Childhood obesity prevention interventions in childcare settings: systematic review of randomized and nonrandomized controlled trials.

For individual use only. Duplication or distribution prohibited by law.

Literature Review: Weight Control; Youth

Childhood Obesity Prevention Interventions in Childcare Settings: Systematic Review of Randomized and Nonrandomized Controlled Trials Yuan E. Zhou, PhD; Janice S. Emerson, PhD; Robert S. Levine, MD; Courtney J. Kihlberg, MD, MSPH; Pamela C. Hull, PhD Abstract Objective. Childcare settings are an opportune location for early intervention programs seeking to prevent childhood obesity. This article reports on a systematic review of controlled trials of obesity prevention interventions in childcare settings. Data Source. The review was limited to English language articles published in PubMed, Web of Science, and Education Resources Information Center (ERIC) between January 2000 and April 2012. Study Inclusion and Exclusion Criteria. Inclusion criteria: childhood obesity prevention interventions in childcare settings using controlled designs that reported adiposity and behavior outcomes. Exclusion criteria: no interventions, non-childcare settings, clinical weight loss programs, non-English publications. Data Extraction. Publications were identified by key word search. Two authors reviewed eligible studies to extract study information and study results. Data Synthesis. Qualitative synthesis was conducted, including tabulation of information and a narrative summary. Results. Fifteen studies met the eligibility criteria. Seven studies reported improvements in adiposity. Six of the 13 interventions with dietary components reported improved intake or eating behaviors. Eight of the 12 interventions with physical activity components reported improved activity levels or physical fitness. Conclusion. Evidence was mixed for all outcomes. Results should be interpreted cautiously given the high variability in study designs and interventions. Further research needs long-term follow-up, multistrategy interventions that include changes in the nutrition and physical activity environment, reporting of cost data, and consideration of sustainability. (Am J Health Promot 2014;28[4]:e92–e103.) Key Words: Review, Childcare Setting, Obesity Prevention, Intervention, Diet, Physical Activity. Manuscript format: literature review; Health focus: weight control; Target population age: youth

OBJECTIVE The rising prevalence of obesity is afflicting progressively younger age groups and is having a global impact. Worldwide, the prevalence of overweight and obesity among preschoolaged children increased from approximately 4% to 7% between 1990 and 2010.1 The secular trend was particularly evident in developed countries, where obesity prevalence grew approximately .25% each year. The estimated prevalence of obesity among 2to 5-year-old children in the United States increased considerably from 5% in 1971 to 19742 to 13.9% in 2003 to 2004,3 and it remained at 12.1% in 2009 to 2010.4 The obesity epidemic also disproportionately affects certain subpopulations. Globally, those with low socioeconomic status in developed countries and those with high socioeconomic status in developing countries are at higher risk.1 In the United States, non-Hispanic black and Hispanic children aged 2 to 5 years show higher prevalence of obesity than do

Yuan E. Zhou, PhD, and Janice S. Emerson, PhD, are with Tennessee State University, Center for Prevention Research, Nashville, Tennessee. Robert S. Levine, MD, and Courtney J. Kihlberg, MD, MSPH, are with Meharry Medical College, Department of Family and Community Medicine, Division of Preventive Medicine, Nashville, Tennessee. Pamela C. Hull, PhD, is with Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee. Send reprint requests to Yuan E. Zhou, PhD, Center for Prevention Research, 3500 John A. Merritt Blvd., PO Box 9580, Nashville, TN 37209-1561; [email protected]. This manuscript was submitted November 29, 2012; revisions were requested April 16, 2013; the manuscript was accepted for publication May 14, 2013. Copyright Ó 2014 by American Journal of Health Promotion, Inc. 0890-1171/14/$5.00 þ 0 DOI: 10.4278/ajhp.121129-LIT-579

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American Journal of Health Promotion

March/April 2014, Vol. 28, No. 4

For individual use only. Duplication or distribution prohibited by law. non-Hispanic whites in the same age group, and these differences widen with age and become statistically significant among older children.5 Overweight and obese children are more likely to become overweight and obese adults and are more likely to develop obesity-related diseases, such as type 2 diabetes mellitus and cardiovascular diseases, at a younger age.6 In addition, an analysis of multinational data collected between 2000 and 2011 showed that childhood obesity was associated with excess health care expenses.7 Early childhood is a vital period of time to intervene for obesity prevention. Behavioral risk factors, such as poor dietary intake patterns and sedentary lifestyles, are likely to be established during this life stage and are closely related to the subsequent development of obesity.8 For example, patterns of poor eating habits and prolonged television (TV) watching among preschoolers tend to persist as children grow older.9 A lack of physical activity during the preschool period is strongly predictive of being overweight in late childhood or adolescence, and screen time is a moderate predictor.10 Interventions based in preschool childcare settings have a variety of advantages for delivering potentially sustainable interventions. Publicly subsidized preschool programs may be provided at no or low cost to many families (e.g., the Head Start program in the United States, daycare centers in Canada, and kindergartens in some western European countries). In childcare centers that provide meals, this is a natural environment in which children can be exposed to healthy dietary choices. Physical activity-related resources such as gyms and playgrounds may be available.11 Moreover, childcare-based interventions could reach a large proportion of children in this age group. Currently more than 70% of 3- to 5-year-old children in industrialized countries attend various types of childcare centers.12 In 2005, approximately 68% of 4- to 5-year-old children in the United States were enrolled in center-based childcare.13 Despite the potential of obesity prevention interventions in childcare settings, only a limited number of controlled efficacy trials in this setting have been published, and this topic has


