Effectiveness of a primary school-based intervention to reduce overweight

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 short and long-term effects of a lifestyle intervention in children with mental illnesses: a randomized controlled trial (Movementss study)

BACKGROUND

A lifestyle including poor diet, physical inactivity, excessive gaming and inadequate sleep hygiene is frequently seen among Dutch children. These lifestyle behaviors can cause long-term health problems later in life. Unhealthy lifestyle and poor physical health are even more prevalent among children with mental illness (MI) such as autism, attention-deficit/hyperactivity disorder, depression, and anxiety. However, research on lifestyle interventions among children with MI is lacking. As a result, there are currently no guidelines, or treatment programs where children with MI and poor lifestyle can receive effective support. To address these issues and to provide insight into the effectiveness of lifestyle interventions in children with MI and their families, the Movementss study was designed. This paper describes the rationale, study design, and methods of an ongoing randomized controlled trial (RCT) comparing the short-term (12 weeks) and long-term (1 year) effects of a lifestyle intervention with care as usual (CAU) in children with MI and an unhealthy lifestyle.

METHODS

A total of 80 children (6-12 years) with MI according to DSM-V and an unhealthy lifestyle are randomized to the lifestyle intervention group or CAU at a specialized child and adolescent mental hospital. The primary outcome measure is quality of life measured with the KIDSCREEN. Secondary outcomes include emotional and behavior symptoms, lifestyle parameters regarding diet, physical activity, sleep, and screen time, cognitive assessment (intelligence and executive functions), physical measurements (e.g., BMI), parenting styles, and family functioning, prior beliefs, adherence, satisfaction, and cost-effectiveness. Assessments will take place at the start of the study (T0), after 12 weeks (T1), six months (T2), and 12 months of baseline (T3) to measure long-term effects.

DISCUSSION

This RCT will likely contribute to the currently lacking knowledge on lifestyle interventions in children with MI.

TRIAL REGISTRATION

trialsearch.who.int/ NL9822. Registered at November 2nd, 2021.

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).

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Study protocol for the evaluation of long-term effects of the school-based obesity prevention program Lekker Fit! ('enjoy being fit'): a retrospective, controlled design

INTRODUCTION

Preventive interventions to reduce overweight and obesity in childhood and adolescence are studied on their effectiveness worldwide. A number with positive results. However, long-term effects of these interventions and their potentially wider influence on well-being and health have been less studied. This study aims to evaluate the long-term effects of a multicomponent intervention in elementary school children targeting individual behaviour as well as environment (Lekker Fit!). The primary outcomeis body mass index and the secondary outcomes are waist circumference, weight status, physical fitness, lifestyle, psychosocial health and academic performance.

METHODS AND ANALYSIS

In a naturalistic effect evaluation with a retrospective, controlled design adolescents in secondary schools, from intervention and non-intervention elementary schools, will be compared on a wide set of outcome variables. Data will be collected by questionnaires and through anthropometric and fitness measurements by trained physical education teachers and research assistants. Baseline data consist of measurements from the adolescents at the age of 5 years old and are gathered from preventive youth healthcare records, from before the intervention took place. Multilevel regression models will be used and adjusted for baseline measurements and potential confounding variables on the individual and environmental level. Furthermore, propensity scores will be applied.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Research Ethics Committee of the Erasmus Medical Centre, Rotterdam, The Netherlands (permission ID: MEC-2020-0644). Study findings will be disseminated in peer-reviewed journals and by conference presentations.

TRIAL REGISTRATION NUMBER

NL8799. Pre-results.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

A Systematic Review of Multi-Component Comprehensive School Physical Activity Program (CSPAP) Interventions

OBJECTIVE

To identify, review, and describe multicomponent physical activity (PA) interventions in terms of: (a) number and combination of Comprehensive School Physical Activity Program (CSPAP) components, (b) study characteristics, and (c) primary outcomes.

DATA SOURCE

Five electronic databases (i.e., PubMed, PsychInfo, Physical Education Index, Sport Discus, and ERIC).

STUDY INCLUSION AND EXCLUSION CRITERIA

Included articles were peer-reviewed, written in English language, published since 1987, and included multicomponent school-based interventions.

DATA EXTRACTION

Data items extracted were: school level, setting, CSPAP component description, health outcomes, academic outcomes, main conclusion, and reference.

DATA SYNTHESIS

Included articles were synthesized by: (1) CSPAP components utilized, and (2) research outcome measured (i.e., health or academic).

RESULTS

Across 32 studies, 11 included physical education plus 1 additional CSPAP component (PE + 1); 10 included PE + 2 additional CSPAP components; 8 included PE + 3 additional CSPAP components; and 1 included all 5 CSPAP components. Two other studies included 2 or 3 CSPAP components without PE. Most interventions targeted health outcomes (94%) rather than academic outcomes (6%).

CONCLUSIONS

Multicomponent approaches aligned with CSPAPs are effective in promoting PA and other positive outcomes for youth in schools. Future research should seek to understand effects of CSPAP components on a variety of outcomes and settings.

Effectiveness of dietary interventions on weight outcomes in childhood: a systematic review meta-analysis of randomized controlled trials

BACKGROUND

Rapid growth and elevated weight in childhood are significantly associated with obesity in later life, but evidence regarding dietary interventions and weight outcomes is lacking. This study aimed to determine the effectiveness of dietary interventions on body mass index (BMI) and BMI z-score in childhood.

METHODS

PubMed, EmBase, and the Cochrane library were searched from inception till June 2019. Studies that investigated the effectiveness of dietary interventions on BMI and BMI z-score in childhood were considered eligible in our study. The changes in BMI and BMI z-score between dietary interventions and control were calculated by pooled weighted mean differences (WMDs) and 95% CIs were evaluated using random-effects model.

RESULTS

Twenty-eight randomized controlled trials involving a total of 17,488 children were included. The summary WMDs indicated that children who received dietary interventions had greater reduction in BMI (WMD: -0.12; 95% CI: -0.20 to -0.05; P=0.001) and BMI z-score (WMD: -0.04; 95% CI: -0.06 to -0.02; P=0.001) when compared to the usual controls. Subgroup analyses revealed that the sample size, mean age, duration of interventions, and study quality could affect the effectiveness of dietary interventions in children.

CONCLUSIONS

The findings of this meta-analysis suggested that dietary interventions improved BMI and BMI z-score, whereas these results are limited due to substantial heterogeneity and study quality of the included studies.

