A meta-analytic review of obesity prevention in the schools: 1997-2008

Efficacy of lifestyle interventions to treat pediatric obesity: A systematic review and multivariate meta-analysis of randomized controlled trials

The aim of this study was to provide a quantitative synthesis of the effects of randomized controlled pediatric lifestyle interventions in treating obesity among 11-17-year-old children. We conducted a systematic review and meta-analysis on the randomized controlled trials, consisting of actual exercise training and nutrition education, published between January 2000 and August 2022. The initial search yielded 2598 articles, with eight articles meeting the inclusion criteria. The articles were analyzed using a multivariate random effects model. The primary outcome variables were body mass index (BMI), standardized BMI (BMIz), and waist circumference (WC). Our analyses showed that lifestyle interventions were efficacious in improving BMI (-1.77 kg/m2, 95% CI [-2.70, -0.83], p < 0.001), BMIz (-0.30, 95% CI [-0.45, -0.16], p < 0.001), and WC (-3.32 cm, 95% CI [-5.35, -1.29], p < 0.001) in children with overweight and obesity. In addition, moderation analyses suggested that the efficacy of the lifestyle interventions correlated positively with participants' weight status and was enhanced when an intervention was boosted with a longer intervention duration and higher frequency. In conclusion, the current evidence suggests that lifestyle interventions are efficacious in treating children with obesity. The available evidence further indicates that duration, frequency, along weight status, were moderating the effectiveness of these lifestyle interventions.

Evaluation of a cluster-randomized controlled trial: Communities for Healthy Living, family-centered obesity prevention program for Head Start parents and children

BACKGROUND

This study reports the outcomes of Communities for Healthy Living (CHL), a cluster randomized obesity prevention trial implemented in partnership with Head Start, a federally-funded preschool program for low-income families.

METHODS

Using a stepped wedge design, Head Start programs (n = 16; Boston, MA, USA) were randomly assigned to one of three intervention start times. CHL involved a media campaign and enhanced nutrition support. Parents were invited to join Parents Connect for Healthy Living (PConnect), a 10-week wellness program. At the beginning and end of each school year (2017-2019), data were collected on the primary outcome of child Body Mass Index z-score (BMIz) and modified BMIz, and secondary outcomes of child weight-related behaviors (diet, physical activity, sleep, media use) and parents' weight-related parenting practices and empowerment. Data from 2 years, rather than three, were utilized to evaluate CHL due to the COVID-19 pandemic. We used mixed effects linear regression to compare relative differences during intervention vs. control periods (n = 1274 vs. 2476 children) in (1) mean change in child BMIz and modified BMIz, (2) the odds of meeting child health behavior recommendations, (3) mean change in parenting practices, and (4) mean change in parent empowerment. We also compared outcomes among parents who chose post-randomization to participate in PConnect vs. not (n = 55 vs. 443).

RESULTS

During intervention periods (vs. control), children experienced greater increases in BMIz and modified BMIz (b = 0.06, 95% CI = 0.02,0.10; b = 0.07, 95% CI = 0.03, 0.12), yet were more likely to meet recommendations related to three of eight measured behaviors: sugar-sweetened beverage consumption (i.e., rarely consume; Odds Ratio (OR) = 1.5, 95% CI = 1.2,2.3), water consumption (i.e., multiple times per day; OR = 1.6, 95% CI = 1.2,2.3), and screen time (i.e., ≤1 hour/day; OR = 1.4, 95% CI = 1.0,1.8). No statistically significant differences for intervention (vs. control) periods were observed in parent empowerment or parenting practices. However, parents who enrolled in PConnect (vs. not) demonstrated greater increases in empowerment (b = 0.17, 95% CI = 0.04,0.31).

CONCLUSIONS

Interventions that emphasize parent engagement may increase parental empowerment. Intervention exposure was associated with statistically, but not clinically, significant increases in BMIz and increased odds of meeting recommendations for three child behaviors; premature trial suspension may explain mixed results.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03334669 , Registered October 2017.

The Role of Parental Support and the Students' Opinions in Active Finnish Physical Education Homework

Prior research indicates that adolescent boys are often more active than girls, implying a need for special attention to increase the physical activity levels of adolescent girls. Adolescents are at an age where they are especially susceptible to environmental and social influences but still have a limited amount of autonomy over their own behaviors. The effective physical activity programs implemented at this age may benefit health into adulthood. The fact that adolescents' physical activity is influenced by many factors indicates that to achieve any behavioral change, interventions must target several levels across the socio-ecological model. During childhood, the family is the primary factor in socializing and shaping engagement in physical activity. This study is part of the Physical Education (PE) Homework Study project which was implemented in a midsized secondary school in the middle of Finland from 2016 to 2020. The goal was to develop one easily approachable way to prevent the decreasing physical activity of adolescent girls. This was done by increasing physical activity times of adolescent girls outside of the school by giving them active PE assignments. The aim was also to explore students' and their parents' perceptions of physically active physical education homework. In this part of the study, there were 43 interviews: 38 student interviews and 5 interviews with parents. The analysis process followed the qualitative content analysis (QCA) strategy by Schreirer. In this study, we combined the views of students and parents, and obtained a broad picture of the PE homework assignments given at school but completed at home. According to students and parents, PE homework assignments should be diverse, interesting, and challenging, they should also be provided at flexible schedules outside of school hours with family support. Physical education homework could be a potential approach to influence the physical activity of the student population by involving school curriculum and families.

School as a Protective Setting for Excess Weight Gain and Child Obesity: A Meta-Analysis

BACKGROUND

The structure provided by school settings even with no specific obesity-intervention may prevent weight gain. This meta-analytic study considered this premise by examining weight outcomes from control groups in published randomized controlled trials of school-year obesity-related interventions conducted in-school and out-of-school.

METHODS

A systematic review and random-effects meta-analysis were conducted in accordance with Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases were systematically searched and resulted in 1976 unique citations, with 14 retained for analysis. Analyses examined the change in weight outcomes among control group participants.

RESULTS

For studies (N = 6) reporting body mass index (BMI) (kg/m² ) the overall standardized mean difference (SMD) from pre- to post-intervention was 0.085 (raw units 0.278 kg/m² ); for studies (N = 9) reporting zBMI, the SMD was 0.022 (0.020 z-scores), for studies (N = 2) reporting waist circumference (cm), the SMD was 0.149 (1.609 cm); for studies (N = 2) reporting BMI percentile, the SMD was 0.064 (0.985 percentiles); and for studies (N = 1) reporting percent body fat, the SMD was 0.031 (0.30 percentage).

CONCLUSIONS

Children assigned to control conditions (as part of school-based obesity-related interventions) experience, on average, minimal changes in weight outcomes during the school year. Therefore, routine practices of schools may protect against unhealthy weight gains.

