Childhood Obesity Prevention in Africa: A Systematic Review of Intervention Effectiveness and Implementation

Randomized Trial to Improve Body Composition and Micronutrient Status Among South African Children

INTRODUCTION

Physical activity (PA) promotion combined with multimicronutrient supplementation (MMNS) among school-age children may reduce fat mass accrual and increase muscle mass through different mechanisms and so benefit child health. This study determined the efficacy of combined interventions on body composition among South African schoolchildren and determined if micronutrients mediate these effects.

STUDY DESIGN

Longitudinal cluster randomized controlled trial of children followed from 2019 to 2021. Statistical analyses carried from 2022 to 2023.

SETTING/PARTICIPANTS

A total of 1,304 children 6-12 years of age recruited from public schools in Gqeberha, South Africa.

INTERVENTION

Children were randomized by classes to either: (a) a physical activity group (PA); (b) a MMNS group; (c) a physical activity + multimicronutrient supplementation group (PA + MMNS); and (d) a placebo control group.

MAIN OUTCOME MEASURES

Trajectories of overall and truncal fat free mass (FFM) and fat mass (FM) estimates in modeled at 9 and 21 months using latent growth curve models (LGCM). Changes in micronutrient concentrations at 9 months from baseline.

RESULTS

An increased FFM trajectory was found among children in the MMNS arm at 9 months (Beta 0.16, 95% CI = 0.12, 0.31). The PA and MMNS arms both had positive indirect effects on this trajectory at 9 months (Beta 0.66, 95% CI = 0.44, 0.88 and Beta 0.32 95% CI = 0.1 0.5, respectively) and similarly at 21 months when mediated by zinc concentration changes. A reduced FM trajectory was found among children in the PA promotion arm at 9 months when using this collection point as the referent intercept. This arm was inversely associated with the FM trajectory at 9 months when mediated by zinc changes.

CONCLUSIONS

PA and MMNS promotion in school-based interventions directly contributed to reductions in FM and increased FFM among South African children and indirectly through changes in micronutrient status.

TRIAL REGISTRATION

ISRCTN, ISRCTN29534081. Registered on August 9, 2018 Institutional review board: Ethikkommission Nordwest- und Zentralschweiz" (EKNZ, project number: Req-2018-00608). Date of approval: 2018.

The missing middle of childhood

Middle childhood, between six and twelve years, is a critical bridge between earlier childhood and adolescence with rapid physical and psychological transitions. Most of the world's 2.6 billion young people, of which the middle childhood age group is a significant portion, live in low- and middle-income countries. Many live in environments that place them at high and growing risk for mental ill-health, injuries, and adoption of risky behaviours that often lead to non-communicable diseases in later years. Still, middle childhood, the 'missing middle,' is omitted from global health information systems, targeted policies, and strategies. The dearth of internationally comparable and standardised indicators on middle childhood in major international development agency databases hampers age-appropriate policy and programme development. Better understanding of the needs of this increasingly vulnerable population is critical. Middle childhood needs to be an explicit focus within child-focused research and implementation. Standardised, comprehensive, and relevant indicators are required to quantify the contribution of middle childhood to the global burden of disease and to facilitate interventions, monitoring, and evaluation, to ensure that all children flourish and thrive.

Barriers and facilitators to implementation of nutrition-related actions in school settings in low- and middle-income countries (LMICs): a qualitative systematic review using the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

Low- and middle-income countries (LMICs) are particularly vulnerable to the double burden of malnutrition: co-existence of underweight, overweight, obesity, and/or diet-related non-communicable diseases. Nutrition-related double-duty actions in school settings have been identified as one of the ways to address this challenge. However, to be able to take full advantage of the potential impact, it is important to understand their implementation as well. The aim of this paper is to systematically review qualitative research on barriers and facilitators to the implementation of nutrition-related actions in the school settings in LMICs.

METHODS

The following databases were searched: EMBASE, ERIC, MEDLINE, Global Health and PsycInfo (all on Ovid), Scopus (Elsevier), the Web of Science Social Sciences Citation Index, and Global Index Medicus from the World Health Organization. Of the 4253 identified records, 4030 were excluded after the abstract and title screen, leaving 223 for the full-text screen. A final 36 papers were included in this review. The consolidated framework for implementation research (CFIR) was used in the analysis.

