Impact of School-Based Interventions on Pediatric Obesity: A Systematic Review

Childhood obesity is a global public health problem with significant implications for the health and well-being of children. The prevalence of childhood obesity is increasing every decade, making it a recognized public health concern. This systematic review aims to explore and evaluate the impact of school-based interventions on reducing pediatric obesity among school-aged children. A systematic review of literature according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 was conducted. Google Scholar, PubMed, and Cochrane were the databases used. After screening for bias, inclusion and exclusion criteria, and quality, 27 studies were included in the systematic review, and data were synthesized. The results show that physical activity reduces obesity and improves cardiovascular health. The nutritional change reduces the risk of obesity more than physical activity alone. When blended, the two provide the most benefits for participants. Motivation, self-efficacy, and behavioral change could help maintain the improvements. Schools should adopt a blend of physical activity and nutritional change to reduce prevent, reduce, and manage obesity.


Introduction And Background
Childhood obesity is a significant health concern characterized by excess body weight in children and adolescents.Typically, childhood obesity occurs when a child or adolescent's weight exceeds the recommended range for their age and height, which in most instances is measured by using body mass index (BMI).A child is considered obese if they have a BMI higher than the 95th percentile [1].The prevalence of childhood obesity is increasing rapidly; in 2022, according to the Centers for Disease Control and Prevention (CDC), in the United States, the prevalence of childhood obesity between 2017 and 2020 was 19.7%, affecting about 14.7 million children and adolescents.Among two-to five-year-olds, the prevalence was 12.7%, 20.7% among six-to eleven-year-olds, and 22.2% among twelve-to nineteen-year-olds.Childhood obesity, like general obesity, affects different ethnicities differently, leading to healthcare inequality.In the United States, Hispanic children have the highest prevalence at 26.2%, followed by non-Hispanic Black at 24.8%, then non-Hispanic White at 16.6%, and then non-Hispanic Asian children at 9% [2].
There are several components that can lead to childhood obesity, such as lifestyle, social and genetic factors.First, a poor diet; consumption of food with high-calorie value, such as sugary snacks, fast food, and soft drinks, contributes to weight gain.Second, a sedentary lifestyle; lack of physical exercise means a greater difference between caloric intake and expenditure.Television, video games, and smartphone overengagement could predict childhood obesity because it reduces calorie expenditure and promotes inactivity.Third, genetic predisposition combined with environmental factors such as access to unhealthy foods and limited access to healthcare information and playgrounds [3].Finally, socio-economic factors where children from lower economic backgrounds are at greater risk because of limited access to healthcare, physical activity tools, and healthy foods.
The ramifications of childhood obesity can extend beyond the early years and have a lasting impact on the child's life through adolescence and adulthood.The individual may be prone to developing psychological issues.Children with obesity are often at risk of stigmatization, low self-esteem, depression, and an increased risk of eating disorders.Although a causal link has not been established, research articles cited by Sahoo et al. show that samples of obese children have higher eating disorder traits, depressive symptoms, anxiety, emotional problems, body dissatisfaction, and low self-esteem compared to the control who are the children with BMI with the normal range [3].Second, childhood obesity is associated with health issues.According to Balasundaram, obese children are at a higher risk of developing health complications, including type II diabetes, high blood pressure, heart diseases, sleep apnea, orthopedic problems, and asthma.These children are at risk of becoming obese adults at high risk for cardiovascular diseases and diabetes, major chronic diseases [1].
Due to the complexity of childhood obesity, effective interventions are needed at the school level to minimize the psychological and physical healthcare challenges these children persevere and to minimize the risk of developing chronic diseases at later stages of life.The United States loses $173 billion per year to obesity, $327 billion due to diabetes, and $217 billion due to cardiovascular diseases [4].The diseases also lead to loss of life and productivity, not to mention that it leads to psychological and financial strain for the families of affected individuals.Timely interventions for childhood obesity can offset the psychological and financial strain for all parties involved.
To this end, school-based interventions have gained considerable attention as a potential strategy for preventing and reducing pediatric obesity.Schools are extremely crucial because they shape children's behavior in the long term, and they increase access to the children creating a unique opportunity to promote healthy habits and lifestyles.As such, researchers have applied the appropriate interventions at schools and studied their effectiveness.
There is a gap in this research topic in that, to date, several studies have examined the impact of schoolbased interventions on pediatric obesity, but the findings have been inconsistent, and there is a need for a comprehensive synthesis of the available evidence.This systematic review aims to explore and evaluate the impact of school-based interventions on reducing pediatric obesity among school-aged children.The systematic review provides a narrative synthesis of the available evidence, examining the effectiveness of these interventions, exploring the research gaps, and reporting the potential of these interventions and how well they can be employed for the maximum benefit of obese children and other stakeholders.This paper is significant for the following parties.First, it will inform the policy-makers by proving them with some background information for decision-making.Second, it is a stepping stone for future researchers on the same topic and will shape community health providers' decision-making.

