Determinants of obesity in the Ulm Research on Metabolism, Exercise and Lifestyle in Children (URMEL-ICE)

Gender differences and climate zones in overweight and obesity prevalence in European elementary school children from 2000 to 2020: a systematic review and meta-analysis

Introduction

After 2000, there are more obese than underweight people in the world. We face a rapid increase in average global warming of 1.5°C, reported as a syndemic problem of three interconnected epidemics: obesity, global warming, and undernutrition. We aimed to analyze the impact and association between global warming and obesity in children and differences by gender across Europe after 2000.

Methods

We searched PubMed, MEDLINE, Google Scholar, ScienceDirect, and Embase databases. The considered population were children aged 6-14. Only cross-sectional studies that defined obesity by the IOTF cutoffs and the subjects' place of residence, used to determine precise climate zones, were included. We assessed the prevalence of obesity and overweight using a random-effects and the Mantel-Haenszel fixed-effect method when heterogeneity was greater/lower than 50%. We did a subgroup analysis for prevalence across gender, obesity, and overweight, two decades, regions, countries, and the Köppen-Geiger climate zones. Random effects of the meta-regression were used to study the global warming impact and differences in trends across European countries by gender for both conditions separately.

Results

We identified 114 studies that included 985,971 children from 39 European countries. A significant difference between genders was in favor of obese girls 4.78 (95% CI: 3.85-5.93) versus boys 5.76% (95% CI: 5.11-6.48, p = 0.03), respectively, but not for overweight children. Most of the obese girls were in South Europe 7.51% (95% CI: 6.61-8.51) versus East Europe 2.86% (95% CI: 23-3.12), versus boys in South Europe 8.66% (95% CI: 7.68-9.74) and North Europe 3.49% (95% CI: 2.90-4.19), respectively. The "cold" Köppen-Geiger climate zone, with lowest temperatures, has the largest trend rise between two decades of 2.8% and 1.53% for obese girls and boys, and 5.31% and 1.81% for overweight girls and boys, respectively, followed by the smallest number of obese girls 3.28% (95% CI: 2.17-4.92) and boys 3.58% (95% CI: 2.39-5.33), versus the zone with the highest temperatures "hot" for girls 7.02% (95% CI: 6.30-7.82) and for boys 8.23% (95% CI: 7.55-8.96), respectively. The meta-regression proved global warming has a significant impact on the distribution of obesity and overweight across climate zones, R2 = 0.52 and R2 = 0.22. No significant gender differences, or significant interaction, was noted.

Conclusion

Our meta-analysis provides a comprehensive overview of the association between and impact of global warming on obesity. This impact increases obesity among children in Europe throughout all climate zones, and emphasizes an urgent call for further preventive methods in schools, since obesity differences continue their trend of disappearing into the future.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021282127, identifier: CRD42021282127.

Unnecessary hospitalisations and polypharmacy practices in Tajikistan: a health system evaluation for strengthening primary healthcare

BACKGROUND

Children and pregnant women require multiple contacts with the healthcare system. While most conditions can be managed by primary healthcare (PHC) providers, hospitalisations are common. This health system evaluation in Tajikistan quantifies unnecessary and unnecessarily prolonged hospitalisations and assesses antibiotic and polypharmacy practices.

METHODS

Data were retrospectively collected from randomly selected medical records from 15 hospitals. Inclusion criteria were children 2-59 months of age with a primary diagnosis of acute respiratory infection or diarrhoea, or pregnant women with threatened preterm labour, threatened miscarriages, premature rupture of membranes or mild pre-eclampsia, hospitalised between January and September 2021.

RESULTS

Among 440 children and 422 pregnant women, unnecessary hospitalisations accounted for 40.5% and 69.2% of hospitalisations, respectively, ranging from 0% to 92.7% across the hospitals. Among necessary hospitalisations, 63.0% and 39.2% were unnecessarily prolonged in children and women, respectively.Prior to admission, 36.8% of children had received antibiotics, in which more than half intramuscularly. During hospitalisation, 92.5% of children and 28.9% of women received antibiotics. Children and women received an average of 5 and 6.5 drugs, respectively; most were not indicated or with no evidence of benefits.

CONCLUSIONS

The methodology is applicable across all health systems and can provide important insights on health service use and resource waste. Findings of this assessment in Tajikistan have led to evidence-based decisions and actions from stakeholders and policy makers with the goal of strengthening PHC and improving the management of common diseases in children and pregnant women.

Birth and Health Outcomes of Children Migrating With Parents: A Systematic Review and Meta-Analysis

Objective

To examine the birth and health outcomes of children migrating with parents internationally and domestically, and to identify whether the healthy migration effect exist in migrant children.

Methods

Five electronic databases were searched for cross-sectional, case-control, or cohort studies published from January 1, 2000 to January 30, 2021and written by English language, reporting the risk of health outcomes of migrant children (e.g., birth outcome, nutrition, physical health, mental health, death, and substance use) We excluded studies in which participants' age more than 18 years, or participants were forced migration due to armed conflict or disasters, or when the comparators were not native-born residents. Pooled odd ratio (OR) was calculated using random-effects models.

Results

Our research identified 10,404 records, of which 98 studies were retrained for analysis. The majority of the included studies (89, 91%) focused on international migration and 9 (9%) on migration within country. Compared with native children, migrant children had increased risks of malnutrition [OR 1.26 (95% CI 1.11-1.44)], poor physical health [OR 1.34 (95% CI 1.11-1.61)], mental disorder [OR 1.24 (95% CI 1.00-1.52)], and death [OR 1.11 (95% CI 1.01-1.21)], while had a lower risk of adverse birth outcome [OR 0.92 (95% CI 0.87-0.97)]. The difference of substance use risk was not found between the two groups.

Conclusion

Migrant children had increased risk of adverse health outcomes. No obvious evidence was observed regarding healthy migration effect among migrant children. Actions are required to address the health inequity among these populations.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/#myprospero, identifier: CRD42021214115.

Family socioeconomic status and childhood adiposity in Europe - A scoping review

Childhood obesity is a considerable public health problem worldwide. In Europe, lower parental socioeconomic status (SES) relates to higher childhood adiposity. This scoping review strives to discover, which SES indicators are the most commonly used and meaningful determinants of childhood adiposity (greater level of continuous adiposity indicator, e.g. body mass index z-score, or overweight or obesity categorized by established definitions). The review focused on studies about European general populations from the 21st century (January 2000-April 2021) considering children and adolescents aged 0-17 years. PubMed and reference lists of articles were searched in February-April 2021. Total of 53 studies with 121 association analyses between different SES indicators and adiposity indicators, were identified and reviewed. Different SES indicators were grouped to 25 indicators and further to six indicator groups. The most used indicator was mother's education (n of association analyses = 24) and the most used indicator group was parental education (n of association analyses = 51). Of all association analyses, 55% were inverse, 36% were non-significant, and 8% were positive. Composite SES (80%), parental education (69%) and parental occupation (64%) indicators showed most frequently inverse associations with obesity measures (i.e. lower parental SES associating with higher adiposity), while parental income (50% inverse; 50% non-significant) and property and affluence (42% inverse; 50% nonsignificant) indicators showed approximately even number of inverse and non-significant associations. Instead, majority of parental employment (60%) indicators, showed non-significant associations and 33% showed positive associations (i.e. higher parental SES associating with higher adiposity). Despite some variation in percentages, majority of the associations were inverse in each age group and with different outcome categorizations. In girls and in boys, non-significant associations predominated. It seems that children with parents of higher SES have lower likelihood of adiposity in Europe. Parents' employment appears to differ from other SES indicators, so that having an employed parent(s) does not associate with lower likelihood of adiposity. Positive associations seem to occur more frequently in poorer countries. Criteria for uniform childhood SES and adiposity measures should be established and used in studies in order to be able to produce comparable results across countries.

Aetiological research on the health of migrants living in Germany: a systematic literature review

BACKGROUND

Germany has become an important immigration country and health services need to adopt to meet the needs of an increasingly multicultural population. For public health planning, it is essential to understand the aetiology of health problems among migrant populations. The main objective was to systematically identify, evaluate and synthesise population-based studies that investigated exposure-outcome relationships among migrant groups in Germany.

