Childhood Obesity Prevention and Treatment Research (COPTR): interventions addressing multiple influences in childhood and adolescent obesity

The Associations between Neighborhood Characteristics and Childhood Overweight and Obesity in a National Dataset

BACKGROUND

National child obesity rates continue to climb. While neighborhood factors are known to influence childhood weight, more work is needed to further our understanding of these relationships and inform intervention and policy approaches reflective of complex real-world contexts.

METHODS

To evaluate the associations between neighborhood components and childhood overweight/obesity, we analyzed sequential, cross-sectional data from the National Survey of Children's Health collected annually between 2016 and 2021. To characterize the complexity of children's neighborhood environments, several interrelated neighborhood factors were examined: amenities, detractions, support, and safety. We used ordinal logistic regression models to evaluate the associations between these exposures of interest and childhood weight status, adjusting for potential confounders.

RESULTS

Our analytic sample contained 96,858 children representing a weighted population of 28,228,799 children ages 10-17 years. Child weight status was healthy in 66.5%, overweight in 16.8%, and obese in 17.2%. All four neighborhood factors were associated with child weight status. The odds of overweight or obesity generally increased with a decreasing number of amenities and increasing number of detractions, with the highest adjusted odds ratio seen with no amenities and all three possible detractions (1.71; 95% confidence interval [1.31, 2.11]).

CONCLUSIONS

Multiple factors within a child's neighborhood environment were associated with child weight status in this sample representative of the US population aged 10-17 years. This suggests the need for future research into how policies and programs can support multiple components of a healthy neighborhood environment simultaneously to reduce rates of childhood overweight/obesity.

Monitoring Activity and Gait in Children (MAGIC) using digital health technologies

BACKGROUND

Digital health technologies (DHTs) can collect gait and physical activity in adults, but limited studies have validated these in children. This study compared gait and physical activity metrics collected using DHTs to those collected by reference comparators during in-clinic sessions, to collect a normative accelerometry dataset, and to evaluate participants' comfort and their compliance in wearing the DHTs at-home.

METHODS

The MAGIC (Monitoring Activity and Gait in Children) study was an analytical validation study which enrolled 40, generally healthy participants aged 3-17 years. Gait and physical activity were collected using DHTs in a clinical setting and continuously at-home.

RESULTS

Overall good to excellent agreement was observed between gait metrics extracted with a gait algorithm from a lumbar-worn DHT compared to ground truth reference systems. Majority of participants either "agreed" or "strongly agreed" that wrist and lumbar DHTs were comfortable to wear at home, respectively, with 86% (wrist-worn DHT) and 68% (lumbar-worn DHT) wear-time compliance. Significant differences across age groups were observed in multiple gait and activity metrics obtained at home.

CONCLUSIONS

Our findings suggest that gait and physical activity data can be collected from DHTs in pediatric populations with high reliability and wear compliance, in-clinic and in home environments.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04823650 IMPACT: Digital health technologies (DHTs) have been used to collect gait and physical activity in adult populations, but limited studies have validated these metrics in children. The MAGIC study comprehensively validates the performance and feasibility of DHT-measured gait and physical activity in the pediatric population. Our findings suggest that reliable gait and physical activity data can be collected from DHTs in pediatric populations, with both high accuracy and wear compliance both in-clinic and in home environments. The identified across-age-group differences in gait and activity measurements highlighted their potential clinical value.

Ultra-processed food consumption and BMI-Z among children at risk for obesity from low-income households

OBJECTIVE

To evaluate the association between baseline ultra-processed food consumption in early childhood and child BMI Z-score over 36 months.

METHODS

We conducted a prospective cohort analysis as a secondary data analysis of the Growing Right Onto Wellness randomised trial. Dietary intake was measured via 24-h diet recalls. The primary outcome was child BMI-Z, measured at baseline and at 3-, 9-, 12-, 24- and 36-month timepoints. Child BMI-Z was modelled using a longitudinal mixed-effects model, adjusting for covariates and stratifying by age.

RESULTS

Among 595 children, median (Q1-Q3) baseline age was 4.3 (3.6-5.0) years, 52.3% of the children were female, 65.4% had normal weight, 33.8% were overweight, 0.8% were obese and 91.3% of parents identified as Hispanic. Model-based estimates suggest that, compared with low ultra-processed consumption (300 kcals/day), high ultra-processed intake (1300 kcals/day) was associated with a 1.2 higher BMI-Z at 36 months for 3-year-olds (95% CI = 0.5, 1.9; p < 0.001) and a 0.6 higher BMI-Z for 4-year-olds (95% CI = 0.2, 1.0; p = 0.007). The difference was not statistically significant for 5-year-olds or overall.

CONCLUSIONS

In 3- and 4-year-old children, but not in 5-year-old children, high ultra-processed food intake at baseline was significantly associated with higher BMI-Z at 36-month follow-up, adjusting for total daily kcals. This suggests that it might not be only the total number of calories in a child's daily intake that influences child weight status, but also the number of calories from ultra-processed foods.

NET-Works paediatric obesity prevention trial: 66 month outcomes

BACKGROUND AND OBJECTIVES

The NET-Works trial (2012-2018) randomized 534 children ages 2-4 years at baseline and their caregivers to either a 3-year multicomponent obesity prevention intervention or a control group. This research examined treatment effects on body mass index and other outcomes at 66 months.

METHODS

Parent-child dyads (n = 338) who agreed to participate in a 66 month measurement visit were measured for child BMI, physical activity, diet, and cardiometabolic risk factor variables.

RESULTS

At 66 months, no significant treatment effects were observed on BMI (Effect = -0.38; 95% CI = -1.13, 0.37). Subgroup results were consistent with the NET-Works 36 month results. Children with overweight at baseline in the intervention group gained significantly less BMI versus children with overweight in the control group (Effect = -1.28; 95% CI = -2.48, -0.07). Among Hispanic children, those in the intervention gained significantly less BMI than those in the control group (Effect = -1.04; 95% CI = -1.97, -0.11).

CONCLUSIONS

Evidence suggests that early intervention with children at highest risk for obesity, using community-based, multicomponent, multisetting interventions, may be effective in reducing excess weight gain and obesity among certain subgroups of children. The intervention appeared to be effective in slowing BMI gain 66 months after randomization among children who were already overweight at ages 2-4 years and among children of Hispanic ethnicity.

