Diet, physical activity, and behavioural interventions for the treatment of overweight or obesity in preschool children up to the age of 6 years

Colquitt J, Loveman E, O'Malley C, Azevedo LB, Mead E, Al-Khudairy L, et al.
Cochrane Database Syst Rev. 2016;3:CD012105

BACKGROUND: Child overweight and obesity has increased globally, and can be associated with short- and long-term health consequences.
OBJECTIVES: To assess the effects of diet, physical activity, and behavioural interventions for the treatment of overweight or obesity in preschool children up to the age of 6 years.
SEARCH METHODS: We performed a systematic literature search in the databases Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, and LILACS, as well as in the trial registers ClinicalTrials.gov and ICTRP Search Portal. We also checked references of identified trials and systematic reviews. We applied no language restrictions. The date of the last search was March 2015 for all databases.
SELECTION CRITERIA: We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions for treating overweight or obesity in preschool children aged 0 to 6 years.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed risk of bias, evaluated the overall quality of the evidence using the GRADE instrument, and extracted data following the Cochrane Handbook for Systematic Reviews of Interventions. We contacted trial authors for additional information.

MAIN RESULTS: We included 7 RCTs with a total of 923 participants: 529 randomised to an intervention and 394 to a comparator. The number of participants per trial ranged from 18 to 475. Six trials were parallel RCTs, and one was a cluster RCT. Two trials were three-arm trials, each comparing two interventions with a control group. The interventions and comparators in the trials varied. We categorised the comparisons into two groups: multicomponent interventions and dietary interventions. The overall quality of the evidence was low or very low, and six trials had a high risk of bias on individual 'Risk of bias' criteria. The children in the included trials were followed up for between six months and three years.In trials comparing a multicomponent intervention with usual care, enhanced usual care, or information control, we found a greater reduction in body mass index (BMI) z score in the intervention groups at the end of the intervention (6 to 12 months): mean difference (MD) -0.3 units (95% confidence interval (CI) -0.4 to -0.2); P < 0.00001; 210 participants; 4 trials; low-quality evidence, at 12 to 18 months' follow-up: MD -0.4 units (95% CI -0.6 to -0.2); P = 0.0001; 202 participants; 4 trials; low-quality evidence, and at 2 years' follow-up: MD -0.3 units (95% CI -0.4 to -0.1); 96 participants; 1 trial; low-quality evidence.One trial stated that no adverse events were reported; the other trials did not report on adverse events. Three trials reported health-related quality of life and found improvements in some, but not all, aspects. Other outcomes, such as behaviour change and parent-child relationship, were inconsistently measured.One three-arm trial of very low-quality evidence comparing two types of diet with control found that both the dairy-rich diet (BMI z score change MD -0.1 units (95% CI -0.11 to -0.09); P < 0.0001; 59 participants) and energy-restricted diet (BMI z score change MD -0.1 units (95% CI -0.11 to -0.09); P < 0.0001; 57 participants) resulted in greater reduction in BMI than the comparator at the end of the intervention period, but only the dairy-rich diet maintained this at 36 months' follow-up (BMI z score change in MD -0.7 units (95% CI -0.71 to -0.69); P < 0.0001; 52 participants). The energy-restricted diet had a worse BMI outcome than control at this follow-up (BMI z score change MD 0.1 units (95% CI 0.09 to 0.11); P < 0.0001; 47 participants). There was no substantial difference in mean daily energy expenditure between groups. Health-related quality of life, adverse effects, participant views, and parenting were not measured.No trial reported on all-cause mortality, morbidity, or socioeconomic effects.All results should be interpreted cautiously due to their low quality and heterogeneous interventions and comparators.
AUTHORS' CONCLUSIONS: Muticomponent interventions appear to be an effective treatment option for overweight or obese preschool children up to the age of 6 years. However, the current evidence is limited, and most trials had a high risk of bias. Most trials did not measure adverse events. We have identified four ongoing trials that we will include in future updates of this review.The role of dietary interventions is more equivocal, with one trial suggesting that dairy interventions may be effective in the longer term, but not energy-restricted diets. This trial also had a high risk of bias.

