A randomized trial of multiple interventions for childhood obesity in China

Improved food habits and anthropometry among primary school children following a novel healthy eating programme

OBJECTIVE

Assess longer-term changes in food habits and anthropometry among Grades 1-2 primary school students from four public schools in Colombo, Sri Lanka, following a 3-week programme including a classroom-based motivational storybook discussion and self-monitoring food diary (FD).

METHODS

This follow-up study assessed changes from baseline (pre-intervention) BMI z-scores and food habits (increased healthy food-item consumption/decreased unhealthy food-item consumption reflected by an increase in FD score) and parental perceptions (anonymous questionnaires) among 863 students (aged 6-8 years), between 9 and 12 months after completing the programme (November 2019-February 2020).

RESULTS

Food habits showed sustained improvement from baseline mean FD score (baseline vs. follow-up: 51 ± 23% vs. 67 ± 22%, p < 0.001), with children from all BMI subgroups (underweight [UW], normal weight [NW], overweight [OW] and obesity [OB]) showing a significant increase in FD scores (ranging from 14.1% to 17.2%, p < 0.001). BMI z-scores increased in children living with UW (-2.85 to -2.21, p < 0.00) and NW (-0.70 to -0.57, p < 0.001), but did not change in children with OW (+1.5 to +1.49, p = 0.83) and OB (+2.85 to +2.21, p = 0.19). Most parents (n = 497, 97.8%) reported satisfaction with programme outcomes.

CONCLUSION

This programme led to sustained improvement in food habits among young primary school children from all BMI categories, increase in BMI towards the median among children living with UW and NW, and stabilization of BMI in children with OW and OB, suggesting it as a useful tool for improving nutritional status of young children in low- and middle-income countries (LMIC) facing the double burden of under- and overnutrition.

The Impact of Parental Involvement in the Prevention and Management of Obesity in Children: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Obesity in children is a critical public health issue in developed countries and developing countries. The establishment of health-related behaviors in childhood, significantly influenced by parental involvement, underscores the need for effective intervention measures.

AIM

This original research is a systematic review and meta-analysis that aimed to investigate the impact of parental involvement on the prevention and management of childhood obesity, focusing on outcomes such as BMI z-score, exercise levels, screen time, dietary self-efficacy, and percentage body fat.

METHODS

Adhering to the PRISMA guidelines, we conducted a systematic review and meta-analysis of 12 randomized controlled trials (RCTs) identified through comprehensive searches of PubMed, Scopus, Web of Science, and the Cochrane Library, including RCTs involving children aged 2-18 years with parental or caregiver participation, reporting on the specified outcomes. Data analysis was performed using RevMan 5.3, employing a random effects model.

RESULTS

A total of 5573 participants were included. The meta-analysis revealed a significant reduction in BMI z-score (MD = -0.06, 95% CI: -0.09 to -0.02, p = 0.005, I2 = 58%), a non-significant increase in exercise levels (SMD = 0.26, 95% CI: -0.01 to 0.52, p = 0.05, I2 = 52%), and a significant reduction in screen time (MD = -0.36 h per day, 95% CI: -0.61 to -0.11, p = 0.005, I2 = 0%). Dietary self-efficacy also improved significantly (MD = 0.59, 95% CI: 0.12 to 1.05, p = 0.01, I2 = 0%). However, changes in percentage body fat did not reach statistical significance (MD = -1.19%, 95% CI: -2.8% to 0.41%, p = 0.15, I2 = 0%).

CONCLUSION

Parental involvement in childhood obesity interventions significantly impacts BMI z-score, exercise levels, screen time, and dietary self-efficacy but not percentage body fat. These findings highlight the importance of engaging parents in obesity prevention and management strategies.

Childhood obesity prevention trials: A systematic review and meta-analysis on trial design and the impact of type 1 error

Effect sizes from previously reported trials are often used to determine the meaningful change in weight in childhood obesity prevention interventions because information on clinically meaningful differences is lacking. Estimates from previous trials may be influenced by statistical significance; therefore, it is important that they have a low risk of type 1 error. A systematic review and meta-analysis were conducted to report on the design of child obesity prevention randomized controlled trials and effectiveness according to risk of type 1 error. Eighty-four randomized controlled trials were identified. A large range of assumptions were applied in the sample size calculations. The most common primary outcome was BMI, with detectable effect size differences used in sample size calculations ranging from 0.25 kg/m2 (followed up at 2 years) to 1.1 kg/m2 (at 9 months) and BMI z-score ranging from 0.1 (at 4 years) to 0.67 (at 3 years). There was no consistent relationship between low risk of type 1 error and reports of higher or lower effectiveness. Further clarity of the size of a meaningful difference in weight in childhood obesity prevention trials is required to support evaluation design and decision-making for intervention and policy. Type 1 error risk does not appear to impact effect sizes in a consistent direction.

