Pediatric Weight Management

PWM: Physical Activity and Inactivity of Youth (2006)

Citation:

Stettler, N., Signer, T.M., Suter, P.M. (2004). Electronic games and environmental factors associated with childhood obesity in Switzerland. Obesity Research, 12 (6), 896-903.

PubMed ID: 15229327
 
Study Design:
Cross-Sectional Study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To identify environmental and behavioral factors, in particular type and duration of sedentary activities, associated with obesity in children living in Switzerland.

Inclusion Criteria:

Grades 1-3 at the start of the study.

Exclusion Criteria:

N/A

Description of Study Protocol:

Recruitment

Convenience sample of 10 schools from 4 communities in Zurich.

Design

All measures were taken before noon. The children were not in a fasting state while height, weight and skinfolds (3 sites) were assessed.  Questionnaires were administered to the children by a physician.

Statistical Analysis

  • Correlations among independent variables were assessed using correlation coefficients. 
  • Unadjusted associations were estimated using simple logistic regression or chi-square and expressed as odds ratios with 95% confidence intervals.
  • Interactions were assessed using logistic regression with an interaction term or Mantel-Haenszel tests.
  • Multiple logistic regression were used to adjust for potential confounding variables.
Data Collection Summary:

Dependent Variables

  • Obesity – BMI at 95th percentile AND sum of skinfolds at or above the 85th percentile.

Independent Variables

  • TV – total duration of all programs watched regularly
  • PA – estimated by the teacher on a scale of 0-10
  • Video games – amount of time playing

Control Variables

  • SES

Description of Actual Data Sample:

Initial N: Initial sample of 922 students

Attrition (final N): 45 absent on day of the assessment, 5 parents did not give consent. Final sample of 872 (94.6%).

Age: grades 1 through 3.

Ethnicity:

Other relevant demographics:

Anthropometrics (e.g., were groups same or different on important measures)

Location: Zurich, Switzerland

Summary of Results:

Foreign nationality were more likely to be obese than Swiss nationals in the unadjusted analyses (17.3% vs. 8.8%). Foreign children also watched more TV (2.1 vs. 1.8 hrs/d, P<.001) than Swiss children

Small but significant correlation between TV and video is .07+

Small but significant correlation between TV and PA is .17

Author Conclusion:

Obesity was independently associated with the time spent watching TV.

The positive association between time spent watching television and childhood obesity was expected and is significant with a 2 to 3 fold increased risk with each additional hour of TV per day.

Funding Source:
Government: NIH
Reviewer Comments:

Limitations

  • PA was assessed by the teacher and they can not assess PA outside of the school day.
  • Present sample was not necessarily representative of the Swiss (it was limited to 4 cultural regions)

Strength:

Used a combination of BMI and skinfolds for a measure of overweight which is appropriate for this age children.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? N/A
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? Yes
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? No
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? No
  7.5. Was the measurement of effect at an appropriate level of precision? ???
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes