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Eglitis E, Singh B, Olds T, Virgara R, Machell A, Richardson M, Brannelly K, Grant A, Gray J, Wilkinson T, Rix Z, Tomkinson GR, Maher C. Health effects of children's summer holiday programs: a systematic review and meta-analysis. Int J Behav Nutr Phys Act 2024; 21:119. [PMID: 39425115 DOI: 10.1186/s12966-024-01658-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 09/13/2024] [Indexed: 10/21/2024] Open
Abstract
BACKGROUND Unfavourable changes occur in children's health behaviours and outcomes during the summer holidays. This systematic review aimed to determine the effectiveness of summer holiday programs in mitigating these changes. METHODS Six databases (MEDLINE, JBI, PsychINFO, Embase, ERIC and Scopus) were systematically searched for experimental controlled studies that investigated programs of at least 5 days' duration conducted exclusively during the summer holiday period on school-aged children (5-18 years). Primary outcomes were moderate-vigorous physical activity and energy intake. Secondary outcomes were sedentary behavior, diet quality, adiposity, and cardiorespiratory fitness. Risk of Bias was assessed using the PEDro tool. Effect sizes were calculated using random-effects meta-analysis with narrative synthesis of effects by student or program characteristics. RESULTS Ten studies (two randomised controlled trials, and eight non-randomised controlled trials) involving 1,446 participants were included. Summer programs had a significant moderate effect on reducing sedentary behaviour (g= -0.59, 95%CI= -1.16, -0.03) and significant small effects on improving moderate-to-vigorous physical activity (g = 0.35, 95%CI = 0.02, 0.67) and adiposity (g= -0.25, 95% CI = -0.39, -0.10). No significant change was detected for cardiorespiratory fitness (g = 0.43, 95%CI= -0.32, 1.17), energy intake (g= -0.06, 95% CI -2.33, 2.22), or diet quality (g = 0.20, 95%CI= -0.43, 0.83). Summer program effectiveness did not appear to differ by child sociodemographic or program characteristics. Concerns regarding bias and high heterogeneity impacted results. CONCLUSIONS Summer programs show potential in promoting healthier movement behaviours in children and supporting healthy body weight during the summer months. Although evidence from the included studies has limitations, these programs produced small to moderate effect sizes and present promising health intervention opportunities for children. Future research with more rigorous study designs and comprehensive reporting is needed to confirm these findings and better understand the impact of summer programs on children's health. PROSPERO REGISTRATION CRD42023409795.
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Affiliation(s)
- Emily Eglitis
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia.
| | - Ben Singh
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Timothy Olds
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
- Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Rosa Virgara
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Amanda Machell
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
- Present address: College of Medicine and Public Health, Flinders University Sturt Road, Bedford Park, SA, 5042, Australia
| | - Mandy Richardson
- Department for Education, Government of South Australia, Adelaide, South Australia, Australia
| | - Kylie Brannelly
- National Outside School Hours Services Alliance, Woodend, Australia
| | - Aniella Grant
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Jessica Gray
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Terri Wilkinson
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Zoe Rix
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Grant R Tomkinson
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Carol Maher
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia
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Beets MW, Burkart S, Pfledderer C, Adams E, Weaver RG, Armstrong B, Brazendale K, Zhu X, Chen B, McLain A. Free Summer Programming and Body Mass Index Among Schoolchildren From Low-Income Households: A Randomized Clinical Trial. JAMA Pediatr 2024:2824896. [PMID: 39401051 DOI: 10.1001/jamapediatrics.2024.3693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2024]
Abstract
Importance Children experience accelerated gains in body mass index (BMI) during the summer months when school is not in session. Children from low-income households are most susceptible. Accelerated BMI gain in summer may be due to the removal of the health-promoting structure provided by schools. During summer, a common form of health-promoting structure is summer day camps (SDCs). Summer day camps are predominately fee for service, which creates a financial barrier for children from low-income households. One solution to mitigate accelerated BMI gain is providing free access to an existing SDC. Objective To investigate whether providing free access to an existing community SDC can mitigate accelerated BMI z score (zBMI) gain in elementary school-age children. Design, Setting, and Participants This randomized clinical trial was conducted during the summers of 2021, 2022, and 2023 in the southeastern United States. Participants were children (kindergarten through fourth grade) from predominantly low-income households who were randomized to attend an SDC operated by a parks and recreation commission or continue summer as usual (control). Intervention Free SDC every weekday (Monday through Friday) for 8 to 10 weeks. Main Outcomes and Measures The primary outcome was between-group differences in change of zBMI measured before school ended (May) and on return to school from summer (late August). Secondary analyses examined the dose response of zBMI change with parent-reported child attendance at SDCs during the summer for all children (intervention and control). Results A total of 422 children (mean [SD] age, 8.2 [1.5] years; 202 [48%] female, 220 [52%] male, 292 [69%] at or below 200% federal poverty level, 127 [30%] with food insecurity) were randomized to 1 of 2 conditions: summer as usual (control, n = 199) or free SDC (n = 223). Intent-to-treat analysis indicated mean (SE) change in zBMI at the end of the summer was 0.046 (0.027) for the control and -0.048 (0.025) for the intervention group, representing a significant between-group difference of -0.094 (95% CI, -0.166 to -0.022). Dose-response analyses indicated that every 1 day per week increase in attending an SDC resulted in a -0.034 to -0.018 zBMI reduction, which translates to a gain of 0.046 to 0.080 zBMI for children never attending summer programming vs -0.09 to -0.04 zBMI reduction for children attending summer programming every weekday. Conclusions and Relevance Providing children free access to existing community summer programming can have a meaningful effect on children's zBMI gain during the summer. Future studies should replicate these findings across different regions and identify the optimal dose of programming to mitigate unhealthy zBMI gains. Trial Registration ClinicalTrials.gov Identifier: NCT04072549.