Reliability and validity of assigning ultraprocessed food categories to 24-h dietary recall data

BACKGROUND

The Nova classification system categorizes foods into 4 processing levels, including ultraprocessed foods (UPFs). Consumption of UPFs is extensive in the United States, and high UPF consumption is associated with chronic disease risk. A reliable and valid method to Nova-categorize foods would advance understanding of UPF consumption and its relationship to health outcomes.

OBJECTIVES

Test the reliability and validity of training coders and assigning Nova categories to individual foods collected via 24-h dietary recalls.

DESIGN

A secondary analysis of 24-h dietary recalls from 610 children who participated in a randomized controlled trial and were 3-5 y old at baseline was conducted. The Nutrition Data System for Research (NDSR) software was used to collect 2-3 dietary recalls at baseline and yearly for 3 y. Trained and certified coder pairs independently categorized foods into one of 4 Nova categories (minimally processed, processed culinary ingredients, processed, and ultraprocessed). Interrater reliability was assessed by percent concordance between coder pairs and by Cohen's κ coefficient. Construct validity was evaluated by comparing the average daily macronutrient content of foods between Nova categories.

RESULTS

In 5546 valid recall days, 3099 unique foods were categorized: minimally processed (18%), processed culinary ingredients (0.4%), processed (15%), and ultraprocessed (67%). Coder concordance = 88.3%, and κ coefficient = 0.75. Descriptive comparisons of macronutrient content across 66,531 diet recall food entries were consistent with expectations. On average, UPFs were 62% (SD 19) of daily calories, and a disproportionally high percentage of daily added sugar (94%; SD 16) and low percentage of daily protein (47%; SD 24). Minimally processed foods were 30% (SD 17) of daily calories, and a disproportionally low percentage of daily added sugar (1%; SD 8) and high percentage of daily protein (43%; SD 24).

CONCLUSIONS

This method of Nova classifying NDSR-based 24-h dietary recalls was reliable and valid for identifying individual intake of processed foods, including UPFs.

Examining adolescents' obesogenic behaviors on structured days: a systematic review and meta-analysis

BACKGROUND

The structured days hypothesis posits that 'structured days' (i.e., days with pre-planned, segmented, and adult-supervised environments) reduce youth obesogenic behaviors. Structured days may be especially important for adolescents', as adolescence (12-19 years) is a period of developmental milestones and increased autonomy. Therefore, the objective of this systematic review and meta-analysis is to evaluate the relationship between structured days and adolescents' obesogenic behaviors (i.e., physical activity, diet, screen time, and/or sleep).

METHODS

From February to April of 2020, four databases (i.e., Embase, PubMed, Web of Science, and PsychINfo) were searched for cross-sectional, longitudinal, and intervention (i.e., baseline data only) studies reporting obesogenic behaviors on more structured versus less structured days (i.e., weekday versus weekend or school year versus summer/holiday).

RESULTS

A total of 42,878 unique titles and abstracts were screened with 2767 full-text articles retrieved. After review of full-text articles, 296 studies were identified (sleep k = 147, physical activity k = 88, screen time k = 81, diet k = 8). Most studies were conducted in North America, Europe & Central Asia, or East Asia & the Pacific used self-report measures and compared school days to weekend days. Meta-analyses indicated that adolescents' physical activity (standardized mean difference [SMD] = -0.25 [95%CI - 0.48, -0.03]) and screen time (SMD = -0.48 [95%CI - 0.66, -0.29]) were less healthy on less structured days. Differences did not reach statistical significance for sleep (SMD = -0.23 [95%CI - 0.48, 0.02]) and diet (SMD = -0.13 [95%CI - 0.77, 0.51]), however, sleep timing (SMD = -1.05 [95%CI - 1.31, -0.79]) and diet quantity (SMD = -0.29 [95%CI - 0.35, -0.23]) were less healthy on less structured days. The review identified studies with large heterogeneity.

CONCLUSIONS

Findings indicate that adolescents' physical activity, screen time, sleep timing, and diet quantity are less healthy on less structured days. Interventions for adolescents to prevent and treat obesity may be more successful if they are designed to target times that are less structured.

The Families Improving Health Together (FIT) Program: Initial evaluation of retention and research in a multispecialty clinic for children with obesity

BACKGROUND

Obesity affects ∼17% of US children, with parallel increases in multiple comorbidities, especially among African-, Asian-, Hispanic-, and Native-Americans. Barriers to patient retention in pediatric obesity programs include lack of centralized care, and frequent subspecialty MD visits which conflict with patient school attendance and parental work attendance as well as with support service utilization. Lack of integration of multispecialty clinical care with interdisciplinary research is a major barrier to fuller exploration of the treatment, prevention, and understanding of obesity in childhood.

OBJECTIVE

To test the hypothesis, a novel multispecialty/interdisciplinary clinical and research infrastructure with strong emphasis on a primary obesity care physician for children with early-onset (<9 years) obesity (Families Improving health Together [FIT]) could promote lower patient attrition (primary goal) and foster productive research in pediatric obesity (secondary goal).

RESULTS

Data support the hypotheses. Over 15 months, FIT reported a >90% participant retention (p < 0.001 vs. expected rate based on other studies of similar programs). Though 90% of children had at least one adiposity-related comorbidity and 70% had at least two, there was no need for additional subspecialist visits with cardiologists, endocrinologists, gastroenterologists, or molecular geneticists. Three abstracts were presented at national meetings, and two manuscripts were published all with junior faculty as primary authors.

CONCLUSION

This pilot study suggests that an integrated multispecialty/interdisciplinary approach to children with obesity improves patient retention and can be integrated successfully with research.

