Interventions to Prevent Global Childhood Overweight and Obesity a Systematic Review

Int J Environ Res Public Health. 2014 Sep; 11(ix): 8940–8961.

Global School-Based Babyhood Obesity Interventions: A Review

Melinda J. Ickes

^aneDepartment of Kinesiology and Health Promotion, College of Instruction, University of Kentucky, Lexington, KY 40506, USA; Email: ude.yku.thou@552cmj

Jennifer McMullen

¹Department of Kinesiology and Wellness Promotion, Higher of Educational activity, University of Kentucky, Lexington, KY 40506, The states; E-mail: ude.yku.g@552cmj

Taj Haider

²The Legal Assist Society, 199 Water Street, New York, NY 10038, United states of america; E-Mail: gro.dia-lagel@rediaht

Manoj Sharma

³Behavioral & Environmental Health, Jackson Land University, Jackson, MS 39213, USA; Due east-Mail: ude.smusj@amrahs.jonam

Received 2014 May 31; Revised 2014 Aug xix; Accepted 2014 Aug twenty.

Abstruse

Background: The consequence of childhood overweight and obesity has become a global public health crisis. School-based interventions have been developed and implemented to combat this growing concern. The purpose of this review is to compare and contrast U.Due south. and international school-based obesity prevention interventions and highlight efficacious strategies. Methods: A systematic literature review was conducted utilizing five relevant databases. Inclusion criteria were: (1) primary research; (ii) overweight or obesity prevention interventions; (iii) schoolhouse-based; (4) studies published between 1 January 2002 through 31 Dec 2013; (5) published in the English language linguistic communication; (6) child-based interventions, which could include parents; and (7) studies that reported outcome data. Results: A total of 20 interventions met the inclusion criteria. Ten interventions each were implemented in the U.S. and internationally. International interventions only targeted uncomplicated-aged students, were less probable to target low-income populations, and were less likely to exist implemented for 2 or more years in elapsing. However, they were more probable to integrate an environmental component when compared to U.S. interventions. Discussion: Interventions implemented in the U.S. and internationally resulted in successful outcomes, including positive changes in educatee BMI. All the same, varying approaches were used to attain success, reinforcing the fact that a one-size-fits-all arroyo is not necessary to impact childhood obesity. Yet, building on successful interventions, hereafter school-based obesity prevention interventions should integrate culturally specific intervention strategies, aim to incorporate an ecology component, and include parents whenever possible. Consideration should be given to the potential touch on of long-term, frequent dosage interventions, and subsequent follow-upward should be given attending to decide long-term efficacy.

Keywords: obese, overweight, school-based, youth, child, prevention, intervention, plan

1. Introduction

Obesity continues to threaten health outcomes and quality of life worldwide, particularly among youth. Obesity, once a problem specific to nations of wealth, now impacts, to varying degree, countries of all economic levels [1]. Overall, global obesity rates are college in adults than children. Still, in the U.S., Brazil, Communist china, and other countries, the epidemic has increased at a faster rate in children than in adults [2]. As indicated in previous studies, the incidence of overweight and obesity differs globally [3]. Babyhood overweight and obesity have increased more dramatically in economically developed countries and in urbanized populations [three]. According to a 2006 study of worldwide childhood obesity trends, the prevalence of obesity in schoolhouse-aged children was the following: Africa, 0.2%; Americas, 9.6%; Eastern Mediterranean, 5.9%; Europe, 5.4%; Due south Due east Asia, 1.five%; and West Pacific, 2.3% [3]. The prevalence of global childhood overweight and obesity increased from 4.2% in 1990 to six.7% in 2010, with a total of 43 meg children estimated to exist overweight or obese in 2010, including 35 1000000 in developing countries. Trends approximate that in 2020 the rates of global babyhood overweight and obesity will increase from half dozen.7% to 9.1% [four]. Although a business organization worldwide, prevalence rates in the U.s. tend to be higher as compared to other adult countries [five]. The obesity rates for children ages 2–nineteen in the United States from 1980 to 2010 have more tripled [six]. The most recent National Health and Nutrition Exam Survey (NHANES) indicated that xvi.9% of two–19 year olds in the Usa were obese and 31.vii% were overweight or obese. Specifically, the prevalence of obesity in 2009–2010 was 12.1% among children ages 2–5, xviii.0% among children ages 6–xi, and 18.four% among children ages 12–nineteen [vii]. While obesity remains a global concern, contempo findings bespeak a plateau in the spiked increases observed over the past 30 years and in some cases a marked decline in several developed countries [5]. Every bit stated past Olds and colleagues [5], "While rates of overweight and obesity announced to be stabilizing at nowadays in many countries, they are still unacceptably high, with significant ramifications for the health and well-being of these children equally they age (p. 355, [5]). As a result, the demand to determine effective strategies to prevent and mitigate overweight and obesity is still urgent.

Obesity has a number of health, social, and economic consequences. From an economical viewpoint, obesity places a strain on the healthcare system [8]. In fact, in a recent review of the economic burden of obesity worldwide, individuals struggling with obesity accept medical costs 30% greater than those of normal weight [eight]. Considering the individual impact, childhood obesity has been associated with a number of negative secondary health-related outcomes. Obese children are more than likely to have increased blood pressure and increased cholesterol levels—both of which are risk factors for cardiovascular disease [ix]. Childhood obesity also increases the likelihood of insulin resistance and glucose intolerance, leading to diabetes mellitus blazon two [10]. In addition, negative psychological and emotional outcomes accept been reported, including low self-esteem and torso-esteem, depression, and stigmatization [xi]. Moreover, obese children are more than likely to get severely obese adults–further necessitating the need to prioritize prevention efforts [9].

