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Systematic Review of Childhood Obesity Prevention

Linda G. Wofford, RN, MSN, CPNP

This systematic review identified the current state of the evidence related to the prevention of obesity in young children. The results indicate five areas of emphasis in the literature: prevalence of the problem; prevention as the best option; preschool population as the target; crucial parental involvement; and numerous guidelines. Because the gap between clear articulation of the problem as well as population and the best strategies to impact the prevention of the problem is evident, health care practitioners must be involved in well-constructed implementation and evaluation studies that build on the limited base of current evidence. 2008 Elsevier Inc. All rights reserved.

ECAUSE OF THE dramatic and alarming increase in childhood obesity and its associated health risks, obesity prevention programs targeting young children can and should be developed to promote the health of the public. A national trend for increased overweight in children is occurring. Information and statistics from national sources (e.g., the Surgeon General and the Centers for Disease Control and Prevention), state sources (e.g., the Tennessee Chapter, Action for Healthy Kids), and local health practitioners document the trend of increasing numbers of children and adolescents at risk for overweight and obesity (Chronic Disease Prevention, 2007; U.S. Department of Health and Human Services, 2001). In 1997, Ogden et al. reported an increased prevalence of overweight among 4- and 5-year olds but not in younger children. Five years later, Ogden, Flegal, Carroll, and Johnson (2002) documented still further increases in the prevalence of overweight for all age groups, not only those older than 4 years. The 2002 data documented prevalence increases from 10.5% to 15.5% in 12- to 19-year olds, from 11.3% to 15.3% in 6- to 11-year olds, 7.2% to 10.4% in 2- to 5-year olds, and a 10-point increase in Mexican American and non-Hispanic black adolescents (Ogden et al., 2002). In 2006, Ogden et al. published further data from 2004 that the prevalence of overweight rose from 13.8% to 16.0% for female children and from 14.0% to 18.2% for male children. There continues to be a significant difference in overweight prevalence by race/ethnicity (Ogden et al., 2006). There is a direct

association between obesity and chronic illnesses, such as heart disease, cancer, diabetes, and musculoskeletal disorders (Tschannen-Moran, Lewis, & Farrell, 2003). Because of the increasing prevalence of obesity in all age groups, the Healthy People 2010 initiative specifically addresses overweight and obesity as a leading health indicator. Highlighting the importance of this health issue is the fact that in addition to specifically naming overweight and obesity as a leading health indicator, physical activity is another leading health indicator that directly impacts obesity and overweight (U.S. Department of Health and Human Services, 2000). The issue is important not only because of its current impact on children but also because of its lifelong impact on the health of children at risk for overweight and obesity. When one considers the psychological impact, such as decreased selfesteem and negative body image, combined with the physical impact of overweight and obesity on an individual basis, such as increased risk for diabetes and impaired ability to participate in active play, the
From the University of Kentucky, Lexington, KY and Belmont University, Nashville, TN. Address correspondence and reprint requests to Linda Wofford, RN, MSN, CPNP, DNP student, University of Kentucky, Belmont University, College of Health Sciences and Nursing, 1900 Belmont Boulevard, Nashville, TN 37212. E-mail: lgwoff2@uky.edu or wofford@mail.belmont.edu 0882-5963/$-see front matter 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2007.07.006

Journal of Pediatric Nursing, Vol 23, No 1 (February), 2008

LINDA G. WOFFORD

impact is significant. However, when one considers the economic implications associated with lost worker productivity over a lifetime, the impact is enormous (Colditz, 1999). When this cost is considered, the investment of resources in the prevention of childhood obesity and its associated health risks is a financially sound one. Since the 1978 landmark study on the subject in Bogalusa, Louisiana, obesity has been a documented health risk for children (Berenson et al., 1978). Over the ensuing years, published data have continued to announce not only the growing size of the obese child population but also the disquieting incidence of comorbidities and typically adult diseases in younger age groups (Tschannen-Moran et al., 2003). During adiposity rebound, weight gain is related to more rapid deposition of fat than lean tissue. When adiposity rebound occurs earlier than it normally does, there is an increased risk for obesity in later years (Taylor, Grant, Goulding, & Williams, 2005). The preschool years appear to be a critical period for obesity prevention as indicated by the association of early adiposity rebound and obesity in later years (Flynn et al., 2006). The trend of increasing obesity has not been incremental and cannot be explained using modifications of the genetic pool. Although there are a myriad of factors contributing to the increased prevalence of overweight and obesity in children, the underlying cause recalls basic physiology knowledge that an imbalance between energy intake and expenditure creates either weight gain or weight loss. The epidemiological approach used in the web of causation model highlights the numerous ways that society's progress has altered the energy balance (Critser, 2003; Friedman, 1980; Goran & Treuth, 2001). The web includes factors at the individual and family levels, such as changing meal environment, increased television viewing, food availability, and decreased leisure time for parents. At the community level, web factors include suburban designs that discourage walking, increased concern for neighborhood safety, and increased availability of fast food as well as high-fat and calorie-dense food. At the societal level, some factors influencing the problem are decreased prevalence of breast-feeding, change in parental work patterns, increased use of out-of-home child care, and increased calorie-saving machines such as cars and computers (Institute of Medicine, 2004). Because the problem of obesity in children is multifactorial, the potential solutions could target a

