EAL

Child Nutrition and Physical Activity and Inactivity

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To present practice-relevant guidance on interventions to reduce at least one measure of adiposity in child populations that do or do not contain overweight or obese children.

Inclusion Criteria:

Randomized controlled trials or controlled trials of interventions aiming to prevent overweight or obesity in non-clinical child populations
The duration of the trials was at least 12 weeks and a minimum of 30 participants aged zero to 18 years were involved
All trials included an outcome that measure an index of adiposity.

Exclusion Criteria:

Ineligible studies that did not meet the inclusion criteria.

Description of Study Protocol:

Recruitment

Articles were identified from literature search on Medline, Embase, Cinhal, and PsycINFO up to 30 April 2006.

Design

Systematic review

Blinding used

Eligible randomized controlled trails were evaluated by two researchers who independently scored these trails using a quality checklist.

Intervention

Randomized controlled trials to prevent overweight or obesity in non-clinical child populations that do or do not contain overweight or obese children. Eligible trails involved at least 30 participants, followed for a duration of at least 12 weeks, and included an outcome that measured an index of adiposity.

Statistical Analysis

Kappa statistic was used in chance-corrected agreement to classify the physical activity intervention as "compulsory" or "voluntary".

Data Collection Summary:

Timing of Measurements

Both descriptive epidemiological and realistic evaluation concepts were adopted to cross-classify and synthesize the eligible identified trails. A proforma was constructed to allow a systematic recording of data from each trail. The extracted data items included reference number, first author, year of publication, country of the trail, design, unit of analysis, age group, ethnicity, numbers in each group, description of intervention, results, researchers' comments, appraisal comments, quality score, intensity score and effectiveness.

Eligible trails were classified as effective or ineffective in reducing adiposity in children. The intensity score of effectiveness of the intervention was estimated based on four elements:

The theoretical basis of the intervention (intervention based on an explicit theory or on pilot studies or formative research)
Whether the Intervention implemented by the researchers
Whether the provision of the physical activity was "compulsory" or "voluntary"
Whether the intervention had more than one element such as nutritional education or nutritional training skills (Multi-component intervention).

A score was assigned to the trail by adding one for presence or zero for the absence of the above mentioned elements.

Dependent Variables

No meta-analysis was performed

Independent Variables

No meta-analysis was performed

Control Variables

No meta-analysis was performed

Description of Actual Data Sample:

Initial N: Initial number of citations identified from the literature search, number of abstracts screened, number of full-text articles screened, and number of articles rejected and the reasons for exclusion were not described
Final N: 28 randomized controlled trails published up to 30 April 2006 were included
Type of Studies reviewed: Population and study design of interest:
- Eligible trials involved at least 30 participants for a duration of at least 12 weeks and involved non-clinical child populations that do or do not contain overweight or obese children
- Outcome of interest: Trials reported at least one measure of adiposity
Age: Zero to 19 years
Ethnicity:
- Caucasian
- Black
- Minority ethnic group
- African American
- Native American and other ethnic group
Setting:
- Home
- Home and school
- Clinic
- Community/other.

Summary of Results:

Out of the 28 eligible trails, 11 were effective in reducing adiposity. The main factor that distinguished effective from ineffective trials was the provision of moderate to vigorous aerobic physical activity on a relatively "compulsory" rather than " voluntary" basis.

No apparent association was observed between a trial’s quality score and its reported effectiveness regarding a measurement of adiposity.

List of randomized controlled and controlled trials of the prevention of obesity in childhood.

