Childhood Obesity Prevention Programs: Comparative Effectiveness

Transcription

1 Childhood Obesity Prevention Programs: Comparative Effectiveness Presented by Youfa Wang, MD, PhD, MS Professor and Chair Department of Epidemiology and Environmental Health School of Public Health and Health Professions University at Buffalo, the State University of New York (SUNY)

2 Outline of What to Expect Definitions, incidence, and prevalence of childhood obesity Grading the strength of a body of evidence Clinical questions addressed What was found What was learned about interventions to prevent childhood obesity How to use these findings 2

3 AHRQ Comparative Effectiveness Review Process Topic Nomination Systematic Review Meta Analysis Public Comment Expert Input Peer Review Final AHRQ report, Clinician Summaries, and Consumer Research Summaries 3

4 Introduction 4

5 Learning Objectives Identify types of obesity prevention programs. Discuss the evidence on the effectiveness and safety of prevention programs. Identify limitations in the current evidence base related to interventions addressing childhood obesity. Summarize future research directions such as additional studies, study design, and analyses. 5

6 How prevalent is obesity in children? What is obesity in children? What are the consequences? 6

7 Prevalence of Childhood Obesity 7

8 Proportion obese Prevalence of Childhood Obesity Prevalence in the US by age: to years 6 11 years years Age of Children 8

9 Health Consequences of Childhood Obesity Obese children Adverse health conditions Cardiovascular outcomes Psychosocial outcomes Metabolic outcomes Eating disorders Depression Low self-esteem 9

10 Medical Complications of Obesity 10

11 Biological Basis for Obesity Individual/Biological Susceptibility Dietary & Physical Activity Patterns Energy Regulation In Out Body Fat Stores 11

12 Factors Affecting Childhood Obesity Individual examples Genetics Nutrition knowledge Nutrition attitude Body weight image Regional and National examples Price of food Food assistance programs Home examples Parenting Home diet Parental weight status Community examples Sidewalks Parks Safety from traffic Crime rate School examples Nutrition service Curriculum Annual BMI 12

13 Defining Obesity and Overweight Different classifications Obesity in children: Medical condition in which excess body fat may have adverse effect on health. age-sex-specific 95 th percentile body mass index (BMI). Overweight in children: age-sex-specific 85 th percentile BMI, but < 95 th percentile. 13

14 Prevention vs Treatment Prevention AKA intervention Goal: Prevent children from becoming overweight or obese May help overweight or obese children lose or stabilize weight Focus of this presentation Treatment AKA weight loss or weight management Goal: Weight loss among pediatric patients. See AHRQ report Effectiveness of Weight Management Interventions in Children: a Targeted Systematic Review for the USPSTF 14

15 Analytic Framework: Evaluation of Childhood Obesity Interventions All children age 2-18 years Settings KQ1 School KQ2 Home KQ3 Primary care KQ 4 Child care KQ 5 Community-level KQ6 Consumer health informatics KQ7 Multi-setting Intermediate Outcomes Nutrition knowledge, attitudes, beliefs Food purchasing behaviors Dietary intake Food access Physical activity Sedentary behavior Obesity-Related Clinical Outcomes Primary Outcomes Change in overweight and obese status Prevalence of overweight and obese BMI Other adiposity measures Cardiovascular outcomes Metabolic outcomes Psychosocial outcomes Adverse Effects of Intervention Burden of intervention Eating disorders Psychosocial outcomes Impact on growth and development Injury Cost Other adverse events 15

16 Scope of the Review Population Interventions Comparators Outcomes Timing Settings Children 2-18 years old, regardless of BMI a) Diet, physical activity, or combination of diet and physical activity b) Setting of intervention No intervention, usual care, or other intervention a) Primary: Weight-related outcomes (e.g., BMI, obesity or overweight rates) b) Intermediate: Dietary intake (e.g., fruits and vegetables, sugarsweetened beverages), physical activity, sedentary activity c) Adverse effects: Eating disorders, psychosocial outcomes, impact on growth and development, injury, cost d) Obesity-related clinical outcomes: Cardiovascular and metabolic outcomes (e.g., blood pressure, blood lipids, blood glucose) a) 6 months for school-based interventions b) 1 year for any other interventions School, home, primary care clinic, childcare, community, environmental-level interventions, or any combination of settings 16

