Designer Schools: The Role of School Space and Architecture in Obesity Prevention

This article discusses the link between school space and architecture and obesity prevention by reviewing and synthesizing available literature in architecture, environmental psychology, and obesity research, in an effort to propose promising ideas for school space design and redesign. The article proposes design strategies aimed at promoting physical activity and healthful eating, with particular emphasis on the design of cafeterias, activity spaces, connectivity with the larger community, and student health centers.

Perspective
Designer Schools: The Role of School Space
and Architecture in Obesity Prevention
Nicholas Gorman,* Jeffery A. Lackney,† Kimberly Rollings,‡ and Terry T.-K. Huang§
Abstract
GORMAN, NICHOLAS, JEFFERY A. LACKNEY,
KIMBERLY ROLLINGS, AND TERRY T.-K. HUANG.
Designer schools: the role of school space and architecture
in obesity prevention. Obesity. 2007;15:2521–2530.
Spatial features of obesogenic environments studied on a
broad community level have been associated with childhood
overweight and obesity, but little research has focused on
the effects of the design of micro spaces, such as schools, on
individual health behaviors. This article aims to generate
thinking and research on the link between school space and
architecture and obesity prevention by reviewing and syn-
thesizing available literature in architecture, environmental
psychology, and obesity research, in an effort to propose
promising ideas for school space design and redesign. The
school environment is defined through 5 dimensions: phys-
ical, legal, policy, social, and cultural domains. Theories
underlying environmental interventions and documented as-
sociations between the environment and health behaviors
and outcomes are reviewed to illustrate how existing envi-
ronmental research could translate to obesity prevention.
Design strategies aimed at promoting physical activity and
healthful eating are proposed, with particular emphasis on
the design of cafeterias, activity spaces, connectivity with
the larger community, and student health centers.
Key words: childhood obesity, environmental factors,
prevention, public health, energy balance
Introduction
Efforts to identify factors contributing to rising obesity
rates in the United States and beyond have implicated the
burgeoning obesogenic environment as a key determinant of
obesity-related health behaviors (1). Given the potential for
long-term individual benefit and large population-level im-
pact, prevention among school-age children has become
critical (2). In today’s society, schools are no exceptions:
exposure to laborsaving technologies and access to un-
healthful foods abound. Walks or bike rides to schools are
increasingly displaced by car rides, as convenience and
safety concerns prevail (3–5). Once at school, students have
ready access to fast food and vending machines due to
partnerships meant to offset school budget shortcomings
(4,6,7). The lack of time, funding, access, and planning and
increased competition with various academic demands have
also reduced in-school opportunities for physical activity
and healthful eating (2,6). The combination of these and
other factors have resulted in an environment that steers
health behaviors away from physical activity and healthful
diets (2,8).
The role of school space design and redesign in obesity
prevention is an area that merits consideration, as school
sites have served as promising venues for both research and
intervention efforts (9). School-based obesity interventions
have demonstrated encouraging but often modest short-term
results (10 –13), an observation that underscores the need
for new directions in school-based prevention efforts. Al-
though the research community has begun studying the role
of the larger environment on children’s diets and physical
activity, little research has focused on the intersection of
school architecture and design and individual health behav-
iors within schools. Previous work on school designs, in-
tended to influence outcomes such as attention or scholastic
performance, documents the profound impact physical
space can have on student behavior and development, pro-
viding much insight into how school space might be de-
signed or redesigned to prevent obesity (14).
Received for review November 14, 2006.
Accepted in final form March 12, 2007.
The costs of publication of this article were defrayed, in part, by the payment of page
charges. This article must, therefore, be hereby marked “advertisement” in accordance with
18 U.S.C. Section 1734 solely to indicate this fact.
*Institute of Health Promotion and Disease Prevention Research, Department of Preventive
Medicine, Keck School of Medicine, University of Southern California, Los Angeles,
California; †Department of Engineering Professional Development, College of Engineering,
and Department of Interior Design, School of Human Ecology, University of Wisconsin,
Madison, Wisconsin; ‡School of Architecture and Urban Planning, University of Wisconsin,
Milwaukee, Wisconsin; and §Endocrinology, Nutrition, and Growth Branch, Center for
Research for Mothers and Children, National Institute of Child Health and Human Devel-
opment, National Institutes of Health, Bethesda, Maryland.
Address correspondence to Terry T.-K. Huang, Pediatric Obesity and Metabolic Syndrome,
National Institute of Child Health and Human Development, 6100 Executive Boulevard,
4B11, Rockville, MD 20852.
