School-based interventions for the treatment of childhood obesity: a systematic review, meta-analysis and meta-regression of cluster randomised controlled trials

Interventions for Childhood Central Obesity: A Systematic Review and Meta-Analysis

Importance

The rapid rise in childhood central obesity and its cardiometabolic complications in adulthood highlight the urgent need for targeted global interventions.

Objective

To examine the association of lifestyle, behavioral, and pharmacological interventions with childhood central obesity.

Data Sources

MEDLINE, Embase, CINHAL, PsycINFO, PubMed, Academic Search Database, and ProQuest from inception to September 25, 2024.

Study Selection

Inclusion criteria included (1) randomized clinical trials (RCTs) focusing on children aged 5 to 18 years with overweight or obesity at baseline and (2) measured central obesity as a primary or secondary outcome.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline was followed. Two authors independently extracted data. Risk of bias was assessed using the revised Cochrane risk-of-bias tool (RoB 2.0). A random-effects meta-analysis was conducted to pool standardized mean differences (SMD) from individual studies. Sensitivity analysis, meta-regression, and subgroup analyses were also conducted.

Main Outcomes and Measures

The main outcome was childhood central obesity measured using waist circumference (WC), waist-to-height ratio, waist-to-hip ratio, and WC z score.

Results

This review included 34 RCTs, involving 8183 children aged 5 to 18 years. Twelve studies had a low risk of bias, whereas 8 were deemed to have a higher risk of bias. The meta-analysis of 2 RCTs examining low-fat lunchboxes and a Mediterranean diet along with physical activity (lasting up to 150 minutes per week over 6 to 9 months) showed a significant association with WC (standard mean difference [SMD], -0.38 [95% CI, -0.58 to -0.19]). Five additional RCTs involved behavioral interventions on dietary education to reduce unhealthy snacks, increase fruit and vegetable intake, promote daily physical activity, and limit screen time, supported by online resources also showed a significant association with WC (SMD, -0.54 [95% CI, -1.06 to -0.03]). However, standalone dietary, physical activity, pharmacotherapy, dietary supplements, motivational interviewing, and combined dietary, physical activity, and behavioral methods did not show a significant association with WC.

Conclusions and Relevance

In this meta-analysis of RCTs, combining dietary changes with physical activity, as well as using behavioral strategies alone, were associated with reduced central obesity in children from high- and middle-income countries. Findings from this study have policy implications for Sustainable Development Goals of ending all forms of malnutrition and reducing premature mortality from noncommunicable diseases.

Title: A Qualitative Systematic Review of Parental Perceptions, Motivators, and Barriers to Management of Childhood Obesity

Background

Childhood obesity is a global epidemic affecting millions worldwide. Children living with obesity face increased risks of health-related and psychosocial problems extending into adulthood. Parents and carers play a crucial role in cultivating healthy habits in their children. This review aims to synthesize qualitative research on parental perceptions, motivators, and barriers in managing childhood obesity and their views on weight management programs.

Methods

This systematic review was performed in accordance with the guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A variety of electronic databases were explored for qualitative studies published between 2006 and 2023. The CASP checklist was employed to assess the quality of the studies. Data extraction and synthesis were carried out utilizing thematic content analysis.

Results

The search identified 20 peer-reviewed studies meeting the inclusion criteria. Key themes were mapped into five distinct groups: perceptions, facilitators and barriers influencing the management of childhood obesity, as well as facilitators and barriers to enrolment into a weight management program. Parents often perceived obesity as a temporary condition, genetically determined and believed it should not be considered as a major health concern. Identified facilitators included the restriction of screen time, school involvement, goal setting, and enhanced child-parent communication. Conversely, barriers included lack of child motivation, peer influence, easy access to junk food, as well as parental denial, insufficient knowledge or control and logistical challenges.

Conclusion

To tackle childhood obesity, it is essential to adopt a comprehensive strategy that fosters a supportive family environment. Successful initiatives should encompass nutritional education for both parents and children, increase access to healthy food choices, implement home-based programs, and improve the infrastructure that encourages physical activity. Additionally, cultural factors and technological advancements should be considered when designing these interventions.

Systematic Review Registration Number

PROSPERO (CRD42024514219).

