International Journal of Health Promotion and Education

ISSN: 1463-5240 (Print) 2164-9545 (Online) Journal homepage: http://www.tandfonline.com/loi/rhpe20

Factors that influence obesity in children at

primary schools in England and France

Yvonne Wake & Sue Reeves

To cite this article: Yvonne Wake & Sue Reeves (2012) Factors that influence obesity in children
at primary schools in England and France, International Journal of Health Promotion and
Education, 50:1, 2-9, DOI: 10.1080/14635240.2012.661951

To link to this article: http://dx.doi.org/10.1080/14635240.2012.661951

Published online: 05 Apr 2012.

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 International Journal of Health Promotion and Education
Vol. 50, No. 1, January 2012, 2–9

Factors that influence obesity in children at primary schools

in England and France
Yvonne Wake* and Sue Reeves

Roehampton University, Holybourne Ave, Roehampton, London SW15 4JD, UK

Overweight and obesity in children are considered a world health problem. In Europe the
incidence of obesity is high, although it has been reported that levels of obesity are lower
in France than in the UK. This study aims to make a comparison of the incidence, and
cultural/lifestyle-related factors that affect obesity in school-aged children living in
England and France. The study was set in Monetier-les-Bains, France and South West
London, UK. Ninety-eight French children and 105 English children were recruited for
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this cross-sectional quantitative study. Anthropometric measurements and a ques-

tionnaire were used to obtain data and information that included details on hobbies and
physical activities, distance to school and travel arrangements. Chi squared and t-tests
were used to statistically compare the data. The results showed a significant difference
(P , 0.01) between the weights, body mass indexes and waist circumferences of French
and English children. Furthermore, 32% of the English children were classified as
overweight or obese, whereas none of the French children were. There were significant
differences (P , 0.01) in the levels of out-of-school physical activity undertaken by the
French children and that of the English children. The level of sedentary activity,
television viewing and computer use was also significantly different (P , 0.01). Factors
such as the role of food in French culture, the lack of fast food outlets in the studied area
of France, distances walked to and from school and choice of physical activities and
hobbies undertaken in and out of school are seen as the main positive influences on
energy balance in the French children. These findings have highlighted areas worthy of
intervention in the battle against obesity.
Keywords: obesity; food; activity; culture

Introduction
Overweight and obesity have become major preventable health challenges around the
globe. In Europe, at least 135 million are affected by this ‘epidemic’ as described by the
International Obesity Task Force [IOTF] (2002). In particular, in the UK the prevalence of
obesity has more than doubled in the last 25 years and nearly a quarter of adults are now
obese (Foresight Report 2007). In France, obesity levels are around 18% (Viguie et al.
2002, Lobstein and Frelut 2003) although there are differences between the regions.
Differences in the obesity levels between children in the UK and children in France have
also been documented, with the UK government figures showing that around 32% of
children aged 2 –15-year-olds are overweight or obese (Foresight Report 2007), whereas
in France approximately 17% of children are overweight or obese (Summerbell 2009).
Recent studies have shown that overweight children are at increased risk of being
overweight adults (Power et al. 1998, Hardy et al. 2004) with significant signs of

*Corresponding author. Email: y.wake@roehampton.ac.uk

ISSN 1463-5240 print/ISSN 2164-9545 online

q 2012 Institute of Health Promotion and Education
http://dx.doi.org/10.1080/14635240.2012.661951
http://www.tandfonline.com
 International Journal of Health Promotion and Education 3