Obesity is shaped by a number of determinants: common genetic variants, influences within the first yr of life, maternal behaviors, family food environs and dietary behaviors, physical action and inactivity, and ecology factors that either hinder or enhance 1's accessibility to good for you food and physical activity [12,13,14,15,16]. Not only should childhood obesity prevention interventions aim to target modifiable determinants of obesity, simply the setting in which these interventions are implemented also needs to be considered to truly impact this global epidemic.

School-based programs have historically been used to impact child health. Specifically, preventive efforts targeting babyhood obesity have often focused on schools as an of import setting [12,16]. Schools have been considered an ideal target, given the propensity to preclude obesity through the promotion of physical activity, nutritious food offerings, and nutrition teaching through practice, policy, and supportive environments [12,16]. Targeting school-aged children is logical given that physical activeness and dietary habits are imprinted at this age, assuasive schools the opportunity to institute life-long healthy habits in children [14]. Past systematic reviews have highlighted the success of school-based obesity prevention interventions [12,17,eighteen,19]. Implications from a review incorporating interventions among children betwixt 1966 and 2001 indicated there were minimal positive weight-related outcomes, but the changes measured were minor and the measures utilized varied amid the studies [19]. Other school-based interventions report varying degrees of success, with modest changes in behavior paired with mixed results with obesity indicators [17,xix]. However, because the global attain of childhood obesity, by reviews have failed to hone in on the differences between approaches taken internationally and within the United states of america. It is imperative health professionals continue to build on previous lessons learned. Notwithstanding, nosotros cannot assume a one-size-fits-all approach will work across such diverse populations. Thus, this systematic review hopes to bridge the gap between the previous major systematic reviews of its kind in an endeavor to proceeds a better understanding of global initiatives aiming to target the critical public health dilemma childhood obesity and overweight pose [20]. Therefore, the purpose of this review is to compare and dissimilarity U.S. and international school-based obesity prevention interventions and highlight efficacious strategies to aid development of futurity interventions.

two. Experimental Section

2.one. Methods

Inclusion/Exclusion Criteria

Inclusion criteria for this review included: (ane) principal research; (two) an overweight or obesity prevention intervention; (3) school-based; (four) peer-reviewed and published between 1 January 2002 through 31 December 2013 in selected databases; (5) bachelor in the English linguistic communication; (6) a child-based program, which could include parents; and (7) outcome-based. Exclusion criteria were: (1) interventions implemented in preschools, early childcare programs, or later on-school programs; (2) not bachelor in the English language language; (3) obesity treatment interventions (i.e., simply focused on an obese population); and (4) articles reporting study pattern and/or process evaluation only. In this review, principal research was defined as studies which were carried out to acquire data kickoff-hand, rather than being gathered from previously published sources. In improver, school-based was operationalized as an intervention that was implemented during regular school hours for children in kindergarten through senior year of high school. Interventions that took identify outside of regular schoolhouse hours, both before and subsequently school, were excluded from this written report.

2.two. Rationale for Review

This systematic review is an update of existing reviews and incorporates babyhood obesity interventions implemented worldwide. The Customs Guide conducted an extensive review published in 2005, covering the years of 1966 through 2001. However, this review resulted in simply 10 studies and included both school and work-based settings [19]. The Cochrane Database System Review was also similar, though it covered school, community, clinic, and family unit-based programs and included pre-school aged children, spanning years 1990 through February 2005 [21]. Similarly, 2 school-based obesity prevention reviews were published in 2006 and 2007 [12,18]. However, the first was express to those interventions conducted outside of the United states of america and the 2d but included interventions within the The states and the United kingdom. Although there is overlap regarding dates of inclusion with these reviews, this systematic review includes interventions inside the United States and worldwide.

2.three. Study Brainchild

Two researchers conducted an extensive literature search in order to incorporate all pertinent studies in this review. Searches were conducted utilizing the following databases: Bookish Search Premier, Cumulative Index to Nursing and Allied Health (CINAHL), Medical Literature Assay and Retrieval System Online (MEDLINE), Instruction Resources Information Center (ERIC), and Psychology and Behavioral Sciences Drove. The following keywords were used: [obese OR overweight] AND [school OR school-based] AND [youth OR child OR adolescent] AND [prevention OR intervention OR handling OR program OR study]. Limits of scholarly journals (peer-reviewed) were gear up. Initially, 12,294 manufactures were originally identified using the keywords. Articles were then further reduced based on inclusion and exclusion criteria. See Figure 1 for a flow diagram summary of the search results. Twenty interventions fulfilled the criteria and are included in this review.

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A summary of search results.

2.four. Data Extraction

Information from the studies were extracted, independently, past two researchers using a standardized course that the researchers created. Discrepancies were examined and final not-disputed data recorded. Extracted data included: author, year of publication, participant data, theory used, research design, outcomes, intervention dosage and duration, strategies utilized, and compunction and follow-up rates.

three. Results and Discussion

iii.1. Results

The included studies have been summarized in Table 1 and Tabular array ii, outlining the target population, intervention strategies and blueprint, measures, outcomes, and relevant findings. The interventions have been divided into ii sections, U.s.a. and international, and arranged alphabetically inside sections.

