Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight.

Martin A, Booth JN, Laird Y, et al. Cochrane Database Syst Rev. 2018 Jan 29;1:CD009728. doi: 10.1002/14651858.CD009728.pub3. (Review) PMID: 29376563

BACKGROUND: The global prevalence of childhood and adolescent obesity is high. Lifestyle changes towards a healthy diet, increased physical activity and reduced sedentary activities are recommended to prevent and treat obesity. Evidence suggests that changing these health behaviours can benefit cognitive function and school achievement in children and adolescents in general. There are various theoretical mechanisms that suggest that children and adolescents with excessive body fat may benefit particularly from these interventions.

OBJECTIVES: To assess whether lifestyle interventions (in the areas of diet, physical activity, sedentary behaviour and behavioural therapy) improve school achievement, cognitive function (e.g. executive functions) and/or future success in children and adolescents with obesity or overweight, compared with standard care, waiting-list control, no treatment, or an attention placebo control group.

SEARCH METHODS: In February 2017, we searched CENTRAL, MEDLINE and 15 other databases. We also searched two trials registries, reference lists, and handsearched one journal from inception. We also contacted researchers in the field to obtain unpublished data.

SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials (RCTs) of behavioural interventions for weight management in children and adolescents with obesity or overweight. We excluded studies in children and adolescents with medical conditions known to affect weight status, school achievement and cognitive function. We also excluded self- and parent-reported outcomes.

DATA COLLECTION AND ANALYSIS: Four review authors independently selected studies for inclusion. Two review authors extracted data, assessed quality and risks of bias, and evaluated the quality of the evidence using the GRADE approach. We contacted study authors to obtain additional information. We used standard methodological procedures expected by Cochrane. Where the same outcome was assessed across different intervention types, we reported standardised effect sizes for findings from single-study and multiple-study analyses to allow comparison of intervention effects across intervention types. To ease interpretation of the effect size, we also reported the mean difference of effect sizes for single-study outcomes.

MAIN RESULTS: We included 18 studies (59 records) of 2384 children and adolescents with obesity or overweight. Eight studies delivered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies delivered dietary interventions. We included five RCTs and 13 cluster-RCTs. The studies took place in 10 different countries. Two were carried out in children attending preschool, 11 were conducted in primary/elementary school-aged children, four studies were aimed at adolescents attending secondary/high school and one study included primary/elementary and secondary/high school-aged children. The number of studies included for each outcome was low, with up to only three studies per outcome. The quality of evidence ranged from high to very low and 17 studies had a high risk of bias for at least one item. None of the studies reported data on additional educational support needs and adverse events.Compared to standard practice, analyses of physical activity-only interventions suggested high-quality evidence for improved mean cognitive executive function scores. The mean difference (MD) was 5.00 scale points higher in an after-school exercise group compared to standard practice (95% confidence interval (CI) 0.68 to 9.32; scale mean 100, standard deviation 15; 116 children, 1 study). There was no statistically significant beneficial effect in favour of the intervention for mathematics, reading, or inhibition control. The standardised mean difference (SMD) for mathematics was 0.49 (95% CI -0.04 to 1.01; 2 studies, 255 children, moderate-quality evidence) and for reading was 0.10 (95% CI -0.30 to 0.49; 2 studies, 308 children, moderate-quality evidence). The MD for inhibition control was -1.55 scale points (95% CI -5.85 to 2.75; scale range 0 to 100; SMD -0.15, 95% CI -0.58 to 0.28; 1 study, 84 children, very low-quality evidence). No data were available for average achievement across subjects taught at school.There was no evidence of a beneficial effect of physical activity interventions combined with healthy lifestyle education on average achievement across subjects taught at school, mathematics achievement, reading achievement or inhibition control. The MD for average achievement across subjects taught at school was 6.37 points lower in the intervention group compared to standard practice (95% CI -36.83 to 24.09; scale mean 500, scale SD 70; SMD -0.18, 95% CI -0.93 to 0.58; 1 study, 31 children, low-quality evidence). The effect estimate for mathematics achievement was SMD 0.02 (95% CI -0.19 to 0.22; 3 studies, 384 children, very low-quality evidence), for reading achievement SMD 0.00 (95% CI -0.24 to 0.24; 2 studies, 284 children, low-quality evidence), and for inhibition control SMD -0.67 (95% CI -1.50 to 0.16; 2 studies, 110 children, very low-quality evidence). No data were available for the effect of combined physical activity and healthy lifestyle education on cognitive executive functions.There was a moderate difference in the average achievement across subjects taught at school favouring interventions targeting the improvement of the school food environment compared to standard practice in adolescents with obesity (SMD 0.46, 95% CI 0.25 to 0.66; 2 studies, 382 adolescents, low-quality evidence), but not with overweight. Replacing packed school lunch with a nutrient-rich diet in addition to nutrition education did not improve mathematics (MD -2.18, 95% CI -5.83 to 1.47; scale range 0 to 69; SMD -0.26, 95% CI -0.72 to 0.20; 1 study, 76 children, low-quality evidence) and reading achievement (MD 1.17, 95% CI -4.40 to 6.73; scale range 0 to 108; SMD 0.13, 95% CI -0.35 to 0.61; 1 study, 67 children, low-quality evidence).