Impact of Strategies for Preventing Obesity and Risk Factors for Eating Disorders among Adolescents: A Systematic Review

An effective behavior change program is the first line of prevention for youth obesity. However, effectiveness in prevention of adolescent obesity requires several approaches, with special attention paid to disordered eating behaviors and psychological support, among other environmental factors. The aim of this systematic review is to compare the impact of two types of obesity prevention programs, inclusive of behavior change components, on weight outcomes. "Energy-balance" studies are aimed at reducing calories from high-energy sources and increasing physical activity (PA) levels, while "shared risk factors for obesity and eating disorders" focus on reducing disordered eating behaviors to promote a positive food and eating relationship. A systematic search of ProQuest, PubMed, PsycInfo, SciELO, and Web of Science identified 8825 articles. Thirty-five studies were included in the review, of which 20 regarded "energy-balance" and 15 "shared risk factors for obesity and eating disorders". "Energy-balance" studies were unable to support maintenance weight status, diet, and PA. "Shared risk factors for obesity and eating disorders" programs also did not result in significant differences in weight status over time. However, the majority of "shared risk factors for obesity and eating disorders" studies demonstrated reduced body dissatisfaction, dieting, and weight-control behaviors. Research is needed to examine how a shared risk factor approach can address both obesity and eating disorders.

Impact of a Three-Year Obesity Prevention Study on Healthy Behaviors and BMI among Lebanese Schoolchildren: Findings from Ajyal Salima Program

Most school-based obesity prevention programs in low- to middle-income countries are of short duration, and few undertake follow-up analyses after the termination of the project. The aims of the current study are to investigate (1) the long-term effects of a school-based intervention program when implemented over two years on body mass index (BMI), healthy dietary behaviors, and physical activity (PA); and (2) whether the effects are sustained after one-year washout. The study is a cluster-randomized trial; 36 public and private schools were randomized into either intervention or control groups. Students (8–12 years) completed pre-and post-assessment anthropometric measurements and questionnaires about their eating and physical activity habits. Students in the intervention groups received the program components for two consecutive years. Multiple logistic regression models were used to examine the effect of the intervention on BMI and healthy behaviors. Students in the intervention groups were less likely to be overweight at washout, only in public schools. The number of children reporting change in dietary behaviors significantly increased in intervention groups, with a sustained effect only in public schools. Policies aiming at securing a positive nutrition environment in schools, and adoption of nutrition programs, are needed for achieving sustained behavior and prompting BMI changes in children.

Differential effects of a school-based obesity prevention program: A cluster randomized trial

School-based healthy living interventions are widely promoted as strategies for preventing obesity. The peer-led Healthy Buddies™ curriculum has been shown to improve obesity-related outcomes in school-aged children. We examined whether these improvements existed among subgroups of children stratified by sex, income level and urban/rural geography. In a cluster-randomized controlled trial, elementary schools in Manitoba, Canada, were randomly allocated to Healthy Buddies™ (10 schools, 340 students) or standard curriculum (10 schools, 347 students). Healthy Buddies™ participants had 21weekly lessons on healthy eating, physical activity and self-efficacy, delivered by children age 9-12 to children age 6-8. We assessed pre- and post-intervention body mass index (BMI) z-scores, waist circumference, healthy living knowledge, dietary intake and self-efficacy among the younger children. Compared to standard curriculum (n = 154), Healthy Buddies™ participants (n = 157) experienced a greater reduction in waist circumference (-1.7 cm; 95% confidence interval [CI][-2.8, -0.5 cm]) and improved dietary intake (4.6; 95% CI [0.9, 8.3]), healthy living knowledge (5.9; 95% CI [2.3, 9.5]) and self-efficacy (5.3; 95% CI [1.0, 9.5]) scores. In subgroup analyses, effects for waist circumference (-2.0 cm; 95% CI [-3.6, -0.5]), healthy living knowledge (9.1; 95% CI [4.4, 13.8]) and self-efficacy (8.3; 95% CI [3.3, 13.3]) were significant among boys. Dietary intake (10.5; 95% CI [5.5, 15.4]), healthy living knowledge (9.8; 95% CI [4.5, 15.0]) and self-efficacy (6.7; 95% CI [0.7, 12.7]) improved among urban-dwelling but not rural-dwelling children. Healthy Buddies™ was effective for boys and children living in urban settings. Enhanced curricula may be needed to improve program effectiveness for select subgroups of school-aged children.

Effectiveness of school-based health promotion interventions prioritized by stakeholders from health and education sectors: A systematic review and meta-analysis

Childhood obesity and associated modifiable risk factors exert significant burden on the health care system. The goal of this systematic review and meta-analysis was to examine the effectiveness of school-based intervention types perceived by Canadian stakeholders in health and education as feasible, acceptable and sustainable in terms of improving physical activity (PA), fruit and vegetable intake, and body weight. We searched multiple databases for studies that evaluated school-based interventions to prevent obesity and associated risk factors (i.e., unhealthy diet, physical inactivity, sedentary behaviour) in children aged 4–18 years from January 1, 2012 to January 28, 2020. From 10,871 identified records, we included 83 and 80 studies in our systematic review and meta-analysis, respectively. Comprehensive School Health (CSH) and interventions which focused on modifications to school nutrition policies showed statistically significant positive effects on fruit intake of 0.13 (95% CI: 0.04, 0.23) and 0.30 (95% CI: 0.1, 0.51) servings per day, respectively. No intervention types showed statistically significant effect on vegetable intake. CSH, modifications to physical education (PE) curriculum, and multicomponent interventions showed statistically significant difference in BMI of −0.26 (95% CI: −0.40, −0.12), −0.16 (95% CI: −0.3, −0.02), and −0.18 (95% CI: −0.29, −0.07), respectively. CSH interventions showed positive effect on step-count per day, but no other types of interventions showed significant effect on any of PA outcome measures. Thus, the results of this systematic review and meta-analysis suggest that decision-makers should carefully consider CSH, multicomponent interventions, modifications to PE curricula and school nutrition policies to prevent childhood obesity.

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

Background

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

Methods

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

Results

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

Conclusions

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

Interventions for preventing obesity in children

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

School-Based Exercise Programs and Cardiometabolic Risk Factors: A Meta-analysis

CONTEXT

The effects of school-based physical activity (PA) programs on different cardiometabolic risk factors and the most appropriate features of PA programs to achieve maximum effectiveness are unclear.

OBJECTIVE

To provide a comprehensive synthesis of the effectiveness of school-based PA interventions on cardiometabolic risk factors in children.

DATA SOURCES

We identified studies from database inception to February 22, 2018.

STUDY SELECTION

We selected studies that were focused on examining the effect of school-based PA interventions on cardiometabolic risk factors in children.

DATA EXTRACTION

Random-effects models were used to calculate the pooled effect size (ES) for the included cardiometabolic risk factors (waist circumference [WC], triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, systolic blood pressure and diastolic blood pressure (DBP), and fasting insulin and glucose).

RESULTS

Nineteen randomized controlled trials (which included 11 988 children aged 3-12 years) were included in the meta-analysis. School-based PA programs were associated with a significant small improvement in WC (ES = -0.14; 95% confidence interval [CI]: -0.22 to -0.07; P < .001), DBP (ES = -0.21; 95% CI: -0.42 to -0.01; P = .040), and fasting insulin (ES = -0.12; 95% CI: -0.20 to -0.04; P = .003).

LIMITATIONS

Authors of few studies described the implementation conditions of their interventions in detail, and compliance rates were lacking in most studies. In addition, results by sex were provided in a small number of studies.