Primary prevention of childhood obesity, second edition.

Primary prevention of childhood obesity, second edition.

Registered Nurses' Association of Ontario (RNAO). Primary prevention of childhood obesity, second edition. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2014 May. 140 p. [265 references]

Major Recommendations

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.

Practice Recommendations

Assessment

Recommendation 1.1

Routinely assess children's nutrition, physical activity, sedentary behaviour, and growth according to established guidelines, beginning as early as possible in a child's lifespan.

(Level of Evidence = IV)

Recommendation 1.2

Assess the family environment for factors (e.g., parenting/primary caregiver influences and socio-cultural factors) that may increase children's risk of obesity.

(Level of Evidence = IV)

Recommendation 1.3

Collaborate with school leaders to assess elementary-school environments for risk and protective conditions that influence childhood obesity, including:

• Student demographics
• School policies
• Food and physical activity environments

(Level of Evidence = IV)

Recommendation 1.4

Assess neighbourhoods for community-level risk and protective conditions that influence childhood obesity.

(Level of Evidence = IV)

Planning

Recommendation 2.1

Engage community stakeholders when planning primary-prevention interventions for childhood obesity.

(Level of Evidence = IIb)

Recommendation 2.2

Develop interventions that are:

• Universally applied, as early as possible (Level of Evidence = IV)
• Targeted toward multiple behaviours (Level of Evidence = IV)
• Implemented using multiple approaches (Level of Evidence = IIa)
• Inclusive of parents/primary caregivers and the family (Level of Evidence = IIa), and
• Implemented simultaneously in multiple settings (Level of Evidence = IIa)

Implementation

Recommendation 3.1

Support exclusive breastfeeding for the first six months of life followed by breastfeeding and complementary feeding up to two years of age or beyond.

(Level of Evidence = III)

Recommendation 3.2

Provide education and social support to help parents/primary caregivers to promote healthy eating and physical activity in infants and toddlers.

(Level of Evidence = Ib)

Recommendation 3.3

Collaborate with parents/primary caregivers, educators and support staff (e.g., teachers, child care providers, school leaders) to promote healthy eating and physical activity in all settings where preschool children gather.

(Level of Evidence = Ib)

Recommendation 3.4

Collaborate with school communities to promote regular physical activity among elementary-school children.

(Level of Evidence = IIb)

Recommendation 3.5

Facilitate and support the integration of health and nutrition education into elementary-school programs and support the improvement of the school food environment.

(Level of Evidence = IIa–III)

Evaluation

Recommendation 4.1

Monitor and evaluate the effectiveness of the family's approach to healthy eating and physical activity.

(Level of Evidence = IV)

Recommendation 4.2

Evaluate the effectiveness and sustainability of school- and community-based primary-prevention initiatives.

(Level of Evidence = IV)

Recommendation 4.3

Advocate and support the evaluation of an organization's compliance with healthy public policies, and the impact of such policies on childhood eating behaviours and physical activity.

(Level of Evidence = III)

Education Recommendations

Recommendation 5.1

Incorporate foundational primary-prevention curricula based on this Guideline into the undergraduate education of nurses and other health-care providers.

(Level of Evidence = IV)

Recommendation 5.2

Health-care professionals should participate in continuing education to enhance their ability to support the positive behavioural and environmental changes for children, families, and communities recommended in this Guideline.

(Level of Evidence = IV)

.../...

Prevention and management of obesity for children and adolescents.

