Encouraging healthy schools

Encouraging healthy schools

What this section covers

Schools can be environments that encourage healthy behaviours; they can help children establish habits of healthy eating and being physically active. This section covers NIHR-funded research into interventions that aim to prevent obesity in schools, and are open to broader groups of children, for example entire year groups. Interventions targeting children living with obesity are covered under ‘Providing weight management programmes’; interventions in the community are covered under ‘Preventing obesity in children and families’.

What’s the context?

  • Rates of obesity in children double in the 7 years between entering primary school and starting secondary school (NHS Digital), and increase further in secondary school (HM Government).
  • National commitments include: updating food standards for schools to reduce sugar consumption; reviewing how the least active children are being engaged in physical activity in and around the school day; and a national ambition for every primary school to adopt an active mile initiative (HM Government).
  • Opportunities for local authority actions include: working with headteachers and governors to adopt a whole school approach in implementing policies and practices to support healthy weight, food and the promotion of physical activity; creating a culture of healthy eating; offering a breakfast club where at least 40% of pupils in areas of deprivation are eligible for free school meals; and promoting safe modes of active travel to and from school and college (Public Health England).

What does NIHR research tell us?

The Daily Mile in primary schools increases activity and may lead to small reductions in BMI

The Daily Mile has been implemented widely in primary schools in disadvantaged urban areas where children are most likely to be living with obesity, and have fewer opportunities for physical activity.(2,3) It had a small (non-significant) effect on body weight (BMI z-score), with a greater effect in girls. The Daily Mile may be cost-effective as part of a system-wide approach to obesity prevention; longer-term follow up is needed.(1)

Other primary school interventions have little effect on physical activity and diet

Interventions in UK primary schools have not been shown to be effective or cost-effective in preventing overweight or obesity (4,5). They include: helping teachers to provide 30 minutes’ additional physical activity; running school-based healthy cooking workshops for parents and children; providing information for families. A gardening intervention was not effective at increasing fruit and vegetable intake.(6) One intervention for children aged 9 to 10 years included teacher training and materials for teachers, children and parents. It did not increase levels of physical activity, reduce sedentary behaviour or increase fruit and vegetable intake. However, it may have had other benefits, such as reducing screen viewing at weekends at home, and the consumption of snacks and high-energy drinks.(7)

School-based interventions in primary schools are unlikely to have a major impact on promoting healthy levels of physical activity and healthy diets. But some children may benefit. The greatest effects are seen in girls, older primary school children, and those whose parents have higher education.(8)

Interventions in UK secondary schools have not increased physical activity

Interventions to increase physical activity in secondary schools tend to involve pupils acting as peer leaders to promote physical activity. These interventions have not been shown to increase levels of moderate to vigorous physical activity (9–11) or to counter the age-related decline in physical activity.(12) Interventions may not have been sufficiently intense, or reached those most in need: a dance-based programme appealed to those who were already active.(11)

A whole school ‘health promotion’ ethos is facilitated by leadership, parent, and local community support

Health promotion in schools is enabled by a headteacher with a health-promoting ethos and a proactive leadership team;(13) parental involvement;(14) and pathways between schools and local communities that reinforce physical activity messages. (13–15)

Barriers include a lack of government support and regulation; school structures and organisation; staff capacity; canteens run by businesses; a lack of family and community engagement; a lack of student involvement; financial constraints; a focus on educational outcomes and school performance. (13,15,16)

Useful resources

  • Government guidance on what works in schools and colleges to promote levels of activity among children and young people.
  • The National Institute for Health and Care Excellence (NICE) provides guidance on whole-school approaches and recommends long-term programmes, with multiple components, including after-school clubs and other activities.
  • NHS Scotland’s overview of evidence found that food and drink policies are most effective when they address the whole food environment; adaptations (such as reducing fat content, age-appropriate portion sizes and limiting unhealthy options) could reduce obesity.
  • Ofsted has recommended that schools and parents need to reinforce each other’s roles more effectively.
  • The Local Government Association gives examples of public health teams working with local schools, many of them academies, to promote activity and healthy nutrition. Examples include ‘Fruity Fridays’ when PE kits are worn, pupils are encouraged to be active during the whole day, and there is a health-themed assembly.

