Parent diet modification, child activity, or both in obese children: an RCT

Targeting Pediatric Obesity via a Healthy Lifestyle Summer Camp Intervention: How Necessary Is a Parenting Component?

Background: Pediatric obesity represents a significant public health concern, especially for Hispanic school-aged children. This study examined via a randomized trial the efficacy of a family-based intervention [Healthy Lifestyle Summer Camp and Parenting program (HLSC+HLPP)] compared with a child-based camp intervention [Healthy Lifestyle Summer Camp (HLSC)] on improving child and parent health outcomes. Methods: Participants included 24 children (n = 11 HLSC+HLPP; n = 13 HLSC) with a mean age of 6.17 years (range 4-9 years) who were mostly Hispanic (87.5%) and were classified as overweight or obese, and their primary caregiver. Various anthropometric, physical activity, nutrition, and parenting outcomes were collected pre-/post-intervention. Results: Results indicated that both interventions were feasible and acceptable. There were no statistically significant differences between groups; however, both groups demonstrated a decrease in child BMI z-score (HLSC+HLPP: g = -0.31; HLSC: g = -0.31) and increase in child fitness (HLSC+HLPP: g = 1.70; HLSC: g = 1.77), nutritional health classification (HLSC+HLPP: g = 1.54; HLSC: g = 0.82), nutrition expressive knowledge (HLSC+HLPP: g = 1.03; HLSC: g = 1.06), and parental monitoring (HLSC+HLPP: g = 0.51; HLSC: g = 0.49) after the intervention. Conclusions: These findings highlight the feasibility, acceptability, and improvement of child health outcomes after both interventions. Future research should examine group differences during a follow-up period as well as employ a larger sample.

Defining paediatric metabolic (dysfunction)-associated fatty liver disease: an international expert consensus statement

The term non-alcoholic fatty liver disease (NAFLD), and its definition, have limitations for both adults and children. The definition is most problematic for children, for whom alcohol consumption is usually not a concern. This problematic definition has prompted a consensus to rename and redefine adult NAFLD associated with metabolic dysregulation to metabolic (dysfunction)-associated fatty liver disease (MAFLD). Similarities, distinctions, and differences exist in the causes, natural history, and prognosis of fatty liver diseases in children compared with adults. In this Viewpoint we, an international panel, propose an overarching framework for paediatric fatty liver diseases and an age-appropriate MAFLD definition based on sex and age percentiles. The framework recognises the possibility of other coexisting systemic fatty liver diseases in children. The new MAFLD diagnostic criteria provide paediatricians with a conceptual scaffold for disease diagnosis, risk stratification, and improved clinical and multidisciplinary care, and they align with a definition that is valid across the lifespan.

Cultural adaptation of an existing children's weight management programme: the CHANGE intervention and feasibility RCT

BACKGROUND

Excess weight in children is a continuing health issue. Community-based children's weight management programmes have had some effect in promoting weight loss. Families from minority ethnic communities are less likely to complete these programmes but, to date, no programmes have been culturally adapted to address this.

OBJECTIVES

We aimed to (1) culturally adapt an existing weight management programme for children aged 4-11 years and their families to make it more suited to Pakistani and Bangladeshi communities but inclusive of all families and (2) evaluate the adapted programme to assess its feasibility and acceptability, as well as the feasibility of methods, for a future full-scale trial.

DESIGN

In phase I, a cultural adaptation of a programme that was informed by formative research and guided by two theoretical frameworks was undertaken and in phase II this adapted programme was delivered in a cluster-randomised feasibility study (for which the clusters were the standard and adapted children's weight management programmes).

SETTING

Birmingham: a large, ethnically diverse UK city.

PARTICIPANTS

In phase I, Pakistani and Bangladeshi parents of children with excess weight, and, in phase II, children aged 4-11 years who have excess weight and their families.

INTERVENTIONS

A culturally adapted children's weight management programme, comprising six sessions, which was delivered to children and parents, targeting diet and physical activity and incorporating behaviour change techniques, was developed in phase I and delivered in the intervention arm to 16 groups in phase II. The eight groups in the comparator arm received the standard (unadapted) children's weight management programme.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of Pakistani and Bangladeshi families completing (attending ≥ 60% of) the adapted programme. Secondary outcomes included the proportion of all families completing the adapted programme, the feasibility of delivery of the programme, the programme's acceptability to participants, the feasibility of trial processes and the feasibility of collection of outcome and cost data.

RESULTS

The proportion of Pakistani and Bangladeshi families and all families completing the adapted programme was 78.8% [95% confidence interval (CI) 64.8% to 88.2%] and 76.3% (95% CI 67.0% to 83.6%), respectively. The programme was feasible to deliver with some refinements and was well received. Ninety-two families participated in outcome data collection. Data collection was mostly feasible, but participant burden was high. Data collection on the cost of programme delivery was feasible, but costs to families were more challenging to capture. There was high attrition over the 6-month follow-up period (35%) and differential attrition in the two study arms (29% and 52% in the intervention and comparator arms, respectively).

LIMITATIONS

The study was not designed to address the issue of low participant uptake of children's weight management programmes. The design of a future trial may include individual randomisation and a 'minimal intervention' arm, the acceptability of which has not been evaluated in this study.

CONCLUSIONS

The theoretically informed, culturally adapted children's weight management programme was highly acceptable to children and families of all ethnicities. Consideration should be given to a future trial to evaluate clinical effectiveness and cost-effectiveness of the adapted programme, but the design of a future trial would need to address the logistics of data collection, participant burden and study attrition.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN81798055.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 33. See the NIHR Journals Library website for further project information. Kate Jolly is part-funded by the Collaboration for Leadership in Applied Health Research and Care West Midlands.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Feasibility and efficacy of a web-based family telehealth nutrition intervention to improve child weight status and dietary intake: A pilot randomised controlled trial

INTRODUCTION

Innovative eHealth solutions that improve access to child weight management interventions are crucial to address the rising prevalence of childhood obesity globally. The study aimed to evaluate the feasibility and preliminary efficacy of a 12-week online telehealth nutrition intervention to improve child weight and dietary outcomes, and the impact of additional text messages (SMS) targeted to mothers and fathers.

METHODS

Families with children aged 4 to 11 were randomised across three groups: Telehealth, Telehealth+SMS, or Waitlist control. Telehealth and Telehealth+SMS groups received two telehealth consultations delivered by a dietitian, 12 weeks access to a nutrition website and a private Facebook group. The Telehealth+SMS group received additional SMS. Feasibility was assessed through recruitment, retention, and intervention utilisation. Efficacy was assessed through changes in measured child body mass index (BMI), waist circumference and diet.

RESULTS

Forty-four (96%) and 36 (78%) families attended initial and second telehealth consultations, respectively. Thirty-six families (78%) completed week 12 assessments. Child BMI and waist circumference changes from baseline to week 12 were not statistically different within or between groups. Children in Telehealth+SMS had significantly reduced percentage energy from energy-dense nutrient-poor food (95% CI -21.99 to -0.03%E; p = .038) and increased percentage energy from healthy core food (95% CI -0.21 to 21.89%E; p = .045) compared to Waitlist control.