variety of factors. Depending on the selected point of intervention, the impact would be variable. The data in the professional literature are clear in their recognition of a significant health problem in the increasing prevalence of childhood overweight and obesity (Drewnowski & Popkin, 1997; Hardy, Harrell, & Bell, 2004; Lobstein, Bauer, & Uauy, 2004; Moyer & Butler, 2004; Ogden et al., 1997, 2002). The lay press is also replete with information about the changing size of the nation's children. Fat Land, an expose and debate of the obesity problem in the United States, is an example (Critser, 2003). Often, the best available evidence related to a particular problem includes large randomized and controlled trials (RCTs) over long periods. Because the evidence currently available related to the prevention of obesity in young children younger than 4 years is limited to studies less than 1 year in length, the ability to critically evaluate the impact of the studied intervention is compromised. Because the prevalence of obesity is increasing in age groups older than 4 years, focusing on the prevention of obesity among children younger than 4 years is more effective than waiting to design an intervention after the problem has occurred. Effective prevention of obesity in children younger than 4 years is rational because of the recalcitrant nature of obesity once present. The American Academy of Pediatrics (2003, p. 424) stated that too few studies on prevention have been performed. The enormity of the epidemic, however, necessitates this call to action for pediatricians using the best information available. However, the variety of programs, products, plans, and propaganda prompted the author to systematically review the literature to determine the best available evidence for prevention strategies. Because there are many published accounts of programs related to obesity prevention with scant or weak evidence, a systematic review of the current literature proved to be helpful in identifying the gaps in the evidence. REVIEW METHODS The author conducted a systematic and comprehensive literature search using the keywords child, obesity, and prevention. Search engines used included PubMed, Cochrane Library, Joanna Briggs Institute, and CRISP (Computer Retrieval of Information on Scientific Projects). In addition to these computer-based strategies, hand review of selected bibliography entries was also executed.

CHILDHOOD OBESITY REVIEW

Because the results were voluminous (N5,000 citations), the author limited the fully reviewed articles to those published within the last 4 years or to seminal articles, articles pertaining to preschoolers, articles in the English language, and articles on studies of human subjects. The selection of pertaining to preschoolers meshed with the literature documentation that prevention of the obesity problem should target this age group (Lobstein et al., 2004; Skinner, Carruth, Bounds, Ziegler, & Reidy, 2002). Of the many captured articles, 41 were selected for inclusion in the review because of their relevance to the prevention of overweight and obesity in the preschool population and the stronger quality of the evidence they presented. The articles were grouped into five categories. The populationspecific group contained 5 articles, whereas there were 7 problem-specific articles. Thirteen articles were included in the guidelines and recommendations group. The intervention category had 11 articles, and the relevant conceptual models and frameworks section contained 5. FINDINGS During the review of the literature, the author discerned five areas of emphasisprevalence of the problem, prevention as the best option, preschoolers as the target group, parental involvement as essential, and professional recommendations for intervention. These areas of emphasis were identified by the author after reading the articles and looking for commonalities and differences across the 41 eclectic articles. These grouping threads are important in that they highlight the current state of the literature and provide the reader with an organizing structure to evaluate the evidence. With the use of the organizing structure of five threads or areas of emphasis, gaps were identified and recommendations, which have the potential to direct future research, provide steady foundation for prevention strategies, and encourage increased methodologically rigorous intervention study construction, were proposed. The initial area of emphasis in the literature is that the prevalence of obesity is increasing in all pediatric age groups (Edmunds et al., 2006; Ogden et al., 1997, 2002). A salient point gleaned from comparison of the two Ogden et al. studies is the change over 5 years' time in increased prevalence of obesity in children younger than 4 years from 7% (1997) to 10% (2002). The Edmunds et al.

study reported a prevalence increase of 33% for the Hispanic, black, and white groups. These studies articulated the significant overall increase and demonstrated increases in racial and ethnic groups (Table 1). Prevention as the best option resounded through the literature as another important emphasis area. Selected articles related to prevention are listed in Table 2. The author highlights two in the text and refers the reader to Table 2 for additional information. Lobstein et al. (2004) expressed eloquently that prevention of obesity in childhood is the only feasible option. Prevention of overweight is more effective than interventions that target the correction of obesity because of the recalcitrant nature of obesity. Strategies focused on building healthy habits related to nutrition and activity have more stable long-term results as compared with strategies focused on limiting behaviors. For example, children who were encouraged to increase their fruit and vegetable intake were more likely to demonstrate significant decreases in percentage of overweight than the children who were encouraged to decrease their fat and sugar intake (Epstein et al., 2001). The focus on positive behaviors, such as increasing fruit and vegetable intake, may be an effective strategy when planning prevention strategies. The preschooler population as the target for prevention was the third identified thread. Although prevention is an important emphasis, it is valuable to identify when the problem of obesity occurs most frequently so that prevention strategies can be used at the most opportune juncture. The literature clearly communicates that the preschool years constitute that critical time ([Ogden et al., 1997; Salsberry & Reagan, 2005]). Although not randomized and controlled studies, both studies were methodologically strong because of their large samples, use of data over two decades, and appropriate statistical methods. The Salsberry et al. study (2005) included secondary analysis of data from the National Longitudinal Survey of Youth's ChildrenMother file with a sample of 3,022 children. The Ogden et al. study used a cross-sectional survey with physical examination and anthropomorphic data from four surveys between 1971 and 1994. The sample size ranged from 1,200 to 7,500 children, depending on the specific survey. These studies identified that most of the time, children at risk for overweight and obesity changed their habits during the