METHODS

In November 2019, we searched PubMed and LIVIVO, and updated this search in November 2020, to identify peer-reviewed publications that fulfilled our eligibility criteria: English or German language; study on disease aetiology among major migrant groups in Germany, according to the latest microcensus; publication date from inception to 01 November 2020 and observational or experimental study designs. For quality appraisal, we used the Critical Appraisal Skills Programme checklists. Outcomes under investigation were categorised according to the WHO major disease groups, and their associations with risk factors were synthesised as a heat map.

RESULTS

Out of 2407 articles retrieved, we included 68 publications with a total number of 864 518 participants. These publications reported on cross-sectional data (n=56), cohort studies (n=11) and one intervention study. The population groups most frequently studied were from the Middle East (n=28), Turkey (n=24), sub-Saharan Africa (n=24), Eastern Europe (n=15) and the former Soviet Union (n=11). The outcomes under study were population group specific. There were consistent associations of demographic and socioeconomic factors with ill health among migrants in Germany.

DISCUSSION

In this systematic review, we observed low risk of bias in two-thirds of the studies. There is an increasing body of evidence for aetiological research on migrants' health in Germany. Still, the directions of associations between a wide range of risk factors and major disease groups seem only partially understood.

PROSPERO REGISTRATION NUMBER

CRD42018085074.

Residential mobility and potentially avoidable hospitalisations in a population-based cohort of New Zealand children

BACKGROUND

Residential moves are common in early childhood and associations have been found between residential mobility and adverse child health and well-being outcomes. Although there are studies on potentially avoidable hospitalisations (PAH) in children, few have examined PAH in relation to residential mobility. Our aim, therefore, was to investigate residential mobility and PAH in a population-based cohort of New Zealand children.

METHODS

Using a retrospective cohort design, we analysed data from the Integrated Data Infrastructure for a cohort of 314 283 children born since the start of 2004, who had at least one residential address recorded by 2 years of age. Residential mobility was derived from address data and PAH were determined from hospital discharge data.

RESULTS

Half of the cohort children (52%) experienced at least one residential move by 2 years of age, and 22% experienced two or more moves. Fifteen per cent of the cohort experienced one or more PAH between 2 and 4 years of age. A linear association between residential mobility and PAH was found (relative risk (RR)=1.18, CI 1.17 to 1.19) and this remained robust when adjusting for several covariates. Sensitivity analyses for ambulatory care sensitive hospitalisations (ACSH) and PAH attributable to the housing/physical environment (PAH-HE) produced results very similar to those for PAH (ACSH: adjusted RR (aRR)=1.10, CI 1.09 to 1.11; PAH-HE: aRR=1.11, CI 1.10 to 1.12).

CONCLUSION

This study found a linear association between higher residential mobility and an increased likelihood of PAH in young children. Avenues for further investigation are suggested.

Lived experience of dietary change among Chinese colorectal cancer survivors in Hong Kong: A qualitative study

OBJECTIVES

This is a qualitative study which aims to understand the lived experience of dietary changes among Chinese survivors of colorectal cancer who participated in a dietary intervention.

SETTING

The surgical and oncological departments of four public hospitals in Hong Kong.

PARTICIPANTS

Fifty-five Chinese colorectal cancer survivors who were aged 18 years or above and had received potentially curative treatment in the surgical and oncological departments in Hong Kong were examined. Participants' mean age was 64 years, with 29 (53%) males.

INTERVENTION

A 12-month dietary intervention delivered via face-to-face motivational interviews, fortnightly motivational phone calls, monthly electronic pamphlets, quarterly newsletters and quarterly group meeting.

OUTCOME MEASURE

We adopted the qualitative approach to capture participants' perspectives and to apply the understanding pragmatically in everyday life. Content analysis was conducted.

RESULTS

We identified themes of motives to changes of dietary practices including (1) individual commitment to dietary change; (2) adaptive strategies in interpersonal contexts and (3) working with healthcare professionals during the journey.

CONCLUSIONS

The findings demonstrated how Chinese custom and culture posing unique challenges to colorectal cancer survivors and the need of having dietary advice from healthcare professionals. Participants were motivated to change their eating habits by support from family, friends and healthcare professionals. Our findings could help healthcare professionals provide specific dietary advice and guidance to Chinese colorectal cancer survivors.

TRIAL REGISTRATION NUMBER

NCT01708824.

And yet Again: Having Breakfast Is Positively Associated with Lower BMI and Healthier General Eating Behavior in Schoolchildren

Given the high prevalence of childhood overweight, school-based programs aiming at nutritional behavior may be a good starting point for community-based interventions. Therefore, we investigated associations between school-related meal patterns and weight status in 1215 schoolchildren. Anthropometry was performed on-site in schools. Children reported their meal habits, and parents provided family-related information via questionnaires. Associations between nutritional behavior and weight status were estimated using hierarchical linear and logistic regression. Analyses were adjusted for age, socio-economic status, school type, migration background, and parental weight status. Having breakfast was associated with a lower BMI-SDS (βadj = -0.51, p = 0.004) and a lower risk of being overweight (ORadj = 0.30, p = 0.009), while having two breakfasts resulting in stronger associations (BMI-SDS: βadj = -0.66, p < 0.001; risk of overweight: ORadj = 0.22, p = 0.001). Likewise, children who regularly skipped breakfast on school days showed stronger associations (BMI-SDS: β = 0.49, p < 0.001; risk of overweight: OR = 3.29, p < 0.001) than children who skipped breakfast only occasionally (BMI-SDS: β = 0.43, p < 0.001; risk of overweight: OR = 2.72, p = 0.032). The associations persisted after controlling for parental SES and weight status. Therefore, our data confirm the school setting as a suitable starting point for community-based interventions and may underline the necessity of national programs providing free breakfast and lunch to children.

Use of Machine Learning to Determine the Information Value of a BMI Screening Program

INTRODUCTION

Childhood obesity continues to be a significant public health issue in the U.S. and is associated with short- and long-term adverse health outcomes. A number of states have implemented school-based BMI screening programs. However, these programs have been criticized for not being effective in improving students' BMI or reducing childhood obesity. One potential benefit, however, of screening programs is the identification of younger children at risk of obesity as they age.

METHODS

This study used a unique panel data set from the BMI screening program for public school children in the state of Arkansas collected from 2003 to 2004 through the 2018-2019 academic years and analyzed in 2020. Machine learning algorithms were applied to understand the informational value of BMI screening. Specifically, this study evaluated the importance of BMI information during kindergarten to the accurate prediction of childhood obesity by the 4th grade.

RESULTS

Kindergarten BMI z-score is the most important predictor of obesity by the 4th grade and is much more important to prediction than sociodemographic and socioeconomic variables that would otherwise be available to policymakers in the absence of the screening program. Including the kindergarten BMI z-score of students in the model meaningfully increases the accuracy of the prediction.

CONCLUSIONS

Data from the Arkansas BMI screening program greatly improve the ability to identify children at greatest risk of future obesity to the extent that better prediction can be translated into more effective policy and better health outcomes. This is a heretofore unexamined benefit of school-based BMI screening.

Which healthy lifestyle habits mitigate the risk of obesity and cardiometabolic risk factors in Caucasian children exposed to in utero adverse gestational factors?

BACKGROUND AND AIMS

This study explored if lifestyle habits [physical activity (PA), sleep duration, intake of fruits and vegetables, grains, and dairy products] can moderate the positive associations between prenatal exposure to suboptimal gestational factors (SGF: i.e. gestational diabetes mellitus, hypertensive disorders during pregnancy, maternal smoking during pregnancy) and obesity and cardiometabolic risk factors in children.