17 Literature Search, Data Collection, and Analysis Data sources: MEDLINE, Embase, PsycInfo, CINAHL, Clinicaltrials.gov, and the Cochrane Library through August 11, Study inclusion criteria Randomized controlled trials, quasi-experimental studies, or natural experiments conducted in high-income countries. Study screening & data extraction: Two reviewers independently reviewed each article for eligibility. For each study, one reviewer extracted the data and a second reviewer verified the accuracy. Meta-analysis 17

18 Key Questions KQ 1 KQ 2 KQ 3 KQ 4 KQ 5 KQ 6 KQ 7 What is the comparative effectiveness of school-based interventions for the prevention of obesity or overweight in children? What is the comparative effectiveness of home-based interventions for the prevention of obesity or overweight in children? What is the comparative effectiveness of primary care based interventions for the prevention of obesity or overweight in children? What is the comparative effectiveness of childcare setting based interventions for the prevention of obesity or overweight in children? What is the comparative effectiveness of community-based or environmental-level interventions for the prevention of obesity or overweight in children? What is the comparative effectiveness of consumer health informatics applications for the prevention of obesity or overweight in children? What is the comparative effectiveness of multi-setting interventions for the prevention of obesity or overweight in children? 18

19 Studies Addressing the Key Questions 104 studies 6 studies 1 study 4 studies 9 studies 0 studies Studies in multi-settings were presented under other KQs. 19

20 Strength of the Evidence High Further research is very unlikely to change the confidence in the estimate of effect. Moderate Further research may change the confidence in the estimate of effect and may change the estimate. Low Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate. Insufficient Evidence either is unavailable or does not permit estimation of an effect. 20

21 What are school-based obesity prevention interventions? 21

22 School-Based Interventions School as primary setting: Change in quantity of food Change in nutritional quality of food Increased physical activity Promotion of walk-to-school Combination of the above with home or community interventions 22

23 School-Based Interventions Dietary interventions: Decrease in BMI or BMI Z-score measures Strength of Evidence: Moderate Physical activity interventions: Impact on BMI, waist circumference (girls), skinfold thickness, percentage body fat Strength of Evidence: Moderate 23

24 School-Based Interventions Diet and physical activity combined intervention and weight-related outcomes: Reduced BMI, BMI Z-score, prevalence of obesity and overweight, percentage of body fat, waist circumference, and skinfold thickness Strength of Evidence: Insufficient 24

25 School-Based Interventions: Change in BMI Meta-Analysis: Change in BMI between Control and Combined Diet and Physical Activity Groups in School-Only Settings

26 School-Based + Home Components Dietary interventions: Effect on preventing obesity unknown Strength of Evidence: Insufficient Physical activity interventions: Improvement in BMI, waist circumference, and skinfold thickness Strength of Evidence: High 26

27 School-Based + Home Components Diet and physical activity combined interventions: Improvement in BMI, BMI percentile, prevalence of overweight or obesity Strength of Evidence: Moderate 27

28 School-Based + Home Components: Change in BMI Meta-Analysis: Change in BMI between Control and Combined Diet and Physical Activity Interventions in a School Setting with a Home Component 28

29 School-Based Intervention + Home + Community Components Combination diet and physical activity interventions: Improvement in weight outcomes Strength of Evidence: High Physical activity interventions: Effect on preventing obesity unknown Strength of Evidence: Insufficient 29

30 School-Based Intervention + Community Component Dietary interventions: Improved BMI and prevalence of overweight and obesity Strength of Evidence: Insufficient Physical activity interventions: No difference in weight-related outcomes Strength of Evidence: Insufficient Combination diet and physical activity interventions: Nonsignificant improvements in weight outcomes Strength of Evidence: Moderate 30

31 School-Based Intervention + Consumer Health Informatics Insufficient Evidence 31

32 School-Based + Consumer Health Informatics + Home Components Insufficient Evidence 32

33 What are home-based obesity prevention interventions? 33

34 Home-Based Interventions Dietary interventions: No difference in BMI, fat mass, or weight Strength of Evidence: Insufficient Combination diet and physical activity interventions: No difference in weight outcomes Strength of Evidence: Low 34

