The effects of a family fitness program on the physical activity and nutrition behaviors of third-grade children

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.

Children’s Changes in Perceptions and Body Composition Following a Family-Based Fitness Intervention

Physical fitness is associated with decreased weight in children, which helps improve youth obesity rates. Family programs can provide practical approaches to improving physical fitness for children. The purpose of this study was to assess the influence of a family-based fitness intervention on changes in body composition, fitness status, and perceptions of obese children. Families attended exercise and education sessions for 60–90 min once per week for 10 weeks. Participants consisted of 10 children who participated in semi-structured interviews, body composition, and fitness assessments at pre- and posttest. Following the intervention, results showed that children had a significant increase in sit-ups (p = .03, effect size = 0.79), lean mass (p < .001, Cohen’s d = 1.95), and bone mineral content (p < .001, Cohen’s d = 0.46). Using thematic analysis, four main themes emerged from the pre- and postintervention interviews: an increase in after-school and weekend intentional physical fitness, rules regarding sedentary behavior and screen time, more prevalent physical fitness reinforcements, and a shift in perception of exercise. Results from this study indicate a family-based intervention had an influence on children’s appreciation for and engagement in physical fitness, as well as healthy body composition and fitness outcomes.

A Harvest of the Month Curriculum Increases Fruit and Vegetable Intake among 4th-6th Grade Students

BACKGROUND

Most children do not eat enough fruits and vegetables (FV). Schools are a critical setting for supporting children to consume FV. To fill a gap in available materials, a classroom curriculum was developed and evaluated to determine impacts on student FV-related knowledge, attitudes, and behaviors.

METHODS

A pre-/post-intervention survey was administered to 4th-6th grade students in 3 intervention and one comparison schools. Post-intervention student focus groups, parent/guardian surveys, and teacher surveys provided complementary information.

RESULTS

Intervention students had a significantly greater increase in total FV intake, fruit intake, and 100% juice consumption, and preference for several types of FV relative to comparison group students. Students, teachers, and parents reported overall high levels of satisfaction with the curriculum.

CONCLUSIONS

The Harvest of the Month curriculum is effective at increasing fruit intake among a low-income, diverse student population in grades 4-6, is acceptable to students, teachers, and parents, and is feasible to implement. Findings suggest this impact is the result of changes in preferences, skills, and motivation but not self-efficacy or perceived social norms. Some tailoring of the curriculum may be needed to increase its appropriateness for 6th-grade students, increase the impact on vegetable intake, and limit intake of juice.

Using a think-aloud methodology to understand online physical activity information search experiences and preferences of parents of children and youth with disabilities

BACKGROUND

The Internet is a preferred source of physical activity (PA) information. However, limited research exists regarding the experiences of parents of children and youth with disabilities (CYWD) in searching for PA programme information online. This research examined the experiences and preferences of parents of CYWD in searching for PA programme information online.

METHOD

Parents of CYWD (n = 10) participated in a think-aloud exercise while searching for PA programme information online. Following the think-aloud exercise, semi-structured interviews were used to further understand parents' experiences and preferences in searching for PA programme information online.

RESULTS

Parents identified key features that contributed to a positive online search experience. Additionally, parents noted challenges and resulting negative affect that was experienced.

CONCLUSIONS

This research can inform the development and dissemination of online PA programme information that is accessible and relevant to the preferences of parents of CYWD and can facilitate positive search experiences.

Correlation analysis between depression and family fitness in chronic obstructive pulmonary disease inpatients: A cross-sectional study

To explore the relationship between depression and family fitness in chronic obstructive pulmonary disease (COPD) inpatients.COPD inpatients (280) in our hospital from Jan to June 2016 were included. Depression level and family fitness were quantified with self-rating depression scale (SDS) and Adaptability, Partnership, Growth, Affection, and Resolve (APGAR) test. The relationship and correlation of SDS value and APGAR score was analyzed.Family fitness for all COPD inpatients was grossly well, among which 93 patients (34.87%) experienced medium-to-severe family unfitness. Further analysis shows that better fitness correlated with less depression and worse fitness correlated with more depression. Depression levels were significantly different in patients under family fitness. Inpatients were grossly in light depression, among which 186 (69.66%) patients exhibited depression symptoms. Family fitness was significantly different among patients with different levels of depression. Correlation analysis showed that depression level was negatively correlated with family fitness.Depression in patients is significantly correlated with family fitness. The condition of patients can be improved by active family fitness and patients' interactions with family members. Thus involvement of family member during admitting should be encouraged.

Characteristics of physical activity interventions and effects on cardiorespiratory fitness in children aged 6-12 years-A systematic review

OBJECTIVES

To examine the characteristics of physical activity (PA) interventions and the effects on cardiorespiratory fitness (CRF) in healthy children based on treatment theory.

