Evidence of Interventions for Preventing Obesity of Children and Adolescents Using Existing Systematic Reviews and Meta-Analyses

Seolhye Kim; Eunju Sung; Sunmi Yoo

doi:10.15384/kjhp.2016.16.4.231

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Kim, Sung, and Yoo: Evidence of Interventions for Preventing Obesity of Children and Adolescents Using Existing Systematic Reviews and Meta-Analyses

Original Article

Korean J Health Promot 2016;16(4):231-250.

Published online: 20 January 2016

DOI: https://doi.org/10.15384/kjhp.2016.16.4.231

Evidence of Interventions for Preventing Obesity of Children and Adolescents Using Existing Systematic Reviews and Meta-Analyses

Seolhye Kim¹, Eunju Sung², Sunmi Yoo^3,

¹Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea

²Department of Family Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea

³Department of Family Medicine, Haeundae-Paik Hospital, Inje University School of Medicine, Busan, Korea

Corresponding author: Sunmi Yoo, MD, MPH, PhD Department of Family Medicine, Haeundae-Paik Hospital, Inje University School of Medicine, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Korea Tel: +82-51-797-3220, Fax: +82-51-797-0589 E-mail: syoo@paik.ac.kr

Received 28 August 2016 Accepted 22 December 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Pediatric obesity is an important global issue in public health. However, previous efforts for childhood obesity prevention have sporadically been implemented in Korea, neither evidence-based nor with proper evaluation. We aimed to investigate the characteristics of an effective intervention for prevention of pediatric obesity by reviewing previous systematic reviews and Meta-analyses.

Methods

PubMed was searched for articles published frombetween January 2005 to November 2015. Inclusion criteria were as follows: (1) articles published in English; (2) child and/or adolescents (between 2 and 18 years of age) as subjects; and (3) systematic reviews or meta-analyses concerning the preventive intervention of pediatric/adolescent obesity. Each study was evaluated via the Assessment of Multiple Systematic Reviews for quality assessment. We conducted a quantitative analysis to evaluate the implications, strengths, and limitations of each study.

Results

Our final analysis included 35 articles, of which 15 were systematic reviews and 20 were meta-analyses. Among these, 24 studies (69%) advocated the efficacy of preventive intervention for pediatric obesity. Multidimensional approach including diet, exercise, and environmental factors conducted in schools with a parent and community involvement wasis more effective at preventing obesity. The efficacy of intervention varied depending on the age, sex, region, and socioeconomic characteristics of participantssubjects.

Conclusions

Preventive intervention of pediatric obesity demonstrated smallminor improvements in body mass index and had positive effects on behavioral and clinical variables, which are associated with obesity. For the efficient prevention of pediatric obesity, it is necessary to consider efforts for developing various intervention programs, with active as well as the participation of school, family, and social community groups.

Keywords: Obesity, Prevention and control, Review, Child, Adolescent

References

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Figure 1.

Flow-chart of literature search.

Table 1.

General characteristics of systematic reviews or meta-analyses

Study	No. of publications included (year)	Meta-analysis	AMSTAR / PRISMA	Target age (y)	Type of intervention	Intervention duration	Intervention setting	Outcome
Study	No. of publications included (year)	Meta-analysis	AMSTAR / PRISMA	Target age (y)	Type of intervention	Intervention duration	Intervention setting	Primary	Intermediate
Wang Y et al. (2015)³⁵⁾	139	Meta	High/22	2–18	PA, N, C	1 y≤	S, H, Cm, Pc,	BMI, BMI Z-score, %	Intermediate behav-
Wang Y et al. (2015)³⁵⁾	(1985–2014)					6 mo≤	Cc, CHI	BMI, WC, %BF,	ioral outcomes (i.e. dietary intakes, PA and sedentary behaviors) and obesity-related clinical outcomes (e.g. blood pressure and blood lipid levels)
						(school-ba sed)		SFT, P