DISCUSSION

A family-focused online telehealth nutrition intervention is feasible. While the modest sample size reduced power to detect between-group changes in weight status, some improvements in child dietary intakes were identified in those receiving telehealth and SMS.

A comparative effectiveness trial of two family-based childhood obesity treatment programs in a medically underserved region: Rationale, design & methods

While there is a large body of literature documenting the efficacy of family-based childhood obesity (FBCO) treatment interventions, there is little evidence that these interventions have been systematically translated into regular practice - particularly in health disparate regions. To address this research-practice gap, this project was guided by a community advisory board (CAB) and the RE-AIM planning and evaluation framework within a systems-based and community-based participatory research approach. Families with overweight or obese children between 5 and 12 years old, in the medically-underserved Dan River Region, were randomly assigned to one of two FBCO treatment programs (iChoose vs. Family Connections) delivered by local Parks & Recreation staff. Both programs have previously demonstrated clinically meaningful child BMI z-score reductions, but vary in intensity, structure, and implementation demands. Two clinical CAB partners embedded recruitment methods into their regional healthcare organization, using procedures representative to what could be used if either program was taken to scale. The primary effectiveness outcome is child BMI z-scores at 6-months, with additional assessments at 3-months and at 12-months. Secondary goals are to determine: (1) reach into the intended audience; (2) effectiveness on secondary child and parent outcomes; (3) intervention adoption by organizations and staff; (4) fidelity, cost, and capacity for intervention implementation; and (5) maintenance of individual-level changes and organizational-level sustainability. This research addresses literature gaps related to the features within clinical and community settings that could improve both child weight status and the translation of FBCO interventions into typical practice in medically-underserved communities. IDENTIFIERS: Clincialtrials.gov: NCT03245775.

Demographics and anthropometrics impact benefits of health intervention: data from the Reduce Obesity and Diabetes Project

OBJECTIVE

To determine the efficacy of a 4-month school-based health, nutrition and exercise intervention on body fatness and examine possible effects of demographic and anthropometric covariates.

METHODS

Height, weight, waist circumference and body composition were measured in a diverse population of 644 NYC middle school students (mean ± SD age 12.7 ± 0.9 years; 46% male; 38% Hispanic, 17% East Asian, 15% South Asian, 13.5% African American, 8.5% Caucasian, 8% other) during the fall and spring semesters. Year 1 participants (n = 322) were controls. Experimental participants (year 2, n = 469) received a 12-session classroom-based health and nutrition educational programme with an optional exercise intervention.

RESULTS

Groups were demographically and anthropometrically similar. The intervention resulted in significant reductions in indices of adiposity (ΔBMI z-scores [-0.035 ± 0.014; p = 0.01], Δ% body fat [-0.5 ± 0.2; p < 0.0001] and Δwaist circumference [-0.73 ± 0.30 cm; p < 0.0001]). Intervention effects were greater (p = 0.01) in men (ΔBMI z-score = -0.052 ± 0.015) versus women (0.022 ± 0.018), participants who were obese (ΔBMI z-score -0.083 ± 0.022 kg m-2) versus lean (-0.0097 ± 0.020 kg m-2) and South Asians (Δ% body fat -1.03 ± 0.35) versus total (-0.49 ± 0.20%) participants (p = 0.005).

CONCLUSION

A 4-month school-based health intervention was effective in decreasing measures of adiposity in middle school students, particularly in men, participants who were obese and South Asians.

Intervention for childhood obesity based on parents only or parents and child compared with follow-up alone

OBJECTIVES

The study aims to assess the effects of family-based interventions targeted to parents only or to parents-and-child for the prevention and treatment of childhood obesity.

METHOD

An open-label randomized study was conducted in 247 children (166 girls, 5-11 years) with body mass index (BMI) in the 85-98th percentile. Participants were allocated to three groups: parents-only (n = 89), parents-and-child (n = 84) and follow-up alone (n = 74). The intervention consisted of 12 once-weekly meetings with a dietician and psychologist. All children were followed for 2 years. Changes in anthropometric, clinical and lifestyle outcomes were assessed.

RESULTS

The 3-month intervention was completed by 58 (65.2%) in the parents-only, 61 (72.6%) in the parents-child and 49 (66.2%) in the control group (P = .554). BMI-standard deviation score (SDS) decreased from baseline to 3 months in both intervention groups (parents-only: from 1.74 ± 0.31 to 1.66 ± 0.36, P < .001; parents-child, 1.83 ± 0.33 to 1.76 ± 0.36, P = .012), with no significant change in the controls (1.73 ± 0.32 to 1.70 ± 0.31, P = .301). The 2-year follow-up was completed by 45 in each of the intervention groups (50.5% and 53.5%, respectively) and 37 controls (50%) (P = .896). Compared with baseline, only the parents-child group showed a significant decrease in BMI-SDS (1.56 ± 0.46, P = .006). The rate of children who met the criteria for metabolic syndrome tended to drop from 6.0% at baseline (14/232) to 1.5% at 3 months (12/137) (P = .109), with no significant between-group differences in the rate of metabolic syndrome at baseline or at completion of the intervention.

CONCLUSIONS

An intervention programme that focuses on both parents and children was found to have positive short-term and long-term effects on BMI-SDS.

Summer Healthy-Lifestyle Intervention Program for Young Children Who Are Overweight: Results from a Nonrandomized Pilot Trial

OBJECTIVE

To examine initial outcomes of an 8-week Healthy-Lifestyle Intervention Program (HIP) which included children's participation in a daily summer camp along with parents' participation in a parenting program focused on overweight/obesity.

METHODS

Using a nonrandomized pilot trial design, 16 children (M child age = 6.42 yr; 81% male; 100% Latino) classified as overweight/obese and their mothers completed 3 assessments (baseline, posttreatment, and 6-8 mo follow-up).

RESULTS

Children who completed HIP experienced significant decreases in their body mass index z-scores (primary outcome) from baseline to posttreatment (d = -1.11) with such decreases being moderately maintained at follow-up (d = -0.64). In terms of secondary outcomes, HIP was effective in improving and maintaining healthy habits in both children and mothers and children's nutritional knowledge and fitness. Objective food data showed that children's dietary intake during HIP improved. High attendance and satisfaction were reported for families who completed HIP.