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Affiliation(s)
- Michael W Beets
- Arnold School of Public Health, University of South Carolina, Columbia
| | - Sarah Burkart
- Arnold School of Public Health, University of South Carolina, Columbia
| | | | - Elizabeth Adams
- Arnold School of Public Health, University of South Carolina, Columbia
| | - R Glenn Weaver
- Arnold School of Public Health, University of South Carolina, Columbia
| | - Bridget Armstrong
- Arnold School of Public Health, University of South Carolina, Columbia
| | - Keith Brazendale
- Department of Health Sciences, University of Central Florida, Orlando
| | - Xuanxuan Zhu
- Arnold School of Public Health, University of South Carolina, Columbia
| | - Brian Chen
- Arnold School of Public Health, University of South Carolina, Columbia
| | - Alexander McLain
- Arnold School of Public Health, University of South Carolina, Columbia
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Guerrero-Magaña DE, Urquijo-Ruiz LG, Ruelas-Yanes AL, Martínez-Contreras TDJ, Díaz-Zavala RG, Candia-Plata MDC, Esparza-Romero J, Haby MM. Interventions for the prevention of weight gain during festive and holiday periods in children and adults: A systematic review. Obes Rev 2024:e13836. [PMID: 39275907 DOI: 10.1111/obr.13836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 08/24/2024] [Accepted: 08/30/2024] [Indexed: 09/16/2024]
Abstract
Some periods during the year, such as festive and summer holiday periods, have been associated with weight gain. We aimed to assess the effect of interventions for the prevention of body weight gain during festive and holiday periods in children and adults. A systematic search was conducted in six databases and supplementary sources until January 4, 2023. We included randomized controlled trials (RCTs), cluster-RCTs, and non-RCTs. Our primary outcome measure was the change in body weight in adults or the change in BMI z-score or BMI percentile in children and adolescents. From 4216 records, 12 primary studies (from 22 reports) met the inclusion criteria-10 from the United States, one from the United Kingdom, and one from Chile. Two studies had a low risk of bias, two moderate, seven high, and one critical risk of bias. The meta-analysis in children included four of seven studies during the summer holidays (six interventions) and showed a mean difference in BMI z-score favoring the intervention group (-0.06 [95% CI -0.10, -0.01], p = 0.01, I2 = 0%, very low certainty evidence). The meta-analysis in adults included five studies during festive periods with a mean difference in weight favoring the intervention group (-0.99 kg [95% CI -2.15, 0.18], p = 0.10, I2 = 89%, very low certainty evidence). This review has highlighted potential interventions to prevent the increase in body weight during holiday periods. More work is needed to improve the quality of the evidence and to extend it to countries outside of the United States and United Kingdom and to the adolescent population.
