A primary-school-based study to reduce the prevalence of childhood obesity--the EdAl (Educació en Alimentació) study: a randomized controlled trial

A Scoping Review of Tailoring in Pediatric Obesity Interventions

Background: Families with children who have or are at risk for obesity have differing needs and a one-size-fits-all approach can negatively impact program retention, engagement, and outcomes. Individually tailored interventions could engage families and children through identifying and prioritizing desired areas of focus. Despite literature defining tailoring as individualized treatment informed by assessment of behaviors, intervention application varies. This review aims to exhibit the use of the term "tailor" in pediatric obesity interventions and propose a uniform definition. Methods: We conducted a scoping review following PRISMA-ScR guidelines among peer-reviewed pediatric obesity prevention and management interventions published between 1995 and 2021. We categorized 69 studies into 6 groups: (1) individually tailored interventions, (2) computer-tailored interventions/tailored health messaging, (3) a protocolized group intervention with a tailored component, (4) only using the term tailor in the title, abstract, introduction, or discussion, e) using the term tailor to describe another term, and (5) interventions described as culturally tailored. Results: The scoping review exhibited a range of uses and lack of explicit definitions of tailoring in pediatric obesity interventions including some that deviate from individualized designs. Effective tailored interventions incorporated validated assessments for behaviors and multilevel determinants, and recipient-informed choice of target behavior(s) and programming. Conclusions: We urge interventionists to use tailoring to describe individualized, assessment-driven interventions and to clearly define how an intervention is tailored. This can elucidate the role of tailoring and its potential for addressing the heterogeneity of behavioral and social determinants for the prevention and management of pediatric obesity.

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.

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

Nally et al. [...].

The effects of hypothetical behavioral interventions on the 13-year incidence of overweight/obesity in children and adolescents

BACKGROUND

In view of the high burden of childhood overweight/obesity (OW/OB), it is important to identify targets for interventions that may have the greatest effects on preventing OW/OB in early life. Using methods of causal inference, we studied the effects of sustained behavioral interventions on the long-term risk of developing OW/OB based on a large European cohort.

METHODS

Our sample comprised 10 877 children aged 2 to < 10 years at baseline who participated in the well-phenotyped IDEFICS/I.Family cohort. Children were followed from 2007/08 to 2020/21. Applying the parametric g-formula, the 13-year risk of developing OW/OB was estimated under various sustained hypothetical interventions on physical activity, screen time, dietary intake and sleep duration. Interventions imposing adherence to recommendations (e.g. maximum 2 h/day screen time) as well as interventions 'shifting' the behavior by a specified amount (e.g. decreasing screen time by 30 min/day) were compared to 'no intervention' (i.e. maintaining the usual or so-called natural behavior). Separately, the effectiveness of these interventions in vulnerable groups was assessed.

RESULTS

The 13-year risk of developing OW/OB was 30.7% under no intervention and 25.4% when multiple interventions were imposed jointly. Meeting screen time and moderate-to-vigorous physical activity (MVPA) recommendations were found to be most effective, reducing the incidence of OW/OB by -2.2 [-4.4;-0.7] and -2.1 [-3.7;-0.8] percentage points (risk difference [95% confidence interval]), respectively. Meeting sleep recommendations (-0.6 [-1.1;-0.3]) had a similar effect as increasing sleep duration by 30 min/day (-0.6 [-0.9;-0.3]). The most effective intervention in children of parents with low/medium educational level was being member in a sports club; for children of mothers with OW/OB, meeting screen time recommendations and membership in a sports club had the largest effects.

CONCLUSIONS

While the effects of single behavioral interventions sustained over 13 years were rather small, a joint intervention on multiple behaviors resulted in a relative reduction of the 13-year OW/OB risk by between 10 to 26%. Individually, meeting MVPA and screen time recommendations were most effective. Nevertheless, even under the joint intervention the absolute OW/OB risk remained at a high level of 25.4% suggesting that further strategies to better prevent OW/OB are required.

