TITLE: Interventions for the Prevention or Management of Childhood Obesity: A Review of the Clinical Evidence

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1 TITLE: Interventions for the Prevention or Management of Childhood Obesity: A Review of the Clinical Evidence DATE: 13 December 2013 CONTEXT AND POLICY ISSUES Over 30% of children and youth in Canada are considered overweight or obese. 1 Obesity is caused by long-term energy imbalances, whereby daily energy intake exceeds daily energy expenditure. 2 Obesity if often defined by body mass index (), calculated as weight in kilograms divided by height in meters squared (kg/m 2 ). varies in children and youth, thus values are typically compared to reference population charts to obtain a ranking of percentile for age and sex. 2 According to the World Health Organization (WHO), among adolescents, overweight is defined as one standard deviation above the reference value for age and sex and obesity is defined as two standard deviations above the reference value for age and sex. 3 As most adolescents do not outgrow obesity, 4 up to 70% of adults aged 40 will either be overweight or obese by 2040 if current trends continue. 5 Both physical and emotional health consequences are more likely to develop in obese children and become increasingly apparent in adulthood as unhealthy weights are associated with increased risk of strokes and type 2 diabetes, 6 heart disease, 7 and cancer. 8 In 2008, the annual economic burden of obesity in Canada was estimated to be $4.6 billion. 9 As Canada continues to face an obesity epidemic, effective prevention and management of childhood obesity is essential to ensure Canadian children and youth have healthy start in life. The objective of this review is to summarize recent clinical evidence of interventions for the prevention and management of childhood obesity. RESEARCH QUESTIONS 1. What is the clinical evidence regarding interventions for the prevention of childhood obesity? 2. What is the clinical evidence regarding interventions for the management of childhood obesity? Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. Rapid responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report. Copyright: This report contains CADTH copyright material and may contain material in which a third party owns copyright. This report may be used for the purposes of research or private study only. It may not be copied, posted on a web site, redistributed by or stored on an electronic system without the prior written permission of CADTH or applicable copyright owner. Links: This report may contain links to other information available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners own terms and conditions.

2 KEY FINDINGS Evidence suggests that multicomponent interventions targeting physical activity, diet and behavior may have a potential benefit on anthropometric outcomes for both the prevention and management of childhood obesity. Given the limitations in the literature, there is a need for further high quality research in both the prevention and management of childhood obesity. METHODS Literature Search Strategy A limited literature search was conducted on key resources including PubMed, The Cochrane Library (2013, Issue 10), University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. Methodological filters were applied to limit retrieval to health technology assessments, systematic reviews, and meta-analyses. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2008 and November 20, Selection Criteria and Methods One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed for relevance. Full texts of relevant titles and abstracts were retrieved and assessed for inclusion. The final article selection was based on the inclusion criteria presented in Table 1. Table 1: Selection Criteria Population Q1: children and youth who are of normal weight Q2: children and youth who are overweight or obese Intervention Non-drug, non-surgical interventions for the management or prevention of obesity (multi-faceted, including physical activity, nutrition and behavioural) Comparator Other formal programs or approaches Outcomes Study Designs Clinical effectiveness Health technology assessments, systematic reviews, and metaanalyses Exclusion Criteria Studies were excluded if they used pharmacological or surgical interventions for the management or prevention of obesity. Due to the availability of an existing review of reviews published in 2011, studies were excluded if they were published prior to that date. For the first question, studies were excluded if they did not include children and youth who are of normal weight. For the second question, studies were excluded if they did not include children and youth who are overweight or obese. For both questions, studies were excluded if the focus was on specific populations (e.g., those not generalizable to the Canadian context), they did not describe research in countries comparable to Canada (i.e., developed countries such as the Interventions for the Prevention or Management of Childhood Obesity 2