Assessment of Attitudes Toward Physical Education by the Implementation of an Extracurricular Program for Obese Children

The World Health Organization (WHO) identifies the importance of implementing physical activity programs such as physical education (PE) classes in schools. This study identifies the attitudes of obese children toward PE, before and after participation in a vigorous-intensity physical exercise program without the participation of normal-weight peers using a questionnaire on Attitudes toward Physical Education (CAEF). 98 children between 8-11 years of age were randomized in an Experimental Group (GE) (n = 48) and a Control Group (CG) (n = 47). They were assessed using a questionnaire on Attitudes toward Physical Education (CAEF). All the study participants exhibited a BMI Z-score ≥ 2. Before the intervention, the only difference between boys and girls was "empathy to teacher and physical education subject" (p = 0.001, d de Cohen = 0.72, r = 0.34). The interaction between gender and training was only present in empathy for the teacher, with a medium effect size (η2 = 0.055). The implementation of PE with two hours per week elicits only a few effects over the attitude of obese children, even though with a certain engagement of gender through training in the adjustment of empathy for teachers and the PE class.

Are primary/elementary school-based interventions effective in preventing/ameliorating excess weight gain? A systematic review of systematic reviews

This systematic review of systematic reviews addresses a current gap in evidence by synthesizing findings relating to weight management interventions set entirely in primary/elementary schools targeting, diet, and/or physical activity as key strategies. Eight databases were searched for systematic reviews of trials of school-based interventions targeting children aged 4 to 12 years that looked at biometric and behavioral outcomes. From the 10 selected systematic reviews, we found that interventions designed to promote physical activity or reduce sedentary behavior were most effective for weight loss. Interventions designed to improve diet and nutrition had a small effect on behavioral and cognitive outcomes, and these outcomes could be enhanced through the use of experiential learning. The most effective interventions involved a range of stakeholders in the development process and included parents and families in implementation. This systematic review of systematic reviews offers evidence-based guidance for the development and implementation of multistrategy weight-management interventions in primary/elementary schools.

Effectiveness of a school-based intervention on knowledge, attitude and practice on healthy lifestyle and body composition in Malaysian adolescents

Background

The ‘Eat Right, Be Positive About Your Body and Live Actively’ (EPaL) intervention programme was developed to prevent overweight and disordered eating in Malaysian adolescents. This study aimed to evaluate the effectiveness of the EPaL programme on knowledge, attitudes and practices on healthy lifestyle and body composition (body mass index z-score [zBMI], waist circumference [WC] and body fat percentage [BF%]) among adolescents.

Methods

All measures were taken at three time points: before intervention (Pre), after intervention (Post I) and 3 months after intervention (Post II). The intervention group (IG) participated in the EPaL programme for 16 weeks, whereas the comparison group (CG) received no intervention. Seventy-six adolescents (IG: n = 34; CG: n = 42) aged 13–14 years were included in the final analysis. Repeated measures analysis of covariance (ANCOVA) was used to assess the impact of the EPaL intervention programme on the measures between groups (IG and CG) at Post I and Post II.

Results

The IG reported significantly higher knowledge scores at both Post I (adjusted mean difference = 3.34; 95% confidence interval [CI] = 0.99, 5.69; p = 0.006) and Post II (adjusted mean difference = 2.82; 95% CI = 0.86, 4.78; p = 0.005) compared with the CG. No significant differences between the IG and CG were found at either Post I or Post II in attitudes, practices, zBMI, WC and BF%. The proportion of participants who were overweight or obese was consistent from Pre to Post II in the IG (35.3%) and increased from 26.2% at Pre to 28.5% at Post II in the CG, but the difference was not statistically significant. The proportion of participants who had abdominal obesity in the IG decreased from 17.6% at Pre to 14.7% at Post II and increased from 16.7% at Pre to 21.4% at Post II in the CG, but the differences were not statistically significant.

Conclusion

Despite no significant reduction of body composition, this programme shows the positive effect on the adolescents’ knowledge regarding healthy lifestyle. This study contributes to the evidence on the effectiveness of school-based health interventions in Malaysian adolescents.

Trial registration

UMIN Clinical Trial Registration UMIN000024349. Registered 11 October 2016.

Can the Healthy Primary School of the Future offer perspective in the ongoing obesity epidemic in young children? A Dutch quasi-experimental study

OBJECTIVES

Schools play an important role in promoting healthy behaviours in children and can offer perspective in the ongoing obesity epidemic. The 'Healthy Primary School of the Future' (HPSF) aims to improve children's health and well-being by enhancing school health promotion. The current study aims to assess the effect of HPSF on children's body mass index (BMI) z-score after 1 and 2 years follow-up and to investigate whether HPSF has different effects within specific subgroups of children.

DESIGN

A longitudinal quasi-experimental design.

SETTING

Four intervention and four control schools participated; located in a low socioeconomic status region in the Netherlands.

PARTICIPANTS

1676 children (aged 4-12 years).

INTERVENTIONS

HPSF uses a contextual systems approach and includes health-promoting changes in the school. Central to HPSF is the provision of a daily healthy lunch and structured physical activity sessions each day. Two intervention schools implemented both changes (full HPSF), two intervention schools implemented only the physical activity change (partial HPSF).

MAIN OUTCOME MEASURES

BMI z-score, determined by measurements of children's height and weight at baseline, after 1 and 2 years follow-up.

RESULTS

The intervention effect was significant after 1-year follow-up in the partial HPSF (standardised effect size (ES)=-0.05), not significant in the full HPSF (ES=-0.04). After 2 years follow-up, BMI z-score had significantly decreased in children of both the full HPSF (ES=-0.08) and the partial HPSF (ES=-0.07) compared with children of the control schools, whose mean BMI z-score increased from baseline to 2 years. None of the potential effect modifiers (gender, baseline study year, socioeconomic status and baseline weight status) were significant.

CONCLUSIONS

HPSF was effective after 1 and 2 years follow-up in lowering children's BMI z-scores. No specific subgroups of children could be identified who benefitted more from the intervention.

TRIAL REGISTRATION NUMBER

NCT02800616.

Noncomprehensive and Intermittent Obesity-Related School Programs and Policies May Not Work: Evidence from the COMPASS Study

BACKGROUND

The school environment has the potential to influence student body mass index (BMI) through programs and policies. Our objective was to examine the effect of modifying obesity-related school policies and programs on youths' BMI trajectories.

METHODS

Obesity-related school policies and programs related to physical activity and healthy eating were collected from 41 schools across Ontario at baseline (2012-2013) and year 2 (2013-2014) of the COMPASS study. Self-reported height and weight were collected from the 4951 grades 9 and 10 students who attended those schools for 3 years. Linear mixed effects regression models examined the effect of modifying obesity-related school policies and programs on youths' BMI trajectories.

