Background: Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school. Objectives: The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are:. • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents;. • to evaluate the effects of school-based interventions on improving body composition; and. • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population. Search methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information. Selection criteria: Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update. Data collection and analysis: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type. Main results: Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias. Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events. Authors' conclusions: Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.
OBJECTIVES: Obesity has been identified as an important risk factor for cardiovascular disease and other chronic diseases. However, dietary treatment of obesity is far from being a closed issue. Therefore, it is critical to identify the most appropriate obesity management approaches. The aim of this review was to summarize the effects, potentialities, and limitations of nutritional interventions aimed at managing obesity in primary and secondary health care settings, highlighting the most effective strategies and theories.
METHODS: This systematic review of randomized controlled trials evaluated nutritional interventions aimed at achieving weight loss in primary and secondary health care patients. All screening and extraction processes were conducted according to PRISMA.
RESULTS: From an initial 7816 studies that were identified, 28 met the criteria and were included in the review. Most studies were conducted in a developed country in primary care, with a higher proportion of women. Most of the nutrition interventions maintained continuous contacts during follow-up, and telephone calls were the most commonly used technology. A physical activity component was included in most studies, and the most common dietary approaches used were energy restrictions, changes in macronutrient distribution, and diet self-monitoring. Regarding theories, interventions mainly incorporated Social Cognitive Theory and Motivational Interviewing. Most trials presented significant and moderate weight loss (~5%), in which the key contributors were behavioral theories, the dietary approach of calorie restriction, and interventions delivered by dietitians and psychologists.
CONCLUSIONS: Most trials presented better weight loss results with the association of calorie restrictions and theory-based interventions delivered by dietitians or psychologists. We identified the need to develop interventions in other contexts, such as low- and middle-income countries; further trials comparing a theory- versus not-theory-driven intervention; group-based versus individually based intervention; and intervention using or not using technology.
EDITORIAL NOTE: This Cochrane review is now out of date and should not be used for reference. It has been split into four age groups and updated. Please refer to the 5‐11 and 12‐18 age group Cochrane reviews which were published in May 2024: https://doi.org/10.1002/14651858.CD015328.pub2 https://doi.org/10.1002/14651858.CD015330.pub2 The 2‐4 age group Cochrane review is planned for publication in September 2024.
BACKGROUND: Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.
OBJECTIVES: To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.
SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.
SELECTION CRITERIA: Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.
DATA COLLECTION AND ANALYSIS: Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.
MAIN RESULTS: We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.
AUTHORS' CONCLUSIONS: Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.
BACKGROUND: Many weight‐loss interventions are delivered in groups but evidence on their effectiveness, and characteristics associated with effectiveness, is limited. We synthesised evidence on (1) design and delivery of group‐based weight‐loss interventions; (2) effectiveness; and (3) associations between intervention characteristics, change techniques, and effectiveness. METHODS: Five online databases were searched to May 2017 for randomised controlled trials (RCTs) of group‐based diet and/or physical activity interventions for overweight/obese adults (BMI ≥ 25). Intervention characteristics were synthesised narratively. Mean differences (MD) in weight loss were calculated using a random‐effects meta‐analysis, and sub‐group analyses were conducted to identify moderators of effectiveness. RESULTS: Forty‐seven RCTs reporting 60 evaluations of group‐based interventions were included. MD in weight loss between intervention and control groups was −3.49 [95% CI −4.15, −2.84], −3.44 [−4.23, −2.85], and −2.56 kg [−3.79, −1.33] at follow‐ups closest to 6, 12, and 24 months, respectively. Explicitly targeting weight loss, men‐only groups providing feedback and dietary goals were significantly associated with greater effectiveness (<i>p</i> < .05). CONCLUSIONS: Diet and physical activity interventions delivered in groups are effective in promoting clinically meaningful weight loss at 12 months. Intervention design and effectiveness vary considerably between studies, and evidence on what optimises the effectiveness of group‐based weight‐loss interventions remains limited. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
AIM OR OBJECTIVE: To evaluate the effectiveness of behavioural interventions that report sedentary behaviour outcomes during early childhood.
