Pediatric Weight Management

Child Nutrition and Physical Activity and Inactivity

Citation:

Connelly JB, Duaso MJ, Butler G. A systematic review of controlled trials of interventions to prevent childhood obesity and overweight: A realistic synthesis of the evidence. Public Health. 2007; 121: 510-517.

PubMed ID: 17467752
 
Study Design:
Meta-analysis or Systematic Review
Class:
M - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To present practice-relevant guidance on interventions to reduce at least one measure of adiposity in child populations that do or do not contain overweight or obese children.

Inclusion Criteria:
  • Randomized controlled trials or controlled trials of interventions aiming to prevent overweight or obesity in non-clinical child populations
  • The duration of the trials was at least 12 weeks and  a minimum of 30 participants aged zero to 18 years were involved
  • All trials included an outcome that measure an index of adiposity.
Exclusion Criteria:

Ineligible studies that did not meet the inclusion criteria.

Description of Study Protocol:

Recruitment

Articles were identified from literature search on Medline, Embase, Cinhal, and PsycINFO up to 30 April 2006. 

Design

Systematic review

Blinding used 

Eligible randomized controlled trails were evaluated by two researchers who independently scored these trails using a quality checklist.

Intervention

Randomized controlled trials to prevent overweight or obesity in non-clinical child populations that do or do not contain overweight or obese children. Eligible trails involved at least 30 participants, followed for a duration of at least 12 weeks, and included an outcome that measured an index of adiposity.

Statistical Analysis

Kappa statistic was used in chance-corrected agreement to classify the physical activity intervention as "compulsory" or "voluntary".

Data Collection Summary:

Timing of Measurements

Both descriptive epidemiological and realistic evaluation concepts were adopted to cross-classify and synthesize the eligible identified trails. A proforma was constructed to allow a systematic recording of data from each trail. The extracted data items included reference number, first author, year of publication, country of the trail, design, unit of analysis, age group, ethnicity, numbers in each group, description of intervention, results, researchers' comments, appraisal comments, quality score, intensity score and effectiveness.

Eligible trails were classified as effective or ineffective in reducing adiposity in children. The intensity score of effectiveness of the intervention was estimated based on four elements: 

  1. The theoretical basis of the intervention (intervention based on an explicit theory or on pilot studies or formative research)
  2. Whether the Intervention implemented by the researchers
  3. Whether the provision of the physical activity was "compulsory" or  "voluntary"
  4. Whether the intervention had more than one element such as nutritional education or nutritional training skills (Multi-component intervention).

A score was  assigned to the trail by adding one for presence or zero for the absence of the above mentioned elements.

Dependent Variables

No meta-analysis was performed

Independent Variables

No meta-analysis was performed

Control Variables

No meta-analysis was performed

Description of Actual Data Sample:
  • Initial N: Initial number of citations identified from the literature search, number of abstracts screened, number of full-text articles screened, and number of articles rejected and the reasons for exclusion were not described
  • Final N: 28 randomized controlled trails published up to 30 April 2006 were included
  • Type of Studies reviewed: Population and study design of interest:
    • Eligible trials involved at least 30 participants for a duration of at least 12 weeks and involved non-clinical child populations that do or do not contain overweight or obese children
    • Outcome of interest: Trials reported at least one measure of adiposity 
  • Age: Zero to 19 years
  • Ethnicity:
    • Caucasian
    • Black
    • Minority ethnic group
    • African American
    • Native American and other ethnic group
  • Setting:
    • Home
    • Home and school
    • Clinic
    • Community/other.

 

Summary of Results:

Out of the 28 eligible trails, 11 were effective in reducing adiposity. The main factor that distinguished effective from ineffective trials was the provision of moderate to vigorous aerobic physical activity on a relatively "compulsory" rather than " voluntary" basis. 

No apparent association was observed between a trial’s quality score and its reported effectiveness regarding a measurement of adiposity.

List of randomized controlled and controlled trials of the prevention of obesity in childhood.

  Design Population Sample Size Description of Intervention Outcome Measures Effectiveness Quality Intensity
Author/Year/Country Units     Control Conditions Primary   Score Score
Simonetti D'Arca et al. (1986) Italy15 RCT; schools

Three to nine years

Not reported 

Schools (N =3)

Individuals: Multimedia (N=367)

Written action (N=358)

Control (N=596)

Printed and multimedia material distributed among pupils, and discussion meetings with families and teachers about physical activity

Control: Only the BMI was taken at zero and 12 months

Change in prevalence of obesity (percent)

Prevalence of overweight (percent)

Prevalence of normal weight (percent)

Prevalence of underweight (percent)

All categories based on BMI

Definitions not given

Effective in reducing obesity/overweight prevalence in boys and girls specially in overweight non-obese children 
Sallis et al. (1993) USA16 

RCT cluster

Schools 

9.25 years

non-Hispanic

White=85% Latino=7%
Asian=6%
Others=1% 

Schools:Specialist led NS=2

Teacher-led: NT=2

Individuals: NS

NS=91

NT=113

Control: NC =3

NC=101

Intervention:

Two intervention groups:

(1) PE specialists implemented the PE and self-regulation components

(2) PE classroom teachers were trained to deliver the components by the research team.

