What childhood obesity prevention programmes work? A systematic review and meta-analysis

Environmental components of childhood obesity prevention interventions: an overview of systematic reviews

Childhood obesity has a complex multi-factorial aetiology grounded in environmental and individual level factors that affect behaviour and outcomes. An ecological, systems-based approach to addressing childhood obesity is increasingly being advocated. The primary aim of this review is to summarize the evidence reported in systematic reviews on the effectiveness of population-level childhood obesity prevention interventions that have an environmental component. We conducted a systematic review of reviews published since 1995, employing a standardized search strategy in nine databases. Inclusion criteria required that reviews be systematic and evaluated at least one population-level, environmental intervention in any setting aimed at preventing or reducing obesity in children (5-18 years). Sixty-three reviews were included, ten of which were of high quality. Results show modest impact of a broad range of environmental strategies on anthropometric outcomes. Systematic reviews vary in methodological quality, and not all relevant primary studies may be included in each review. To ensure relevance of our findings to practice, we also report on relevant underlying primary studies, providing policy-relevant recommendations based on the evidence reviewed. Greater standardization of review methods and reporting structures will benefit policymakers and public health professionals seeking informed decision-making.

Metabolic Syndrome in Children and Adolescents

BACKGROUND

Juvenile obesity is associated with multiple cardiometabolic comorbidities, which may culminate in the metabolic syndrome (MetS).

METHODS

Based on a narrative review, the current knowledge of prevalence and the underlying metabolic principles regarding juvenile obesity and MetS are summarized to compile up-to-date information. In addition, the role of lifestyle as well as positive and negative influencing factors are focused on.

RESULTS

The prevalence of MetS occurs between 1 and up to 23% in the total pediatric population and in up to 60% amongst the obese and overweight. It can be considered as the consequence of multiple processes in terms of lifestyle, perinatal programming, and (epi-)genetic pathways; however, the complex underlying mechanisms and their interplay are not completely understood.

CONCLUSION

Besides preventive approaches, the growing number of obese children and youth as well as its consequences call for effective and lasting therapeutic measures.

Systematic review of paediatric weight management interventions delivered in the home setting

To increase their accessibility, paediatric weight management interventions are increasingly designed to be delivered in the home setting by trained staff. This systematic review summarizes the available evidence for interventions featuring home visitation and identifies key gaps in the literature. PubMed, CINAHL, Cochrane and PsycINFO were searched for intervention studies that reported change in objectively measured adiposity outcomes in youth ages 2-18 years. Studies published between 1 January 1995 and 12 February 2016 were analysed. Of 15 eligible studies, nine reported that interventions with home visitation were either superior to a control/comparison condition or achieved significant within-subjects reductions in adiposity. Interventions in which professional staff (e.g. dietitians and exercise trainers) conducted home visits tended to be more efficacious than those delivered by paraprofessional or community-based staff, as were interventions with more frequent contact. Most studies were judged to have low or unclear risk of bias across various domains. As most studies compared interventions with home visits with less intensive and qualitatively different approaches, it remains unclear whether home visitation per se enhances weight loss efficacy. Overall, paediatric weight management interventions that feature home visitation are promising, but the incremental benefit of the home visitation treatment modality remains to be rigorously evaluated. © 2016 World Obesity.

Economic Evaluation of Obesity Prevention in Early Childhood: Methods, Limitations and Recommendations

Despite methodological advances in the field of economic evaluations of interventions, economic evaluations of obesity prevention programmes in early childhood are seldom conducted. The aim of the present study was to explore existing methods and applications of economic evaluations, examining their limitations and making recommendations for future cost-effectiveness assessments. A systematic literature search was conducted using PubMed, Cochrane Library, the British National Health Service Economic Evaluation Databases and EconLit. Eligible studies included trial-based or simulation-based cost-effectiveness analyses of obesity prevention programmes targeting preschool children and/or their parents. The quality of included studies was assessed. Of the six studies included, five were intervention studies and one was based on a simulation approach conducted on secondary data. We identified three main conceptual and methodological limitations of their economic evaluations: Insufficient conceptual approach considering the complexity of childhood obesity, inadequate measurement of effects of interventions, and lack of valid instruments to measure child-related quality of life and costs. Despite the need for economic evaluations of obesity prevention programmes in early childhood, only a few studies of varying quality have been conducted. Moreover, due to methodological and conceptual weaknesses, they offer only limited information for policy makers and intervention providers. We elaborate reasons for the limitations of these studies and offer guidance for designing better economic evaluations of early obesity prevention.

