Active play in ASP -a matched-pair cluster-randomized trial investigating the effectiveness of an intervention in after-school programs for supporting children's physical activity

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

Changing trajectory of daily physical activity levels among at-risk adolescents: influences of motivational mechanisms

BACKGROUND

Guided by Self-Determination Theory (SDT), the purpose of this study was to determine changes in the 16-week moderate-to-vigorous physical activity (MVPA) trajectory of underserved adolescents who participated in the Connect through PLAY afterschool program intervention and the effects of changes in participating adolescents' intrinsic and autonomous extrinsic motivations on their MVPA trajectory over the 16-week intervention.

METHODS

A subsample of 113 adolescents (56.64% female; 61.06% African American; average age = 11.29) provided complete data throughout the 16-week intervention were examined. Adolescents' objective daily MVPA was measured using 7- day accelerometer data. Changes in adolescents' intrinsic motivation and autonomous extrinsic motivation were assessed using subscales from the Intrinsic Motivation Inventory [1] and the Treatment Self-Regulation Questionnaire [2] respectively. A hierarchical linear model was built and tested to address the research aims.

RESULTS

The results of hierarchical linear models showed that, on average, youth daily MVPA increased 6.36 minutes in each 8-week period. Intrinsic motivation change, but not autonomous extrinsic motivation, was a positive and significant level-2 predictor of daily MVPA changes.

CONCLUSION

The findings provide significant evidence suggesting a benefit of integrating SDT-based approaches and further suggest that nurturing intrinsic motivation can be an effective approach to supporting youth daily MVPA in under-resourced afterschool programs.

TRIAL REGISTRATION

Connect Through PLAY: A Staff-based Physical Activity Intervention for Middle School Youth (Connect). https://clinicaltrials.gov/ct2/show/NCT03732144 . Registered November 6th, 2018.

Effects of out-of-school physical activity interventions based on self-determination theory in children and adolescents: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to examine the effects of out-of-school physical activity (PA) interventions, based on Self-Determination Theory (SDT), on basic psychological needs (BPN), motivation toward PA, and PA levels in youths.

DESIGN

Systematic review and meta-analyses.

METHOD

We searched for intervention studies examining the effects of PA interventions based on SDT implemented outside the school published in English and Spanish in six electronic databases up to January 2022.

RESULTS

Outcomes of interest were BPN, motivation, and PA levels. In total, nine studies were included in this review. Seven individual meta-analyses were conducted for each variable, revealing nonsignificant clustered effects for the outcomes autonomy satisfaction (g = 0.12, 95% CI [-0.31, 0.55]), competence satisfaction (g = 0.02, 95% CI [-0.28, 0.32]), relatedness satisfaction (g = 0.13, 95% CI [-0.43, 0.68]), autonomous motivation (g = 0.15, 95% CI [-0.38, 0.67]), controlled motivation (g = 0.12, 95% CI [-0.32, 0.55]), amotivation (g = -0.36, 95% CI [-0.88, 0.16]), and PA behavior (g = 0.02, 95% CI [-0.08, 0.12]).

CONCLUSION

Meta-analyses suggest that out-of-school PA interventions based on SDT are not effective in increasing levels of needs satisfaction, types of motivation, and PA levels.

The influence of social support, social affiliation and intrinsic motivation for increasing underserved youth's physical activity: A social climate-based intervention study

The purpose of this study was to investigate the influences of intrinsic motivation, social affiliation orientations and reciprocal social support for physical activity (PA) on underserved youths' afterschool period moderate-to-vigorous (MVPA) changing trajectories across the 16-week Connect through PLAY intervention, a social-motivational climate intervention. A total of 113 youth (61.06% African American, 56.64% girls) provided full data. Youths' intrinsic motivation, social affiliation orientations and social support were measured by youth responses to a set of surveys at baseline and post-intervention. Youths' afterschool period MVPA was measured using data from 7-day ActiGraph accelerometer wear at baseline, midpoint and post-intervention. Hierarchical linear modelling analysis found that youth daily afterschool period (3pm-6pm) MVPA increased, on average, 37.94 min across the 16-week intervention. Increases in intrinsic motivation, social affiliation orientations and social support were positive predictors of youth afterschool MVPA changing trajectory. The findings clarify the contributions that a social-motivational climate intervention can have on youth afterschool period MVPA through increasing youth intrinsic motivation, social affiliation and reciprocal social support.