3 U.S., the U.K. and Europe), that did not provide detailed results for anthropometric outcomes (i.e., weight, waist circumference) or were already included in other systematic reviews, meta-analyses or review of reviews. Critical Appraisal of Individual Studies A numeric score was not calculated for each study, instead key methodological aspects relevant to each study design were appraised and summarized narratively. The methods used when conducting the literature search, study selection, quality assessment, data, and summarizing the data were appraised for systematic reviews and meta-analyses, based on the AMSTAR instrument. 10 SUMMARY OF EVIDENCE Quantity of Research Available The literature search yielded 300 citations. Upon screening titles and abstracts, 250 citations were excluded and 50 potentially relevant articles were retrieved for full-text review. An additional potentially relevant report was retrieved from the grey literature hand searching. Of the 51 potentially relevant reports 36 were excluded. One review of reviews 11 and 14 systematic reviews and meta-analyses published since met the inclusion criteria. The process of study selection is outlined in the PRISMA flowchart (Appendix 1). Summary of Study Characteristics Individual study characteristics for the included studies are provided in Appendix 2 (Obesity Prevention) and Appendix 3 (Obesity Management) Obesity Prevention One review of reviews 11 two systematic review (SRs), 12,13 and four meta-analyses 14-16,26 met the inclusion criteria and were included in the review. The included studies compared physical activity (PA) and diet (both individually and in combination with one another) and behaviour interventions compared with usual care/no intervention, health education, or waiting list to receive an obesity prevention intervention. Anthropometric outcomes included, z-score (an expression of standard deviations above the of a distribution adjusted for sex, height and age), weight, and waist circumference. The interventions in the included studies ranged from 1 month to 7 years (Appendix 2). Obesity Management One review of reviews, 11 one systematic review (SR), 25 and 9 meta-analyses 15,17-24 met the inclusion criteria and were included in the review. The included studies compared physical activity (PA), diet, and behaviour interventions (individually and in combination with one another) and were either compared before and after the interventions or were compared with usual care/no intervention, diet interventions only, health education, or waiting list. Anthropometric outcomes included, z-score, weight, percent body fat, and waist circumference. The interventions in the included studies ranged from 2 weeks to 6 years (Appendix 3). Interventions for the Prevention or Management of Childhood Obesity 3

4 Summary of Critical Appraisal Details of the appraisal of individual studies is provided in Appendix 4 and Appendix 5 for studies on obesity prevention and obesity management, respectively. Obesity Prevention The included review of reviews, 11 SRs, 12,13 and MAs on obesity prevention had major strengths and limitations. The major strengths in all included studies were the use of a priori designs, duplicate study selection and data, comprehensive literature searches, the assessment and documentation of the scientific quality of the included studies which was appropriately used to formulate conclusions, and statements of conflict of interest. The characteristics of the included studies were provided in all but one 13 of the included systematic reviews/meta-analyses. The included SRs and MAs were limited as only one review 16 provided a list of the excluded studies. In the three MAs, heterogeneity was moderate in one, 15 while one did not present heterogeneity results, 14 and another did not pool studies due to the heterogeneity. 16 Heterogeneity between included studies was commonly a result of variation in intervention activities, delivery, duration and settings. The majority of the included studies were of low methodological quality in three of the reviews 11,14,15 and of moderate methodological quality in the other three reviews 12,13,16 Common potential sources of bias that led to low to moderate study ratings included inadequate allocation concealment, blinding, and either a substantial loss to follow-up, or number of individuals discontinuing not being reported (Appendix 4). Obesity Management The included review of reviews 11, SR 25, and MAs 15,17-24 on obesity management had major strengths and limitations. The major strengths in all included studies were the use of a priori designs and comprehensive literature searches. The characteristics of the included studies were provided in all but one 13 of the included systematic reviews/meta-analyses. Duplicate study selection and data was not in two reviews, 18,19 was unclear in another, 25 and was only for study selection in another review. 21 The remaining reviews reported duplicate study selection and data. The assessment and documentation of the scientific quality of the included studies were appropriately used to formulate conclusions, and statements of conflict of interest were seen in all reviews with the exception of one MA 23 and one SR. 25 Appropriate methods were used to combine findings in all MAs but one (heterogeneity was only reported as significant or not with no values provided). 18 The included SR and MAs were limited as no reviews provided a list of the excluded studies and publications not written in English were excluded in 6 reviews. 11,17,18,20,22,23 In the nine MAs, 15,17-24 heterogeneity was high, 17,20-24 in two it was deemed moderate, 15,18 and one review having low heterogeneity. 19 Heterogeneity between included studies was commonly a result of varying intervention activities, delivery, duration and settings.the majority of studies in six of the included reviews were of low quality, 11,15,18,20,22,24 and studies in three reviews were of moderate 12,13,16 methodological quality. Common potential sources of bias that led to low to moderate study ratings included inadequate allocation concealment, blinding, and either a substantial loss to follow-up, or number of individuals discontinuing not being reported. Only one review consisted of high quality studies. 21 There was a lack of detailed description of which control interventions were used in three reviews (Appendix 5). 11,17,24 Interventions for the Prevention or Management of Childhood Obesity 4

