The potential for long-term cost-effectiveness of obesity prevention interventions in the early years of life

FirstStep2Health: A cluster randomised trial to promote healthy behaviours and prevent obesity amongst low-income preschoolers

OBJECTIVE

To evaluate the preliminary effects of a theory-based, multi-component intervention on improving healthy lifestyle behaviours and preventing obesity amongst low-income preschoolers.

METHODS

A cluster randomised controlled trial was conducted at 10 daycare centres. The 16-week FirstStep2Health intervention, grounded in the Actor-Partner Interdependence Model and the Social Cognitive Theory, included five components: a Facebook-based parent programme, three virtual parent meetings, three weekly motivational text messages, parent-child learning via weekly child letters and daycare centre-based child programme.

RESULTS

A total of 95 preschoolers (53 intervention and 42 control) participated. Preschoolers' mean age was 49.27 months, with 57.9% being female, 12.6% being Hispanic and 40% being African American. The intervention significantly decreased intervention preschoolers' fat intake (B = -33.76, p = 0.047) and % body fat (B = -1.18, p = 0.036) compared to the control. During year 2, there were significant intervention effects on increasing skin carotenoids (B = 87.06, p = 0.035). Although not statistically significant, the intervention showed positive effects on increasing preschoolers' fruit/vegetable intake; and decreasing screen time, body mass index z-score and proportion of overweight/obesity.

CONCLUSIONS

Even with some potential limitations (small sample size, measurement concerns and confounding with Coronavirus Disease 2019 pandemic), the study's results support the preliminary efficacy of the FirstStep2Health intervention in preventing obesity amongst low-income racially diverse preschoolers.

Impact of an educational intervention about healthy lifestyles in teenagers

BACKGROUND

During the last years, lifestyle has worsened along the entire European population, causing an alarming boom-up regarding overweight and obese people. Pediatric population is also influenced in this sense, which may predispose to suffer from several diseases in adulthood. Educational interventions at early ages could be an effective strategy to face this situation.

AIM

To describe the impact of an educational intervention about healthy lifestyle in adolescents.

METHODS

A quasi-experimental study analyzing the knowledge of high school students, before and after a brief educational intervention based on a self-elaborated questionnaire including questions from the validated questionnaire CAPA (from Spanish, Conocimientos en Alimentación de Personas Adolescentes).

RESULTS

The results of this study show a significant increase in knowledge about healthy lifestyles in the study population after the educational intervention (14.3±3.8 vs. 16.5±4.5; p<0.001). In addition, this improvement presents an asymmetric distribution according to gender (13.2±3.6 vs. 14.9±4.6; p=0.002 in men; 15.6±3 vs. 18.1±3.6; p<0.001 in women) and the type of educational center (14.17±3.6 vs. 16.48±4.17; p<0.001 in public schools and 14.86±4.15 vs. 16.54±5.32; p=0.047 in private schools). Parents' educational level was associated with improvement in knowledge about healthy lifestyles (13.44±2.9 vs. 15.67±5.37; p=0.132 at low level, 14.22±3.42 vs. 16.9±4.68; p<0.001 at medium level and 15.75±3.3 vs. 17.39±4.5; p=0.022 at high level).

CONCLUSION

Educational intervention taught by primary health care professionals is a useful and efficient tool for the acquisition of nutritional and healthy lifestyle knowledge in adolescents.

The prevalence and prevention strategies of pediatric obesity: a narrative review

Pediatric obesity has rapidly increased globally over the past few decades, including in Korea. We aimed to discuss trends in the prevalence of pediatric obesity and effective prevention strategies. Its prevalence has markedly increased in most high-income nations. According to recent reports, this increase has slowed in developed countries, but the levels remain alarmingly high. In Korea, the rate of pediatric obesity has surged notably since the 1990s; however, since the 2000s, this increase has become more gradual. According to recently published 2017 growth charts, the prevalence of pediatric obesity in Korea varies slightly depending on the data source. The National School Health Examination data showed that pediatric obesity gradually increase from 11.5% in 2014 to 15.1% in 2019, and after the coronavirus disease 2019 pandemic, it sharply increased to 19% in 2021. Based on data from the Korea National Health and Nutrition Examination Survey, the prevalence of pediatric obesity gradually increased from 10.8% in 2017 to 13.6% in 2019. This trend, which accelerated sharply to 15.9% in 2020 and 19.3% in 2021, was especially severe in boys and older children. Pediatric obesity not only affects health during childhood but also increases the risk of developing obesity and associated health conditions in adulthood. Despite ongoing research on treatment options, obesity prevention and control remain challenging. Hence, prioritizing early intervention and prevention of pediatric obesity through healthy eating habits and lifestyles is crucial. This requires intervention at the individual, family, school, and community levels.

Childhood Transitions Between Weight Status Categories: Evidence from the UK Millennium Cohort Study

BACKGROUND

Assessing the cost-effectiveness of interventions targeting childhood excess weight requires estimates of the hazards of transitioning between weight status categories. Current estimates are based on studies characterized by insufficient sample sizes, a lack of national representativeness, and untested assumptions.

OBJECTIVES

We sought to (1) estimate transition probabilities and hazard ratios for transitioning between childhood weight status categories, (2) test the validity of the underlying assumption in the literature that transitions between childhood bodyweight categories are time-homogeneous, (3) account for complex sampling procedures when deriving nationally representative transition estimates, and (4) explore the impact of child, maternal, and sociodemographic characteristics.

METHODS

We applied a multistate transition modeling approach accounting for complex survey design to UK Millennium Cohort Study (MCS) data to predict transition probabilities and hazard ratios for weight status movements for children aged 3-17. Surveys were conducted at ages 3 (wave 2 in 2004), 5 (wave 3 in 2006), 7 (wave 4 in 2008), 11 (wave 5 in 2012), 14 (wave 6 in 2015), and 17 (wave 7 in 2018) years. We derived datasets that included repeated body mass index measurements across waves after excluding multiple births and children with missing or implausible bodyweight records. To account for the stratified cluster sample design of the MCS, we incorporated survey weights and jackknife replicates of survey weights. Using a validation dataset from the MCS, we tested the validity of our models. Finally, we estimated the relationships between state transitions and child, maternal, and sociodemographic factors.

RESULTS

The datasets for our primary analysis consisted of 10,399 children for waves 2-3, 10,729 for waves 3-4, 9685 for waves 4-5, 8593 for waves 5-6, and 7085 for waves 6-7. All datasets consisted of roughly equal splits of boys and girls. Under the assumption of time-heterogeneous transition rates (our base-case model), younger children (ages 3-5 and 5-7 years) had significantly higher annual transition probabilities of moving from healthy weight to overweight (0.033, 95% confidence interval [CI] 0.026-0.041, and 0.027, 95% CI 0.021-0.033, respectively) compared to older children (0.015, 95% CI 0.012-0.018, at ages 7-11; 0.018, 95% CI 0.013-0.023, at ages 11-14; and 0.018, 95% CI 0.013-0.025 at ages 14-17 years). However, the resolution of unhealthy weight was more strongly age-dependent than transitions from healthy weight to non-healthy weight states. Transition hazards differed by child, maternal, and sociodemographic factors.

CONCLUSIONS

Our models generated estimates of bodyweight status transitions in a representative UK childhood population. Compared to our scenario models (i.e., time-homogeneous transition rates), our base-case model fits the observed data best, indicating a non-time-homogeneous pattern in transitions between bodyweight categories during childhood. Transition hazards varied significantly by age and across subpopulations, suggesting that conducting subgroup-specific cost-effectiveness analyses of childhood weight management interventions will optimize decision-making.

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

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

Impact of the UK soft drinks industry levy on health and health inequalities in children and adolescents in England: An interrupted time series analysis and population health modelling study

BACKGROUND

The soft drinks industry levy (SDIL) in the United Kingdom has led to a significant reduction in household purchasing of sugar in drinks. In this study, we examined the potential medium- and long-term implications for health and health inequalities among children and adolescents in England.

METHODS AND FINDINGS

We conducted a controlled interrupted time series analysis to measure the effects of the SDIL on the amount of sugar per household per week from soft drinks purchased, 19 months post implementation and by index of multiple deprivation (IMD) quintile in England. We modelled the effect of observed sugar reduction on body mass index (BMI), dental caries, and quality-adjusted life years (QALYs) in children and adolescents (0 to 17 years) by IMD quintile over the first 10 years following announcement (March 2016) and implementation (April 2018) of the SDIL. Using a lifetable model, we simulated the potential long-term impact of these changes on life expectancy for the current birth cohort and, using regression models with results from the IMD-specific lifetable models, we calculated the impact of the SDIL on the slope index of inequality (SII) in life expectancy. The SDIL was found to have reduced sugar from purchased drinks in England by 15 g/household/week (95% confidence interval: -10.3 to -19.7). The model predicts these reductions in sugar will lead to 3,600 (95% uncertainty interval: 946 to 6,330) fewer dental caries and 64,100 (54,400 to 73,400) fewer children and adolescents classified as overweight or obese, in the first 10 years after implementation. The changes in sugar purchasing and predicted impacts on health are largest for children and adolescents in the most deprived areas (Q1: 11,000 QALYs [8,370 to 14,100] and Q2: 7,760 QALYs [5,730 to 9,970]), while children and adolescents in less deprived areas will likely experience much smaller simulated effects (Q3: -1,830 QALYs [-3,260 to -501], Q4: 652 QALYs [-336 to 1,680], Q5: 1,860 QALYs [929 to 2,890]). If the simulated effects of the SDIL are sustained over the life course, it is predicted there will be a small but significant reduction in slope index of inequality: 0.76% (95% uncertainty interval: -0.9 to -0.62) for females and 0.94% (-1.1 to -0.76) for males.

CONCLUSIONS

We predict that the SDIL will lead to medium-term reductions in dental caries and overweight/obesity, and long-term improvements in life expectancy, with the greatest benefits projected for children and adolescents from more deprived areas. This study provides evidence that the SDIL could narrow health inequalities for children and adolescents in England.

Cost-effectiveness of reducing children's sedentary time and increasing physical activity at school: the Transform-Us! intervention

BACKGROUND

Improving physical activity and reducing sedentary behavior represent important areas for intervention in childhood in order to reduce the burden of chronic disease related to obesity and physical inactivity in later life. This paper aims to determine the cost-effectiveness of a multi-arm primary school-based intervention to increase physical activity and/or reduce sedentary time in 8-9 year old children (Transform-Us!).