RESULTS

Between Y₁ and Y₂ , 26 of the 41 schools implemented distinct new obesity-related programs or policies related to physical activity or healthy eating. Five of the interventions were associated with BMI trajectories of students attending those schools compared to students attending a pooled sample of control schools, predicting a higher BMI trajectory.

CONCLUSIONS

Isolated programs and policies may not successfully improve youths' BMI trajectories. Further research is required to test the implementation of policies and programs that follow a comprehensive school health (CSH) approach, targeting BMI and associated behaviors.

Schoolteachers' Nutrition Knowledge, Beliefs, and Attitudes Before and After an E-Learning Program

OBJECTIVE

Το explore teachers' nutrition knowledge, beliefs, and attitudes and to examine the effectiveness of an electronic learning (e-learning) program in teachers' nutrition knowledge.

DESIGN

Cross-sectional and experimental design.

SETTING

The study took place in Greece, while schoolteachers were invited by e-mail.

PARTICIPANTS

Teachers of primary and secondary education, with no exclusion criteria, were enrolled in the study between March, 2015 and 2016.

MAIN OUTCOME MEASURES

Schoolteachers' nutrition knowledge, beliefs, and attitudes.

INTERVENTION

Teachers completed a 36-item nutrition questionnaire and then a subgroup participated in an e-learning program. After the intervention, teachers completed the same questionnaire.

ANALYSIS

Principal component analysis and multivariate logistic regression were used for data analysis.

RESULTS

A total of 1,094 teachers completed the questionnaire; 619 participated in the e-learning program. Teachers showed moderate nutrition knowledge scores (ie, 65% correct answers) before the intervention, whereas their attitudes regarding acting as role models and their belief in the importance of the role of nutrition were associated with 74% (odds ratio, 1.28; 95% confidence interval, 1.13-1.45) and 79% (odds ratio, 1.21; 95% confidence interval, 1.07-1.37) increased possibility of having good nutrition knowledge, respectively. The e-learning program was effective in strengthening teachers' nutrition knowledge (P < .001) and improving their beliefs and attitudes (P < .05).

CONCLUSIONS AND IMPLICATIONS

Future research is needed to validate the current results, which can be used to design and implement similar educational programs to teachers as a means of creating health-promoting schools.

Unravelling the Effects of the Healthy Primary School of the Future: For Whom and Where Is It Effective?

The 'Healthy Primary School of the Future' (HPSF) aims to integrate health and well-being within the whole school system. This study examined the two-year effects of HPSF on children's dietary and physical activity (PA) behaviours at school and at home and investigated whether child characteristics or the home context moderated these effects. This study (n = 1676 children) has a quasi-experimental design with four intervention schools, i.e., two full HPSF (focus: nutrition and PA), two partial HPSF (focus: PA), and four control schools. Measurements consisted of accelerometry (Actigraph GT3X+) and questionnaires. Favourable effects on children's dietary and PA behaviours at school were found in the full HPSF; in the partial HPSF, only on PA behaviours. Children in the full HPSF did not compensate at home for the improved health behaviours at school, while in the partial HPSF, the children became less active at home. In both the full and partial HPSF, less favourable effects at school were found for younger children. At home, less favourable effects were found for children with a lower socioeconomic status. Overall, the effect of the full HPSF on children's dietary and PA behaviours was larger and more equally beneficial for all children than that of the partial HPSF.

Prevention and treatment of childhood and adolescent obesity: a systematic review of meta-analyses

BACKGROUND

The goal of this systematic review is to synthesize the published meta-analyses assessing the role of nutritional, behavioral and physical activity factors/interventions on the prevention or treatment of pediatric and adolescent obesity.

METHODS

An online search was conducted in PubMed (end-of-search: September 30, 2015); English-language meta-analyses pooling observational and/or interventional studies examining weight-related indices on children and adolescents were included.

RESULTS

Sixty-six meta-analyses corresponding to more than 900,000 children and adolescents were retrieved. The majority of meta-analyses included interventional studies most of which referred to mixed or combined interventions, including components such as diet, physical activity and sedentary behavior reduction. Discrepancies between meta-analyses on observational and interventional studies were noted. Combined interventions including physical activity and nutritional modifications seemed to represent the most effective means for tackling childhood obesity.

CONCLUSIONS

Synthesis of interventional or observational evidence may yield discrepant results. The combination of enhanced physical activity and improved nutrition emerged as a promising intervention in the fight against childhood/adolescent obesity. However, further research is needed about the most effective multidimensional prevention strategy.

Generalizability of an adult-validated model for predicting increased physical activity in after-school program children: Effects of treatment formats on fitness indicators

Inappropriately high weight in children is a persistent problem in the United States, and physical activity is often reduced in schools due to academic demands. Effective after-school programs could positively impact both physical activity and overweight/obesity, however previous reviews and meta-analyses have indicated minimal effects. Both 4- and 3-day/week versions of a social cognitive theory-driven physical activity/nutrition after-school program were evaluated against unstructured care to assess effects in children (overall M_age = 10.00 years, SD = .80). For changes over 9 months in body mass index (BMI), effects sizes (Cohen's d) were .68, .40, and .07 in the 4-day (n = 70), 3-day (n = 70), and unstructured (n = 50) groups, respectively. Similar patterns of effects were found for changes in free-time physical activity and cardiovascular endurance. Incorporating a theory-based prediction model previously supported in teens through older adults, with and without medical disorders and health-risk factors, improvements in exercise-related self-regulation and self-efficacy, and mood, significantly predicted increased free-time physical activity (R² = .48). Effects significantly strengthened to R² = .62 when completion/non-completion of the recommended 300 min/week of physical activity was also accounted for. Change in BMI was inversely related to physical activity change, β=-.14, p < .05. The present evaluation process indicated promising effects, and indicated theory-based targets to foster future program improvements.

The short- and long-term impact of an incentive intervention on healthier eating: a quasi-experiment in primary- and secondary-school cafeterias in Brazil

OBJECTIVE

To assess the short- and long-term effectiveness of a lottery incentive intervention to promote the purchase of healthy products in school cafeterias.

DESIGN

A quasi-experiment in which students' purchases in intervention schools were analysed in a pre-post analysis and also compared with a control school in a difference-in-differences model. A hierarchical linear model assessed the mean number of promoted healthy products purchased daily per participant before (twenty-six weekdays), during (nine weekdays) and after (twenty-eight weekdays) the intervention period. Sex, age and prior purchasing behaviour served as covariates.

SETTING

Convenience sample of school cafeterias using a debit-card payment method that allowed for the assessment of students' purchasing behaviour.ParticipantsStudents who used the pre-paid card to buy snacks at the school cafeteria. A total of 352 students (208 in intervention schools and 144 in control school) were included in the final analyses.

