A parent-based intervention to promote healthy eating and active behaviours in pre-school children: evaluation of the MEND 2-4 randomized controlled trial

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-randomised controlled trials (C-RCTs) and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no-intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child-feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child-focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate-certainty evidence that child-feeding practice interventions versus no-intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as-desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post-intervention follow-up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low-certainty evidence). Multicomponent interventions versus no-intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate-certainty evidence; mean post-intervention follow-up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden-based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low-certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short-term impact on child consumption of fruit and vegetables versus no-intervention control (SMD 0.10, 95% CI -0.02 to 0.22; 14 trials, 4122 participants; low-certainty evidence; mean post-intervention follow-up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low-certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low-certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding.

AUTHORS' CONCLUSIONS

There was moderate-certainty evidence that child-feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low- and middle-income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Intergenerational care and rural childhood obesity in the digital era: Based on screen exposure perspective

Background

Rural Chinese children are experiencing increasing obesity rates, yet studies often neglect the impact of IT and screen media growth on obesity risks in the context of intergenerational care, leading to incomplete strategies for the digital era.

Methods

By comprehensively utilizing the data on rural children aged 6-17 from the China Family Panel Studies (CFPS) and the China Health and Nutrition Survey (CHNS), this study aims to test the logical chain and specific mechanisms regarding "intergenerational care - screen exposure - rural childhood obesity". We employ the Propensity Score Matching (PSM) and Generalized Propensity Score Matching (GPSM) methods to respectively address the self-selection biases associated with inter-generational care and children's screen exposure behaviors.

Results

1) Intergenerational care significantly increases screen exposure among rural children. 2) Gender bias increases the risk of screen exposure for rural boys under intergenerational care. 3) Children with higher screen exposure levels are more affected by intergenerational care, which further undermines parental supervision. 4) Children's screen exposure leads to increased sedentary time and higher probability of purchasing unhealthy foods, thereby exacerbating obesity. This process is facilitated by enhancing preferences for snacks, fast food, and beverages, and weakening preferences for physical activity. 5) GPSM analysis indicates that children's screen exposure has an inverted "U"-shaped impact on unhealthy dietary preferences and a "U"-shaped impact on activity preferences. It results in a nonlinear positive impact of screen exposure on obesity. This study reveals a positive association between screen exposure and obesity, offering new insights into how intergenerational care in the digital era may elevate obesity prevalence through excessive screen time for rural children.

Replicability, adaptability and long-term impact of the 'Healthy Youngsters, Healthy Dads' program in Newcastle, Australia

'Healthy Youngsters, Healthy Dads' (HYHD) targets fathers to improve the health of their preschool-aged children. In a previous randomized trial, fathers and children experienced meaningful improvements in physical activity and eating behaviours. The next phase is to test the replicability and adaptability of HYHD when delivered in the community by trained facilitators. Fathers/father-figures and children aged 3-5 years were recruited from Newcastle, Australia into a 9-week, non-randomized trial with assessments at baseline, 10 weeks, and 12 months. The primary outcome was achievement of pre-registered targets for recruitment (≥ 96 dyads), attendance (≥ 70%), compliance (completing ≥ 70% of home-based tasks), fidelity (≥ 80% of content delivered as intended) and program satisfaction (≥ 4/5). Secondary outcomes included physical activity, nutrition, screen time and parenting measures. Process targets were surpassed for recruitment (140 fathers, 141 children), attendance (79% for fathers-only workshops, 81% for father-child sessions), compliance (80% of home-tasks completed), fidelity (99% for education, ≥ 97% for practical) and program satisfaction (4.8/5). Mixed effects regression models revealed significant effects in fathers for moderate-to-vigorous physical activity, co-physical activity, dietary intake and parenting practises, which were maintained at 12 months. Significant effects were also established for screen time at 10 weeks only. For children, significant effects were observed for screen time and dietary intake at 10 weeks, while effects on energy-dense, nutrient-poor foods and healthy, nutrient-dense core food intake were maintained at 12 months. Findings demonstrate the replicability and adaptability of HYHD when delivered in the community by local trained facilitators. Further investigation into how to optimally scale-up HYHD is warranted.

Relationships between Math Skills, Motor Skills, Physical Activity, and Obesity in Typically Developing Preschool Children

There is evidence of a relationship between motor and cognitive development. The literature has shown that of all the motor skills, fine motor skills are those that contribute most to mathematical performance in preschool children. As this is a sensitive period in the development of motor skills, low levels of physical activity in this period can compromise their development and contribute to weight gain and obesity. The aim of this study was therefore to analyze the relationship between mathematical and motor skills, physical activity levels, and obesity. The sample consisted of 62 preschool children (32 males) with an average age of 4.63 ± 0.81. The Weschler preschool and primary scale of intelligence-revised arithmetic test was used to assess mathematical skills. The tests to assess fine motor skills were the "Adapted Threading Beads Test" and the "Adapted Visuomotor Integration Test". The movement assessment battery for children-2, band 1, "Aiming & Catching", and "Balance" tests were used to assess gross motor skills. Levels of physical activity were assessed using the "Preschool-age physical activity questionnaire" and obesity using the body mass index. The results indicated that only the fine motor skills of visuomotor integration were included in the multiple linear regression model (F < 0.001; r = 0.464; R2 = 0.215; p < 0.001), with the exclusion of gross motor skills, physical activity levels, and obesity levels. Thus, it was concluded that mathematical skills were only directly and significantly influenced by visuomotor integration. However, visuomotor integration was positively and significantly associated with gross motor skills (r = 0.269; p < 0.05) and not with levels of physical activity and obesity. Thus, gross motor skills could contribute to improving visuomotor integration directly and consequently mathematical skills indirectly. The results of this study suggest that the implementation of structured physical activity programs can contribute to mathematical performance.

Systems map of interventions to improve dietary intake of pre-school aged children: A scoping review

Implementation and sustaining impact of early childhood nutrition interventions in practice remains a challenge. An understanding of the extent to which determinants across multiple levels of the food system are being addressed may improve success. This literature review aimed to synthesise the evidence on interventions targeting dietary intake and eating behaviours in preschool children using a systems approach. Eligible studies included intervention studies targeting the dietary intake of preschool children aged 2-5 years in high income countries, published in English after January 2000. Interventions were categorised to the Determinants of Nutrition and Eating (DONE) framework for children developed and evaluated by experts across multiple fields. The framework maps and ranks 411 factors driving eating behaviours and nutrition and can be used to systematically summarise determinants. DONE ranks each determinant for its perceived research priority. A total of 160 eligible studies were identified. Most interventions targeted interpersonal (n = 101, 63.1%) and individual (n = 85, 53.1%) level determinants, with fewer targeting environmental (n = 55, 34.4%) and policy level (n = 17, 10.6%) determinants. The most frequently addressed determinants were Parental Resources and Risk Factors (n = 85) and Children's Food Knowledge, Skills and Abilities (n = 67). These determinants had a Moderate research priority rating. Home Food Availability and Accessibility at the environmental level is classified as the highest research priority, however, only 15 of 160 interventions addressed this determinant. This review highlights home food availability and accessibility as potential leverage points for future interventions to improve children's dietary intake and eating behaviours.

Changes in Anxiety following Taste Education Intervention: Fussy Eating Children with and without Neurodevelopmental Disorders

Despite the surge in studies on fussy eating in recent years, anxiety as an associated factor is generally not considered, even though children with fussy eating and those with neurodevelopmental disorders, including Autism Spectrum Disorder or Attention Deficit/Hyperactivity Disorder (ADHD) often have higher levels of anxiety than typically developing children. The current study investigated changes in anxiety scores during a Taste Education intervention, a seven-week school-based intervention for 71 children with fussy eating. Comparisons were made based on neurodevelopmental status (between children with (n = 30) and without (n = 41) neurodevelopmental disorders). Participants were paired based on age, sex, and neurodevelopmental disorder. The Multidimensional Anxiety Scale for Children (MASC) was administered at delayed intervention (for those waiting 7 weeks before starting the intervention), pre-intervention, post-intervention, and at six-month follow-up. Results did not indicate elevated anxiety based on mean MASC T-scores. MASC Total T-scores ranged from slightly elevated to average, decreasing significantly between pre-intervention and post-intervention, plateauing at six-month follow-up. Significant reductions between measurement points were seen for the physical symptoms, social anxiety, and separation anxiety subscales, but not for harm avoidance. Repeated measures analysis of variance with neurodevelopmental disorders as between-subjects factors did not reveal a significant interaction effect between neurodevelopmental disorders and changes in MASC Total score or subscales. The results indicated that our food-based intervention did not elevate MASC scores in fussy eating children, with or without neurodevelopmental disorders.