5 Summary of Findings Details of individual study findings are provided in Appendix 6 and Appendix 7. Obesity Prevention Physical Activity and/or Nutrition interventions The review of reviews 11 included 5 SRs and MAs that reported anthropometric outcomes When PA and/or diet interventions were compared with control, standardized differences in ranged from to 0.05, though none of these results were statistically significant. Bleich et al.(2013) 12 measured the when combined PA and diet interventions were compared with usual care, no intervention, or health education and revealed results that ranged from to 0.2, though statistical significance was not achieved in three of the four studies. Two studies revealed a statistically significant z-score ranging from to when compared with control. Showell et al. (2013) 13 measured the difference in, z-score and weight when a combined PA and diet intervention was compared with usual care or no intervention. Results did not favour the intervention groups and were not statistically significant. Behavioural and/or Educational Interventions School-based obesity preventions programs which included informative, behavioural, and cognitive components were compared with no intervention. Pooled results for standardized change favoured the intervention groups with a standardized change in of (95% confidence interval [CI] to ). 14 Sbruzzi et al. (2013) 18 measured and z-score when an educational interventions was compared with usual care, no interventions or waiting list. Pooled results favoured the intervention groups, but were not statistically significant. Dobbins et al. (2013) 16 measured for schoolbased interventions promoting PA and fitness compared with standard currently existing education programs. Results ranged from to 0.10, demonstrating statistical significance in 8 of the 12 included studies (Appendix 6). Obesity Management Multicomponent interventions The review of reviews 11 included 2 MAs 32,33 that reported anthropometric outcomes. When a multi-component intervention including PA education, nutrition, peer facilitation, and problem solving involving family was compared with controls in schools and other settings, the pooled effect size across included studies (Cohen s d) was 0.41 (95% CI, 0.26 to 0.55). 32 Another MA 33 which assessed lifestyle interventions including dietary, PA and/or behavioural therapy compared with single behaviour interventions, revealed a standardized z-score of (95% CI, to -0.12) for youth over the age of 12 years. The analysis for youth under 12 years of age also favoured the lifestyle interventions, but did not reach statistical significance (Appendix 7). Schranz et al. (2013) 18 measured the and percent body fat when aerobic training was combined with resistance training, and/or nutrition education, and/or motivational Interventions for the Prevention or Management of Childhood Obesity 5

6 interviewing, compared with no intervention or diet interventions only. Results were converted so that a positive standardized difference reflected a favourable change in the intervention group relative to the control group for RCTs/NRCTs and a favourable change postintervention for UCTs. The standardized was 0.16 (95% CI, 0.01 to 0.30) when RCTs and non-randomized controlled trials (NRCTs) were pooled, and 0.32 (95% CI, 0.09 to 0.39) when uncontrolled clinical trials (UCTs) were pooled indicating a decrease in among the combination interventions. The standardized percent body fat was 0.24 (95% CI, 0.09 to 0.39) when RCTs and NRCTs were pooled, and 0.32 (95% CI, 0.09 to 0.39) when uncontrolled clinical trials (UCT) were pooled. The results therefore favoured the combination intervention groups. Williams et al. (2013) 19 measured the when combined diet and PA policies, PA policies, and diet policies were compared with no intervention or measured postintervention. differences ranged from to 0, with two of the five studies not demonstrating statistical significance when the combined policies were compared with no intervention or measured post-intervention. Pooled results for PA policies and diet policies did not reach statistical significance. Ho et al. (2013) 20 measured the when the combination of diet and aerobic training were compared with diet only, the combination of diet and resistance training compared with diet only, and the combination of diet, resistance and aerobic training compared with diet only. Pooled results favoured the combination interventions of diet and aerobic training, and diet, resistance and aerobic training when compared with diet only, though results were not statistically significant. The combination of diet and resistance training compared with diet only demonstrated a standardized difference of 0.40 (95%CI, 0.08 to 0.71) favouring the diet only interventions (Appendix 7). Sbruzzi et al. (2013) 15 measured differences in, z-score, and waist circumference when multicomponent behavioural interventions were compared with usual care, no intervention or waiting lists. Results favoured the multicomponent intervention groups and demonstrated a standardized of (95%CI, to -0.14) and standardized waist circumference of -3.1 (95%CI, to -0.07). Results for z-scores were not statistically significant (Appendix 7). Ho et al. (2012) 22 measured differences in and z-score when lifestyle interventions including diet, exercise, and/or behaviour modification were compared with no intervention or waiting list, usual care, and written education. Lifestyle interventions compared with no intervention or waiting demonstrated a standardized of (95% CI, to -0.32), and a z-score of (95%CI to -0.02) favouring the lifestyle interventions. Lifestyle interventions compared with usual care demonstrated a standardized of (95% CI, to -1.03) favouring the lifestyle interventions. Compared with written education, lifestyle interventions demonstrated a standardized difference of (95% CI, to -0.91) for standardized difference in and (95% CI, to -0.91) favouring the lifestyle interventions (Appendix 7). Lavelle et al. (2012) 23 measured differences in when school-based multicomponent interventions including PA, educational and behavioural components, combined school-based PA and nutrition interventions, and school-based PA interventions only were compared with no intervention. The standardized difference was (95% CI, to -0.08) for the multicomponent interventions including PA, educational and behavioural components, Interventions for the Prevention or Management of Childhood Obesity 6