METHODS

Modelled cost-utility analysis, using costs and effects from a cluster randomized controlled trial of a 30-month intervention that used pedagogical and environmental strategies to reduce and break up sedentary behaviour (SB-I), promote physical activity (PA-I), or a combined approach (PA + SB-I), compared to current practice. A validated multiple-cohort lifetable model (ACE-Obesity Policy model) estimated the obesity and physical activity-related health outcomes (measured as change in body mass index and change in metabolic equivalent task minutes respectively) and healthcare cost-savings over the cohort's lifetime from the public-payer perspective, assuming the intervention was delivered to all 8-9 year old children attending Australian Government primary schools. Sensitivity analyses tested the impact on cost-effectiveness of varying key input parameters, including maintenance of intervention effect assumptions.

RESULTS

Cost-effectiveness results demonstrated that, when compared to control schools, the PA-I and SB-I intervention arms were "dominant", meaning that they resulted in net health benefits and healthcare cost-savings if the intervention effects were maintained. When the costs and effects of these intervention arms were extrapolated to the Australian population, results suggested significant potential as obesity prevention measures (PA-I: 60,780 HALYs saved (95% UI 15,007-109,413), healthcare cost-savings AUD641M (95% UI AUD165M-$1.1B); SB-I: 61,126 HALYs saved (95% UI 11,770 - 111,249), healthcare cost-savings AUD654M (95% UI AUD126M-1.2B)). The PA-I and SB-I interventions remained cost-effective in sensitivity analysis, assuming the full decay of intervention effect after 10 years.

CONCLUSIONS

The PA-I and SB-I Transform-Us! intervention arms represent good value for money and could lead to health benefits and healthcare cost-savings arising from the prevention of chronic disease in later life if intervention effects are sustained.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN83725066). Australia and New Zealand Clinical Trials Registry Number (ACTRN12609000715279).

Supporting Healthy Weight in Statewide Quality Rating and Improvement Systems: A Review of 2020 Standards and Comparison to 2015 Standards

Background: Quality Rating and Improvement Systems (QRISs) are used to assess, improve, and communicate quality in early care and education (ECE) programs. One strategy for supporting healthy growth in early childhood is embedding nutrition, physical activity, infant feeding, and screen time content into state QRIS standards, using the Caring for Our Children high-impact obesity prevention standards (HIOPS) and the CDC Spectrum of Opportunities framework (CDC Spectrum). We assessed the number of obesity prevention standards in QRISs in 2020 and compared results to an analysis published in 2015. Methods: We collected state QRIS standards for ECE centers from March to April 2020. Two analysts coded documents for standards related to 47 HIOPS and 6 Spectrum areas. Results: Thirty-nine states and the District of Columbia had statewide QRISs in early 2020. Of these, 21 QRISs (53%) embedded 1 or more HIOPS, and 26 (65%) embedded 1 or more Spectrum components. On average, 6.9% of HIOPS were embedded in QRIS standards in 2020, an increase from 4.6% in 2015. Nine QRISs included more HIOPS in 2020 than in 2015. Five QRISs added 10% or more of the 47 HIOPS between 2015 and 2020. Physical activity and screen time standards continued to be most often included; infant feeding standards were least included. Conclusion: Obesity prevention components were embedded in three-quarters of state QRISs, and more were embedded in 2020 than in 2015, suggesting that QRISs can be levers for supporting healthy weight in ECE settings.

Burden of diseases attributable to excess body weight in the Middle East and North Africa region, 1990-2019

High body mass index (BMI), or excess body weight (EBW), represents a significant risk factor for a range of diseases, including cardiovascular diseases and cancers. The study sought to determine the burden of diseases attributable to EBW in the Middle East and North Africa (MENA) region from 1990 and 2019. The analysis also included an exploration of this burden by age, sex, underlying cause, and sociodemographic index (SDI). We utilized publicly available data from the Global Burden of Disease (GBD) study 2019 to identify the deaths and disability-adjusted life-years (DALYs) of diseases associated with EBW in MENA, spanning the period from 1990 to 2019. The GBD estimated the mean BMI and the prevalence of EBW using hierarchical mixed-effects regression, followed by spatiotemporal Gaussian process regression to determine the most accurate BMI distribution through comparison with actual data. In 2019, there were an estimated 538.4 thousand deaths (95% UI 369.9-712.3) and 17.9 million DALYs (12.9-23.1) attributable to EBW in the region. The DALYs attributable to EBW were higher in men (9.3 million [6.5-12.4]) than in women (8.5 million [6.4-10.8]). The age-standardized death and DALY rates for the diseases associated with EBW increased by 5.1% (- 9.0-25.9) and 8.3% (- 6.5-28.8), respectively, during the study period which was not significant. Egypt had the highest age-standardized mortality rate due to EBW (217.7 [140.0, 307.8]), while Yemen (88.6 [45.9, 143.5]) had the lowest. In 2019, the highest number of DALYs occurred among individuals aged 60 to 64 years old. Furthermore, we found a positive association between a nation's SDI and the age-standardized DALY rate linked to EBW. Cardiovascular disease emerged as the leading contributor to the EBW burden in MENA. The disease burden attributable to EBW showed a non-significant increase in MENA from 1990 to 2019.