Dietary patterns and associations with BMI in low-income, ethnic minority youth in the USA according to baseline data from four randomised controlled trials

Few studies have derived data-driven dietary patterns in youth in the USA. This study examined data-driven dietary patterns and their associations with BMI measures in predominantly low-income, racial/ethnic minority US youth. Data were from baseline assessments of the four Childhood Obesity Prevention and Treatment Research (COPTR) Consortium trials: NET-Works (534 2-4-year-olds), GROW (610 3-5-year-olds), GOALS (241 7-11-year-olds) and IMPACT (360 10-13-year-olds). Weight and height were measured. Children/adult proxies completed three 24-h dietary recalls. Dietary patterns were derived for each site from twenty-four food/beverage groups using k-means cluster analysis. Multivariable linear regression models examined associations of dietary patterns with BMI and percentage of the 95th BMI percentile. Healthy (produce and whole grains) and Unhealthy (fried food, savoury snacks and desserts) patterns were found in NET-Works and GROW. GROW additionally had a dairy- and sugar-sweetened beverage-based pattern. GOALS had a similar Healthy pattern and a pattern resembling a traditional Mexican diet. Associations between dietary patterns and BMI were only observed in IMPACT. In IMPACT, youth in the Sandwich (cold cuts, refined grains, cheese and miscellaneous) compared with Mixed (whole grains and desserts) cluster had significantly higher BMI (β = 0·99 (95 % CI 0·01, 1·97)) and percentage of the 95th BMI percentile (β = 4·17 (95 % CI 0·11, 8·24)). Healthy and Unhealthy patterns were the most common dietary patterns in COPTR youth, but diets may differ according to age, race/ethnicity or geographic location. Public health messages focused on healthy dietary substitutions may help youth mimic a dietary pattern associated with lower BMI.

A community-based, multi-level, multi-setting, multi-component intervention to reduce weight gain among low socioeconomic status Latinx children with overweight or obesity: The Stanford GOALS randomised controlled trial

BACKGROUND

There are few long-term studies of interventions to reduce in low socioeconomic status children with overweight or obesity. The Stanford GOALS trial evaluated a 3-year, community-based, multi-level, multi-setting, multi-component (MMM) systems intervention, to reduce weight gain among low socioeconomic status, Latinx children with overweight or obesity.

METHODS

We did a two-arm, parallel group, randomised, open-label, active placebo-controlled trial with masked assessment over 3 years. Families from low-income, primarily Latinx communities in Northern California, CA, USA, with 7-11-year-old children with overweight or obesity were randomly assigned to a MMM intervention or a Health Education (HE) comparison intervention. The MMM intervention included home environment changes and behavioural counselling, community after school team sports, and reports to primary health-care providers. The primary outcome was child BMI trajectory over three years. Secondary outcomes included one- and two-year changes in BMI. This trial is registered with ClinicalTrials.govNCT01642836.

FINDINGS

Between July 13, 2012, and Oct 3, 2013, 241 families were recruited and randomly assigned to MMM (n=120) or HE (n=121). Children's mean age was 9·5 (SD 1·4) years, 134 (56%) were female and 107 (44%) were male, and 236 (98%) were Latinx. 238 (99%) children participated in year 1, 233 (97%) in year 2, and 227 (94%) in year 3 of follow-up assessments. In intention-to-treat analysis, over 3 years, the difference between intervention groups in BMI trajectory was not significant (mean adjusted difference -0·25 [95% CI -0·90 to 0·40] kg/m²; Cohen's d=0.10; p=0·45). Children in the MMM intervention group gained less BMI over 1 year than did children in the HE intervention group (-0·73 [-1·07 to -0·39] kg/m², d=0.55); the same was true over 2 years (-0·63 [-1·13 to -0·14] kg/m²; d =0.33). No differential adverse events were observed.

INTERPRETATION

The MMM intervention did not reduce BMI gain versus HE over 3 years but the effects over 1 and 2 years in this rigorous trial show the promise of this systems intervention approach for reducing weight gain and cardiometabolic risk factors in low socioeconomic status communities.

FUNDING

US National Institutes of Health.

Public Policy to Promote Healthy Cardiovascular Lifestyles in Children

Health policy is an important component of prevention of cardiovascular disease (CVD) and promotion of health in childhood and adolescence, when major health behaviours are formed. Development of CVD-related health policy begins with continuous systematic collection, analysis, and interpretation of health-related data to establish the baseline prevalence of CV risk factors and behaviours. These findings allow identification of problems, initiation of focused research, and development of evidence-based interventions. Ultimately, these results inform development and implementation of population-level policies. This review focuses on CVD health-promotion policies in North American youth, for whom health surveillance is an ongoing part of public health policy, providing direct, objective, measurements of growth, lipids, blood pressure, physical activity and tobacco exposure for development of CV health research and policy. When national surveillance data identified significant risk of CVD in youth in the 1970s, major pediatric epidemiologic studies established the strong association between these risk factors and behaviours in childhood and the initiation and progression of atherosclerosis. This knowledge promoted development of the targeted public policies, which are reviewed in this paper. Public policy can directly and positively address cardiovascular health promotion in youth; the effective approach to smoking cessation exemplifies this. For more complex risk factors and behaviours, health policy can be a significant element in a comprehensive CV health promotion program.

Baseline diet quality of predominantly minority children and adolescents from households characterized by low socioeconomic status in the Childhood Obesity Prevention and Treatment Research (COPTR) Consortium

Background

The Healthy Eating Index (HEI-2010) is a measure of diet quality that examines conformance with the Dietary Guidelines for Americans. The objectives of this study were to estimate baseline diet quality of predominantly low-income minority children using the HEI-2010 and to identify the most important HEI components to target for dietary intervention.

Methods

Two or three baseline 24 h dietary recalls were collected in-person or over telephone between May 2012 and June 2014 from 1,745 children and adolescents from four randomized clinical trials in the Childhood Obesity Prevention and Treatment Research (COPTR) Consortium. Nine adequacy and three moderation food components were calculated and averaged to determine overall HEI scores. The overall HEI-2010 scores were categorized as ≥81, 51–80, or ≤ 50 based on the HEI-2005 classification. For each study, mean overall and component HEI scores were estimated using linear regression models.

Results

Mean (95% CI) overall HEI scores ranged from 47.9 (46.8, 49.0) to 64.5 (63.6, 65.4). Only 0.3 to 8.1% of children and adolescents had HEI-2010 score ≥ 81. The average component score for green and beans was less than 30% of maximum score for all trials. In contrast, the average component score for protein, dairy (except for IMPACT), and empty calories (except forIMPACT) was more than 80% of maximum score.

Conclusions

Based on HEI-2010 scores, few children and adolescents consumed high quality diets. Dietary interventions for children and adolescents should focus on improving intakes of green vegetables and beans.