	Design	Population	Sample Size	Description of Intervention	Outcome Measures	Effectiveness	Quality Intensity
Author/Year/Country	Units			Control Conditions	Primary		Score	Score
Simonetti D'Arca et al. (1986) Italy¹⁵	RCT; schools	Three to nine years Not reported	Schools (N =3) Individuals: Multimedia (N=367) Written action (N=358) Control (N=596)	Printed and multimedia material distributed among pupils, and discussion meetings with families and teachers about physical activity Control: Only the BMI was taken at zero and 12 months	Change in prevalence of obesity (percent) Prevalence of overweight (percent) Prevalence of normal weight (percent) Prevalence of underweight (percent) All categories based on BMI Definitions not given	Effective in reducing obesity/overweight prevalence in boys and girls specially in overweight non-obese children	9	2
Sallis et al. (1993) USA¹⁶	RCT cluster Schools	9.25 years non-Hispanic White=85% Latino=7% Asian=6% Others=1%	Schools:Specialist led NS=2 Teacher-led: NT=2 Individuals: NS NS=91 NT=113 Control: NC =3 NC=101	Intervention: Two intervention groups: (1) PE specialists implemented the PE and self-regulation components (2) PE classroom teachers were trained to deliver the components by the research team. PE component: this was delivered in three 30-minute sessions a week Self regulation: self-management skills were taught in weekly classes for 30 minutes; control: usual PE programme	BMI (TSF) thickness	Ineffective in reducing rate of increase in BMI or TSF	12	2
Flores (1995), USA¹⁷	RCT Cluster; Classes N=4 inches One school	10-13 years Mean 12.6 (US 7th grade) Hispanic 43% African-American 44% Other 13%	Intervention: 43 (26 girls; 17 boys) Control: 38 (23 girls; 15 boys)	Aerobic dance: ‘Dance for Health’ consisted of three 50-min compulsory sessions of moderate to high intensity aerobic dance for 12 weeks Health education: students met twice a week for 25 minutes Control: usual physical activity , mainly playground activities	Timed mile run Resting heart rate BMI added for sexual maturation stage and age Attitudes towards physical activity	Effective in girls Not effect in boys BMI reduced heart rate reduced	11	4
Vandongen et al. (1995), Australia¹⁸	Factoral RCT Schools stratified into five socio-demographicstrata then randomized to one of six groups (N=1 to N=6)	10-12 years Not reported	Intervention Total N=869 n1=75 girls and 75 boys n2=77 girls and 72 boys n3=91 girls and 73 boys n4=65 girls and 54 boys n5=75 girls and 86 boys total number originally randomized N=1,147 Control: n6 (control =63 girls and 63 boys	n1 fitness: this included six 30-minute classroom sessions providing a rational basis for activity. Fitness programme 15 minutes per day for every school day n2 fitness and school nutrition: this consisted of 10 one-hour lessons aimed to improve knowledge, attitude and eating habits. Plus the n1 intervention n3 school nutrition: this consisted of the n2 program without the addition of n1 n4 school and home nutrition: n3 plus home nutrition programme using comics containing educational material for both the child and parent n5 home nutrition: this consisted of n4 without addition of n3 n6 control group: same measurements at baseline and follow-up but no additional nutrition or fitness programmes	Dietary intake Physical fitness BMI TSF thickness Systolic and diastolic blood pressure Percentage body fat Total cholesterol	Ineffective in reducing BMI increase Effective on TSF of the combined fitness and nutrition intervention (n2) group	17	3
Leupker et al. (1996), USA¹⁹	RCT Cluster Schools	Mean age 8.76 years White 69% African-American 13% Hispanic 14% Other 4%	Intervention: Schools (N=56) then further randomized (n1=28; n2=28) Individuals: total N=5,106 Control: 40	Intervention Schools were randomized to either the three or four components: (1) intervention in the school food service to lower total fat and sodium per serving (2) intervention to increase the amount of moderate to vigorous physical activity in PE classes to 40% of the time (3) curricula: 15 lessons focused on psychosocial factors and involving health-skills training (4) home-based curriculum involving parent/child assignments and family fun nights involving student performances of dance Control: usual routine	Food service meals PE sessions time spent on moderate to vigorous physical activity Cholesterol level Secondary: reported dietary intake Reported physical activity BMI	Ineffective in decreasing rate of BMI increase over three school years.	20	3
Donnelly et al. (1996), USA²⁰	Controlled-clinical trial Schools	8-9 years 94% Caucasian	Intervention: 102 Control: 236	Nutrition Intervention: school meals were planned with existing kitchen staff to reduce energy, fat and sodium Physical activity intervention:existing classroom teachers delivered the activities. Activities were designed to use large muscle groups for 30-40 minutes per day for three sessions a week Control: usual nutrition and physical activity practices	Primary: one mile run time BMI secondary: nutrition knowledge; Outside school physical activity recall Percentage of body fat Observed PE class physical activity Peak aerobic capacity Cholesterol 24-hour energy intake	Ineffective	14	2
Stolley and Fitzgibbon (1997), USA²¹	RCT Cluster Child-mother Dyads	Children aged 7-12 years and Mothers African-American	Intervention: dyads: 32 Control: 0	Intervention: a culturally sensitive curriculum taught to mother and daughter dyads in a one-hour session over 11 weeks. The programme addressed the importance of eating a low-fat, low-cholesterol diet and increasing activity Control: groups of seven to 11 dyads attended 11 x one-hour sessions focused on general health topics.	BMI Percentage overweight Secondary: dietary intake of saturated fat Percentage of fat energy Dietary cholesterol Parental support and role modeling	Ineffective in BMI	16	4
Mo-Suwan et al. (1998), Thailand²²	RCT Cluster Classes in two schools: school one two classes and school two six classes	Mean: 4.5 years; Thai	158 75% of children participated in the study Control: 152	Five-minute walk before morning class began and 20 min aerobic dance session after the afternoon nap three times a week Control: these classes continued their routine activities.	BMI TSF thickness Ponderal Index (weight/ height)³ Child obesity (BMI ≥95 centile for age/ sex)	Effective School- based exercise programme Decreased rate of increase of BMI in pre-school girls but not boys.	16	3
Robinson, 1999, USA²³	RCT Cluster Two classes	Eight to nine years Mean: 8.9 years Not described	Intervention: 106 11 dropouts Control:121 18 dropouts	Intervention: based on Bandura's social cognition model Children received an 18-lesson, six-month classroom curriculum to reduce television, videotape and video game use Control: before and after assessment of outcomes with no other intervention	BMI TSF Waist to hip ratio Secondary: reported time spent ‘watching TV’ Reported time spent in sedentary behaviors Reported physical activity Reported dietary intake Multistage shuttle run	Effective. Decreasing eight to nine-year-old children’ watching TV and video and playing videogames effectively decreases rate of BMI increase in boys and girls.	19	1
Gortmaker et al. (1999), USA²⁴	RCT Cluster Schools	10-11 years Mean age: 11.7 years White 66% African-American 13% Hispanic 12% Asian 7% Other 2%	Intervention: 641 Analysis based on 65% participation rate Control 654	Intervention: school-based interdisciplinary intervention based on behavioral-choice theory and social cognition theory over two school years. Sessions focused on decreasing television viewing Decreasing consumption of high-fat foods Increasing fruit and vegetable intake Increasing moderate and vigorous physical activity Control: followed their usual health education curriculum.	BMI and TSF Obesity defined as both ≥85th centile for age/sex Self-reported hours spent watching TV and video Self-reported moderate to vigorous physical activity Self-reported dietary intake Self-reported weight-loss behavior	Effectiveness in decreasing obesity prevalence in girls but not boys and particular effectiveness in African-American girls.	16	3
Sahota et al. (2001), England²⁵	RCT Cluster Schools (N=10)