DESIGN

Systematic review.

METHODS

PubMed and Embase were searched for studies published between 2003 and 2016. Inclusion criteria were: Participants: healthy children aged 6-12.

INTERVENTIONS

interventions with activities to increase PA behaviour or physical fitness (PF) regardless of setting.

CONTROL

no or alternative intervention.

OUTCOME

exercise-based CRF measure with appropriate analysis of CRF effects.

STUDY DESIGN

randomized controlled trial. Effect size was calculated using d_ppc2 and the methodological quality of the studies was assessed using the PEDro scale.

RESULTS

Of 1002 studies screened, 23 met the inclusion criteria. Thirteen of the 23 studies found statistically significant improvements in CRF and eight studies showed medium to high effect sizes. Interventions with medium to high effect sizes focused more often on PF than PA behaviour, had slightly higher frequencies of activities and had a shorter duration than the less effective interventions.

CONCLUSIONS

The fact that thirteen studies demonstrated statistically significant improvements in CRF is promising but also emphasizes the need to keep improving research methods and the development and execution of interventions. Interventions with larger effect sizes appear to be more controlled, as they usually relied on smaller sample sizes and the components of these interventions encompassed protocolled training sessions which defined and monitored the relative training intensity intended. A duration of at least six weeks and a frequency of three to four times a week is recommended.

Design and methods for a cluster-controlled trial conducted at sixty-eight daycare facilities evaluating the impact of "JolinchenKids - Fit and Healthy in Daycare", a program for health promotion in 3- to 6-year-old children

BACKGROUND

The prevention of overweight and obesity during infancy is a highly relevant public health topic given the significant impact of childhood obesity on acute and chronic diseases, general health, and well-being in later stages of life. Apart from the family setting, daycare facilities (DFs) represent a key setting for health promotion among children under the age of six years. "JolinchenKids - Fit and Healthy in Daycare" is a multi-component program promoting physical activity (PA), healthy eating, and mental well-being in 3- to 6-year-old preschoolers at DFs, originally designed by the German health insurance AOK. To evaluate program effectiveness, a cluster-controlled trial involving 68 DFs is currently conducted. The objective of this article is to describe the background, study design, and aims of this trial.

METHODS/DESIGN

Sixty-eight DFs across Germany will be recruited to take part in the study, half of them serving as intervention DFs and half of them as delayed intervention control DFs (which receive the program upon completion of the study). At each DF, height, weight, and body composition, as well as motor skills, will be assessed in twenty 3- to 6-year-old children. Children's eating and PA habits, and mental well-being will be assessed via parental questionnaires. A subsample of children (i.e., at 24 DFs which are randomly selected within a geographic region) will be asked to wear accelerometers at their wrists to objectively measure PA over the course of seven days. To compare changes in body composition, motor skills, eating and PA habits, and mental well-being of children at intervention DFs with those observed among children at delayed intervention control DFs over one year, all measurements will take place at baseline and twelve months after the launch of the program at all DFs.

DISCUSSION

This study investigates the influence of a health promotion program in the daycare setting on various outcomes, including body composition and objectively measured PA, in a nationwide sample of 3- to 6-year-old preschoolers. This study will provide evidence regarding the effectiveness of a multi-component program for health promotion in this setting and may provide insights into new strategies for preventing obesity in early life.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00011065 (Date of registration 16-09-2016).

Systematic review of control groups in nutrition education intervention research

Background

Well-designed research trials are critical for determining the efficacy and effectiveness of nutrition education interventions. To determine whether behavioral and/or cognition changes can be attributed to an intervention, the experimental design must include a control or comparison condition against which outcomes from the experimental group can be compared. Despite the impact different types of control groups can have on study outcomes, the treatment provided to participants in the control condition has received limited attention in the literature.

Methods

A systematic review of control groups in nutrition education interventions was conducted to better understand how control conditions are described in peer-reviewed journal articles compared with experimental conditions. To be included in the systematic review, articles had to be indexed in CINAHL, PubMed, PsycINFO, WoS, and/or ERIC and report primary research findings of controlled nutrition education intervention trials conducted in the United States with free-living consumer populations and published in English between January 2005 and December 2015. Key elements extracted during data collection included treatment provided to the experimental and control groups (e.g., overall intervention content, tailoring methods, delivery mode, format, duration, setting, and session descriptions, and procedures for standardizing, fidelity of implementation, and blinding); rationale for control group type selected; sample size and attrition; and theoretical foundation.

Results

The search yielded 43 publications; about one-third of these had an inactive control condition, which is considered a weak study design. Nearly two-thirds of reviewed studies had an active control condition considered a stronger research design; however, many failed to report one or more key elements of the intervention, especially for the control condition. None of the experimental and control group treatments were sufficiently detailed to permit replication of the nutrition education interventions studied.