METHODS AND RESULTS

Data from the "Quebec Adiposity and Lifestyle Investigation in Youth" (QUALITY) study collected between 2005 - 2008 in Montreal and Quebec City, were used. Analyses included a sample of 619 children aged 8-10 years. Children's PA and sleep duration were obtained using an accelerometer and daily servings of food were assessed using three 24 h diet recalls. Moderation analyses were performed to investigate if each lifestyle habit, in all children, and in boys and girls, could reduce the positive associations between SGF, and obesity and cardiometabolic risk factors. High LPA duration was protective against low levels of HDL cholesterol in boys who were exposed to more than one SGF (p = 0.005). Sleep duration did not have a protective effect respectively against high waist circumference and obesity in children and girls who were prenatally exposed to maternal smoking during pregnancy. Diet and MVPA did not moderate the positive associations between SGF, obesity and cardiometabolic risk factors in children.

CONCLUSION

Among the three lifestyle habits, only LPA had a protective effect against low levels of HDL-cholesterol in boys. More studies are needed to confirm these results to inform future lifestyle intervention in this population.

A cross-sectional study using the Childhood Measurement Programme for Wales to examine population-level risk factors associated with childhood obesity

OBJECTIVE

The aim of this cross-sectional study was to examine the association between childhood obesity and modifiable population-level risk factors, after accounting for deprivation.

DESIGN

A review of the literature identified population-level risk factors including a healthy childcare setting, the local food environment, accessible open space, community safety and crime. Data for these risk factors were then identified and matched by each of the twenty-two local government areas in Wales to each child that had data on height and weight in the Wales Childhood Measurement Programme (CMP) (2012-2017). Multivariable logistic regression was used to identify associations with childhood obesity.

SETTING

The current study was undertaken in Wales, UK, where approximately one in eight 4-5-year-olds are classified as obese.

PARTICIPANTS

All participants were children aged 4 or 5 years who attend school, measured as part of the CMP, between 2012 and 2017 (n 129 893, mean age 5·0 (sd 0·4) years).

RESULTS

After adjusting for deprivation, small but statistically significant associations were found between childhood obesity and percentage of land available as accessible open space OR 0·981 (95 % CI: 0·973, 0·989) P < 0·001) and density of fast food outlets OR 1·002 (95 % CI 1·001, 1·004, P = 0·001). No other population-level risk factors were associated with childhood obesity.

CONCLUSIONS

The current study indicates that, even after accounting for deprivation, risk factors such as the density of fast food outlets and access to green space should be considered when tackling childhood obesity as a public health issue.

Potentially preventable hospitalisations in children: a comparison of definitions

OBJECTIVE

To compare admission rate, cumulative incidence and social distribution of potentially preventable hospitalisations (PPHs) among children according to the current Australian adult definition, and the child definition developed in New Zealand.

DESIGN, SETTING, PARTICIPANTS

Deidentified, linked public hospital, births registry and perinatal data of children aged 0-10 years born 2002-2012 in South Australia (n=1 91 742).

MAIN OUTCOME MEASURES

PPH admission rates among 0-10 year olds and cumulative incidence by age 5 under the adult and child definitions. Cumulative incidence was assessed across indicators of social and health disadvantage.

RESULTS

PPH admission rates among 0-10 year olds were 25.6 (95% CI 25.3 to 25.9) and 59.9 (95% CI 59.5 to 60.4) per 1000 person-years for the adult and child definitions, respectively. Greater absolute differences in admission rates between definitions were observed at younger ages (age <1 difference: 75.6 per 1000 person-years; age 10 difference: 1.4 per 1000 person-years). Cumulative incidence of PPHs among 0-5 year olds was higher under the child (25.0%, 95% CI 24.7 to 25.2) than the adult definition (12.8%, 95% CI 12.6 to 13.0). Higher PPH incidence was associated with social and health disadvantage. Approximately 80% of the difference in admission rate between definitions was due to five conditions.

CONCLUSIONS

Respiratory conditions and gastroenteritis were key contributors to the higher PPH admission rate and cumulative incidence among children when calculated under the child definition compared to the adult definition. Irrespective of definition, higher PPH cumulative incidence was associated with social and health disadvantage at birth.

Skipping breakfast is associated with overweight and obesity: A systematic review and meta-analysis

OBJECTIVE

In recent years, many original studies have shown that skipping breakfast has been associated with overweight and obesity; however, the results of different studies are inconsistent. Therefore, we conducted a systematic review and meta-analysis of observational studies to synthesize the associations between skipping breakfast and the risk of overweight/ obesity.

METHODS

We did a systematic search using Pubmed, and Ovid searched up to August 2019. Observational studies (cohort studies and cross-sectional studies) reporting adjusted Odds Ratio or Risk Ratio estimates for the association between breakfast skipping and overweight/obesity (including abdominal obesity). Summary odds ratio (or Risk Ratio) and 95% confidence intervals calculated with a random-effects model.

RESULTS

45 observational studies (36 cross-sectional studies and 9 cohort studies) were included in this meta-analysis. In cross-sectional studies, The ORs of low frequency breakfast intake per week versus high frequency were 1.48 (95% CI 1.40-1.57; I²=54.0%; P=0.002) for overweight/obesity, 1.31 (95% CI 1.17-1.47; I²=43.0%; P=0.15) for abdominal obesity. In cohort studies, The RR of low-frequency breakfast intake per week versus high frequency was 1.44 (95% CI 1.25-1.66; I²=61%; P=0.009) for overweight/obesity.

CONCLUSIONS

This meta-analysis confirmed that skipping breakfast is associated with overweight/obesity, and skipping breakfast increases the risk of overweight/obesity. The results of cohort studies and cross-sectional studies are consistent. There is no significant difference in these results among different ages, gender, regions, and economic conditions.

Association of sport participation in preterm and full term born children and body and fat mass indices from age 3 to 14 years

OBJECTIVES

To assess the association of gestational age groups (VP: <32 weeks, MP: 32-33 weeks, LP: 34-36 weeks and FT: ≥37 weeks of gestation) and club sport participation in childhood on body mass index (BMI), fat free mass index (FFMI) and fat mass index (FMI).

DESIGN

Longitudinal, cross sectional.

METHODS

BMI (age 3, 5, 7, 11 and 14 years; N=10581-14702) and FFMI/FMI (age 7, 11 and 14 years; N=10446-12996) and consistent club sport participation at age 5, 7 and 11 years (ranging from never participating to participating at all three ages) were assessed prospectively. These were compared by gestational age and their associations with BMI and FMI were investigated, while controlling for confounders (socio-economic, maternal obesity, child related, diet).

RESULTS

BMI and FFMI was lower in VP or MP until age 7, but no differences were found in BMI, FFMI or FMI after age 11 with regard to gestational age. Consistent club sport participation from age 5-11 was unrelated to BMI at ages 3-7. However, FT children with club sport participation had lower BMI and FMI at ages 11 and 14; but this association was not found in VP or MP.

CONCLUSIONS

During adolescence body composition of VP and MP become similar to FT born peers. Consistent sport participation reduces BMI and FMI in FT only. In VP or MP children modifying effects of sport on body composition might not be detected due to the catch-up growth in weight, height and fat mass at the same time.

Prevalence and Trends of Overweight and Obesity in European Children From 1999 to 2016: A Systematic Review and Meta-analysis

IMPORTANCE

Studies of trends in excess weight among European children throughout the last few decades have rendered mixed results. Additionally, some studies were outdated, were based on self-reported weight and height, or included only a few European countries.

OBJECTIVE

To assess prevalence trends in measured overweight and obesity among children across Europe from 1999 to 2016 using a systematic methodology.

DATA SOURCES

MEDLINE, Embase, CINAHL, and Web of Science were searched from their inception until May 2018. Moreover, searches were conducted on health institutions' websites to identify studies not published in scientific journals.

STUDY SELECTION

The inclusion criteria were: (1) studies reporting the population-based prevalence of excess weight (overweight plus obesity) or obesity according to body mass index cutoffs proposed by the International Obesity Task Force; (2) cross-sectional or follow-up studies; and (3) studies including populations aged 2 to 13 years.

DATA EXTRACTION AND SYNTHESIS

Literature review and data extraction followed established guidelines. The Mantel-Haenszel method was used to compute the pooled prevalence estimates and their 95% CI whenever there was no evidence of heterogeneity (I2 < 50%); otherwise, the DerSimonian and Laird random-effects method was used. Subgroup analyses by study year, country, or European region (Atlantic, Iberian, Central, and Mediterranean) were conducted. Prevalence estimates were calculated as an aggregate mean, weighted by the sample size and the number of individuals in each study.