morbidity including elevated blood pressure, cholesterol, triglyceride and insulin levels,
diabetes and many other disorders (Freedman et al. 1999, Foresight Report 2007).
Research has even shown that being overweight or obese in childhood can be associated
with poorer levels of academic achievement (Taras and Potts-Datema 2005); however,
studies such as this do not always account for confounding factors such as socio-economic
status and parents educational achievements. Furthermore, obesity in childhood can create
poor life-long eating habits, poor social skills and can damage a child psychologically if
taunted by peers which may carry on into adult life (Janssen et al. 2004). Therefore, it is
important to identify and tackle the causes of childhood obesity.
There are many reasons why levels of obesity may be so different between the UK and
France. Factors that influence energy balance such as differences in food intake and
physical activity are likely causative agents. However, many studies have actually
suggested that the diet in France may be higher in saturated fat than in the UK. ‘The French
Paradox’ was first recognized by Renaud in 1992 (Renaud and de Lorgeril 1992).
Essentially it appears that despite high intakes of saturated fat, there is a low incidence of
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coronary heart disease mortality in France. There are various theories as to the basis of this
phenomenon, many attributing this finding to the consumption of wine (Criqui and Ringel
1994); however, this does not account for differences in the incidence of obesity in
childhood. Therefore, other factors more relevant to children, such as the cultural role of
food, appetite and portion control as well as differences in levels of physical activity, have
been cited as possible reasons to explain the differences in the incidence of obesity in
France compared to that in the UK (North East Public Health Observatory 2009), but
elucidation is required.
Given that children spend 6 –8 h a day at school, this is an obvious place for health
prevention programmes (Audrey et al. 2008). Obesity programmes that consider aspects
of both nutrition and physical activity are more likely to be successful (Finnerty et al.
2010). Both the UK and France offer the option of dinner at school. In the past, school
dinners in the UK have been criticized heavily, and studies have shown that there is need
for improvement in school dinners as well as packed lunches; packed lunches actually
faring worse (Rogers et al. 2007). However, new nutrient standards have been introduced
for school meals but the effects of these standards have yet to be documented (Hulks 2009).
In France the government has provided guidelines for school meals since 1971. More
recently in 2001, a circular notice was established to improve the nutrient composition of
school meals (Dubuisson et al. 2009). Traditionally, French school dinners comprised
three or even four courses and allowed at least 45 min (Henley 2009).
Nutritional knowledge has been shown to affect dietary intakes as determined by an
interviewer-led food frequency questionnaire (Robinson et al. 2004), and increased
portion sizes and snacking patterns have been linked to increased energy intakes and
obesity (Niklas et al. 2001). Whilst snacking is common amongst children in the UK
(Howard and Reeves 2005), reports from France suggest that snacking in between meals is
strongly discouraged (Guiliano 2005). Although studies (Howard and Reeves 2005) have
suggested that snacking is common, it is also implied that snacking is essential to meet
recommended nutrient intakes; however, little detail is provided in the reported study as to
what the snacks actually consisted of and hence it is possible that it is the type of snack as
well as the frequency of snacking that affects the risk of obesity.
Low levels of physical activity have long been associated with increased risk of
obesity, and children who spend greater amounts of time in front of computer or television
(TV) screens seem to be at greater risk (Wen et al. 2009). Low levels of physical activity
have certainly been noted amongst English children using pedometers as a measure of
 4 Y. Wake and S. Reeves

activity (Duncan et al. 2007). Even in France a recent study reported a clear association
between low levels of physical activity, sedentary behaviour and childhood overweight
and socioeconomic status (Lioret and Volatier 2007).
Reasons for the differences in the obesity levels between children in France and the
UK remain worthy of investigation. Therefore, this study aimed to explore factors that
influence risk of obesity and identify possible strategies that could be learned from the
cultural differences.