Database and Search Strategy
The systematic review was conducted based on the recommendations of the

TABLE 1: Keywords and MeSH terms used
MeSH: Medical Subject Headings

Inclusion Criteria
The articles included in the systematic review are randomized and non-randomized controlled trials (RCTs), cross-sectional and quasi-experimental studies, and clinical trials conducted primarily in the school-based setting.Participants included students aged six to eighteen years.The studies conducted obesity interventions and reported outcomes of BMI or body fat.The interventions reported health and nutrition education or physical activity promotion as the primary intervention.

Exclusion Criteria
All clinical trials were excluded if they were not published in English, the setting was not at school, did not report outcomes on BMI or body fat, or primarily discussed the cost-effectiveness of interventions.Google Scholar 16100.The duplicates were removed using the Endnote program, where nine records were removed.Automation tools marked 43199 records as ineligible for not being RCT, nRCTs, cross-sectional, and quasi-experimental studies clinical trials and 1009 records were removed after screening the titles based on the inclusion criteria.We screened 1248 records, and 1210 records were excluded.Of those, 38 records were sought to be retrieved, and all of them were found, and assessed for eligibility, where four were excluded since they are ongoing, two were excluded for using children younger than five years and not using BMI nor body fat as an outcome measure, two were literature reviews, two were not school-based, and one was published in 2017.The rest, 27, were included in a systematic review after being assessed for eligibility (Table 2).

Quality Assessment
The articles were screened independently according to the inclusion and exclusion criteria.To evaluate the methodological quality of the 27 individual studies, we employed the Critical Appraisal Skills Programme (CASP) checklist shown in Table 2.The CASP checklists allowed us to assess the risk of bias, validity, relevance, and applicability of the included studies.Additionally, to ensure transparent and comprehensive reporting of our systematic review, we followed the PRISMA guidelines.The PRISMA checklist guided us in reporting the necessary information, such as the study selection process, data extraction methods, and synthesis techniques.The combined use of CASP and PRISMA facilitated a rigorous evaluation of study quality and enhanced the transparency of this systematic review.

Data Extraction
The data were extracted from the articles and tabulated in Table 3 below.We organized it starting with the author, study design, and country.Second, age in years and sample size, intervention (i), and control (c), with there being multiple interventions in some articles.Third, the intervention characteristics, including the type and duration of the intervention and follow-up.Finally, the outcome measures include changes in BMI, body fat, or obesity.For data synthesis, the studies were grouped by the type of intervention and the outcome measured reported.

