Changes in BMI and blood pressure after a school based intervention: The CHILDREN study

The effectiveness of physical activity interventions on blood pressure in children and adolescents: A systematic review and network meta-analysis

BACKGROUND

High blood pressure (BP) is a major contributor to mortality and cardiovascular diseases. Despite the known benefits of exercise for reducing BP, it is crucial to identify the most effective physical activity (PA) intervention. This systematic review and network meta-analysis (NMA) aimed to evaluate the available evidence on the effectiveness of various PA interventions for reducing BP and to determine their hierarchy based on their impact on BP.

METHODS

A search of PubMed, SPORTDiscus, PsycINFO, Web of Science, CINAHL, Cochrane, and Eric databases was conducted up to December 2022 for this systematic review and NMA. Randomized controlled trials and quasi-experimental studies targeting healthy children and adolescents aged 6-12 years old were included in this study. Only studies that compared controlled and intervention groups using PA or exercise as the major influence were included. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent investigators performed the literature screening, data extraction, and risk of bias assessment. We used Bayesian arm-based NMA to synthesize the data. The primary outcomes were systolic BP and diastolic BP. We calculated the mean differences (MDs) in systolic BP and diastolic BP before and after treatment. Mean treatment differences were estimated using NMA and random-effect models.

RESULTS

We synthesized 27 studies involving 15,220 children and adolescents. PA combined with nutrition and behavior change was the most effective intervention for reducing both systolic BP and diastolic BP (MD = -8.64, 95% credible interval (95%CI):-11.44 to -5.84; MD = -6.75, 95%CI: -10.44 to -3.11), followed by interventions with multiple components (MD = -1.39, 95%CI: -1.94 to -0.84; MD = -2.54, 95%CI: -4.89 to -0.29).

CONCLUSION

Our findings suggest that PA interventions incorporating nutrition and behavior change, followed by interventions with multiple components, are most effective for reducing both systolic BP and diastolic BP in children and adolescents.

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

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

Control of blood pressure in hypertensive children and adolescents assessed by ambulatory blood pressure monitoring

BACKGROUND

There have been few studies evaluating the control of hypertension (HT) in children. This study aimed to assess the control of HT using ambulatory blood pressure monitoring (ABPM) and to compare the parameters between the uncontrolled HT and controlled HT groups.

METHODS

Hypertensive patients aged ≥ 5 years who underwent ABPM to assess the control of HT were enrolled. Demographics, office blood pressure (BP), ABPM, and echocardiographic data were collected. Controlled HT was defined using a BP goal recommended by the 2016 European Society of Hypertension guidelines.

RESULTS

There were 108 patients (64.8% males) with a mean age of 14.3 years and 51.9% had primary HT. Controlled HT was detected in 41.1% and 33.3% by office BP and ABPM, respectively. Based on ABPM, there was a greater prevalence of controlled HT in the primary HT than the secondary HT group (44.6% vs. 21.2%, P = 0.01). In the primary HT group, BMI z-score at the last follow-up had a significant decrease in the controlled HT than the uncontrolled HT group (-0.39 vs. 0.01, P = 0.032). Primary HT was negatively associated with uncontrolled HT by ABPM. In addition, ABPM showed greater sensitivity (77.8% vs. 55.8%) and negative predictive value (80.9% vs. 70.8%) to predict LVH than those of office BP measurement.

CONCLUSION

Only one-third of patients achieved the BP goal by ABPM and most were in the primary HT group. Weight reduction is an important measure of BP control in patients with primary HT to attenuate the risk of LVH.

Healthy lifestyle interventions within the curriculum in school-age children: systematic review and meta-analysis

Childhood obesity is a major public health challenge. Previous research has identified the impact of school-based interventions for preventing and treating obesity; we hypothesized that when curricular changes are integrated, results could be exponentiated. This study aimed to systematically review and conduct a meta-analysis of the published literature analyzing information about school-based interventions inserted in the curriculum. The Cochrane Handbook methodology was followed. An electronic search was conducted in five databases, with a specific design strategy per database. Randomized controlled trials or quasi-experimental studies of children with nutrition and physical activity (PA) interventions inserted into the school curricula were included. The risk of bias was assessed with the Risk of Bias tool. The mean differences were pooled using a fixed-effects model for the meta-analysis. The certainty of the evidence was evaluated according to the guidelines of the Grading of the Recommendations, Assessment, Development, and Evaluations working group (Protocol ID: CRD42021270557). After the screening and selection process, 12 studies were included. The interventions identified, based on the school curricula, include classroom activities and homework, among others. A meta-analysis with five intervention groups presented an overall mean difference of -0.14 body mass index (BMI) Z-score (95% CI: -0.25, -0.03) after this intervention with high certainty of the evidence. This systematic review and meta-analysis suggest that nutrition and PA lessons inserted into the curricula and supported with additional activities (i.e. homework, workshops, etc.) could increase nutrition knowledge and improve attitudes toward fruit, vegetables, and water consumption, and BMI Z-score reduction.

Effects of school nurse-led health education to reduce malnutrition among primary school children in Bangladesh: Cluster nonrandomized controlled trial

Background

Malnutrition is a major health concern among children especially in low and middle-income countries. However, there are limited studies on school health in Bangladesh. This study aimed to reduce malnutrition among primary school children in Bangladesh by increasing awareness and knowledge through school nurse-led health education.

Methods and Materials

A prospective, open-label, parallel-group (1:1), cluster nonrandomized controlled trial on primary school children conducted in rural Bangladesh. The study lasted 13 months between September 2021 and September 2022. Four schools were selected and assigned to the intervention and control groups (CGs). Next, school nurses provided evidence-based health education to the children in the intervention group (IG) for 9 months to improve awareness and knowledge of malnutrition. Data were collected at baseline, midline, and endline.

Results

Overall, 604 children were enrolled at the baseline; among them, 455 (CG, n = 220; IG, n = 235) completed the study. Changes in the malnutrition rate-the primary outcome-were not significant (P = 0.225). However, after adjusting the endline data with baseline and sociodemographic data, the children's body mass index improved significantly in the IG than in the CG (P < 0.05). Changes in eating behavior, and awareness and knowledge of malnutrition-the secondary outcomes-significantly differed between the groups (P < 0.001).

Conclusion

The school nurse-led health education program significantly improved primary school children's awareness and knowledge of malnutrition. This study revealed the effectiveness of school nurses in reducing malnutrition among children, which may decrease future morbidity and mortality rates in children.

The estimated effect of increasing fruit interventions on controlling body weight in children and adolescents: A meta-analysis

BACKGROUND

The impact of increased fruit consumption on weight change remains a matter of debate.

OBJECTIVE

This study aimed to evaluate the effects of interventions targeted at promoting fruit consumption and managing body weight in children and adolescents.

METHODS

Four electronic databases, including PubMed, Web of science, Embase, and the Cochrane Library, were searched from January 1, 2000, to October 10th, 2023, to identify Randomized controlled trials (RCTs) that assessed changes in fruit consumption and obesity indicators.

RESULTS

A total of 22 trials including 12,678 participants who met our inclusion criteria were selected for this review. The meta-analysis demonstrated that the interventions increased fruit intake (MD = 78.58 g/day (95% CI 53.09 to 104.07), P < 0.001) in children and adolescents. The mean reduction of body mass index was 0.27 kg/m2 (95% CI -0.59 to 0.05 kg/m2, P = 0.101). And no significant decreases were observed in body mass index-z scores, but there was a significant decrease in waist circumference (MD = -0.65 cm (95% CI -1.15 to -0.05 cm), P < 0.05). Increased fruit intake was shown to be associated with a lower prevalence of obesity when compared to the control group (odds ratio [OR]: 0.74, 95% CI 0.60 to 0.90), P < 0.05).