The long-term effects of primary school-based obesity prevention interventions in children: A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis investigate the long-term effects of primary school-based obesity prevention interventions on body-mass index (and z-scores), waist circumference (and z-scores) and weight status.

METHODS

Four databases were searched for studies from date of inception until June 8th, 2021. We included randomized controlled trials (RCT) and non-RCTs investigating effects ≥12 months post-intervention of primary school-based interventions with intervention duration ≥6 months and containing a diet and/or physical activity component on outcomes of interest. Articles were assessed on risk of bias and methodological quality by RoB2 and ROBINS-I. Meta-analysis was performed and results were narratively summarized. Evidence quality was assessed with GRADE.

RESULTS

Nineteen studies were included, 9 were pooled in a meta-analysis. No long-term effects were found on body-mass index (+0.06 kg/m² ; CI95% = -0.38, 0.50; I²  = 66%), body-mass index z-scores (-0.08; CI95% = -0.20, 0.04; I²  = 36%), and waist circumference (+0.57 cm; CI95% = -0.62, 1.75; I²  = 13%). Non-pooled studies reported mixed findings regarding long-term effects on body-mass index, body-mass index z-scores and weight status, and no effects on waist circumference and waist circumference z-scores. Evidence certainty was moderate to very low.

DISCUSSION

No clear evidence regarding long-term effects of primary school-based interventions on obesity-related outcomes was found. Recommendations for further research and policy are discussed. Prospero registration ID: CRD42021240446.

Effects of foods, beverages and macronutrients on BMI z-score and body composition in children and adolescents: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

A healthy diet is fundamental for healthy growth and for future disease prevention. However, scientific consensus on how to compose healthy diets for children has not been established. Therefore, a systematic review and meta-analysis was performed to investigate if an independent effect exists between foods, beverages or the composition of macronutrients and body composition in children and adolescents.

METHODS

A systematic search was performed in four databases up to July 2021. A systematic review of randomized controlled studies (RCTs) and meta-analyses were carried out by extracting mean difference (MDs) and standard deviation (SD) and performed using the random effect model.

RESULTS

Sixteen RCTs met inclusion criteria. Beyond dairy, sugar-sweetened beverages and macronutrient composition, no trials were identified for other food groups. Based on five RCTs (n:5), a higher-dairy diet was found to reduce body fat percentage - 0.47 [- 0.92, - 0.03] (p = 0.04). A higher-dairy diet was also found to increase lean body mass (kg) 0.34 [0.06, 0.62] (p = 0.02) (n:2), but did not affect BMI z-score - 0.05 [- 0.16, 0.06] (p = 0.39) (n:4). Substituting sugar-sweetened beverage with non-caloric beverages or flavored milk reduced body fat percentage (- 0.70 [- 0.78, - 0.62] (p < 0.001)) (n:3) but did not change BMI z-score (- 0.05 [- 0.20, 0.09] (p = 0.48)) (n:2). No significant effects were found between different macronutrient compositions and BMI z-score or body fat percentage.

CONCLUSION

Changes in diet from low to higher-dairy consumption and from sugar-sweetened beverages to non-caloric beverages or flavored milk resulted in favorable changes in body composition among children and adolescents. Eligible studies investigating other foods are lacking.

TRIAL REGISTRATION

PROSPERO registration number (CRD42020173201).

Clinical and school-based intervention strategies for youth obesity prevention: A systematic review

Introduction

In the last couple of decades, numerous intervention strategies (ISs) have been formulated in school/community or clinical sectors using physical activity (PA) in order to prevent youth obesity because they have been highly effective in addressing this issue. These two sectors have revealed some interesting information in terms of efficient results and best practice mechanisms, but comparisons between them to learn about their functioning have been rare.

