Settings-based approaches for children and adolescents

Childhood obesity is one of the most important public health challenges of our time, with the worldwide prevalence of overweight and obesity being high or rising rapidly, even among young children.¹

The proportion of Australia children and adolescents living with overweight or obesity has increased by 3% over five years (2017-2022), and by 20% since 1995. In Australia, there are significant disparities in the prevalence of overweight and obesity between children and adolescents from low and high socio-economic status (SES). In 2022, Australian children and adolescents living in the most disadvantaged areas were significantly more likely to be living with overweight or obesity, compared to their peers living in the least disadvantaged areas.²³ The risk of living with overweight and obesity for Aboriginal and Torres Strait Islander children and adolescents is also significantly higher compared to non-Indigenous children and adolescents (based on estimates from 2017-2019 data).

There is strong evidence showing that weight and related factors, such as physical activity and healthy eating behaviours, established in childhood tend to persist into later life. This highlights the importance of implementing interventions during childhood and adolescence to reduce the risk of obesity and chronic disease both now and in the future.

A recent Cochrane review (published 2024) found evidence that combined diet and physical activity interventions can reduce body mass index (BMI) among children aged 5-11 years⁴ but do not reduce BMI for those aged 12-18 years.⁴ Interventions that only focus on physical activity can reduce the risk of obesity (BMI) among children aged 6 -11 years and 12-18 years in the medium term.³⁴ There is limited evidence that dietary interventions alone are effective for children aged 6-11 years and 12-18 years.³⁴ For those aged 0-5 years, a 2019 Cochrane review found that diet combined with physical activity interventions may be beneficial in reducing child weight.⁵ These reviews found that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities. In terms of sleep, a systematic review found that interventions to increase child sleep duration can significantly reduce child BMI.⁶

Delivering these interventions in settings that children and adolescents live, play and learn ensures that they are exposed to supportive environments that promote healthy eating and physical activity across their life course. Such findings are reinforced by an umbrella review (2025) which identified settings-based interventions as effective interventions for preventing obesity. This section covers the evidence related to the effectiveness of interventions in these different settings including home-based (parent targeted), ECEC services, primary school, outside of school care, high schools and community settings.⁷

Home-based settings in young children (0–2 years)

One in four Australian children are already affected by overweight or obesity by the time they start school.⁸ Early childhood presents a critical window to establish healthy behaviours as many obesity-related behaviours are established in, and track from, early childhood. These include poor diet quality and preferences for unhealthy foods, low physical activity levels, high sedentary time and reduced sleep duration. Life-course studies suggest that interventions in early life, which reduce the amount of time children are exposed to these risks, are more likely to show positive outcomes on weight and weight related behaviours.

Review evidence suggests that interventions to prevent obesity in the early years targeting infant feeding (including breastfeeding) can improve weight outcomes, although efforts to scale up such interventions have been challenging.⁹ A pooled analysis of four Australasian early interventions, including data from Healthy Beginnings and INFANT, has shown that, compared with usual care, early interventions do lead to improvements in Body Mass Index (BMI) at ages 18-24 months. In addition, there were improvements in behaviours known to be related to reducing obesity, such as increasing breastfeeding duration and a reduction in TV viewing time.¹⁰

These two included interventions are discussed here. The first is Healthy Beginnings, where mothers in a socially disadvantaged region of Sydney were visited at home by nurses beginning in late pregnancy continuing to age 2 years.¹¹ Advice on breastfeeding, introduction to solids and appropriate complementary feeding, healthy diets for young children, physical activity, limiting screen time and methods to improve settling and sleep were given over the two-year period by maternal child health nurses via home-based visits. To support scale up, Healthy Beginnings was adapted from nurse delivered to telephone consultations and text messages with some of the broad effects on nutrition and infant feeding practice retained.¹²