DESIGN: Systematic review and meta-analysis.
DATA SOURCES: Academic Search Complete, CINAHL Complete, Global Health, MEDLINE Complete, PsycINFO, SPORTDiscus with Full Text and EMBASE electronic databases were searched in March 2016.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Inclusion criteria were: (1) published in a peer-reviewed English language journal; (2) sedentary behaviour outcomes reported; (3) randomised controlled trial (RCT) study design; and (4) participants were children with a mean age of ≤5.9 years and not yet attending primary/elementary school at postintervention.
RESULTS: 31 studies were included in the systematic review and 17 studies in the meta-analysis. The overall mean difference in screen time outcomes between groups was -17.12 (95% CI -28.82 to -5.42) min/day with a significant overall intervention effect (Z=2.87, p=0.004). The overall mean difference in sedentary time between groups was -18.91 (95% CI -33.31 to -4.51) min/day with a significant overall intervention effect (Z=2.57, p=0.01). Subgroup analyses suggest that for screen time, interventions of ≥6 months duration and those conducted in a community-based setting are most effective. For sedentary time, interventions targeting physical activity (and reporting changes in sedentary time) are more effective than those directly targeting sedentary time.
SUMMARY/CONCLUSIONS: Despite heterogeneity in study methods and results, overall interventions to reduce sedentary behaviour in early childhood show significant reductions, suggesting that this may be an opportune time to intervene.
TRIAL REGISTRATION NUMBER: CRD42015017090.
BACKGROUND: School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear.
OBJECTIVE: To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children.
METHODS: We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children's dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg's and Egger's test evaluated potential publication bias.
RESULTS: From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified.
CONCLUSIONS: Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.
OBJECTIVE: We conducted this systematic review to support the U.S. Preventive Services Task Force (USPSTF) in updating its 2012 recommendation on screening for and treatment of adult obesity. Our review addressed three key questions: 1) Do primary care–relevant behavioral and/or pharmacotherapy weight loss and weight loss maintenance interventions lead to improved health outcomes among adults who are overweight or have obesity and are a candidate for weight loss interventions? 2) Do primary care–relevant behavioral and/or pharmacotherapy weight loss and weight loss maintenance interventions lead to weight loss, weight loss maintenance, or a reduction in the incidence or prevalence of obesity-related conditions among adults who are overweight or have obesity and are a candidate for weight loss interventions? 3) What are the adverse effects of primary care–relevant behavioral and/or pharmacotherapy weight loss and weight loss maintenance interventions in adults who are overweight or have obesity and are a candidate for weight loss interventions?
DATA SOURCES: We performed a search of MEDLINE, PubMed Publisher-Supplied, PsycINFO, and the Cochrane Central Registry of Controlled Trials for studies published through June 6, 2017. Studies included in the 2011 USPSTF review were re-evaluated for potential inclusion. We supplemented searches by examining reference lists from related articles and expert recommendations and searched federal and international trial registries for ongoing trials. We conducted ongoing surveillance through March 23, 2018 to identify any major studies published in the interim.
STUDY SELECTION: Two researchers reviewed 15,483 titles and abstracts and 572 full-text articles against prespecified inclusion criteria. Eligible studies were those that focused on weight loss in adults who are overweight or have obesity, or maintenance of previous weight loss. Trials among populations selected based on the presence of a chronic disease in which weight loss or maintenance is part of disease management (e.g., known cardiovascular disease, type 2 diabetes) were excluded. Studies included for health and intermediate outcomes (including weight loss) were randomized or clinically controlled trials that report data at least 12 months following the start of the intervention. In addition, for studies of potential harms of interventions we included large cohort, case-control, or event monitoring studies in addition to trials with fewer than 12 months of followup. Included interventions were those conducted in or recruited from primary care or a health care system or were judged to be feasible for implementation or referral from primary care and included behavior-based interventions as well as five U.S. Food and Drug Administration–approved medications for long-term chronic weight management (liraglutide, lorcaserin, naltrexone and bupropion, orlistat, and phentermine-topiramate). Studies of surgical and nonsurgical weight loss devices and procedures were excluded. We conducted dual, independent critical appraisal of all provisionally included studies and abstracted all important study details and results from all studies rated fair or good quality. Data were abstracted by one reviewer and confirmed by another.