RESULTS

We identified barriers and facilitators to implementation linked to the following CFIR constructs/sub-constructs: design quality and packaging, cost (intervention characteristics); target group needs and resources, cosmopolitanism, external policy and incentives (outer setting); structural characteristics, readiness for implementation (inner setting); knowledge and beliefs (characteristics of individuals) and engaging, executing (process). All identified constructs apart from target group needs and resources, knowledge and beliefs, and engaging were predominantly barriers. Available resources were the most prevalent barriers across studies.

CONCLUSION

This review identified barriers and facilitators to the implementation of nutrition-related actions based on qualitative articles in the school setting in LMICs, using the CFIR. Schools face continuous challenges in regard to funding and the government sector may have a role to play not only by offering financial assistance, but also through policy-making that would support healthy eating practices on school grounds.

REGISTRATION

PROSPERO ID: CRD42022296159.

Temporal trends in overweight and obesity and chronic disease risks among adolescents and young adults: A ten-year review at a tertiary institution in Nigeria

There is an increasing prevalence of obesity among college/university students in low- and middle-income countries, similar to the trend observed in high-income countries. This study aimed to describe the trend and burden of overweight/obesity and emerging associated chronic disease risks among students at the University of Ibadan (UI), Nigeria. This is a ten-year retrospective review of medical records of students (undergraduate and post-graduate) admitted between 2009 and 2018 at UI. Records of 60,168 participants were analysed. The Body Mass Index (BMI) categories were determined according to WHO standard definitions, and blood pressure was classified according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7). The mean age of the participants was 24.8, SD 8.4 years. The majority were ≤ 40 years (95.1%). There was a slight male preponderance (51.5%) with a male-to-female ratio of 1.1:1; undergraduate students constituted 51.9%. The prevalence of underweight, overweight, and obesity were 10.5%, 18.7% and 7.2%, respectively. We found a significant association between overweight/obesity and older age, being female and undergoing postgraduate study (p = 0.001). Furthermore, females had a higher burden of coexisting abnormal BMI characterised by underweight (11.7%), overweight (20.2%) and obese (10.4%). Hypertension was the most prevalent obesity-associated non-communicable disease in the study population, with a prevalence of 8.1%. Also, a third of the study population (35.1%) had prehypertension. Hypertension was significantly associated with older age, male sex, overweight/obesity and family history of hypertension (p = 0.001). This study identified a higher prevalence of overweight and obesity than underweight among the participants, a double burden of malnutrition and the emergence of non-communicable disease risks with potential lifelong implications on their health and the healthcare system. To address these issues, cost-effective interventions are urgently needed at secondary and tertiary-level educational institutions.

The Nexus of Sports-Based Development and Education of Mental Health and Physical Fitness

Physical inactivity has increased globally, particularly in developed nations. A high proportion of the human population is unable to meet the physical activity recommendation of the World Health Organisation due to hypertension, metabolic syndrome, obesity, and other medical conditions. Non-communicable diseases and mental health problems are becoming more prevalent, particularly in low and middle-income nations. This study aimed to determine the effectivenessof a mentorship programmeon university students' mental health and physical fitness. The intervention comprised the effects of sports-based development and education on physical fitness and mental health. A total of 196 and 234 students from two universities were randomly assigned to the intervention and control groups, respectively. The primary outcomes were engagement in physical activities (number of push-ups for 1 min, the strength of hand grip (kg), and the Jump test while standing (cm)), body fat proportion and psychological resilience, self-efficacy, and relationship with family and schoolmates. Participants in the control group had access to a web-based health education game, whereas the intervention group wassubjected to intensive interventional activities for one month based on the eight principles of the National Research Council and Institute of Medicine. Data were analysed using Analysis of Variance (ANOVA) to compare the physical and mental components between the intervention and control groups. Relative to baseline, all the physical health components (push-ups, sit-ups, and jump tests), psychological resilience, relationship with family members, and self-efficacy increased significantly in the intervention compared to the control group. Body fat composition was significantly reduced in the intervention when compared tothe control group. In conclusion, the mentorship programme effectively improved the participants' physical and psychological health and could be developed further for application in a larger population.