Improving reflective evaluations of sport through repeated experiences of fun-rationale, design, feasibility, and acceptability of the PlayFit Youth Sport Program

INTRODUCTION

Adolescents who drop out of sport often report that it had become less 'fun' and 'enjoyable' over time. Although preadolescent sport typically emphasizes experiences of fun, emphases on competition and elite performance often dominate during adolescence. We theorized that adherence to adolescent sport might be improved if the overarching goal were to maximize repeated experiences of fun during sport and, subsequently, increase reflective evaluations of sport enjoyment. To that end, this manuscript reports on the rationale and design of the PlayFit Youth Sport Program (PYSP), as well as its preliminary feasibility and acceptability. The main objectives were to evaluate the feasibility of recruitment strategies and data collection procedures and the acceptability of the intervention.

SETTING

An outdoor, multipurpose grass field at a south-central Pennsylvania middle school.

METHODS

A mixed-methods, single-arm feasibility trial lasting for 8 weeks (August-October 2021) offered 3-times per week for 1-h per session. The equipment, ruleset, and psychosocial environment of the PYSP sport games were modified to reduce several of the constraints theorized to impair experiences of fun during sport and hamper reflective evaluations of enjoyment afterward.

RESULTS

Eleven healthy, but sedentary adolescents in grades 5-7 completed the program. The median number of sessions attended (of 16 possible) was 12 (range = 6-13). Post-intervention, 9/10 respondents indicated that they 'looked forward' to the PYSP, 8/10 would recommend it to a friend, and 8/10 were interested in continuing the program. Ten of 11 participant guardians expressed interest in reenrolling their children if the PYSP were offered again. Some changes recommended were to improve recruitment via advertising the positive aspects of the program and "word of mouth" techniques, offering the program immediately following the school day, having contingencies for inclement weather, and minor changes to the sport equipment to improve the experience among the population the PYSP intends to attract.

CONCLUSIONS

The adjustments recommended in this preliminary work could be used to further refine the PYSP. A future efficacy trial could explore whether the PYSP may reduce attrition for adolescents who experience existing sport programs negatively by offering an alternative that better matches their unique needs and preferences.

Effects of a Theory-Based, Multicomponent eHealth Intervention for Obesity Prevention in Young Children from Low-Income Families: A Pilot Randomized Controlled Study

The purpose of this study was to evaluate a theory-based, multicomponent eHealth intervention aimed at improving child health behaviors and parental psychosocial attributes and feeding practices. A pilot randomized controlled trial was conducted among 73 parents with children (1-3 years). Intervention group participants (IG, n = 37) received theory-based educational videos, cooking tutorials, and text messages with key information for a total of 8 weeks. Control group participants (CG, n = 36) received a booklet about general nutrition recommendations for children. A parent-administered questionnaire was used for data collection at baseline and post-intervention. Linear models were performed using R version 4.1.1. for data analysis. Children in the IG significantly increased their daily intake of fruit (ΔΔ = 0.89 servings, p = 0.00057) and vegetables (ΔΔ = 0.60 servings, p = 0.0037) and decreased use of screen time (ΔΔ = -33.87 min, p = 0.026), compared to the CG. Parents in the IG improved significantly more than the CG in self-efficacy (p = 0.0068) and comprehensive feeding practices (p = 0.0069). There were no significant differences between the study groups for changes in child outcomes, such as physical activity and sedentary behaviors, and parental nutrition knowledge and attitudes.

Evaluation of community-based health promotion interventions in children and adolescents in high-income countries: a scoping review on strategies and methods used

BACKGROUND

In recent decades, community-based interventions have been increasingly adopted in the field of health promotion and prevention. While their evaluation is relevant for health researchers, stakeholders and practitioners, conducting these evaluations is also challenging and there are no existing standards yet. The objective of this review is to scope peer-reviewed scientific publications on evaluation approaches used for community-based health promotion interventions. A special focus lies on children and adolescents' prevention.

METHODS

A scoping review of the scientific literature was conducted by searching three bibliographic databases (Medline, EMBASE, PsycINFO). The search strategy encompassed search terms based on the PCC (Population, Concept, Context) scheme. Out of 6,402 identified hits, 44 articles were included in this review.

RESULTS

Out of the 44 articles eligible for this scoping review, the majority reported on studies conducted in the USA (n = 28), the UK (n = 6), Canada (n = 4) and Australia (n = 2). One study each was reported from Belgium, Denmark, Germany and Scotland, respectively. The included studies described interventions that mostly focused on obesity prevention, healthy nutrition promotion or well-being of children and adolescents. Nineteen articles included more than one evaluation design (e.g., process or outcome evaluation). Therefore, in total we identified 65 study designs within the scope of this review. Outcome evaluations often included randomized controlled trials (RCTs; 34.2%) or specific forms of RCTs (cluster RCTs; 9.8%) or quasi-experimental designs (26.8%). Process evaluation was mainly used in cohort (54.2%) and cross-sectional studies (33.3%). Only few articles used established evaluation frameworks or research concepts as a basis for the evaluation.

CONCLUSION

Few studies presented comprehensive evaluation study protocols or approaches with different study designs in one paper. Therefore, holistic evaluation approaches were difficult to retrieve from the classical publication formats. However, these publications would be helpful to further guide public health evaluators, contribute to methodological discussions and to inform stakeholders in research and practice to make decisions based on evaluation results.

Interventions for Picky Eaters among Typically Developed Children-A Scoping Review

Picky eating in children is often a major source of concern for many parents and caregivers. Picky eaters (PEs) consume limited foods, demonstrate food aversion, and have a limited food repertoire, which hinders their growth and health. These behaviours are common in children with special health care needs despite the rise in typically developing children. This leads to less attention being given to intervention programmes for typically developing children. Therefore, this scoping review aims to investigate the key concept of an existing intervention programme for PE among typically developing children, primarily on the types and approaches selected. A thorough literature search was conducted on three primary databases (PubMed, Emerald In-sight, and Web of Science) using predefined keywords. The literature was then appraised using the Joanna Briggs Institute's guidelines and protocols, and the PRISMScR checklist. Inclusion and exclusion criteria were also specified in the screening procedure. Results showed that the majority of the interventions in these studies were single-component interventions, with the sensory approach being the type that was most frequently utilised, followed by the nutrition approach and parenting approach. Single and multiple intervention components improved the assessed outcome, with a note that other components may or may not show a similar outcome, as they were not assessed in the single-component intervention. Given the evidence that picky eating is influenced by various factors, a multi-component intervention can provide a substantial impact on future programmes. In addition, defining picky eaters using standardised tools is also essential for a more inclusive subject selection.

FAMILY INFLUENCE ON THE FORMATION OF CHILDREN'S MOTIVATION FOR A HEALTHY LIFESTYLE

OBJECTIVE

The aim: To study the family influence on the formation of children's motivation for a healthy lifestyle.

PATIENTS AND METHODS

Materials and methods: The medical and sociological study among parents was conducted to assess their children's adherence to the principles of a healthy lifestyle and the influence of the family on the formation of children's motivation for a healthy lifestyle. The survey was conducted using a specially designed questionnaire using Google Forms. The design of the questionnaire was typical and contained the following structural components: addressing the respondent, obtaining informed consent to participate in the survey, and blocks with targeted questions (25 questions in total). The research involved 150 parents (including 54.7 % (82 people) of women and 45.3 % (68 people) of men). Methods: bibliosemantic, system-oriented analysis and logical generalization, medical and sociological (questionnaire), statistical data processing.

RESULTS

Results: It has been found that positive attitudes towards a healthy lifestyle prevail in the families of the respondents (44.0 %), 42.0 % of parents indicated that their family members regularly adhere to a healthy lifestyle. Herewith, 48.0 % are interested in teaching their children about a healthy lifestyle. The main motives that most parents form in their children regarding a healthy lifestyle are maintaining and promoting health (38.0 %), improving physical condition (16.0 %), and creating a healthy family (10.0 %). However, almost a third of parents do not instill responsibility for their children's life and health due to a lack of time and knowledge about a healthy lifestyle.