Child health promotion program in South Korea in collaboration with US National Aeronautics and Space Administration: Improvement in dietary and nutrition knowledge of young children

BACKGROUND/OBJECTIVES

Childhood obesity has become a global epidemic. Development of effective and sustainable programs to promote healthy behaviors from a young age is important. This study developed and tested an intervention program designed to promote healthy eating and physical activity among young children in South Korea by adaptation of the US National Aeronautics and Space Administration (NASA) Mission X (MX) Program.

SUBJECTS/METHODS

The intervention program consisted of 4 weeks of fitness and 2 weeks of nutrition education. A sample of 104 subjects completed pre- and post-surveys on the Children's Nutrition Acknowledgement Test (NAT). Parents were asked for their children's characteristics and two 24-hour dietary records, the Nutrition Quotient (NQ) at baseline and a 6-week follow-up. Child weight status was assessed using Korean body mass index (BMI) percentiles.

RESULTS

At baseline, 16.4% (boy: 15.4%; girl: 19.2%) of subjects were overweight or obese (based on BMI≥85%tile). Fat consumption significantly decreased in normal BMI children (48.6 ± 16.8 g at baseline to 41.9 ± 18.1 g after intervention, P < 0.05); total NQ score significantly increased from 66.4 to 67.9 (P < 0.05); total NAT score significantly improved in normal BMI children (74.3 at baseline to 81.9 after the program), children being underweight (from 71.0 to 77.0), and overweight children (77.1 at baseline vs. 88.2 after intervention, P < 0.001).

CONCLUSIONS

The 6-week South Korean NASA MX project is feasible and shows favorable changes in eating behaviors and nutritional knowledge among young children.

The Unchartered Frontier: Preventive Cardiology Between the Ages of 15 and 35 Years

It is well established that atherosclerosis, the pathological basis of cardiovascular disease (CVD), begins in childhood and progresses steadily between the ages of 15 to 35 years. These adolescent and young adult years are also marked by significant physiological, psychological, and sociodemographic changes that impact both CVD risk factor development and CVD prevention and treatment strategies. In this review, we highlight the importance of the primordial prevention of CVD risk factors before they ever occur and the primary prevention of CVD by treating CVD risk factors in this age group. Although the long time to first CVD event for most young people precludes the availability of clinical trials with hard end-points, findings from epidemiology, health psychology, health services research, and clinical trials with surrogate endpoints are discussed to inform an evidence-based approach to CVD prevention in adolescents and young adults.

Validity and Reliability of Behavior and Theory-Based Psychosocial Determinants Measures, Using Audience Response System Technology in Urban Upper-Elementary Schoolchildren

OBJECTIVE

To examine the validity and reliability of a questionnaire administered with an audience response system (ARS).

DESIGN

Cross-sectional study.

SETTING

Two New York City public elementary schools.

PARTICIPANTS

Fourth- and fifth-grade students.

MAIN OUTCOME MEASURES

A Food, Health, and Choices questionnaire (FHC-Q) assessed energy balance-related behaviors (EBRBs) including intake of fruits and vegetables, sugar-sweetened beverages, processed packaged snacks, and fast food; physical activity; recreational screen time; and associated psychosocial determinants (≥ 3 questions/outcome scale). Previously validated reference instruments were used for relative validation. The ARS format was compared with a paper-and-pencil format. All measures were administered in a classroom setting.

ANALYSIS

Pearson correlation coefficients between the reference instruments and the FHC-Q were calculated. Internal consistency reliabilities were evaluated with Cronbach α. Spearman rank correlation, intra-class correlation, and percent agreement were used for test-retest reliability between paper-and-pencil and ARS, and between 2 ARS FHC-Q administrations.