AUTHORS' CONCLUSIONS: Despite the large number of childhood and adolescent obesity treatment trials, we were only able to partially assess the impact of obesity treatment interventions on school achievement and cognitive abilities. School and community-based physical activity interventions as part of an obesity prevention or treatment programme can benefit executive functions of children with obesity or overweight specifically. Similarly, school-based dietary interventions may benefit general school achievement in children with obesity. These findings might assist health and education practitioners to make decisions related to promoting physical activity and healthy eating in schools. Future obesity treatment and prevention studies in clinical, school and community settings should consider assessing academic and cognitive as well as physical outcomes.


Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke.

Behbod B, Sharma M, Baxi R, et al. Cochrane Database Syst Rev. 2018 Jan 31;1:CD001746. doi: 10.1002/14651858.CD001746.pub4. (Review) PMID: 29383710

BACKGROUND: Children's exposure to other people's tobacco smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children in child care or educational settings are also at risk of exposure to ETS. Preventing exposure to ETS during infancy and childhood has significant potential to improve children's health worldwide.

OBJECTIVES: To determine the effectiveness of interventions designed to reduce exposure of children to environmental tobacco smoke, or ETS.

SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), and the Social Science Citation Index & Science Citation Index (Web of Knowledge). We conducted the most recent search in February 2017.

SELECTION CRITERIA: We included controlled trials, with or without random allocation, that enrolled participants (parents and other family members, child care workers, and teachers) involved in the care and education of infants and young children (from birth to 12 years of age). All mechanisms for reducing children's ETS exposure were eligible, including smoking prevention, cessation, and control programmes. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions.

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies and extracted data. Due to heterogeneity of methods and outcome measures, we did not pool results but instead synthesised study findings narratively.

MAIN RESULTS: Seventy-eight studies met the inclusion criteria, and we assessed all evidence to be of low or very low quality based on GRADE assessment. We judged nine studies to be at low risk of bias, 35 to have unclear overall risk of bias, and 34 to have high risk of bias. Twenty-one interventions targeted populations or community settings, 27 studies were conducted in the well-child healthcare setting and 26 in the ill-child healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether visits were made to well- or ill-children, and another included visits to both well- and ill-children. Forty-five studies were reported from North America, 22 from other high-income countries, and 11 from low- or middle-income countries. Only 26 of the 78 studies reported a beneficial intervention effect for reduction of child ETS exposure, 24 of which were statistically significant. Of these 24 studies, 13 used objective measures of children's ETS exposure. We were unable to pinpoint what made these programmes effective. Studies showing a significant effect used a range of interventions: nine used in-person counselling or motivational interviewing; another study used telephone counselling, and one used a combination of in-person and telephone counselling; three used multi-component counselling-based interventions; two used multi-component education-based interventions; one used a school-based strategy; four used educational interventions, including one that used picture books; one used a smoking cessation intervention; one used a brief intervention; and another did not describe the intervention. Of the 52 studies that did not show a significant reduction in child ETS exposure, 19 used more intensive counselling approaches, including motivational interviewing, education, coaching, and smoking cessation brief advice. Other interventions consisted of brief advice or counselling (10 studies), feedback of a biological measure of children's ETS exposure (six studies), nicotine replacement therapy (two studies), feedback of maternal cotinine (one study), computerised risk assessment (one study), telephone smoking cessation support (two studies), educational home visits (eight studies), group sessions (one study), educational materials (three studies), and school-based policy and health promotion (one study). Some studies employed more than one intervention. 35 of the 78 studies reported a reduction in ETS exposure for children, irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure but rather sought to reduce symptoms of asthma, and found a significant reduction in symptoms among the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.

