The CHIRPY DRAGON intervention in preventing obesity in Chinese primary-school--aged children: A cluster-randomised controlled trial

The Overflow Effects of Movement Behaviour Change Interventions for Children and Adolescents: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Considering the finite time within a 24-h day, the distribution of time spent on movement behaviours has been found to be associated with health outcomes.

OBJECTIVES

This systematic review and meta-analysis aimed to summarise and evaluate the overflow effects of interventions targeting a single behaviour (physical activity, sedentary behaviour/screen time, or sleep) on other non-targeted behaviours among children and adolescents.

METHODS

Six databases (MEDLINE [Ovid], PsycINFO [ProQuest], EMBASE [Ovid], PubMed, Web of Science and SPORTDiscus [EBSCO]) were searched for relevant studies published before 13 May, 2024. Randomised controlled trials and clustered randomised controlled trials that targeted a single behaviour and also assessed the effects on non-targeted behaviours, comprised of healthy children under the age of 18 years, were included. Movement behaviours can be measured either objectively or subjectively. The revised Cochrane risk-of-bias tool for randomised trials was adopted to evaluate the risk of bias.

RESULTS

A total of 102 studies with 45,998 participants from 21 countries were identified, and 60 of them with 26,183 participants were incorporated into the meta-analysis. The meta-analysis demonstrated that physical activity interventions led to a reduction in the proportion of each day spent in sedentary behaviour (mean difference =  - 0.95% of wear time, 95% confidence interval - 1.44, - 0.45, I2 = 39%). Sedentary behaviour interventions resulted in increased standing time (mean difference = 3.87%, 95% confidence interval 1.99, 5.75, I2 = 0%). Interventions targeting screen time did not yield changes in physical activity or sleep. The findings on the effectiveness of sleep interventions on non-targeted behaviours and of physical activity interventions on sleep were inconclusive.

CONCLUSIONS

Overall, the findings suggested that interventions aimed at increasing physical activity or reducing sedentary behaviour had overflow effects on non-targeted behaviours, but the effect sizes were small. Additional evidence is needed to reach definitive conclusions regarding the impact of behaviour change interventions on sleep and of the overflow effects of sleep interventions.

The Return on Investment for the Prevention and Treatment of Childhood and Adolescent Overweight and Obesity in Beijing: A Modeling Study

Background: The increasing prevalence of child and adolescent overweight and obesity (CAOAO) in Beijing poses significant health and economic challenges. This study assesses the potential health and economic outcomes of implementing specific interventions to address CAOAO in Beijing. Methods: A deterministic Markov cohort model was used to estimate the impact of five interventions from 2025 to 2115: restrictions on unhealthy food marketing to children, mandatory front of package labeling (FOPL), family-based nutrition and exercise education, school-based nutritional health education, and nutritional counseling in primary healthcare. The model evaluated societal costs, healthcare savings, wages, and economic productivity in adulthood, calculating the return on investment (ROI) for each intervention and their combined effect. Result: Without intervention, Beijing is projected to experience a loss of 13.4 million disability-adjusted life years (DALYs) due to CAOAO. The health and economic impact of childhood obesity in Beijing is projected to be CNY 14.6 trillion (USD 2.1 trillion), or a lifetime loss of CNY 6.8 million (USD 0.96 million) per affected child, exceeding the sum of Beijing's GDP from 2021 to 2023. Restrictions on unhealthy food marketing to children and nutrition counseling in primary healthcare are projected to yield the highest returns, with benefits accruing within one year of implementation. Owing to the substantial upfront costs, including personnel, materials, and training, school-based and family-based interventions require a longer time horizon to realize significant health and economic benefits. Conclusions: Effective management of CAOAO in Beijing demands a multifaceted approach. The combination of restrictions on unhealthy food marketing to children, mandatory front of package labeling, nutrition counseling in primary healthcare, school-based intervention, and family-based intervention presents the most substantial health and economic returns. This comprehensive strategy aligns with global best practices and addresses the unique challenges faced by Beijing in combating childhood obesity.

Childhood obesity and comorbidities-related perspective and experience of parents from Black and Asian minority ethnicities in England: a qualitative study

Background

Preventing childhood obesity and associated comorbidities is often hampered by disproportionate disparity in healthcare provision in minority ethnic populations. This study contextualized factors influencing childhood obesity and related comorbidity from the perspectives and experiences of parents of ethnic minority populations.

Methods

Following ethical approval, families (n = 180) from ethnic minority populations in the Northeast of England were contacted through flyers, community social groups and online forum. Of the 180 families contacted, 22 expressed interests, of whom 12 parents were eligible to participate in the study, and one family dropped out due to time constraints. Therefore 11 parents from ethnic minority communities living with at least one child with obesity were interviewed. Each family was separately visited at home and took part in a semi-structured interview based on the study's qualitative, descriptive phenomenological design. Nine of the families had one child who was diagnosed with an obesity-related comorbidity (non-alcoholic fatty liver disease, musculoskeletal problems or respiratory disorder). Semi-structured interviews were standardized around parents' perspective and experience on how their children were impacted by obesity and comorbidities, healthcare preventative interventions including lifestyle physical activity and nutrition, and views on tackling obesity impact on their lives. All interviews were analyzed using qualitative thematic analysis.

Results

Parents' perspectives revealed 11 themes centered around experience of living with a child with obesity, risks, and impact of obesity related Non-Communicable Diseases; and access to support, and barriers unique to minority ethnic groups. Parents revealed social disadvantages, fear of victimization by social services, perceptions on their cultural and religious traditions, and racial stigmatization related to their child's weight. Parents reported closer bonding with their children to protect them from the untoward consequences of overweight, and little awareness of healthcare obesity prevention programs. Work pressure, lack of time, absence of guidance from professionals were seen as barriers to healthy lifestyle, while support from friends and closer family bond in adopting healthy lifestyle behaviors were facilitators. However, there was little awareness or access to current healthcare obesity preventive offerings.

Conclusion

Minority ethnic communities' perspective on childhood obesity prevention does not match the healthcare system preventative offerings. Community and family-oriented obesity preventative approaches, especially lifestyle interventions are needed beyond those administered by the primary healthcare system.

The range of outcomes and outcome measurement instruments collected in multisectoral community-based obesity prevention interventions in children: A systematic review

Multicomponent and multisectoral community-based interventions (CBIs) have proven potential in preventing overweight and obesity in children. Synthesizing evidence on the outcomes collected and reported in such CBIs is critical for the evidence of effectiveness and cost-effectiveness. This systematic review aimed to identify the range of outcomes and outcome measurement instruments collected and reported in multisectoral and multicomponent CBIs for obesity prevention in children. A systematic search updated an existing review and extended the search to 11 academic databases (2017-2023) and gray literature. Outcomes were classified into outcome domains, and common measurement instruments were summarized. Seventeen outcome domains from 140 unique outcomes were identified from 45 included interventions reported in 120 studies. The most frequently collected outcome domains included anthropometry and body composition (91% of included interventions), physical activity (84%), dietary intake (71%), environmental (71%), and sedentary behavior (62%). The most frequently collected outcomes from each of these domains included body mass index (89%), physical activity (73%), fruit and vegetable intake (58%), school environment (42%), and screen time (58%). Outcome measurement instruments varied, particularly for behavioral outcomes. Standardization of reported outcomes and measurement instruments is recommended to facilitate data harmonization and support quantifying broader benefits of CBIs for obesity prevention.

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.

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

The cost-effectiveness of school-based interventions for chronic diseases: a systematic review

BACKGROUND

Chronic diseases, or non-communicable diseases (NCD), are conditions of long duration and often influenced and contributed by complex interactions of several variables, including genetic, physiological, environmental, and behavioral factors. These conditions contribute to death, disability, and subsequent health care costs. Primary and secondary school settings provide an opportunity to deliver relatively low cost and effective interventions to improve public health outcomes. However, there lacks systematic evidence on the cost-effectiveness of these interventions.