RESULTS

Correlations for EBRBs with reference instruments ranged from 0.38 to 0.61 (P < .01). Cronbach α ranged from .77 to .92 for EBRBs and .74 to .90 for psychosocial determinants. Test-retest reliability correlations ranged from 0.36 to 0.87 (P < .001). Agreement for knowledge questions ranged from 69.8% to 84.8%.

CONCLUSIONS AND IMPLICATIONS

The ARS FHC-Q has acceptable validity and reliability for collecting data on EBRBs and associated psychosocial determinants for upper-elementary students.

The effects of a 2-year individualized and family-based lifestyle intervention on physical activity, sedentary behavior and diet in children

OBJECTIVE

To investigate the effects of a long-term, individualized and family-based lifestyle intervention on physical activity, sedentary behavior and diet quality in children.

METHODS

We carried out a 2-year intervention study in a population sample of 506 children aged 6-8years in Finland in 2007-2012. We allocated the participants at baseline in the intervention and control group. We assessed physical activity and sedentary behavior by questionnaires and diet by food records.

RESULTS

Total physical activity (+9min/d in intervention group vs. -5min/d in control group, p=0.001 for time*group interaction), unsupervised physical activity (+7min/d vs. -9min/d, p<0.001) and organized sports (+8min/d vs. +3min/d, p=0.001) increased in the intervention group but not in the control group. Using computer and playing video games increased less in the intervention group than in the control group (+9min/d vs. +19min/d, p=0.003). Consumption of vegetables (+12g/d vs. -12g/d, p=0.001), high-fat vegetable-oil based margarine (+10g/d vs. +3g/d, p<0.001) and low-fat milk (+69g/d vs. +11g/d, p=0.042) and intake of dietary fiber (+1.3g/d vs. +0.2g/d, p=0.023), vitamin C (+4.5mg/d vs. -7.2mg/d, p=0.042) and vitamin E (+1.4mg/d vs. +0.5mg/d, p=0.002) increased in the intervention group but not in the control group. Consumption of butter-based spreads increased in the control group but not in the intervention group (+2g/d vs. -1g/d, p=0.002).

CONCLUSIONS

Individualized and family-based lifestyle intervention increased physical activity, attenuated increase in sedentary behavior and enhanced diet quality in children.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01803776.

Adolescent exercise in association with mortality from all causes, cardiovascular disease, and cancer among middle-aged and older Chinese women

BACKGROUND

Little is known regarding the role of early-life exercise, a potentially modifiable factor, in long-term adult morbidity and mortality. We utilized the Shanghai Women's Health Study (SWHS) to investigate adolescent exercise in association with cancer, cardiovascular disease (CVD), and all-cause mortality among middle-aged and older women.

METHODS

The SWHS is a prospective cohort of 74,941 Chinese women ages 40 to 70 years recruited from 1996 to 2000. In-person interviews at enrollment assessed adolescent and adult exercise history, medical and reproductive history, and other lifestyle and socioeconomic (SES) factors. Mortality follow-up occurs via annual linkage to the Shanghai Vital Statistics Registry. Adjusted hazard ratios (HR) and 95% confidence intervals (CI) were derived from Cox regression models.

RESULTS

Adjusting for birth year and other adolescent factors, adolescent exercise was associated with reduced risk of cancer, CVD, and total mortality [HRs (95% CI), 0.83 (0.72-0.95), 0.83 (0.70-0.98), and 0.78 (0.71-0.85), respectively for ≤1.33 hours (h)/week, and 0.83 (0.74-0.93), 0.62 (0.53-0.72), and 0.71 (0.66-0.77), respectively for >1.33 h/week (reference = none)]. Results were attenuated after adjustment for adult SES and lifestyle factors. Participation in sports teams was inversely associated with cancer mortality [HR (95% CI), 0.86 (0.76-0.97)]. Joint adolescent and adult exercise was associated with reduced risk of all-cause, CVD, and cancer mortality [HRs (95% CIs), 0.80 (0.72-0.89), 0.83 (0.69-1.00), and 0.87 (0.74-1.01), respectively], adjusting for adult/adolescent factors, and adolescence exercise only was inversely associated with cancer mortality [HR (95% CI), 0.84 (0.71-0.98)].

