Effectiveness of Interventions in the Prevention of Childhood Obesity

Abstract

The prevalence of childhood obesity, as with that of adulthood, has increased considerably over the past few years and has become a serious public health problem. Once established, its treatment is very difficult and, hence, prevention of childhood obesity using different types of intervention appears promising. The objective of this present report is to review interventions that had been conducted over the past 11 years in the environment of the family, schools and community, and directed towards the prevention of childhood obesity. We reviewed the different strategies employed, the different criteria used in defining weight status, the evaluation and follow-up methods, and the degree of effectiveness.
Benefits other than reduced weight gain were assessed, as well. In our review, we selected 14 intervention studies. The differences in design, duration and outcome assessments make direct comparison difficult. Nevertheless, it seems that nutritional education and promotion of physical activity together with behaviour modifications, decrease in sedentary activities and the collaboration of the family could be the determining factors in the prevention of childhood obesity. Other important benefits regarding healthy habits apart from the changes in weight status were pursued in the majority of the studies reviewed. The need for well-designed studies that examine a range of interventions remains a priority.

Full text

REVIEW
Effectiveness of interventions in the prevention of childhood obesity
Inmaculada Bautista-Castan
˜o, Jorge Doreste & Lluis Serra-Majem
A
´rea de Medicina Preventiva y Salud Pu
´blica, Departamento de Ciencias Clı´nicas, Universidad de Las Palmas de Gran
Canaria, Spain
Abstract. The prevalence of childhood obesity, as with
that of adulthood, has increased considerably over the
past few years and has become a serious public health
problem. Once established, its treatment is very diffi-
cult and, hence, prevention of childhood obesity using
different types of intervention appears promising. The
objective of this present report is to review interven-
tions that had been conducted over the past 11 years in
the environment of the family, schools and commu-
nity, and directed towards the prevention of childhood
obesity. We reviewed the different strategies employed,
the different criteria used in defining weight status, the
evaluation and follow-up methods, and the degree of
effectiveness.
Benefits other than reduced weight gain were as-
sessed, as well. In our review, we selected 14 inter-
vention studies. The differences in design, duration
and outcome assessments make direct comparison
difficult. Nevertheless, it seems that nutritional edu-
cation and promotion of physical activity together
with behaviour modifications, decrease in sedentary
activities and the collaboration of the family could be
the determining factors in the prevention of child-
hood obesity. Other important benefits regarding
healthy habits apart from the changes in weight sta-
tus were pursued in the majority of the studies re-
viewed. The need for well-designed studies that
examine a range of interventions remains a priority.
Key words: Childhood obesity, Life-style modification, Nutritional education, Parental involvement, Physical
activity, School-meals
Introduction
Obesity in infancy and adolescence has increased
alarmingly over the past few years in developed coun-
tries [1–4] and has become a serious public health
problem [5]. Further, obesity in youth presents char-
acteristics that are different from those of the adult-
hood. The added difficulty is not only its prevention,
but also its treatment. One of these difficulties is the
lack of consensus diagnostic criteria [6–9] which makes
comparisons of prevalence between different countries
difficult. The long-term clinical evolution and compar-
isons of efficacy between the different therapeutic
interventions and preventions are also complicated by
the use of different cut-off points in the definition of
obesity, together with different anthropometric refer-
ence parameters. Also, dietary interventions during in-
fancy and adolescence should be administered with
caution since one is dealing with important periods of
growth and maturation which include not only physical
but psychological changes as well and, as such, nutri-
tional deficits can rebound negatively on the subsequent
physical development of the child and adolescent [10].
The results could be poor dietary behaviour which is of
considerable importance in these stages of growth [11].
Another difficulty is that, because of the lack of indi-
vidual autonomy in childhood, applying preventive and
therapeutic measures to combat infant-juvenile obesity
depends on the collaboration of the family and, in
many cases, on the school environment where the child
spends the greater part of his time.
All these circumstances could help explain the
observation that the majority of the treatments avail-
able for infant-juvenile obesity have achieved only
modest results and are barely maintainable over long
periods of time. Further, there are not many studies
that have investigated the efficacy of the measures of
prevention in these early ages of development [12, 13].
The consequences of childhood obesity are very
considerable and pervasive and, as such, ought to be
made an international public health priority [14, 15].