Fitch A, Fox C, Bauerly K, Gross A, Heim C, Judge-Dietz J, Kaufman T, Krych E, Kumar S, Landin D, Larson J, Leslie D, Martens N, Monaghan-Beery N, Newell T, O'Connor P, Spaniol A, Thomas A, Webb B. Prevention and management of obesity for children and adolescents. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Jul. 94 p. [110 references] Prevention Recommendations: Obesity prevention messages should be targeted at all families, starting at the time of the child's birth (Strong Recommendation, High Quality Evidence) (Barlow & Expert Committee, 2007). An assessment of diet, physical activity and sedentary behaviors should be done annually, preferably at a well child visit. This assessment should be used to target appropriate messages to each family (Strong Recommendation, High Quality Evidence) (Barlow & Expert Committee, 2007). Clinicians may suggest that children get at least 60 minutes of moderate exercise daily (Strong Recommendation, High Quality Evidence) (Barlow & Expert Committee, 2007). Clinicians should counsel children and families to: Limit their child's consumption of sugar-sweetened beverages Eat a diet with the recommended quantities of fruits and vegetables Eat breakfast daily Eat meals together as much as possible Limit eating out, especially eating at fast food restaurants Adjust portion sizes appropriately for age Avoid television for children under the age of two Limit television and "screen time" to less than two hours per day (Strong Recommendation, High Quality Evidence) (Barlow & Expert Committee, 2007) The following counseling messages should be directed to all parents, regardless of the weight status of their child. Healthy Diet Breastfeeding: Studies suggest that exclusive breastfeeding to six months of age is associated with decreased rates of obesity later in childhood [High Quality Evidence]. See the NGC Summary of the ICSI guideline Preventive services for children and adolescents for further information. Milk: The American Academy of Pediatrics recommends that children be started on cow's milk at 1 year of age. Whole milk is recommended for most children ages 12 months to two years. However, if the child is at risk for overweight or if there is a family history of obesity or cardiovascular disease, 2% milk is recommended. For children ages two years and up, a low-fat (skim or 1%) milk should be used. Sugar-sweetened beverages: Families should limit their child's consumption of sugar-sweetened beverages [High Quality Evidence]. Current evidence indicates a strong association between sugar-sweetened beverage consumption and total daily energy intake. Decreasing consumption of sugar-sweetened beverages is one strategy to decrease total daily energy intake [Reference]. Refer to the original guideline document for information regarding fruit juice and fruits and vegetables. Meal Structure Children should eat breakfast daily [High Quality Evidence]. Evidence shows that skipping breakfast decreases the nutritional quality of the diets of both children and adults [Reference]. Families should eat meals together at the table as much as possible. Family meals are associated with a higher quality diet [High Quality Evidence]. Snacking should be neither encouraged nor discouraged. The current data on meal frequency and snacking are inconclusive [Reference]. It is the opinion of the work group that if this issue is addressed with families, the focus should be on the quality of meals and snacks, not on the quantity. Eating out: Eating out at restaurants, especially fast food restaurants, should be limited. Restaurants, especially fast food restaurants, serve energy-dense food that can contribute significantly to a child's daily energy intake [High Quality Evidence]. The frequency of eating out is associated with body fatness in children and adults [Reference]. Refer to the original guideline document for information about portion sizes, child self-regulation, physical exercise, sleep, television, and the importance of the community in promoting a healthy lifestyle. For a detailed review of age appropriate "well care," including screening, assessment and anticipatory guidance, the work group recommends http://www.brightfutures.org . Screening and Diagnosis Recommendations: BMI should be calculated and documented in the medical record on all children ages 2 to 18 at least annually, ideally at a well child visit (Strong Recommendation, High Quality Evidence) (Barlow & Expert Committee, 2007). The Centers for Disease Control and Prevention (CDC) growth charts should be used for children ages 2 to 18; World Health Organization (WHO) growth curves should be used from birth through 23 months of age (Strong Recommendation, High Quality Evidence) (Barlow & Expert Committee, 2007). Appropriate terminology should be used to classify pediatric overweight and obesity. (Strong Recommendation, High Quality Evidence) (Barlow & Expert Committee, 2007).

