obesity reviews

1 Obesity prevention in preschool children C. D. Summerbell et al. obesity reviews

doi: 10.1111/j.1467-789X.2011.00940.x

Evidence-based recommendations for the

development of obesity prevention programs
targeted at preschool children
C. D. Summerbell1, H. J. Moore1, C. Vögele2, S. Kreichauf3, A. Wildgruber3, Y. Manios4, W. Douthwaite1,
C. A. Nixon1 and E. L. Gibson5 on behalf of the ToyBox-study group

1
Obesity Related Behaviours Group, School of
Medicine and Health, Wolfson Research
Institute, Durham University Queen’s Campus,
Stockton-on-Tees, UK; 2Research Unit INSIDE,
Faculty of Language and Literature,
Humanities, Arts and Education, University of
Luxembourg, Luxembourg; 3Staatsinstitut für
Frühpädagogik, München, Germany;
4
Department of Nutrition and Dietetics,
Harokopio University, Kallithea, Greece;
5
Department of Psychology, Roehampton
University, London, UK
Received 27 May 2011; revised 24 August
2011; accepted 24 August 2011
Address for correspondence: Professor CD
Summerbell, Obesity Related Behaviours
Group, School of Medicine and Health,
Wolfson Research Institute, John Snow
College Office, Holliday Building, Durham
University Queen’s Campus, Stockton-on-Tees
TS17 6BH, UK. E-mail:
Carolyn.summerbell@durham.ac.uk
Summary
The ToyBox intervention was developed using an evidence-based approach, using
the findings of four reviews. These reviews included three critical and narrative
reviews of educational strategies and psychological approaches explaining young
children’s acquisition and formation of energy-balance related behaviours, and
the management of these behaviours, and also a systematic review of behavioural
models underpinning school-based interventions in preschool and school settings
for the prevention of obesity in children aged 4–6 years.
This paper summarises and translates the findings from these reviews into
practical evidence based recommendations for researchers and policy-makers to
consider when developing and implementing interventions for the prevention of
overweight and obesity in young (aged 4–6 years) children.
The recommendations focus on two behaviours, physical activity and sedentary
behaviour, and healthy eating, and include general recommendations, intervention
approaches, interventions content, and simple messages. The review also briefly
examines the role that the commercial sector plays in hindering or facilitating
attempts to create healthy food environments for children. This paper also rec-
ognises that childhood obesity is not an issue for the education sector alone; it
needs to be tackled at a multi sectoral level, recognizing the particularly important
role of local governments, nongovernment organizations and the media.
Keywords: Children, evidence-based recommendations, obesity prevention,
preschool.

obesity reviews (2012) 13 (Suppl. 1), 129–132

As previously discussed in other papers in this Supple-
ment of Obesity Reviews, the ToyBox intervention was
developed using an evidence-based approach, and refined
through pilot testing. As part of that evidence base, two
pieces of work were carried out. First, a series of narra-
tive reviews of educational strategies and psychological
approaches explaining young children’s acquisition and
formation of energy-balance related behaviours, and
facilitating their management (Gibson et al. (1); Gibson
et al. (2), all published in this supplement). Second,
a systematic review to identify behavioural models
underpinning school-based interventions in preschool
and school settings for the prevention of obesity in
children aged 4–6 years (Nixon et al. (3); published in this
supplement).
The aim of this short paper is to summarize and translate
the findings from these two reviews into practical evidence-
based recommendations for researchers and policy-makers
to consider when developing and implementing interven-
tions for the prevention of overweight and obesity in
young (aged 4–6) children. We have divided these recom-
mendations into sections for ease of reading: (i) general

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obesity reviews © 2012 International Association for the Study of obesity
Obesity reviews
13 (Suppl.
© 2012
1), 129–132
International Association for the Study of Obesity 13 (Suppl. 1), 129–132
obesity reviews
2 Obesity prevention in preschool children C. D. Summerbell et al. obesity reviews
doi: 10.1111/j.1467-789X.2011.00940.x

considerations; (ii) intervention approaches; (iii) inter- a) Physical activity and dietary behaviours should be
vention content; and (iv) simple messages. The authors targeted together in a combined intervention, although this
of this paper hope that the recommendations listed below should be made as simple as possible.
will help policy-makers, both in Europe and other coun-
tries, who are developing and implementing interventions,
which aim to prevent overweight and obesity in young
children.

