A Randomized Trial of Multiple

Interventions for Childhood Obesity in China

Zhi-Juan Cao, BM, Shu-Mei Wang, PhD, Yue Chen, PhD

Introduction: Family- and school-based interventions for childhood obesity have been widely
applied; however, the prevalence of childhood obesity remains high. The purpose of this RCT is to
evaluate the effectiveness of a family-individual-school–based comprehensive intervention model.
Design: Cluster RCT.
Setting/participants: Fourteen primary schools were selected from 26 primary schools in a
district of Shanghai, China, and then randomly divided into intervention and control groups with
seven schools in each. The trial started with first-grade students. A total of 1,287 students in the
intervention group and 1,159 in the control group were studied overall.

Intervention: The baseline study was conducted in January 2011, and family-individual-school–
based interventions started in March 2011 and ended in December 2013 for intervention group
students. Three follow-up studies were conducted in January 2012, January 2013, and January 2014.
Data analysis was conducted in March 2014.

Main outcome measures: Students’ weight and height were measured. The prevalence of
obesity/overweight and BMI z-scores were calculated and analyzed using a generalized estimating
equation approach.

Results: The overall prevalence of overweight/obesity declined from 28.92% in 2011 to 24.77% in
2014, with a difference of 4.15% in the intervention group compared with a 0.03% decline (from
30.71% to 30.68%) in the control group. The intervention group had significantly lower odds of
developing obesity or overweight and had decreased average BMI z-scores compared with the
control group, especially for obese or overweight students.

Conclusions: The family-individual-school–based comprehensive intervention model is effective

for controlling childhood obesity and overweight.
(Am J Prev Med 2015;48(5):552–560) & 2015 American Journal of Preventive Medicine. This is an open access
article under the CC BY-NC-SA license (http://creativecommons.org/licenses/by-nc-sa/4.0/).

Introduction 19%–28%, respectively, in the European region in 2008.

CDC reported an obesity prevalence as high as 17% for

I
n the past 30 years, rates of childhood obesity have
increased rapidly worldwide.1–3 Obesity has become a
global epidemic, with substantial impacts on children’s
health.4 Childhood obesity is the focus of the WHO
Childhood Obesity Surveillance Initiative,2,5 which reported
the prevalence of obesity and overweight to be 6%–12% and
From the School of Public Health (Cao, Wang), Key Laboratory of Public
Health Safety, Ministry of Education, Fudan University, Xuhui District,
Shanghai, China; and the Department of Epidemiology and Community
Medicine (Chen), University of Ottawa, Ontario, Ottawa, Canada
Address correspondence to: Shu-Mei Wang, PhD, School of Public
Health, Key Laboratory of Public Health Safety, Ministry of Education,
Fudan University, 130 Dong’ an Road, Xuhui District, Shanghai, China.
E-mail: smwang@fudan.edu.cn.
0749-3797/$36.00
http://dx.doi.org/10.1016/j.amepre.2014.12.014
children and adolescents aged 2–19 years.2,6 In China, 6.2%
of children, or 16 million, are either overweight or obese,7
and of those children, 75.9% have at least one metabolic
abnormality and 20.4% have metabolic syndrome.8 Over-
weight or obese children are disproportionately affected by
adverse physical and psychosocial health outcomes, includ-
ing hypertension, diabetes, low self-esteem, and increased
engagement in high-risk behaviors,9–11 and are at increased
risk of becoming obese adults.11–13 These negative health
outcomes increase their risk of other obesity-related
medical conditions later in life.2,4,14,15
Childhood obesity prevention and control have become
international public health priorities.16 It is widely recog-
nized that both family and home environments significantly