CONCLUSIONS

Adolescent exercise participation, independent of adult exercise, was associated with reduced risk of cancer, CVD, and all-cause mortality.

IMPACT

Results support promotion of exercise in adolescence to reduce mortality in later life.

Single-center assessment of nutritional counseling in preventing excessive weight gain in pediatric renal transplants recipients

Post-transplantation obesity is a common complication that is associated with a higher risk for decreased allograft function and hypertension. However, the role of diet intervention on reducing post-transplantation obesity is relatively unknown. We investigated the clinical relevance of dietary counseling on the prevalence of overweight/obesity during the first two yr following renal transplantation. The computerized patient records of 42 recipients (31 males) aged 6.3 ± 4.8 yr at transplantation were reviewed. All patients systematically underwent yearly dietary assessment/counseling (motivational interviewing technique) and measurement of renal function and ABPM. At transplantation, 14.2% of patients were overweight/obese, which increased to 42.8% by two yr post-transplantation (p = 0.004). The majority of patients experienced a significant increase in BMI SDS during the first six months post-transplantation that remained sustained throughout the duration of the follow-up period (p = 0.001). By two yr post-transplantation, there were no observable differences between patients classified as having normal BMI or being overweight/obese with regard to renal function and controlled hypertension. The application of yearly tailored dietary assessment/counseling had a poor effect on preventing post-transplantation weight gain, suggesting the need for more comprehensive interventions to reduce post-transplant obesity.

Obesogenic environment - intervention opportunities

OBJECTIVES

To evaluate environmental obesogenic-related factors, such as physical activity in neighborhoods and schools, nutritional behavior, and intervention programs.

SOURCES

Critical analysis of literature with personal point of view from infant obesity experts and political advisors for public intervention.

DATA SYNTHESIS

Although obesity is a public health problem affecting several age groups, it is among children and adolescents that it plays a more important role, due to treatment complexity, high likelihood of persistence into adulthood, and association with other non-transmissible diseases while still in early age. Environment is a main component of the genesis and outcomes in the near future or long term. Modification of intake with high-density food, meal skipping, and high intake of saturated fat, sugar, and salt, associated to high levels of sedentarism are main causes of obesity.

CONCLUSION

Intervention opportunities are related to modifications in political, environmental, and individual settings. School and physical activities in the educational environment are intertwined with nutrition intervention in continuous education. A critical review of some different scenarios in Latin American countries is presented.

Systematic review and meta-analysis of interventions targeting sleep and their impact on child body mass index, diet, and physical activity

OBJECTIVE

This review aimed to examine the impact of interventions involving an explicit sleep component on child body mass index (BMI), diet, and physical activity.

METHODS

A systematic search was undertaken in six databases to identify randomized controlled trials examining the impact of interventions with a sleep component on child BMI, dietary intake, and/or physical activity. A random effects meta-analysis was conducted assessing the impact of included interventions on child BMI.

RESULTS

Of the eight included trials, three enforced a sleep protocol and five targeted sleep as part of multicomponent behavioral interventions either exclusively or together with nutrition and physical activity. Meta-analysis of three studies found that multicomponent behavioral interventions involving a sleep component were not significantly effective in changing child BMI (n = 360,-0.04 kg/m(2) [-0.18, 0.11], I(2)  = 0%); however, only one study included in the meta-analysis successfully changed sleep duration in children. There were some reported improvements to adolescent diet, and only one trial examined the impact on child physical activity, where a significant effect was observed.

CONCLUSIONS

Findings from the included studies suggest that where improvements in child sleep duration were achieved, a positive impact on child BMI, nutrition, and physical activity was also observed.

