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 that governments, communities and families can implement to prevent obesity, and promote health, has been accumulating but remains unclear.
Objectives
This review primarily aims to update the previous Cochrane review of childhood obesity prevention research and determine the effectiveness of evaluated interventions intended to prevent obesity in children, assessed by change in Body Mass Index (BMI). Secondary aims were to examine the characteristics of the programs and strategies to answer the questions “What works for whom, why and for what cost?”
Search methods
The searches were re-run in CENTRAL, MEDLINE, EMBASE, PsychINFO and CINAHL in March 2010 and searched relevant websites. Non-English language papers were included and experts were contacted.
Selection criteria
The review includes data from childhood obesity prevention studies that used a controlled study design (with orwithout randomisation).
Studies were included if they evaluated interventions, policies or programs in place for twelve weeks or more. If studies were randomised at a cluster level, 6 clusters were required.
Data collection and analysis
Two review authors independently extracted data and assessed the risk of bias of included studies. Data was extracted on intervention implementation, cost, equity and outcomes. Outcome measures were grouped according to whether they measured adiposity, physical activity (PA)-related behaviours or diet-related behaviours. Adverse outcomes were recorded. A meta-analysis was conducted using available BMI or standardised BMI (zBMI) score data with subgroup analysis by age group (0-5, 6-12, 13-18 years, corresponding to stages of developmental and childhood settings).
Main results
This review includes 55 studies (an additional 36 studies found for this update). The majority of studies targeted children aged 6- 12 years. The meta-analysis included 37 studies of 27,946 children and demonstrated that programmes were effective at reducing adiposity, although not all individual interventions were effective, and there was a high level of observed heterogeneity (I2=82%).
Overall, children in the intervention group had a standardised mean difference in adiposity (measured as BMI or zBMI) of -0.15kg/m 2 (95% confidence interval (CI): -0.21 to -0.09). Intervention effects by age subgroups were -0.26kg/m2 (95% CI:-0.53 to 0.00) (0- 5 years), -0.15kg/m2 (95% CI -0.23 to -0.08) (6-12 years), and -0.09kg/m2 (95% CI -0.20 to 0.03) (13-18 years). Heterogeneity was apparent in all three age groups and could not explained by randomisation status or the type, duration or setting of the intervention.
Only eight studies reported on adverse effects and no evidence of adverse outcomes such as unhealthy dieting practices, increased prevalence of underweight or body image sensitivities was found. Interventions did not appear to increase health inequalities although this was examined in fewer studies.
Authors’ conclusions
We found strong evidence to support beneficial effects of child obesity prevention programmes on BMI, particularly for programmes targeted to children aged six to 12 years. However, given the unexplained heterogeneity and the likelihood of small study bias, these findings must be interpreted cautiously. A broad range of programme components were used in these studies and whilst it is not possible to distinguish which of these components contributed most to the beneficial effects observed, our synthesis indicates the following to be promising policies and strategies:
· school curriculum that includes healthy eating, physical activity and body image
· increased sessions for physical activity and the development of fundamental movement skills throughout the school week
· improvements in nutritional quality of the food supply in schools
· environments and cultural practices that support children eating healthier foods and being active throughout each day
· support for teachers and other staff to implement health promotion strategies and activities (e.g. professional development, capacity building activities)
· parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in screen based activities
However, study and evaluation designs need to be strengthened, and reporting extended to capture process and implementation factors, outcomes in relation to measures of equity, longer term outcomes, potential harms and costs.
Childhood obesity prevention research must now move towards identifying how effective intervention components can be embedded within health, education and care systems and achieve long term sustainable impacts.
P L A I N L A N G U A G E S U M M A R Y
Childhood obesity can cause social, psychological and health problems, and is linked to obesity later in life and poor health outcomes as an adult. Obesity development is related to physical activity and nutrition. To prevent obesity, 55 studies conducted internationally have looked at programmes aiming to improve either or both of these behaviours. Although many studies were able to improve children’s nutrition or physical activity to some extent, only some studies were able to see an effect of the programme on children’s levels of fatness. When we combined the studies, we were able to see that these programmes made a positive difference, but there was much variation between the study findings which we could not explain. Also, it appeared that the findings may be biased by missing small studies with negative findings. We also tried to work out why some programmes work better than others, and whether
there was potential harm associated with children being involved in the programmes. Although only a few studies looked at whether programmes were harmful, the results suggest that those obesity prevention strategies do not increase body image concerns, unhealthy dieting practices, level of underweight, or unhealthy attitudes to weight, and that all children can benefit. It is important that more studies in very young children and adolescents are conducted to find out more about obesity prevention in these age groups, and also that we assess how long the intervention effects last. Also, we need to develop ways of ensuring that research findings benefit all children by embedding the successful programme activities into everyday practices in homes, schools, child care settings, the health system and the wider community.