7 (95% CI, to -0.04) for the combined school-based PA and nutrition interventions, and (95% CI, to -0.06) for PA interventions only when compared with no intervention (Appendix 7). Friedrich et al. (2012) 24 measured differences in when combined PA and nutritional education interventions, PA only interventions, and nutritional education interventions were compared with control. The standardized was (95% CI, to ) for combined PA and nutritional education intervention, (95% CI, to -0.04) for PA only interventions, and (95% CI, to -0.04) for nutritional education interventions when compared to control (Appendix 7). Physical activity Guerra et al. (2013) 17 measured and body weight when school-based physical activity interventions were compared with control. Both outcomes favoured the school-based physical activity interventions, though results did not reach statistical significance (Appendix 7). Dietz et al. (2012) 25 measured differences in, weight, and body fat with resistance training when measured before and after the interventions in UCTs and compared with no exercise in RCTs and NRCTs. When resistance training was measured post-intervention, differences in ranging from -0.6 to 0.8 (statistical significance was only achieved in two of the five studies), results for weight (kg) ranged from 0.6 to 4.0 (statistical significance was only achieved in two of the six studies) and results for body fat ranged from -0.1 to -0.4 (statistical significance was only achieved in one of the three studies). When resistance training was compared with no intervention, differences in ranged from to -0.4 (statistical significance was only achieved in one of the three studies), results for weight ranged from -0.5 to 1.1 (statistical significance was only achieved in one of the four studies) and results for body fat ranged from -0.4 to 3.2 (statistical significance was only achieved in two of the three studies) (Appendix 7). Nutrition Silveria et al. (2013) 21 measured differences in when comparing school-based nutrition education interventions compared with control. The standardized difference was (95% CI, to -0.11) favouring the nutrition interventions (Appendix 7). Limitations While this report is built upon a review of reviews published in 2011, the studies included in the selected reviews were published between 1979 and 2013 Although the SRs and MAs were generally of moderate quality, the majority of included studies within these reviews were typically of low to moderate methodological quality and at risk of bias. Furthermore, the pooled results are subject to bias given the high amount of heterogeneity caused by various interventions, delivery, durations and settings seen among the included studies. Although we aimed to only include research in countries comparable to Canada, some the larger SRs and MAs included studies in countries that may not be generalizable to the Canadian population. Given the large sample sizes, it was not deemed appropriate to excluded these reviews if the majority (>50%) of studies were in developed countries comparable to Canada. Pooled data presented in this review should therefore be interpreted with caution. With a high degree of heterogeneity, the results may not be precise and may mask real effects in Interventions for the Prevention or Management of Childhood Obesity 7

8 particular settings or with specific interventions. Furthermore, anthropometric outcomes such as, weight and waist circumference which are proxy measures for actual health. Other behavioural outcomes that may be of importance such as changes in patterns of physical activity and health eating, which were not reported in the studies included in this review. CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING This report aimed to evaluate the clinical evidence regarding interventions for the prevention and management of childhood obesity. In regards to obesity prevention, evidence suggested a benefit of PA, nutrition and behavioural interventions either in combination with one another or alone on anthropometric outcomes, though results did not always reach statistical significance. In regards to obesity management, evidence suggested that multicomponent lifestyle interventions targeting PA, diet and behaviour may have a beneficial effect on anthropometric outcomes, though results did not always reach statistical significance. Overall, given the limitations discussed in this report, there is a need for further high quality research in both the prevention and management of childhood obesity. PREPARED BY: Canadian Agency for Drugs and Technologies in Health Tel: Interventions for the Prevention or Management of Childhood Obesity 8

9 REFERENCES 1. Childhood Obesity Foundation [Internet]. Vancouver: The Foundation [cited 2013 Dec 2]. Available from: 2. Canoy D, Bundred P. Obesity in children. Clin Evid (Online) [Internet] [cited 2013 Dec 2];2011(04):325. Available from: 3. World Health Organization (WHO) [Internet]. Geneva: WHO; c2013. Childhood overweight and obesity; 2013 [cited 2013 Dec 2]. Available from: 4. Singh AS, Mulder C, Twisk JW, van MW, Chinapaw MJ. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev Sep;9(5): Le Petit C, Bertholot JM. Obesity: a growing issue [Internet]. Ottawa: Statistics Canada; (Component of Statistics Canada catalogue no MWE ). [cited 2013 Dec 2]. Available from: eng.pdf 6. Smith SC Jr. Multiple risk factors for cardiovascular disease and diabetes mellitus. Am J Med Mar;120(3 Suppl 1):S3-S Zalesin KC, Franklin BA, Miller WM, Peterson ED, McCullough PA. Impact of obesity on cardiovascular disease. Endocrinol Metab Clin North Am. 2008;37(3): Danaei G, Vander HS, Lopez AD, Murray CJ, Ezzati M, Comparative Risk Assessment collaborating group (Cancers). Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. Lancet Nov 19;366(9499): Obesity in Canada: a joint report from the Public Health Agency of Canada and the Canadian Institute for Health Information [Internet]. Ottawa: Public Health Agency of Canada; Health and economic implications. [cited 2013 Dec 2]. Available from: Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol [Internet] [cited 2013 Nov 5];7:10. Available from: Ontario Agency for Health Protection and Promotion (Public Health Ontario). Addressing obesity in children and youth: evidence to guide action for Ontario [Internet]. Toronto: Queen's Printer for Ontario; 2013 Sep. [cited 2013 Dec 2]. Available from: ept2013.pdf 12. Bleich SN, Segal J, Wu Y, Wilson R, Wang Y. Systematic review of community-based childhood obesity prevention studies. Pediatrics [Internet] Jul [cited 2013 Nov Interventions for the Prevention or Management of Childhood Obesity 9