DATA ANALYSIS: We synthesized data for behavior- and medication-based weight loss and weight loss maintenance interventions separately. Health outcomes and harms were sparsely reported and the specific outcomes measured differed across trials, precluding meta-analysis, so we summarized those data in tables and narratively. For weight loss outcomes related to behavior-based weight loss interventions, we ran random-effects meta-analyses using the DerSimonian and Laird method to calculate the pooled differences in mean changes (for continuous data) and pooled risk ratio (for binary data). We examined statistical heterogeneity among the pooled studies using standard χ2 tests and estimated the proportion of total variability in point estimates using the I2 statistic. Meta-regression was used to explore potential effect modification by various study, population, and intervention characteristics. We generated funnel plots and conducted tests for small-study effects for all pooled analyses. Meta-analysis of the medication trials was not performed due to the small number of included trials and inconsistency in outcome reporting; therefore, results from these trials were summarized narratively and in illustrative forest plots. Using established methods, we assessed the strength of evidence for each question.
RESULTS: We included 124 studies that were reported in 238 publications. We carried forward 41 studies from our previous review and 83 new studies were added. Of the 124 included studies, 89 trials focused on behavior-based weight loss (80 trials) or weight loss maintenance (nine trials) interventions. Thirty-five studies addressed medications for weight loss (32 studies) or weight loss maintenance (three trials). The majority of trials took place in the United States. Over half (73 trials) represented a general, unselected population of adults who were eligible for participation based on being overweight or having obesity; the remaining trials specifically enrolled participants who were also at elevated clinical or subclinical risk of cardiovascular disease or cancer. The mean baseline body mass index ranged from 25 to 42 kg/m2 and mean age ranged from 22 to 66 years. Eleven trials focused on specific racial/ethnic groups (African American, Asians and South Asians, American Indian, or those of Hispanic ethnicity). In the remaining trials, race/ethnicity and socioeconomic status were not well reported and when described, the majority of participants were white, with medium to high socioeconomic status. The behavior-based interventions were highly variable across the included trials in terms of the modes of delivery, number of sessions and contacts, and interventionists. Across the 120 intervention arms, the primary mode of intervention delivery was: group based (41 arms), individual-based (37 arms), technology-based (22 arms), “mixed” (18 arms), or print only (two arms). Twenty-three interventions included interaction with a primary care provider. The 41 medication-based studies addressed: liraglutide (four trials), lorcaserin (four trials), naltrexone and bupropion (three trials), orlistat (19 trials, two observational studies), and phentermine-topiramate (three trials).HEALTH OUTCOMES: Health outcomes were minimally reported in the behavior-based weight loss and maintenance trials (k=20; n=9910). In four weight loss trials (n=4442) reporting mortality, there were no significant differences between groups over 2 to 16 years. Two weight loss trials (n=2666) reported on cardiovascular events, with neither finding differences between groups over 3 and 10 years, respectively. Health-related quality of life (QOL) was evaluated in 17 weight loss and maintenance trials (n=7120), with almost all showing no differences between groups. Trials of medication-based weight loss interventions examined few health outcomes beyond QOL (k=10; n=13,145). Although most studies showed evidence of a greater improvement in obesity-specific QOL among those on medication compared with placebo, the differences were small and of unclear clinical significance. In addition, interpretation of these finding was limited given high study dropout rates (≥35% in half the included trials). Two medication-based trials (n=6210) examined cardiovascular events, finding few events in any group. None of the medication-based maintenance trials reported the effects of the interventions on health outcomes. WEIGHT OUTCOMES: Pooled results of 67 behavior-based weight loss trials indicated greater weight loss from interventions compared to control conditions at 12 to 18 months (mean difference in weight change [MD], −2.39 kg [−5.3 lb] [95% CI, −2.86 to −1.93]; k=67; n=22,065; I2=90.0%). Mean absolute changes in weight ranged from −0.5 kg (−1.1 lb) to −9.3 kg (−20.5 lb) among intervention participants and from 1.4 kg (3.0 lb) to −5.6 (−12.3 lb) among control participants. Weight change at followup beyond 12 to 18 months was not as well reported but effects were consistent with short-term weight loss, although generally attenuated, over time. A meta-analysis of 38 trials found that intervention participants had a 1.94 times greater probability of losing 5 percent of their initial weight compared with control groups over 12 to 18 months (risk ratio [RR], 1.94 [95% CI, 1.70 to 2.22]; k=38; n=12,231; I2=67.2%), which translated into a number needed to treat of 8. Among the majority of trials of behavior-based weight loss maintenance interventions, both intervention and control participants regained weight over 12 to 18 months of maintenance; however, the intervention participants experienced less weight regain (pooled MD, −1.59 kg [−3.5 lb] [95% CI, −2.38 to −0.79]; k=8; n=1408; I2=26.8%). Among 32 medication-based weight loss trials, those randomized to medications experienced greater weight loss compared to those on placebo at 12 to 18 months (mean/least squares mean [LSM] MD ranged from −1.0 kg [−2.2 lb] to −5.8 kg [−12.8 lb]; no meta-analysis conducted). Absolute changes in weight ranged from mean/LSM of −3.3 kg (−7.3 lb) to −10.5 kg (−23.4 lb) among medication participants compared to −0.9 kg (−2.0 lb) to −7.6 kg (−16.8 lb) among placebo participants over 12 to 18 months. Medication participants had a 1.2 to 3.9 times greater probability of losing 5 percent of their initial weight compared with placebo participants over 12 to 18 months. Three medication-based trials indicate greater weight maintenance in medication than placebo participants over 12 to 36 months (MD ranged from −0.6 to −3.5; no meta-analysis conducted). INTERMEDIATE OUTCOMES: Thirteen trials (n=4095) examined incident diabetes among those in behavior-based interventions compared to control conditions. Absolute cumulative incidence of diabetes at up to 3 years of followup ranged from 0 to 15 percent in the intervention group and 0 to 29 percent in controls. The DPP and Finnish DPS trials found statistically significant lower incidences of developing diabetes at 3 to 9 years; no other trial found differences between groups. However, these trials generally had smaller sample sizes and shorter followup. The pooled relative risk of developing incident diabetes was 0.67 (95% CI, 0.51 to 0.89; k=9; n=3140; I2=49.2%). Four trials of weight loss medications (three weight loss and one maintenance trial) examined incident diabetes. Absolute cumulative incidence of diabetes at up to 4 years of followup ranged from 0 to 6 percent in medication arms and 1 to 11 percent in placebo arms; between-group differences were statistically different in most medication trials. Prevalence of hypertension, metabolic syndrome, use of CVD medications, and estimated 10-year risk of CVD were sparsely reported. There was limited evidence from larger trials that those in behavior-based weight loss arms had reduced prevalence of hypertension and use of CVD medications compared to control conditions; data were limited and mixed for metabolic syndrome and 10-year CVD risk. Four medication trials reported on use of lipid-lowering and antihypertensive medications, prevalence of metabolic syndrome, and 10-year CVD risk score with mixed results. ADVERSE EVENTS: There were no serious harms related to the behavior-based interventions and most trials noted no differences between groups in the rates of adverse events, including cardiovascular events. In the three behavior-based trials large enough to examine musculoskeletal issues between groups, results were mixed. Although serious adverse events were relatively uncommon in medication trials and generally similar between groups, adverse event rates were high in both groups by 12 months, with 80 to 96 percent experiencing an adverse event in the medication arms compared with 63 to 94 percent in the placebo arms. The higher rates of adverse events in the medication arms resulted in higher dropout rates than in the placebo arms.