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Affiliation(s)
- Diego E Guerrero-Magaña
- Posgrado en Ciencias de la Salud, Facultad Interdisciplinaria de Ciencias Biológicas y de la Salud, Universidad de Sonora, Hermosillo, Sonora, Mexico
- Departamento de Ciencias Químico-Biológicas, Facultad Interdisciplinaria de Ciencias Biológicas y de la Salud, Universidad de Sonora, Hermosillo, Sonora, Mexico
| | - Lucía G Urquijo-Ruiz
- Posgrado en Ciencias de la Salud, Facultad Interdisciplinaria de Ciencias Biológicas y de la Salud, Universidad de Sonora, Hermosillo, Sonora, Mexico
| | - Alma L Ruelas-Yanes
- Posgrado en Ciencias de la Salud, Facultad Interdisciplinaria de Ciencias Biológicas y de la Salud, Universidad de Sonora, Hermosillo, Sonora, Mexico
| | - Teresita de J Martínez-Contreras
- Departamento de Ciencias Químico-Biológicas, Facultad Interdisciplinaria de Ciencias Biológicas y de la Salud, Universidad de Sonora, Hermosillo, Sonora, Mexico
| | - Rolando G Díaz-Zavala
- Departamento de Ciencias Químico-Biológicas, Facultad Interdisciplinaria de Ciencias Biológicas y de la Salud, Universidad de Sonora, Hermosillo, Sonora, Mexico
| | - Maria Del Carmen Candia-Plata
- Departamento de Medicina y Ciencias de la Salud, Facultad Interdisciplinaria de Ciencias Biológicas y de la Salud, Universidad de Sonora, Hermosillo, Sonora, Mexico
| | - Julián Esparza-Romero
- Unidad de Investigación en Obesidad y Diabetes, Coordinación de Nutrición, Centro de Investigación en Alimentación y Desarrollo (CIAD), Carretera Gustavo Enrique Astiazarán Rosas, Hermosillo, Sonora, Mexico
| | - Michelle M Haby
- Departamento de Ciencias Químico-Biológicas, Facultad Interdisciplinaria de Ciencias Biológicas y de la Salud, Universidad de Sonora, Hermosillo, Sonora, Mexico
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
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Beets MW, Burkart S, Pfledderer C, Adams E, Weaver RG, Armstrong B, Brazendale K, Zhu X, McLain A, Turner-McGrievy B, Pate R, Kaczynski A, Fairchild A, Saelens B, Parker H. Differences in elementary-age children's accelerometer - measured physical activity between school and summer: three-year findings from the What's UP (Undermining Prevention) with summer observational cohort study. Int J Behav Nutr Phys Act 2024; 21:86. [PMID: 39107808 PMCID: PMC11304806 DOI: 10.1186/s12966-024-01637-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 07/26/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Among elementary-aged children (5-12yrs), summer vacation is associated with accelerated gains in Body Mass Index (BMI). A key behavioral driver of BMI gain is a lack of physical activity (PA). Previous studies indicate PA decreases during summer, compared to the school year but whether this difference is consistent among boys and girls, across age, and by income status remains unclear. This study examined differences in school and summer movement behaviors in a diverse cohort of children across three years. METHODS Children (N = 1,203, age range 5-14 years, 48% girls) wore wrist-placed accelerometers for a 14-day wear-period during school (April/May) and summer (July) in 2021 to 2023, for a total of 6 timepoints. Mixed-effects models examined changes in school vs. summer movement behaviors (moderate-to-vigorous physical activity [MVPA], sedentary) for boys and girls, separately, and by age and household income groups (low, middle, and upper based on income-to-poverty ratio). RESULTS Children provided a total of 35,435 valid days of accelerometry. Overall, boys (+ 9.1 min/day, 95CI 8.1 to 10.2) and girls (+ 6.2 min/day, 95CI 5.4 to 7.0) accumulated more MVPA during school compared to summer. Boys accumulated less time sedentary (-9.9 min/day, 95CI -13.0 to -6.9) during school, while there was no difference in sedentary time (-2.7 min/day, 95CI -5.7 to 0.4) for girls. Different patterns emerged across ages and income groups. Accumulation of MVPA was consistently greater during school compared to summer across ages and income groups. Generally, the difference between school and summer widened with increasing age, except for girls from middle-income households. Accumulation of sedentary time was higher during school for younger children (5-9yrs), whereas for older children (10-14yrs), sedentary time was greater during summer for the middle- and upper-income groups. For boys from low-income households and girls from middle-income households, sedentary time was consistently greater during summer compared to school across ages. CONCLUSIONS Children are less active and more sedentary during summer compared to school, which may contribute to accelerated BMI gain. However, this differs by biological sex, age, and income. These findings highlight the complex factors influencing movement behaviors between school and summer.
