Childhood Obesity Prevention Programs: Comparative Effectiveness

1
Childhood Obesity Prevention Programs
Comparative Effectiveness

• Prepared for
• Agency for Healthcare Research and Quality (AHRQ)
• www.ahrq.gov

2
Outline of Material

• Introduction to childhood obesity and the various
  programs designed to prevent it
• Systematic review methods
• The clinical questions addressed by the
  comparative effectiveness review
• Results of the review and evidence-based
  conclusions about the relative effectiveness of
  currently available programs to prevent childhood
  obesity
• Gaps in knowledge and future research needs
• What to discuss with patients and their caregivers

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

3
Background Prevalence of Childhood Obesity

• Childhood overweight and obesity are highly
  prevalent in the United States, affecting
  one-third of children and adolescents.
• Since 1980, the rates of obesity have tripled for
  children aged 2 to 19 years.
• The risk of obesity is higher among minority and
  low-income populations.

• Ogden CL, Carroll MD, Kit BK, et al. JAMA.
  2012307(5)483-490. PMID 22253364.
• Wang Y, Beydoun M. Epidemiol Rev. 2007296-28.
  PMID 17510091.
• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

4
BackgroundHealth Consequences of Childhood
Obesity

• Overweight children and adolescents are at
  greater risk for health problems when compared
  with their normal-weight peers and are more
  likely to become obese adults.
• Obese children and adolescents are more likely to
  have serious illnesses such as type 2 diabetes,
  hypertension, high cholesterol, stroke, heart
  disease, nonalcoholic fatty liver disease,
  certain types of cancer, and arthritis.
• Other reported health consequences of childhood
  obesity include eating disorders and mental
  health issues such as depression and low
  self-esteem

• Centers for Disease Control and Prevention.
  Available at www.cdc.gov/obesity/childhood/index.h
  tml.
• Reilly JJ, Kelly J. Int J Obes (Lond). 2011
  Jul35(7)891-8. PMID 20975725.
• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

5
BackgroundFactors Contributing to Childhood
Obesity

• Many factors interact to contribute to obesogenic
  environments and affect childrens weight. These
  include
• Genetic and individual factors
• Home influences
• The school environment
• Factors in the local community
• Policies implemented at the regional and national
  levels

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

6
Background Preventing Childhood Obesity

• Obesity is difficult to treat, and prevention of
  childhood obesity has been identified as a key to
  fight the growing obesity epidemic.
• Leading health organizations, including the World
  Health Organization and an Institute of Medicine
  expert panel, have recommended comprehensive
  interventions to fight obesity.
• The main goal of most childhood obesity
  prevention interventions is to prevent children
  who are not overweight from becoming overweight
  or obese.
• Interventions designed for obesity prevention may
  also help overweight or obese children lose
  excess weight or stabilize their weight.

• Koplan JP, Liverman CT, Kraak VA, eds. Preventing
  Childhood Obesity Health in the Balance.
• Available at www.nap.edu/catalog.php?record_id110
  15.
• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115. Available at
  www.effectivehealthcare.ahrq.gov/child-obesity-pre
  vention.cfm.
• World Health Organization. www.who.int/dietphysica
  lactivity/childhood_what_can_be_done/
  en/index.html.

7
Background Objectives of This Comparative
Effectiveness Review

• This review aimed to compare the effectiveness of
  obesity prevention programs for children and
  adolescents conducted in the United States and
  other high-income countries.
• All studies of children that tested interventions
  of diet, physical activity, or any combination of
  these in any of the following settings were
  included in this review.
• School
• Home
• Primary care clinic
• Childcare center
• Community setting
• A combination of the above
• The authors of this review also assessed consumer
  health informatics interventions.

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

8
Settings of Obesity Prevention Interventions
Assessed in This Comparative Effectiveness Review
(1 of 2)
Setting of Intervention Definition
School-Based Interventions These took place primarily in schools (e.g., change in quantity and nutritional quality of food served at school, increase in physical activity at school, promotion of walk-to-school days), although they might also have involved community (e.g., improving community parks, performing community service) or at-home activities (e.g., daily physical activity homework of about 10 minutes, preparing a healthy breakfast at home).
Home-Based Interventions These took place in the childs home (e.g., interventions to alter the foods purchased for home use, family fitness).
Primary Care-Based Interventions These took place in the offices of a primary care practitioner, a clinic, or other health care entity delivering primary health care to children. They included advice to parents and/or caregivers to make changes at home (e.g., encouraging more than five daily servings of fruits and vegetables , limiting screen time to less than 2 hours per day, and promoting greater than 1 hour of physical activity per day).