A family-based and mobile-assisted intervention for lifestyle behaviors in youths: A randomized controlled trial

This randomized controlled trial was conducted to assess the effectiveness of a family-based and mobile-assisted lifestyle intervention in reducing weight gain among school-age children with overweight and obesity. A total of 164 school-age children with overweight or obesity and their parents were randomized to the treatment intervention (n = 82) or an attention-control group (n = 82). The treatment intervention included three face-to-face education sessions, augmented by monthly text messages sent to parents on their mobile devices. The primary outcome was child BMI-for-age z-score. Secondary outcomes included child BMI, percent body fat, and actigraphy-assessed sleep as well as parental sleep quality. Outcomes were assessed at baseline, 3, 6, and 12 months after the intervention, with treatment effects analyzed using general linear models for repeated measures. Our results showed that children in the treatment intervention group had significantly lower BMI-for-age z score, BMI, and percent body fat than did those in the control group, with an adjusted mean difference of 0.31 units (95% CI: -0.59 to -0.03; p = 0.03), 1.34 kg/m² (95% CI, -2.42 to -0.26; p = 0.01), and 3.12% (95% CI, -5.93 to -0.30; p = 0.03), respectively. No treatment effects were observed for child and parental sleep. Our findings suggest that family-based and mobile-assisted lifestyle intervention results in significant and sustained benefits to enhanced weight management for school-age children with overweight and obesity. Nurses planning and delivering childhood overweight and obesity treatment interventions should consider a family-based approach with the assistance of mobile devices.

Modeling approaches for assessing device-based measures of energy expenditure in school-based studies of body weight status

Background

Obesity has become an important threat to children's health, with physical and psychological impacts that extend into adulthood. Limited physical activity and sedentary behavior are associated with increased obesity risk. Because children spend approximately 6 h each day in school, researchers increasingly study how obesity is influenced by school-day physical activity and energy expenditure (EE) patterns among school-aged children by using wearable devices that collect data at frequent intervals and generate complex, high-dimensional data. Although clinicians typically define obesity in children as having an age-and sex-adjusted body mass index (BMI) value in the high percentiles, the relationships between school-based physical activity interventions and BMI are analyzed using traditional linear regression models, which are designed to assess the effects of interventions among children with average BMI, limiting insight regarding the effects of interventions among children categorized as overweight or obese.

Methods

We investigate the association between wearable device-based EE measures and age-and sex-adjusted BMI values in data from a cluster-randomized, school-based study. We express and analyze EE levels as both a scalar-valued variable and as a continuous, high-dimensional, functional predictor variable. We investigate the relationship between school-day EE (SDEE) and BMI using four models: a linear mixed-effects model (LMEM), a quantile mixed-effects model (QMEM), a functional mixed-effects model (FMEM), and a functional quantile mixed-effects model (FQMEM). The LMEM and QMEM include SDEE as a summary measure, whereas the FMEM and FQMEM allow for the modeling of SDEE as a high-dimensional covariate. The FMEM and FQMEM allow the influence of the time of day at which physical activity is performed to be assessed, which is not possible using the LMEM or the QMEM. The FMEM assesses how frequently collected SDEE data influences mean BMI, whereas the FQMEM assesses the effects on quantile levels of BMI.

Results

The LMEM and QMEM detected a statistically significant effect of overall mean SDEE on log (BMI) (the natural logarithm of BMI) after adjusting for intervention, age, race, and sex. The FMEM and FQMEM provided evidence for statistically significant associations between SDEE and log (BMI) for only a short time interval. Being a boy or being assigned a stand-biased desk is associated with a lower log (BMI) than being a girl or being assigned a traditional desk. Across our models, age was not a statistically significant covariate, and white students had significantly lower log (BMI) than non-white students in quantile models, but this significant effect was observed for only the 10th and 50th quantile levels of BMI. The functional regression models allow for additional interpretations of the influence of EE patterns on age-and sex-adjusted BMI, whereas the quantile regression models enable the influence of EE patterns to be assessed across the entire BMI distribution.

Conclusion

The FQMEM is recommended when interest lies in assessing how device-monitored SDEE patterns affect children of all body types, as this model is robust and able to assess intervention effects across the full BMI distribution. However, the sample size must be sufficiently large to adequately power determinations of covariate effects across the entire BMI distribution, including the tails.

Challenges and Opportunities in Diagnosis and Management of Cardiometabolic Risk in Adolescents

PURPOSE OF REVIEW

This review aims to elucidate the limitations of diagnosing metabolic syndrome in adolescents as well as challenges and opportunities in the identification and reduction of cardiometabolic risk in this population.

RECENT FINDINGS

There are multiple criticisms of how we define and approach obesity in clinical practice and scientific research, and weight stigma further complicates the process of making and communicating weight-related diagnoses. While the goal of diagnosing and managing metabolic syndrome in adolescents would be to identify individuals at elevated future cardiometabolic risk and intervene to reduce the modifiable component of this risk, there is evidence that identifying cardiometabolic risk factor clustering may be more useful in adolescents than establishing a cutoff-based diagnosis of metabolic syndrome. It has also become clear that many heritable factors and social and structural determinants of health contribute more to weight and body mass index than do individual behavioral choices about nutrition and physical activity. Promoting cardiometabolic health equity requires that we intervene on the obesogenic environment and mitigate the compounding effects of weight stigma and systemic racism. The existing options to diagnose and manage future cardiometabolic risk in children and adolescents are flawed and limited. While striving to improve population health through policy and societal interventions, there are opportunities to intervene at all levels of the socioecological model in order to decrease future morbidity and mortality from the chronic cardiometabolic diseases associated with central adiposity in both children and adults. More research is needed to identify the most effective interventions.