Contents of this publication do not necessarily reflect the views or policies of the National
Institutes of Health.
E-mail: [e-mail]
Copyright © 2007 NAASO
OBESITY Vol. 15 No. 11 November 20072521

Directing built environmental efforts into the school set-
ting has the benefit of ensuring both sustained contact with
target populations and access to large segments of youth (6).
Indeed, both the number of hours spent in school each year
and total enrollment are on the rise, while drop-out rates
have declined since 1972 (15). In addition, a significant
portion of students stay on campus after classes; recent
surveys suggest that almost 1 in 5 students in grades K-8
engage in campus-based after-school activities (16). Simi-
larly, studies suggest that anywhere from 19% to 50% of
students’ daily food intake occurs at school (6). The case for
environmental interventions within schools is further sup-
ported by precedent; plans for novel school design and the
redesign of existing spaces have been proposed and imple-
mented to influence everything from academic performance
to toxic environmental exposures (14). The goal of this
paper is to generate thinking and research on similar obesity
prevention interventions by reviewing and synthesizing
available literature in architecture, environmental psychol-
ogy, and obesity research in an effort to propose promising
ideas for school space design and redesign.
The scope of the current paper focuses on feasible micro-
level school design and redesign to promote healthful phys-
ical activity and diets. In our discussions on school design,
one distinction should be drawn to distinguish between
micro- and macro-level environments. The behaviors that
take place in any school system are likely to be moderated
by the broader macro-environment. Examples of macro-
level changes include efforts to promote walking and bicy-
cling to and from school through healthful urban planning.
Geographic information system mapping technologies have
allowed for the construction of detailed environmental maps
that may prove useful in investigating the impact of macro-
level factors, such as the location and density of fast food
restaurants in a given community. Details on these macro-
environmental investigations can be found elsewhere (5). In
the current article, we discuss the larger built environment
only in terms of optimizing the connectivity of schools with
their exterior community context.
Defining School Spaces
It has been previously suggested that, for public health
practices, the built environment may be conceptualized as
containing 3 sub-domains, the physical, legal, and policy
environments, each of which may operate on multiple levels
to discourage or facilitate any given health behavior (5). For
example, students’ meal choices at school could be viewed
as the result of these forces. In this case, the legal environ-
ment would include regulations regarding the nutritional
content of foods sold on campus. Meals provided as part of
the National School Lunch Program, for instance, are held
to federal nutrition standards, while competing foods are not
(6). In addition, the decision of which foods to eat could be
affected by physical environment factors such as ease of
access to competing foods. Are these foods available
through vending machines, cafeterias, or student stores?
Furthermore, school policies, such as the amount of time
allocated for lunch, may also influence children’s decisions.
In many cases, the influences of these domains interact,
further strengthening their impact on health behaviors. For
instance, in situations where cafeteria designs are inefficient
or insufficient to handle growing enrollment rates, shorter
lunch periods could be especially likely to steer children
away from more nutritious cafeteria meals.
While these 3 domains provide the beginnings of a frame-
work for public health researchers to describe environ-
ments, expanding on previous conceptualization to also
include social and cultural domains, both critical compo-
nents of the school environment, may be important. One
field of study within environmental psychology that ad-
dresses the impact of space on social domains is proxemics,
the study of how physical space passively influences and is
actively used in social interactions. Proposed by Edward T.
Hall in the 1960s (17), the study of proxemics grew from the
concept of territoriality and revolves around measuring the
distance maintained between individuals. Hall maintained
that the distance between 2 or more people could be defined
as intimate, personal, social, or public, and that each dis-
tance would have implications that could influence social
behaviors. Such behaviors, in turn, may have ramifications
for health outcomes worth considering during school design
and redesign efforts.
The environmental psychology literature has long recog-
nized the transactional relationship between social life and
the built environment (18). Within the school environment
literature, this transactional nature between social and phys-
ical environments became clear during the 1970s when new
school designs featured open-space planning that diverged
from traditional teaching methods (19 –21). The spatial def-
inition of learning spaces, especially reading nooks, has
been shown, for example, to improve children’s reading
behavior (22).
The impact of class layouts on both children’s and teach-
ers’ behaviors is attributable to more than simply wall
placement (23). Spatiality and proxemics acknowledge that
occupants of space take an active role in constructing the
meanings of that space, which, in turn, may influence be-
haviors (19). The influence of a given school space on
behavior may be markedly different throughout a typical
school day. In a classroom, for instance, although physical
characteristics of the classroom remain constant, its influ-
ence on behaviors may vary throughout the day based on
factors such as the subject being taught, the teacher, student
age, or group dynamics, among other factors (21).