RESULTS

A total of 103 studies (477 620 children aged 2 to 13 years) with data from 28 countries were included. The combined prevalence of overweight and obesity in the Iberian region tended to decrease from 30.3% (95% CI, 28.3%-32.3%) to 25.6% (95% CI, 19.7%-31.4%) but tended to increase in the Mediterranean region from 22.9% (95% CI, 17.9%-27.9%) to 25.0% (95% CI, 14.5%-35.5%). No substantial changes were observed in Atlantic Europe or Central Europe, where the overweight and obesity prevalence changed from 18.3% (95% CI, 14.0%-23.9%) to 19.3% (95% CI, 17.7%-20.9%) and from 15.8% (95% CI, 13.4%-18.5%) to 15.3% (95% CI, 11.6%-20.3%), respectively.

CONCLUSIONS AND RELEVANCE

The prevalence of childhood overweight and obesity is very high, but trends have stabilized in most European countries. There are substantial between-country differences in the current levels and trends of overweight and obesity. The rising prevalence in some Mediterranean countries is worrisome.

TRIAL REGISTRATION

PROSPERO identifier: CRD42017056924.

A Systematic Review of the Association of Skipping Breakfast with Weight and Cardiometabolic Risk Factors in Children and Adolescents. What Should We Better Investigate in the Future?

The incidence of skipping breakfast in pediatric subjects is rising, and a relationship with overweight (OW) and obesity (OB) has been shown. Associations with cardiovascular outcomes and skipping breakfast in adults have been reported. The purpose of this systematic review was to summarize the association of skipping breakfast with body weight and metabolic outcomes in the pediatric population. We searched relevant databases (2008–2018) and identified 56 articles, of which 39 were suitable to be included, basing on inclusion criteria (observational; defined breakfast skipping; weight and/or metabolic outcomes). Overall, 286,804 children and adolescents living in 33 countries were included. The definitions of OW/OB, skipping breakfast, and the nutrient assessment were highly heterogeneous. Confounding factors were reported infrequently. The prevalence of skipping breakfast ranged 10–30%, with an increasing trend in adolescents, mainly in girls. Skipping breakfast was associated with OW/OB in the 94.7% of the subjects. The lack of association was shown mainly in infants. Moreover, 16,130 subjects were investigated for cardiometabolic outcomes. Skipping breakfast was associated with a worse lipid profile, blood pressure levels, insulin-resistance, and metabolic syndrome. Five studies reported a lower quality dietary intake in breakfast skippers. This review supports skipping breakfast as an easy marker of the risk of OW/OB and metabolic diseases, whether or not it is directly involved in causality. We encourage intervention studies using standardized and generalizable indicators. Data on confounders, time of fasting, chronotypes, and nutrition quality are needed to establish the best practice for using it as a tool for assessing obesity risk.

Directed acyclic graphs: a tool for causal studies in paediatrics

Many paediatric clinical research studies, whether observational or interventional, have as an eventual aim the identification or quantification of causal relationships. One might ask: does screen time influence childhood obesity? Could overuse of paracetamol in infancy cause wheeze? How does breastfeeding affect later cognitive outcomes? In this review, we present causal directed acyclic graphs (DAGs) to a paediatric audience. DAGs are a graphical tool which provide a way to visually represent and better understand the key concepts of exposure, outcome, causation, confounding, and bias. We use clinical examples, including those outlined above, framed in the language of DAGs, to demonstrate their potential applications. We show how DAGs can be most useful in identifying confounding and sources of bias, demonstrating inappropriate statistical adjustments for presumed biases, and understanding threats to validity in randomised controlled trials. We believe that a familiarity with DAGs, and the concepts underlying them, will be of benefit both to the researchers planning studies, and practising clinicians interpreting them.

Sugar Restriction for Caries Prevention: Amount and Frequency. Which Is More Important?

The World Health Organization guideline to use less sugar may be an opportunity and support for dentistry in its goal to get the message of using less sugar across to the public. Two ways (with all the combinations of these) to achieve a reduction of sugar consumption are the reduction of the amount of sugar in products or the reduction of the frequency of consumption of sugar-containing products. Which sugar-reducing strategy is best for caries prevention? To answer this question, this manuscript discusses the shape of the dose-response association between sugar intake and caries, the influence of fluoridated toothpaste on the association of sugar intake and caries and the relative contribution of frequency and amount of sugar intake to caries levels. The results suggest that when fluoride is appropriately used, the relation between sugar consumption and caries is very low or absent. The high correlation between amount and frequency hampers the decision related to which of both is of more importance, but frequency (and stickiness) fits better in our understanding of the caries process. Reducing the amount without reducing the frequency does not seem to be an effective caries preventive approach in contrast to the reciprocity. Goals set in terms of frequency may also be more tangible for patients to follow than goals set in amount. Yet, in sessions of dietary counselling to prevent dental caries, the counsellor should not forget the importance of quality tooth brushing with fluoride toothpaste.

Risk of rehospitalisation and death for vulnerable New Zealand children

OBJECTIVES

There is considerable need to improve the effectiveness of healthcare to reduce morbidity and mortality. Child hospitalisations are influenced by determinants of health, including the home environment. Our aims were: (1) To investigate whether children hospitalised with potentially avoidable conditions thought to be associated with the home have an increased risk of rehospitalisation and death, (2) To investigate whether children hospitalised with particular subgroups of potentially avoidable conditions have an increased risk of rehospitalisation and death, (3) To assess the usefulness of these subgroups for identifying at-risk children.

DESIGN

We used four existing groups of potentially avoidable conditions developed based on expert opinion: 1. the potentially avoidable hospitalisations (PAH) group, associated with social/environmental conditions, 2. the potentially avoidable hospitalisations attributable (at least in part) to the home environment (PAHHE) group, 3. the crowding group, and 4. the Ministry of Health (MoH) group. We analysed national New Zealand hospital discharge data (2000-2014). Rehospitalisation and death were described using Kaplan-Meier curves. Group effectiveness for identifying at-risk children was assessed using Cox proportional hazard models with children hospitalised for non-PAH conditions as comparison.

RESULTS

In total, 1425085 hospital admissions occurred, for 683115 unique children. Rehospitalisation was relatively common (71.0%). Death was rare (0.6%). All groups performed moderately well identifying at-risk children. Children with PAH have increased risk of rehospitalisation (adjusted HR (aHR):2.30-3.60) and death (aHR:3.07-10.44). PAH group had highest sensitivity (75.1%). The MoH group has the highest positive predictive value (rehospitalisation: 86.2%, death: 2.5%).

CONCLUSIONS

Children in the MoH group are very likely to benefit from housing interventions. Rehospitalisation and early mortality are useful assessment measures. Rehospitalisation exerts a considerable burden, and child deaths are catastrophic.

Sedentary time among primary school children in south-west Germany: amounts and correlates

BACKGROUND

Sedentary behaviour in children is related to different health consequences such as overweight and cardio-metabolic diseases that can track into adulthood. Previous studies have shown that children spend hours being sedentary, but no data of sedentary time (ST) among German children has been available, yet. Therefore, this study investigated objectively measured amounts and correlates of ST in a sample of German primary school children.

METHODS

Children's physical activity (PA) was objectively assessed for 6 days using a multi-sensor device (Actiheart®; CamNtech, Cambridge, UK). Activity levels were categorized on the basis of energy expenditure (MET) into sedentary, light PA (LPA), and moderate to vigorous PA (MVPA). ST excluding sleeping hours was assessed for 231 children (7.1 ± 0.6 years, male: 45.9%) and analysed for independent groups. Examined factors (parental education, household income, and migration background) were assessed by parental questionnaire. Children's weight, height and gender were collected in schools. Weight status was calculated on the basis of BMI percentiles.