CONCLUSIONS

School-based PA interventions improve some cardiometabolic risk factors in children, such as WC, DBP, and fasting insulin.

Effect of educational interventions on health in childhood: a meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this study was to summarize the findings of randomized controlled trials (RCTs) investigating any potential effects of educational interventions on health in childhood.

STUDY DESIGN

Meta-analysis.

METHODS

PubMed, Embase, and the Cochrane Library databases were searched to identify all RCTs that fit our analysis through May 2016. Weighted mean difference (WMD) was used to measure the effect of educational interventions in childhood by using a random effects model.

RESULTS

Thirty RCTs reporting data on 35,296 children were included in the meta-analysis. The summary WMD indicated that children who received educational interventions had lower levels of body mass index (BMI) (WMD: -0.15; 95% CI: -0.24 to -0.05; P = 0.003), BMI z-score (WMD: -0.03; 95% CI: -0.05 to -0.02; P < 0.001), waist circumference (WMD: -0.97; 95% CI: -1.95 to -0.00; P = 0.050), triceps skinfold (WMD: -1.39; 95% CI: -2.41 to -0.37; P = 0.008), systolic blood pressure (WMD: -1.13; 95% CI: -2.20 to -0.07; P = 0.037), total cholesterol (WMD: -4.04; 95% CI: -7.18 to -0.90; P = 0.012), and triglyceride (WMD: -2.62; 95% CI: -4.33 to -0.90; P = 0.003). However, educational interventions were found to have little or no significant impact on the waist-to-hip ratio, diastolic blood pressure, high-density lipoprotein, and low-density lipoprotein.

CONCLUSIONS

The study findings prove the positive effects of educational interventions on BMI, BMI z-score, waist circumference, triceps skinfold, systolic blood pressure, total cholesterol, and triglyceride.

Effect of educational interventions on health in childhood: A meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this study was to summarize the evidences from randomized controlled trials (RCTs) investigating the effects of educational interventions in overweight/obesity childhood by using meta-analytic approach.

METHODS

PubMed, Embase, and the Cochrane Library databases were searched from the inception to April 2018. Weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were used to measure the effects of educational interventions during childhood in the random-effects models.

RESULTS

Thirty RCTs reporting data on 35,296 children were included in the meta-analysis. The summary WMD indicated that children received educational interventions had lower levels of body mass index (BMI) (WMD: -0.15; 95% CI: -0.24 to -0.05; P = .003), BMI z-score (WMD: -0.03; 95% CI: -0.05 to -0.02; P < .001), waist circumference (WMD: -0.97; 95% CI: -1.95 to -0.00; P = 0.050), triceps skinfold (WMD: -1.39; 95% CI: -2.41 to -0.37; P = .008), systolic blood pressure (WMD: -1.13; 95% CI: -2.20 to -0.07; P = .037), total cholesterol (WMD: -4.04; 95% CI: -7.18 to -0.90; P = .012), and triglyceride (WMD: -2.62; 95% CI: -4.33 to -0.90; P = .003). However, educational interventions were not associated with the levels of waist-to-hip ratio, diastolic blood pressure, high-density lipoprotein, and low-density lipoprotein.

CONCLUSION

The study findings elucidate the positive effects of educational interventions on BMI, BMI z-score, waist circumference, triceps skinfold, systolic blood pressure, total cholesterol, and triglyceride.

Effectiveness of interventions to improve lifestyle behaviors among socially disadvantaged children in Europe

Background

Unhealthy lifestyle behaviors and childhood overweight are more common among children from families with a low socioeconomic position and ethnic minority children (referred to as social disadvantaged children). : This systematic review evaluates the effectiveness of interventions aimed to improve lifestyle behaviours and/or prevent overweight among socially disadvantaged children in Europe. : Six major databases were searched for studies reporting intervention effects on adiposity measures, sedentary behaviours, physical activity behaviours or dietary behaviours. Studies were included when the study sample consisted of at least 50% socially disadvantaged children or when results were presented for subgroups of socially disadvantaged children separately. Methodological quality assessment was based on Cochrane criteria. In total, 11 studies reporting on eight interventions (one among infants 0-2 years, one among preschoolers 2-6 years, six among school-aged children 6-12 years) were identified. Of these eight interventions, five interventions primarily aimed to improve at least one adiposity measure and three primarily aimed to improve a specific lifestyle behaviour. In general, modest positive effects were found but interventions were limited by a short follow-up duration. Despite an urgent need for effective interventions to improve lifestyle behaviours and prevent overweight among socially disadvantaged children, research on the effectiveness of interventions in Europe is still scarce. Those interventions that have been evaluated show modest effects on lifestyle behaviours and adiposity measures, but long-term follow-up is needed to establish whether these effects are sustained over a longer period of time.

The CHANGE! Project: Changes in Body Composition and Cardiorespiratory Fitness in 10- to 11-Year-Old Children After Completing the CHANGE! Intervention

PURPOSE

To assess the effects of the Children's Health, Activity and Nutrition: Get Educated! intervention on body size, body composition, and peak oxygen uptake in a subsample of 10- to 11-year-old children.

METHODS

Sixty children were recruited from 12 schools (N = 6 intervention) to take part in the CHANGE! subsample study. Baseline, postintervention, and follow-up measures were completed in October 2010, March-April 2011, and June-July 2011, respectively. Outcome measures were body mass index z score, waist circumference, body composition assessed using dual-energy X-ray absorptiometry (baseline and follow-up only), and peak oxygen uptake.

RESULTS

Significant differences in mean trunk fat mass (control = 4.72 kg, intervention = 3.11 kg, P = .041) and trunk fat % (control = 23.08%, intervention = 17.75%, P = .022) between groups were observed at follow-up. Significant differences in waist circumference change scores from baseline to follow-up were observed between groups (control = 1.3 cm, intervention = -0.2 cm, P = .023). Favorable changes in body composition were observed in the intervention group; however, none of these changes reached statistical significance. No significant differences in peak oxygen uptake were observed.

CONCLUSIONS

The results of the present study suggest the multicomponent curriculum intervention had small to medium beneficial effects on body size and composition health outcomes.

Obesity Prevention: A Systematic Review of Setting-Based Interventions from Nordic Countries and the Netherlands

AIM

Effective evidence-based interventions have an important role in obesity prevention. Our aim was to present a qualitative synthesis of setting-based health promotion interventions on obesity, from Nordic countries and the Netherlands.

METHODS

A systematic review of the literature was completed for studies in the community, schools, and worksite, with BMI as an outcome. A descriptive analysis was completed for all full-text articles meeting the inclusion criteria.

RESULTS

Thirty-three articles were identified: 7 whole of community, 3 worksite, and 23 school-based interventions. The studies were largely quasiexperimental in design (21/33), with follow-up from 4 months to 8 years. The explicit use of theory was not featured in many of the studies (20/33). No consistent direction for BMI change could be identified in the whole of community interventions (2/7 positive, 2/7 negative, and 3/7 no effect) and no effect for worksite (3/3 no effect) or many of the school-based interventions (1/23 negative, 4/23 positive, 15/23 no effect, 1/23 BMI significant increase only for control group and 3/23 no data available).

