Prevention of Childhood Obesity:

A Review of Systematic Reviews

Scottish Evidence Based Child Health Unit

(SEBCHU)

Dr Amudha Poobalan1,
Dr Lorna Taylor1,
Christine Clar 1,
Prof Peter Helms1,
Prof WCS Smith2

1 Scottish Evidence Based Child Health Unit

Department of Child Health
University of Aberdeen
Royal Aberdeen Children’s Hospital
Westburn Road
Aberdeen, AB25 2ZG

2Department of Public Health

University of Aberdeen
Foresterhill
Aberdeen, AB25 2ZD

Correspondence to: Dr Amudha Poobalan

E-mail: a.poobalan@abdn.ac.uk

Published by NHS Health Scotland,

Woodburn House, Canaan Lane, Edinburgh, EH10 4SG
© NHS Health Scotland 2008

i
 Contents

Executive Summary .......................................................................................... i

1. Background...............................................................................................1
1.1 Aetiology...................................................................................................... 1
1.2 Definition ..................................................................................................... 4
1.3 Prevalence .................................................................................................. 5
1.4 Health Consequences of Obesity ................................................................ 5
1.5 Costs Associated with Obesity
1.6 Justification for this review of reviews
1.7 Prevention-Issues and strategies
1.8 Aims of the study
1.5 Justification.................................................................................................. 6
1.6 Aims ............................................................................................................ 7
2. Methodology .............................................................................................8
2.1 Inclusion Criteria.......................................................................................... 8
2.2 Systematic Literature search....................................................................... 9
2.3 Method of Review........................................................................................ 9
3. Results of the Literature Search ............................................................. 10
4. Description of Reviews and Results ....................................................... 11
4.1 Physical Activity......................................................................................... 11
4.2 Behavioural Interventions.......................................................................... 13
4.3 Combined Approaches .............................................................................. 13
5. Discussion .............................................................................................. 18
5.1 Strengths ................................................................................................... 18
5.2 Weaknesses .............................................................................................. 18
5.3 Physical Activity......................................................................................... 18
5.4 Behavioural Interventions.......................................................................... 19
5.5 Combined Approaches .............................................................................. 19
5.6 Previous Reviews of Reviews ................................................................... 19
6. Conclusions ............................................................................................ 20
6.1 Implications for Practice ............................................................................ 20
6.2 Implications for Future Research .............................................................. 20

List of Tables
Table 1 Results of the Literature Search
Table 2 Details of the Included Studies

List of Appendicies
Appendix A: Medline Search Strategy .......................................................... 22
Appendix B: Quality Assessment Form .......................................................... 23
Appendix C: Excluded studies with reasons .................................................. 24
Appendix D: References ................................................................................ 27
Acknowledgements
We would like to thank Dr Lorna Aucott (Medical Statistician, Department of
Public Health, Aberdeen) and Prof Norman Waugh (Department of Public
Health, Aberdeen) for their advice and contribution. We would also like to
thank Mrs Flora Buthlay and Mrs Jennifer Brechin for the secretarial help.

It was peer reviewed by Professor Carolyn Summerbell, Professor of Human

Nutrition, University of Teesside.

Funding: This review was funded by NHS Health

Scotland.

i
 Executive Summary
Background

Obesity is defined as an excess of body fat. Levels of obesity among children

and adults are high in the Western world and have been increasing
dramatically over the last two decades. In Scotland in 1998/9 approximately
9% of 3 to 4 year olds were obese, and in secondary school children this was
approximately 15%. In 2003, the overall prevalence of obesity in boys was
18%. It ranged from almost 10% at age 2-4 to a peak of 22% at age 11-12.
The prevalence of obesity in girls was just under 14%; this ranged from
approximately 10% at age 2-4 to approximately 16% at age 8-10.
Between 1998 and 2003 there was an increase among boys in the prevalence
of overweight from approximately 29% to approximately 35%, including an
increase in the prevalence of obesity from approximately 14% to 18%,
however a similar change among girls was not noted between these same
years. The prevalence of overweight, including obesity was higher among
boys in Scotland than in England (approximately 35% and approximately 30%
respectively), but once again there was no similar difference noted among
girls. According to the Child Health Surveillance Programme – School (CHSP-
S), among Scottish children born in 2001, approximately 21% were
overweight by the time they reached around 3½ years of age; nearly 9% were
obese, and approximately 4% were severely obese (see
http://www.isdscotland.org/isd/ISD), and these levels were higher than the
levels expected for the UK as a whole. However, Scotland is not unique, in
1995 10% of boys and 12% of girls in England were obese and by 2002 thes e
figures had risen to 17% for both sexes. In the United States 25% of children
aged 6 to 17 are overweight or obese.
The obesity epidemic is not confined to the Western world. Increasingly
developing countries are being faced with the dual burden of under nutrition
and obesity.

Obesity can be from a primary or secondary cause. Primary obesity has no

underlying medical condition associated with it and is caused by an interplay
of genetic and environmental factors. Secondary obesity is rare, but can be
associated with a number of medical syndromes and endocrine conditions.
The long-term consequences of childhood obesity include cardiovascular
complications such as hypertension and increased cholesterol levels, with
insulin resistance and non-insulin dependent diabetes mellitus being two of
the associated endocrine complications. Obese children are twice as likely to
become obese adults.

Overweight and obesity at all ages is an increasing problem throughout the

world. As the psychological consequences of obesity can be devastating,
prevention should start at an early stage.

ii
 Aims
The aim of this study was to conduct a systematic review of reviews in order
to synthesize the available evidence on the prevention of childhood obesity.

Methods
A comprehensive search strategy was developed to identify systematic
reviews published between 1992 and 2005. The target population included
children up to 18 years of age, teachers or parents. Any type of intervention,
such as physical activity, dietary, or behavioural change and a combination of
approaches, in children with normal weight aimed at preventing obesity were
included in this review. Only reviews that assessed the weight changes using
some anthropometric measures such as BMI; body weight and percentage
body fat were included in this review of reviews. Two reviewers
independently selected studies based on a set of agreed criteria, assessed
their methodological quality, and extracted the relevant information.

Results of Literature Search

The search strategy identified 555 citations. Fifty-two reviews were

considered as being potentially eligible for inclusion and full texts were
obtained. Five systematic reviews met the final inclusion criteria.
Results from the Reviews

Physical Activity
Three reviews looked at physical activity. Each of these reviews agreed that
the primary studies were of poor quality because of the inclusion of short term
interventions, limited follow up and small sample sizes.

The first review by Dobbins & Thomas (2001) 23 found that in terms of body
mass index as an outcome, there was good quality evidence that physical
activity promotion in the school setting was not effective in changing body
mass index (BMI). The review by Reilly & McDowell in 2002 25 concluded that
there remained serious doubt about the long-term efficacy, clinical
significance and the generalisability of published interventions in this area.
The most recent review in 2005 by Wareham et al 24 stated that there was
limited good quality data on which to draw conclusions about obesity
prevention in children and adolescents, but suggested that perhaps there was
enough evidence to suggest that school-based interventions may be more
iii
promising than family based trials.
Behavioural Change
There was only one moderate quality review of 9 different behavioural
interventions that met the inclusion criteria conducted by Hardeman et al in
200022. They concluded that behavioural interventions were variable in nature
and that the studies were generally of poor quality. The studies demonstrated
positive results in relation to improved self-reported eating and physical
activityApproaches
Combined levels, howev er in the majority of studies these dimensions were not
The Cochrane review by Summerbell et al26 from 2005 looked at combined
translated
approaches intoactivity
(Physical a positive impact
and diet on ontogether)
its own or weight.and included 10
long-term studies (i.e. with a follow-up greater than 12 months), and 12 short-
term trials (i.e. with a follow-up 3 to 12 months).

Of the 10 long-term studies, two focused on Physical activity (PA), two

focused on diet and the other 6 focused on a combination of PA and diet. In
the long-term studies there was no treatment effect that could be attributed to
dietary interventions alone. In terms of physical activity, one study found a
significant effect on the BMI of girls, however, the other study in this group
similarly showed no effect.

Consideration of combined approaches of physical ac tivity and diet together

was also disappointing, with 4 studies showing no treatment effect, although
one study had a significant effect on skin fold thickness, but not BMI. There
were no studies that compared dietary intervention to a PA intervention.