RESULTS

On average, children spent 3.5 ± 1.5 h daily being sedentary, excluding sleeping hours. Significantly higher ST was found in girls (t = -4.6; p < 0.01), in children with migration background (t = -6.9; p < 0.01), at the weekend (t = -2.8; p < 0.01), and among inactive children (t = 6.8; p < 0.01). Additionally, significant correlations with ST in this sample were identified for MVPA (B = -0.99; [-1.09;-0.88], p < 0.01), LPA (B = -0.89; [-0.97;-0.82], p < 0.01), migration background (B = -17.64; [5.24;30.04], p < 0.01), gender (B = -13.48; [-25.94;-1.01], p < 0.05) and household income (B = -4.80; [-9.07; -0.53], p < 0.05).

CONCLUSION

Girls, children with migration background, and inactive children were identified as potential risk groups. A higher income was associated with less ST. In general, ST was higher at the weekend. Furthermore, as PA was found to be negatively correlated to ST, these activities may replace each other. Therefore, these findings should be considered in future health interventions.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), DRKS-ID: DRKS00000494 DATE: 25/08/2010.

Sociocultural Influence on Obesity and Lifestyle in Children: A Study of Daily Activities, Leisure Time Behavior, Motor Skills, and Weight Status

BACKGROUND

Juvenile overweight is increasing, and effective preventive measures are needed. After years of arbitrarily assigning these measures disregarding socioeconomic and/or cultural differences, it has become necessary to tailor interventions more specific to these target groups. Providing data for such an intervention is the objective of this study.

METHODS

Influencing variables on children's weight status, motor skills and lifestyle have been analyzed among 997 first graders (53.2% male) involved in the Children's Health InterventionaL Trial (CHILT).

RESULTS

Median age was 6.9 years; 7.3% were obese, 8.8% were overweight. Children with low socioeconomic status (SES) were more likely to be obese (p = 0.029). Low SES (p ˂ 0.001), migration background (p = 0.001) and low sports activity levels (p = 0.007) contributed most to an increased consumption of television. Migration background (p = 0.003) and male gender (p < 0.001) were the strongest factors in predicting a greater consumption of computer/video games. Children with higher SES (p = 0.02), lower BMI (p = 0.035), and males (p = 0.001) performed better in motor tests.

CONCLUSION

Children with a low SES and migration background were more likely to exhibit unfavorable health behavior patterns, higher BMI scores, and poorer motor skills. Interventions should integrate motivational and targeting strategies and consider cultural and educational differences to address these vulnerable groups.

Building healthy eating habits in childhood: a study of the attitudes, knowledge and dietary habits of schoolchildren in Malaysia

Background

Overweight and obesity have increased rapidly in incidence to become a global issue today. Overweight and obesity problems are significantly linked to unhealthy dietary patterns, physical inactivity and misperception of body image. This study aimed to determine whether Malaysian children build healthy eating habits from childhood.

Methods

A survey on eating habits was conducted among primary school students in standards 4 to 6 in the state of Selangor, Malaysia. The findings of the study were reported in the form of descriptive statistics involving frequencies and percentages. Data from 400 respondents were analyzed.

Results

Our findings showed that the students understood the definition of healthy food and the types of food that are considered healthy. Although the students knew that food such as deep-fried drumsticks and hamburgers contain a high amount of saturated fat and cholesterol, these foods were still consumed by them. There was also a high consumption of foods that are fried and contain sugar, salt and saturated fat. In choosing food, two major factors contributed to the students’ decisions: cleanliness (65.8%) and the preference of their parents (12.3%).

Discussion

Our findings indicate that by implementing the Integrated School Health Program (ISHP) properly, students’ eating habits can be improved by creating a school with a healthy environment.

Compression or expansion of dementia in Germany? An observational study of short-term trends in incidence and death rates of dementia between 2006/07 and 2009/10 based on German health insurance data

INTRODUCTION

There have been recent reports about a decline in dementia incidence, but only little is known about trends in the mortality of patients with dementia. Only the simultaneous analysis of both trends can inform whether the reported decline in dementia has led to a compression of dementia into higher ages.

METHODS

We used health claims data from the largest public health insurer in Germany over the two time periods 2004/07 and 2007/10. Dementia was defined according to the International Classification of Disease 10th revision (ICD-10) numbers G30, G31.0, G31.82, G23.1, F00, F01, F02, F03 and F05.1 or by a prescription of cholinesterase inhibitors or memantine or both. In the two time periods, we observed 502,065 person-years of exposure and 10,881 incident dementia cases and 10,013 person-years of exposure among the newly demented and 3049 deaths. We estimated the relative risks of the two time periods applying proportional hazard models and calculated years with or without dementia using the illness-death model.

RESULTS

Dementia incidence was significantly higher in 2006/07 than in 2009/10, whereas mortality with dementia tended to be lower in the first period, albeit statistically significant among women only. Mortality without dementia tended to be higher in the first period for men and remained stable for women. Combining these trends, we found that at age 65 remaining life years with dementia were compressed by a yearly 0.4 months for men and 1.4 months for women. At the same time, remaining life years without dementia increased by a yearly 1.4 months for men and 1.1 months for women.

CONCLUSIONS

This study provides evidence that the increase in dementia-free life years went together with an absolute compression of life years with dementia. This positive trend was particularly strong among women. Results were controlled for trends in multi-morbidity and care need, suggesting that the postponement in dementia incidence is not simply caused by a delay in diagnosis.

Students' Consumption of Beverages and Snacks at School and Away from School: A Case Study in the North East of Italy

In North-East Italy (the Veneto region), several public school nutrition policies have been developed to reduce the consumption of high-caloric snacks and beverages. However, little is known about whether the policies actually influence students’ dietary behaviors. In order to address this point, a multi-center cross-sectional survey of 691 Italian students was conducted. Students completed the Beverage and Snack Questionnaire, which assesses the consumption of beverages and snacks at school and out of school. Three-level Poisson Models with random intercept with students (level 1 units) nested into classroom (level 2 units), and nested into schools (level 3 units), were used to examine the influence of the school setting vs. the out of school environment (independent variable) on students’ consumption of sweet beverages, snacks, milk-based beverages, low-carbohydrate drinks, fruit, and vegetables (dependent variable) (p ≤ 0.05). The results showed a significantly higher consumption of sweet beverages, snacks, milk-based beverages, low-carbohydrate drinks, fruit, and vegetables out-of-the school, suggesting a school-protective association Thus, the policies aimed to limit or deny access to unhealthy foods in the school environment may play an important role in promoting more healthful dietary patterns for school children. Additional studies should be conducted to compare students’ dietary behaviors between schools with nutrition policies to those without nutrition policies.

Socioeconomic position and childhood-adolescent weight status in rich countries: a systematic review, 1990-2013

Background

Childhood obesity is a major problem in rich countries due to its high prevalence and its harmful health consequences. An exploratory analysis conducted in the PubMed database highlighted that the number of papers published on the relationship between socioeconomic position (SEP) and childhood-adolescent weight status had risen substantially with respect to an earlier review which had covered the period 1990–2005.

Methods

To describe the findings on the relationship between SEP and childhood-adolescent weight status in papers published in rich countries from 1990 through 2013, studies were identified in the following databases: PubMed; Web of Knowledge (WOK); PsycINFO; Global Health; and Embase. We included observational studies from the 27 richest OECD countries, which covered study populations aged 0 to 21 years, and used parental education, income and/or occupation as family SEP indicators. A total of 158 papers met the inclusion criteria and reported 134 bivariable and 90 multivariable analyses.

Results

Examination of the results yielded by the bivariable analyses showed that 60.4 % of studies found an inverse relationship, 18.7 % of studies did not found relationship, and 20.9 % of studies found a relationship that varied depending on another variable, such as age, sex or ethnic group; the corresponding percentages in the multivariable analyses were 51.1, 20.0 and 27.8 %, respectively. Furthermore, 1.1 % found a positive relationship.

Conclusion

The relationship between SEP and childhood-adolescent weight status in rich countries is predominantly inverse and the positive relationship almost has disappeared. The SEP indicator that yields the highest proportion of inverse relationships is parents’ education. The proportion of inverse relationships is higher when the weight status is reported by parents instead using objective measurements.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0443-3) contains supplementary material, which is available to authorized users.

