A systematic review of associations between the primary school built environment and childhood overweight and obesity
Highlights
► Research on the obesogenic nature of the school built environment is scarce. ► Playground and gymnasium availability and adequacy were most frequently examined. ► Further research is needed in this area specifically on adequacy and acceptability. ► Future studies should examine probable individual and contextual mediating factors.
Introduction
Within the United Kingdom (UK), between 1995 and 2008, the prevalence of overweight and obesity among 2–10 years old rose from 23.1% to 27.3% (The NHS Information Centre, 2010). Obesity in childhood is associated with increased risk of asthma, chronic inflammation, cardiovascular disease, low self-esteem and behavioral problems (Reilly et al., 2003). In addition to these health consequences there are social and financial ramifications (House of Commons Health Select Committee, 2004, Reilly et al., 2003). In 2004 the UK House of Commons Health Select Committee estimated the total annual cost of overweight and obesity in England to have been nearly £7 billion in 2002 (House of Commons Health Select Committee, 2004). The combination of these issues has made childhood obesity both a national and international public health concern (Cross-Government Obesity Unit, 2008, World Health Organization, 2008). Subsequently, the Foresight report was commissioned in the UK to investigate this epidemic (Butland et al., 2007).
The Foresight report identified the complex system of elements involved in the development of obesity and highlighted the need for population based behavior change interventions (Butland et al., 2007). Those elements external to the individual that are involved in the development of obesity have become known as the obesogenic environment (Swinburn et al., 1999). The purpose of this systematic review was to identify those elements of the primary school built environment (see Box 1 for definition) that may be associated with overweight or obesity in children aged 4–11 years and, therefore, could be part of the obesogenic environment.
In adults, the associations between the built environment and obesity have been extensively researched, including two comprehensive systematic reviews (Feng et al., 2010, Papas et al., 2007). A systematic map of reviews on social and environmental interventions to reduce childhood obesity identified a need for reviews focusing on interventions or changes to the built environment (Woodman et al., 2008). Currently, no consistent associations between elements of the built environment and obesity in children, of all ages, gender, socioeconomic strata and locations have been identified (Dunton et al., 2009, Galvez et al., 2010). However, some built environment factors have been identified as having mainly small but significant associations with body mass index (BMI) in some subgroups of children (Dunton et al., 2009, Galvez et al., 2010). In particular distance to playgrounds, school playgrounds being locked outside of school hours, heavy traffic, and density of fast food restaurants, convenience stores and underground (subway) stations were positively associated with BMI in some subgroups of children (Dunton et al., 2009, Galvez et al., 2010). While neighborhood hazards and vegetation, intersection (road junction) density, road safety, walkability, and access to physical activity facilities, including paths for cycling and walking, were negatively associated with BMI in some subgroups of children, neither study considered the built environment within the school (Dunton et al., 2009, Galvez et al., 2010). Both reviews conclude by calling for more research on the association between the built environment and obesity, and especially studies designed to provide better quality evidence (Dunton et al., 2009, Galvez et al., 2010).
In order to monitor the prevalence of childhood overweight and obesity in the UK, the National Child Measurement Programme (NCMP) was introduced in 2005 (Ridler et al., 2009). As part of this program, the BMI of all school children is measured in the first and final year of their primary education (Ridler et al., 2009). Within the UK, children undertake primary education from the age of 4–11 years during which a child may attend a junior or primary schools which are equivalent to elementary schools in the United States of America (USA). Early results from the NCMP program demonstrated a significant rise in the prevalence of obesity during the period of primary education, while the prevalence of overweight did not change (Ridler et al., 2009). This demonstrated that in the UK, the period of primary education is an important time for obesity development. This systematic review was, therefore, developed to examine the effect of the school built environment during the period of primary education.
Given the range of study designs that previous reviews (Dunton et al., 2009, Feng et al., 2010, Galvez et al., 2010, Papas et al., 2007) have encountered, this systematic review was designed to be able to incorporate both experimental and observational studies. The search strategy was designed to be sensitive to identify any studies which examined the school built environment rather than specific to certain elements of the built environment (Box 2). Key definitions and the study inclusion and exclusion criteria are listed in Box 1. Within this review the built environment was limited to the environment within the school boundaries as the authors considered this environment to be more accessible to change. The built environment was also restricted to larger infrastructural or more permanent items thereby excluding small items of play equipment and vending machines. This decision was taken to incorporate any changes to the built environment which had the potential to influence the whole school population not just individuals, e.g. food bought by individuals from vending machines.
Section snippets
Methods
The methodology of this review was informed by the guidance from the Cochrane Collaboration and the National Health Service (NHS) Centre for Reviews and Dissemination and followed a protocol which is available from the corresponding author (Higgins and Green, 2011, NHS Centre for Reviews and Dissemination, 2009).
Identified studies
Fig. 1 illustrates the study identification process. Bibliographic databases identified 5015 unique articles and the search of clinical trials registers and gray literature identified 233 unique items. Through the study identification process described above, eleven eligible articles were identified including six intervention articles and five observational articles (Amigo et al., 2007, Fernandes and Sturm, 2010, Kelly et al., 2010, Muckelbauer et al., 2009a, Muckelbauer et al., 2009b,
Discussion
The aim of this systematic review was to examine the evidence around the potential influence of the school built environment upon childhood obesity. Unlike previous reviews our search strategy incorporated a wide variety of bibliographic databases to ensure that research from outside the medical field was identified and, where relevant, retrieved. However, a number of these retrieved studies did not incorporate an anthropometric outcome, which prevented inclusion in this review. The search
Conclusion
Using an extensive search strategy and systematic review process this study aimed to build on previous work to provide an insight into the role of the school built environment upon childhood overweight and obesity (Dunton et al., 2009, Feng et al., 2010, Galvez et al., 2010, Papas et al., 2007). The review was designed to be able to incorporate the wide range of study designs likely to be used by researchers investigating the effects of the built environment. However, whilst previous reviews
Acknowledgments
The authors would like to thank the reviewers for their insightful comments, which have helped to improve the article. The authors also wish to acknowledge the contributions of Mary Reece, Kate Boddy and the Systematic Review group at the Peninsula College of Medicine and Dentistry. AJW is funded by a Medical Research Council Doctoral Training Grant and Sport and Health Sciences, University of Exeter. KMW and AJH were also partially supported by the National Institute for Health Research (NIHR)
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