Of the 12 short-term studies, none considered diet alone. Four studies looked
at physical activity; two of which showed significant effects on BMI with one of
these also showing an effect on skin fold thickness. The other eight studies
looked at the combination of diet and physical activity with no signific ant
positive results.

The authors of the review conclude that ov erall, the interventions to date have
not impacted on the weight status of children and thus there needs to be
further high quality research to examine these issues more fully.

iv
Table 2. Details of the included reviews
General Information and quality rating Details of Review Details of Interventions Outcome Measurements/Results
of each review
Hardeman et al (2000) Primary studies=11 Behavioural – 4 used health Primary: Weight
United Kingdom (9 interventions) 7 in children education model, 1 behavioural
BMI
model, 1 social learning theory and
Types 3 RCTs, 4 non-randomised 1 social cognitive theory. Skinfold
Secondary: thickness
self-reported Physical
Quality of Review=Moderatetrials. 2 were in adults (see above)
Delivery By – teachers activity
1. Search strategy comprehensive Search period=1966-2000
psychologistsResults
2. Quality assessment of primary studies
Number of databases searched = 8
Setting – community or school- No meta-analysis performed
Generalisability to Scotland
7 unclear
is Interventions conducted in USA based because of varied interventions and
settings
3. Adequate data to
2 Interventions support conclusions
conducted in Italy No significant differences in weight
2 Conducted with African American in any of the trials in children.

populations
Dobbins & Thomas (2001)
Canada
Quality of Review=Strong
1. Search strategy comprehensive
2. Adequate quality assessment of
3. Adequate data to
primary studies Numbersupport
of databases searched = 7
Primary studies = 19
Types - RCT or CCT
Search period=1985-2000
Physical Activity – involved Primary: BMI
printed educational materials,
Results:
altering of school curriculum, BMI reported in 11 studies
No meta-analysis performed
educational sessions, audio-visual
because of varied interventions and
Delivered By – teachers in 10,
materials
research staff inand
1 mass media.
settings

conclusions Not reported in 8 7 studies – showed no effect on

Setting – school BMI
3 studies – showed sig. effect in
both sexes - re BMI
1 study – showed sig. effect in boys

v
General Information and quality rating Details of Review Details of Interventions Outcome Measurements/Results
of each review
Generalisability to Scotland only - re BMI (p = 0.016)
13 studies conducted in USA Only 1 long term follow-up – no
with mixed ethnicity groups effect
(The nos above account for the 11
that considered BMI)
Wareham et al (2005) Primary studies = 11 Physical Activity – extra PE in weight
Primary
Ireland Body
schools, raising awarenessBody of composition
Quality of Review=ModerateTypes – RCTs or CCTs
television viewing times, altering
1. Search strategy – unclear therefore Secondary
Search period=2000 – 2004 school curriculum, familyPhysical activity or dietary changes
unable to establish if comprehensive
Delivered
informationby events,
teachersinternet
Results
2. Unclear quality assessmentNumber of primary
of databases searched –
not stated intervention,parents
dance lessons.
No meta analysis
studies 3 trials RCTs or CCTs Showed
Generalisability to Scotland nutritionist small intervention effect, 2 in boys
83.studies
Adequate conducted
data toinsupport
USA conclusions Setting - 8 school based only (p<0.001 and p=0.044)
2 studies conducted in England 1 parent based
2 community based Majority showed positive behaviour
1 study conducted in Chile changes, but no change in BMI.

Out of 11, 3 studies conducted in African

– American
Reilly populations
& McDowell (2002) Primary studies = 5 Physical Activity – information
Objective measurement of body
Scotland
Types – RCTs only available for 2 studies,
weight,
whichBMI or body composition
Quality of Review=Strong Results
1. Comprehensive search strategy – Search period = 1966 – 2002
both stated increasing physical
No meta-analysis
2. Good quality assessment of primary Number of databases searched = 5 activity and 1 of these 2 studies
2 studies were given negative
studies quality grading by Reilly &
3. Adequate data to support conclusions also increased the intensity of
McDowell
physical activity as well as
decreasing fat consumption in diet.
vi
 General Information
Details of Review
and quality
Detailsrating
of Interventions Outcome Measurements/Results
of each review
2 studies showed nobydecrease
Delivered unclear in
Generalisability to Scotland
4 studies conducted in USA BMI
Setting 3 school-based
1 study conducted in England 1 study showed a significant
2 community-based

decrease in obesity prevalence in

girls only (p<0.05)
Primary Summerbell
studies – 22 et al (2005) Physical Activity – 3 x 30 mins
Weight/height
United Kingdom
Types – RCTs or CCTs PA/week, dance classes, 4 Body
x PA fat
Quality of the Review = Strong
1. Comprehensive search strategy –classes/week, increasing physical
Search period = 1990 – 2004
BMI
2. Excellent quality assessment of primary play,
Diet –increasing
decreasingPE,
fat,decreasing
Ponderal index
increasing Results
studies Number of databases searched = 5 video game usage Skinfold
fruit & vegetable intake, decreasing thickness No meta analysis
3. Adequate data to support conclusions
Generalisability to Scotland fizzy juice consumption. Long term outcome
16 conducted in USA Physical Activity + Diet – PA -no sig. effect
3 conducted in UK combinations of positive changes
Diet -noinsig. effect
1 conducted in Thailand
1 conducted in Chile diet and increasing physical activity of PA & diet –1
Combination
1 conducted in Germany levels via extra PE, dance showed
classes, sig. decrease in skinfold
walking to school. Some were thickness, 5 noShort
effect
term outcome
PA 2 no effect, 2 decrease BMI
based on increasing lifestyle Combination of PA & diet-8 showed
Delivered by – Teachers 5
exercise, whilst others usedno significant effect
Researchers
structured exercise 2
programmes.
Nutritionist 1
Trained 9
Unknown 5

vii
 Discussion

The strength of this review is that it is the first review of reviews to

concentrate
solely on children, using anthropometric measures. Its weaknesses
reflect
the poor quality of the primary reviews.

The reviews looking at physical activity had mixed conclusions, 2

found there
was limited evidence to show that physical activity programmes
resulted in
improvements in anthropometric measures of body composition, such
Conclusions

as body
Childhood obesity is a growing problem and prevention is crucial in
weight,
this age.body fat or body mass index whilst the other one considered
there
In spite of increasing research in this area, recommendations for
was enough
practice are evidence to say that school based approaches were more
promising than of
limited because family based
a lack trials.quality
of high The trials.
behavioural interventions
Available evidence
seemed
suggeststo
result in positive
that obesity behaviour
is a product of changes but unfortunately
social, economic, lifestyle this
and was not
cultural
converted
changes
into
whicha positive
requireeffectcomprehensive,
on weight. The combined approaches
co-ordinated, showed the
multi-component
most
approaches to
promise
diet and but good quality
physical activitytrials
overare againyears.
many in the High
minority in this
quality group. is
research
needed to
Most of the
identify the best
primary studies included
intervention in this ageingroup.
these reviews were conducted
in
developed countries and in white Caucasian populations and the results
could viii

be generalised to the Scottish population.

 1. Background

1.1 Aetiology
Obesity results from an increase in number or size of adipocyte cells. This is
caused by a positive energy balance, i.e. more energy is ingested than is
used by the body. Obesity causes can be split into primary or secondary
causes. Primary obesity has no underlying medical condition associated with
it and is caused by an interplay of genetic and environmental factors.
Secondary obesity is rare and is associated with a number of syndromes and
endocrine disorders.
1.1.1 Genetics
In recent years there has been a lot of interest in the genetic basis of obesity.
Parental obesity is one of the major risk factors for childhood obesity. This is
because of both genetic and environmental contributory factors. Twin studies
suggest that between 40 – 70% of fat mass is inheritable. This is shown by
0.7 to 0.9 concordance in monozygotic twins compared with 0.35-0.45 in
dizygotic twins 1.1.2
1. Environmental Factors
Various environmental factors contribute to obesity in children from an early
age. These include influences during the gestational period, (relating to
maternal health, lifestyle, eating habits and metabolism ), breastfeeding, family
lifestyles and food choices, parental neglect, and sedentary lifestyle and
television viewing. Physical activity in children is affected by their parents’
physical activity levels, the safety of the environment, seasonal and
geographic influences, the availability of facilitites and access to equipment
and peer influences. Culture, local/national policies, and the media and
advertising will further influence health behaviours. In a systematic review
about the effects of food promotion in children, Hastings et al2 found that in a
lot of food advertising to children, the advertised diet was less healthy than
the recommended one, but nonetheless that children enjoyed and engaged
with food advertising. They also found that food advertising had an effect,
particularly on children’s preferences, purchase behaviour and consumption
and this advertising effect was independent of other factors known to
influence diet and was seen to operate both at a brand and food category
level.
1.1.3 Breastfeeding
Two large observational studies suggest that there is a link between
breastfeeding and childhood obesity. Armstrong et al 3. investigated a cohort
of 32200 Scottish children aged between three and four years, and found that
significantly fewer children were obese in the group that was exclusively
breastfed, compared to the group that was exclusively formula-fed (7.2%
versus 9.1% obese, odds ratio (OR) 0.72 (95% confidence interval (CI) 0.65-
0.79); 3.4% versus 4.6% severely obese, OR 0.70 (95% CI 0.61-0.80); odds
ratios adjusted for socioeconomic status, sex, birth weight). Similarly, a study
of 9206 German children 4 aged between five and six years old showed that
children who had been exclusively breastfed for six to twelve months were
significantly less likely to be obese than children who had never been

