[What are the determinants of childhood obesity? : A literature review as part of the project "Nationwide Monitoring of Childhood Obesity Determinants"]

Urban environment and children's health: An umbrella review of exposure response functions for health impact assessment

BACKGROUND

Urban settlements have become the main living environment. Understanding the impact of urban exposures on human health has therefore become a growing area of research. Up-to-date knowledge about the influence of urban exposures on pregnant women's and children's health is especially relevant, as they are particularly vulnerable to certain external influences.

AIM

This review aims to provide a synthesis of systematic reviews with meta-analyses reporting on an association between the urban environmental risk factors and health outcomes in pregnancy, infants, children and adolescents.

METHODS

We conducted an umbrella review, methodically analysing systematic reviews with meta-analyses, published between January 2016 and December 2022 in PubMed or Scopus. Adhering to the PRISMA checklist, we searched for free text using Medical Subject Headings (MeSH) terms related to air pollution, noise pollution, temperature, green space exposure, built and food environment, health outcomes, children (aged 0-18 years), pregnancy and systematic reviews with meta-analyses. We extracted key characteristics of each included study and assessed the quality of the included studies via the R-AMSTAR 2 tool.

RESULTS

Twenty-four studies met our inclusion criteria and identified 104 associations including 15 exposures and 60 health outcomes. The most frequently studied associations were related to air pollutants, followed by the built and food environment and noise. Birth outcomes (including low birth weight, pre-term birth or stillbirth) were the most commonly affected health outcomes, followed by respiratory outcomes such as asthma or respiratory infections. A total of 45 exposure-response function were reported to be statistically significant, including 10 exposures and 23 health effects.

CONCLUSION

This umbrella review provides an overview of the evidence and availability of exposure response functions between selected urban exposures and child health outcomes. This helps to identify research gaps and to build the basis for health impact assessment.

[Reference evaluations for estimating prevalence, incidence, and mortality of public health relevant diseases based on routine data]

The routine data of all statutorily insured persons according to the Data Transparency Regulation (DaTraV data) represent a promising data source for the recurrent and timely surveillance of non-communicable diseases (NCDs) in Germany. Thereby, it has become apparent that there is a high demand for reference evaluations that enable quick and regularly repeatable analyses on important NCDs. Against this background, ReFern-01 was initiated, a joint project of the Robert Koch Institute (RKI) and the Federal Institute for Drugs and Medical Devices (BfArM). In collaboration with experts from the field of secondary data analysis and healthcare research, reference evaluations for estimating prevalence, incidence, and mortality for important public health-relevant diseases were developed. First, 11 central NCDs were selected by means of an online survey, and initial case definitions were created in conjunction with a literature review. These were then discussed and agreed upon in a virtual workshop. The created reference evaluations (analysis scripts) allow a standardized estimation of the mentioned epidemiological figures, which are comparable over time and regionally. In addition to providing the results, the scripts will be available at the BfArM for further analysis. Provided that remote access to the analysis of the DaTraV data is available in the future, the results of the ReFern project can strengthen the surveillance of NCDs and support public health actors, for example, in the planning and implementation of health promotion and prevention measures at the federal, state, county, and local levels.

Neighborhood and Behavioral Effects on Weight Change Across Immigrant Generations: Evidence from the National Longitudinal Study of Adolescent to Adult Health (Add Health)

BACKGROUND

Childhood obesity is a global problem that disproportionately affects minority populations in the USA. Relative to all US-born individuals, some foreign-born populations also experience higher obesity risk. Prior research focuses on the role of healthy behaviors in increasing obesity risk, but the neighborhoods in which individuals reside shape those behaviors. The aim of this study is to examine how changes in health behaviors and neighborhood characteristics affect weight change across immigrant generational groups.

METHODS

The study uses a prospective longitudinal cohort of 3,506 adolescents first interviewed in 1994 (The National Longitudinal Study of Adolescent to Adult Health). To examine the relationship between immigrant generational status and weight change over time while considering healthy behaviors and the neighborhood environment, this research relies on linear multilevel methods.

RESULTS

Neighborhood disadvantage, not health behaviors, has a significant effect on weight change - for both first-generation Asians (β = 1.52; p < 0.001) and Latinxs across all immigrant generations. In neighborhoods where residents do not engage in much exercise, the role that one's level of physical activity plays in weight change is lower than in places where residents engage in much exercise, irrespective of immigrant generation.