CONCLUSIONS

This meta-analysis provided evidence that interventions aimed at increasing fruit consumption were effective at reducing obesity prevalence.

Effects of "Football and Nutrition for Health" program on body composition, physical fitness, eating behaviours, nutritional knowledge, and psychological status among 7 to 10 years school children

Introduction

Noncommunicable diseases and obesity are between the major health threat due to consumption of unhealthy foods and limited time spent on physical activities, a situation of particular concern among children. Since children spend most of their time at school, this study intends to investigate the effect of a school intervention program, which combines recreational football and nutrition education, on body composition, physical fitness, physical activity, blood pressure and heart rate, eating behaviours, nutritional knowledge, and psychological status in elementary school children.

Methods

A total of 67 children, between 7 and 10 years old, were allocated into three groups: the Football Group (FG) which held 2 weekly sessions of 60 min of recreational football, the Nutrition and Football Group (NFG) which held 2 sessions per week of 60 min of recreational football plus 60 min of nutritional education and the Control Group (CG) which maintained its usual curriculum. The intervention lasted 12 weeks. All measurements were collected before and after the intervention.

Results

Intervention groups significantly (p < 0.05) improved BMI Z-score, rest heart rate, horizontal jump and shuttle test, physical activity level, and psychosocial health. The NFG group significantly decreased (p < 0.05) waist-to-height ratio and blood pressure, and significantly increased (p < 0.05) nutritional knowledge, fruit, and fish consumption. While FG significantly decreased (p < 0.05) the percentage of fat mass and significantly increased (p < 0.05) muscle mass and performance in the 20 m sprint.

Discussion

The results have shown to improve nutritional status, explosive strength, aerobic and neuromuscular fitness, as well as increase the level of physical activity. The nutritional education sessions contributed to increase nutritional knowledge and to improve the consumption of healthy food groups in a ludic-educational way. The "Football and Nutrition for Health" program was able to induce short-term improvements in several health markers, highlighting the role of the school curriculum in children's health.

Unreliable Findings Due to Miscalculations and Errors. Comment on Nally et al. The Effectiveness of School-Based Interventions on Obesity-Related Behaviours in Primary School Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Children 2021, 8, 489

Nally et al. [...].

A Community Guide Systematic Review: School Dietary and Physical Activity Interventions

CONTEXT

Schools can play an important role in supporting a healthy lifestyle by offering nutritious foods and beverages and providing opportunities for physical activity. A healthy diet and regular physical activity may reduce the risk of obesity. This manuscript reports on a Community Guide systematic review examining the effectiveness of interventions in schools combining school meal or fruit and vegetable snack programs and physical activity.

EVIDENCE ACQUISITION

Studies meeting the intervention definition were identified from a literature search (search period: January 1990-November 2019). Community Guide systematic review methods were used to assess effectiveness as measured by dietary behavior, physical activity, and weight changes; analyses were conducted in 2020.

EVIDENCE SYNTHESIS

Interventions (n=24 studies) were considered effective for increasing physical activity (median increase=21.8 minutes/day; interquartile interval= -0.8 to 27.4 minutes/day), modestly increasing fruit and vegetable intake (median relative increase=12.1%; interquartile interval= -4.6%, 73.4%), and decreasing the prevalence of overweight and obesity (median decrease=2.5 percentage points; interquartile interval= -8.1, -1.6 percentage points) among elementary school students through sixth grade. There were not enough studies to determine the effectiveness of interventions for middle- and high-school students.

CONCLUSIONS

School meal or fruit and vegetable snack interventions combined with physical activity were effective in increasing physical activity, with modest effects for improving fruit and vegetable consumption and reducing the prevalence of overweight and obesity among elementary students. These results may inform researchers and school administrators about healthy eating and physical activity interventions.

Psychological factors that may influence use of long-acting reversible contraceptives (LARC): A qualitative study

Although long-acting reversible contraceptives (LARC) remain the most effective method of contraception for teenagers, most adolescents continue to use less reliable methods. The purpose of this study was to investigate possible psychological factors that may lead to this low uptake rate by studying the LARC decisionmaking process among teenagers. In-depth, semistructured, open-ended interviews of sexually active teenagers who had LARC devices placed prior to 18 years of age were conducted. Four key themes emerged from the interviews: (a) the influences of peers (friends and family members) on LARC decision-making; (b) the lack of awareness about obtaining LARC devices; (c) the fear of weight gain as a driving force during contraceptive and LARC decision-making; and (d) the disproportional anxiety about pain from LARC insertion. The results suggest that a paradigm shift in contraceptive counseling is necessary in order to tackle these psychological barriers to teenage LARC use.

Obesity and Cardiometabolic Risk Factors: From Childhood to Adulthood

Obesity has become a major epidemic in the 21st century. It increases the risk of dyslipidemia, hypertension, and type 2 diabetes, which are known cardiometabolic risk factors and components of the metabolic syndrome. Although overt cardiovascular (CV) diseases such as stroke or myocardial infarction are the domain of adulthood, it is evident that the CV continuum begins very early in life. Recognition of risk factors and early stages of CV damage, at a time when these processes are still reversible, and the development of prevention strategies are major pillars in reducing CV morbidity and mortality in the general population. In this review, we will discuss the role of well-known but also novel risk factors linking obesity and increased CV risk from prenatal age to adulthood, including the role of perinatal factors, diet, nutrigenomics, and nutri-epigenetics, hyperuricemia, dyslipidemia, hypertension, and cardiorespiratory fitness. The importance of 'tracking' of these risk factors on adult CV health is highlighted and the economic impact of childhood obesity as well as preventive strategies are discussed.

Trends in the Number of Behavioural Theory-Based Healthy Eating Interventions Inclusive of Dietitians/Nutritionists in 2000-2020

Nutrition interventions developed using behaviour theory may be more effective than those without theoretical underpinnings. This study aimed to document the number of theory-based healthy eating interventions, the involvement of dietitians/nutritionists and the behaviour theories employed from 2000 to 2020. We conducted a review of publications related to healthy eating interventions that used behaviour change theories. Interventional studies published in English between 2000 and 2020 were retrieved from searching Medline, Cinahl, Embase, Psycinfo and Cochrane Central. Citation, country of origin, presence or absence of dietitian/nutritionist authors, participants, dietary behaviours, outcomes, theories and any behaviour change techniques (BCTs) stated were extracted. The publication trends on a yearly basis were recorded. A total of 266 articles were included. The number of theory-based interventions increased over the two decades. The number of studies conducted by dietitians/nutritionists increased, but since 2012, increases have been driven by other researchers. Social cognitive theory was the most used behaviour theory. Dietitians/nutritionists contributed to growth in publication of theory-based healthy eating interventions, but the proportion of researchers from other professions engaged in this field increased markedly. The reasons for this growth in publications from other professions is unknown but conjectured to result from greater prominence of dietary behaviours within the context of an obesity epidemic.

