Rosenkranz et al. BMC Public Health 2010, 10:81 http://www.biomedcentral.com/1471-2458/10/81 brief review of behavioral influences on pediatric obesity and settings for intervention that serves to inform the present study’s health promotion approach. Influences on overweight and obesity in children The American Academy of Pediatrics (http://www.aap. org, accessed July 10, 2009) has made several recom- mendations for children’s obesity prevention and health improvement, and among these are: 1) Eat five fruits and vegetables per day; 2) Limit consumption of sugar- sweetened beverages; 3) Limit screen time to less than two hours a day; 4) Get one hour of physical activity a day; and 5) Regularly eat family meals together. Fruit and vegetable consumption The consumption of fruits and vegetables (FV) is nega- tively related to obesity, and researchers and practi- tioners often focus on boosting the intake of FV in both clinical obesity treatments and primary preven- tion efforts [4]. Among the numerous positive attri- butes of FV, is the fact that they contain abundant water and fiber, which may promote satiety and reduce overeating [5]. Studies have shown that enhancing availability and accessibility of FV increases consump- tion in children [6]. In school-based settings, both Sahota and colleagues and Müller and colleagues were able to modify FV consumption patterns, and the latter study achieved a corresponding indicator of obesity prevention [7,8]. Interventions designed to boost FV consumption in children have also been effectively delivered through scouting programs in earlier studies [9-11]. Sugar-sweetened beverage consumption Many studies have identified the consumption of sugar-sweetened beverages (SSB) to be a risk factor for obesity [12,13]. James and colleagues used a rando- mized controlled trial to demonstrate the effectiveness of an intervention designed to decrease the consump- tion of SSB in primary school children [13,14]. The children received an educational program and music designed to teach them SSB-related oral health risks, and to limit their consumption of such drinks, repla- cing SSB with water. James’ intervention showed short- term success in decreasing SSB consumption and the percentage of overweight and obese children. Recent pilot work by Ebbeling and colleagues has demon- strated effectiveness in replacing SSB with low-calorie beverages for obesity prevention in adolescents [15]. Television Viewing Television (TV- one form of screen time) may promote childhood obesity through three avenues of influence: promotion of sedentary behavior, food advertising, and eating while watching TV [16]. Gortmaker and co-work- ers based much of their Planet Health intervention cur- riculum on the reduction of TV for 6th and 8th graders Page 2 of 13 [17]. Planet Health achieved success in reducing TV viewing and the frequency of eating with TV. The inter- vention was effective for obesity prevention only for girls, and the effect was mediated by decreased TV view- ing. In another study aiming to decrease TV viewing in third and fourth graders, Robinson enlisted the aid of parents and an electronic device to restrict the amount of TV time [18]. This study achieved success in chan- ging TV behavior and preventing obesity for both boys and girls. Thus, interventions designed to limit chil- dren’s TV viewing, and to eliminate the connection between eating and TV may be effective in preventing obesity. Physical Activity Increasing physical activity (PA) of children may be use- ful in public health interventions to prevent obesity [19-21]. Previous research studies have used scouting programs to boost PA in children [22,23]. Outcomes have been modest for these interventions, and many have successfully increased PA without a concomitant change in BMI or prevalence of obesity [24,25]. To pre- vent obesity and to gain other health benefits, regular opportunities for enjoyable PA is a desirable and useful component of health promotion efforts. Family Meals As societal eating patterns have shifted, children and parents of the 21st century may not be eating family meals (FM) together at the dinner table as in previous generations [26]. Instead, individuals are likely eating alone or in more casual fashion, mindlessly snacking while watching television [27]. Eating alone and with the TV may be associated with higher speed of eating and greater caloric consumption [28]. Although FM appears to be an important modifiable determinant of nutritional intake and children’s weight status, few interventions have attempted to increase the frequency, or improve the quality of FM [29-31]. Potential barriers to bolster- ing FM include lack of time and skills needed to prepare food [32]. Settings to Influence Health Behaviors for Obesity Prevention According to a meta-analytic review, many obesity pre- vention interventions have not shown strong effective- ness [33]. Systematic reviews have been generally unsupportive of obesity prevention intervention effec- tiveness [34]. Interventions with larger effect sizes were brief, focused on weight control outcomes, and targeted younger children and adolescents. Some authors have argued for the necessity of including parents, but this approach has been difficult to achieve, and has led to limited success [35,8]. Many school-based interventions have failed to engage parents, or to achieve beneficial outcomes with this approach [24,36].