Encouraging Healthy Eating
Healthy eating is vital in preventing and managing obesity.A nutritious diet contributes to weight control, improves overall health, and reduces the risk of obesity-related complications.A healthy diet works by controlling the caloric intake, hence creating a caloric balance, provides essential nutrients that support overall health through weight management, helps in understanding the significance of portion sizes and therefore encourages healthy eating patterns and servings, reduces the intake of added sugar and processed food, not to mention it helps in the balance of macronutrients.In this systematic review, seventeen studies included nutrition, dietary change, and education.Fourteen of the seventeen studies recorded statistically significant results in at least one of the measures taken, including a reduction in waist size, reduction in the percentage of fat, reduced zBMI, or improved diet and nutritional knowledge.
Administering dietary change lessons with a follow-up, such as lessons on cooking or the provision of food, significantly reduces obesity.Arlinghaus et al. included 20% nutritional change education in their study and reported a significant decrease in zBMI [6], which was more significant at the end of the intervention, 12 months.Likewise, three studies featured dietary counseling [12,22,27], such as lessons in healthy eating, where Nickel et al. offered 21 lessons making this the priority compared to physical activity and self-efficacy [20].These studies reported a great reduction in waist circumference, BMI Z-score, percentage of fat mass, and improvements in dietary intake.
Nutritional knowledge helps foster personal responsibility vis-à-vis healthy eating.While diet programs can help the child reduce their anthropometric measures, they might lose effectiveness over time when not linked with nutritional knowledge.Nutritional knowledge helps children make informed decisions about their food intake and adopt healthier eating patterns.Education also helps in portion control and helps in reducing the excess calories that could be stored as fat by maintaining a balance between caloric intake and expenditure.This explains the favorable outcomes shown by lessons on dietary change [13,17,22].
While nutrition knowledge can be sufficient, some children need more tools and modeling, such as lessons on cooking, correct portions, and a balanced diet.To some, poverty can hinder practicing the changes highlighted during the lessons.Koo et al. offered nutritional education lessons and delivered whole-grain food daily for 12 weeks to fill this gap [17].It is worth noting that this was the only intervention offered in this program.This program yielded a reduced zBMI score, reduced body fat percentage, and reduced waist circumference, where each effect increased as time elapsed [17].Takacs et al. offered education and afterschool cooking classes, and as a result, while the control gained significant waist circumference in summer, this group reduced [26].However, this was the only significant change in anthropometric measures.Vieira et al. enhanced the consumption of vegetables, decreased sugary food, and consumption of high-fat and energy-dense food consumption, and reported decreased waist circumference [28].These programs might be more effective on children since, at times, they need modeling.It is also effective for children coming from poor backgrounds.
The systematic review also reveals that while not all nutrition interventions were statistically significant in the anthropometric measures, they all positively impacted the children in diverse ways.For example, Habib-Mourad et al. improved dietary change and reduced the risk of obesity, in the intervention group compared to the control group [13].Likewise, Ickovics et al. reported a healthier BMI trajectory as time elapsed and a decrease in the consumption of unhealthy foods [14].Kenney et al. reported that with the passage of the Healthy, Hunger-Free Kids Act the odds of obesity reduce by 9% annually for youth in poverty [16].Davis et al. and Landry et al. recorded more vegetable and dietary fiber intake [9,18].
These studies show that even when not statistically significant, nutritional interventions reduce the risk of obesity.Increasing vegetable and fruit intake with high fiber, essential nutrients, and low calories promotes satiety, provides vitamins, and helps manage caloric intake reducing the risk of obesity.Whole grains such as wheat, brown rice, oats, and quinoa boost the fiber and nutrient intake, which helps the children feel full for longer, reducing their yearning for food and the risk of obesity by extension [18].Water helps keep one hydrated and helps avoid caloric consumption through soft drinks [31].

Physical Activity Effect on Pediatric Obesity
Physical activity is crucial in the prevention and management of obesity.The conventional knowledge is that through moderated physical activity, there is an increase in energy expenditure, creating an energy deficit critical for weight loss.However, the importance of physical activity is more than an energy deficit.In this systematic review, seventeen studies included physical activity in practice or education.However, statistical significance when the anthropometric was achieved in only nine of them body fat and waist ratio, increased lean mass, and reduced BMI and zBMI measures [30,24,15].Most of them featured over forty-five minutes of physical activity.
The positive effects can be explained by the following.First, an increased expenditure allows the body to burn calories.Second, it increases metabolism during the intervention and afterward, making the body burn calories even when not exercising.Third, engaging in strength training exercises not only aids in reducing body fat but also plays a vital role in promoting the growth and preservation of lean muscle mass, emphasizing the significance of prioritizing muscle gain over fat loss.[24].Fourth, regular exercise regulates hunger hormones such as ghrelin and leptin, contributing to weight management.Further, it helps in maintaining weight loss and sustaining intermediate results.As such, despite the lower significance achievement rates, the importance of physical activity cannot be understated.
Five studies coupled physical activity with nutritional health lessons and attained significance.[6,12,20,22,28].The studies take longer than nine months, and the intensity of the physical exercises is comparable to those with physical exercise as an intervention only.As the studies show, coupling dietary change with exercise is more associated with significant results than physical activity in isolation.
Coupling dietary change with physical activity works for several reasons.First, while physical activity maximizes caloric expenditure, diet change ensures the deficit is not filled by more caloric intake.This favors weight loss.Second, a healthy diet is needed to maintain lean and muscle mass after exercise.Third, coupling physical activity and dietary change ensures the children do not overdo the diet.This is because physical activity reduces appetite to some extent.
The studies that featured non-intensive physical activity in terms of the session or the program length were more likely to have insignificant positive effects.[15,12,11,8].Obesity is more lethal when coupled with cardiovascular diseases, especially in the latter stages of life.These studies illustrate that physical activity significantly reduces this chance by increasing cardiovascular health [32].