1
breastfed, (2.8% versus 4.5%; OR 0.79 (95% CI 0.68-0.93) for children ever
breastfed; OR 0.67 (95% CI 0.49-0.91) for children exclusively breastfed for
six to twelve months; odds ratios adjusted for level of parental education,
maternal smoking during pregnancy low birth weight, own bedroom, frequent
consumption
1.1.4 of butter).
Physical Activity
Apart from genetic and more general environmental factors, the main factors
responsible for the increase in childhood obesity are changes in the diet
(quantity and composition) and changes in the level of physical ac tivity. Reilly
and Dorosty 5 (1999) suggest that the case for physical inactivity being largely
responsible for the increas e in childhood obesity is stronger than the case for
the role of increased energy intake. Between 1967 and 1992, energy intake
in children in the UK, aged between 1.5 and 4.5 years decreased by 20%,
whereas overweight and obesity increased. Similar data has been shown for
UK children aged 14-15 years and for Swedish and North American children.
Additionally, physical inactivity (including television viewing) is predictive of
subsequent overweight and obesity in children and adolescents. Television
viewing not only leads to inactivity but also decreases resting metabolic rate,
leading to further decreases in energy expenditure. Direct studies of
children’s activity tend to suggest that activity levels, both in primary and
secondary school children, are quite low, but is it difficult to draw any firm
conclusions as the methodologies used and the criteria applied differed
greatly between studies.

Surveys using self-report techniques have been quite diverse, but tend to
suggest that children on the whole are not inactive, but that activity is less in
girls than in boys and tends to decease with age. Heart rate studies in
children aged 4 to 18 years suggest that 15-40 minutes daily are spent in
moderate activity and 4-22 minutes daily in vigorous activity. Much activity is
spent in the lower activity zones (where heart rate is not very predictive of
physical activity). In studies using the doubly labelled water method, the ratio
of total energy expenditure to basal metabolic rate has been used as an
indicator of physical activity, with 1.7 corresponding to moderate and 1.9 to
vigorous activity. Of eleven studies, about half yielded values that were
clearly below 1.7; with three others including values just below 1.7. Both
cross-sectional and longitudinal studies investigating the relationship between
obesity and physical activity have tended to generate quite diverse results,
partly because the energy requirement for the same activity in obese children
is much higher than in children of normal weight, but many studies do suggest
that activity levels and obesity are correlated 6.

According to the UK national diet and nutrition survey of young people aged 4
to 18 years7, a large proportion of children (between 33% and over 50%)
failed to meet the recommendation of engaging in at least moderate activity
for an hour a day. Activity was reduced in girls compared to boys and fell with
increasing age. About 50% of young people walked to school and between
1% and 6% cycled. There was no significant variation in physical activity with
respect to social class, region, household income or attending school or work

2
The Scottish Health survey8 (www.show.scot.nhs.uk/sehd/publications)
published in 2003 showed that 74% of boys and 63% of girls aged 2-15 years
participated in physical activity for 60 minutes or more, on 7 days a week, (i.e.
the level of activity that is currently recommended for children). Children in
Scotland were slightly more likely than those in England to participate in the
recommended amount of activity, (74% vs. 70% in boys and 63% vs. 61% in
girls).

Other UK statistics also indicated low levels of physical activity in children and
young people (see www.statistics.gov.uk). Data showed that for the 16 to 24
year age group in 1998, 37% of boys and 60% of girls either spent no time on
sports or exercise at all, or spent less than one hour per week; 35% of boys
and 32% of girls spent between one hour and less than five hours per week
on sports and exercise, and only 27% of boys and 9% of girls spent 5 hours or
more on sport or exercise. Five to 10 year olds cycled an average of 19 km
per year in 1998, 11 to 17 year olds cycled 119 km per year, and in 18 to 29
year olds, this 1.1.5 declined
Dietaryto 85 km per year. In the older age groups, the
Habits
Dietary habits have also changed considerably. Fast food consumption, the
distances
consumption offor girls/women
sugary were
drinks, and portion substantially
size have all increased less than for boys/men. The
average distance
considerably over the past walked per child
decades, (according to dataper
fromyear declined from 343 km in 1985-86
the USA7).
Television viewing is not only correlated with inactivity but also with snacking
in the 0High
frequency. to 4fat,year
energyolds
dense to 298
foods, kmasinpalatable,
as well 1997-99, from
low cost, easily 340 km to 254 km in the 5
to 10 year
available olds,
foods and largeand from
portion 605
sizes are kmincrease,
on the to 424 alongkmwithin the 11 to 15 year olds. In
sedentary behaviour, while phy sical activities in daily life and work-related
general, international
activity are decreasing. However,surveys
robust data of youth
showing physical
a link between theseactivity show that less than
50% and
factors of the
young people
development are issufficiently
of obesity lacking. active; that a considerable smaller
proportion
The UK national of
dietgirls thansurvey
and nutrition of boysof youngarepeople
active aged and that
4 to 188 yearsactivity participation
suggested that the foods most commonly consumed by young people (i.e. by
declines throughout adolescence.
over 80%) were white bread, savoury snacks, potato chips, biscuits, boiled,
mashed and jacket potatoes and chocolate confectionary. These food
choices were followed by meat dishes , (mostly chicken and turkey),
consumed by over 70%. Raw and salad vegetables were eaten by 47% of
boys and 59% of girls, 40% ate cooked green leafy vegetables and 60% other
cooked vegetables. Over 50% ate apples and pears, just under 40% ate
bananas, and 25% ate citrus fruit. Intakes of vitamins and minerals were
lower in Scotland than elsewhere in the UK.

The Scottish Health survey 8 (www.show.scot.nhs.uk/sehd/publications)

published in 2003 showed that on average, children aged 5-15 consumed 2.6
3
portions of fruit and vegetables per day. Only 12% consumed the
recommended amount of five or more portions per day and 12% consumed
none at all. Fruit and vegetable consumption varied by socio-economic group
and was higher in managerial households than among those in semi-routine
and routine households.

Young people from lower socio-economic status households had a lower

quality diet, including a lower intake of vitamins and minerals. It has been
suggested that healthy eating promotion, especially in young preschool age
children should aim to increase the consumption of iron rich foods, fruit and
vegetables (both in variety and quantity), starch rich foods, food rich in non-
1.1.6 Other factors
starch polysaccharides,
Socioeconomic factors are also related foods
to obesity rich in unsaturated
as energy-dense food is fatty acids, and should aim
to decrease the consumption of foods high in sugar, salt or saturated fatty
often cheaper and healthy diets are more expensiv e, leading to a diet of
poorer quality among those of lower socio-economic status9. Vulnerability to
acids, and
developing obesityof tea9. atDespite
is increased there
certain critical being
periods little objective evidence, establishing
in life. These
include the pre-natal period, with evidence suggesting that foetal nutrition and
gooddevelopment
in-utero eating behaviours early
has permanent effects in childhood
on factors may lay the foundation for
associated with later
obesity; adiposity rebound, i.e. a renewed increase of fat content, (at 5 to 7
maintaining
years of age because ofhealthy
changes toeating behaviours
food and activity patterns as alater
result ofin life.
exposure to new environments); adolescence, (as increased autonomy is
often associated with irregular meals, changed food habits and periods of
inactivity, with girls being particularly at risk), early adulthood (when there is a
marked reduction in physical activity, usually between 15 and 19 years in
women, and in the early 30s in men), pregnancy and menopause10.