Methods

Therefore, the aim of this systematic review was to analyze and synthesize PA ISs from school/community or clinical domains for the period 2013-2017, in French or English, targeting youths aged 5-19 years old through primary, secondary, and tertiary prevention.

Results

In total, 68 full articles were reserved for data extraction and synthesis and 617 were excluded because they did not meet eligibility criteria (61 of 68 were kept for the final analysis). The results identified a number of differences between the studies of the various IS sectors and also a third type of IS, mixed sector. Mixed ISs (clinical and school-community) have a special advantage because they can benefit from the strengths of both school/community-based and clinical-based ISs. Mixed ISs showed the most promising results. This review also highlighted the differences between sectors and their ISs in terms of intervention teams, prevention objectives, duration, materials, and efficiency.

Conclusion

Future studies should focus on establishing a prevention program in a given geographical area involving all stakeholders with their respective skills/knowledge, in the area of decision-making and in the development of ISs, to ensure that the program is the most efficient and best adapted to its environment.

Role of adipocyte Na,K-ATPase oxidant amplification loop in cognitive decline and neurodegeneration

Recent studies suggest that a western diet may contribute to clinical neurodegeneration and dementia. Adipocyte-specific expression of the Na,K-ATPase signaling antagonist, NaKtide, ameliorates the pathophysiological consequences of murine experimental obesity and renal failure. In this study, we found that a western diet produced systemic oxidant stress along with evidence of activation of Na,K-ATPase signaling within both murine brain and peripheral tissues. We also noted this diet caused increases in circulating inflammatory cytokines as well as behavioral, and brain biochemical changes consistent with neurodegeneration. Adipocyte specific NaKtide affected by a doxycycline on/off expression system ameliorated all of these diet effects. These data suggest that a western diet produces cognitive decline and neurodegeneration through augmented Na,K-ATPase signaling and that antagonism of this pathway in adipocytes ameliorates the pathophysiology. If this observation is confirmed in humans, the adipocyte Na,K-ATPase may serve as a clinical target in the therapy of neurodegenerative disorders.

Systematic Review of Setting-Based Interventions for Preventing Childhood Obesity

Introduction

Child obesity is recognized as one of the major public health problems globally, which demands multicomponent and comprehensive interventions. The objective of this systematic review is to evaluate, synthesize, and combine the existing evidence of various setting-based interventions across developed and developing countries that aim to prevent childhood obesity.

Methods

An electronic and systematic search was conducted on setting-based interventions related to childhood obesity both in developed and developing countries. A study was considered eligible if it was a randomized controlled trial that focused on home-based, school-based, or community-based intervention for childhood obesity and published in English from 2010 to 2020. A wide range of electronic bibliographic databases, such as PubMed, Medline, Embase, and ERIC were searched. The various studies were carried out among children aged 4-18 years old. A total of 32 studies were identified; out of which 24 were school-based interventions, and the remaining were nonschool-based.

Results

The studies in this review highlighted important school and nonschool-based interventions to avoid obesity among children and adolescents. School-based interventions that had considered both physical activity (PA) and diet along with home elements showed great effectiveness. These findings reveal that the specific intervention components such as nutrition education curriculum, prolonged time for PA, and upgrading self-efficacy of study participants should be considered to prevent obesity across developed and developing countries. However, the findings from nonschool-based interventions were restricted by the scarcity of the studies.

Conclusion

Multisetting and multipronged strategies are required to avoid or reduce childhood obesity across the globe. However, additional studies are needed with a large sample size. Further study designs based on theory should be conducted in nonschool settings for the creation of meaningful and detailed guidelines that can support the prevention of obesity in children.

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

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

Nutrition education improves knowledge and BMI-for-age in Ghanaian school-aged children

BACKGROUND

Adequate nutrition is required for growth and development in children. This study tested the effectiveness of nutrition education on knowledge and BMI-for-age (BFA) of school-aged children in the Kumasi Metropolis.