8 Table 1. Prevalence of the Problem


Reference Publication data Sample Method

LINDA G. WOFFORD

Findings

Data from Berenson et al. (1978)

Cardiovascular disease risk factor variables at the preschool age. The Bogalusa Heart Study. Circulation, 57(3), 603612

714 children, (age range = 2.55.5 years) from Bogalusa, Louisiana

Height, weight, triceps skinfold, blood pressure, serum lipid, and nutritional data were collected

Data from Edmunds et al. (2006)

Data from Ogden et al. (2006)

Overweight trends among children enrolled in the New York State Special Supplemental Nutrition Program for Women, Infants and Children. Journal of American Dietetic Association, 106(1), 113117 Prevalence of overweight and obesity in the United States, 19992004. The Journal of the American Medical Association, 295 (13), 15491555

Yearly records of 2- to 4-year-old children enrolled in the New York Women, Infants and Children Program between 1989 and 2003; 58,000 83,000 records depending on year 3,958 aged between 2 and 19 years and 4,431 at least 20 years old who were children in previous surveys

Cross-sectional analysis

Foundational study of cardiovascular risk in young children Age and weight/height 2 positively associated with pre-beta-lipoproteins as compared with previously studied school-aged children Magnitude of interaction of risk factor variables increases with age Observations in young children more important because they show less compounding environmental effects on risk factors that occur at older ages Overweight prevalence increased significantly overall (33%, from 12% 16%) and for each race/ ethnic group 18% to 22% for Hispanics 11% to 15% for blacks 8% to 13% for whites In 20032004, 17.1% of children and adolescents were overweight Trends: Increased prevalence of overweight from 13.8% to 16.0% in female children and from 14.0% to 18.2% in male children Significant difference in obesity prevalence remained by race/ethnicity and age Prevalence of overweight among children and adolescents increased significantly during 19992004 Prevalence of overweight continues to increase in all age groups: From 10.5% to 15.5% in those aged between 12 and 19 years From 11.3% to 5.3% in those aged between 6 and 11 years From 7.2% to 10.4% in those aged between 2 and 5 years

Analysis of height and weight measurements obtained from National Health and Nutrition Examination Survey (NHANES) 19992000 and 20012002 as compared with 20032004

Data from Ogden et al. (2002)

Prevalence and trends in overweight among US children and adolescents, 19992000. The Journal of the American Medical Association, 288, 17281732

Survey of 4,722 children (age range = birth through 19 years) in 19992000

Part of NHANES crosssectional, stratified, and multistage probability sample of U.S. population; weight and height measurements

CHILDHOOD OBESITY REVIEW Table 1 (continued)


Reference Publication data Sample Method Findings

Data from Ogden et al. (1997)

Prevalence of overweight among preschool children in the United States, 1971 through 1994. Pediatrics, 99(4), e1

1,2007,500 children younger than 6 years in four surveys between 1971 and 1994: NHANES I, II, III and Hispanic Health and Nutrition Examination Survey

Nationally representative cross-sectional surveys with physical examination including measurements of stature, length, and weight

Data from Drewnowski and Popkin (1997) Data from Hardy et al. (2004)

The nutrition transition: New trends in the global diet. Nutrition Reviews, 55 (2), 3143 Overweight in children: Definitions, measurements, confounding factors, and health consequences. Journal of Pediatric Nursing, 19(6), 376384

Not applicable; not a research article

Not applicable

Not applicable; not a research article

Not applicable

10-point increase in Mexican American and non-Hispanic black adolescents In the last 20 years, increased prevalence of overweight among 4- to 5-year olds but not in younger children Efforts to prevent overweight, including encouraging physical activity and improved diets, should begin in early childhood Provides clear warning regarding potential consequences of nutrition transition for child health Provides an overview of the current body of literature surrounding the definition and measurement of overweight and morbidity association with childhood overweight

Note. Research articles are listed first in alphabetical order, followed by nonresearch articles.