Methods
Ethical approval for the study was granted by Roehampton University. Parents of all
participants gave informed consent for their children to participate in this study.
In addition, consent was given by the head teachers and the school governors at schools
both in the UK and in France.
This study was conducted in France and England (UK). Two groups of children
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between the ages of 3 and 12 years were recruited. One group lived in a small village
called Le Monêtier-les-Bains in the south-eastern region of France, classified by the
‘ObEpI 2000’ survey as having a 3.5% prevalence of obesity (ObEpI 2001). The other
group lived in London within a small ‘village’ type area. Both groups were from similar
socioeconomic backgrounds. The French children were mostly born in the village
(or in other parts of France), whereas the English children were from culturally diverse
backgrounds and included children of the following nationalities: Jamaican, Indian,
Croatian, Polish, Swedish, Albanian, Korean and Venezuelan.
A power calculation was carried out (G Power 3; Düsseldorf, Germany) based on a
similar study investigating dietary intakes and physical activity in school-aged children by
Finnerty et al. (2010), which indicated that a minimum of 47 children would be required
for each group. However, recruitment was opportunistic, and with the support of teachers
and parents it was possible to exceed the minimum. A total of 146 children completed the
study, 26% of all children attending in both the schools. In France, 98 children who all
attended the same primary school were invited to take part in the study, 71 of whom
completed all aspects of the study. In the UK, 105 children from one primary school were
recruited and 75 of whom completed all aspects of the study. All children were recruited at
the school they attended, the researchers were assisted by the Head teacher and class
teachers during the recruitment phase, parents were also welcome to attend the
measurements. Data were collected at both schools during the summer term.
The children’s weight was measured using electronic scales (Salter 920; Tonbridge,
UK) and determined to the nearest 0.1 kg. The children were fully clothed and without
shoes. Height was measured using a portable stadiometer with a wooden extending rule
(Findel Education; Hyde, UK) and determined to the nearest 0.1 cm. Waist circumference
was measured midway between the 10th rib and the top of the iliac crest (World Health
Organisation 1995) using a plastic tape measure and determined to the nearest 0.1 cm.
Body mass index (BMI) was calculated as the ratio of an individual’s weight to height
squared (kg/m2). All measurements were made by the lead author using the same
equipment in both settings.
Questionnaires written in both English and French were used to ascertain dietary and
physical activity habits. The questionnaire was piloted in a small number of children
(n ¼ 4) in the UK and France to ensure that the questions were clear and understandable in
both languages. The questionnaire completed by the child on their own or with the
assistance of an adult asked for information detailing all activities undertaken in and out of
 International Journal of Health Promotion and Education 5

school and their duration including transport to school. The questionnaire asked about
food habits and preferences such as favorite meals and snacks and the frequency of
snacking in total and at specific times of the day, e.g. what food would you choose for a
snack at school break time? They were also asked whether they consumed a school meal, a
packed lunch or went home at lunch time and what the meal consisted of. There were also
questions regarding nutritional knowledge, in which children were asked to rate the
healthiness of different foods, list healthy and unhealthy foods, and show awareness of
the five main food groups. Explanations and examples of how to correctly complete the
questionnaire were given by the lead researcher at the time of distribution. All
questionnaires were kept strictly anonymous and confidential and were kept securely in
accordance with data protection.
Data were analysed using Excel (Microsoft; Silicon Valley, CA) and SPSS (15.0,
SPSS, Inc.; Chicago, IL) packages. All data are presented as mean þ standard deviation
(SD). One way analysis of variance and x 2 tests were used to test for differences between
the French and English children. A significance level of P , 0.05 was adopted.
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Results
A summary of the French and UK children’s anthropometric measurements can be seen in
Table 1, which gives the mean (SD) for age, and height, weight, waist circumference and
BMI.
A significant difference (P , 0.05) was revealed between the BMI of the French
children (mean 15.29 ^ 2.0 kg/m 2) and that of the English children (mean
17.76 ^ 6.23 kg/m2). The French children (mean 24.0 ^ 50.2 kg) weighed significantly
(P , 0.01) less than the English children (mean 29.8 ^ 100.0 kg). There was also a
significant difference (P , 0.01) between the waist circumference of the French children
(mean 0.55 ^ 0.0041 cm) and the waist circumference of English children (mean
0.60 ^ 0.0048 cm).
In terms of BMI classification, 81% and 68% of French and English children,
respectively, were classified as normal weight, and is depicted in Table 2. Nineteen
percent of the French children were classified as underweight, whereas no English children
were categorized as underweight. Furthermore, 16% English children were classified as
overweight, 16% as obese: 3% of whom were morbidly obese. There were no French
children in an overweight or obese category. A x 2 test revealed significant differences
(P , 0.05) in the distribution of the body weight classifications between French and
English children.
There was a significant difference (P , 0.01) in the level of physical exercise
undertaken by the French children (mean 2.30 ^ 0.73 h/day) and that undertake by the
Table 1. Physical characteristics of the subjects: mean (^ SD).
French English