1.2 Definition of Obesity

Obesity is defined as an excess of body fat. In adults the definition of obesity

is standard worldwide using the body mass index. This takes into account
differences in height and is calculated by dividing the weight in kilograms by
the height in metres squared. The normal BMI is taken as between 20 to 25,
with a level of 25 to 29 considered overweight, and greater than 30 being
obese.

Body mass percentile charts are used, with overweight being defined as
greater than the 85th percentile for age, and obesity as greater than the 97th
percentile for age.

Other measures are also used to estimate different aspects

4
of overweight and
fat distribution. These include the measurement of waist to hip ratio, skinfold
thickness, percentage body fat and visceral obesity, (measured by computer
tomography or magnetic resonance imaging).
The definition of childhood obesity is more difficult because the body mass
index changes and increases with age therefore using the adult definitions
would result in an underestimation of the prevalence of childhood obesity.
1.3 Prevalence of Obesity

Levels of obesity among children and adults are high in the Western world
and have been increasing dramatically over the last two decades. In Scotland
in 1998/9 approximately 9% of 3 to 4 year old were obese and in secondary
school children this was 15% 3. In 2003, the overall prevalence of obesity in
boys was 18%; it ranged from 10% at age 2-4 to a peak of 22% at age 11-12.
The prevalence of obesity in girls was 14%; this ranged from 10% at age 2-4
to 16% at age 8-10 8. Between 1998 and 2003 there was an increase among
boys in the prevalence of overweight (from 29% to 35%), including obesity
(from 14% to 18%) but no change in girls was noted between these years.
The prevalence of overweight including obesity was higher among boys in
Scotland than in England (35% and 30% res pectively), however, there was no
such significant difference among girls. 8 According to the Child Health
Surveillance Programme – School (CHSP-S), of Scottish children born in
2001, appr oximately 21% were overweight by the time they reached 3.5 years
of age, approximately; 9% were obese,
http://www.isdscotland.org/isd/ISD), and 4%than
- higher were
theseverely obese (see
levels expected in the
UK. Scotland is not unique; in 1995 10% of boys and 12% of girls in England
were obese and by 2002 these figures had risen to 17% for both sexes. In the
United States 25% of children aged 6 to 17 are overweight or obese. This
epidemic is not confined to the western world. Increasingly developing
countries are being faced with the dual burden of under-nutrition and
obesity 11.

1.4 Health Consequences of Obesity

The complications of childhood obesity are vast12 ,13. They include

cardiovascular, respiratory, endocrine and orthopaedic complications.

Probably the most concerning complication of childhood obesity is the

development of adult obesity, since obese children are twice as likely to
become obese adults 14.

In adults, overweight and obesity are associated with increased mortality

(although this effect may be reduced in women) in people who are physically
inactive, and in older people15,16,17 . Similarly, follow-up data from the Harvard
Growth Study that has more than fifty years follow-up, suggests that overall
mortality and cardiovascular mortality were increased in those who were
overweight as adolescents, (13 to 18 years) (relative risk 1.8, 95% CI 1.2 to
2.7, p=0.004 for all cause mortality; relative risk 2.3, 95% CI 1.4 to 4.1,
p=0.002 for cardiovascular mortality). Additionally, the risk of colorectal
cancer and gout was increased among men and the risk of arthritis was
increased among women who had been overweight as adolescents18.

5
 1.4.1 Psychological consequences of obesity
Children are aware from an early age that obesity is socially undesirable, but
the evidence regarding the relationship between psychological variables and
obesity is inconclusive. Some data suggests that obesity in children has more
of an impact on their perception of appearance and physical ability than on
their social competence and feelings of self worth. In 25 studies studying the
relationship between obesity and self-esteem, only about half found lower
self-esteem in obese children. An inverse relationship between self-esteem
and obesity may1.5beCosts more associated
consistent with obesity
in adolescents. Conversely, high self-
esteem
During the last may protect
decades hospital against
costs associated obesity19
with obesity in children ,20 .
have increased significantly. In the USA, the percentage of hospital
discharges with a diagnosis of obesity-associated diseases in children aged 6
to 17 have increased between 1979 and 1981 and 1997 and 1999 as follows
(data from the National Hospital Discharge Survey): diabetes 1.43 to 2.36%,
gallbladder disease 0.18% to 0.59%, and sleep apnoea 0.14% to 0.75%.
Obesity-associated annual hospital costs increased from $35 million (0.43%
of total hospital costs) during 1979-1981 to $127 million (1.70% of total
hospital costs) in 1997-1999 21.

In the UK adult obesity complications cost the NHS £2.1 billion in 2001 and
this figure increases every year13.

1.6 Justification for this review of reviews

Overweight and obesity, both in adults and in children are growing problems
throughout the world. Healthy eating and physical activity are key factors in
the prevention of the problem. Prevention should start at an early age, as risk
factors for cardiovascular disease can be present in childhood and healthy
behaviours, (e.g. those related to eating and exercise) of young people can
probably be more easily influenced in childhood when habits are still
developing.

The Scottish Executive and NHS Health Scotland (NHSHS) have identified
the improvement of diet (especially in deprived communities and in children)
and an increase of physical activity to be high priority areas. The Scottish
Diet Action Plan aims to double the consumption of fruit and vegetables,
reduce the consumption of total fat and saturated fat by over 5%, and double
the consumption of oily fish by 2005. Various projects have been put in place
to implement these targets, for example the Scottish Community Diet Project,
working with low-income communities, and the Scottish Healthy Choices
Award Scheme, which includes an initiative to improve food in schools.
Additional projects include dev eloping and delivering a food and health
vocational training course, an initiative to encourage mothers to breastfeed,
and the development of health promoting schools. In relation to physical

6
activity, the Scottish Executive aims to increase the percentage of school
children achieving the recommended level of activity to 80%, (from 70% in
boys and 60% in girls at present). To implem ent this target, the ‘Class Moves’
initiative is run in primary schools and encourages daily physical activity and
body awareness.
1.7 Prevention – issues and strategies

Intervention programmes will be preventative. As most communities

and
schools will include children who are already obese, most community-
based
or school-based prevention programmes will include both children who
are
and children who are not obese.

One of the requirements1.8 Aims of the study

of preventive interventions is to reach as many
members
The of
aim of this study was the target
to conduct population
a systematic as
review of reviews in orderis possible.
to synthesize the available evidence on the prevention of childhood obesity.
School-based
interventions
have the advantage of reaching most of the child/adolescent population
and
school programmes can be conducted at low or no costs to families.
Primary
care may also be a useful partner in childhood obesity prevention,
especially
in the early years when the physical development of infants and small
children
is closely monitored. However, the potential role of primary care
appears to
be under-valued and under-utilised.

7
 2. Methodology

2.1 Inclusion Criteria

2.1.1 Types of studies
Systematic reviews fulfilling the inclusion criteria below were assessed. As
older reviews were considered to be less likely to conform to current quality
standards and review practice, and were considered likely to miss the large
number of primary studies completed in recent years, reviews were only
considered in detail if they were published more recently, between 1992 and
2.1.2 Types of participants
Reviews
November that considered children and adolescents less than eighteen years
2005.
were included. Reviews that focused on adults, but in which children were
considered separately were also included. The target population was the
general population, notofthe
2.1.3 Types obese population.
interventions
Interventions were considered that combined the following components in
relation to the target population, setting, delivery, contents and objectives.

Target Population:
The target populations were children and adolescents, parents, teachers,
other school staff and the combination of these.

Setting:
Schools, community, family, primary care and a combination of these settings
were considered.
Delivery of interventions:
Teachers and other school staff, researchers, peers and a combination of
these who delivered the interventions were considered.

Type of Intervention:
Any intervention that aimed at preventing obesity was considered for
inclusion. They fell under four headings:
1. Physical Activity Interventions
2. Dietary Interventions
3. Multi-component Interventions
4. Behavioural Interventions

2.1.4 Outcome measures

Some form of objective anthropometric measure was required for a
publication to be included in this review, e.g. weight, body mass index,
percentage body fat, waist-hip ratio and/or skinfold thickness.