Peirson L et al. (2015)³⁰⁾	90 (1998–2013)	Meta	High/25	0–18	PA, N, Ed	12 wk≤	S, H, Cm, Cc	BMI, BMI Z-score, P
Vasques C et al. (2014)³⁴⁾	52 (2000–2011)	Meta	Mod/23	≤ 19	PA, N, Ed	6 wk≤	S, after-school	BMI, BMI Z-score, %BMI,
								%over-weight/obesity, %BF
Marsh et al. (2014)¹³⁾	17	SR	Mod/21	2–18	SB	6 wk-2 y	S, H, Cm, Pc	Sedentary time	Diet, PA, body
Marsh et al. (2014)¹³⁾	(2001–2011)								composition, Bwt
Langford et	67	Meta	High/26	4–18	PA, N, C	8 wk-6 y	S, H, Cm, En	BMI, BMI Z-score,	School attendance,
al. (2014)³⁸⁾	(1998–2013)							PA, physical fitness, fruit and vegetable intake	Non-academic school, process, curriculum, school environment, engagement with families or communities or both
Chen and	14	SR	Mod/21	12–18	Technolog	10 wk-2 y	NA	BMI, BMI Z-score	Diet intake, phys-
Wilkosz (2014)¹⁷⁾	(1990–2014)				y-based (internet, video-game, social media, mobile)				ical fitness, physical activity, psychosocial variable (self-esteem, self-competence)
Williams et al. (2013)¹⁸⁾	26	Meta	High/24	4–11	School	8 mo-9 y	S	BMI, BMI Z-score,
Williams et al. (2013)¹⁸⁾	(2003–2012)				policy related to PA or N			%BMI, %BF, BMI healthy fitness zone
Sobol-Gold-	32	Meta	Mod/26	5–18	N, PA, Ed,	NA	S	BMI
berg et al. (2013)³³⁾	(2006–2012)				environmental, paren-tal/social support
Silveira et al. (2013)³²⁾	8 (2004–2010)	Meta	High/27	5–18	N, Ed	4 mo-3 y	S	BMI
Showell et al. (2013)⁴⁰⁾	6 (2001–2013)	SR	Mod/23	3–17	PA, N, C	52–104 wk	H±S, Cm, Pc, CHI	BMI, BMI Z-score, %BF, Bwt, P	Diet intake (FV, energy), PA, SB
Sbruzzi et al. (2013)³¹⁾	26 (1989–2012)	Meta	Mod/26	6–12	PA, N, Ed	6–72 mo	S, H, Cm En	BMI, BMI Z-score, WC, BP, lipid
Bleich et al. (2013)³⁹⁾	9 (2003–2010)	SR	Mod/21	2–18	PA, C	12–48 mo	C±S, H, Pc, Cc	BMI, BMI Z-score, fat mass, P	Diet intake (FV, fatty food, sugar sweetened beverages, totalE), PA (MVA, TV watching time, active commuting to school, accelerometer)
von Grieken et al. (2012)¹⁵⁾	34 (1999–2010)	Meta	Mod/24	1.9–18.2	SB, PA, N, Ed	7 d-4 y	S, H, Pc, Cm, nursery	SB	BMI, BMI Z-score, %BF, SFT, WC, %overweight
Osei-Assibey et al. (2012)¹⁹⁾	35 (1978–2011)	SR	Mod/21	birth-13	N	4 d-4 y	En	Bwt, BMI, BMI Z-score, dietary intake, food choice, nutrition knowledge
Niemeier et al. (2012)²⁹⁾	36 (2004–2010)	Meta	Low/23	4–18	PA, N, Ed, C, B	9 wk-4 y	S, H, clinic	BMI
Luckner et al. (2012)¹²⁾	68 (1982–2008)	Meta	Mod/26	<18	PA, N, Ed, TV viewing	1 mo-7 y <	NA	BMI, %BF
Lavelle et al. (2012)¹¹⁾	43 (1991–2010)	Meta	Mod/23	≤18	PA, N, Ed, SB, C, B	1 mo-6 y	S	BMI
Friedrich et al. (2012)⁴²⁾	23 (1998–2010)	Meta	Mod/21	7–17	PA, N	3–72 mo	NA	BMI
Branscum et al. (2012)²¹⁾	25 (2006–2011)	SR	Low/14	7.3–14	PA, N	4 wk-3 y	After-school	Bwt, antecedent of behavior (self-efficacy), B (PA, D), body composition, aerobic fitness, BP
Waters et al. (2011)³⁶⁾	55 (1993–2009)	Meta	High/26	0–18	PA, N, C	12 wk≤	S, H, Cm, Cc	Bwt, Ht, %BF, BMI, ponderal index, SFT, P
Wahi et al. (2011)¹⁶⁾	13 (1995–2010)	SR	Mod/26	3.9–11.7	PA, N, SB	1–24 mo	S, Cc, Cm, clinic	BMI	Screen time
Zenzen et al. (2009)³⁷⁾	16 (2001–2006)	SR	Low/16	5 y-12th grade	PA, N, C, Ed	5 wk-8 y (mean 16.8 mo)	S, H	BMI, SFT, %BF, WC, Bwt, knowledge, B, fitness, dietary intake, psychological measure
Harris et al. (2009)²⁵⁾	18 (1993–2008)	Meta	Mod/27	1–12th grade	PA	6 mo-3 y	S	BMI, %BF, WC, WHR, SFT
Gonzalez-Suarez et al. (2009)²⁴⁾	19 (1996–2007)	Meta	Mod/21	11≤	PA, N, behavior, combination	6 mo, 1 y, 2 y	S	BMI, %BF, WC, SFT, WHR, P
Cook-Cot-tone et al. (2009)⁹⁾	40 (1997–2008)	Meta	Mod/20	Prescho ol-12th grade	PA, N, SB, psycho-educa- tion	0–12, 13–27, 28–32, 32 wk ＜	S	BMI, BMI Z-score, %BMI, SFT, %obesity, %BF
Brown et al. (2009)²⁰⁾	38 (1993–2007)	SR	Low/19	4–18	PA, N, C	12 wk-22 y	S	Bwt, BMI, BMI Z-score, %BF, SFT, %overweight
Katz et al. (2008)¹⁰⁾	8 (1985–2004)	Meta	Mod/21	3–18	PA, N, SB, B, C	6 mo-5 y	S, H, En	BMI, standardized BMI, Bwt, SFT, %BF, %obesity
Li et al. (2008)⁴¹⁾	22 (1993–2006)	SR	Mod/21	3–21 y	PA, N, Ed, B, school environment, acupuncture	10 wk-3 y	S	P, Bwt, SFT, BMI Z-score, biochemical marker, changes in knowledge and behavior
Kropski et al. (2008)²⁷⁾	14 (1993–2005)	SR	Mod/17	4–14	PA, N, C	6 mo-6 y	S±En	BMI, BF, %obesity	Dietary intake, PA (fitness level, accelerometer), SB, serum cholesterol
Kamath et al. (2008)²⁶⁾	36 (1988–2006)	Meta	Mod/23	2–18	PA, N	<3, 3–6, >6 mo	6 S, H, Cm, clinic	BMI, PA, SB, dietary habit
Lissau (2007)²⁸⁾	14 (1995–2005)	SR	Low/13	5–15	PA, N, PA+N	12 wk-3 y	S	Bwt, BMI, SKT, WC, %BF
Connelly et al. (2007)²²⁾	28 (1986–2005)	SR	Mod/18	9 m-17	7 PA, N, Ed	12 wk≤	S, H, Cm	BMI, weight-for-height-Z
								–score, WC, WHR, %BF, SFT, %obesity, dietary
								intake, PA, fitness level, BP, cholesterol, insulin
Stice et al. (2006)¹⁴⁾	46 (1983–2006)	Meta	Mod/21	0–22	PA, N, psycoe-duca- tional, SB	7–140 wk	NA	BMI
Doak et al. (2006)²³⁾	25 (1977–2004)	SR	Low/12	4–16	PA, N	8–260 wk	S, H, En, Cm	m BMI, %obesity, WC, WHR, SFT, %BF
Budd and Volpe (2006)⁸⁾	12 (1988–2005)	SR	Mod/11	1–10th grade	h PA, N, SB Ed	, 8 wk-3 y	S	BMI, %BF, SFT, dietary habit, nutritional knowledge, PA, SB, fitness level, BP, cholesterol