However, the numbers of studies that have evaluated
the effectiveness of different strategies are few. Hence,
the objective of this present report was to review the
interventions conducted over the past 11 years. The
published studies included were those conducted not
only in the school environment but also in the family
or community. The interventions involved nutritional
education, physical activity, behaviour modification
together with collaboration of the parents and inter-
vention in the school dining facilities; all of which
were directed towards the prevention of the child’s
excessive weight gain. The studies had explored a
variety of intervention strategies, of criteria for
defining obesity, of methods of follow-up and of
evaluating the degree of effectiveness.
Literature search and methods
To identify articles of interest in the evaluation of
interventions to prevent infant-juvenile obesity, we
conducted a Medline (National Library of Medicine)
European Journal of Epidemiology 19: 617–622, 2004.
Ó2004 Kluwer Academic Publishers. Printed in the Netherlands.

search of original articles published between January
1993 and December 2003. Further, we performed a
review of all the specialist journals in associated areas
(paediatrics, internal medicine, public health, family
and general medicine) and secondary journals in-
volved in dissemination of evidence (ACP Journal
Club, Evidence-based Medicine, Clinical Evidence,
Bandolier) available physically, or electronically, in
the libraries of our Institutions (Hospital Insular,
Hospital Materno-Infantil and Hospital Dr. Negrı
´n)
in the Gran Canaria (Canary Islands) as well as those
in the Faculty of Health Sciences of the Universidad
de Las Palmas de Gran Canaria and of the Hospital
Clinic de la Universitat de Barcelona.
Search terms used were ‘‘obesity’’, ‘‘children’’,
‘‘childhood’’, ‘‘prevention’’ singly and in combina-
tion (‘‘childhood and obesity’’, ‘‘childhood and/or
obesity and prevention’’). The age criterion was
0–18 years. Journal languages were English, Spanish,
Italian and Portuguese, and the studies needed to
have been conducted in humans. The following
selection criteria were applied:
(1) Type of participants: Populations of between 0
and 18 years of age.
(2) Types of intervention: Prevention interventions
published between 1993 and 2003, that deal with
the effects on ponderal status.
(3) Type of study: Randomised controlled trials, and
non-randomised intervention studies but with con-
trol groups, observed for a minimum of 12 weeks.
Data were synthesised narratively.
Results
We encountered 16 interventional studies comparing
different interventions in the prevention of childhood
obesity. From these, two were discarded [16, 17] be-
cause of a lack of a control group in the study design.
Table 1 summarises the remaining 14 studies that
fulfilled our selection criteria listed in order of length
of follow-up. Of these, 12 were conducted within the
environment of the school [18–29] and two were in
the community [30, 31].
Three of the studies [29–31] had between 50 and
100 subjects, six [20–22, 24, 26–28] between 100 and
500, one [25] between 500 and 1000 and the remaining
four [18, 19, 22, 23] had more than 1000 subjects.
The majority of the studies were conducted in the USA,
one each in Germany [24], and the UK [25] with one study
[28] conducted in an Asian country (Thailand).
The length of follow-up was very variable, and this
made between-study comparisons difficult. Two of
the studies were for a period of follow-up of 3 years
[18, 19], four for 2 years [20–23], five for between
7 months and 1 year [24–28], and the three shortest
were for 3 months [29–31].
Of the 14 interventions reviewed, 10 were interven-
tions of general type (all in the school environment)
and 4 were interventions in high-risk populations, ra-
cial US groups: American Indians [19], African-
Americans [30, 31] and Hispanic and Afro-American
[29] children. All the studies were randomised con-
trolled trials, usually with the school as the unit of
randomisation, intervention and analysis, or the
school-classes [28, 29], except for the study of Stolley
et al. [30, mother–daughter dyads], the study of Rob-
inson et al [31, individuals randomisation] and the
study of Mu
¨ller et al. [24, randomised school inter-
vention, but non-randomised family intervention].
The most common variables used to evaluate effi-
cacy of the interventions were body mass index
(BMI), measurements of the skin-folds and percent-
age of body fat mass. The measurements were
conducted during the course of the follow-up or at
open-end of the study to evaluate changes (absolute
or percentage) relative to baseline values.
In some studies, the changes in abdominal fat
distribution were measured as the waist measurement
or as the waist–hip ratio. Additionally, prevalence of
overweight and/or obesity were compared in some
studies, but using different criteria for their definition.