8
2.1.5 Exclusion Criteria
Reviews that targeted the already obese population were excluded. Reviews
in which children and adults were not analysed separately were also
excluded. Studies that considered surrogate outcome measures, such as
improved diet or increase in physical activity without an objectiv e
anthropometric
2.2 measurement,
Systematic Literature search were similarly excluded.
The electronic databases MEDLINE, EMBASE, the Cochrane Library and
various websites including NICE, (formerly the HDA), the database of the
centre of reviews and dissemination (CRD), the NHS Research and
Development HTA website and the Scottish Intercollegiate Guidelines
Network (SIGN) website were searched systematically from 1992 to 2002. An
update was carried out on MEDLINE until November 2005. The search was
restricted to the English language. The Medical Subject Headings (MESH)
terms
2.3 Methodwere combined with text words to identify all relevant reviews. Full
of Review
details
2.3.1 of the
Management searchrelevant
of potentially are described
reviews in appendix A.
Two reviewers independently assessed the first two hundred abstracts and
any disagreement was resolved by discussion. One reviewer assessed the
The reference lists of all reviews were checked to identify any other relevant
remaining abstracts, although queries about the inclusion of studies were
review
discussed
2.3.2
articles.
with theofsecond
Quality assessment the reviewsreviewer.
The methodological quality of the identified reviews was assessed
independently by two reviewers using a method by Miccucci 27 which is
included in appendix B. Differences were resolved by discussion. Reviewers
wereData
2.3.3 notextraction
blind to
andauthors,
analysis institutions nor journals.
Two reviewers independently extracted data from identified studies, which
met the inclusion criteria. A data extraction form was developed for this
purpose, (See appendix B). Data was recorded about the year of publication
and authors, the number of primary studies included in the review, the type of
review, target populations, the setting and outcomes.

Owing to the lack of meta-analysis in any of the reviews, between-review

comparisons could only be made qualitatively.

The results are summarized according to the type of interventions.

9
 3. Results of the Literature Search
In total, 555 titles and abstracts were identified by the search strategy.

52 reviews were considered as being potentially eligible for inclusion and full
text were obtained for each. Five systematic reviews met the final inclusion
criteria (see table 1). The 47 excluded studies, with reasons for exclusion are
Table 1: Results of the search
presented in appendix C.
Author Country Year Intervention Quality
Hardeman et al2 2 UK 2000 Behavioural Moderate
Dobbins & Thomas23
Canada 2001 Physical Activity Strong
Ireland
Wareham et al242005
Physical Activity Moderate
Reilly & McDowell25 Scotland 2003 Physical Activity Strong
UK 2005 Combined Approach Strong
Summerbell et al26

10
 4. Description of Reviews and Results

4.1 Physical Activity

Three of the reviews focused on the role of physical activity in the prevention
of obesity.
4.1.1 Dobbins & Thomas (2001)
The first such review was conducted in Canada in 2000. It looked specifically
at school-based interventions to increase physical activity among children and
young people.

In terms of quality, this was a strong review with a comprehensive fifteen-year

search, which resulted in the inclusion of 19 studies. As anthropometric
changes were secondary outcomes in this review, only 11 of the studies
commented on body mass index changes. Six of these studies focused
exclusively on children, 3 on adolescents and the remaining 2 considered
children and adolescents. Several of the studies reported BMI outcomes by
gender groupings. The length of intervention varied from 7 weeks to three
years.

In the children section of this review, only 1 out of the 5 studies, which
grouped the genders together, showed a significant effect of increased
physical activity on body mass index when compared with controls. The study
in children that considered the results by gender found a significant treatment
effect for boys in the low intensity intervention group.

The studies in adolescents were slightly more promising; with two of the three
studies showing a significant change in BMI, although the combined age
group interventions failed to show an effect on BMI.
4.1.2 Reilly & McDowell (2003)
The second review in this category was conducted in 2002 in Glasgow. Again
Only
this was one study
a strong qualityreported results
review although
were carried out in the USA.
fromof the
the majority long-term follow-up,
which showed that
primary studies

the short-term results were not sustained in a 4-year follow-up.

This study was an update of a previous review but in contrast to the previous
one, these reviewers only included studies that had objective measurements
of bodyreview
This weight, BMIconcluded that in terms of body mass index
or body composition. as an outcome, there
was good quality evidence that physical activity promotion in the school
11
setting was not effective in changing BMI.

The primary aim of this review was to examine the impact of increasing
physical activity rates and duration amongst school children. It found that
school-based physical activity interventions were effective in increasing
physical activity rates amongst adolescents but not in children.
This resulted in the inclusion of 3 new studies, plus 2 high quality studies from
their previous review. The two American studies from 2001 were criticised on
account of very poor quality. The third study from 2001 was a school-based
intervention in England. This was a better quality randomised study however,
it failed to show a significant change in BMI, SD scores or overweight/obesity
prevalence in the intervention group.

The two studies from the previous reviews were both large studies from the
USA, which had long-term follow-up results. Again, these were school-based
projects. The CATCH study showed no significant change in body mass
index at follow-up while the
4.1.3 Wareham et al Planet
(2005) Health group showed significant decreases
The most recent systematic review that considered the role of physical activity
in the prevalence of obesity, but in girls only.
in the prevention of obesity in children, was conducted by an Irish research
group in 2005.
These authors
This review concluded
was appraised that; “there
as being of moderate remains
quality, mainly serious
because of doubt as to the long-
term efficacy,
uncertainty clinical
over quality assessmentsignificance and generalisability
in relation to the primary studies. This of published
review only searched the literature from 2000 to 2004, which resulted in the
interventions inthat
inclusion of 11 studies this
had area”.
outcome measures of body weight or body
composition. It also looked at the literature regarding self-reported increases
in physical activity levels.

The majority of studies reviewed therein used the school setting (8). They
varied in who carried out the interventions, including parents, teachers and
trained personnel.

Of the eleven trials, only three showed a significant treatment effect in terms
of anthropometric measurements. Gender differences in the results were
indicated, with two of the three studies showing an effect only in boys.

Some of the other trials showed an improvement in physical activity levels but
these were not converted into improvements in body weight or composition.

The authors concluded that there was limited good quality data on which to
draw conclusions in the area of obesity prevention in children and
adolescents. However, they suggested that perhaps there was enough
evidence to indicate that school-based interventions may be more promising
than family-based trials.

12
There was one review that focused on the use of behavioural
interventions.
This was a UK review, conducted in 2000, that was considered only to
be of 4.2 Behavioural Interventions

moderate quality, again

4.2.1 Hardeman et albecause
(2000) of the lack of information regarding
the
quality assessment of the primary studies. The authors did however
carry out
a comprehensive search of eight databases from 1966 to 2000.

Hardeman et al found 11 studies that related to nine different

interventions;
seven of which were USA-based interventions. The studies varied in
terms of
their behavioural approaches, with 4 using the health education model,
2 the
behavioural model and 1 each of social learning theory and social
cognitive
theory. This was one of the reasons that a meta-analysis could not be
undertaken. 4.3 Seven
CombinedofApproaches
the studies used the school as their route of
intervention, while
4.3.1 the
Summerbell other 2 interventions were community-based.
et al (2005)
There was one systematic review that looked at all approaches to obesity
prevention in children and was conducted by the Cochrane Group. The initial
review, published in 2001 was then updated in 2005. This was the strongest
Out of these, 9 interventions were randomised controlled trials. All of
review in our included publications in terms of its quality.
the
These authors had s trict inclusion criteria and limited their search to studies
studies had objective measurements of body weight, BMI or body
published from 1990 onwards. All included studies had to have outcome
measures relating to the following: body weight/height, body fat percentage,
composition,
body mass index, ponderal andindex 7 ofskinfold
and/or themthickness.
also commented upon self-reported diet
and
They included 22 studies in their review and
up (i.e. greater than 12 months) and short-term follow-up (i.e. between 3 and
split them into long-term follow –

physical
12 activity
months) and included behaviours.
only randomised Only
controlled trials or controlledone
trials. of the RCTs showed a

significant
The effect
settings of theses interventions included school, community and clinic
bases and the intervention was delivered by a variety of personnel including
on weight.
teachers, researchers and trained individuals.

13
The review authors concluded that behavioural interventions were
variable in
nature and that the studies were generally of poor quality. In terms of
self-
reported eating and physical activity levels, the studies indicated
positive
The authors split the results into long and short-term outcomes and again into
dietary interventions, physical activity interventions, and combined
approaches.