Abbreviations: AMSTAR, assessment of multiple systematic reviews; PRISMA, preferred reporting items for systematic reviews an meta-analysis; PA, physical activity; N, nutrition; C, combined nutrition and physical activity; y, year; mo, month; S, school; H, home; Cm community; Pc, primary care; Cc, child care; CHI, consumer health informatics; BMI, body mass index; WC, waist circumference; BF, bod fat; SFT, skin fold thickness; P, prevalence of obese or overweight; Ed, educational intervention; wk, week; Mod, moderate; SR, systematic re view; SB, sedentary behavior; Bwt, body weight; En, environment; NA, not assessed; FV, fruit and vegetables; MVA, moderate to vigorous a tivity; B, behavior; Ht, height; WHR, waist/hip ratio.

Table 2.

Summary of the positive results of the systematic reviews or meta-analysis for childhood obesity prevention

Study	Main findings	Strengths	Limitations	Implications for practice	Implications for research
Wang et al. (2015)³⁵⁾	School-based interventions were significantly effective (mean BMI SMD=-0.30; 95% CI −0.45 to −0.15; P<0.001). Multi-setting studies demonstrated beneficial results compared with single-setting interventions.	Comprehensive analysis was performed with large numbers of studies. Assessed the strength of evidence for each study. Identified some important implications for clinical decision and policy making.	Great heterogeneity in the included studies. Did not perform stratified analyses based on intervention types or settings.	Combined nutrition plus physical activity intervention based on school with family or parent involvement are effective in childhood obesity prevention.	Future research is needed to evaluate interventions conducted in other environments than in school, and the impact of policy and CHI. Research based on established behavioural theories and novel methodologies is needed.
Peirson et al. (2015)³⁰⁾	Behavioural prevention interventions showed a small but significant effect on BMI and BMI Z-score (SMD=-0.07; 95% CI=-0.10 to −0.03; a reduction in BMI (mean difference −0.09 kg/m², 95% CI −0.16 to −0.03); and a reduced prevalence of overweight and obesity (RR=0.94; 95% CI=0.89–0.99).	Detailed description of research objective, search strategy, the risk of bias in individual studies and analysis plan.	Did not assess the risk of bias in present study. Great heterogeneity in the included studies.		Trials with larger sample sizes that are powered to detect small differences across subgroups are needed. Future researches involving normal-weight children and very young children are required.
Vasques et al. (2014)³⁴⁾	Interventions had a small but significant positive effect in prevention and decreasing childhood obesity. (r=0.068, P<0.001, 95% CI=0.058–0.079). Programs conducted with children aged between 15–19 years were the most effective.	Present the effect size of weight related outcomes by quantitative analysis. Detailed description about classification and definition of moderator variables.	BMI may not accurately reflect a child's fat mass loss. No detailed description of physical activities including types, intensity and frequency. Did not examine socio-economic status of subjects and the risk of bias in individual studies.	Programs have to consider the characteristics of each participant, such as gender, age. Interventions lasting 1 year, with physical activity and nutritional education, with parental involvement are effective.	A detailed description of the methodologies used in the measurement is important for further research. Reviews should be conducted using several anthropometric measurements and evaluating their impact on the metabolic profile of children.
Marsh et al. (2014)¹³⁾	Studies including a parental component of medium-to-high intensity were associated with significant changes in sedentary behaviours. TV exposure appeared to be related to changes in energy intake rather than physical activity.	Detailed description of study characteristics and the risk of bias in individual studies.	Great heterogeneity of the included studies. Included studies with small sample sizes and short follow up. Inclusion of studies that did not have change in sedentary time as a primary endpoint.	Parental involvement is more important than environmental component. If it is difficult to manage actual screen time itself, parents can focus on associated dietary behaviours.	Future research needs to assess whether targeting of parents considered to be at high risk for low intervention compliance may help improve outcomes, and the mechanism(s) underlying the relationship between screen time and body weight in children.
Langford et al. (2014)³⁸⁾	Interventions had positive effects for BMI, physical activity, physical fitness, fruit and vegetable intaketobacco use, and being bullied. Physical activity (mean BMI=-0.38, 95% CI 0.73–0.03) and physical activity plus nutrition intervention are effective in obesity prevention (mean BMI=-0.11, 95% CI 0.24–0.02).	Included cluster-RCT that addressed all points in the HPS framework. Assessed the quality of evidence and the risk of bias in the individual studies. Categorized timing of outcome assessment as short, medium or long term. Detailed description of study objective, data collection, data extraction and analysis plan.	Great heterogeneity of included studies. Difficulty in assessing complicated interventions. Limited generalizability due to inclusion of standardized interventions.	School-based intervention, like the HPS framework, can be effective at improving a number of health outcomes in students including BMI. Despite the inextricable links between health and education, there are structural barriers in reality. Cross-departmental working between health and education is required to allow the HPS policy to achieve its potential	More evaluations are required that target older children (over 12 years of age). Future research should use outcome measures including academic achievement and behaviours. Studies should evaluate cost effectiveness of the interventions.