10 25];132(1):e201-e210. Available from: Showell NN, Fawole O, Segal J, Wilson RF, Cheskin LJ, Bleich SN, et al. A systematic review of home-based childhood obesity prevention studies. Pediatrics [Internet] Jul [cited 2013 Nov 25];132(1):e193-e200. Available from: Sobol-Goldberg S, Rabinowitz J, Gross R. School-based obesity prevention programs: A meta-analysis of randomized controlled trials. Obesity (Silver Spring) Jun Sbruzzi G, Eibel B, Barbiero SM, Petkowicz RO, Ribeiro RA, Cesa CC, et al. Educational interventions in childhood obesity: a systematic review with meta-analysis of randomized clinical trials. Prev Med May;56(5): Dobbins M, Husson H, DeCorby K, LaRocca RL. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database Syst Rev. 2013;2:CD Guerra PH, Nobre MR, Silveira JA, Taddei JA. The effect of school-based physical activity interventions on body mass index: a meta-analysis of randomized trials. Clinics (Sao Paulo) [Internet] Sep [cited 2013 Nov 25];68(9): Available from: Schranz N, Tomkinson G, Olds T. What is the effect of resistance training on the strength, body composition and psychosocial status of overweight and obese children and adolescents? A Systematic review and meta-analysis. Sports Med Sep;43(9): Williams AJ, Henley WE, Williams CA, Hurst AJ, Logan S, Wyatt KM. Systematic review and meta-analysis of the association between childhood overweight and obesity and primary school diet and physical activity policies. Int J Behav Nutr Phys Act [Internet] [cited 2013 Nov 25];10(1):101. Available from: Ho M, Garnett SP, Baur LA, Burrows T, Stewart L, Neve M, et al. Impact of dietary and exercise interventions on weight change and metabolic outcomes in obese children and adolescents: a systematic review and meta-analysis of randomized trials. JAMA Pediatr Aug 1;167(8): Silveira JA, Taddei JA, Guerra PH, Nobre MR. The effect of participation in school-based nutrition education interventions on body mass index: a meta-analysis of randomized controlled community trials. Prev Med Mar;56(3-4): Ho M, Garnett SP, Baur L, Burrows T, Stewart L, Neve M, et al. Effectiveness of lifestyle interventions in child obesity: systematic review with meta-analysis. Pediatrics [Internet] Dec [cited 2013 Nov 25];130(6):e1647-e1671. Available from: Interventions for the Prevention or Management of Childhood Obesity 10

11 23. Lavelle HV, Mackay DF, Pell JP. Systematic review and meta-analysis of school-based interventions to reduce body mass index. J Public Health (Oxf) [Internet] Aug [cited 2013 Nov 25];34(3): Available from: Friedrich RR, Schuch I, Wagner MB. Effect of interventions on the body mass index of school-age students. Rev Saude Publica [Internet] Jun [cited 2013 Nov 25];46(3): Available from: Dietz P, Hoffmann S, Lachtermann E, Simon P. Influence of exclusive resistance training on body composition and cardiovascular risk factors in overweight or obese children: a systematic review. Obes Facts. 2012;5(4): Luckner H, Moss JR, Gericke CA. Effectiveness of interventions to promote healthy weight in general populations of children and adults: a meta-analysis. Eur J Public Health [Internet] Aug [cited 2013 Nov 25];22(4): Available from: Waters E, de Silva-Sanigorski A, Hall BJ, Brown T, Campbell KJ, Gao Y, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2011;(12):CD Cook-Cottone C, Casey CM, Feeley TH, Baran J. A meta-analytic review of obesity prevention in the schools: Psychol Sch. 2009;46(8): Gonzalez-Suarez C, Worley A, Grimmer-Somers K, Dones V. School-based interventions on childhood obesity: a meta-analysis. Am J Prev Med Nov;37(5): Harris KC, Kuramoto LK, Schulzer M, Retallack JE. Effect of school-based physical activity interventions on body mass index in children: a meta-analysis. CMAJ [Internet] Mar 31 [cited 2013 Dec 2];180(7): Available from: Kanekar A, Sharma M. Meta-analysis of school-based childhood obesity interventions in the U.K. and U.S. International Quarterly of Community Health Education. 2009;29(3): Kitzman-Ulrich H, Wilson DK, St George SM, Lawman H, Segal M, Fairchild A. The integration of a family systems approach for understanding youth obesity, physical activity, and dietary programs. Clin Child Fam Psychol Rev [Internet] Sep [cited 2013 Dec 2];13(3): Available from: Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O'Malley C, Stolk RP, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev. 2009;(1):CD Interventions for the Prevention or Management of Childhood Obesity 11