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

Development and piloting of a primary school-based salt reduction programme: Formative work and a process evaluation in rural and urban Malawi

Excess salt intake is a major modifiable risk factor for cardiovascular disease. Promoting salt reduction as part of routine school-health programming may be a pragmatic way to address this risk factor early in the life course but has not been tested in sub-Saharan Africa (SSA). Here we describe the formative work with stakeholders and process evaluation of pilot work to develop a school-based salt reduction programme for children aged 11-14 years, in preparation for a cluster-randomised trial in rural/urban Malawi. Collection of observational data and documentary evidence (meeting minutes/field notes) from the earliest key stakeholder engagement with Malawi Ministries of Health, Education, Local Government and Rural Development and Malawi Institute of Education, and non-governmental stakeholders; and a series of semi-structured interviews and focus groups (with head teachers (n = 2); teachers (n = 4); parents (n = 30); and learners (n = 40)). Data was analysed thematically and conceptualised through a Normalization Process Theory lens. Formative work illustrated a range of administrative, technical, and practical issues faced during development of the programme; including allocation of stakeholder roles and responsibilities, harmonisation with pre-existing strategies and competing priorities, resources required for programme development, and design of effective teaching materials. While participants were positive about the programme, the process evaluation identified features to be refined including perceived challenges to participation, recommended adaptations to the content and delivery of lessons, and concerns related to quantity/quality of learning resources provided. This study demonstrates the importance of comprehensive, sustained, and participatory stakeholder engagement in the development of a novel school health programme in SSA; and highlights the factors that were critical to successfully achieving this. We also demonstrate the value of detailed process evaluation in informing development of the programme to ensure that it was feasible and relevant to the context prior to evaluation through a cluster-randomised trial.

Effectiveness of Health Promotion Interventions in Primary Schools-A Mixed Methods Literature Review

School-based health promotion interventions (HPIs) are commonly used in schools, but scientific evidence about the structures of effective interventions is lacking. Therefore, we conducted a mixed methods systematic literature review to recognize the HPI structures related to their effectiveness. Based on the inclusion criteria, 49 articles were selected for the literature review. The articles, published in 2011-2022, described 46 different school-based interventions conducted in 20 different countries. The average duration of the interventions was 12 months, and they were implemented mostly with an RCT study design (61.2%) and by targeting children (69.4%). Three main groups of interventions were identified and explained: (1) extensive and long-term interventions; (2) school policy-changing interventions; and (3) highly effective interventions. Effective school-based HPIs included multiple target groups, multiple providers with external experts, and an efficient duration and timing of follow-ups. The implications for educational research and school practice are presented. Evidence on the effectiveness of health-related interventions is still lacking and needs to be addressed in further studies.

The long-term effects of primary school-based obesity prevention interventions in children: A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis investigate the long-term effects of primary school-based obesity prevention interventions on body-mass index (and z-scores), waist circumference (and z-scores) and weight status.

METHODS

Four databases were searched for studies from date of inception until June 8th, 2021. We included randomized controlled trials (RCT) and non-RCTs investigating effects ≥12 months post-intervention of primary school-based interventions with intervention duration ≥6 months and containing a diet and/or physical activity component on outcomes of interest. Articles were assessed on risk of bias and methodological quality by RoB2 and ROBINS-I. Meta-analysis was performed and results were narratively summarized. Evidence quality was assessed with GRADE.

RESULTS

Nineteen studies were included, 9 were pooled in a meta-analysis. No long-term effects were found on body-mass index (+0.06 kg/m² ; CI95% = -0.38, 0.50; I²  = 66%), body-mass index z-scores (-0.08; CI95% = -0.20, 0.04; I²  = 36%), and waist circumference (+0.57 cm; CI95% = -0.62, 1.75; I²  = 13%). Non-pooled studies reported mixed findings regarding long-term effects on body-mass index, body-mass index z-scores and weight status, and no effects on waist circumference and waist circumference z-scores. Evidence certainty was moderate to very low.

DISCUSSION

No clear evidence regarding long-term effects of primary school-based interventions on obesity-related outcomes was found. Recommendations for further research and policy are discussed. Prospero registration ID: CRD42021240446.

Interventions to prevent obesity in school-aged children 6-18 years: An update of a Cochrane systematic review and meta-analysis including studies from 2015-2021

Background

Childhood obesity remains a global public health priority due to the enormous burden it generates. Recent surveillance data suggests there has been a sharp increase in the prevalence of childhood obesity during the COVID-19 pandemic. The Cochrane review of childhood obesity prevention interventions (0-18 years) updated to 2015 is the most rigorous and comprehensive review of randomised controlled trials (RCTs) on this topic. A burgeoning number of high quality studies have been published since that are yet to be synthesised.

Methods

An update of the Cochrane systematic review was conducted to include RCT studies in school-aged children (6-18 years) published to 30 June 2021 that assessed effectiveness on child weight (PROSPERO registration: CRD42020218928). Available cost-effectiveness and adverse effect data were extracted. Intervention effects on body mass index (BMI) were synthesised in random effects meta-analyses by setting (school, after-school program, community, home), and meta-regression examined the association of study characteristics with intervention effect.