A systematic review of economic evidence for community-based obesity prevention interventions in children

Multicomponent community-based obesity prevention interventions that engage multiple sectors have shown promise in preventing obesity in childhood; however, economic evaluations of such interventions are limited. This systematic review explores the methods used and summarizes current evidence of costs and cost-effectiveness of complex obesity prevention interventions. A systematic search was conducted using 12 academic databases and grey literature from 2006 to April 2022. Studies were included if they reported methods of costing and/or economic evaluation of multicomponent, multisectoral, and community-wide obesity prevention interventions. Results were reported narratively based on the Consolidated Health Economic Evaluation Reporting Standards. Seventeen studies were included, reporting costing or economic evaluation of 13 different interventions. Five interventions reported full economic evaluations, five interventions reported economic evaluation protocols, two interventions reported cost analysis, and one intervention reported a costing protocol. Five studies conducted cost-utility analysis, three of which were cost-effective. One study reported a cost-saving return-on-investment ratio. The economic evidence for complex obesity prevention interventions is limited and therefore inconclusive. Challenges include accurate tracking of costs for interventions with multiple actors, and the limited incorporation of broader benefits into economic evaluation. Further methodological development is needed to find appropriate pragmatic methods to evaluate complex obesity prevention interventions.

A systematic review of economic evaluations of interventions targeting childhood overweight and obesity

This systematic review critically appraised and synthesized evidence from economic evaluations of interventions targeting childhood excess weight. We conducted systematic searches in 11 databases from inception to April 19, 2023. Studies were eligible if they evaluated interventions targeting children up to 18 years and the study intervention(s) targeted childhood excess weight or sought to improve diet or physical activity, regardless of the type of economic evaluation or the underpinning study design. We synthesized evidence using narrative synthesis methods. One-hundred fifty-one studies met the eligibility criteria and were classified into three groups based on the intervention approach: prevention-only (13 studies), prevention and treatment (100 studies), and treatment-only (38 studies). The predominant setting and study design differed considerably between the three groups of studies. However, compared with usual care, most interventions were deemed cost-effective. The study participants' ages, sex, and socioeconomic status were crucial to intervention cost-effectiveness. Interventions whose effects were projected beyond childhood, such as bariatric surgery, lower protein infant formula, and home-based general practitioner consultations, tended to be cost-effective. However, cost-effectiveness was sensitive to the assumptions underlying the persistence and intensity of such effects. Our findings can inform future recommendations on the conduct of economic evaluations of interventions targeting childhood overweight and obesity, as well as practice and policy recommendations.

Adoption, implementation, and sustainability of early childhood feeding, nutrition and active play interventions in real-world settings: a systematic review

BACKGROUND

Instilling healthy dietary habits and active play in early childhood is an important public health focus. Interventions supporting the establishment of nutrition and active play behaviours in the first years of life have shown positive outcomes and long-term cost-effectiveness, however, most are research trials, with limited evidence regarding real-world application. Implementation science theories, models and frameworks (TMFs) can guide the process of research translation from trial to real-world intervention. The application of TMFs within nutrition and active play intervention studies in early childhood (< 5 years) is currently unknown. This systematic review identified the use of TMFs and barriers/ enablers associated with intervention adoption, implementation, and sustainability in early childhood nutrition and active play interventions implemented under real-world conditions.

METHODS

Six databases were searched for peer-reviewed publications between 2000-2021. Studies were included if primary outcomes reported improvement in diet, physical activity or sedentary behaviours amongst children aged < 5 years and interventions were delivered under real-world conditions within a community and/or healthcare setting. Two reviewers extracted and evaluated studies, cross checked by a third and verified by all authors. Quality assessment of included studies was completed by two authors using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Eleven studies comprising eleven unique interventions were included. Studies represented low, middle and high-income countries, and were conducted across a range of settings. Five TMFs were identified representing four of Nilsen's implementation model categories, predominantly 'evaluation models'. Ninety-nine barriers/facilitators were extracted across the three intervention phases-Implementation (n = 33 barriers; 33 facilitators), Sustainability (n = 19 barriers; n = 9 facilitators), Adoption (n = 2 barriers; n = 3 facilitators). Identified barriers/facilitators were mapped to the five domains of the Durlak and DuPre framework, with 'funding', 'compatibility' and 'integration of new programming' common across the three intervention phases.

CONCLUSIONS

Findings demonstrate that there is no systematic application of TMFs in the planning, implementation and/or evaluation of early childhood nutrition and active play interventions in real-world settings, and selective and sporadic application of TMFs occurs across the intervention lifespan. This apparent limited uptake of TMFs is a missed opportunity to enhance real-world implementation success.

TRIAL REGISTRATION

PROSPERO (CRD42021243841).

Methods for the economic evaluation of obesity prevention dietary interventions in children: A systematic review and critical appraisal of the evidence

OBJECTIVES

We aim to describe and provide a discussion of methods used to conduct economic evaluations of dietary interventions in children and adolescents, including long-term modelling, and to make recommendations to assist health economists in the design and reporting of such evaluations.

METHODS

A systematic review was conducted in 11 bibliographic databases and the grey literature with searches undertaken between January 2000 and December 2021. A study was included if it (1) was an economic evaluation or modelling study of an obesity-prevention dietary intervention and (2) targeted 2- to 18-year-olds.

RESULTS

Twenty-six studies met the inclusion criteria. Twelve studies conducted an economic evaluation alongside a clinical trial, and 14 studies modelled long-term health and cost outcomes. Four overarching methodological challenges were identified: modelling long-term impact of interventions, measuring and valuing health outcomes, cost inclusions and equity considerations.

CONCLUSIONS

Variability in methods used to predict, measure and value long-term benefits in adulthood from short-term clinical outcomes in childhood was evident across studies. Key recommendations to improve the design and analysis of future economic evaluations include the consideration of weight regain and diminishing intervention effects within future projections; exploration of wider intervention benefits not restricted to quality-of-life outcomes; and inclusion of parental or caregiver opportunity costs.