Effects of a school-based intervention to reduce cardiovascular disease risk factors among secondary school students: A cluster-randomized, controlled trial

BACKGROUND

Cardiovascular diseases (CVDs) are the number cause of death worldwide. In Ghana CVD has been the leading cause of death since 2001. The prevalence of CVD risk factors among adolescents in Ghana has been increasing. This study seeks to develop, implement and evaluate the effects of a behavioral modification intervention program to reduce CVD risk factors among secondary school students in Brong Ahafo, Ghana.

METHODS

A cluster-randomized controlled trial was conducted with schools as clusters over a period of six-months with pre and post intervention evaluations. Participants were public secondary school students (14-19 years) from four schools in Brong Ahafo, Ghana. Students in the intervention group were trained by the researchers whereas those of the control group received no intervention. The intervention included health education and physical activity modules. Follow-up data using same questionnaire were collected within two weeks after the intervention was completed. Intention-to-treat analysis was performed after replacing missing values using the multiple imputation method. The generalized linear mixed model (GLMM) was used to assess the effects of the intervention study.

RESULTS

The GLMM analyses showed the intervention was effective in attaining 0.77(p<0.001), 0.72(p<0.001), 0.47(p<0.001), 0.56(p<0.001), and 0.39(p = 0.045) higher total physical activity, fruits, vegetables, seafood, and water scores respectively for the intervention group over the control group. The intervention was also significant in reducing -0.15(p<0.001),-0.23(p<0.001),-0.50(p<0.001),-0.32(p<0.001),-0.90(p<0.001),-0.87(p<0.001),-0.38(p<0.001), -0.63(p<0.001), -1.63(p<0.001), 0.61(p<0.001), and -1.53(p = 0.005) carbohydrates, fats and oils, fried eggs, fried chicken, carbonated drinks, sugar, sweet snacks, salted fish, weight, BMI, and diastolic BP. The odds of quitting alcohol use in the intervention group were 1.06 times more than the control group. There was no significant effect on reducing smoking and systolic BP.

CONCLUSION

There is an urgent need for the intervention program to be integrated into the existing curriculum structure of secondary school schools. Implementing the intervention will allow for longer and more consistent impact on the reduction of CVD risk factors among secondary school students.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Physiotherapy and related management for childhood obesity: A systematic scoping review

INTRODUCTION

Despite targeted efforts globally to address childhood overweight/obesity, it remains poorly understood and challenging to manage. Physiotherapists have the potential to manage children with obesity as they are experts in movement and physical activity. However, their role remains unclear due to a lack of physiotherapy-specific guidelines. This scoping review aims to explore existing literature, critically appraising and synthesising findings to guide physiotherapists in the evidence-based management of childhood overweight/obesity.

METHOD

A scoping review was conducted, including literature up to May 2020. A review protocol exists on Open Science Framework at https://osf.io/fap8g/. Four databases were accessed including PubMed, Embase, CINAHL, Medline via OVID, with grey literature searched through google via "file:pdf". A descriptive synthesis was undertaken to explore the impact of existing interventions and their efficacy.

RESULTS

From the initial capture of 1871 articles, 263 intervention-based articles were included. Interventions included qualitative focused physical activity, quantitative focused physical activity and multicomponent interventions. Various outcome measures were utilised including health-, performance- and behaviour-related outcomes. The general trend for physiotherapy involvement with children who are obese appears to favour: 1) multicomponent interventions, implementing more than one component with environmental modification and parental involvement and 2) quantitative physical activity interventions, focusing on the quantity of bodily movement. These approaches most consistently demonstrated desirable changes across behavioural and health-related outcome measures for multicomponent and quantitative physical activity interventions respectively.

CONCLUSION

When managing children with obesity, physiotherapists should consider multicomponent approaches and increasing the quantity of physical activity, given consistent improvements in various obesity-related outcomes. Such approaches are well suited to the scope of physiotherapists and their expertise in physical activity prescription for the management of childhood obesity. Future research should examine the effect of motor skill interventions and consider the role of environmental modification/parental involvement as factors contributing to intervention success.

The Effectiveness of School-Based Interventions on Obesity-Related Behaviours in Primary School Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

School-based interventions are promising for targeting a change in obesity-related behaviours in children. However, the efficacy of school-based interventions to prevent obesity remains unclear. This review examined the effectiveness of school-based interventions at changing obesity-related behaviours (increased physical activity, decreased sedentary behaviour and improved nutrition behaviour) and/or a change in BMI/BMI z-score. Following PRISMA guidelines, seven databases were systematically searched from 1 January 2009 to 31 December 2020. Two review authors independently screened studies for eligibility, completed data extraction and assessed the risk of bias of each of the included studies. Forty-eight studies met the inclusion criteria and were included in a narrative synthesis. Thirty-eight studies were eligible for inclusion in a meta-analysis. The findings demonstrate that interventions in children when compared to controls resulted in a small positive treatment effect in the control group (2.14; 95% CI = 0.77, 3.50). There was no significant effect on sedentary behaviour, energy intake and fruit and vegetable intake. Significant reductions were found between groups in BMI kg/m2 (-0.39; 95% CI = -0.47, -0.30) and BMI z-score (-0.05; 95% CI = -0.08, -0.02) in favour of the intervention. The findings have important implications for future intervention research in terms of the effectiveness of intervention components and characteristics.

Nutrition across the curriculum: a scoping review exploring the integration of nutrition education within primary schools

Primary schools contribute to promoting healthy eating behaviour and preventing overweight and obesity by providing nutrition education. Research highlights the importance of improving teachers' programme implementation to enhance intervention effectiveness. An integrative approach has been suggested to reduce time barriers that teachers currently experience in teaching nutrition. This scoping review explores use and effectiveness of integrative teaching in primary-school-based nutrition education programmes. Six databases were searched for primary-school-based interventions on nutrition education. Papers reporting on integration of nutrition topics within core curriculum were included. Abstracts and full texts of potentially relevant articles were screened to determine eligibility. Next, data were extracted and tabulated. Findings were collated and summarised to describe intervention characteristics, subject integration and effectiveness of the included programmes. Data describing integration of nutrition into the primary school curriculum were extracted from 39 eligible papers. Nutrition education programmes often involve lessons about food groups and are frequently embedded within the mathematics, science or literacy syllabus. Although articles report on the integration of nutrition, the use of this approach was not commonly described in detail. Only seven papers discussed student outcomes related to the integration of nutrition education within core subjects. The ability to draw strong conclusions about school-based nutrition intervention effectiveness is limited by the current lack of programme description and methodological issues. Hence, more research is warranted to inform evidence on effectiveness of integrative nutrition education for both teacher and student outcomes. Future studies that include greater detail regarding the integrative approach are needed.

The effect of physical activity intervention and nutritional habits on anthropometric measures in elementary school children: the health oriented pedagogical project (HOPP)

BACKGROUND

Overweight and obesity are a burden of the modern world that requires urgent action. Prevention has proven to be efficient in the fight against overweight and obesity. As many children gain excessive weight at an early age, intervention during school years are important. While daily physical activity (PA) is known to have an influence on overweight and obesity prevention, the importance of a healthy lifestyle, including dietary habits, should not be underestimated. The aim of this study was to assess how a combination of daily PA and healthy/unhealthy diet affect the anthropometric measures of 4th graders in Norway.

METHODS

The Health Oriented Pedagogical Project (HOPP) is a longitudinal intervention in primary school children, which includes increased amount of daily physical activity during teaching- active learning. Assessed were weight, muscle and bone mass, as well as fat mass, using a bio-impedance Tanita scale. A dietary survey, Ungkost 2000, with 18 multiple-choice questions was used to evaluate the overall nutrition characteristics of the children.