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Affiliation(s)
- Michael W Beets
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
| | - Sarah Burkart
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | | | - Elizabeth Adams
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - R Glenn Weaver
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Bridget Armstrong
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Keith Brazendale
- Department of Health Sciences, University of Central Florida, Orlando, FL, USA
| | - Xuanxuan Zhu
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Alexander McLain
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | | | - Russell Pate
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Andrew Kaczynski
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Amanda Fairchild
- College of Arts and Sciences, University of South Carolina, Columbia, SC, USA
| | | | - Hannah Parker
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
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Eglitis E, Simpson C, Singh B, Olds T, Machell A, Virgara R, Richardson M, Brannelly K, Grant A, Gray J, Wilkinson T, Rix Z, Maher C. Effect of Summer Holiday Programs on Children's Mental Health and Well-Being: Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2024; 11:887. [PMID: 39201822 PMCID: PMC11352663 DOI: 10.3390/children11080887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 07/17/2024] [Accepted: 07/18/2024] [Indexed: 09/03/2024]
Abstract
Poor youth mental health is an area of global concern. Summer holiday programs may provide environments that support mental health when the structures and supports of school are not available. The aim of this review was to determine the effectiveness of summer holiday programs in improving the mental health, social-emotional well-being, and cognitive (non-academic) outcomes of children and adolescents. Studies of summer holiday programs for school-aged children (5-18 years) were included if they measured any mental, socio-emotional or cognitive (non-academic) outcome. Studies were excluded if they were published prior to 2000, targeted clinical populations or lasted less than five days. Six databases were searched (April 2023). Risk of bias was assessed using the PEDro tool. Study outcomes were grouped according to three main constructs: mental health (psychological well-being, anxiety, depression, distress, and self-perception including self-esteem, self-worth, self-concept, confidence, and competence); social-emotional well-being (behavior and social skills, e.g., communication, bullying, conflict resolution, empathy, and social skills); and cognitive function (memory, selective attention, and executive function). A fourth "other" group captured substance use, personality traits, character skills, and values. Effect sizes were calculated as the standardized mean difference between pre- and post-intervention scores. The synthesis involved a random-effects meta-analysis (presented in forest plots), where possible, with the remaining outcomes narratively synthesized. Twenty-six studies (n = 6812 participants) were included. The results of the meta-analysis suggested that summer programs showed a statistically non-significant trend toward reducing symptoms of anxiety and depression (k = 2 studies, SMD = -0.17, 95% CI -2.94, 2.60), psychological distress (k = 2 studies, SMD -0.46, 95% CI -1.71, 0.79), and no effect on self-esteem (k = 6 studies, SMD = 0.02, 95% CI -0.02, 0.06) or self-worth (k = 3 studies, SMD = 0.05, 95% CI 0.00, 0.11). Narrative syntheses indicated a pattern toward improvements in general mental health, self-perception, social-emotional outcomes, and cognition. Studies were generally small, with a high risk of bias. Summer holiday programs for children and adolescents show trends toward improving mental, social, emotional, and cognitive outcomes. Programs targeting disadvantaged children showed stronger patterns of improvement related to mental health and self-perception than programs targeting the general population. While effect sizes are small to negligible, they consistently indicate improvements. Summer programs present a promising avenue to promote mental health in children; however, further rigorously designed, clearly reported control-group studies are required to more fully understand their effects.
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Affiliation(s)
- Emily Eglitis
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
| | - Catherine Simpson
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
| | - Ben Singh
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
| | - Timothy Olds
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
- Centre for Adolescent Health, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
| | - Amanda Machell
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
| | - Rosa Virgara
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
| | - Mandy Richardson
- Department for Education, Government of South Australia, Adelaide, SA 5000, Australia;
| | - Kylie Brannelly
- National Outside School Hours Services Alliance (NOSHA), Woodend, QLD 4305, Australia;
| | - Aniella Grant
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
| | - Jessica Gray
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
| | - Terri Wilkinson
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
| | - Zoe Rix
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
| | - Carol Maher
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, SA 5000, Australia (B.S.); (T.O.); (A.M.); (R.V.); (A.G.); (J.G.); (T.W.); (Z.R.); (C.M.)
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Evans EW, Darling KE, Egbert A, Hayes JF, Jelalian E, Warnick J, Topor LS, Goldschmidt AB. Leveraging seasonality and timing to optimize pediatric weight management interventions: Novel directions for future research. Obes Sci Pract 2023; 9:688-695. [PMID: 38090686 PMCID: PMC10712410 DOI: 10.1002/osp4.694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/08/2023] [Accepted: 06/26/2023] [Indexed: 02/01/2024] Open
Abstract
National estimates suggest that more than 35% of American children, ages 2-19 years, are overweight or obese, which increases their risk for weight-related comorbidities including diabetes, cancer, cardiovascular disease risk factors, depression, and anxiety. While obesity prevention is most cost-effective, for youth with existing obesity, the United States Preventive Services Task Force recommends ≥26 h of comprehensive lifestyle intervention over 6-12 months. This include standard behavioral therapy, dietary counseling, and an emphasis on physical activity. Although such programs are effective in reducing weight status, there are many barriers to completing these programs. A novel consideration for both the prevention and treatment of childhood obesity is the recognition that the timing of intervention, both duration and time of the year, can impact family engagement and intervention effectiveness. This paper discusses the potential of targeting high-risk periods for weight gain and offering brief behavioral intervention, in hopes of inspiring research on novel approaches to the prevention and treatment of childhood obesity.