CONCLUSION

This pilot treatment development study shows that a family lifestyle intervention conducted in a summer camp setting that targets both children and parents is a promising option for addressing pediatric obesity in young children.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2018. We searched Proquest Dissertations and Theses in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 63 trials with 178 trial arms and 11,698 participants. Thirty-nine trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fourteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Nine studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 63 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.There is very low quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 3.50 g as-desired consumption of vegetables (SMD 0.33, 95% CI 0.13 to 0.54; participants = 1741; studies = 13). Multicomponent interventions versus no intervention may have a very small effect on child consumption of fruit and vegetables (SMD 0.35, 95% CI 0.04 to 0.66; participants = 2009; studies = 5; low-quality evidence), equivalent to an increase of 0.37 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; participants = 3078; studies = 11; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for four studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 63 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low- and low-quality evidence respectively that child-feeding practice and multicomponent interventions may lead to very small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up is required and future research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase to identify eligible trials on 25 September 2017. We searched Proquest Dissertations and Theses and two clinical trial registers in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 55 trials with 154 trial arms and 11,108 participants. Thirty-three trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Thirteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 55 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% confidence interval (CI) 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 g of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for three studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 55 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains sparse. There was very low-quality evidence that child-feeding practice interventions are effective in increasing vegetable consumption in children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption in children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase Classic and Embase to identify eligible trials on 30 September 2016. We searched CINAHL and PsycINFO in July 2016, Proquest Dissertations and Theses in November 2016 and three clinical trial registers in November 2016 and June 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures.We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 50 trials with 137 trial arms and 10,267 participants. Thirty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Eleven trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.Thirteen of the 50 included trials were judged as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias of remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% CI 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 grams of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions.Studies reported receiving governmental or charitable funds, except for two studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 50 eligible trials of various intervention approaches, the evidence for how to increase fruit and vegetable consumption of children remains sparse. There was very low-quality evidence child-feeding practice interventions are effective in increasing vegetable consumption of children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption of children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Parent, partner, co-parent or partnership? The need for clarity as family systems thinking takes hold in the quest to motivate behavioural change

Research is increasingly pointing to the importance of extending the focus of childhood obesity intervention to include fathers, fathering figures, and other members of a child's primary parenting network. Advances in communication technology are now making it possible to achieve this aim, within current resources, using modalities such text messaging, web-based resources and apps that extend intervention to parents not in attendance at face to face interactions. However, published research is often unclear as to which parent/s they targeted or engaged with, whether interventions planned to influence behaviours and capabilities across family systems, and how this can be achieved. As childhood obesity research employing information technology to engage with family systems takes hold it is becoming important for researchers clearly describe who they engage with, what they hope to achieve with them, and the pathways of influence that they aim to activate. This paper integrates extant knowledge on family systems thinking, parenting efficacy, co-parenting, and family intervention with the way parents are represented and reported in childhood obesity research. The paper concludes with recommendations on terminology that can be used to describe parents and parenting figures in future studies.

Communicating with parents of obese children: which channels are most effective?

BACKGROUND

One of the strategies proven most successful in curbing rising rates of childhood obesity involves targeting parents as agents of change. Prior studies have focused on what messages to communicate, but few have investigated how they should be communicated.

OBJECTIVE

To identify the channels most effective for communicating with parents of overweight and obese children and understand whether their use of parenting information sources differs from others in the community.

DESIGN/SETTING

This study utilizes data from the Longitudinal Study of Australian Children (LSAC). Families were included if weight and height information was available for parents and children at three data collection points: Waves 1, 2 and 4 (collected 2004, 2006 and 2010, respectively, n = 5107).

ANALYSIS

A priori and a posteriori segmentation methods identified groups of parents that were similar in the sources used to obtain information about parenting, and examined whether some segments were more likely to have obese children.

RESULTS

Four segments were identified that differed in their information source use: the 'personal networks', 'books', 'official sources' and 'mixed approach' segments. The 'official sources' and 'mixed approach' segments were most likely to have obese children, and they used doctors, government/community organizations and friends to obtain information on parenting. These segments were also less educated and had lower employment.

CONCLUSIONS

Messages are most likely to reach families with obese children if communicated through doctors, government publications and community organizations. Further, messages targeting social groupings of parents will leverage the power of advice from friends, which is another valuable information source for this group.

Increasing physical activity among young children from disadvantaged communities: study protocol of a group randomised controlled effectiveness trial

BACKGROUND

Participation in regular physical activity (PA) during the early years helps children achieve healthy body weight and can substantially improve motor development, bone health, psychosocial health and cognitive development. Despite common assumptions that young children are naturally active, evidence shows that they are insufficiently active for health and developmental benefits. Exploring strategies to increase physical activity in young children is a public health and research priority.

METHODS

Jump Start is a multi-component, multi-setting PA and gross motor skill intervention for young children aged 3-5 years in disadvantaged areas of New South Wales, Australia. The intervention will be evaluated using a two-arm, parallel group, randomised cluster trial. The Jump Start protocol was based on Social Cognitive Theory and includes five components: a structured gross motor skill lesson (Jump In); unstructured outdoor PA and gross motor skill time (Jump Out); energy breaks (Jump Up); activities connecting movement to learning experiences (Jump Through); and a home-based family component to promote PA and gross motor skill (Jump Home). Early childhood education and care centres will be demographically matched and randomised to Jump Start (intervention) or usual practice (comparison) group. The intervention group receive Jump Start professional development, program resources, monthly newsletters and ongoing intervention support. Outcomes include change in total PA (accelerometers) within centre hours, gross motor skill development (Test of Gross Motor Development-2), weight status (body mass index), bone strength (Sunlight MiniOmni Ultrasound Bone Sonometer), self-regulation (Heads-Toes-Knees-Shoulders, executive function tasks, and proxy-report Temperament and Approaches to learning scales), and educator and parent self-efficacy. Extensive quantitative and qualitative process evaluation and a cost-effectiveness evaluation will be conducted.

DISCUSSION

The Jump Start intervention is a unique program to address low levels of PA and gross motor skill proficiency, and support healthy lifestyle behaviours among young children in disadvantaged communities. If shown to be efficacious, the Jump Start approach can be expected to have implications for early childhood education and care policies and practices, and ultimately a positive effect on the health and development across the life course.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry No: ACTRN12614000597695 , first received: June 5, 2014.

Social influence in childhood obesity interventions: a systematic review

The objective of this study is to understand the pathways through which social influence at the family level moderates the impact of childhood obesity interventions. We conducted a systematic review of obesity interventions in which parents' behaviours are targeted to change children's obesity outcomes, because of the potential social and environmental influence of parents on the nutrition and physical activity behaviours of children. PubMed (1966-2013) and the Web of Science (1900-2013) were searched, and 32 studies satisfied our inclusion criteria. Results for existing mechanisms that moderate parents' influence on children's behaviour are discussed, and a causal pathway diagram is developed to map out social influence mechanisms that affect childhood obesity. We provide health professionals and researchers with recommendations for leveraging family-based social influence mechanisms to increase the efficacy of obesity intervention programmes. © 2016 World Obesity.

Motivational Interviewing to Treat Overweight Children: 24-Month Follow-Up of a Randomized Controlled Trial

BACKGROUND

Pediatrician-led motivational interviewing can be an effective way of controlling BMI in overweight children in the short term. Its long-term efficacy is unknown. The primary aim was to determine whether the short-term (12-month) impact of family pediatrician-led motivational interviews on the BMI of overweight children could be sustained in the long term (24 months), in the absence of any other intervention.