METHODS

We systematically searched four databases (PubMed/Medline, Cochrane, Embase, and Web of Science) for published studies on the cost-effectiveness of chronic-disease interventions in school settings. Studies were eligible for inclusion if they assessed interventions of any chronic or non-communicable disease, were conducted in a school setting, undertook a full cost-effectiveness analysis and were available in English, Spanish, or French.

RESULTS

Our review identified 1029 articles during our initial search of the databases, and after screening, 33 studies were included in our final analysis. The most used effectiveness outcome measures were summary effectiveness units such as quality-adjusted life years (QALYs) (22 articles; 67%) or disability-adjusted life years (DALYs) (4 articles; 12%). The most common health condition for which an intervention targets is overweight and obesity. Almost all school-based interventions were found to be cost-effective (30 articles; 81%).

CONCLUSION

Our review found evidence to support a number of cost-effective school-based interventions targeting NCDs focused on vaccination, routine physical activity, and supplement delivery interventions. Conversely, many classroom-based cognitive behavioral therapy for mental health and certain multi-component interventions for obesity were not found to be cost-effective.

Cost-effectiveness analysis of individual-level obesity treatment in paediatrics: A scoping review

OBJECTIVES

This scoping review informs a health economics perspective on the treatment of paediatric obesity. The results detail recently published research findings on the cost-effectiveness of paediatric obesity treatments and identify key characteristics of cost-effective interventions.

METHODS

A structured search was applied to six databases with no data restriction through March 2023: Medline, Embase, Cochrane CENTRAL, CINAHL, and PsycINFO. Studies that included a cost analysis of an individual level, weight management intervention (behavioural, pharmacotherapy, and surgical) in youth, with obesity, ages 2 to 21 years were eligible for inclusion.

RESULTS

Of the 4371 records identified in the initial search, 353 underwent full-text review, 39 studies met the pre-specified inclusion criteria. The majority were published after 2010 (n = 36/39, 92%) and applied to high-income countries (n = 39/39, 100%). Thirty-five of the studies assessed the cost-effectiveness of lifestyle interventions (90%), and four studies assessed surgical outcomes (10%). No pharmacotherapy studies met eligibility criteria. Although the outcome measures differed across the studies, all four surgical interventions were reported to be cost-effective. Thirty of the 35 (85%) lifestyle modification studies were reported to be cost-effective compared to the study comparator examined.

CONCLUSIONS

There is a small amount of evidence that individual-level paediatric obesity treatment interventions are cost-effective and, in some cases cost-saving, with most of this work conducted on behavioural interventions. The economic evaluation of paediatric obesity interventions poses various methodologic challenges, which should be addressed in future research to fully use the potential of economic evaluation as an aid to decision-making.

Study Protocol for a Controlled Trial of Nutrition Education Intervention about Celiac Disease in Primary School: ZELIAKIDE Project

The only treatment for celiac disease (CD) is a strict and lifelong gluten-free diet (GFD), which must be safe and nutritionally balanced. Avoiding gluten brings difficulties with following the diet and can affect the social life of people with CD. The Zeliakide Project is a nutrition education program aimed at increasing the knowledge of the general population about healthy diets, CD and GFD, and, therefore, to improve the social inclusion and quality of life of people with CD. It is a one-month intervention program, two-armed cluster, non-randomised and controlled trial, conducted among 10-12-year-old children. Pre- and post-intervention evaluation and 1 month follow-up will be carried out to assess the effectiveness of the program. It is based on competencies and their respective learning outcomes. The teaching methodology chosen is a STEAM methodology: inquiry-based learning (IBL). A teaching unit has been created to develop the project, which, in the future, will be useful for the self-application of the program. This study will provide a valid and useful tool to achieve changes in the diet at the school level and will help to promote the social inclusion of people with CD. Moreover, it will enforce the STEAM competences of children.

Incentive based emergency demand response effectively reduces peak load during heatwave without harm to vulnerable groups

The incentive-based emergency demand response measure serves as an important regulatory tool during energy system operations. However, whether people will sacrifice comfort to respond to it during heatwave and what the effect on heat vulnerable populations will be are still unclear. A large-scale emergency demand response pilot involving 205,129 households was conducted in southwestern China during continuous extreme high temperatures in summer. We found that the incentive-based emergency demand response causes a statistically significant decline in electricity use with no additional financial burden on vulnerable groups. The electricity conservation potential of urban households was higher than that of rural households. Households with children did not respond to the emergency demand response, while the response of households with elderly individuals proved to be more positive. The repeated and frequent implementation of this policy did not result in an attenuation of the regulatory effect. This research can serve as a reference for countries with similar regulated power markets.

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.

Recent progress in plant-derived polysaccharides with prebiotic potential for intestinal health by targeting gut microbiota: a review

Natural products of plant origin are of high interest and widely used, especially in the food industry, due to their low toxicity and wide range of bioactive properties. Compared to other plant components, the safety of polysaccharides has been generally recognized. As dietary fibers, plant-derived polysaccharides are mostly degraded in the intestine by polysaccharide-degrading enzymes secreted by gut microbiota, and have potential prebiotic activity in both non-disease and disease states, which should not be overlooked, especially in terms of their involvement in the treatment of intestinal diseases and the promotion of intestinal health. This review elucidates the regulatory effects of plant-derived polysaccharides on gut microbiota and summarizes the mechanisms involved in targeting gut microbiota for the treatment of intestinal diseases. Further, the structure-activity relationships between different structural types of plant-derived polysaccharides and the occurrence of their prebiotic activity are further explored. Finally, the practical applications of plant-derived polysaccharides in food production and food packaging are summarized and discussed, providing important references for expanding the application of plant-derived polysaccharides in the food industry or developing functional dietary supplements.

Experiences, Perspectives, and Barriers to Physical Activity Parenting Practices for Chinese Early Adolescents

BACKGROUND

Parents play an important role in shaping youth's lifestyle behaviors. This study aimed to investigate physical activity parenting practices (PAPP) for Chinese early adolescents and compare reporting discrepancies between parents and adolescent boys and girls.

METHODS

Fifty-five adolescent-parent dyads participated in 16 paired focus group interviews, and an additional 122 dyads completed questionnaire surveys with open-ended questions. Participants were recruited from 3 public middle schools in Suzhou, China. Qualitative data were analyzed inductively using an open-coding scheme. Frequencies of codes were compared by parent-child role and adolescent gender using chi-square tests.

RESULTS

Eighteen types of PAPP were identified and grouped into 6 categories: goals/control, structure, parental physical activity participation, communication, support, and discipline. These PAPP were viewed as promotive, preventive, or ineffective. Participants had mixed opinions on the effects of 11 PAPP and identified parental, adolescent, and environmental barriers for parents to promote youth physical activity. Compared with parents, adolescents were more likely to value the effects of setting expectation, scheduling, and coparticipation as well as dislike pressuring, restriction, and punishment. Girls were more likely to favor coparticipation and were more sensitive about negative communication than boys. Parents paid more attention to environmental barriers, whereas adolescents, especially girls, focused more on personal issues.

CONCLUSIONS

Future studies need to address both positive and negative PAPP as well as perception discrepancies by child-parent role and adolescent gender to generate more evidence to promote parents as favorable socialization agents of youth physical activity.