Clinical trial registry numbers

GROW study (clinical trial # NCT01316653); NET-Works study (clinical trial #NCT01606891); Stanford Goals (clinical trial #NCT01642836); IMPACT (clinical trial # NCT01514279).

Predictors of Weight-Related Quality of Life in Adolescents Who Are Overweight or Obese

OBJECTIVE

Weight-related quality of life (WRQOL) is a type of health-related QOL that may serve as a patient-reported outcome of the potential burden of overweight. The present study uses structural equation modeling path analysis methods to examine body mass index (BMI) and other potential predictors of WRQOL components among adolescents who were overweight/obese from predominantly low-income, urban households.

METHODS

Baseline data were obtained from 360 participants (10-13 year olds; 57.8% female; 76.7% black; average BMI of 27.12) and their parents/legal guardians from a randomized, controlled, treatment trial. Youth completed measures of WRQOL, depressive symptoms, and family/friend social support for healthy eating. Parents completed measures of demographics and child social problems.

RESULTS

The initial model included BMI, gender, parent education, family/friend social support for healthy eating, child social problems, body esteem and social life WRQOL, and depressive symptoms. The final model fit the data well (χ = 27.738; df = 16; p = .034). Higher BMI was indirectly related to lower social life and body esteem WRQOL through greater social problems. Physical comfort and family relations WRQOL were unrelated to BMI and were not included. Lower social life and body esteem related to more depressive symptoms. Family/friend discouragement for healthy eating was associated with lower body esteem; also, family discouragement was related to lower social life.

CONCLUSION

Body mass index may not directly relate to WRQOL but may be associated through other factors, including child social problems. Interventions should screen for and treat mood and social problems and address family/friend support for healthy eating.

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.

Two Family Interventions to Reduce BMI in Low-Income Urban Youth: A Randomized Trial

BACKGROUND

Our primary aim was to evaluate the effects of 2 family-based obesity management interventions compared with a control group on BMI in low-income adolescents with overweight or obesity.

METHODS

In this randomized clinical trial, 360 urban-residing youth and a parent were randomly assigned to 1 of 2 behaviorally distinct family interventions or an education-only control group. Eligible children were entering the sixth grade with a BMI ≥85th percentile. Interventions were 3 years in length; data were collected annually for 3 years. Effects of the interventions on BMI slope (primary outcome) over 3 years and a set of secondary outcomes were assessed.

RESULTS

Participants were primarily African American (77%), had a family income of <25 000 per year, and obese at enrollment (68%). BMI increased over time in all study groups, with group increases ranging from 0.95 to 1.08. In an intent-to-treat analysis, no significant differences were found in adjusted BMI slopes between either of the family-based interventions and the control group (P = .35). No differences were found between the experimental and control groups on secondary outcomes of diet, physical activity, sleep, perceived stress, or cardiometabolic factors. No evidence of effect modification of the study arms by sex, race and/or ethnicity, household income, baseline levels of child and parent obesity, or exposure to a school fitness program were found.

CONCLUSIONS

In this low-income, adolescent population, neither of the family-based interventions improved BMI or health-related secondary outcomes. Future interventions should more fully address poverty and other social issues contributing to childhood obesity.

Recruitment strategies for predominantly low-income, multi-racial/ethnic children and parents to 3-year community-based intervention trials: Childhood Obesity Prevention and Treatment Research (COPTR) Consortium

BACKGROUND

The recruitment of participants into community-based randomized controlled trials studying childhood obesity is often challenging, especially from low-income racial/ethnical minorities and when long-term participant commitments are required. This paper describes strategies used to recruit and enroll predominately low-income racial/ethnic minority parents and children into the Childhood Obesity Prevention and Treatment Research (COPTR) consortium.

METHODS

The COPTR consortium has run four independent 3-year, multi-level (individual, family, school, clinic, and community) community-based randomized controlled trials. Two were prevention trials in preschool children and the other two were treatment trials in pre-adolescents and adolescent youth. All trials reported monthly participant recruitment numbers using a standardized method over the projected 18-24 months of recruitment. After randomization of participants was completed, recruitment staff and investigators from each trial retrospectively completed a survey of recruitment strategies and their perceived top three recruitment strategies and barriers.

RESULTS

Recruitment was completed in 15-21 months across trials, enrolling a total of 1745 parent-child dyads- out of 6314 screened. The number of children screened per randomized child was 4.6 and 3.5 in the two prevention trials, and 3.1 and 2.5 in the two treatment trials. Recruitment strategies reported included: (1) careful planning, (2) working with trusting community partners, (3) hiring recruitment staff who were culturally sensitive, personality appropriate, and willing to work flexible hours, (4) contacting potential participants actively and repeatedly, (5) recruiting at times and locations convenient for participants, (6) providing incentives to participants to complete baseline measures, (7) using a tracking database, (8) evaluating whether participants understand the activities and expectations of the study, and (9) assessing participants' motivation for participating. Working with community partners, hiring culturally sensitive staff, and contacting potential participants repeatedly were cited by two trials among their top three strategies. The requirement of a 3-year commitment to the trial was cited by two trials to be among the top three recruitment barriers.

CONCLUSIONS

Comprehensive strategies that include community partnership support, culturally sensitive recruitment staff, and repeated contacts with potential participants can result in successful recruitment of low-income racial/ethnic minority families into obesity prevention and treatment trials.

TRIAL REGISTRATION

NET-Works trial: ClinicalTrials.gov, NCT01606891 . Registered on 28 May 2012. GROW trial: ClinicalTrials.gov, NCT01316653 . Registered on 16 March 2011. GOALS trial: ClinicalTrials.gov, NCT01642836 . Registered on 17 July 2012. IMPACT trial: ClinicalTrials.gov, NCT01514279 . Registered on 23 January 2012.

Snacking characteristics and patterns and their associations with diet quality and BMI in the Childhood Obesity Prevention and Treatment Research Consortium

OBJECTIVE

To describe snacking characteristics and patterns in children and examine associations with diet quality and BMI.

DESIGN

Children's weight and height were measured. Participants/adult proxies completed multiple 24 h dietary recalls. Snack occasions were self-identified. Snack patterns were derived for each sample using exploratory factor analysis. Associations of snacking characteristics and patterns with Healthy Eating Index-2010 (HEI-2010) score and BMI were examined using multivariable linear regression models.