Findings

Meta-analysis of 140 of 195 included studies (183,063 participants) found a very small positive effect on body mass index for school-based studies (SMD -0·03, 95%CI -0·06,-0·01; trials = 93; participants = 131,443; moderate certainty evidence) but not after-school programs, community or home-based studies. Subgroup analysis by age (6-12 years; 13-18 years) found no differential effects in any setting. Meta-regression found no associations between study characteristics (including setting, income level) and intervention effect. Ten of 53 studies assessing adverse effects reported presence of an adverse event. Insufficient data was available to draw conclusions on cost-effectiveness.

Interpretation

This updated synthesis of obesity prevention interventions for children aged 6-18 years, found a small beneficial impact on child BMI for school-based obesity prevention interventions. A more comprehensive assessment of interventions is required to identify mechanisms of effective interventions to inform future obesity prevention public health policy, which may be particularly salient in for COVID-19 recovery planning.

Funding

This research was funded by the National Health and Medical Research Council (NHMRC), Australia (Application No APP1153479).

The triple benefits of slimming and greening the Chinese food system

The Chinese food system has undergone a transition of unprecedented speed, leading to complex interactions with China's economy, health and environment. Structural changes experienced by the country over the past few decades have boosted economic development but have worsened the mismatch between food supply and demand, deteriorated the environment, driven obesity and overnutrition levels up, and increased the risk for pathogen spread. Here we propose a strategy for slimming and greening the Chinese food system towards sustainability targets. This strategy takes into account the interlinkages between agricultural production and food consumption across the food system, going beyond agriculture-focused perspectives. We call for a food-system approach with integrated analysis of potential triple benefits for the economy, health and the environment, as well as multisector collaboration in support of evidence-based policymaking.

Impacts of School Nutrition Interventions on the Nutritional Status of School-Aged Children in Asia: A Systematic Review and Meta-Analysis

This review aims to describe school nutrition interventions implemented in Asia and quantify their effects on school-aged children’s nutritional status. We searched Web of Science, Embase, Ovid MEDLINE, Global Health, Econlit, APA PsycInfo, and Social Policy and Practice for English articles published from January 2000 to January 2021. We quantified the pooled effects of the interventions on the changes in body mass index (BMI) and body mass index z score (BAZ), overall and by type of intervention. In total, 28 articles were included for this review, of which 20 articles were multi-component interventions. Twenty-seven articles were childhood obesity studies and were included for meta-analysis. Overall, school nutrition interventions reduced school-aged children’s BMI and BAZ. Multi-component interventions reduced the children’s BMI and BAZ, whereas physical activity interventions reduced only BMI and nutrition education did not change BMI or BAZ. Overweight/obesity reduction interventions provided a larger effect than prevention interventions. Parental involvement and a healthy food provision did not strengthen school nutrition interventions, which may be due to an inadequate degree of implementation. These results suggested that school nutrition interventions should employ a holistic multi-component approach and ensure adequate stakeholder engagement as well as implementation to maximise the effects.

School-Based Physical Activity Intervention: A Qualitative Process Evaluation of a Feasibility Trial in Yangzhou, China

Background: There is an urgent need for children in China to increase their physical activity levels. We first developed a 16-week school-based behavior change intervention based on the Behavior Change Wheel and Theoretical Domains Framework. We then conducted a cluster feasibility non-randomized controlled trial (RCT) among children in Yangzhou, China. Aim: This qualitative process evaluation was embedded within the cluster feasibility non-RCT and aimed to: (1) explore the experiences and perceptions of participants and providers in the intervention and trial; and (2) generate recommendations to inform a future intervention and full-scale cluster RCT. Methods: A qualitative study, using semi-structured interviews with trial participants (n = 20 children: 10 intervention, 10 control), parents (n = 20), and health education providers (n = 2), was conducted in two public schools in Yangzhou, China. Interviews were audio-recorded, transcribed, and translated verbatim from Mandarin to English. Data were analyzed using thematic analysis. Results: Findings believed to reflect experiences and perceptions of participants in the intervention and the trial are presented as eight major themes: (1) perceived high efficacy of the intervention components to help children become more active, (2) appreciation of the intervention features, (3) factors that facilitated or impeded intervention attendance and delivery, (4) positive experiences and feelings gained through the data collection process, (5) satisfaction regarding the organization and implementation of the trial, (6) influences of personal beliefs and emotional responses to the trial, (7) social influences on participatory decision-making, and (8) key barriers to consider regarding the recruitment of participants. Conclusions: The intervention and trial methods were acceptable to children, parents, and health education providers. School-based behavior change intervention was perceived to be a useful approach to increase physical activity in children aged 10–12 years in China. However, there were barriers to intervention delivery and engagement that should be considered when designing a future cluster RCT to assess the intervention efficacy.

