Childhood Obesity Prevention Programs: Comparative Effectiveness

Childhood Obesity Prevention Programs: Comparative

EffectivenessPrepared for:

Agency for Healthcare Research and Quality (AHRQ)

www.ahrq.gov

Introduction to childhood obesity and the various programs designed to prevent it

Systematic review methods The clinical questions addressed by the comparative

effectiveness review Results of the review and evidence-based conclusions

about the relative effectiveness of currently available programs to prevent childhood obesity

Gaps in knowledge and future research needs What to discuss with patients and their caregivers

Outline of Material

Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115.Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

Childhood overweight and obesity are highly prevalent in the United States, affecting one-third of children and adolescents.

Since 1980, the rates of obesity have tripled for children aged 2 to 19 years.

The risk of obesity is higher among minority and low-income populations.

Background: Prevalence of Childhood Obesity

Ogden CL, Carroll MD, Kit BK, et al. JAMA. 2012;307(5):483-490. PMID: 22253364.Wang Y, Beydoun M. Epidemiol Rev. 2007;29:6-28. PMID: 17510091.Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115.Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

Overweight children and adolescents are at greater risk for health problems when compared with their normal-weight peers and are more likely to become obese adults.

Obese children and adolescents are more likely to have serious illnesses such as type 2 diabetes, hypertension, high cholesterol, stroke, heart disease, nonalcoholic fatty liver disease, certain types of cancer, and arthritis.

Other reported health consequences of childhood obesity include eating disorders and mental health issues such as depression and low self-esteem

Background:Health Consequences of Childhood Obesity

Centers for Disease Control and Prevention. Available at www.cdc.gov/obesity/childhood/index.html.Reilly JJ, Kelly J. Int J Obes (Lond). 2011 Jul;35(7):891-8. PMID: 20975725.Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115.Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

Many factors interact to contribute to obesogenic environments and affect children’s weight. These include: Genetic and individual factors Home influences The school environment Factors in the local community Policies implemented at the regional and national levels

Background:Factors Contributing to Childhood Obesity


Obesity is difficult to treat, and prevention of childhood obesity has been identified as a key to fight the growing obesity epidemic.

Leading health organizations, including the World Health Organization and an Institute of Medicine expert panel, have recommended comprehensive interventions to fight obesity.

The main goal of most childhood obesity prevention interventions is to prevent children who are not overweight from becoming overweight or obese.

Interventions designed for obesity prevention may also help overweight or obese children lose excess weight or stabilize their weight.

Background: Preventing Childhood Obesity

Koplan JP, Liverman CT, Kraak VA, eds. Preventing Childhood Obesity: Health in the Balance. Available at www.nap.edu/catalog.php?record_id=11015.Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.World Health Organization. www.who.int/dietphysicalactivity/childhood_what_can_be_done/ en/index.html.

This review aimed to compare the effectiveness of obesity prevention programs for children and adolescents conducted in the United States and other high-income countries.

All studies of children that tested interventions of diet, physical activity, or any combination of these in any of the following settings were included in this review.

School Home Primary care clinic Childcare center Community setting A combination of the above

The authors of this review also assessed consumer health informatics interventions.

Background: Objectives of This Comparative Effectiveness Review


Settings of Obesity Prevention Interventions Assessed in This Comparative Effectiveness Review (1 of 2)

Setting of Intervention

Definition

School-Based Interventions

These took place primarily in schools (e.g., change in quantity and nutritional quality of food served at school, increase in physical activity at school, promotion of walk-to-school days), although they might also have involved community (e.g., improving community parks, performing community service) or at-home activities (e.g., daily physical activity homework of about 10 minutes, preparing a healthy breakfast at home).

Home-Based Interventions

These took place in the child’s home (e.g., interventions to alter the foods purchased for home use, family fitness).

Primary Care-Based Interventions

These took place in the offices of a primary care practitioner, a clinic, or other health care entity delivering primary health care to children. They included advice to parents and/or caregivers to make changes at home (e.g., encouraging more than five daily servings of fruits and vegetables , limiting screen time to less than 2 hours per day, and promoting greater than 1 hour of physical activity per day).