Tabular array ane

Summary of included interventions—sample, design, intervention description.

Writer, Year, Reference #	Sample Description	Sample Size	Research Design	Dosage and Duration	Intervention Strategies
United States
Chehab et al. 2007 [22]	U.S.; HS; Depression-income; BL 49% OW; 28% OB	N = 46 girls	Pre-experimental	Weekly two-h sessions; 29 weeks	Homework, aerobic activeness, sampling of healthy foods, cooking exercises, grouping recitation of motivational grab phrases
DeVault et al. 2009 [23]	U.S.; ELEM; Depression-income; BL BMI non assessed	N = 140; Tx. = 71, Cnt. = 69	Quasi-experimental	Six 30-min. weekly lessons; vi weeks	Fruit and vegetable bingo, baking whole-grain breadstuff to bring home, comparison portion sizes of snack foods
Donnelly et al. 2009 [24]	U.S.; ELEM; depression-income; BL BMI Int. 17.9 +/− three.i; Cnt. 18.0 +/−3.7	N = 1527; Cnt. = 713, Tx. = 814	RCT	90 min/week of physically active bookish lessons; 3 years	EI; Existing lessons from Take 10!^®, PA incorporated across all content areas
Foster et al. 2008 [25]	U.South.; Low-income; BL 17% OW, 22–25% OB	North = 1349; Tx. = 749, Cnt. = 600	RCT	50 h/twelvemonth; 2 years	EI; PC; School cocky-cess, nutrition teaching, nutrition policy, social marketing
Hollar et al. 2010 [26]	U.S.; ELEM, Low-income; seven.three% Tx. OW; viii.5% Cnt. OW; 17.half dozen% Tx. OB; 22.9% Cnt. OB	N = 1173; Tx. = 974, Cnt. = 199	Quasi-experimental	Monthly nutritional activities, 10–15 min. PA/day, & structured activities during PE; 2 years	EI; incorporated nutritious ingredients and whole foods, provided a healthy lifestyle curricula, hands on school-based health activities such equally gardens
Johnston et al. 2013 [27]	U.South.; ELEM; BL 33% OW/OB	N = 835; PFI (professional facilitated information): N = 509 SH (cocky-aid): North = 326	RCT	v teaching moments/week, one lesson/week, 1 action/ii weeks, and i schoolhouse-broad action/semester; 2 years	EI; PC; Healthy messages and lessons were applied to all subject areas
Manger et al. 2012 [28]	U.S.; ELEM; BL Cnt. OW 21%; Tx. OW 15%; Cnt. OB 14%; Tx. OB 14%	North = 697; Tx. = 396, Cnt. = 301	Quasi-experimental	8 weekly lessons, 30 min. each; 2 years	PC; Food charts and games, hula hoops and skip ropes, songs to promote healthy eating
Melnyk et al. 2009 [29]	U.S.; HS; BL Mean BMI percentile 80.5 Tx.; 71.33 Cnt.	N = xix; Tx. = 12, Cnt. = 7	RCT	2–3 times/week; nine weeks	Educational information on leading a healthy lifestyle, role-playing, participation in group PA wearing pedometers.
Pbert et al. 2013 [thirty]	U.Southward.; HS; Depression-income; BL 78.six% Int. OB; sixty% Cnt. OB	Northward = 82; Tx. = 42, Cnt. = 40	RCT	6 one-on-one sessions; 2 months	5-3-ii-1-0 approach to back up making 5 key behavior changes
Wang et al. 2010 [31]	U.S.; ELEM; Low-income; BL: OW/OB non assessed	Due north = 327	Prospective	Integrated daily; 2 years	EI; PC; Modify in school nutrient, school dining, offering of cooking classes, schoolhouse gardens, lesson integration, food diaries
International
Graf et al. 2008 [32]	International; ELEM; BL: OW 8.1%; OB vi.6%	North = 615	Quasi-experimental	I extra health lesson/week (twenty–30 min.), and one 5 min. PA break/morning; 4 years	PC; health lessons, mini PA breaks
Hartmann et al. 2010 [33]	International; ELEM; OW And/or OB: 1st grade Cnt. 25%; 1st grade Tx. 26%; fifth class Cnt. 26%; 5th grade Tx. 25%	N = 411; 1st grade Cnt.=69; 1st grade Tc.p:=111; 5th grade Cnt.=85; 5th class Tx. p = 146	RCT	Daily PE, short activity breaks/day during lessons, PA homework playground changes; i year	EI;PC; Increased PA, playground changes, PA homework
James et al. 2004 [34]	International; ELM; BL: 27.half-dozen% F Tx. OW; xx.i% Thou Tx. OW; v.seven% F Tx. OB; 4.one% Grand Tx. OB; 28% F Cnt. OW; xviii.8% Yard Cnt. OW.; seven.iii% F Cnt. OB; 1.vii% 1000 Cnt. OB	Tx. =fifteen clusters, N = 325. Cnt. = xiv clusters, Northward = 319	RCT	Iv i h sessions; ane year	EI; Educational sessions, drink diary
Kanyamee et al. 2013 [35]	International; ELEM; Low-income; Mean BMI z scores Tx. = 2.39 (SD = 0.42); Cnt.=ii.53 (SD = 0.56)	N = 136; 68 per grouping	RCT	Weekly; eighteen weeks	Dietary intake recorded daily, computer games, cartoon animation, and comic books
cLlargues et al. 2011 [36]	International; ELEM; BL 16.7% Cnt. OW; xx.3% Tx. OW; 18.i% Cnt. OB; 9.6% Tx. OB	N = 509; Tx. = 272, Cnt. = 237	RCT	3 h/week; ii years	EI; PC; CR; Regular PA, hands on activities like cooking workshops and promotion of playground games.
Lopes et al. 2009 [37]	International;ELEM; BL BMI mean and southward.d. in girls 6–7: 16.four +/− 3, girls age 8 and +: 17.7 +/− three.six. Boys 6–7: 16.8 +/− 2.6 and boys viii and +: 17.8 +/− 3.2	N = 168; 81 from i schoolhouse and 87 from another	Quasi-experimental	30 min/day; 2 weeks	EI; access to actress practise/play equipment
Muckelbauer et al. 2009 [38]	International; ELEM; low-income; BL OW Tx. 23.4%; Cnt. 25.9%	North = 2950; Tx. = 1641, Cnt. = 1309	RCT	Daily (water fountain exposure), four 45-min. classroom lessons; one year	EI; installment of h2o fountains, distribution of water bottles, associated classroom lessons
Sachetti et al. 2013 [39]	International; ELEM; BL Cnt. OW 24.1%; Tx. 25% OW; Cnt. viii.8% OB; Tx. 10.iv% OB.	North = 428; Tx. = 212, Cnt. = 216	RCT	30 min PA, ii 50 min. sessions/calendar week of extra PE/week; 2 years	EI; Schoolhouse k & classroom action including circuits, games, exercises
Walther et al. 2009 [forty]	International; ELEM; BL BMI percentile Cnt. 52.5 +/− 28.8; Int. 50.5 +/− 28.ix.	Due north = 188; Tx. = 112, Cnt. = 76	RCT	Int. = 45 min. PA/day. Cnt. = 45 min. exercise twice/week, good for you lifestyles session once/ month; 1 year	EI; Increased PA, lessons on lifestyles
Wong & Cheng, 2013 [41]	International; ELEM; BL 100% OW/OB	N = 185; MI (due north =seventy) ; MI + group (n = 66); Cnt. = 49	Quasi-experimental	xiv-calendar week, six-section program. 30-min./session; eleven months.	PC; Diet periodical, exercise log, motivational interviewing