METHODS

Children, aged 9-13 years old were recruited from ten randomly selected primary schools in the Metropolis. The schools were randomly allocated into 3 groups: nutrition education (3 schools), physical activity (PA) education (3 schools), both interventions (2 schools), or control (2 schools). Following a baseline nutrition and PA knowledge and status assessment in 433 children, twice-monthly nutrition and PA education and demonstrations were carried out for 6 months, followed by a post-intervention assessment.

RESULTS

PA and nutrition knowledge improved in all groups (P<0.001); the highest improvement was among those who received both interventions (31.0%), followed by the nutrition education group (29.8%), and the least, the control group (19.1%). Overall, BFA improved by +0.36, from baseline (-0.26) to end of the intervention (+0.10, P<0.001). Within the groups, the nutrition group (+0.65, P<.001) had the highest improvement, then, both the intervention group (+0.27, P<0.001), the PA group (+0.23, P<0.001) and lastly, the control group (+0.18, P=0.001).

CONCLUSION

Nutrition education could improve knowledge and BMI-for-age in school-aged children in Ghana.

Effect of a school-based intervention in eating habits among school children: quasi experimental study, Tunisia

OBJECTIVE

The present study aimed to assess whether six months intervention program with parents' implication in primary schools is able to decrease morning snack consumption among children aged 6-12 years.

METHODS

We carried out a quasi-experimental study with two groups of schoolchildren in the region of Sousse (Tunisia) from 2015 to 2016. One primary school in each group was selected. In each school, we randomly selected a sample size of schoolchildren and their parents. The intervention was based on healthy eating habits promotion.

RESULTS

The consumption of morning snacks the day before data collection, reported by children, decreased significantly in post-intervention in both intervention and control groups. The decrease of consumption of morning snacks was significantly higher in intervention group (p=0.009). According to parents, the proportion of children who had the habit of eating morning snack decreased significantly from pre to post-intervention in intervention group (p<0.001).

CONCLUSION

A healthy environment should be created through effective school policies to prevent obesity.

High adherence to a mediterranean diet at age 4 reduces overweight, obesity and abdominal obesity incidence in children at the age of 8

BACKGROUND/OBJECTIVES

A higher adherence to a Mediterranean diet has been shown to be protective against obesity in adults, but the evidence is still inconclusive in children at early ages. Our objective was to explore the association between adherence to Mediterranean Diet at the age of 4 and the prevalence of overweight, obesity, and abdominal obesity at 4 years of age, and incidence at the age of 8.

SUBJECTS/METHODS

We analyzed data from children of the INMA cohort study who attended follow-up visits at age 4 and 8 years (n = 1801 and n = 1527, respectively). Diet was assessed at the age of 4 using a validated food frequency questionnaire. The adherence to MD was evaluated by the relative Mediterranean diet (rMED) score, and categorized as low (0-6), medium (7-10), and high (11-16). Overweight and obesity were defined according to the age-sex specific BMI cutoffs proposed by the International Obesity Task Force, and abdominal obesity as waist circumference >90th percentile. We used Poisson regression models to estimate prevalence ratios at 4 years of age, and Cox regression analysis to estimate hazard ratios (HR) from 4-8 years of age.

RESULTS

In cross-sectional analyses at the age of 4 no association was observed between adherence to MD and overweight, obesity, or abdominal obesity. In longitudinal analyses, a high adherence to MD at age 4 was associated with lower incidence of overweight (HR = 0.38; 95% CI: 0.21-0.67; p = 0.001), obesity (HR = 0.16; 95% CI: 0.05-0.53; p = 0.002), and abdominal obesity (HR = 0.30; 95% CI: 0.12-0.73; p = 0.008) at the age of 8.

CONCLUSION

This study shows that a high adherence to MD at the age of 4 is associated with a lower risk of developing overweight, obesity, and abdominal obesity at age 8. If these results are confirmed by other studies, MD may be recommended to reduce the incidence of obesity at early ages.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interventions for preventing obesity in children

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.

