Skip to main content

The effects of a one year school-based comprehensive lifestyle intervention among Chinese kids against obesity (CLICK-obesity) in Nanjing, China



Limited data regarding the effects of school-based obesity prevention programs focusing on the changes in obesity-related knowledge and behaviors in China are available. The objective of this paper was to evaluate the effects of a school-based comprehensive lifestyle intervention among Chinese kids against obesity (CLICK-Obesity) in primary schools in Nanjing.


We designed a cluster randomized controlled trial in eight randomly selected urban primary schools among 4th graders between May 2011 to April 2012 in Jianye, an urban district of Nanjing. Each school was randomly assigned to either the intervention or control group (four schools in each group). Mixed regression models and generalized estimating equations (GEE) were used to adjust for individual-level covariates under cluster randomization.


In this study, 1178 students (96.2%; 665 boys and 513 girls, 544 in control and 634 in intervention) participated in the baseline survey with mean age 10.2 ± 0.5 years. At the end of one-year intervention, 1125 students (91.8%; 628 boys and 497 girls, 513 in control and 612 in intervention) were reassessed. Notably, we found that the intervention group improved the knowledge and awareness of obesity-related risk factors, presented a lower increase of consumption of red/white meat (with a mean difference of −180.9 g/week, 95% CI: −350.6 to −11.2, p = 0.040), a larger increase in the time spent playing ball (with a mean difference of 24.2 min/week, 95% CI: −5.3 to 53.7, p = 0.090), and a significant reduction in screen time (with a mean difference of −71.0 min/week, 95% CI: −125.3 to −16.6, p = 0.020) compared to the control group after cluster (school) adjustment.


The school-based integrated intervention was successful to modify unhealthy lifestyle behaviors and had a potential effect on childhood obesity prevention in urban China. However, the long-term effects and cost-effectiveness need to be evaluated in through further study.

This is a preview of subscription content, access via your institution.

Data availability

No data relevant to the study are included in the article or uploaded as supplementary information. Data of the survey are not public, aiming to preserve anonymity of information from participants.


  1. Abarca-Gómez L, Abdeen ZA, Hamid ZA et al (2017) Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128.9 million children, adolescents, and adults. Lancet 390:2627–2642.

    Article  Google Scholar 

  2. Adab P, Pallan MJ, Lancashire ER, Hemming K, Frew E, Barrett T, Bhopal R, Cade JE, Canaway A, Clarke JL (2018) Effectiveness of a childhood obesity prevention programme delivered through schools, targeting 6 and 7 year olds: cluster randomised controlled trial (WAVES study). BMJ 360:k211

    Article  Google Scholar 

  3. Afshin A, Forouzanfar MH, Reitsma MB et al (2017) Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med 377:13–27.

    Article  PubMed  Google Scholar 

  4. Bleich SN, Vercammen KA, Zatz LY, Frelier JM, Ebbeling CB, Peeters A (2018) Interventions to prevent global childhood overweight and obesity: a systematic review. Lancet Diabetes Endocrinol 6:332–346.

    Article  PubMed  Google Scholar 

  5. Cao ZJ, Wang SM, Chen Y (2015) A randomized trial of multiple interventions for childhood obesity in China. Am J Prev Med 48:552–560.

    Article  PubMed  Google Scholar 

  6. Cao Z, Hua J, Zhang D, Thapa JR, Wang S (2019) A cohort study assessing the sustainable long-term effectiveness of a childhood-obesity intervention in China. Int J Epidemiol 48:108–115.

    Article  PubMed  Google Scholar 

  7. Carles A, Francesca SM, Gemma S et al (2019) The incidence of obesity, assessed as adiposity, is reduced after 1 year in primary schoolchildren by the POIBA intervention. J Nutr 149:258–269.

    Article  Google Scholar 

  8. Cauchi D, Glonti K, Petticrew M, Knai C (2016) Environmental components of childhood obesity prevention interventions: an overview of systematic reviews. Obes Rev 17:1116–1130.

    CAS  Article  PubMed  Google Scholar 

  9. Centis E, Marzocchi R, Luzio RD, Moscatiello S, Salardi S, Villanova N, Marchesini G (2012) A controlled, class-based multicomponent intervention to promote healthy lifestyle and to reduce the burden of childhood obesity. Pediatr Obes 7:436–445.