Behavioral Change
There were only four studies that used behavioral modification as an intervention.None of the studies involved behavioral modification without additional intervention.Arlinghaus et al. and Vieira et al. were the only studies that included behavioral change and got significant results [6,28].However, it should be noted that behavioral change is hugely included in diet and physical activity modification which have been discussed in the earlier sections.Nonetheless, behavioral change as an intervention includes other strategies such as goal setting, where the children are shown how to create attainable goals and work toward them, problem-solving and coping mechanisms, where children are shown how to overcome adversity and challenges that could lead to unhealthy eating patterns and consequently obesity.Furthermore, children learn long-term maintenance of the behavioral change adopted in other programs and learn how to engage with a supportive social network and self-monitor.As such, the importance of behavioral change in this systematic review cannot be established.However, behavioral change could help reduce the emotional, psychological, and environmental factors that are likely to lead to an eating disorder.Moreover, after achieving intermediate positive results, behavioral change lessons such as goal setting, self-monitoring, and long-term maintenance could be critical in sustaining them.

Motivation and Self Efficacy
Self-efficacy and motivation are key factors in mediating behavioral change through physical activity, dietary change, long-term maintenance of the change, problem-solving, and self-monitoring.In the systematic review, four studies focused on this aspect.Freira et al. recorded significant changes in BMI zscore, abdominal circumference, fat mass reduction, and increase in the percentage of muscular mass [12].Nickel et al. found favorable results in reducing waist circumference [20].Waters et al. did not find significant results but observed improvements in healthy eating [31].Finally, Sundgot-Borgen et al. found that girls were likelier to have a positive body image which is critical in their psychosocial health.By using the Healthy Body Image intervention female students were more likely to have a positive body image leading to body acceptance which may transform into better psychological well-being.Positive correlations with measures of body esteem were found to be negatively associated with objectified body consciousness, eating problems, alexithymia, and depression [25].
External factors such as rewards, recognition, or support from others influence motivation.For example, participating in a weight loss program, joining a support group, or receiving praise and encouragement from loved ones can boost motivation and help individuals stay on track with their weight management efforts.
On the other hand, self-efficacy can be built through successful experiences, modeling, verbal persuasion, and managing emotional and physiological states.Setting realistic goals, breaking them down into smaller achievable steps, and celebrating small victories can enhance self-efficacy and boost confidence in children's ability to address obesity effectively.By fostering motivation and building self-efficacy, individuals are more likely to engage in and sustain the behavior changes necessary for addressing obesity.

Limitations and suggestions
Despite the valuable insights provided by this systematic review, there are several limitations that need to be acknowledged.First, the included studies varied in terms of design, sample size, duration of intervention, and outcome measures, which may introduce heterogeneity and limit the generalizability of the findings.The lack of standardization across studies makes it difficult to directly compare the results and draw definitive conclusions.There is a need for standardized protocols and outcome measures across studies to facilitate comparability and enhance the strength of evidence.Researchers should consider using validated tools and guidelines, such as the WHO's Health Promoting Schools framework, to ensure consistency and improve the quality of research in this field.Second, the majority of the studies relied on self-reported data, which may be subject to recall bias and social desirability bias.Participants might overestimate their level of physical activity or underestimate their dietary intake, leading to inaccurate measurements.

Conclusions
We established that nutritional change through education alone or through education coupled with further action, such as lessons on cooking or provision of food, is the most effective strategy when each intervention is taken alone.It is followed by physical activity that exceeds forty minutes for over nine months.Conventional wisdom supports behavioral change, motivation, and self-efficacy, but the evidence from the systematic review fails to support them in isolation.However, each of them shows some effectiveness when coupled with other interventions such as dietary change or physical activity.The intervention blend with the highest likelihood of influencing obesity measures is coupling physical activity and nutritional change education.These findings have implications for various stakeholders, including policy-makers, school administrators, community health officials, and parents among others.This paper recommends the adoption of a blend of physical activity and nutritional change in schools.The intervention must take longer than a year to determine its effectiveness with regard to obesity.
Future work on this topic should focus on addressing the effect of physical activity on children's mental health.While it is known that imposed physical activity takes a mental toll on children, none of these studies directly addressed it or the children's perception of physical activity in the latter stages of life.A longitudinal study on this topic could be informative.Further, more studies across populations and regions are needed to confirm the finding that coupling physical activity with dietary change has the highest level of significance.In conclusion, while school-based interventions show promise in reducing pediatric obesity, there are limitations that need to be addressed to enhance the quality and effectiveness of these interventions.By addressing the identified limitations and implementing the suggested strategies, future research and interventions can contribute to the development of evidence-based approaches to combat pediatric obesity and improve the health and well-being of children.