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

9
Settings of Obesity Prevention Interventions
Assessed in This Comparative Effectiveness Review
(2 of 2)
Setting of Intervention Definition
Childcare Center-Based Interventions These took place in settings where children received nonparental/ noncustodial care, generally outside the home (e.g., offering fruits and vegetables throughout the day, enhancing physical activity, designing exercise programs that improve pleasure of movement).
Community-Based and Environment-Level Interventions These were delivered by enforcing policies or legislation (e.g., regulations on food retailing and distribution) or by changes to the built environment (e.g., restaurants, farmers markets, recreation facilities). Additionally, these interventions involved interaction with the community (such as the YMCA or church groups).
Consumer Health Informatics-Based Interventions Consumer health informatics are technologies that deliver interventions and information indirectly (as opposed to in person) to patients or individuals in the community. These interventions might include Web-based, phone-based, and video-based programs, games, and information storehouses.

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

10
Agency for Healthcare Research and Quality (AHRQ)
Comparative Effectiveness Review (CER) Development

• Topics are nominated through a public process,
  which includes submissions from health care
  professionals, professional organizations, the
  private sector, policymakers, members of the
  public, and others.
• A systematic review of all relevant clinical
  studies is conducted by independent researchers,
  funded by AHRQ, to synthesize the evidence in a
  report summarizing what is known and not known
  about the select clinical issue. The research
  questions and the results of the report are
  subject to expert input, peer review, and public
  comment.
• The results of these reviews are summarized into
  Clinician Research Summaries and Consumer
  Research Summaries for use in decisionmaking and
  in discussions with patients and/or caregivers.
• The Research Summaries and the full report, with
  references for included and excluded studies, are
  available at www.effectivehealthcare.ahrq.gov/
  child-obesity-prevention.cfm.

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

11
Clinical Questions Addressed by This Comparative
Effectiveness Review (1 of 2)

• Key Question 1. What is the comparative
  effectiveness of school-based interventions for
  the prevention of obesity or overweight in
  children?
• Key Question 2. What is the comparative
  effectiveness of home-based interventions for the
  prevention of obesity or overweight in children?
• Key Question 3. What is the comparative
  effectiveness of primary care-based interventions
  for the prevention of obesity or overweight in
  children?
• Key Question 4. What is the comparative
  effectiveness of childcare setting-based
  interventions for the prevention of obesity or
  overweight in children?

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

12
Clinical Questions Addressed by This Comparative
Effectiveness Review (2 of 2)

• Key Question 5. What is the comparative
  effectiveness of community-based or
  environment-level interventions for the
  prevention of obesity or overweight in children?
• Key Question 6. What is the comparative
  effectiveness of consumer health informatics
  applications for the prevention of obesity or
  overweight in children?
• Key Question 7. What is the comparative
  effectiveness of multisetting interventions for
  the prevention of obesity or overweight in
  children?
• Key Question 7 was addressed as part of the other
  six Key Questions.

Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
Effectiveness Review No. 115. Available at
www.effectivehealthcare.ahrq.gov/child-obesity-pre
vention.cfm.
13
Rating the Strength of Evidence From the
Comparative Effectiveness Review

• The strength of evidence was classified into four
  broad categories

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 a conclusion.

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

14
Evidence for the Benefits of School-Based
Interventions in Preventing Obesity or Overweight
in Children (1 of 3)

• School-Based Interventions Only
• School-based diet or physical activity
  interventions prevent obesity or overweight in
  children. ???
• Strength of Evidence Moderate
• ??School-based combination diet and physical
  activity interventions prevent obesity or
  overweight in children.
• Strength of Evidence Insufficient
• School-Based Interventions With a Home Component
• Physical activity interventions within
  school-based settings with a home component
  prevent obesity or overweight in children.
• Strength of Evidence High
• Combined diet and physical activity interventions
  in a school-based setting with a home component
  prevent obesity or overweight in children.
• Strength of Evidence Moderate

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

15
Meta-analysis of Change in Body Mass Index
Between the Control Group and Combined Diet and
Physical Activity Interventions in a School
Setting With a Home Component

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

16
Evidence for the Benefits of School-Based
Interventions in Preventing Obesity or Overweight
in Children (2 of 3)

• School-Based Interventions With a Community
  Component
• Combined diet and physical activity interventions
  in a school-community setting prevent obesity or
  overweight in children. ???
• Strength of Evidence Moderate
• School-Based Interventions With Home and
  Community Components
• Combined diet and physical activity interventions
  in a school-home-community setting prevent
  obesity or overweight in children. ???
• Strength of Evidence High