All children Boys Girls All children Boys Girls

n 71 36 35 75 38 37
Age (years) 7.0 (2.5) 7.0 (2.6) 7.0 (2.5) 7.4 (2.9) 7.6 (2.6) 7.3 (2.3)
Height (m) 1.24 (0.2) 1.25 (0.2) 1.24 (0.2) 1.27 (0.6) 1.29 (0.2) 1.27 (0.175)
Weight (kg) 24.0 (50.2)* 24.0 (41.4)* 24.2 (60.7)* 29.8 (100.0) 30.0 (84.2) 30.0 (110.0)
BMI (kg/m2) 15.29 (2.05)** 15.2 (1.65)** 15.4 (2.5)** 17.76 (6.23) 17.6 (4.4) 17.9 (7.3)
Waists (cm) 0.55 (0.004)* 0.55 (0.001)* 0.56 (0.006)* 0.60 (0.0048) 0.61 (0.003) 0.61 (0.005)

Note: *P , 0.01, **P , 0.05.

 6 Y. Wake and S. Reeves

Table 2. Body weight classification according to BMI.

French English
Obese 0 16
Overweight 0 16
Normal 81 68
Underweight 19 0
Note: Significant (P , 0.05) difference between the distribution of body weight classifications between French
and English children.

English children (mean 0.99 ^ 0.66 h/day). The level of sedentary activity, TV viewing
and computer use was also significantly different (P , 0.01) in the French children (mean
1.49 ^ 0.54 h/day) compared with that of the English children (mean 3.09 ^ 2.3 h/day).
In addition, the children were questioned on the number of different physical activity
pursuits undertaken in 1 week. On average, the majority of French children participated in
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4 þ 2 physical pursuits per week which included skiing, athletics, mountain walking,
swimming, football and bicycling. The English children on average participated in 3 þ 1
physical pursuits per week which included football, bicycling, swimming and gym at
school.
Transport to school was also investigated. All (n ¼ 71) the French children reported
that they walked to and from school everyday (average distance covered 2 km).
The English children also walked to school (average distance 0.5 km), although some
(n ¼ 19) did report that they occasionally went by car.
When nutrition knowledge was investigated, it was observed that both sets of children
were knowledgeable of the benefits of fruit and vegetables, which were listed at the top of
foods considered ‘healthy’. However, the French children appeared to have a far better
understanding of a healthy balanced diet and an awareness of the five food groups.
Noticeably, 49% of French children rated dairy produce as being examples of healthy
foods compared to only 16% of English children. Red meats, lentils, pulses, rice, cereals
and bread were also highly rated by the French children, these foods were not selected by
the English children. The English children favoured chicken, as a good source of protein,
significantly (P , 0.05) more than the French children.
The French children all reported going home or to a grandparents home for lunch,
whereas 95% of the English children had packed lunches or school dinners. There were no
fast food outlets in the area where French children studied, whereas the English children
reported living in proximity to several well-known fast-food chains.

Discussion
The results of this study showed greater incidence of overweight, obesity and morbid
obesity in English children than in the French children. It also indicated a number of
underweight French children in this study. A difference was also seen in waist
circumferences, being larger in the English children, although the mean age and mean
height of the English children were very slightly higher than those of the French children,
and this may have played a role in the higher BMIs seen in this study.
Low levels of physical exercise were observed in the English children and high levels
seen in the French children in this study. High levels of sedentary activity (TV and
computer use) were seen in the English children and low levels seen in the French children
in this study. Certainly there are plenty of studies that have investigated the role of
 International Journal of Health Promotion and Education 7