RESULTS

Between 2015 and 2018, a total of 917 (intervention group n = 614, control group n = 303) 4th graders from nine different schools from the south-east part of Norway participated. We observed that daily PA and a regular healthy diet increases-while an unhealthy diet decreases-muscle and bone mass despite daily PA. Daily PA appears to counteract some of the effects of an unhealthy diet on weight and fat mass. In addition, daily PA and a regular intake of fruits and berries lowers weight and fat mass in children with overweight.

CONCLUSION

Combination of daily 45-minute of PA and a healthy diet leads to reductions in body weight and incease in muscle and bone mass in elementary school children.

Effect of Comprehensive Interventions Including Nutrition Education and Physical Activity on High Blood Pressure among Children: Evidence from School-Based Cluster Randomized Control Trial in China

Childhood hypertension has increasingly become a public health problem globally. However, limited literature research examined the effect of comprehensive interventions including nutrition education and physical activity on blood pressure among children. A total of 6764 children aged 7–13 years were analyzed based on a multicenter randomized controlled trial for comprehensive interventions in 30 primary schools in China to evaluate the effects on blood pressure, which lasted for two semesters. The standards used for the diagnosis of high blood pressure were the cut-off points based on age and sex for Chinese children. Compared with the control group, the intervention effects were −0.5 mm Hg (95% confidence interval (CI): −1.1, 0; p = 0.064) for diastolic blood pressure and −0.9 mmHg (95% CI: −1.5, −0.3; p = 0.005) for systolic blood pressure. For the incidence of high blood pressure, the changes were −1.4% in the intervention group and 0.4% in the control group (1.8% difference between the two groups, p = 0.015) after trial. The school-based comprehensive interventions appeared to have moderate effects on high blood pressure prevention among children in China.

Impact of a randomized school-based intervention program on blood pressure levels

Abstract Objectives: to evaluate the impact of a health program performed in a school setting on the blood pressure levels of schoolchildren in the public school system in Vitória/ES-Brazil. Methods: a randomized community trial was performed with 237 schoolchildren (6 to 12 years) from two public schools, randomly defined as the intervention and control school. Participants of the intervention group attended 11 education sessions over 4 months (July to October 2014). To test for differences between groups, the chi-square (categorical variables), and the paired t test or Wilcoxon (continuous variables) was used. The rate of variation of systolic blood pressure (SBP) and diastolic blood pressure (DBP) throughout the follow-up, according to allocation group, was evaluated using linear generalized models for time-repeated measures. Results: there was a reduction in the means of SBP (0.5 mmHg) and DBP (0.6 mmHg) in the intervention group and an increase in the control group, with a significant difference in the BP variation between groups over the follow-up period (p<0.05). Conclusion: a low-cost and easily implemented intervention may be one of the factors associated with the lowest blood pressure levels in the group studied, and reproduction in a school environment is feasible.

Program Evaluation of Environmental and Policy Approaches to Physical Activity Promotion in a Lower Income Latinx School District in Southeast Los Angeles

There is alarming population wide prevalence of low adolescent physical activity as this represents a risk factor for later chronic disease development. There is evidence to suggest that schools with strong wellness policies have students that are more frequently active. We designed an intervention to enhance students' physical activity levels in five majority Latinx, underserved school districts. Evaluation consisted of assessment of written quality of school-district wellness policies; observation of student's physical activity during leisure times; and after-school program practices and policies. We examined one of these district's results more closely, the only participating district with a community coalition, and extracted lessons learned. On the physical activity section of the wellness policy, this district covered a moderate extent of recommended content areas using weak language. Compared to previous reports, we identified low vigorous activity levels for girls and boys at baseline (respectively, 12% and 18%). Finally, we identified that of four after school program sites assessed at baseline, no program reported the recommended 50% or more of program time dedicated to physical activity. Based on these evaluation findings, additional strategies are urgently needed to encourage all students and particularly more girls to be physically active throughout the school day.

A systematic review and meta-analysis of the overall effects of school-based obesity prevention interventions and effect differences by intervention components

BACKGROUND

Childhood obesity is a serious public health concern. School-based interventions hold great promise to combat the rising trend of childhood obesity. This systematic review aimed to assess the overall effects of school-based obesity prevention interventions, and to investigate characteristics of intervention components that are potentially effective for preventing childhood obesity.

METHODS

We systematically searched MEDLINE, CENTRAL and Embase databases to identify randomized- or cluster randomized- controlled trials of school-based obesity interventions published between 1990 and 2019. We conducted meta-analyses and subgroup analyses to determine the overall effects of obesity prevention programs and effect differences by various characteristics of intervention components on body mass index (BMI) or BMI Z-score of children.

RESULTS

This systematic review included a total of 50 trials (reported by 56 publications). Significant differences were found between groups on BMI (- 0.14 kg/m2 (95% confidence interval: - 0.21, - 0.06)) and BMI Z-score (- 0.05 (- 0.10, - 0.01)) for single-component interventions; significant differences were also found between groups on BMI (- 0.32 (- 0.54, - 0.09) kg/m2) and BMI Z-score (- 0.07 (- 0.14, - 0.001)) for multi-component interventions. Subgroup analyses consistently demonstrated that effects of single-component (physical activity) interventions including curricular sessions (- 0.30 (- 0.51, - 0.10) kg/m2 in BMI) were stronger than those without curricular sessions (- 0.04 (- 0.17, 0.09) kg/m2 in BMI); effects of single-component (physical activity) interventions were also strengthened if physical activity sessions emphasized participants' enjoyment (- 0.19 (- 0.33, - 0.05) kg/m2 in BMI for those emphasizing participants' enjoyment; - 0.004 (- 0.10, 0.09) kg/m2 in BMI for those not emphasizing participants' enjoyment). The current body of evidence did not find specific characteristics of intervention components that were consistently associated with improved efficacy for multi-component interventions (P > 0.05).

CONCLUSIONS

School-based interventions are generally effective in reducing excessive weight gain of children. Our findings contribute to increased understandings of potentially effective intervention characteristics for single-component (physical activity) interventions. The impact of combined components on effectiveness of multi-component interventions should be the topic of further research. More high-quality studies are also needed to confirm findings of this review.

Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption

BACKGROUND

Overconsumption of food, alcohol, and tobacco products increases the risk of non-communicable diseases. Interventions to change characteristics of physical micro-environments where people may select or consume these products - including shops, restaurants, workplaces, and schools - are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers.

OBJECTIVES

1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non-alcoholic beverages), (b) alcohol, and (c) tobacco products.2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches.

SELECTION CRITERIA

We included randomised controlled trials with between-participants (parallel group) or within-participants (cross-over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product.

DATA COLLECTION AND ANALYSIS

We used a novel semi-automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random-effects meta-analysis and meta-regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE.

MAIN RESULTS

We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between-participants designs (19/24). All studies were conducted in high-income countries, predominantly in the USA (14/24).Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less-healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta-analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD -1.13 (95% confidence interval (CI) -1.90 to -0.37) (low certainty evidence). For consumption outcomes, meta-analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD -0.55 (95% CI -1.27 to 0.18) (low certainty evidence).Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD -0.65 (95% CI -1.29 to -0.01) (very low certainty evidence). For consumption outcomes, meta-analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD -0.60 (95% CI -0.84 to -0.36) (low certainty evidence). Meta-regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias.