1. General considerations when developing interven-

tions for the prevention of obesity in preschool (aged 4–6)
children.
a) As most successful interventions have parental com-
ponents, parental engagement that includes role model-
ling should be a key part of any intervention in this
age group, and mere provision of knowledge and infor-
mation although distribution of letters and newsletters
to parents is not sufficient. There is particularly good
evidence to suggest that increasing the physical activity
levels of fathers/male carers (as role models) increases
the physical activity levels of young children. Where
parents’ attempts to increase their physical activity levels
are limited because of a lack of local opportunities,
local authorities should provide appropriate support, for
example, through free or incentivized play and activity
areas and schemes. If the intervention takes place only in
the school/kindergarten setting, and attempts to engage
parents fail, then teachers could be considered as role
models.
b) A limited number of clear and simple messages
(strategies), which aim to effect positive behaviour change
in young children, underpinned by theoretical knowledge,
are required for parents and teachers.
c) When considering the resource materials for inter-
ventions, the literacy levels of parents should be taken into
account, alongside the acceptability of the intervention
material for parents, teachers and children. Unless the
materials are easily accessible to all members of that com-
munity, only those who are more literate will feel able to
participate in the intervention. Usability of testing of new
or existing materials in the target population before imple-
menting the intervention is a prudent move (4). If this is not
carried out, the intervention may, inadvertently, increase
health inequalities in the target population.
d) Parents and caregivers should be the major target of
the intervention, but outcomes for evaluation (change in
body mass index, change in physical activity and dietary
behaviours) should be focused on children (5).

2. Intervention approaches to consider when developing

interventions for the prevention of obesity in young (aged
4–6) children.

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© 2012 The Authors
obesity reviews © 2012 International Association for the Study of obesity
Obesity reviews
13 (Suppl.
© 2012
1), 129–132
International Association for the Study of Obesity 13 (Suppl. 1), 129–132
 obesity reviews
3 Obesity prevention in preschool children C. D. Summerbell et al. obesity reviews
doi: 10.1111/j.1467-789X.2011.00940.x

b) Rewards for children (which can include praise, but

not food) for uptake of desired energy-balance behaviour
should be included in the intervention.
c) The key elements of successful approaches are ‘mod-
elling’ (through older peers, teachers and parents) and tech-
niques to facilitate skill development. These approaches
increase the success of an intervention because they increase
levels of self-efficacy in parents, teachers and children.
d) The intervention should have a common framework,
and within this there should be enough flexibility for tai-
loring it to the target population. In school-based interven-
tions, the teachers must be allowed to adapt the modules to
their different classes, and they should be encouraged to
include country- and cultural-specific activities (based on
the same theoretical underpinning).

Physical activity and sedentary behaviour

a) The physical activity element of the intervention
should take into account the fact that there may be children
in the target population who would have problems, or feel
uncomfortable, following certain physical activity regimes.
b) In school-based interventions, the physical activity
element of the intervention should be incorporated into the
daily curriculum, wherever possible, without affecting the
pre- or post-school program.
c) Promotion of at least 120–180 min/d of physical
activity for children at both weekdays and weekends
should be included in the intervention. Participation in
Physical Education classes and active play time at school
count, as do all physical activities of all intensities, towards
this goal. It is important to suggest ways in which children
can achieve the recommended levels of physical activity at
weekends, for example, by participating in organized
physical activities with local clubs and societies, or visits to
playground areas.
d) Limitation of leisure screen time to <1 h/d (or the
amount of time recommended by appropriate national
guidelines, if less than 1 h/d) should be included in the
intervention.
e) The activities that aim to increase levels of physical
activity should be playful, and be able to be performed in
many environments and have a chance of being feasible for
all children; forced participation in competitive sports or
activities which some children cannot (or feel they cannot)
succeed in can cause more harm than good.

