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Title: Fit for School: Results of a 10-week school-based child healthy weight pilot

intervention for primary school students

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AKNOWLEGEMENTS: This work was supported by the National Health Service (NHS)

Lanarkshire Health Improvement programme. Jonathan Cavana, NHS Lanarkshire Child Healthy

Weight Programme Manager, developed the intervention content as well as the design.

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ABSTRACT

BACKGROUND: The purpose of this pilot study was to report body mass index standard

deviation score (BMI-SDS) changes following a Child Healthy Weight pilot intervention.

METHODS: Children (n = 3290) aged 4 – 12 years from southwest Scotland participated in a

10-week school-based pilot intervention comprised of parental engagement, behaviour change,

and health literacy and physical activity modules. Children’s height and weight were measured

during the first and last weeks of the intervention. A sub-group was followed-up at 6 and 24

months after the interventions. Raw data was converted to BMI-SDS.

RESULTS: Significant reductions in BMI-SDS occurred in the total group [-0.03 ± 0.29 (95%

CI -0.036 to -0.015), p < 0.001], non-overweight (p = 0.001), and combined overweight and

obese children (p < 0.001). While BMI-SDS decreased in younger boys [-0.02 ± 0.30 (-0.037 to -

0.002), p < 0.05] and girls [-0.04 ± 0.30 (-0.061 to -0.025), p < 0.001] as well as older boys [-

0.03 ± 0.29 (-0.058 to -0.010), p < 0.01], no change was evident in older girls [-0.01 ± 0.29 (-

0.031 to 0.017), p = 0.56]. Follow-up assessments confirmed that BMI-SDS significantly

decreased from baseline to 6 months post intervention but returned to pre intervention levels 24

months post intervention.

CONCLUSIONS: Significant reductions in BMI-SDS were apparent in the short-term

evaluation but values regressed to the initial baseline levels after 24 months. Future work is

needed to examine the long-term effects sustained intervention programmes.

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KEYWORDS: physical activity, obesity, BMI, BMI-SDS, school health

Word Count: 3954

Disclosure Statement: There are no financial interests to disclose.

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Introduction

Child obesity is a global health concern with estimates suggesting that prevalence rates have

increased by 47.1% from the years 1980 – 2013 (Ng et al., 2014). Childhood obesity is

associated with a number of health issues such as hypertension and dyslipidemia (Caprio et al.,

1996; de Silva, Wickramasinghe, and Gooneratne. 2006; Flechtner-Mors et al., 2012), which if

left unabated can track into adulthood increasing the risk of developing cardiovascular disease

(de Kroon et al., 2010; Field, Cook, and Gillman, 2005; Juonala et al., 2011). Furthermore, it is

worrying that several studies have indicated that obese children are at an increased risk of

becoming obese adults (Freedman et al., 2001; Juonala et al., 2011; Trudeau et al., 2003). Within

20 years, healthcare costs associated with obesity in the United States and the United Kingdom

are projected to increase by $48 – 66 billion and £1.9 – 2 billion a year, respectively (Wang et

al., 2011). Given this anticipated economic burden, many governments and organizations

globally have recognized the importance of early intervention through health enhancing

initiatives at a young age. Schools are considered ideal settings for imparting health improving

behaviours in children to prevent obesity because of pre-established infrastructure, the large

amount of time children spend there, and the role schools play regarding the health and education

of communities (Committee on Physical Activity and Physical Education in the School

Environment, 2013).

School-based interventions that include healthy eating (HE), physical (PA), parental

involvement, and behaviour change strategies have shown promise in recent years for improving

weight status in youth which is often measured by body mass index (BMI) or BMI standard

deviation scores (BMI-SDS) (Gorely et al., 2009; Llargues et al., 2012; Spiegel and Foulk,

2006). Because concerns of obesity and associated health risks are prevalent worldwide, low-

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cost, easily implemented measures such as BMI are needed for tracking. Although other

measures of adiposity change including waist circumference (WC), skinfold (Gorely et al.,

2009), and waist to height ratio (WtHR) (Grydeland et al., 2014) are also used to evaluate

interventions, BMI is the most widely used because of its simplicity, low cost, and minimal

training. Since BMI-SDS permits a comparison of weight-for-height across age and sex within

populations using established reference data (Cole, Freeman, and Preece, 1998), it is a common

measure for evaluating effectiveness in school-based interventions (Angelopoulos et al., 2009;

Fairclough et al., 2013; Gorely et al., 2009).