CONCLUSION

Conclusions: To foster a positive attitude toward a healthy lifestyle in children, parents should set their example, create favorable conditions for a healthy lifestyle, and follow traditions related to active recreation, sensible nutrition, and the absence of bad habits. Children's motivation for a healthy lifestyle is the main responsibility of the family.

An interactive Malaysian Childhood Healthy Lifestyle (i-MaCHeL) intervention programme to change weight-related behaviour in preschool child-parent dyads: Study protocol of a cluster randomised controlled trial

Introduction

Unhealthy weight, especially childhood obesity, is emerging as a growing epidemic and a challenge in developed and developing countries. Partnership with parents to promote healthy lifestyle changes may have a lifelong impact on weight-related outcomes in children. This study aims to determine the efficacy of an Interactive Malaysian Childhood Healthy Lifestyle (i-MaCHeL) intervention programme to change weight-related behaviour in preschool child-parent dyads.

Materials and methods

The i-MaCHeL programme is a single-blind, theory-driven intervention, two-group cluster randomised controlled trial that evaluates the efficacy of a 3-month health promotion intervention in preschool child-parent dyads. In recognition of the value of multiple theoretical approaches, the strong theoretical basis consists of Social Cognitive Theory, Health Belief Model, and Trans-Theoretical Model principles underpinning the development of the intervention programme. In total, 460 child-parent dyads from 12 preschools in Terengganu, Malaysia, will be recruited. The children in the intervention group will expose to the i-MaCHeL classroom activities, while the parents will access the i-MaCHeL Web-based educational programme and numerous parent-child home-based online activities. The children in the control group will continue with any existing health-related activities, while the parents will receive the link to the general health newsletters. BMI z-score, dietary intake, physical activity, screen time duration, health-related quality of life, parental self-efficacy, parental role modelling, and parental policies will be assessed at baseline, 3 months’ post-baseline, and at 6 months’ follow-up (9 months’ post-baseline). General linear model repeated measure analysis will be used to determine differences between groups at the 3- and 9-month surveys with adjustment for potential covariates. Statistical analyses will follow intention-to-treat principles.

Conclusion

We hypothesise that the combination of the classroom and interactive Web-based activities will have a strong potential to be effective strategies to sustain child-parent engagement and participation in the weight-related behaviour change programme.

Clinical trial registration

ClinicalTrials.gov Identifier:NCT04711525.

Grandchild care, inadequate medical insurance protection, and inequalities in socioeconomic factors exacerbate childhood obesity in China

This study examines the influences of grandchild care and medical insurance on childhood obesity. Nationally representative longitudinal data-from the China Family Panel Studies 2010-2020-of 26,902 school-age children and adolescents aged 6-16 years and China's new reference standard ("WS/T586-2018") are used to identify a child's obesity status. Using binary mixed-effects logistic regression models and the Blinder-Oaxaca decomposition method, this study explores the roots of obesity inequalities and finds that at least 15% of Chinese children aged 6-16 were obese in the 2010s. The logistic regression analysis results indicate that grandchild care, public medical insurance, and commercial medical insurance are key risk factors of child obesity. However, the influences are heterogeneous in different groups: Grandchild care and public medical insurance increase urban-rural obesity inequalities because of a distribution effect, and grandchild care may also exacerbate children obesity inequalities between left-behind and non-left-behind children owing to the event shock of parental absence. Inequalities in socioeconomic status (SES) factors such as income, education, and region also cause obesity inequalities. These results indicate that child obesity and its inequalities are rooted in multidimensional environmental inequalities, including medical protection policies and its benefit incidence; intergenerational behavior and family SES factors; and urban-rural and left-behind risk shocks. This study provides new evidence for the development of population-based interventions and equitable medical insurance policies to prevent the deterioration of child obesity among Chinese school-age children and adolescents.

Preventing and treating childhood overweight and obesity in children up to 5 years old: A systematic review by intervention setting

The prevalence of childhood obesity is increasing worldwide with long-term health consequences. Effective strategies to stem the rising childhood obesity rates are needed but systematic reviews of interventions have reported inconsistent effects. Evaluation of interventions could provide more practically relevant information when considered in the context of the setting in which the intervention was delivered. This systematic review has evaluated diet and physical activity interventions aimed at reducing obesity in children, from birth to 5 years old, by intervention setting. A systematic review of the literature, consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was performed. Three electronic databases were searched from 2010 up to December 2020 for randomised controlled trials aiming to prevent or treat childhood obesity in children up to 5 years old. The studies were stratified according to the setting in which the intervention was conducted. Twenty-eight studies were identified and included interventions in childcare/school (n = 11), home (n = 5), community (n = 5), hospital (n = 4), e-health (n = 2) and mixed (n = 1) settings. Thirteen (46%) interventions led to improvements in childhood obesity measures, including body mass index z-score and body fat percentage, 12 of which included both parental/family-based interventions in conjunction with modifying the child's diet and physical activity behaviours. Home-based interventions were identified as the most effective setting as four out of five studies reported significant changes in the child's weight outcomes. Interventions conducted in the home setting and those which included parents/families were effective in preventing childhood obesity. These findings should be considered when developing optimal strategies for the prevention of childhood obesity.

Impact of the 'Healthy Youngsters, Healthy Dads' program on physical activity and other health behaviours: a randomised controlled trial involving fathers and their preschool-aged children

Background

Targeting fathers may be a key strategy to increase physical activity among their preschool-aged children, but limited research exists in this area. The primary study aim was to examine the impact of a lifestyle program for fathers and their preschool-aged children on child physical activity levels.

Methods

A total of 125 fathers (aged: 38 ± 5.4 years, BMI: 28.1 ± 4.9 kg/m²) and 125 preschool-aged children (aged: 3.9 ± 0.8 years, BMI z-score: 0.3 ± 0.9, 39.2% girls) recruited from Newcastle, Australia, NSW were randomised to (i) the Healthy Youngsters, Healthy Dads (HYHD) program, or (ii) wait-list control group. The program included two fathers-only workshops (2 h each) and eight father-child weekly educational and practical sessions (75 min each), plus home-based activities targeting family physical activity and nutrition. Assessments took place at baseline, 10-weeks (post-intervention) and 9-months follow-up. The primary outcome was the children’s mean steps/day at 10-weeks. Secondary outcomes included: co-physical activity, fathers’ physical activity levels and parenting practices for physical activity and screen time behaviours, children’s fundamental movement skill (FMS) proficiency, plus accelerometer based light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA), screen time and adiposity for fathers and children. Process measures included; attendance, satisfaction, fidelity and retention. Linear mixed models estimated the treatment effect at all time-points for all outcomes.

Results

Intention-to-treat analyses revealed a significant group-by-time effect for steps per day at 10-weeks (+ 1417, 95%CI: 449, 2384) and 9-months follow-up (+ 1480, 95%CI: 493, 2467) in intervention children compared to control. There were also favourable group-by-time effects for numerous secondary outcomes including fathers’ physical activity levels, children’s FMS proficiency, and several parenting constructs. No effects were observed for both fathers’ and children’s accelerometer based LPA or MVPA, co-physical activity, screen-time and adiposity measures. Process evaluation data revealed very high levels of satisfaction, attendance, retention, and intervention fidelity.

Conclusion

Engaging fathers in a lifestyle program is a promising strategy to increase physical activity among preschool-aged children. Additional benefits to fathers’ physical activity levels, children’s FMS proficiency and parenting practices further support the importance of engaging fathers to improve family health outcomes.

Trial Registration

Australian New Zealand Clinical Trials Registry: ACTRN12619000105145. Registered 24/01/2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13424-1.

Efficacy of Mobile Instant Messaging-Delivered Brief Motivational Interviewing for Parents to Promote Physical Activity in Pediatric Cancer Survivors: A Randomized Clinical Trial

Importance

Physical activity has beneficial effects that mitigate cancer- and treatment-related late effects. However, children who survive cancer are often physically inactive. Brief motivational interviewing may be an effective approach for increasing children's physical activity levels.

Objective

To examine the effects of mobile instant messaging-delivered brief motivational interviewing for parents in promoting regular physical activity in children who have survived cancer.

Design, Setting, and Participants

An assessor-blinded randomized clinical trial was conducted at 2 Hong Kong pediatric oncology outpatient clinics from March 1, 2019, to January 29, 2021. A total of 161 children who had survived cancer, aged 9 to 16 years, and their parents were randomized (1:1) to an intervention or control group.