Apart from these limitations, we evaluated the studies
on the basis of having adjusted for confounding
variables such as age, gender, initial value of the
variables, maturation stage, etc.
Effectiveness of the interventions in the prevention
of excessive weight gain
The strategies of intervention that had been employed
included nutritional education, behaviour modifications,
promotion of greater physical activity, parental partici-
pation, modification of school meal content and, in the
majority of studies, a combination of these factors.
Studies that included nutritional education
and physical activity
There were nine studies which had used these strate-
gies in the prevention of obesity [18, 19, 21, 22, 24, 25,
27, 29, 30]. The three interventions that did show an
effect, in boys as well as in girls [24] or in girls alone [22,
29], combined, as well, a life-style habit modification.
Gortmaker et al. [22] designed, under the name of
‘‘Planet Health’’, a program lasting 2 school-years
which was directed towards reducing the hours spent
watching television and the consumption of food items
rich in saturated fats. This was combined with advice
to increase the consumption of fruits and vegetables
and to increase the amount of physical activity, whe-
ther moderate or intense. The efficacy was evaluated
by comparing the prevalence of obesity in the inter-
vention groups versus the control. The evaluation was
an indicator derived from BMI and triceps skin-fold
>85th percentile for age and gender. Also, the chan-
ges were adjusted for the initial level of obesity. At the
end of the intervention, there was a decrease in the
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Table 1. Intervention studies (1993–2003) in the prevention of childhood obesity
Intervention components
Study Duration N Age Intervention NE BM PA PI SFI Obesity prevention evaluation Effective
Luepker et al., 1996 [18] 3 years 4019 8.7 School X X X Changes in BMI, TS and SS after adjustment for
baseline values, gender, age, race and school random
effect
No
Caballero et al., 2003 [19] 3 years 1704 7.6 School X X X X X Changes in BMI, TS, SS and percentage fat mass No
Sallis et al., 1993 [20] 2 years 305 9.25 School X Changes in BMI, TS, SS adjusted for gender and
baseline values
No
Donnelly et al., 1996 [21] 2 years 338 9.2 School X X X Changes in BMI and percentage fat mass No
Gortmaker et al., 1999 [22] 2 years 1295 11.7 School X X X Prevalence, incidence and remission of obesity;
(85
th
percentile)
Girls only
Sallis et al., 2003 [23] 2 years 1109 ¿–? School X X X Changes in BMI Boys only
Mu
¨ller et al., 2001 [24] 1 year 297 5–7 School X X X X Changes in TS and fat mass percentage of obese
children (P90th of TS age/sex specific)
Yes
Sahota et al., 2001 [25] 1 year 636 7–11 School X X X X Changes in BMI,TS and SS adjusted by age, sex
and baseline values
No
Robinson, 1999 [26] 8 months 192 8.9 School X X Changes in BMI, TS, WC and WHR adjusted by
sex and baseline values
Yes
Neumark-Sztainer et al., 2003 [27] 8 months 208 9–12 School X X X Changes in BMI No
Mo-Suwan et al., 1998 [28] 7 months 292 4.5 School X Obesity prevalence (>95
th
percentile); BMI and TS
adjusted for age, gender, baseline values, parental
monthly income and family history of obesity
Yes
Flores, 1995 [29] 3 months 81 10–13 School X X X Changes in BMI adjusted by maturity stage and age Girls only
Stolley et al., 1997 [30] 3 months 65 9.9 Com-
munity
X X X X Changes in BMI Overweight prevalence
a
No
Robinson et al., 2003 [31] 3 months 52 8–10 Com-
munity
X X X Changes in BMI and WC No
NE=Nutritional education; BM= behaviour modification; PA= physical activity; PI= parent involvement; SFI= school-food intervention; BMI= body mass index; TS= triceps
skin-fold; SS=sub-scapular skin-fold; WC= waist circumference; WHR= waist–hip ratio.
a
Diagnoses by 50
th
percentile; weight-for-height as the ideal body weight based on the 1983 Metropolitan Life Insurance Tables for mothers and the Tanner Height–Weight charts for
girls.
619

prevalence of obesity in girls (odds ratio (OR): 0.47;
95% confidence interval (CI): 0.24–0.93) and, again in
girls, a greater remission of obesity in the intervention
group (OR: 2.16; 95% CI: 1.07–4.35).