Cost-effectiveness of scaling up a whole-of-community intervention: The Romp & Chomp early childhood obesity prevention intervention

BACKGROUND

Given the high prevalence of early childhood overweight and obesity, more evidence is required to better understand the cost-effectiveness of community-wide interventions targeting obesity prevention in children aged 0-5 years.

OBJECTIVES

To assess the cost-effectiveness of the Romp & Chomp community-wide early childhood obesity prevention intervention if delivered across Australia in 2018 from a funder perspective, against a no-intervention comparator.

METHODS

Intervention costs were estimated in 2018 Australian dollars. The annual Early Prevention of Obesity in Childhood micro-simulation model estimated body mass index (BMI) trajectories to age 15 years, based on end of trial data at age 3.5 years. Results from modelled cost-effectiveness analyses were presented as incremental cost-effectiveness ratios (ICERs): cost per BMI unit avoided, and cost per quality-adjusted life year (QALY) gained at age 15 years.

RESULTS

All Australian children aged 0-5 years (n = 1 906 075) would receive the intervention. Total estimated intervention cost and annual cost per participant were AUD178 million and AUD93, respectively, if implemented nationally. The ICERs were AUD1 126 per BMI unit avoided and AUD26 399 per QALY gained (64% probability of being cost-effective measured against a AUD50 000 per QALY threshold).

CONCLUSIONS

Romp & Chomp has a fair probability of being cost-effective if delivered at scale.

Improved management of pediatric obesity in the primary care setting through implementation of the healthy care for healthy kids obesity toolkit

Pediatric obesity has become a major health care concern over the last several decades. This condition can lead to detrimental life-long physical and mental comorbidities. Pediatric primary care providers have a unique opportunity to both prevent and treat pediatric obesity in their clinics. However, discussing this topic with families can be uncomfortable and time consuming. Time efficient resources to educate and increase confidence are needed to improve the management of pediatric obesity. This quality improvement project integrated the Healthy Care for Healthy Kids by the National Institute for Children's Healthcare Quality (2014) into the electronic medical record at a pediatric primary care office in rural East Tennessee. This toolkit included handouts, management algorithms, and provider education for pediatric obesity. After an 8-week implementation period, improvements in lab draws and evaluation of a family''s readiness to change were noted. Overall, providers reported the toolkit was helpful and improved patient interaction. Currently, the clinic is still utilizing the integrated resources and handouts.

Childhood obesity prevention: what can be achieved?

PURPOSE OF REVIEW

Childhood obesity is a pandemic generating an enormous individual and socioeconomic burden worldwide. This narrative review summarizes recent evidence on successful and recommended prevention strategies according to age groups and different levels of interventions.

RECENT FINDINGS

Effective prevention of childhood obesity is feasible and most successful early in life up to preschool age, and it should include a multicomponent approach, integrating individuals, family and society. Trials that improve nutrition and/or enhance physical activity are the cornerstones of childhood obesity prevention on an individual level. However, their efficacy is determined by the combination of interventions for the target age group. Further, improving family support and sleep, as well as reducing screen time, lead to favourable results. Many research gaps remain, including a lack of effective interventions for high-risk groups.

SUMMARY

As a multifactorial condition, childhood obesity requires a multicomponent approach. Interventions should be developmental stage-specific and adjusted to the setting. Current research gaps need to be targeted by future trials, with a special focus on the benefit of the most vulnerable groups. From a systems response perspective, a paradigm shift from interventions focusing on the individual to approaches that target society as a whole is warranted.

Health Economic Aspects of Childhood Excess Weight: A Structured Review

An economic perspective is crucial to understand the broad consequences of childhood excess weight (CEW). These can manifest in the form of elevated health care and societal costs, impaired health status, or inefficiencies in the allocation of resources targeted at its prevention, management, or treatment. Although existing systematic reviews provide summaries of distinct economic research strands covering CEW, they have a restricted focus that overlooks relevant evidence. The overarching aim of this structured review was to update and enhance recent key reviews of four strands of economic evidence in this area, namely, (1) economic costs associated with CEW, (2) health utilities associated with CEW, (3) economic evaluations of interventions targeting CEW, and (4) economic determinants and broader consequences of CEW. Our de novo searches identified six additional studies for the first research strand, five studies for the second, thirty-one for the third, and two for the fourth. Most studies were conducted in a small number of high-income countries. Our review highlights knowledge gaps across all the research strands. Evidence from this structured review can act as data input into future economic evaluations in this area and highlights areas where future economic research should be targeted.

A child-centered health dialogue for the prevention of obesity in child health services in Sweden - A randomized controlled trial including an economic evaluation

BACKGROUND

Prevention of child obesity is an international public health priority and believed to be effective when started in early childhood. Caregivers often ask for an early and structured response from health professionals when their child is identified with overweight, yet cost-effective interventions for children aged 2-6 years and their caregivers in Child Health Services are lacking.

OBJECTIVES

To evaluate the effects and cost-effectiveness of a child-centered health dialogue in the Child Health Services in Sweden on 4-year-old children with normal weight and overweight.

METHODS

Thirty-seven Child Health Centers were randomly assigned to deliver intervention or usual care. The primary outcome was zBMI-change.