Objectively measured physical activity and sedentary time: cross-sectional and prospective associations with adiposity in the Millennium Cohort Study

OBJECTIVE

To examine whether physical activity (PA) and sedentary time (ST) in primary school-aged children are associated with adiposity at the start of secondary school, and whether these associations differ by sex or ethnic group.

DESIGN

Nationally representative prospective cohort study.

SETTING

Children born across the UK, between 2000 and 2002.

PARTICIPANTS

6497 singleton children.

OUTCOME MEASURES

Measures of adiposity (body mass index (BMI), fat mass index (FMI) and fat free mass index (FFMI))--obtained at 7 and 11 years.

EXPLANATORY MEASURES

Total daily PA (mean counts per minute (cpm)); minutes of moderate-to-vigorous PA (MVPA); and ST. All assessed at 7 years using accelerometers.

RESULTS

In cross-sectional analyses, total PA was inversely associated with FMI (3.7% (95% CI 2.7% to 4.7%) reduction per 150 cpm increase), as was MVPA (4.2% (CI 3.2% to 5.2%) reduction per 20 min/day increase). Associations were stronger in black and South Asian ethnic groups. Total PA and MVPA were not associated with FFMI. ST was positively associated with FMI (1.3% (CI 0.2% to 2.3%) increase per 50 min/day increase) and inversely associated with FFMI (0.5% (CI 0.2% to 0.7%) reduction per 50 min/day increase). Longitudinally, MVPA at age 7 years remained inversely associated with FMI at age 11 years (1.5% (CI 0.4% to 2.6%) reduction per 20 min/day increase). No association was found between total PA and ST and any of the later adiposity measures.

CONCLUSIONS

7-year-old children who are more physically active are less likely to be obese at that age and at age 11 years. These associations were particularly evident in children from black or South Asian ethnicity at age 7 years and in boys at age 11 years. Measurements of fat mass provide valuable insights into ethnic differences in associations between adiposity and activity.

Child Obesity and Mental Health: A Complex Interaction

Prevalence rates of childhood obesity have risen steeply over the last 3 decades. Given the increased national focus, the frequency of this clinical problem, and the multiple mental health factors that coexist with it, make obesity a public health concern. The complex relationships between mental health and obesity serve to potentiate the severity and interdependency of each. The purpose of this review is to create a contextual connection for the 2 conditions as outlined by the research literature and consider treatment options that affect both health problems.

Community Stakeholders' Perceptions of Major Factors Influencing Childhood Obesity, the Feasibility of Programs Addressing Childhood Obesity, and Persisting Gaps

Prior research has identified numerous factors contributing to increased rates of childhood obesity. However, few studies have focused explicitly on the experience of community stakeholders in low-income communities. This study sought to capture the perspectives of these on-the-ground experts regarding major factors contributing to childhood obesity as well as gaps in current prevention and control efforts. We conducted semi-structured interviews with 39 stakeholders from different community sectors (e.g., healthcare providers, childcare providers, teachers). Data were drawn from the Massachusetts Childhood Obesity Research Demonstration project, a multi-level, multi-sector intervention designed to reduce childhood obesity being implemented in two low-income communities in Massachusetts. Interviews were conducted at baseline, transcribed, coded using grounded theory approach, and analyzed in NVivo 10.0. The vast majority of stakeholders had recently participated in obesity prevention strategies, and nearly all of them identified gaps in prevention efforts either within their organizations or in the broader community. In addition to factors previously identified in the literature, several themes emerged including the need to change policies to increase physical activity during school, offer healthier snacks in schools and afterschool programs, and increase communication and collaboration within the community in prevention efforts. Community stakeholders can impact the success of interventions by bridging the gap between science and lived experience. The results of this study can guide future research by highlighting the importance of including stakeholders' frontline experiences with target populations, and using information on identified gaps to augment intervention planning efforts.

