Universal childhood and adolescent obesity prevention programs: Review and critical analysis

https://doi.org/10.1016/j.cpr.2011.09.006Get rights and content

Abstract

Authors reviewed randomly controlled studies of universal prevention of childhood obesity, identifying 29 studies that met review criteria. Review suggested that outcomes are generally modest across all age groups and there were few replications of any program; thus, at this time no universal prevention program for childhood obesity meets criteria for a well-established intervention of the American Psychological Association. A wide variety of intervention targets have been investigated (knowledge and attitudes, family involvement, physical activity, television watching, water consumption, vegetable consumption, breast feeding, etc.) in a wide number of countries. Effects seem to be stronger for girls than for boys, for unknown reasons. Many studies fail to achieve sufficient statistical power and/or a sophisticated measurement strategy, neglecting key variables such as cost, treatment fidelity, longer-term follow up data, and process variables. Questions as to the theories of change associated with the interventions are also raised and suggestions for future research in this area are provided.

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

References (75)

  • Y. Li et al.

    Report on childhood obesity in China (8): Effects and sustainability of physical activity intervention on body composition of Chinese youth

    Biomedical and Environmental Sciences

    (2010)
  • L.M. Mauriello et al.

    Results of a multi-media multilple behavior obesity prevention program for adolescents

    Preventative Medicine

    (2010)
  • L. Mo-suwan et al.

    Effects of a controlled trial of a school-based exercise program on the obesity indexes of preschool children

    American Journal of Clinical Nutrition

    (1998)
  • M. Tanofsky-Kraff et al.

    Comparison of child interview and parent reports of children's eating disordered behaviors

    Eating Behaviors

    (2005)
  • L.S. Webber et al.

    Cardiovascular risk factors among children after a 2½ year intervention—The CATCH study

    Preventative Medicine

    (1996)
  • S. Amaro et al.

    Kalèdo, a new educational board-game, gives nutritional rudiments and encourages healthy eating in children: A pilot cluster randomized trial

    European Journal of Pediatrics

    (2006)
  • American Psychological Association Division of Clinical Psychology

    Training in and dissemination of empirically validated psychological treatments: Report and recommendations

    Clinical Psychologist

    (1995)
  • P.D. Angelopoulos et al.

    Changes in BMI and blood pressure after a school based intervention: The CHILDREN study

    European Journal of Public Health

    (2009)
  • S. Austin et al.

    The impact of a school-based obesity prevention trial on disordered weight-control behaviors in early adolescent girls

    Archives of Pediatric and Adolescent Medicine

    (2005)
  • E. Calle et al.

    Body mass index and mortality in a prospective cohort of US adults

    The New England Journal of Medicine

    (1999)
  • I. Caterson

    Keynote address

  • P.J. Ciampa et al.

    Interventions aimed at decreasing obesity in children younger than 2 years: A systematic review

    Archives of Pediatric and Adolescent Medicine

    (2010)
  • R. Cornette

    The emotional impact of obesity on children

    Worldviews on Evidence-Based Nursing

    (2008)
  • S.R. Daniels

    The consequences of childhood overweight and obesity

    The Future of Children

    (2006)
  • L. DeMattia et al.

    Childhood obesity prevention: Successful community-based efforts

    The Annals of the American Academy of Political and Social Science

    (2008)
  • W.H. Dietz

    What constitutes successful weight management in adolescents?

    Annals of Internal Medicine

    (2006)
  • L.H. Epstein et al.

    Treatment of pediatric obesity

    Pediatrics

    (1998)
  • L. Epstein et al.

    Family-based obesity treatment, then and now: Twenty-five years of pediatric obesity treatment

    Health Psychology

    (2007)
  • H. Fors et al.

    Body composition, as assessed by bioelectrical impedence spectroscopy and dual-energy X-ray absorptiometry in a healthy pediatric population

    Acta Peadiatrica

    (2002)
  • J.A. Fulkerson et al.

    Healthy Home Offerings via the Mealtime Environment (HOME): Feasibility, acceptability, and outcomes of a pilot study

    Obesity (Silver Spring)

    (2010)
  • D.A. Gentile et al.

    Evaluation of a multiple ecological level child obesity prevention program: Switch what you do, view, and chew

    BMC Medicine

    (2009)
  • M. Goran et al.

    Interactive multimedia for promoting physical activity (IMPACT) in children

    Obesity Research

    (2005)
  • S. Gortmaker et al.

    Impact of a school-based interdisciplinary intervention on diet and physical activity among urban primary school children: eat well and keep moving

    Archives of Pediatric and Adolescent Medicine

    (1999)
  • S. Gortmaker et al.

    Reducing obesity via a school-based interdisciplinary intervention among youth: Planet health

    Archives of Pediatric and Adolescent Medicine

    (1999)
  • J. Haines et al.

    Prevention of obesity and eating disorders: A consideration of shared risk factors

    Health Education Research

    (2006)
  • T.K. Harrell et al.

    Effectiveness of a school-based intervention to increase knowledge of cardiovascular disease risk factors among rural Mississippi middle school children

    Southern Medical Journal

    (2005)
  • S. Hayes

    Understanding and treating the theoretical emaciation of behavior therapy

    The Behavior Therapist

    (1998)
  • Cited by (60)

    • Technological Interventions for Eating and Weight Disorders

      2022, Comprehensive Clinical Psychology, Second Edition
    • Factors Associated With Healthy Lifestyle Behaviors Among Adolescents

      2018, Journal of Pediatric Health Care
      Citation Excerpt :

      Reviews by Haynos and O'Donohue (2012) and Kaisari, Yannakoulia, and Panagiotakos (2013) reported that compared with males, females had slightly more favorable outcomes to interventions to increase healthy lifestyle behaviors. Thus, a basic understanding of cognitive behavioral processes between sexes may inform how behavioral interventions are most likely to succeed (Haynos & O'Donohue, 2012; Melnyk et al., 2013, 2015; Tate, Spruijt-Metz, Pickering, & Pentz, 2015). Scalable interventions to increase healthy lifestyle behaviors should target this population to improve health outcomes during adolescence and into adulthood.

    View all citing articles on Scopus
    View full text