SETTING

Childhood Obesity Prevention and Treatment Research (COPTR) Consortium, USA: NET-Works, GROW, GOALS and IMPACT studies.

PARTICIPANTS

Predominantly low-income, racial/ethnic minorities: NET-Works (n 534, 2-4-year-olds); GROW (n 610, 3-5-year-olds); GOALS (n 241, 7-11-year-olds); IMPACT (n 360, 10-13-year-olds).

RESULTS

Two snack patterns were derived for three studies: a meal-like pattern and a beverage pattern. The IMPACT study had a similar meal-like pattern and a dairy/grains pattern. A positive association was observed between meal-like pattern adherence and HEI-2010 score (P for trend < 0⋅01) and snack occasion frequency and HEI-2010 score (β coefficient (95 % CI): NET-Works, 0⋅14 (0⋅04, 0⋅23); GROW, 0⋅12 (0⋅02, 0⋅21)) among younger children. A preference for snacking while using a screen was inversely associated with HEI-2010 score in all studies except IMPACT (β coefficient (95 % CI): NET-Works, -3⋅15 (-5⋅37, -0⋅92); GROW, -2⋅44 (-4⋅27, -0⋅61); GOALS, -5⋅80 (-8⋅74, -2⋅86)). Associations with BMI were almost all null.

CONCLUSIONS

Meal-like and beverage patterns described most children's snack intake, although patterns for non-Hispanic Blacks or adolescents may differ. Diets of 2-5-year-olds may benefit from frequent meal-like pattern snack consumption and diets of all children may benefit from decreasing screen use during eating occasions.

Disparities in childhood overweight and obesity by income in the United States: an epidemiological examination using three nationally representative datasets

BACKGROUND/OBJECTIVES

Overweight and obesity (OWOB) is a global epidemic. Adults and adolescents from low-income households are at higher risk to be OWOB. This study examined the relationship between income and OWOB prevalence in children and adolescents (518 years) in the United States (US) within and across race/ethnicities, and changes in this relationship from 1971 to 2014.

SUBJECTS/METHODS

A meta-analysis of a nationally representative sample (N = 73,891) of US children and adolescents drawn from three datasets (i.e., National Health and Nutrition Examination Survey, National Longitudinal Survey of Youth, & the Early Childhood Longitudinal Program) which included 14 cross-sectional waves spanning 1971-2014 was conducted. The exposure was household income-to-poverty ratio (low income = 0.00-1.00, middle income = 1.01-4.00, high income >4.00) with prevalence of overweight or obesity (body mass index ≥ 85th percentile) as the outcome.

RESULTS

Children and adolescents from middle-income and high-income households were 0.78 (95% CI = 0.72, 0.83) and 0.68 (95% CI = 0.59, 0.77) times as likely to be OWOB compared to children and adolescents in low-income households. Separate analyses restricted to each racial/ethnic group showed children and adolescents from middle- and high-income households were less likely to be OWOB compared to their low-income peers within the White, Hispanic, and Other race/ethnic groups. Children and adolescents from low-income households who were Black were not more likely to be OWOB than their high- and middle-income counterparts. Analyses within each income stratum indicated that race/ethnicity was not related to the prevalence of OWOB in low-income households. However, racial/ethnic differences in OWOB were evident for children and adolescents in middle- and high-income households. Disparities in the prevalence of OWOB between low-income children and adolescents and their middle- and high-income counterparts have increased from 1971 to 2014.

CONCLUSIONS

Income and OWOB are related in US children and adolescents. Racial/ethnic differences in the prevalence of OWOB emerge in middle- and high-income households. Disparities in OWOB prevalence are growing.

Challenges and Lessons Learned from Multi-Level Multi-Component Interventions to Prevent and Reduce Childhood Obesity

Multi-level multi-component (MLMC) strategies have been recommended to prevent and reduce childhood obesity, but results of such trials have been mixed. The present work discusses lessons learned from three recently completed MLMC interventions to inform future research and policy addressing childhood obesity. B’more Healthy Communities for Kids (BHCK), Children’s Healthy Living (CHL), and Health and Local Community (SoL) trials had distinct cultural contexts, global regions, and study designs, but intervened at multiple levels of the socioecological model with strategies that address multiple components of complex food and physical activity environments to prevent childhood obesity. We discuss four common themes: (i) How to engage with community partners and involve them in development of intervention and study design; (ii) build and maintain intervention intensity by creating mutual promotion and reinforcement of the intervention activities across the multiple levels and components; (iii) conduct process evaluation for monitoring, midcourse corrections, and to engage stakeholder groups; and (iv) sustaining MLMC interventions and its effect by developing enduring and systems focused collaborations. The paper expands on each of these themes with specific lessons learned and presents future directions for MLMC trials.

Multicomponent Obesity Prevention Intervention in Low-Income Preschoolers: Primary and Subgroup Analyses of the NET-Works Randomized Clinical Trial, 2012-2017

OBJECTIVES

To evaluate a multicomponent obesity prevention intervention among diverse, low-income preschoolers.

METHODS

Parent-child dyads (n = 534) were randomized to the Now Everybody Together for Amazing and Healthful Kids (NET-Works) intervention or usual care in Minneapolis, MN (2012-2017). The intervention consisted of home visits, parenting classes, and telephone check-ins. The primary outcomes were adjusted 24- and 36-month body mass index (BMI).

RESULTS

Compared with usual care, the NET-Works intervention showed no significant difference in BMI change at 24 (-0.12 kg/m2; 95% confidence interval [CI] = -0.44, 0.19) or 36 months (-0.19 kg/m2; 95% CI = -0.64, 0.26). Energy intake was significantly lower in the NET-Works group at 24 (-90 kcal/day; 95% CI = -164, -16) and 36 months (-101 kcal/day; 95% CI = -164, -37). Television viewing was significantly lower in the NET-Works group at 24 (rate ratio = 0.84; 95% CI = 0.75, 0.93) and 36 months (rate ratio = 0.88; 95% CI = 0.78, 0.99). Children with baseline overweight or obesity had lower BMI in the NET-Works group than those in usual care at 36 months (-0.71 kg/m2; 95% CI = -1.30, -0.12). Hispanic children had lower BMI in the NET-Works group than those in usual care at 36 months (-0.59 kg/m2; 95% CI = -1.14, -0.04).