CONCLUSIONS

There is a need to prioritise interventions with study designs of high quality, theory, and a participatory approach, for optimal implementation and evaluation of obesity prevention interventions.

Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost-effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children

Background

Approximately one-third of children in England leave primary school overweight or obese. There is little evidence of effective obesity prevention programmes for children in this age group.

Objective

To determine the effectiveness and cost-effectiveness of a school-based healthy lifestyles programme in preventing obesity in children aged 9–10 years.

Design

A cluster randomised controlled trial with an economic and process evaluation.

Setting

Thirty-two primary schools in south-west England.

Participants

Children in Year 5 (aged 9–10 years) at recruitment and in Year 7 (aged 11–12 years) at 24 months’ post-baseline follow-up.

Intervention

The Healthy Lifestyles Programme (HeLP) ran during the spring and summer terms of Year 5 into the autumn term of Year 6 and included four phases: (1) building a receptive environment, (2) a drama-based healthy lifestyles week, (3) one-to-one goal setting and (4) reinforcement activities.

Main outcome measures

The primary outcome measure was body mass index (BMI) standard deviation score (SDS) at 24 months post baseline measures (12 months post intervention). The secondary outcomes comprised waist circumference SDS, percentage body fat SDS, proportion of children overweight and obese at 18 and 24 months, accelerometer-assessed physical activity and food intake at 18 months, and cost-effectiveness.

Results

We recruited 32 schools and 1324 children. We had a rate of 94% follow-up for the primary outcome. No difference in BMI SDS was found at 24 months [mean difference –0.02, 95% confidence interval (CI) –0.09 to 0.05] or at 18 months (mean difference –0.02, 95% CI –0.08 to 0.05) between children in the intervention schools and children in the control schools. No difference was found between the intervention and control groups in waist circumference SDS, percentage body fat SDS or physical activity levels. Self-reported dietary behaviours showed that, at 18 months, children in the intervention schools consumed fewer energy-dense snacks and had fewer negative food markers than children in the control schools. The intervention effect on negative food markers was fully mediated by ‘knowledge’ and three composite variables: ‘confidence and motivation’, ‘family approval/behaviours and child attitudes’ and ‘behaviours and strategies’. The intervention effect on energy-dense snacks was partially mediated by ‘knowledge’ and the same composite variables apart from ‘behaviours and strategies’. The cost of implementing the intervention was approximately £210 per child. The intervention was not cost-effective compared with control. The programme was delivered with high fidelity, and it engaged children, schools and families across the socioeconomic spectrum.

Limitations

The rate of response to the parent questionnaire in the process evaluation was low. Although the schools in the HeLP study included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, the number of children for whom English was an additional language was considerably lower than the national average.

Conclusions

HeLP is not effective or cost-effective in preventing overweight or obesity in children aged 9–10 years.

Future work

Our very high levels of follow-up and fidelity of intervention delivery lead us to conclude that it is unlikely that school-based programmes targeting a single age group can ever be sufficiently intense to affect weight status. New approaches are needed that affect the school, the family and the wider environment to prevent childhood obesity.

Trial registration

Current Controlled Trials ISRCTN15811706.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

Effectiveness of school-based physical activity programmes on cardiorespiratory fitness in children: a meta-analysis of randomised controlled trials

Objective

To conduct a meta-analysis of randomised controlled trials aimed at testing whether school-based physical activity programmes improve cardiorespiratory fitness (CRF) in children.

Design

Systematic review with meta-analysis.

Data sources

Using keywords, we performed a computerised search in five databases: MEDLINE, EMBASE, CINAHL, Web of Science and SportDiscus.

Eligibility criteria for selecting studies

Studies that assessed the effectiveness of school-based physical activity programmes on improving CRF in children (3–12 years old). We selected interventions that included an additional physical activity programme and not only a physical activity educational component. The reference lists of selected full-text articles and systematic reviews were also searched for relevant studies. Pooled effect size (Hedges′ g) was calculated assuming a random-effects model.

Results

Twenty trials with 7287 healthy children aged 3–12 years were included in the meta-analysis. School-based physical activity interventions with aerobic games and activities were associated with a significant small increase in CRF (Hedges′ g=0.22; 95% CI 0.14 to 0.30; p<0.001). Based on subgroup analysis, the increase in CRF was significant in girls (Hedges′ g=0.25; 95% CI 0.13 to 0.37; p<0.001), but not in boys (Hedges′ g=0.02; 95% CI −0.10 to 0.14; p=0.731).

Summary

Moderate quality evidence supports the effectiveness of school-based physical activity interventions on improving CRF in children.

Trial registration number

Protocol PROSPERO registration number CRD42016050173.

Playful Interventions Increase Knowledge about Healthy Habits and Cardiovascular Risk Factors in Children: The CARDIOKIDS Randomized Study

BACKGROUND

Childhood obesity is an important health problem worldwide. In this context, there is a need for the development and evaluation of innovative educational interventions targeting prevention and formation of health habits.

OBJECTIVES

To ascertain the impact of ludic workshops on children's knowledge, self-care, and body weight.

METHODS

This was a randomized, clinical study with 79 students aged 7-11 years, conducted from March to November 2012. Anthropometric measurements were collected and two questionnaires (Typical Day of Physical Activities and Food Intake, in Portuguese, and the CARDIOKIDS, a questionnaire of knowledge about cardiovascular risk factors) were applied at baseline, at the end of intervention, and three months thereafter. The intervention consisted of eight playful workshops, which involved the presentation of a play.

RESULTS

Seventy-nine students were randomized to the intervention (n = 40) or the control group (n = 39). Mean age was 10.0 ± 1.1 years. After eight weeks, the intervention group showed significant improvement in the knowledge score (p < 0.001). There was an increase in physical activity scores in both groups, but with no difference between the groups at the end of intervention (p = 0.209). A reduction in the BMI percentile was observed in the intervention group, but there was no significant statistical difference between the two groups after the intervention.

CONCLUSIONS

Playful interventions may improve knowledge and physical activity levels in children and, when combined with other strategies, may be beneficial to prevent child obesity and improve self-care.

Can targeted policies reduce obesity and improve obesity-related behaviours in socioeconomically disadvantaged populations? A systematic review

This review synthesized evidence from controlled studies pertaining to the impact of targeted policies on anthropometric, dietary and physical activity outcomes amongst socioeconomically disadvantaged children and adults. Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity guidelines were followed. Eligible studies were published from 2004 to August 2015 and examined the impact of targeted policies on anthropometric, dietary and physical activity outcomes amongst socioeconomically disadvantaged populations. Twenty articles (18 studies) were included. Eight studies examined organizational policies within multi-component interventions in schools. Common elements of successful policy-containing interventions included nutritional standards, enhancements to physical education, additional physical activity opportunities, school self-assessments, and nutrition and physical activity education. Of the 10 studies of government policies, policies providing information/education and fruit and vegetable subsidies had positive impacts amongst children, but no impact amongst adults. Policies involving changes to built environments yielded nearly uniformly null findings in children and adults. Overall, the largest quantity of high-quality evidence of effectiveness was for comprehensive interventions that included school policies, and government policies targeting disadvantaged children in schools. None of the government policies targeting disadvantaged adults proved effective. Interventions during childhood may ameliorate negative obesity-related manifestations of socioeconomic disadvantage. Gaps in knowledge remain surrounding effective policies in adults, adolescents and very young children.