Table 2

Summary of interventions—outcomes, measures, salient findings.

Author, Yr	Primary Issue (s)	Measures	Measures-Time	Attrition	Salient Findings
United states
Chehab et al. 2007 [22]	BMI	Ht., wt.	Baseline, 29 weeks	84.8% completed all components	For OB & OW girls, positive relationship (p < 0.01) between wt. loss and extent of program participation
DeVault et al. 2009 [23]	Nutrition-related knowledge, attitudes, behaviors	Surveys	Baseline, half dozen weeks, three weeks follow up	46% Cnt. & 54% of the Tx. completed both surveys all three times	Behavioral intent for food choice sig. increased at post- for Int. vs. Cnt. p < 0.014
Donnelly et al. 2009 [24]	BMI	Ht., wt., academic achievement	Baseline, 3 years	2.v% dropped out	Change for overweight to at-adventure approached significance (p = 0.08).
Foster et al. 2008 [25]	OW, OB	Ht., wt. dietary intake, PA, sedentary behavior	Baseline, spring of yr 1, 2 years	Int. & Cnt. schools at 1 (31.nine% vs. 31.5%) & 2 years (36.0% vs. 39.2%)	Cnt. = 15%, Int. = 7.v% overweight in ii years. After controlling for gender, race/ethnicity, age, predicted ORI of overweight were ~33% for the Int. group (OR = 0.67; 95% CI: 0.47–0.96; p < 0.05)
Hollar et al. 2010 [26]	BMI	Ht., wt., FCAT scores	Baseline, 2 years	Not mentioned	Decrease BMI between baseline and mail-intervention: Cnt.: OW = 6.8 %, Tx. = two.1% (p = .27)
Johnston et al. 2013 [27]	zBMI, academic outcomes	Ht., wt., year-cease final grades, GPA	Baseline, 24 months	79% completed all msmnts.	Students who were OW/OB in the PFI sig. reduced (zBMI) compared to SH group (p < 0.001).
Manger et al. 2012 [28]	BMI	Ht., wt.	Baseline, annually	The last data set included 697 students, 125 of whom had 2 and 572 of whom had 3 assessments of BMI	Adjusted Mean BMI % declined from 66.ane to 65.0 in Cnt., 62.viii to 58.9 in Int. (p = 0.015)
Melnyk et al. 2009 [29]	Triglycerides, lipoproteins, beliefs, nutritional knowledge, depressive symptoms	Ht., wt., BMI, waist circum., claret piece of work, pupil- completed evaluations	Baseline, post-intervention	89% provided consummate baseline and post-intervention data	Tx.: increased commitment to make healthy choices (via choices scale)—at baseline: 54.v and post-intervention: 58.91 (p = 0.07)
Pbert et al. 2013 [30]	BMI, waist circum., percent body fat, BP	Ht., wt., BMI, BP, waist circum., dietary intake, PA via accelerometer	Baseline, 2 months, 6 months	100% remained	Adjusted Mean modify BMI 6 months post 95% CI (p < 0.676) Cnt.: = 0.23 (−0.46, 0.910, Tx. = 0.01 (−0.66, 0.68)
Wang et al. 2010 [31]	Nutrition knowledge, fruits & vegetables	Surveys, food diaries, interviews with teachers & administration	Food behavior assessed annually, surveys completed past students (not specified)	82.iii% remained	Students nigh exposed to intervention increased fruits & vegetables by 0.2 cups, students least exposed decreased 0.3 cups (p < 0.05)
International
Graf et al. 2008 [32]	Endurance, motor, coordination tests	Ht., wt., BMI, motor tests, body coordination tests	Baseline, end of second school yr, end of 4th schoolhouse year	two% dropped out	23.2% (thirteen/56) of OB and OW children from the Tx. reached normal weight at final exam
Hartmann et al. 2010 [33]	Physical, psychosocial QOL	QOL (survey), pubertal stages, anthropometry, body composition, sociodemographic variables	Baseline, 1 year	90% had valid postal service-intervention data (North = 411)	PA had sig. consequence on psychosocial QOL in OW (p < 0.05) and urban first graders (p < 0.05)