Conclusions

Findings advocate for improved intervention study design and more complete reporting of nutrition education interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0546-3) contains supplementary material, which is available to authorized users.

The effects of school-based lifestyle interventions on body mass index and blood pressure: a multivariate multilevel meta-analysis of randomized controlled trials

Primary prevention of childhood obesity and related hypertension is warrant given that both risk factors are intertwined and track into adulthood. This systematic review and meta-analysis assess the impact of school-based lifestyle interventions on children's body mass index (BMI) and blood pressure. We searched databases and prior reviews. Eligibility criteria were the following: randomized controlled trial design, evaluation of a school-based intervention, targeting children aged 4-12 years, reporting on BMI and/or related cardiovascular risk factors, reporting data on at least one follow-up moment. The effects on BMI, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were evaluated by means of univariate and multivariate three-level random effects models. A total of 85 RCTs (91 papers) were included in the meta-analyses. In univariate models, the pooled effects were -0.072 (95%CI: -0.106; -0.038) for BMI, -0.183 (95%CI: -0.288; -0.078) for SBP and -0.071 (95%CI: -0.185; 0.044) for DBP. In multivariate analyses, the pooled effects of interventions were -0.054 (95%CI: -0.131; 0.022) for BMI, -0.182 (95%CI: -0.266; -0.098) for SBP and -0.144 (95%CI: -0.230; -0.057) for DBP. Parental involvement accentuated the beneficial effects of interventions. School-based lifestyle prevention interventions result in beneficial changes in children's BMI and blood pressure, and the effects on the latter may be stronger than and accrue independently from those in the former.

Obesity Prevention Program in Childcare Centers: Two-Year Follow-Up

PURPOSE

To assess the impact of an early childhood obesity prevention intervention "Healthy Caregivers-Healthy Children" (HC2) on dietary patterns and body mass index percentile (PBMI) over 2 school years.

DESIGN

Randomized controlled trial.

SETTING

Childcare centers.

PARTICIPANTS

Low-income families.

INTERVENTION

Intervention centers (N = 12) received HC2 which consisted of (1) menu modifications, (2) a healthy eating and physical activity curriculum for children, and (3) a parent curriculum for healthy meal preparation, reinforced through a role-modeling curriculum. Control centers (N = 16) received an injury prevention/safety intervention.

MEASURES

Child PBMI and parent report of child's consumption of fruits/vegetables and unhealthy food.

ANALYSIS

Confirmatory factor analysis verified the psychometric properties of factor scores for children's consumption of fruits/vegetables and unhealthy food. Growth curve analysis assessed the impact of HC2 on change in consumption of fruits/vegetables and unhealthy food and PBMI over 2 school years.

RESULTS

Children in the intervention group (n = 754) had a negative slope (β = -1.95, standard error [SE] = 0.97, P = .04), indicating less increase in PBMI versus control children (n = 457). Stratified analyses showed that obese children in the intervention arm had a significantly higher increase in fruit/vegetable consumption versus control group obese children (β = 0.24, SE = 0.08, P = .003).

CONCLUSION

The HC2 intervention resulted in the maintenance of healthy PBMI over 2 preschool years among low-income multiethnic children. These findings support efforts to implement healthy weight programs in the childcare setting.

Physical Activity Programs with Post-Intervention Follow-Up in Children: A Comprehensive Review According to Categories of Intervention

Only 9% of Canadian children meet the National Guidelines of 60 min of daily moderate-to-vigorous intensity physical activity. The aim of this review is to assess the mid- and long-term effectiveness of physical activity interventions and their impact on cardiovascular risk factors in children. We assessed the success of interventions within three different categories: those using a behavioural and social approach, an informational approach or an environmental approach. The average number of children included in these studies was 860 (range of 30-5106); the age range was from 2 to 18 years; and the mean intervention duration was 1607 min (range of 12-8160 min). The length of follow-up post-intervention averaged 13 months (ranging from 0.25 to 96 months). A positive impact on physical activity was found in 74% and on any measured outcomes in 90% of the studies reviewed. However, the benefits of physical activity interventions decreased with longer follow-up. Regardless of the approaches, physical activity interventions improved cardiovascular risk factors. However, the challenge of any program is to maintain beneficial effects once the intervention is completed. These findings will inform the development of future intervention programs in order to optimize sustained cardiovascular benefits.