METHODS

Children were recruited in 2011 by family pediatricians working in the province of Reggio Emilia, Italy, and randomly allocated to receive either 5 interviews delivered over a 12-month period or usual care. Eligible participants were all 4- to 7-year-old overweight children resident in the province of Reggio Emilia who had been receiving care from the pediatrician for ≥ 12 months. The primary outcome of this study was individual variation in BMI between the baseline visit and the 24-month follow-up, assessed by pediatricians not blinded to treatment group allocation.

RESULTS

Of 419 eligible families, 372 (89%) participated; 187 children were randomized to receive intervention and 185 to usual care. Ninety-five percent of the children attended the 12-month follow-up, and 91% attended the 24-month follow-up. After the 12-month intervention period, BMI in the intervention group increased less than in the control group (0.46 and 0.78, respectively; difference -0.32; P = .005). At the 24-month follow-up, the difference had disappeared (1.52 and 1.56, respectively; difference -0.04; P = .986).

CONCLUSIONS

The intervention lost its effectiveness within 1 year of cessation. Sustainable boosters are required for weight control and obesity prevention.

Parent-only interventions for childhood overweight or obesity in children aged 5 to 11 years

BACKGROUND

Child and adolescent overweight and obesity have increased globally, and are associated with short- and long-term health consequences.

OBJECTIVES

To assess the efficacy of diet, physical activity and behavioural interventions delivered to parents only for the treatment of overweight and obesity in children aged 5 to 11 years.

SEARCH METHODS

We performed a systematic literature search of databases including the Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS as well trial registers. We checked references of identified trials and systematic reviews. We applied no language restrictions. The date of the last search was March 2015 for all databases.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of diet, physical activity and behavioural interventions delivered to parents only for treating overweight or obesity in children aged 5 to 11 years.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for risk of bias and evaluated overall study quality using the GRADE instrument. Where necessary, we contacted authors for additional information.

MAIN RESULTS

We included 20 RCTs, including 3057 participants. The number of participants ranged per trial between 15 and 645. Follow-up ranged between 24 weeks and two years. Eighteen trials were parallel RCTs and two were cluster RCTs. Twelve RCTs had two comparisons and eight RCTs had three comparisons. The interventions varied widely; the duration, content, delivery and follow-up of the interventions were heterogeneous. The comparators also differed. This review categorised the comparisons into four groups: parent-only versus parent-child, parent-only versus waiting list controls, parent-only versus minimal contact interventions and parent-only versus other parent-only interventions.Trial quality was generally low with a large proportion of trials rated as high risk of bias on individual risk of bias criteria.In trials comparing a parent-only intervention with a parent-child intervention, the body mass index (BMI) z score change showed a mean difference (MD) at the longest follow-up period (10 to 24 months) of -0.04 (95% confidence interval (CI) -0.15 to 0.08); P = 0.56; 267 participants; 3 trials; low quality evidence. In trials comparing a parent-only intervention with a waiting list control, the BMI z score change in favour of the parent-only intervention at the longest follow-up period (10-12 months) had an MD of -0.10 (95% CI -0.19 to -0.01); P = 0.04; 136 participants; 2 trials; low quality evidence. BMI z score change of parent-only interventions when compared with minimal contact control interventions at the longest follow-up period (9 to 12 months) showed an MD of 0.01 (95% CI -0.07 to 0.09); P = 0.81; 165 participants; 1 trial; low quality evidence. There were few similarities between interventions and comparators across the included trials in the parent-only intervention versus other parent-only interventions and we did not pool these data. Generally, these trials did not show substantial differences between their respective parent-only groups on BMI outcomes.Other outcomes such as behavioural measures, parent-child relationships and health-related quality of life were reported inconsistently. Adverse effects of the interventions were generally not reported, two trials stated that there were no serious adverse effects. No trials reported on all-cause mortality, morbidity or socioeconomic effects.All results need to be interpreted cautiously because of their low quality, the heterogeneous interventions and comparators, and the high rates of non-completion.

AUTHORS' CONCLUSIONS

Parent-only interventions may be an effective treatment option for overweight or obese children aged 5 to 11 years when compared with waiting list controls. Parent-only interventions had similar effects compared with parent-child interventions and compared with those with minimal contact controls. However, the evidence is at present limited; some of the trials had a high risk of bias with loss to follow-up being a particular issue and there was a lack of evidence for several important outcomes. The systematic review has identified 10 ongoing trials that have a parent-only arm, which will contribute to future updates. These trials will improve the robustness of the analyses by type of comparator, and may permit subgroup analysis by intervention component and the setting. Trial reports should provide adequate details about the interventions to be replicated by others. There is a need to conduct and report cost-effectiveness analyses in future trials in order to establish whether parent-only interventions are more cost-effective than parent-child interventions.

Nutrition Interventions for Prevention and Management of Childhood Obesity: What Do Parents Want from an eHealth Program?

With the growth of Internet technologies, offering interventions for child and family weight management in an online format may address barriers to accessing services. This study aimed to investigate (i) whether an eHealth family healthy lifestyle program would be of interest to parents; and (ii) preferences and/or expectations for program components and features. Parents of children aged four to18 years were recruited through social media and completed an online survey (54 items) including closed and open-ended questions. Responses were collated using descriptive statistics and thematic analysis. Seventy-five participants were included (92% mothers, mean age 39.1 ± 8.6 years, mean BMI 27.6 ± 6.3 kg/m²). The index child had a mean age of 11 ± 6.2 years with 24% overweight/obese. The majority of parents (90.3%) reported interest in an online program, with preference expressed for a non-structured program to allow flexibility users to log-on and off as desired. Parents wanted a program that was easy to use, practical, engaging, endorsed by a reputable source, and able to provide individual tailoring and for their children to be directly involved. The current study supports the need for online delivery of a healthy lifestyle program that targets greater parental concerns of diet rather than child weight.

Impact Evaluation of an After-school Cooking Skills Program in a Disadvantaged Community: Back to Basics

PURPOSE

Few efficacious child obesity interventions have been converted into ongoing community programs in the after-school setting. The aim of this study was to evaluate the impact of phase 2 of the Back to Basics cooking club on dietary behaviours and fruit and vegetable variety in a population at risk of obesity at a low income school with > 10% indigenous population.

METHODS

Baseline and 3-month dietary intake and social cognitive theory (SCT) constructs were collected in 51 children, mean age 9 years, 61% female. McNemar tests were used for comparison of proportions between categorical variables. Cohen's d was used to compare effect sizes across different measures.

RESULTS

Consumption of one or more fruit servings per day significantly increased from 41% to 67% (P = 0.02, d = 0.13) and there was a trend for increasing the weekly variety of fruit and vegetables. The SCT constructs assessed within the current study improved significantly (P < 0.05), with moderate to large effect sizes (d = 0.33-0.78).

CONCLUSION

This study documents that a previous efficacious healthy lifestyle program can be adapted for use as an obesity prevention program addressing improvements in vegetable and fruit intakes in a low income community with a relatively high indigenous population.

