Moving Midstream: A Community Approach to Childhood Obesity Prevention

I still remember one of the virtual posters a 9-year-old child made during our H₂GO! program. He had featured his favorite NBA player alongside the words, “Drink water to play strong.” Other children wrote poems, songs, and raps. Some made short videos or acted out skits. Our program taught them about the link between what we drink and our health, but we did not tell them exactly what to say. This was an intentional part of our empowerment approach to childhood obesity prevention.

We tend to talk about improving health as though change happens in only two places: downstream within individuals, perhaps at a doctor’s office, or far upstream, through policy and environmental change. But there is a lot of space in between. Communities occupy the midstream, where policies and environments meet everyday life, where behaviors are shaped, and where people build relationships, develop norms, and exercise agency.

H₂GO! was designed to work in this space. Our research team sought to reach children where they already spend time, partnering with trusted community organizations to deliver health programming focused on reducing sugary drink consumption. H₂GO! is a six-week childhood obesity prevention program delivered through Boys & Girls Clubs across Massachusetts, with a focus on school-aged youth and their parents and caregivers. Results from our recent cluster randomized trial, published in JAMA Network Open, suggest that this community-based approach can support healthier growth over time.

The need for more effective childhood obesity prevention efforts is clear, with one in five U.S. children and adolescents having obesity. The World Health Organization describes obesity as a chronic, complex disease shaped by interactions among biology, behavior, and broader factors such as food prices, marketing, neighborhood resources, social norms, and access to healthy options.

While structural change is essential, it can also be demoralizing and disempowering to imply that communities cannot experience better health until the policies, systems, and environments around them change.

We need policies and environmental change that make nutritious foods affordable and accessible, safe places to be active, clean drinking water readily available, and healthy choices easier where we live. But those changes can require years if not decades of resources, political support, and coordination across sectors. Families are still living their lives in the meantime.

This tension is one that I constantly grapple with: the idea that public health cannot change health behaviors or health outcomes until we change systems. While structural change is essential, it can also be demoralizing and disempowering to imply that communities cannot experience better health until the policies, systems, and environments around them change. We should keep working toward long-term structural change while also investing in what communities can do in the present. This includes building skills, strengthening relationships, and creating opportunities for people to shape their own health.

For H₂GO!, we started with one concrete behavior change: drink fewer sugary beverages and more water. National data show that nearly two-thirds of U.S. children and adolescents consumed at least one sugary drink on a given day, contributing an average of 143 calories, or about 7% of daily energy intake. It is difficult for a child simply to “choose differently” when those drinks are available at home, at friends’ houses, at parties and sporting events, and when everyone around them is drinking them too.

That is why H₂GO! was designed as a group-based program rather than individual health education sessions. Developed collaboratively with youth, parents, and Club staff from the Massachusetts Alliance of Boys & Girls Clubs, H₂GO! combined interactive health sessions, storytelling, and parent-child activities. Trained Club staff delivered these in-person sessions to youth.

H₂GO! reminds us that waiting for perfect policies and environments is not our only option.

Youth empowerment was central to this approach. We invited children to become health messengers. Children at intervention sites created print, audio, and video stories connecting water to things they cared about, such as sports, energy, family, and feeling good. They then brought those messages home and shared them with their families. This allowed children to shift from being passive recipients of health information to active health ambassadors in shaping what healthier norms could look like around them. A child’s own words, creativity, and enthusiasm can also make health information more relatable and engaging to peers and families and may strengthen the child’s own sense of agency at the same time.

We tested H₂GO! in a randomized trial of 437 children ages 8 to 13 across 11 Boys & Girls Club sites. About two-thirds of participants qualified for free or reduced-price school lunch. One year later, children in H₂GO! sites had a more favorable change in BMI than children in comparison clubs. Among children who began the study with overweight or obesity, 28.9% of those in the intervention moved to a lower BMI category, compared with 17.8% in the comparison group. Importantly, the program did not mention weight or obesity and instead focused on behaviors, skills, participation, and healthy growth over time.

A six-week after-school program does not address larger structural issues such as healthy food affordability and access, targeted food and beverage marketing, or neighborhood design. We should continue our long-term efforts to advocate for such improvements.

H₂GO! reminds us that waiting for perfect policies and environments is not our only option. I believe in the power of investing in community organizations, trusted relationships, and the creativity of young people themselves. Public health can work upstream to change the conditions that shape health while simultaneously strengthening communities’ capacity to act within the world as it exists today. The question is not whether change should begin with policy or with people, but how we make sure they meet.