A number of multi-component school-based interventions have been successful in

reducing obesity in youth in the short-term, but few studies have investigated the long-term

effects of these types of interventions (Fairclough et al., 2013; Hatzis, Papandreou, and Kafatos,

2010; Rush et al., 2012). These interventions included HE and PA education as well as actual PA

sessions. Because of the global high child obesity levels and the potential to abate this trend

through these types of programmes, school-based multicomponent child obesity treatment and

prevention interventions are needed worldwide.

Fit for School (FFS) is a school-based intervention developed and implemented in

schools across Lanarkshire, Scotland which is comprised of a number of components associated

with obesity such as PA and HE education, PA activity sessions, behaviour change, and parental

engagement (Gorely et al., 2009; Llargues et al., 2012; Spiegel et al., 2006). In order to gain

information upon the efficacy, fidelity, and effectiveness of these types of interventions, it is

important to examine changes in adiposity that may be a result of the intervention. Thus, the

purpose of this pilot study was to report BMI-SDS changes following a Child Healthy Weight

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(CHW) pilot intervention. A secondary aim of this study was to report the sustained effects of

the intervention at 6- and 24-month follow-up points from a specific sub-group analysis.

Methods

Participants and study design

A multi-agency interdisciplinary partnership approach was used to recruit schools for

participation and to provide participants with ongoing support beyond the end of the intervention

(Goodkind et al., 2011). The support was accomplished through providing participants with

information on extracurricular PA programmes hosted by Leisure Trusts (Stokols, 1992). A one-

group, repeated measures design was used and schools were not randomly selected but rather a

quota sample was used. Participants took part in the intervention from January 2010 – June 2012.

A sub-group of these participants (n = 73) were followed up at 6- and 24-months post-

intervention to examine sustained effects from January 2012 – September 2014 and included 29

(39.7%) boys and 44 (60.3%) girls. The mean age of the boys was 8.57 (SD = 0.94) years, and

the mean age of the girls was 8.67 (SD = 0.86) years. See Figure 1 for the flow of schools and

participants through the study.

[Figure 1 near here]

Ethical approval was obtained from National Health Service (NHS) Lanarkshire. One

hundred thirteen schools in Lanarkshire participated in FFS, and informed parental consent and

participant assent were collected from 5214 participants from primary classes 1 - 7 aged 4 – 12

years. The Scottish Index of Multiple Deprivation (SIMD) was used as a measure of social

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deprivation with a lower SIMD quintile representing a more deprived area (Kinra, Nelder, and

Lewendon, 2000). The sample represented schools from a range of socioeconomic backgrounds

with 34.7%, 31.2%, 19.7%, 8.8%, and 6.6% of participants attending schools with SIMD

quintiles of 1, 2, 3, 4, and 5, respectively. Participants were recruited from 2 local authorities –

North Lanarkshire and South Lanarkshire. Across North Lanarkshire white children aged 0 - 4, 5

- 9, and 10 – 14 years comprised 96.1%, 96.5%, and 97.2% of the population, respectively.

Similarly across South Lanarkshire white children aged 0 – 4, 5 – 9, and 10 – 14 years comprised

95.9%, 96.2%, and 96.8% of the population, respectively (National Records of Scotland, 2011).