The ALINFA Intervention Improves Diet Quality and Nutritional Status in Children 6 to 12 Years Old

The study aimed to evaluate the efficacy of a new nutritional intervention, focused on improving the quality of the diet in children aged 6 to 12 years. A 2-month parallel, controlled randomized trial was conducted in the Spanish child population. The children were randomized to ALINFA nutritional intervention, which consisted of a normocaloric diet that incorporates products, ready-to-eat meals and healthy recipes specifically designed for the study, or a control group, which received the usual advice on healthy eating. The change in diet quality was assessed through the Kidmed index. The secondary outcomes were anthropometry, glucose and lipid profiles, inflammation markers, dietary intake and lifestyle. The participants in the intervention group showed an increase in the mean score of the Kidmed index (p < 0.001). Alongside that, these children decreased their intake of calories (p = 0.046), and total and saturated fat (p = 0.016//p = 0.011), and increased fiber intake (p < 0.001). Likewise, the children in the ALINFA group increased the intake of white fish (p = 0.001), pulses (p = 0.004), whole grains (p < 0.001) and nuts (p < 0.001), and decreased fatty meat (p = 0.014), refined grain (p = 0.008), pastry (p < 0.001), fast food (p < 0.001) and sugar (p = 0.001) intake. Moreover, these children had a significantly decreased BMI (p < 0.001), BMI z-score (p < 0.001), waist circumference (p = 0.016) and fat mass (p = 0.011), as well as leptin (p = 0.004). Participants in the control group did not report significant changes in diet quality. In conclusion, ALINFA nutritional intervention is possibly a useful strategy to increase the diet quality in children, which is associated to improvements in the nutritional status. These results highlight the importance of developing well-designed nutritional interventions.

Recommendations for the prevention and management of obesity in the Iraqi population

Obesity is a chronic metabolic disease that has become one of the leading causes of disability and death in the world, affecting not only adults but also children and adolescents. In Iraq, one third of the adult population is overweight and another third obese. Clinical diagnosis is accomplished by measuring body mass index (BMI) and waist circumference (a marker for intra-visceral fat and higher metabolic and cardiovascular disease risk). A complex interaction between behavioral, social (rapid urbanization), environmental and genetic factors underlies the etiology of the disease. Treatment options for obesity may include a multicomponent approach, involving dietary changes to reduce calorie intake, an increase in physical activity, behavioral modification, pharmacotherapy and bariatric surgery. The purpose for these recommendations is to develop a management plan and standards of care that are relevant to the Iraqi population and that can prevent/manage obesity and obesity-related complications, for the promotion of a healthy community.

Interventions to prevent obesity in school-aged children 6-18 years: An update of a Cochrane systematic review and meta-analysis including studies from 2015-2021

Background

Childhood obesity remains a global public health priority due to the enormous burden it generates. Recent surveillance data suggests there has been a sharp increase in the prevalence of childhood obesity during the COVID-19 pandemic. The Cochrane review of childhood obesity prevention interventions (0-18 years) updated to 2015 is the most rigorous and comprehensive review of randomised controlled trials (RCTs) on this topic. A burgeoning number of high quality studies have been published since that are yet to be synthesised.

Methods

An update of the Cochrane systematic review was conducted to include RCT studies in school-aged children (6-18 years) published to 30 June 2021 that assessed effectiveness on child weight (PROSPERO registration: CRD42020218928). Available cost-effectiveness and adverse effect data were extracted. Intervention effects on body mass index (BMI) were synthesised in random effects meta-analyses by setting (school, after-school program, community, home), and meta-regression examined the association of study characteristics with intervention effect.

Findings

Meta-analysis of 140 of 195 included studies (183,063 participants) found a very small positive effect on body mass index for school-based studies (SMD -0·03, 95%CI -0·06,-0·01; trials = 93; participants = 131,443; moderate certainty evidence) but not after-school programs, community or home-based studies. Subgroup analysis by age (6-12 years; 13-18 years) found no differential effects in any setting. Meta-regression found no associations between study characteristics (including setting, income level) and intervention effect. Ten of 53 studies assessing adverse effects reported presence of an adverse event. Insufficient data was available to draw conclusions on cost-effectiveness.

Interpretation

This updated synthesis of obesity prevention interventions for children aged 6-18 years, found a small beneficial impact on child BMI for school-based obesity prevention interventions. A more comprehensive assessment of interventions is required to identify mechanisms of effective interventions to inform future obesity prevention public health policy, which may be particularly salient in for COVID-19 recovery planning.

Funding

This research was funded by the National Health and Medical Research Council (NHMRC), Australia (Application No APP1153479).

Effectiveness of school-based interventions targeting physical activity and sedentary time among children: a systematic review and meta-analysis of accelerometer-assessed controlled trials

OBJECTIVES

To date, no meta-analysis has examined the influence of specific intervention characteristics in the overall effectiveness of school-based interventions measured only with accelerometer devices. Thus, the main purpose of this systematic review and meta-analysis was to evaluate the overall and specific variables of the effectiveness of school-based interventions assessed with accelerometer devices among children aged 5-12 years.

STUDY DESIGN

A systematic review and meta-analysis to assess the effectiveness of school-based interventions.

METHODS

Studies published in English, French and Spanish from five electronic databases between January 2010 and December 2021 were identified. Intervention designs with control group measure that assessed daily moderate-to-vigorous physical activity (MVPA) and sedentary time (ST) with accelerometer devices in children aged 5-12 years were included.

PROSPERO ID

CRD42022326859.

RESULTS

A total of 24 trials comprising of 19,487 children (51.3% girls) were included. Intervention studies were ineffective for improving daily MVPA (Hedges' g = 0.07, 95% confidence interval [CI] -0.03 to 0.17; I² = 84.80%) but were effective for reducing ST (g = -0.08, 95% CI -0.12 to -0.03; I² = 20.94%). Also, subgroup analyses for MVPA revealed that when studies had two intervention components (g = 0.21, 95% CI 0.06-0.36; I² = 77.67%), and high quality (g = 0.12, 95% CI 0.01-0.22; I² = 88.30%) they were effective.

CONCLUSION

School-based interventions have been effective to reduce children's daily time spent in ST. There is no evidence of overall effectiveness of school-based interventions for enhancing daily MVPA in children. Nevertheless, improving the quality of interventions and interventions with two components are effective to increase students' daily MVPA.

Survey of South Carolina Public School Personnel Perspectives on Barriers and Facilitators to Regular Physical Activity and Healthy Eating Behaviors in Schools

BACKGROUND

In South Carolina (SC), 42% of youth are overweight or obese. Two sets of modifiable behaviors contributing to obesity are physical activity (PA) and dietary habits. School-based interventions have successfully improved these behaviors. The purpose of this study was to identify SC public school personnel perspectives on the most common barriers and facilitators to regular PA and healthy eating behaviors in schools.

METHODS

A needs assessment survey was conducted with school personnel statewide. There were 17 questions on the survey that addressed: (1) demographic information about participants' educational backgrounds, (2) barriers to regular PA and healthy eating behaviors in schools, and (3) facilitators to regular PA and healthy eating behaviors in schools. Univariate and bivariate descriptive statistical analyses were performed using IBM SPSS Statistics 27.

RESULTS

Participants (N = 1311) indicated insufficient time for regular PA (n = 514, 39.2%) and limited access to healthy foods for healthy eating (n = 271, 20.7%) as main barriers. The primary facilitators were support from administrators for regular PA (n = 264, 20.1%) and support from cafeteria staff for healthy eating (n = 234, 17.8%). Further analyses explored how factors compared based on roles in schools, academic levels, and school district classifications.

CONCLUSIONS

Results suggest that overarching barriers and facilitators to school-based interventions addressing childhood obesity exist, so common strategies to mitigate challenges and maximize supports can be used in schools. Future studies are needed to examine how decreasing barriers and enhancing facilitators affect the implementation and outcomes of these school-based interventions.

Relationship between energy balance-related behaviors and personal and family factors in overweight/obese primary school students aged 10-12 years in China: a cross-sectional study

Background

Increasing rates of childhood obesity worldwide are a serious threat to the health of school-aged children. Unhealthy behavioral habits are modifiable factors in the control of childhood obesity, and personal and family factors are key influencing factors of behavioral habits in school-aged children. This study assessed the relationship between overweight/obesity, energy balance-related behaviors (EBRB), and their influencing factors in school-aged children.

Methods

This cross-sectional survey included 4412 primary school-aged (10–12 years) students who underwent body tests and were selected through stratified sampling in the Northeast, North, Northwest, and Southwest regions of China from March to July 2021. Independent sample t test was used to compare differences between behaviors and influencing factors of energy balance among overweight/obesity and normal weight students. Logistic regression analysis was used to assess the influence of EBRB on body shape. Multiple linear regression was used to assess the influence of personal and family factors on EBRB effects.

