 21st century (WHO, 2016b). As the World Health Organization outlines, interventions to help manage and prevent childhood obesity have continued to gain a lot of support from different stakeholders. As children and adolescents spend most of their lifetime in school, school-interventions continue to offer an excellent opportunity to help make learning a success. Therefore, this systematic review sought to review literature from 2005-2016 regarding the use of school-based interventions in helping manage and prevent childhood obesity. In particular, the study focused on the individual effect of physical activity and education on diet as well as their joint effectiveness in managing and preventing childhood obesity. These aspects formed the objectives of the study and guided the use of different research methods utilized in this study. With the use of various databases, the researcher identified possible studies using the PICO framework. Further, since the researcher wanted to narrow down to studies that had randomised controlled trials, the cluster RCT, quasi-RCT, and RCT tools were used in the research design. The use of this methodological framework helped narrow down to 10 studies that met the requirements of the researcher from the initial 716 studies. Most studies were, therefore, excluded from the research since they did not use the research design and reflected a high percentage of duplication. In addition, some studies did not report on the rates of dropouts among participants during different phases of the study, which led to their disqualification. With the CASP framework, the researcher managed to live out studies that indicated low scores and those that did not meet most provisions provided by this criterion. Further, using the CASP framework to ensure that studies included in the research met the set minimum requirements, the researcher noted that most studies were facing challenges related to small samples. With small samples, it was hard to understand different characteristics of participants, which made it extremely hard to provide necessary recommendations and conclusions.

Using the CASP tool, the researcher reduced the number of studies from the initial search in the databases based on; lack of process valuation (n=15), no proper description of the number of dropouts of participants across different periods in intervention (n=13), no report on integrity (n=30), unblinded assessors (n=28), and unclear methods of randomization (n=8). Further, the researcher reduced the studies from the initial the initial 716 articles to 155 studies that met the requirements for the study from the screening of titles. Further screening of abstracts reduced the studies to 22 while a look at the full texts reduced them to 10 studies that formed the basis for this review.

All studies (Li, et al., 2010; Carell, et al. 2005) that focused only on physical activity interventions were significant in helping reduce obesity prevalence. Physical activity, as highlighted in previous research, was an effective intervention in helping manage obesity. Both Li, et al., (2010) and Carell, et al., (2005) indicated that physical education was something that schools and curriculum developers had to look at while encouraging students to participate in different physical exercises. The importance of physical activity spanned from its involving nature and the fact that most children found it fun. Although physical activity is obviously effective as an intervention, managing the time that teachers have to see students through these activities is a major challenge for most schools. Besides, physical activities rely on resources that schools have and their ability to fund them through training and employment of necessary personnel. For instance, in the case of gym sessions, most schools do not have the necessary equipment and trainers to facilitate them. Therefore, studies that solely rely on physical activities as interventions have to use available resources and little training that most teachers and students have to ensure the effectiveness of this method.

Previous research had indicated that to improve physical activity rates, teachers and researchers should focus on using various games that students engage in daily. Using activities that did not seem as punishments to students remained an important factor to consider. While suggesting the use of the AFLY5 programme, Kipping, et al. (2014) reiterated in their recommendation that physical activity could only be more effective and lasting through long-term initiatives. The effectiveness of such interventions on a short-term basis was seen as less effective in helping manage obesity. Children who got accustomed to physical activities would most likely continue with the practice even in their adult life.

For studies (Grydeland, et al. 2013; Sichieri, et al., 2009) that only focused on diet-based education interventions, Sichieri, et al., (2009) opine that this intervention was effective while Grydeland, et al. (2013) found it only effective for girls. Gryedeland, et al.’s (2013) study shows that factors such as age and gender would have a slight impact on different interventions. With previous meta-analysis and systematic reviews suggesting further research on characteristics of participants and the resultant impact on the success of various interventions, a big issue arises on explanations of such deviations. Sichieri, et al. (2009) opined that sweeteners from sweetened beverages and snacks formed part of the foods consumed in scores among most children. Therefore, discouraging children from consumption of such foods offered a hope and lasting solution to this challenge. The authors further advise that schools should reduce the amount of sweeteners sold in school set-ups and improve on the diet offered by schools. Reducing the amount of sweeteners children take in schools will most likely see them translate the same while at home.