AUTHORS' CONCLUSIONS

The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real-world settings, intervening across a wider range of foods - as well as alcohol and tobacco products - and over sustained time periods.

Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption

BACKGROUND

Overconsumption of food, alcohol, and tobacco products increases the risk of non-communicable diseases. Interventions to change characteristics of physical micro-environments where people may select or consume these products - including shops, restaurants, workplaces, and schools - are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers.

OBJECTIVES

1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non-alcoholic beverages), (b) alcohol, and (c) tobacco products.2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches.

SELECTION CRITERIA

We included randomised controlled trials with between-participants (parallel group) or within-participants (cross-over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product.

DATA COLLECTION AND ANALYSIS

We used a novel semi-automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random-effects meta-analysis and meta-regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE.

MAIN RESULTS

We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between-participants designs (19/24). All studies were conducted in high-income countries, predominantly in the USA (14/24).Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less-healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta-analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD -1.13 (95% confidence interval (CI) -1.90 to -0.37) (low certainty evidence). For consumption outcomes, meta-analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD -0.55 (95% CI -1.27 to 0.18) (low certainty evidence).Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD -0.65 (95% CI -1.29 to -0.01) (very low certainty evidence). For consumption outcomes, meta-analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD -0.60 (95% CI -0.84 to -0.36) (low certainty evidence). Meta-regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias.

AUTHORS' CONCLUSIONS

The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real-world settings, intervening across a wider range of foods - as well as alcohol and tobacco products - and over sustained time periods.

How are behavioural interventions delivered to children (5-11 years old): a systematic mapping review

CONTEXT

Behavioural interventions are used to prevent, manage and treat a wide variety of conditions including obesity, diabetes, chronic pain, asthma and emotional difficulties. There has been inadequate attention to the delivery of behavioural interventions to younger children (5-11 years old).

OBJECTIVE

Our objectives were to describe the characteristics of behavioural interventions for children aged 5-11 years.

DATA SOURCES

We searched five databases: CINAHL, EMBASE, PsycINFO, MEDLINE and Cochrane Library, from January 2005 to August 2019.

STUDY SELECTION

The inclusion criteria were (1) children aged 5-11, (2) cognitive and/or behavioural interventions, (3) randomised controlled trials and (4) 2005 onward. Two researchers independently identified studies for inclusion.

DATA EXTRACTION

Two researchers independently extracted data from eligible papers.

RESULTS

The search identified 10 541 papers. We extracted information on 117 interventions (from 152 papers). Many of the interventions were categorised as complex. This was particularly true for clinical populations; 78.7% were delivered to both the child and parent, and 33.9% took place across multiple settings, typically health and school settings. Most (70.9%) were 'First Wave' (behavioural) interventions, and few (4.3%) were 'Third Wave' (characterised by metacognition, acceptance and mindfulness). Thirty-nine per cent used interactive techniques (play, arts, story and/or games). Purely digital and paper-based interventions were rare, but around a third used these tools as supplements to face-face delivery. There were differences in interventions for younger (5-7 years) and older (8-11 years) children.

CONCLUSIONS

Interventions designed and delivered to children should be developmentally sensitive. This review highlights characteristics of interventions delivered to children 5-11 years old: the involvement of the child's parent, using behavioural (rather than cognitive) modalities, using interactive techniques and some interventions were delivered across multiple settings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

The Effects of a Community-Based Lifestyle Intervention on Metabolic Syndrome and Its Components in Adolescents: Findings of a Decade Follow-Up

BACKGROUND

The increasing prevalence of metabolic syndrome (MetS) in childhood makes lifestyle interventions imperative during adolescence. This study aimed to assess the effects of a community-based lifestyle intervention on MetS and its components in adolescents.

METHODS

Adolescents, based on their residential area were categorized into three groups: complete intervention (residing in the intervention area at baseline and during all follow-ups), incomplete intervention (residing in either the intervention or control areas and were in transition between these two areas), and control group (residing in the control area at baseline and throughout all follow-ups). All measurements were repeated every 3 years for up to 9 years. Lifestyle intervention aimed at achieving healthy dietary patterns and increasing physical activity. Generalized estimating equation models were used to analyze data.

RESULTS

In boys with incomplete intervention versus controls, the prevalence of MetS was significantly lower in the short term (14.0 vs. 22.9), but not in long term. In boys with complete intervention, the prevalence was significantly lower versus controls (9.0 vs. 23.4) in the long term. In girls, the short-term prevalence of MetS was significantly lower in the complete intervention group compared with controls (2.5 vs. 9.1) and then remained constantly low in all study groups after that. Among MetS components, in boys, triglycerides and fasting plasma glucose in the short term and high-density lipoprotein mid term, and in girls HDL in mid and long term were both significantly improved. The odds of MetS decreased significantly in the complete [odds ratio (OR): 0.516, confidence interval (95% CI): 0.273-0.973] and incomplete (OR: 0.591, 95% CI: 0.358-0.976) intervention groups only in boys. The short- and long-term interventions resulted improvement in some of the MetS components in both genders.

CONCLUSIONS

The healthy lifestyle intervention reduced the risk of MetS in both genders in short and long term, but with different patterns and improved some of the MetS components.

[Interdisciplinarity as a strategy for the prevention of systemic arterial hypertension in children: a systematic review]

Researches that developed interdisciplinary actions in schools seeking to modify the arteial pressure levels or salt and/or sodium consumption by children were analyzed. Studies available on the PubMed, ScienceDirect and Lilacs databases, associating the keywords: intervention study, nutrition intervention, schoolchildren, school health, blood pressure, sodium and salt were included. The research included articles from the last 15 years, in Portuguese, English and Spanish, which had preschool or school children as participants. With respect to the change of the blood pressure levels, 7 studies with positive and significant results and 6 without variation were identified. In terms of modification of the ingestion of food with high salt and/or sodium content, 4 studies revealed positive and significant results, and only one was unsuccessful. The conclusions drawn are that the interventions that use nutritional education combined with physical activities prevail in the literature. However, these actions proved to be more effective when implemented over a long period of time.

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.

Environmental components of childhood obesity prevention interventions: an overview of systematic reviews

Childhood obesity has a complex multi-factorial aetiology grounded in environmental and individual level factors that affect behaviour and outcomes. An ecological, systems-based approach to addressing childhood obesity is increasingly being advocated. The primary aim of this review is to summarize the evidence reported in systematic reviews on the effectiveness of population-level childhood obesity prevention interventions that have an environmental component. We conducted a systematic review of reviews published since 1995, employing a standardized search strategy in nine databases. Inclusion criteria required that reviews be systematic and evaluated at least one population-level, environmental intervention in any setting aimed at preventing or reducing obesity in children (5-18 years). Sixty-three reviews were included, ten of which were of high quality. Results show modest impact of a broad range of environmental strategies on anthropometric outcomes. Systematic reviews vary in methodological quality, and not all relevant primary studies may be included in each review. To ensure relevance of our findings to practice, we also report on relevant underlying primary studies, providing policy-relevant recommendations based on the evidence reviewed. Greater standardization of review methods and reporting structures will benefit policymakers and public health professionals seeking informed decision-making.