Home environmental determinants of children's fruit and vegetable consumption across different SES backgrounds

OBJECTIVE

To investigate the association between home environmental determinants of fruit and vegetable consumption with childhood overweight separately for low, medium and high social economic status (SES) families.

METHOD

A cross-sectional study was carried out in 2006 among 4072 children aged 4-13 years in the city of Zwolle, the Netherlands. Of these children, data were available on measured height and weight, and from a parental questionnaire, on sociodemographic characteristics and children's fruit and vegetables intake. Associations were studied using logistic regression analyses.

RESULTS

Not eating the recommended amounts of vegetables daily was associated with overweight for children with a low SES background (odds ratio [OR]: 1.17; 95% confidence interval [CI]: 0.66-2.07) and medium SES background (OR: 1.73; 95% CI: 1.20-2.49). Eating < 2 pieces of fruit daily was associated with a lower OR for overweight among children with a high SES background (OR: 0.66; 95% CI: 0.50-0.88). Determinants of eating vegetables < 7 d were: permission to take candy without asking, eating at the table < 7 d per week, eating a takeaway meal ≥ 1 d per week, eating a home cooked meal < 6 d per week and cooking together with caregiver less than 5 d per week.

CONCLUSION

Interventions regarding vegetable consumption should be tailored to families with low and medium SES background. The most promising avenues for intervention seem to be (i) to prevent eating takeaway meals on a weekly basis and, (ii) to promote eating a home cooked meal at the table and (iii) to involve children in the cooking process. Interventions should support parents in making these home environmental changes.

Early life cognitive abilities and body weight: cross-sectional study of the association of inhibitory control, cognitive flexibility, and sustained attention with BMI percentiles in primary school children

The objective of this study was to investigate the association of different cognitive abilities with children's body weight adjusted for further weight influencing sociodemographic, family, and lifestyle factors. Cross-sectional data of 498 primary school children (7.0 ± 0.6 years; 49.8% boys) participating in a health promotion programme in southwest Germany were used. Children performed a computer-based test battery (KiTAP) including an inhibitory control task (Go-Nogo paradigm), a cognitive flexibility task, and a sustained attention task. Height and weight were measured in a standardized manner and converted to BMI percentiles based on national standards. Sociodemographic features (migration background and parental education), family characteristics (parental body weight), and children's lifestyle (TV consumption, physical activity, consumption of sugar-sweetened beverages and breakfast habits) were assessed via parental questionnaire. A hierarchical regression analysis revealed inhibitory control and cognitive flexibility to be significant cognitive predictors for children's body weight. There was no association concerning sustained attention. The findings suggest that especially cognitive abilities known as executive functions (inhibitory control and cognitive flexibility) are associated with children's body weight. Future longitudinal and intervention studies are necessary to investigate the directionality of the association and the potential of integrating cognitive training in obesity prevention strategies. This trial is registered with ClinicalTrials.gov DRKS00000494.

Parents' willingness to pay for the prevention of childhood overweight and obesity

OBJECTIVE

To determine parental willingness-to-pay (WTP) for childhood obesity prevention.

METHODS

Cross-sectional data from the follow-up measurements (2011) of a health promotion programme in German primary schools. Data collection included anthropometric measurements of children and self-administered questionnaires for parents, including WTP assessment. Mann-Whitney U-Test was used for differences between groups, and regression analysis to identify factors associated with general WTP and amount of WTP.

RESULTS

From 1 534 parents, 97.8% considered overweight/obesity to be serious public health problems. A general WTP to reduce the incidence of childhood overweight/obesity by half, was declared by 48.8%. Parents of overweight/obese children showed with 61.4%, significantly more frequently, their general WTP than the others with 47.2% (p = 0.001). Mean WTP was <euro>23.04 (99% confidence interval (CI) [22.45; 23.75]) per month. Parents of centrally obese children showed significantly higher WTP than parents of the other children (p = 0.001). General WTP and the amount of WTP were associated with the central obesity of the child, migration status and household income. Additionally, general WTP was associated with maternal obesity.

CONCLUSIONS

Nearly half of the parents were willing to invest in prevention of obesity. The general WTP significantly occurs more often and with higher amount in affected parents.

Impact of lifestyle factors on caries experience in three different age groups: 9, 15, and 21-year-olds

OBJECTIVES

To study the impact of lifestyle factors on dental caries experiences in addition to the effect of demographic characteristics at the ages of 9, 15, and 21 years.

METHODS

The data were obtained from the study 'Oral health in children and adolescents in the Netherlands'. Data were collected through questionnaires and a clinical oral examination. Because the DMFS count data were highly skewed with a peak at zero, the negative binomial hurdle model was used for the analyses. The first part of the hurdle predicted the probability of having caries experience or not, and the second part predicted the degree of caries experience.

RESULTS

For the 9- and 15-year-old age groups, the breakfast frequency per week was related with having caries experience, while the frequency of brushing teeth per day was related with the degree of caries experience. In addition, the number of food and drinks consumed per day was important for the younger age group. These relations were not found in the 21-year-olds age group.

CONCLUSIONS

Findings of this study suggest that components to promote structure and regularity, including having breakfast and the number of food and drink moments, may be important to include in programs to prevent dental caries in children.

Plasma insulin levels in childhood are related to maternal factors--results of the Ulm Birth Cohort Study

AIMS

The cardiovascular risk factor profile of a child as well as the development of body weight are influenced by genetic and childhood factors. Circulating insulin concentrations reflect the metabolic cardiovascular risk and may trigger weight gain. We aimed at identifying parental and childhood factors which may influence fasting plasma insulin concentrations in children.

METHODS

The Ulm Birth Cohort study (UBCS) is a prospective birth cohort study. At baseline, birth characteristics, maternal pre-pregnancy body mass index (BMI) values as well as parental socioeconomic parameters were obtained. At the 8-yr follow-up examination, weights, heights, and fasting plasma insulin concentrations in n = 422 children and their parents were measured. Offspring of women with gestational diabetes mellitus were excluded from statistical analysis.

RESULTS

Fasting plasma insulin concentrations of children were significantly correlated with maternal pre-pregnancy BMI values (r = 0.16) as well as with maternal (r = 0.26) but not with paternal fasting plasma insulin concentrations (r = 0.11) at the 8-yr follow-up examination. The risk for high fasting plasma insulin concentrations (≥75th internal percentile) was 2.30 (1.34-3.92) in children who also had high plasma insulin concentrations in umbilical cord blood compared to children having lower plasma insulin concentrations (<75th internal percentile) in umbilical cord blood. In addition, we observed that children with high fasting plasma insulin concentrations at the age of 8 had an altered BMI trajectory in childhood, characterized by higher BMI values from the age of 1 onwards, compared to children with lower insulin concentrations.

CONCLUSION

Our observations support the hypothesis of perinatal programming of offspring insulin concentrations and BMI values by maternal pre-pregnancy BMI values.

Psychosocial Profile of Mexican American Youths Who Play Aggressive Video Games

The effects of video games on youths have been subject to debate. Some researchers have linked video games to behavioral and emotional problems, while others have found no adverse effects. The behavioral and emotional problems experienced by some gamers may be linked to certain types of video games. We hypothesized that Mexican American youths with lower socioeconomic status and who play “aggressive” video games have more emotional and behavioral problems than those who do not play such games. We examined a total of 579 youths using the Child Behavior Checklist and analyzing the games played within the last 6 months. Youths who played aggressive video games had higher scores and more emotional and behavioral problems compared with those who did not play aggressive video games.

Excess of weight, but not underweight, is associated with poor physical fitness in children and adolescents from Castilla-La Mancha, Spain

We estimated the prevalence of underweight, overweight and obesity of children and adolescents from Castilla-La Mancha region (Spain), applying the new International Obesity Task Force (IOTF) 2012 criteria, and analysed differences in physical fitness components in relation to weight status. The sample was 2,330 schoolchildren aged 6-17 years. We measured height and weight, calculated body mass index (BMI) and assessed physical fitness using four tests included in the EUROFIT battery. Differences in physical fitness components across BMI categories, by sex, were calculated using ANOVA models. In children aged 6-11 years, 4.9 % were underweight, 26.7 % overweight and 11.0 % obese; in adolescents aged 12-17 years, 6.4 % were underweight, 16.7 % overweight and 5.8 % obese. Overall, overweight and obesity were associated with worse physical fitness but students in the underweight category did not score worse than their normal weight counterparts on fitness tests.