Of the 10 long-term studies, two focused on Physical activity (PA), two

focused on diet and the other 6 focused on a combination of PA and diet. In
the long-term studies there was no treatment effect that could be attributed to
dietary interventions alone. In terms of physical activity, one study found a
significant effect on the BMI of girls, however, the other study in this group
similarly showed no effect.

Consideration of combined approaches of physical activity and diet together

was also disappointing, with 4 studies showing no treatment effect, although
one study had a significant effect on skin fold thickness, but not BMI. There
were no studies that compared dietary intervention to a PA intervention.

Of the 12 short-term studies, none considered diet alone. Four studies looked
physical activity, two of which showed significant effects on BMI; with one
of
these also showing an effect on skin fold thickness. The other eight studies
looked at the combination of diet and physical activity with no significant
positive results.

The authors of the review conclude that ov erall, the interventions to date
have
not impacted on the weight status of children and thus there needs to be
further high quality research to examine these
14
issues more fully.

The results with details of the interventions are tabulated in Table 2.

Table 2. Details of the included reviews
General Information and quality rating Details of Review Details of Interventions Outcome Measurements/Results
of each review
Hardeman et al (2000) Primary studies=11 Behavioural – 4 used health Primary: Weight
United Kingdom (9 interventions) 7 in children education model, 1 behavioural
BMI
model, 1 social learning theory and
Types 3 RCTs, 4 non-randomised 1 social cognitive theory. Skinfold
Secondary: thickness
self-reported Physical
Quality of Review=Moderatetrials. 2 were in adults (see above)
Delivery By – teachers activity
1. Search strategy comprehensive Search period=1966-2000
psychologistsResults
2. Quality assessment of primary studies
Number of databases searched = 8
Setting – community or school- No meta-analysis performed
Generalisability to Scotland
7 unclear
is Interventions conducted in USA based because of varied interventions and
settings
3. Adequate data to
2 Interventions support conclusions
conducted in Italy No significant differences in weight
2 Conducted with African American in any of the trials in children.

populations
Dobbins & Thomas (2001)
Canada
Quality of Review=Strong
1. Search strategy comprehensive
2. Adequate quality assessment of
3. Adequate data to
primary studies Numbersupport
of databases searched = 7
Primary studies = 19
Types - RCT or CCT
Search period=1985-2000
Physical Activity – involved Primary: BMI
printed educational materials,
Results:
altering of school curriculum, BMI reported in 11 studies
No meta-analysis performed
educational sessions, audio-visual
because of varied interventions and
Delivered By – teachers in 10,
materials
research staff inand
1 mass media.
settings

conclusions Not reported in 8 7 studies – showed no effect on

Setting – school BMI
3 studies – showed sig. effect in
both sexes - re BMI
1 study – showed sig. effect in boys

15
General Information and quality rating Details of Review Details of Interventions Outcome Measurements/Results
of each review
Generalisability to Scotland only - re BMI (p = 0.016)
13 studies conducted in USA Only 1 long term follow-up – no
with mixed ethnicity groups effect
(The nos above account for the 11
that considered BMI)
Wareham et al (2005) Primary studies = 11 Physical Activity – extra PE in weight
Primary
Ireland Body
schools, raising awarenessBody of composition
Quality of Review=ModerateTypes – RCTs or CCTs
television viewing times, altering
1. Search strategy – unclear therefore Secondary
Search period=2000 – 2004 school curriculum, familyPhysical activity or dietary changes
unable to establish if comprehensive
Delivered
informationby events,
teachersinternet
Results
2. Unclear quality assessmentNumber of primary
of databases searched –
not stated intervention,parents
dance lessons.
No meta analysis
studies 3 trials RCTs or CCTs Showed
Generalisability to Scotland nutritionist small intervention effect, 2 in boys
83.studies
Adequate conducted
data toinsupport
USA conclusions Setting - 8 school based only (p<0.001 and p=0.044)
2 studies conducted in England 1 parent based
2 community based Majority showed positive behaviour
1 study conducted in Chile changes, but no change in BMI.

Out of 11, 3 studies conducted in African

– American
Reilly populations
& McDowell (2002) Primary studies = 5 Physical Activity – information
Objective measurement of body
Scotland
Types – RCTs only available for 2 studies,
weight,
whichBMI or body composition
Quality of Review=Strong Results
1. Comprehensive search strategy – Search period = 1966 – 2002
both stated increasing physical
No meta-analysis
2. Good quality assessment of primary Number of databases searched = 5 activity and 1 of these 2 studies
2 studies were given negative
studies quality grading by Reilly &
3. Adequate data to support conclusions also increased the intensity of
McDowell
physical activity as well as
decreasing fat consumption in diet.
16
 General Information
Details of Review
and quality
Detailsrating
of Interventions Outcome Measurements/Results
of each review
2 studies showed nobydecrease
Delivered unclear in
Generalisability to Scotland
4 studies conducted in USA BMI
Setting 3 school-based
1 study conducted in England 1 study showed a significant
2 community-based

decrease in obesity prevalence in

girls only (p<0.05)
Primary Summerbell
studies – 22 et al (2005) Physical Activity – 3 x 30 mins
Weight/height
United Kingdom
Types – RCTs or CCTs PA/week, dance classes, 4 Body
x PA fat
Quality of the Review = Strong
1. Comprehensive search strategy –classes/week, increasing physical
Search period = 1990 – 2004
BMI
2. Excellent quality assessment of primary play,
Diet –increasing
decreasingPE,
fat,decreasing
Ponderal index
increasing Results
studies Number of databases searched = 5 video game usage Skinfold
fruit & vegetable intake, decreasing thickness No meta analysis
3. Adequate data to support conclusions
Generalisability to Scotland fizzy juice consumption. Long term outcome
16 conducted in USA Physical Activity + Diet – PA -no sig. effect
3 conducted in UK combinations of positive changes
Diet -noinsig. effect
1 conducted in Thailand
1 conducted in Chile diet and increasing physical activity of PA & diet –1
Combination
1 conducted in Germany levels via extra PE, dance showed
classes, sig. decrease in skinfold
walking to school. Some were thickness, 5 noShort
effect
term outcome
PA 2 no effect, 2 decrease BMI
based on increasing lifestyle Combination of PA & diet-8 showed
Delivered by – Teachers 5
exercise, whilst others usedno significant effect
Researchers
structured exercise 2
programmes.
Nutritionist 1
Trained 9
Unknown 5

17
 5. Discussion

The problem of overweight and obesity in children is an increased

threat to
the health of children in the industrialized world. Ironically both
obesity andfirst
This is the 5.1 Strengths
review of reviews to concentrate solely on children and
under
The
focusingnutrition
reviews hadaremixed
anthropometric in the top 10 conditions
conclusions;
outcomes. twoThe contributing
found that review
other to of
there was the Global
limited
reviews
burden
evidence ofto show that physical activity programmes resulted in an
concentrated
disease and some
improvement
on behaviour change,developing
in anthropometric
which does countries have the dual
measurements24,
not necessarily 26burden
equate whilst oftheboth.
to improvementsother
5.2 Weaknesses
This
one is only an overview. We were unable to generate an effect size
in
because
anthropometric
indicated measures
that there 27 ,28. evidence to suggest that school-based
was enough
of the lack ofwere
approaches meta-analyses
more promising in the original reviews.
than family Therefore,
based trials25.because
Since
of
exercise 5.3 Physical Activity
the limited
increases results
energy reporting theoretically
expenditure, only short-term
this benefits
should helpfrom treatment
to prevent a
studies
positiveinenergy imbalance and thus prevent weight gain.
this area the emphasis must be put on prevention.
All the reviews in this area have identified similar problems with the
quality of
the primary studies. While a large number of research studies have
been
carried out in this area, most of the studies are with small groups and
with
short-term and therefore inadequate follow-up periods. Furthermore,
the
methods of physical activity interventions are very heterogeneous,
which does
not make meta-analysis feasible.

One cannot therefore discount the benefits of physical

18 activity,
however high
quality research in this area is needed so that the issues can be
addressed
with reference to a sound evidence base.
Behavioural 5.4 interventions
Behavioural Interventions
were variable in nature and even
improvements in
behaviour did not result in a positive effect on weight. There was only
one 5.5 Combined Approaches
This
review in thisof area23
is the area most promise and againbut good
thequality trials studies
primary are againwere
in the very
minority.27
heterogeneous
and of poor quality. Consequently,
5.6 Previous Reviews of Reviews the results were are unconvinc ing.
There have been two other review of reviews that have sections on the
prevention of obesity in children.27, 28

The first was a Canadian rev iew looking at the effectiveness of school-based
strategies for the primary prevention of obesity and for the promoting of
physical activity and/or nutrition-the major modifiable risk factors for type II
diabetes 27.