Williams et al. (2013)¹⁸⁾	Unlike the results of National School Lunch Program, the results of school breakfast program showed a significantly reduced BMI-SDS (ES=-0.080, 95% CI −0.143 to −0.017).	Analysis of school policies according to PICOS format. Detailed description of the quality and risk of individual studies. Inclusion of the variety of databases.	Poor description of the risk of bias across studies	Obesity prevention interventions should focus on multiple factors, such as diet, physical activity, sedentary behaviour, self-esteem, and environment.	Natural experiments could be used to evaluate new policies. The policy would need to be multidimensional and to extend outside of schools.
Sobol-Goldberg et al. (2013)³³⁾	School-based obesity prevention intervention were significantly, but mildly effective in reducing BMI, primarily in children but not teenagers (SMD= −0.076; 95% CI −0.123 to −0.028; P<0.01). Long-term interventions (lasting 1–4 years) with parental involvement were more effective.	Present the effect size of BMI by quantitative analysis. Good description of search strategy, study selection, data extraction, data collection process, data items.	Poor presentation of the study characteristics Did not report the study limitation.		Interventions for teenagers are required. Future researches should clearly identify the theoretical model guiding their intervention so that more precise data would be available regarding what interventions work and for which populations.
Silveira et al. (2013)³²⁾	School-based nutrition education interventions were effective in reducing BMI (mean SMD=-0.33; 95% CI −0.55 to −0.11).	84% of included studies assessed as high quality studies. Low risk of publication bias. Good external validity due to inclusion of various countries.	Small number of included study due to the limited number of available RCTs.	Nutrition education intervention needs to be longer than one school year. BMI Z score standardized to age and sex may be an ideal outcome measurer. Result should be interpreted considering different gender characteristics and stages of sexual maturation	Future researches need to identify which approaches, considering the theoretical framework and intervention components, are most effective in obtaining the expected effect over medium- and long-term periods.
Bleich et al. (2013)³⁹⁾	Significant changes in BMI or BMI Z-score found in 4 of the 9 included studies.	A range of community-based childhood obesity prevention interventions from various countries were included.	Many included studies have suboptimal study designs, which may lead to biased results.	Combination interventions implemented in multiple settings may be more effective at childhood obesity prevention.	More research and more consistent methods are needed to understand the comparative effectiveness of these intervention programs.
von Grieken et al. (2012)¹⁵⁾	Results showed significant decreases for the amount of sedentary behavior (mean SMD=-17.95 min/D; 95% CI −30.69 to –10.20) and BMI (mean SMD=-0.25; 95% CI −0.40 to −0.09).	Researchers included many studies and were able to estimate an effect based on all interventions combined.	Did not include unpublished studies. Included studies reported several distinct types of sedentary behavior.		Future researches need to provide details on the intervention and the types of outcome measures taken. Studies with longer follow-up time are required.
Osei-Assibey et al. (2012)¹⁹⁾	There was moderately strong evidence to support interventions on food promotion, large portion sizes and sugar-sweetened soft drinks. These interventions would support individual and family-level bahaviour change.	This study is the first focus on the influence of the food environment on overweight and obesity in younger children. Used experts' and practitioners' perceptions about food environment.	The majority of the intervention studies were short term. Not all the evidence outcomes in this review were reported in anthropometric indices.	Reducing food promotion to young children, increasing the availability of smaller portions and providing alternatives to sugar-sweetened soft drinks should be considered in obesity prevention programs aimed at younger children.	Future researches are needed to identify the optimal design and delivery of the interventions, and impact on body weight and BMI rather than food intake.
Niemeier et al. (2012)²⁹⁾	Longer interventions that include parental involvement appear to have greater success. Interventions that require parent participation are likely to reduce child and adolescent participants' BMIs roughly 1.2 kg/m² relative to controls.	Focus on the influence of the parental participant on childhood obesity. Detailed description of study characteristics in individual studies.	The lack of ability to clearly distinguish between participant age groups. Great heterogeneity of included studies. Poor description of the risk of bias in the individual studies and across studies.	Childhood obesity prevention interventions should include parental involvement and have longer duration.	This study supports the development and testing of interventions that focus primarily on parents to aid them in helping their children develop positive weight-related health behaviors.