Perception of childhood obesity in mothers of preschool children

Objectives

The purpose of this study was to identify the perception of childhood obesity in mothers of preschool children using Q methodology.

Methods

A total of 38 Q statements about childhood obesity were obtained from 41 participants. The QUANL PC program was used to analyze the results.

Results

There were three types of perception toward obesity in mothers of preschool children: the “authoritative discipline type,” the “generous home meal focused type,” and the “home meal based on household financial situation type.”

Conclusion

The perception of mothers toward childhood obesity can affect the extent of maternal interaction with children or meal preparation for the family. Based on these results, it is necessary to plan specific programs according to the types of maternal perception toward childhood obesity.

Evidence update on the treatment of overweight and obesity in children and adolescents

Childhood obesity is associated with increased medical and psychosocial consequences and mortality and effective interventions are urgently needed. Effective interventions are urgently needed. This article reviews the evidence for psychological treatments of overweight and obesity in child and adolescent populations. Studies were identified through searches of online databases and reference sections of relevant review articles and meta-analyses. Treatment efficacy was assessed using established criteria, and treatments were categorized as well-established, probably efficacious, possibly efficacious, experimental, or of questionable efficacy. Well-established treatments included family-based behavioral treatment (FBT) and Parent-Only Behavioral Treatment for children. Possibly efficacious treatments include Parent-Only Behavioral Treatment for adolescents, FBT-Guided Self-Help for children, and Behavioral Weight Loss treatment with family involvement for toddlers, children, and adolescents. Appetite awareness training and regulation of cues treatments are considered experimental. No treatments are considered probably efficacious, or of questionable efficacy. All treatments considered efficacious are multicomponent interventions that include dietary and physical activity modifications and utilize behavioral strategies. Treatment is optimized if family members are specifically targeted in treatment. Research supports the use of multicomponent lifestyle interventions, with FBT and Parent-Only Behavioral Treatment being the most widely supported treatment types. Additional research is needed to test a stepped care model for treatment and to establish the ideal dosage (i.e., number and length of sessions), duration, and intensity of treatments for long-term sustainability of healthy weight management. To improve access to care, the optimal methods to enhance the scalability and implementability of treatments into community and clinical settings need to be established.

Weight loss in children and adolescents

BACKGROUND

15% of children and adolescents in Germany are overweight, including 6.3% who are affected by obesity. The efficacy of conservative weight-loss treatments has been demonstrated, but there has not yet been a detailed analysis of their efficacy in terms of the amount of weight loss that can be expected. We re-evaluated the available evidence on this question, with particular attention to the methodological quality of clinical trials, in order to derive information that might be a useful guide for treatment.

METHODS

We conducted a systematic literature search of Medline for the period May 2008 (final inclusion date for a 2009 Cochrane Review) to December 2013. The identified studies were analyzed qualitatively.

RESULTS

48 randomized controlled clinical trials with a total of 5025 participants met the predefined inclusion criteria for this analysis. In the ones that met predefined criteria for methodological quality, conservative weight-loss treatments led to weight loss in amounts ranging from 0.05 to 0.42 BMI z score (standard deviation score of the body mass index) over a period of 12-24 months. Information on trial dropout rates was available for 41 of the 48 trials; the dropout rate was 10% or higher in 27 of these (66% ), and 25% or higher in 9 (22% ).

CONCLUSION

The available evidence consistently shows that only a modest degree of weight loss can be expected from conservative treatment. Families seeking treatment should be informed of this fact. Future research should focus on determining predictive factors for therapeutic benefit, and on the evaluation of additional types of psychological intervention to promote coping with obesity.

Obesity risk factors in a representative group of Polish prepubertal children

INTRODUCTION

The study aim was to evaluate risk factors of obesity in Polish children aged 7 to 9 years.

MATERIAL AND METHODS

A representative group of 2571 children (1268 girls and 1303 boys) was randomly selected according to the European Childhood Obesity Group protocol. Weight and height were measured and body mass index (BMI) was calculated. A questionnaire was completed by the children's parents with respect to behavioural and family-related risk factors of obesity. International Obesity Task Force criteria were used for classification of children's obesity.

RESULTS

Obesity was found in 3.7% of girls and 3.6% of boys. There was a statistically significant association between the prevalence of obesity in girls and their mother's obesity: OR = 5.06 (1.96-13.05), p < 0.001, father's obesity: OR = 5.19 (1.96-13.69), p < 0.001, and both parents' obesity: OR = 5.43 (1.39-21.29), p = 0.01. Obesity in boys was significantly associated with mother's obesity: OR = 5.6 (2.6-12.02), p < 0.001, father's obesity: OR = 6.21 (2.89-13.37), p < 0.001, and both parents' obesity: OR = 7.22 (2.44-31.33), p < 0.001. Skipping or irregular eating of breakfast was a risk factor for obesity in girls with OR = 2.71 (1.33-5.51), p = 0.005. Neither family income nor parents' education level was related to their offspring's obesity. TV watching, physical activity level and eating in fast food places were not significant risk factors for obesity.

CONCLUSIONS

Eating breakfast regularly seems to protect girls from obesity development while low physical activity is not a significant obesity risk factor in this age group for either boys or girls. This finding stresses the more important role of healthy diet than physical activity promotion in obesity prevention in prepubertal children.

Impact evaluation of Enabling Mothers to Prevent Pediatric Obesity through Web-Based Education and Reciprocal Determinism (EMPOWER) Randomized Control Trial

BACKGROUND

The family and home environment is an influential antecedent of childhood obesity. The purpose of this study was to pilot test The Enabling Mothers to Prevent Pediatric Obesity through Web-Based Education and Reciprocal Determinism (EMPOWER) intervention; a newly developed, theory-based, online program for prevention of childhood obesity.

METHOD

The two-arm, parallel group, randomized, participant-blinded trial targeted mothers with children between 4 and 6 years of age. Measures were collected at baseline, 4 weeks, and 8 weeks to evaluate programmatic effects on constructs of social cognitive theory (SCT) and obesity-related behaviors. Process evaluation transpired concurrently with each intervention session.

RESULTS

Fifty-seven participants were randomly assigned to receive either experimental EMPOWER (n = 29) or active control Healthy Lifestyles (n = 28) intervention. Significant main effects were identified for child physical activity, sugar-free beverage consumption, and screen time, indicating that both groups improved in these behaviors. A significant group-by-time interaction was detected for child fruit and vegetable (FV) consumption as well as the SCT construct of environment in the EMPOWER cohort. An increase of 1.613 cups of FVs (95% confidence interval = [0.698, 2.529]) was found in the experimental group, relative to the active control group. Change score analysis found changes in the home environment accounted for 31.4% of the change in child FV intake for the experimental group.

CONCLUSIONS

Child physical activity, sugar-free beverage consumption, and screen time improved in both groups over the course of the trial. Only the theory-based intervention was efficacious in increasing child FV consumption. The EMPOWER program was robust for inducing change in the home environment leading to an increase in child FV intake (Cohen's f = 0.160).