552 Am J Prev Med 2015;48(5):552–560 & 2015 American Journal of Preventive Medicine
Published by Elsevier Inc. This is an
open access article under the CC BY-NC-SA license (http://creativecommons.org/licenses/by-nc-sa/4.0/).
 Cao et al / Am J Prev Med 2015;48(5):552–560
17,18
influence child diet and physical activity (PA) behaviors.
Family-centered interventions (also known as family-based
interventions) to reduce the risk of childhood obesity focus
on changing weight-related behaviors of multiple family
members, not just those of the child.19 Three recent system-
atic reviews have highlighted the importance of these
influences on childhood obesity prevention and treatment,
mainly for young children.3,20,21 Unfortunately, most family-
centered interventions focus on obesity treatment, partic-
ularly in school-aged children and adolescents,22,23 whereas
family-centered interventions focusing on the prevention of
childhood obesity are limited.24 Children spend most of their
time at school; therefore, implementation of school-based
programs, such as promoting PA and healthy eating, could
play an important role in childhood obesity intervention and
prevention.25 Although a variety of programmatic changes
have been evaluated, the overall effectiveness of school-based
programs on health-related outcomes in youth has been
poor.26–29 A main reason for this is that many interventions
have not built in the needed support from families to allow
behavior changes to be maintained over time.29
In order to develop effective programmatic actions, a
controlled family-individual-school (FIS)–based compre-
hensive childhood obesity prevention/intervention model
is recommended. Because parents play a critical role in
shaping children’s dietary intake, PA behavior, and body
weight,30 involving the family in childhood obesity inter-
ventions may be effective for promoting and sustaining
healthy changes in children’s diets and PA.31 Schools
provide environments for healthy eating and PA behaviors
that influence body weight, and provide staff and resour-
ces (teachers and coaches) that can support the imple-
mentation of interventions.26 In the FIS model, a primary
intervention program is aimed at all students with parents’
involvement. Students connect the family and school,
whereas parents collaborate with the school to contribute
to the intervention program. The family, individual, and
school can form a rigorous intervention circle, which
guarantees a comprehensive intervention. To date, few
RCTs have integrated family- and school-based childhood
obesity interventions and conducted a follow-up evalua-
tion of effectiveness in developing countries.
Methods
Study Design and Participants
This was a cluster RCT conducted in Shanghai, China. All 26
primary schools in a district of the city were divided into three
groups according to average obesity prevalence quartile among all
first-grade students in 2011. There were seven schools with an
obesity prevalence 475th percentile (P75, ie, high), 12 schools
between the 25th percentile (P25) and P75 (middle), and seven
schools oP25 (low). A sample size of 476 each for the intervention
May 2015
553
and control groups was estimated based on an expected decrease of
at least 4% in the obesity prevalence (from 14% to 10%) in the
intervention group. According to the economic level of the
communities in which the schools were located and the condition
of school sports fields and canteens, four of seven schools with
high obesity prevalence were selected and divided into interven-
tion and control groups randomly by sortation. Similarly, six of 12
schools with middle obesity prevalence and four of seven with low
obesity prevalence were selected and divided into intervention and
control groups. The study began with first-grade students, and a
total of 2,446 students in the selected schools participated in the
study (1,287 in the intervention group and 1,159 in the control
group). Then, three follow-ups were conducted when the students
were in second, third, and fourth grade. Some of the students did
not participate in the baseline or follow-up surveys.
The students’ parents were informed of the study aims and
methods, and written consent was obtained through a self-
administered questionnaire. At the same time, the weight and
height of parents were self-reported. Students were free of serious
physical or mental disorders that could impede participation in
scheduled PA. The study was approved by the Ethics Committee of
Fudan University (International Registration Number: 112
IRB00002408, FWA00002399).
The baseline study was conducted in January 2011, with 965 (322
missing) students in the intervention group and 889 (270 missing)
students in the control group who had complete personal identifica-
tion, weight, height, age, and gender information. The intervention