However, Kipping, et al. (2014) and Van Nasser, et al., (2014) noted that diet on education was not effective in helping prevent and reduce obesity respectively. Van Nasser, et al. (2014) suggested behaviour change in diet as boys increased the amount of breakfast consumption. The researchers had focused on the importance of breakfasts in helping live a healthy life while emphasising on a well-distributed meal system. Although the study was not significant in helping reduce rates of obesity, it showed that a long-term intervention would encourage behaviour change. A look at diet-based interventions, therefore, indicates that diet was hard to manage, as students would easily switch to different foods at home despite efforts to maintain their diet in school and educate them on the same. Additionally, diet change unlike physical activities, was mostly not focused on the reduction of body weight but prevention of further weight gain. Therefore, the intervention focused more on prevention and control of weight gain and could only work based on characteristics of participants such as age, sex, BMI, and other biological characteristics. Most studies were not critical of the role played by such factors and only looked at the general effectiveness of this method.

Most studies aimed at helping reduce the prevalence of obesity and weight gain among participants through their respective intervention programs. Six studies (Carell, et al. 2005; Vissers, et al., 2008; Jiang, et al. 2007; Li, et al., 2010; Rush, et al., 2012) reported reduced body fat and obesity prevalence. The efforts of most interventions, whether physical activity, dietary education, or a combination of the two was an overall decrease in body fat and weight among obese participants. For instance, Vissers, et al. (2008) used a multidisciplinary model involving physical activity and education on diet. The researchers sought to include more factors in developing an appropriate school-based program and saw a multidisciplinary model as the best choice to increase the overall efficiency of school-based interventions. In fact, four studies that used multi-disciplinary interventions involving both education on diet and increasing physical activity among children showed the significance of these interventions in helping prevent and manage obesity among children (Vissers, et al., 2008; Francis, et al., 2010; Jiang, et al. 2007; Rush, et al., 2012). Previous research had indicated that the overall effect of multidisciplinary interventions was way better than the use of individual interventions (Katz, et al., 2008; Khambalia, et al., 2012; Waters, et al., 2011). Multidisciplinary interventions ensure that those methods that may not work with some individuals can work with others. While physical activity helps in reducing excess body fat, education on diet helps participants maintain a healthy diet and refrain from taking foods that may make them overweight or obese, making their overall effect significant. Therefore, this reflection means that the challenges posed by diet education can easily be handled using physical activities and vice versa.

An important aspect that stood out was the effectiveness of using BMI as a measure of obesity and overweight among children. Grydeland, et al., (2013) showed a decrease in BMI only in girls with no overall effect on BMI. Five studies (Francis, et al., 2010; Vissers, et al., 2008; Jiang, et al. 2007; Sichieri, et al., 2009; Li, et al., 2010) showed a decrease in BMI. Thus, most studies continue to use BMI as an outcome measure despite its challenges as identified by Khambalia, et al. (2012). The use of BMI was, therefore, a major limitation since most studies solely relied on it. Waist circumference presents a different measure to help determine the effectiveness of school-based interventions, which can be used in future studies.

In addition, the use of language to exclude studies was also a major limitation as this locked out possible potential studies that could have helped shed more light on this review. More researchers continue to diversify on the language used in their studies, making it a factor that future researchers could focus on to ensure consideration of many studies. Translations from primary researchers or professional researchers could contribute to making it easier to develop updated systematic reviews covering a broad scope of literature.