12 APPENDIX 1: Selection of Included Studies 300 citations identified from electronic literature search and screened 250 citations excluded 50 potentially relevant articles retrieved for scrutiny (full text, if available) 1 potentially relevant report retrieved from other sources (grey literature, hand search) 51 potentially relevant reports 36 reports excluded: -irrelevant population (6) -irrelevant intervention (5) -irrelevant outcomes (11) -already included in at least one of the selected systematic reviews (9) -other (review articles, editorials)(2) -unable to retrieve publication (3) 15 reports included in review Interventions for the Prevention or Management of Childhood Obesity 12

13 APPENDIX 2: Characteristics of Included Systematic Reviews for the prevention of childhood obesity First author, year, funding source Public Health Ontario, Government of Ontario Study type, N studies, sample size (n) Review of MAs and SRs, 7 MAs and 22 SRs; n=nr Range of years of included studies Age 2009 to to 19 years Interventions, range of duration Physical activity Nutrition Computer/internet-based interventions Outcomes z- score Weight Bleich, Agency for Healthcare Research and Quality, US Department of Health and Human Services Showell, Agency for Healthcare Research and Quality, US Department of Health and Human Services SR, 5 RCTs, 4 NRCTs, n=54,239 SR, 6 RCTs, n=2, to to 18 years 2001 to to 17 years Duration NR Physical activity Nutrition Combined physical activity and nutrition 4 to 48 months Nutrition Combined physical activity and nutrition Primary care and consumer health informatics components School and community components z- score z- score Weight Sobel-Goldberg, MA, 32 RCTs, n=52, to 52 weeks 2006 to 2011 NR Physical activity Nutrition Sbruzzi, Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq) and Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior (CAPES) MA, 26 RCTs, n=23,617 Duration NR 1989 to 2012 NR Educational/Behavioural 6 to 28 months z- score Waist circumfere nce Dobbins, Cochrane Health Promotion and Public Health Field, Australia and City of Hamilton Public Health Services, Canada. MA, 44 RCTs, n=36, to years Physical activity Nutrition Educational/Behavioural 12 weeks to 6 years 1: excludes participants from two cross-sectional studies (total n was not provided) 2: 13 studies involved adults (>18 years) 3: The total number of participantsunknown as sample sizes were reported by type of intervention and outcome measure. 4: Range of s = body mass index; MA= meta-analyses; NRCT= non-randomized controlled trial; NR= not reported; RCT= randomized controlled trial; SR = systematic reviews; UCT= uncontrolled trials Interventions for the Prevention or Management of Childhood Obesity 13

14 APPENDIX 3: Characteristics of Included Systematic Reviews for the Management of Childhood Obesity First author, year, funding source Public Health Ontario, Government of Ontario Study type, N studies, sample size (n) Review of MAs and SRs, 5 MAs and 10 SRs; n=nr Range of years of included studies Age 2008 to to 19 years Interventions, range of duration Physical activity Nutrition Computer/internet-based interventions Outcomes z- score Guerra, Fundacao de Amparo a Pesquisa de Sao Paulo Schranz, NR Williams, Medical Research Council Doctoral Training Grant and Sport and Health Sciences, University of Exeter Ho, Australian National Health and Medical Research Council Sbruzzi, Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq) and Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior (CAPES) MA, 12 RCTs, n=4,273 for, n=1,330 for body weight, n=1,549 for blood pressure MA, 18 RCTs, 5 NRCTs, and 17 UCT, n=1,734 MA, 2 RCTs, 11 Cohort studies, 3 controlled before/after studies, 5 crosssectional studies, n=164,533 for nutrition policies, n=243,348 for physical activity policies, n=5,477 a for combined policies MA, 15 RCTs, n=879 MA, 26 RCTs, n=23, to years 1998 to to 18 years 2003 to to 11 years 1984 to to 18 years Duration NR Physical activity 2 weeks to 48 months Physical activity Nutrition Combined physical activity and nutrition 6 to 52 weeks Physical activity policy Nutrition policy Combined physical activity and nutrition policies Duration NR Physical activity Nutrition Combined physical activity and nutrition 1989 to 2012 NR Educational/Behavioural 6 to 28 months Body weight Percent body fat Waist circumfer ence Weight z- score Waist circumfer ence Silveira, MA, 8 SRs, n=8, to to 13 Nutrition Educational/Behavioural Interventions for the Prevention or Management of Childhood Obesity 14

