Reductions in the energy content of meals served in the Chilean National Nursery School Council Program did not consistently decrease obesity among beneficiaries

Implementation strategies used in policy, systems, and environmental interventions addressing obesity-related outcomes in early childhood education settings: a systematic review

BACKGROUND

Policy, systems, and environmental (PSE) approaches, including those enacted in early childhood education (ECE) settings, can improve child health outcomes. The use of implementation strategies, or the ways in which these approaches are enacted across settings, may modify intervention impact. Therefore, the purpose of this review was to examine the implementation strategies used among interventions utilizing PSE approaches in the ECE setting.

METHODS

Seven databases including MEDLINE, PubMed, Web of Science, and EMBASE, were searched for interventions in ECE settings including children (0-6 years) that utilized ≥ 1 PSE approach. Eligible studies included either a child-level outcome (i.e., weight, physical activity, or diet) or an environmental outcome (i.e., nutrition and physical activity environment). Data extracted included study characteristics, description of the intervention, and description of the implementation of the intervention. Implementation strategies were coded using the School Implementation Strategies Translating ERIC Resources (SISTER) taxonomy. The Downs and Black checklist was completed to assess study quality.

RESULTS

One hundred and four studies representing 97 interventions were identified. Fourteen (14%) did not report any implementation strategies. Of the remaining 83 interventions reporting implementation strategies, the mean number of implementation strategies employed per intervention was 3.8 (± 2.3) (range 1-11). However, few interventions (5/83, 6%) clearly named and defined implementation strategies. Most implementation strategies came from the "train and educate stakeholders" SISTER domain (177/318, 56%), and the most frequently used implementation strategy was "conduct educational meetings (50/83, 60%). Most studies were classified as good (59/104, 57%) or fair (40/104, 38%) quality.

CONCLUSIONS

In this review, many interventions appeared to use multiple implementation strategies to support ECE PSE interventions, though few explicitly documented or described those strategies. These findings suggest that more precise documentation of implementation strategies is needed to enhance replication and scalability of ECE interventions.

REGISTRATION

PROSPERO# CRD42022306670.

Effects of policies or interventions that influence the school food environment on children's health and nonhealth outcomes: a systematic review

CONTEXT

Globally, 1 in 3 children under 5 years is undernourished or overweight, and 1 in 2 suffers from hidden hunger due to nutrient deficiencies. As children spend a considerable time at school, school-based policies that aim to improve children's dietary intake may help address this double burden of malnutrition.

OBJECTIVE

This systematic review aimed to assess the effects of implementing policies or interventions that influence the school food environment on children's health and nonhealth outcomes.

DATA SOURCES, EXTRACTION, AND ANALYSIS

Eleven databases were searched up to April 2020 and the World Health Organization (WHO) released a call for data due in June 2020. Records were screened against the eligibility criteria, and data extraction and risk-of-bias assessment were conducted by 1 reviewer and checked by another. The synthesis was based on effect direction, and certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

CONCLUSIONS

Seventy-four studies reporting 10 different comparisons were included. The body of evidence indicates that interventions addressing the school food environment may have modest beneficial effects on certain key outcomes. Nutrition standards for healthy foods and beverages at schools, interventions that change how food is presented and positioned, and fruit and vegetable provision may have a beneficial effect on the consumption of healthy foods and beverages. Regarding effects on the consumption of discretionary foods and beverages, nutrition standards may have beneficial effects. Nutrition standards for foods and beverages, changes to portion size served, and the implementation of multiple nudging strategies may have beneficial effects on energy intake. Regarding effects of purchasing or selecting healthier foods, changes to how food is presented and positioned may be beneficial. This review was commissioned and supported by the WHO (registration 2020/1001698-0). WHO reviewed and approved the protocol for the systematic review and reviewed the initial report of the completed systematic review.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no: CRD42020186265.

Policy, system, and environmental interventions addressing obesity and diet-related outcomes in early childhood education settings: A systematic review

Early childhood education (ECE) settings play an important role in child dietary intake and excess weight gain. Policy, systems, and environment (PSE) approaches have potential to reduce disparities in children at higher risk for obesity. The purpose of this review was to (1) characterize the inclusion of populations at higher risk for obesity in ECE interventions and (2) identify effective ECE interventions in these populations. Seven databases were searched for ECE interventions. Intervention characteristics and methodological quality were assessed in 35 articles representing 34 interventions. Interventions identified were mainly a combination of ECE and parent interventions (41%) or stand-alone ECE intervention (29%), with few multisector efforts (23%) or government regulations assessed (5%). Many included policy (70%) or social environment components (61%). For Aim 1, two thirds were conducted in primarily populations at higher risk for obesity (67%). Studies were rated as fair or good methodological quality. For Aim 2, 10 studies demonstrated effectiveness at improving diet or reducing obesity in populations at higher risk for obesity. Most included a longer intervention (i.e., >6 months), multiple PSE components, and formative work. Opportunities to incorporate more PSE components in ECE-based interventions and collaborate with parents and communities are warranted to improve child health.

Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms

Actions to address different forms of malnutrition are typically managed by separate communities, policies, programmes, governance structures, and funding streams. By contrast, double-duty actions, which aim to simultaneously tackle both undernutrition and problems of overweight, obesity, and diet-related non-communicable diseases (DR-NCDs) have been proposed as a way to effectively address malnutrition in all its forms in a more holisitic way. This Series paper identifies ten double-duty actions that have strong potential to reduce the risk of both undernutrition, obesity, and DR-NCDs. It does so by summarising evidence on common drivers of different forms of malnutrition; documenting examples of unintended harm caused by some undernutrition-focused programmes on obesity and DR-NCDs; and highlighting examples of double-duty actions to tackle multiple forms of malnutrition. We find that undernutrition, obesity, and DR-NCDs are intrinsically linked through early-life nutrition, diet diversity, food environments, and socioeconomic factors. Some evidence shows that programmes focused on undernutrition have raised risks of poor quality diets, obesity, and DR-NCDs, especially in countries undergoing a rapid nutrition transition. This Series paper builds on this evidence to develop a framework to guide the design of double-duty approaches and strategies, and defines the first steps needed to deliver them. With a clear package of double-duty actions now identified, there is an urgent need to move forward with double-duty actions to address malnutrition in all its forms.