What childhood obesity prevention programmes work? A systematic review and meta-analysis

Previous reviews of childhood obesity prevention have focused largely on schools and findings have been inconsistent. Funded by the US Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health, we systematically evaluated the effectiveness of childhood obesity prevention programmes conducted in high-income countries and implemented in various settings. We searched MEDLINE®, Embase, PsycINFO, CINAHL®, ClinicalTrials.gov and the Cochrane Library from inception through 22 April 2013 for relevant studies, including randomized controlled trials, quasi-experimental studies and natural experiments, targeting diet, physical activity or both, and conducted in children aged 2-18 in high-income countries. Two reviewers independently abstracted the data. The strength of evidence (SOE) supporting interventions was graded for each study setting (e.g. home, school). Meta-analyses were performed on studies judged sufficiently similar and appropriate to pool using random effect models. This paper reported our findings on various adiposity-related outcomes. We identified 147 articles (139 intervention studies) of which 115 studies were primarily school based, although other settings could have been involved. Most were conducted in the United States and within the past decade. SOE was high for physical activity-only interventions delivered in schools with home involvement or combined diet-physical activity interventions delivered in schools with both home and community components. SOE was moderate for school-based interventions targeting either diet or physical activity, combined interventions delivered in schools with home or community components or combined interventions delivered in the community with a school component. SOE was low for combined interventions in childcare or home settings. Evidence was insufficient for other interventions. In conclusion, at least moderately strong evidence supports the effectiveness of school-based interventions for preventing childhood obesity. More research is needed to evaluate programmes in other settings or of other design types, especially environmental, policy and consumer health informatics-oriented interventions.

Effect of childhood obesity prevention programmes on blood lipids: a systematic review and meta-analysis

We aimed to assess the effects of childhood obesity prevention programmes on blood lipids in high-income countries. We searched MEDLINE®, Embase, PsychInfo, CINAHL®, clinicaltrials.gov, and the Cochrane Library up to 22 April 2013 for relevant randomized controlled trials, quasi-experimental studies and natural experiments published in English. Studies were included if they implemented diet and/or physical activity intervention(s) with ≥1 year follow-up (or ≥6 months for school-based intervention studies) in 2-18-year-olds, and were excluded if they targeted only overweight/obese children, or those with a pre-existing medical condition. Seventeen studies were finally included. For total cholesterol, the pooled intervention effect was -0.97 mg dL(-1) [95% confidence interval (CI): -3.26, 1.32; P = 0.408]; for low-density lipoprotein cholesterol (LDL-C), -6.06 mg dL(-1) (95% CI: -11.09, -1.02; P = 0.018); for high-density lipoprotein cholesterol (HDL-C), 1.87 mg dL(-1) (95% CI: 0.39, 3.34; P = 0.013); and for triglycerides, -1.95 mg dL(-1) (95% CI: -4.94, 1.04; P = 0.202). Most interventions (70%) showed similar significant or no effects on adiposity- and lipids outcomes: 15% interventions improved both adiposity- and lipids outcomes; 55% had no significant effects on either. Childhood obesity prevention programmes had a significant desirable effect on LDL-C and HDL-C. Two-thirds of interventions showed similar significant or no effects in adiposity- and lipids outcomes. Assessing lipids outcomes provide additional useful information on obesity prevention programme benefits.

School-based physical activity and nutritional education interventions on body mass index: a meta-analysis of randomised community trials - project PANE

OBJECTIVE

To evaluate the effect of school-based physical activity (PA) and nutritional education (NE) interventions on children's and adolescents' body mass index.

METHODS

We conducted a systematic search in fourteen databases until September 2012 for randomised controlled trials on PA and NE, conducted in the school setting, and delivered to children and adolescents. Additionally, we performed a cross-reference check in related papers. The title and abstract review and the quality assessment were performed by two independent researchers. The software EPPI-Reviewer3 was used to store, manage and analyse all data. The meta-analysis was conducted using the random-effects model, and the outcomes were reported as standardised mean difference (SMD). As a secondary analysis, we pooled together the interventions that considered PA or NE alone.

RESULTS

Thirty-eight studies met the eligibility criteria. The main analysis showed a SMD between intervention and control groups of -0.03 (95% CI: -0.09, 0.04; n=28,870; I(2)=83%). When we considered all 57 trials, there was no difference between the results of the primary analysis.

CONCLUSION

The synthesis of school-based PA and NE interventions showed no statistically significant mean reduction on children's and adolescents' body mass index. The high heterogeneity among studies requires caution in the generalisation of the results.

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

BACKGROUND

The World Health Organization (WHO) estimates that 1.9 million deaths worldwide are attributable to physical inactivity and at least 2.6 million deaths are a result of being overweight or obese. In addition, WHO estimates that physical inactivity causes 10% to 16% of cases each of breast cancer, colon, and rectal cancers as well as type 2 diabetes, and 22% of coronary heart disease and the burden of these and other chronic diseases has rapidly increased in recent decades.

OBJECTIVES

The purpose of this systematic review was to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents.

SEARCH METHODS

The search strategy included searching several databases to October 2011. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information.