started in March 2011 and ended in December 2013 for the
intervention group, and no intervention was conducted for the control
group. The first follow-up study was conducted in January 2012, with
906 (381 missing) students in the intervention group and 800 (359
missing) students in the control group who provided all the key
information. The second follow-up study was conducted in January
2013, with 954 (342 missing) students in the intervention group and
797 (362 missing) students in the control group participating. The last
follow-up study was conducted in January 2014, a month after the
completion of the interventions, with 985 (302 missing) students in
the intervention group and 828 (331 missing) students in the control
group who provided all key information (Fig. 1).
Family-Individual-School–Based Comprehensive
Intervention
Table 1 lists the FIS-based comprehensive intervention measures for
the study. The FIS-based comprehensive intervention model com-
bined models of family- and school-based interventions and had
three aspects: health knowledge, dietary behavior, and exercise
behavior. Parent involvement was a part of the intervention, and
parents were the agents of the intervention measures at home.
Teachers were the agents of the intervention measures at school. The
research team included researchers from Fudan University and
members of the district Education Bureau and Institute of Education.
The FIS-based childhood obesity intervention addressed the
disadvantages of single school- and family-based childhood
obesity interventions. According to the results from a previous
survey on childhood obesity risk factors32 and a literature review,
health knowledge, dietary behavior, and exercise behavior were the
three areas targeted by this intervention. The intervention meas-
ures were detailed under the guidance of the Advice of Communist
Party of China Central Committee and the State Council on
554 Cao et al / Am J Prev Med 2015;48(5):552–560
Figure 1. CONSORT 2010 flow diagram.
Strengthening Youth Sports and Enhancing Adolescent Health,33 A
Brief Analysis of Nutrition Dietary Guidelines for Chinese Resi-
dents,34 and the Primary and Middle School Students Health
Education Guidelines35 issued by the Chinese Ministry of Education,
which form the basis on which we designed the intervention program.
The team planned the content and forms of the intervention for each
semester and organized school staff trainings for integrating the
intervention program into the school curriculum. The curriculum
covered childhood obesity risk factors, health consequences, and obesity
prevention. Members of the Education Bureau and Institute of
Education established an administrative system, including relevant rules
and regulations. They emphasized the importance of obesity prevention
to students and provided periodic supervision of the intervention. They
also supervised school canteens and provided financial support for the
project. One important feature of this intervention model was the
collaboration between the Education Bureau and Institute of Education,
which guaranteed the sustainability of the intervention. In the
intervention schools, the research team strengthened the quality control
for sports activities that have already been carried out by schools and
developed new sports activities, such as a 20-meter shuttle run with
music. In addition, the research team invited experts to conduct lectures
for students and their parents (Table 1). Successful completion of
intervention activities required administrative measures and expert
resources as well as financial support.
The district is large and includes 181 neighborhoods. School-
aged children and adolescents are enrolled in neighborhood
schools near their residence. In this study, the intervention
measures were conducted by considering each class of the
intervention schools as a unit. Although we could not guarantee
total isolation of intervention and control group students, the
control schools were not likely to be seriously contaminated.
Otherwise, the intervention effect would be underestimated.
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 Cao et al / Am J Prev Med 2015;48(5):552–560
Table 1. Family-Individual-School (FIS) Comprehensive Intervention on Child Obesity
Intervention School
Health 6-hour health education course per semester
education Obesity-related health information dissemination through
school publicity platform, such as blackboard newspaper,
morning meeting and class meeting, and brochures
Theme class meetings or seminars about childhood
obesity provided by health teacher.
Dietary Teachers' control of eating speed for students during
intervention lunch and advice on eating less junk foods
Reducing fat content of food at canteens and making
more fruits and vegetables available
Exercise 20-meter music shuttle run 2–3 times per week