    CAS  Article  PubMed  Google Scholar 

  10. Du B (2015) Study on prevalence of overweight and obesity in 2005, 2010, 2014 and its association with hypertension of school students of 7 to 22 years old in Anhui Province. Dissertation, Anhui Medical School

  11. Gonzalez-Suarez C, Worley A, Grimmer-Somers K, Dones V (2009) School-based interventions on childhood obesity: a meta-analysis. Am J Prev Med 37:418–427.

    Article  PubMed  Google Scholar 

  12. Group of China Obesity Task Force Correspondence (2004) Body mass index reference norm for screening overweight and obesity in Chinese children and adolescents. Chin J Epidemiol 25:10–15.

    Article  Google Scholar 

  13. Harris KC, Kuramoto LK, Schulzer M, Retallack JE (2009) Effect of school-based physical activity interventions on body mass index in children: a meta-analysis. CMAJ 180:719–726.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Jansen W, Borsboom G, Meima A, Zwanenburg EJ, Mackenbach JP, Raat H, Brug J (2011) Effectiveness of a primary school-based intervention to reduce overweight. Int J Pediatr Obes 6:e70–e77.

    Article  PubMed  Google Scholar 

  15. Juliana K, Fernando C, Lorena M, Bárbara L (2014) School-based obesity prevention intervention in Chilean children: effective in controlling, but not reducing obesity. J Obes 2014:1–8.

    Article  Google Scholar 

  16. Khambalia AZ, Dickinson S, Hardy LL, Gill T, Baur LA (2012) A synthesis of existing systematic reviews and meta-analyses of school-based behavioural interventions for controlling and preventing obesity. Obes Rev 13:214–233.

    CAS  Article  PubMed  Google Scholar 

  17. Kipping RR, Howe LD, Jago R, Campbell R, Wells S, Chittleborough CR, Mytton J, Noble SM, Peters TJ, Lawlor DA (2014) Effect of intervention aimed at increasing physical activity, reducing sedentary behaviour, and increasing fruit and vegetable consumption in children: active for life year 5 (AFLY5) school based cluster randomised controlled trial. BMJ 348:g3256–g3256.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Klakk H, Chinapaw M, Heidemann M, Andersen LB, Wedderkopp N (2013) Effect of four additional physical education lessons on body composition in children aged 8-13 years - a prospective study during two school years. BMC Pediatr 13:170.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Kobes A, Kretschmer T, Timmerman G , Schreuder P (2018) Interventions aimed at preventing and reducing overweight/obesity among children and adolescents: a meta-synthesis. Obes Rev.

  20. Kriemler S, Zahner L, Schindler C, Meyer U, Hartmann T, Hebestreit H, Brunner-La Rocca HP, van Mechelen W, Puder JJ (2010) Effect of school based physical activity programme (KISS) on fitness and adiposity in primary schoolchildren: cluster randomised controlled trial. BMJ 340:c785.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lavelle HV, Mackay DF, Pell JP (2012) Systematic review and meta-analysis of school-based interventions to reduce body mass index. J Public Health (Oxf) 34:360–369.

    CAS  Article  Google Scholar 

  22. Li B, Liu WJ, Adab P et al (2017) Cluster-randomised controlled trial to assess the effectiveness and cost-effectiveness of an obesity prevention programme for Chinese primary school-aged children: the CHIRPY DRAGON study protocol. BMJ Open 7:e018415.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Liu Z, Li Q, Maddison R et al (2019) A school-based comprehensive intervention for childhood obesity in China: A Cluster Randomized Controlled Trial. Child Obes.

  24. Llargués E, Franco R, Recasens A et al (2011) Assessment of a school-based intervention in eating habits and physical activity in school children: the AVall study. J Epidemiol Community Health 65:896–901.

    Article  PubMed  Google Scholar 

  25. Llargués E, Recasens A, Franco R et al (2012) Medium-term evaluation of an educational intervention on dietary and physical exercise habits in schoolchildren: the Avall 2 study. Endocrinol Nutr 59:288–295.