Interventions in outside-school hours childcare settings for promoting physical activity amongst schoolchildren aged 4 to 12 years

BACKGROUND

Insufficient physical activity is one of four primary risk factors for non-communicable diseases such as stroke, heart disease, type 2 diabetes, cancer and chronic lung disease. As few as one in five children aged 5 to 17 years have the physical activity recommended for health benefits. The outside-school hours period contributes around 30% of children's daily physical activity and presents a key opportunity for children to increase their physical activity. Testing the effects of interventions in outside-school hours childcare settings is required to assess the potential to increase physical activity and reduce disease burden.

OBJECTIVES

To assess the effectiveness, cost-effectiveness and associated adverse events of interventions designed to increase physical activity in children aged 4 to 12 years in outside-school hours childcare settings.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, ERIC and SportsDISCUS to identify eligible trials on 18 August 2020. We searched two databases, three trial registries, reference lists of included trials and handsearched two physical activity journals in August 2020. We contacted first and senior authors on articles identified for inclusion for ongoing or unpublished potentially relevant trials in August 2020.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials, of any intervention primarily aimed at increasing physical activity in children aged 4 to 12 years in outside-school hours childcare settings compared to usual care. To be eligible, the interventions must have been delivered in the context of an existing outside-school hours childcare setting (i.e. childcare that was available consistently throughout the school week/year), and not set up in the after-school period for the purpose of research. Two review authors independently screened titles and abstracts of identified papers with discrepancies resolved via a consensus discussion. A third review author was not required to resolve disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included trials with discrepancies resolved via a consensus discussion; a third review author was not required to resolve disagreements. For continuous measures of physical activity, we reported the mean difference (MD) with 95% confidence intervals (CIs) in random-effects models using the generic inverse variance method for each outcome. For continuous measures, when studies used different scales to measure the same outcome, we used standardised mean differences (SMDs). We conducted assessments of risk of bias of all outcomes and evaluated the certainty of evidence (GRADE approach) using standard Cochrane procedures.

MAIN RESULTS

We included nine trials with 4458 participants. Five trials examined the effectiveness of staff-based interventions to change practice in the outside-school hours childcare setting (e.g. change in programming, activities offered by staff, staff facilitation/training). Two trials examined the effectiveness of staff- and parent-based interventions (e.g. parent newsletters/telephone calls/messages or parent tool-kits in addition to staff-based interventions), one trial assessed staff- and child-based intervention (e.g. children had home activities to emphasise physical activity education learnt during outside-school hours childcare sessions in addition to staff-based interventions) and one trial assessed child-only based intervention (i.e. only children were targeted).  We judged two trials as free from high risk of bias across all domains. Of those studies at high risk of bias, it was across domains of randomisation process, missing outcome data and measurement of the outcome. There was low-certainty evidence that physical activity interventions may have little to no effect on total daily moderate-to-vigorous physical activity compared to no intervention (MD 1.7 minutes, 95% CI -0.42 to 3.82; P = 0.12; 6 trials; 3042 children). We were unable to pool data on proportion of the OSHC session spent in moderate-to-vigorous physical activity in a meta-analysis. Both trials showed an increase in proportion of session spent in moderate-to-vigorous physical activity (moderate-certainty evidence) from 4% to 7.3% of session time; however, only one trial was statistically significant. There was low-certainty evidence that physical activity interventions may lead to little to no reduction in body mass index (BMI) as a measure of cardiovascular health, compared to no intervention (SMD -0.17, 95% CI -0.44 to 0.10; P = 0.22; 4 trials, 1684 children). Physical activity interventions that were delivered online were more cost-effective than in person. Combined results suggest that staff-and-parent and staff-and-child-based interventions may lead to a small increase in overall daily physical activity and a small reduction or no difference in BMI. Process evaluation was assessed differently by four of the included studies, with two studies reporting improvements in physical activity practices, one reporting high programme satisfaction and one high programme fidelity. The certainty of the evidence for these outcomes was low to moderate. Finally, there was very low-certainty evidence that physical activity interventions in outside-school hours childcare settings may increase cardiovascular fitness. No trials reported on quality of life or adverse outcomes. Trials reported funding from local government health grants or charitable funds; no trials reported industry funding.