CONCLUSION

These findings provide some evidence that neighborhood features and physical activity in the neighborhood may curb obesity risk among adolescents and young adults. The results can inform urban planning efforts and community-based interventions to increase physical activity across ethnic minority populations.

Preschoolers BMI: Associations with Patterns of Caregivers' Feeding Practices Using Structural Equation Models

Background: Childhood obesity is a major health concern. Caregivers' feeding practices are modifiable targets of obesity prevention. The study tested two hypotheses: (1) autonomy-promoting feeding practices are associated with lower BMI; and (2) diet mediates the association. We also explored examined whether feeding practices and BMI z-score (BMIz) associations are moderated by child sex, caregiver race, education, family poverty level, and food insecurity. Methods: Cross-sectional study of 437 preschoolers (44.4% girls, 38.2% Black/Other, mean age 48.1 months) and caregivers (90.2% female) from 50 child care centers. Feeding Practices were measured by Comprehensive Feeding Practices Questionnaire, child-size perception by preschooler silhouettes, temperament by the Behavior Rating Inventory of Executive Function, child diet by Young Children Food and Drink Questionnaire, and BMIz by measured weight and height. Latent profile analysis delineated feeding practice patterns. Structure equation modeling assessed the patterns in relationship to BMIz. Mediation and multiple-group analyses were used to assess mechanisms of feeding practice patterns and BMIz association. Results: From the three feeding practice patterns, Controlling, Balancing, and Regulating, Regulating was associated with lower child BMIz (b = -0.09) compared to Controlling. Higher difficult temperament (b = 0.09), higher caregiver BMIz (b = 0.26), and caregiver desire for thinner (b = 0.23) were associated with BMIz (p < 0.05). Evaluations of moderators and mediators were not significant. Conclusions: Comprehensive feeding practices support family factors related to child BMIz. Longitudinal research is needed to examine temporal associations between feeding practices and BMIz, with attention to autonomy-supporting practices, promotion of young children's self-regulation, and caregivers' perceptions of child temperament and size. Trial Registration: NCT03111264.

Kommunal verankerte Versorgungsstrukturen zur Förderung der Ernährungsgesundheit in den ersten 1000 Tagen – eine Analyse des aktuellen Status quo

Ziel

Die Ernährung in den ersten 1000 Tagen stellt einen relevanten Einflussfaktor für eine gesunde (Gewichts)entwicklung von Kindern dar. Verhältnispräventive, kommunalbasierte Ansätze scheinen am Erfolg versprechendsten in der Bekämpfung von (kindlichem) Übergewicht bzw. nicht übertragbaren Erkrankungen zu sein. Ziel dieser Arbeit war es, Strategien zum Gelingen der Ernährungsgesundheit in den ersten 1000 Tagen herauszuarbeiten.

Methodik

Auf Basis einer internetbasierten Recherche möglicher kommunalbasierter Praxisprojekte wurden standardisierte, leitfadengestützte Interviews mit Expertinnen und Experten aus Wissenschaft und Praxis durchgeführt. Der Fokus lag auf der allgemeinen Einschätzung der Versorgungslage bzw. einem möglichen Handlungs- und Versorgungsbedarf sowie konkreten Handlungsempfehlungen unter besonderer Berücksichtigung von Schwangeren bzw. jungen Familien in belasteten Lebenslagen. 14 von 40 im Schneeballverfahren ausgewählten Personen nahmen teil.

Ergebnisse

Alle Teilnehmenden schätzen die aktuelle primärpräventive Versorgung als nicht ausreichend ein. Als kritisch wurden von ihnen v. a. die fehlenden strukturellen und politischen Rahmenbedingen, insbesondere die häufig bestehenden zeitlich begrenzten Programme, gesehen. Dadurch seien Maßnahmen zur Förderung der Ernährungsgesundheit oder vergleichbare Interventionen nicht erfolgreich zu etablieren. Gefordert wurde daher eine deutlichere Unterstützung durch politische und andere relevante Stakeholder, z. B. Krankenversicherungen und Vernetzung mit bzw. Einbettung dieses Themenfeldes in den öffentlichen Gesundheitsdienst.

Schlussfolgerung

Unsere Ergebnisse bestätigen aus Sicht von Expertinnen und Experten, dass die Förderung der Ernährungsgesundheit in den ersten 1000 Tagen sinnvoll und wichtig ist. Allerdings ist ein deutlicher Optimierungsbedarf hinsichtlich der Versorgungsstrukturen und der konkreten nachhaltigen Umsetzung von primärpräventiven Angeboten sowie niederschwelligen Zugängen für belastete Schwangere und Familien erkennbar.