Figure 1
Figure1displays the PRISMA flow diagram.The articles found in PubMed were 46, Cochrane 29614, and Google Scholar 16100.The duplicates were removed using the Endnote program, where nine records were removed.Automation tools marked 43199 records as ineligible for not being RCT, nRCTs, cross-sectional, and quasi-experimental studies clinical trials and 1009 records were removed after screening the titles based on the inclusion criteria.We screened 1248 records, and 1210 records were excluded.Of those, 38 records were sought to be retrieved, and all of them were found, and assessed for eligibility, where four were excluded since they are ongoing, two were excluded for using children younger than five years and not using BMI nor body fat as an outcome measure, two were literature reviews, two were not school-based, and one was published in 2017.The rest, 27, were included in a systematic review after being assessed for eligibility (Table2).

FIGURE 1 :
FIGURE 1: PRISMA flow diagram for the search process lower BMI Score in the intervention arm compared to the control.(mean difference −0.075 (95% confidence interval −0.183 to 0.033, P=0.18) at 15 months.At 30 months, Lower BMI Score, Insignificant −0.137 to 0.083, p=0.63).No statistically significant difference between the groups for other anthropometric, dietary, week (n = 59) Three days per week (n = 58) Five days per week (n = 63) Zero days c(n = 63) Established efficacy zero (control), one, three, or five days per week (equating to 0, 40, 120, or 200 min of contact each week) 80% of intervention time on physical activity and 20% to nutritionby time interaction was observed ((F = 9.42, P < .001).Receiving intervention 2/3 times per week significantly decreased zBMI than control (−0.19 zBMI units/y; 95% CI, −0.28 to −0.11; and −0.18 zBMI units/y; 95% CI, −0.27 to −0.10, both P < .001)Bagherniya et al. [7] RCT Iran 12-16 (Females) i(n = 104) c(n = 98) Sessions of sport (each session 90 min) were held twice a week (60 sessions in 7 months) delivered by a specialist in physical education and sport workshops and interactive seminars twice a month for Seven months 3.5 months & seven months BMI The subject's mean BMI and Waist circumference was reduced in the intervention group from 29.47 (4.05) kg/m2 to 28.5 (4.35) kg/m2 and 89.65 (8.15) cm to 86.54 (9.76) cm.However, the changes were not statistically significant (p=0.127 and 2023 Klein et al.Cureus 15(8): e43153.DOI 10.7759/cureus.SH) project, which aims to promoting physical activity and an active lifestyle through rope skipping during childhood; with a one-time 90-min Basic-Workshop and the subsequent Champion-Program with ten 45-min rope skipping lessons Three years Three years BMI, body fat Standard deviation of BMI and systolic blood pressure decreased insignificantly while the motor performance, physical fitness, subjective physical activity and screen-based media use increased.In all p>0.05 Davis et al. change in BMI in the intervention group (−2.4 ± 0.6 kg/m2) than the control group.The same is true for waist circumference, waist-to-height ratio, and physic fitness.Further, obesity decrease was significant, i.e., 17% Dias et al. , n = 15) i(MICT, n = 15) c(n = 15).3groups: high-intensity interval training (HIIT), moderate-intensity continuous training (MICT)significant reduction for obesity risk for children in poverty where the policy reduced the expected prevalence of obesity among children living in poverty in 2023 Klein et al.Cureus 15(8): e43153.DOI 10.7759/cureus.12;95% CI: −0.21, −0.03; p = 0.009), body fat percentage (weighted difference: −2.6%; 95% CI: −3.7, −1.5; p < 0.001) and waist circumference (weighted difference: −2.4 cm; 95% CI: −3.8, −1.0; p = 0.001) than the control group.Time was a factor since the body fat percentage and waist circumference was lower at three months Landry et al. (−0.1 vs. −0.04,respectively; p=0.01) and WC (−1.2 vs. 0.1cm; p<0.001).Fewer had the metabolic syndrome (MetSyn) after the intervention than before, while controls with MetSyn increased.Increase in cooking behaviors significantly predicted increase in fiber intake (p=0.004) and increase in vegetable intake (p=0.03).Increase in gardening behavior was highly associated with dietary fiber intake (No differences were found for BMI in the effect of the intervention between the IG and the CG.Children in the intervention group had significantly better healthy habits regarding physical activity(16.2%IG vs. 11.9%CG; p = 0.012) and nutrition lobal score (63.9% IG vs. 58.5% CG; p = 0.025).The trend loses significance at three years but continues to be positive Systolic blood pressure reduced 2023 Klein et al.Cureus 15(8): e43153.DOI 10.7759/cureus.significantchanges in the BMI score in the intervention group.However, they were more likely to consume more daily fruit serves and water and less likely to have fruit cordial Future studies should consider using objective measures, such as accelerometers or dietary logs, to obtain more reliable data.Third, the duration of the interventions varied widely, ranging from a few weeks to several months.Short-term interventions may not fully capture the long-term effects of school-based interventions on pediatric obesity.Longer follow-up periods are needed to assess the sustainability of the interventions and their impact on obesity prevention and management over time.Tracking participants' progress beyond the intervention period can provide valuable insights into the maintenance of healthy habits and inform strategies for long-term weight management.Fourth, the studies included in the review focused primarily on physical activity and nutritional change as interventions.While these two components are essential, other factors such as psychological and social determinants of behavior change were not adequately addressed.Future research should explore the incorporation of behavioral change strategies, such as goal setting, problem-solving, and social support, to enhance the effectiveness of school-based interventions.Lastly, future research should explore the potential benefits of involving multiple stakeholders, including parents, teachers, and healthcare professionals, in the design and implementation of school-based interventions.Collaboration among these key stakeholders can create a supportive environment for behavior change and promote a comprehensive approach to pediatric obesity prevention and management.