School-Based Interventions to Improve Cardiorespiratory Fitness in Adolescents: Systematic Review with Meta-analysis

BACKGROUND

School-based intervention can contribute to the promotion of cardiorespiratory fitness (CRF) in adolescents. However, it is neces sary to systematize how intervention strategies and the methodological characteristics of studies influence the effects of CRF interventions.

OBJECTIVE

A meta-analysis review of school-based intervention studies aimed at increasing CRF in adolescents (10-19 years of age) was conducted.

METHODS

A search for studies was conducted using the Medline, Web of Science, LILACS, PsycINFO, Embase, Scopus, SPORTDiscus and Cochrane databases and the reference lists of the selected studies. The peer selection process included consideration of school-based randomized or non-randomized controlled trials with a duration ≥12 weeks published in English, Portuguese or Spanish, and with some CRF measures. The methodological quality of the studies was also assessed. The standardized mean differences (SMDs) and 95 % confidence intervals (95 % CIs) were calculated as an effect measure.

RESULTS

Forty publications of 30 interventions were included in the review, and 25 of these were meta-analysed. The effects of CRF interventions were moderate and significant (SMD = 0.68, 95 % CI 0.45-0.90), with high heterogeneity (I (2) = 97 %). The effect size varied significantly according to the age group, sample size, intervention environment, strategies in experimental groups, CRF priority in the study, CRF test and indicator, session length, weekly frequency, intervention duration and presentation of results by sex.

CONCLUSION

Interventions in the school environment seem to have a positive effect on CRF among adolescents, but there is high heterogeneity between studies. Some intervention characteristics can explain better effects on CRF (e.g. exercise sessions in addition to physical education classes; primary focus on this outcome; combination of aerobic and resistance exercises; classes lasting ≥60 min; frequency of three times weekly; and intensity control).

"Skinny is prettier and normal: I want to be normal"-Perceived body image of non-Western ethnic minority children in the Netherlands

While the prevalence of overweight and obesity is higher among children of some non-Western ethnic minorities than among their Caucasian counterparts, their body image is understudied. The current study examined the body image of Dutch children of non-Western ethnic minorities (i.e., Surinamese, Antillean, Moroccan, and Turkish). Sociocultural influences from school, media and home environments and their perceptions of overweight prevention programs were taken into account. Fifty-two non-Western ethnic minority children (aged 8-12 years) participated in semi-structured interviews and focus groups. Results showed that the children generally underestimated their current body size, which was often overweight, and preferred thin and 'normal' body sizes. Results further revealed important insights into culturally determined themes, relating to perceived preferences in media, peers, parents, and teachers, nutritional habits, and children's beliefs about school-based health interventions. We conclude that targeting culturally sensitive awareness about actual body size and healthy body images seems paramount in future interventions.

The Health Promoting Schools Framework: Known Unknowns and an Agenda for Future Research

The World Health Organization’s Health Promoting Schools (HPS) framework is a whole-school approach to promoting health that recognizes the intrinsic relationship between health and education. Our recent Cochrane systematic review found HPS interventions produced improvements in a number of student health outcomes. Here we reflect on what this review was not able to tell us: in other words, what evidence is missing with regard to the HPS approach. Few HPS interventions engage with schools’ “core business” by examining impacts on educational outcomes. Current evidence is dominated by obesity interventions, with most studies conducted with children rather than adolescents. Evidence is lacking for outcomes such as mental or sexual health, substance use, and violence. Activities to engage families and communities are currently weak and unlikely to prompt behavioral change. The HPS approach is largely absent in low-income settings, despite its potential in meeting children’s basic health needs. Intervention theories are insufficiently complex, often ignoring upstream determinants of health. Few studies provide evidence on intervention sustainability or cost-effectiveness, nor in-depth contextual or process data. We set out an agenda for future school health promotion research, considering implications for key stakeholders, namely, national governments, research funders, academics, and schools.

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

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

The effects of school-based lifestyle interventions on body mass index and blood pressure: a multivariate multilevel meta-analysis of randomized controlled trials

Primary prevention of childhood obesity and related hypertension is warrant given that both risk factors are intertwined and track into adulthood. This systematic review and meta-analysis assess the impact of school-based lifestyle interventions on children's body mass index (BMI) and blood pressure. We searched databases and prior reviews. Eligibility criteria were the following: randomized controlled trial design, evaluation of a school-based intervention, targeting children aged 4-12 years, reporting on BMI and/or related cardiovascular risk factors, reporting data on at least one follow-up moment. The effects on BMI, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were evaluated by means of univariate and multivariate three-level random effects models. A total of 85 RCTs (91 papers) were included in the meta-analyses. In univariate models, the pooled effects were -0.072 (95%CI: -0.106; -0.038) for BMI, -0.183 (95%CI: -0.288; -0.078) for SBP and -0.071 (95%CI: -0.185; 0.044) for DBP. In multivariate analyses, the pooled effects of interventions were -0.054 (95%CI: -0.131; 0.022) for BMI, -0.182 (95%CI: -0.266; -0.098) for SBP and -0.144 (95%CI: -0.230; -0.057) for DBP. Parental involvement accentuated the beneficial effects of interventions. School-based lifestyle prevention interventions result in beneficial changes in children's BMI and blood pressure, and the effects on the latter may be stronger than and accrue independently from those in the former.

The Healthy Primary School of the Future: study protocol of a quasi-experimental study

BACKGROUND

Unhealthy lifestyles in early childhood are a major global health challenge. These lifestyles often persist from generation to generation and contribute to a vicious cycle of health-related and social problems. This design article presents a study evaluating the effects of two novel healthy school interventions. The main outcome measure will be changes in children's body mass index (BMI). In addition, lifestyle behaviours, academic achievement, child well-being, socio-economic differences, and societal costs will be examined.

METHODS

In close collaboration with various stakeholders, a quasi-experimental study was developed, for which children of four intervention schools (n = 1200) in the southern part of the Netherlands are compared with children of four control schools (n = 1200) in the same region. The interventions started in November 2015. In two of the four intervention schools, a whole-school approach named 'The Healthy Primary School of the Future', is implemented with the aim of improving physical activity and dietary behaviour. For this intervention, pupils are offered an extended curriculum, including a healthy lunch, more physical exercises, and social and educational activities, next to the regular school curriculum. In the two other intervention schools, a physical-activity school approach called 'The Physical Activity School', is implemented, which is essentially similar to the other intervention, except that no lunch is provided. The interventions proceed during a period of 4 years. Apart from the effectiveness of both interventions, the process, the cost-effectiveness, and the expected legal implications are studied. Data collection is conducted within the school system. The baseline measurements started in September 2015 and yearly follow-up measurements are taking place until 2019.