Dairy intake and long-term body weight status in German children and adolescents: results from the DONALD study

PURPOSE

To analyse the association between intake of total dairy (TD) and types of dairy [liquid dairy (LD), solid dairy (SD), low-fat dairy (LFD), high-fat dairy (HFD), high sugar dairy (HSD), low-sugar dairy (LSD), not fermented dairy (NFD), as well as fermented dairy (FD)] and long-term changes in body weight status and composition among children and adolescents in Germany.

METHODS

In total, 9999 3-day dietary records collected between 1985 and 2019 by 1126 participants (3.5-18.5 years; boys: 50.8%) of the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) study were analysed. Polynomial mixed-effects regression models were used to examine whether changes (median follow-up: 9 years) in the intake of TD and dairy types (in 100 g/1000 kcal total energy intake) were associated with changes in body-mass-index-standard-deviation-score (BMI-SDS); fat mass index (FMI); fat-free mass index (FFMI) over time.

RESULTS

An individual increase in TD intake was slightly but significantly associated with an increase in BMI-SDS (β = 0.0092; p = 0.0371), FMI (β = 0.022; p = 0.0162), and FFMI (β = 0.0156; p = 0.0417) after adjustment for potential confounder. Analyses for LD (BMI-SDS: β = 0.0139; p = 0.0052; FMI: β = 0.0258; p = 0.0125; FFMI: β = 0.0239; p = 0.0052) and LSD intake (BMI-SDS: β = 0.0132; p = 0.0041, FMI: β = 0.02; p = 0.0316, FFMI: β = 0.0183; p = 0.0189) showed similar results to TD. Both processing method and fat content showed no association with body composition in our analyses.

CONCLUSION

Increases in TD, LD, and LSD intake showed small but significant increases in BMI and concomitant increases in fat mass and lean mass. However, the observed changes were too small to expect biological or physiological meaningful effects. Overall, our results showed that policies to promote dairy intake in childhood are to be welcomed, as no negative effects on body composition are expected, while the intake of important nutrients for growth is ensured. The type of dairy does not seem to matter.

Impact of self-determination theory in a physiotherapeutic training : A pilot-study on motivation for movement of obese adolescents

Background

This study determined to what extent the underpinning of physiotherapeutic interventions with the evidence-based motivational psychological concept of the self-determination theory (SDT) by Ryan and Deci can increase motivation and enjoyment of movement in obese adolescents.

Methods

In this study 12 obese adolescents aged 14–18 years were offered a targeted group-specific sports program including a home exercise program of 8 weeks. The group leaders were trained in the SDT and supported to integrate motivational aspects. A SDT-based questionnaire by Kohake and Lehnert was used to evaluate motivational interventions.

Results

In total, seven (58%) patients finished the study. In the before-after comparison there were little changes in motivation. Results showed that contrary to expectations the motivation of the obese adolescents to move and to participate in the study was generally high. In the study, more internalized forms of motivation dominated, the highest quality form of motivation.

Conclusion

Digital technologies could be a successful way to further increase motivation and compliance of our target group. This MotiMove study is a basis for future research programs and empower physiotherapists and movement experts to develop and implement training programs for obese adolescents and children.

Supplementary Information

The online version of this article (10.1007/s00508-021-01849-4) contains supplementary material, which is available to authorized users.

Health-related quality of life in children and adolescents with overweight and obesity: results from the German KIGGS survey

BACKGROUND

The well-being of persons with overweight and obesity, in particular of children and adolescents, may be impaired. The present study investigates the health-related quality of life (HRQoL) of girls and boys with overweight and obesity living in Germany as compared to those of normal-weight, while taking a selection of relevant determinants of HRQoL into account.

METHODS

The sample comprises 1771 children and adolescents aged 11 to 17 years that took part in the cross-sectional German Health Interview and Examination Survey for Children and Adolescents (KIGGS Wave 2, 2014-2017). Sex-and age-specific BMI (kg/m2) percentiles were utilized to classify overweight and obesity. HRQoL was measured with the KIDSCREEN-27 questionnaire, which gathers detailed information about the five dimensions physical and psychological well-being, well-being regarding peers (i.e., social acceptance), parents (i.e., autonomy) and within the school environment. Multiple regression analyses were performed with HRQoL dimensions as outcomes to test for differences between children and adolescents with normal-weight vs. those with overweight and vs. those with obesity, separately for girls and boys. In a next step, age, physical activity, media consumption, social support and self-efficacy were considered as potential confounders in the analyses.