RESULTS

A total of 4598 children with normal weight (zBMI: 0.1 [SD = 0.6] and 490 children with overweight (zBMI: 1.6 [SD = 0.3]) (mean age: 4.1 years [SD = 0.1]; 49% females) were included. At follow-up, at a mean age of 5.1 years [SD = 0.1], there was no intervention effect on zBMI-change for children with normal weight. Children with overweight in the control group increased zBMI by 0.01 ± 0.50, while children in the intervention group decreased zBMI by 0.08 ± 0.52. The intervention effect on zBMI-change for children with overweight was -0.11, with a 95% confidence interval of -0.24 to 0.01 (p = 0.07). The estimated additional costs of the Child-Centered Health Dialogue for children with overweight were 167 euros per child with overweight and the incremental cost-effectiveness ratio was 183 euros per 0.1 zBMI unit prevented.

CONCLUSIONS

This low-intensive multicomponent child-centered intervention for the primary prevention of child obesity did not show statistical significant effects on zBMI, but is suggested to be cost-effective with the potential to be implemented universally in the Child Health Services. Future studies should investigate the impact of socio-economic factors in universally implemented obesity prevention programs.

Preventing Childhood Obesity in Primary Schools: A Realist Review from UK Perspective

Childhood obesity is a global public health concern. While evidence from a recent comprehensive Cochrane review indicates school-based interventions can prevent obesity, we still do not know how or for whom these work best. We aimed to identify the contextual and mechanistic factors associated with obesity prevention interventions implementable in primary schools. A realist synthesis following the Realist And Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES) guidance was with eligible studies from the 2019 Cochrane review on interventions in primary schools. The initial programme theory was developed through expert consensus and stakeholder input and refined with data from included studies to produce a final programme theory including all of the context-mechanism-outcome configurations. We included 24 studies (71 documents) in our synthesis. We found that baseline standardised body mass index (BMIz) affects intervention mechanisms variably as a contextual factor. Girls, older children and those with higher parental education consistently benefitted more from school-based interventions. The key mechanisms associated with beneficial effect were sufficient intervention dose, environmental modification and the intervention components working together as a whole. Education alone was not associated with favourable outcomes. Future interventions should go beyond education and incorporate a sufficient dose to trigger change in BMIz. Contextual factors deserve consideration when commissioning interventions to avoid widening health inequalities.

Stakeholders' Views on Mobile Applications to Deliver Infant and Toddler Feeding Education to Latina Mothers of Low Socioeconomic Status

Infant- and toddler-feeding (ITF) practices are critical to long-term health and chronic disease prevention. Using mobile applications (apps) to promote desirable ITF practices shows promise for overcoming challenges of in-person education. However, the viability of ITF apps for Latina mothers of low-socioeconomic status (SES) remains unclear. The objective of this study was to characterize stakeholders' views on Latina mothers' capability, motivation, and barriers to using ITF apps. New York City-based health professionals who frequently engage with Latina mothers of low SES completed in-depth interviews. Directed content analysis was used to identify themes through theoretical and inductive codes. Participants included dietitians, nutrition educators, and physicians (n = 17). The following themes were identified: (1) Most Latina mothers of low-SES are tech-savvy (i.e., high capability and experience using smartphones and apps); (2) Apps are an appealing way to deliver ITF education; (3) There are challenges to using apps that must be carefully considered for ITF education development. Overall, ITF apps are a viable option as skills and use appear high among Latina mothers. Key considerations for app development include targeted app promotion; detailed instructions for obtaining and using app; more visuals, less text for low literacy and multiple dialects; making key features available offline.

Overview of pediatric obesity: diagnosis, epidemiology, and significance

Background: The prevalence of pediatric obesity has increased over the past several decades worldwide and in Korea. Childhood obesity has become a serious social problem.Current Concepts: Diagnosis of obesity is based on body mass index (BMI) in children and adolescents aged ≥2 years. Overweight and obese are defined as BMI ≥85th percentile to <95th percentile and BMI ≥95th percentile, respectively, corresponding to sex and age. Obesity is further classified as Class I (BMI ≥95th percentile to <120% of 95th percentile), Class II (BMI ≥120% of 95th percentile to <140% of 95th percentile), and Class III (BMI ≥140% of 95th percentile). Waist circumference and waist-height ratio are used to evaluate abdominal obesity. Pediatric obesity can cause childhood comorbidities, including type 2 diabetes, dyslipidemia, non-alcoholic fatty liver disease, and hypertension. Adult obesity, cardiovascular diseases, and other adult comorbidities, together with increased medical costs are additional consequences of pediatric obesity.Discussion and Conclusion: Prevention, diagnosis, and proper management of pediatric obesity are important.

Interventions that prevent or reduce obesity in children from birth to five years of age: A systematic review

Childhood obesity worldwide affects 5.6% or 38.3 million children under five years of age. The longer children are overweight or obese, the more likely they are to become obese adults with all the contingent morbidity involved. An extensive number of preventive interventions to combat childhood obesity have been carried out worldwide. This article reports a systematic review of interventions aimed to reducing or preventing obesity under-fives. The search was performed with six different databases: Web of Science, PsycINFO, Cochrane, PubMed, Medline, and CINAHL. Studies meeting the inclusion criteria were independently assessed using Joanna Briggs Institute methodology. Thirty studies involving 23,185 children across nine countries were included. Twenty-two were randomised controlled trials, and 8 quasi-experimental pretest/post-test design with comparison. These studies fell into four different categories: home-based interventions with family involvement (n = 12), preschool/early childhood settings (n = 9), multicomponent interventions across multiple settings (n = 6) and healthcare setting (n = 3). Future research should focus on increasing the accessibility of education on diet and physical activity for deprived families as well as the cultural acceptability of interventions to prevent childhood obesity.