Revisión sistemática sobre la caries en niños y adolescentes con obesidad y/o sobrepeso

María González Muñoz1, Milagros Adobes Martín1 y Javier González de Dios
Nutr Hosp. 2013;28(5):1372-1383

Resumen
Introducción: Obesidad y el sobrepeso (O/SP) infantil han alcanzado caracteres de epidemia y son un factor de riesgo de enfermedades crónicas graves para la salud. El objetivo es realizar una revisión sistemática (RS) sobre la relación de O/SP con caries en pediatría.

Material y métodos: RS de la literatura 2007-2011 en fuentes de información terciaria (Trip, Cochrane y
NGC), secundaria (PubMed, IME, IBECS y MEDES) y primarias (revisión de referencias). Criterios de inclusión: Pacientes (niños de 0-18 años), factor de riesgo (O/SP) y variable de interés (primaria: caries; secundarias: resto patología bucodental). Datos recogidos: Autor, año, país, tipo de estudio, edad pacientes, casos (con O/SP) y controles (con índice de masa corporal —IMC— normal o bajo), estado socioeconómico, prevalencia de caries y otros resultados en salud bucodental.

Resultados: Se localizaron un total de 48 documentos, de los que 37 cumplieron los criterios de búsqueda de la RS, distribuidos temporalmente: 6 artículos del año 2007, 6 del 2008, 5 del 2009, 11 del 2010 y 9 del 2011. Presentaron un grado de heterogeneidad muy amplio (en pacientes, intervención, variable principal de interés y tipo de diseño), lo que no permite aplicar síntesis cuantitativa (metanálisis) de los datos, pero si cualitativa. Los estudios son discordantes respecto a la relación entre IMC y frecuencia de caries (CAOD, caod).

Conclusiones: La RS permite al odontólogo y pediatra conocer la potencial relación entre O/SP y caries dental.

School-based obesity prevention programs: A meta-analysis of randomized controlled trials.

Sobol-Goldberg S, Rabinowitz J, Gross R

Obesity (Silver Spring). 2013 Jun 22. doi: 10.1002/oby.20515. [Epub ahead of print].  PMID: 23794226

Objective: 

Attempts have been made to reduce childhood obesity through school-based programs. Systematic reviews of studies until 2006 reported a lack of consistency about effectiveness of such programs. Presented is an updated systematic review and meta-analysis. 

Design and Methods: 

Replication of methodology used in previous comprehensive systematic review and meta-analysis of randomized controlled trials of school based obesity prevention programs covering studies until 2006 to review studies thru January 2012. 

Results: Based on 32 studies (n=52,109), programs were mildly effective in reducing BMI relative to controls not receiving intervention. Studies of children had significant intervention effects, those of teenagers did not, though the difference between the two groups was not statistically significant. Meta-regression showed a significant linear hierarchy of studies with the largest effects for comprehensive programs more than 1 year-long that aimed to provide information on nutrition and physical activity, change attitudes, monitor behavior, modify environment, involve parents, increase physical activity and improve diet, particularly among children. 

Conclusions: Unlike earlier studies, more recent studies showed convincing evidence that school-based prevention interventions are at least mildly effective in reducing BMI in children, possibly because these newer studies tended to be longer, more comprehensive and included parental support.

Systematic Review of Community-Based Childhood Obesity Prevention Studies.

Bleich SN, Segal J, Wu Y, Wilson R, Wang Y.

Pediatrics. 2013 Jun 10. [Epub ahead of print] 

PMID:

 

23753099

Source

OBJECTIVE:

This study systematically reviewed community-based childhood obesity prevention programs in the United States and high-income countries.