Instruments

Height and weight. Coaches were trained on measuring height (cm) and weight (kg) according to

Child Measurement Programme Operational Guidance (Public Health England, 2014). SecaTM

899 digital scales were used to measure body weight in kilograms. Children were weighed in

light clothing without shoes, and stood with both feet in the centre of the scale while the coach

recorded values rounded to the nearest 0.1kg. Height was assessed with a Seca Leicester Height

Measure stadiometer. The wall stop was positioned against the wall prior to assessment. For

height, participants stood up straight with their back against the wall and feet together while their

heels touched the vertical measuring column. Measurements were recorded in centimetres and

rounded to the nearest 0.1cm. Height and weight were recorded for each child in weeks 1 and 10

of the intervention.

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Intervention

Design. Table 1 describes the project titles, unit titles, and content summary for each primary

class. FFS was a whole class, 90-minute, 10-week primary school intervention consisting of PA

and HE education, PA activity sessions, behaviour change, and parental engagement

components. The primary goal of the intervention was to help children above a healthy weight

range to achieve and maintain a healthy weight. Although the target population assigned by NHS

Health Scotland were those equal to or greater than the 91st centile of the UK1990 Growth

Reference (Cole, Freeman, and Preece, 1998), the delivery was designed for and given to the

whole class, therefore the intervention had a secondary aim of supporting children who were

within a healthy weight range to remain so.

[Table 1 near here]

Education. The programme was divided into 7 age-specific units. Sub-topics varied with each

age group to ensure age-appropriate material. For example, HE topics for younger children in

Primary 1 (aged 4 - 6 years) included an understanding that people need more of some foods and

less of others, while topics for older children in Primary 7 (10 – 12 years) included how different

foods and drinks have energy and nutrients in varying amounts. Individual units were made up of

6 thematic modules including PA, HE, physical education, healthy lifestyle topics, home-link,

and class projects, and were delivered over 8 weeks.

Behaviour change. Topics and activities addressing childhood obesity-related behaviours

combined with multiple theories of behaviour change including transtheoretical model (TTM)

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(Prochaska and DiClemente, 1983), Theory of Planned Behaviour (TPB) (Ajzen, 1991), and

Social Ecological model (SEM) (Stokols, 1992) were formatted into a health education

framework. Children were supported while moving through the TTM stages of change

paralleling assumptions of TPB which allow children to go through a conscious process deciding

the benefits of changing behaviours and then designing individual plans about making specific

changes. To promote student interaction, coaches employed a motivational interviewing

technique which is a viable and effective approach to improving weight status in children

(Macdonell et al., 2012; Saelens, Lozano, and Scholz, 2013; Taveras et al., 2011). By asking the

class questions regarding behavior while reinforcing self-efficacy, the coach aimed to induce

self-reflection and elicit positive motivation for change statements.

Physical activity. The PA module focused on fun, enjoyable activities that kept the children

moving the majority of the time.

Parental involvement. Because parents serve as role models and the home environment can have

a profound effect on child diet and PA (Golan and Crow, 2004), a parental component was

included in the intervention. Parental involvement was accomplished though pre-programme

information, consent forms, and weekly homework tasks with information about each week’s

lessons and key messages for parents. All of these documents required a parent’s or guardian’s

signature.

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Procedure

Healthy lifestyle coaches with PA backgrounds hired by NHS Lanarkshire delivered the sessions

and also performed assessments. The coaches were experienced in working with children

through various PA initiatives from Local Authorities and received a 2-day training and

certification in elementary food and health. All staff underwent additional training that included

health behaviour change theory with a focus on supporting student engagement, motivational

interviewing techniques, FFS ethos, content and delivery, height and weight measurement, and

information governance. The training was consistent for all coaches and was conducted by the

NHS Lanarkshire CHW Programme Manager and lasted a total of 7 hours. Coaches were given

all the resources required to conduct the sessions. The classroom teachers were present during

each session to provide support but did not deliver the intervention. Although coaches delivered

the intervention, FFS was designed to eventually be led by teachers for sustainability purposes.