Luckner et al. (2012)¹²⁾	In children, the reductions in mean BMI were achieved through promoting reduced television viewing (MD=-0.27; 95% CI −0.4 to −0.13) and programmes combining physical activity, specifically themed or general health education and nutrition (MD=-0.1; 95% CI −0.17 to −0.04).	Researchers analyzed the effectiveness of intervention according to intervention type and outcome measure. Detailed description of study characteristics in individual studies.	A potential risk of bias due to including controlled but non-randomized studies. Great heterogeneity of included studies. BMI does not fully capture changes in body composition. Body fat was measured differently across the studies that reported it.	Interventions with physical activity and nutritional education are effective.	Future studies should evaluate the effect on both body mass index and percentage of body fat and should report confidence intervals around all outcome estimates.
Lavelle et al. (2012)¹¹⁾	School-based interventions were effective in reducing BMI (ES=-0.17 kg/m²; 95% CI 0.08–0.26; P<0.001), especially if they include a physical exercise component. The reduction in BMI was greater for interventions targeted at overweight and obese children.	This review was conducted in accordance with the PRISMA guideline. Good description of the risk of bias across studies.	BMI may not be the best measure of childhood adiposity. A potential risk of bias due to including non-randomized studies. Poor description of data collection and extraction.	The interventions examined to date appear to be less effective in boys than girls and further work is required to explore the reasons and whether they require modifications to the school-based interventions or an alternative approach.	Further research is required to determine whether the effect of study is maintained after 6 years. Further research is required to determine the ideal type of intervention, taking cognisance of cost-effectiveness as well as clinical effectiveness.
Friedrich et al. (2012)⁴²⁾	Interventions that combine physical activity and nutritional education present better effects on the reduction of BMI among students, (SMD −0.37; 95% CI −0.63 to −0.12) than if applied in an isolated manner.	Researchers analyzed the effectiveness of intervention according to intervention type.	The majority of included studies was performed with a small sample and was considered of low quality. This review is subject to publication bias.	The most challenging aspect for health promotion strategies is adherence outside of schools, since health is negatively impacted by the food industry through advertisements and commercials for calorie-dense foods.	There is a need for randomized controlled studies with well-designed methodologic criteria in order to evaluate the effect of interventions.
Waters et al. (2011)³⁶⁾	Interventions were significantly effective in reducing BMI or BMI Z-score (SMD= −0.15 kg/m²; 95% CI −0.21 to −0.09).	Good description of study objective, methods, analysis, results. Researchers attempted to provide a synthesis of a variety of “implementation factors”, such as age, intervention type, setting, duration, the risk of bias.	Great heterogeneity of included studies. A potential risk of publication bias.	Curriculum on healthy eating, physical activity and body image integrated into regular curriculum Creating an environment and culture that support children eating nutritious foods and being active throughout each day Engaging with parents to support activities in the home setting to encourage children to be more active, eat more nutritious foods and spend less time in screen-based activities	Future trials should be larger, longer term and include assessments of costs, harm, equity impacts, implementation factors and sustainability.
Cook-Cottone et al. (2009)⁹⁾	Results indicated a small but significant effect for school-based interventions to reduce obesity in children (r=0.05; 95% CI 0.04–0.05; P<0.001).	Researchers analyzed the effectiveness of intervention according to moderating factors.	There is a distinction between a lower weight and actual physical fitness and health. This study did not examine socioeconomic status, parental weight and follow-up periods, which may be moderating factors.	Interventions must be carefully planned and suited to each school's population, risk, and needs. Additional intervention goals should include the following: improved nutrition and health knowledge through psychoeducation, encouragement of nutritional change, reduction of sedentary behaviors, and a high level of parental involvement.	Future research should address the efficacy of integrating a holistic body and mind approach to obesity prevention that integrates an attention to the causes of binge eating and eating disorder risk and prevention.
Brown and Summerbell (2009)²⁰⁾	Combined diet and physical activity interventions prevent children from becoming obese in the long term.	Detailed description of the individual study result. Some interventions appear to vary in effectiveness according to gender, age or weight status of the children.	Some studies pilot studies and have low statistical power. Some of the interventions were of insufficient length or intensity to produce change weight or BMI. The findings are inconsistent.	Dietary interventions providing breakfast for adolescents and PA interventions particularly in girls may help to prevent becoming overweight in the short term.	Studies using quantitative and qualitative outcomes and focusing on study population characteristics that may impact on effectiveness were needed. Study to view behavior change within the context of an obesogenic environment was needed.
