Article 1:
How children eat may contribute to rising levels
of obesity Children’s eating behaviours:
An intergenerational study of family infl uences
By N Kime, Research Offi cer, Centre for Health Promotion Research,
Leeds Metropolitan University, LS1 3HE, UK
Key words: children’s eating behaviours; obesity;
family environment; intergenerational; grounded
theory; ordering of eating.
Abstract
The term ‘obesogenic environment’ is rapidly
becoming part of common phraseology. However, the
infl uence of the family and the home environment
on children’s eating behaviours is little understood.
Research that explores the impact of this micro
environment and intergenerational infl uences
affecting children’s eating behaviours is long
overdue.
A qualitative, grounded theory approach,
incorporating focus groups and semi-structured
interviews, was used to investigate the family
environment and specifi cally, the food culture of
different generations within families.
What emerged was a substantive theory based
on ‘ordering of eating’ that explains differences
in eating behaviours within and between families.
Whereas at one time family eating was highly
ordered and structured, typifi ed by the grandparent
generation, nowadays family eating behaviours are
more haphazard and less ordered, evidenced by the
way the current generation of children eat. Most
importantly, in families with an obese child eating
is less ordered compared with those families with a
normal weight child.
‘Ordering of eating’ is a unique concept to emerge.
It shows that an understanding of the eating process
is crucial to the development and improvement of
interventions targeted at addressing childhood
obesity within the family context.
Introduction
The number of people, both adults and children, who
are obese continues to rise throughout the world.
According to the International Obesity Task Force
(IOTF), within the UK, obesity prevalence has more
than tripled in the past 25 years, and obesity among
children has tripled in a decade (IOTF 2003). The
Department of Health (DOH) estimates that if no
Article 2:
PEDIATRIC HIGHLIGHT
A 4-year, cluster-randomized, controlled childhood
obesity prevention study: STOPP
C Marcus1, G Nyberg1, A Nordenfelt1, M Karpmyr1, J Kowalski1 and U Ekelund2
1Division of Pediatrics, Karolinska Institutet, Department of Clinical Science, Intervention and Technology, National
Childhood Obesity Centre, Stockholm, Sweden and 2MRC Epidemiology Unit, Institute of Metabolic Science, Addenbrooke’s
Hospital, Cambridge, UK
Objective: To assess the efficacy of a school-based intervention programme to reduce the prevalence of overweight in 6 to
10-year-old children.
Design: Cluster-randomized, controlled study.
Subjects: A total of 3135 boys and girls in grades 1–4 were included in the study.
Methods: Ten schools were selected in Stockholm county area and randomized to intervention (n¼5) and control (n¼5)
schools. Low-fat dairy products and whole-grain bread were promoted and all sweets and sweetened drinks were eliminated in
intervention schools. Physical activity (PA) was aimed to increase by 30 min day_1 during school time and sedentary behaviour
restricted during after school care time. PA was measured by accelerometry. Eating habits at home were assessed by parental
report. Eating disorders were evaluated by self-report.
Results: The prevalence of overweight and obesity decreased by 3.2% (from 20.3 to 17.1) in intervention schools compared
with an increase of 2.8% (from 16.1 to 18.9) in control schools (Po0.05). The results showed no difference between
intervention and controls, after cluster adjustment, in the longitudinal analysis of BMIsds changes. However, a larger proportion
of the children who were initially overweight reached normal weight in the intervention group (14%) compared with the
control group (7.5%), P¼0.017. PA did not differ between intervention and control schools after cluster adjustment. Eating
habits at home were found to be healthier among families with children in intervention schools at the end of the intervention.
There was no difference between children in intervention and control schools in self-reported eating disorders.
Conclusions: A school-based intervention can reduce the prevalence of overweight and obesity in 6 to 10-year-old children and
may affect eating habits at home. The effect of the intervention was possibly due to its effect on healthy eating habits at school
and at home rather than on increased levels of PA.
International Journal of Obesity (2009) 33, 408–417; doi:10.1038/ijo.2009.38; published online 17 March 2009
Keywords: childhood obesity; prevention; physical activity; school intervention; healthy eating
Introduction
Childhood overweight and obesity are emerging health
problems in all western countries and also in urban areas
in developing countries.1,2
In Sweden, the prevalence of overweight and obesity
has been rapidly increasing.3,4 Approximately 15–25% of
Swedish 10-year-old children are overweight or obese.5,6
Childhood obesity affects self-esteem and increases the
risk of future diabetes, cardiovascular disease and malignancies.