RESULTS

The incentives programme significantly increased the purchase of promoted healthy products during (v. before) the intervention period in intervention schools (P&lt;0·001), especially among younger children (P=0·036). Among the students who purchased the promoted healthier products during the intervention, there was an increase in total number of purchased products (healthy non-promoted, but also of less healthy products). Sex and past consumption behaviour did not influence the response to incentives in the short term. On average, no long-term effect was observed.

CONCLUSIONS

Long-term and negative spillover effects must be taken into consideration for a complete understanding of the effects of incentives on healthier eating.

Interventions aimed at preventing and reducing overweight/obesity among children and adolescents: a meta-synthesis

The prevalence of child and adolescent obesity has been a major worldwide problem for decades. To stop the number of youth with overweight/obesity from increasing, numerous interventions focusing on improving children's weight status have been implemented. The growing body of research on weight-related interventions for youth has been summarized by several meta-analyses aiming to provide an overview of the effectiveness of interventions. Yet, the number of meta-analyses is expanding so quickly and overall results differ, making a comprehensive synopsis of the literature difficult. To tackle this problem, a meta-synthesis was conducted to draw informed conclusions about the state of the effectiveness of interventions targeting child and adolescent overweight. The results of the quantitative synthesis of 26 meta-analyses resulted in a standardized mean difference (SMD) of -0.12 (95%CI: -0.16, -0.08). Several moderator analyses showed that participant and intervention characteristics had little impact on the overall effect size. However, a moderator analysis distinguishing between obesity treatment and obesity prevention studies showed that obesity treatment interventions (SMD: -0.048, 95%CI: -0.60, -0.36) were significantly more effective in reducing body mass index than obesity prevention interventions (SMD: -0.08, 95%CI: -0.11, -0.06). Overall, the results of this meta-synthesis suggest that interventions result in statistically significant effects albeit of relatively little clinical relevance.

Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost-effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children

Background

Approximately one-third of children in England leave primary school overweight or obese. There is little evidence of effective obesity prevention programmes for children in this age group.

Objective

To determine the effectiveness and cost-effectiveness of a school-based healthy lifestyles programme in preventing obesity in children aged 9–10 years.

Design

A cluster randomised controlled trial with an economic and process evaluation.

Setting

Thirty-two primary schools in south-west England.

Participants

Children in Year 5 (aged 9–10 years) at recruitment and in Year 7 (aged 11–12 years) at 24 months’ post-baseline follow-up.

Intervention

The Healthy Lifestyles Programme (HeLP) ran during the spring and summer terms of Year 5 into the autumn term of Year 6 and included four phases: (1) building a receptive environment, (2) a drama-based healthy lifestyles week, (3) one-to-one goal setting and (4) reinforcement activities.

Main outcome measures

The primary outcome measure was body mass index (BMI) standard deviation score (SDS) at 24 months post baseline measures (12 months post intervention). The secondary outcomes comprised waist circumference SDS, percentage body fat SDS, proportion of children overweight and obese at 18 and 24 months, accelerometer-assessed physical activity and food intake at 18 months, and cost-effectiveness.

Results

We recruited 32 schools and 1324 children. We had a rate of 94% follow-up for the primary outcome. No difference in BMI SDS was found at 24 months [mean difference –0.02, 95% confidence interval (CI) –0.09 to 0.05] or at 18 months (mean difference –0.02, 95% CI –0.08 to 0.05) between children in the intervention schools and children in the control schools. No difference was found between the intervention and control groups in waist circumference SDS, percentage body fat SDS or physical activity levels. Self-reported dietary behaviours showed that, at 18 months, children in the intervention schools consumed fewer energy-dense snacks and had fewer negative food markers than children in the control schools. The intervention effect on negative food markers was fully mediated by ‘knowledge’ and three composite variables: ‘confidence and motivation’, ‘family approval/behaviours and child attitudes’ and ‘behaviours and strategies’. The intervention effect on energy-dense snacks was partially mediated by ‘knowledge’ and the same composite variables apart from ‘behaviours and strategies’. The cost of implementing the intervention was approximately £210 per child. The intervention was not cost-effective compared with control. The programme was delivered with high fidelity, and it engaged children, schools and families across the socioeconomic spectrum.

Limitations

The rate of response to the parent questionnaire in the process evaluation was low. Although the schools in the HeLP study included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, the number of children for whom English was an additional language was considerably lower than the national average.

Conclusions

HeLP is not effective or cost-effective in preventing overweight or obesity in children aged 9–10 years.

Future work

Our very high levels of follow-up and fidelity of intervention delivery lead us to conclude that it is unlikely that school-based programmes targeting a single age group can ever be sufficiently intense to affect weight status. New approaches are needed that affect the school, the family and the wider environment to prevent childhood obesity.

Trial registration

Current Controlled Trials ISRCTN15811706.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

Adolescents with at-risk eating and lifestyle behaviors are affected by after school schedules across the clinical weight spectrum

OBJECTIVE

Evaluate adolescent lifestyle patterns to develop more effective health promotion programs.

METHODS

An interview approach was employed to gain in-depth understanding of eating and activity behaviors. Adolescents aged 13-18 years (n=43) from clinically normal and obese weight categories were enrolled. Nutrient intake and food group servings were obtained from a food frequency questionnaire.

RESULTS

Four participant subgroups were identified and labeled: "Idle, Engaged, Balanced and Working." "Idle" adolescents were sedentary, sometimes napped, and often snacked after dinner. "Engaged" adolescents participated in extra-curricular activities for the majority of their after school hours. "Balanced" adolescents participated in a single after-school activity followed by sedentary time; they consumed meals consistently and often snacked after dinner. "Working" adolescents were the least sedentary with limited sleep duration and inconsistent meals; they often substituted a meal with a snack. Weight status did not differentiate subgroups effectively.

CONCLUSIONS

Each group demonstrated at-risk behaviors for obesity. Future programs should consider after-school schedules and use activity and meal pattern assessments, not simply weight status, for program tailoring.

PRACTICE IMPLICATIONS

Pediatric health care providers could identify at-risk behaviors through routine assessment of diet and activity patterns in combination with weight monitoring.

Evaluation of the Good Start Program: a healthy eating and physical activity intervention for Maori and Pacific Islander children living in Queensland, Australia

Background

Reducing the prevalence of obesity and chronic disease are important priorities. Maori and Pacific Islander communities living in Australia have higher rates of obesity and chronic disease than the wider Australian population. This study aims to assess the effectiveness of the Good Start program, which aims to improve knowledge, attitudes and practices related to healthy eating and physical activity amongst Maori and Pacific Islander communities living in Queensland.

Methods

The intervention was delivered to children aged 6–19 years (N = 375) in schools by multicultural health workers. Class activities focused on one message each term related to healthy eating and physical activity using methods such as cooking sessions and cultural dance. The evaluation approach was a quantitative uncontrolled pre-post design. Data were collected each term pre- and post-intervention using a short questionnaire.