preschool age. Because of this identified critical period, preventative interventions should target the preschool age group. Table 3 offers additional information about these studies. Although the threads of prevalence, prevention, and preschool target are prominent in the literature, parental involvement is the fourth critical area of emphasis. The adults in a child's life are incredibly influential and must be considered in any program that attempts to influence preschool health behaviors. Salmon, Timperio, Telford, Carver, and Crawford (2005) found in their study that the family environment is complex in its influence on activity levels. Although the study sample of Salmon et al. included children from 19 primary schools in Melbourne, Australia, the emphasis of family importance echoed throughout the health care industry in slogans and mottoes that espouse family-centered care. Families model behaviors related to nutritional patterns and physical activity. Positive family modeling is vital to the establishment of lifelong healthy habits. Practitioners involved with children have long recognized that the family is a critical piece in the success of the health promotion of children (American Academy

of Pediatrics, 2003; Barlow et al., 1998; Institute of Medicine, 2004; Koplan, Liverman, Kraak, & Committee on Prevention of Obesity in Children and Youth, 2005; Skinner et al., 2002; Williams et al., 2002; Table 4). The fifth and final area of emphasis identified was the importance practitioners place on recommendations and guidelines. Because of the alarming trend of increased overweight and obesity, healthrelated professional organizations have produced numerous practice guidelines and recommendations. The list is impressive in its multidisciplinary breadthnursing, medicine, physical education, federal government, consumer advocacy groups, and industry experts. Table 5 lists various organizations and the source of their recommendation and/or guideline. However, each recommendation or guideline is prefaced with a disclaimer that although the evidence is limited, the group felt strongly that some type of recommendation or guideline would be more helpful than waiting for more definitive evidence of effectiveness of preventative interventions. In general, the recommendations encourage appropriate nutrition choices and increased physical activity. As the volume of

10 Table 2. Prevention as the Best Option


Reference Publication data Sample Method

LINDA G. WOFFORD

Findings

Data from Epstein et al. (2001)

Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity. Obesity Research, 9(3), 171178

30 families with one obese parent and one nonobese child between 6 and 11 years old

RCT; assignment to one of two groups with follow-up at 1 year

Data from Moyer and Butler (2004)

Gaps in the evidence for well-child care: A challenge to our profession. Pediatrics, 114(6), 15111521

42 preventive interventions were recommended by two or more organizations

Well child care recommendations from seven organizations were tabulated into three categories (behavioral counseling, screening, and prophylaxis) Three consecutive interviews plus prenatal and birth characteristics were analyzed using chisquared analysis of bivariate association

Data from Salsberry and Reagan (2005)

Dynamics of early childhood overweight. Pediatrics, 116(6), 13291338

3,022 children (age range = birth through 7 years); secondary analysis of data from National Longitudinal Survey of Youth's ChildMother file

Data from Lobstein et al. (2004)

Obesity in children and young people: A crisis in public health. Obesity Reviews, 5(Suppl.1), 1104

Not applicable; not a research article

Panel of experts from the International Association for the Study of Obesity International Obesity Task Force endorsed by Federation of International Societies for Pediatric Gastroenterology and by International Pediatrics Association

Targeted treatment of increased fruit and vegetable resulted in greater decrease in body mass index (BMI) as compared with focus on decreased fat and sugar intake Limited direct evidence to support recommended interventions Authors admonish to give priority to implementation research and to setting of priorities for research into unproven interventions Early development of childhood overweight associated with race, ethnicity, maternal prepregnancy obesity, maternal smoking during pregnancy, and later birth years Suggests overweight prevention begins before pregnancy AND in early childhood Reviews measurement of obesity in young children Reviews global and regional trends in childhood obesity Notes increased risk for health problems for obese children Considers treatment and management options and effectiveness Emphasizes need for prevention as only feasible solution

Note. Research articles are listed first in alphabetical order, followed by nonresearch articles.

evidence grows, the current recommendations and guidelines will undoubtedly be revised to reflect increased specificity. DISCUSSION Although the literature indisputably shows the prevalence of overweight and obesity in children, the solutions offered in that literature are to this point merely editorial and opinionated. Although there are a few methodologically strong studies published, these well-constructed studies have

limited follow-up. However, most proposed solutions are weak methodically. (Table 6 contains information from selected intervention studies and programs that are methodologically sound with appropriate follow-up.) Health care practitioners desire strategies with a twofold resultstrategies that positively alter a child's health in the short term and those that positively impact the child's lifetime health trajectory. Knowledge of this scope will only be achieved through the kind of well-constructed longitudinal studies that are rare at this point. The difficulties in executing such studies are myriad.