It is important to note that these concepts extend beyond
the classroom as well. The entire school grounds deserve
consideration in the design or redesign of school space, as
they also pose constantly reinterpreted barriers and facilita-
School Design and Obesity Prevention, Gorman et al.
2522 OBESITY Vol. 15 No. 11 November 2007

tors to health-related behaviors. In the example of physical
education (PE) 1 classes, static spaces are sometimes trans-
formed daily to accomplish various goals with different
student populations. Should a single large space be used to
conduct group sports emphasizing teamwork, or should a
variety of smaller spaces be used to offer a greater diversity
of activities? The answer to this and other questions requires
consideration of the intersection between the PE environ-
ment and the changing needs of the different student groups
using it.
Theories of Environmental Intervention
Many current theories may be adapted to describe the
relationship between environmental factors and health be-
haviors. As noted by Gordon-Larsen and Reynolds (5), such
adaptations have included elements drawn from the pre-
cede-proceed model, system theory, social ecology, and
social cognitive theory. Similarly, other fields of study,
including motivation theory, environmental psychology,
and efforts to influence health norms may bear implications
for environment-based health behavior interventions. The
common theme underlying these theories is their ability to
be applied across diverse facets composing the school en-
vironment. For example, examining social ecological the-
ory, the most frequently adopted underlying framework for
environmental interventions, reveals how its flexibility suits
a number of environmental studies (5). First, social ecolog-
ical models of health typically approach several contributors
to health behavior decisions, including factors unique to the
individual, factors external to the individual, and an inter-
action between the two (24). Gordon-Larsen and Reynolds
(5) note that the proposed external environmental factors
vary across studies, but this flexibility has allowed research-
ers to test hypotheses on a wide range of environmental
facets encompassing the interpersonal, social, cultural, and
physical domains (25–27).
One example of such a theory in application may be seen
in a recent school-based fitness intervention targeting eighth
grade girls in an effort to increase PE participation (28).
Social cognitive theory was used to derive a social ecolog-
ical model for intervention. Not only were students offered
a variety of gender-specific PE options, but their choices
were further broadened to include competitive and non-
competitive activities. In addition, the intervention ad-
dressed several environmental facets by promoting im-
proved faculty role-modeling, involving school nurses, and
extending activities off campus to promote community and
parental involvement.
That a single, integrative theory for interventions
grounded in environmental design and redesign has yet to
emerge underscores the importance of continuing collabo-
ration. Successful school-based environmental interventions
for obesity are likely to require the participation of archi-
tects, psychologists, health behavior researchers, students,
and other stakeholders, each of whom will bring a unique
perspective and explicit or implicit theoretical model to the
table.
Environment, Health, and Obesity
A growing body of literature documents the effects of the
environment on health behaviors and outcomes (14). As
obesity is frequently marked by comorbidity with other
physical and mental health problems, consideration of sev-
eral environmental factors will be vital in school design and
redesign efforts. In this section, we discuss the wide range
of pertinent environmental factors. We then illustrate how
previous environmental research can impact or be translated
to obesity prevention by exploring the case of air pollution
in further depth.
Range of Environmental Factors. An increasing number
of environmental factors, such as air quality, acoustics,
climate control, crowding, ergonomics, and lighting, may be
implicated in activity patterns, stress, and/or appetite and
food choices, all relevant facets of overweight and obesity.
The relationship between exposure to these factors and the
subsequent development of unhealthful behaviors is, in
many cases, multifactorial and complex. For instance, ex-
posure to high levels of noise not only affects scholastic
measures, such as attention, but has also been linked to
heightened blood pressure and stress, which may, in turn,
influence health behaviors and outcomes (14).
These facets of the environment, while not appearing
directly relevant to obesity prevention at first thought,
could, indeed, interfere with school-based obesity interven-
tions. For example, the effect of an intervention focused on
improving PE spaces may be moderated by factors such as
air quality. If school or PE attendance were to decrease due
to respiratory complications, then the success of any phys-
ical activity program could be limited.