SELECTION CRITERIA

To be included, the intervention had to be relevant to public health practice (focused on health promotion activities), not conducted by physicians, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, included all school-attending children, and be implemented for a minimum of 12 weeks. In addition, the review was limited to randomized controlled trials and those that reported on outcomes for children and adolescents (aged 6 to 18 years). Primary outcomes included: rates of moderate to vigorous physical activity during the school day, time engaged in moderate to vigorous physical activity during the school day, and time spent watching television. Secondary outcomes related to physical health status measures including: systolic and diastolic blood pressure, blood cholesterol, body mass index (BMI), maximal oxygen uptake (VO2max), and pulse rate.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to assess each study for relevance and for data extraction. In addition, each study was assessed for risk of bias as specified in the Cochrane Handbook for Systematic Reviews of Interventions. Where discrepancies existed, discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated, and outcomes measured.

MAIN RESULTS

In the original review, 13,841 records were identified and screened, 302 studies were assessed for eligibility, and 26 studies were included in the review. There was some evidence that school-based physical activity interventions had a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally, school-based interventions had little effect on physical activity rates, systolic and diastolic blood pressure, BMI, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity resulted in positive effects.In this update, given the addition of three new inclusion criteria (randomized design, all school-attending children invited to participate, minimum 12-week intervention) 12 of the original 26 studies were excluded. In addition, studies published between July 2007 and October 2011 evaluating the effectiveness of school-based physical interventions were identified and if relevant included. In total an additional 2378 titles were screened of which 285 unique studies were deemed potentially relevant. Of those 30 met all relevance criteria and have been included in this update. This update includes 44 studies and represents complete data for 36,593 study participants. Duration of interventions ranged from 12 weeks to six years.Generally, the majority of studies included in this update, despite being randomized controlled trials, are, at a minimum, at moderate risk of bias. The results therefore must be interpreted with caution. Few changes in outcomes were observed in this update with the exception of blood cholesterol and physical activity rates. For example blood cholesterol was no longer positively impacted upon by school-based physical activity interventions. However, there was some evidence to suggest that school-based physical activity interventions led to an improvement in the proportion of children who engaged in moderate to vigorous physical activity during school hours (odds ratio (OR) 2.74, 95% confidence interval (CI), 2.01 to 3.75). Improvements in physical activity rates were not observed in the original review. Children and adolescents exposed to the intervention also spent more time engaged in moderate to vigorous physical activity (with results across studies ranging from five to 45 min more), spent less time watching television (results range from five to 60 min less per day), and had improved VO2max (results across studies ranged from 1.6 to 3.7 mL/kg per min). However, the overall conclusions of this update do not differ significantly from those reported in the original review.

AUTHORS' CONCLUSIONS

The evidence suggests the ongoing implementation of school-based physical activity interventions at this time, given the positive effects on behavior and one physical health status measure. However, given these studies are at a minimum of moderate risk of bias, and the magnitude of effect is generally small, these results should be interpreted cautiously. Additional research on the long-term impact of these interventions is needed.

Design and methods for evaluating an early childhood obesity prevention program in the childcare center setting

BACKGROUND

Many unhealthy dietary and physical activity habits that foster the development of obesity are established by the age of five. Presently, approximately 70 percent of children in the United States are currently enrolled in early childcare facilities, making this an ideal setting to implement and evaluate childhood obesity prevention efforts. We describe here the methods for conducting an obesity prevention randomized trial in the child care setting.

METHODS/DESIGN

A randomized, controlled obesity prevention trial is currently being conducted over a three year period (2010-present). The sample consists of 28 low-income, ethnically diverse child care centers with 1105 children (sample is 60% Hispanic, 15% Haitian, 12% Black, 2% non-Hispanic White and 71% of caregivers were born outside of the US). The purpose is to test the efficacy of a parent and teacher role-modeling intervention on children's nutrition and physical activity behaviors. . The Healthy Caregivers-Healthy Children (HC2) intervention arm schools received a combination of (1) implementing a daily curricula for teachers/parents (the nutritional gatekeepers); (2) implementing a daily curricula for children; (3) technical assistance with meal and snack menu modifications such as including more fresh and less canned produce; and (4) creation of a center policy for dietary requirements for meals and snacks, physical activity and screen time. Control arm schools received an attention control safety curriculum. Major outcome measures include pre-post changes in child body mass index percentile and z score, fruit and vegetable and other nutritious food intake, amount of physical activity, and parental nutrition and physical activity knowledge, attitudes, and beliefs, defined by intentions and behaviors. All measures were administered at the beginning and end of the school year for year one and year two of the study for a total of 4 longitudinal time points for assessment.

DISCUSSION

Although few attempts have been made to prevent obesity during the first years of life, this period may represent the best opportunity for obesity prevention. Findings from this investigation will inform both the fields of childhood obesity prevention and early childhood research about the effects of an obesity prevention program housed in the childcare setting.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

NCT01722032.