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Affiliation(s)
- E. Whitney Evans
- Weight Control and Diabetes Research CenterThe Miriam HospitalProvidenceRhode IslandUSA
- Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Katherine E. Darling
- Weight Control and Diabetes Research CenterThe Miriam HospitalProvidenceRhode IslandUSA
- Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Amy Egbert
- Department of Psychological SciencesUniversity of ConnecticutStorrsConnecticutUSA
| | - Jacqueline F. Hayes
- Weight Control and Diabetes Research CenterThe Miriam HospitalProvidenceRhode IslandUSA
- Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Elissa Jelalian
- Weight Control and Diabetes Research CenterThe Miriam HospitalProvidenceRhode IslandUSA
- Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Jennifer Warnick
- Weight Control and Diabetes Research CenterThe Miriam HospitalProvidenceRhode IslandUSA
- Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Lisa Swartz Topor
- Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
- Pediatric Endocrinology and Diabetes CenterHasbro Children's HospitalProvidenceRhode IslandUSA
| | - Andrea B. Goldschmidt
- Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
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Hopkins L, Schier H, May L, Westrick M, O'Piela D, Mazurek Melnyk B, Smith L, Gunther C. Patterns of participation in summer programming among United States' elementary children from low-income urban households: Results from the project SWEAT study. Prev Med Rep 2023; 36:102475. [PMID: 37886725 PMCID: PMC10598049 DOI: 10.1016/j.pmedr.2023.102475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023] Open
Abstract
Food insecurity increases among marginalized children during the summer when school is out of session. Summer programming that offers access to healthy meals and snacks may reduce the risk. There is a national call in the US for more research to assure equitable access to summer programming. The objective of this prospective observational study was to characterize patterns of participation in summer programming among elementary children from low-income urban neighborhoods of metropolitan[Blinded]. Summer programming was broadly defined (e.g., church, school, recreation center, community center). Caregivers(n = 100) received weekly text messages via TextIt during the summer (Jun-Aug 2017). They were asked: "How many days this week did [ChildName] attend a summer program? Please respond with a number from 0 to 5, where 0 - no days, 2 - 2 days, etc." Weekly counts were summed. Stepwise logistic and linear regression models were conducted to examine differences in patterns of attendance according to key sociodemographic characteristics. Mean age was 7.03 ± 0.23. 52 % identified as female, 70 % were low-income, and 80.0 % identified as Black. 51 % attended summer programming at least once; 49 % never attended. Those who attended at least once vs. not at all were more likely to be male(p < 0.01); 62.75 % males vs. 37.25 % females attended summer programming at least once, whereas 67.35 % females compared to 32.65 % males never attended. Overall mean attendance was 10.40 ± 1.43 days(out of 50). Mean + SE attendance was lower for females (7.52 + 1.76) vs. males (13.52 + 2.21)(p < 0.05), and non-Black (4.30 + 1.97) vs. Black (11.93 + 1.67)(p = 0.01) children. Future research is needed to understand barriers to participation in summer programming.
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Affiliation(s)
- Laura Hopkins
- Department of Public Health and Prevention Science, College of Education and Health Sciences, Baldwin Wallace University, USA
| | - Heather Schier
- College of Nursing, Martha S. Pitzer Center for Woman, Children, and Youth, The Ohio State University, USA
| | - Leah May
- College of Nursing, Martha S. Pitzer Center for Woman, Children, and Youth, The Ohio State University, USA
| | - Miranda Westrick
- College of Nursing, Martha S. Pitzer Center for Woman, Children, and Youth, The Ohio State University, USA
| | - Devin O'Piela
- College of Nursing, Martha S. Pitzer Center for Woman, Children, and Youth, The Ohio State University, USA
| | - Bernadette Mazurek Melnyk
- College of Nursing, Martha S. Pitzer Center for Woman, Children, and Youth, The Ohio State University, USA
| | - Laureen Smith
- College of Nursing, Martha S. Pitzer Center for Woman, Children, and Youth, The Ohio State University, USA
| | - Carolyn Gunther
- College of Nursing, Martha S. Pitzer Center for Woman, Children, and Youth, The Ohio State University, USA
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Davison GM, Monocello LT, Lipsey K, Wilfley DE. Evidence Base Update on Behavioral Treatments for Overweight and Obesity in Children and Adolescents. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023; 52:589-603. [PMID: 37683261 PMCID: PMC10586458 DOI: 10.1080/15374416.2023.2251164] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
OBJECTIVE This review provides an update to a previous Evidence Base Update addressing behavioral treatments for overweight and obesity in children and adolescents. METHOD Articles were identified through a systematic search of the biomedical literature in PubMed/MEDLINE (1946-), Elsevier EMBASE (1947-), SCOPUS (1823-), Clarivate Web of Science Core Collection (WOS, 1900-), PsycINFO (1800-), The Cochrane Library and Clinicaltrials.gov published between June 2014 and August 2022. RESULTS Family-based treatment (FBT) remains a well-established treatment for overweight and obesity in children and is now well-established in adolescents and toddlers. Parent-only behavioral treatment remains well-established in children and is now well-established among adolescents and children. Possibly effective treatments continue to include FBT-parent only for adolescents, and behavioral weight loss (BWL) with a family component for adolescents, children, and toddlers. Several variations of FBT and BWL can now be considered possibly effective including FBT+motivational interviewing, FBT+social facilitation maintenance, group-based FBT, low-dose FBT, BWL+stress management, and camp-based BWL. Cognitive behavioral treatment (CBT) for adolescents also met criteria for possibly effective treatments. Current research has also established that behavioral treatments can be effectively delivered in alternative settings (e.g. primary care) and through alternative mediums (e.g. telehealth). CONCLUSIONS Research continues to support the use of multicomponent lifestyle interventions in accordance with recent recommendations from the American Academy of Pediatrics, the American Psychological Association, and the United State Preventative Services Task Force. However, more work is needed to ensure appropriate access for children with comorbid medical and psychiatric disorders and children from socially, politically, and economically marginalized groups.