Data Analysis

Data cleansing. Quality control measures were taken to minimize measurement error. Because

data was not available to determine individual measurement error per coach, exclusion criteria

for analysis was based on a combination of biological and statistical likelihood similar to Berkey

and colleagues’ approach (Berkey et al., 2000). Since diurnal variation in child height can vary

between +1.8cm to -2.7cm (Siklar et al., 2005), any child whose height changed < -2.7cm from

pre to post was excluded from the analyses (n = 66). In accordance with Berkey and colleagues’

approach (Berkey et al., 2000), participants whose change in BMI exceeded > 3SD beyond age

and sex specific means from pre to post, post to 6 months, or post to 24 months were excluded

from analyses (n = 72). Children with heights declining > 2.54cm at 6 months (n = 12) and

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declining > 0cm at 24 months (n = 7) were excluded from analyses. Additionally, children whose

height increased > 3SD beyond age and sex specific means from post to 6 months (n = 5), or post

to 24 months (n = 1) were excluded from analyses.

Height and weight transformations. Height and weight values were transformed to BMI-SDS

values using Cole’s LMS method and were based on the UK1990 reference (Pan and Cole,

2011). Centiles were computed in order to classify the weight status of each child. Weight

categories were based on UK1990 clinical definitions. For clinical evaluation in Scotland,

definitions of overweight and obesity are based on recommendations from the Scottish

Intercollegiate Guidelines Network (SIGN) and are defined as ≥ 91st but less than the 98th centile

and ≥ 98th centile, respectively (Hering et al., 2010). Children categorized into the overweight

and obese categories were considered to have a high BMI. From this point forward any reference

to the overweight group will include overweight and obese children.

Statistical analyses. All statistical procedures were conducted using IBM SPSS Statistics for

Windows, Version 20.0, Armonk, New York. Because the data pertaining to sub-groups of

overweight children and non-overweight children as well those with 6- and 24-month follow-ups

did not meet the assumptions for parametric tests, non-parametric tests were used for these

specific analyses. An independent samples t-test was conducted to compare baseline BMI-SDS

of children who completed pre and post measures against those who did not complete post

measures in order to determine a potential for bias in pre to post changes. A mixed design

ANOVA was used to compare changes in BMI-SDS from pre to post across total group, age, and

sex in the entire sample. Similar to Stock’s approach (Stock et al., 2007), age groups were

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segregated into younger (< 9 years) and older (≥ 9 years) sub-groups for analyses. A Wilcoxon

signed-rank test was used to determine changes in BMI-SDS in the normal weight group and the

overweight group in the entire sample. A Kruskal-Wallis test was used to determine changes in

BMI-SDS at pre, post, 6-month, and 24-month follow-ups in a specific sub-group of participants.

Statistical significance was set a priori at p < 0.05.

When participants are clustered into groups less variance between individuals is

expected (Campbell, Grimshaw, and Elbourne, 2004). The control of clustering as well as

extraneous covariates was statistically reduced through the large sample size.

Results

Preliminary results

For participants with baseline measurements and completed demographic information, the

retention rate from pre to post was 74.7%. Characteristics of the participants at baseline with

complete measures at pre and post as well as the sub-group with 6- and 24-month follow-ups are

presented in Table 2. The prevalence of individuals classified as overweight was 22.9%. Baseline

BMI-SDS differed significantly (p < 0.001) between children who completed pre and post

measures and those who only completed pre intervention measures. Those who did not complete

post measures had a significantly higher BMI-SDS (m = 0.57, SD = 1.38) than those who

completed pre and post measures (m = 0.49, SD = 1.16), p < 0.001.

[Table 2 near here]

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Total group, sex, age

For the total group, there was a significant main effect for time from pre to post, F(1, 3286) =

23.17, p < 0.001, such that BMI-SDS decreased over time. A post hoc power analysis revealed

that the observed power for total within-group BMI-SDS change was β = 0.98. There was also a

significant main effect for sex, F(1, 3286) = 5.70, p = 0.02, such that boys had a higher BMI-

SDS than girls. No significant main effect occurred for age group, F(1, 3286) = 2.08, p = 0.15. A

significant interaction occurred between time, age group, and sex, F(1, 3286) = 5.36, p = 0.02,

such that younger boys (p = 0.03) and girls (p < 0.001) as well as older boys (p = 0.006) reduced

BMI-SDS from pre to post while older girls (p = 0.56) did not. No significant interaction was

evident between time and age group (p = 0.31) or time and sex (p = 0.89). Table 3 displays the

pre and post means for sex and age group.