This study reiterates that while school-based interventions were effective in helping manage childhood obesity among children, its effectiveness depended on the periods of interventions and responsiveness of participants. Managing the behaviour of children at home remains a challenge that should be handled in future studies. The best way to tame the problem is through a combination of school-based and family-based interventions to manage childhood obesity. While schools offer an excellent environment for a collective management of children through education and physical activities, parents will go a long way in helping ensure that behaviour change toward diet management and taking part in physical activities is not temporary but permanent. Besides, the use of family-based interventions offers an opportunity to move across the border and handle adult obesity. In a recent systematic review, Kothandan (2014), compared family-based and school-based interventions in helping fight obesity. Although family-based interventions were seen to be more efficient for children less than 12 years, both interventions recorded a significant level of effectiveness in managing childhood obesity. Further, the author opines that these interventions differed in performance with aspects such as methodological quality of trials, long-term and short-term outcome, and age playing a great role in the level of effectiveness. The findings on effectiveness of long-term durations of interventions in helping manage obesity can easily be illustrated in previous studies, which have seen longer intervention periods as effective in helping make follow-ups (Endevelt, et al., 2012; Ho, et al., 2013). With most children likely to go back to their previous habits before respective school-based childhood obesity management interventions, a period of more than a year is relatively better than one with a shorter timespan; for instance, less than three to six months. Similarly, Kothandan’s (2014) study shares that family-based interventions mainly focus on the use of sociological theories such as the trans-theoretical and social cognitive theories, which are not present in school-based interventions that focus on physical education.

However, despite the limitations of this study, the use of CASP as an evaluation criterion was effective in helping settle on studies used in the review. Therefore, as the researcher also established that all studies included had aspects of randomization and controlled trials, the quality of individual studies were assessed. Besides, the research balanced its analysis in terms of years that actual studies were made, making the conclusions span different times.

6.0 Conclusion

Obesity continues to become a major health issue globally. Thus, as the U.K. and the world continue to implement different ways that will be useful in helping achieve a situation that allows for better health care, devising various mechanisms to handle the condition is of great importance. While this research did not involve an actual experiment, its successful completion helped update available systematic reviews on school-based interventions in handling obesity among children and adolescents. Since the study aimed at using updated information from 2005 to 2016, it was influential in determining what researchers established ten years ago and compare that with what recent research have suggested. Thus, this mechanism was an opener on the effectiveness of different interventions for decades. By offering information on tools that have stood the test of time, the researcher did shed light on what can be improved in the fight against obesity. Health caregivers, health organisations, governments, researchers, parents, school administrators, and most important, obesity victims will be able to get information on some of the interventions they can use and their effectiveness. Additionally, the study provided insight on the best mechanisms to use to handle challenges of implementation of each intervention.

Overall, the study found the use of physical activity as effective in helping manage and prevent childhood obesity. Most studies that have based their interventions on increasing physical activity and physical education among children and adolescents through a school platform reported reduced BMI and prevalence of obesity. Similarly, education on diet was found to be effective in helping manage childhood obesity. Diet intervention methods enabled children to manage the types of food they eat and how often they ate them. Further, multidimensional interventions involving both physical activity and education on diet were more effective than the use of individual interventions in helping manage childhood obesity. Researchers suggested that using both models meant that participants who were not good at one intervention would most likely perform better with a different one.

However, a common observation was that studies that failed to use a longer time to implement their respective interventions did not show positive results. Thus, future studies should aim at long-term periods to help ensure that children get used to the various interventions for their models. In addition, an evident role of teachers and parents was presented in all studies used in this research. Therefore, there is a clear need to include parents in helping their children during holidays, weekends, and when at home achieve the objectives of childhood obesity management. Further, the use of BMI in measuring obesity/overweight was a common phenomenon in most studies. However, as seen in already reviewed literature, BMI is not a perfect measure for obesity. Other measures such as waist circumference can be used together with BMI and weight measures to help make conclusions on the effectiveness of different interventions. Further, researchers can also look at modalities to incorporate health education and encourage physical education into the school curriculum from a young age for all schools. These modalities will help fight not only childhood obesity but also other diseases that can be managed from a young age. Finally, future studies should focus on using a large number of participants as opposed to a small sample. Conclusions from studies using many participants provide more reliable deductions, which further reflect results from the whole population. Besides, with a large sample, researchers can identify other characteristics not initially targeted in the study.

As more research continues to stream in to help handle issues relating to childhood obesity, a major focus in theory development should focus on how to manage obesity and related chronic diseases at a young age. Instead of managing obesity at developed stages, school-based interventions should work to relate healthy eating, behaviour development, and physical activity with prevention of these diseases. In addition, while this study did not focus on family-based interventions, a combination of school-based and family-based interventions will most likely yield better results. Health organisations and governments must focus on multidimensional methods if there is any hope of handling obesity.

6.0 References

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