Similarly, Flores et al. [29] observed significant
outcomes in girls only, with a decrease of the BMI
following a ‘‘Dance for Health Program’’ which pro-
moted an increase in physical activity using dancing
classes as the medium. Additionally, there were mod-
ifications in other life-style habits and nutritional
education. However, the study sample population was
much lower than that of the Gortmaker et al. study
[22]. The study involved 81 Afro-American and His-
panic children and the outcomes were evaluated after
only three months of the intervention.
Finally, Mu
¨ller et al. [24] published their results of
the first year of the KOPS study (Kiel Obesity Pre-
vention Study). The original study is a cohort study
and the follow-up period was scheduled for 8 years.
The study involved programs carried-out in the school
as well as in the family context, including parent
participation. The outcomes showed that the normal
age-related increase in the mean triceps skin-fold is
lower in the intervention group and that, in the group
of obese children, the annual increment in the
percentage body fat mass is reduced in the interven-
tion group relative to controls (0.4% vs 3.6%).
The remaining studies in this group were ineffective
in preventing excessive weight gain. There were two
[18, 21] that included, as well, an intervention
involving school meals.
Studies that advocated physical activity but not
nutritional education
There were four studies [20, 23, 28, 31] that promoted
physical activity in the prevention of obesity, without
additional nutritional education. Two of these
showed no effectiveness in the prevention of excessive
weight gain [20, 31].
The intervention carried-out by Robinson et al. [31]
consisted of a pilot community study, the ‘‘Stanford
GEMS Pilot Study’’, conducted on a small sample of 52
Afro-American girls over a period of only 3 months of
follow-up. The objective was to demonstrate the
acceptability, ease and potential efficacy of an inter-
vention consisting of after-school dance classes and a
family intervention to reduce the hours spent watching
television, videos and playing video games. No signifi-
cant change was achieved with respect to BMI or waist
measurement perhaps due to the small number of
children studied. However, there was a reduction in the
amount of time spent watching television.
Sallis et al. in 1993 began the SPARK trial [20]
involving seven schools in different programs of
physical activity directed by specialists. The school
teachers of the intervention group underwent a spe-
cial training course while the control group did not.
The program was for 2 years. Apart from the BMI,
adiposity was determined as triceps skin-fold mea-
surements. The children in whom there was no spe-
cific intervention tended to have higher levels of body
fat compared to controls. The differences did not
reach statistical significance when adjusted for base-
line values and gender.
The M-SPAN Study by Sallis et al. [23] showed that,
at the end of an intervention lasting 2 school-years,
there was a significant reduction in the BMI, but only in
the males. In this case, apart from the promotion of
physical activity, using the SOFT program (System for
Observing Fitness Instruction), there was an attempt to
increase the consumption of food items low in fats not
only in the school canteen and vending machines in the
school but also, with the participation of the parents, in
the food-item content of the child’s school satchel.
Nevertheless, no significant reductions were achieved
with respect to the total percentage of fat or in the
quantity of saturated fat intake, neither were there
differences in the number of hours spent in sedentary
activities, as measured by SOPLAY (System for
Observing Play and Leisure Activity of Youth).
The study by Mo-suwan et al. [28] was conducted
in Asian children of around 4.5 years of age. The
intervention program involved aerobic exercise three
times a week over a period of almost 30 weeks. The
measurements included the prevalence of obesity de-
fined as the 95th percentile of the triceps skin-fold
measurements specific for age and gender for the
population of Thailand. The skin-fold measurement
in the exercise group decreased from 12.2% at base-
line to 8.8%, whereas that of the control group de-
creased from 11.7% to 9.7%. A gender difference in
the response of BMI to exercise was observed: girls in
the exercise group had a lower likelihood of having
an increasing BMI slope than the control girls.
Studies involving the parental participation
There were seven studies in which parental support
was sought in achieving the objectives [19, 23, 24, 26,
27, 30, 31]. However, there were no comparisons
made between the same interventions, with or with-
out parental participation. Of these studies, three [23,
24, 26] showed an effectiveness, with the previously
described study by Sallis et al. [23], but in boys only.
Another study of note was the one by Stolley et al.
[30] in which the intervention involved the mother-
daughter approach. This study showed no effective-
ness after 3 months of follow-up.
Studies involving school-food facilities interventions
There were five studies involving the schools’ dining
facilities [18, 19, 21, 23, 25]. There is no evidence that
such an intervention could be considered efficacious
without additional interventions. In the only one with
positive results, reported by Sallis et al. [23], there was
an additional participation on the part of the parents.