35 Home-Based + School + Community Component Insufficient Evidence 35

36 Home-Based + Primary Care + Consumer Health Informatics Insufficient Evidence 36

37 What are primary care based obesity prevention interventions? 37

38 Primary Care Based Interventions Insufficient Evidence 38

39 What are childcare center obesity prevention interventions? 39

40 Childcare Center Interventions Physical activity interventions: May improve BMI and percent body fat Strength of Evidence: Insufficient Combination diet and physical activity interventions: No difference in weight outcomes Strength of Evidence: Low 40

41 What are community-based or environmental-level obesity prevention interventions? 41

42 Community-Based or Environmental-Level Interventions Combination of diet and physical activity interventions: Community + school involvement resulted in a beneficial effect on preventing obesity Strength of Evidence: Moderate Diet, physical activity, or combination of interventions: Community level alone or other settings ability to prevent obesity unknown Strength of Evidence: Insufficient 42

43 What are consumer health informatics applications for the prevention of obesity? 43

44 Consumer Health Informatics Applications Insufficient Evidence Insufficient Evidence 44

45 Harms of Interventions 45

46 Conclusions What did we learn? 46

47 Conclusions & Discussion School-based interventions: Moderate evidence of effectiveness School-based physical activity with family component or combined interventions in school with home and community components: Most evidence for effectiveness Interventions conducted as environmental strategies, consumer health informatics strategies, or testing policies: Lack of evidence to determine impact on preventing obesity 47

48 Summary of Key Evidence Setting Intervention Measure Result School-Based School-Based School-Based + Home School-Based + Home School-Based + Community School-Based + Home + Community Diet Physical activity Physical activity Diet + physical activity Diet + physical activity Diet + physical activity BMI BMI Z-score BMI Waist circumference (girls) Skinfold thickness % body fat BMI Waist circumference Skinfold thickness BMI BMI percentile Prevalence of obesity or overweight BMI BMI Z-score Improved Improved Improved Improved Improved Strength of Evidence Moderate Moderate High Weight outcomes Improved High Moderate Moderate 48

49 Limitations of the Evidence Base Lack of studies in clinical settings Limited evidence testing environmental-based or policy interventions Insufficient evidence on the effect of consumer health informatics 49

50 Gaps in the Evidence Need for greater understanding of contextual factors associated with implementation Allow decision makers a better idea of applicability of any given intervention Need for subgroup analyses by: Sex, age, race/ethnicity, socioeconomic status Need for additional evaluations of adolescents Obesity among adolescents more predictive of obesity during adulthood 50

51 Applicability of the Results Children in high-income countries May not be applicable to children in middle- and lowincome countries Studies with subgroup analysis Applicability to very young children and select racial/ethnic groups unknown Age of studies Older studies may not be as effective in current populations Setting of studies Focus on RCTs may understate interventions in nonschool settings 51

52 What should I discuss with patients and their caregivers? 52

53 What to Discuss with Patients Concerns about childhood obesity and the patient s welfare Patient s BMI and how to diagnose overweight and obesity in children Factors contributing to overweight/obesity in children: Less physical activity More sedentary/screen time High calories, too much unhealthy food Inappropriate use of food rewards 53

54 What to Discuss with Patients Appropriate food serving size Monitoring total daily caloric intake What can be done at home Health consequences of obesity in children Effectiveness of obesity prevention interventions Community or school obesity prevention programs What to do if healthy food or safe physical activity locations are not accessible 54

55 Patient & Caregiver Information Available at: 55

56 CONTINUING EDUCATION CREDIT 56

57 Continuing Education Credit To obtain credit: Complete the online evaluation. Pass the posttest with a grade of 80% or higher. If you have any problems receiving certification, please contact: Postgraduate Institute for Medicine 304 Inverness Way South, Suite 100 Englewood, Colorado Phone: (303) Fax: (303) information@pimed.com 57

58 Acknowledgements Research team: Youfa Wang (PI), Yang Wu (Coordinator), Jodi Segal (Task Leader), Li Cai, Renee F. Wilson (Project Manager), Christine Weston, Oluwakemi Fawole, Sara Bleich, Lawrence J. Cheskin, Nakiya N. Showell, Brandyn Lau, Dorothy T. Chiu, Allen Zhang Reviewers and experts who contributed to the project 58