Results

Compared with normal-weight students, number of breakfasts consumed per week by overweight/obese students was significantly lower (p < 0.01), and weekly screen-viewing time was significantly longer (p < 0.01). Overweight/obese students’ health beliefs, parental subjective norms, parental modelling, parental practices, and home availability scores increased significantly in terms of beverage consumption behavior (p < 0.01 or p < 0.05). Attitude, health beliefs, self-efficacy, parental subjective norms, and parental support scores decreased significantly in terms of breakfast consumption (p < 0.01 or p < 0.05). Health belief scores on physical activity increased significantly (p < 0.01), while preference and autonomy scores decreased significantly (p < 0.01). Health beliefs, parental subjective norms, and parental practices scores of screen-viewing activities increased significantly (p < 0.01 or p < 0.05). Breakfast consumption (odds ratio [OR]: 0.911; 95% confidence interval [CI]: 0.870–0.954) and screen-viewing activities (OR:1.055; 95% CI: 1.030–1.080) correlated negatively and positively with overweight/obesity, respectively. The main influencing factors of breakfast behavior in overweight/obese students were self-efficacy (0.14), preference (0.11), attitude (0.07), home availability (0.18), and parent modelling (0.09); those for screen-viewing behavior were preference (0.19), self-efficacy (− 0.15), parental practices (0.13), and parental subjective norm (0.12).

Conclusions

Irregular breakfast consumption and excessive screen-viewing time are key EBRB associated with overweight/obesity among these Chinese participants. Their unhealthy breakfast consumption and screen-viewing activities result from a combination of personal and family factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14238-x.

Total and Added Sugar Intakes Are Increasing among Children and Adolescents in China: Findings from CHNS 1997-2011

A high level of sugar intake has been linked to poor dietary quality and a wide range of chronic diseases. However, data on sugar intake are still scarce in China. This study aimed to provide time trends in the total and added sugar intakes among Chinese children and adolescents from 1997 to 2011. A nationwide ongoing open prospective cohort study of Chinese children and adolescents aged 3−17 years (n = 13,212) was conducted by using data from the China Health and Nutrition Survey (CHNS) 1997−2011 (six 1-year cycles). An individual dietary intake was collected from three consecutive 24-h recalls during randomly allocated home visits. Data for total and added sugar contents were determined based on the U.S. Department of Agriculture (USDA) National Nutrient Database for Standard Reference, Release 28 (SR28), the Food Patterns Equivalents Database (FPED) 2015−2016, and the labeled ingredients and nutrient contents. General linear regression was used to estimate time trends. Over the 15-year period, total sugar and added sugar intakes increased among all age groups studied (3−17 years: total sugar increased from 11.2 ± 0.3 g/d to 28.1 ± 0.5 g/d, added sugar increased from 1.0 ± 0.1 g/d to 7.2 ± 0.3 g/d; 3−6 years: 9.5 ± 0.6 g/d to 25.1 ± 0.9 g/d, 1.3 ± 0.2 g/d to 6.9 ± 0.4 g/d; 7−12 years: 11.4 ± 0.5 g/d to 28.1 ± 0.8 g/d, 0.9 ± 0.1 g/d to 7.1 ± 0.5 g/d; 13−17 years: 11.8 ± 0.4 g/d to 31.4 ± 1.1 g/d, 1.0 ± 0.2 g/d to 7.6 ± 0.6 g/d) (all p for trend < 0.001). Adolescents aged 13−17 years had the highest total sugar intake, and children aged 3−6 years had the highest added sugar intake, except for 2011. Children and adolescents living in urban areas and who were overweight had much higher total and added sugar intakes than those residing in rural areas and of non-overweight/obesity. Furthermore, the dietary sources of total and added sugars have become more diverse over the study period. In conclusion, we observed a notable rise in total and added sugar intakes among children and adolescents across all age groups, both genders, both urban and rural areas, and all BMI categories, with dietary sources of total and added sugars becoming more diverse in China over 15 years.

The Effect of a Multifaceted Intervention on Dietary Quality in Schoolchildren and the Mediating Effect of Dietary Quality between Intervention and Changes in Adiposity Indicators: A Cluster Randomized Controlled Trial

Some studies have found associations between dietary quality and obesity and their concurrent changes were observed in a few interventions. The present study aimed to assess the effect of a multifaceted intervention for childhood obesity on dietary quality and examine the mediating effect of dietary quality between the intervention and changes in adiposity indicators. Based on the social ecological model, the cluster randomized controlled trial included five components (three targeted children and two targeted their environment). In total, 1176 children from three cities in China participated in a baseline (2018) and end-of-trial (2019) examination, including 605 children in the intervention group and 571 in the control group. Self-reported behavior and anthropometric measures were collected at both time points. The Diet Balance Index Revision (DBI-07) was calculated to assess dietary quality. Generalized linear mixed models were used to estimate the intervention effect on dietary quality and its mediating effects were examined. Compared to the controls, the proportion of sugar-sweetened beverage (SSB) intake (OR = 0.27, p < 0.001, corrected p < 0.001) decreased in the intervention group. Higher bound scores (HBS) of the DBI-07 indicating over-intake decreased in the intervention group compared to the controls (mean difference = −1.52, p = 0.005, corrected p = 0.015). Changes in the HBS partially mediated the associations between the intervention and changes in body mass index, waist circumference, and body fat percentage. Future intervention should promote knowledge, attitudes, and behaviors related to dietary quality.

Infancy Dietary Patterns, Development, and Health: An Extensive Narrative Review

Correct dietary patterns are important for a child’s health from birth to adulthood. Understanding a child’s health as a state of entire physical, mental, and social well-being is essential. However, reaching adulthood in a complete health proper state is determined by feeding and dietary habits during preconception, pregnancy, or children infancy. Different factors, such as the mother’s lifestyle, culture, or socioeconomic status, are crucial during all these phases. In this review, we aimed to assess the long-term associations between infancy dietary patterns and health and their influence on development and growth. To reach this objective, a consensus critical review was carried out using primary sources such as scientific articles, and secondary bibliographic indexes, databases, and web pages. PubMed, SciELO, and Google Scholar were the tools used to complete this research. We found that high-income countries promote high-calorie foods and, consequently, obesity problems among children are rising. However, undernutrition is a global health issue concerning children in low- and middle-income countries; thus, parental socioeconomic status in early life is essential to children’s health and development, showing that biological, social, and environmental influences are increased risk factors for chronic diseases. This narrative review is aimed to collect evidence for early nutritional intervention and future disease prevention.

Describing South Carolina Public School Administrators' Perceptions and Experiences Related to School-Based Interventions and Strategies to Promote Healthy Physical Activity and Eating Behaviors: A Qualitative Study

BACKGROUND

School-based interventions and strategies targeting physical activity (PA) and eating patterns have successfully addressed unhealthy behaviors contributing to excess weight in school-age children. The purpose of this study was to investigate South Carolina (SC) public school administrators' perceptions of and experiences with weight-related issues in schools and associated barriers and facilitators to awareness, selection, and implementation of school-based healthy PA and eating interventions and strategies.

METHODS

This qualitative descriptive study, guided by the Social Ecological Model and the Steps in Quality Intervention Development Model, involved semistructured interviews with SC public school administrators from all academic levels (N = 28). Data were analyzed using thematic analysis.

RESULTS

Four themes were identified from interviews (N = 28): weight-related terminology or stigma, experiences with school-based healthy PA and eating interventions and strategies, barriers to school-based healthy PA and eating interventions and strategies, and facilitators to school-based healthy PA and eating interventions and strategies.

CONCLUSIONS

Schools are well-positioned to provide interventions and strategies to improve PA and dietary habits leading to childhood obesity. School administrators, while knowledgeable and experienced with weight-related issues and school-based interventions and strategies, encounter barriers and facilitators that impact offerings and delivery. Understanding these challenges and supports is important in the development, adaptation, and implementation of school-based interventions and strategies focused on healthy PA and eating behaviors.