Cost-Effectiveness of the EdAl (Educació en Alimentació) Program: A Primary School-Based Study to Prevent Childhood Obesity

Background

The cost-effectiveness of childhood obesity prevention interventions is critical for their sustained implementation. This study evaluated the cost-effectiveness of the Educació en Alimentació (EdAl) program, a school-based intervention for reducing obesity.

Methods

Total EdAl program implementation costs and per-child costs were estimated. Cost-effectiveness, defined using the incremental cost-effectiveness ratio (ICER), was estimated as the difference between the intervention and control group costs divided by the obesity-related outcome effects for boys (avoided cases of obesity, obesity prevalence, body mass index [BMI], and BMI z-score units) for each group. As a significant difference (4.39%) in the reduction of obesity prevalence between the intervention and control groups was observed for boys in the EdAl program, the data were calculated only for boys.

Results

The intervention cost was 24,246.53 € for 1,550 children (15.64 €/child/3 years) or 5.21 €/child/year. The ICERs/boy were 968.66 € to avoid one case of obesity, 3.6 € to reduce the obesity prevalence by 1%, 44.68 € to decrease BMI by one unit, and 65.16 € to reduce the BMI z-score by one unit.

Conclusions

The cost of reducing the obesity prevalence in boys by 4.39% was 5.21 €/child/year, half the cost proposed by the Spanish Health Ministry, indicating that the EdAl program is cost-effective.

A workplace intervention to reduce alcohol and drug consumption: a nonrandomized single-group study

BACKGROUND

The consumption of alcohol and other drugs causes social and health problems in industrialized societies. Furthermore, alcohol and drug consumption in the workplace is associated with work accidents, absenteeism and low productivity. The aim of the current study is to reduce alcohol and drug consumption among workers in the service industry and, as a secondary aim, to improve their healthy habits through the reduction of alcohol and other drug consumption in their leisure time.

METHODS

This nonrandomized, single-group study was conducted in 12 work centers. The intervention began in 2009 and emphasized 1) health promotion and health monitoring, which included a) alcohol and drug awareness and b) the evaluation and monitoring of alcohol and drug consumption through a semistructured interview designed to assess risky consumption; urine tests aimed at detecting alcohol, cannabis and cocaine use; an Alcotest based on expired air to test for the recent consumption of alcohol and a saliva exam to test for the recent consumption of six drugs; and 2) secondary prevention if risky consumption was identified. Risky alcohol consumption was defined as the ingestion of more than 28 standard drink units (SDUs)/week among men and more than 17 SDUs/week among women (taking into account both work and leisure time). Drug consumption was considered risky consumption.

RESULTS

A total of 1103 workers participated, and each received 5 h of awareness training. Those who presented with risky consumption received secondary prevention training. The prevalence of risky alcohol consumption decreased by 4.1% (baseline: 14.7% reduced to 10.6% in the first year; p = 0.001), a reduction that was maintained over a 3-year follow-up period.

CONCLUSION

A comprehensive program of worker health surveillance that involves stakeholders and includes monitoring can be a means of potentially improving compliance with workplace promotion programs, resulting in the facilitation of such beneficial, desired behavior change in areas such as alcohol and drug consumption.

Interventions to prevent global childhood overweight and obesity: a systematic review