Taking Steps Together

Objectives. Successful childhood obesity intervention models that build sustainable behavioral change are needed, particularly in low-income, ethnic minority communities disparately affected by this problem. Method. Families were referred to Taking Steps Together (TST) by their primary care provider if at least one child had a body mass index ≥85%. The TST intervention comprised 16 weekly 2-hour classes including educational activities, group cooking/eating, and physical activities for parents and children. TST’s approach emphasized building self-efficacy, targeting both children and parents for healthy change, and fostering intrinsic motivation for healthier living. Pre–post intervention data were collected on health-related behaviors using a survey, and trained staff measured weight and height. Results. Adults ( n = 33) and children ( n = 62) were largely Hispanic/Latino and low-income. Adults and children significantly increased their fruit and vegetable consumption and weekly physical activity, and adults significantly decreased sugared beverage consumption and screen time. No change in body mass index was observed for adults or children. Conclusions. This family-focused childhood obesity intervention integrated evidence-based principles with a nonprescriptive approach and produced significant improvements in key healthy behaviors for both adults and children.

Dietary Intake Is Related to Multifactor Cardiovascular Risk Score in Obese Boys

Cardiovascular disease (CVD) originates in childhood and early identification of risk factors provides an early intervention opportunity. The aim was to identify children at higher risk using a CVD risk score, developed from factors known to cluster in childhood. Risk was scored as very high (≥97.5th centile), high (≥95th), moderate (≥90th) or threshold (<90th) using normal pediatric reference ranges for 10 common biomedical risk factors. These were summed in a multifactor CVD risk score and applied to a sample of 285 observations from 136 overweight Australian children (41% male, aged 7-12 years). Strength of associations between CVD risk score and individual biomedical and dietary variables were assessed using univariate logistic regression. High waist circumference (Odds Ratio: 5.48 [95% CI: 2.60-11.55]), body mass index (OR: 3.22 [1.98-5.26]), serum insulin (OR: 3.37 [2.56-4.42]) and triglycerides (OR: 3.02 [2.22-4.12]) were all significantly related to CVD risk score. High intakes of total fat (OR: 4.44 [1.19-16.60]), sugar (OR: 2.82 [1.54-5.15]) and carbohydrate (OR 1.75 [1.11-2.77]) were significantly related to CVD risk score in boys only. This multifactor CVD risk score could be a useful tool for researchers to identify elevated risk in children. Further research is warranted to examine sex-specific dietary factors related to CVD risk in children.

Diffusing obesity myths

Misinformation or myths about obesity can lead to weight bias and obesity stigma. Counteracting myths with facts and evidence has been shown to be effective educational tools to increase an individuals' knowledge about a certain condition and to reduce stigma.The purpose of this study was to identify common obesity myths within the healthcare and public domains and to develop evidence-based counterarguments to diffuse them. An online search of grey literature, media and public health information sources was conducted to identify common obesity myths. A list of 10 obesity myths was developed and reviewed by obesity experts and key opinion leaders. Counterarguments were developed using current research evidence and validated by obesity experts. A survey of obesity experts and health professionals was conducted to determine the usability and potential effectiveness of the myth-fact messages to reduce weight bias. A total of 754 individuals responded to the request to complete the survey. Of those who responded, 464 (61.5%) completed the survey. All 10 obesity myths were identified to be deeply pervasive within Canadian healthcare and public domains. Although the myth-fact messages were endorsed, respondents also indicated that they would likely not be sufficient to reduce weight bias. Diffusing deeply pervasive obesity myths will require multilevel approaches.

Volumes and bouts of sedentary behavior and physical activity: associations with cardiometabolic health in obese children

OBJECTIVE

To examine associations of volumes and bouts of sedentary behavior (SED) and moderate-to-vigorous physical activity (MVPA) with individual and clustered cardio-metabolic outcomes in overweight/obese children.

METHODS

Cross-sectional data from 120 overweight/obese children (8.3 ± 1.1 years, 62% girls, 74% obese) with SED and MVPA assessed using accelerometry. Children were categorized into quartiles of mean bouts per day of SED (10, 20, and 30 min) and MVPA (5, 10, and 15 min). Associations with triglycerides, HDL cholesterol, glucose, insulin, systolic/diastolic blood pressure, and clustered cardio-metabolic risk (cMet) were examined using linear regression, adjusted for confounders.

RESULTS

Independent of MVPA, SED volume was inversely associated with HDL cholesterol (β [95% CI] = -0.29 [-0.52, -0.05]). MVPA volume was inversely associated with diastolic blood pressure, independent of SED (β = -0.22 [-0.44, -0.001]), and cMet (β = -0.19 [-0.36, -0.01]) although not after adjustment for SED (β = -0.14 [-0.33, 0.06]). Independent of MVPA and SED volumes, participants in the highest quartile of 30 min bouts per day of SED had 12% lower HDL cholesterol than those in the lowest quartile (d = 0.53, P = 0.046, Ptrend = 0.11).

CONCLUSIONS

In addition to increasing MVPA, targeting reduced SED and limiting bouts of SED to <30 min may contribute to improved HDL cholesterol levels and cardio-metabolic health in overweight/obese children.

Assessing parental self-efficacy for obesity prevention related behaviors

Background

Reliable, valid and theoretically consistent measures that assess a parent’s self-efficacy for helping a child with obesity prevention behaviors are lacking.

Objectives

To develop measures of parental self-efficacy for four behaviors: 1) helping their child get at least 60 minutes of moderate intensity physical activity every day, 2) helping one’s child consume five servings of fruits and vegetables each day, 3) limiting sugary drinks to once a week, and 4) limiting consumption of fruit juice to 6 ounces every day.

Methods

Sequential methods of scale development were used. An item pool was generated based on theory and qualitative interviews, and reviewed by content experts. Scales were administered to parents or legal guardians of children 4–10 years old. The item pool was reduced using principal component analysis. Confirmatory factor analysis tested the resulting models in a separate sample.

Subjects

304 parents, majority were women (88%), low-income (61%) and single parents (61%). Ethnic distribution was 40% Black and 37% white.

Results

All scales had excellent fit indices: Comparative fit index > .98 and chi-squares (Pediatrics 120 Suppl 4:S229-253, 2007) = .85 – 7.82. Alphas and one-week test-retest ICC’s were ≥ .80. Significant correlations between self-efficacy scale scores and their corresponding behaviors ranged from .13-.29 (all p < .03).

Conclusions

We developed four, four-item self-efficacy scales with excellent psychometric properties and construct validity using diverse samples of parents.

Trial registration

Clinical trial registration: NCT01768533.