Interventions

The intervention group received a 6-month mobile instant messaging-delivered brief motivational interviewing using a strategy menu. Parent-child dyads in both groups received a health advice session and were directed to a physical activity website at baseline.

Main Outcomes and Measures

The primary outcome was the children's physical activity levels at 12-month follow-up, measured by the Chinese University of Hong Kong: Physical Activity Rating for Children and Youth (total sores: 0-10, higher scores indicate greater physical activity levels). Secondary outcomes were cancer-related fatigue levels, handgrip strength, peak expiratory flow rate, and quality of life. Intention-to-treat analysis was performed.

Results

Of the 161 children included in the study, 93 were boys (57.8%), and the mean (SD) age was 12.4 (2.4) years. Generalized estimating equation analyses showed a significant improvement in outcomes in the intervention group compared with the control group: physical activity levels (group-by-time interaction, 6 months: β = 3.09; 95% CI, 2.65-3.53; P < .001; 12 months: β = 3.91; 95% CI, 3.45-4.36; P < .001), cancer-related fatigue (6 months: β = -5.69; 95% CI, -8.03 to -3.35; P < .001; 12 months: β = -9.16; 95% CI, -11.31 to -7.00; P < .001), left handgrip strength (6 months: β = 2.69; 95% CI, 0.96-4.43; P = .002; 12 months: β = 5.52; 95% CI, 3.70-7.33; P < .001), right handgrip strength (6 months: β = 2.75; 95% CI, 1.01-4.50; P = .002; 12 months: β = 5.45; 95% CI, 3.62-7.27; P < .001), peak expiratory flow rate (12 months: β = 28.51; 95% CI, 16.10-40.92; P < .001), and quality of life (6 months: β = 5.01; 95% CI, 1.19-8.82; P = .01); 12 months: β = 14.19; 95% CI, 10.84-17.54; P < .001).

Conclusions and Relevance

In this randomized clinical trial, mobile instant messaging-delivered brief motivational interviewing was effective in promoting the adoption and maintenance of regular physical activity and ameliorating cancer- or treatment-related adverse effects in children who survived cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT03859271.

Identifying effective intervention strategies to reduce children's screen time: a systematic review and meta-analysis

BACKGROUND

Excessive screen time ([Formula: see text] 2 h per day) is associated with childhood overweight and obesity, physical inactivity, increased sedentary time, unfavorable dietary behaviors, and disrupted sleep. Previous reviews suggest intervening on screen time is associated with reductions in screen time and improvements in other obesogenic behaviors. However, it is unclear what study characteristics and behavior change techniques are potential mechanisms underlying the effectiveness of behavioral interventions. The purpose of this meta-analysis was to identify the behavior change techniques and study characteristics associated with effectiveness in behavioral interventions to reduce children's (0-18 years) screen time.

METHODS

A literature search of four databases (Ebscohost, Web of Science, EMBASE, and PubMed) was executed between January and February 2020 and updated during July 2021. Behavioral interventions targeting reductions in children's (0-18 years) screen time were included. Information on study characteristics (e.g., sample size, duration) and behavior change techniques (e.g., information, goal-setting) were extracted. Data on randomization, allocation concealment, and blinding was extracted and used to assess risk of bias. Meta-regressions were used to explore whether intervention effectiveness was associated with the presence of behavior change techniques and study characteristics.

RESULTS

The search identified 15,529 articles, of which 10,714 were screened for relevancy and 680 were retained for full-text screening. Of these, 204 studies provided quantitative data in the meta-analysis. The overall summary of random effects showed a small, beneficial impact of screen time interventions compared to controls (SDM = 0.116, 95CI 0.08 to 0.15). Inclusion of the Goals, Feedback, and Planning behavioral techniques were associated with a positive impact on intervention effectiveness (SDM = 0.145, 95CI 0.11 to 0.18). Interventions with smaller sample sizes (n < 95) delivered over short durations (< 52 weeks) were associated with larger effects compared to studies with larger sample sizes delivered over longer durations. In the presence of the Goals, Feedback, and Planning behavioral techniques, intervention effectiveness diminished as sample size increased.

CONCLUSIONS

Both intervention content and context are important to consider when designing interventions to reduce children's screen time. As interventions are scaled, determining the active ingredients to optimize interventions along the translational continuum will be crucial to maximize reductions in children's screen time.

Measurement of screen time among young children aged 0-6 years: A systematic review

The impact of screen-based devices on children's health and development cannot be properly understood without valid and reliable tools that measure screen time within the evolving digital landscape. This review aimed to summarize characteristics of measurement tools used to assess screen time in young children; evaluate reporting of psychometric properties; and examine time trends related to measurement and reporting of screen time. A systematic review of articles published in English across three databases from January 2009 to April 2020 was undertaken using PROSPERO protocol (registration: CRD42019132599) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included articles measured screen time as outcome, exposure, or confounder in children 0-6 years. The search identified 35,868 records, 1035 full-text articles were screened for eligibility, and 622 met inclusion criteria. Most measures (60%) consisted of one to three items and assessed duration of screen time on a usual day. Few measures assessed content (11%) or coviewing (7%). Only 40% of articles provided a citation for the measure, and only 69 (11%) reported psychometric properties-reliability n = 58, validity n = 19, reliability and validity n = 8. Between 2009 and 2019, the number of published articles increased from 28 to 71. From 2015, there was a notable increase in the proportion of articles published each year that assessed exposure to mobile devices in addition to television. The increasing number of published articles reflects increasing interest in screen time exposure among young children. Measures of screen time have generally evolved to reflect children's contemporary digital landscape; however, the psychometric properties of measurement tools are rarely reported. There is a need for improved measures and reporting to capture the complexity of children's screen time exposures.

"Oh I try, but it's so hard": parental experiences of health promotion in children withdisabilities

PURPOSE

The purpose of this study was to explore how parents support the health behaviours of their child with a disability, and their motivations for registering their child in a health promotion program for children with physical and/or intellectual disabilities.

METHODS

Using a descriptive qualitative design, semi-structured face-to-face interviews were conducted with individual parents (n = 8) and one group (n = 3) to explore their experiences of health promotion for their child with a disability. Data were analyzed using thematic analysis to identify themes and patterns to develop an understanding of parental perspectives.

RESULTS

Three themes were identified in the analysis of parents' experiences supporting their children in health behaviours and registering them in a disability health promotion program: (1) Parents struggle to meet all of their child's health promotion needs; (2) Parents recognize the social components of healthy behaviours; and (3) Health promotion opportunities tailored for children with disabilities are limited. These themes were not mutually exclusive and had overlapping factors that influenced parental experiences.

CONCLUSION

Parents experience many challenges supporting the health behaviours of their children with disabilities. This study reinforces the need for accessible, developmentally appropriate, social health promotion programs for children with disabilities.IMPLICATIONS FOR REHABILITATIONChildren with disabilities frequently demonstrate significantly higher sedentary behaviours, lower rates of physical activity and consumption of high-fat foods than their typically developing peers.Promoting healthy behaviours such as healthy eating and physical activity among children with disabilities and their families is therefore crucial to the child's physical and psychosocial wellbeing.Parents of children with disabilities have sufficient health literacy and knowledge but report a lack of appropriate opportunities and strategies to support their child in developing healthy behaviours.Parents need increased availability and accessibility of socially inclusive programs that promote healthy behaviours for children of all physical and cognitive abilities.

Engaging Fathers to Improve Physical Activity and Nutrition in Themselves and in Their Preschool-Aged Children: The "Healthy Youngsters, Healthy Dads" Feasibility Trial

BACKGROUND

Few lifestyle programs for young children have targeted fathers. This study examined the feasibility of a lifestyle intervention for fathers and their preschool-aged children.

METHOD

A total of 24 father/preschool child dyads were recruited from Newcastle, Australia, into a single-arm, feasibility trial (baseline and 3-mo postbaseline assessments). The 9-session program aimed to improve physical activity and dietary habits of fathers and children. A priori feasibility benchmarks targeted recruitment (15 dyads), eligibility rate (>60%), attendance (80%), retention (≥85%), and program acceptability (≥4 out of 5). Acceptability of data collection procedures, research team program/resource management, home-program compliance, and preliminary intervention outcomes were also assessed.