In view of the prevalence, health consequences, and costs of childhood obesity, there has been substantial interest in identifying effective interventions to prevent excess weight gain in young people. In this systematic review, we expand on previous reviews of obesity prevention interventions by including recent studies (until May 23, 2017) from all parts of the world. We searched MEDLINE, Embase, CINAHL Plus, Web of Science, CAB Abstracts, and PAIS Index and included randomised controlled trials, quasi-experimental studies, or natural experiments with: (1) a control group; (2) minimum follow-up of 12 months for community-based and home-based interventions or 6 months for school-based and preschool-based interventions; and (3) a primary outcome of BMI, BMI Z score, BMI percentile, body fat percentage, skinfold thickness, waist circumference, or prevalence of overweight or obesity. School-based interventions with combined diet and physical activity components and a home element (n=41) had greatest effectiveness; evidence in support of the effect of preschool-based (n=6), community-based (n=7), and home-based (n=2) interventions was limited by a paucity of studies and heterogeneity in study design. The effectiveness of school-based interventions that combined diet and physical activity components suggests that they hold promise for childhood obesity prevention worldwide. More research with rigorous evaluation and consistent reporting is needed in non-school settings and in combinations of settings.

Follow-up of a healthy lifestyle education program (the EdAl study): four years after cessation of randomized controlled trial intervention

BACKGROUND

An important challenge of school-based childhood obesity (OB) intervention programs is understanding the maintenance of the effects after cessation of the intervention to overcome the limitations of follow-up studies. The aim of this study is to verify the sustainability of the benefits achieved at a 4-year follow-up of the post-Educació en Alimentació (EDAl) program intervention cessation by assessing the OB-related outcomes and lifestyles of 13- to 15-year-old adolescents.

METHODS

This paper describes a 4-year follow-up study after the cessation of a school-based randomized controlled intervention in adolescents (n = 349, intervention; n = 154, control) with baseline and 4-year follow-up data from high schools in Reus (intervention group), Salou, Cambrils and Vila-seca (control group). The outcomes are body mass index (BMI), BMI z-score, and OB prevalence according to the World Health Organization and International Obesity Task Force criteria and lifestyle data (obtained from questionnaires).

RESULTS

Compared with the control girls, the intervention girls showed reduced BMI z-scores (-0.33 units, p < 0.01) from baseline (2007) to the 4-year follow-up post-intervention (2014). Compared with the control boys, the intervention boys showed reduced OB prevalence (-7.7%; p = 0.02). Compared with the control boys, more boys in the intervention group (19% increase; p = 0.059) showed ≥4 h/week after-school physical activity (PA). A decrease in the consumption of dairy products, fruits and fish was observed in both groups.

CONCLUSIONS

At the 4-year post-intervention follow-up of the EdAl program, compared with the control groups, girls had lower BMI z-scores and boys had lower OB prevalence from the intervention. The encouragement in after-school PA was long-lasting and maintained after the cessation of the intervention, whereas healthy food habits must be further reinforced in adolescents.

TRIAL REGISTRATION

ISRCTN29247645 .

[Improving diet quality in children through a new nutritional education programme: INFADIMED]

OBJECTIVE

To assess the results of a nutritional education programme developed by using available local resources to improve diet quality and decrease overweight and obesity prevalence among children.

METHOD

A longitudinal intervention study by means of nutritional education (INFADIMED) in children (aged 3-7 years) from Vilafranca del Penedès (Barcelona, Spain), recruited from preschool centres and primary schools, with an intervention or INFADIMED group (n=319; 50.2% female) and a control group (n=880; 49.8% female). Weight, height and body mass index were measured in both groups at the beginning and at the end of the programme. Adherence to the Mediterranean diet was also assessed using the KIDMED test.

RESULTS

Consumption of fruit or juices, vegetables, yogurt and/or cheese, pasta or rice, and nuts increased, while skipping breakfast, consumption of bakery products for breakfast, and/or consumption of sweets several times per day decreased in the INFADIMED group. INFADIMED also changed, from the beginning to the end of the study, the adherence to a Mediterranean diet: high (39.2% to 70.5%), acceptable (49.2% to 28.2%), and low (11.6% to 1.3%). Approximately 2.6% of the participants in the control group and 11.3% of the participants in the INFADIMED group who were overweight and obese changed to normal weight (odds ratio: 4.08; 95% confidence interval: 2.37-7.04).