Healthy eating
a) The healthy eating element of the intervention should
raise awareness in parents, carers and teachers about how
children can vary in their reluctance to try new foods, and
the importance of familiarization with new healthy foods at
a young age.
b) Healthy food and drink items, including fruits and
vegetables, should be made available and accessible for

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13 (Suppl.
© 2012
1), 129–132
International Association for the Study of Obesity 13 (Suppl. 1), 129–132
obesity reviews
4 Obesity prevention in preschool children C. D. Summerbell
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et al.
prevention in preschool children obesity
C. D. reviews
Summerbell et al. 131

children, both at school and home. Conversely, children diets. We believe that the commercial sector has a poten-
should have limited exposure and availability to unhealthy tially important role in helping young children and families
foods and drinks such as sweetened soft drinks and energy-
dense snacks.
c) Teachers should discuss with children what barriers
exist for them in choosing healthy foods and having a
well-balanced diet, and how these might be overcome (e.g.
vegetables with a favourite sauce, fruit with pudding).
Tasting sessions that involve new healthy foods and drinks
are particularly useful. Another useful strategy is to allow
children to get involved in the menu choices, preparation
and service of their food, both at home and at school.

3. Simple messages to consider when developing inter-

ventions for the prevention of obesity in young (aged 4–6)
children.
Physical activity and sedentary behaviour
a) Encourage the use of active transport (walking and
cycling) for short distances.
b) Encourage visiting places where children can be
active.
c) Discourage the provision of a screen in the bedroom
(television [TV], computer or PlayStation).
d) Encourage the provision of non-competitive partici-
pation in physical activity.
e) Encourage parents to provide their children with
appropriate clothing for indoor and outdoor activities.
f) Encourage the development of a large, active play
enhancing all weather play areas in kindergartens and
schools.
g) Provide game equipment during lesson breaks, and
encourage children to be active.
h) Decrease total sedentary time in the classroom and at
home by changing activities from passive to active.

Healthy eating
a) Encourage eating together with others, and as a
family unit when at home.
b) Encourage the provision of a broad variety of
healthy foods especially fruits and vegetables, and discour-
age the provision of unhealthy foods such as sweetened soft
drinks and energy-dense snacks.
c) Discourage the behaviour of eating while watching
TV or using game consoles, etc.
There is also strong evidence that the current activities of
parts of the commercial sector are actively undermining
attempts to create healthy food environments for children
(6,7), and it is therefore recognized that the setting-based
approach to preventing childhood obesity described in this
paper needs to be complemented by policies to reduce the
negative influences of the commercial sector on children’s

© 2012 The Authors © 2012 The Authors

obesity reviews © 2012 International Association for the Study of obesity
Obesity reviews
13 (Suppl.
© 2012
1), 129–132
International Association for the Study of Obesity 13 (Suppl. 1), 129–132
 obesity reviews
5 Obesity prevention in preschool children C. D. Summerbell
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et al.
prevention in preschool children obesity
C. D. reviews
Summerbell et al. 131

consume a healthy diet that they enjoy, at a price they can

afford (8).
Policy-makers and service providers should feel con-
fident that there are effective strategies, as listed above,
for preventing obesity in young children. However, it is
also important to consider how these strategies (which
focus on improving diet and physical activity behaviours)
are incorporated with other critical aspects of an inter-
vention program, if that program is to be effective. World
Health Organisation has stated that the greatest challenge
in tackling childhood obesity is the need to sensitize
and mobilize all sectors of society, and to involve all
levels of government in joint efforts with ministries
of health (9). Childhood obesity is not an issue for the
education sector alone; it needs to be tackled at a multi-
sectoral level, recognizing the particularly important
role of local governments, non-government organizations
and the media. Indeed, any effective intervention program
will need to include components for which there is
little specific efficacy evidence, for example, leadership
support, coordination, workforce development, communi-
cations, network development, monitoring feedback,
appropriate cultural adaptation, and policy development
and implementation.
As suggested in a recent Cochrane review of interven-
tions to prevent childhood obesity (10), further research
in this area should focus on translational research, and
assess how best to implement interventions which can be
embedded into ongoing practice and operating systems, be
effectively scaled up, be sustained over time and ensure
equitable outcomes.

Conflict of Interest Statement

None of the authors have any conflicts of interests to
declare.

Acknowledgements
The ToyBox-study is funded by the Seventh Framework
Programme (CORDIS FP7) of the European Commission
under Grant agreement No. 245200. The content of this
article reflects only the authors’ views, and the European
Community is not liable for any use that may be made of
the information contained therein.

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obesity reviews © 2012 International Association for the Study of obesity
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13 (Suppl.
© 2012
1), 129–132
International Association for the Study of Obesity 13 (Suppl. 1), 129–132
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