RESULTS

Feasibility benchmarks were surpassed for recruitment (24 dyads), eligibility rate (61.5%), attendance (89%), retention (100%), and program acceptability (4.6 out of 5). Data collection procedures were acceptable. Challenges included mothers reporting their own dietary intake rather than their child's, children moving during body composition measurement, and resetting pedometers. Resource and program management were excellent. Most families met home-program requirements (83%). Preliminary intervention outcomes were encouraging for fathers and children.

CONCLUSION

Program feasibility was demonstrated by excellent recruitment, attendance, acceptability, retention, program administration, and promising preliminary intervention outcomes. A few data collection difficulties were identified. A larger scale efficacy trial is warranted.

Effects of Family Intervention on Physical Activity and Sedentary Behavior in Children Aged 2.5-12 Years: A Meta-Analysis

Introduction: To use a quantitative approach to examine the effects of family interventions on physical activity (PA) and sedentary behavior (SB) in children aged 2. 5-12 years. Methods: PubMed, OVID, Web of Science, and others were searched from their inception to May 2020. Intervention studies that examined the effects of family interventions on PA among children aged 2.5-12 years were included in this meta-analysis. Lastly, subgroup analyses were conducted to examine the potential modifying effects of family intervention's characteristics and study quality. Results: Eleven articles met the inclusion criteria for this review. Studies investigated a range of PA outcomes, including moderate-to-vigorous PA (MVPA), total PA (TPA), daily steps, and SB levels. Meta-analysis showed that family intervention had a significant effect on PA [standardized mean difference (SMD) = 0.10; 95% CI = 0.01-0.19], especially for daily steps [weight means difference (WMD) = 1,006; 95% CI = 209-1,803], but not for SB (WMD = -0.38; 95% CI = -7.21-6.46). Subgroup analyses indicated the improvements in PA occurred when children were 6-12 years old, intervention focused on PA only, intervention duration ≤ 10 weeks, and "low risk of bias" study performed. Conclusions: Family intervention may be a promising way to promote children's PA levels, especially for daily steps. Trial Registration: Meta-analysis protocol was registered on PROSPERO: CRD42020193667.

Does connectedness to nature improve the eating behaviours of pre-schoolers? Emerging evidence from the Play&Grow randomised controlled trial in Hong Kong

BACKGROUND

Nature-based interventions, which focus on outdoor play, mental health, and self-directed autonomous play, are becoming popular in promoting well-being. The objective of this study was to test whether connecting to nature would contribute to better feeding and eating habits in families with pre-schoolers.

METHODS

241 families with children aged two to five were randomly assigned to the Intervention (IG) and Control Groups (CG). IG received 10 sessions of a family-based programme, which included a novel Connectedness to Nature (CN) element. CG received only the government's health recommendations. The effectiveness of the intervention's primary outcomes (CN, eating/feeding behaviours) was analysed by a repeated measures structural equation model with intervention status as a causal predictor.

RESULTS

204 families (IG, n = 120; CG, n = 84) completed the measurements before and after the trial. The intervention had a medium effect on caregivers' CN (f² = 0.16, (95%CI = 0.06, 0.30)) and a large effect on children's CN (f² = 0.58, (95%CI = 0.36, 0.89)). In the IG, children's CN strongly predicted caregivers' feeding style (β = 0.48 (p < .01, 95%CI = 0.14, 0.83)) and moderately, children's eating behaviours (β = 0.21 (p = .16, 95%CI = -0.09, 0.52)). This produced a positive trend for greater vegetable consumption in the IG compared to the CG (β = 0.20 (95%CI = 0.01, 0.39) vs. β = -0.05, (95%CI = -0.18, 0.08)). Interestingly, the path values in the CG significantly reflected the traditional pattern, (e.g., parental feeding style strongly influenced children's eating behaviour (β = 0.33, p = .001, 95%CI = 0.13, 0.54).

CONCLUSIONS

The Play&Grow intervention positively increased caregivers' and children's CN. It also improved eating behaviors in children independent of their caregivers' feeding style. This may indicate a higher degree of autonomy in children's eating behaviour if they are exposed to nature. Further research should test the CN component in promotion of healthy eating in pre-schoolers.

Measuring commissioners' willingness-to-pay for community based childhood obesity prevention programmes using a discrete choice experiment

BACKGROUND

In the UK, rates of childhood obesity remain high. Community based programmes for child obesity prevention are available to be commissioned by local authorities. However, there is a lack of evidence regarding how programmes are commissioned and which attributes of programmes are valued most by commissioners. The aim of this study was to determine the factors that decision-makers prioritise when commissioning programmes that target childhood obesity prevention.

METHODS

An online discrete choice experiment (DCE) was used to survey commissioners and decision makers in the UK to assess their willingness-to-pay for childhood obesity programmes.

RESULTS

A total of 64 commissioners and other decision makers completed the DCE. The impact of programmes on behavioural outcomes was prioritised, with participants willing to pay an extra £16,600/year if average daily fruit and vegetable intake increased for each child by one additional portion. Participants also prioritised programmes that had greater number of parents fully completing them, and were willing to pay an extra £4810/year for every additional parent completing a programme. The number of parents enrolling in a programme (holding the number completing fixed) and hours of staff time required did not significantly influence choices.

CONCLUSIONS

Emphasis on high programme completion rates and success increasing children's fruit and vegetable intake has potential to increase commissioning of community based obesity prevention programmes.

Rationale, design and study protocol of the 'Strong Families Start at Home' feasibility trial to improve the diet quality of low-income, ethnically diverse children by helping parents improve their feeding and food preparation practices

There is an urgent need to create effective interventions that help parents establish a healthy diet among their children early in life, especially among low-income and ethnically and racially diverse families. U.S. children eat too few fruits, vegetables and whole grains, and too many energy dense foods, dietary behaviors associated with increased morbidity from chronic diseases. Parents play a key role in shaping children's diets. Best practices suggest that parents should involve children in food preparation, and offer, encourage and model eating a variety of healthy foods. In addition, while parents help to shape food preferences, not all children respond in the same way. Certain child appetitive traits, such as satiety responsiveness (sensitivity to internal satiety signals), food responsiveness (sensitivity to external food cues), and food fussiness may help explain some of these differences. Prior interventions to improve the diet of preschool children have not used a holistic approach that targets the home food environment, by focusing on food quality, food preparation, and positive feeding practices while also acknowledging a child's appetitive traits. This manuscript describes the rationale and design for a 6-month pilot randomized controlled trial, Strong Families Start at Home, that randomizes parents and their 2-to 5-year old children to either a home-based environmental dietary intervention or an attention-control group. The primary aim of the study is to explore the feasibility and acceptability of the intervention and evaluation and to determine the intervention's preliminary efficacy on child diet quality, feeding practices, and availability of healthy foods in the home.

Evaluation of the scale-up and implementation of mind, exercise, nutrition … do it! (MEND) in British Columbia: a hybrid trial type 3 evaluation

BACKGROUND

The Mind, Exercise, Nutrition … Do it! (MEND) childhood obesity intervention was implemented in British Columbia (B.C.), Canada from April 2013 to June 2017. The study objective was: a) to describe and explore program reach, attendance, satisfaction, acceptability, fidelity, and facilitators and challenges during scale-up and implementation of MEND in B.C. while b) monitoring program effectiveness in improving children's body mass index (BMI) z-score, waist circumference, dietary and physical activity behaviours, and psychological well-being.

METHODS

This prospective, pragmatic implementation evaluation (Hybrid Type 3 design) recruited families with children and adolescents aged 7-13 with a BMI ≥ 85th percentile for age and sex. The 10-week MEND B.C. program was delivered in 27 sites, throughout all five B.C. health regions (Northern, Interior, Island, Fraser, and Vancouver Coastal) over 4 years. Families attended two weekly in-person group sessions aimed to increase physical activity and promote healthy eating. BMI z-score and waist circumference were measured at baseline and follow-up. Dietary and physical activity behaviours and psychological well-being were measured using validated questionnaires. A mixed-method approach was used to collect and analyze the data.

RESULTS

One hundred thirty-six MEND B.C. programs were delivered over 4 years. The program reached 987 eligible participants. 755 (76.5%) children and adolescents completed the program. The average program attendance was 81.5%. Parents reported the program content was easy to understand, culturally suitable, respectful of family's financial situation, and provided adequate information to build a healthy lifestyle. Children achieved significant positive changes across all four evaluation years in BMI z-score (d = - 0.13), nutrition behaviours (d = 0.64), physical activity levels (d = 0.30), hours of screen time per week (d = - 0.38) and emotional distress (d = - 0.21). Challenges to continued program implementation included: recruitment, resource requirement for implementation, and the need to tailor the program locally to be more flexible and culturally relevant.