These authors concluded that in most cases there was evidence to show that
multi-component interventions were more effective in modifying risk factors for
obesity, physical activity and nutrition than single component interventions.
They included reviews that only looked at behaviour change and not
necessarily in relation to a change in anthropometric measurement.

The other review of reviews was based on both adults and children28. These
authors concluded that there was limited high quality evidence to support the
use of family therapy or to support a reduction in sedentary behaviour on the
prevention of obesity in children. There was limited high quality evidence to
support school-based health promotion for the prevention of obesity in
children. School-based physical activity programmes were unlikely to be
effective for the prevention of obesity in children.

Finally, despite adopting more stringent inclusion criteria in our review it is

noteworthy that our conclusions are similar to the second review of reviews.

19
 6. Conclusions

6.1 Implications for Practice

Owing to a lack of high quality trials addressing some of the important
issues
raised, recommendations for practice are limited and remain tentative
thereby
suggesting that any interventions put in place should be thoroughly
6.2 Implications for Future Research
Many questions relating to the prevention of childhood obesity require further
evaluated.
research, including the use of a more sophisticated and stringent
Nonetheless, the evidence suggests that a global approach – including a
methodology, the additional inclusion of various population groups and the
variety of components
consideration of a wide varietyand settings, isthatmore
of interventions, likely
may have to succeed
an influence on than a
more
the environment and policy. Additionally, gender differences, in relation to
responsiveness
limited one. to prevention programmes, warrants further investigation.
In conclusion, as obesity is a product of social, economic, lifestyle and cultural
changes which require comprehensive, co-ordinated, multi-component
approaches to diet and physical activity over many years, the public health
evidence we seek is unlikely to come from randomised controlled trials,
thereby suggesting that other approaches to developing and evaluating public
health policies in relation to preventing childhood obesity are needed.29

20
APPENDICES

21
Appendix A: Medline Search Strategy
1. meta-analysis.pt.
2. (meta#analy$ or meta analy$).tw.
3. review academic.pt.
4. review tutorial.pt.
5. meta-analysis/
6. data extraction.ti,ab.
7. extract$ data.ti,ab.
8. review literature.pt.
9. guideline.pt.
10. practice guideline.pt.
11. (integrative research review$ or research integration).ti,ab.
12. quantitativ$ synthes$.ti,ab.
13. (pooling$ or pooled analys$ or mantel$ haenszel$).ti,ab.
14. (peto$ or der simonian$ or dersimonian$ or fixed effect$ or random

effect$).ti,ab.
15. ((systematic$ or quantitative$ or methodologic$) and (review$ or
overview$)).ti,ab.
16. exp review literature/
17. review.pt.
18. review of reported cases.pt.
19. review multicase.pt.
20. (meta anal$ or metaanal$).ti,ab.
21. or/1-20
22. exp Child/
23. (child$ or pediatric or paediatric).tw.
24. exp ADOLESCENT/
25. adolescen$.tw.
26. (preschool or pre-school or pre school).tw.
27. or/22-26
28. exp PRIMARY PREVENTION/
29. prevent$.tw.
30. (primary adj1 prevent$).tw.
31. or/28-30
32. exp OBESITY/ or exp OBESITY, MORBID/
33. overweight.tw.
34. (weight adj1 reduc$).tw.
35. (weight adj1 control$).tw.
36. (weight adj1 chang$).tw.
37. (weight adj5 maintain$).tw.
38. (body adj3 mass adj3 index adj chang$).tw.
39. (body adj3 mass adj3 index adj3 maintain$).tw.
40. or/32-39
41. 21 and 27 and 31 and 40
42. exp Skinfold Thickness/
43. exp Adipose Tissue/
44. (body adj1 fat).tw.
45. or/42-44
46. 21 and 27 and 31 and 45
47. 41 or 46

22
Appendix B: Quality Assessment Form

Yes No Unknown
Was Search Strategy for primary studies stated?
Was the search comprehensive?
Were the relevance criteria for the primary studies
described?
Crietria include: participants, interventions,
outcome, design

Was the quality(strengths and weaknesses) of the

primary studies assessed?
Did the quality assessment include:(minimum
requirement 3 from 6)
Study design
Study sample/population
Confounders
Intervention
Outcome measures
Follow-up

Does the review integrate findings beyond

describing or listing primary study results?

Is the reported data from all studies adequate to

support the reviewers conclusions?
Total Score

Quality rating

Strong (score 6-7) Moderate(score 4-5) Weak(<3)

23
Appendix C: Excluded studies with reasons

Authors Title Reference Reason for

Exclusion
Baronoski et School based obesity prevention Am J Health Behav Weak
al 2002; 26 (6):486-493 Quality
Batch et al Management and Prevention of Med J Aust 2005; Weak
obesity and its complications in 182(3):130-135 Quality
children and adolescents
Bautista et al Effectiveness of interventions in Eur J Epidemiol 2004; Not a
the prevention of childhood obesity 19(7): 617-622 systematic
review
Binns et al Guidelines help clinicians identify Paediatric Ann 2004; Not a
risk factors for overweight in 33(1): 18-22 systematic
children review
Broussard et Towards comprehensive obesity Obesity Res 1995;3 Not a
al prevention programs in Native Supp2:S289-297 systematic
American Communities review
Burrows et al Prevention and treatment of Rev Med Chil 2000; Not a
obesity since childhood 128(1) 105-110 systematic
review
Caballero et Obesity prevention in children: Int J Obes Relat Metab Not a
al opportunities & challenges Disord, 2004; 28 systematic
Supp3: S90-S95 review
Campbell et Intervention for preventing obesity Obesity Rev Weak
al in childhood: A systematic review 2001;2(3):149-157 Quality
Carlisle et al Can obesity prevention work for J La State Med Soc Not a
our children? 2005; 157 Spec No systematic
1:S34-S41 review
Caroli et al Role of Television in childhood Int J Obes relat Metab Weak
obesity prevention Disord 2004;28 Supp Quality
3:S104-S108
Carraro et al Role of prevention in the Eur Jour of Clin Nutr Not a
contention of the obesity epidemic 2003;57supp1:S94-S96 systematic
review
Daniels et al Overweight in children & Circulation Not a
adolescents:pathophysiology, 2005;111(15):1999- systematic
consequences, prevention & 2012 review
treatment
Dietz et al Preventing Obesity in children & Ann Rev Public Health Not a
adolescents 2001;22:337-353 systematic
review
Ells et al Prevention of childhood obesity Baillieres best Practice Based on
Res Clin Endocrinol other
Metab 2005;19(3):441- reviews
454
Elliot et al Paeidatric Obesity prevention and Minerva Paediatrica Not a
management 2004;56(3):265-276 systematic
Review
Flynn et al Fear of Fatness and adolescent Proc Nutr Soc Not a
girls:implications for obesity 1997;56:305-317 systematic
prevention review
Foreyt et al Primary Prevention of obesity in Ann NY Acad Sci Not a
Mexican-American children 1993;699:137-146 systematic
review
Fulton et al Interventions for weight loss and Sports med Weak
weight gain prevention among 2001;31(3):153-165 Quality
youth:current issues