[Table 3 near here]

Weight status

For non-overweight participants, BMI-SDS was significantly lower at post (Mdn = 0.08) than at

pre (Mdn = 0.10), z = -3.40, p = 0.001, r = - 0.048. Similarly, for overweight participants BMI-

SDS was significantly lower at post (Mdn = 1.96) than at pre (Mdn = 2.00), z = -6.39, p = <

0.001, r = -0.164.

Follow-ups

For the sub-group with 6- and 24-month follow-ups, BMI-SDS significantly changed across time

points, X2(3) = 60.32, p < 0.001. Wilcoxon signed-rank tests were calculated to follow up this

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finding, and a Bonferroni correction was used to account for multiple tests such that a finding

was only considered significant if p < 0.008. BMI-SDS significantly decreased from pre to post,

z = -3.8, r = -.0.31, p < 0.001, pre to 6 months, z = -5.7, r = -0.47, p < 0.001, and post to 6

months, z = -5.11, r = -0.42, p < 0.001. BMI-SDS significantly increased from 6 months to 24

months, z = -5.14, r = -0.43, p < 0.001, and there was no difference in BMI-SDS from pre to 24

months, z = -1.58, r = -0.13, p = 0.12 or from post to 24 months, z = -0.06, r = -0.005, p = 0.95.

Table 2 describes the baseline characteristics of this sub-group, and Figure 2 presents mean

change in BMI-SDS over time.

[Figure 2 near here]

Discussion

The aim of this paper was to report BMI-SDS changes in children who participated in a CHW

intervention. The findings of this study suggest that FFS may be a means for reducing BMI-SDS

in children through health education and PA in the short-term. Positive intervention effects for

BMI-SDS were evident in the entire group from pre to post (m Δ BMI-SDS = -0.03). Cook-

Cottone and colleagues’ review concluded that school-based interventions lasting over 12 weeks

were associated with BMI improvement (Cook-Cottone et al., 2009). BMI reductions in

programmes lasting 12 weeks or less are more common in community settings. A short-term

multicomponent community-based intervention for overweight children aged 8-14 years

demonstrated significant reductions in BMI in as little as five weeks (Hutchens et al., 2010).

Although longer and more frequent sessions were applied in Hutchens’ intervention, a decrease

in BMI in half the time of the present study demonstrates the likelihood of achieving BMI

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reductions in multi-level short-term interventions. Aspects of FFS that may have contributed to

the reduced BMI-SDS outcomes include a detailed healthy lifestyle curriculum with an emphasis

on behaviour change (Watson-Jarvis, Johnston, Clark, 2011), a motivational interviewing

technique with students (Macdonell et al., 2012; Saelens, Lozano, and Scholz, 2013; Taveras et

al., 2011), and a holistic multicomponent approach (Fairclough et al., 2013; Hatzis, Papandreou,

and Kafatos, 2010; Rush et al., 2012). Although BMI-SDS was reduced in the short-term,

because BMI-SDS returned to pre-intervention levels at 24-month follow-up, this highlights the

need for on-going sustainable interventions.

While FFS resulted in a reduction of BMI-SDS in younger boys and girls as well as older

boys, the intervention had no effect on older girls. In terms of sex differences, this finding is

consistent with Sallis and colleagues’ findings in which a combined PA and nutrition

intervention resulted in a significant decrease in BMI in boys but not in girls (Sallis et al., 1993).