Case of Air Quality. School air quality may indirectly
influence health behaviors relevant to overweight and obe-
sity. Respiratory infection, allergy, and absenteeism rates
have been shown to rise with increasing exposure to air-
borne allergens, such as those introduced through heating
and ventilation systems, cleaning chemicals, caulks and
sealants used to insulate buildings, and other building ma-
terials at school sites (14,29). Outdoor air pollution levels
have also been linked to absenteeism, exacerbation of pre-
existing asthmatic conditions, and a rising incidence of new
asthma cases (30,31).
The exacerbation of asthma is of special concern because
in the absence of carefully tailored asthma management
programs, asthmatic students may be less likely to partici-
pate in physical activity (32). In addition to their impact on
asthma rates, indoor and outdoor air quality levels can also1 Nonstandard abbreviation: PE, physical education.
School Design and Obesity Prevention, Gorman et al.
OBESITY Vol. 15 No. 11 November 20072523

bleacher seating
Playfields
running
track
open field for frisbee
and other informal sports
Playfields designed to allow for multiple sporting
opportunities both formal and recreational
(soccer, football, field hockey, etc.)
nature path &
running circuit
nature path &
running circuit
nature path &
running circuit
large breakout space from gymnasium to allow
for outdoor sporting in good weather
provide areas for observation
of physical activity and places
to rest in between activities
Gymnasium
Outdoor
Hardcourts
racket
sports
Beach Volleyball
Cafe & Juice Bar
views to activity
outdoor
seating
Dance
Studio views to
physical
activity
Yoga &
Meditation
Exercise
Bikes
Weight
Room
Design for physical fitness such that students and
community have an abundance of fitness choices.
Figure 1: An example of redesigned physical fitness grounds. The inclusion of facilities that support both competitive/group sports (e.g.,
gymnasium, courts, and play field) and non-competitive/individual physical activities (e.g., weight room, dance studio, and nature paths)
accommodates multiple forms of physical activity. In addition, flexible studio spaces (e.g., yoga and dance) and specialized facilities (e.g.,
tennis courts) may supplement community resources and foster facility-sharing efforts between schools and their community. Paths that
run beyond traditional school grounds also enhance physical activity opportunities and connectivity with the larger community.
School Design and Obesity Prevention, Gorman et al.
2524 OBESITY Vol. 15 No. 11 November 2007

impact school policies regarding PE. For instance, a Cali-
fornia statewide policy bans certain forms of athletic train-
ing during very unhealthful air conditions (33), and Sacra-
mento regional schools have been urged to reduce or
eliminate outdoor PE classes when ground-level ozone lev-
els reach the Unhealthy for Sensitive Groups category of the
U.S. Environmental Protection Agency’s Air Quality Index
(34,35). The result is that poor indoor and outdoor air
quality may limit the motivation or opportunities for phys-
ical activity.
Indoor air quality may be improved by increasing fresh
air ventilation in some areas, implementing air cleaning
technologies, and ensuring that air conditioning and heating
systems are serviced regularly (14,29). Similarly, indoor
facilities may be used to promote activity when the outdoor
air quality reaches unhealthful levels.
Innovative Elements of School Design and
Redesign
Physical Activity. Efforts to increase physical activity at
schools may begin with designs that augment traditional
recreational spaces (Figure 1). One opportunity to encour-
age unstructured physical activity during recess is the cre-
ation of transitional spaces. Providing weather-protected
spaces, such as porches, overhangs, or covered courts on the
borders of indoor and outdoor spaces, can provide unique
areas for physical activity that may be utilized by students
who normally avoid activity on fields, basketball courts, and
similar outdoor playgrounds. In addition, such spaces en-
able physical activity during unfavorable weather condi-
tions (29).
Existing outdoor spaces may be designed to facilitate
both group and individual activities. While large, unstruc-
tured spaces such as fields facilitate cooperative team play,
they may provide little support for individual and small
group activities. One way to address this concern is to
define small, resource-rich activity pockets within larger
spaces. Playground redesigns of this nature are not unprec-
edented; indeed, the Environmental Yard, a playground that
was redesigned in Berkeley, CA in the early 1970s, fol-
lowed this approach and has subsequently become an
award-winning facility and grounds for subsequent research
into children’s activity patterns (36). The introduction of a
broad spectrum of spaces, including spaces for personal or
small group play, may serve to promote physical activity
among students who would have otherwise underutilized
large, unstructured spaces.