MaestraNatura Reveals Its Effectiveness in Acquiring Nutritional Knowledge and Skills: Bridging the Gap between Girls and Boys from Primary School

MaestraNatura (MN) is a nutrition education program developed to both enhance awareness about the importance of healthy eating behaviour and skills on food and nutrition in primary school students. The level of knowledge about food and nutritional issues was assessed by a questionnaire administered to 256 students (9–10 years old) attending the last class of primary school and was compared with that of a control group of 98 students frequenting the same schools that received traditional nutrition education based on curricular science lessons and one frontal lesson conducted by an expert nutritionist. The results indicated that students in the MN program showed a higher percentage of correct responses to the questionnaire when compared with the control group (76 ± 15.4 vs. 59 ± 17.7; p < 0.001). Furthermore, the students attending the MN program were requested to organise a weekly menu before (T0) and when finished (T1) the MN program. The results evidenced an overall significant improvement in the score obtained at T1 with respect to those at T0 (p < 0.001), indicating a strong improvement in the ability to translate the theoretical concepts of nutrition guidelines in practice. In addition, the analysis revealed a gender gap between boys and girls, with boys showing a worse score at T0 that was ameliorated after the completion of the program (p < 0.001). Overall, MN program is effective in improving nutrition knowledge amongst 9–10-year-old students. Furthermore, students showed an increased ability to organise a weekly dietary plan after completing the MN program, a result which also bridged gender gaps. Thus, preventive nutrition education strategies specifically addressed to boys and girls, and involving both the school and family, are needed to make children aware of the importance of a healthy lifestyle and to correct inadequate eating habits.

Physical Activity and Nutrition Intervention for Middle Schoolers (Move More, Get More): Protocol for a Quasi-Experimental Study

BACKGROUND

Physical activity and nutrition behaviors are important to reducing the prevalence of childhood obesity. Previous research has identified school-based interventions as effective strategies to improve physical activity and nutrition. However, the results are often mixed, and middle schoolers are an under-studied population.

OBJECTIVE

Our study aims to fill this gap by developing an after-school intervention to increase physical activity and fruit and vegetable consumption that is influenced by national guidelines and formative research.

METHODS

This study was an after-school, quasi-experimental study spanning 9 months. Enrollment began in September 2021 and continued on a rolling basis through February 2022. Weekly, middle schoolers were offered 2-3 physical activity sessions and 1 produce kit. Physical activity was measured using accelerometers and questionnaires. Nutrition behaviors were assessed using questionnaires, and physical literacy was assessed using researcher observations. Follow-up data collection occurred in December 2021 and in April 2022. Difference scores will be calculated and analyzed for each outcome variable.

RESULTS

The intervention started in September 2021 and will conclude in May 2022. Published study results are expected in late 2022.

CONCLUSIONS

An increase in physical literacy, physical activity, and fruit and vegetable consumption is expected. If successful, future studies will focus on reach and sustainability. Lastly, this study may serve as a model for improving health outcomes in middle schools.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/37126.

A Natural Experiment Comparing the Effectiveness of the "Healthy Eagles" Child Weight Management Intervention in School Versus Community Settings

Behavioural weight management interventions are recommended for the treatment of obesity in children. However, the evidence for these is limited and often generated under trial conditions with White, middle-class populations. Healthy Eagles is a behavioural weight management intervention designed to treat excess weight in children. It ran in the London Borough of Croydon from 2017 to 2020 and was delivered in both school and community settings, providing a natural experiment to compare outcomes. A total of 1560 participants started the Healthy Eagles programme; 347 were in the community setting and 703 in the school setting. Data were analysed for those who completed 70% of the programme. In the school setting, there was a small but significant reduction in BMI z-score (M = −0.04, 95% CI = −0.08, −0.01) for participants above a healthy weight, especially in those with severe obesity (M = −0.09, 95% CI = −0.15, −0.03); there was no significant change in any subgroup in the community setting. Linear regression analysis showed the school setting was associated with a 0.26 (95% CI = 0.13, 0.49) greater reduction in BMI z-score than the community setting after adjusting for ethnicity, deprivation, age and gender. Across both programmes, the effect was somewhat greater in participants from a Black (African/Caribbean/Other) ethnic background (M = −0.06, 95% CI = −0.09, −0.02) and from the two most deprived quintiles (M = −0.06, 95% CI = −0.11, −0.01). Data were limited, but minimal changes were measured in nutrition and physical activity behaviours regardless of setting. This evaluation provides indirect evidence of a small but significant benefit to running weight management interventions in a school versus community setting.