PE component: this was delivered in three 30-minute sessions a week

Self regulation: self-management skills were taught in weekly classes for 30 minutes; control: usual PE programme

BMI

(TSF) thickness 

Ineffective in reducing rate of increase in BMI or TSF  12 
Flores (1995), USA17 

RCT

Cluster;

Classes

N=4 inches

One school 

10-13 years
Mean 12.6 (US 7th grade)

Hispanic 43%

African-American 44%

Other 13% 

Intervention: 43 (26 girls; 17 boys)

Control: 38 (23 girls; 15 boys) 

Aerobic dance: ‘Dance for Health’ consisted of  three 50-min compulsory sessions of moderate to high intensity aerobic dance for 12 weeks

Health education: students met twice a  week for 25 minutes

Control: usual physical activity , mainly playground activities 

Timed mile run

Resting heart rate

BMI added for sexual maturation stage and age

Attitudes towards physical activity 

Effective in girls Not effect in boys

BMI reduced heart rate reduced 

11 
Vandongen et al. (1995), Australia18 

Factoral

RCT

Schools stratified into five socio-demographicstrata then randomized
to one of six groups (N=1 to N=6)
 

10-12 years

Not reported

 
Intervention
Total N=869
 
n1=75 girls and 75 boys
 
n2=77 girls and 72 boys
 
n3=91 girls and 73 boys
 
n4=65 girls and 54 boys
 
n5=75 girls and 86 boys
 
total number
originally randomized N=1,147
 
Control: n6 (control =63 girls and 63 boys
 

n1 fitness: this included six 30-minute classroom sessions providing a rational basis for activity.

Fitness programme 15 minutes per day for every school day

n2 fitness and school nutrition: this consisted of 10 one-hour lessons aimed to improve knowledge, attitude and eating habits. Plus the n1 intervention

n3 school nutrition:  this consisted of the n2 program without the addition of n1

n4 school and home nutrition: n3 plus home nutrition programme using comics containing educational material for both the child and parent

n5  home nutrition: this consisted of n4 without addition of n3

n6 control group: same measurements at baseline and follow-up but no additional nutrition or fitness programmes 

Dietary intake
 
Physical fitness
 
BMI
 
TSF thickness
 
Systolic and diastolic blood pressure
 
Percentage body fat
 
Total cholesterol
 
Ineffective in reducing BMI increase
 
Effective on TSF of the combined fitness and nutrition intervention (n2) group
 
17 

Leupker et al. (1996), USA19  

RCT

Cluster

Schools 

Mean age 8.76 years

White 69%

African-American 13%

Hispanic 14%

Other 4%

Intervention:

Schools (N=56) then further randomized (n1=28; n2=28)

Individuals: total N=5,106

Control: 40 

Intervention Schools were randomized to either the three or four components:

(1) intervention in the school food service to lower total fat and sodium per serving

(2) intervention to increase the amount of moderate to vigorous physical activity in PE classes to 40% of the time

(3) curricula: 15 lessons focused on psychosocial factors and involving health-skills training

(4) home-based curriculum involving parent/child assignments and family fun nights involving student performances of dance

Control: usual routine

Food service meals

PE sessions time spent on moderate to vigorous physical activity

Cholesterol level

Secondary: reported dietary intake

Reported physical activity

BMI 

Ineffective in decreasing rate of BMI increase over three school years.  20 

Donnelly et al. (1996), USA20 

Controlled-clinical trial

Schools 

8-9 years

94% Caucasian 

Intervention: 102

Control: 236 

Nutrition Intervention: school meals were planned with existing kitchen staff to reduce energy, fat and sodium

Physical activity intervention:existing classroom teachers delivered the activities. Activities were designed to use large muscle groups for 30-40 minutes per day for three sessions a week

Control: usual nutrition and physical activity practices 

Primary: one mile run time

BMI secondary: nutrition knowledge;

Outside school physical activity recall

Percentage of body fat

Observed PE class physical activity

Peak aerobic capacity

Cholesterol

24-hour energy intake 

Ineffective 

14 

Stolley and Fitzgibbon (1997), USA21 

RCT

Cluster

Child-mother

Dyads

 

Children aged 7-12 years and Mothers

African-American

 

Intervention: dyads: 32

Control: 0

 

Intervention: a culturally sensitive curriculum taught to mother and daughter dyads in a one-hour session over 11 weeks. The programme addressed the importance of eating a low-fat, low-cholesterol diet and increasing activity

Control: groups of seven to 11 dyads attended 11 x one-hour sessions focused on general health topics.