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Affiliation(s)
- Genevieve M. Davison
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Lawrence T. Monocello
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Kim Lipsey
- Bernard Becker Medical Library, Washington University School of Medicine, St. Louis, MO, USA
| | - Denise E. Wilfley
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
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Almas A, Iqbal R, Ghani A, Samad Z, Sabir S, Kazmi K. School Health Education Program in Pakistan (SHEPP): findings from a feasibility trial in pre-adolescent school children from a lower middle-income country. Pilot Feasibility Stud 2023; 9:123. [PMID: 37461089 PMCID: PMC10351151 DOI: 10.1186/s40814-023-01344-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 06/16/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The school environment plays an essential role in promoting health education and physical activity for children and adolescents. We aim to assess the feasibility of threefold health education program in children and its potential efficacy on physical activity and diet and cardiometabolic risk factors including blood pressure, body mass index (BMI), and waist circumference. METHODS The SHEPP was a parallel group feasibility intervention trial conducted in two schools over 23 months. All children aged 9-11 years enrolled in the schools were included. The SHEPP intervention comprised of health education on healthy lifestyle and physical activity sessions for children, training of teachers, and awareness sessions for parents conducted over 10 months. One school received the intervention of SHEPP while the other school continued routine activity. The primary outcome was the feasibility of SHEPP in terms of recruitment, retention, and treatment fidelity. Secondary outcomes were physical activity levels, dietary intake (of fruits and vegetables), and cardiometabolic risk factors (blood pressure, BMI, and waist circumference (WC)). RESULTS A total of 1280 preadolescent children were assessed for eligibility and 1191 were found eligible. The overall recruitment n (%) was 982/1191(82.5%) with 505(51.4) from SHEPP intervention school and 477(48.6) in routine activity school. The overall retention rate n (%) at 10-month follow-up was 912/982(92.8), with 465/505(92) in SHEPP intervention school and 447/477(93.7) in routine activity school. In treatment fidelity, 132/144(92) %). Physical activity sessions and all (100%) health education sessions were conducted for each of the twelve classes. Mean (SD) Seven-day Physical activity increased by 134 (196) min in the SHEPP intervention school v 29.8(177) in the routine activity school (P value < 0.001) from baseline to follow-up. Overall, there was an increase in vegetable intake (> 3 serving /day) in SHEPP intervention school of 5.5 to 21.4% from baseline to follow-up compared to 7.5 to 14.9% in routine activity school. The mean change (SD) in systolic blood pressure was 1.3(12) mmHg, 2.2(19.0) mm Hg in in diastolic blood pressure, - 0.09(5.4) kg/m2 in BMI and 6.2 cm in waist circumference in the intervention arm versus - 3.4(11.1) mm Hg in SBP, - 4.3(9.9) mm Hg in DBP, - 0.04((4.6) kg/m2 in BMI, and 3.8 cm in WC in the control arm. CONCLUSION We found that intervention using SHEPP is feasible in schools and may help children to adopt a healthy lifestyle as they age by increasing physical activity. However, the potentially beneficial effect on diet, MI, and BP needs further exploration and a longer follow-up, more specifically at the juncture of teenage and adulthood. TRIAL REGISTRATION NCT03303287.
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Affiliation(s)
- Aysha Almas
- Department of Medicine, Aga Khan University, Karachi, Pakistan.