CONCLUSIONS

In secondary analyses, NET-Works significantly reduced BMI over 3 years among Hispanic children and children with baseline overweight or obesity.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01606891.

Childhood obesity research at the NIH: Efforts, gaps, and opportunities

Childhood obesity is a major public health challenge. This article describes an overview of the National Institutes of Health (NIH) behavioral and social sciences childhood obesity research efforts. The overview will highlight five areas of childhood obesity research supported by the NIH: (a) basic behavioral and social sciences; (b) early childhood; (c) policies, programs, and environmental strategies; (d) health disparities; and (e) transagency and public-private collaboration. The article also describes potential gaps and opportunities in the areas of childhood obesity and severe obesity, measurement, and sleep.

Fruits and vegetables embedded in classic video games: a health-promoting potential?

The proliferation of the video game era has increased sedentary behaviours among children and adolescents. Contemporary interventions involve the use of video games to introduce fruit and vegetable (F&V) consumption among children and adolescents. A comprehensive list of licenced video games (n = 671) released for the Nintendo Entertainment System (NES) console were reviewed for thematic content and qualitative characteristics of the game's activity relevant to F&V. Seventy-five video games were included in the study sample and categorised by release year, prevalence of F&V, and thematic content. Mild associations were found comparing release year to F&V totals (r = 0.21) and release year to theme (r = 0.19). F&V themes embedded within classic video games could serve as health-promoting lessons for forthcoming video games. Future games produced by the video gaming industry should continue to focus on nutrition-embedded messages promoting F&V. Video game development and marketing could be an avenue that incorporates healthy nutrition themes.

Memphis FitKids: implementing a mobile-friendly web-based application to enhance parents' participation in improving child health

Background

Child obesity is a major public health challenge, increasing the risk of chronic medical conditions such as type 2 diabetes, metabolic syndrome, and hypertension. Among U.S. states, Tennessee has one of the highest rates of child obesity. Emerging communication technologies can help to deliver highly disseminable population-level interventions to improve health behavior. The aim of this paper is to report the implementation and the evaluation of the reach of Memphis FitKids, a web-based application, intended to promote healthy behaviors for families and children.

Methods

A community-level demonstration project, Memphis FitKids, was developed and implemented in Tennessee’s Greater Memphis Area. This application (www.memphisfitkids.org) was designed for parents to assess their children’s obesity risk through determinants such as weight, diet, physical activity, screen time, and sleep adequacy. A built-in “FitCheck” tool used this collected information to create a report with tailored recommendations on how to make healthy changes. A Geographic Information Systems component was implemented to suggest low-cost neighborhood resources that support a healthy lifestyle. A social marketing framework was used to develop and implement FitKids, and a Community Advisory Board with representatives from community partners (e.g., the YMCA of Memphis, the Pink Palace Family of Museums, and the Memphis Public Library) supported the implementation of the project. Five kiosks distributed in the community served as public access points to provide a broad reach across socioeconomic strata. Presentations at community events and the use of Facebook facilitated the promotion of FitKids. Website traffic and Facebook usage were evaluated with Google Analytics and Facebook Insights, respectively.

Results

In Tennessee, 33,505 users completed 38,429 FitCheck sessions between July 2014 and December 2016. Among these, 6763 sessions were completed at the five kiosks in the community. FitKids was presented at 112 community events and the social media posts reached 23,767 unique Facebook users.

Conclusions

The Memphis FitKids demonstration project showed that web-based health tools may be a viable strategy to increase access to information about healthy weight and lifestyle options for families. Mobile-friendly web-based applications like Memphis FitKids may also serve health professionals in their efforts to support their clients in adopting healthy behaviors.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5968-6) contains supplementary material, which is available to authorized users.

Reducing pediatric caries and obesity risk in South Asian immigrants: randomized controlled trial of common health/risk factor approach

Background

This paper describes the design and methods of a multi-phase study to reduce early childhood caries and obesity in vulnerable South Asian (SA) immigrants in the United States. Early childhood caries and obesity are the most common diseases of early childhood. Risk factors for both diseases are rooted in early childhood feeding practices such as bottle feeding and intake of sweets and sweetened beverages. The Common Health/Risk Factor Approach to addressing oral health is widely promoted by the WHO and other policy makers. This approach recognizes links between oral health and other diseases of modernity. Our CHALO! (“Child Health Action to Lower Obesity and Oral health risk”--from a Hindi word meaning "Let's go!") study targets SA families at high risk for early childhood caries and obesity. CHALO! addresses common risk factors associated with these two common diseases of childhood.

Methods

This two part project includes a randomized controlled trial, and a Knowledge Translation campaign. A randomized controlled trial will enroll n =  360 families from pediatric practices serving South Asians in the New York metro area. The intervention group will receive home visits by SA community health workers at 6, 8, 10, 12, 14, and 16 months of age. Controls will receive culturally tailored educational material. Primary outcomes-- cariogenic and obesogenic feeding practices at 6, 12, and 18 months-- will be assessed with the MySmileBuddy iPad based tool. Secondary outcomes include: oral hygiene practices, anthropometrics, and caries incidence at 18 months. A public education campaign will focus on both families and health care providers.

Discussion

There are few Common Health/Risk Factor Approach published studies on obesity and oral health risk in children, despite health morbidity and costs associated with both conditions. CHALO! comprises a multi-level interventions designed to promote culturally competent, sustainable change.

Trial registration

ClinicalTrials.govNCT03077425.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5317-9) contains supplementary material, which is available to authorized users.

Preserving Cardiovascular Health in Young Children: Beginning Healthier by Starting Earlier

PURPOSE OF REVIEW

The goals of this paper are to review current literature regarding maternal-fetal-pediatric diet and nutritional factors related to preserving cardiovascular health in the very young child and the emerging data implicating nutritional influences on neurodevelopmental factors. Questions related to maternal diet and influences of human milk on child's growth, neurodevelopment, and risk of developing obesity were addressed.