Primary prevention of fat and weight gain among obesity susceptible healthy weight preschool children. Main results from the "Healthy Start" randomized controlled intervention

BACKGROUND

A vital public health challenge lies in understanding the primary drivers behind excessive weight gain among healthy weight individuals.

OBJECTIVES

To examine if excessive weight and fat gain can be prevented among healthy weight, obesity susceptible children aged 2 to 6 years.

METHODS

Eligible children were identified based on information on either a high birth weight, maternal pre-pregnancy obesity or maternal low educational level from national registries, and randomized into an intervention group, a control group and a shadow control group. All children with overweight at baseline were excluded from subsequent analysis (n = 196), while healthy weight children were included (n = 926). The intervention was designed to deliver improvements in diet and physical activity habits, optimization of sleep quantity and quality, and reduction of family stress. The average intervention period was 1.3 years.

RESULTS

Intention-to-treat analyses indicated a lower gain in percentage fat mass and a higher gain in fat-free mass in the intervention group compared with the control group. However, the results should be interpreted with caution, as they were clinically small and borderline significant, only.

CONCLUSION

This primary prevention intervention among young healthy weight children with susceptibility to future obesity had clinically small effects on growth and body composition. More interventions, conducting primary obesity prevention, are urgently needed.

BMI trajectories after primary school-based lifestyle intervention: Unravelling an uncertain future. A mixed methods study

This mixed methods study aimed to examine plausible body mass index (BMI) trajectories after exposure to a primary school-based lifestyle intervention to aid in estimating the long-term intervention benefits. BMI trajectories for children at control schools (mean 7.6 years of age) were modelled until 20 years of age through extrapolating trial evidence (N = 1647). A reference scenario assumed that the observed 2-year effects of the 'Healthy Primary Schools of the Future' (HPSF) and 'Physical Activity Schools' (PAS) were fully maintained over time. This was modelled by applying the observed 2-year BMI effects until 20 years of age. Expert opinions on likely trends in effect maintenance after the 2-year intervention period were elicited qualitatively and quantitatively, and were used for developing alternative scenarios. Expert elicitation revealed three scenarios: (a) a constant exposure-effect and an uncontrolled environment with effect decay scenario, (b) a household multiplier and an uncontrolled environment with effect decay scenario, and (c) a household multiplier and maintainer scenario. The relative effect of HPSF at 20 years of age was -0.21 kg/m2 under the reference scenario, and varied from -0.04 kg/m2 (a) to -0.06 kg/m2 (b), and -0.50 kg/m2 (c). For PAS, the relative effect was -0.17 kg/m2 under the reference scenario, and varied from -0.04 kg/m2 (a, b), to -0.21 kg/m2 (c). The mixed methods approach proved to be useful in modelling plausible BMI trajectories and specifying uncertainty on effect maintenance. Further observations until adulthood could reduce the uncertainty around future benefits. This trial was retrospectively registered at Clinicaltrials.gov (NCT02800616).

Testing the feasibility of a sustainable preschool obesity prevention approach: a mixed-methods service evaluation of a volunteer-led HENRY programme

BACKGROUND

Over the last 10 years HENRY has been working to reduce and prevent child obesity by training health and early years professionals to deliver its evidence-based programme to parents. The aim and unique contribution of this study was to evaluate whether training volunteers to deliver this programme on a one-to-one basis was feasible.

METHODS

Mixed-methods service evaluation with parent-reported pre- and post-programme outcomes and focus groups conducted with parents and volunteer facilitators. The programme consisted of 8 one-to-one sessions delivered weekly by volunteers (n = 18) to build food and activity-related knowledge, skills, and understanding, and improve parenting efficacy, and parent and child eating and physical activity. Programmes took place at parent's (n = 69) home or local community venues in four London boroughs, United Kingdom. Parent-reported parenting efficacy, emotional wellbeing, eating, and physical activity data were captured, alongside parent ratings of the programme and volunteer ratings of the training. Parent and volunteer focus groups explored involvement, expectations, and experiences of the programme, training and delivery, feedback, and impact.

RESULTS

Parents were mostly female, had varied ethnic backgrounds, and were often not working but well educated. There were statistically significant improvements of a medium-to-large size in parent and child emotional wellbeing, parenting efficacy, fruit and vegetable consumption, family eating and food purchasing behaviours. Parent ratings of the programme were positive and qualitative data highlighted the holistic nature of the programme, which focused on more than just food, and the relationships with volunteers as key facets. Volunteers were also mostly female, had varied ethnic backgrounds, and were often well educated, but more likely to be employed than parents. Volunteers rated the training and delivery as useful in enabling them to deliver the programme confidently and for their own wellbeing. Despite finding some sessions challenging emotionally, volunteers reported positive family lifestyle improvements by parents and children and that the experience would be useful for future employment.

CONCLUSIONS

It is feasible to recruit and train volunteers to deliver a structured preschool obesity prevention programme, which parents considered acceptable and enjoyable, with preliminary reports of parent and child benefits.

Cost comparison of five Australasian obesity prevention interventions for children aged from birth to two years

BACKGROUND

In the absence of rigorous evidence of cost-effectiveness for early childhood obesity prevention interventions, the next-best option may be for decision-makers to consider the relevant costs of interventions when allocating resources.

OBJECTIVES

This study aimed to estimate systematically the cost of five obesity prevention interventions in children aged 0-2 years, undertaken in research settings in Australia and New Zealand.