Settings of Obesity Prevention Interventions Assessed in This Comparative Effectiveness Review (2 of 2)

Setting of Intervention

Definition

Childcare Center-Based Interventions

These took place in settings where children received nonparental/ noncustodial care, generally outside the home (e.g., offering fruits and vegetables throughout the day, enhancing physical activity, designing exercise programs that improve pleasure of movement).

Community-Based and Environment-Level Interventions

These were delivered by enforcing policies or legislation (e.g., regulations on food retailing and distribution) or by changes to the built environment (e.g., restaurants, farmers’ markets, recreation facilities). Additionally, these interventions involved interaction with the community (such as the YMCA or church groups).

Consumer Health Informatics-Based Interventions

Consumer health informatics are technologies that deliver interventions and information indirectly (as opposed to in person) to patients or individuals in the community. These interventions might include Web-based, phone-based, and video-based programs, games, and information storehouses.


Topics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, members of the public, and others.

A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the select clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment.

The results of these reviews are summarized into Clinician Research Summaries and Consumer Research Summaries for use in decisionmaking and in discussions with patients and/or caregivers.

The Research Summaries and the full report, with references for included and excluded studies, are available at www.effectivehealthcare.ahrq.gov/ child-obesity-prevention.cfm.

Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Review (CER) Development


Key Question 1. What is the comparative effectiveness of school-based interventions for the prevention of obesity or overweight in children?

Key Question 2. What is the comparative effectiveness of home-based interventions for the prevention of obesity or overweight in children?

Key Question 3. What is the comparative effectiveness of primary care-based interventions for the prevention of obesity or overweight in children?

Key Question 4. What is the comparative effectiveness of childcare setting-based interventions for the prevention of obesity or overweight in children?

Clinical Questions Addressed by This Comparative Effectiveness Review (1 of 2)


Clinical Questions Addressed by This Comparative Effectiveness Review (2 of 2)

Key Question 5. What is the comparative effectiveness of community-based or environment-level interventions for the prevention of obesity or overweight in children?

Key Question 6. What is the comparative effectiveness of consumer health informatics applications for the prevention of obesity or overweight in children?

Key Question 7. What is the comparative effectiveness of multisetting interventions for the prevention of obesity or overweight in children?

Key Question 7 was addressed as part of the other six Key Questions.


The strength of evidence was classified into four broad categories:

Rating the Strength of Evidence From the Comparative Effectiveness Review


School-Based Interventions Only School-based diet or physical activity interventions prevent obesity or

overweight in children. ˜˜™

Strength of Evidence: Moderate „„School-based combination diet and physical activity interventions

prevent obesity or overweight in children.

Strength of Evidence: Insufficient

School-Based Interventions With a Home Component Physical activity interventions within school-based settings with a

home component prevent obesity or overweight in children.

Strength of Evidence: High Combined diet and physical activity interventions in a school-based setting

with a home component prevent obesity or overweight in children.

Strength of Evidence: Moderate

Evidence for the Benefits of School-Based Interventions in Preventing Obesity or Overweight in Children (1 of 3)


Meta-analysis of Change in Body Mass Index Between the Control Group and Combined Diet and Physical Activity Interventions in a School Setting With a Home Component

Burke, 1998

Burke, 1998

Dzewaltowski, 2010

Siegrist, 2011

Story, 2012

Hatzis, 2010

Mihas, 2010

Llargues, 2011

Overall (I-squared = 99.1%, p =

0.000)

0.00 (-0.16, 0.16) 12.49

0.10 (-0.05, 0.25) 12.51

-0.10 (-0.18, -0.02) 12.67

0.10 (0.06, 0.14) 12.71

0.34 (0.15, 0.53) 12.36

1.00 (0.80, 1.20) 12.34

-1.20 (-1.32, -1.08) 12.59

-1.60 (-1.80, -1.40) 12.33

-0.17 (-0.57, 0.23) 100.00

NOTE: Weights are from random effects analysis

Intervention Control-1.9 0 1.4

Study ID WMD

(95% CI)