Impact of policy and built environment changes on obesity-related outcomes: a systematic review of naturally occurring experiments

Policies and changes to the built environment are promising targets for obesity prevention efforts and can be evaluated as 'natural'- or 'quasi'-experiments. This systematic review examined the use of natural- or quasi-experiments to evaluate the efficacy of policy and built environment changes on obesity-related outcomes (body mass index, diet or physical activity). PubMed (Medline) was searched for studies published 2005-2013; 1,175 abstracts and 115 papers were reviewed. Of the 37 studies included, 18 studies evaluated impacts on nutrition/diet, 17 on physical activity and 3 on body mass index. Nutrition-related studies found greater effects because of bans/restrictions on unhealthy foods, mandates offering healthier foods, and altering purchase/payment rules on foods purchased using low-income food vouchers compared with other interventions (menu labelling, new supermarkets). Physical activity-related studies generally found stronger impacts when the intervention involved improvements to active transportation infrastructure, longer follow-up time or measured process outcomes (e.g., cycling rather than total physical activity), compared with other studies. Only three studies directly assessed body mass index or weight, and only one (installing light-rail system) observed a significant effect. Studies varied widely in the strength of their design and studies with weaker designs were more likely to report associations in the positive direction.

Scientific decision making, policy decisions, and the obesity pandemic

Rising and epidemic rates of obesity in many parts of the world are leading to increased suffering and economic stress from diverting health care resources to treating a variety of serious, but preventable, chronic diseases etiologically linked to obesity, particularly type 2 diabetes mellitus and cardiovascular diseases. Despite decades of research into the causes of the obesity pandemic, we seem to be no nearer to a solution now than when the rise in body weights was first chronicled decades ago. The case is made that impediments to a clear understanding of the nature of the problem occur at many levels. These obstacles begin with defining obesity and include lax application of scientific standards of review, tenuous assumption making, flawed measurement and other methods, constrained discourse limiting examination of alternative explanations of cause, and policies that determine funding priorities. These issues constrain creativity and stifle expansive thinking that could otherwise advance the field in preventing and treating obesity and its complications. Suggestions are made to create a climate of open exchange of ideas and redirection of policies that can remove the barriers that prevent us from making material progress in solving a pressing major public health problem of the early 21st century.

Association of food form with self-reported 24-h energy intake and meal patterns in US adults: NHANES 2003-2008

BACKGROUND

Laboratory studies suggest that food form (beverages compared with solid foods) evokes behavioral and physiologic responses that modify short-term appetite and food intake. Beverage energy may be less satiating and poorly compensated, which leads to higher energy intake.

OBJECTIVE

We examined associations between 24-h energy consumed in beverages and a variety of meal and dietary attributes to quantify the contribution of beverage consumption to the energy content of diets in free-living individuals consuming their self-selected diets.

DESIGN

We used dietary recall data for adults (n = 13,704) in NHANES 2003-2008 to examine the multiple covariate-adjusted associations between 24-h energy from beverages and nonbeverages and associations between beverage intake, eating behaviors, and the energy density of beverage and nonbeverage foods.

RESULTS

In the highest tertile of 24-h beverage energy intake, beverages provided >30% of energy. Total 24-h energy and nonbeverage energy consumption and energy density (kcal/g) of both beverage and nonbeverage foods increased with increasing energy from beverages (P < 0.0001). With increasing 24-h beverage energy consumption, the reported frequency of all, snack, and beverage-only ingestive episodes and length of the ingestive period increased, whereas the percentage of energy from main meals decreased (P < 0.0001).

CONCLUSIONS

Higher 24-h beverage energy intake was related to higher energy intake from nonbeverage foods, quality of food selections, and distribution of 24-h energy into main meal and snack episodes. Moderation of beverage-only ingestive episodes and curtailing the length of the ingestion period may hold potential to lower uncompensated beverage energy consumption in the US population.

Fat free mass explains the relationship between stunting and energy expenditure in urban Mexican Maya children

BACKGROUND

Childhood stunting has been associated with an increased risk of obesity in adulthood, but the causes are unclear. This study hypothesizes that stunting significantly reduces both resting and activity energy expenditure.

AIM

To assess and describe energy expenditure of low socio-economic Maya children and to determine whether stunting is independently related to energy expenditure after controlling for lean mass.

SUBJECTS AND METHODS

Thirty-three urban Maya children, 17 boys, aged 7-9 years, living in Merida, Mexico, were measured for height, weight and bioelectrical impedance analysis (BIA). Body composition was estimated from BIA. Energy expenditure was measured for one week using the Actiheart (combined heart rate and accelerometer).

RESULTS

Stunting (height-for-age below the 5(th) percentile of NHANES III based references) affected 35% of these physically active children. Using multiple linear regression analysis, greater lean body mass predicted higher resting and activity energy expenditure. Stature was not a significant predictor of resting energy expenditure. A lower height-for-age z-score, but not stunting as a categorical variable, significantly predicted lower activity energy expenditure.

CONCLUSION

The hypothesis that stunting reduces total energy expenditure (resting + active) in children is not supported. Rather, children with shorter stature and less lean body mass have lower total energy expenditure. Complex interactions between body size, body composition, and metabolic activity appear to elevate the risk for later life obesity in these Maya children.