James et al. 2004 [34]	Beverage consumption, OW, OB	Ht., wt., waist circum., BMI	Baseline, half dozen months, 1 year	89% remained at 1year	12 months mail, Mean %> than 91st percentile for BMI Cnt. = 26.9%., Tx. = twenty.1%
Kanyamee et al. 2013 [35]	Intention to perform eating behaviors, eating behaviors, BMI	Intention to perform eating behavior for wt. control; eating behaviors for wt. control, ht., wt., BMI	Baseline, vi weeks, 18 weeks	100% remained	At 18 weeks, Mean BMI for age (z scores) p < 0.001—Tx. = 2.00, Cnt.: = two.55
Llargues et al. 2011 [36]	BMI	Changes in eating habits, PA	Baseline, ii years	Complete data obtained 72.three%, Cnt. = 237 (78.viii%), Tx. = 272 (72.vii%)	Cnt.: OW = 24.nine%, OB = x.7%. Tx.: OW = 25.ane%, OB = 8.9%, p < 0.001
Lopes, Lopes, and Pereira, 2009 [37]	PA levels	Gender, age, BMI accelerometer	Baseline, 2-weeks	24 students were excluded	Sig. effects for full PA (p<0.001). Sig. interaction between gender & age (p = 0.009)
Muckelbauer et al. 2009 [38]	BMI	Ht., wt., gender, historic period, migrational groundwork, survey	Baseline, 1 year	92% completed intervention	BMI SDS changes from baseline to follow-upward cess were 0.005 +/− 0.289 in the Tx. & 0.007 +/− 0.295 in the Cnt.
Sachetti et al. 2013 [39]	PA habits, physical performances, and BMI	Ht., wt., BMI, motor tests	Baseline, 2 years	14.ii% and xiii.9% in Tx. and Cnt. groups did non complete	Subtract (boys: ten%; girls: 12%) in daily sedentary activities, p < 0.05; Int. lower rise in BMI compared to the Cnt. (p < 0.001)
Walther et al. 2009 [twoscore]	BMI-SDS, leukocyte msmt., HDL, motor caliber score	Torso limerick, BP, Hour, body coordination, spirometry. Blood piece of work, survey	Baseline, one year	3 were lost in follow upwardly for both the Cnt. and Int. groups (6 full)	Decrease OW and OB in Tx. from 12.8% to 7.three%
Wong & Cheng, 2013 [41]	Alter in wt.-for-ht. %	Changes in weight-related behaviors, anthropometric measures	From the fourth to the 11th calendar month later baseline	4 did non complete, non specified every bit to which group	Sig. increment in the avg. calories consumed due to increase in PA in past 7 days in MI group (p < 0.01) and MI+ group (p < 0.01). Sig. change at post in BMI, fatty %, anthropometric measures

three.1.1. Sample and Design

The review was limited to interventions that took identify in a school-based environment. Of the interventions, half (n = 10) took identify outside of the The states [32,33,34,35,36,37,38,39,40,41] while the remaining half (north = 10) were implemented in the United states of america. Overall, the majority (85%) of interventions took place at the elementary school level [23,24,25,26,27,28,31,32,33,34,35,36,37,38,39,40,41] and 15% (n = 3) took place at the loftier school level [22,29,30]. However, no international interventions targeted high school populations and none of the interventions focused on middle school settings. More U.Due south. interventions indicated they specifically targeted low-income schools (70%, north = vii) compared to international interventions (thirty%, due north = iii). The number of participants within the interventions varied significantly, ranging from 19 to 2950 participants. Overall, the average number of participants in the interventions implemented in the Usa (M = 619.5) was higher compared to those implemented internationally (Grand = 591.5), but both varied immensely in terms of range.