Several approaches may be taken to redesign existing
spaces. For example, walking or nature trails may be used to
divide or encircle undifferentiated outdoor spaces. Such
paths can also serve as a means to connect smaller play
environments designed to accommodate various levels of
development. Examples of resource-rich, small activity cen-
ters could include small outdoor auditoriums, ponds, or
exploratoriums. The underlying theme is that each provides
a clear context for small group games and fills an activity
niche that may not be supported by larger spaces. The
addition of signage and instructions at each activity center
may further supplement the space by removing knowledge
barriers to using unfamiliar equipment and by providing
guidelines to help influence health norms. Borrowing from
the transitional space concept, such environments should
make use of a combination of natural and built shelters to
ensure that resources are accessible regardless of the season
and weather (29).
One specific small, resource-rich activity center merits
further discussion. The creation of school gardening pro-
grams offers unique learning opportunities. For instance,
programs such as the Pennsylvania-based Urban Nutrition
Initiative illustrate the potential of such garden programs
not only as a means of encouraging physical activity and
healthful eating, but also as a means of encouraging com-
munity partnerships with groups such as local farmers mar-
kets (37). By integrating fruit and vegetable gardens into
existing academic or PE programs, students are given the
chance to explore a physical activity outlet that does not
emphasize physical competition and evaluation. Further-
more, collaborations with off-campus organizations may
serve to defray costs if the partner is able to provide man-
power, planning, equipment, or direct financial support.
Within schools, integrating gardening activities with ed-
ucation on produce and food preparation may encourage
students to eat healthier and may remove barriers to prepar-
ing fruits and vegetables. In a California-based study of
fourth graders’ nutritional knowledge and dietary prefer-
ences, researchers found that students who received nutri-
tion education and participated in school garden programs
not only showed demonstrably higher levels of nutrition
education than did controls but also expressed new food
preferences attributable to their garden exposure (6).
Current research being conducted by the Mayo Clinic’s
Active Life research team seeks to illustrate the potential of
innovative designs within classrooms as well. By incorpo-
rating features such as personal electronics, “standing”
desks that encourage students to stand while working, and
other innovations into their school of the future, researchers
hope to increase the amount of physical activity children
engage in during the course of typical daily activities (38).
Previous research on this form of activity, coined “non-
exercise activity thermogenesis,” suggests that these behav-
iors may serve as a protective factor against the develop-
ment of overweight or obesity (39).
Another relatively simple design involves improvements
to stairwells. In one worksite study, stairwells were system-
atically improved through the sequential addition of carpet-
ing, artwork, signage, and, finally, music. The placement of
signs encouraging stair use resulted in significantly greater
School Design and Obesity Prevention, Gorman et al.
OBESITY Vol. 15 No. 11 November 20072525

foot traffic over a 3-month period after the sign posting.
Similarly, playing music in stairwells was also found to
increase foot travel during the subsequent 3 months (40).
Within the school setting, stairwell improvements may be
most relevant to multi-storied buildings used in urban
schools. Stairwell improvements may serve not only to
increase foot traffic, but also to provide a venue for posting
motivational or educational advertising. Moreover, although
widescale stairwell foot traffic may be restricted to break
periods, emerging research suggests that even relatively
modest increases in physical activity incorporated into ev-
eryday life could show promise for obesity prevention (41).
Recreational space designs may be used to benefit struc-
tured PE courses as well. Even small changes to PE curric-
ulum have been shown to result in measurable changes in
cardiovascular fitness and body composition (8). The cre-
ation of diverse outdoor spaces capable of accommodating
both large and small group activities may allow schools to
offer a greater variety of PE activities and allow students to
choose activities that suit them best. Providing opportunities
for a variety of team-based competitive sports and small
group, non-competitive activities should remove barriers to
physical activity for those who are disinterested in or fear
the evaluation and competition of organized sports. Provid-
ing multiple activity options also allows for creating tar-
geted programs. For instance, one study found that provid-
ing gender-tailored physical fitness options to high school
girls resulted in higher levels of daily physical activity (28).
One final consideration for designs to promote physical
activity is the possibility of opening school resources to the
surrounding community. Sharing facilities, such as pools,
gymnasiums, and other physical activity grounds, with the
surrounding community may accomplish several goals in
the right setting. First, by sharing facilities, schools may be
able to share the cost of both the creation and maintenance
of their physical activity centers. With increasing pressure
placed on limited school funding, seeking out external fi-
nancial support for physical activity programs and facilities
will likely be vital for the implementation of many health-
promoting designs and redesigns. In addition, partnering
with community organizations increases the connectivity of
schools with their neighborhoods. The benefits of close
connections between the school and the community in
which it lies are manifold and could include partnerships or
reciprocity granting students access to off-campus physical
activity opportunities that could not otherwise be supported
on campus.