Results

There were significant increases in knowledge of correct servings of fruit and vegetables, knowledge of sugar and caffeine content of common sugar-sweetened drinks, recognition of the consequences of marketing and upsizing, and the importance of controlling portion size (all P < 0.05). There was also increases in knowledge of physical activity recommendations (P < 0.001), as well as the importance of physical activity for preventing heart disease (P < 0.001) and improving self-esteem (P < 0.001). In terms of attitudes, there were significant improvements in some attitudes to vegetables (P = 0.02), and sugar-sweetened drinks (P < 0.05). In terms of practices and behaviours, although the reported intake of vegetables increased significantly (P < 0.001), the proportion of children eating discretionary foods regularly did not change significantly, suggesting that modifying the program with an increased emphasis on reducing intake of junk food may be beneficial.

Conclusion

The study has shown that the Good Start Program was effective in engaging children from Maori and Pacific Island backgrounds and in improving knowledge, and some attitudes and practices, related to healthy eating and physical activity. The evaluation contributes valuable information about components and impacts of this type of intervention, and considerations relevant to this population in order to successfully change behaviours and reduce the burden of chronic disease.

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.

A Systematised Review of Primary School Whole Class Child Obesity Interventions: Effectiveness, Characteristics, and Strategies

Background. A systematised review was conducted to examine the effectiveness of school-based interventions that focus on changing dietary intake and physical activity levels to reduce childhood obesity. Methods. Multiple databases were searched for randomised and nonrandomised interventions from 2007 to 2016 in full-time elementary schools, which were delivered to the whole class, included dietary and physical activity components, involved both sexes, were written in English, and used body mass index (BMI) as an outcome. Results. The database search produced 8,866 titles from which 78 were deemed relevant and assessed for inclusion resulting in 15 studies meeting all inclusion criteria. From these 15 studies, 9 yielded a reduction or stabilisation in BMI or BMI z-score in the entire intervention group and/or subgroups. Programmes lasting between 6 and 12 months that involve multiple environmental, educational, and physical strategies appear to be most likely to result in BMI or BMI z-score improvement. Moderators most likely influencing an improvement in BMI included increased physical activity, decreased sugar sweetened beverages intake, and increased fruit intake. Conclusions. School-based interventions may be an effective means for child obesity prevention. The identification of consistent elements used in school-based interventions that have demonstrated effectiveness may aid in preventing child obesity.

Prevention of eating disorders: A systematic review of randomized, controlled trials

OBJECTIVE

This systematic review evaluated the efficacy of universal, selective, and indicated eating disorder prevention.

METHOD

A systematic literature search was conducted in Medline, PsycINFO, Embase, Scopus, and the Cochrane Collaboration Library databases to January 2016. Studies were included if they were randomized, controlled trials (RCT) and tested an eating disorder prevention program. We retrieved 13 RCTs of universal prevention (N = 3,989 participants, 55% female, M age = 13.0 years), 85 RCTs of selective prevention (N = 11,949 participants, 99% female, M age = 17.6 years), and 8 RCTs of indicated prevention (N = 510 participants, 100% female, M age = 20.1 years). Meta-analysis was performed with selective prevention trials. As there were a limited number of universal and indicated trials, narrative synthesis was conducted.

RESULTS

Media literacy had the most support for universal prevention. Most universal approaches showed significant modest effects on risk factors. Dissonance-based was the best supported approach for selective prevention. Cognitive-behavior therapy (CBT), a healthy weight program, media literacy, and psychoeducation, were also effective for selective prevention and effects were maintained at follow-up. CBT was supported for indicated prevention and effects were maintained at follow-up.

DISCUSSION

The modest effects for universal prevention were likely due to floor effects. The evidence for selective prevention suggests that empirically supported approaches should be disseminated on a wider basis. Our findings suggest CBT should be offered for indicated populations. Overall, results suggest efficacy of several prevention programs for reducing risk for eating disorders, and that wider dissemination is required. © 2016 Wiley Periodicals, Inc.

Planning and self-efficacy interventions encouraging replacing energy-dense foods intake with fruit and vegetable: A longitudinal experimental study

OBJECTIVE

This longitudinal experimental study compared effects of self-efficacy, planning and education-based conditions, encouraging adolescents to eat fruit and vegetable in place of energy-dense foods.

DESIGN

Data were collected among 506 adolescents (13-18 years old) who were randomly assigned to control (n = 181), planning (n = 153) or self-efficacy (n = 172) conditions. Measurements were taken at baseline (T1), at a 2-month follow-up (T2), and at a 14-month follow-up (T3). Interventions/control group procedures were delivered at T1 and T2.

OUTCOME MEASURES

Self-reports of fruit and vegetable intake (FVI) and energy-dense foods intake were collected at three times. Cognitive mediators (self-efficacy and planning) were assessed at T1 and T2. Body weight and height were objectively measured at T1 and T3.

RESULTS AND CONCLUSIONS

Similar significant increases of FVI were found for planning and self-efficacy interventions (T3). The planning intervention did not influence energy-dense food intake (T3), but the self-efficacy intervention tended to result in stabilising intake (compared to an increase found in the control group). There were no effects on body weight. Similar patterns were found for the total sample and for a subsample of adolescents with overweight/obesity. The effects of interventions on FVI were mediated by respective cognitions.

Targeting Parents for Childhood Weight Management: Development of a Theory-Driven and User-Centered Healthy Eating App

Background

The proliferation of health promotion apps along with mobile phones' array of features supporting health behavior change offers a new and innovative approach to childhood weight management. However, despite the critical role parents play in children’s weight related behaviors, few industry-led apps aimed at childhood weight management target parents. Furthermore, industry-led apps have been shown to lack a basis in behavior change theory and evidence. Equally important remains the issue of how to maximize users’ engagement with mobile health (mHealth) interventions where there is growing consensus that inputs from the commercial app industry and the target population should be an integral part of the development process.

Objective

The aim of this study is to systematically design and develop a theory and evidence-driven, user-centered healthy eating app targeting parents for childhood weight management, and clearly document this for the research and app development community.

Methods

The Behavior Change Wheel (BCW) framework, a theoretically-based approach for intervention development, along with a user-centered design (UCD) philosophy and collaboration with the commercial app industry, guided the development process. Current evidence, along with a series of 9 focus groups (total of 46 participants) comprised of family weight management case workers, parents with overweight and healthy weight children aged 5-11 years, and consultation with experts, provided data to inform the app development. Thematic analysis of focus groups helped to extract information related to relevant theoretical, user-centered, and technological components to underpin the design and development of the app.