Impact of 20 Week Lifestyle Intervention Package on Anthropometric Biochemical and Behavioral Characteristics of Schoolchildren in North India

BACKGROUND

Childhood obesity is a public health problem worldwide. There is convincing evidence that school-based interventions are effective in managing childhood obesity. However, the nature of interventions, its impact on prevention of obesity and how they work remain poorly understood. The primary objective of this study was to examine the impact of a multicomponent lifestyle intervention on weight and body mass index (BMI) of children in a school-based setting.

METHODS

It is a cluster randomized trial where four schools were randomly selected and allocated to intervention and control arm equally. Of the 462 schoolchildren selected, 201 were assigned to the intervention group and 261 belonged to the control group. Children in the intervention arm received a multicomponent lifestyle package. Primary outcome measures included anthropometric measurements (weight, BMI, skinfold thickness and waist and hip circumference), whereas secondary outcomes were biochemical parameters, physical activity and dietary intake.

RESULTS

Compared with controls and adjusting for age, sex and clustering within classes, children in the intervention group showed decrease in the weight by - 0.08 (-0.15 to - 0.00, p  =  0.048) z-score units, waist circumference by - 0.14 (-0.25 to - 0.03, p  =  0.01) and triceps thickness by - 0.35 (-0.47 to - 0.22, p < 0.001) z-score units; however, BMI showed no significant decrease. There was significant reduction in intake of energy, protein and fat but no to minimal reduction in biochemical parameters.

CONCLUSION

A school-based lifestyle intervention package favorably affected anthropometric (weight, waist circumference and triceps and biceps thickness) and behavioral parameters. At least 20 weeks of healthy lifestyle promoting intervention package should be included in school curriculum in each academic year for sustainable impact and behavioral change to reduce the burden of lifestyle disorders.

A Systematised Review of Primary School Whole Class Child Obesity Interventions: Effectiveness, Characteristics, and Strategies

Background. A systematised review was conducted to examine the effectiveness of school-based interventions that focus on changing dietary intake and physical activity levels to reduce childhood obesity. Methods. Multiple databases were searched for randomised and nonrandomised interventions from 2007 to 2016 in full-time elementary schools, which were delivered to the whole class, included dietary and physical activity components, involved both sexes, were written in English, and used body mass index (BMI) as an outcome. Results. The database search produced 8,866 titles from which 78 were deemed relevant and assessed for inclusion resulting in 15 studies meeting all inclusion criteria. From these 15 studies, 9 yielded a reduction or stabilisation in BMI or BMI z-score in the entire intervention group and/or subgroups. Programmes lasting between 6 and 12 months that involve multiple environmental, educational, and physical strategies appear to be most likely to result in BMI or BMI z-score improvement. Moderators most likely influencing an improvement in BMI included increased physical activity, decreased sugar sweetened beverages intake, and increased fruit intake. Conclusions. School-based interventions may be an effective means for child obesity prevention. The identification of consistent elements used in school-based interventions that have demonstrated effectiveness may aid in preventing child obesity.

Implications for public health research of models and theories of disability: a scoping study and evidence synthesis

Background

Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments.

Objectives

(1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice.

Review methods

The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people.

Results

The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability.

Limitations

The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action.

Conclusions

Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability.

Future work

Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

Funding

The National Institute for Health Research Public Health Research programme.

Systematic Review of School-Based Interventions to Modify Dietary Behavior: Does Intervention Intensity Impact Effectiveness?

BACKGROUND

Owing to the associations between diet and health, it is important that effective health promotion strategies establish healthful eating behaviors from an early age. We reviewed the intensity of school-based interventions aimed to modify dietary behavior in preadolescent and adolescents and related intervention characteristics to effectiveness.

METHODS

Our systematic literature search of 8 databases sought to identify interventions measuring dietary intake in school settings to students aged 9 to 18. We evaluated these studies for effectiveness, intensity, intervention category, and follow-up measures.

RESULTS

Of the 105 interventions 81 were found to be effective immediately postintervention, irrespective of intensity. Studies that were 6 weeks to 5 months in duration, targeted students' environment or group (alone or in combination), and reached students only in schools were more effective. Only one-fifth of interventions conducted a follow-up measure, and a majority showed a loss of effectiveness from postintervention to follow-up.

CONCLUSIONS

We identified characteristics of effective interventions. These findings may inform the development of future interventions targeting dietary behavior in preadolescents and adolescents in the school-based setting.

Effectiveness of social marketing strategies to reduce youth obesity in European school-based interventions: a systematic review and meta-analysis

CONTEXT

The use of social marketing to modify lifestyle choices could be helpful in reducing youth obesity. Some or all of the 8 domains of the National Social Marketing Centre's social marketing benchmark criteria (SMBC) are often used but not always defined in intervention studies.

OBJECTIVE

The aim of this review is to assess the effectiveness of European school-based interventions to prevent obesity relative to the inclusion of SMBC domains in the intervention.

DATA SOURCES

The PubMed, Cochrane, and ERIC databases were used.

STUDY SELECTION

Nonrandomized and randomized controlled trials conducted from 1990 to April 2014 in participants aged 5 to 17 years were included.

DATA EXTRACTION

After the study selection, the 8 domains of the SMBC were assessed in each included study.

RESULTS

Thirty-eight publications were included in the systematic review. For the meta-analysis, randomized controlled trials (RCTs) reporting body mass index or prevalence of overweight and obesity were considered. Eighteen RCTs with a total of 8681 participants included at least 5 SMBC. The meta-analysis showed a small standardized mean difference in body mass index of -0.25 (95%CI, -0.45 to -0.04) and a prevalence of overweight and obesity odds ratio of 0.72 (95%CI, 0.5-0.97).

CONCLUSION

Current evidence indicates that the inclusion of at least 5 SMBC domains in school-based interventions could benefit efforts to prevent obesity in young people. PROSPERO registration number: CRD42014007297.

The impact of long-term school-based physical activity interventions on body mass index of primary school children - a meta-analysis of randomized controlled trials

Background

Physical activity (PA) intervention is a commonly recommended strategy to combat childhood obesity. However, its effectiveness has long been controversial. This paper aims to examine the effectiveness of long-term (≥12 months) school-based PA interventions on body mass index (BMI) in primary school children, who are gaining BMI.

Methods

Original papers were retrieved from PubMed, Google Scholar, the Cochrane Library and Web of Science, published between 1990 and 2015. The inclusion criteria were those research studies that were: randomized controlled trials (RCTs), conducted in primary school settings, had valid data on BMI at baseline and at the final follow up (or on BMI changes), and involved PA intervention that lasted for at least 12 months.

Results

Out of 11,158 potentially eligible articles, 18 papers were included in the analysis, involving 22,381 primary school children with intervention durations ranging from 12 to 72 months. Compared to the control groups, the BMI increment was 2.23 kg/m² less in the intervention groups (p < 0.05). The heterogeneity was high across the studies (99.8 %), but declined after sub-group analyses. The intervention type, intervention duration, and weekly PA intervention time were among the factors leading to the heterogeneity.

Conclusion

Long-term school-based interventions containing PA as a core component appear to be effective in achieving healthier BMI. However, the results should be interpreted with caution due to the high heterogeneity among the studies. More high quality school-based RCTs among diverse populations are needed to improve the homogeneity and to yield a more robust conclusion.

Changes in the Use of Contraception at First Intercourse: A Comparison of the National Survey of Family Growth 1995 and 2006-2010 Databases

STUDY OBJECTIVE

To determine trends in characteristics associated with contraceptive use at coitarche from 1995 to 2006-2010.