The prevalence of hypertension and elevated blood pressure and its correlation with overweight/obesity among students aged 6-17 years in Suzhou

OBJECTIVES

Lifestyle changes have led to an increase in the prevalence of hypertension in Chinese children and adolescents. The aim of this study was to analyze the prevalence of hypertension and its association with overweight and obesity among students aged 6-17 years in Suzhou. This retrospective analysis included physical examination data of primary and junior high school students in Suzhou Industrial Park from 2016 to 2019.

METHODS

Elevated blood pressure and hypertension were defined using blood pressure criteria appropriate for age, sex, and height percentile. Overweight and obesity were defined using the 2007 diagnostic criteria proposed by the World Health Organization for school-age children. Logistic regression analysis was used to evaluate the association between hypertension and overweight and obesity.

RESULTS

A total of 128,113 students were included. The prevalence of elevated BP and hypertension was 9.92% and 13.56%, respectively. The incidence of high blood pressure was higher in boys than in girls and increased with an increase in body mass index (BMI). The prevalence of hypertension in obese boys and girls (27.07% and 27.49%, respectively) was 2.3-fold and 2.8-fold higher than that in normal-weight boys and girls (11.58% and 9.83%, respectively).

CONCLUSIONS

Blood pressure was positively correlated with BMI, and the risk of high blood pressure due to overweight/obesity was 10.44%. Overweight and obesity significantly increased the risk of hypertension in students aged 6-17 years in Suzhou. Targeted weight-loss programs during childhood and adolescence may reduce the risk of hypertension in adulthood.

Relationship Between Weight Status and Health-Related Quality of Life in School-age Children in China

Background: Some studies from high-income countries suggest that overweight and/or obesity in children are negatively associated with health-related quality of life (HRQOL). However, the relationship between weight status and HRQOL is not well established in China, where obesity trends follow a different pattern compared with high-income countries. The risk of obesity is greater in children from higher socioeconomic backgrounds and higher in boys compared with girls. Objective: The aim of this study was to examine the relationship between weight status and HRQOL in children between 6 and 7 years old in this unique country context. Methods: Baseline HRQOL and demographic data were collected from children recruited to the CHIRPY DRAGON obesity prevention trial in China. HRQOL was measured using the Chinese version of the Child Health Utility-9D (CHU-9D-CHN) and the Pediatric Quality of Life Inventory™ (PedsQL™) instruments. CHU-9D-CHN utility scores were generated using 2 scoring algorithms (UK and Chinese tariffs). Height and weight measures were taken at school by trained researchers using standardized methods, and BMI z scores were calculated using the World Health Organization 2007 growth charts. The relationship between HRQOL and weight status was examined using multivariable analyses, adjusting for age, gender, and socioeconomic status. Results: Full data were available for 1539 children (mean age, 6 years). In both unadjusted and adjusted analyses, HRQOL, using both the CHU-9D-CHN and the PedsQL™, was marginally higher in children who were overweight or living with obesity compared with children with healthy weight, although this difference did not reach statistical significance. Separate analyses and models by gender showed that the relationship between weight status and HRQOL scores was similar in boys and girls. Conclusions: Our results suggest no statistically significant difference in HRQOL between children with overweight/obesity compared with those with healthy weight. These results have implications for the methods of economic evaluation for obesity treatment and prevention interventions within this population cohort and country setting, as there appears to be no discernible consequences on children's HRQOL from living with overweight and obesity.

Effectiveness of education intervention to reduce sugar-sweetened beverages and 100% fruit juice in children and adolescents: a scoping review

OBJECTIVE

To determine the impact of educational intervention in reducing the consumption of sugar-sweetened beverages (SSBs) and 100% fruit juice in children and adolescents.

DESIGN

We conducted a comprehensive Ovid Medline and Scopus search. Articles had to be peer-reviewed, full-text and published in English. Studies had to be controlled intervention, published between 1 January 2010 to 7 February 2021, and in children and adolescents. Study quality was measured using the Quality Assessment Tool for Controlled Intervention Studies.

RESULTS

Forty intervention articles were included in this review involving 25,069 children and adolescents. All studies employed a quantitative research method using the Randomized Controlled Trial designs. Twenty-eight out of forty interventions used psychosocial theories. Study quality ranged from 'fair' to 'good.' Results showed that education intervention effectively reduced SSBs, and reduced 100% fruit juice in children.

EXPERT OPINION

Reducing the SSBs consumption in children should be initiated by conducting school-based programs consisting of interactive learning process, psychosocial theories and the involvement of parents or caregivers. Theories that focus on personal, behavior and environment factors improve the effectiveness of the intervention. More research is warranted to investigate the impacts of 100% fruit juice on obesity, dental caries and risk of co-morbidities in children.

Economics of sedentary behaviour: A systematic review of cost of illness, cost-effectiveness, and return on investment studies

AIMS

METHODS: RESULTS: We identified nine articles (conducted in Australia (n = 5), Europe (n = 3) and China (n = 1)); three reported healthcare costs associated with excessive sedentary time, whilst six were economic evaluations of interventions targeting sedentary behaviour. Healthcare costs associated with excessive sedentary time as reported in cost of illness studies were substantial; however, none explored non-health sector costs. In contrast, all full economics evaluations adopted a societal perspective; however, costs included differed depending on the intervention context. One sedentary behaviour intervention in children was cost-saving. The five interventions targeting occupational sitting time of adults in office workplaces were cost-effective. Physical environmental changes such as sit-stand desks, active workstations etc., were the key cost driver.

CONCLUSIONS

Sedentary behaviour is likely associated with excess healthcare costs, although future research should also explore costs across other sectors. Cost-effectiveness evidence of sedentary behaviour reduction interventions in workplaces is limited but consistent. Key gaps relate to the economic credentials of interventions targeting children, and modelling of long-term health benefits of interventions.

Understanding children's perspectives of the influences on their dietary behaviours

OBJECTIVE

This study aimed to examine the intrapersonal, interpersonal, environmental and macrosystem influences on dietary behaviours among primary school children in Singapore.

DESIGN

A qualitative interpretive approach was used in this study. Focus group discussions guided by the socio-ecological model (sem), of which transcripts were analysed deductively using the sem and inductively using thematic analysis to identify themes at each sem level.

SETTING

Two co-educational public primary schools in Singapore.

PARTICIPANTS

A total of 48 children (n 26 girls) took part in the semi-structured focus group discussions. Their mean age was 10·8 years (sd = 0·9, range 9-12 years), and the majority of the children were Chinese (n 36), along with some Indians (n 8) and Malays (n 4).

RESULTS

Children's knowledge of healthy eating did not necessarily translate into healthy dietary practices and concern for health was a low priority. Instead, food and taste preferences were pivotal influences in their food choices. Parents had a large influence on children with regards to their accessibility to food, their attitudes and values towards food. Parental food restriction led to some children eating in secrecy. Peer influence was not frequently reported by children. Competitions in school incentivised children to consume fruits and vegetables, but reinforcements from teachers were inconsistent. The proximity of fast-food chains in the neighbourhood provided children easy access to less healthy foods. Health advertisements on social media rather than posters worked better in drawing children's attention.

CONCLUSIONS

Findings highlighted important factors that should be considered in future nutrition interventions targeting children.

Impacts of School Nutrition Interventions on the Nutritional Status of School-Aged Children in Asia: A Systematic Review and Meta-Analysis

This review aims to describe school nutrition interventions implemented in Asia and quantify their effects on school-aged children’s nutritional status. We searched Web of Science, Embase, Ovid MEDLINE, Global Health, Econlit, APA PsycInfo, and Social Policy and Practice for English articles published from January 2000 to January 2021. We quantified the pooled effects of the interventions on the changes in body mass index (BMI) and body mass index z score (BAZ), overall and by type of intervention. In total, 28 articles were included for this review, of which 20 articles were multi-component interventions. Twenty-seven articles were childhood obesity studies and were included for meta-analysis. Overall, school nutrition interventions reduced school-aged children’s BMI and BAZ. Multi-component interventions reduced the children’s BMI and BAZ, whereas physical activity interventions reduced only BMI and nutrition education did not change BMI or BAZ. Overweight/obesity reduction interventions provided a larger effect than prevention interventions. Parental involvement and a healthy food provision did not strengthen school nutrition interventions, which may be due to an inadequate degree of implementation. These results suggested that school nutrition interventions should employ a holistic multi-component approach and ensure adequate stakeholder engagement as well as implementation to maximise the effects.