NIHR research in progress

  • How to engage teenagers in a programme to promote healthy diets and physical activity. (17)
  • How effective is an environmental nutrition and physical activity programme for children aged 2 to 4 in nurseries?(18)

NIHR studies included in this section

  1. Breheny K, Passmore S, Adab P, Martin J, Hemming K, Lancashire ER, et al. Effectiveness and cost-effectiveness of The Daily Mile on childhood weight outcomes and wellbeing: a cluster randomised controlled trial. Int J Obes. 2020 Apr;44(4):812–22.
  2. Venkatraman T, Honeyford K, Costelloe CE, Bina R, Sluijs EMF van, Viner RM, et al. Sociodemographic profiles, educational attainment and physical activity associated with The Daily MileTM registration in primary schools in England: a national cross-sectional linkage study. J Epidemiol Community Health. 2021 Feb 1;75(2):137–44.
  3. Venkatraman T, Honeyford K, Ram B, M F van Sluijs E, Costelloe CE, Saxena S. Identifying local authority need for, and uptake of, school-based physical activity promotion in England–a cluster analysis. J Public Health. 2021 May 4;fdab138.
  4. Adab P, Barrett T, Bhopal R, Cade JE, Canaway A, Cheng KK, et al. The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study: a cluster randomised controlled trial testing the clinical effectiveness and cost-effectiveness of a multifaceted obesity prevention intervention programme targeted at children aged 6-7 years. Health Technol Assess. 2018 Feb 13;22(8):1–608.
  5. Wyatt K, Lloyd J, Creanor S, Green C, Dean SG, Hillsdon M, et al. Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children. Public Health Res. 2018 Jan 19;6(1):1–204.
  6. Christian M, Evans C, Cade J. Does the Royal Horticultural Society Campaign for School Gardening increase intake of fruit and vegetables in children? Results from two randomised controlled trials. Public Health Res. 2014 Aug 26;2(4).
  7. Lawlor D, Kipping R, Anderson E, Howe L, Chittleborough C, Moure-Fernandez A, et al. Active for Life Year 5: a cluster randomised controlled trial of a primary school-based intervention to increase levels of physical activity, decrease sedentary behaviour and improve diet. Public Health Res. 2016 Jun 28;4(7).
  8. Ijaz S, Nobles J, Johnson L, Moore T, Savović J, Jago R. Preventing Childhood Obesity in Primary Schools: A Realist Review from UK Perspective. Int J Environ Res Public Health. 2021 Dec 20;18(24):13395.
  9. Harrington DM, Davies MJ, Bodicoat D, Charles JM, Chudasama YV, Gorely T, et al. A school-based intervention (‘Girls Active’) to increase physical activity levels among 11- to 14-year-old girls: cluster RCT. Public Health Res. 2019 Feb 19;7(5):1–162.
  10. Jago R, Tibbitts B, Willis K, Sanderson E, Kandiyali R, Reid T, et al. Effectiveness and cost-effectiveness of the PLAN-A intervention, a peer led physical activity program for adolescent girls: results of a cluster randomised controlled trial. Int J Behav Nutr Phys Act. 2021 Dec;18(1):63.
  11. Jago R, Edwards M, Sebire S, Bird E, Tomkinson K, Kesten J, et al. Bristol Girls Dance Project: a cluster randomised controlled trial of an after-school dance programme to increase physical activity among 11- to 12-year-old girls. Public Health Res. 2016 May 31;4(6).
  12. Corder KL, Brown HE, Croxson CH, Jong ST, Sharp SJ, Vignoles A, et al. A school-based, peer-led programme to increase physical activity among 13- to 14-year-old adolescents: the GoActive cluster RCT. Public Health Res. 2021 May 4;9(6):1–134.
  13. McHugh CA, Lloyd J, Logan S, Wyatt K. Implementing a set of health promoting processes in English secondary schools: A comparative case study. Public Health Pract. 2021 Nov 1;2:100214.
  14. Daly-Smith A, Quarmby T, Archbold VSJ, Corrigan N, Wilson D, Resaland GK, et al. Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework. Int J Behav Nutr Phys Act. 2020 Feb 7;17(1):13.
  15. Tibbitts B, Willis K, Reid T, Sebire SJ, Campbell R, Kipping RR, et al. Considerations for Individual-Level Versus Whole-School Physical Activity Interventions: Stakeholder Perspectives. Int J Environ Res Public Health. 2021 Jan;18(14):7628.
  16. McHugh C, Lloyd J, Logan S, Wyatt K. Enablers and barriers English secondary schools face in promoting healthy diet and physical activity behaviours. Health Promot Int. 2022 Apr;37(2):daab148
  17. Inskip H, Barker M. Engaging adolescents in changing behaviour (EACh-B): a programme of research to improve the diets and physical activity levels of teenagers RP-PG-0216-20004. NIHR Funding and Awards Search Website. [cited 2022 Feb 4].
  18. Kipping R. A multicentre cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of an environmental nutrition and physical activity intervention in nurseries (Nutrition and Physical Activity Self Assessment for Child Care – NAP SACC UK) NIHR127551. NIHR Funding and Awards Search Website. [cited 2022 Feb 4].