METHODS:

We searched Medline, Embase, PsychInfo, CINAHL, clinicaltrials.gov, and the Cochrane Library for relevant English-language studies. Studies were eligible if the intervention was primarily implemented in the community setting; had at least 1 year of follow-up after baseline; and compared results from an intervention to a comparison group. Two independent reviewers conducted title scans and abstract reviews and reviewed the full articles to assess eligibility. Each article received a double review for data abstraction. The second reviewer confirmed the first reviewer's data abstraction for completeness and accuracy.

RESULTS:

Nine community-based studies were included; 5 randomized controlled trials and 4 non-randomized controlled trials. One study was conducted only in the community setting, 3 were conducted in the community and school setting, and 5 were conducted in the community setting in combination with at least 1 other setting such as the home. Desirable changes in BMI or BMI z-score were found in 4 of the 9 studies. Two studies reported significant improvements in behavioral outcomes (1 in physical activity and 1 in vegetable intake).

CONCLUSIONS:

The strength of evidence is moderate that a combined diet and physical activity intervention conducted in the community with a school component is more effective at preventing obesity or overweight. More research and consistent methods are needed to understand the comparative effectiveness of childhood obesity prevention programs in the community setting.

A Systematic Review of Home-Based Childhood Obesity Prevention Studies.

Showell NN, Fawole O, Segal J, et al. Pediatrics. 2013 Jun 10. (Review) PMID: 23753095

BACKGROUND AND OBJECTIVES:

Childhood obesity is a global epidemic. Despite emerging research about the role of the family and home on obesity risk behaviors, the evidence base for the effectiveness of home-based interventions on obesity prevention remains uncertain. The objective was to systematically review the effectiveness of home-based interventions on weight, intermediate (eg, diet and physical activity [PA]), and clinical outcomes.

METHODS:

We searched Medline, Embase, PsychInfo, CINAHL, clinicaltrials.gov, and the Cochrane Library from inception through August 11, 2012. We included experimental and natural experimental studies with >/=1-year follow-up reporting weight-related outcomes and targeting children at home. Two independent reviewers screened studies and extracted data. We graded the strength of the evidence supporting interventions targeting diet, PA, or both for obesity prevention.

RESULTS:

We identified 6 studies; 3 tested combined interventions (diet and PA), 1 used diet intervention, 1 combined intervention with primary care and consumer health informatics components, and 1 combined intervention with school and community components. Select combined interventions had beneficial effects on fruit/vegetable intake and sedentary behaviors. However, none of the 6 studies reported a significant effect on weight outcomes. Overall, the strength of evidence is low that combined home-based interventions effectively prevent obesity. The evidence is insufficient for conclusions about home-based diet interventions or interventions implemented at home in association with other settings.

CONCLUSIONS:

The strength of evidence is low to support the effectiveness of home-based child obesity prevention programs. Additional research is needed to test interventions in the home setting, particularly those incorporating parenting strategies and addressing environmental influences.

Weight Gain in Infancy and Vascular Risk Factors in Later Childhood

Michael R. Skilton, PhD^a,^b, 

Guy B. Marks, PhD^c, 

Julian G. Ayer, PhD^b,

Frances L. Garden, MBiostat^b,^c,^d, 

Sarah P. Garnett, PhD^b,^e,^f,

Jason A. Harmer, MBBS^b, 

Stephen R. Leeder, PhD^b,^d,^g, 

Brett G. Toelle, PhD^c, 

Karen Webb, PhD^h, 

Louise A. Baur, PhD^b,^d,^e, and

David S. Celermajer, PhD^b

PEDIATRICS Vol. 131 No. 6 June 1, 2013 pp. e1821 -e1828

(doi: 10.1542/peds.2012-2789)

1. ^aBoden Institute of Obesity, Nutrition, Exercise, and Eating Disorders,
2. ^bSydney Medical School;
3. ^dSydney School of Public Health;
4. ^eThe Children's Hospital at Westmead Clinical School; and
5. ^gMenzies Centre for Health Policy, University of Sydney, Sydney, Australia;
6. ^cWoolcock Institute of Medical Research, Glebe, Australia;
7. ^fInstitute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, Australia; and
8. ^hAtkins Center for Weight and Health, Department of Nutritional Sciences and Toxicology and School of Public Health, University of California, Berkeley, California

ABSTRACT

OBJECTIVE: We hypothesized that early weight gain would be associated with incident obesity, higher blood pressure, systemic inflammation, and arterial wall thickening in later childhood.