AUTHORS' CONCLUSIONS

Although the review included nine trials, the evidence for how to increase children's physical activity in outside-school hours care settings remains limited, both in terms of certainty of evidence and magnitude of the effect. Of the types of interventions identified, when assessed using GRADE there was low-certainty evidence that multi-component interventions, with a specific physical activity goal may have a small increase in daily moderate-to-vigorous physical activity and a slight reduction in BMI. There was very low-certainty evidence that interventions increase cardiovascular fitness. By contrast there was moderate-certainty evidence that interventions were effective for increasing proportion of time spent in moderate-to-vigorous physical activity, and online training is cost-effective.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school.

OBJECTIVES

The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are: • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents; • to evaluate the effects of school-based interventions on improving body composition; and • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information.

SELECTION CRITERIA

Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update.  DATA COLLECTION AND ANALYSIS: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type.

MAIN RESULTS

Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias.  Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events.

AUTHORS' CONCLUSIONS

Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.

Effect of Linear and Nonlinear Pedagogy Physical Education Interventions on Children's Physical Activity: A Cluster Randomized Controlled Trial (SAMPLE-PE)

Background: School-based interventions are a key opportunity to improve children’s physical activity (PA); however, there is lack of evidence about how pedagogical approaches to motor learning in physical education (PE) might affect PA in children. Therefore, this study aimed to assess how different pedagogical approaches in PE might affect children’s PA. Methods: Participants (n = 360, 5–6 years) from 12 primary schools within the SAMPLE-PE randomized controlled trial were randomly allocated to either Linear Pedagogy (LP: n = 3) or Nonlinear Pedagogy (NP: n = 3) interventions, where schools received a 15-week PE intervention delivered by trained coaches, or to a control group (n = 6), where schools followed usual practice. ActiGraph GT9X accelerometers were used to assess PA metrics (moderate-to-vigorous PA, mean raw acceleration and lowest acceleration over the most active hour and half hour) over whole and segmented weeks at baseline, immediately post-intervention and 6 months follow-up. Intention to treat analysis employing multilevel modelling was used to assess intervention effects. Results: LP and NP interventions did not significantly affect children’s PA levels compared to the control group. Conclusion: PE interventions based on LP and NP alone might not be effective in improving habitual PA in children.

Intervention Effects of the Health Promotion Programme "Join the Healthy Boat" on Objectively Assessed Sedentary Time in Primary School Children in Germany

Sedentary behaviour (SB) in children is related to negative health consequences that can track into adulthood. The programme "Join the Healthy Boat" promotes reduced screen time and a less sedentary lifestyle in schoolchildren. This study investigated the effects of the programme on children's SB. For one year, teachers delivered the programme. A total of 231 children (7.0 ± 0.6 years) participated in the cluster-randomised study; there were 154 one year later at follow-up. Children's SB was assessed using multi-sensor accelerometery, screen time via parental questionnaire. Effects were analysed using (linear) mixed effects regression models. At baseline, children spent 211 (±89) min daily in SB, at follow-up 259 (±109) min/day with no significant difference between the intervention (IG) and control group (CG). SB was higher during weekends (p < 0.01, for CG and IG). However, at follow-up, daily screen time decreased in IG (screen time of >1 h/day: baseline: 33.3% vs. 27.4%; follow-up: 41.2% vs. 27.5%, for CG and IG, respectively). This multi-dimensional, low-threshold intervention for one year does not seem to achieve a significant reduction in children's SB, although screen time decreased in IG. Therefore, it should be considered that screen time cannot be the key contributor to SB and should not solely be used for changing children's SB. However, if screen time is targeted, interventions should promote the replacement of screen time with active alternatives.