CONCLUSIONS

The program reached a broad demographic of children and adolescents in B.C. Families were highly satisfied with the program delivery. MEND. B.C. at scale was effective across all four evaluation years in improving BMI z-score, lifestyle behaviours and psychological well-being among children. Future interventions need to explore strategies to enhance program delivery flexibility.

Community-Based Prevention Programs for Disordered Eating and Obesity: Updates and Current Limitations

PURPOSE OF REVIEW

To review the status of community-based disordered eating and obesity prevention programs from 2014 to 2019.

RECENT FINDINGS

In the last 5 years, prevention programs have found success in intervening with children and parental figures in wellness centers, physical activity centers, childcare centers, workplaces, online, and over-the-phone through directly reducing disordered eating and obesity or by targeting risk factors of disordered eating and obesity. Community-based prevention programs for disordered eating and programs targeting both disordered eating and obesity were scarce, highlighting the critical need for the development of these programs. Qualities of the most effective programs were those in which parents and children were educated on physical activity and nutrition via multiple group-based sessions. Limitations of current prevention programs include few programs targeting high-risk populations, a dearth of trained community members serving as facilitators, inconsistent reporting of adherence rates, and few direct measurements of disordered eating and obesity, as well as few long-term follow-ups, precluding the evaluation of sustained effectiveness.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

A developmental cascade perspective of paediatric obesity: A systematic review of preventive interventions from infancy through late adolescence

The goals of this systematic review were to identify and describe paediatric obesity prevention interventions from infancy to late adolescence and to provide recommendations for future intervention research in light of a recently proposed developmental cascade (DC) model of paediatric obesity. We conducted an electronic search of randomized controlled trials with a minimum 6-month postintervention follow-up published between 1995 and 2019. We included 74 interventions: prenatal/infancy (n = 4), early childhood (n = 11), childhood (n = 38), early to mid-adolescence (n = 18), and late adolescence (n = 3). Infancy and early childhood trials targeted early feeding and positive parenting skills. Half of the childhood and adolescence trials were school based and used universal prevention strategies; those classified as selective or indicated prevention tended to involve the family for more intensive lifestyle modification. Less than 10% of studies followed participants over long periods of time (greater than or equal to 5 years), and only 16% and 31% of studies assessed intervention mediators and moderators, respectively. We recommend that future interventions focus on early prevention, assess long-term intervention effects, use a standardized taxonomy for defining intervention behavioural strategies, assess underlying mechanisms of action and intervention moderators, target parent and family management strategies across development, and increase scientific equity. We also provide specific recommendations regarding intervention targets for each developmental stage.

Impact of Parent Engagement in Childhood Obesity Prevention Interventions on Anthropometric Indices among Preschool Children: A Systematic Review

Background: Home environment, modeling of weight-related behaviors, and general parenting style are very important predictors of obesity in children. The effect of parent engagement in prevention of obesity in children is not clear. The main objective of this systematic review was to address the effects of parent engagement in obesity prevention interventions on anthropometric changes among preschool children. Methods: PubMed/Medline, Cochrane Library, ISI Web of Knowledge, Scopus, Science Direct, and Google Scholar were searched. Eligible studies were randomized controlled trials in last 10 years (from 2008 until February 14, 2018), which had a parent engagement in obesity prevention interventions (as an intervention) and children's anthropometric indices (as an outcome). Results: Twenty-six studies were included. Half of studies targeted both parents and children, and the rest targeted only parents. Types of interventions ranged from a simple motivational interviewing to professional skill training approaches. Studies that targeted overweight or obese children in their intervention containing training sessions followed by maintenance for parents and those that focused on individual support for overweight children and their parents, resulted in higher improvement in BMI and other outcomes. Conclusions: Anthropometric indices and BMI are not appropriate for reflecting the effectiveness of parent engagement in obesity prevention interventions. Having an individual component in the intervention and focusing more on parents vs. children in the intervention may result in improvement in anthropometric outcomes. Focusing on weight-related behaviors as the main outcome in both, children and parents, rather than anthropometric indices, is highly recommended for future reviews.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Parent-targeted home-based interventions for increasing fruit and vegetable intake in children: a systematic review and meta-analysis

Context

Parent interventions delivered in the home represent a valuable approach to improving children's diets.

Objective

This review aims to examine the effectiveness of parent-targeted in-home interventions in increasing fruit and vegetable intake in children.

Data Sources

Five electronic databases were searched: MEDLINE, Embase, PubMed, CINAHL, and PsycINFO.

Study Selection

Randomized and nonrandomized trials conducted in children aged 2 to 12 years and published in English from 2000 to 2016 were eligible.

Data Extraction

Eighteen publications were reviewed, and 12 randomized trials were analyzed. Studies were pooled on the basis of outcome measure and type of intervention, resulting in 3 separate meta-analyses.

Results

Nutrition education interventions resulted in a small but significant increase in fruit intake (Hedges' g = 0.112; P = 0.028). Taste exposure interventions led to a significant increase in vegetable intake, with a moderate effect (Hedges' g = 0.438; P < 0.001). Interventions involving daily or weekly sessions reported positive outcomes more frequently than those using monthly sessions.

Conclusions

Future interventions should incorporate regular taste exposure to maximize increases in vegetable intake in children. This is particularly important because fewer children meet national recommendations for vegetable intake than for fruit intake.

Interventions for preventing obesity in children

EDITORIAL NOTE

This Cochrane review is now out of date and should not be used for reference. It has been split into four age groups and updated. Please refer to the 5‐11 and 12‐18 age group Cochrane reviews which were published in May 2024: https://doi.org/10.1002/14651858.CD015328.pub2 https://doi.org/10.1002/14651858.CD015330.pub2 The 2‐4 age group Cochrane review is planned for publication in September 2024.

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.

Title: efficacy of a food parenting intervention for mothers with low income to reduce preschooler's solid fat and added sugar intakes: a randomized controlled trial

Background

Few interventions have shown efficacy to influence key energy balance behaviors during the preschool years.

Objective

A randomized controlled trial (RCT) was used to evaluate the efficacy of Food, Fun, and Families (FFF), a 12 week authoritative food parenting intervention for mothers with low-income levels, to reduce preschool-aged children’s intake of calories from solid fat and added sugar (SoFAS).

Methods

Mothers were randomly assigned to receive FFF (n = 59) or to a delayed treatment control (n = 60). The primary outcome was children’s daily energy intake from SoFAS at the end of the 12 week intervention, controlling for baseline levels, assessed by 24-h dietary recalls. Secondary outcomes included children’s daily energy intake, children’s BMI z-scores, and meal observations of maternal food parenting practices targeted in FFF (e.g. providing guided choices).

Results

Participating mothers were predominantly African American (91%), with 39% educated beyond high school and 66% unemployed. Baseline demographics and child SoFAS intakes did not differ by group. Lost to follow-up was 13% and did not differ between groups. At post-intervention, FFF children consumed ~ 94 kcal or 23% less daily energy from SoFAS than children in the control group, adjusting for baseline levels (307.8 (95%CI = 274.1, 341.5) kcal vs. 401.9 (95%CI = 369.8, 433.9) kcal, FFF vs. control; p < 0.001). FFF mothers also displayed a greater number of authoritative parenting practices when observed post-intervention with their child at a buffet-style meal (Wilcoxon z = − 2.54, p = 0.012). Neither child total daily energy intake nor BMI z-scores differed between groups post-intervention.

Conclusions

Findings demonstrate the initial efficacy of an authoritative food parenting intervention for families with low-income to reduce SoFAS intake in early childhood. Additional research is needed to evaluate longer-term effects on diet and growth.

Trial registration

Retrospectively registered at ClinicalTrials.gov: #NCT03646201.