Written report blueprint reported throughout the interventions included lx% (n = 12) [24,25,29,30,31,33,34,35,36,38,39,forty] randomized controlled trials, in which participants were randomly assigned to command or intervention groups. Seven international interventions compared to five interventions implemented in the Us incorporated use of a randomized controlled trial. 6 of the interventions (xxx%) were quasi-experimental [23,26,28,32,37,41] in which participants were not randomly assigned to a control or comparison group. I written report was of a pre-experimental blueprint [22] and ane study incorporated a prospective inquiry blueprint [31], both of which were implemented in the United States.

iii.1.ii. Theoretical Framework

Use of theory was simply mentioned in 30% (n = half dozen) of the interventions [29,30,32,35,36,38], 4 of which were implemented internationally. The virtually ordinarily used theory was the Theory of Planned Behavior (n = 3, 14.3%) [32,35,38]. Other theories mentioned included: Cognitive Behavioral Theory, Social Cerebral Theory, the Precaution Adoption Process Model, and Investigations, Vision, Action, Change (IVAC). Of the interventions that did utilize a theory and/or model, 4 of the six studies detailed how the theory was operationalized [29,xxx,35,36].

three.1.3. Intervention Arroyo

Duration of the interventions ranged from ii weeks (northward = i) [37] to 4 years (n = 1) [32]. Interventions lasting one yr or less comprised 55% (n = 11) of those included in this review. The remaining studies, 45% (due north = 9), lasted two years or more, six of which were implemented in the United states. Dosage of the interventions varied from daily to weekly sessions. Of the included interventions, 45% (north = 9) took identify weekly or more than once throughout the week, while 35% n = 7) of the interventions took place daily. Additionally, 20% of the studies (n = 4) did non specify dosage, reporting only that the intervention was administered throughout the full duration of the implementation menses.

A variety of strategies were utilized throughout the included interventions. Strategies included providing and/or implementing educational sessions, cooking classes, schoolhouse-based gardens, sampling healthy foods, modify in school nutrient options, and promotion of physical activity. Almost half of the interventions, 45% (n = ix) [22,23,26,31,34,35,36,41], explicitly mentioned incorporating hands-on nutritional activities such as schoolhouse gardens, journaling of food intake, participating in cooking classes, sampling healthy foods, and playing games such as "fruit and vegetable bingo." Hands-on nutrition activities were implemented in five Usa vs. four international interventions. Increasing the amount of physical activity was some other common strategy overall (40%, northward = 8) [22,23,24,28,33,37,39,forty], more than so with interventions implemented internationally (n = 5). Twelve of the interventions (sixty%) involved some form of environmental alter(south) [24,25,26,27,31,33,34,36,37,38,39,twoscore], seven of which were implemented internationally. Environmental changes ranged from increasing the required fourth dimension allotted daily for physical teaching to modification of nutritional offerings. 8 of the interventions (40%) included a parental component [25,27,28,31,32,33,36,41], with varying degrees of involvement ranging from parental telephone calls, meetings, and data and instructions sent home to reinforce information given at schools. Parental interest was similar when comparing international and The states interventions.

Over one-half (57%) of the programs were implemented by a classroom teacher. Others implementing the interventions included physical education teachers, researchers, enquiry assistants, school nurses, support staff, occupational therapists, physicians, and nutritionists. One quarter of the interventions mentioned the apply of incentives [22,25,xxx,31,38]. Among the incentives used were a reusable water bottle, weekly raffle prizes, a group television appearance on "The Today Show," $25 gift certificates, and raffle tickets for concrete activity-related prizes.

3.one.4. Intervention Outcomes and Measures

All of the interventions provided outcome data, although the primary outcome varied. BMI was the primary upshot for the majority of interventions (55%, northward = xi). In improver, the following principal outcomes were mentioned: academics (north = 2) [26,27], cholesterol levels (n = 2) [29,40], physical activity habits (n = 2) [37,39], incidence of overweight/obesity (distinctive from BMI) (north = 2) [25,34], and nutrition knowledge (n = 2) [29,31].

Too all of the interventions reported positive changes throughout the interventions related to at least one of their identified primary outcomes, equally summarized in Table 2. Successful outcomes included positive changes in endurance and coordination tests, physical activity levels, depressive and anxiety symptoms, triglycerides, lipoproteins, physical and psychological quality of life, HDL cholesterol, leukocyte measurement, intention to change and improvement in eating behaviors, and water consumption. Overall, 70% of the interventions reported a subtract in BMI and/or overweight or obesity. More international interventions (n = viii) compared to those implemented in the Us (n = six) reported this as a significant outcome.

Of the 20 interventions, 30% (n = six) [23,27,32,38,39,41] followed-upwards with participants post-intervention, but the findings from such follow-ups varied. Of the five interventions that explicitly mentioned the follow-up results [23,32,38,39,41], three noted positive findings, including significantly lower increases in BMI and/or risk of overweight [38,39], improved food self-efficacy, enhanced perception of one's ain body image, and attempted weight loss [23]. Additionally, i intervention resulted in a significant increase in anthropometric information equally a outcome of growth [31] and another showed no significant difference in BMI betwixt the control and intervention groups at a six-month follow-up [41].

three.2. Discussion

Given the concern of babyhood obesity [1,two,4] and the consequential health-related outcomes and societal impact worldwide [9,10,eleven], the purpose of this review was to compare and dissimilarity U.S. and international school-based obesity prevention interventions and highlight efficacious strategies.Overall, findings are promising, because each of the global school-based interventions included in this review resulted in at least ane positive, measurable issue. The majority of interventions, both international and in the Usa, took place at the unproblematic school level. Unproblematic schools appear to be an ideal setting for childhood obesity prevention interventions given the vast assortment of opportunities for promoting physical activity and nutrition education through practice, policy, and supportive environments [12]. Targeting specific grades and classrooms within uncomplicated schools may be easier when compared to targeting heart schools and loftier schools due to scheduling, built in opportunities for physical action, and flexibility in the curriculum. This may very well help to explicate a more marked stabilization in childhood obesity rates across developed nations among this age group [5]. Interestingly, no international interventions were implemented in high schoolhouse settings and none, either in the The states or internationally, were implemented in heart schools. There is a need for future obesity prevention interventions to target these at adventure groups, specially considering the lack of decline and/or plateau in contempo obesity prevalence amongst young and older adolescents, and the likelihood that the health behaviors and associated risk volition go along into machismo [ix].