intervention Ensure the participation rate of regular school physical
education and extracurricular activities
More than 1-hour physical activity time each school day
Featured sports activities such as rope skipping and
football
Measures
Children’s weight and height were measured by trained research
staff. Height was measured to an accuracy of 1 mm with a
freestanding stadiometer. Body weight was measured to the
nearest 0.1 kg on a digital scale. BMI was calculated from weight
and height (weight in kilograms divided by height in meters
squared)15 and BMI z-scores for gender and age were derived
using WHO growth references.15 Children were defined as
overweight or obese according to standards set by the Working
Group on Obesity in China,36 which were age- and gender-
specific. The weight and height of parents were obtained from a
self-administered questionnaire in each survey, and the average
weight and height from four surveys were used in the analysis.
Parents were grouped into three BMI categories: BMI r24
(normal weight), 24o BMI r28 (overweight), and BMI 428
(obese).
Statistical Analysis
The primary data analysis was conducted in March 2014. A logistic
model was used to estimate the OR and 95% CI for the association
between the intervention and prevalence of obesity/overweight.
Previous studies have shown that BMI z-scores are the optimal
measure of annual adiposity change in elementary school chil-
dren.37,38 In this study, a linear model was used to test the effect of
the intervention on BMI z-scores. The aforementioned models all
accounted for age, gender, and parents’ and children’s BMIs at
baseline. A generalized estimating equation (GEE) approach was
used to deal with the repeated measurements in regression
analyses.39 Conventional statistical analysis methods, such as t
tests, single-factor variance analysis, and chi-square tests, ignore
the correlation between repeated measures and the difference in
the distribution of random errors at different levels40 and increase
the probability of Type I error in hypothesis testing.41 GEEs allow
adjustment for correlations between observations.42,43 GEEs do
not require correct specification of the multivariate distribution
but only the mean structure.42 Even if the working correlation
matrix is incorrectly specified, the estimation of model parameters
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555
Family
Parent-school meeting every semester
Distribution of brochures on childhood obesity prevention
and intervention
Parents' participation of obesity prevention lectures
Information to parents about balanced diet principles and
methods
Instructions to parents about healthy eating habits of
children
A strip of skipping rope provided to each student and
appropriate level of physical activity at home supervised
and monitored by parents
Parents' completion of “Students' Extracurricular Physical
Activity Registration Form” during summer and winter
vacations, including frequency, duration, intensity, and
other information of physical activity
and their SEs is robust as long as the marginal link function is
specified correctly. In this study, the working correlation matrix
was specified as “unstructured.” In addition, GEEs can also deal
with data that have missing values, and as long as the missing value
is completely random, parameter estimation can still yield robust
results; therefore, this approach is often used to analyze longi-
tudinal and other correlated response data, particularly if
responses are binary.22,44 In this study, students with missing
weight, height, age, or gender were excluded from the analysis.
All analyses were performed using SPSS, version 16.0, and all tests
were two-sided. Statistical significance was defined as po0.05.
Results
Table 2 shows the gender and age distributions of the
study participants. The gender distribution was similar
for the intervention and control groups. The average age
was greater for the intervention group (7.01 years)
compared with the control group (6.81 years), and age
was adjusted in regression analyses.
Childhood Overweight/Obesity Prevalence and
BMI z-Score Changes
Table 3 shows the prevalence of overweight and obesity
from the baseline survey to the final follow-up, for both
the intervention and control groups. The prevalence of
obesity decreased from 13.89% to 9.95% (3.94%
decrease) in the intervention group and from 14.40%
to 13.04% (1.36% decrease) in the control group. The
percentage of individuals with normal weight
increased from 71.08% to 75.23% (4.15% increase) in
the intervention group and from 69.29% to 69.32% (an
increase of only 0.03%) in the control group. The
change in the prevalence of overweight was trivial for
the intervention group (0.21%). The BMI z-score
556 Cao et al / Am J Prev Med 2015;48(5):552–560
Table 2. Gender and Age Distribution of Study Participants