Inclusion of Sleep Promotion in Family-Based Interventions To Prevent Childhood Obesity

Sleep promotion in childhood may reduce the risk of obesity, but little is known of its inclusion in family-based interventions. This study examines the proportion and context of family-based interventions to prevent childhood obesity that promote child sleep. We drew on data from a recent systematic review and content analysis of family-based interventions for childhood obesity prevention published between 2008 and 2015, coupled with new data on sleep promotion strategies, designs, and measures. Out of 119 eligible family-based interventions to prevent childhood obesity, 24 (20%) promoted child sleep. In contrast, 106 (89%) interventions targeted diet, 97 (82%) targeted physical activity, and 63 (53%) targeted media use in children. Most interventions that promoted sleep were implemented in clinics (50%) and home-based settings (38%), conducted in the United States (57%), and included children 2-5 years of age (75%). While most interventions utilized a randomized controlled design (70%), only two examined the promotion of sleep independent of other energy-balance behaviors in a separate study arm. Sleep was predominately promoted by educating parents on sleep hygiene (e.g., age-appropriate sleep duration), followed by instructing parents on responsive feeding practices and limiting media use. One intervention promoted sleep by way of physical activity. A large number promoted sleep by way of bedtime routines. Most interventions measured children's sleep by parent report. Results demonstrate that sleep promotion is underrepresented and variable in family-based childhood obesity interventions. While opportunities exist for increasing its integration, researchers should consider harmonizing and being more explicit about their approach to sleep promotion.

Vitamin D Status and Analysis of Specific Correlates in Preschool Children: A Cross-Sectional Study in Southern Croatia

Vitamin D deficiency is a globally important problem, particularly in children, but there is a lack of information regarding this deficiency in preschool children from southeastern Europe. This study aimed to establish the levels of 25-hydroxyvitamin D (25(OH)D) and associations of gender, time spent outdoors, physical activity (PA), and body mass index (as predictors) with the 25(OH)D level (outcome) in healthy preschool children. The participants were preschoolers (all 5⁻6 years of age) from southern Croatia. All the participants were tested during their mandatory medical examination 6⁻7 months prior to school enrollment. The PA was obtained using the preschool-age physical activity questionnaire (Pre-PAQ), which categorizes PA into five levels (from sedentary to vigorous PA). The prevalence of 25(OH)D deficiency was high: 58% of the children had 25(OH)D levels of <50 nmol/L (deficiency), and an additional 29% had an insufficient level of 25(OH)D (50⁻75 nmol/L). Boys had higher levels of 25(OH)D than girls. A multinomial regression using 25(OH)D categories as the outcome and a sufficient level (>75 nmol/L) as the reference value identified gender as the only significant predictor of 25(OH)D status, with boys being at lower risk for 25(OH)D deficiency than girls. These results showed a high prevalence of 25(OH)D deficiency in preschoolers from the southern part of Croatia, which is additionally alarming based on the geographical position of the studied region (42° N) and its high number of sunshine hours (>2600 h per year). Future studies examining other potential correlates of 25(OH)D in the region are warranted.

A systematic review of strategies to reduce sugar-sweetened beverage consumption among 0-year to 5-year olds

OBJECTIVE

The objective of this study is to summarize evidence for strategies designed to reduce sugar-sweetened beverage (SSB) consumption among children aged 0 to 5 years.

DATA SOURCES

PubMed, Web of Science, EMBASE, CINAHL, ERIC, Cab Abstracts and the Cochrane Central Register of Controlled Trials are the electronic databases searched in this systematic review.

STUDY SELECTION

Each included study evaluated an intervention to reduce SSB consumption in children aged 0 to 5 years, was conducted in a high-income country and was published between 1 January 2000 and 15 December 2017.

DATA SYNTHESIS

Twenty-seven studies met the inclusion criteria. The primary intervention settings were healthcare (n = 11), preschool/daycare (n = 4), home (n = 3), community venues (n = 3) and other settings (n = 6). Overarching strategies which successfully reduced SSB consumption included (i) in-person individual education, (ii) in-person group education, (iii) passive education (e.g. pamphlets), (iv) use of technology, (v) training for childcare/healthcare providers and (vi) changes to the physical access of beverages. Studies were of moderate methodological quality (average score of 20.7/29.0 for randomized studies; 3.1/9.0 for non-randomized studies).

CONCLUSIONS

Evidence suggests that interventions successful at reducing SSB consumption among 0-year to 5-year olds often focused on vulnerable populations, were conducted in preschool/daycare settings, specifically targeted only SSBs or only oral hygiene, included multiple intervention strategies and had higher intervention intensity/contact time.

A mHealth randomized controlled trial to reduce sugar-sweetened beverage intake in preschool-aged children

BACKGROUND

Sugar-sweetened beverages and maternal weight are strong drivers of child obesity, but few studies have targeted these risk factors as an obesity prevention strategy in children.

OBJECTIVE

The objective of this study was to test the efficacy of a smartphone-delivered intervention to reduce parent-provided sugar-sweetened beverage and juice (SSB/juice) consumption among children ages 3-5 and maternal weight.

METHODS

Mothers with overweight or obesity, who had a child ages 3-5 that consumed at least 12 fl. oz./day of SSB/juice (N = 51 dyads) were randomized to the Smart Moms group that received one group session, lessons on a mobile website, and text messages, or to a waitlist control group. Mothers self-monitored their children's beverages in addition to their own beverages, high-calorie foods, and weight. Assessments at baseline, 3, and 6 months included dietary recalls to measure SSB/juice intake and objectively measured maternal weight.

RESULTS

Using linear mixed models controlling for baseline values, child age and race, there was a greater reduction in child SSB/juice in Smart Moms compared with control at 6 months (-9.7 oz./day vs. 1.7 oz./day, p < .01). Mothers in Smart Moms lost 2.4 kg at 6 months compared with a 0.9-kg gain in the control group (p < .01).

CONCLUSIONS

An intervention delivered using mHealth technologies can target mothers to change child dietary behaviours and improve maternal weight, which suggests a novel approach to family-based obesity prevention.

How to reduce parental provision of unhealthy foods to 3- to 8-year-old children in the home environment? A systematic review utilizing the Behaviour Change Wheel framework

BACKGROUND AND OBJECTIVE

The effectiveness of obesity prevention interventions to improve children's diet can be enhanced. Deconstructing past interventions can identify components with potential to change behaviour. This systematic review using the Behaviour Change Wheel aimed to examine the behaviour change content of interventions supporting parents of 3- to 8-year olds to reduce provision of unhealthy foods to children.

METHODS

Ebscohost, Ovid, Scopus and Web of Science were searched. Eligible studies included controlled interventions with active parent involvement, at least one intervention strategy and outcome measure for unhealthy foods ≥3 months from baseline. Seventeen interventions were included describing 18 intervention arms.

RESULTS

Interventions frequently targeted parents' reflective motivation (n = 17) and psychological capability (n = 15), through education (n = 15) or enablement (n = 15) intervention functions and service provision (n = 18) policy category. Only 24 of the 93 behaviour change techniques were used with an average of five techniques used per intervention.

CONCLUSIONS

Existing interventions achieving small reductions in unhealthy food intake are homogenous in approach. There is potential to utilize untapped behaviour change techniques, through comprehensive intervention design and behavioural analysis guided by the Behaviour Change Wheel. Interventions targeting opportunity through persuasion, modelling or environmental restructuring, and using different policy categories are urgently needed to provide an evidence base to inform policy and practice.

Effectiveness of targeting the health promotion settings for non-communicable disease control in low/middle-income countries: systematic review protocol

INTRODUCTION

Settings-based approaches to health promotion, involving holistic and multidisciplinary methods, which integrate action across risk factors are important. Major advantage of focusing on these settings is the continuous and intensive contact with the participant. Despite the apparent advantages of addressing non-communicable diseases (NCDs) using targeted interventions for several developed country settings, a relative lack of evidence of effectiveness of such interventions in low/middle-income countries has led to poor allocation of resources towards these interventions. The focus is therefore on the settings rather than any one condition, and we therefore expect the findings to generalise to NCD prevention and control efforts. We intend to estimate the effectiveness of targeted interventions in low/middle-income countries.

METHODS AND ANALYSIS

We will search PubMed, Excerpta Medica Database, OVID, WHO Library and The Cochrane Library from the year 2000 to March 2018 without language restrictions. Study designs to be included will be randomised controlled trials. The primary outcome of effectiveness will be the percentage change in population having different behavioural risk factors. Subgroup analyses will be performed, and sensitivity analyses will be conducted to assess the robustness of the findings.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. The Institute Ethics Committee of the Post Graduate Institute of Medical Education and Research approved the doctoral research protocol under which this review is being done. Dissemination will be done by submitting scientific articles to academic peer-reviewed journals. We will present the results at relevant conferences and meetings.

STUDY DESIGN

Systematic review.