A critical component of successful schoolhouse-based obesity prevention interventions is tailoring the program to the targeted audience [16]. Incorporating formative research prior to intervention implementation may assist with these efforts and thereby enhance sustainability and the likelihood of positive outcomes [35]. This seems to exist specially important when working in schools with a high prevalence of low-income children. Seventy percent of the interventions implemented in the Us indicated they specifically targeted low-income schools compared to merely xxx% internationally. This is, perhaps, explained by the focus on reducing health disparities in the United states and the resulting funding initiatives typically giving precedent to those interventions which target low-income, at-risk populations. It is encouraging that intervention outcomes among low-income children were establish to simultaneously improve academic functioning and weight status [41]. Given the determinants of obesity linked to socioeconomic status [7,12], future consideration needs to be given to this population. In developing countries, there is support that the 'adiposity gap' between low-income, middleclass, and upper class is widening [5]. Therefore, other developing countries may deem it necessary to also target low-income, high-gamble groups equally cost considerations are taken into account [five].

There were several commonalities and singled-out differences when contrasting approaches used with interventions implemented internationally and in the United States. All of the interventions focused on promoting physical activeness and/or good for you food behaviors. Interventions implemented in the The states tended to integrate more than easily on nutrition activities, whereas international interventions were more likely to incorporate promotion of physical activity as an intervention strategy. Interventions that utilize both a physical activity and nutrition component may increment the effectiveness of school-based childhood obesity prevention programs [17]. Notwithstanding, the majority of interventions included in this review did not take such an arroyo. Hereafter interventions should build on successful nutrition and physical activity strategies as role of a multi-pronged arroyo [16]. Yet, feasibility needs to exist considered, as some schools may not have the resources necessary to implement strategies targeting diet and physical activity simultaneously. A tiered, stage-based plan can be put into place and so efficacious school-based strategies are strengthened each yr of implementation. This type of arroyo will enhance sustainability and likelihood of long-term impact [16] and may exist more than appealing to schools considering obesity prevention interventions.

Parental influence with regards to children's nutrition and physical activity behaviors is a well known determinant of babyhood obesity [12,14,15,16]. However, simply 40% of the included interventions incorporated parental involvement as a targeted strategy. Of those that involved parents throughout the intervention, 75% reported meaning weight and/or BMI reductions, warranting back up for this strategy equally function of school-based programs aiming to forbid childhood obesity. While the role that schools can play in childhood obesity interventions is important, it is besides important to consider the crucial role that parents play in implementing, encouraging, and reinforcing healthy behaviors. Enquiry indicates the cooperation of parents in addressing physical activity and nutrition concerns in children is essential [21]. Incorporating motivational interviewing equally a component of parental teaching seems to exist a beneficial strategy [41] forth with requesting parents to complete food diaries to make up one's mind change in kid efficacy and parental involvement [31]. Future research should determine the feasibility of such approaches as well as the potential positive health outcomes garnered, not only with the child, but also with the parents and related family members. Considering the lack of parental involvement was similar across interventions implemented in the United states of america and internationally, there is a demand to further explore cultural barriers as to why this might be the case.

Another intervention strategy worth mentioning is the integration of some grade of environmental alter. Over half of the interventions incorporated at least one ecology change, seven of which were implemented internationally. Significant changes in BMI and/or weight outcomes were reported in 75% of the interventions that included an environmental component, giving support to include as an impactful strategy. Environmental strategies seem to accept become a focus with more than contempo interventions, as represented by the included studies, with all only i beingness implemented after 2008. Consequently, evaluation of such efforts needs to be conducted to determine the most efficacious schoolhouse-based strategies. Although there is a push for policy modify related to obesity prevention efforts in the United States [16], it is articulate that the United states of america tin build on lessons learned from the successful ecology strategies incorporated in several of the included international interventions.

Incorporating evidence-based strategies is disquisitional to increment the likelihood of successful school-based obesity prevention interventions. However, equally important is the use of theory when designing intervention programs, every bit evidence suggests they are more effective compared to interventions that practise non utilize a theory [17]. Of the interventions included in this review, less than one 3rd incorporated a behavioral theory, with the TPB occurring about frequently. The applicability of TPB for childhood obesity interventions is difficult to decide, given the pocket-sized number of interventions reporting use of this theory and fifty-fifty fewer fully describing how the theory was operationalized. Without such information, information technology is difficult to make comparisons across interventions. Futurity research should explore integration of behavioral theories and their related theoretical constructs to measure intervention outcomes. This may aid in a researcher'due south ability to prioritize intervention strategies and consequently replicate these successful strategies [42].

Although difficult to compare outcomes due to the varying nature of the intervention design, target population, and selected master outcomes, study findings demonstrate the potential for school-based obesity prevention interventions. Overall, lxx% of the interventions reported a subtract in BMI and/or overweight or obesity, with BMI serving every bit the most mutual primary outcome. More international interventions compared to those implemented in the The states reported these significant outcomes. This is somewhat conflicting with contempo enquiry indicating an increased likelihood of pregnant anthropometric changes in populations with higher incidence of obesity [5]. The rates of obesity in the The states go on to be greater as compared to other developed countries [5], then i would expect the potential for significant changes in BMI and overweight/obesity to be higher, even in full general population school-based obesity prevention interventions. Given this fact, there is a need to further investigate factors impacting intervention outcomes.