RECENT FINDINGS

The majority of US women in their reproductive years have overweight or obese status thereby increasing the risk of developing obesity in their children. Efforts to restrict gestational weight gain, perpetuate breast-feeding, and introduce heart-healthy complementary feeding after 6 months of age are now more commonly recommended and offer practical translational approaches to prevent pediatric obesity and encourage neurodevelopment intended to support cognitive and executive function. There is growing literature on the role of maternal-fetal-pediatric nutrition on cardiometabolic and neurodevelopmental health in children. Potential influences of maternal diet quality and obesity on not only birth outcomes but subsequent risk factor development in the child are increasingly apparent. Further investigation of these factors has become a major research focus in developing future diet recommendations to better inform underlying potential mechanisms and identify opportunities for primary prevention starting in utero.

Novel patterns of physical activity in a large sample of preschool-aged children

Background

Moderate-to-vigorous physical activity (MVPA), shown to be associated with health benefits, is not well-characterized in preschool-aged children. MVPA is commonly described as a threshold amount to achieve. We examined a novel way to characterize MVPA patterns in preschool-aged children by gender and age.

Methods

Preschool-aged children from Nashville, TN and Minneapolis, MN wore triaxial accelerometers. Four distinct MVPA patterns were identified: isolated spurt (IS), isolated sustained activity (ISA), clustered spurt (CS), and clustered sustained activity (CSA). Multivariable linear regression models were used to test associations of gender and age with each pattern.

Results

One thousand one hundred thirty-one children (3.9 years old, 51% girls, 30% overweight, 11% obese, and 76% Hispanic) wore accelerometers for 12.9 (SD = 1.4) hours/day for 6.7 (SD = 0.7) days. Children spent 53% of wear time in sedentary behavior and 13% in MVPA. On average, boys and girls achieved > 90 min/day of MVPA (98.2 min, SD = 32.3). Most MVPA (80%) was obtained in spurt-like (IS and CS) MVPA; however, girls spent a higher proportion of MVPA in IS and CS, and lower proportion of time in CSA (all p < 0.001). Controlling for gender, an increase of 1-year in age corresponded to a 1.5% increase in CSA (p < 0.05).

Conclusions

How MVPA was obtained varied depending on the gender and age of the child. On average, boys spent more time in sustained MVPA than girls and MVPA was more sustained in older children. Utilizing these patterns could inform PA practice and policy guidelines.

Trial registration

NCT01316653, date of registration: March 3, 2011; NCT01606891, date of registration: May 23, 2012.

Summer Weight Gain and Fitness Loss: Causes and Potential Solutions

Over the past 3 decades, public health professionals have worked to stem the rising childhood obesity epidemic. Despite the field's best efforts, no progress has been made in reducing child obesity. One reason for this failure may be that obesity prevention and treatment efforts have predominately been delivered during the 9-month school year. However, recent evidence suggests that the summer, not the school year, is when unhealthy changes in body composition (ie, accelerated increases in percent body fat) and fitness losses occur. This unhealthy change in body composition and fitness loss during the summer could be explained by the "Structured Days Hypothesis," which posits that children engage in a greater number of unhealthy obesogenic behaviors on unstructured days when compared with structured days. Furthermore, the summer may be contributing to a widening "health gap" between children from low-income and middle- to upper-income families. During summer, fewer opportunities exist for children from low-income households to access healthy structured programs that do not require fees for participation. Moving forward, public health professionals should prioritize efforts to mitigate unhealthy changes in body composition and fitness loss during the summer by identifying ways to provide access to structured programming during this timeframe for children from low-income households.

Overview of the obesity intervention taxonomy and pooled analysis working group

The National Heart, Lung, and Blood Institute and the National Institutes of Health Office of Disease Prevention convened a meeting on August 29-30, 2013 entitled "Obesity Intervention Taxonomy and Pooled Analysis." The overarching goals of the meeting were to understand how to decompose interventions targeting behavior change, and in particular, those that focus on obesity and to combine data from groups of related intervention studies to supplement what can be learned from the individual studies. This paper summarizes the workshop recommendations and provides an overview of the two other papers that originated from the workshop and that address decomposition of behavioral change interventions and pooling of data across diverse studies within a consortium.

Statistical methodologies to pool across multiple intervention studies

Combining and analyzing data from heterogeneous randomized controlled trials of complex multiple-component intervention studies, or discussing them in a systematic review, is not straightforward. The present article describes certain issues to be considered when combining data across studies, based on discussions in an NIH-sponsored workshop on pooling issues across studies in consortia (see Belle et al. in Psychol Aging, 18(3):396-405, 2003). Several statistical methodologies are described and their advantages and limitations are explored. Whether weighting the different studies data differently, or via employing random effects, one must recognize that different pooling methodologies may yield different results. Pooling can be used for comprehensive exploratory analyses of data from RCTs and should not be viewed as replacing the standard analysis plan for each study. Pooling may help to identify intervention components that may be more effective especially for subsets of participants with certain behavioral characteristics. Pooling, when supported by statistical tests, can allow exploratory investigation of potential hypotheses and for the design of future interventions.

Introduction to special issue: Self-regulation of appetite-it's complicated

OBJECTIVE

A meeting of multidisciplinary biobehavioral scientists and National Institutes of Health (NIH) program staff was convened by the Office of Behavioral and Social Sciences Research, Division of Program Coordination, Planning, and Strategic Initiatives, Office of the Director, NIH to examine mechanisms associated with humans' ability to self-regulate appetite and appetitive behavior.

METHODS

Based upon prior discussions of the NIH Obesity Research Task Force Behavioral Phenotyping Work Group, the premise was adopted that, in modern society, multiple factors on multiple levels interact to create circumstances wherein self-control of appetite is difficult, leading to overconsumption of unhealthy foods versus healthy eating patterns, contributing to our current levels of obesity. Through presentations and group discussions, the panel examined how foundational processes/mechanisms directly and indirectly affect appetitive behavior and how these processes can be manipulated to affect food intake and thereby weight. The meeting identified evidence-based mechanisms with the potential to impact self-regulation of appetite and appetitive states (hunger, satiety, food wanting, restraint, reward) and associated behaviors such as overconsumption, eating in the absence of hunger, food seeking, and decision-making that could inform novel weight intervention strategies in free-living, nonlaboratory settings.