Katz et al.	Nutrition plus physical	Standardized data	Did not report quality	If we want more	Future studies need to
(2008)¹⁰⁾	activity intervention was	extraction according to	assessment of	evidence-based	focus on intermediate
	significantly effective in	CDC community guide	individual study and	practice, we need more	outcome such as
	reducing weight	data abstraction form	limitation of the study.	practice-based	attitude, knowledge as
	(SMD=-0.29; 95% CI			evidence. Because the	early measures of
	–0.45 to −0.14).			primary mission of	success in obesity
	Comprehensive			schools is to educate not	control.
	interventions including			to promote health, a
	family or parent			priori evidence should
	involvement were			be presented.
	effective (SMD=-0.20;
	95% CI −0.41 to 0.00).
Lissau (2007)²⁸⁾	⁾ Half of the 14 included	Good description of	The included studies	The barriers of	Further studies need to be
	studies had an effect on	study objective and	differred greatly in	school-based	evaluated using various
	overweight.	search strategy.	regards to age group,	interventions are (1)	outcome measure as
			type and length of	healthy eating has a low	well as BMI. A
			intervention, type and	priority, (2) lack of	prevention project must
			amount of actions and	support at the school	be theory-based.
			statistical power.	for healthy food and
				meals, (3) the school
				staff are not motivated
				or are too overloaded
				with work to give
				attention to nutrition,
				and (4) poor or lack of
				supervision of the
				school meals.
Connelly et al.	The main factor	Comparative analysis	Did not validate intensity	Compulsory aerobic	Further research is
(2007)²²⁾	distinguishing effective	between studies	score as elements of an	physical activity may be	required to identify
	from ineffective trials	reporting effective and	effective intervention.	related to a decrease in	how compulsory
	was the provision of	ineffective outcomes		adiposity in children.	physical activity can be
	moderate to vigorous	was done.		Nutritional education	sustained and
	aerobic physical activity			and skills training may	transformed into a
	in the former on a			reasonably be	personally chosen
	relatively ‘compulsory'			considered useful in a	behaviour by children
	rather than ‘voluntary'			general health	and over the life course.
	basis.			promotion sense.
Stice et al.	21% of the 64 included	Researchers evaluated	Poor description of the	Larger effect sizes tended	Future studies are needed
(2006)¹⁴⁾	studies had a significant	putative moderators of	risk of bias in the	to emerge in trials	to conduct follow-up
	weight gain prevention	obesity intervention	individual studies and	involving children and	trials of enhanced
	effect (average effect size	effects.	across studies. Great	adolescents, in	versions of the
	r=0.04, range −0.25 to		heterogeneity of	female-only trials, in	programs and to design
	0.5).		included studies.	interventions below the	new programs. Need to
				median of 16 weeks, in	determine how to better
				interventions that	design obesity
				targeted only weight	prevention programs
				change.	for preadolescents and
					males. Future trials
					should include
					multi-year follow-ups.
					Need to evaluate the
					mediators that
					putatively account for
					any weight gain
					prevention effects.
Doak et al. (2006)²³⁾	68% the interventions, or 17 of the 25, were ‘effective' based on a statistically significant reduction in BMI or skin-folds for the intervention group.	Researchers evaluated potential adverse effect. Inclusion criteria were kept broad in order to include interventions focusing on ‘health promotion' as well as prevention' of obesity and obesity-related behaviours.	A potential risk of publication bias. Difficulty in comparing outcomes that are reported in different ways, including height for weight as well as skin-fold measures.	Future interventions should take body composition measures such as skin-folds as well as height and weight to better assess body composition changes. More attention should be given to improving the participation rates of interventions. Health promotion messages should be tailored appropriately according to ethnicity, gender and age.	Future studies targeting a broader age range could test whether the 8–10-year-old age group requires a specific approach. Additional studies are needed to measure the costs and benefits of interventions, as well as potential adverse effects.
Budd and Volpe (2006)⁸⁾	The use of a multicomponent, comprehensive, and detailed nutrition and physical activity curricula for the students in higher grades greatly contributed to the success of programs.	Detailed description of study characteristics and implication for practice.	The randomization was either by school or by classroom while the findings were reported on individuals. When classrooms were randomized, it was likely that the control group was aware of the study objectives, which may have weakened the findings.	Strategies might include using behavior modification techniques with younger students to reduce sedentary behavior, increase physical activity, and encourage proper nutrition and instituting a schedule of physical education classes with longer and more vigorous exercise.	The new participatory action models of community-centered and community-partnered research are required. Future studies can use the framework that the Prevention Group of the International Obesity Task Force presented.