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Article title Author Type of study Quality assessment tool used Quality score
"FIFA 11 for Health" for Europe in the Faroe Islands: Effects on health markers and physical fitness in 10-to 12-year-old schoolchildren Effectiveness of the "Planning Health in School" Programme on Children's Nutritional Status Vieira et al. [28] Non-RCT CASP 12/12 100% Effectiveness of national multicentric school-based health lifestyles 2023 Klein et al.Cureus 15(8): e43153.DOI 10.7759/cureus.431535 of 14 intervention among Chinese children and adolescents on knowledge, belief, and practice toward obesity at individual, family and schools' levels.Wang X et al. [29] RCT CASP 10/12 92%Childhood obesity prevention through a community-based cluster randomized controlled physical activity intervention among schools in China: the health legacy project of the 2nd world summer youth Olympic Games (YOG-Obesity study).Cluster randomised trial of a school-community child health promotion and obesity prevention intervention: findings from the evaluation of fun 'n healthy in Moreland!

TABLE 2 : Critical appraisal for included studies
RCT: randomized controlled trial, CASP: Critical Appraisal Skills Programme

TABLE 3 : Study description and results
RCT: randomized control trial, BMI: body mass index, i: intervention group, c: control group, HIIT: high-intensity interval training, MICT: moderate-intensity continuous training, PA: physical activity 2023 Klein et al.Cureus 15(8): e43153.DOI 10.7759/cureus.43153 [10]cluding studies that incorporated nutritional interventions, only four studies reached statistical significance.Positive effects for physical activity were closely associated with higher than four months of physical activity and moderate to intensive physical exercise.Four studies attained statistical significance without including dietary changes.Di Maglie et al. found a statistically significant reduction in BMI, waist circumference, waist-to-height ratio, and physical fitness for those who had forty minutes of physical training five-six days a week for six months[10].Wanget al., Skoradal et al., and Isensee et al. all reported improved anthropometric measures such as reduced decreased Arlinghaus et al., Freira et al., Nickel et al., Ramírez-Rivera et al., and Vieira et al. found statistically significant results [5,7,8,23]., Bagherniya et al., Baumgartner et al., and Sánchez-Martínez et al. all feature sessions shorter than forty minutes or programs shorter than nine months, light exercises or all[5,7,8,23].This points toward the argument that the length of the exercise sessions and the program influences the effectiveness of an obesity program.There is a need for research testing this hypothesis since none of the studies answers the question.Another observation was made for physical activity.Physical activation was the only intervention that was associated with improved cardiac health, including diastolic and systolic blood pressure and cardiorespiratory fitness.Isensee et al., Freira et al., Dias et al., and Baumgartner et al. all reported significant improvements in cardiovascular health