AUTHORS' CONCLUSIONS: A minority of interventions have been shown to reduce children's exposure to environmental tobacco smoke and improve children's health, but the features that differentiate the effective interventions from those without clear evidence of effectiveness remain unclear. The evidence was judged to be of low or very low quality, as many of the trials are at a high risk of bias, are small and inadequately powered, with heterogeneous interventions and populations.


High-Intensity Interval Training Interventions in Children and Adolescents: A Systematic Review.

Eddolls WTB, McNarry MA, Stratton G, Winn CON, Mackintosh KA.
Sports Med. 2017 Nov;47(11):2363-2374. doi: 10.1007/s40279-017-0753-8.

BACKGROUND: Whilst there is increasing interest in the efficacy of high-intensity
interval training in children and adolescents as a time-effective method of
eliciting health benefits, there remains little consensus within the literature
regarding the most effective means for delivering a high-intensity interval
training intervention. Given the global health issues surrounding childhood
obesity and associated health implications, the identification of effective
intervention strategies is imperative.
OBJECTIVES: The aim of this review was to examine high-intensity interval
training as a means of influencing key health parameters and to elucidate the
most effective high-intensity interval training protocol.
METHODS: Studies were included if they: (1) studied healthy children and/or
adolescents (aged 5-18 years); (2) prescribed an intervention that was deemed
high intensity; and (3) reported health-related outcome measures.
RESULTS: A total of 2092 studies were initially retrieved from four databases.
Studies that were deemed to meet the criteria were downloaded in their entirety
and independently assessed for relevance by two authors using the pre-determined 
criteria. From this, 13 studies were deemed suitable. This review found that
high-intensity interval training in children and adolescents is a time-effective 
method of improving cardiovascular disease biomarkers, but evidence regarding
other health-related measures is more equivocal. Running-based sessions, at an
intensity of >90% heart rate maximum/100-130% maximal aerobic velocity, two to
three times a week and with a minimum intervention duration of 7 weeks, elicit
the greatest improvements in participant health.
CONCLUSION: While high-intensity interval training improves cardiovascular
disease biomarkers, and the evidence supports the effectiveness of running-based 
sessions, as outlined above, further recommendations as to optimal exercise
duration and rest intervals remain ambiguous owing to the paucity of literature
and the methodological limitations of studies presently available.


Association of Childhood Body Mass Index and Change in Body Mass Index With First Adult Ischemic Stroke.

Gjærde LK, Gamborg M, Ängquist L, Truelsen TC, Sørensen TIA, Baker JL.

JAMA Neurol. 2017 Aug 21. doi: 10.1001/jamaneurol.2017.1627. [Epub ahead ofprint]
Importance: The incidence of ischemic stroke among young adults is rising and is 
potentially due to an increase in stroke risk factors occurring at younger ages, 
such as obesity.
Objectives: To investigate whether childhood body mass index (BMI) and change in 
BMI are associated with adult ischemic stroke and to assess whether the
associations are age dependent or influenced by birth weight.
Design, Setting, and Participants: This investigation was a population-based
cohort study of schoolchildren born from 1930 to 1987, with follow-up through
national health registers from 1977 to 2012 in Denmark. Participants were 307 677
individuals (8899 ischemic stroke cases) with measured weight and height at ages 
7 to 13 years. The dates of the analysis were September 1, 2015, to May 27, 2016.
Main Outcomes and Measures: Childhood BMI, change in BMI, and birth weight.
Ischemic stroke events were divided into early (≤55 years) or late (>55 years)
age at diagnosis.
Results: The study cohort comprised 307 677 participants (approximately 49%
female and 51% male). During the study period, 3529 women and 5370 men
experienced an ischemic stroke. At all ages from 7 to 13 years, an above-average 
BMI z score was positively associated with early ischemic stroke. At age 13
years, a BMI z score of 1 was associated with hazard ratios (HRs) of 1.26 (95%
CI, 1.11-1.43) in women and 1.21 (95% CI, 1.10-1.33) in men. No significant
associations were found for below-average BMI z scores. Among children with
above-average BMI z scores at age 7 years, a score increase of 0.5 from ages 7 to
13 years was positively associated with early ischemic stroke in women (HR, 1.10;
95% CI, 1.01-1.20) and in men (HR, 1.08; 95% CI, 1.00-1.16). Similarly, among
children with below-average BMI z scores at age 7 years, a score increase of 0.5 
from ages 7 to 13 years was positively associated with early ischemic stroke in
women (HR, 1.14; 95% CI, 1.06-1.23) and in men (HR, 1.10; 95% CI, 1.04-1.18).
Adjusting for birth weight minimally affected the associations.
Conclusions and Relevance: Independent of birth weight, above-average childhood
BMI and increases in BMI during childhood are positively associated with early
adult ischemic stroke. To avoid the occurrence of early ischemic stroke
associated with childhood overweight and obesity, these results suggest that all 
children should be helped to attain and maintain healthy weights.