In Melbourne, the INFANT program, which is based on the Infant Feeding Activity and Nutrition Trial, involves anticipatory guidance and discussion on introduction to solids, tummy time and physical activity through parents groups.¹³ The program is being offered in Victoria to all local governments, and includes four sessions delivered by Maternal and Child Health Nurses, Dietitians, and Health Promotion Officers who have received INFANT facilitator training, and has also been enhanced by use of web-based materials, apps and social media engagement.¹⁴

Although these interventions have demonstrated positive effects on child outcomes, it has been noted that scalability of some of these interventions is limited potentially necessitating some modification to intervention delivery modality.⁹

Early childhood education and care settings

Early childhood education and care centres (ECEC) including long day care centres, preschools and kindergartens are in a unique position to provide a healthy environment in an important developmental phase and can also be central to educating parents about healthy eating and activity habits. To support this, many countries have developed recommendations to promote child healthy eating and physical activity in ECEC.¹⁵

A recent (2023) Cochrane review of healthy eating interventions delivered in ECEC has shown that such programs may decrease children’s weight.¹⁶ Strategies to improve outcomes in ECEC include providing healthy eating education to children, training educators, changing menus to serve children age-appropriate healthy foods, and limiting unhealthy food, sugary drinks and juice, role modelling and providing resources to parents. Programs that include a healthy eating curriculum delivered by educators are also more likely to be effective in achieving healthy weight outcomes than those which do not include a healthy eating curriculum.

ECEC programs that target physical activity have also been shown to improve physical activity and child weight outcomes.¹⁷ Most programs included the provision of opportunities for active play, educator training and creating an environment that promotes physical activity.

In the United States, the Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC) program has been delivered across 22 states.¹⁸ The program, which supports ECEC services to deliver healthy eating and physical activity recommendations through assessment, planning, actioning, learning and maintaining, has been adapted to reach more children (as an online resource) and extended to the United Kingdom.¹⁹ This program has been successful in improving child BMI outcomes in racially and ethnically diverse populations.²⁰

Munch & Move is an initiative that offers training and resources to educators working in ECEC services in New South Wales. The training is based on implementing four key health promoting messages: breastfeeding, healthy eating, physical activity, and oral health. The program was launched in 2008 and it has been monitored state-wide since 2012. The monitoring data has demonstrated improvements in the delivery of training, practice achievements and program adoption in ECEC centres, especially in disadvantaged and remote communities.²¹ A number of randomised controlled trials have demonstrated the effectiveness of web interventions delivered in this setting on improving food provision and child weight and dietary outcomes.²²

School-based settings

Schools are an ideal setting for promoting health and most obesity prevention efforts in older children (5-12 years) and adolescents (13-18 years) are centred in schools or in after-school settings. It is important to recognise that, once established, obesity is very difficult to reverse, and most school-based interventions focus on prevention of weight gain rather than weight reduction. Substantial evidence indicates that dietary interventions delivered in primary schools can lead to long-term reductions in children’s body weight (relative to weight and growth). Physical activity interventions can reduce children’s weight in the medium term, while combined interventions focusing on both diet and physical activity can lead to short term and medium-term reductions in weight.⁴

In high schools, a small number of studies suggests that dietary interventions may improve students weight in the medium-term, with longer term benefits seen for weight (relative to age and growth). Physical activity interventions, especially those that include a home-based component, have shown effects on weight in both the medium and long term. Interventions that combine diet and physical activity appear to reduce weight in the short term, with sustained benefits over the medium term.¹⁸

Across both primary and high schools, nutrition interventions that provide nutrition education, create healthier food environments and/or incorporate eHealth approaches have been shown to improve child dietary outcomes, including increased consumption of fruit and vegetables.²³

Programs that target both the school and home environments have demonstrated significant potential to improve child health outcomes. For example, in Victoria, Australia, the Transform-Us! program combines classroom education, activity breaks, standing lessons and physical resources with homework tasks and parent newsletters, offering tips to promote physical activity and reduce sedentary behaviour at home. Aimed at year 3 students, the program has been found to positively influence physical activity levels, sedentary behaviours and weight outcomes. Transform-Us! has been made available to all primary schools in Victoria and has expanded to secondary schools, inclusive education settings, higher education institutions, and other state and countries. To date, it is implemented in over 700 schools, with over 2,000 teachers registered.²⁴