It may be that older girls have less perceived PA competence than boys which may reduce their

motivation to participate in PA (Eccles, Wigfield, Harold, & Blumenfeld 1993; Seabra et al.,

2013). Girls tend to be less active than boys (Verloigne et al., 2012), and PA decreases with age

prior to adolescence (Basterfield et al., 2011). Therefore, older girls may represent a sub-group in

which specific strategies are necessary to increase PA in order to reduce obesity.

When examining the effects of FFS in non-overweight and overweight children

separately, both groups significantly decreased BMI-SDS. A high BMI-SDS in childhood is

associated with cardiovascular disease risk factors (Freedman et al., 2007), and it has been

suggested that a minimum reduction of 0.25 SD is required for improvements in insulin

sensitivity, total cholesterol/high-density lipoprotein ratio and blood pressure (Ford et al., 2010).

Although the shift in BMI-SDS from pre to post in the overweight group decreased by only 0.04

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SD, even small shifts in BMI at the population-level could have a tremendous impact on

population health (Rose, 1992).

While there were no significant differences in BMI-SDS when comparing age groups, a

sex difference was evident. Overall, boys had a significantly higher BMI-SDS than girls. This

finding is consistent with the Scottish National Health Survey that reported trends in increasing

overweight incidence rates over the last decade which have been attributed to a greater increase

in boys (Scottish Health Survey Team, 2012). Another explanation for this sex difference may be

the effect maturation has on BMI variance. BMI does not fully adjust for the effects of height on

weight in children who were in the early stages of puberty (Lewitt et al., 2012), and, therefore,

comparing children’s BMI as a marker for obesity without known pubertal stages may be

misleading.

Although BMI-SDS significantly declined 6 months post-intervention, the 24-month

follow-up indicated BMI-SDS returned to pre-intervention levels. Fairclough demonstrated

sustained intervention effects in terms of reduced BMI z-score up to 5 months post-intervention

with the CHANGE! Project, a school-based HE and PA intervention (Fairclough et al., 2013).

Additionally, a 6-year school-based health education intervention with parental involvement

demonstrated significant BMI reductions compared to controls 4 years post-intervention (Hatzis,

Papandreou, and Kafatos, 2010). It may be that longer, more intensive school-based

interventions are necessary for imparting sustained health behaviours necessary for long-term

obesity prevention and treatment.

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Limitations

A limitation of this study was the lack of control groups. Although recruiting control participants

by putting them on a waiting list to receive the intervention may have been a viable alternative

for younger participants, the inclusion of older participants who would soon change schools

made this approach less feasible. Another limitation is the high attrition rate. Of the 3290

participant that were included in pre- to post-intervention analyses, 73 (2.2%) were included in

6- and 24-month analyses. Although the attrition rate was not as high as the present study,

Reinehr and colleagues’ (2009) 2-year follow-up study of clinical lifestyle interventions were

only able to obtain complete data in 8% of their participants. While the high overweight

prevalence at baseline may have contributed to attrition at long-term follow up, the main reasons

for attrition are likely due to many schools dropping out of the study after post-intervention and

6-months and because some participants progressed to various secondary schools making them

difficult to track. A further limitation was the use of BMI as a measure of adiposity. Other

measures that could have been used that have demonstrated stronger predictive utility than BMI

for cardiovascular disease risk include WC, skinfold, and WtHR (van Dijk, 2012). Another

limitation is the lack of long-term follow-up with children who may have participated in

advertised programmes offered by the Leisure Trusts. A last limitation is the limited role of

parental involvement in the intervention which included information about FFS, consent forms,

and homework assignments. Although a greater level of parental involvement may have

produced a stronger effect, the techniques used in FFS were more practical for a sustainable

teacher-led intervention (Cook-Cottone, Casey, & Feeley, 2009).