Intervention group Control group

Variable
gender Boy Girl Total Boy Girl Total χ2 p-value

Baseline 529 436 965 468 421 889 0.881 0.348

First follow-up 482 424 906 422 378 800 0.035 0.852
Second follow-up 509 445 954 410 387 797 0.636 0.425
Third follow-up 526 459 985 427 401 828 0.605 0.437
Age na
M SD n M SD t p-value
Baseline 965 7.01 0.44 889 6.81 0.24 –12.196 o0.001
First follow-up 906 7.91 0.34 800 7.92 0.40 0.771 0.441
Second follow-up 954 8.92 0.38 797 8.94 0.42 0.871 0.384
Third follow-up 985 9.91 0.39 828 9.93 0.42 1.252 0.211

Note: Boldface indicates statistical significance (po0.05).

a
Number of students.

increased in both the intervention group and control
group during the study period from January 2011 to
January 2014, but the increase was less marked for the
intervention group.
Intervention Effects on Obesity and Overweight
Independent variables in GEE-based regression analyses
included intervention (intervention/control); time
(third follow-up/second follow-up/first follow-up);
interaction of intervention and time; gender (boy/girl);
age (continuous variable); BMI category of the mother
(obesity/overweight/normal); BMI category of the
father (obesity/overweight/normal); and children’s
BMI at baseline (continuous). Dependent variables were
student obesity (yes/no) and student obesity or over-
weight (yes/no).
The interaction between intervention and time
was not statistically significant in both the obesity
model (p¼0.497) and the obesity or overweight model
(p¼0.351); thus, this variable was excluded from the
models. Table 4 shows that the intervention was
effective for reducing the odds of developing obes-
ity and the odds of developing obesity or over-
weight. The odds of developing obesity differed
significantly between the intervention and control
groups after 3 years of intervention (OR¼0.583).
The odds of developing obesity or overweight in the

Table 3. Body Weight Measures in the Intervention and Control Groups at Baseline and Follow-Up Surveys

Baseline (n [%]) First follow-up (n [%]) Second follow-up (n [%]) Third follow-up (n [%])
Body weight
measures Intervention Control Intervention Control Intervention Control Intervention Control

Obesity 134 (13.89) 128 99 (10.93) 98 93 (9.75) 94 98 (9.95) 108

(14.40) (12.25) (11.79) (13.04)
Overweight 145 (15.03) 145 128 (14.13) 123 124 (13.00) 115 146 (14.82) 146
(16.31) (15.38) (14.43) (17.63)
Normal 686 (71.08) 616 679 (74.94) 579 737 (77.25) 588 741 (75.23) 574
(69.29) (72.38) (73.78) (69.32)
Total 965 (100.00) 889 906 (100.00) 800 954 (100.00) 797 985 (100.00) 828
(100.00) (100.00) (100.00) (100.00)
BMI z-score
na 965 889 906 800 954 797 985 828
M (SD) 0.066 0.066 0.078 0.082 0.072 0.089 0.083 0.113
(0.158) (0.157) (0.166) (0.171) (0.188) (0.187) (0.202) (0.209)
a
Number of students.

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 Cao et al / Am J Prev Med 2015;48(5):552–560 557
Table 4. OR and 95% CI for Intervention and Other Factors Associated With Excess Body Weight

Independent variable (Y) Parameters OR (95% CI) χ² p-value

Obesity Intervention versus control 0.583 (0.428, 0.794) 11.724 0.001

Third follow-up versus first follow-up 1.372 (0.613, 3.068) 0.592 0.442
Second follow-up versus first follow-up 1.069 (0.672, 1.699) 0.079 0.778
Paternal obesity versus normal 1.542 (0.962, 2.472) 3.232 0.072
Paternal overweight versus normal 1.250 (0.927, 1.686) 2.149 0.143
Maternal obesity versus normal 0.932 (0.380, 2.287) 0.023 0.879
Maternal overweight versus normal 1.523 (1.072, 2.162) 5.516 0.019
Girl versus boy 0.854 (0.621, 1.173) 0.955 0.329
Age 0.704 (0.482, 1.027) 3.317 0.069
BMI at baseline 2.520 (2.294, 2.768) 371.879 o0.001
Obesity or overweight Intervention versus control 0.625 (0.493, 0.793) 15.052 o0.001
Third follow-up versus first follow-up 2.597 (1.425, 4.731) 9.720 0.002
Second follow-up versus first follow-up 1.300 (0.936, 1.806) 2.458 0.117
Paternal obesity versus normal 1.378 (0.951, 1.998) 2.870 0.090
Paternal overweight versus normal 1.001 (0.802, 1.250) 0.000 0.993
Maternal obesity versus normal 0.821 (0.419, 1.607) 0.332 0.564
Maternal overweight versus normal 1.352 (1.023, 1.787) 4.508 0.034
Girl versus boy 0.587 (0.461, 0.748) 18.604 o0.001
Age 0.589 (0.441, 0.787) 12.842 o0.001
BMI at baseline 2.681 (2.430, 2.958) 387.050 o0.001

Note: Boldface indicates statistical significance (po0.05).