CONCLUSION: We found that behavior-based weight-loss interventions with or without weight loss medications resulted in more weight loss than usual care conditions. The degree of weight loss we observed with the behavior-based weight loss interventions in the current review is slightly smaller but consistent in magnitude with our 2011 review on this topic. As in the previous review, we noted that weight loss interventions resulted in a decreased risk of developing diabetes, particularly among those with prediabetes, although the prevalence of other intermediate health outcomes was less well reported. Limited evidence exists regarding health outcomes associated with weight loss interventions. Weight loss medications, but not behavior-based interventions, were associated with higher rates of harms compared with control arms. Heterogeneity within each individual intervention arm confounded with differences in the populations, settings, and trial quality, making it difficult to disentangle which variables may be driving larger effects. Long-term weight and health outcomes data, as well as data on important subgroups (e.g. those who are older, nonwhite, or overweight) were lacking and should be a high priority for future study.
BACKGROUND: Treatment of childhood obesity is important in preventing development of obesity-related diseases later in life. This systematic review evaluates the effect of multicomponent lifestyle interventions for children and adolescents from 2 to 18 years.
METHODS AND RESULTS: We performed systematic searches in nine databases. Thirty-nine studies met the criteria for meta-analyses. We found a significant difference in body mass index (BMI) after 6 months (MD -0.99 (95% CI -1.36 to -0.61)), 12 months (MD -0.67 (95% CI -1.01 to -0.32)), and 24 months (MD -0.96 (95% CI -1.63 to -0.29)) in favour of multicomponent lifestyle interventions compared to standard, minimal, and no treatment. We also found a significant difference in BMI Z scores after 6 months (MD -0.12 (95% CI -0.17 to -0.06)), 12 months (MD -0.16 (95% CI -0.21 to -0.11)), and 24 months (MD -0.16 (95% CI -0.21 to -0.10)) in favour of multicomponent lifestyle interventions. Subgroup analyses suggested an increased effect in specialist health care with a group treatment component included in the intervention.
CONCLUSION: Multicomponent lifestyle interventions have a moderate effect on change in BMI and BMI Z score after 6, 12, and 24 months compared with standard, minimal, and no treatment.
INTRODUCTION: Social marketing is a promising planning approach for influencing voluntary lifestyle behaviours, but its application to nutrition and physical activity interventions in the early care and education setting remains unknown.
METHODS: PubMed, ISI Web of Science, PsycInfo and the Cumulative Index of Nursing and Allied Health were systematically searched to identify interventions targeting nutrition and/or physical activity behaviours of children enrolled in early care centres between 1994 and 2016. Content analysis methods were used to capture information reflecting eight social marketing benchmark criteria.
RESULTS: The review included 135 articles representing 77 interventions. Two interventions incorporated all eight benchmark criteria, but the majority included fewer than four. Each intervention included behaviour and methods mix criteria, and more than half identified audience segments. Only one-third of interventions incorporated customer orientation, theory, exchange and insight. Only six interventions addressed competing behaviours. We did not find statistical significance for the effectiveness of interventions on child-level diet, physical activity or anthropometric outcomes based on the number of benchmark criteria used.
CONCLUSION: This review highlights opportunities to apply social marketing to obesity prevention interventions in early care centres. Social marketing could be an important strategy for early childhood obesity prevention efforts, and future research investigations into its effects are warranted.