Effectiveness of national multicentric school-based health lifestyles intervention among chinese children and adolescents on knowledge, belief, and practice toward obesity at individual, family and schools' levels

BACKGROUND

This study aims to evaluate the effectiveness of the trial of national multicentric school-based health lifestyles intervention toward childhood obesity on the KBP at individual, family and schools' levels.

METHODS

The national trial was a multi-centered, cluster-controlled trial, which was conducted in seven provinces from September 2013 to February 2014, aiming at preventing childhood overweight and obesity. Integrated intervention strategies focused on changing specific practice related to energy intake and expenditure, such as decreasing the consumption of sweetened fizzy drinks, increasing the consumption of vegetables, ensuring proper protein intake, reducing sedentary practice including screen time, and maintaining at least 1 h of moderate to vigorous physical activity. A total of 27,477 children and adolescents in the control group and 30,997 in the intervention group were recruited with a mean follow-up period of 6.7 months. The binomial response mixed-effects model was used for assessing the effects of the national school-based health lifestyles intervention on obesity-related KBP at students individual, parents' and schools' levels.

RESULTS

Children and adolescents in the intervention group mastered better obesity-related knowledge, and they had higher correct response rates to all questions about obesity-related knowledge compared to the control group (P < 0.05). In terms of obesity-related belief, individuals in the intervention group was more motivated than the control group, participants in the intervention group had higher correctness of 71.18, 52.94, and 56.60% than the control group of 68.61, 49.86, and 54.43%, (P < 0.05). In addition, healthier habits of eating breakfast and drinking milk every day were observed in the intervention group. For the beliefs toward obesity, parents of the intervention group had higher correctness than the control group. At the same time except for the fruit consumption, other obesity-related practice in the intervention group were healthier than the control group (P < 0.05). Except for some beliefs and practice, the intervention effect at the parent level was not significant in other aspects.

CONCLUSION

The obesity-related knowledge and beliefs of children and adolescents got improved significantly. However, the effects on the knowledge, beliefs and certain practices of their parents and school administrators failed to reach significance.

Effectiveness of a Multifaceted Intervention for Prevention of Obesity in Primary School Children in China: A Cluster Randomized Clinical Trial

IMPORTANCE

A rapid nutritional transition has caused greater childhood obesity prevalence in many countries, but the repertoire of effective preventive interventions remains limited.

OBJECTIVE

To determine the effectiveness of a novel multifaceted intervention for obesity prevention in primary school children.

DESIGN, SETTING, AND PARTICIPANTS

A cluster randomized clinical trial was conducted during a single school year (from September 11, 2018, to June 30, 2019) across 3 socioeconomically distinct regions in China according to a prespecified trial protocol. Twenty-four schools were randomly allocated (1:1) to the intervention or the control group, with 1392 eligible children aged 8 to 10 years participating. Data from the intent-to-treat population were analyzed from October 1 to December 31, 2019.

INTERVENTIONS

A multifaceted intervention targeted both children (promoting healthy diet and physical activity) and their environment (engaging schools and families to support children's behavioral changes). The intervention was novel in its strengthening of family involvement with the assistance of a smartphone app. The control schools engaged in their usual practices.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in body mass index (BMI; calculated as weight in kilograms divided by height in square meters) from baseline to the end of the trial. Secondary outcomes included changes in adiposity outcomes (eg, BMI z score, prevalence of obesity), blood pressure, physical activity and dietary behaviors, obesity-related knowledge, and physical fitness. Generalized linear mixed models were used in the analyses.

RESULTS

Among the 1392 participants (mean [SD] age, 9.6 [0.4] years; 717 boys [51.5%]; mean [SD] BMI, 18.6 [3.7]), 1362 (97.8%) with follow-up data were included in the analyses. From baseline to the end of the trial, the mean BMI decreased in the intervention group, whereas it increased in the control group; the mean between-group difference in BMI change was -0.46 (95% CI, -0.67 to -0.25; P < .001), which showed no evidence of difference across different regions, sexes, maternal education levels, and primary caregivers (parents vs nonparents). The prevalence of obesity decreased by 27.0% of the baseline figure (a relative decrease) in the intervention group, compared with 5.6% in the control group. The intervention also improved other adiposity outcomes, dietary, sedentary, and physical activity behaviors, and obesity-related knowledge, but it did not change moderate- to vigorous-intensity physical activity, physical fitness, or blood pressure. No adverse events were observed during the intervention.

CONCLUSIONS AND RELEVANCE

The multifaceted intervention effectively reduced the mean BMI and obesity prevalence in primary school children across socioeconomically distinct regions in China, suggesting its potential for national scaling.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03665857.