School-Based Physical Activity Intervention: A Qualitative Process Evaluation of a Feasibility Trial in Yangzhou, China

Background: There is an urgent need for children in China to increase their physical activity levels. We first developed a 16-week school-based behavior change intervention based on the Behavior Change Wheel and Theoretical Domains Framework. We then conducted a cluster feasibility non-randomized controlled trial (RCT) among children in Yangzhou, China. Aim: This qualitative process evaluation was embedded within the cluster feasibility non-RCT and aimed to: (1) explore the experiences and perceptions of participants and providers in the intervention and trial; and (2) generate recommendations to inform a future intervention and full-scale cluster RCT. Methods: A qualitative study, using semi-structured interviews with trial participants (n = 20 children: 10 intervention, 10 control), parents (n = 20), and health education providers (n = 2), was conducted in two public schools in Yangzhou, China. Interviews were audio-recorded, transcribed, and translated verbatim from Mandarin to English. Data were analyzed using thematic analysis. Results: Findings believed to reflect experiences and perceptions of participants in the intervention and the trial are presented as eight major themes: (1) perceived high efficacy of the intervention components to help children become more active, (2) appreciation of the intervention features, (3) factors that facilitated or impeded intervention attendance and delivery, (4) positive experiences and feelings gained through the data collection process, (5) satisfaction regarding the organization and implementation of the trial, (6) influences of personal beliefs and emotional responses to the trial, (7) social influences on participatory decision-making, and (8) key barriers to consider regarding the recruitment of participants. Conclusions: The intervention and trial methods were acceptable to children, parents, and health education providers. School-based behavior change intervention was perceived to be a useful approach to increase physical activity in children aged 10–12 years in China. However, there were barriers to intervention delivery and engagement that should be considered when designing a future cluster RCT to assess the intervention efficacy.

Effectiveness of Nutritional Strategies on Improving the Quality of Diet of Children from 6 to 12 Years Old: A Systematic Review

Dietary habits, that are formed during childhood and consolidated in adulthood, are known to influence the development of future chronic diseases such as metabolic syndrome or type 2 diabetes. The aim of this review was to evaluate the effectiveness of nutritional interventions carried out in recent years focused on improving the quality of the diet of the child population. A systematic search of the PubMed and Scopus databases was performed from January 2011 until September 2021. A total of 910 articles were identified and screened based on their title, abstract and full text. Finally, 12 articles were included in the current systematic review. Of those, in six studies the intervention was based on the provision of healthy meals and in the other six studies the intervention focused on modifying the school environment. Six of the studies selected included other components in their intervention such as nutritional education sessions, physical activity and/or families. A wide variety of methods were used for diet assessments, from direct method to questionnaires. The results suggest that interventions that modify the school environment or provide different meals or snacks may be effective in improving children’s dietary patterns, both in the short and long term. Further research is necessary to evaluate the real effectiveness of strategies with multidisciplinary approach (nutritional sessions, physical activity and family’s involvement).

Effectiveness of a Multifaceted Intervention for Prevention of Obesity in Primary School Children in China: A Cluster Randomized Clinical Trial

IMPORTANCE

A rapid nutritional transition has caused greater childhood obesity prevalence in many countries, but the repertoire of effective preventive interventions remains limited.

OBJECTIVE

To determine the effectiveness of a novel multifaceted intervention for obesity prevention in primary school children.

DESIGN, SETTING, AND PARTICIPANTS

A cluster randomized clinical trial was conducted during a single school year (from September 11, 2018, to June 30, 2019) across 3 socioeconomically distinct regions in China according to a prespecified trial protocol. Twenty-four schools were randomly allocated (1:1) to the intervention or the control group, with 1392 eligible children aged 8 to 10 years participating. Data from the intent-to-treat population were analyzed from October 1 to December 31, 2019.

INTERVENTIONS

A multifaceted intervention targeted both children (promoting healthy diet and physical activity) and their environment (engaging schools and families to support children's behavioral changes). The intervention was novel in its strengthening of family involvement with the assistance of a smartphone app. The control schools engaged in their usual practices.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in body mass index (BMI; calculated as weight in kilograms divided by height in square meters) from baseline to the end of the trial. Secondary outcomes included changes in adiposity outcomes (eg, BMI z score, prevalence of obesity), blood pressure, physical activity and dietary behaviors, obesity-related knowledge, and physical fitness. Generalized linear mixed models were used in the analyses.

RESULTS

Among the 1392 participants (mean [SD] age, 9.6 [0.4] years; 717 boys [51.5%]; mean [SD] BMI, 18.6 [3.7]), 1362 (97.8%) with follow-up data were included in the analyses. From baseline to the end of the trial, the mean BMI decreased in the intervention group, whereas it increased in the control group; the mean between-group difference in BMI change was -0.46 (95% CI, -0.67 to -0.25; P < .001), which showed no evidence of difference across different regions, sexes, maternal education levels, and primary caregivers (parents vs nonparents). The prevalence of obesity decreased by 27.0% of the baseline figure (a relative decrease) in the intervention group, compared with 5.6% in the control group. The intervention also improved other adiposity outcomes, dietary, sedentary, and physical activity behaviors, and obesity-related knowledge, but it did not change moderate- to vigorous-intensity physical activity, physical fitness, or blood pressure. No adverse events were observed during the intervention.

CONCLUSIONS AND RELEVANCE

The multifaceted intervention effectively reduced the mean BMI and obesity prevalence in primary school children across socioeconomically distinct regions in China, suggesting its potential for national scaling.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03665857.

"We've Had to Build the Plane as We Flew It.": Impacts of the COVID-19 Pandemic on School-Based Weight Management Interventions

Background: In response to the coronavirus disease 2019 (COVID-19) pandemic, elementary and secondary schools in the United States transitioned to remote learning to slow viral spread and protect students and school officials. This move interrupted academic education and school-based health interventions focused on physical activity (PA) and healthy eating behaviors to help combat childhood obesity. Little is known on how these interventions were affected by COVID-19. Methods: This concurrent multimethodological study incorporated two independent components: qualitative descriptive semistructured interviews with public school administrators and quantitative descriptive cross-sectional needs assessment survey of public school personnel. Results: Three themes were identified from interviews with school administrators (N = 28): changes in school-based interventions addressing PA and healthy eating behaviors, changes in academic delivery affecting PA and healthy eating behaviors, and needs of school administrators. From the survey (N = 1311), 635 (48.4%) participants indicated that schools' abilities to address PA and healthy eating behaviors were negatively impacted by COVID-19. The majority (n = 876, 66.8%) of participants strongly agreed or agreed that the pandemic would affect future school-based interventions related to PA and healthy eating behaviors. Conclusions: While schools are prime locations for delivering school-based weight management interventions related to childhood obesity, participants reported the pandemic had overall negative impacts on interventions addressing PA and healthy eating behaviors. Understanding these impacts is essential to adapting school-based interventions to changes from COVID-19 so students may receive health information and access health promotion interventions in remote learning environments and during social distancing.

School-based behaviour change intervention to increase physical activity levels among children: a feasibility cluster non-randomised controlled trial in Yangzhou, China

OBJECTIVES

Children in China have low levels of physical activity. We developed a school-based behaviour change intervention to increase their physical activity levels. The study aimed to determine the feasibility of undertaking a cluster randomised controlled trial (RCT) in the future. This future cluster RCT will evaluate the effectiveness of the intervention.