% Weight

WMD = weighted mean difference


School-Based Interventions With a Community Component Combined diet and physical activity interventions in a

school-community setting prevent obesity or overweight in children. ˜˜™


School-Based Interventions With Home and Community Components Combined diet and physical activity interventions in a

school-home-community setting prevent obesity or overweight in children. ˜˜™

Strength of Evidence: High



School-Based Interventions With a Consumer Health Informatics Component

Evidence is insufficient to determine if physical activity or combined diet and physical activity interventions in a school setting with a consumer health informatics component prevent childhood obesity or overweight.˜˜™

Strength of Evidence: Insufficient



Home-Based Interventions Only Home-based combination (diet and physical activity)

interventions prevent obesity or overweight in children.

Strength of Evidence: Low

Childcare Center-Based Interventions Only Combined diet and physical activity interventions in a

childcare center setting showed no beneficial effect on childhood obesity or overweight prevention. ˜˜™

Strength of Evidence: Low

Evidence for the Benefits of Home-Based or Childcare

Center-Based Interventions in Preventing Obesity or Overweight in Children


Community-Based Interventions With a School Component Combined diet and physical activity interventions in a

community setting with some school involvement prevent childhood obesity or overweight.˜˜™


Primary Care-Based Interventions Only Evidence is insufficient to determine if combined diet and

physical activity interventions in a primary care setting prevent obesity or overweight in children.˜˜™

Strength of Evidence: Insufficient This does not mean that interventions do not work in the primary

care setting, but more research is needed.

Evidence for the Benefits of Community-Based or Primary Care–Based Interventions in Preventing Obesity or Overweight in Children


School-based programs involving dietary or physical activity interventions are effective in preventing childhood obesity.

Combining a home or community component with a school-based program also works.

The magnitude of effects appears to be modest, although the heterogeneity in study interventions, outcomes, and duration make it difficult to estimate a precise effect size.

Conclusions (1 of 2)


Evidence is limited regarding the effectiveness of interventions in other settings including those in primary care.

This does not mean that such interventions do not work but that more research is needed.

Conclusions (2 of 2)


Several gaps in knowledge were identified in the evidence base reviewed for this report:

„„A lack of sufficient information on the effectiveness of the following types of obesity and overweight prevention interventions

Interventions tested in the primary care or childcare settings

††Environment-based and policy-based interventions (e.g., agriculture policies and regulations on food retailing and distribution)

Consumer health informatics interventions

Gaps in Knowledge (1 of 2)


The need for an improved understanding of the contexts and challenges associated with implementing prevention programs in different settings

A paucity of information on the effects of various interventions in preventing childhood obesity in populations stratified by sex, age, ethnicity, demographics, or socioeconomic status

Limited information on the effectiveness of obesity prevention programs in adolescents

Gaps in Knowledge (2 of 2)


That clinicians are concerned about childhood obesity and the welfare of their patients

The patient’s body mass index and how to diagnose overweight/ �obesity in children

The possible factors contributing to overweight and obesity in ��children, including less physical activity, more sedentary/screen time, increased empty and liquid calories in the diet, and inappropriate use of food rewards or eating when not hungry

What constitutes an appropriate serving size�� The importance of monitoring total daily caloric intake as opposed to ��

total daily food intake

Important things that can be done at home to keep children at a ��healthy weight

What To Discuss With Your Patients andTheir Caregivers (1 of 2)


The potential health consequences of overweight and obesity in children

„„The relative effectiveness of the various interventions in preventing overweight and obesity

„„The programs and resources that help children maintain a healthy weight that are available at school or in the community

If a list of such resources could not be obtained, encourage parents and caregivers to explore schools, school district offices, and community centers for the available resources.

„„What can be done if healthy food or safe locations for physical activity are not easily accessible to patients and their families

What To Discuss With Your Patients andTheir Caregivers (2 of 2)


Documents

Childhood Obesity Prevention Programs: Comparative Effectiveness