CHILDHOOD OBESITY REVIEW Table 3. Preschoolers as the Target Group


Reference Publication data Sample Method Findings

11

Data from Ogden et al. (2002)

Prevalence and trends in overweight among US children and adolescents, 19992000. The Journal of the American Medical Association, 288, 17281732

Survey of 4,722 children (age range = birth through 19 years) in 19992000

Part of NHANES crosssectional, stratified, and multistage probability sample of U.S. population; weight and height measurements

Data from Ogden et al. (1997)

Prevalence of overweight among preschool children in the United States, 1971 through 1994. Pediatrics, 99(4), e1

1,2007,500 children younger than 6 years in four surveys between 1971 and 1994: NHANES I, II, as well as III and Hispanic Health and Nutrition Examination Survey

Nationally representative cross-sectional surveys with physical examination including measurements of stature, length, and weight

Data from Salsberry and Reagan (2005)

Dynamics of early childhood overweight. Pediatrics, 116(6), 13291338

3,022 children (age range = birth through 7 years); secondary analysis of data from National Longitudinal Survey of Youth's ChildMother file

Three consecutive interviews plus prenatal and birth characteristics were analyzed using chi-squared analysis of bivariate association

Prevalence of overweight continues to increase in all age groups: From 10.5% to 15.5% in those aged between 12 and 19 years From 11.3% to 15.3% in those aged between 6 and 11 years From 7.2% to 10.4% in those aged between 2 and 5 years 10-point increase in Mexican American and non-Hispanic black adolescents In the last 20 years, increased prevalence of overweight among 4- to 5-year olds but not in younger children Efforts to prevent overweight, including encouraging physical activity and improved diets, should begin in early childhood Early development of childhood overweight associated with race, ethnicity, maternal prepregnancy obesity, maternal smoking during pregnancy, and later birth years Suggests overweight prevention begins before pregnancy AND in early childhood

However, the basis for growth of the evidence for the prevention of childhood overweight and obesity depends on surmounting these difficulties. In augmenting the current state of the evidence related to the prevention of overweight and obesity in young children, studies must be constructed and conducted such that the results are definitive whether quantitative or qualitative in nature. However, these definitive results are missing. When Moyer and Butler (2004) evaluated 42 intervention recommendations, they concluded that there is little evidence to support the recommendations by the various health-focused organizations. The limits of the evidence beg practitioners to engage in studies that will facilitate the expansion of the evidence. Strategies for follow-up should be included in the original study design along with determination of the appropriate sample size to

allow for statistical power after subject attrition. Access to validated tools, tested curricula, and structured interviews would facilitate more rapid dissemination of promising prevention programs. Practitioners involved in the implementation of strategies for prevention must be encouraged to share their barriers and successes through formal (e.g., peer-reviewed journals) and informal (e.g., special interest group chat rooms through professional networking) dissemination channels. It is imperative that the prevention programs that are created to augment the evidence target not only the specific preschool children and their parents but also the system in which they live. Attention to the system or environment implies that practitioners will become advocates of involvement in community awareness and policy review. It is possible that policies that are counterproductive to health

12 Table 4. Parental Involvement is Essential


Reference Publication data Sample Method

LINDA G. WOFFORD

Findings

Data from Salmon et al. (2005)

Association of family environment with children's television viewing and with low levels of physical activity. Obesity Research, 13(11), 19391951

878 children (mean age = 11.5 0.6 years)

Parents and children from 19 primary schools in Melbourne, Australia, completed questionnaires and wore accelerators for 8 days

Data from Skinner et al. (2002)

Do food-related experiences in the first 2 years of life predict dietary variety in school-age children? Journal of Nutrition Education and Behavior, 34(6), 310315

Child/mother pairs interviewed seven to eight times when the child was between 2 and 24 months old and then again when the child was 6, 7, and 8 years old; there were 70 pairs in this longitudinal study

Randomized incomplete block design for interview schedule; 3 days of dietary data at 6, 7, and 8 years

Data from American Academy of Pediatrics (2003)

Policy statement: Prevention of pediatric overweight and obesity. Pediatrics, 112, 424430

Expert committee opinion

Review of literature: too few studies on prevention have been performed. The enormity of the epidemic, however, necessitates this call to action for pediatricians using the best information available (p. 424)

Data from Barlow and Dietz (1998)

Obesity evaluation and treatment: Expert committee recommendations. Pediatrics, 102, e29

Consensus recommendation

Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services convened committee of pediatric obesity experts to develop the recommendations: Because so few studies of this problem have been performed, the approaches to evaluation and treatment presented here rarely are

Relationship between television viewing and family environment is complex Factors include individual, family or social, and environmental influences Authors recommend reduction of sedentary behaviors and increasing physical activity Parents may be important mediators of their child's sedentary behavior Vegetable variety in school-aged children predicted by mother's vegetable preference Fruit variety in school-aged children predicted by breast-feeding duration AND either early fruit variety or fruit exposure Emphasize importance of early food-related experiences to school-age acceptance of variety of vegetables and fruits Proposes strategies for early identification of excessive weight gain by using BMI, for dietary and physical activity interventions during health supervision encounters, and for advocacy and research Identify and track patients at risk Plot BMI every year Use BMI change Promote breast-feeding Promote physical activity Limit screen time to 2 hours per day Identify changes in risk 85% BMI, then evaluate and possibly treat Be aware of rare exogenous causes of obesity Assess patient and family readiness Goal is healthy eating and activity Use of weight maintenance versus weight loss depends on patient's age, BMI, and complications

CHILDHOOD OBESITY REVIEW Table 4 (continued)


Reference Publication data Sample Method Findings

13

evidence-based. Nonetheless, they represent the consensus of a group of professionals who [treat] obese children and [adolescents] (p. e29)