DISCUSSION

A whole-school approach is a new concept in the Netherlands. Due to its innovative, multifaceted nature and sound scientific foundation, these integrated programmes have the potential to form a template for primary schools worldwide. The effects of this approach may extend further than the outcomes associated with well-being and academic achievement, potentially impacting legal and cultural aspects in our society.

TRIAL REGISTRATION

The study protocol was registered in the database ClinicalTrials.gov on 14-06-2016 with the reference number NCT02800616 .

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

CONTEXT

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

OBJECTIVE

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

DATA SOURCES

The PubMed, Cochrane, and ERIC databases were used.

STUDY SELECTION

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

DATA EXTRACTION

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

RESULTS

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

CONCLUSION

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

What childhood obesity prevention programmes work? A systematic review and meta-analysis

Previous reviews of childhood obesity prevention have focused largely on schools and findings have been inconsistent. Funded by the US Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health, we systematically evaluated the effectiveness of childhood obesity prevention programmes conducted in high-income countries and implemented in various settings. We searched MEDLINE®, Embase, PsycINFO, CINAHL®, ClinicalTrials.gov and the Cochrane Library from inception through 22 April 2013 for relevant studies, including randomized controlled trials, quasi-experimental studies and natural experiments, targeting diet, physical activity or both, and conducted in children aged 2-18 in high-income countries. Two reviewers independently abstracted the data. The strength of evidence (SOE) supporting interventions was graded for each study setting (e.g. home, school). Meta-analyses were performed on studies judged sufficiently similar and appropriate to pool using random effect models. This paper reported our findings on various adiposity-related outcomes. We identified 147 articles (139 intervention studies) of which 115 studies were primarily school based, although other settings could have been involved. Most were conducted in the United States and within the past decade. SOE was high for physical activity-only interventions delivered in schools with home involvement or combined diet-physical activity interventions delivered in schools with both home and community components. SOE was moderate for school-based interventions targeting either diet or physical activity, combined interventions delivered in schools with home or community components or combined interventions delivered in the community with a school component. SOE was low for combined interventions in childcare or home settings. Evidence was insufficient for other interventions. In conclusion, at least moderately strong evidence supports the effectiveness of school-based interventions for preventing childhood obesity. More research is needed to evaluate programmes in other settings or of other design types, especially environmental, policy and consumer health informatics-oriented interventions.

The World Health Organization's Health Promoting Schools framework: a Cochrane systematic review and meta-analysis

BACKGROUND

Healthy children achieve better educational outcomes which, in turn, are associated with improved health later in life. The World Health Organization's Health Promoting Schools (HPS) framework is a holistic approach to promoting health and educational attainment in school. The effectiveness of this approach has not yet been rigorously reviewed.

METHODS

We searched 20 health, education and social science databases, and trials registries and relevant websites in 2011 and 2013. We included cluster randomised controlled trials. Participants were children and young people aged four to 18 years attending schools/colleges. HPS interventions had to include the following three elements: input into the curriculum; changes to the school's ethos or environment; and engagement with families and/or local communities. Two reviewers identified relevant trials, extracted data and assessed risk of bias. We grouped studies according to the health topic(s) targeted. Where data permitted, we performed random-effects meta-analyses.

RESULTS

We identified 67 eligible trials tackling a range of health issues. Few studies included any academic/attendance outcomes. We found positive average intervention effects for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small. On average across studies, we found little evidence of effectiveness for zBMI (BMI, standardized for age and gender), and no evidence for fat intake, alcohol use, drug use, mental health, violence and bullying others. It was not possible to meta-analyse data on other health outcomes due to lack of data. Methodological limitations were identified including reliance on self-reported data, lack of long-term follow-up, and high attrition rates.

CONCLUSION

This Cochrane review has found the WHO HPS framework is effective at improving some aspects of student health. The effects are small but potentially important at a population level.

How effective are interventions at reducing socioeconomic inequalities in obesity among children and adults? Two systematic reviews

Background

Tackling obesity is one of the major contemporary public health policy challenges and is vital in terms of addressing health inequalities.

Objectives

To systematically review the effectiveness of interventions (individual, community and societal) in reducing socioeconomic inequalities in obesity among (1) children aged 0–18 years (including prenatal) and (2) adults aged ≥18 years, in any setting, in any country, and (3) to establish how such interventions are organised, implemented and delivered.

Data sources

Nine electronic databases including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and NHS Economic Evaluation Database were searched from database start date to 10 October 2011 (child review) and to 11 October 2012 (adult review). We did not exclude papers on the basis of language, country or publication date. We supplemented these searches with website and grey literature searches.

Review methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Experimental studies and observational studies with a duration of at least 12 weeks were included. The reviews considered strategies that might reduce existing inequalities in the prevalence of obesity [i.e. effective targeted interventions or universal interventions that work more effectively in low socioeconomic status (SES) groups] as well as those interventions that might prevent the development of inequalities in obesity (i.e. universal interventions that work equally along the SES gradient). Interventions that involved drugs or surgery and laboratory-based studies were excluded from the reviews. The initial screening of titles and abstracts was conducted by one reviewer with a random 10% of the sample checked by a second reviewer. Data extraction was conducted by one reviewer and independently checked by a second reviewer. The methodological quality of the included studies was appraised independently by two reviewers. Meta-analysis and narrative synthesis were conducted focusing on the ‘best-available’ evidence for each intervention type (defined in terms of study design and quality).

Results

Of 56,967 papers of inequalities in obesity in children, 76 studies (85 papers) were included, and of 70,730 papers of inequalities in obesity in adults, 103 studies (103 papers) were included. These studies suggested that interventions that aim to prevent, reduce or manage obesity do not increase inequalities. For children, there was most evidence of effectiveness for targeted school-delivered, environmental and empowerment interventions. For adults, there was most evidence of effectiveness for primary care-delivered tailored weight loss and community-based weight loss interventions, at least in the short term among low-income women. There were few studies of appropriate design that could be included on societal-level interventions, a clear limitation of the evidence base found.

Limitations

The reviews located few evaluations of societal-level interventions and this was probably because they included only experimental study designs. The quality assessment tool, although described as a tool for public health interventions, seemed to favour those that followed a more clinical model. The implementation tool was practical but enabled only a brief summary of implementation factors to be made. Most of the studies synthesised in the reviews were from outside the UK and related to women.

Conclusions

The reviews have found some evidence of interventions with the potential to reduce SES inequalities in obesity and that obesity management interventions do not increase health inequalities. More experimental studies of the effectiveness and cost-effectiveness of interventions (particularly at the societal level) to reduce inequalities in obesity, particularly among adolescents and adult men in the UK, are needed.

Study registration

The studies are registered as PROSPERO CRD42011001740 and CRD42013003612.

Funding

The National Institute for Health Research Public Health Research programme.