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Strengths

This pilot study was a part of the first evaluation of the effects of school-based CHW

interventions in Scotland in children of this age. Strengths of the study include the large sample

size, wide age range, range of deprivation backgrounds, and follow-up measures. Observing

BMI-SDS changes in 3290 children increases the confidence of the likelihood of similar results

occurring in other children in this region. Although secondary students were not included in the

study and it is unknown how FFS may have an impact on older adolescents, the use of

participants aged 4-12 years provides a broad age range of primary school children from 2 local

authorities. Conducting follow-up assessments permits the evaluation of sustained intervention

effects necessary for shifts in population health.

Conclusions

Concerns of rising levels of child and adult obesity, related adverse health outcomes, and

associated healthcare costs have spurred the implementation for CHW programmes worldwide.

Although the present analysis suggested FFS may be successful in immediately reducing BMI-

SDS in children, future studies using a range of parameters and inclusion of control groups will

strengthen the effectiveness evaluation. Future research may investigate other measures such as

HE and PA knowledge and attitudes, PA, WC, and biomarkers for determining programme

effectiveness. The initial results of this pilot study seem promising but further work is needed

which will include control groups and additional measures.

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Human Subjects Approval Statement: This study was approved by the National Health

Service Lanarkshire ethics committee.

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Figure 1 Flow of classes and participants through the study

Missing outcome measures for entire class [n=67 (3 classes)]Missing outcome measures for individuals (n=257)Missing demographic information (n=487)Baseline measures completed with demographic variables (n=4403)

Enrollment

Classes agreed to follow-up [n=187 (12 classes)]Individuals lost to data cleansing (n=25)Missing 6mo or 24mo time point (n=89)Total participants included in post to 6 month analyses (n=73)

Pre Intervention

Post Intervention

6 and 24 Month Follow-Up

Approached and agreed to participate [n=5214 (229 classes)]

Missing outcome measures for entire class [n=637 (33 classes)]Missing part of outcome measure for individual (n=3)Individuals lost to follow-up (n=335)Post measures completed (n=3430)Individuals lost to data cleansing (n=138)Total participants included in pre to post analyses (n=3290)

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Table 1 FFS Primary classes and project titles, unit titles and content summary1

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Primary class and project title Unit title Content summary

P1: Healthy Habits for Life Healthy food, healthy me! Fruit and vegetablesBeing active is fun! Fun gamesWays I can move Gymnastics, games, and danceWhat is healthy and how do I know? Healthy lifestylesMaking healthy choices fun Incentives

P2: Healthy Me Enjoy healthy food and drink 5-a-day

Get active!60 minutes of physical activity per day

Learn to move well Dance

Explore the balanceHealthy lifestyles and how I feel

Understanding influences on choice

Learned behaviours and their influence on choice

P3: Get Healthy Stay Healthy Enjoy healthy food and drink

Where does my food come from?

Get active! Ways to be activeLearn to move well Games

Explore the balanceWhy people choose unhealthy options

Understanding influences on choice

Healthy lifestyles and how I feel

P4: Food for Thought Enjoy healthy food and drink Eatwell plateGet active! Exercise and your bodyLearn to move well GymnasticsExplore the balance Food and diseasesUnderstanding influences on choice Learned behaviours

P5: Energy for Exercise Eating and drinking well! Food in schoolStay active! Physical activity in my areaMove to learn well DanceGetting the balance right Healthy lifestyles and learningMaking informed choices Self determination

P6: Finding the Balance Eating and drinking well! Food labelsStay active! Green activityMove to learn well GamesGetting the balance right Benefits of being outsideMaking informed choices Changing habits

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P7: Be Health Literate Eating and drinking well!Food advertising, be media smart

Stay active! FitnessMove to learn well GymnasticsGetting the balance right Lifestyle and mental wellbeingMaking informed choices Decisional balance

Table 2. Baseline characteristics of participants - total and 6 and 24 month follow-up sub-group

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Mean (SD)

Younger Group (< 9 years) Older Group (≥ 9 years) Follow-up Sub-group

Non-overweight

Overweight Non-Overweight Overweight

n 1682 460 854 294 73Sex

Male, n (%) 844 (50.2) 263 (57.2) 424 (49.6) 149 (50.7) 29 (39.7)Female, n (%) 838 (49.8) 197 (42.8) 430 (50.4) 145 (49.3) 44 (60.3)