Questionnaire surveys of dentists on radiology

OBJECTIVES

Survey by questionnaire is a widely used research method in dental radiology. A major concern in reviews of questionnaires is non-response. The objectives of this study were to review questionnaire studies in dental radiology with regard to potential survey errors and to develop recommendations to assist future researchers.

METHODS

A literature search with the software search package PubMed was used to obtain internet-based access to Medline through the website www.ncbi.nlm.nih.gov/pubmed. A search of the English language peer-reviewed literature was conducted of all published studies, with no restriction on date. The search strategy found articles with dates from 1983 to 2010. The medical subject heading terms used were "questionnaire", "dental radiology" and "dental radiography". The reference sections of articles retrieved by this method were hand-searched in order to identify further relevant papers. Reviews, commentaries and relevant studies from the wider literature were also included.

RESULTS

53 questionnaire studies were identified in the dental literature that concerned dental radiography and included a report of response rate. These were all published between 1983 and 2010. In total, 87 articles are referred to in this review, including the 53 dental radiology studies. Other cited articles include reviews, commentaries and examples of studies outside dental radiology where they are germane to the arguments presented.

CONCLUSIONS

Non-response is only one of four broad areas of error to which questionnaire surveys are subject. This review considers coverage, sampling and measurement, as well as non-response. Recommendations are made to assist future research that uses questionnaire surveys.

Efficacy of a compulsory homework programme for increasing physical activity and healthy eating in children: the healthy homework pilot study

BACKGROUND

Most physical activity and nutrition interventions in children focus on the school setting; however, evidence suggests that children are less active and have greater access to unhealthy food at home. The aim of this pilot study was to examine the efficacy of a compulsory homework programme for increasing physical activity and healthy eating in children.

METHODS

The six-week 'Healthy Homework' programme and complementary teaching resource was developed under the guidance of an intersectoral steering group. Eight senior classes (year levels 5-6) from two diverse Auckland primary schools were randomly assigned into intervention and control groups. A total of 97 children (57 intervention, 40 control) aged 9-11 years participated in the evaluation of the intervention. Daily step counts were monitored immediately before and after the intervention using sealed multiday memory pedometers. Screen time, sports participation, active transport to and from school, and the consumption of fruits, vegetables, unhealthy foods and drinks were recorded concurrently in a 4-day food and activity diary.

RESULTS

Healthy Homework resulted in a significant intervention effect of 2,830 steps.day-1 (95% CI: 560, 5,300, P = 0.013). This effect was consistent between sexes, schools, and day types (weekdays and weekend days). In addition, significant intervention effects were observed for vegetable consumption (0.83 servings.day-1, 95% CI: 0.24, 1.43, P = 0.007) and unhealthy food consumption (-0.56 servings.day-1, 95% CI: -1.05, -0.07, P = 0.027) on weekends but not weekdays, with no interactions with sex or school. Effects for all other variables were not statistically significant regardless of day type.

CONCLUSIONS

Compulsory health-related homework appears to be an effective approach for increasing physical activity and improving vegetable and unhealthy food consumption in children. Further research in a larger study is required to confirm these initial results.

Combined home and school obesity prevention interventions for children: what behavior change strategies and intervention characteristics are associated with effectiveness?

This review identifies studies describing interventions delivered across both the home and school/community setting, which target obesity and weight-related nutrition and physical activity behaviors in children. Fifteen studies, published between 1998 and 2010, were included and evaluated for effectiveness, study quality, nutrition/activity content, behavior change techniques, and theoretical basis, using validated assessment tools/taxonomies. Seven studies were rated as effective. Behavior change techniques used to engage families, and techniques associated with intervention effectiveness were coded. Effective studies used about 10 behavior change techniques, compared with 6.5 in ineffective studies. Effective interventions used techniques including providing general information on behavior-health links, prompting practice of behavior, and planning for social support/social changes. Different behavior change techniques were applied in the home and school setting. The findings of this review provide novel insights into the techniques associated with intervention effectiveness that can inform the development of public health obesity prevention strategies.

A healthy school start - parental support to promote healthy dietary habits and physical activity in children: design and evaluation of a cluster-randomised intervention

Background

Childhood obesity is multi-factorial and determined to a large extent by dietary habits, physical activity and sedentary behaviours. Previous research has shown that school-based programmes are effective but that their effectiveness can be improved by including a parental component. At present, there is a lack of effective parental support programmes for improvement of diet and physical activity and prevention of obesity in children.