    Article  PubMed  Google Scholar 

  26. Manger WM, Manger LS, Minno AM, Killmeyer M, Holzman RS, Schullinger JN, Roccella EJ (2012) Obesity prevention in young schoolchildren: results of a pilot study. J Sch Health 82:462–468.

    Article  PubMed  Google Scholar 

  27. Meng L, Xu H, Liu A et al (2013) The costs and cost-effectiveness of a school-based comprehensive intervention study on childhood obesity in China. PLoS One 8:e77971.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  28. Metcalf B, Henley W, Wilkin T (2012) Effectiveness of intervention on physical activity of children: systematic review and meta-analysis of controlled trials with objectively measured outcomes (early bird 54). BMJ 345:e5888–e5888.

    Article  PubMed  Google Scholar 

  29. Sahota P, Rudolf MC, Dixey R, Hill AJ, Barth JH, Cade J (2001) Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. BMJ 323:1029–1032.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  30. Silveira J, Taddei J, Guerra PH, Nobre M (2011) Effectiveness of school-based nutrition education interventions to prevent and reduce excessive weight gain in children and adolescents: a systematic review. J Pediatr 87:382–392.

    Article  Google Scholar 

  31. Tran BX, Dang KA, Le HT et al (2019) Global evolution of obesity research in children and youths: setting priorities for interventions and policies. Obes Facts 12:137–149.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M (2011) Health and economic burden of the projected obesity trends in the USA and the UK. Lancet 378:815–825.

    Article  PubMed  Google Scholar 

  33. World Health Organization (2018) Obesity and overweight. IOP Publishing PhysicsWeb. Accessed 7 June 2018

  34. Xu F, Ware RS, Tse LA, Wang Z, Hong X, Song A, Li J, Wang Y (2012) A school-based comprehensive lifestyle intervention among chinese kids against obesity (CLICK-obesity): rationale, design and methodology of a randomized controlled trial in Nanjing city, China. BMC Public Health 12:316.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Xu F, Wang XR, Ware RS, Tse LA, Wang Z, Hong X, Chan EY, Li J, Wang Y (2014) A school-based comprehensive lifestyle intervention among Chinese kids against obesity (CLICK-obesity) in Nanjing City, China: the baseline data. Asia Pac J Clin Nutr 23:48–54.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Zhang N, Ma GS (2017) Interpretation of report on childhood obesity in China. Acta Nutrimenta Sinica 39:530–534. (Ma GS (2017) report on childhood obesity in China. Beijing, China)

    Article  Google Scholar 

  37. Zhang JG, Wang HJ, Wang ZH et al (2018) Prevalence and stabilizing trends in overweight and obesity among children and adolescents in China, 2011-2015. BMC Public Health 18:571.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


The authors thank the children and their parents/guardians for their participation and the schools for their cooperation, as well as the study investigators and staff.


This research work was funded by the Nanjing Municipal Science and Technique Foundation (200901088) and Medical Science and Technique Development Foundation (2009-ZKX09034). The funder had no role in the decision to collect data, data analysis, or reporting of the results.

Author information




Xin Hong and HaiRong Zhou conceived and designed the study. Xin Hong, HaiRong Zhou, Huafeng Yang, Shengxiang Qi, and Chenchen Wang performed the study. Xin Hong, HaiRong Zhou, and Huafeng Yang collected the data. Xin Hong, HaiRong Zhou, and WeiWei Wang analyzed the data. Xin Hong and HaiRong Zhou contributed to the drafts. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Xin Hong.

Ethics declarations

Competing of interest

The authors declare that they have no competing interest.

Ethics approval and consent to participate

The study was approved by the academic and ethical committee of Nanjing Municipal Center for Disease Control and Prevention (Nanjing CDC). Written informed consent from all participants was obtained.

Informed consent

Written informed consent regarding baseline and follow-up surveys as well as participation in the lifestyle intervention were obtained from parents/guardians and the schools prior to the baseline survey.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Zhou, HR., Wang, WW., Yang, HF. et al. The effects of a one year school-based comprehensive lifestyle intervention among Chinese kids against obesity (CLICK-obesity) in Nanjing, China. J Public Health (Berl.) (2021).

Download citation


  • School-based intervention
  • Children
  • Obesity prevention
  • China