15 First author, year, funding source Fundacao de Amparo a Pesquisa de Sao Paulo (FAPESP) Study type, N studies, sample size (n) Range of years of included studies Age years Interventions, range of duration 4 months to 3 years Outcomes Ho, Australian National Health and Medical Research Council, Cancer Institute NSW Early Career Development Fellowship Grant, Priority Research Centre in Physical Activity and Nutrition, National Health and Medical Research Council MA, 38 RCTs, 1979 to to n=3086 b 18 years Physical activity Nutrition 1 month to 4 years z- score Lavelle, NR MA, 38 RCTs, 5 NRCTs, n=ns 1991 to years Physical activity Nutrition Educational/Behavioural Combined physical activity and nutrition Combined physical activity, nutrition, and educational/behavioural 1 to 72 months Friedrich, Conselho Nacional de Desenvolvimento Científi co e Tecnológico (CNPq National Council for Scientific Development; Dietz, Unknown MA, 23 RCTs, n=17,693 SR, 2 RCTs, 2 NRCTs, 2 UCTs, n= to to 17 years 1998 to to 15 years Physical activity Nutrition Combined physical activity and nutrition 3 to 72 months Physical activity 8 weeks to 5 months Weight Percent body fat a: total excludes participants from two cross-sectional studies (total n was not provided) b: total excludes participants from 5 RCTs c: based on totals provided by systematic review and RCT outcome measurements = body mass index; MA= meta-analyses; NRCT= non-randomized controlled trial; NR= not reported; RCT= randomized controlled trial; SR = systematic reviews; UCT= uncontrolled trials Interventions for the Prevention or Management of Childhood Obesity 15

16 APPENDIX 4: Critical Appraisal of Obesity Prevention Systematic Reviews and Meta-analyses Author, year Strengths Limitations Systematic reviews Public Health Ontario, 'a priori' design provided duplicate study selection and data characteristics of the included studies provided used appropriately in formulating conclusions conflict of interest stated Bleich, 'a priori' design provided duplicate study selection and data characteristics of the included studies provided used appropriately in formulating conclusions conflict of interest stated Showell, 'a priori' design provided duplicate study selection and data characteristics of the included studies provided used appropriately in formulating conclusions conflict of interest stated Sobel-Goldberg, 'a priori' design provided duplicate study selection and data used appropriately in formulating conclusions conflict of interest stated methods used to combine the findings of studies appropriate A list of excluded studies was not provided Non-English articles were excluded The included SRs and MAs were of generally of low methodological quality lack of detailed description of which control interventions were used A list of excluded studies was not provided Non-English articles were excluded The majority of studies were of moderate risk of bias A list of excluded studies was not provided The majority of studies were of moderate risk of bias limited by paucity of studies A list of excluded studies was not provided non-english articles were excluded limited information provided on the characteristics of the included studies provided heterogeneity results not presented, though authors confirmed studies large heterogeneity Sbruzzi, 'a priori' design provided most included studies were of low Interventions for the Prevention or Management of Childhood Obesity 16

17 Author, year Strengths Limitations duplicate study selection and data characteristics of the included studies provided used appropriately in formulating conclusions conflict of interest statedmethods used to combine the findings of studies appropriate Dobbins, 'a priori' design provided duplicate study selection and data characteristics of the included studies provided list of included and excluded studies provided used appropriately in formulating conclusions conflict of interest stated methodological quality (no double-blind studies and did not have enough statistical power) list of excluded studies not provided moderate heterogeneity for studies assessing, and high heterogeneity for studies assessing waist circumference heterogeneity between studies was not assessed majority of studies were of moderate risk of bias Interventions for the Prevention or Management of Childhood Obesity 17

18 APPENDIX 5: Critical Appraisal of Obesity Management Systematic Reviews and Meta-analyses Author, year Strengths Limitations Public Health Ontario, 'a priori' design provided duplicate study selection and data Government of Ontario characteristics of the included studies provided used appropriately in formulating conclusions conflict of interest stated Guerra, 'a priori' design provided duplicate study selection and data characteristics of the included studies provided conflict of interest stated scientific quality of the includedtudies used appropriately in formulating conclusions methods used to combine the findings of studies appropriate Schranz, 'a priori' design provided characteristics of the included studies provided studies used appropriately in formulating conclusions conflict of interest stated Williams, 'a priori' design provided characteristics of the included studies provided used appropriately in formulating conclusions conflict of interest stated methods used to combine the findings of studies appropriate a list of excluded studies was not provided non-english articles were excluded lack of detailed description of which control interventions were used list of excluded studies not provided high heterogeneity among included studies measuring lack of detailed description of which control interventions were used The majority of studies were of moderate risk of bias non-english articles were excluded list of excluded studies not provided no duplicate study selection and data methodological variability (different types of exercise interventions) between studies seven of the twenty-five studies did not use a true control group as they also received some type of intervention heterogeneity was only reported as significant or not. Heterogeneity was significant in UCTs, % body fat RCTs, NRCTs, and UCTs list of excluded studies not provided no duplicate study selection and data high loss to follow-up in several of the included studies Included various study designs and intervention durations heterogeneity was not reported for the combined policy cluster The majority of studies were of moderate risk of bias Interventions for the Prevention or Management of Childhood Obesity 18