DESIGN

Feasibility cluster non-RCT design.

SETTING

Two public schools (one intervention and one control) in Yangzhou, China.

PARTICIPANTS

Children aged 10-12 years and their parents.

INTERVENTION

The 16-week school-based behaviour change intervention to increase physical activity levels consisted of three components (a) health education (physical education), (b) family involvement and (c) school environment support.

OUTCOMES MEASURES

We estimated important parameters that are needed to design the future cluster RCT, such as SD of the primary outcome (ie, 7-day steps in children), intracluster correlation coefficient (ICC), recruitment of child-parent dyads, follow-up of children, completion of and time needed for data collection among children and intervention attendance.

RESULTS

Sixty-four children and their parents participated in the study (32 per study group). The SD of the primary outcome was 34 519 steps. The ICC was 0.03. The recruitment and follow-up rates were 100%. The completion of data collection was 100% (except for the 7-day steps at baseline-one child lost the step log in the intervention group and two children lost their pedometer in the control group). The time needed to complete the self-reported questionnaire by children was around 15 min per study group, and the measurement of their anthropometric parameters took around 40 min per study group. The intervention attendance was 100%.

CONCLUSIONS

Based on the promising recruitment, follow-up, completion of and time needed for data collection and intervention attendance, it would be feasible to undertake the future cluster RCT in China.

TRIAL REGISTRATION NUMBER

ChiCTR1900026865.

Dietary Interventions to Prevent Childhood Obesity: A Literature Review

Several dietary interventions have been conducted to prevent/reduce childhood obesity, but most of them are known to have failed in tackling the obesity epidemic. This study aimed to review the existing literature on dietary interventions for the prevention of childhood obesity and their effectiveness. A literature search was conducted using PubMed Central®. Only articles published between 2009 and 2021, written in English, conducted in humans, and including children and/or adolescents (<18 years old) were considered. The majority of studies were school-based interventions, with some addressing the whole community, and including some interventions in the food sector (e.g., taxation of high fat/sugar foods, front-of-pack labelling) and through mass media (e.g., restrictions on food advertising for children) that directly or indirectly could help to manage childhood obesity. Most of the programs/interventions conducted focus mainly on person-based educational approaches, such as nutrition/diet education sessions, allied to the promotion of physical activity and lifestyles to students, parents, and school staff, and less on environmental changes to offer healthier food choices. Only a few trials have focused on capacity building and macro-policy changes, such as the adaptation of the built environment of the school, serving smaller portion sizes, and increasing the availability and accessibility of healthy foods and water in schools, and restricting the access to vending machines, for example. Overall, most of the intervention studies showed no consistent effects on changing the body mass index of children; they have only reported small weight reductions, clinically irrelevant, or no effects at all. Little is known about the sustainability of interventions over time.

Cost-Effectiveness of a School-and Family-Based Childhood Obesity Prevention Programme in China: The "CHIRPY DRAGON" Cluster-Randomised Controlled Trial

Objectives: Rapid socioeconomic and nutrition transitions in Chinese populations have contributed to the growth in childhood obesity. This study presents a cost-effectiveness analysis of a school- and family-based childhood obesity prevention programme in China.

Methods: A trial-based economic evaluation assessed cost-effectiveness at 12 months. Forty schools with 1,641 children were randomised to either receive the multi-component (diet and physical activity) intervention or to continue with usual activities. Both public sector and societal perspectives were adopted. Costs and benefits in the form of quality-adjusted life years (QALYs) were compared and uncertainty was assessed using established UK and US thresholds.

Results: The intervention cost was 35.53 Yuan (£7.04/US$10.01) per child from a public sector perspective and 536.95 Yuan (£106/US$151) from a societal perspective. The incremental cost-effectiveness ratio (ICER) was 272.7 Yuan (£54/US$77)/BMI z-score change. The ICER was 8,888 Yuan (£1,760/US$2,502) and 73,831 Yuan (£14,620/US$20,796) per QALY from a public sector and societal perspective, respectively and was cost-effective using UK (£20,000) and US (US$50,000) per QALY thresholds.

Conclusion: A multi-component school-based prevention programme is a cost-effective means of preventing childhood obesity in China.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An assessment of the construct validity of the Child Health Utility 9D-CHN instrument in school-aged children: evidence from a Chinese trial

Background

Although there is emerging data regarding the psychometric properties of the Child Health Utility-9D instrument, more evidence is required with respect to its validity for use in different country settings. The aim of this study was to examine the construct validity of the CHU-9D-CHN instrument in Chinese children.

Methods

Baseline Health-Related Quality of Life (HRQoL) and demographic data were collected from children recruited to the CHIRPY DRAGON obesity prevention intervention randomised controlled trial in China. HRQoL was measured using the Chinese version of the CHU-9D instrument (CHU-9D-CHN) and the PedsQL instrument. CHU-9D-CHN utility scores were generated using two scoring algorithms [UK and Chinese tariffs]. Discriminant validity, known-group validity and convergent validity were evaluated using non-parametric test for trend, Kruskal–Wallis test and Spearman correlation coefficient analysis respectively.

Results

Data was available for 1,539 children (mean age 6 years). The CHU-9D-CHN was sensitive to known group differences determined by the median PedsQL total score. Furthermore, the mean CHU-9D-CHN utility values decreased linearly with increasing levels of severity on each dimension of the PedsQL for emotional and social functioning domains. They decreased monotonically with increasing levels of severity on each dimension of the PedsQL for physical and school functioning domains (p < 0.001). Contrary to studies conducted in Western countries, and although not statistically significant, we found an indication that HRQoL, using both the CHU-9D-CHN and the PedsQL, was higher in children whose parents had lower levels of education, compared to those whose parents were university educated. The correlation between the CHU-9D-CHN utility values using UK and Chinese tariffs, and PedsQL total scores showed a statistically significant moderate positive correlation (Spearman’s rho = 0.5221, p < 0.001 and Spearman’s rho = 0.5316, p < 0.001), respectively. However, each CHU-9D-CHN dimension was either weakly, or very weakly correlated with each of the predetermined PedsQL domain functioning scores.

Conclusions

Overall, the findings provide some support for the construct validity of the CHU-9D-CHN within a Chinese population aged 6–7 years. However, some uncertainty remains. We recommend future studies continue to test the validity of the CHU-9D in different country settings.

Trial registration: ISRCTN Identifier ISRCTN11867516, Registered on 19/08/2015

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01840-7.

Health policy and public health implications of obesity in China

China has experienced many drastic social and economic changes and shifts in people's lifestyles since the 1990s, in parallel with the fast rising prevalence of obesity. About half of adults and a fifth of children have overweight or obesity according to the Chinese criteria, making China the country with the highest number of people with overweight or obesity in the world. Assuming that observed time trends would continue in the future, we projected the prevalence of and the number of people affected by overweight and obesity by 2030, and the associated medical costs. The rising incidence of obesity and number of people affected, as well as the related health and economic consequences, place a huge burden on China's health-care system. China has made many efforts to tackle obesity, including the implementation of relevant national policies and programmes. However, these measures are inadequate for controlling the obesity epidemic. In the past decade, China has attached great importance to public health, and the Healthy China 2030 national strategy initiated in 2016 provides a historical opportunity to establish comprehensive national strategies for tackling obesity. China is well positioned to explore an effective model to overcome the obesity epidemic; however, strong commitment and leadership from central and local governments are needed, as well as active participation of all related society sectors and individual citizens. TRANSLATION: For the Chinese translation of the paper see Supplementary Materials section.

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.

Clinical management and treatment of obesity in China

China has one of the largest populations with obesity in the world, and obesity has become a major challenge for the country's health-care system. Current guidelines for obesity management are not adequately supported by evidence from clinical studies in Chinese populations. Effective lifestyle interventions suitable for Chinese populations are scarce, insufficient weight-loss medications have been approved by regulatory bodies, and there is low acceptance of non-lifestyle interventions (ie, medications and surgery) among both health-care providers and the general public. Large, well designed, and well implemented clinical trials are needed to strengthen the evidence base for the clinical management of obesity in China. Obesity management can be improved through use of a tiered system involving health management centres, integrated lifestyle interventions and medical treatments, strengthened obesity education and training, and use of advanced electronic health technologies. Resource mobilisation, support from major stakeholders for people with overweight or obesity, and education and changes to social norms among the wider public are also needed. National health policies should prioritise both obesity prevention and improvement of the treatment and management of obesity.