CONCLUSION

Childhood obesity in Spain remains a public health problem. Our results show low physical fitness levels in overweight/obese children and adolescents and low levels of handgrip strength in underweight adolescents compared with normal weight subjects. Exercise programmes must be tailored to the specific needs of the subjects according to the different weight status.

The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

BACKGROUND

The World Health Organization's (WHO's) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.

OBJECTIVES

To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.

SEARCH METHODS

We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.

SELECTION CRITERIA

We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school's ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.

DATA COLLECTION AND ANALYSIS

At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

MAIN RESULTS

We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.

AUTHORS' CONCLUSIONS

The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

Correlates of parental misperception of their child's weight status: the 'be active, eat right' study

Objective

This study reported on correlates of parental perception of their child’s weight status. Associations between parental misperception (i.e., underestimation of the child’s weight) and parental intention to improve their child’s overweight-related health behaviors and their child meeting guidelines regarding these behaviors were also investigated.

Methods

Baseline data from the population-based ‘Be active, eat right study’ were used. The population for analysis consisted of 630 overweight and 153 obese five year-old children and their parents. Questionnaires were used to measure parental perception of the child’s weight status, correlates of misperception (i.e., child age, child gender, child BMI, parental age, parental gender, parental country of birth, parental educational level and parental weight status), overweight-related health behaviors (i.e., child playing outside, having breakfast, drinking sweet beverages, and watching TV), and parental intention to improve these behaviors. Height and weight were measured using standardized protocols. Multivariable logistic regression analyses were performed.

Results

In total, 44.40% of the parents misperceived their child’s weight status. Parental misperception was associated with lower child BMI, the parent being the father, a foreign parental country of birth, and a lower parental education level (p<0.05). Parental misperception was not associated with parental intention to improve child overweight-related health behavior, nor with child meeting the guidelines of these behaviors.

Discussion

This study showed that almost half of the parents with an overweight or obese child misperceived their child’s weight status. A correct parental perception may be a small stepping-stone in improving the health of overweight and obese children.

Effect of parental migration background on childhood nutrition, physical activity, and body mass index

BACKGROUND

Poor nutrition, lack of physical activity, and obesity in children have important public health implications but, to date, their effects have not been studied in the growing population of children in Sweden with immigrant parents.

METHODS

We estimated the association between parental migration background and nutrition, physical activity, and weight in 8-year-old children born in Stockholm between 1994 and 1996 of immigrants and Swedish parents (n = 2589). Data were collected through clinical examination and questionnaires filled out by parents. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using multivariable logistic regression.

RESULTS

Children of immigrants complied more closely with Nordic Nutrition Recommendations compared with those of Swedes (OR = 1.35, 95% CI 1.11-1.64). They had higher intake of dietary fibre, vitamins C, B6, and E, folic acid, and polyunsaturated fatty acids (omega-3 and omega-6) reflecting higher consumption of foods of plant origin, but lower intake of vitamins A and D, calcium, and iron reflecting lower consumption of dairy products. Children of immigrants had higher intake of sucrose reflecting higher consumption of sugar and sweets. Furthermore, these children had a higher risk of having low physical activity (OR = 1.31, 95% CI 1.06-1.62) and being overweight (OR = 1.33, 95% CI 1.06-1.65) compared with children of Swedish parents. The odds of having low physical activity and being overweight were even higher in children whose parents were both immigrants. A low level of parental education was associated with increased risk of low physical activity regardless of immigration background.

CONCLUSIONS

Culturally appropriate tools to capture the diverse range of ethnic foods and other lifestyle habits are needed. Healthcare professionals should be aware of the low levels of physical activity, increased weight, and lack of consumption of some important vitamins among children of immigrants.

Associations between inhibitory control and body weight in German primary school children

Deficits in inhibitory control are supposed to be a risk factor for overweight but literature concerning childhood and beyond the clinical setting is scarce. The objective of this study was to investigate the role of inhibitory control in regards to body weight in a large non-clinical sample of primary school children. Baseline data of 498 children (1st and 2nd grade; 7.0 ± 0.6 years; 49.8% boys) participating in a school-based intervention study in Germany were used. Children performed a Go-Nogo-task to assess inhibitory control. Height and weight were collected and converted to BMI percentiles based on national standards. Relevant influencing factors (sociodemographic data, health characteristics of parents, children's health behaviour) were assessed via parental questionnaire. Inhibitory control was significantly associated with body weight and contributed to the statistical prediction of body weight above and beyond parent education, migration background, parent weight, TV consumption and breakfast habits. Moreover, obese children displayed significantly lower inhibitory control compared to non-overweight and overweight children. The findings suggest that deficits in inhibitory control constitute a risk factor for paediatric obesity.

Effects of supervised exercise program on metabolic function in overweight adolescents

BACKGROUND

Inactivity is a primary factor related to childhood obesity, yet aerobic exercise has been shown to prevent weight gain and improve fitness in adolescents. Moreover, children become less active during their summer break from school. This study compared the effects of 4 and 8 weeks of supervised summer activity versus an unsupervised summer break on metabolic function and fitness in adolescents.

METHODS

Twenty-two adolescents were divided into 4-week (n=6, weight 48.1±14.9 kg, body fat 27.4±8.4%) and 8-week exercise groups (n=6, weight 43.4±10.9 kg, body fat 28.5±12.8%), that performed supervised, play-based physical activity, versus an age-matched 8 week control group that maintained their typical summer break (n=10, weight 41.7±10.0 kg, body fat 23.7±8.0%). Anthropometrics, resting energy expenditure (REE), resting heart rate (RHR) and peak aerobic capacity (VO(2peak)) were evaluated before and after the intervention (4 or 8 weeks).

RESULTS

REE showed group differences in posttraining conditions (the 4-week group vs. the control group, 1220±169 vs. 1067±144 kcal/die, and the 8-week group vs. the control group, 1202±151 vs. 1067±144 kcal/die, P=0.047), but RHR decreased (pre-program vs. post program: 97±22 vs. 80±8 beat/min, P=0.001) and VO(2peak) significantly increased (pre-program vs. post program: 27.8±7.8 vs. 34.8±6.5 mL/kg/min, P=0.001) in the 8-week group compared to the control group.

CONCLUSIONS

Eight weeks of supervised play-based activity increased REE and VO(2peak) in adolescents with concomitant decreases in RHR. These data suggest that this novel model of exercise prescription could be considered world-wide by clinicians to improve fitness base in adolescents and help to combat the growing epidemic of childhood obesity.

Health consequences of cricket - view from South Asia

Although cricket has origins in the British Empire, it is followed as a religion in South Asia, probably due to the influence of the former during their rule. The sport is equally popular among all groups of the society, and is not subject to gender or age constraints. It marks the epitome of reverence and is considered a battle for self-esteem, not only for those playing, but for those watching as well. The intensity of emotional attachment with this sport renders certain public health benefits as well as drawbacks to the general masses.

Economic evaluation of URMEL-ICE, a school-based overweight prevention programme comprising metabolism, exercise and lifestyle intervention in children

OBJECTIVE

Measuring the impact of the URMEL-ICE school-based overweight prevention programme on anthropometric measures in primary-school children, computing incremental cost-effectiveness relation (ICER) and net monetary benefit (NMB).

METHODS

This is an intervention study with historical control. Propensity score method is applied to account for group differences. One-year teacher-driven classroom implementation is used, which is based on especially developed teaching material including health education, physical activity breaks and parent involvement. 354 children in the control and 365 children in the intervention group at baseline and follow-up were analysed. Effectiveness is measured as cm waist circumference (WC) and unit (0.01) waist-to-height ratio (WHtR) increase prevented in intervention vs. control group using an adjusted two-level model. Standard cost-effectiveness analysis methods, net benefit regression and a societal perspective for a 1-year time horizon are applied.