intervention group were 37.5% lower than in the Discussion

control group after 3 years of intervention (OR¼
0.625).
The OR of obesity for girls versus boys was 0.854,
indicating that girls were less likely to be obese than boys.
A similar trend was observed for being obese or over-
weight (OR¼0.587). Maternal overweight was signifi-
cantly associated with increased odds of their child
developing obesity or overweight.
Intervention Effects on BMI z-Scores
Students were divided into three groups according to their
weight status (normal weight, overweight, and obese)
when they first participated in the study. The interaction
between intervention and time was statistically significant
only in the normal weight group and was not statistically
significant in the overweight group (p¼0.158) or obese
group (p¼0.169). Table 5 shows that the intervention
decreased the mean BMI z-scores for all three groups, with
the largest decline (–0.046) in the obese group and the
smallest decline (–0.023) in the normal weight group.
There was an obvious growth trend in mean BMI z-scores
over the study period in the normal weight and overweight
groups for both the intervention and control groups. It is
worth mentioning that parental obesity or overweight
increased their children’s BMI z-scores in the normal
weight and obese groups.
A sensitivity analysis was conducted based on data
from baseline survey participants and excluded those
who were newcomers in the follow-up surveys; the
conclusions remained unchanged.
After 3 years of intervention, the prevalence of childhood
obesity and overweight declined by 4.15% in the inter-
vention group compared with only 0.03% in the control
group. The decline in the intervention group was mainly
due to the decreased prevalence of obesity (3.94%) rather
than overweight (0.21%). It was estimated that the
intervention lowered the odds of developing obesity by
about a quarter. The reason why the prevalence of
overweight did not change substantially was most likely
because the number of children who moved from the
overweight group to the normal weight group was similar
to the number of children who moved from the obese
group to the overweight group. The intervention had a
positive effect on moving children from the overweight
group to the normal group in addition to reducing
obesity. The fact that the BMI z-scores decreased for
each group would support this conclusion. The results
suggested that the FIS comprehensive intervention was
effective for decreasing average BMI z-scores for students
with both normal and excess weight (obesity or over-
weight); however, it was more effective for obese and
overweight students. Interventions in previous studies
focused primarily on reducing body weight of obese
children,22,23 whereas the current study indicated that the
intervention measures were also effective for children at
normal weight. There was an obvious growth trend for
mean BMI z-scores over the study period in the normal
weight (at baseline) group, indicating that it is also
necessary to prevent obesity and overweight among
normal weight students.

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558 Cao et al / Am J Prev Med 2015;48(5):552–560
Table 5. Parameters Estimation in Stratified GEE Analysis for BMI z-Score

Dependent variable (Y) Parameters βa (95% CI) χ² p-value

BMI z-score (Normal weight at Intervention versus control 0.002 (–0.007, 0.011) 0.222 0.638
baseline) Third follow-up versus first follow-up 0.050 (0.027, 0.074) 17.240 o0.001
Second follow-up versus first follow-up 0.019 (0.006, 0.033) 7.654 0.006
Paternal obesity versus normal 0.028 (0.012, 0.044) 11.157 0.001
Paternal overweight versus normal 0.012 (0.004, 0.020) 7.984 0.005
Maternal obesity versus normal –0.015 (–0.046, 0.016) 0.893 0.345
Maternal overweight versus normal 0.028 (0.015, 0.042) 16.533 o0.001
Girl versus boy –0.025 (–0.034, –0.017) 31.576 o0.001
Age –0.020 (–0.031, –0.009) 12.093 0.001
BMI at baseline 0.050 (0.045, 0.055) 416.839 o0.001
Intervention versus control at the third –0.023 (–0.037, –0.010) 11.324 0.001
follow-up –0.012 (–0.023, –0.001) 4.418 0.036
Intervention versus control at the second
follow-up
BMI z-score (Overweight at Intervention versus control –0.030 (–0.049, –0.011) 9.616 0.002
baseline) Third follow-up versus first follow-up 0.103 (0.049, 0.157) 13.831 o0.001
Second follow-up versus first follow-up 0.043 (0.016, 0.070) 9.995 0.002
Girl versus boy –0.017 (–0.037, 0.002) 3.022 0.082
Age –0.038 (–0.063, –0.013) 8.741 0.003
BMI at baseline 0.046 (0.037, 0.056) 87.256 o0.001