Prevention of overweight and obesity in children and youth: a systematic review and meta-analysis

BACKGROUND

One-third of Canadian children are overweight or obese. This problem carries considerable concern for negative impacts on current and future health. Promoting healthy growth and development is critical. This review synthesized evidence on the effectiveness of behavioural interventions for preventing overweight and obesity in children and adolescents.

METHODS

We updated the search of a previous Cochrane review. Five databases were searched up to August 2013. Randomized trials of primary care-relevant behavioural (diet, exercise and lifestyle) interventions for preventing overweight and obesity in healthy normal- or mixed-weight children or youth aged 0-18 years were included if 12-week postbaseline data were provided for body mass index (BMI), BMI z-score, or prevalence of overweight or obesity. Any study reporting harms was included. Meta-analyses were performed if possible. Features of interventions showing significant benefits were examined.

RESULTS

Ninety studies were included, all with mixed-weight populations. Compared with controls, interventions showed a small but significant effect on BMI and BMI z-score (standardized mean difference -0.07, 95% confidence interval [CI] -0.10 to -0.03, I (2) = 74%), a reduction in BMI (mean difference -0.09 kg/m(2), 95% CI -0.16 to -0.03, I (2) = 76%) and a reduced prevalence of overweight and obesity (risk ratio [RR]; RRintervention - RRcontrol 0.94, 95% CI 0.89 to 0.99, I (2) = 0%; number needed to treat 51, 95% CI 29 to 289). Little evidence was available on harms. There was variability across efficacious interventions, although many of the interventions were short-term, involved school-aged children and were delivered in educational settings.

INTERPRETATION

Behavioural prevention interventions are associated with small improvements in weight outcomes in mixed-weight populations of children and adolescents. No intervention strategy consistently produced benefits.

REGISTRATION

PROSPERO no. CRD42012002754.

Physical activity and cardiovascular risk factors in children: meta-analysis of randomized clinical trials

OBJECTIVE

To assess the effects of physical activity interventions in preventing cardiovascular risk factors in childhood through a systematic review and meta-analysis of randomized clinical trials (RCTs).

METHODS

A search of online databases (PubMed, EMBASE and Cochrane CENTRAL) was conducted from inception until June 2013. RCTs enrolling children 6-12years old conducted physical activity interventions longer than 6months, assessing their effect on body mass index (BMI), systolic (SBP) and diastolic blood pressure (DBP), total cholesterol (TC) and triglycerides (TG) were included. Data analysis was performed using a random-effects model.

RESULTS

Of 23.091 articles retrieved, 11 RCTs (10.748 subjects) were included. Physical activity interventions were not associated with reductions of BMI [-0.03kg/m(2) (95%CI -0.16, 0.13) I(2) 0%]. However, there was an association between the interventions and reduction of SBP [-1.25mmHg (95%CI -2.47, -0.02) I(2) 0%], DBP [-1.34mmHg (95%CI -2.57, -0.11) I(2) 43%] and TG [-0.09mmol/L (95%CI -0.14, -0.04) I(2) 0%], and increase of TC [0.14mmol/L (95%CI 0.01, 0.27) I(2) 0%].

CONCLUSION

As physical activity intervention programs lasting longer than 6months are associated with reductions in blood pressure levels and triglycerides, they should be considered to be included in prevention programs for cardiovascular diseases in schoolchildren.

Childhood obesity: prevention and strategies of intervention. A systematic review of school-based interventions in primary schools

PURPOSE

Two crucial aspects of obesity prevention are early childhood and school-based interventions. The main purpose of this systematic review wass to evaluate the efficacy and the feasibility of school-based interventions performed in primary schools.

METHODS

All pertinent data from the literature have been critically examined and reviewed to evaluate the efficacy and the feasibility of different strategies of interventions. In particular, many studies have been performed in school-aged children.

RESULTS

Data from literature suggest that educational interventions toward healthy eating habits and physical activity at school could be a key strategy in the prevention of obesity, because it has been shown that is difficult to treat obesity in adults through changes in the lifestyle rather than during childhood. Recent advances in technology, especially web-based interventions, have been used to provide a specific content addressing healthy lifestyle with regard diet and exercise. These data suggest the opportunity to use web-interactive programs as a new challenging technique of communication in order to promote healthy behaviors.

CONCLUSIONS

The early detection and treatment of obesity in children may be the best approach to prevent future increases in morbidity, as well as healthcare costs that will likely occur as overweight and obese children age.

A systematic review of the effectiveness of individual, community and societal level interventions at reducing socioeconomic inequalities in obesity amongst children

BACKGROUND

Tackling childhood obesity is one of the major contemporary public health policy challenges and vital in terms of addressing socioeconomic health inequalities.We aimed to systematically review studies of the effectiveness of interventions (individual, community and societal) operating via different approaches (targeted or universal) in reducing socio-economic inequalities in obesity-related outcomes amongst children.

METHODS

Nine electronic databases were searched from start date to October 2012 along with website and grey literature searches. The review examined the best available international evidence from interventions that aimed to prevent obesity, treat obesity, or improve obesity-related behaviours (diet and/or physical activity) amongst children (aged 0-18 years) in any setting and country, so long as they provided relevant information and analysis on both socioeconomic status and obesity-related outcomes. Data extraction and quality appraisal were conducted using established mechanisms and narrative synthesis was conducted.

RESULTS

We located 23 studies that provided the 'best available' (strongest methodologically) international evidence. At the individual level (n = 4), there was indicative evidence that screen time reduction and mentoring health promotion interventions could be effective in reducing inequalities in obesity. For the community level interventions (n = 17), evidence was inconclusive - with some studies suggesting that school-based health promotion activities and community-based group-based programmes were effective in reducing obesity - others not. Societal level evaluations were few (n = 1). However, there was no evidence to suggest that any of these intervention types increase inequalities and several studies found that interventions could at least prevent the widening of inequalities in obesity. The majority of studies were from America and were of 6-12 year old children.

CONCLUSIONS

The review has found only limited evidence although some individual and community based interventions may be effective in reducing socio-economic inequalities in obesity-related outcomes amongst children but further research is required, particularly of more complex, societal level interventions and amongst adolescents.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of an intervention aimed at reducing the intake of sugar-sweetened beverages in primary school children: a controlled trial

BACKGROUND

Since sugar-sweetened beverages (SSB) may contribute to the development of overweight in children, effective interventions to reduce their consumption are needed. Here we evaluated the effect of a combined school- and community-based intervention aimed at reducing children's SSB consumption by promoting the intake of water. Favourable intervention effects on children's SSB consumption were hypothesized.

METHODS

In 2011-2012, a controlled trial was conducted among four primary schools, comprising 1288 children aged 6-12 years who lived in multi-ethnic, socially deprived neighbourhoods in Rotterdam, the Netherlands. Intervention schools adopted the 'water campaign', an intervention developed using social marketing. Control schools continued with their regular health promotion programme. Primary outcome was children's SSB consumption, measured using parent and child questionnaires and through observations at school, both at baseline and after one year of intervention.