Comparing the most impactful school-based interventions, the following commonalities existed, regardless of whether they were implemented internationally or in the United States: (1) large sample size; (two) elementary schoolhouse setting; (3) weekly or daily dosage; (iv) duration of one twelvemonth or greater; (5) inclusion of environmental strategy; and (6) multi-pronged approach. Tabular array 3 summarizes recommendations for future schoolhouse-based obesity prevention interventions.

Table 3

Recommendations for school-based obesity prevention interventions.

Strength of research design should be considered.
Theoretical framework should assistance program development and implementation.
Intervention should be tailored to target audience (i.eastward., depression-income, class level, geographic location).
Integrate a combination of nutrition and physical activity strategies.
Parents play a crucial role in childhood behavior change and should be included.
Environmental strategies should be considered.
Teachers are virtually likely to help with program implementation and should receive adequate training.
Intervention elapsing of one yr correlates with positive BMI outcomes and sustainability.
Incorporate multiple outcomes, including cognition, attitudes, behaviors, related theoretical constructs, and anthropometric data.Implement follow-up measures to decide long-term efficacy of the intervention.

Ane important benefit of schoolhouse-based obesity prevention interventions non all the same mentioned is minimal attrition throughout the implementation menstruum. Schools provide a captive audience for the majority of the year. Ii interventions [30,35] reported 100% of participants completing the duration of the intervention, with lengths of two to 4 months. Although attrition rates tended to increase the longer the intervention duration, the majority of participants completed all measures. Interventions with a duration of one year and BMI as a primary outcome resulted in an average of 92% completion—lending support for a long-term intervention. Attrition in school-based interventions tin oftentimes not be helped, peculiarly when students move to a new schoolhouse, consequently making information technology difficult to follow-upward. Therefore, the reasons participants did not complete the interventions were often not reported in the included school-based studies. Future research should aim to differentiate attrition categories to include those students who moved to another school and/or other extenuating reasons. This will assist feasible intervention design and development of appropriate follow-upwardly measures. Additionally, international interventions tended to have higher attrition rates compared to their U.South. counterparts. Every bit a result, the methodology of international interventions should be more closely studied to determine if the higher rates of compunction are related to cultural influences, efficacy of program implementation, or other factors. Likewise, follow-upwardly of any kind was exceptional throughout studies and its value should be considered in time to come interventions, given the demand to determine lasting efficacy.

four. Limitations

Limitations within this review should be noted. As this is a qualitative review, data were nerveless, examined, and summarized in a narrative format; a quantitative meta-analysis was not performed. For that reason, all written report designs were included. Although the majority of the interventions incorporated a RCT or quasi-experimental pattern, this is important to mention. Furthermore, studies were omitted if they were not in English, which could limit the applicability of this review to other countries as well suffering from a childhood overweight and obesity epidemic. Studies that were conducted outside of regular school hours were excluded considering differences in potential intervention strategies and target population. In addition, interventions that failed to written report one or more outcomes were excluded as information technology was not possible to evaluate the efficacy of such studies. Studies that were published prior to 1 January 2002 were excluded, but many were included in a previous comprehensive review—justifying the reasoning to limit studies published after that date. Only peer-reviewed articles within the included databases were included, increasing the likelihood of publication bias, since unpublished studies were not reported. Although babyhood obesity is a pop topic and an abundance of articles were retrieved from the initial search, every endeavor was fabricated to be comprehensive and systematic throughout data drove.

five. Conclusions

With 43 million children globally considered overweight or obese, 92 million at risk of condign overweight, and a projected increase of babyhood overweight and obesity estimated to reach 9.ane% worldwide in 2020, babyhood obesity has become a public wellness crisis in dire demand of back up [four]. Schoolhouse-based interventions are essential in the fight against global childhood obesity since many children lack diet and/or concrete activity educational activity, resource, and back up exterior of their homes [12,thirteen,14,fifteen,16]. As supported past the promising outcomes reported in this review, childhood obesity can be mitigated through the use of school-based interventions. Given the number of hours per 24-hour interval that children spend in schools, they afford an first-class medium through which to implement obesity prevention interventions. Although differences did be when comparing interventions implemented in the United States and internationally, common themes emerged which should be shared widely with health professionals and schoolhouse personnel planning and implementing school-based obesity prevention programs. There is a demand to incorporate multi-pronged, tailored strategies in interventions with duration of one yr or more. Environmental changes as well seem to be promising as impactful intervention strategies. In addition, in that location is a need to include extensive follow-upwardly measures to assess the long-term efficacy of school-based interventions [21]. In that location is no need to reinvent the wheel when designing similar obesity prevention programs. Health professionals need to work together to share lessons learned in gild to promote cost-constructive and efficacious school-based interventions that volition impact the childhood obesity epidemic. The continued support, implementation, and monitoring of these types of prove-based programs will help to combat the rising rates of childhood obesity worldwide.

Author Contributions

All authors contributed extensively to the work presented in this paper. Manoj Sharma conceptualized the written report and reviewed all pieces. Melinda J. Ickes supervised the progress, reviewed included interventions, wrote and reviewed manuscript. Jennifer McMullen conducted the search, organized table, wrote and reviewed manuscript. Taj Haider conducted initial search, reviewed manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

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