Diet. School design and redesign may be a promising
approach to encourage healthful eating at school. In many
schools, the cafeteria may serve as the primary source for
promoting healthy diets because of the high participation
rate of schools in the National School Lunch Program,
which should ensure the availability of nutritious meals.
Given the importance of school cafeterias, they may be
designed to compete more effectively with vending ma-
chines, student stores, and off-campus fast food restaurants.
In addition, traditional cafeteria spaces may be redesigned
to take advantage of nutrition education opportunities
through the introduction of commercial teaching kitchens
and demonstration areas (Figure 2).
In practice, many cafeterias also offer competing foods
that are not held to federal nutrition guidelines (6). Simi-
larly, not all competing food sources need to be considered
categorically bad; some schools have begun offering health-
ful snacks through vending machines in place of, or in
competition with, traditional junk foods (6,42). The follow-
ing design ideas may be tested in future research and should
be considered in concert with individual school dietary
environments. Such design efforts are also likely to be most
effective when paired with school policies that promote
healthful eating, such as providing nutrition education, of-
fering healthful and appealing alternatives to junk foods,
restricting on-campus junk food sales, implementing pricing
incentives, encouraging faculty and food service staff to
serve as positive role models and provide social support,
and conducting obesity screening efforts through school
health services (6,42,43).
One of the first factors to consider in promoting healthful
eating through school design should be not only the avail-
ability of healthful foods at cafeterias, but also the quality of
such options. The preparation and presentation of healthful
food options are a vital consideration for any environmental
intervention, as motivational and educational messages will
be effective only if viable, esthetically and gastronomically
pleasing healthful options are available to students. Increas-
ing the proportion of low-fat foods available in school
cafeterias has been shown to improve students’ meal
choices, even in the absence of supplemental classroom or
home-based interventions (43). Similarly, providing attrac-
tive produce and opportunities to try new foods used as part
of a larger dietary promotion campaign has been shown to
increase students’ fruit consumption (44).
The lunchtime school environment is one typically teem-
ing with competing food vendors. One of the simplest ways
to promote the use of cafeteria facilities may be to control
the location and density of competing food resources. For
instance, vending machines are often placed in close prox-
imity to school cafeterias, encouraging their use as an al-
ternative to school meals (6). One approach to reducing
lunchtime use of vending machines is to locate such ma-
chines away from cafeteria sites, lunch seating, or routes to
the cafeteria. If a school sells sports drinks through a vend-
ing machine, they could locate their vending machine near
their athletics program rather than near the cafeteria or
lunch grounds. While environmental designs alone do not
reduce the quantity of energy dense, low nutritional value
foods available to students, relocating competing foods
away from lunch areas may shift the use of such foods from
School Design and Obesity Prevention, Gorman et al.
2526 OBESITY Vol. 15 No. 11 November 2007

lunchtime meal alternatives to snacks, impact students’
overall junk food consumption, and introduce healthful
foods into students’ diets.
Another consideration for the school dietary environment
is the role of nutrition messages around campus. The label-
ing of foods sold on campus, for example, could be useful
in allowing students to make healthful choices, especially
when paired with health education on label use (2). In one
study of pricing and labeling effects on low-fat snack pur-
chases, labeling low-fat vending machine options and post-
ing signs encouraging low-fat purchases resulted in modest
increases in low-fat snack sales, independently of pricing
(42).
While health promotion messages show promise for en-
couraging healthful diets, they compete with existing ad-
vertisements for unhealthful foods, which have been dispro-
portionately marketed to youths. In a recent study of the
advertising environment around New Zealand school
grounds, over one half of the surrounding outdoor adver-
tisements were for food products and over 70% of these
promoted unhealthful options (45). Incorporating de´cor that
involves health education messages into classrooms, hall-
ways, stairwells, cafeterias, and other school grounds may
help to offset exposure to such advertising by influencing
student health norms. Creating school advertising environ-
ments that bar advertising unhealthful products may further
contribute to students’ dietary choices both on and off
campus. As noted by Hayne et al. (2), the $33 billion spent
annually by U.S. food retailers to promote consumption
stands in stark contrast to the combined $2.5 million cur-
rently spent by the National Cancer Institute and National
Heart, Lung, and Blood Institute to promote healthful eat-
ing. With the numbers stacked against health promotion, it
seems likely that a combination of both advertising mes-
sages promoting healthful food and restrictions on existing
advertising practices will be required to make an impact on
prevailing student health norms and provide motivation for
new behaviors.