The empowerment of low-income parents engaged in a childhood obesity intervention

Parents influence children's obesity risk factors but are infrequently targeted for interventions. This study targeting low-income parents integrated a community-based participatory research approach with the Family Ecological Model and Empowerment Theory to develop a childhood obesity intervention. This article (1) examines pre- to postintervention changes in parents' empowerment; (2) determines the effects of intervention dose on empowerment, and (3) determines whether changes in parent empowerment mediate previous changes identified in food-, physical activity-, and screen-related parenting. The pre-post quasi-experimental design evaluation demonstrated positive changes in parent empowerment and empowerment predicted improvement in parenting practices. The integrated model applied in this study provides a means to enhance intervention relevance and guide translation to other childhood obesity and health disparities studies.

The 'Healthy Dads, Healthy Kids' community randomized controlled trial: a community-based healthy lifestyle program for fathers and their children

OBJECTIVE

To evaluate the effectiveness of the 'Healthy Dads, Healthy Kids (HDHK)' program when delivered by trained facilitators in community settings.

METHOD

A two-arm randomized controlled trial of 93 overweight/obese fathers (mean [SD] age=40.3 [5.3] years; BMI=32.5 [3.8] kg/m(2)) and their primary school-aged children (n=132) from the Hunter Region, Australia. In 2010-2011, families were randomized to either: (i) HDHK intervention (n=48 fathers, n=72 children) or (ii) wait-list control group. The 7-week intervention included seven sessions and resources (booklets, pedometers). Assessments were held at baseline and 14-weeks with fathers' weight (kg) as the primary outcome. Secondary outcomes for fathers and children included waist, BMI, blood pressure, resting heart rate, physical activity (pedometry), and self-reported dietary intake and sedentary behaviors.

RESULTS

Linear mixed models (intention-to-treat) revealed significant between-group differences for fathers' weight (P<.001, d=0.24), with HDHK fathers losing more weight (-3.3 kg; 95%CI, -4.3, -2.4) than control fathers (0.1 kg; 95%CI, -0.9,1.0). Significant treatment effects (P<.05) were also found for fathers' waist (d=0.41), BMI (d=0.26), resting heart rate (d=0.59), energy intake (d=0.49) and physical activity (d=0.46) and for children's physical activity (d=0.50) and adiposity (d=0.07).

DISCUSSION

HDHK significantly improved health outcomes and behaviors in fathers and children, providing evidence for program effectiveness when delivered in a community setting.

Single versus multiple-family intervention in childhood overweight--Finnmark Activity School: a randomised trial

OBJECTIVE

To compare a new comprehensive lifestyle programme performed in groups of families with overweight (included obese) children with a more conventional single-family programme. The study design and interim anthropometrical results after 12 months are presented.

DESIGN

Altogether 97 overweight and obese children aged 6-12 years with body mass index (BMI) corresponding to cut-off point ≥ 27.5 in adults were included. Study participants were randomised to multiple-family intervention (MUFI) or single-family intervention (SIFI) in a parallel design. MUFI comprised a 3-day inpatient programme at the hospital with other families and a multidisciplinary team, follow-up visits in their hometown individually and in groups, organised physical activity twice weekly and a 4-day family camp after 6 months. SIFI comprised individual counselling by paediatric nurse, paediatric consultant and nutritionist at the hospital and follow-up by public health nurse in the community. Solution focused approach was applied in both interventions. Primary outcome measures were change in BMI kg/m(2) and BMI SD score (BMI SDS).

RESULTS

BMI increased by 0.37 units in the MUFI compared to 0.77 units in the SIFI (p=0.18). BMI SDS decreased by 0.16 units in the MUFI group compared to 0.07 units in the SIFI group (p=0.07). Secondary endpoint waist circumference decreased 0.94 cm in the multiple-family group and increased 0.95 cm in the single-family group, p=0.04.

CONCLUSIONS

Interim analysis after 12 months showed no between-group difference in terms of BMI or BMI SDS. The MUFI group had a significant decrease in waist circumference compared to the SIFI group.

THE TRIAL IS REGISTERED

at http://www.clinicaltrials.gov (NCT00872807).

Effects of parental origins and length of residency on adiposity measures andnutrition in urban middle school students: a cross-sectional study

Background

The prevalence of obesity in U.S. has been rising at an alarming rate, particularly among Hispanic, African, and Asian minority groups. This trend is due in part to excessive calorie consumption and sedentary lifestyle. We sought to investigate whether parental origins influence eating behaviors in healthy urban middle school students.

Methods

A multiethnic/racial population of students (N = 182) enrolled in the ROAD (Reduce Obesity and Diabetes) Study, a school-based trial to assess clinical, behavioral, and biochemical risk factors for adiposity and its co-morbidities completed questionnaires regarding parental origins, length of US residency, and food behaviors and preferences. The primary behavioral questionnaire outcome variables were nutrition knowledge, attitude, intention and behavior, which were then related to anthropometric measures of waist circumference, BMI z-scores, and percent body fat. Two-way analysis of variance was used to evaluate the joint effects of number of parents born in the U.S. and ethnicity on food preference and knowledge score. The Tukey-Kramer method was used to compute pairwise comparisons to determine where differences lie. Analysis of covariance (ANCOVA) was used to analyze the joint effects of number of parents born in the US and student ethnicity, along with the interaction term, on each adiposity measure outcome. Pearson correlation coefficients were used to examine the relationships between maternal and paternal length of residency in the US with measures of adiposity, food preference and food knowledge.

Results

African Americans had significantly higher BMI, waist circumference and body fat percentage compared to other racial and ethnic groups. Neither ethnicity/race nor parental origins had an impact on nutrition behavior. Mothers’ length of US residency positively correlated with students’ nutrition knowledge, but not food attitude, intention or behavior.

Conclusions

Adiposity measures in children differ according to ethnicity and race. In contrast, food behaviors in this middle school sample were not influenced by parental origins. Longer maternal US residency benefited offspring in terms of nutrition knowledge only. We suggest that interventions to prevent obesity begin in early childhood.

Parent-only interventions in the treatment of childhood obesity: a systematic review of randomized controlled trials

BACKGROUND

An effective and cost-effective treatment is required for the treatment of childhood obesity. Comparing parent-only interventions with interventions including the child may help determine this.

METHODS

A systematic review of published and ongoing studies until 2013, using electronic database and manual searches.

INCLUSION CRITERIA

randomized controlled trials, overweight/obese children aged 5-12 years, parent-only intervention compared with an intervention that included the child, 6 months or more follow-up. Outcomes included measures of overweight.

RESULTS

Ten papers from 6 completed studies, and 2 protocols for ongoing studies, were identified. Parent-only groups are either more effective than or similarly effective as child-only or parent-child interventions, in the change in degree of overweight. Most studies were at unclear risk of bias for randomization, allocation concealment and blinding of outcome assessors. Two trials were at high risk of bias for incomplete outcome data. Four studies showed higher dropout from parent-only interventions. One study examined programme costs and found parent-only interventions to be cheaper.

CONCLUSIONS

Parent-only interventions appear to be as effective as parent-child interventions in the treatment of childhood overweight/obesity, and may be less expensive. Reasons for higher attrition rates in parent-only interventions need further investigation.