Results

Inputs from parents and experts working in the area of childhood weight management helped to identify the main target behavior: to help parents provide appropriate food portion sizes for their children. To achieve this target behavior, the behavioral diagnosis revealed the need for eliciting change in parents’ capability, motivation, and opportunity in 10-associated Theoretical Domains Framework (TDF) domains. Of the 9 possible intervention functions, 6 were selected to bring about this change which guided the selection of 21 behavior change techniques. Parents’ preferences for healthy eating app features revolved around four main themes (app features, time saving and convenience, aesthetics, and gamification) whereupon a criterion was applied to guide the selection on which preferences should be integrated into the design of the app. Collaboration with the app company helped to build on users’ preferences for elements of gamification such as points, quizzes, and levels to optimize user engagement. Feedback from parents on interactive mock-ups helped to inform the final development of the prototype app.

Conclusions

Here, we fully explicate a systematic approach applied in the development of a family-oriented, healthy eating health promotion app grounded in theory and evidence, and balanced with users’ preferences to help maximize its engagement with the target population.

Health behaviors: is there any distinction for teachers? A cross-sectional nationwide study

Background

Health behaviors, as important modifiable determinants of health, are consistently targeted by prevention messages. Teachers, as educators and role models, may play a key-role in bringing such messages to children and adolescents. It is not clear which areas of prevention could be improved in collaboration with teachers to promote healthy behaviors at the population level through health education in schools.

Methods

to evaluate teacher’s health awareness, we compared their health/risk behaviors to those of non-teachers, taking into account demographic and socioeconomic factors that could confound crude differences. We used data from the 2010 Health Barometer, a cross-sectional nationally-representative French survey conducted by telephone among 27,653 persons aged 15–85. Adjusting sequentially for potential confounders, we compared six indicators of lifestyle and risky conducts (at-risk drinking, current smoking, cannabis use, gambling, corpulence, sleep duration) between teachers (n = 725) and two comparison groups: other occupations (n = 12,483) on the one hand, and other intermediate and managerial/professional occupations (n = 6,026) on the other.

Results

In the fully-adjusted models, teachers were less likely than other occupations to smoke, to have used cannabis in the last 12 months, to gamble regularly and to be overweight or obese. When restricting the comparison group to other occupations belonging to the same socio-professional category, differences were attenuated, but remain highly significant for tobacco, cannabis and gambling. No significant differences were observed between teachers and non-teachers regarding alcohol use and sleep duration, once important confounders had been adjusted for.

Conclusions

Our results suggest that teachers behave on the whole more healthily than other adults with a similar demographic and socioeconomic profile. The absence of a teacher distinction toward at-risk drinking needs to be examined in more detail.

[Effectiveness of a school-based program to prevent obesity]

INTRODUCTION

Intervention for childhood obesity is a public health priority. The purpose of this study was to evaluate the effectiveness of an elementary school-based intervention against obesity in children.

MATERIAL AND METHODS

Non-randomised controlled trial was conducted on children from first to fifth grade from two public schools of Avilés (Spain). The intervention lasted for 2 school years comprising healthy diet workshops, educational chats, educational meetings, informative written material, and promotion of physical activities. Primary outcome measure was body mass index z-score. Secondary outcomes included: obesity and overweight prevalence, waist circumference, dietary habits, and physical activity.

RESULTS

A total of 382 (177 girls, 205 boys) out of 526 pupils of both schools were included in the study. Complete anthropometric data were obtained in 340 of the 382 individuals. Compared to children in control group, those in intervention group decreased body mass index z-score from 1.14 to 1.02 (P=.017), and improved KIDMED score from 7.33 to 7.71 points (P=.045). The percentage of students who carried on an optimal diet increased from 42.6% to 52.3% (P=.021). There were no statistical differences in the prevalence of obesity and overweight, or in waist circumference between the intervention and control groups.

CONCLUSIONS

This school-based program resulted in modest beneficial changes in body mass index and diet quality.

Impact evaluation of Enabling Mothers to Prevent Pediatric Obesity through Web-Based Education and Reciprocal Determinism (EMPOWER) Randomized Control Trial

BACKGROUND

The family and home environment is an influential antecedent of childhood obesity. The purpose of this study was to pilot test The Enabling Mothers to Prevent Pediatric Obesity through Web-Based Education and Reciprocal Determinism (EMPOWER) intervention; a newly developed, theory-based, online program for prevention of childhood obesity.

METHOD

The two-arm, parallel group, randomized, participant-blinded trial targeted mothers with children between 4 and 6 years of age. Measures were collected at baseline, 4 weeks, and 8 weeks to evaluate programmatic effects on constructs of social cognitive theory (SCT) and obesity-related behaviors. Process evaluation transpired concurrently with each intervention session.

RESULTS

Fifty-seven participants were randomly assigned to receive either experimental EMPOWER (n = 29) or active control Healthy Lifestyles (n = 28) intervention. Significant main effects were identified for child physical activity, sugar-free beverage consumption, and screen time, indicating that both groups improved in these behaviors. A significant group-by-time interaction was detected for child fruit and vegetable (FV) consumption as well as the SCT construct of environment in the EMPOWER cohort. An increase of 1.613 cups of FVs (95% confidence interval = [0.698, 2.529]) was found in the experimental group, relative to the active control group. Change score analysis found changes in the home environment accounted for 31.4% of the change in child FV intake for the experimental group.

CONCLUSIONS

Child physical activity, sugar-free beverage consumption, and screen time improved in both groups over the course of the trial. Only the theory-based intervention was efficacious in increasing child FV consumption. The EMPOWER program was robust for inducing change in the home environment leading to an increase in child FV intake (Cohen's f = 0.160).

School-based obesity prevention programs: a meta-analysis of randomized controlled trials

OBJECTIVE

Attempts have been made to reduce childhood obesity through school-based programs. Systematic reviews of studies until 2006 reported a lack of consistency about effectiveness of such programs. Presented is an updated systematic review and meta-analysis.

DESIGN AND METHODS

Replication of methodology used in previous comprehensive systematic review and meta-analysis of randomized controlled trials of school-based obesity prevention programs covering studies until 2006 to review studies thru January 2012.

RESULTS

Based on 32 studies (n = 52,109), programs were mildly effective in reducing BMI relative to controls not receiving intervention. Studies of children had significant intervention effects, those of teenagers did not, though the difference between the two groups was not statistically significant. Meta-regression showed a significant linear hierarchy of studies with the largest effects for comprehensive programs more than 1 year long that aimed to provide information on nutrition and physical activity, change attitudes, monitor behavior, modify environment, involve parents, increase physical activity and improve diet, particularly among children.

CONCLUSIONS

Unlike earlier studies, more recent studies showed convincing evidence that school-based prevention interventions are at least mildly effective in reducing BMI in children, possibly because these newer studies tended to be longer, more comprehensive and included parental support.

An adaptive CBPR approach to create weight management materials for a school-based health center intervention

PURPOSE

From our previous clinical work with overweight/obese youth, we identified the need for research to create an effective weight management intervention to address the growing prevalence of adolescent metabolic syndrome. Formative assessment through an adaptive community-based participatory research (CBPR) approach was conducted toward the development of a nutritional and physical activity (DVD) and clinician toolkit for a school-based health center (SBHC) weight management intervention.