been scarcely covered in literature reviews. A 2011 Cochrane systematic review of childhood obesity prevention research in any setting included 55 studies,14 but only three of them were based in childcare settings. This Cochrane review excluded the studies with intervention duration of less than 12 weeks. Given that more evidence is needed to understand fully the minimum necessary duration of interventions in childcare settings and their associated efficacy, the current review did not set inclusion criteria based on the intervention duration. The present report addresses a gap in available reviews by focusing specifically on obesity prevention interventions in preschool childcare settings. Obesity is defined as excessive fat accumulation, and the basic biological explanatory framework of obesity is energy imbalance: body weight increases when energy intake (calories consumed) exceeds energy expenditure (calories burned through basal metabolism and physical activity) over time. Thus, obesity prevention interventions generally target changes in dietary and physical activity behaviors in order to reduce adiposity. However, desirable changes in these intermediate behaviors do not necessarily always lead to expected adiposity changes. In addition, it is not clear how intense changes in diet and physical activity need to be or how long they need to be sustained in young children to produce reductions in adiposity. Thus, it is important to examine interventions that have reported both intermediate behavioral outcomes and ultimate adiposity outcomes, which provide the most compelling evidence for the efficacy of interventions in preventing obesity. A variety of anthropometric measures to assess adiposity levels among preschoolers has been applied in previous intervention studies and systematic reviews. In several recent reviews of childhood obesity prevention interventions for children ages 0 to 5 years, body mass index (BMI) and skin-fold thickness were among the primary outcomes examined.14–16 BMI, sex- and age-specific BMI percentile, skin-fold thickness, and waist circumference have all been demonstrated to be valid, objective measures of adiposity in children as young as 3 years of

age,17,18 and sex- and age-specific BMI percentile is recommended as the measure of fatness for children as young as 2 years of age.19 The primary objective of this systematic review was to assess the current state of science regarding the efficacy of childhood obesity interventions in childcare settings across a variety of countries on outcomes of dietary intake, physical activity, and adiposity, which were tested using randomized or nonrandomized controlled designs. The secondary objective was to identify gaps and limitations of the existing studies and recommend priorities for future research.

METHODS Data Sources The literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines.20 The lead author searched peer-reviewed, published articles in PubMed, Web of Science, Cochrane Library, and the Education Resources Information Center (ERIC). The electronic search was limited to articles published between January 2000 and April 2012, using the search terms listed in Table 1. The last search was conducted in August 2012. The authors also reviewed reference lists of included intervention studies and other relevant review articles. Duplicate papers were excluded. The lead author screened the titles and abstracts and, when necessary, the full text of the articles produced by the searches to apply the inclusion and exclusion criteria and identify eligible studies. The eligible studies were reviewed and confirmed by a second author. The study selection process is summarized in the Figure (review flow diagram of obesity intervention studies). Inclusion and Exclusion Criteria Before the searches were performed, the authors agreed on the following inclusion and exclusion criteria to be used to determine the eligibility of studies. Inclusion Criteria Peer-reviewed publications Interventions aimed at childhood obesity prevention


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Childcare facilities for preschoolaged children who are not old enough to attend primary or elementary schools in the respective country, including childcare centers, preschools, daycares, nursery schools, and kindergartens (except United States and anglophone Canada and parts of Australia [New South Wales, Tasmania, and the Australian Capital Territory], where kindergarten refers to the first year of education in primary or elementary schools) Controlled study design (randomized or nonrandomized) Outcome measures included adiposity (e.g., body mass index)

Exclusion Criteria Publications in languages other than English Review papers Study design with only cross-sectional studies or surveys, longitudinal studies without intervention, or interventions without control groups School/home/clinic/communitybased intervention studies Study participants attending primary or elementary school Clinical obesity treatment or weight loss programs Data Extraction The articles that met the above selection criteria were reviewed to extract the following information: research design, intervention duration and data collection follow-up time period, location, sample size, ages of participants, type of childcare setting, description of intervention components, and efficacy results. One review author extracted the data from the included studies, and a second review author checked the extracted data. The two review authors resolved any disagreements by discussion. The primary outcome of interest was adiposity, measured as BMI, BMI z score, waist circumference, skinfold thickness, or percent overweight or obese. Secondary outcomes were dietary and physical activity behaviors, measured in various ways across studies. Data Synthesis The authors summarized the extracted information from each study in