Data from Institute of Medicine (2004)

Preventing childhood obesity: Health in the balance. Washington, DC: National Academies Press

Full report

Data from Koplan et al. (2005)

Data from Williams et al. (2002)

Preventing childhood obesity: Health in the balance: Executive summary. Journal of American Dietetic Association, 105(1), 131138 Cardiovascular health in childhood: A statement for health professionals from the Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young. Circulation, 106, 143160

Preventing childhood obesity: Health in the balance: Executive summary from the Institute of Medicine

Request from Congress for a prevention-oriented action plan to tackle the alarming rise in childhood obesity, the Institute of Medicine Committee on Prevention of Obesity in Children and Youth developed a comprehensive national strategy that recommends specific actions for families, schools, industry, communities, and the government; the committee's findings and recommendations are described in the report Executive summary from the Institute of Medicine's report released in September 2004

Institute permanent change in a stepwise manner Parenting skills are foundational Gradual and targeted increases in activity and healthy eating Ongoing support for families Recommend immediate steps for confronting epidemic of childhood obesity by organizational category Federal government Industry and media State and local governments Health care providers Community and nonprofit organizations Schools Parents and families

Same findings as those in the Institute of Medicine's (2004) report

Expert committee

Although the evidence base is insufficient to provide specific and generalizable guidelines for assessment and treatment of childhood and adolescent obesity, the following recommendations reflect critical reviews of the literature and are consistent with the recommendations of a recent consensus panel (p. 145)

Encourage a more active lifestyle with children, adolescents, parents, schools, and community leaders Take patient's physical activity history Promote daily moderate to vigorous physical activity that is part of the lifestyle Reduce screen time Advocate for daily school physical education plus safe and convenient community facilities and programs for childhood and adolescent physical activity Encourage parents in regular play with children to enhance development of physical skills and model an active lifestyle and set link between fun and exercise

Note. Research articles are listed first in alphabetical order, followed by nonresearch articles.

14 Table 5. Professional Recommendations and Guidelines


Reference Publication data

LINDA G. WOFFORD

Data from American Academy of Pediatrics (2003) Data from Barlow and Dietz (1998)

Data from Byers et al. (2002)

Data from Fulton et al. (2004)

Data from Institute of Medicine (2004)

Data from National Association for Sport and Physical Education (2004) Data from National Association of Pediatric Nurse Practitioners (2006)

Data from U.S. Preventive Services Task Force (2005)

Data from Whitlock et al. (2005) Data from Williams et al. (2002)

Policy statement: Prevention of pediatric overweight and obesity. Pediatrics, 112, 424430 Obesity evaluation and treatment: Expert committee recommendations. Pediatrics, 102, e29 American Cancer Society guidelines on nutrition and physical activity for cancer prevention: Reducing the risk of cancer with healthy food choices and physical activity. CA Cancer Journal for Clinicians, 52, 92119 Public health and clinical recommendations for physical activity and physical fitness: Special focus on overweight youth. Sports Medicine, 34, 581599 Preventing childhood obesity: Health in the balance. Washington, DC: National Academies Press Physical activity for infants and toddlers [brochure]. Reston, VA: National Association for Sport and Physical Education Healthy Eating and Activity Together (HEAT) clinical practice guideline: Identifying and preventing overweight in childhood. Cherry Hill, NJ: National Association of Pediatric Nurse Practitioners Screening and interventions for overweight in children and adolescents: Recommendation statement. Pediatrics, 116(1), 205209 Pediatrics, 116(1), e125e144 Cardiovascular health in childhood: A statement for health professionals from the Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association. Circulation, 106, 143160

promotion exist in the environment. A broad understanding of the multiple factors contributing to the problem of overweight and obesity in children is necessary to effect change so that community and local policies promote health. The epidemiological web of causation is an example of a model that could be used in evaluating the myriad

contributing factors as discussed earlier in the first section of this article (Mausner & Kramer, 1985). Although the purpose of the systematic review was not to evaluate the utility of models used in the prevention of childhood obesity, the author did identify several models that could be helpful to the reader in framing the issue of childhood obesity prevention. The Life Course Health Development model is useful in the advancement of prevention strategies in young children (Halfon & Hochstein, 2002). This model embodies the rationale for use of resourcestime, personnel, economicat critical periods of a child's life to positively affect the child's lifetime health trajectory. From individual and population viewpoints, the Life Course Health Development model suggests that investing community economic resources in the development of parks and playgrounds will affect an individual's as well as a group's physical activity and ultimately affect individual and community lifetime health trajectories. Forrest and Riley (2004) described a model that is similar in its focus on prevention but details the transition between child health and adult health. The social ecology model with its nested concepts is particularly helpful because prevention strategies with children are considered and planned (Earls & Carlson, 2001). The Social Cognitive Theory and Self-Determination Theory were used in a series of studies focusing on the prevention of obesity in preschoolers (Fitzgibbon, Stolley, Dyer, VanHorn, & KauferChristoffel, 2002; Fitzgibbon et al., 2005; Stolley et al., 2003). The concept of resilience is another useful idea in planning prevention strategies for overweight and obesity because it details internal (biological and psychological) and external (family and non-family) factors influencing the acceptance of the intervention (Mandleco & Peery, 2000). For practitioners to be successful in their efforts to impact the health of young children, they must consider not only conceptual models of the problem and population but also the health care system itself. Schor (2004) challenged primary care providers to rethink the model of periodicity that is considered the standard framework of care for well child care. He suggested that because the framework is not achieving its intended outcomes, other frameworks should be considered.