Preventing Childhood Obesity in Primary Schools: A Realist Review from UK Perspective

Childhood obesity is a global public health concern. While evidence from a recent comprehensive Cochrane review indicates school-based interventions can prevent obesity, we still do not know how or for whom these work best. We aimed to identify the contextual and mechanistic factors associated with obesity prevention interventions implementable in primary schools. A realist synthesis following the Realist And Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES) guidance was with eligible studies from the 2019 Cochrane review on interventions in primary schools. The initial programme theory was developed through expert consensus and stakeholder input and refined with data from included studies to produce a final programme theory including all of the context-mechanism-outcome configurations. We included 24 studies (71 documents) in our synthesis. We found that baseline standardised body mass index (BMIz) affects intervention mechanisms variably as a contextual factor. Girls, older children and those with higher parental education consistently benefitted more from school-based interventions. The key mechanisms associated with beneficial effect were sufficient intervention dose, environmental modification and the intervention components working together as a whole. Education alone was not associated with favourable outcomes. Future interventions should go beyond education and incorporate a sufficient dose to trigger change in BMIz. Contextual factors deserve consideration when commissioning interventions to avoid widening health inequalities.

Systematic Review of Setting-Based Interventions for Preventing Childhood Obesity

Introduction

Child obesity is recognized as one of the major public health problems globally, which demands multicomponent and comprehensive interventions. The objective of this systematic review is to evaluate, synthesize, and combine the existing evidence of various setting-based interventions across developed and developing countries that aim to prevent childhood obesity.

Methods

An electronic and systematic search was conducted on setting-based interventions related to childhood obesity both in developed and developing countries. A study was considered eligible if it was a randomized controlled trial that focused on home-based, school-based, or community-based intervention for childhood obesity and published in English from 2010 to 2020. A wide range of electronic bibliographic databases, such as PubMed, Medline, Embase, and ERIC were searched. The various studies were carried out among children aged 4-18 years old. A total of 32 studies were identified; out of which 24 were school-based interventions, and the remaining were nonschool-based.

Results

The studies in this review highlighted important school and nonschool-based interventions to avoid obesity among children and adolescents. School-based interventions that had considered both physical activity (PA) and diet along with home elements showed great effectiveness. These findings reveal that the specific intervention components such as nutrition education curriculum, prolonged time for PA, and upgrading self-efficacy of study participants should be considered to prevent obesity across developed and developing countries. However, the findings from nonschool-based interventions were restricted by the scarcity of the studies.

Conclusion

Multisetting and multipronged strategies are required to avoid or reduce childhood obesity across the globe. However, additional studies are needed with a large sample size. Further study designs based on theory should be conducted in nonschool settings for the creation of meaningful and detailed guidelines that can support the prevention of obesity in children.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school.

OBJECTIVES

The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are: • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents; • to evaluate the effects of school-based interventions on improving body composition; and • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information.

SELECTION CRITERIA

Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update.  DATA COLLECTION AND ANALYSIS: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type.

MAIN RESULTS

Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias.  Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events.

AUTHORS' CONCLUSIONS

Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.

Randomised trial of IV metoclopramide vs IV ketorolac in treatment of acute primary headaches

INTRODUCTION

Headache is one of the most common neurological conditions among emergency department visits (ED), although the best therapy has not been identified yet. Therefore, in the current study, we aimed to compare the pain-relieving effect of metoclopramide and ketorolac in acute primary headaches patients.

METHODS

This double-blind, randomised clinical trial was conducted at Golestan Hospital, Ahvaz, Iran. This research involved all adult patients with acute primary (migraine or tension-type) headaches presented to the ED. Pain intensity was assessed with 0 to 10 verbal Numeric Rating Scales (NRS). The subjects were randomised into 10 mg intravenous (IV) metoclopramide or 30 mg IV ketorolac groups. Pain score and drug adverse reactions were compared between the two groups at baseline, 15, 30, and 60 min after baseline.

RESULTS

108 patients completed this trial and were equally divided into two groups (mean age of 34 ± 8.54 years; 57.4% female). Before treatment, the mean pain score was 6.9 and 6.8 in metoclopramide and ketorolac groups, respectively (p > 0.05). Metoclopramide failed to provide more improvement in pain score at 30 min (p = 0.55) and 60 min (p = 0.15) from baseline. There were no serious adverse events in this study. Only five patients required rescue medication which four of them were in ketorolac group.

CONCLUSION

We were unable to reject the null hypothesis that there would be no difference in pain outcomes between metoclopramide and ketorolac.

Intervention empowerment of families in preventing and controlling overweight and obesity in children: A systematic review

There have been an increasing overweight and obesity in very anxious children. Furthermore, obesity is a condition that occurs due to the accumulation of excess or abnormal fat. This disorder is believed to be the most significant public health problem that affects children in the 21^st century. This study aimed to examine the literature review, articles and research results analyzing the effectiveness of family or parent empowerment interventions through health education. Many research articles were searched on several databases such as PubMed and PreQuest, using the following keywords which include “family empowerment”, “overweight”, “obesity”, “health lifestyle”, “BMI”, “children”, “RCT” starting from 2014 to 2019. The searched results obtained 162 articles on family empowerment, overweight and obesity. Out of the 162 articles, 20 were selected that discussed family empowerment interventions for overweight and obesity. Critical analysis of the 20 articles was carried out based on design, sample, treatment, parameters, findings and conclusions. The literature review analysis showed that family empowerment interventions in the form of health education or promotion activities vary widely in terms of methods, components, duration, individuals involved, specificity and effectiveness. Furthermore, this intervention consists of training activities, courses, and teaching practices. Statistical analysis showed that all these methods significantly increased the ability and independence of the family in controlling overweight and obesity. In conclusion, health education interventions that are packaged in various programs are proven to significantly improve the ability of families or parents in preventing and controlling overweight and obesity in children.