Four-Year Behavioral, Health-Related Quality of Life, and BMI Outcomes from a Cluster Randomized Whole of Systems Trial of Prevention Strategies for Childhood Obesity

OBJECTIVE

This study aimed to test the effectiveness of the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS Childhood Obesity) for behavioral, health-related quality of life (HRQoL), and BMI outcomes.

METHODS

This was a cluster randomized trial of 10 communities randomly allocated (1:1) to start intervention in 2015 (step 1) or in 2019 (after 4 years) in South West Victoria, Australia. Data were collected from participating primary schools in April to June of 2015 (73% school participation rate), 2017 (69%), and 2019 (63%). Student participation rates were 80% in 2015 (1,792/2,516 invited), 81% in 2017 (2,411/2,963), and 79% in 2019 (2,177/2,720). Repeat cross-sectional analyses of measured height and weight (grades two, four, and six [aged approximately 7 to 12 years]), self-reported behavior, and HRQoL (grades four and six) were conducted.

RESULTS

There was an intervention by time interaction in BMI z scores (P = 0.031) and obesity/overweight prevalence (P = 0.006). BMI z score and overweight/obesity prevalence decreased between 2015 and 2017 and increased between 2017 and 2019 in intervention communities. The intervention significantly reduced takeaway food consumption (P = 0.034) and improved physical (P = 0.019), psychosocial (P = 0.026), and global (P = 0.012) HRQoL. Water consumption increased among girls (P = 0.033) in the intervention communities, as did energy-dense, nutrient-poor snack consumption among boys (P = 0.006).

CONCLUSIONS

WHO STOPS had a positive impact on takeaway food intake and HRQoL.

Program for Healthier School Cafeterias in Rio Grande do Sul, Brazil: Protocol for a Community-Based Randomized Trial

Background

School cafeterias can promote poor eating habits, as these retail outlets have a variety of foods considered to be nonnutritive and unhealthy. However, despite the need for effective preventive strategies, there is still disagreement on the best approach due to the lack of evidence on interventions to prevent and treat obesity in the school settings.

Objective

We aim to verify the efficacy of an educational intervention program to improve the hygienic conditions and the composition of the menu offered in school cafeterias in the state of Rio Grande do Sul, Brazil.

Methods

We will conduct a randomized, parallel, two-arm, community-based controlled study. Elementary and high schools, both public and private, in the State of Rio Grande do Sul, Brazil, that have a cafeteria will be eligible. Schools will be recruited and randomly assigned to the intervention (n=27) or control (n=27) group. The intervention group will receive an educational intervention program based on the guidelines issued by the Ministry of Health of Brazil, consisting of a 160-hour distance-learning qualification course, for 10 weeks, and using the Moodle platform and WhatsApp app. The intervention targets the owners and people in charge of the cafeterias, food handlers, principals, vice principals, teachers, pedagogical coordinators, dietitians, representatives of students' parents, and students over 16 years old. Meanwhile, the control group will receive only a printed copy of the book containing the guidelines used. The efficacy of the intervention will be determined by the hygienic conditions of the cafeteria and the composition of the menu offered, also considering the levels of processing of food sold. All outcomes will be analyzed as intention-to-treat and per-protocol. We will use covariance analysis or a generalized linear model for continuous data and ordinal logistic regression for ordinal categorical data. The level of statistical significance considered will be P<.05 for a 95% CI.

Results

This project was funded in early 2018. We administered the intervention program in 2019. All data have already been collected, and we are analyzing the data. The results are expected in 2021.

Conclusions

To our knowledge, this may be the first randomized controlled study in school cafeterias held in Brazil. The results will provide evidence for the formulation of public food and nutritional security policies and for the development of effective strategies to provide safe and healthy school meals.

Trial Registration

Brazilian Clinical Trials Registry RBR-9rrqhk; https://ensaiosclinicos.gov.br/rg/RBR-9rrqhk

International Registered Report Identifier (IRRID)

DERR1-10.2196/22680

Effects of Lifestyle Modification Interventions to Prevent and Manage Child and Adolescent Obesity: A Systematic Review and Meta-Analysis

The objective of this review was to assess the impact of lifestyle interventions (including dietary interventions, physical activity, behavioral therapy, or any combination of these interventions) to prevent and manage childhood and adolescent obesity. We conducted a comprehensive literature search across various databases and grey literature without any restrictions on publication, language, or publication status until February 2020. We included randomized controlled trials and quasi-experimental studies from both high income countries (HIC) and low-middle-income countries (LMICs). Participants were children and adolescents from 0 to 19 years of age. Studies conducted among hospitalized children and children with any pre-existing health conditions were excluded from this review. A total of 654 studies (1160 papers) that met the inclusion criteria were included in this review. A total of 359 studies targeted obesity prevention, 280 studies targeted obesity management, while 15 studies targeted both prevention and management. The majority of the studies (81%) were conducted in HICs, 10% of studies were conducted in upper middle income countries, while only 2% of the studies were conducted in LMICs. The most common setting for these interventions were communities and school settings. Evidence for the prevention of obesity among children and adolescents suggests that a combination of diet and exercise might reduce the BMI z-score (MD: -0.12; 95% CI: -0.18 to -0.06; 32 studies; 33,039 participants; I2 93%; low quality evidence), body mass index (BMI) by 0.41 kg/m2 (MD: -0.41 kg/m2; 95% CI: -0.60 to -0.21; 35 studies; 47,499 participants; I2 98%; low quality evidence), and body weight (MD: -1.59; 95% CI: -2.95 to -0.23; 17 studies; 35,023 participants; I2 100%; low quality evidence). Behavioral therapy alone (MD: -0.07; 95% CI: -0.14 to -0.00; 19 studies; 8569 participants; I2 76%; low quality evidence) and a combination of exercise and behavioral therapy (MD: -0.08; 95% CI: -0.16 to -0.00; 9 studies; 7334 participants; I2 74%; low quality evidence) and diet in combination with exercise and behavioral therapy (MD: -0.13; 95% CI: -0.25 to -0.01; 5 studies; 1806 participants; I2 62%; low quality evidence) might reduce BMI z-score when compared to the control group. Evidence for obesity management suggests that exercise only interventions probably reduce BMI z-score (MD: -0.13; 95% CI: -0.20 to -0.06; 12 studies; 1084 participants; I2 0%; moderate quality evidence), and might reduce BMI (MD: -0.88; 95% CI: -1.265 to -0.50; 34 studies; 3846 participants; I2 72%) and body weight (MD: -3.01; 95% CI: -5.56 to -0.47; 16 studies; 1701 participants; I2 78%; low quality evidence) when compared to the control group. and the exercise along with behavioral therapy interventions (MD: -0.08; 95% CI: -0.16 to -0.00; 8 studies; 466 participants; I2 49%; moderate quality evidence), diet along with behavioral therapy interventions (MD: -0.16; 95% CI: -0.26 to -0.07; 4 studies; 329 participants; I2 0%; moderate quality evidence), and combination of diet, exercise and behavioral therapy (MD: -0.09; 95% CI: -0.14 to -0.05; 13 studies; 2995 participants; I2 12%; moderate quality evidence) also probably decreases BMI z-score when compared to the control group. The existing evidence is most favorable for a combination of interventions, such as diet along with exercise and exercise along with behavioral therapy for obesity prevention and exercise alone, diet along with exercise, diet along with behavioral therapy, and a combination of diet, exercise, and behavioral therapy for obesity management. Despite the growing obesity epidemic in LMICs, there is a significant dearth of obesity prevention and management studies from these regions.