METHODS

The National Survey of Family Growth (NSFG) 1995 and 2006-2010 databases were used to abstract variables of interest. Generalized linear models (GLM) were applied to examine the association between the use of contraceptive methods at coitarche and variables abstracted for each database.

RESULTS

Of the 9599 women from the 1995 database included in this study, 3885 (40%) used contraception at coitarche in comparison to 4860 (82%) out of 5931 women assessed in 2006-2010. For both time periods, Hispanic women were significantly less likely to use contraception at coitarche when compared to White women. In the 1995 database, only women from families with incomes >$50,000 were more likely to use contraception at coitarche, while women from families with income > $20,000 were more likely to use contraception at coitarche in 2006-2010. There were some differences noted in the association between age at coitarche and contraception use at coitarche, but in general, women who had a higher age at coitarche were more likely to use contraception. For both time periods, women were more likely to use contraception at coitarche if they used barrier methods as their first form of contraception or if they obtained their first contraceptive method from a spouse, partner, or friend.

CONCLUSIONS

Our results suggest that access to contraception may be associated with use of a contraceptive method at coitarche. Innovative measures need to be investigated so that this young population has increased access to more reliable methods before their first sexual experience.

Evaluation of physical activity interventions in children via the reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) framework: A systematic review of randomized and non-randomized trials

CONTEXT

Existing reviews of physical activity (PA) interventions designed to increase PA behavior exclusively in children (ages 5 to 11years) focus primarily on the efficacy (e.g., internal validity) of the interventions without addressing the applicability of the results in terms of generalizability and translatability (e.g., external validity).

OBJECTIVE

This review used the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance) framework to measure the degree to which randomized and non-randomized PA interventions in children report on internal and external validity factors.

METHODS AND RESULTS

A systematic search for controlled interventions conducted within the past 12years identified 78 studies that met the inclusion criteria. Based on the RE-AIM criteria, most of the studies focused on elements of internal validity (e.g., sample size, intervention location and efficacy/effectiveness) with minimal reporting of external validity indicators (e.g., representativeness of participants, start-up costs, protocol fidelity and sustainability).

CONCLUSIONS

Results of this RE-AIM review emphasize the need for future PA interventions in children to report on real-world challenges and limitations, and to highlight considerations for translating evidence-based results into health promotion practice.

Moving Focus from Weight to Health. What Are the Components Used in Interventions to Improve Cardiovascular Health in Children?

Introduction

Obesity in childhood impacts on many areas of the child’s current and future health, including their cardiovascular health. To date many attempts have been made to design interventions to tackle excess childhood weight but with limited success. We aimed to establish the components common to interventions in children that improve cardiovascular health parameters.

Methods

We searched the following databases: EMBASE 1974-week 3 November 2014, Ovid Medline 1946 Present, and PsychINFO 1967-Present for studies reporting interventions in healthy young people under the age of 18. Included interventions had to contain an education component and have been carried out in a community, school, or clinical setting. Papers had to report on at least one of the pre-specified CVD risk parameters and at least one non-biological outcome from knowledge, attitudes or behaviours.

Results

We retrieved 2451 papers, from which 12 studies (18 papers) of 3046 participants were included. From the selected papers we identified four component themes; Health Behaviours, Self-Concept, Practical and Cognitive Tools, and Intervention Characteristics. The subcomponents that made up these themes were fairly consistent across the studies analysed although the studies varied in their duration, settings and children with which they were carried out. Nine of the studies were able to bring about positive change in at least one biological and one non-biological aspect of child cardiovascular health.

Conclusion

The component themes identified here were common to intervention studies that had success in improving parameters of cardiovascular health. We suggest that the focus of childhood health interventions be moved from weight onto cardiovascular health parameters and that future interventions use the lessons learned by their predecessors to incorporate those components that are associated with successful interventions.

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.

Factors affecting fruit and vegetable school lunch waste in Wisconsin elementary schools participating in Farm to School programmes

OBJECTIVE

To examine characteristics potentially associated with school lunch fruit and vegetable waste, both overall and pre/post implementation of the Healthy, Hunger-Free Kids Act.

DESIGN

Multi-year (2010-2013) cross-sectional study using pre- and post-meal digital photographs of students' school lunch trays to estimate fruit and vegetable availability and consumption. Fruit and vegetable items were categorized for factors suspected to impact waste: prior farm to school years, placement (main menu, salad bar), procurement (local, conventional), preparation (cooked, raw) and meal component (entrée, side, topping). Analyses to assess within-category differences in waste volume were performed using a Tobit model.

SETTING

Wisconsin elementary schools participating in farm to school programmes, USA.

SUBJECTS

Children in third to fifth grade.

RESULTS

Many within-factor differences were detected overall and/or across time. Cooked fruits were wasted less than raw, while cooked vegetables were wasted more than raw. Where identified, locally sourced items were wasted more than conventionally sourced (+0·1 cups, P<0·0001) and salad bar items more than main menu items (+0·01 cups, P<0·0001). Increasing prior farm to school years decreased waste (-0·02 cups, P<0·0001). Items previously tried were wasted at the same volume whether reported as liked or not. New school lunch meal pattern requirement implementation did not uniformly impact fruit and vegetable waste across all categories and there was no change in waste for seven of fifteen assessed categories.

CONCLUSIONS

Many factors impact elementary students' school lunch waste. These factors may be helpful for school food-service authorities to consider when planning school menus.

Physical activity interventions in schools for improving lifestyle in European countries

Background : In the last decades, children’s and adolescents’ obesity and overweight have increased in European Countries. Unhealthy eating habits and sedentary lifestyle have been recognized to determine such an epidemic. Schools represent an ideal setting to modify harmful behaviors, and physical activity could be regarded as a potential way to avoid the metabolic risks related to obesity. Methods : A systematic review of the literature was carried out to summarize the evidence of school-based interventions aimed to promote, enhance and implement physical activity in European schools. Only randomized controlled trials were included, carried out in Europe from January 2000 to April 2014, universally delivered and targeting pupils aged between 3 and 18 years old. Results : Forty-seven studies were retrieved based either on multicomponent interventions or solely physical activity programs. Most aimed to prevent obesity and cardiovascular risks among youths. While few studies showed a decrease in BMI, positive results were achieved on other outcomes, such as metabolic parameters and physical fitness. Conclusion : Physical activity in schools should be regarded as a simple, non-expensive and enjoyable way to reach all the children and adolescents with adequate doses of moderate to vigorous physical activity.

Influence of behavioral theory on fruit and vegetable intervention effectiveness among children: a meta-analysis

OBJECTIVE

To test the hypotheses that interventions clearly based on theory, multiple theories, or a formal intervention planning process will be more effective in changing fruit and vegetable consumption among children than interventions with no behavioral theoretical foundation.

DESIGN

Systematic review and meta-analysis.

SETTING

Identification of articles in PubMed, PsycInfo, Medline, Cochrane Collaborative database, and existing literature reviews and meta-analyses.

PARTICIPANTS

Children aged 2-18 years.

INTERVENTIONS

Change in fruit and/or vegetable consumption in dietary change interventions.

METHODS

Meta-analysis, meta-regression analysis, and summary reporting for articles.

