Universal childhood and adolescent obesity prevention programs: Review and critical analysis
Highlights
► Universal obesity prevention programs for children and adolescents are reviewed. ► Studies are evaluated based on study and intervention design and procedures. ► Currently no program meets APA criteria for a well-established intervention. ► Tighter study design and independent replication of existing programs are needed. ► More information about mechanisms of change is needed in obesity prevention trials.
Introduction
Pediatric obesity is a public health issue of growing concern. Caterson (2006) has suggested that for the first time in human history there are more overfed than hungry persons inhabiting the planet. In the last 30 years, childhood and adolescent obesity rates have doubled (Ogden et al., 2004, Ogden et al., 2006), and it is now estimated that approximately one third of U.S. children are overweight or obese (DeMattia & Denney, 2008). This is particularly problematic as obesity in childhood typically persists into adulthood (Magarey, Daniels, Boulton, & Cockington, 2003), placing obese individuals at risk for a variety of persisting medical (Calle, Thun, Petrelli, Rodriguez, & Heath, 1999) and psychological problems. The high prevalence and serious consequences of childhood obesity has led the current First Lady to make the prevention of child obesity her major cause.
Prevention of a problem is preferable to treatment of the problem for many reasons, and this is certainly true in the case of childhood and adolescent obesity. The first clear reason is that when a problem is prevented individuals do not suffer from any of the negative effects of the problem. This is particularly salient in the case of childhood and adolescent obesity, which is associated with both serious medical problems, including heart disease, diabetes, some forms of cancer (Daniels, 2006), and mental health consequences, such as depression, anxiety, social difficulties, poor self-esteem, and heightened suicide risk (Cornette, 2008, Whetstone et al., 2007). Second, treatment is often not universally effective or available and thus many, if not most, of affected individuals will not successfully overcome the problem given the available resources. Such is true in the case of child and adolescent obesity; approximately 10% of obese children and adolescents receive treatment for weight-loss (Stice, Shaw, & Marti, 2006) and effects of such treatment can be quite modest (O'Donohue, Moore, & Scott, 2008). Third, prevention can be less expensive than treatment and, given the current health care crisis, this is no small concern. It has been estimated that the annual cost of treating obesity-related illnesses is as high as $100 billion (Wolf, 1998); therefore, prevention efforts have the potential for substantially reducing financial burden on the health care system. These three advantages all contrive to make the prevention of childhood obesity a preferable strategy to the treatment of obese children.
However, prevention is often a difficult goal to realize. Complex decisions need to be made regarding key issues, such as the design of an effective intervention, selection of appropriate intervention targets, social acceptability, cost, and scale, as well as how best to evaluate prevention programs, e.g., whether a given prevention trial has adequate statistical power and sensitive measurement needed to demonstrate effectiveness. Prevention efforts often produce modest effects, therefore it is important to consider both the variables that contribute to the success of a prevention program and the adequacy of the research methods utilized to evaluate outcomes. Such efforts are particularly pressing in the case of childhood obesity, due to the magnitude and severity of the problem.
Therefore, we sought to review randomly controlled trials (RCTs) of universal prevention of obesity in children. While some reviews already exist regarding the prevention of childhood obesity, these have either focused on a single setting, such as schools (e.g., Gonzalez-Suarez et al., 2009, Story et al., 2006) or age group (e.g., Ciampa et al., 2010) or are somewhat outdated (e.g., Baranowski et al., 2000). Additionally, no reviews were identified by the authors that specifically examined universal obesity prevention programs.
Universal (or primary) prevention, refers to prevention efforts delivered to the widest scope of individuals possible within a given population (Müller et al., 2001, Wake and McCallum, 2004). This contrasts with selected (or secondary) prevention, in which individuals at heightened risk for an adverse outcome (e.g., obesity) are targeted for intervention. Both universal and selected prevention programs have distinct sets of strengths and weaknesses. Universal approaches often have been thought to be most desirable in the prevention of obesity in children for two primary reasons: 1) Excess weight among children has reached such epidemic proportions that programs that confer benefit to the most children are encouraged, and 2) Universal prevention programs reduce stigma that may occur when specific high-risk populations (e.g., overweight children, ethnic minorities) are targeted for intervention. For these reasons, we chose to focus this review on universal obesity prevention programs, thus excluding interventions that specifically targeted particular high-risk groups based on variables such as sex, ethnicity, weight status, etc.
Section snippets
Method of study selection
In order to compile a comprehensive list of childhood obesity prevention outcome studies, the authors conducted an initial search of relevant databases (i.e., Medline, PsychInfo), using keywords of “child,” “pediatric,” and “adolescent” crossed with “obesity prevention,” with limits set to only include clinical trials. Additional articles were located by examining reference sections from all articles found in this manner. This initial search yielded 203 clinical trials examining efficacy of an
Criteria for study evaluation
Several criteria were used to evaluate the selected studies of universal obesity prevention programs. These criteria include: description of participant sample, interventionist variables, and intervention settings, intervention components, study design, and criterion measures.
Review of universal obesity prevention programs
Studies in this review have been organized according to the age characteristics of the selected sample. This method of organization was selected as different prevention techniques may produce varying effects on weight and adiposity at different age levels (e.g., Stice et al., 2006). When more than one study evaluating a prevention program for childhood obesity was found in an age group, the studies were organized according to whether the study reported positive outcomes, mixed outcomes (only
Treatment effectiveness
At this time, no childhood obesity prevention program meets the American Psychological Association's criteria for a well-established treatment. The Task Force on Promotion and Dissemination of Psychological Procedures (American Psychological Association Division of Clinical Psychology, 1995), which is used in this review as a model for evaluating clinical trials, suggested that an intervention be considered well-established if: “(1) At least two good group design studies, conducted by different
Conclusions
The field of universal childhood obesity prevention is far from having identified empirically supported prevention programs. Though some programs have produced results through techniques such as knowledge transfer regarding health eating and exercise habits and mandated exercise or reductions of sedentary behavior, results are generally modest and not uniform across prevention studies. This may be due to problems with intervention or research design. The authors have noted a number of areas for
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