Wang et al. (2015)35)
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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)
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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. |
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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)
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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)
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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)
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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)
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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)
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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. |
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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)
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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)
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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)
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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. |
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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activity intervention was |
extraction according to |
assessment of |
evidence-based |
focus on intermediate |
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significantly effective in |
CDC community guide |
individual study and |
practice, we need more |
outcome such as |
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reducing weight |
data abstraction form |
limitation of the study. |
practice-based |
attitude, knowledge as |
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(SMD=-0.29; 95% CI |
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evidence. Because the |
early measures of |
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–0.45 to −0.14). |
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primary mission of |
success in obesity |
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Comprehensive |
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schools is to educate not |
control. |
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interventions including |
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to promote health, a |
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family or parent |
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priori evidence should |
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involvement were |
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be presented. |
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effective (SMD=-0.20; |
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95% CI −0.41 to 0.00). |
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Lissau (2007)28)
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) Half of the 14 included |
Good description of |
The included studies |
The barriers of |
Further studies need to be |
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studies had an effect on |
study objective and |
differred greatly in |
school-based |
evaluated using various |
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overweight. |
search strategy. |
regards to age group, |
interventions are (1) |
outcome measure as |
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type and length of |
healthy eating has a low |
well as BMI. A |
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intervention, type and |
priority, (2) lack of |
prevention project must |
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amount of actions and |
support at the school |
be theory-based. |
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statistical power. |
for healthy food and |
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meals, (3) the school |
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staff are not motivated |
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or are too overloaded |
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with work to give |
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attention to nutrition, |
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and (4) poor or lack of |
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supervision of the |
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school meals. |
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Connelly et al. |
The main factor |
Comparative analysis |
Did not validate intensity |
Compulsory aerobic |
Further research is |
(2007)22)
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distinguishing effective |
between studies |
score as elements of an |
physical activity may be |
required to identify |
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from ineffective trials |
reporting effective and |
effective intervention. |
related to a decrease in |
how compulsory |
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was the provision of |
ineffective outcomes |
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adiposity in children. |
physical activity can be |
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moderate to vigorous |
was done. |
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Nutritional education |
sustained and |
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aerobic physical activity |
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and skills training may |
transformed into a |
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in the former on a |
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reasonably be |
personally chosen |
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relatively ‘compulsory' |
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considered useful in a |
behaviour by children |
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rather than ‘voluntary' |
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general health |
and over the life course. |
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basis. |
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promotion sense. |
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Stice et al. |
21% of the 64 included |
Researchers evaluated |
Poor description of the |
Larger effect sizes tended |
Future studies are needed |
(2006)14)
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studies had a significant |
putative moderators of |
risk of bias in the |
to emerge in trials |
to conduct follow-up |
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weight gain prevention |
obesity intervention |
individual studies and |
involving children and |
trials of enhanced |
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effect (average effect size |
effects. |
across studies. Great |
adolescents, in |
versions of the |
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r=0.04, range −0.25 to |
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heterogeneity of |
female-only trials, in |
programs and to design |
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0.5). |
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included studies. |
interventions below the |
new programs. Need to |
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median of 16 weeks, in |
determine how to better |
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interventions that |
design obesity |
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targeted only weight |
prevention programs |
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change. |
for preadolescents and |
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males. Future trials |
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should include |
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multi-year follow-ups. |
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Need to evaluate the |
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mediators that |
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putatively account for |
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any weight gain |
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prevention effects. |
Doak et al. (2006)23)
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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)
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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. |