BMI z-score (Obesity at baseline) Intervention versus control –0.046 (–0.072, –0.021) 12.777 o0.001
Third follow-up versus first follow-up 0.023 (–0.041, 0.087) 0.496 0.481
Second follow-up versus first follow-up 0.018 (–0.017, 0.053) 1.037 0.309
Paternal obesity versus normal 0.039 (0.005, 0.072) 5.035 0.025
Paternal overweight versus normal 0.018 (–0.008, 0.044) 1.779 0.182
Girl versus boy –0.059 (–0.090, –0.028) 13.809 o0.001
Age 0.002 (–0.029, 0.033) 0.018 0.894
BMI at baseline 0.058 (0.053, 0.064) 443.582 o0.001

Note: Boldface indicates statistical significance (po0.05).

a
Regression coefficient.
GEE, generalized estimating equation.

The data also indicated that it took about 2–3 years to
reach the intervention effect size of interest among
normal weight students, which was consistent with the
results of previous reviews.25 Other intervention studies
of childhood obesity had various intervention durations
ranging from several months to several years. The FIS-
based comprehensive intervention likely needs a mini-
mum of 2 years to achieve the intervention goals.
Parental obesity or overweight could increase their
children’s BMI z-scores among normal weight and obese
students. The recommended FIS comprehensive inter-
vention model emphasized that family involvement and
parental participation in health education can benefit
their children, while improving outcomes for parents
themselves. Through learning obesity prevention infor-
mation and supervising their children’s physical activities
and diet, parents also gained awareness of controlling
their body weight. Results also suggested that boys were
more likely to become overweight or obese than girls.
Girls typically pay more attention to their body image
and are more sensitive to weight gain than boys, and their
exercise and dietary behavior are associated with this
greater self-awareness. Therefore, more attention should
be given to boys in future interventions.
In contrast to previous studies, this study emphasized
the collaboration between families and schools for child-
hood obesity prevention. At the same time, the partic-
ipation of administrative departments of education
ensured successful intervention implementation and the
possibility of expanding the intervention to all schools in
the district if it was found to be effective. Sustainability of
the intervention was often ignored in previous childhood
obesity intervention studies. The intervention measures
of the current study are relatively easy to implement, and
it should not be difficult to adapt the current intervention
to other schools with similar systems.
With the economic development and urbanization of
China, the rapid increase in obesity prevalence among
children and adolescents has attracted great attention
from all sectors of society. Results of the National Student
Physical Health Survey in 2005 and 2010 showed that
obesity prevalence among boys aged 7–18 years increased
from 0.63% to 10.50%; obesity prevalence among girls
aged 7–18 years increased from 0.60% to 4.71%.45 The
Chinese Center for Disease Control and Prevention46
reported that childhood obesity prevalence rose from
8.5% in 2010 to 12% in 2012 with a persistent increasing
trend, and obesity prevalence among school-aged children

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 Cao et al / Am J Prev Med 2015;48(5):552–560
in Shanghai is the highest in China. After 3 years of
intervention, the prevalence of excess weight (overweight or
obesity) among the students remained high, at 24.77% in
the intervention group and 30.36% in the control group.
These results are comparable to those from the U.S.1 The
successful experience of this study, including the interven-
tion package (courseware and brochure of health education,
PA template, and dietary and PA record charts), could
provide a reference for childhood obesity control in China.
Limitations
The first limitation of this study is that we did not
consider the effect of the intervention in underweight
students. Second, we did not evaluate childhood obesity–
related knowledge/attitude/behavior changes in the cur-
rent report because they have been discussed.47 Third,
this evaluation was conducted 1 month after the com-
pletion of the 3-year intervention; mid-term and long-
term effects of this intervention will be assessed further.
Conclusions
The FIS comprehensive intervention model is effective in
reducing the prevalence of childhood overweight/obesity
and mean BMI z-scores. However, the prevalence of
excess weight (overweight or obesity) remained high after
3 years of intervention. Therefore, additional efforts
should be made to reduce the risk of excess weight
among school-aged children.
This project was supported by an award (Award Number
12GWZX0301) from the Shanghai Municipal Health Bureau.
The content is the sole responsibility of the authors and does
not necessarily represent the official views of the Shanghai
Municipal Health Bureau.
No financial disclosures were reported by the authors of
this paper.
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