CONCLUSIONS AND IMPLICATIONS

Predicating an intervention on behavioral theory had a small to moderate enhancement (P < .001) of outcome effectiveness. Differences in mean Hedges' g effect sizes between theory and non-theory interventions were 0.232 for fruit, 0.043 for vegetables, and 0.333 for fruit and vegetables combined. There was mixed support, however, for enhanced dietary change with multiple theories or a formal planning process. After controlling for study quality, theory use was related only to vegetable consumption (β = 0.373; P < .001). More research is needed on theory's influences on dietary behaviors to guide future interventions among children. More research is also needed to identify what may be effective practical- or experience-based procedures that complement theory, to incorporate into interventions.

Overview of 71 European community-based initiatives against childhood obesity starting between 2005 and 2011: general characteristics and reported effects

BACKGROUND

Community-based initiatives (CBIs) on childhood obesity are considered a good practice approach against childhood obesity. The European Commission called for an overview of CBIs implemented from 2005-2011. A survey was executed by the National Institute for Public Health and the Environment of the Netherlands, in collaboration with the World Health Organization Regional Office for Europe. The objective of this paper is to provide an overview of the European CBIs, as identified in the survey, presenting their general characteristics, applied strategies (separately for actions targeting the environment and/or directly the children's behaviour) and the reported effects on weight indicators.

METHODS

Potentially eligible CBIs were identified by informants in 27 European Union countries, Iceland, Liechtenstein, Norway, and Switzerland, and through desk research. School based approaches could be included if they complied with criteria related to being 'community-based'. In total, 278 potential eligible CBIs were identified and of these, 260 projects were approached. For 88 an electronic questionnaire was completed; of these 71 met all criteria. The included projects were reported by 15 countries.

RESULTS

66% of the 71 CBIs implemented actions in more than one setting or throughout the neighbourhood. Most frequently reported environmental actions were professional training (78%), actions for parents (70%), and changing the social (62%) and physical (52%) environment. Most frequently reported educational activities were group education (92%), general educational information (90%), and counselling sessions (58%). The vast majority (96%) implemented both environmental and individual strategies and about half of the CBIs reported a public-private partnership. Eight CBIs provided evidence supporting positive effects on weight indicators and/or overweight prevalence in a general population of children (aged 6 to 12 yrs), and one CBI did not support this. Two of those CBIs were also conducted among adolescents (aged 12 to 16,5 yrs), but showed no effect in this age-group.

CONCLUSIONS

Despite diversity of included CBIs, common characteristics were the application of integrated actions at a local level, aimed at changing the environment and the children's behaviour directly. Evidence supporting effectiveness on weight indicators is available, although the design and conduct of most of these studies were suboptimal (i.e. no control group, a small sample size, not random).

Effectiveness of school-based intervention programs in reducing prevalence of overweight

Objectives:

To assess the effectiveness of school-based interventions program in reducing the prevalence of overweight or obesity among schoolchildren.

Data source:

Ovid Medline (1950-December 2012), Embase (1980-2012), CINAHL (1982-2012), secondary references, review articles, and expert in the field.

Study selection:

All published clinical trials were eligible for study if were randomized, methodologically strong-based on a validity assessment, aimed to evaluate a school-based intervention for childhood overweight or obesity, and measured outcome in term of prevalence/incidence difference in overweight and obesity among both groups. Studies involved in cost-effective analysis of school-based intervention have been excluded. Data from eligible studies abstracted and pooled for relative risk.

Results:

Five trials with 3,904 schoolchildren were included. Mean age of the students (boys and girls) ranges 8.6-12.6 years. Meta-analysis showed a statistical significance beneficial effect of school-based intervention programs on obesity status of schoolchildren (risk ratio (RR) 0.58, 95% confidence interval (CI) 0.43-0.78) and suggested 42% reduction in prevalence of obesity among schoolchildren through school-based intervention programs. Individual studies also showed effectiveness of these school-based interventions.

Conclusion:

School-based intervention programs are effective in prevention of childhood overweight and obesity problem and our results quantitatively supported this argument.

Theory of reasoned action and theory of planned behavior-based dietary interventions in adolescents and young adults: a systematic review

BACKGROUND

Childhood obesity has reached epidemic proportions in many nations around the world. The theory of planned behavior (TPB) and the theory of reasoned action (TRA) have been used to successfully plan and evaluate numerous interventions for many different behaviors. The aim of this study was to systematically review and synthesize TPB and TRA-based dietary behavior interventions targeting adolescents and young adults.

METHODS

THE FOLLOWING DATABASES WERE SYSTEMATICALLY SEARCHED TO FIND ARTICLES FOR THIS REVIEW: Academic Search Premier; Cumulative Index to Nursing and Allied Health (CINAHL); Education Resources Information Center (ERIC); Health Source: Nursing/Academic Edition; Cochrane Central Register of Controlled Trials (CENTRAL); and MEDLINE. Inclusion criteria for articles were: 1) primary or secondary interventions, 2) with any quantitative design, 3) published in the English language, 4) between January 2003 and March 2014, 5) that targeted adolescents or young adults, 6) which included dietary change behavior as the outcome, and 7) utilized TPB or TRA.

RESULTS

Of the eleven intervention studies evaluated, nine resulted in dietary behavior change that was attributed to the treatment. Additionally, all but one study found there to be a change in at least one construct of TRA or TPB, while one study did not measure constructs. All of the studies utilized some type of quantitative design, with two employing quasi-experimental, and eight employing randomized control trial design. Among the studies, four utilized technology including emails, social media posts, information on school websites, web-based activities, audio messages in classrooms, interactive DVDs, and health-related websites. Two studies incorporated goal setting and four employed persuasive communication.

CONCLUSION

Interventions directed toward changing dietary behaviors in adolescents should aim to incorporate multi-faceted, theory-based approaches. Future studies should consider utilizing randomized control trial design and operationalize variables. More research is needed to identify the optimal TPB and TRA modalities to modify dietary behaviors.

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.

Effect of childhood obesity prevention programs on blood pressure: a systematic review and meta-analysis

BACKGROUND

Childhood overweight and obesity are associated with elevated blood pressure (BP). However, little is known about how childhood obesity lifestyle prevention programs affect BP. We assessed the effects of childhood obesity prevention programs on BP in children in developed countries.

METHODS AND RESULTS

We searched databases up to April 22, 2013, for relevant randomized, controlled trials, quasi-experimental studies, and natural experiments. Studies were included if they applied a diet or physical activity intervention(s) and were followed for ≥ 1 year (or ≥ 6 months for school-based intervention studies); they were excluded if they targeted only overweight/obese subjects or those with a medical condition. In our meta-analysis, intervention effects were calculated for systolic BP and diastolic BP with the use of weighted random-effects models. Of the 23 included intervention studies (involving 18 925 participants), 21 involved a school setting. Our meta-analysis included 19 studies reporting on systolic BP and 18 on diastolic BP. The pooled intervention effect was -1.64 mm Hg (95% confidence interval, -2.56 to -0.71; P=0.001) for systolic BP and -1.44 mm Hg (95% confidence interval, -2.28 to -0.60; P=0.001) for diastolic BP. The combined diet and physical activity interventions led to a significantly greater reduction in both systolic BP and diastolic BP than the diet-only or physical activity-only intervention. Thirteen interventions (46%) had a similar effect on both adiposity-related outcomes and BP, whereas 11 interventions (39%) showed a significant desirable effect on BP but not on adiposity-related outcomes.

CONCLUSIONS

Obesity prevention programs have a moderate effect on reducing BP, and those targeting both diet and physical activity seem to be more effective.