  

BMI

Percentage overweight

Secondary: dietary intake of saturated fat

Percentage of fat energy

Dietary cholesterol

Parental support and role modeling

 
Ineffective in BMI

 

16 

Mo-Suwan et al. (1998), Thailand22 

RCT

Cluster

Classes in two schools: school one two classes and school two six classes

 

Mean: 4.5 years;

Thai

 

158

75% of children participated in the study

Control: 152

 

Five-minute walk before morning class began and 20 min aerobic dance session after the afternoon nap three times a week

Control: these classes continued their routine activities.

 

BMI

TSF thickness

Ponderal Index (weight/ height)³

Child obesity

(BMI ≥95 centile for age/ sex)

 

Effective

School- based exercise programme

Decreased rate of increase of BMI in pre-school girls but not boys.

 

16 

Robinson, 1999, USA23 

RCT
 
Cluster
 
Two classes
 
Eight to nine years
 
Mean: 8.9 years
 
Not described
 
Intervention:
106
 
11 dropouts
 
Control:121
 
18 dropouts
 

Intervention: based on Bandura's social cognition model

Children received an 18-lesson, six-month classroom curriculum to reduce television, videotape and video game use

Control: before and after assessment of outcomes with no other intervention  

BMI
 
TSF
 
Waist to hip ratio
 
Secondary: reported time spent ‘watching TV’
 
Reported time spent in sedentary behaviors
 
Reported physical activity
 
Reported dietary intake
 
Multistage shuttle run
 
Effective. Decreasing eight to nine-year-old children’ watching TV and video and playing videogames effectively decreases rate of BMI increase in boys and girls.
 
19 

Gortmaker et al. (1999), USA24 

RCT

Cluster

Schools

 

10-11 years

Mean age:

11.7 years

White 66%

African-American 13%

Hispanic 12%

Asian 7%

Other 2%

 

Intervention: 641

Analysis based on 65% participation rate

Control 654

 

Intervention: school-based interdisciplinary intervention based on behavioral-choice theory and social cognition theory over two school years.
Sessions focused on decreasing television viewing
 
Decreasing consumption of high-fat foods
 
Increasing fruit and vegetable intake
 
Increasing moderate and vigorous physical activity
 
Control: followed their usual health education curriculum.
 
BMI and
TSF
 
Obesity defined
as both ≥85th centile for age/sex
 
Self-reported hours spent watching TV and video
 
Self-reported moderate to vigorous physical activity
 
Self-reported dietary intake
 
Self-reported weight-loss behavior
 
Effectiveness in decreasing obesity prevalence in girls but not boys and particular effectiveness in African-American girls.
 
16 

Sahota et al. (2001), England25

RCT

Cluster

Schools

(N=10)
             
Author Conclusion:

By using a novel approach to synthesizing trials, a decisive role for the ‘compulsory’ provision of aerobic physical activity has been demonstrated. Further research is required to identify how such activity can be sustained and transformed into a personally chosen behavior by children and over the life course.

Funding Source:
University/Hospital: Reading Uinversity, UK
Reviewer Comments:

"Compulsory" aerobic physical activity was associated with the trail effectiveness in terms of reducing adiposity; whereas, nutritional education and skills did not distinguish effective from ineffective intervention trails regarding childhood adiposity. The author postulated that nutritional education and skills may be hypothesized to be a necessary basis for compulsory physical activity to be effective.

 

Quality Criteria Checklist: Review Articles
Relevance Questions
  1. Will the answer if true, have a direct bearing on the health of patients? Yes
  2. Is the outcome or topic something that patients/clients/population groups would care about? Yes
  3. Is the problem addressed in the review one that is relevant to dietetics practice? Yes
  4. Will the information, if true, require a change in practice? No
 
Validity Questions
  1. Was the question for the review clearly focused and appropriate? Yes
  2. Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? Yes
  3. Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? No
  4. Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? Yes
  5. Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? Yes
  6. Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? Yes
  7. Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? Yes
  8. Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? Yes
  9. Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? No
  10. Was bias due to the review's funding or sponsorship unlikely? N/A