Abbreviations: BMI, body mass index; SMD, standardized mean difference; CI, confidence interval; CHI, consumer health informatics; RR, relative risk; RCT, randomized controlled trial; HPS, health-promoting school; SDS, standard deviation score; MD, mean difference; ES, effect size; PICOS, population, interventions, comparators, main outcome, study design; PRISMA, preferred reporting items for systematic reviews and meta-analysis; PA, physical activity; CDC, Centers for Disease Control and Prevention.

Table 3.

Summary of the negative results of the systematic reviews or meta-analysis for childhood obesity prevention

Study	Main findings	Strengths	Limitations	Implications for practice	Implications for research
Chen and	There is no clear evidence	Researchers evaluated the	Did not assess study	Technology-based	Future study should
Wilkosz	that technology-based	intervention effects	limitations.	intervention for weight	include evaluation of
(2014)¹⁷⁾	interventions decreased	according to		management needs to	cost-effectiveness, the
	obesity in adolescents.	technology.		be continued in order to	mediating and
				see sustainability.	moderating factors
				Depending on the age	associated with
				of the participants,	effective
				different modalities	technology-based
				might be more	interventions, more
				attractive than others.	long-term follow-up,
					and assessment of
					weight-related health
					outcomes, such as
					physical activity,
					sedentary activity,
					dietary behaviors,
					self-efficacy, and
					quality of life.
Showell	None of the 6 included	Good description of	Researchers limited	Studies with larger	More research is needed
et al.	studies reported a	study characteristics	review to studies with at	sample sizes, testing the	to evaluate the impact
(2013)⁴⁰⁾	significant effect on	and the risk of bias in	least 1 year of	intervention effect in	of home- and
	weight outcomes.	individual studies.	follow-up and only	the various settings, and	family-based
	Combined interventions	Evaluated the effects of	included those from	targeted entire families	interventions with
	had beneficial effects on	the interventions on	high-income countries.	in households showed	larger sample sizes,
	fruit/vegetable intake	multiple outcomes		favorable diet or PA	greater intervention
	and sedentary behaviors.	including		outcomes.	duration and intensity,
		weight-related			and adequate
		outcomes and			participant follow up to
		behavioral outcomes.			improve statistical
					power of studies.
Sbruzzi	There were no differences	The focused review	Most of the studies	The use of BMI and waist	Future studies should be
et al.	in outcomes assessed in	questions	included were of low	circumference for the	carried out with a larger
(2013)³¹⁾	prevention studies.	A comprehensive and	methodological quality.	prediction of risk factor	number of participants.
	Educational	systematic literature		clustering among
	interventions were	search with no language		children and
	associated with a	restrictions		adolescents is useful for
	significant reduction in	The collaboration of a		clinical practice.
	waist circumference,	multidisciplinary team		Short-term
	BMI and diastolic blood	of cardiologists,		interventions may be
	pressure in treatment	endocrinologist,		more intensive and have
	studies.	healthcare researchers		higher frequency and
		and methodologists		adherence of the
				participants, which may
				have contributed to
				better results.
Branscum	Interventions resulted in	Good description of	Poor description of study	Obesity prevention	Future study is needed to
and	modest changes in	study characteristics	method.	interventions should	be based on behavioral
Sharma	behaviors and behavioral	such as outcome		target both physical	theories and to
(2012)²¹⁾	antecedents, and results	measures, sample size		activity and nutrition	implement more than
	were mixed and	calculation, process		behaviors.	one type of process
	generally unfavorable	evaluation, setting.			evaluation.
	with regards to
	indicators of obesity.
Wahi et al. (2011)¹⁶⁾	Interventions aimed at reducing screen time had no overall effect on the reduction of BMI. A subgroup analysis of preshcool children showed a difference in mean change in screen time (unadjusted difference in mean=-3.72; 95% CI −7.23 to −0.20).	Explored the methodological quality and quality of evidence using the GRADE criteria	Parent reporting of screen time might have biased the measurement. Great heterogeneity of included studies		Future study should include a report of potential adverse effects. Future study is required to evaluate pragmatic interventions that could feasibly be implemented in fewer sessions, over shorter periods of time, with longer follow-up, and focused on key age groups where behavior change may be sustainable, such as the preschool age group.