7–11 Thus, childhood obesity is a major threat to public
health and may reduce life expectancy.11–14
Behavioural obesity treatment approaches, including
changes in dietary habits and exercise, have limited longterm
effect on body weight.5,15,16 Anti-obesity drugs appear
to have modest effects on body weight in adolescents.17–22
Furthermore, the use of drugs to treat a disease, which in the
vast majority of children is associated with environmental
changes contributing to an unhealthy lifestyle is controversial.
Article 3:

Economic and other barriers to adopting recommendations to
prevent childhood obesity: results of a focus group study with
parents
Kendrin R Sonneville*1,2, Nancy La Pelle3, Elsie M Taveras2,4,5,
Matthew W Gillman1,2,4,5 and Lisa A Prosser6
Address: 1Department of Nutrition, Harvard School of Public Health, Boston, MA, USA, 2Children's Hospital, Boston, Boston, MA, USA,
3Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, USA, 4Obesity Prevention Program,
Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, USA, 5Division of General Pediatrics,
Children's Hospital Boston, Boston, MA, USA and 6Child Health Evaluation and Research Unit, Division of General Pediatrics, University of
Michigan Health System, Ann Arbor, MI, USA
Email: Kendrin R Sonneville* - ksonnevi@hsph.harvard.edu; Nancy La Pelle - Nancy.LaPelle@umassmed.edu;
Elsie M Taveras - Elsie_Taveras@harvardpilgrim.org; Matthew W Gillman - Matthew_Gillman@harvardpilgrim.org;
Lisa A Prosser - lisapros@med.umich.edu
* Corresponding author
Abstract
Background: Parents are integral to the implementation of obesity prevention and management recommendations for
children. Exploration of barriers to and facilitators of parental decisions to adopt obesity prevention recommendations
will inform future efforts to reduce childhood obesity.
Methods: We conducted 4 focus groups (2 English, 2 Spanish) among a total of 19 parents of overweight (BMI ≥ 85th
percentile) children aged 5-17 years. The main discussion focused on 7 common obesity prevention recommendations:
reducing television (TV) watching, removing TV from child's bedroom, increasing physically active games, participating in
community or school-based athletics, walking to school, walking more in general, and eating less fast food. Parents were
asked to discuss what factors would make each recommendation more difficult (barriers) or easier (facilitators) to follow.
Participants were also asked about the relative importance of economic (time and dollar costs/savings) barriers and
facilitators if these were not brought into the discussion unprompted.
Results: Parents identified many barriers but few facilitators to adopting obesity prevention recommendations for their
children. Members of all groups identified economic barriers (time and dollar costs) among a variety of pertinent barriers,
although the discussion of dollar costs often required prompting. Parents cited other barriers including child preference,
difficulty with changing habits, lack of information, lack of transportation, difficulty with monitoring child behavior, need
for assistance from family members, parity with other family members, and neighborhood walking safety. Facilitators
identified included access to physical activity programs, availability of alternatives to fast food and TV which are
acceptable to the child, enlisting outside support, dietary information, involving the child, setting limits, making behavior
changes gradually, and parental change in shopping behaviors and own eating behaviors.
Conclusions: Parents identify numerous barriers to adopting obesity prevention recommendations, most notably child
and family preferences and resistance to change, but also economic barriers. Intervention programs should consider the
context of family priorities and how to overcome barriers and make use of relevant facilitators during program
development.
Article 4:
Obesity Prevention Opinions of School
Stakeholders: A Qualitative Study
SOPHIE BUCHER DELLA TORRE, SWISS RDa
CHRISTINA AKR´E, MAb
JOAN-CARLES SURIS, MD, PhDc
ABSTRACT
BACKGROUND: In general, schools are an important setting to implement current
recommendations for obesity prevention in children because the vast majority of
children attend school. This study investigated the opinions of different school
stakeholders on the feasibility and acceptability of current obesity prevention strategies
that could be implemented in Swiss schools.
METHODS: Research methods were comprised of a qualitative study which included
school directors, physical education teachers, catering staff, school nurses and health
educators, parents of young adolescents, and young adolescents interviewed (N = 40)
categorized into 6 focus groups. Open-ended questions were used to determine the
participants’ opinion regarding current obesity prevention recommendations, and
healthy eating and physical activity promotion strategies.
RESULTS: All participants approved the implementation of nutritional standards for
food and drinks sold in schools, but thought that increasing the attractiveness of healthy
options was the best strategy to improve eating habits. Enjoying participation in physical
activity classes or after-school activities was stressed. Participants suggested offering
classes for all students with poor physical condition, independent of weight status.
Stakeholders called for governmental support and global coordination of interventions
balanced with providing schools with enough autonomy to adapt programs relevant to
their individual circumstances. They recommended integrating all school stakeholders in
obesity prevention initiatives, with special attention to students and local authorities.