Improving the school food environment for the prevention of childhood obesity: What works and what doesn't

The food environment has a significant influence on dietary choices, and interventions designed to modify the food environment could contribute to the prevention of childhood obesity. Many interventions have been implemented at the school level, but effectiveness in addressing childhood obesity remains unclear. We undertook a systematic review, a meta-analysis, and meta-regression analyses to assess the effectiveness of interventions on the food environment within and around schools to improve dietary intake and prevent childhood obesity. Estimates were pooled in a random-effects meta-analysis with stratification by anthropometric or dietary intake outcome. Risk of bias was formally assessed. One hundred papers were included. Interventions had a significant and meaningful effect on adiposity (body mass index [BMI] z score, standard mean difference: -0.12, 95% confidence interval: 0.15, 0.10) and fruit consumption (portions per day, standard mean difference: +0.19, 95% confidence interval: 0.16, 0.22) but not on vegetable intake. Risk of bias assessment indicated that n = 43 (81%) of non-randomized controlled studies presented a high risk of bias in the study design by not accounting for a control. Attrition bias (n = 34, 79%) and low protection of potential contamination (n = 41, 95%) presented the highest risk of bias for randomized controlled trials. Changes in the school food environment could improve children's dietary behavior and BMI, but policy actions are needed to improve surrounding school food environments to sustain healthy dietary intake and BMI.

Effectiveness of school-based interventions to prevent obesity among children aged 4 to 12 years old in middle-income countries: A systematic review and meta-analysis

Economic and accompanying nutrition transition in middle-income countries is resulting in rapidly increasing childhood obesity prevalence, exceeding acceleration rates in the West. Previous school-based obesity prevention reviews have mainly included studies from high-income countries. This review aimed to summarize the evidence from randomized controlled trials evaluating the effectiveness of school-based interventions in preventing childhood obesity in middle-income countries. Six electronic databases were searched: MEDLINE, EMBASE, CINAHL Plus, LILACS, IBECS and WPRIM. Eligibility criteria included middle-income country setting, randomized/cluster-randomized controlled trials, children aged 4-12 years and school-based interventions targeting dietary intake and/or physical activity. Twenty-one cluster-randomized controlled trials, conducted in Asia (n = 10), South America (n = 4), North America (n = 4) and the Middle East (n = 3), were included. Fifteen studies reported a significant intervention effect on at least one adiposity-related outcome. Characteristics of effective interventions included combined diet and PA interventions, school teacher-delivery, duration of >8 months, parental involvement, education sessions and school food modifications. The risk of bias in these trials was mixed. The pooled estimate of the odds ratio for obesity in intervention versus control schools (nine studies) was 0.77; 95% CI, 0.63 to 0.94; p = 0.009. In conclusion, there is some evidence to support school-based interventions in preventing childhood obesity in middle-income countries.

Impact of a Three-Year Obesity Prevention Study on Healthy Behaviors and BMI among Lebanese Schoolchildren: Findings from Ajyal Salima Program

Most school-based obesity prevention programs in low- to middle-income countries are of short duration, and few undertake follow-up analyses after the termination of the project. The aims of the current study are to investigate (1) the long-term effects of a school-based intervention program when implemented over two years on body mass index (BMI), healthy dietary behaviors, and physical activity (PA); and (2) whether the effects are sustained after one-year washout. The study is a cluster-randomized trial; 36 public and private schools were randomized into either intervention or control groups. Students (8-12 years) completed pre-and post-assessment anthropometric measurements and questionnaires about their eating and physical activity habits. Students in the intervention groups received the program components for two consecutive years. Multiple logistic regression models were used to examine the effect of the intervention on BMI and healthy behaviors. Students in the intervention groups were less likely to be overweight at washout, only in public schools. The number of children reporting change in dietary behaviors significantly increased in intervention groups, with a sustained effect only in public schools. Policies aiming at securing a positive nutrition environment in schools, and adoption of nutrition programs, are needed for achieving sustained behavior and prompting BMI changes in children.