sedentary activities including TV and computer use on diet, body fatness and physical
activity levels. Grund et al. (2001) showed that the number of hours of TV viewing was
related to fatness, although they found no effect of TV viewing on overall energy
expenditure, muscle strength or diet. It is likely that sedentary behaviour may also be
associated with increased snacking, and it has been reported that TV viewing has often
been associated with passive eating and the consumption of fast foods and confectionary
(Jeffery et al. 2006). Alternatively, it has been suggested that TV viewing is a consequence
not a cause of obesity (Robinson 2001). However, it is likely that sedentary activities
including TV viewing may be indicative of an unhealthy lifestyle in general and thus
contribute to overweight and obesity in this way. Time spent outdoors has been used as an
indicator of a healthy lifestyle, spending less than an hour outdoors and hence more time in
front of TV and computer screens can have serious implications for obesity risk (Wen et al.
2009). The French children in this study spent considerably greater time doing outside
activities than the English. Increasing physical activities and reducing TV viewing has also
been seen as an effective obesity prevention measure.
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The method of getting to school can also be related to physical activity levels and even
body weight (Faulkner et al. 2009). Children who walk to school may have lower BMIs,
although it is not clear whether it is the walking that contributes to preventing weight gain
or whether simply leaner children walk to school (Rosenberg et al. 2006). Although both
the French and English children in this study walked to school, the French children walked
a considerably greater distance.
In both England and France, the quality of the diet has been linked to nutritional
knowledge, education and socio-economic status (Robinson et al. 2004, Vernay et al.
2009). The French have a history of dietary awareness dating back to the year 1904 when
the French Health Public Health Act was introduced and the emergence of Puericulture.
The point of puericulture was to encourage and teach parents to behave responsibly and
consider the quality and quantity of the diet, the legacy of which is still alleged to exist
today (Borgenicht and Borgenicht 2003). The nutritional knowledge of the French
children in this study was certainly superior to that of the English and this will also have
positively influenced dietary intake.
All the French children in this study went home for lunch, whereas the English either
had a school dinner or a packed lunch. Both school dinners and packed lunches in the UK
have been noted as being poor (Rogers et al. 2007) and could certainly be a key area for
improvement.
Several studies (Jeffery et al. 2006, Crawford et al. 2008) have failed to show an
association between fast food outlet proximity to schools and BMI, most finding that it is
the frequency of visits that is key. However if there are no fast food outlets in the area being
studied, then there is no opportunity for visits and hence consumption. The difference
between the distribution of fast food outlets in the studied area of France and London could
be a further reason for differences between the two sample groups.
It is recognized that this study is a cross-sectional snapshot, that number of subjects
were limited and that the locations from where the subjects were recruited may not be
wholly representative of the nations they represent. There is also risk of measurement bias
for self-report questions regarding the reported physical activity patterns and food
preferences of the children. Future studies should endeavour to make detailed dietary
analysis to examine differences in the food composition of these two northern European
countries. Nonetheless this study identifies some factors that may be indicative of the
differences between incidence of obesity in England and incidence of obesity in France.
 8 Y. Wake and S. Reeves

In summary the French children in this study were thinner, more active, walked farther
to school and were not involved in long periods of sedentary activity. Whereas a third of
the English children were overweight or obese, they were extremely physically inactive
and spent long periods of time viewing TV or on a computer outside of school. The French
children also appeared to be more nutritionally aware. The lifestyle differences between
the two groups are striking and may help to explain the differences in BMI between these
two nations.

Conclusion
Childhood obesity is on the increase and this can have a negative effect on health and
well-being and result in lower levels of academic achievement. It is of interest to compare
the school-aged children in France and England because of the differences in obesity rates
between the two countries, and the apparent cultural differences. It appears that energy
balance, in terms of both physical activity and food intake, is a key factor in the differences
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in the incidence of overweight and obesity between the French and English children in this
study. Given that most children spend up to 8 h a day at school, this is the ideal
environment for an obesity prevention programme. Knowledge of nutrition, distance
walked to school and participation in physical and outdoor activities have all been shown
to have positive effects on obesity prevention. Furthermore, these factors can be easily
facilitated and incorporated into the daily school routine to help prevent and reduce the
incidence of obesity amongst school-aged children.

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