19 Author, year Strengths Limitations low heterogeneity among individual diet and PA policy clusters Ho, 'a priori' design provided duplicate study selection and data list of included studies provided characteristics of the included studies provided scientific quality of the includedtudies used appropriately in formulating conclusions conflict of interest stated methods used to combine the findings of studies appropriate Sbruzzi, 'a priori' design provided duplicate study selection and data characteristics of the included studies provided studies used appropriately in formulating conclusions conflict of interest stated methods used to combine the findings of studies appropriate Silveira, 'a priori' design provided status of publication used as an inclusion criterion characteristics of the included studies provided scientific quality of the includedtudies used appropriately in formulating conclusions conflict of interest stated methods used to combine the findings of studies appropriate majority of the studies were of high methodological quality Ho, 'a priori' design provided duplicate study selection and data characteristics of the included studies provided non-english articles were excluded list of excluded studies not provided review was confined to published literature high heterogeneity among aerobic training interventions, likely due to variations in study population, and intensity and duration of interventions low methodological quality of included studies in including small sample sizes and short durations of follow-up most included studies were of low methodological quality (no double-blind studies and did not have enough statistical power) list of excluded studies not provided moderate heterogeneity for studies assessing, and high heterogeneity for studies assessing waist circumference list of excluded studies not provided high heterogeneity among included studies duplicate study selection, but not for data lack of detailed description of which control interventions were used non-english articles were excluded list of excluded studies not provided review was confined to published literature high heterogeneity among all intervention groups likely due to variations in study population, and intensity and duration of interventions low methodological quality of included studies and lack of isolation of the effects Interventions for the Prevention or Management of Childhood Obesity 19

20 Author, year Strengths Limitations used appropriately in formulating conclusions conflict of interest statedmethods used to combine the findings of studies appropriate of the dietary intervention components Lavelle, 'a priori' design provided non-english articles were excluded duplicate study selection and data list of excluded studies not provided not conflict of interest not stated characteristics of the included high heterogeneity among included studies provided methods used to combine the findings studies likely caused by the inclusion of non-randomized studies of studies appropriate Friedrich, 'a priori' design provided duplicate study selection and data characteristics of the included studies provided scientific quality of the include studies used appropriately in formulating conclusions conflict of interest stated methods used to combine the findings of studies appropriate Dietz, 'a priori' design provided characteristics of the included studies provided conflict of interest stated list of excluded studies not provided high heterogeneity among combined PA and nutritional education studies majority of included studies were of low methodological quality with small sample sizes lack of detailed description of which control interventions were used non-english articles were excluded list of excluded studies not provided unclear if duplicate study selection and data was not limited by paucity of studies Interventions for the Prevention or Management of Childhood Obesity 20

21 APPENDIX 6. Summary of Findings from Obesity Prevention Systematic Reviews and Metaanalyses First Author, Publication Year Main Study Findings N Studies Intervention Public Health Ontario, a PA and/or diet interventions versus control in schools and other settings 40 School-based PA and/ or diet interventions versus control 19 School-based PA and/ or diet interventions versus control 15 School-based PA interventions versus control Outcome measure change in Effect size of interventions on weight outcomes (Cohen s d) change in change in. Summary effect (95% CI), Heterogeneity (I 2 ) (-0.21 to -0.09) 27 I 2 =NR 0.05 (0.04 to 0.06) 28 I 2 =NR (-1.39 to 0.14) 29 I 2 =NR (-0.19 to 0.20) 30 I 2 =NR Author s Conclusions Overall, the obesity prevention interventions summarized in the reviews appear to have a modest beneficial effect on anthropometric outcomes, particularly among children aged six to 12. Results revealed that the most effective interventions tended to be those that were multi-component in nature, addressing both diet and physical activity, included educational and environmental components, and an element of parental involvement. p School-based PA and/ or diet interventions versus control Bleich, Combined physical activity and diet interventions compared to usual care, no intervention, or health education change in Difference in change of from baseline (control versus intervention) (-0.29 to 0.16) 31 I 2 =NR Pooled results not presented. differences ranged from to 0.2 (statistical significance was only achieved in one study) There are currently not enough studies with consistent methods and outcomes to determine the impact of community-based childhood obesity prevention programs on primary or secondary weight outcomes. However, the evidence suggests that combination interventions implemented in multiple settings may be more effective at preventing weight gain in children than single-component interventions located in the community only p change of z-score from baseline Pooled results not presented. differences Interventions for the Prevention or Management of Childhood Obesity 21