CONCLUSIONS

INFADIMED is a nutritional education programme with benefits on both diet quality and overweight and obesity prevalence among children.

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

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

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

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

A School-Based Intervention to Reduce Excess Weight in Overweight and Obese Primary School Students

BACKGROUND

This study evaluated the effect of an intervention for reducing excess weight gain in primary school-age children in Tehran.

METHODS

A cluster-randomized controlled trial was conducted in 12 primary schools in Tehran. Three hundred thirty-four pupils, 167 in the intervention and 167 in the comparison group, determined to be overweight or obese based on World Health Organization standards, were recruited for the study. The intervention included nutrition education and increased physical activity (PA) for the pupils, lifestyle modification for parents, and a change in food items sold at the schools' canteens. The entire intervention lasted approximately 18 weeks. Measures were taken before and immediately after the intervention.

RESULTS

The intervention significantly reduced body mass index Z-score and hip circumference (p = .003 and p < .001, respectively). Waist circumference increased in both groups, but the increase was higher in the comparison group (p = .001). No significant difference was seen in time spent on TV viewing between groups (p = .08). Vigorous PA increased in the intervention group (p < .001), while the comparison group showed an increase in moderate activity only (p < .001). Energy intake increased significantly in the intervention group (p < .001). Neither triceps skinfold thickness nor time spent on the computer changed in the intervention group (p = .51 and p = .1, respectively), while they increased in the comparison group (p < .001 and p = .004, respectively).

CONCLUSION

The study provides a successful model for the implementation of similar interventions throughout the country.

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

CONTEXT

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

OBJECTIVE

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

DATA SOURCES

The PubMed, Cochrane, and ERIC databases were used.

STUDY SELECTION

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

DATA EXTRACTION

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Best (but oft-forgotten) practices: designing, analyzing, and reporting cluster randomized controlled trials

Cluster randomized controlled trials (cRCTs; also known as group randomized trials and community-randomized trials) are multilevel experiments in which units that are randomly assigned to experimental conditions are sets of grouped individuals, whereas outcomes are recorded at the individual level. In human cRCTs, clusters that are randomly assigned are typically families, classrooms, schools, worksites, or counties. With growing interest in community-based, public health, and policy interventions to reduce obesity or improve nutrition, the use of cRCTs has increased. Errors in the design, analysis, and interpretation of cRCTs are unfortunately all too common. This situation seems to stem in part from investigator confusion about how the unit of randomization affects causal inferences and the statistical procedures required for the valid estimation and testing of effects. In this article, we provide a brief introduction and overview of the importance of cRCTs and highlight and explain important considerations for the design, analysis, and reporting of cRCTs by using published examples.

Physical activity interventions in schools for improving lifestyle in European countries

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

Follow-up of a healthy lifestyle education program (the Educació en Alimentació Study): 2 years after cessation of intervention

PURPOSE

The Educació en Alimentació (EdAl) program conducted over 28 months in primary school children reduced obesity (OB) prevalence in boys and increased voluntary physical activity (PA). The continued benefit after cessation of EdAl is unknown. We assessed the changes in OB prevalence and healthy lifestyle in 11- to 13-year-old adolescents, the age group that had complete inclusion data available 2 years after the EdAl program's conclusion.

METHODS

Adolescents (n = 421 intervention; n = 198 control) with data at baseline and 2-year follow-up were recruited. Analyses included body mass index (BMI), BMI z-score, and lifestyle data (from questionnaires).

RESULTS

Between baseline and 2-year follow-up, OB prevalence was reduced (-5.5%; p < .01) and BMI z-score (-.29; p < .001) in intervention compared with control group. BMI z-score was effectively reduced in intervention in both genders: -.26 units in boys and -.32 units in girls, compared with control group. The ≥4 hours/week after-school PA was increased significantly by 13.1% in adolescents of intervention group compared with control group (p = .023); a tendency toward increased PA in intervention girls was observed (p = .062). At 2-year follow-up, participating in ≥4 hours/week after-school PA (odds ratio, .240; p = .002) and daily fruit consumption (odds ratio, .447; p = .025) were protective factors against OB, whereas ≤2 hours/week after-school PA was a risk factor for OB.