Novel school obesity prevention programs have recognised that students themselves serve as powerful motivators and role models for others and have implemented peer education and leadership programs. The Students As LifeStyle Activists (SALSA) program in Western Sydney uses a peer educational model, driven by students, to promote physical activity and healthy eating in a supportive high school environment. Under the SALSA program, university students train year 10 students to become effective peer leaders, who in turn educate their younger year 8 peers. Evaluation of the program shows an increase in fruit and vegetable consumption and reduced consumption of sugar-sweetened beverages.²⁵ The program has been extended to SALSA Youth Voices, which provides peer leaders with the opportunity to further develop their leadership skills and design and implement a program to promote healthy eating and physical activity within their school.²⁶

Outside of School Hours care

Several programs have targeted outside of school hours care settings (also known as after school programs) to prevent the development of obesity among children under 12 years. A recent review of evidence of effectiveness for programs delivered in outside of school hours care, all of which included physical activity components and some which also included diet components, indicates that these programs may not impact child BMI for children aged 4-12 years.²⁷ However, when looking only at the high quality studies the impact on BMI appears to be promising.

Several diet only interventions have been delivered in outside of school hours care, mostly in the United States. For example, the OSNAP intervention in Boston, Massachusetts involved providing technical assistance to change the types of foods and beverages offered for afterschool snacks. The program also included collaborative sessions for staff to build skills and create action plans, as well as family and child nutrition education. The program led to improvements in child snack consumption.²⁸ Different delivery modalities (face-to-face and online) have since been tested, with online delivery not reaching the impact of the face-to-face delivery.²⁹

Community-based settings

Community-wide approaches show promise for addressing complex local drivers of childhood obesity by implementing multiple strategies across various settings, such as homes, school and primary care, and are often community driven.³⁰ Trials to date have mostly involved settings such as gyms, recreation centres or playgrounds, often incorporating family-centred components such as group workshops and home visits. Systematic review evidence has shown that these interventions resulted in small reduction in weight, particularly for children aged five to 11 years, with these effects being more pronounced for those from lower socio-economic backgrounds.³¹

In Victoria, an innovative systems approach to mobilizing community action, the RESPOND trial, has been trialled in 10 communities in north east of the state.³² The intervention was adaptive and co-created with communities. Community leaders, identify areas where actions can be taken to reduce obesity related risk factors. Organisations within their communities (including local government, health services, schools and sporting clubs) plan, support and monitor the community-led actions. Some positive outcomes were noted for health related quality of life and prevalence of overweight and obesity in children in the intervention arm.³² Efforts to support and understand how implementation occurs is also in progress to ensure sustained impact of the intervention.³³

The "Shape Up Somerville" program in Massachusetts (USA) involved collaboration between government agencies, schools, local businesses, and community organizations to implement multi-level interventions targeting nutrition, physical activity, and built environment changes between 2003 and 2005. The program led to positive changes in both child and parent BMI post intervention, with an estimated net benefit of $197,120 USD over 10-years. The authors suggested that this positive outcome, which extended beyond improvements in individual children’s health, was largely due to the community-wide, systems-based nature of the interventions.³⁴

Focusing on the upstream determinants of obesity

The approaches described above should be complemented with policies that are health promoting, improving diets and preventing obesity. Such policies include effective nutrition labelling, initiatives to make healthy foods available in school and across other settings, restrictions on unhealthy food marketing to children, fiscal policies to reduce consumption of sugar sweetened beverages,³⁵ as well as macro-environmental factors such as improving public transport and the built environment (proximity to parks, bike paths, green space, schools and shops) which influence play time spent outdoors, walking and cycling.

Content for this page was updated by Melanie Lum, Research Fellow and Serene Yoong, Associate Professor at the Global Centre for Preventive Health and Nutrition at Deakin University. For more information about the approach to content on the site please see About | Obesity Evidence Hub.