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

17
Evidence for the Benefits of School-Based
Interventions in Preventing Obesity or Overweight
in Children (3 of 3)

• School-Based Interventions With a Consumer Health
  Informatics Component
• Evidence is insufficient to determine if physical
  activity or combined diet and physical activity
  interventions in a school setting with a consumer
  health informatics component prevent childhood
  obesity or overweight.???
• Strength of Evidence Insufficient

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

18
Evidence for the Benefits of Home-Based or
Childcare Center-Based Interventions in
Preventing Obesity or Overweight in Children

• Home-Based Interventions Only
• Home-based combination (diet and physical
  activity) interventions prevent obesity or
  overweight in children.
• Strength of Evidence Low
• Childcare Center-Based Interventions Only
• Combined diet and physical activity interventions
  in a childcare center setting showed no
  beneficial effect on childhood obesity or
  overweight prevention. ???
• Strength of Evidence Low

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

19
Evidence for the Benefits of Community-Based or
Primary CareBased Interventions in Preventing
Obesity or Overweight in Children

• Community-Based Interventions With a School
  Component
• Combined diet and physical activity interventions
  in a community setting with some school
  involvement prevent childhood obesity or
  overweight.???
• Strength of Evidence Moderate
• Primary Care-Based Interventions Only
• Evidence is insufficient to determine if combined
  diet and physical activity interventions in a
  primary care setting prevent obesity or
  overweight in children.???
• Strength of Evidence Insufficient
• This does not mean that interventions do not work
  in the primary care setting, but more research is
  needed.

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

20
Conclusions (1 of 2)

• School-based programs involving dietary or
  physical activity interventions are effective in
  preventing childhood obesity.
• Combining a home or community component with a
  school-based program also works.
• The magnitude of effects appears to be modest,
  although the heterogeneity in study
  interventions, outcomes, and duration make it
  difficult to estimate a precise effect size.

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

21
Conclusions (2 of 2)

• Evidence is limited regarding the effectiveness
  of interventions in other settings including
  those in primary care.
• This does not mean that such interventions do not
  work but that more research is needed.

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

22
Gaps in Knowledge (1 of 2)

• Several gaps in knowledge were identified in the
  evidence base reviewed for this report
• ??A lack of sufficient information on the
  effectiveness of the following types of obesity
  and overweight prevention interventions
• Interventions tested in the primary care or
  childcare settings
• ??Environment-based and policy-based
  interventions (e.g., agriculture policies and
  regulations on food retailing and distribution)
• Consumer health informatics interventions

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

23
Gaps in Knowledge (2 of 2)

• The need for an improved understanding of the
  contexts and challenges associated with
  implementing prevention programs in different
  settings
• A paucity of information on the effects of
  various interventions in preventing childhood
  obesity in populations stratified by sex, age,
  ethnicity, demographics, or socioeconomic status
• Limited information on the effectiveness of
  obesity prevention programs in adolescents

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

24
What To Discuss With Your Patients andTheir
Caregivers (1 of 2)

• That clinicians are concerned about childhood
  obesity and the welfare of their patients
• ?The patients body mass index and how to
  diagnose overweight/ obesity in children
• ??The possible factors contributing to overweight
  and obesity in children, including less physical
  activity, more sedentary/screen time, increased
  empty and liquid calories in the diet, and
  inappropriate use of food rewards or eating when
  not hungry
• ??What constitutes an appropriate serving size
• ??The importance of monitoring total daily
  caloric intake as opposed to total daily food
  intake
• ??Important things that can be done at home to
  keep children at a healthy weight

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.

25
What To Discuss With Your Patients andTheir
Caregivers (2 of 2)

• The potential health consequences of overweight
  and obesity in children
• ??The relative effectiveness of the various
  interventions in preventing overweight and
  obesity
• ??The programs and resources that help children
  maintain a healthy weight that are available at
  school or in the community
• If a list of such resources could not be
  obtained, encourage parents and caregivers to
  explore schools, school district offices, and
  community centers for the available resources.
• ??What can be done if healthy food or safe
  locations for physical activity are not easily
  accessible to patients and their families

• Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative
  Effectiveness Review No. 115.
• Available at www.effectivehealthcare.ahrq.gov/chil
  d-obesity-prevention.cfm.