CONCLUSIONS

At 2-year follow-up, the EdAl program induced a lowering of BMI z-score and OB prevalence, compared with control group. After-school PA practice can be stimulated in primary school as part of a healthy lifestyle and maintained subsequently despite cessation of the intervention program.

EdAl-2 (Educació en Alimentació) programme: reproducibility of a cluster randomised, interventional, primary-school-based study to induce healthier lifestyle activities in children

OBJECTIVES

To assess the reproducibility of an educational intervention EdAl-2 (Educació en Alimentació) programme in 'Terres de l'Ebre' (Spain), over 22 months, to improve lifestyles, including diet and physical activity (PA).

DESIGN

Reproduction of a cluster randomised controlled trial.

SETTING

Two semi-rural town-group primary-school clusters were randomly assigned to the intervention or control group.

PARTICIPANTS

Pupils (n=690) of whom 320 constituted the intervention group (1 cluster) and 370 constituted the control group (1 cluster). Ethnicity was 78% Western European. The mean age (±SD) was 8.04±0.6 years (47.7% females) at baseline. Inclusion criteria for clusters were towns from the southern part of Catalonia having a minimum of 500 children aged 7-8 year; complete data for participants, including name, gender, date and place of birth, and written informed consent from parents or guardians.

INTERVENTION

The intervention focused on eight lifestyle topics covered in 12 activities (1 h/activity/session) implemented by health promoting agents in the primary school over three academic years.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was obesity (OB) prevalence and the secondary outcomes were body mass index (BMI) collected every year and dietary habits and lifestyles collected by questionnaires filled in by parents at baseline and end-of-study.

RESULTS

At 22 months, the OB prevalence and BMI values were similar in intervention and control groups. Relative to children in control schools, the percentage of boys in the intervention group who performed ≥4 after-school PA h/week was 15% higher (p=0.027), whereas the percentage of girls in both groups remained similar. Also, 16.6% more boys in the intervention group watched ≤2 television (TV) h/day (p=0.009), compared to controls; and no changes were observed in girls in both groups.

CONCLUSIONS

Our school-based intervention is feasible and reproducible by increasing after-school PA (to ≥4 h/week) in boys. Despite this improvement, there was no change in BMI and prevalence of OB.

TRIAL REGISTRATION NUMBER

Clinical Trials NCT01362023.

[Effectiveness of a school-based program to prevent obesity]

INTRODUCTION

Intervention for childhood obesity is a public health priority. The purpose of this study was to evaluate the effectiveness of an elementary school-based intervention against obesity in children.

MATERIAL AND METHODS

Non-randomised controlled trial was conducted on children from first to fifth grade from two public schools of Avilés (Spain). The intervention lasted for 2 school years comprising healthy diet workshops, educational chats, educational meetings, informative written material, and promotion of physical activities. Primary outcome measure was body mass index z-score. Secondary outcomes included: obesity and overweight prevalence, waist circumference, dietary habits, and physical activity.

RESULTS

A total of 382 (177 girls, 205 boys) out of 526 pupils of both schools were included in the study. Complete anthropometric data were obtained in 340 of the 382 individuals. Compared to children in control group, those in intervention group decreased body mass index z-score from 1.14 to 1.02 (P=.017), and improved KIDMED score from 7.33 to 7.71 points (P=.045). The percentage of students who carried on an optimal diet increased from 42.6% to 52.3% (P=.021). There were no statistical differences in the prevalence of obesity and overweight, or in waist circumference between the intervention and control groups.

CONCLUSIONS

This school-based program resulted in modest beneficial changes in body mass index and diet quality.