Zenzen and Kridli (2009)³⁷⁾	This review points to no specific intervention or combination of interventions as the most beneficial.	Good description of study characteristics such as level of evidence and theoretical framework.	A potential risk of publication bias. Study duration did not appear to be adequate, especially in studies looking for outcomes related to changes in BMI.	School-based obesity intervention programs should be guided by behavioral theoretical frameworks. Intervention components should include physical activity, diet, healthy lifestyle education and parental involvement.	The program should be of a duration long enough to give the participants ample time to exhibit the desired outcome. Intervention need to have aspects specifically tailored to each community.
Harris et al. (2009)²⁵⁾	Results showed that BMI did not improve with school-based physical activity interventions.	Researchers conducted sensitivity analysis according to study characteristics, such as duration of intervention, quality of studies, genders of participants.	It is possible that school-based physical activity could increase lean muscle mass and decrease fat mass with no overall change in BMI. There was a variation among the studies. Did not assess the adherence to study protocols and the “dose” of physical activity.	Current population-based policies that mandate increased physical activity in schools are unlikely to have a significant effect on the increasing prevalence of childhood obesity.	Having a study that is appropriately powered is critical. In addition to collecting appropriate anthropometric data, future studies should also assess the impact of such interventions on the metabolic profile of children.
Gonzalez-Suarez et al. (2009)²⁴⁾	The risk of overweight and obesity was significantly lower in intervention program (OR=0.74; 95% CI 0.60–0.92), and programs with duration of 1≤ years are more effective. The results showed no significant differences in decreasing BMI (WMD= −0.62; 95% CI −1.39 to 0.14).	Detailed description of search strategy, data extraction and analysis plan. Systematic presentation of study according to PICOS framework.	Poor description of individual study characteristics.	Multidimensional programs with longer in duration were more effective.	Intervention with larger scales, longer than 2 years in duration and with better reporting of methodology are needed.
Li et al. (2008)⁴¹⁾	Most studies reported a beneficial effect of the intervention with one or more of the study outcomes, but most of the intervention studies suffered from weak methodology.	The kindergartens and schools that participated in these interventions are likely to be largely representative of Chinese educational establishments in urban areas.	All of the studies had serious, or moderate, methodological weaknesses. Limited external validity for countries other than China.	The interventions that focused on health education and/or lifestyle behavioural changes are effective in knowledge improvement and in the prevention of overweight and obesity.	Future studies should address the methodological weakness of previous interventions.
Kropski et al. (2008)²⁷⁾	Quantity and quality of evidence were insufficient. Twelve of 14 studies reported significant improvement in at least one measure of dietary intake, physical activity and/or sedentary behaviour.	Good description of the risk of bias and the quality of evidence in individual studies.	A potential risk of publication bias. Great heterogeneity of included studies. No flow chart/description of selection process.	Programs grounded in social learning may be more appropriate for girls, while structural and environmental interventions enabling physical activity may be more effective for boys.	Future studies should include a well-designed evaluation protocol that assesses appropriate outcome measures, appropriate target age, optimal duration of intervention and cost-effectiveness.
Kamath et al. (2008)²⁶⁾	Included interventions caused small changes on their respective target behaviors and no significant effect on BMI compared with control (ES =-0.02; 95% CI −0.06 to 0.02).	Good description of the quality of evidence in individual studies. Researchers conducted subgroup analyses by grouping studies.	Included studies are prevention studies that mostly included a mixed group, a proportion of which was already overweight. Included studies have important methodological shortcomings (loss of follow-up, lack of blinding).	. Strategies attempting to reduce unhealthy behaviors (i.e. decreasing sedentary behaviors and dietary fat) seem to be more effective than those promoting positive behaviors (i.e. increasing physical activity and consumption of fruits and vegetables).	The long-term impact of behavioral interventions on maintenance of target behaviors needs further exploration along with methodological rigor in the definition and measurement of the target behaviors. Future studies should evaluate the adverse effects of behavioral interventions or the targeted bahaviors.

Abbreviations: PA, physical activity; BMI, body mass index; CI, consumer health informatics; GRADE, the grading of recommendations assessments, developments and evaluation; OR, odds ratio; WMD, weighted mean difference; PICOS, population, interventions, comparators, main outcome, study design; ES, effect size.

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