Priority setting in paediatric preventive care research.

To identify the unanswered research questions in paediatric preventive care that are most important to parents and clinicians, and to explore how questions from parents and clinicians may differ.
Iterative mixed methods research priority setting process.
Toronto, Ontario, Canada.
Parents of children aged 0–5 years enrolled in a research network in Toronto, and clinicians practising in Toronto, Ontario, Canada.
Informed by the James Lind Alliance’s methodology, an online questionnaire collected unanswered research questions in paediatric preventive care from study participants. Similar submissions were combined and ranked. A consensus workshop attended by 28 parents and clinicians considered the most highly ranked submissions and used the nominal group technique to select the 10 most important unanswered research questions.
Forty-two clinicians and 115 parents submitted 255 and 791 research questions, respectively, which were combined into 79 indicative questions. Most submissions were about nutrition, illness prevention, parenting and behaviour management. Parents were more likely to ask questions about screen time (49 parents vs 8 clinicians, p<0.05) and environmental toxins (18 parents vs 0 clinicians, p<0.05). The top 10 unanswered questions identified at the workshop related to mental health, parental stress, physical activity, obesity, childhood development, behaviour management and screen time.
The top 10 most important unanswered research questions in paediatric preventive care from the perspective of parents and clinicians were identified. These research priorities may be important in advancing preventive healthcare for children.


Facilitators and barriers for the adoption, implementation and monitoring of child safety interventions: a multinational qualitative analysis. (Qué funciona y qué no, y por qué, en intervenciones para prevenir accidentes infantiles).

Scholtes, B, Schröder-Bäck P, MacKay JM, Vincenten J, Förster K, Brand H.
Inj Prev.2017 Jun;23(3):197-204. doi: 10.1136/injuryprev-2016-042138. Epub 2016 Dec 2.

The efficiency and effectiveness of child safety interventions are determined by the quality of the implementation process. This multinational European study aimed to identify facilitators and barriers for the three phases of implementation: adoption, implementation and monitoring (AIM process). Twenty-seven participants from across the WHO European Region were invited to provide case studies of child safety interventions from their country. Cases were selected by the authors to ensure broad coverage of injury issues, age groups and governance level of implementation (eg, national, regional or local). Each participant presented their case and provided a written account according to a standardised template. Presentations and question and answer sessions were recorded. The presentation slides, written accounts and the notes taken during the workshops were analysed using thematic content analysis to elicit facilitators and barriers. Twenty-six cases (from 26 different countries) were presented and analysed. Facilitators and barriers were identified within eight general themes, applicable across the AIM process: management and collaboration; resources; leadership; nature of the intervention; political, social and cultural environment; visibility; nature of the injury problem and analysis and interpretation. The importance of the quality of the implementation process for intervention effectiveness, coupled with limited resources for child safety makes it more difficult to achieve successful actions. The findings of this study, divided by phase of the AIM process, provide practitioners with practical suggestions, where proactive planning might help increase the likelihood of effective implementation.


Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales.

Carter G, Milner A, McGill K, Pirkis J, Kapur N, Spittal MJ.

Prediction of suicidal behaviour is an aspirational goal for clinicians and policy makers; with patients classified as 'high risk' to be preferentially allocated treatment. Clinical usefulness requires an adequate positive predictive value (PPV). AimsTo identify studies of predictive instruments and to calculate PPV estimates for suicidal behaviours.
A systematic review identified studies of predictive instruments. A series of meta-analyses produced pooled estimates of PPV for suicidal behaviours.
For all scales combined, the pooled PPVs were: suicide 5.5% (95% CI 3.9-7.9%), self-harm 26.3% (95% CI 21.8-31.3%) and self-harm plus suicide 35.9% (95% CI 25.8-47.4%). Subanalyses on  self-harm found pooled PPVs of 16.1% (95% CI 11.3-22.3%) for high-quality studies, 32.5% (95% CI 26.1-39.6%) for hospital-treated self-harm and 26.8% (95%  CI 19.5-35.6%) for psychiatric in-patients.
No 'high-risk' classification was clinically useful. Prevalence imposes a ceiling on PPV. Treatment should reduce exposure to modifiable risk factors and offer effective interventions for selected subpopulations and unselected clinical populations.