An overview of national clinical guidelines for the management of childhood obesity in primary care

STUDY DESIGN

Review of clinical guidelines.

BACKGROUND

Most national clinical guidelines for the management of childhood obesity in primary care were published since 2003. It is unknown whether there is international consensus concerning the diagnosis and management of childhood obesity.

OBJECTIVE

To present an overview of available guidelines for the management of childhood obesity in primary care

METHODS

Guidelines were included if they met the following criteria: (1) the guideline makes recommendations concerning the management of childhood obesity, (2) the target group consists of primary care health practitioners, (3) the guideline is available in English or Dutch.

RESULTS

Clinical guidelines from six different countries published from 2003 until 2010 met the selection criteria and were included in this review. The recommendations of the guidelines regarding the management of childhood obesity appeared to be quite similar. A consistent feature was the recommended combined intervention, with diet, physical activity and counselling being the three most important elements. There were discrepancies between the guidelines for recommendations regarding diagnostic classification criteria for childhood obesity.

CONCLUSION

The present review shows that there is international consensus regarding the recommendations for management of childhood obesity. There is less international consensus regarding the diagnostic classification of childhood obesity.

Health promotion in adolescent and young adult cancer survivors: mobilizing compliance in a multifaceted risk profile

With rising cure rates of childhood cancer, nurse practitioners have an increased chance of encountering a large survivor cohort in practice. A variety of late effects programs exist; however, funding is limited for these programs and is not accessible for all patients. Primary providers may increasingly act as a medical home for childhood cancer survivors (CCS). Understanding the inherent risks of cytotoxic treatment and the progressive consequences of late effects is vital to limit morbidity and mortality. Adolescent and young adult survivors (AYA) are particularly apt to make health behavior decisions that create risks for comorbidities. Developmentally appropriate experimentation with drug, alcohol, or tobacco use and increased ultraviolet ray exposure intensifies the risk for secondary malignancies and novel diseases. The paucity of evidence-based surveillance guidelines and survivor-specific health promotion programs cumulatively widen the gap in noncompliance and misinformation. This article overviews the risk profile of CCS. It explores health practices, as well as emerging health promotion techniques, within the AYA survivor population and the role nurse practitioners have in enhancing health maintenance.

Tackling overweight and obesity: does the public health message match the science?

BACKGROUND

Despite the increasing understanding of the mechanisms relating to weight loss and maintenance, there are currently no validated public health interventions that are able to achieve sustained long-term weight loss or to stem the increasing prevalence of obesity in the population. We aimed to examine the models of energy balance underpinning current research about weight-loss intervention from the field of public health, and to determine whether they are consistent with the model provided by basic science. EMBASE was searched for papers published in 2011 on weight-loss interventions. We extracted details of the population, nature of the intervention, and key findings for 27 articles.

DISCUSSION

Most public health interventions identified were based on a simple model of energy balance, and thus attempted to reduce caloric consumption and/or increase physical activity in order to create a negative energy balance. There appeared to be little consideration of homeostatic feedback mechanisms and their effect on weight-loss success. It seems that there has been a lack of translation between recent advances in understanding of the basic science behind weight loss, and the concepts underpinning the increasingly urgent efforts to reduce excess weight in the population.

SUMMARY

Public health weight-loss interventions seem to be based on an outdated understanding of the science. Their continued failure to achieve any meaningful, long-term results reflects the need to develop intervention science that is integrated with knowledge from basic science. Instead of asking why people persist in eating too much and exercising too little, the key questions of obesity research should address those factors (environmental, behavioral or otherwise) that lead to dysregulation of the homeostatic mechanism of energy regulation. There is a need for a multidisciplinary approach in the design of future weight-loss interventions in order to improve long-term weight-loss success.

A randomised study on the effectiveness of therapist-led v. self-help parental intervention for treating childhood obesity

A strategy is needed on how to treat the growing number of obese children with the limited resources available. We compared the long-term (24 months) effectiveness of therapist-led groups (TLG) v. self-help groups (SHG) for parents on changes in children's adiposity and dietary intake. The study included ninety-nine children (forty-eight girls) who were referred to obesity treatment (7–12 years, BMI z-scores ≥ 2, attendance of at least one parent). Parents (ninety-one mothers, fifty-four fathers) were randomised to TLG aimed at increasing parents' competence to accomplish lifestyle changes (n 47), or SHG (n 52), both with fifteen sessions. All children participated in children's groups, and all families attended individual counselling by a clinical dietitian and physiotherapist. Percentage of body fat (BF) was measured by dual-energy X-ray absorptiometry, BMI z-score was calculated by international reference values and dietary intake was calculated from 4 d estimated food records at baseline and after 6 and 24 months. No significant between-group differences were detected in the children's changes in adiposity or dietary intake after 6 and 24 months. BF, BMI z-scores and energy intake were significantly decreased after 6 months (P< 0·05) in both intervention groups, and this persisted throughout 24 months without compromising the diet macronutrient composition. In conclusion, the TLG and SHG intervention groups appear to be equally effective in improving long-term adiposity and dietary intake in obese children. Further research should be performed to clarify whether the SHG should be preferred to parental group treatment for similar children with obesity.

An individual, community-based treatment for obese children and their families: the solution-focused approach

BACKGROUND

This study evaluates an individual, community-based treatment for obese children and their families. In this program, a treatment team applied solution-focused techniques to develop a custom-made treatment plan in collaboration with the participants. The treatment plan consisted of community-based lifestyle activities.

METHODS

559 obese children with an average BMI z-score of 2.76 ± 0.54 took part in the 12-month study, and 372 children with an average BMI z-score of 2.75 ± 0.52 took part in the 24-month study. At the start of the study, ethnicity and special school needs were recorded. Before, after 12 months, and after 24 months of the treatment, body weight and height were measured. The effect of the treatment on body weight was evaluated using BMI z-scores.

RESULTS

291 children (52%) completed 12 months of treatment, whereas 22 children (4%) were dismissed earlier due to a good response. After 12 months, the children showed a significant decrease in BMI z-score by 0.16 (95% confidence interval (CI) 0.11-0.20; p < 0.005). After 24 months, 103 children (28%) were participating in the program, with a significant decrease in BMI z-score of 0.15 (95% CI 0.07-0.22; p < 0.005). 50 children (13%) were dismissed before the end of the second year due to significant weight loss (standard deviation z-score reduction -0.38; 95% CI 0.30-0.46; p < 0.005; with an average treatment duration of 12.9 ± 6.4 months). There was a negative correlation of age and reduction in BMI z-score: children younger than 6 years showed a decrease in BMI z-score of 0.45 (95% CI 0.26-0.65) and 0.31 (95% CI 0.11-0.53) after 12 and after 24 months, respectively.

CONCLUSIONS

Children showed a significant decrease in BMI z-score after the treatment. We found a negative correlation of age and weight loss. Special attention to patients with a high risk of drop-out might further improve these results. We advise a referral to obesity treatment as early as possible since a 'wait and see' policy might have adverse results in obese children.