RESULTS

18.7% of the children and adolescents under study were affected by overweight and among them 8.0% by obesity. After adjusting for potential confounders, overweight and obesity were associated with lower physical well-being as compared to normal weight in both sexes (boys with overweight: standardized beta [β] = -.14, standard error [SE] = .03, p < .001, and obesity: β = -.16, SE = .03, p < .001; girls with overweight: β = -.09, SE = .04, p = .011, and obesity: β = -.11, SE = .03, p = .003). Results moreover suggest lower levels of psychological (β = -.10, SE = .04, p = .002) and parent-related well-being (β = -.08, SE = .04, p = .036) of boys with obesity as compared to normal-weight peers.

CONCLUSION

HRQoL of German children and adolescents with overweight and obesity is impaired according to physical well-being in general, while psychological and parent-related well-being is particularly affected in boys. Public health approaches should therefore promote children and adolescents with overweight and obesity by improving diverse facets of HRQoL as well as relevant associated factors (i.e., media consumption, self-efficacy) in general and in boys in particular.

Body Mass Index Changes in Early Childhood

OBJECTIVE

To longitudinally investigate body mass index (BMI) in young children in Ireland and identify factors and critical time points associated with changes in BMI.

STUDY DESIGN

Data on 11 134 children were collected in the nationally representative Growing Up in Ireland infant cohort study. Height and weight were measured at 9 months, 3 years, and 5 years of age. Multilevel regression was used to identify risk factors associated with changes in BMI over time (n = 10 377), combining a unique set of covariates collected from the child and the 2 main caregivers (usually the mother and father).

RESULTS

The proportion of children ≥85th percentile of World Health Organization growth criteria was 39% at 9 months, 44% at 3 years, and 30% at 5 years. Children born large for gestational age (13%) and those with rapid infant weight gain (25%) consistently had higher BMI. Low average BMIs were consistently seen in children born small for gestational age (10%) or before 37 weeks (7%). Smaller variations in BMI existed for other factors including ethnicity, household structure, caregiver weight status, breastfeeding, sex, socioeconomic status, sleeping hours, childcare, and region.

CONCLUSIONS

In this study, differences at birth and in infancy appear to be most strongly associated with variation in BMI at all ages. Nevertheless, belonging to a number of other high-risk groups cumulatively could lead children to develop critical weight states. Policy-makers should target families with interventions before and during pregnancy when dominant risk factors are still modifiable. Longer-term follow-up of children may be needed to study associations later in childhood.

Preconception Optimization of Glucose and Insulin Metabolism in Women Wanting to Conceive - High Rate of Spontaneous Conception Prior to Planned Assisted Reproduction

Background

A hyperglycemic metabolic status with insulin resistance can have a negative effect on fertility and pregnancy outcomes. The aim of this retrospective study was to investigate disorders of glucose and insulin metabolism in women wanting to conceive who conceived spontaneously prior to planned assisted reproduction (ART). Associated risk factors of patients in terms of live births and miscarriages were also analyzed.

Method

Out of total study population of 589 pregnancies, the pregnancies of 129 women wishing to have children who conceived spontaneously prior to planned ART were analyzed in more detail. A 75 g OGTT (OGTT: oral glucose tolerance test) was carried out prior to conception and after determination of pregnancy, including glucose measurement and testing of insulin resistance. If anomalies or risk factors for gestational diabetes (GDM) were detected, patients received metformin therapy prior to conception (off-label use). The course and outcome of pregnancies in the defined cohort were recorded.

Results

The rate of spontaneous conception before planned ART after treatment for disorders of glucose/insulin metabolism was 21.9% (n = 129/589). 66.7% of the 129 pregnancies resulted in a live birth, 32 patients had a miscarriage. 76.0% of patients were treated with metformin (off-label use) for polycystic ovary syndrome (PCOS), positive risk profile for GDM, or abnormal glucose/insulin metabolism prior to conception. 55.8% of the cohort developed GDM. The insulin requirements of patients with GDM differed significantly depending on their metformin intake. 24.6% of GDM patients receiving metformin treatment developed GDM requiring insulin treatment compared to 53.8% who did not receive metformin medication. The PCOS rate in the study population who had live births was significantly higher (57.0%) than in the group who had miscarriages (31.3%). There were no significant differences with regard to rate of live births and rate of miscarriages with/without metformin treatment and GDM and metformin intake.