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Studies involving the reduction of sedentary activities
The study by Robinson et al. [26] has already been
mentioned. The intervention was to reduce the
number of hours spent watching television, videos
and video games. It is of note that the collaboration
of the parents was sought using informative letters
containing strategies for limiting the children’s use of
the television and video games. The evaluation was
conducted at 8 months, and included measurements
of height, weight, triceps skin-fold, and the distribu-
tion of abdominal fat based on measurement of waist
and waist–hip ratio. There was a significantly lower
increase in these indices in the intervention group
relative to the group of control subjects, but no
change in physical activity or fat consumption, de-
spite a significant reduction in the number of meals
consumed in front of the television.
Other effects of interventions
Overall, the effects on dietary habits, physical exer-
cise, and other cardiovascular disease risk factors
were noted irrespective of whether the studies were
efficacious in preventing excessive weight gain. These
outcomes were as follows.
Interventions without effect on BMI
– Sahota et al. [25]: higher consumption of vegetables
and improvement in life-style attitudes, knowledge
and habits.
– Donnelly et al. [21]: increase in physical activity,
increase in high-density lipoprotein cholesterol,
reduction in the total/HDL-cholesterol ratio.
– Robinson et al. [31]: decrease in the number of
hours spent watching television.
– Stolley et al. [30]: decrease in the percentage of
caloric intake derived from fat.
– Neumark-Sztainer et al. [27]: greater intention to
participate in physical activity.
– Luepker et al. [18]: more physical activity, reduc-
tion in fat intake in the school and of the propor-
tion of fats in the daily energy intake.
– Caballero et al. [19]: lower percentage of energy
derived from fats, improvement in knowledge,
attitudes and healthy life-style patterns.
Interventions with positive effect on BMI
– Sallis et al. [23]: greater physical activity, in boys.
– Gortmaker et al. [22]: fewer hours watching tele-
vision and greater consumption of fruit and vege-
tables, in girls.
– Robinson [26]: less number of hours of television; less
number of meals consumed in front of the television.
–Mu
¨ller et al. [24]: better nutritional awareness,
more physical activity, greater intake of food items
low in fat, lower number of hours of television.
Discussion and conclusions
The differences in study design, duration of follow-
up, and procedures of evaluation of the different
studies make a clear evaluation of the efficacy of the
intervention almost impossible. However, in general,
it must be taken into account that even small weight
losses would be very beneficial because childhood and
adolescence are periods of growth [32].
Because of the frequency of negative outcomes of
these types of interventions, it cannot be ruled out that
there could be a publication bias. Further, there are
many factors apart from the school or family factors
that would influence weight status of the children [32].
As such, future studies will need to focus on pre-
ventive intervention in childhood obesity using more
rigorous and reproducible methodology and better
defined objectives. Also, the cost-benefit needs to be
assessed with respect to the generalized application of
different strategies in the appropriate environments.
Bearing in mind the shortcomings of the published
studies, our conclusions are:
(1) Interventions designed to prevent excessive
weight gain and applied over 6 months to 1 year
seems to be more effective than shorter-term
interventions and, as well, to those extending over
longer periods.
(2) Interventions involving nutritional education to-
gether with the promotion of physical activity are
more effective if, additionally, they are combined
with behaviour modifications.
(3) Parental involvement can help in ensuring a degree
of effectiveness of programs designed to reduce
excessive weight gain and obesity in children.
(4) As we have seen in our survey of the literature,
intervention involving school canteen facilities is
not decisive in improving the effectiveness of the
interventions.
(5) Conversely, decreasing sedentary activity such as
watching television does positively influence the
effectiveness of interventions designed to prevent
childhood obesity.
(6) The interventions that we have reviewed,
regardless of their impact on obesity, have a
beneficial effect on children’s health, as far as they
improve dietary habits which could lead to a
decrease in cardiovascular disease risk factors
increase awareness of the importance of healthy
nutritional habits and of physical activity.
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Address for correspondence: Lluis Serra-Majem, Catedra
´tico de
Medicina Preventiva y Salud Pu´blica, Departamento de Cien-
cias Clı´nicas, Universidad de Las Palmas de Gran Canaria,
Apdo Correos 550, 35080 Las Palmas de Gran Canaria
E-mail: lserra@dcc.ulpgc.es
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