Association between Parental Workaholism and Body Mass Index of Offspring: A Prospective Study among Japanese Dual Workers

The purpose of the study was to investigate the association between parental workaholism and child body mass index (BMI) among Japanese dual-income families. In 2011, 379 dual-income families from urban Tokyo with children aged 0-5 years were recruited for a baseline survey, and 160 (42.2%) were followed up in 2012. Demographics, workaholism, work demands, work control, time spent with children, and parental and child weights and heights were assessed using a questionnaire. Structural equation modeling was performed to determine the association between maternal and paternal workaholism in 2011 and child BMI in 2012, considering the mediating effects of time spent with children. Paternal workaholism showed a direct significant positive association with child BMI after 1 year (standardized coefficient: 0.19; p < 0.001), while maternal workaholism was not associated with child BMI. Both maternal and paternal time spent with children did not mediate the association. Paternal work demands showed a strong positive association with workaholism but paternal work control did not. Paternal, but not maternal, workaholism was associated with an increase in child BMI over 1 year. Interventions that target workaholism by reducing paternal work demands might be effective in preventing overweight in offspring.

Play it forward! A community-based participatory research approach to childhood obesity prevention

BACKGROUND

To date there has been limited success with childhood obesity prevention interventions. This may be due in part, to the challenge of reaching and engaging parents in interventions. The current study used a community-based participatory research (CBPR) approach to engage parents in cocreating and pilot testing a childhood obesity prevention intervention. Because CBPR approaches to childhood obesity prevention are new, this study aims to detail the creation, including the formation of the citizen action group (CAG), and implementation of a childhood obesity prevention intervention using CBPR methods.

METHOD

A CBPR approach was used to recruit community members to partner with university researchers in the CAG (n = 12) to create and implement the Play It Forward! childhood obesity intervention. The intervention creation and implementation took 2 years. During Year 1 (2011-2012), the CAG carried out a community needs and resources assessment and designed a community-based and family focused childhood obesity prevention intervention. During Year 2 (2012-2013), the CAG implemented the intervention and conducted an evaluation. Families (n = 50; 25 experimental/25 control group) with children ages 6-12 years participated in Play It Forward!

RESULTS

Feasibility and process evaluation data suggested that the intervention was highly feasible and participants in both the CAG and intervention were highly satisfied. Specifically, over half of the families attended 75% of the Play It Forward! events and 33% of families attended all the events.

CONCLUSION

Equal collaboration between parents and academic researchers to address childhood obesity may be a promising approach that merits further testing.

Association between a school-based intervention and adiposity outcomes in adolescents: The Italian "EAT" project

OBJECTIVE

To evaluate whether a school-based multicomponent educational program could improve adiposity measures in middle-school adolescents.

METHODS

A non-randomized controlled pilot study was conducted in six state middle schools (487 adolescents, 11-15 years) in townships in an urban area around Milan, three schools (n = 262 adolescents) being assigned to the intervention group and three schools (n = 225 adolescents) to the control group. The two-school-year intervention included changes in the school environment (alternative healthy vending machines, educational posters) and individual reinforcement tools (school lessons, textbook, text messages, pedometers, re-usable water bottles). The main outcome measure was change in BMI z-score. The secondary outcomes were changes in waist-to-height ratio (WHtR) and behavioral habits.

RESULTS

The intervention was associated with a significant difference in BMI z-score (-0.18 ± 0.03, P<0.01) and in WHtR (-0.04 ± 0.002, P < 0.001), after controlling for baseline covariates. Subgroup analysis showed the maximum association between the intervention and the difference in BMI z-score for girls with overweight/obesity. Physical activity increased and consumption of sugar-sweetened beverages and high-energy snacks decreased in adolescents after the intervention.

CONCLUSIONS

A school-based multicomponent intervention conducted at both environmental and individual levels may be effective for reducing adiposity measures mainly in adolescents with overweight/obesity.

Impacts of Physical Activity on the Obese

Approximately two-thirds of the US population is overweight or obese. Physical activity is recommended for preventing obesity, aiding in weight loss, and decreasing rates of chronic diseases. This article reviews current statistics for obesity, physical activity, and physician counseling patterns. Principles of exercise physiology relating to cardiopulmonary fitness and chronic disease are also reviewed and methods for increasing physical activity in adults and children are suggested.