Limitations
This systematic review is limited in that the author selected 41 articles from the voluminous literature. Although the author made a valiant attempt to select the best and most significant articles

CHILDHOOD OBESITY REVIEW Table 6. Selected Intervention Programs on and Studies of Obesity Prevention
Reference Publication data Sample Method Findings

15

Data from Fitzgibbon et al. (2002)

Data from Fitzgibbon et al. (2005)

A community-based obesity prevention program for minority children: Rationale and study design for Hip-Hop to Health Jr. Preventive Medicine, 34, 289297 Two-year follow-up results for Hip-Hop to Health Jr.: A randomized controlled trial for overweight prevention in preschool minority children. Journal of Pediatrics, 145(5), 618625

Minority children (age range = 35 years) enrolled in 24 Head Start centers

5-year RCT targeting minority children aged between 3 and 5 years enrolled in 24 Head Start centers

Rationale and study design of proposed program

420 children from 12 Head Start programs in Chicago from September 1999 through June 2002

Randomized and controlled trial whose objective was to alter the trajectory toward overweight among preschool minority children by reducing increases in weight after a weight control intervention

Data from Flynn et al. (2005)

Promotion of healthy weights at preschool public health vaccination clinics in Calgary: An obesity surveillance program. Canadian Journal of Public Health, 96(6), 421426

7,048 preschool children attending public health clinics in Calgary between 2002 (pilot) and 2003

Data from Horodynski and Stommel (2005)

Nutrition Education Aimed at Toddlers: An intervention study. Pediatric Nursing, 31(5), 2425

135 low-income families at Early Head Start center in Michigan; 43 parent toddler dyads in intervention group, whereas 53 parenttoddler dyads in control group

Data from Perrin et al. (2005)

Preventing and treating obesity: Pediatricians' selfefficacy, barriers, resources, and advocacy. Ambulatory Pediatrics, 5(3), 150156

Members of North Carolina Pediatrician Society and American Academy of Pediatrics, N = 356

Multidisciplinary team development of protocol for preschool vaccination visit to include weight surveillance; pilot tested at 4 clinics and then used at all 13 clinics after modification; public health nurses trained with standardized measurement techniques and information resources; developed links to community physicians for continuity of care Quasi-experiment assessing Nutrition Education Aimed at Toddlers intended to enhance parenttoddler feeding practices; included four nutrition lessons and structured reinforcements over 6 months Cross-sectional self-administered mail survey

Intervention children had significantly smaller increases in BMI as compared with control children at the 1- and 2-year follow-up points Effective in decreasing subsequent increased BMI in preschoolers Promising approach to prevention of overweight in minority population of preschoolers Three-pronged approach to promote healthy weight (healthy eating, active living, and positive body image) Article includes protocol Parents and stakeholders satisfied with information Maximized existing resources and provided opportunity to give parents health promotion advice

Data from Reilly and McDowell (2003)

Physical activity interventions in the prevention and treatment of paediatric obesity: Systematic review and critical appraisal. Proceedings of the Nutrition Society, 62, 611619

Four new RCTs, two systematic reviews, and one meta-analysis were identified

Update systematic review and critical appraisal of evidence concerning the prevention and treatment of pediatric obesity; identified recent RCTs that targeted activity or inactivity with follow-up at least 1 year,

Intervention group showed significant increase in knowledge of feeding No significant difference in mealtime behaviors Need to focus on other avenues to enhance parents' abilities, not just knowledge With adjusted response rate of 71% (n = 356), most pediatricians reported feeling ineffective in their ability to treat obesity Most welcomed practicebased tool kits and effort to engage others in advocacy Authors conclude that evidence base has increased but that highquality studies are still lacking

(continued on next page)

16 Table 6 (continued)
Reference Publication data Sample Method

LINDA G. WOFFORD

Findings

Data from Salmon et al. (2005)

Association of family environment with children's television viewing and with low levels of physical activity. Obesity Research, 13(11), 19391951

878 children (mean age = 11.5 0.6 years)

including weight-related outcomes Parents and children from 19 primary schools in Melbourne, Australia, completed questionnaires and wore accelerators for 8 days

Data from Salsberry and Reagan (2005)

Dynamics of early childhood overweight. Pediatrics, 116(6), 13291338

3,022 children (age range = birth through 7 years); secondary analysis of data from National Longitudinal Survey of Youth's ChildMother file

Three consecutive interviews plus prenatal and birth characteristics were analyzed using chisquared analysis of bivariate association