RESULTS

Significant positive intervention effects were found for average SSB consumption (B -0.19 litres, 95% CI -0.28;-0.10; parent report), average SSB servings (B -0.54 servings, 95% CI -0.82;-0.26; parent report) and bringing SSB to school (OR 0.51, 95% CI 0.36;0.72; observation report).

CONCLUSIONS

This study supports the effectiveness of the water campaign intervention in reducing children's SSB consumption. Further studies are needed to replicate our findings.

TRIAL REGISTRATION

Current Controlled Trials: NTR3400.

School-based obesity prevention intervention in Chilean children: effective in controlling, but not reducing obesity

OBJECTIVE

To evaluate the effectiveness of a 12-month multicomponent obesity prevention intervention. Setting. 9 elementary schools in Santiago, Chile. Subjects. 6-8 y old low-income children (N = 1474).

DESIGN

Randomized controlled study; 5 intervention/4 control schools. We trained teachers to deliver nutrition contents and improve the quality of PE classes. We determined % healthy snacks brought from home, children's nutrition knowledge, nutritional status, duration of PE classes, and % time in moderate/vigorous activity (MVA). Effectiveness was determined by comparing Δ BMI Z between intervention and control children using PROCMIXED.

RESULTS

% obesity increased in boys from both types of schools and in girls from control schools, while decreasing in girls from intervention schools (all nonsignificant). % class time in MVA declined (24.5-16.2) while remaining unchanged (24.8-23.7%) in classes conducted by untrained and trained teachers, respectively. In boys, BMI Z declined (1.33-1.24) and increased (1.22-1.35) in intervention and control schools, respectively. In girls, BMI Z remained unchanged in intervention schools, while increasing significantly in control schools (0.91-1.06, P = 0.024). Interaction group ∗ time was significant for boys (P < 0.0001) and girls (P = 0.004).

CONCLUSIONS

This intervention was effective in controlling obesity, but not preventing it. Even though impact was small, results showed that when no intervention is implemented, obesity increases.

The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

BACKGROUND

The World Health Organization's (WHO's) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.

OBJECTIVES

To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.

SEARCH METHODS

We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.

SELECTION CRITERIA

We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school's ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.

DATA COLLECTION AND ANALYSIS

At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

MAIN RESULTS

We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.

AUTHORS' CONCLUSIONS

The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

School-based physical activity and nutritional education interventions on body mass index: a meta-analysis of randomised community trials - project PANE

OBJECTIVE

To evaluate the effect of school-based physical activity (PA) and nutritional education (NE) interventions on children's and adolescents' body mass index.

METHODS

We conducted a systematic search in fourteen databases until September 2012 for randomised controlled trials on PA and NE, conducted in the school setting, and delivered to children and adolescents. Additionally, we performed a cross-reference check in related papers. The title and abstract review and the quality assessment were performed by two independent researchers. The software EPPI-Reviewer3 was used to store, manage and analyse all data. The meta-analysis was conducted using the random-effects model, and the outcomes were reported as standardised mean difference (SMD). As a secondary analysis, we pooled together the interventions that considered PA or NE alone.

RESULTS

Thirty-eight studies met the eligibility criteria. The main analysis showed a SMD between intervention and control groups of -0.03 (95% CI: -0.09, 0.04; n=28,870; I(2)=83%). When we considered all 57 trials, there was no difference between the results of the primary analysis.

CONCLUSION

The synthesis of school-based PA and NE interventions showed no statistically significant mean reduction on children's and adolescents' body mass index. The high heterogeneity among studies requires caution in the generalisation of the results.

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

BACKGROUND

Obesity is one of the main determinants of avoidable disease burden.To implement a program by university students acting as "health promoting agents" (HPAs) and to evaluate the effects on obesity prevalence of the primary-school-based program that promotes healthy lifestyle, including dietary and physical activity recommendations over 28 months.

METHODS

Two school clusters were randomly assigned to intervention (24 schools, 1,222 pupils) or control (14 schools, 717 pupils); 78% of pupils were Western European. Mean age (±SD) was 8.4±0.6 years (49.9% females) at baseline. Generalized linear mixed models were used to analyze differences in primary outcome between both groups. Data collected included body mass index (BMI) every year. Dietary habits and lifestyle questionnaires were filled in by the parents at baseline and at the end of the study. The interventions focused on eight lifestyle topics covered in 12 activities (1 hour/activity/session) implemented by HPAs over 3 school academic years.

RESULTS

At 28 months, obesity prevalence in boys was decreased -2.36% in the intervention group (from 9.59% to 7.23%) and increased 2.03% (from 7.40% to 9.43%) in the control group; the difference was 4.39% (95% CI 3.48 to 5.30; P=0.01). The boys in the intervention group had an effective reduction of -0.24 units in the change of BMI z-score (from 0.01 to -0.04), compared to control (from -0.10 to 0.09); 5.1% more intervention pupils undertook physical activity>5 hours/week than control pupils (P=0.02).Fish consumption was a protector (odds ratio 0.39; 95% CI 0.23 to 0.67) while "fast-food" consumption was a risk factor for childhood obesity (odds ratio: 2.27; 95% CI 1.08 to 4.77).

CONCLUSIONS

Our school-based program, conducted by HPA students, successfully reduced childhood obesity prevalence in boys.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number: ISRCTN29247645.

ActiTrainer-determined segmented moderate-to-vigorous physical activity patterns among normal-weight and overweight-to-obese Czech schoolchildren

This study uncovered the patterns of moderate-to-vigorous physical activity (MVPA) in normal-weight and overweight/obese children before, during, and after school lessons. ActiTrainer-based MVPA was assessed over 2 school days (with and without a physical education lesson [PEL] in a sample of three hundred thirty-eight 9- to 11-year-old children (50.3 % female; 29.6 % overweight/obese), in the Czech Republic, during spring 2012. MVPA was quantified based on the step count (number), MVPA duration, and MVPA heart-rate response (minutes). No differences in the MVPA based on the time during the school day were confirmed in normal-weight versus overweight/obese girls, whereas normal-weight boys significantly exceed their overweight/obese peers in step count and after-school and daylong MVPA. Active participation in PEL contributes to a significantly higher step count, exercise duration, and MVPA heart-rate response in normal-weight and overweight/obese boys (p < 0.001) and normal-weight (p < 0.001) and overweight/obese (p < 0.04) girls during school time. Moreover, active participation in PEL significantly (p < 0.04) increases the overall daily step count, duration, and MVPA heart-rate response in normal-weight boys and overweight/obese girls. Active exercise during PEL accounted for 16.7 % of the total number of steps, 25.1 % of overall MVPA duration, and 24.1 % of the MVPA heart-rate response in 9- to 11-year-old children. During days with a PEL, a significantly (p < 0.02) higher number of overweight/obese girls and a higher number of normal-weight boys achieved the duration of 60 min/day of MVPA compared with days without a PEL.

CONCLUSION

Adding one PEL or an equivalent amount of MVPA to the daily school routine appears to be a promising strategy to effectively increase daily MVPA, particularly among overweight/obese girls.