CONCLUSIONS: Participants agreed that schools are a crucial setting to implement
childhood obesity prevention strategies. They called on school stakeholders to join
efforts aiming to encourage healthy behaviors and to support and reinforce parents’
efforts by spreading consistent and coherent health messages.
Keywords: obesity; school-based prevention; qualitative research.
Citation: Bucha Della Torre S, Akr´e C, Suris J-C. Obesity prevention opinions of school
stakeholders: a qualitative study. J Sch Health. 2010; 80: 233-239.
Received January 16, 2009
Accepted September 24, 2009
aResearch Assistant, (sophie.bucher@hesge.ch), ResearchGroup on Adolescent Health, Institute of Social and PreventiveMedicine, University of Lausanne, 17, Rue du Bugnon, CH
1005 Lausanne, Switzerland.
bResearch Assistant, (Christina.Akre@chuv.ch), Research Group on Adolescent Health, Institute of Social and Preventive Medicine, University of Lausanne, 17, Rue du Bugnon CH
1005 Lausanne, Switzerland.
cUnit Head, (Joan-Carles.Suris@chuv.ch), Research Group on Adolescent Health, Institute of Social and Preventive Medicine, University of Lausanne, 17, Rue du Bugnon, CH 1005
Lausanne, Switzerland.
Address correspondence to: Sophie Bucher Della Torre, Research Assistant, (sophie.bucher@hesge.ch), ResearchGroup on Adolescent Health, Instituteof Social and Preventive
Medicine, University of Lausanne, 17, Rue du Bugnon, CH1005 Lausanne, Switzerland.
Journal of School Health • May 2010, Vol. 80, No. 5 • © 2010, American School Health Association • 233
Childhood obesity is a serious public health problem
worldwide, including Switzerland. In 2002, among
Swiss children 6 to 12 years of age, the prevalence of
overweight reached 17% and 19%. The prevalence of
childhood obesity in 2002 was 4%, which represented
a 5-fold increase compared to 1980.1 Important
physical and psychological consequences,2,3 enormous
associated costs,4 and difficulties encountered in the
treatment of obesity clearly point toward the need for
prevention as a public health focus.5,6
Multiple factors at the intra- and interpersonal,
institutional, community, and societal levels contribute
to the onset and maintenance of weight gain
during childhood and adolescence.7 To reverse obesity
trends, preventive interventions need to be based
on an ecological approach and take into account the
multiple etiologies and ‘‘system level’’ contributions to
childhood obesity. Particularly, educational and environmental
strategies need to be developed in family
and school contexts.2,8,9
To date, prevention programs have mostly focused
on schools, as schools reach a majority of children
and have long-term and in-depth contact with
them. These school-based prevention programs have
shown changes in behaviors, even if the impact
on body weight or body fatness is less evident.10,11
Published recommendations for prevention efforts
aiming at promoting healthy eating habits and active
lifestyle12,13 are detailed in Table 1.
Schools encounter at least 2 barriers to implementing
these recommendations: (1) the structure
and schedule constraints and (2) the different views
and perceptions of the different stakeholders (eg,
teachers, students, school nurses, parents, or vendors).
To increase success in the implementation
of current guidelines, our study investigated
the opinions of those different school stakeholders
Table 1. Current Recommendations for Obesity Prevention in Schools (adapted from Refs 12,13)
Schools should:
• Ensure that all schoolmealsmeet nutritional guidelines.
• Develop and implement nutritional standards for all competitive foods and beverages sold or served in schools.
• Change availability and access to both healthy and less healthy foods, pricing of foods and beverages, promotional programs to support healthful foodchoices.
• Ensure that all children and youthparticipate in aminimumof 30minutes ofmoderate to vigorous physical activity during the school day.
• Expand opportunities for physical activity through physical education classes (moderate to vigorous activity for at least 50%of the class time), and extracurriculum
activities.
• Promote after-school use of school facilities andwalking- and biking-to-school programs.
• Enhance health curricula to devote adequate attention to nutrition, physical activity, reducing sedentary behaviors, and energy balance, and to include a behavioral
skills focus.
• Develop, implement, and enforce school policies to create schools that are advertising-free to the greatest possible extent.
• Evaluate the impact of programs on competitive foods’ nutritional value and availability, student dietary quality, revenues generated by food and beverage sales,
academic performance, and classroomand social behavior.
• Involve school healthservices inobesitypreventionefforts. Conduct annual assessments of eachstudent’sweight, height, andgender- andage-specific BMI percentile
andmake this information available to parents.
about