PROSPERO REGISTRATION NUMBER

CRD42016042647; Pre-results.

Sustained impact of the "Healthy Habits, Healthy Girls - Brazil" school-based randomized controlled trial for adolescents living in low-income communities

Pediatric obesity is a major public health concern in low- and middle-income countries, such as Brazil. There is an urgent need for preventive programs for adolescents and, the assessment of their sustained impact. This paper reports the longer-term (6-month post intervention) effects of the "H3G-Brazil" obesity prevention program on weight status and weight-related behaviors. A cluster randomized controlled trial starting with 10 public schools in the city of São Paulo, Brazil involved 253 adolescent girls [mean (se) age = 15.6 (0.87) years]. Body mass index (BMI), waist circumference (WC), dietary intake, physical activity (PA) and sedentary behaviors (SB) were assessed at baseline, immediate post-intervention and 6-month post-intervention (follow-up). ANCOVA was performed using intention to treat principles. There was no effect on BMI, the primary outcome. Although, meaningful increases occurred in waist circumference for both groups, the intervention group presented a lower increase (F = 3.31, p = 0.04). This effect size, however, was lower than the criterion for small (d = 0.102). Unfortunately, significant results favored the control group for time spent on TV/weekdays (F = 5.13, p = 0.01), TV/weekends (F = 5.46, p = 0.01) and sedentary behaviors/weekdays (F = 5.32, p = 0.04). No other significant results were found. This obesity prevention intervention among Brazilian adolescent girls did not have the desire effect on BMI. The significantly lower increase in waist circumference in the intervention groups is inconsistent with the adverse changes detected in sedentary time.

Prevention of overweight and obesity in early life

Childhood obesity is a serious challenge for public health. The problem begins early with most excess childhood weight gained before starting school. In 2016, the WHO estimated that 41 million children under 5 were overweight or obese. Once established, obesity is difficult to reverse, likely to persist into adult life and is associated with increased risk of CVD, type 2 diabetes and certain cancers. Preventing obesity is therefore of high importance. However, its development is multi-factorial and prevention is a complex challenge. Modifiable lifestyle behaviours such as diet and physical activity are the most well-known determinants of obesity. More recently, early-life factors have emerged as key influencers of obesity in childhood. Understanding risk factors and how they interact is important to inform interventions that aim to prevent obesity in early childhood. Available evidence supports multi-component interventions as effective in obesity prevention. However, relatively few interventions are available in the UK and only one, TrimTots, has been evaluated in randomised controlled trials and shown to be effective at reducing obesity risk in preschool children (age 1-5 years). BMI was lower in children immediately after completing TrimTots compared with waiting list controls and this effect was sustained at long-term follow-up, 2 years after completion. Developing and evaluating complex interventions for obesity prevention is a challenge for clinicians and researchers. In addition, parents encounter barriers engaging with interventions. This review considers early-life risk factors for obesity, highlights evidence for preventative interventions and discusses barriers and facilitators to their success.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2018. We searched Proquest Dissertations and Theses in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 63 trials with 178 trial arms and 11,698 participants. Thirty-nine trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fourteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Nine studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 63 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.There is very low quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 3.50 g as-desired consumption of vegetables (SMD 0.33, 95% CI 0.13 to 0.54; participants = 1741; studies = 13). Multicomponent interventions versus no intervention may have a very small effect on child consumption of fruit and vegetables (SMD 0.35, 95% CI 0.04 to 0.66; participants = 2009; studies = 5; low-quality evidence), equivalent to an increase of 0.37 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; participants = 3078; studies = 11; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for four studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 63 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low- and low-quality evidence respectively that child-feeding practice and multicomponent interventions may lead to very small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up is required and future research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Parental health behaviour predictors of childhood and adolescent dietary trajectories

OBJECTIVE

To determine which parental health behaviours early in childhood most strongly predict whole-of-childhood dietary trajectories.

DESIGN

Population-based Longitudinal Study of Australian Children (LSAC, waves 1-6; 2004-2014). Exposures were parents' fruit/vegetable consumption, alcohol, smoking and physical activity at child age 0-1 years (B Cohort) or 4-5 years (K Cohort). Outcomes, from repeated biennial short diet diaries, were group-based trajectories of (i) dietary scores and empirically derived patterns of (ii) healthful and (iii) unhealthful foods consumed, spanning ages 2-3 to 10-11 years (B Cohort) and 4-5 to 14-15 years (K Cohort). We investigated associations of baseline parental health behaviours with child dietary trajectories using multinomial logistic regression.

SETTING

Australian homes.

SUBJECTS

Of children, 4443 (87·0 %) from the B Cohort and 4620 (92·7 %) from the K Cohort were included in all trajectories. Multivariable analyses included 2719 to 2905 children and both parents.

RESULTS

Children whose primary caregiver reported the lowest fruit/vegetable consumption had markedly higher odds of belonging to the least healthy score and pattern trajectories (K Cohort: OR=8·7, 95 % CI 5·0, 15·1 and OR=8·4, 95 % CI 4·8, 14·7, respectively); associations were weaker (K Cohort: OR=2·3, 95 % CI 1·0, 5·2) for the unhealthiest pattern trajectory. Secondary caregiver fruit/vegetable associations were smaller and inconsistent. Parental alcohol, smoking and physical activity were not predictive in multivariable analyses. Results were largely replicated for the B Cohort.

CONCLUSIONS

Low primary caregiver fruit/vegetable consumption increased nearly ninefold the odds of children being in the lowest intake of healthy, but only weakly predicted unhealthy, food trajectories. Healthy and unhealthy food intake may have different determinants.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase to identify eligible trials on 25 September 2017. We searched Proquest Dissertations and Theses and two clinical trial registers in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 55 trials with 154 trial arms and 11,108 participants. Thirty-three trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Thirteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 55 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% confidence interval (CI) 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 g of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for three studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 55 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains sparse. There was very low-quality evidence that child-feeding practice interventions are effective in increasing vegetable consumption in children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption in children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase Classic and Embase to identify eligible trials on 30 September 2016. We searched CINAHL and PsycINFO in July 2016, Proquest Dissertations and Theses in November 2016 and three clinical trial registers in November 2016 and June 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures.We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 50 trials with 137 trial arms and 10,267 participants. Thirty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Eleven trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.Thirteen of the 50 included trials were judged as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias of remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% CI 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 grams of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions.Studies reported receiving governmental or charitable funds, except for two studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 50 eligible trials of various intervention approaches, the evidence for how to increase fruit and vegetable consumption of children remains sparse. There was very low-quality evidence child-feeding practice interventions are effective in increasing vegetable consumption of children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption of children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Efficacy of a Community- Versus Primary Care-Centered Program for Childhood Obesity: TX CORD RCT

OBJECTIVE

This randomized controlled trial was conducted to determine comparative efficacy of a 12-month community-centered weight management program (MEND2-5 for ages 2-5 or MEND/CATCH6-12 for ages 6-12) against a primary care-centered program (Next Steps) in low-income children.

METHODS

Five hundred forty-nine Hispanic and black children (BMI ≥ 85th percentile), stratified by age groups (2-5, 6-8, and 9-12 years), were randomly assigned to MEND2-5 (27 contact hours)/MEND/CATCH6-12 (121.5 contact hours) or Next Steps (8 contact hours). Primary (BMI value at the 95th percentile [%BMI_p95 ]) and secondary outcomes were measured at baseline, 3 months (Intensive Phase), and 12 months (Transition Phase).

RESULTS

For age group 6-8, MEND/CATCH6-12 resulted in greater improvement in %BMI_p95 than Next Steps during the Intensive Phase. Effect size (95% CI) was -1.94 (-3.88, -0.01) percentage points (P = 0.05). For age group 9-12, effect size was -1.38 (-2.87, 0.16) percentage points for %BMI_p95 (P = 0.07). MEND2-5 did not differentially affect %BMI_p95 . Attendance averaged 52% and 22% during the Intensive and Transition Phases. Intervention compliance was inversely correlated to change in %BMI_p95 during the Intensive Phase (P < 0.05). In the Transition Phase, %BMI_p95 was maintained or rebounded in both programs (P < 0.05).

CONCLUSIONS

MEND/CATCH6-12 was more efficacious for BMI reduction at 3 months but not 12 months compared to Next Steps in underserved children. Intervention compliance influenced outcomes, emphasizing the need for research in sustaining family engagement in low-income populations.