RESULTS

WC gain was 1.61 cm and WHtR gain was 0.014 significantly less in intervention vs. control group. Intervention costs were euro24.09 per child. ICER was euro11.11 (95% confidence interval (CI) [8.78; 15.02]) per cm WC and euro18.55 (95% CI [14.04; 26.86]) per unit WHtR gain prevented. At a maximum willingness to pay (MWTP) of euro35, both values of the CIs for NMB regarding WC and WHtR are located in the positive range.

CONCLUSIONS

The study gives new information about the cost-effectiveness of structured health promotion embedded in daily routine at primary schools. Assuming a MWTP of euro35 the intervention is cost-effective with a positive NMB. This result may help decision makers in implementing programmes to prevent childhood overweight in school settings.

Organized sports, overweight, and physical fitness in primary school children in Germany

Physical inactivity is associated with poor physical fitness and increased body weight. This study examined the relationship between participation in organized sports and overweight as well as physical fitness in primary school children in southern Germany. Height, weight, and various components of physical fitness were measured in 995 children (7.6 ± 0.4 years). Sports participation and confounding variables such as migration background, parental education, parental body weight, and parental sports participation were assessed via parent questionnaire. Multiple logistic regression as well as multivariate analysis of covariance (MANCOVA) was used to determine associations between physical fitness, participation in organized sports, and body weight. Participation in organized sports less than once a week was prevalent in 29.2%, once or twice in 60.2%, and more often in 10.6% of the children. Overweight was found in 12.4% of the children. Children participating in organized sports more than once per week displayed higher physical fitness and were less likely to be overweight (OR  =  0.52, P < 0.01). Even though causality cannot be established, the facilitation of participation in organized sports may be a crucial aspect in public health efforts addressing the growing problems associated with overweight and obesity.

Mutation screen in the GWAS derived obesity gene SH2B1 including functional analyses of detected variants

Background

The SH2B1 gene (Src-homology 2B adaptor protein 1 gene) is a solid candidate gene for obesity. Large scale GWAS studies depicted markers in the vicinity of the gene; animal models suggest a potential relevance for human body weight regulation.

Methods

We performed a mutation screen for variants in the SH2B1 coding sequence in 95 extremely obese children and adolescents. Detected variants were genotyped in independent childhood and adult study groups (up to 11,406 obese or overweight individuals and 4,568 controls). Functional implications on STAT3 mediated leptin signalling of the detected variants were analyzed in vitro.

Results

We identified two new rare mutations and five known SNPs (rs147094247, rs7498665, rs60604881, rs62037368 and rs62037369) in SH2B1. Mutation g.9483C/T leads to a non-synonymous, non-conservative exchange in the beta (βThr656Ile) and gamma (γPro674Ser) splice variants of SH2B1. It was additionally detected in two of 11,206 (extremely) obese or overweight children, adolescents and adults, but not in 4,506 population-based normal-weight or lean controls. The non-coding mutation g.10182C/A at the 3’ end of SH2B1 was only detected in three obese individuals. For the non-synonymous SNP rs7498665 (Thr484Ala) we observed nominal over-transmission of the previously described risk allele in 705 obesity trios (nominal p = 0.009, OR = 1.23) and an increased frequency of the same allele in 359 cases compared to 429 controls (nominal p = 0.042, OR = 1.23). The obesity risk-alleles at Thr484Ala and βThr656Ile/γPro674Ser had no effect on STAT3 mediated leptin receptor signalling in splice variants β and γ.

Conclusion

The rare coding mutation βThr656Ile/γPro674Ser (g.9483C/T) in SH2B1 was exclusively detected in overweight or obese individuals. Functional analyzes did not reveal impairments in leptin signalling for the mutated SH2B1.

Impact of mother tongue and gender on overweight, obesity and extreme obesity in 24,989 Viennese children/adolescents (2-16 years)

The present survey aims at determining the prevalence of extreme obesity (defined as a body mass index (BMI) ≥ 99.5th percentile) for the first time in Austria and at investigating the relationship between weight status and mother tongue in a representative Viennese sample of 24,989 children and adolescents (2-16 years) with a percentage of approximately 46 % of migration background.Directly measured anthropometric data on body weight and height were collected and BMI was calculated. Prevalence of overweight, obesity and extreme obesity was determined for every subgroup according to mother tongue using the German national reference criteria by Kromeyer-Hauschild et al.In this sample, 2.1 % of all children and adolescents had to be classified as being extremely obese. More boys (2.3 %) than girls (1.9 %) suffered from extreme obesity (p = 0.048). Total 1.7 % of children and adolescents with German as their native language, 2.5 % of Turkish native speakers and 2.9 % of children and adolescents with another mother tongue were extremely obese (p ≤ 0.001). The highest prevalence of overweight or obesity was found in Turkish-native-speaking children and adolescents (p ≤ 0.001), whereas the lowest one was found in German-native-speaking children and adolescents (p ≤ 0.001).This large study clearly shows that extreme obesity is a common disease and largely neglected. Apparently, another native language than German, as an indicator for a migration background, may be associated with a substantially higher probability for the development of extreme obesity in Vienna, Austria. Thus, effective preventive measures to overcome obesity are urgently needed.

Evaluation of a health promotion program in children: Study protocol and design of the cluster-randomized Baden-Württemberg primary school study [DRKS-ID: DRKS00000494]

Background

Increasing prevalences of overweight and obesity in children are known problems in industrialized countries. Early prevention is important as overweight and obesity persist over time and are related with health problems later in adulthood. "Komm mit in das gesunde Boot - Grundschule" is a school-based program to promote a healthier lifestyle. Main goals of the intervention are to increase physical activity, decrease the consumption of sugar-sweetened beverages, and to decrease time spent sedentary by promoting active choices for healthy lifestyle. The program to date is distributed by 34 project delivery consultants in the state of Baden-Württemberg and is currently implemented in 427 primary schools. The efficacy of this large scale intervention is examined via the Baden-Württemberg Study.

Methods/Design

The Baden-Württemberg Study is a prospective, stratified, cluster-randomized, and longitudinal study with two groups (intervention group and control group). Measurements were taken at the beginning of the academic years 2010/2011 and 2011/2012. Efficacy of the intervention is being assessed using three main outcomes: changes in waist circumference, skinfold thickness and 6 minutes run. Stratified cluster-randomization (according to class grade level) was performed for primary schools; pupils, teachers/principals, and parents were investigated. An approximately balanced number of classes in intervention group and control group could be reached by stratified randomization and was maintained at follow-up.

Discussion

At present, "Komm mit in das Gesunde Boot - Grundschule" is the largest school-based health promotion program in Germany. Comparative objective main outcomes are used for the evaluation of efficacy. Simulations showed sufficient power with the existing sample size. Therefore, the results will show whether the promotion of a healthier lifestyle in primary school children is possible using a relatively low effort within a school-based program involving children, teachers and parents. The research team anticipates that not only efficacy will be proven in this study but also expects many other positive effects of the program.

Trial registration

German Clinical Trials Register (DRKS), DRKS-ID: DRKS00000494

Assessment tools of energy balance-related behaviours used in European obesity prevention strategies: review of studies during preschool

Valid and reliable measures of energy balance-related behaviours are required when evaluating the effectiveness of public health interventions aiming at prevention of childhood obesity. A structured descriptive review was performed to appraise food intake, physical activity and sedentary behaviour assessment tools used in obesity intervention strategies targeting mainly preschool children across Europe. In total, 25 papers are described, addressing energy balance-related behaviours as study outcomes and targeting individuals or clusters of individuals at school- or home-based environment. Parentally reported food records and 24-h recalls were commonly used to assess food intake. Subjective levels of physical activity and sedentary behaviour were commonly accessed via parentally reported questionnaires. Accelerometry was used to obtain objective measures of physical activity. Insufficient evidence of tool evaluation was provided. When feasible, food records and accelerometry are recommended as the most appropriate methods to assess food intake in young children. Sedentary behaviour could be assessed via questionnaires that include key indicators of sedentarism and are able to differentiate individual practices. The choice of methodology for the assessment of specific intervention effects should be equally balanced between required accuracy levels and feasibility, and be guided by the intervention targets.