METHODS

We first conducted parent and adolescent interviews on views and experiences about obesity while convening a community advisory council (CAC) recruited from two participating urban New Mexico high schools. Thematic findings from the interviews were analyzed with the CAC to develop culturally and developmentally appropriate intervention materials.

RESULTS

Themes from the parent and adolescent interviews included general barriers/challenges, factors influencing motivation, and change facilitators. The CAC and university-based research team reached consensus on the final content of nutrition and physical activity topics to produce a DVD and clinician toolkit through six monthly sessions. These materials used in the SBHC intervention resulted in a greater reduction of body mass index when compared to adolescents receiving standard care.

CONCLUSIONS

Formative assessment using an adaptive CBPR approach resulted in the creation of culturally and age appropriate weight reduction materials that were acceptable to study participants. This trial is registered with ClinicalTrials.gov NCT00841334.

Interventions with children and parents to improve physical activity and body mass index: a meta-analysis

OBJECTIVE

Examine the effect of interventions with parents and children on children's physical activity and body mass index (BMI).

DATA SOURCE

Computerized searches for intervention studies published between 1990 and 2011 used multiple ProQuest databases, including unpublished dissertations and theses to minimize publication bias.

STUDY INCLUSION AND EXCLUSION CRITERIA

English-language, intervention-testing studies of children, parents, or families with outcomes of physical activity or BMI were retrieved from peer-reviewed journals, dissertations, and theses. Eliminated studies had no control or comparison group; had no continuous outcome variable; had no physical activity/exercise and/or BMI as outcomes; or had incomplete statistics necessary for meta-analysis (means, standard deviations, or confidence intervals).

DATA EXTRACTION

Twenty-one studies met inclusion criteria. Quality criteria were control group, objective outcome variable measure, clarity of variable definitions, and number and reason for subject withdrawal.

DATA SYNTHESIS

Meta-analysis on the raw difference of means estimated mean weighted effect size (MWES) assessed dispersion of effects and computed a summary effect.

RESULTS

MWES for interventions with parents and children on physical activity (Z = 2.92; confidence interval [CI] = .09 to .48; p = .002) and on BMI for interventions with children alone (Z = -2.10; CI = -.16 to -.01; p = .02) was significant.

CONCLUSION

A significant effect on physical activity but not on BMI was found when interventions included both parents and their children.

Incorporating physical activity into the schools using a 3-tiered approach

BACKGROUND

Public health models have been used to address a number of school-based concerns, notably in the identification and treatment of students at-risk for academic or behavioral deficits. Significant benefits are associated with this model as, compared to a traditional approach, the focus is shifted from remediation to prevention, and from student pathology to student strengths.

METHODS

Although this model has been applied to multiple populations and used across a variety of settings, it has yet to be conceptualized as a framework for the integration of school-based physical activity (PA).

RESULTS

This article first reviews the public health service delivery model as well as the benefits of PA on children's physical health, mental health, and cognitive outcomes. Second, suggestions for incorporating PA into the schools using a 3-tiered system and as barriers to success are discussed.

CONCLUSION

School-based PA is a promising tool-and yet an overlooked and undervalued intervention-for a number of concerns applicable to children's academic achievement and overall mental health.

The effect of a communications campaign on middle school students' nutrition and physical activity: results of the HEALTHY study

The HEALTHY Study was a 3-year school-based intervention designed to change the behaviors of middle school students to reduce their risk for developing type 2 diabetes mellitus. This report examines the relation between exposure to communications campaign materials and behavior change among students in the HEALTHY intervention schools. Using data from campaign tracking logs and student interviews, the authors examined communications campaign implementation and exposure to the communications campaign as well as health behavior change. Campaign tracking documents revealed variability across schools in the quantity of communications materials disseminated. Student interviews confirmed that there was variability in the proportion of students who reported receiving information from the communication campaign elements. Correlations and regression analysis controlling for semester examined the association between campaign exposure and behavior change across schools. There was a significant association between the proportion of students exposed to the campaign and the proportion of students who made changes in health behavior commensurate with study goals. The results suggest that, in the context of a multifaceted school-based health promotion intervention, schools that achieve a higher rate of exposure to communication campaign materials among the students may stimulate greater health behavior change.

A true challenge for any superhero: an evaluation of a comic book obesity prevention program

The purpose of this study was to pilot test the Comics for Health program, a theory-based nutrition and physical activity intervention for children. Twelve after-school programs were randomized to either a theory-based (n = 37) or a knowledge-based (n = 34 children) version of the intervention. Pretests, posttests, and 3-month follow-up tests were administered to evaluate the programmatic effects on body mass index percentile, obesity-related behaviors, and constructs of social cognitive theory. Both interventions found significant, yet modest effects for fruit and vegetable consumption (P < .005), physical activities (P < .004), and water and sugar-free beverage consumption (P < .001) and self-efficacy for fruit and vegetable consumption (P < .015) and physical activities (P < .009).

A process evaluation of a social cognitive theory-based childhood obesity prevention intervention: the Comics for Health program

Process evaluations are an often overlooked yet essential component of health promotion interventions. This study reports the results of a comprehensive process evaluation for the "Comics for Health" program, a childhood obesity prevention intervention implemented at 12 after-school programs. Qualitative and quantitative process data were collected using surveys, field notes, and open-item questionnaires, which assessed program fidelity, dose delivered, dose received, reach, recruitment, and context. Triangulation of methods was also employed to better understand how the program was implemented and received by the facilitator, staff members, and children in the program. Results indicated that program implementation had an almost perfect rate of fidelity with most lessons recording 100% tasks completed. Lessons were implemented in their intended order and lasted approximately 30 minutes as planned. After-school staff members reported that the program was well received by children, and this program should be replicated in the future. Attendance records showed that a majority of the children attended each lesson on the initial day of delivery (70.4%) and informal make-up lessons were implemented to compensate for the other children. Finally, several known sources of contamination were found such as past and concurrent exposure to similar health promotion interventions, which could potentially influence study outcomes. These findings will be used to help explain the results of this intervention and make recommendations for future intervention efforts.

Systematic review of family and home-based interventions targeting paediatric overweight and obesity

The family and home environment is a highly influential psychosocial antecedent of paediatric obesity. The purpose of this investigation was to systematically analyze family and home-based randomized control trials aimed at treating overweight and obesity in children ages 2-7 years. In gathering materials for this review, a search of Cumulative Index to Nursing and Allied Health, MEDLINE, Education Resources Information Center, Psychology and Behavioural Sciences Collection and CENTRAL databases was conducted for the time frame of January 2001 to August 2011. The data extraction spanned three phases resulting in a total of nine interventions that met the specified inclusion criteria. Among the identified studies, eight produced significant outcomes. The majority of the programmes incorporated educational sessions targeting parents as the primary modality for intervention delivery. Less than one-quarter of the interventions included home visitations; however, all of the interventions included home-based activities to reinforce behaviour modification. Only three of the interventions applied social and behavioural theory, and only two interventions employed process evaluation. Additional research is needed to gauge the efficacy of the home and family milieu for treating paediatric obesity.

