Relationship between primary school healthy eating and physical activity promoting environments and children’s dietary intake, physical activity and weight status: A longitudinal study in the West Midlands, UK

Elizabeth Mairenn Garden, Miranda Pallan, Joanne Clarke, Tania Griffin, Kiya Hurley, Emma Lancashire, Alice Sitch, Sandra Passmore, Peymane Adab

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Objective We aimed to examine the association between food and physical activity environments in primary schools and child anthropometric, healthy eating and physical activity measures. Design Observational longitudinal study using data from a childhood obesity prevention trial. Setting State primary schools in the West Midlands region, UK. Participants 1392 pupils who participated in the WAVES (West Midlands ActiVe lifestyle and healthy Eating in School children) childhood obesity prevention trial (2011-2015). Primary and secondary outcome measures School environment (exposure) was categorised according to questionnaire responses indicating their support for healthy eating and/or physical activity. Child outcome measures, undertaken at three time points (ages 5-6, 7-8 and 8-9 years), included body mass index z-scores, dietary intake (using a 24-hour food ticklist) and physical activity (using an Actiheart monitor over 5 days). Associations between school food and physical activity environment categories and outcomes were explored through multilevel models. Results Data were available for 1304 children (94% of the study sample). At age 8-9 years, children in 10 schools with healthy eating and physical activity-supportive environments had a higher physical activity energy expenditure than those in 22 schools with less supportive healthy eating/physical activity environments (mean difference=5.3 kJ/kg body weight/24 hours; p=0.05). Children in schools with supportive physical activity environments (n=8) had a lower body mass index z-score than those in schools with less supportive healthy eating/physical activity environments (n=22; mean difference=-0.17, p=0.02). School food and physical activity promoting environments were not significantly associated with dietary outcomes. Conclusions School environments that support healthy food and physical activity behaviours may positively influence physical activity and childhood obesity. Trial registration number ISRCTN97000586.

Original languageEnglish
Article numbere040833
JournalBMJ open
Issue number12
Publication statusPublished - 22 Dec 2020

Bibliographical note

Funding Information:
The WAVES trial was funded by the National Institute for Health Research (NIHR) Health Technology Assessment Programme (project reference 06/85/11). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. We would like to acknowledge the contribution of all the WAVES study trial investigators: University of Birmingham: Peymane Adab (Professor of Chronic Disease Epidemiology and Public Health and Chief Investigator), Tim Barrett (Leonard Parsons Professor of Paediatrics and Child Health), KK Cheng (Professor of Public Health and Primary Care), Jonathan J Deeks (Professor of Biostatistics), Joan L Duda (Professor of Sport and Exercise Psychology), Emma Frew (Professor in Health Economics), Karla Hemming (Professor of Biostatistics), Miranda J Pallan (Reader in Public Health and Epidemiology) and Jayne Parry (Professor of Policy and Public Health); University of Cambridge, Cambridge MRC Epidemiology Unit/Norwegian School of Sport Sciences: Ulf Ekelund (Professor in Physical Activity and Health); University of Leeds: Janet E Cade (Professor of Nutritional Epidemiology and Public Health); Loughborough University: Amanda Daley (Professor of Behavioural Medicine); University of Edinburgh: Raj Bhopal (Emeritus Professor of Public Health); University of Warwick: Paramjit Gill (Professor of General Practice); Birmingham Community Healthcare NHS Trust: Eleanor McGee (Public Health Nutrition Lead); and Birmingham Services for Education: Sandra Passmore (Education Advisor). We thank the children, school staff and parents who participated in the trial; the study team, including Behnoush Mohammadpoor Ahranjani and Emma Popo, who helped in overseeing the study measurements and data collection; the administrative team who facilitated the running of the project; the research staff who undertook the study measurements; and Robert Lancashire, who developed the trial database and oversaw data management. We also thank our collaborators at the Institute of Metabolic Science at the Medical Research Council (MRC) Epidemiology Unit (University of Cambridge) for their support and assistance, particularly Soren Brage, Kate Westgate and Stefanie Hollidge, for training of field staff on use and maintenance of Actiheart, for overseeing data preparation, and for analysis and interpretation of the physical activity data; Timo Lakka (principal investigator of the PANIC study, University of Eastern Finland) for sharing exercise data in a similarly aged cohort of children to allow translation of observed heart rate into activity energy expenditure; staff who are working, or have previously worked, at the Nutrition Epidemiology Group in Leeds, who have supported the trial team in terms of administration of the CADET food ticklist and processing of the data to enable us to undertake dietary intake analysis, in particular Neil Hancock, Cristina Cleghorn, Meagan Christian, Jayne Hutchinson, Holly Rippin and Catherine Rycroft. We also thank Sayeed Haque for his statistical advice on the analyses for this particular study.


  • nutrition & dietetics
  • preventive medicine
  • public health

ASJC Scopus subject areas

  • General Medicine


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