Window wall
for visibility into
and out of
Restaurant.
display wall
variety of tables
for 4-6 “customers”
sink
customers have
visibility into kitchen
ceiling mounted mirror
for demonstration
Teacher
Office
educational display wall
teaching wall
Canopy cover.
landscaping to provide
additional opportunities
for shading outdoor
seating areas
computer kiosks
located in kitchen for
internet research
and printing out
recipes
casual cafe
seating
educational display wall
wireless access
Comercial
Teaching
Kitchen
Figure 2: This figure presents an example of a redesigned cafeteria integrating nutrition education opportunities and cafe´ elements. The
inclusion of a teaching kitchen, demonstration area, and projector/teaching wall enables both nutrition education as well as contact with food
service staff who may provide positive role modeling and social support. Cafe´ elements such as a food-court styled serving area, natural
lighting, and varied seating arrangements and locations result in an esthetically inviting dining space, which supports varied food preferences
and provides distinct spaces for various social groups. The inclusion of a vegetable or herb garden could segue into a school gardening
program.
School Design and Obesity Prevention, Gorman et al.
OBESITY Vol. 15 No. 11 November 20072527

While the impact of competing foods on campus may be
controlled through design or policy interventions, access to
off-campus fast foods remains a concern. From an environ-
mental perspective, one way to encourage the use of school
facilities is to ensure that they are functionally, esthetically,
and developmentally competitive with off-campus dining
options. Introducing design elements used in food courts
and teaching kitchens may help to address these issues.
The design and redesign of cafeterias to improve effi-
ciency will be critical in ensuring their use. One of the
reasons cited for students’ use of competing food vendors is
that accessing the cafeteria takes too long. Between long
lines at cafeterias and short lunch periods, time pressures
encourage students to rely on alternative food vendors for
their lunch (6). While the duration of lunch periods is a
matter of school policy, efficient cafeteria designs could be
used to reduce waiting time and line lengths. Design con-
siderations affecting student circulation during lunch hours
could include incorporating clear divisions of space so that
school lunch employees do not have to compete with stu-
dent traffic, separating dining and serving areas, promoting
circulation patterns that discourage students from doubling
back or meandering during high traffic periods, placing
trash receptacles so as not to interfere with circulation
patterns, and using self-service stations liberally. Ulti-
mately, less than one third of students’ mealtime should be
spent obtaining food (46,47).
Another goal in cafeteria design should be creating dining
environments that are esthetically appealing. Esthetic de-
signs using student stakeholders may be one approach to
making cafeterias more student-friendly. The use of student
artwork in cafeteria spaces may serve as an inexpensive way
to involve the school community in the cafeteria while
ensuring that the cafeteria esthetic avoids becoming stag-
nant or outdated. As artwork, music, and lighting improve-
ments have been documented to improve stairwell use, these
elements could be promising and testable first steps for
cafeteria design and redesign as well (40). While studies of
the effects of artificial light levels and natural lighting in
classroom settings remain contentious (14), the use of full-
spectrum or natural lighting in cafeterias may play an im-
portant role in creating an inviting environment for students
(29). Additional design efforts could include reducing con-
versational noise levels and crowding in cafeteria and din-
ing spaces, introducing natural elements such as plant or
water displays, or using displays to promote accomplish-
ments that could encourage school spirit and cohesion.
Further research in school cafeteria and dining area designs
may benefit from existing restaurant and food court designs,
which could serve as models for competitive, visually ap-
pealing dining centers.
One additional approach to improving student lunch
grounds is to provide developmentally appropriate social-
ization areas near or in cafeterias to encourage on-campus
eating. Dividing undifferentiated school lunch spaces into
smaller niches may allow students to claim spaces as their
own and reduce stigmas associated with eating on campus.
This goal may also be promoted by including various stu-
dent groups in the design or redesign of school lunch
grounds. The end result is a “home-like” environment,
which is inviting to students and allows for the creation and
claiming of personal spaces (29).
School-based Health Centers. The past decade has seen a
renewed interest in expanding school nurse offices to com-
prehensive school-based health centers (48). The number of
centers has increased from a scant 200 in 1990 to 1500 in
2005 (6,49). While the missions associated with and ser-
vices offered through such centers vary, many emphasize
prevention and education (6). Obesity prevention efforts
may be facilitated through several channels with the expan-
sion of existing nursing offices or creation of comprehen-
sive school-based health centers. School-based health cen-
ters also have the additional benefit of targeting students at
high risk for obesity, especially those who are under-insured
or who may not otherwise receive healthcare (6,49).