Conclusion

The high rate of spontaneous conceptions in the cohort of women wishing to conceive emphasizes the importance of optimizing glucose/insulin metabolism prior to conception. The high rate of GDM in a cohort of pregnant women with a history of sterility also emphasizes the importance of expanding diagnostic testing for sterility to include the investigation of glucose metabolism and testing for insulin resistance. It is possible that PCOS patients in particular could benefit from treatment with metformin prior to conception, and this could explain the high rate of live births in this patient cohort.

[Prevention of overweight and obesity in children and adolescents : Critical appraisal of the evidence base]

BACKGROUND

Despite careful planning and implementation, overweight/obesity prevention interventions in children and adolescents typically show no, inconsistent or merely weak effects. Such programs usually aim at behavior changes, rarely also at environmental changes, that draw upon conventional wisdom regarding the commonly accepted determinants of childhood overweight/obesity.

OBJECTIVE

This paper evaluates the evidence base of the apparently overweight-/obesity-related determinants diet, physical activity and stress. The results of international intervention studies are discussed against this background.

METHODS AND MATERIALS

Based on the mediating-moderating variable model, we investigate the effect of theory specified mediating variables and how potential moderating variables may impact these relationships.

RESULTS

Contrary to common beliefs, recent research has revealed inconsistent evidence regarding associations between potentially obesogenic behaviors and overweight/obesity in youth. Moreover, the evidence for strong and causal relationships between mediating variables and targeted behaviors seems to be inconsistent. In addition, inadequate attention is paid to moderating effects.

DISCUSSION

The etiology of overweight/obesity in youth is likely the result of a complex interplay of multi-causal influences. Future prevention interventions would benefit from a more thorough understanding of the complex relationships that have been hypothesized and of the mechanisms of suspected behaviors for affecting overweight/obesity. Only if substantial change can be demonstrated in mediators with reasonable effort under real world circumstances, it will make sense to progress to community behavior change trials.

[Non-selective primary prevention programs for childhood overweight : An overview]

BACKGROUND

Despite an obvious stabilization the prevalence of childhood overweight and obesity is still too high. Since childhood obesity may track into adulthood and lead to major health consequences, effective primary prevention programs are of high relevance.

OBJECTIVE

In recent years several universal primary prevention programs, measures or projects have been developed and evaluated in Germany. This paper gives an overview.

METHODS

An internet search and a search in the archive of the Deutsche Ärzteblatt were conducted to identify universal programs in Germany from 2006 to 2015. We used the combination of primary prevention, children, obesity and project for this online search.

RESULTS

We identified 38 programs and measures. After exclusion of non-adequate interventions (e. g. selective instead of universal) and any duplicates we selected 13 projects to be described.

DISCUSSION

Some projects provided insufficient information since they have not been adequately published. On the positive side, most projects simultaneously addressed various potential risk factors and achieved a successful networking of various relevant actors. In addition, many projects strived for creating the groundwork to allow for a sustainable change in the living environment of children. However, despite the fact that the concept of most projects was theory-based in most cases only weak intervention effects were observed on strong endpoints like anthropometric indicators and on health-related behaviors.

[Effectiveness of combined interventions for the prevention of overweight for children and youths : A systematic review]

BACKGROUND

Prevalence rates of overweight children and youths remain high meaning that preventive measures are still necessary. Combined interventions are rated highly in the field of overweight prevention, particularly with regard to the key areas of diet, physical activity and life skills.

OBJECTIVES

It is our aim to give an overview of current studies with combined interventions for the prevention of overweight, to derive comprehensive insights and to identify knowledge gaps.

METHODS

A systematic review of combined interventions for 6-16 year old children and youths forms the basis of this contribution. Twelve data bases, the internet and references were searched for controlled studies. Study quality was appraised with the EPHPP-tool; if randomisation was present the risk of bias was assessed. Studies with the explicit aim of preventing overweight were analysed separately.

RESULTS

Thirteen studies remained from 12,136 screened titles. Interventions were school-based and occasionally different intervention sites were linked to each other. All 13 interventions involved measures focusing on diet, physical activity and life skills; measures targeting structures and conditions were inadequately represented. The duration of intervention and follow-up time points varied widely. More than half of the studies reported positive effects on body mass index.

CONCLUSIONS

The number of published controlled studies with combined interventions is surprisingly low. With regard to the prevention of overweight, the potential of life skills programs seems not yet to be exhausted; measures targeting structures and conditions are insufficiently utilised.