Effect of Food Environment Interventions on Anthropometric Outcomes in School-Aged Children and Adolescents in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Food environments may promote access to unhealthy foods, contributing to noncommunicable diseases in low- and middle- income countries (LMICs). This review assessed published evidence on the effects of food environment interventions on anthropometric (BMI and weight status) outcomes in school-aged children (5-9 y) and adolescents (10-19 y) (SACA) in LMICs. We summarized randomized controlled trials (RCTs) and quasi-experimental studies (QES) published since 2000 to August 2019 in the peer-reviewed and gray literature that assessed the effects of food-related behavioral and environmental interventions on diet-related health outcomes in SACA in LMICs. Electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library) were searched using appropriate keywords, Medical Subject Headings, and free text terms. Eleven RCTs and 6 QES met the inclusion criteria, testing multicomponent behavioral and environmental interventions in schools. Analysis of 6 RCTs (n  = 17,054) suggested an overall effect on change in BMI [mean difference (MD): -0.11, 95% CI: -0.19 , -0.03], whereas there was no observed effect in 5 studies using endline BMI (n  = 17,371) (MD: 0.05, 95% CI: -0.32, 0.21). There was no significant pooled effect among the 3 QES (n  = 5,023) that reported differences in change in BMI or endline (MD: -0.37, 95% CI: -0.95, 0.22). There is limited evidence to support the modification of diet-related health outcomes through school-based food environment interventions in SACA in LMICs. Further studies are needed to understand the impact of school and community-based food environment interventions on nutritional status in this population.

A cohort study assessing the sustainable long-term effectiveness of a childhood-obesity intervention in China

BACKGROUND

Obesity has become a global epidemic, with substantial impacts on children's health. Numerous intervention studies for the prevention of obesity in children have been conducted during the most recent decade, but very few have evaluated the long-term and sustainable effectiveness of such prevention efforts.

METHODS

We conducted a follow-up study during September 2015 and September 2017, based upon a previous 3-year cluster randomized-controlled study (RCT) for a comprehensive childhood-obesity intervention in 14 primary schools in Shanghai, China. A total of 929 students were enrolled in the study. Generalized estimating equation approaches were applied to analyse student's body mass index (BMI), BMI z-score at baseline and three annual long-term follow-ups.

RESULTS

Three years after the end of the RCT study, the odds of developing obesity and the odds of developing obesity or overweight in the intervention group were both lower than in the control group among girls [OR(obesity) = 0.299, p = 0.010 and OR (overweight/obesity) = 0.493, p = 0.013]; the odds of developing obesity or overweight in the intervention group was lower than in the control group among boys (OR = 0.369, p = 0.017). Compared with the baseline, the BMI z-scores in the intervention group were lower than those in the control group for both normal-weight students (-0.027) and overweight or obese students (-0.074).

CONCLUSIONS

The 3-year RCT showed significant and reliable long-term effects on preventing childhood obesity, particularly among girls.

Interventions for preventing obesity in children

EDITORIAL NOTE

This Cochrane review is now out of date and should not be used for reference. It has been split into four age groups and updated. Please refer to the 5‐11 and 12‐18 age group Cochrane reviews which were published in May 2024: https://doi.org/10.1002/14651858.CD015328.pub2 https://doi.org/10.1002/14651858.CD015330.pub2 The 2‐4 age group Cochrane review is planned for publication in September 2024.

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

Home-Based Interventions to Treat and Prevent Childhood Obesity: A Systematic Review and Meta-Analysis

Childhood obesity has adverse impacts on premature mortality and morbidity. Managing obesity could prevent premature mortality and several types of complications among high-risk groups. This study aimed to review and examine the effects of home-based interventions to treat and prevent childhood obesity. Three databases, i.e., PubMed, Scopus, and Science Direct, were included to extract articles related to the topic. The terms “childhood obesity”, “home-based intervention”, “parental program”, and “parental involvement” were used as the primary keywords. Appraisal of the systematic review was based on PRISMA formats. Of 1556 publications identified, 22 studies fulfilled the inclusion criteria and were appropriate to conduct a meta-analysis. Overall, the home-based interventions reduced the body mass index (BMI) z-score by 36.99% (z = 36.99, p = 0.00). The data analysis indicated considerable heterogeneity among all interventions (Chi-square = 926.41, df = 22 (p < 0.000001), I² = 98%). The home-based intervention positively reduced BMI. Our findings could guide future meaningful home-based interventions to treat and prevent childhood obesity.

Effectiveness of school-based physical activity and nutrition interventions with direct parental involvement on children's BMI and energy balance-related behaviors - A systematic review

BACKGROUND

The aims of this systematic review were to study the effectiveness of primary school-based physical activity, sedentary behavior and nutrition interventions with direct parental involvement on children's BMI or BMI z-score, physical activity, sedentary behavior and nutrition behavior and categorize intervention components into targeted socio-cognitive determinants and environmental types using the Environmental Research framework for weight Gain prevention.

METHODS

In March 2018, a systematic search was conducted in four electronic literature databases. Articles written in English about effectiveness studies on school-based interventions with direct parental involvement targeting 4-12 year olds were included. Interventions with indirect parental involvement, interventions not targeting the school environment, and pilot studies were excluded. Study and intervention characteristics were extracted. Study quality and study effectiveness were assessed and effect sizes (Cohen's d) were calculated for the outcome measures. Types of socio-cognitive factors and environmental types targeted were distinguished.