METHODS

A standardised costing protocol informed the costing methodology, ensuring comparability of results across interventions. Micro-costing was undertaken, with intervention costs defined from the funder perspective and valued in 2018 Australian dollars using unit costs from the trials or market rates.

RESULTS

Interventions varied widely in their resource use. The total cost per participant ranged from $80 for the CHAT SMS intervention arm (95% UI $77-$82) to $1135 for the Healthy Beginnings intervention (95% UI $1059-$1189). Time costs of personnel delivering interventions contributed >50% of total intervention costs for all included studies.

CONCLUSIONS

An understanding of the costs associated with intervention delivery modes is important, alongside effectiveness. Telephone delivery may include unexpected costs associated with connection to intervention participants at convenient times. A SMS-based intervention had the lowest delivery cost in this study.

Evaluating body composition in infancy and childhood: A comparison between 4C, QMR, DXA, and ADP

BACKGROUND

Accurate and precise methods to measure of body composition in infancy and childhood are needed.

OBJECTIVES

This study evaluated differences and precision of three methods when compared with the four-compartment (4C) model for estimating fat mass (FM).

METHODS

FM of children (age 14 days to 6 years of age, N = 346) was obtained using quantitative nuclear magnetic resonance (QMR, EchoMRI-AH), air-displacement plethysmography (ADP, PeaPod, less than or equal to 8 kg, BodPod age 6 years or older), and dual-energy X-ray absorptiometry (DXA, Hologic QDR). The 4C model was computed. Correlation, concordance, and Bland-Altman analyses were performed.

RESULTS

In infants, PeaPod had high individual FM accuracy, whereas DXA had high group FM accuracy compared with 4C. In children, DXA had high group and individual FM accuracies compared with 4C. QMR underestimated group FM in infants and children (300 and 510 g, respectively). The instrument FM precision was best for QMR (10 g) followed by BodPod (34 g), PeaPod (38 g), and DXA (45 g).

CONCLUSIONS

In infants, PeaPod was the best method to estimate individual FM whereas DXA was best to estimate group FM. In children, DXA was best to estimate individual and group FM. QMR had the highest instrument precision.

Prevention of Childhood Obesity: A Position Paper of the Global Federation of International Societies of Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN)

Global childhood obesity increased more than 8-fold over 40 years, inducing a very large personal, societal, and economic burden. Effects of available treatments are less than satisfactory; therefore, effective prevention is of high priority. In this narrative review, we explore preventive opportunities. The available evidence indicates large benefits of improving nutrition and lifestyle during early life, such as promoting breast-feeding and improving the quality of infant and early childhood feeding. Promoting healthy eating patterns and limiting sugar-containing beverage consumption from early childhood onwards are of great benefit. Regular physical activity and limited sedentary lifestyle and screen time alone have limited effects but are valuable elements in effective multicomponent strategies. The home environment is important, particularly for young children, and can be improved by educating and empowering families. School- and community-based interventions can be effective, such as installing water fountains, improving cafeteria menus, and facilitating regular physical activity. Reducing obesogenic risk factors through societal standards is essential for effective prevention and limiting socioeconomic disparity; these may comprise food, drink, and physical activity standards for day cares and schools, general food quality standards, front-of-pack food labeling, taxation of unhealthy foods, restriction of food advertisements to children, and others. Effective prevention of childhood obesity is not achieved by single interventions but by integrated multicomponent approaches involving multiple stakeholders that address children, families, and societal standards. Pediatricians and their organizations should be proactive in supporting and empowering families to support their children's health, and in promoting societal measures that protect children.

Associations among amino acid, lipid, and glucose metabolic profiles in childhood obesity

Background

Plasma-free amino acid profiles have been reported to correlate with obesity and glucose metabolism, and have been studied as potentially useful biomarkers of lifestyle-related diseases affecting metabolism in adulthood. However, knowledge of these relationships is lacking in children, despite the growing public health problem posed by childhood obesity.

The aim of this study was to assess whether plasma-free amino acid profiles can serve as useful biomarkers of lifestyle-related diseases in children with obesity.

Methods

This retrospective study used the medical records of 26 patients (15 male, 11 female) aged 9 or 10 years presenting with moderate to severe obesity and hyperlipidemia between April 2015 and March 2017. A degree of obesity of 30% or more was defined as moderate or severe. Amino acid levels were compared between obese children with and without impaired glucose tolerance using a t-test or Mann–Whitney U test. In addition, the influence of factors such as intima media thickness, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, amino acids, and homeostasis model assessment-insulin resistance (HOMA-IR) were analyzed pairwise using Pearson’s correlation or Spearman’s rank correlation.

Results

HOMA-IR was positively correlated with valine, leucine (Leu), isoleucine, phenylalanine, tryptophan, methionine, threonine, lysine, alanine, tyrosine, glutamate (Glu), proline, arginine, ornithine, total free amino acids (all P < 0.01), and aspartate (P = 0.010). Moreover, blood uric acid levels were positively correlated with Leu (P = 0.005) and Glu (P = 0.019), and negatively correlated with serine, glycine, and asparagine (P = 0.007, P = 0.003, and P = 0.013, respectively).

Conclusions

Amino acid profile reflects impaired glucose tolerance and hyperuricemia at an early stage of obesity. It is therefore a useful marker to inform early intervention in children with obesity, as in adults.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1647-8) contains supplementary material, which is available to authorized users.