CONCLUSION

The three summary papers contained in this issue represent the synthesis of the material presented at the meeting and the panel's recommendations on how existing evidence regarding mechanisms and pathways to appetitive behavior can be used to inform future research and novel prevention and intervention strategies to impact prevalence of obesity.

Multilevel Interventions Targeting Obesity: Research Recommendations for Vulnerable Populations

INTRODUCTION

The origins of obesity are complex and multifaceted. To be successful, an intervention aiming to prevent or treat obesity may need to address multiple layers of biological, social, and environmental influences.

METHODS

NIH recognizes the importance of identifying effective strategies to combat obesity, particularly in high-risk and disadvantaged populations with heightened susceptibility to obesity and subsequent metabolic sequelae. To move this work forward, the National Heart, Lung, and Blood Institute, in collaboration with the NIH Office of Behavioral and Social Science Research and NIH Office of Disease Prevention convened a working group to inform research on multilevel obesity interventions in vulnerable populations. The working group reviewed relevant aspects of intervention planning, recruitment, retention, implementation, evaluation, and analysis, and then made recommendations.

RESULTS

Recruitment and retention techniques used in multilevel research must be culturally appropriate and suited to both individuals and organizations. Adequate time and resources for preliminary work are essential. Collaborative projects can benefit from complementary areas of expertise and shared investigations rigorously pretesting specific aspects of approaches. Study designs need to accommodate the social and environmental levels under study, and include appropriate attention given to statistical power. Projects should monitor implementation in the multiple venues and include a priori estimation of the magnitude of change expected within and across levels.

CONCLUSIONS

The complexity and challenges of delivering interventions at several levels of the social-ecologic model require careful planning and implementation, but hold promise for successful reduction of obesity in vulnerable populations.

"Whole-of-Community" Obesity Prevention: A Review of Challenges and Opportunities in Multilevel, Multicomponent Interventions

The causes of obesity worldwide are complex and multilevel, including changing food environments, physical activity levels, policies, and food production systems. This intricate context requires multilevel and multicomponent (MLMC) interventions to improve health outcomes. We conducted a literature review of MLMC interventions for obesity prevention and mitigation; 14 studies meeting search criteria were identified. We found examples of successes in preventing obesity, reducing overweight, improving healthful behaviors, and enhancing some psychosocial indicators. Of eight studies that reported health and behavioral results, five showed no significant impact and three showed reductions in obesity. Four studies showed significant improvement in dietary behavior, and five reported significant desirable effects in physical activity or screen time. Five studies reported psychosocial impacts, and three of these showed significant improvements. MLMC approaches show promising results, particularly when they are able to integrate components at the policy, community, and interpersonal levels.

Fit Families Program Improves Self-Perception in Children

OBJECTIVE

To determine the impact of the Fit Families youth weight management program on self-perception of participants.

METHODS

Fit Families was delivered through Cooperative Extension and provided education to overweight and obese children and their families on healthful eating and physical activity along with building self-esteem and social competence. At the beginning and end of the 7-week program, a convenience sample of 46 youth completed the Self-Perception Profile for Children questionnaire to evaluate changes in self-perception.

RESULTS

Youth had improved self-perception in the areas of athletic competence (P = .04) and physical appearance (P = .007) after participating in Fit Families.

CONCLUSIONS AND IMPLICATIONS

Fit Families provides a holistic approach to weight management that promotes positive self-perception, which may decrease the burden of depression, anxiety, and low self-esteem obese youth face.

Prediction of percent body fat measurements in Americans 8 years and older

BACKGROUND/OBJECTIVES

Although numerous equations to predict percent body fat have been published, few have broad generalizability. The objective of this study was to develop sets of equations that are generalizable to the American population 8 years of age and older.

SUBJECTS/METHODS

Dual-emission X-ray absorptiometry (DXA) assessed percent body fat from the 1999-2006 National Health and Nutrition Examination Survey (NHANES) was used as the response variable for development of 14 equations for each gender that included between 2 and 10 anthropometrics. Other candidate variables included demographics and menses. Models were developed using the Least Absolute Shrinkage and Selection Operator (LAASO) and validated in a ¼ withheld sample randomly selected from 11 884 males or 9215 females.

RESULTS

In the final models, R(2) ranged from 0.664 to 0.845 in males and from 0.748 to 0.809 in females. R(2) was not notably improved by development of equations within, rather than across, age and ethnic groups. Systematic over or under estimation of percent body fat by age and ethnic groups was within 1 percentage point. Seven of the fourteen gender-specific models had R(2) values above 0.80 in males and 0.795 in females and exhibited low bias by age, race/ethnicity and body mass index (BMI).

CONCLUSIONS

To our knowledge, these are the first equations that have been shown to be valid and unbiased in both youth and adults in estimating DXA assessed body fat. The equations developed here are appropriate for use in multiple ethnic groups, are generalizable to the US population and provide a useful method for assessment of percent body fat in settings where methods such as DXA are not feasible.

Metabolic Syndrome and its Profound Effect on Prevalence of Ischemic Stroke

Ischemic stroke represents a leading cause of death worldwide and the leading cause of disability in the United States. Greater than 8% of all deaths are attributed to ischemic stroke. This rate is consistent with the heightened burden of cardiovascular disease deaths. Treatments for acute ischemic stroke remain limited to tissue plasminogen activator and mechanical thrombolysis, both of which require significant medical expertise and can only be applied to a select number of patients based on time of presentation, imaging, and absence of contraindications. Over 1,000 compounds that were successful in treating ischemic stroke in animal models have failed to correlate to success in clinical trials. The search for alternative treatments is ongoing, drawing greater attention to the importance of preclinical models that more accurately represent the clinical population through incorporation of common risk factors. This work reviews the contribution of these commonly observed risk factors in the clinical population highlighting both the pathophysiology as well as current clinical diagnosis and treatment standards. We also highlight future potential therapeutic targets, areas requiring further investigation, and recent changes in best-practice clinical care.

Forging a future of better cardiovascular health: addressing childhood obesity

This paper describes ongoing National, Heart, Lung, and Blood Institute (NHLBI)-initiated childhood obesity research. It calls on clinicians, researchers, and cardiologists to work with other healthcare providers, community agencies, schools and caregivers to foster better cardiovascular health in children by intervening on multiple levels of influence on childhood obesity.