One mechanism by which school health centers can in-
fluence obesity prevention is the implementation of height,
weight, and BMI screening to inform primary and second-
ary prevention efforts and increase students’ self-awareness
(6). While concerns exist over the privacy of such informa-
tion, the stigmatization of labeling children, and the risk of
promoting eating disorders, the implementation of annual
health report cards has shown promising results as a means
of increasing the connectivity between schools and stu-
dents’ families (6). Additional concerns include the fear that
parents may place the children on diets without first seeking
medical guidance, but these fears may be at least partially
addressed by pairing such report cards with in-school nu-
trition education, medical referrals, and the inclusion of
educational materials sent home with such report cards.
Additional benefits of building and staffing school-based
health centers include promoting close ties between schools
and the healthcare community. The presence of or access to
nutritionists, health educators, and similar medical staff at
school sites could help to ensure that the potential of school-
based physical space designs and redesigns is realized. With
health education offered to as few as 20% of high school
juniors and seniors, educational programs supported by
school-based health center staff may serve to augment other
school-based obesity interventions (2). For instance, the
feedback of a nutritionist would likely benefit the previ-
ously mentioned school garden programs. Similarly, mental
health services may be of use in the fight against obesity, as
the disease is often associated with mental health disorders
and frequently results in teasing or social ostracism (6).
Pro-health educational messages for corridors, common
spaces, cafeterias, and classrooms may also be designed or
promoted with support from health center experts. Further-
School Design and Obesity Prevention, Gorman et al.
2528 OBESITY Vol. 15 No. 11 November 2007

more, of great importance, such centers could represent an
access point for public health researchers to evaluate exist-
ing school spaces and school-based health behavior inter-
ventions.
Future Research Directions
While promising findings are emerging from several
fields of study, substantial research remains warranted be-
fore comprehensive school design and redesign can be
promoted to scale as a means of encouraging physical
activity and healthful diets among school age children.
Stimulating new research is, thus, the goal of the current
paper. With preliminary evidence emerging from fields as
disparate as architecture and nursing, the pressing need for
collaboration is clear. In particular, researchers in the fields
of physical activity, nutrition, health communications, and
obesity will need to partner with environmental psycholo-
gists and design professionals to ensure that both the pre-
dictor and outcome variables of future studies are of high
relevance, quality, and comparability. In addition, partner-
ships with education specialists will ensure that health-
promoting school designs are compatible with efforts to
promote academic goals. Through collaboration, it may be
possible to find common goals for both health researchers
and education specialists. Similarly, feedback from school
stakeholders, such as students and teachers, may help to
guide research and design methods.
Another direction for future research includes creating
methodologies to evaluate existing school spaces. The cre-
ation of standardized guidelines to evaluate the extent to
which school grounds promote healthful behaviors and dis-
courage unhealthful behaviors will be vital if designs and
redesigns are to be implemented efficiently. A number of
models and theories have been proposed to evaluate the
quality of comprehensive school-based health centers (50).
Similarly, evaluation tools such as the School Health Index
have been found to assist schools in identifying areas in
which they can further promote physical activity and good
nutrition (51). Additional tools, such as the Analysis Grid
for Environments Linked to Obesity, may also be adaptable
to school evaluations and would expand evaluation criteria
to encompass economic, political, and socio-cultural ele-
ments (1). Because the meanings of spaces are created by
people who live and work in a given space, such evaluative
tools may also benefit from the inclusion of qualitative data
collected from the students, teachers, and staff who use the
school facilities regularly (52). The inclusion of such qual-
itative data may help ensure that design efforts remain
accessible and meaningful to constituents over time.
A final consideration for future school design and rede-
sign is the role of ethical and equitable access to designed
spaces. As school design interventions progress from theory
to application, care must be taken to ensure that both high-
risk and underserved demographics are represented in the
process. In many cases, these communities may be the least
prepared organizationally and fiscally to engage in school
renovations or construction, so a critical role for scientists,
educators, and policymakers will be learning to work within
such communities to create the infrastructure needed to
push for and maintain designed facilities and working with
funding agencies to ensure that funds are channeled to those
most in need.
Acknowledgments
The authors thank Dr. Kyle Snow for his insight in the
initial development of this manuscript. There was no fund-
ing/outside support for this study.
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