AgeTotal 7.84 (0.88) 7.95 (0.80) 10.17 (0.99) 10.16 (0.99) 8.63 (0.89)Male 7.81 (0.89) 7.97 (0.81) 10.15 (0.99) 10.11 (0.97) 8.57 (0.94)

Female 7.86 (0.88) 7.93 (0.78) 10.19 (0.98) 10.22 (0.99) 8.67 (0.86)Weight, kg

Total 25.7 (3.99) 36.63 (6.85) 32.67 (6.12) 46.94 (9.36) 29.15 (7.7)Male 25.73 (3.88) 36.33 (7.02) 32.32 (5.55) 45.74 (10.25) 28.97 (7.31)

Female 25.66 (4.10) 37.06 (6.61) 33.14 (6.60) 48.21 (8.22) 29.27 (8.02)Height, cm

Total 126.66 (7.16) 130.76 (6.88) 138.11 (8.52) 142.14 (8.06) 130.67 (8.52)Male 126.75 (7.26) 131.16 (7.15) 138.11 (7.95) 141.65 (7.83) 130.77 (8.7)

Female 125.77 (7.02) 130.29 (6.56) 138.12 (9.06) 142.62 (8.3) 130.61 (8.5)BMI, kg/m2

Total 16.03 (1.32) 21.28 (2.62) 16.99 (1.74) 23.04 (2.93) 16.82 (2.84)Male 15.93 (1.18) 20.97 (2.75) 16.77 (1.57) 22.57 (3.4) 16.72 (2.76)

Female 16.13 (1.44) 21.69 (2.39) 17.21 (1.88) 23.55 (2.26) 16.88 (2.92)BMI-SDS

Total 0.02 (0.78) 2.15 (0.61) 0.003 (0.86) 2.05 (0.54) 0.09 (1.22)Male 0.04 (0.77) 2.17 (0.65) 0.03 (0.85) 2.06 (0.61) 0.15 (1.33)

Female 0.00 (0.78) 2.11 (0.55) - 0.02 (0.87) 2.05 (0.46) 0.06 (1.15)

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Table 3. Intervention effects of FFS on BMI-SDS from pre to post; total sample and by sex and age group

Pre Intervention Mean (SD)

Post Intervention Mean (SD)

Δ BMI-SDS (SD) 95% CI p Value Effect Size (d)

BMI-SDS, total sample (n = 3290) 0.49 (1.16) 0.47 (1.17) -0.03 (0.29) (-0.036, -0.015) < 0.001* 0.12

Younger group (n = 2142) 0.48 (1.15) 0.44 (1.15) -0.03 (0.28) (-0.044, -0.019) < 0.001* 0.15

Boys (n = 1105) 0.54 (1.17) 0.52 (1.18) -0.02 (0.30) (-0.037, -0.002) 0.03* 0.1Girls (n = 1035) 0.40 (1.11) 0.36 (1.11) -0.04 (0.30) (-0.061, -0.025) < 0.001* 0.21

Older group (n = 1150) 0.53 (1.19) 0.51 (1.21) -0.02 (0.31) (-0.037, -0.003) 0.02* 0.1

Boys (n = 575) 0.56 (1.19) 0.53 (1.2) -0.03 (0.29) (-0.058, -0.010) 0.006* 0.16Girls (n = 575) 0.50 (1.2) 0.49 (1.22) -0.01 (0.29) (-0.031, 0.017) 0.56 0.04

* signifies p < 0.05BMI-SDS = body mass index standard deviation score d = Cohen's d

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Figure 2. Follow-up sub-group’s change in mean BMI-SDS over time

Pre Post 6 Month 24 Month-0.6

-0.5

-0.4

-0.3

-0.2

-0.1

0

0.1

0.2

Mean (± 1 SE) Change in BMI-SDS Over Time

Time Points

Mea

n BM

I-SDS

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