METHODS: A longitudinal birth cohort was recruited antenatally from 2 maternity hospitals in Sydney, Australia, between September 1997 and December 1999. Three hundred ninety-five nondiabetic children who were followed to age 8 years had complete data for early weight gain and arterial wall thickness.

RESULTS: Independent predictors of excess early weight gain (age 0–18 months; adjusted for height gain) included male gender (0.411 kg [SE: 0.103],P < .001), fewer weeks’ gestation (−0.121 kg [SE: 0.044] per week, P = .006), birth length (0.156 kg [SE: 0.024] per cm, P < .001), and failure to breastfeed to 6 months of age (0.498 kg [SE: 0.108], P < .001). Early height-adjusted weight gain was significantly associated with later childhood overweight (odds ratio [OR]: 1.67 [95% confidence interval (CI): 1.26 to 2.20] per kg) and obesity (OR: 2.07 [95% CI: 1.53 to 2.79] per kg), excess central adiposity (OR: 1.54 [95% CI: 1.20 to 1.98] per kg), higher systolic blood pressure (1.24 mm Hg [SE: 0.33] per kg, P < .001), higher C-reactive protein (0.17 mg/dL [SE: 0.06] per 100% increase in weight gain, P = .006), and greater carotid intima-media thickness (0.012 mm [SE: 0.004] per kg, P = .002).

CONCLUSIONS: Early postnatal weight gain from birth to age 18 months is significantly associated with later childhood overweight and obesity, excess central adiposity, and greater arterial wall thickness.

Association between different growth curve definitions of overweight and obesity and cardiometabolic risk in children

CMAJ. 2012 Jul 10;184(10):E539-50. Epub 2012 Apr 30.
Kakinami L, Henderson M, Delvin EE, Levy E, O'Loughlin J, Lambert M, Paradis G.

Abstract

BACKGROUND:

Overweight and obesity in young people are assessed by comparing body mass index (BMI) with a reference population. However, two widely used reference standards, the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) growth curves, have different definitions of overweight and obesity, thus affecting estimates of prevalence. We compared the associations between overweight and obesity as defined by each of these curves and the presence of cardiometabolic risk factors.

METHODS:

We obtained data from a population-representative study involving 2466 boys and girls aged 9, 13 and 16 years in Quebec, Canada. We calculated BMI percentiles using the CDC and WHO growth curves and compared their abilities to detect unfavourable levels of fasting lipids, glucose and insulin, and systolic and diastolic blood pressure using receiver operating characteristic curves, sensitivity, specificity and kappa coefficients.

RESULTS:

The z scores for BMI using the WHO growth curves were higher than those using the CDC growth curves (0.35-0.43 v. 0.12-0.28, p < 0.001 for all comparisons). The WHO and CDC growth curves generated virtually identical receiver operating characteristic curves for individual or combined cardiometabolic risk factors. The definitions of overweight and obesity had low sensitivities but adequate specificities for cardiometabolic risk. Obesity as defined by the WHO or CDC growth curves discriminated cardiometabolic risk similarly, but overweight as defined by the WHO curves had marginally higher sensitivities (by 0.6%-8.6%) and lower specificities (by 2.6%-4.2%) than the CDC curves.

INTERPRETATION:

The WHO growth curves show no significant discriminatory advantage over the CDC growth curves in detecting cardiometabolic abnormalities in children aged 9-16 years.

PMID:

 

22546882

 

[PubMed - in process] 

PMCID:

 

PMC3394848

 

Free PMC Article