RESULTS

In total, 25 studies were included. Most studies on BMI or BMI z-score, physical activity and sedentary behavior found favorable results: 61.1%, 81.1% and 75%, respectively. Results regarding nutrition behavior were inconclusive. Methodological study quality varied. All interventions targeted multiple environmental types in the school and family environment. Five targeted socio-cognitive determinants (knowledge, awareness, attitude, self-efficacy and intrinsic motivation) of the children were identified. No consistent pattern was found between either type of environment targeted, number of type of environment targeted, or the child's targeted socio-cognitive determinants and intervention effectiveness.

DISCUSSION

School-based interventions with direct parental involvement have the potential to improve children's weight status, physical activity and sedentary behavior. Based on the results, it is recommended that school-based interventions with direct parental involvement target more than one EBRB, last at least one year, and focus particularly on the physical and social environment within both the school and the family environment.

Interventions to prevent global childhood overweight and obesity: a systematic review

In view of the prevalence, health consequences, and costs of childhood obesity, there has been substantial interest in identifying effective interventions to prevent excess weight gain in young people. In this systematic review, we expand on previous reviews of obesity prevention interventions by including recent studies (until May 23, 2017) from all parts of the world. We searched MEDLINE, Embase, CINAHL Plus, Web of Science, CAB Abstracts, and PAIS Index and included randomised controlled trials, quasi-experimental studies, or natural experiments with: (1) a control group; (2) minimum follow-up of 12 months for community-based and home-based interventions or 6 months for school-based and preschool-based interventions; and (3) a primary outcome of BMI, BMI Z score, BMI percentile, body fat percentage, skinfold thickness, waist circumference, or prevalence of overweight or obesity. School-based interventions with combined diet and physical activity components and a home element (n=41) had greatest effectiveness; evidence in support of the effect of preschool-based (n=6), community-based (n=7), and home-based (n=2) interventions was limited by a paucity of studies and heterogeneity in study design. The effectiveness of school-based interventions that combined diet and physical activity components suggests that they hold promise for childhood obesity prevention worldwide. More research with rigorous evaluation and consistent reporting is needed in non-school settings and in combinations of settings.

Systematic review and meta-analysis of school-based obesity interventions in mainland China

Background

Numerous school-based interventions for childhood obesity have been emerging in mainland China in recent decades, but little is known about the effectiveness of such interventions. This study aims to assess the effectiveness of school-based interventions for childhood obesity conducted in mainland China.

Methods

A systematic search was undertaken in eight databases to identify both randomized and non-randomized controlled trials from January 1990 to December 2015 examining the effectiveness of school-based obesity interventions. A random effects meta-analysis was conducted assessing the impact of included interventions on (body mass index) BMI. The quality of each included studies were assessed using Effective Public Health Practice Project Quality Assessment Tool. A P value <0.05 (two-sided) was considered statistically significant.

Result

Of the seventy-six included studies, we found physical activity and health education were the two most common components of interventions. More treatment studies were effective compared with prevention studies (85.0% vs. 58.3%). Comprehensive interventions involving physical activity and health education appeared more effective than the physical activity only interventions in both obesity treatment and prevention studies. The meta-analyses showed comprehensive interventions involving physical activity and health education had larger effect on the change of BMI than physical activity only interventions (treatment studies: -1.80 kg/m² (95% CI: -2.15,-1.44) vs. -0.91 kg/m² (95% CI: -1.15,-0.67); prevention studies: -0.19 kg/m² (95% CI: -0.27, -0.11) vs. +0.05 kg/m² (95% CI: -0.04, +0.15)).

Conclusions

Comprehensive school-based interventions may assist in tackling the rising prevalence of childhood obesity in mainland China.

Preventing childhood obesity in Asia: an overview of intervention programmes

The rapid economic growth in Asia in the past few decades has contributed to the global increase in childhood obesity prevalence. Yet, little is known about obesity prevention efforts in this region. This systematic review provides an overview of child obesity prevention programmes in Asia. Searches were performed in six electronic databases. Out of 4,234 studies, 17 were included, among them 11 controlled trials (of which five were randomized). Only one study was published before 2007. Identified studies were predominantly conducted in China and Thailand and targeted primary school children in a school setting. Most studies implemented different programmes, frequently targeting behavioural modification through nutrition/health education lectures and/or physical activity sessions. Programme effects related to obesity outcome measures were mixed. Most substantial effects were found for outcomes such as improved health knowledge and/or favourable lifestyle practices. The relatively small number of relevant publications in Asia highlights the need for scientific evaluations of existing and future programmes. This will help ensure the implementation and dissemination of evidence-based approaches that have been proven to be effective in the Asian context. Targeting preschool settings and applying a comprehensive multisectoral approach may increase the effectiveness and sustainability of childhood obesity prevention programmes.