Methods/Design

This paper describes the rationale and design of a parental support programme to promote healthy dietary habits and physical activity in six-year-old children starting school. The study is performed in close collaboration with the school health care and is designed as a cluster-randomised controlled trial with a mixed methods approach. In total, 14 pre-school classes are included from a municipality in Stockholm county where there is large variation in socio-economic status between the families. The school classes are randomised to intervention (n = 7) and control (n = 7) groups including a total of 242 children. The intervention is based on social cognitive theory and consists of three main components: 1) a health information brochure; 2) two motivational interviewing sessions with the parents; and 3) teacher-led classroom activities with the children. The primary outcomes are physical activity in the children measured objectively by accelerometry, children's dietary and physical activity habits measured with a parent-proxy questionnaire and parents' self-efficacy measured by a questionnaire. Secondary outcomes are height, weight and waist circumference in the children. The duration of the intervention is six months and includes baseline, post intervention and six months follow-up measurements. Linear and logistic regression models will be used to analyse differences between intervention and control groups in the outcome variables. Mediator and moderator analysis will be performed. Participants will be interviewed.

Discussion

The results from this study will show if it is possible to promote a healthy lifestyle and a normal weight development among children from low-income districts with relatively limited efforts involving parents. Hopefully the study will provide new insights to the further development of effective programmes to prevent overweight and obesity in children.

Trial registration

ISRCTN: ISRCTN32750699

Intergenerational energy balance interventions: a systematic literature review

Many nations have witnessed a dramatic increase in the prevalence of obesity and overweight across their population. Recognizing the influence of the household environment on energy balance has led many researchers to suggest that intergenerational interventions hold promise for addressing this epidemic. Yet few comprehensive reviews of intergenerational energy balance interventions have been undertaken. Our review of the literature over the past decade revealed that intergenerational intervention approaches to enhance energy balance use a broad array of designs, target populations, and theoretical models, making results difficult to compare and "best practices" challenging to identify. Additional themes include variation in how interventions incorporate the intergenerational component; an increasing acknowledgment of the importance of ecological models; variations in the location of interventions delivery; diversity in the intervention flexibility/structure, intensity, and duration; and variation in outcomes and measures used across studies. We discuss implications and future directions of intergenerational energy balance approaches.

School-based screening of the dietary intakes of third graders in rural Appalachian Ohio

BACKGROUND

Children in Appalachia are experiencing high levels of obesity, in large measure because of inferior diets. This study screened the dietary intake of third graders residing in 3 rural Appalachian counties in Ohio and determined whether the Food, Math, and Science Teaching Enhancement Resource Initiative (FoodMASTER) curriculum improved their dietary intake.

METHODS

Dietary intake was measured for 238 third graders at the beginning of the 2007 to 2008 school year and for 224 third graders at the end of that year. The FoodMASTER curriculum was delivered to 204 students (test group). Intake was measured using the Block Food Frequency Questionnaire 2004. The final analysis included 138 students.

RESULTS

The FoodMASTER curriculum did not significantly affect the diets of the students in the test group, as no significant differences in intake of macronutrients, specific nutrients, or food groups were found between the test and control groups. Majorities of students did not meet the Recommended Dietary Allowance or Adequate Intakes for fiber, calcium, iron, vitamin A, and vitamin E. The students as a whole did not meet the MyPyramid recommendations for any food group, and nearly one fifth of their calories came from sweets. Significant differences in percentages of kilocalories from protein and sweets and in servings of fats, oils, and sweets were seen between groups of higher and lower socioeconomic status.

CONCLUSIONS

Energy-dense foods are replacing healthy foods in the diets of Ohio children living in rural Appalachia. The prevalence of poor dietary intake in Appalachia warrants further nutrition interventions involving programming for nutrition, such as future FoodMASTER curricula.

The integration of a family systems approach for understanding youth obesity, physical activity, and dietary programs

Rates of overweight in youth have reached epidemic proportions and are associated with adverse health outcomes. Family-based programs have been widely used to treat overweight in youth. However, few programs incorporate a theoretical framework for studying a family systems approach in relation to youth health behavior change. Therefore, this review provides a family systems theory framework for evaluating family-level variables in weight loss, physical activity, and dietary approaches in youth. Studies were reviewed and effect sizes were calculated for interventions that manipulated the family system, including components that targeted parenting styles, parenting skills, or family functioning, or which had novel approaches for including the family. Twenty-one weight loss interventions were identified, and 25 interventions related to physical activity and/or diet were identified. Overall, family-based treatment programs that incorporated training for authoritative parenting styles, parenting skills, or child management, and family functioning had positive effects on youth weight loss. Programs to improve physical activity and dietary behaviors that targeted the family system also demonstrated improvements in youth health behaviors; however, direct effects of parent-targeted programming is not clear. Both treatment and prevention programs would benefit from evaluating family functioning and parenting styles as possible mediators of intervention outcomes. Recommendations are provided to guide the development of future family-based obesity prevention and treatment programs for youth.