24
Authors Title Reference Reason for
Exclusion
Gill Key issues in the prevention Br Med Bullet Not a
among youth 1997;53(2):359-388 systematic
review
Glenny et al The treatment & prevention of Int J Obes Relat Metab Weak quality
obesity:a systematic review of the Disorders
literature 1997;21(9):715-737
Golan et al Parents are key players in the Nutr Rev Not a
prevention & treatment of weight 2004;62(1):39-50 systematic
related problems review
Goran et al Role of Physical Activity in the Int J Obes Relat Metab Not a
prevention of obesity in children Disord systematic
1999;23Supp3:S18-33 review
Gutin et al Physical activity in the prevention Ann NY Acad Sci Not a
of childhood obesity 1993:699:115-126 systematic
review
Hassink Problems in childhood obesity Prim Care Not a
2003;30(2):357-374 systematic
review
Jerum et al Effectiveness of interventions to Ped Nursing Weak
prevent obesity related 2001;27(6):606-610 Quality
complications in children and
adolescents
Kiess et al Clinical Aspects of obesity in In J Obes Relat Metab Not a
Childhood and adolescence – Disord 2001;25 systematic
diagnosis, treatment & prevention supp1:S75-79 review
Koplan et al Preventing childhood J Am Diet Assoc Not a
obesity:health in the 2005;105(1):131-138 systematic
balance;executive summary review
Krebs et al Prevention of pediatric overweight Pediatrics 2003 Not
and obesity 112(2);424-430 systematic
Kumanyika et Pathways to obesity Obesity Res Not a
al prevention:report of a national 2003;11(10):1263-1274 systematic
institutes of health workshop review
Maffeis Prevention of Obesity in childhood J Endocrinol Ix Not a
2002;25(10):919-921 systematic
review
Magnusson Childhood Obesity; prevention, Commun Pract 2005 Not a
treatment and recommendations 78(4);147-149 systematic
for health review
Mascarenhas Nutrition Interventions in childhood Curr Opin Pediatr Treatment
et al for the prevention of chronic 1999;11(6):598-604 orientated
diseases in adulthood
Muller et al Prevention of Obesity – is it Obes Rev Not a
possible? 2001;2(1):15-28 systematic
review
Muller et al School and Family based Proc Nutr Soc Not
interventions to prevent overweight 2005;64(2):249-254 systematic
in children review
Nichol et al Preventing pediatric J Am Acad Nurse Pract Not a
obesity:assessment and 2002;14(2):55-62 systematic
management in the primary care review
setting
Phillipas et al Childhood obesity:etiology, Nutr Clin Care Not a
prevention and treatment 2005;8(2):77-88 systematic
review

25
Reilly et al Obesity:diagnosis, prevention and Arch Dis Childhood Not a
treatment 2002;86(6):392-394 systematic
review
Resnicow School Based Obesity Prevention Ann NY Acad Sci Weak
1993;699:154-166 Quality
Saris et al How much Physical activity is Obes Rev 2003 Not
enough to prevent unhealthy 4(2):101-114 systematic
weight gain
Scmitz et al Public Health interventions for the Med Clin North Am Not a
prevention and treatment of obesity 2000;84(2);491-512 systematic
review
Sothern et al Prevention of obesity in young Clin Pediat Not a
children:a critical challenge for 2003;42(2):491-512 systematic
medical professionals review
Sothern Prevention of Obesity in Nutrition 2004;20(7- Not a
children:physical activity and 8):704-8 systematic
nutrition review
Steinbeck The role of Physical Activity in the Obes Rev Not
prevention of overweight and 2001;2(2):117-130 systematic
obesity in childhood:a review and
an opinion
Story School Based approaches for Int J Obes Relat Metab Not a
preventing and treating obesity Disord systematic
1999;23supp2:S43-S51 review
Swinburn et Diet, nutrition and the prevention of Public Health Nutr Weak
al weight gain and obesity 2004 7(1A):123-146 Quality
Wilson et al The prevention and treatment of Qual Saf Health Care Based on
childhood obesity 2003;12(1):65-74 already
included
Cochrane
Review
Zwiauer Prevention and treatment of Eur J Pediatrics Not a
overweight and obesity in children 2000:159 supp1:S56- systematic
and adolescents S68 review

26
Appendix D: References
17 Bender R, Jockel KH, Trautner C, Spraul M, Berger M, Bender R. (1998)
Effect of age on excess mortality in obesity. Journal of the American Medical
1Association; 281S (2000)
Farooqi IS, O’Rahilly (16):Recent
1498-1504
Advances in the genetics of severe childhood
obesity. Archives of Disease in Childhood 2000; 83:31-34
18 Must A, Jacques PF, Dallal GE, Bajema CL, Dietz WH (1992) Long-term Morbidity
and Mortality
2 Hastings G etofal.
overweight
(2003) Review adolescents. A follow-up
of the research on the of effects
the Harvard Growth
of food Studytoof
promotion
1922-1935.
children: Food NEJM ; 327:1350-1355
Standards Agency.
19 French S, Story
3 Armstrong J, Reilly J. TeamM, Perry C TCHI
(1995)(2002)
Self esteem and obesity
Breastfeeding andin childrenthe
lowering andrisk of
adolescents:
childhood obesity. a literature review.; Obesity
The Lancet Research ; 3 (5): 479-490
359:2003-2004
20 Edmunds
4 von Kries R, l, Waters
Koletzko E,B, Elliot EJ (2001)
Sauerwald Evidence
T, von MutiusBased Paediatrics:
E, Barnert Evidence
D, Grunert V. (1999)
based
Breastmanagement
feeding and obesity:of childhoodcrossobesity.
sectionalBritish
study.Medical Journal ;Journal;
British Medical 323(7318):916-
319:147-
919
150
21 WangJ,G,
5 Reilly Dietz W
Dorosty A (2002)
(1999) Economic
Epidemic of burden
obesity of in
obesity in youthsThe
UK children. aged 6 to 17 years:
Lancet;
1979-1999.
354:1874-1875 Pediatrics; 109(5): E81-1
22 Hardeman
6 Molnar W, Griffin S,
D, Livingstone Johnston
B (2000) M, Kinmonth
Physical activity AL, Wareham
in relation NJ, Hardeman
to overweight and W
(2000)
obesityInterventions
in children and to adolescents.
prevent weight gain: a Journal
European systematic review of psychological
of Paediatrics; 159 (Suppl
models
1):S45-S55 and behaviour change methods. International Journal of Obesity; 24:131-143
723Bloomgardden
Dobbins M, Thomas Z (2002)H (2001)
New sights The Effectiveness
in obesity. Diabetes of Care;
School 25Based Interventions in
(4):789-795
Promoting Physical Activity and Fitness among Children and Youth: A Systematic
8Review.
ScottishEffective
Health SurveyPublic 2003. VolPractice
Health 3 Children. Healthier Scotland, Scottish Executive
Project
24 WarehamAN,
9 Tedstone van Sluijs
(1998) EMF, Ekelund
Effectiveness U (2005) to
of interventions Physical
promote Activity
healthyand obesity
eating in a
prevention:a
preschool children reviewaged of the1 tocurrent
5 years: evidence.
a review. Proceedings of the Nutrition
Health Education Authority.Society; 64:
229-247
Effectiveness review no. 10
25
10 Reilly
Gill TPJ,(1997)
McDowell Z (2003)
Key Issues Physical
in the activity
prevention of in the prevention
obesity. and treatment
British Medical Bulletin;of 53
paediatric
(2):359-388 obesity:systematic review and critical appraisal. Proceedings of the
Nutrition
11 Caballero Society;62
B (2001) (3):611-619
Symposium: Obesity in Developing Countries: Biological and
26 Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, Waters E (2005)
Ecological factors. American Society for Nutritional Sciences; S866-S870
Interventions for preventing obesity in children. The Cochrane Database of
12 Pinhas-Hamiel
Systematic Reviews, O, Issue
Zeitler3 P (2000) “Who is the Wise Man? – The One who
Foresees
27 Miccuci Consequences”
S, Thomas H,Childhood Vohra J (2002) Obesity,TheNew associatedofcomorbidity
effectiveness school basedand strategies
prevention.
for the primary Preventative
prevention Medicine;31:702-705
of obesity and for promoting physical activity and/or
13
nutrition, the major modifiable 2002:
Topic of the Month: March Obesity forintype
Children. Directorate ofof
Information
risk factors 2 diabetes: a review reviews.
and Clinical Effectiveness.
Ontario: Canadian Effective Public Health Practice Project
2814Mulvihill
Campbell K, RWales
C, Quigley (2003) AE, O’meara
review S, Summerbell
of the systematic C (2001) Intervention for
review and meta-analysis
literature on the prevention and treatment of obesity and overweight, and the
Preventing
maintenance obesity
of weight in Childhood:
loss. Health A systematic
Development Agency, London. Review. Obesity Reviews; 2:149-157
15 Peeters A, Barendregt JJ, Willekens F, Mackenbach JP, Al Mamun A, Bonneux L
(2003). Obesity in adulthood and its consequences for life expectancy: A Life table
analysis. Annals of internal Medicine ;138(1):24-32
16 Barlow C, Kohl H, Gibbons L, Blair S (1995) Physical Fitness, mortality and
obesity. International Journal of Obesity; 19 (Suppl 4):S41-S44

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