Author Conclusion:

By using a novel approach to synthesizing trials, a decisive role for the ‘compulsory’ provision of aerobic physical activity has been demonstrated. Further research is required to identify how such activity can be sustained and transformed into a personally chosen behavior by children and over the life course.

Funding Source:

University/Hospital:

Reading Uinversity, UK

Reviewer Comments:

"Compulsory" aerobic physical activity was associated with the trail effectiveness in terms of reducing adiposity; whereas, nutritional education and skills did not distinguish effective from ineffective intervention trails regarding childhood adiposity. The author postulated that nutritional education and skills may be hypothesized to be a necessary basis for compulsory physical activity to be effective.

Quality Criteria Checklist: Review Articles
Relevance Questions
	1.	Will the answer if true, have a direct bearing on the health of patients?	Yes
	2.	Is the outcome or topic something that patients/clients/population groups would care about?	Yes
	3.	Is the problem addressed in the review one that is relevant to dietetics practice?	Yes
	4.	Will the information, if true, require a change in practice?	No

Validity Questions
	1.	Was the question for the review clearly focused and appropriate?	Yes
	2.	Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described?	Yes
	3.	Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased?	No
	4.	Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible?	Yes
	5.	Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined?	Yes
	6.	Was the outcome of interest clearly indicated? Were other potential harms and benefits considered?	Yes
	7.	Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described?	Yes
	8.	Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included?	Yes
	9.	Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed?	No
	10.	Was bias due to the review's funding or sponsorship unlikely?	N/A