Family-related predictors of body weight and weight-related behaviours among children and adolescents: a systematic umbrella review

This umbrella review analysed the relationships between family variables and child/adolescent body weight, diet and physical activity. In line with theories of health behaviour change, it was assumed that behaviour-specific family variables (i.e. beliefs, perceptions and practices referring to food intake or physical activity) would have stronger support than more general family variables (i.e. socio-economic status or general parental practices). Data obtained from 18 systematic reviews (examining 375 quantitative studies) were analysed. Reviews of experimental trials generally supported the effectiveness of reward/positive reinforcement parental strategies, parental involvement in treatment or prevention programmes, and cognitive-behavioural treatment in reducing child/adolescent body mass and/or obesity. Results across reviews of correlational studies indicated that healthy nutrition of children/adolescents was related to only one parental practice (parental monitoring), but was associated with several behaviour-specific family variables (e.g. a lack of restrictive control over food choices, high intake of healthy foods and low intake of unhealthy foods by parents and siblings, low pressure to consume foods). With regard to adolescent physical activity, stronger support was also found for behaviour-specific variables (e.g. physical activity of siblings), and for certain socio-economic variables (e.g. parental education). Child and adolescent obesity prevention programmes should account for behaviour-specific family variables.

After-school based obesity prevention interventions: a comprehensive review of the literature

The purpose of this article was to review primary prevention interventions targeting childhood obesity implemented in the after school environment from 2006 and 2011. A total of 20 interventions were found from 25 studies. Children in the interventions ranged from kindergarten to middle schoolers, however a majority was in the 4th and 5th grades. Most of the interventions targeted both physical activity and dietary behaviors. Among those that focused on only one dimension, physical activity was targeted more than diet. The duration of the interventions greatly varied, but many were short-term or brief. Many interventions were also based on some behavioral theory, with social cognitive theory as the most widely used. Most of the interventions focused on short-term changes, and rarely did any perform a follow-up evaluation. A major limitation among after school interventions was an inadequate use of process evaluations. Overall, interventions resulted in modest changes in behaviors and behavioral antecedents, and results were mixed and generally unfavorable with regards to indicators of obesity. Recommendations for enhancing the effectiveness of after school based childhood obesity interventions are presented.

A synthesis of existing systematic reviews and meta-analyses of school-based behavioural interventions for controlling and preventing obesity

Schools are an attractive and popular setting for implementing interventions for children. There is a growing body of empirical research exploring the efficacy of school-based obesity prevention programs. While there have been several reviews on the topic, findings remain mixed. To examine the quality of evidence and compare the findings from existing systematic reviews and meta-analyses of school-based programs in the prevention and control of childhood obesity. This paper systematically appraises the methodology and conclusions of literature reviews examining the effectiveness of school-based obesity interventions published in English in peer-reviewed journals between January 1990 and October 2010. Eight reviews were examined, three meta-analyses and five systematic reviews. All of the reviews recognized that studies were heterogeneous in design, participants, intervention and outcomes. Intervention components in the school setting associated with a significant reduction of weight in children included long-term interventions with combined diet and physical activity and a family component. Several reviews also found gender differences in response to interventions. Of the eight reviews, five were deemed of high quality and yet limited evidence was found on which to base recommendations. As no single intervention will fit all schools and populations, further high-quality research needs to focus on identifying specific program characteristics predictive of success.

A systematic review to determine the effectiveness of interventions designed to prevent overweight and obesity in pre-adolescent girls

Childhood overweight/obesity is recognized as an increasing health problem. The objective of this review was to determine the effectiveness of interventions designed to prevent overweight and obesity in pre-adolescent girls. The papers included were those studying children (must include results for girls) from within the 7-11 years age range from any country and ethnic background. The included interventions lasted at least 12 weeks and modified a combination of nutrition, physical activity, knowledge, attitudes or health-related behaviours associated with the development of childhood overweight and obesity. Effect sizes were calculated where possible using Cohen's classifications of small (0.2-0.5), medium (0.5-0.8) and large (>0.8) effect sizes. Thirty studies met the inclusion criteria of which four were cluster randomized controlled trials, 14 were randomized controlled trials, 11 were controlled trials and one was a cohort pre-post trial. There were four weak, 11 moderate and 15 strong quality studies. Eleven studies were considered short term and 19 long term (≥12 months). There were 66 effect sizes less than 0.2, 56 categorized as low, 16 as medium and two as high. There is the potential for interventions aimed at pre-adolescent girls to reduce the risk factors associated with childhood overweight and obesity, although the sustainability of the effects of such interventions is less clear.

Links Between Adolescent Physical Activity, Body Mass Index, and Adolescent and Parent Characteristics

Identification of the relationships between adolescent overweight and obesity and physical activity and a range of intrapersonal and interpersonal factors is necessary to develop relevant interventions which target the health needs of adolescents. This study examined adolescent body mass index (BMI) and participation in moderate and vigorous physical activity (MVPA) and their associations with school year, adolescent nutrition and sedentary behaviors, parent BMI, parent physical activity, and parent support adolescent physical activity. Participants included 295 adolescents and their parents. Logistic regression was used to examine associations between adolescent BMI, MVPA, and the range of adolescent and parent characteristics. Results indicated that parents and home environments play significant roles in the development and maintenance of adolescent overweight/obesity of physical activity behaviors. School-based interventions should ensure high levels of parent involvement and target male adolescents to reduce time spent in small screen recreation and female adolescents to increase participation in MVPA.

Effects of school-based interventions targeting obesity-related behaviors and body weight change: a systematic umbrella review

This umbrella review analyzed the effectiveness of school-based interventions, applying body weight or behavioral outcomes. Twelve systematic reviews and five meta-analyses (examining 196 trials) were included. Results indicated that the effectiveness was usually referred to body weight or BMI change, with 1/3 of trials (per review) indicating significant changes in BMI or obesity prevalence. Meta-analyses yielded mixed effects (three showed significant changes in weight, BMI, or obesity). Interventions were more effective if they aimed at a reduction of sedentary behaviors, incorporated moderate-to-vigorous physical activity, and parental involvement. The inclusion of a nutrition component moderated the long-term effects of interventions. More efficient interventions lasted at least 3 months, did not aim solely at environmental changes, and were implemented in general population. Female and younger participants may benefit more from the interventions. The role of psychological theories and behavioral or cognitive mediators was rarely investigated.