| | - Romaina Iqbal
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Abdul Ghani
- Institute of Public Health, Quetta, Pakistan
| | - Zainab Samad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Sania Sabir
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Khawar Kazmi
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
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von Klinggraeff L, Dugger R, Brazendale K, Hunt ET, Moore JB, Turner-McGrievy G, Vogler K, Beets MW, Armstrong B, Weaver RG. Healthy Summer Learners: An explanatory mixed methods study and process evaluation. EVALUATION AND PROGRAM PLANNING 2022; 92:102070. [PMID: 35339766 PMCID: PMC9851796 DOI: 10.1016/j.evalprogplan.2022.102070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/03/2021] [Accepted: 03/13/2022] [Indexed: 06/03/2023]
Abstract
Healthy Summer Learners (HSL), a novel, 6-week summer program for 2-4th grade children from low-income families in the Southeastern United States, aimed to prevent accelerated summer BMI gain and academic learning loss by providing healthy meals and snacks, 15 min of nutrition education, 3 h of physical activity opportunities and 3.5 h of reading instruction daily. This three-armed pilot quasi-experimental study used a repeated measure within- and between-participant design to compare HSL, to an active comparator-21st Century Summer Learning Program (21 C), and no-treatment control. A mixed-methods process evaluation was employed to evaluate program implementation and provide insight for future program development. Though the program was well received, student attendance was lower than anticipated and full program fidelity was not achieved. During interviews, both parents and teachers noted that the bussing schedule was inconsistent, making attendance difficult for some families. These process evaluation findings may help explain why no statistically significant group-by-time interactions at 3- or 12-month follow up were found for the primary outcomes of zBMI or MAP reading score. Future iterations of HSL should seek to extend program hours, lengthen program duration, and explore ways to lower projected cost of attendance.
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Affiliation(s)
- Lauren von Klinggraeff
- Department of Exercise Science, University of South Carolina Arnold School of Public Health, Columbia 29208, USA.
| | - Roddrick Dugger
- Department of Exercise Science, University of South Carolina Arnold School of Public Health, Columbia 29208, USA
| | - Keith Brazendale
- Department of Health Sciences, University of Central Florida, Orlando 32816, USA
| | - Ethan T Hunt
- Department of Exercise Science, University of South Carolina Arnold School of Public Health, Columbia 29208, USA
| | - Justin B Moore
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem 27101, USA
| | - Gabrielle Turner-McGrievy
- Department of Health Promotion, Education, and Behavior, University of South Carolina Arnold School of Public Health, Columbia 29208, USA
| | - Kenneth Vogler
- Department of Instruction and Teacher Education, University of South Carolina, Columbia 29208, USA
| | - Michael W Beets
- Department of Exercise Science, University of South Carolina Arnold School of Public Health, Columbia 29208, USA
| | - Bridget Armstrong
- Department of Exercise Science, University of South Carolina Arnold School of Public Health, Columbia 29208, USA
| | - R Glenn Weaver
- Department of Exercise Science, University of South Carolina Arnold School of Public Health, Columbia 29208, USA
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Weaver RG, Hunt E, Armstrong B, Beets MW, Brazendale K, Turner-McGrievy G, Pate RR, Maydeu-Olivares A, Saelens B, Youngstedt SD, Dugger R, Parker H, von Klinggraeff L, Jones A, Burkhart S, Ressor-Oyer L. Impact of a year-round school calendar on children's BMI and fitness: Final outcomes from a natural experiment. Pediatr Obes 2021; 16:e12789. [PMID: 33763967 PMCID: PMC8440426 DOI: 10.1111/ijpo.12789] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Structure may mitigate children's accelerated summer BMI gain and cardiorespiratory-fitness (CRF) loss. OBJECTIVES Examine BMI and CRF change during school and summer for year-round and traditional calendar school children. METHODS Three schools (N = 2279, 1 year-round) participated in this natural experiment. Children's BMI z-score (zBMI) and CRF (PACER laps) were measured from 2017 to 2019 each May/August. Mixed effects regression estimated monthly zBMI and CRF change during school/summer. Secondary analyses examined differences by weight status and race. Spline regression models estimated zBMI and CRF growth from kindergarten-sixth grade. RESULTS Compared to traditional school, children attending a year-round school gained more zBMI (difference = 0.015; 95CI = 0.002, 0.028) during school, and less zBMI (difference = -0.029; 95CI = -0.041, -0.018), and more CRF (difference = 0.834; 95CI = 0.575, 1.093) monthly during summer. Differences by weight status and race were observed during summer and school. Growth models demonstrated that the magnitude of overall zBMI and CRF change from kindergarten-sixth grade was similar for year-round or traditional school children. CONCLUSIONS Contrary to traditional school children zBMI increased during the traditional 9-month school calendar and zBMI decreased during the traditional summer vacation for year-round school children. Structured summer programming may mitigate accelerated summer BMI gain and CRF loss especially for overweight or obese, and/or Black children.