Perceptions of healthy food, and perceived facilitators and barriers to buying and consuming healthy food, among female caregivers in Soweto, South Africa

Background. Obesity poses a continuous health challenge in South Africa and disproportionately affects black African households. To target obesity in these settings, it is crucial to have an in-depth understanding of food choices made by affected households. Objectives. To explore how healthy food is perceived by women living in Soweto, and the facilitators of and barriers to buying and consuming this food. Methods. This was a qualitative study that utilised semi-structured interviews. Ten participants were recruited using purposive sampling. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. The study took place in Soweto, South Africa, and was conducted from February to May 2019.Results. Six themes were developed from the data: perceptions of healthy food; protecting family members from unhealthy food; learning about healthy food; appreciation by the family; home-cooked food v. food bought on the street; and budgetary restrictions. The first three themes were grouped by the overarching theme ‘consciousness of healthfulness of food’, and the last three themes were grouped by the theme ‘influences of the family and environment on food choices’. Conclusions. A focus on the whole family’s dietary behaviours is recommended and, in future interventions, guidance communicated in intervention materials should be tailored to existing knowledge of healthy eating.

Coping Strategies for Household Food Insecurity, and Perceived Health in an Urban Community in Southern Mozambique: A Qualitative Study

In low- and middle-income countries, food insecurity (FI) is a living reality for many households, particularly among the most vulnerable groups. The burden of household FI in Mozambique and how FI and coping strategies relate to perceived health are unknown. This study investigated the lived experiences and coping strategies of food-insecure households, along with their perceived health. Altogether, 16 in-depth interviews were performed, audio-recorded, and transcribed verbatim. A qualitative content analysis was carried out and five themes emerged: lived experiences of FI, coping strategies used in situations of FI, food choices, climate change and food security, and FI and perceived health. A wide range of lived experiences and coping strategies were reported, including cooking whatever is available, skipping meals, receiving money or food from friends and relatives, eating unsafe and low-quality foods, taking on additional work, cooking least-preferred foods, and having a monotonous and less-nutritious diet. Furthermore, the participants reported emotional distress, anxiety and depression, substance use, and other negative health outcomes. Some had diagnoses of hypertension, diabetes or HIV/AIDS. The findings suggest the need for employment creation and women’s empowerment, as well as the implementation of appropriate policies and programmes to alleviate household FI.

Childhood obesity prevention: what can be achieved?

PURPOSE OF REVIEW

Childhood obesity is a pandemic generating an enormous individual and socioeconomic burden worldwide. This narrative review summarizes recent evidence on successful and recommended prevention strategies according to age groups and different levels of interventions.

RECENT FINDINGS

Effective prevention of childhood obesity is feasible and most successful early in life up to preschool age, and it should include a multicomponent approach, integrating individuals, family and society. Trials that improve nutrition and/or enhance physical activity are the cornerstones of childhood obesity prevention on an individual level. However, their efficacy is determined by the combination of interventions for the target age group. Further, improving family support and sleep, as well as reducing screen time, lead to favourable results. Many research gaps remain, including a lack of effective interventions for high-risk groups.

SUMMARY

As a multifactorial condition, childhood obesity requires a multicomponent approach. Interventions should be developmental stage-specific and adjusted to the setting. Current research gaps need to be targeted by future trials, with a special focus on the benefit of the most vulnerable groups. From a systems response perspective, a paradigm shift from interventions focusing on the individual to approaches that target society as a whole is warranted.

Food Insecurity and Health Outcomes Other than Malnutrition in Southern Africa: A Descriptive Systematic Review

Food insecurity (FI) is one of the major causes of malnutrition and is associated with a range of negative health outcomes in low and middle-income countries. The burden of FI in southern Africa is unknown, although FI continues to be a major public health problem across sub-Saharan Africa as a whole. Therefore, this review sought to identify empirical studies that related FI to health outcomes among adults in southern Africa. Altogether, 14 publications using diverse measures of FI were reviewed. The majority of the studies measured FI using modified versions of the United States Department of Agriculture Household Food Security Survey Module. A wide range in prevalence and severity of FI was reported (18-91%), depending on the measurement tool and population under investigation. Furthermore, FI was mostly associated with hypertension, diabetes, anxiety, depression and increased risk of human immunodeficiency virus (HIV) acquisition. Based on the findings, future research is needed, especially in countries with as yet no empirical studies on the subject, to identify and standardize measures of FI suitable for the southern African context and to inform public health policies and appropriate interventions aiming to alleviate FI and potentially improve health outcomes in the region.

Impact of a school-based health intervention program on body composition among South African primary schoolchildren: results from the KaziAfya cluster-randomized controlled trial

BACKGROUND

The prevalence of overweight and obesity is increasing among African children potentially predisposing them to greater obesity and non-communicable diseases (NCDs) in adulthood. This risk may be higher among growth-impaired children who may have greater fat mass. Therefore, we examined the effects of school-based physical activity (PA) promotion and multi-micronutrient supplementation (MMNS) on body composition among South African children enrolled in a longitudinal school-based randomized controlled trial.

METHODS

Children were cluster-randomized by class to one of four groups: (a) a physical activity group (PA), (b) a multi-micronutrient supplementation group (MMNS), (c) a physical activity + multi-micronutrient supplementation group (PA + MMNS), and (d) control group, and were being followed for 3 years. Linear random effects regression models with random intercepts for school classes tested the associations of each intervention arm with overall fat mass (FM), fat-free mass (FFM), truncal fat mass (TrFM), and truncal fat-free mass (TrFFM) at 9 months (T2) for boys and girls. These differences were then explored among children who differed in height velocity (HV).

RESULTS

A total of 1304 children (614 girls, 667 boys) in twelve clusters were assessed at baseline and after 9 months follow-up (T2). At baseline, approximately 15% of children were classified as overweight or obese while approximately 38% of children were classified as mildly stunted or moderately/severely stunted. Among girls, promotion of PA was associated with reduced FM and TrFM at T2 while MMNS was associated with increased FFM. Children with reduced HV in the PA arm had reduced FM while children in the MMNS arm with lower HV had increased FM compared to children in the control arm. Similarly, children with lower HV in the MM and PA groups had reduced TrFM compared to children in the control arm.

CONCLUSIONS

Our study suggests that the promotion of school-based physical activity programs and micronutrient supplementation can reduce childhood adiposity and so reduce the risk of obesity and chronic diseases later in adulthood.

TRIAL REGISTRATION

ISRCTN, ISRCTN29534081 . Registered on August 9, 2018. The trial was designed, analyzed, and interpreted based on the CONSORT protocol (Additional file 1: CONSORT checklist for randomized trial).

Causative Mechanisms of Childhood and Adolescent Obesity Leading to Adult Cardiometabolic Disease: A Literature Review

The past few decades have shown a worrisome increase in the prevalence of obesity and its related illnesses. This increasing burden has a noteworthy impact on overall worldwide mortality and morbidity, with significant economic implications as well. The same trend is apparent regarding pediatric obesity. This is a particularly concerning aspect when considering the well-established link between cardiovascular disease and obesity, and the fact that childhood obesity frequently leads to adult obesity. Moreover, most obese adults have a history of excess weight starting in childhood. In addition, given the cumulative character of both time and severity of exposure to obesity as a risk factor for associated diseases, the repercussions of obesity prevalence and related morbidity could be exponential in time. The purpose of this review is to outline key aspects regarding the current knowledge on childhood and adolescent obesity as a cardiometabolic risk factor, as well as the most common etiological pathways involved in the development of weight excess and associated cardiovascular and metabolic diseases.

Associations of Growth Impairment and Body Composition among South African School-Aged Children Enrolled in the KaziAfya Project

(1) Background: Early childhood malnutrition may result in increased fat mass (FM) among school-aged children in low- and middle-income countries (LMICs). We explored whether South African children with shorter stature have greater overall and abdominal FM compared to normal stature children. (2) Methods: Baseline assessments of body composition and weight were determined among school-aged children enrolled in a randomized controlled trial in Port Elizabeth, South Africa, using bioelectrical impedance analysis. Multiple linear regression models tested associations of children’s height and degree of stunting with FM, fat free mass (FFM), truncal fat mass (TrFM), and truncal fat free mass (TrFFM) overall and by sex. (3) Results: A total of 1287 children (619 girls, 668 boys) were assessed at baseline. Reduced child height was associated with higher FM and lower FFM and TrFFM, but these associations were reversed with increases in height. Girls classified as mildly or moderately/severely stunted had higher FM and TrFM but lower FFM and TrFFM, while no association was found for boys. (4) Conclusions: Our study suggests that efforts to reduce the non-communicable disease burden in LMICs should target growth-impaired children who may have greater overall FM and greater abdominal FM.

Monitoring Information-Seeking Patterns and Obesity Prevalence in Africa With Internet Search Data: Observational Study

BACKGROUND

The prevalence of chronic conditions such as obesity, hypertension, and diabetes is increasing in African countries. Many chronic diseases have been linked to risk factors such as poor diet and physical inactivity. Data for these behavioral risk factors are usually obtained from surveys, which can be delayed by years. Behavioral data from digital sources, including social media and search engines, could be used for timely monitoring of behavioral risk factors.

OBJECTIVE

The objective of our study was to propose the use of digital data from internet sources for monitoring changes in behavioral risk factors in Africa.

METHODS

We obtained the adjusted volume of search queries submitted to Google for 108 terms related to diet, exercise, and disease from 2010 to 2016. We also obtained the obesity and overweight prevalence for 52 African countries from the World Health Organization (WHO) for the same period. Machine learning algorithms (ie, random forest, support vector machine, Bayes generalized linear model, gradient boosting, and an ensemble of the individual methods) were used to identify search terms and patterns that correlate with changes in obesity and overweight prevalence across Africa. Out-of-sample predictions were used to assess and validate the model performance.

RESULTS

The study included 52 African countries. In 2016, the WHO reported an overweight prevalence ranging from 20.9% (95% credible interval [CI] 17.1%-25.0%) to 66.8% (95% CI 62.4%-71.0%) and an obesity prevalence ranging from 4.5% (95% CI 2.9%-6.5%) to 32.5% (95% CI 27.2%-38.1%) in Africa. The highest obesity and overweight prevalence were noted in the northern and southern regions. Google searches for diet-, exercise-, and obesity-related terms explained 97.3% (root-mean-square error [RMSE] 1.15) of the variation in obesity prevalence across all 52 countries. Similarly, the search data explained 96.6% (RMSE 2.26) of the variation in the overweight prevalence. The search terms yoga, exercise, and gym were most correlated with changes in obesity and overweight prevalence in countries with the highest prevalence.

CONCLUSIONS

Information-seeking patterns for diet- and exercise-related terms could indicate changes in attitudes toward and engagement in risk factors or healthy behaviors. These trends could capture population changes in risk factor prevalence, inform digital and physical interventions, and supplement official data from surveys.

Evidence for factors associated with diet and physical activity in African and Caribbean countries

Objective

To identify and describe summarized evidence on factors associated with diet and physical activity in low- and middle-income countries in Africa and the Caribbean by performing a scoping review of reviews.

Methods

We searched the Medline®, LILACS, Scopus, Global Health and Web of Science databases for reviews of factors associated with diet or physical activity published between 1998 and 2019. At least 25% of studies in reviews had to come from African or Caribbean countries. Factors were categorized using Dahlgren and Whitehead's social model of health. There was no quality appraisal.

Findings

We identified 25 reviews: 13 on diet, four on physical activity and eight on both. Eighteen articles were quantitative systematic reviews. In 12 reviews, 25-50% of studies were from Africa or the Caribbean. Only three included evidence from the Caribbean. Together, the 25 reviews included primary evidence published between 1926 and 2018. Little of the summarized evidence concerned associations between international health or political factors and diet or associations between any factor and physical activity across all categories of the social model of health.

Conclusion

The scoping review found a wide range of factors reported to be associated with diet and physical activity in Africa and the Caribbean, but summarized evidence that could help inform policies encouraging behaviours linked to healthy diets and physical activity in these regions were lacking. Further reviews are needed to inform policy where the evidence exists, and to establish whether additional primary research is needed.

Mobile Health Interventions Addressing Childhood and Adolescent Obesity in Sub-Saharan Africa and Europe: Current Landscape and Potential for Future Research

Child and adolescent overweight is a growing public health problem globally. Europe and low and middle-income (LMIC) countries in Sub-Saharan Africa provide sufficiently suitable populations to learn from with respect to the potential for mobile health (mHealth) interventions in this area of research. The aim of this paper is to identify mHealth interventions on prevention and treatment of childhood and adolescent obesity in Sub-Saharan Africa and Sweden and report on their effects, in order to inform future research in this area. A search of peer-reviewed publications was performed using PubMed, ScienceDirect, EBSCOhost, and Scopus. The search included all articles published up to August 2019. The search strings consisted of MeSH terms related to mHealth, overweight or obesity, children, adolescents or youth and individual countries in Europe and Sub-Saharan Africa. Second, a combination of free-text words; mobile phone, physical activity, exercise, diet, weight, BMI, and healthy eating was also used. Seven studies were reported from Europe and no eligible studies from Sub-Saharan Africa. The results of this narrative review indicate a lack of research in the development and testing of mHealth interventions for childhood and adolescent obesity. There is a need for an evidence base of mHealth interventions that are both relevant and appropriate in order to stem the epidemic of overweight and obesity among children and adolescents in these countries. Uptake of such interventions is likely to be high as there is high penetrance of mobile phone technology amongst adolescents, even within poor communities in Africa.

Can public sector community health workers deliver a nurturing care intervention in South Africa? The Amagugu Asakhula feasibility study

Background

Nurturing care interventions have the potential to promote health and development in early childhood. Amagugu Asakhula was designed to promote developmentally important dietary and movement behaviours among children of preschool age (3–5 years) in South Africa. An initial formative study in Cape Town found the intervention to be feasible and acceptable when delivered by community health workers (CHWs) linked to a community-based organisation. This study evaluated the delivery of the Amagugu Asakhula intervention by CHWs linked to a public sector primary health care facility in Soweto, as this mode of delivery could have more potential for sustainability and scalability.

Methods

A qualitative design was utilised to assess feasibility, acceptability, adoption, appropriateness, implementation, fidelity and context. CHWs (n = 14) delivered the intervention to caregivers (n = 23) of preschool-age children in Soweto over 6 weeks. Following the completion of the intervention, focus group discussions were held with CHWs and caregivers. Further data were obtained through observations, study records and key informant interviews (n = 5). Data were analysed using deductive thematic analysis guided by a process evaluation framework.

Results

The delivery of the Amagugu Asakhula intervention through CHWs linked to a primary health care facility in Soweto was not found to be feasible due to contextual challenges such as late payment of salaries influencing CHW performance and willingness to deliver the intervention. CHWs expressed dissatisfaction with their general working conditions and were thus reluctant to take on new tasks. Despite barriers to successful delivery, the intervention was well received by both CHWs and caregivers and was considered a good fit with the CHWs’ scope of work.

Conclusions

Based on these findings, delivery of the Amagugu Asakhula intervention is not recommended through public sector CHWs in South Africa. This feasibility study informs the optimisation of implementation and supports further testing of the intervention’s effectiveness when delivered by CHWs linked to community-based organisations. The present study further demonstrates how implementation challenges can be identified through qualitative feasibility studies and subsequently addressed prior to large-scale trials, avoiding the wasting of research and resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00802-6.

Spatial analysis of the prevalence of obesity and overweight among women in Ghana

OBJECTIVE

Identifying hot spots for the overweight aids in effective public health interventions due to the associated public health burden and morbidities. This study, therefore aimed to explore and determine the spatial disparities in the overweight/obesity prevalence among women in Ghana. The study also aims at modelling the average body mass index (BMI) values using the spatial regression and the performance compared with the standard regression model.

DESIGN

This is a cross-sectional study using data from the 2014 Ghana Demographic and Health Survey (GDHS).

SETTING

The study was set in Ghana.

PARTICIPANTS AND METHODS

Data on 4393 non-pregnant women aged 15-49 years from the 2014 GDHS. Both global (Moran's I) and the local indicators for spatial dependence were examined through the mapped BMI values across the country by clusters. An estimated spatial lag model was used to explain the spatial differences in the average body sizes of women.

RESULTS

The overall prevalence of overweight/obesity among reproductive women in Ghana was 35.4%, and this was highly prevalent among educated women (p<0.001), those from wealthy households (p<0.001) and dwelling in an urban setting (p<0.001). Significant clustering (Moran's I=0.3145, p<0.01) of overweight/obesity was observed with hot spots (clustering) in Greater Accra, Central, Western and Ashanti regions. The spatial lag model was the best fit based on the Likelihood ratio test and the Akaike information criterion and Bayesian information criterion values. The mean age of women and household wealth were significant factors accounting for the increase in the average cluster body size (BMI) of women and the spatial differences.

CONCLUSION

The prevalence of overweight/obesity was high and spatially clustered in the southern, middle and coastal regions. Geographic specific and effective public health interventions and strategies are needed to address the growing morbidity burden associated with the rise in the average body sizes of reproductive women.

A systematic review and meta-analysis of school-based interventions with health education to reduce body mass index in adolescents aged 10 to 19 years

BACKGROUND

Adolescents are increasingly susceptible to obesity, and thus at risk of later non-communicable diseases, due to changes in food choices, physical activity levels and exposure to an obesogenic environment. This review aimed to synthesize the literature investigating the effectiveness of health education interventions delivered in school settings to prevent overweight and obesity and/ or reduce BMI in adolescents, and to explore the key features of effectiveness.

METHODS

A systematic search of electronic databases including MEDLINE, CINAHL, PsychINFO and ERIC for papers published from Jan 2006 was carried out in 2020, following PRISMA guidelines. Studies that evaluated health education interventions in 10-19-year-olds delivered in schools in high-income countries, with a control group and reported BMI/BMI z-score were selected. Three researchers screened titles and abstracts, conducted data extraction and assessed quality of the full text publications. A third of the papers from each set were cross-checked by another reviewer. A meta-analysis of a sub-set of studies was conducted for BMI z-score.

RESULTS

Thirty-three interventions based on 39 publications were included in the review. Most studies evaluated multi-component interventions using health education to improve behaviours related to diet, physical activity and body composition measures. Fourteen interventions were associated with reduced BMI/BMI z-score. Most interventions (n = 22) were delivered by teachers in classroom settings, 19 of which trained teachers before the intervention. The multi-component interventions (n = 26) included strategies such as environment modifications (n = 10), digital interventions (n = 15) and parent involvement (n = 16). Fourteen studies had a low risk of bias, followed by 10 with medium and nine with a high risk of bias. Fourteen studies were included in a random-effects meta-analysis for BMI z-score. The pooled estimate of this meta-analysis showed a small difference between intervention and control in change in BMI z-score (- 0.06 [95% CI -0.10, - 0.03]). A funnel plot indicated that some degree of publication bias was operating, and hence the effect size might be inflated.

CONCLUSIONS

Findings from our review suggest that school-based health education interventions have the public health potential to lower BMI towards a healthier range in adolescents. Multi-component interventions involving key stakeholders such as teachers and parents and digital components are a promising strategy.

Understanding the underlying drivers of obesity in Africa: a scoping review protocol

INTRODUCTION

The worldwide prevalence of obesity and overweight has doubled since 1980, such that approximately a third of the world's population is reported as obese or overweight. Obesity rates have increased in all ages and both sexes irrespective of geographical area, ethnicity or socioeconomic status. Due to the high prevalence, related health consequences and costs of childhood and adult obesity, there is a need to comprehensively identify and assess the major underlying drivers of obesity and overweight in the African context.

METHODS AND ANALYSIS

This scoping review will be carried out as per the methodological outline by Arksey and O'Malley. The search strategy will be developed and search performed in the Scopus and PubMed electronic databases. In the first search, we will identify concepts that are used as an equivalent to obesity and overweight. Subsequently, we will search for studies comprising of search terms on the underlying factors that drive the development of obesity and overweight. Lastly, we will check reference lists for additional publications. Abstracts and full-text studies will independently be screened by two authors.

ETHICS AND DISSEMINATION

The proposed study will generate evidence from published data and hence does not require ethics approval. Evidence generated from this review will be disseminated through journal publications and conference presentations.

"The thing is, kids don't grow the same": Parent perspectives on preschoolers' weight and size in Soweto, South Africa

The prevalence of overweight and obesity is high among preschool age (3-5 years) children in South Africa, and children in urban low-income settings are particularly at risk. A better understanding of how parents or caregivers of young children perceive children's weight and size, as well as contextual factors influencing perceptions, is needed to inform interventions. The aim of this study was to examine how parents of preschool children in Soweto, South Africa, view childhood obesity, and to situate these perspectives in the context of the home environment in which preschool age children in Soweto live. Semi-structured in-depth interviews were conducted with 16 parents in four neighbourhoods of Soweto. Interviews were audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis following a contextualist approach. Three themes were developed: growing differently, the 'right' way to be, and weight is not health. These themes capture parents' views on complex and reportedly inevitable causes of obesity, ideas about acceptable and preferred body sizes, and the low priority of weight per se compared to health. The findings suggest that childhood obesity prevention in South Africa needs to be done in a non-stigmatising way that recognises environmental and contextual factors, such as parents' limited sense of agency in relation to their children's health and weight, and concrete resource constraints. Environmental barriers to healthy behaviours need to be addressed in order to overcome the coexisting challenges of childhood undernutrition and obesity in urban low-income South African settings.

The Influence of Socioeconomic Status on Snacking and Weight among Adolescents: A Scoping Review

Eating behaviors, including unhealthy snacking or excessive snacking leading to excess calorie consumption, may contribute to obesity among adolescents. Socioeconomic status (SES) also significantly influences eating behaviors, and low SES is associated with increased risk for obesity. However, little is known regarding the relationship between snacking behavior and SES among adolescents and how this may contribute to obesity-related outcomes. The primary objective of this scoping review was to review the literature to assess and characterize the relationship between SES and snacking in adolescents. The secondary objective was to assess weight-related outcomes and their relation to snacking habits. Included articles were published between January 2000 and May 2019; written in English, Portuguese, or Spanish; and focused on adolescents (13-17 years). In total, 14 bibliographic databases were searched, and seven studies met the inclusion criteria. Preliminary evidence from the seven included studies suggests a weak but potential link between SES and snacking. Additionally, these dietary patterns seemed to differ by sex and income type of country. Finally, only three of the included studies addressed weight-related outcomes, but the overall available evidence suggests that snacking does not significantly affect weight-related outcomes. Due to the small number of included studies, results should be interpreted with caution.

Physical Activity, Body Mass, and Adherence to the Mediterranean Diet in Preschool Children: A Cross-Sectional Analysis in the Split-Dalmatia County (Croatia)

Physical activity, body mass, and dietary habits are known to be important determinants of overall health status, but there is an evident lack of studies that examine these issues specifically in preschool children. The aim of this study was to identify associations that may exist between adhering to the Mediterranean diet (MD), levels of physical activity (PA), and body composition indices in apparently healthy preschool children from southern Croatia. Participants were 5- to 6-year-old preschoolers from the Mediterranean part of the country (the Split-Dalmatia County; n = 260, 126 females). Adherence to the MD was observed by the Mediterranean Diet Quality Index (KIDMED), PA level was evaluated by the Preschool-age Children’s Physical Activity Questionnaire (Pre-PAQ), and responses were collected from the parents. The participants’ waist circumferences (in cm), waist-to-hip ratios, and body mass index (in kg/m², and in a z-score calculated relative to the normative value for age and sex) were used as indicators of body composition. All children were of the same age and tested over a one-month period of the same year as a part of the regular examination undertaken before attending elementary school. With only 6% of the children having a low KIDMED score, adherence to the MD was high. MD adherence was higher in girls (Chi-square = 15.31, p < 0.01) and children who live on the coast of the Adriatic Sea (Chi-square = 18.51, p < 0.01). A mixed effects logistic regression (with kindergarten as random factor) identified sedentary activity to be negatively associated with MD adherence (OR per point: 0.65, 95% CI: 0.44–0.91). High adherence to the MD in the studied sample may be attributed to regulated feeding in kindergarten. Considering that most Croatian elementary schools do not provide food to their students, MD adherence should be investigated later in life and also in other parts of the country where the MD is culturally less prevalent.

Obesity and the Mediterranean Diet: A Review of Evidence of the Role and Sustainability of the Mediterranean Diet

Several different socio-economic factors have caused a large portion of the population to adopt unhealthy eating habits that can undermine healthcare systems, unless current trends are inverted towards more sustainable lifestyle models. Even though a dietary plan inspired by the principles of the Mediterranean Diet is associated with numerous health benefits and has been demonstrated to exert a preventive effect towards numerous pathologies, including obesity, its use is decreasing and it is now being supplanted by different nutritional models that are often generated by cultural and social changes. Directing governments' political actions towards spreading adherence to the Mediterranean Diet's principles as much as possible among the population could help to tackle the obesity epidemic, especially in childhood. This document intends to reiterate the importance of acting in certain age groups to stop the spread of obesity and proceeds with a critical review of the regulatory instruments used so far, bearing in mind the importance of the scientific evidence that led to the consideration of the Mediterranean Diet as not just a food model, but also as the most appropriate regime for disease prevention, a sort of complete lifestyle plan for the pursuit of healthcare sustainability.