Effect of school-based physical activity interventions on body mass index in children: a meta-analysis

BACKGROUND

The prevalence of childhood obesity is increasing at an alarming rate. Many local governments have enacted policies to increase physical activity in schools as a way to combat childhood obesity. We conducted a systematic review and meta-analysis to determine the effect of school-based physical activity interventions on body mass index (BMI) in children.

METHODS

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials up to September 2008. We also hand-searched relevant journals and article reference lists. We included randomized controlled trials and controlled clinical trials that had objective data for BMI from before and after the intervention, that involved school-based physical activity interventions and that lasted for a minimum of 6 months.

RESULTS

Of 398 potentially relevant articles that we identified, 18 studies involving 18 141 children met the inclusion criteria. The participants were primarily elementary school children. The study duration ranged from 6 months to 3 years. In 15 of these 18 studies, there was some type of co-intervention. Meta-analysis showed that BMI did not improve with physical activity interventions (weighted mean difference -0.05 kg/m(2), 95% confidence interval -0.19 to 0.10). We found no consistent changes in other measures of body composition.

INTERPRETATION

School-based physical activity interventions did not improve BMI, although they had other beneficial health effects. Current population-based policies that mandate increased physical activity in schools are unlikely to have a significant effect on the increasing prevalence of childhood obesity.

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

BACKGROUND

The World Health Organization estimates that 1.9 million deaths worldwide are attributable to physical inactivity. Chronic diseases associated with physical inactivity include cancer, diabetes and coronary heart disease.

OBJECTIVES

The purpose of this systematic review is to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents.

SEARCH STRATEGY

The search strategy included searching several databases. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information.

SELECTION CRITERIA

To be included, the intervention had to be relevant to public health practice, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, report on outcomes for children and adolescents (aged 6 to 18 years), and use a prospective design with a control group.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to rate each study's methodological quality and for data extraction. Where discrepancies existed discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated and outcomes measured.

MAIN RESULTS

13,841 titles were identified and screened and 482 articles were retrieved. Multiple publications on the same project were combined and counted as one project, resulting in 395 distinct project accounts (studies). Of the 395 studies 104 were deemed relevant and of those, four were assessed as having strong methodological quality, 22 were of moderate quality and 78 were considered weak. In total 26 studies were included in the review. There is good evidence that school-based physical activity interventions have a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally school-based interventions had no effect on leisure time physical activity rates, systolic and diastolic blood pressure, body mass index, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity result in positive effects.

AUTHORS' CONCLUSIONS

Given that there are no harmful effects and that there is some evidence of positive effects on lifestyle behaviours and physical health status measures, ongoing physical activity promotion in schools is recommended at this time.

Targeting obesity to reduce the risk for type 2 diabetes and other co-morbidities in African American youth: a review of the literature and recommendations for prevention

Over the last decade, the prevalence of obesity has continued to rise within the adolescent population of the US. Data show that African American youth are disproportionately affected by the obesity epidemic due to their higher risk for obesity-related co-morbidities, such as type 2 diabetes. Interventions that target risk factors for obesity at the individual, family and community levels are needed in order to prevent the onset of type 2 diabetes and related complications. This article provides an overview of the prevalence of obesity and type 2 diabetes in African American youth, the pathophysiology of the disease, and the behavioural risk factors that have contributed to its high prevalence within the African American adolescent population. Successful intervention strategies that target modifiable risk factors, such as diet and physical activity, will be identified. Finally, recommendations for programmes to prevent the onset of type 2 diabetes within the African American adolescent population are presented.

Endocrine and metabolic adverse effects of psychotropic medications in children and adolescents

OBJECTIVE

Despite increasing use of psychotropic medications in children and adolescents, data regarding their efficacy and safety are limited. Endocrine and metabolic adverse effects are among the most concerning adverse effects of commonly used psychotropic medications.

METHOD

Selective review of endocrine and metabolic effects of psychotropic medications in pediatric populations, with a focus on monitoring and management strategies.

RESULTS

Because youth are still developing at the time of psychotropic drug exposure, most reference values need to be adjusted for gender and age. As in adults, youngsters receiving lithium require monitoring for thyroid dysfunction. Psychostimulants appear to cause mild reversible growth retardation in some patients, most likely because of decreased weight or slowing of expected weight gain; some patients may experience clinically significant reductions in adult height. Although still controversial, valproate use has been associated with an increased risk for polycystic ovary syndrome, in addition to causing weight gain. Although more data are required, children and adolescents appear to be at higher risk than adults for antipsychotic-induced hyperprolactinemia, weight gain, and possibly, associated metabolic abnormalities, which is of particular concern.

CONCLUSIONS

Clinicians and caregivers need to be aware of potential endocrine and metabolic adverse effects of psychiatric medications. A careful selection of patients, choice of agents with potentially lesser risk for these adverse events, healthy lifestyle counseling, as well as close health monitoring are warranted to maximize effectiveness and safety.