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Affiliation(s)
- Robert Glenn Weaver
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina
| | - Ethan Hunt
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina
| | - Bridget Armstrong
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina
| | - Michael W. Beets
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina
| | - Keith Brazendale
- Department of Health Sciences, University of Central Florida, Orlando, Florida
| | - Gabrielle Turner-McGrievy
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina
| | - Russell R. Pate
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina
| | | | - Brian Saelens
- Center for Child Health Behavior and Development, Seattle Children’s Hospital, Seattle, Washington
| | - Shawn D. Youngstedt
- Department of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona
| | - Roddrick Dugger
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina
| | - Hannah Parker
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina
| | | | - Alexis Jones
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina
| | - Sarah Burkhart
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina
| | - Layton Ressor-Oyer
- Department of Exercise Science, University of South Carolina, Columbia, South Carolina
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12
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Evans EW, Wing RR, Pierre DF, Howie WC, Brinker M, Jelalian E. Testing the effect of summer camp on excess summer weight gain in youth from low-income households: a randomized controlled trial. BMC Public Health 2020; 20:1732. [PMID: 33203385 PMCID: PMC7670692 DOI: 10.1186/s12889-020-09806-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Children from racial and ethnic minority groups, low-income households, and those with overweight or obesity gain more weight during the summer than the school year. Summer day camps, which offer routine opportunities for physical activity and regular meal and snack times, have potential to mitigate excess weight gain. This randomized controlled trial was done to determine the feasibility and preliminary effectiveness of summer camp in preventing excess summer weight gain among youth from low-income households. METHODS Children, ages 6 to 12 years, were randomized to attend 8-weeks of summer day camp (CAMP) or to experience an unstructured summer as usual (SAU) in 2017-2018. Primary feasibility outcomes included retention, engagement and completion of midsummer measures. Secondary outcomes included changes in BMIz, engagement in moderate to vigorous physical activity (MVPA) and sedentary behavior, and diet quality and energy intake from the school year to summer. Multivariable linear mixed models were used to assess group differences. RESULTS Ninety-four participants were randomized to CAMP (n = 46) or SAU (n = 48), of whom 93.0 and 91.6% completed end of school and end of summer assessments, respectively. While CAMP participants attended only 50% of camp days offered, on average, they lost - 0.03 BMIz units while those in SAU gained 0.07 BMIz units over the summer (b = 0.10; p = .02). Group differences in change in energy intake from the school year to summer were borderline significant, as energy intake remained relatively unchanged in CAMP participants but increased among participants in SAU (p = 0.07). CONCLUSIONS Randomizing children to attend summer day camp or experience an unstructured summer as usual was effective in this low-income sample. Our findings support the potential for summer camps in mitigating excess summer weight gain. A larger randomized trial is needed explore efficacy, cost-effectiveness and longer-term effects of attending summer camp on weight and weight-related behaviors. TRIAL REGISTRATION ClinicalTrials.gov Registration: NCT04085965 (09/2019, retrospective registration).
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Affiliation(s)
- E Whitney Evans
- Weight Control and Diabetes Research Center, The Miriam Hospital, 196 Richmond St, Providence, RI, 02903, USA.
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Providence, RI, USA.
| | - Rena R Wing
- Weight Control and Diabetes Research Center, The Miriam Hospital, 196 Richmond St, Providence, RI, 02903, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Providence, RI, USA
| | - Denise F Pierre
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Hartford, CT, USA
| | - Whitney C Howie
- Department of Psychological & Brain Science, Texas A&M University, College Station, TX, USA
| | - Morgan Brinker
- School of Public Health, Brown University, Providence, RI, USA
| | - Elissa Jelalian
- Weight Control and Diabetes Research Center, The Miriam Hospital, 196 Richmond St, Providence, RI, 02903, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Providence, RI, USA
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13
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Hart CN, Jelalian E, Raynor HA. Behavioral and social routines and biological rhythms in prevention and treatment of pediatric obesity. AMERICAN PSYCHOLOGIST 2020; 75:152-162. [PMID: 32052991 PMCID: PMC7839074 DOI: 10.1037/amp0000599] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A growing body of research supports the potential importance of behavioral and social routines for children's health promotion and obesity risk reduction. Evidence in support of this comes from multiple lines of research, which suggest that specific behavioral routines, namely, eating and sleep routines, may be protective against excessive weight gain and development of pediatric obesity. Emerging work also supports the potential importance of the timing of these behavioral routines. From a circadian perspective, alignment of behavioral and social routines with underlying circadian rhythms may be particularly important for enhancing children's weight regulation. Specifically, engaging in appropriately timed behavioral routines may serve to entrain circadian rhythms that affect metabolism and weight regulation. Thus, in addition to promoting healthier eating, activity, and sleep behaviors for prevention and treatment of pediatric obesity, it may also be important to consider promotion of consistency in, and optimal timing of, these behaviors in an effort to enhance extant prevention and treatment approaches. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Chantelle N Hart
- Department of Social and Behavioral Sciences, College of Public Health, Temple University
| | - Elissa Jelalian
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University
| | - Hollie A Raynor
- Department of Nutrition, College of Education, Health and Human Sciences, University of Tennessee
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The need for synergy between biological and behavioral approaches to address accelerated weight gain during the summer in children. Int J Behav Nutr Phys Act 2019; 16:39. [PMID: 31036022 PMCID: PMC6489252 DOI: 10.1186/s12966-019-0800-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/17/2019] [Indexed: 11/10/2022] Open
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