Data from Stolley et al. (2003)

Data from Summerbell et al. (2006)

Hip-Hop to Health Jr., an obesity prevention program for minority preschool children: Baseline characteristics of participants. Preventive Medicine, 36, 320329 Interventions for preventing obesity in children. The Cochrane Database of Systematic Reviews, 2006, Issue 1

3- to 5-year olds; 416 black children and 337 black parents, and 362 Latino children and 309 Latino parents

5-year RCT targeting minority children aged between 3 and 5 years enrolled in 24 Head Start centers

Relationship between television viewing and family environment is complex Factors include individual, family or social, and environmental influences Recommend reduction of sedentary behaviors and increasing physical activity Parents may be important mediators of their child's sedentary behavior Early development of childhood overweight associated with race, ethnicity, maternal prepregnancy obesity, maternal smoking during pregnancy, and later birth years Suggests overweight prevention begins before pregnancy AND in early childhood 15% of black children and 28% of Latino children were overweight N75% of parents were overweight or obese

Systematic review of 22 studies; 10 long term (at least 12 months) and 12 short term (12 weeks to 12 months)

MEDLINE, PsycINFO, EMBASE, CINAHL, and CENTRAL database search from 1990 to February 2005; non-English language articles were included

The 22 studies reviewed included a variety of intervention programs that involved increased physical activity and dietary changes, singly or in combination Participants younger than 18 years Not enough evidence from trials to prove that any one particular program can prevent obesity in children, although comprehensive strategies to address dietary and physical activity change, together with psychosocial support and environmental change, may help Trend for newer interventions to involve their respective communities and to include evaluations

CHILDHOOD OBESITY REVIEW Table 6 (continued)


Reference Publication data Sample Method Findings

17

Data from Beckham et al. (2005)

One health center's response to the obesity epidemic: An overview of three innovative, culturally appropriate, communitybased strategies. Hawaii Medical Journal, 64(6), 151155, 168

Not applicable; not a research article

Report of three communitybased multidisciplinary programs with decreased fat diet, exercise, and behavioral therapy

Data from Dennison and Boyer (2004)

Risk evaluation in pediatric practice: Aids in prevention of childhood overweight. Pediatric Annals, 33(1), 2530

Not applicable; not a research article

Expert opinion of MDs and MSNs from pediatric preventive cardiology clinic in New York

Data from Hood (2005)

Sharing solutions for childhood obesity. Environmental Health Perspectives, 113(8), A520A522

Not applicable; not a research article.

Descriptive

Lifestyle Enhancement Program: counseling, fitness training and behavioral counseling to formulate individualized weight management program KidFit: biweekly fitness and nutrition program targeting school-aged children and youth; high attrition rate after summer holiday Hawaii Community Research Obesity Project: collaborative efforts to increase healthy agricultural products, increase availability of healthy food, and decrease prevalence of obesity All programs showed promising results after 6 months Recommends recognition and classification of overweight using norms of BMI for age Communication of child's weight status to parent in a nonjudgmental manner followed by age-specific anticipatory guidance related to food, beverages, physical activity, and television Admonition for office environment to be supportive Recommendations for future research prospective controlled trials with cultural and socioeconomic diversity, as well as role of providers, parents, and older children as advocates of change Author highlights the various venues and programs already in place combating obesity in children Selected programs included (1) KaiserPermanente's Health Eating, Active Living, (2) Girls on the Run aimed at third- to fifth-grade girls, (3) Sesame Street multiyear (continued on next page)

18 Table 6 (continued)
Reference Publication data Sample Method

LINDA G. WOFFORD

Findings

Data from Hood (2005)

Healthy Habits for Life, (4) yogurt in vending machines, (5) ad campaign to limit/ban food advertising during video/ computer games, and (6) We Can! program (Ways to Enhance Children's Activity and Nutrition) by the National Heart, Lung, and Blood Institute

Note. Research articles are listed first in alphabetical order, followed by nonresearch articles.

in the recent health-related literature, it is possible that strong and noteworthy articles were overlooked or omitted. Another reviewer might have selected different articles as the best and most significant. Because the five areas of emphasis identified by the author were not validated by other readers, these areas of emphasis may not be enduring. The systematic review is also limited in that there are minimal RCTs available for review. The 22 RCTs identified by the 2006 Cochrane Review do not provide longitudinal data (Summerbell et al., 2006). Typically, the studies reported on interventions lasting between 12 weeks and 12 months. Such a dearth of longitudinal data when considering the long-term health promotion of healthy eating and physical activity is a major weakness in the current literature.

CONCLUSIONS The purpose of this systematic review was to identify the current state of the evidence related to the prevention of overweight and obesity in young children. The results indicate five areas of emphasis or threads in the literature: prevalence of the problem; prevention as the best option; preschool population as the target; crucial parental involvement; and numerous guidelines. Because the gap between clear articulation of the problem as well as population and the best strategies to impact the prevention of the problem is evident, health care practitioners must be involved in developing and implementing well-constructed implementation and evaluation studies that build on the limited base of current evidence.

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