The iCook 4-H Study: Report on Physical Activity and Sedentary Time in Youth Participating in a Multicomponent Program Promoting Family Cooking, Eating, and Playing Together

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.

Dyadic Analysis of a Self-report Physical Activity Measure for Adult-Youth Dyads

Adult physical activity levels influence youth physical activity levels, but the nature of this relationship is still unknown. Most research focusing on this topic has been conducted with accelerometers, which are ideal since self-report physical activity measures can be biased. However, self-report measures for physical activity are useful to include in studies to gather information at low-cost. The purpose of this study was to further develop a self-report adult-youth dyad measure of physical activity. This study was conducted using secondary data analysis of the physical activity measures used in an intervention on behavioral nutrition (iCook 4-H). Participants were a sample of 214 adults (M = 39.0, SD = 8.0 years) and youth (M = 9.4, SD = 0.7 years) pairs. Accelerometer data was collected for a subset of youth (n = 122). There was dependency between the adult-youth physical activity data, and a dyadic confirmatory factor analysis model showed good fit to the data and achieved metric invariance, a measure to determine if the same construct was being measured in both youth and adults. Invariance was confirmed across matched versus unmatched sex pairs and some evidence of invariance with youth accelerometer data. Based on study findings, when using self-report measures of physical activity, researchers should measure both members of the adult-youth dyad to get more accurate measurements. Further validation of these findings is needed using an objective physical activity measure, like accelerometers, with all participants and more diverse samples.

Parent and School-Age Children's Food Preparation Cognitions and Behaviors Guide Recommendations for Future Interventions

OBJECTIVE

To investigate parent and child food preparation cognitions and behaviors qualitatively to create recommendations for nutrition programs targeting these audiences.

DESIGN

Focus groups were conducted in community settings with school-age children (n = 37) and parents (n = 38) in Florida, West Virginia, and New Jersey.

SETTING

Community settings in Florida, West Virginia, and New Jersey.

PARTICIPANTS

School-age children (n = 37) and parents (n = 38).

PHENOMENON OF INTEREST

Factors influencing food preparation of school-aged children and their parents to inform Social Cognitive Theory-based recommendations.

ANALYSIS

Content analysis.

RESULTS

Parents believed that child involvement in meal preparation was important for developing cooking skills, responsibility, and self-esteem, but noted that involvement was limited by time scarcity and concern regarding child safety in the kitchen. Parents recommended having children engage in age-appropriate food preparation activities, such as packing their own snacks. Children echoed parents' beliefs, stating they would need to know how to cook later in life. Many children acknowledged being a part of meal preparation by setting the table and helping grocery shop. Food preparation's link to improving diet quality was not mentioned by parents or children. To increase involvement, children suggested that parents demonstrate skills, select age-appropriate tasks for them, and reward them for helping.

CONCLUSIONS AND IMPLICATIONS

This research provides insight into parents' and children's food preparation cognitions (eg, beliefs, attitudes) and behaviors and assembles results into recommendations that may guide decisions during nutrition intervention development and potentially improve nutrition intervention.

The iCook 4-H Study: An Intervention and Dissemination Test of a Youth/Adult Out-of-School Program

OBJECTIVE

To describe outcomes from intervention and dissemination of iCook 4-H.

DESIGN

Five-state, community-based participatory research and a randomized, controlled trial followed by a 5-state, nonrandomized dissemination test of the iCook 4-H curriculum with control and treatment groups.

SETTING

Community and university sites.

PARTICIPANTS

Youths aged 9-10 years and their adult food preparer; 228 dyads in the intervention and 74 dyads in dissemination.

INTERVENTION(S)

Theoretical frameworks were Social Cognitive Theory and the experiential 4-H learning model. Six 2-hour, biweekly sessions on cooking, eating, and playing together followed by monthly newsletters and boosters until 24 months, expanded to 8 sessions for dissemination.

MAIN OUTCOME MEASURE(S)

Youth body mass index (BMI) z-scores, measured height and weight, and youth/adult program outcome evaluations surveys.

ANALYSIS

Linear mixed models, group, time, and group × time interaction for BMI z-score and program outcomes changes. Significance levels = P ≤ .05; interaction term significance = P ≤ .10.

RESULTS

In intervention, treatment BMI z-scores increased compared with controls based on significant interaction (P = .04). For odds of being overweight or obese at 24 months, there was no significant interaction (P = .18). In dissemination, based on significant interaction, treatment youths increased cooking skills (P = .03) and treatment adults increased cooking together (P = .08) and eating together (P = .08) compared with controls.

CONCLUSIONS AND IMPLICATIONS

iCook 4-H program outcomes were positive for mealtime activities of cooking and eating together. The program can be successfully implemented by community educators. The increase in BMI z-scores needs further evaluation for youths in cooking programs.

Ripple Effect Mapping Outcomes of a Childhood Obesity Prevention Program From Youth and Adult Dyads Using a Qualitative Approach: iCook 4-H

OBJECTIVE

To describe the impact of the iCook 4-H intervention study based on data gathered through ripple effect mapping focus groups through an explorative approach.

DESIGN

Youth-adult dyads responded about ways in which iCook had affected the individual, family, and community. Three questions were asked: (1) What were people doing differently as a result of iCook? (2) Who benefited from iCook and how? (3) Were there changes in the way community groups and institutions did things as a result of iCook?

SETTING

Ripple effect mapping sessions took place across 5 states (Maine, Nebraska, South Dakota, Tennessee, and West Virginia).

PARTICIPANTS

Seventy dyad participants (n = 35 youth, n = 35 adults) from the iCook 4-H intervention.

MAIN OUTCOME MEASURE

Three core themes of iCook 4-H were assessed: cooking, eating, and playing together.

ANALYSIS

Direct content analysis and word frequencies were used.

RESULTS

Seven categories emerged: improved health, increased community involvement, increased knowledge, increased communication, changed motivation, financial mindfulness, and increased appreciation for family. An overarching theme that was determined was that learning new skills together through trying new things (cooking, eating, and playing) leads to positive individual family and community change.

CONCLUSIONS AND IMPLICATIONS

Ripple effect mapping was effective in determining the perceived impact of iCook 4-H on oneself, family, and community.