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Table 1 Key Word Search Strategy Key Words Pre-school* OR preschool* OR day care OR daycare OR childcare OR child care OR toddler OR young child* OR early child* OR pediatr* OR paediatr* OR Head start Combined with each of the following: And: Diet* OR diet records OR feed* OR feeding behavior OR nutrition OR nutrition instruction OR eat* OR healthy eating OR eating habits OR eating behavior OR food OR food habits OR food services OR energy balance OR energy intake OR fruit* OR vegetable* OR beverage* OR snack* OR soft drink OR soft drink* OR drink* OR soda* OR juice* OR milk* OR high fat OR low fat OR fatty food* OR breakfast OR supper OR dinner OR lunch* OR meal* And: Physical activ* OR physical activity level OR physical inactivity OR physical training OR physical education OR fitness OR aerobic* OR exercise* OR exercise therapy OR walking OR cycling OR sport* OR sedentary behavior And: Obesity intervention OR obesity prevention OR obesity control OR obesity program OR obesity interference OR obesity intercession OR health promotion OR health education OR health behavior OR life style OR primary prevention And: Obes* OR weight* OR weight change OR weight gain* OR weight loss* OR weight increase OR weight control OR overweight OR over weight OR growth chart OR weight-forheight percentile OR adipose OR BMI OR waist circumference OR skinfold thickness

table form. Multiple publications from the same studies were reviewed and results combined into one entry for the study. The studies were separated into three tables based on intervention focus: nutrition and physical activity, nutrition only, and physical activity only (see Tables 2 through 4). The authors also described the qualitative synthesis of study results in a narrative summary. Because of the large variety of the intervention approaches, outcome measures, and length of followup across the eligible studies in the current review, the authors limited the review to a qualitative synthesis; study outcomes were not combined in quantitative meta-analysis. The Cochrane Collaboration’s Tool for Assessing Risk of Bias21 was used to evaluate possible sources of bias in the eligible studies; these sources include selection bias, performance bias, detection bias, attrition bias, and reporting bias. In addition to the Cochrane tool’s five domains of bias risk, the authors also evaluated possible risk of recruitment bias. In cluster randomized trials, recruitment bias can occur when facilities are allocated to study arms prior to the enrollment of individuals within each facility and results in lower recruitment in the control arm compared to the intervention

arm.22,23 Two authors assessed each article independently for the possible areas of bias, then compared evaluations and resolved any differences through discussion.

RESULTS The results of the study selection process are reported in the Figure. The key word searches in the electronic databases returned 1575 articles, and hand searches of reference lists returned 80 articles. After excluding duplicate publications, 502 articles remained. After applying inclusion and exclusion criteria to the abstracts, 484 records were excluded. Next, full-text articles for the remaining 27 records, representing 18 studies, were reviewed in more detail to apply inclusion and exclusion criteria. One study was excluded because it was a communitywide intervention that targeted both childcare centers and a variety of other local facilities. Two studies were excluded because they reported only on intermediate behavioral outcomes and did not report on adiposity outcomes. After combining multiple publications from single studies and excluding redundant articles, 15 intervention studies were identified as eligible and were included in the review.



Figure Review Flow Diagram of Obesity Intervention Studies

Study Characteristics Tables 2 through 4 present a detailed summary of the characteristics of the 15 reviewed studies, including the study design, intervention components, and efficacy outcomes on adiposity and diet-related and/or physical activity–related behaviors. The majority of the studies tested multicomponent intervention strategies. Table 2 summarizes the 10 interventions that combined both nutrition and physical activity components. Table 3 reports the three studies that addressed nutrition only, and Table 4 lists the two studies of physical activity–only interventions. The studies were conducted in eight different countries, which included seven high-income countries (United


States, Israel, Australia, Germany, Scotland, France, Switzerland) and one upper-middle-income country (China). The age of the study populations in preschool childcare centers across the various countries ranged from 2 to 6 years of age. Some included diverse samples in terms of ethnic groups and socioeconomic levels. Nearly half of the interventions targeted or included socioeconomically disadvantaged populations. Three studies tested the same interventions in different target groups. The Hip Hop to Health Jr. Intervention was examined in different samples of predominantly low-income African-American or Hispanic children in Chicago, Illinois (USA).24–26 Tooty Fruity Vegie tested the same intervention in primary school students27 (not

included in this review) and then in preschool students in Australia.28,29 A diet and physical activity intervention was examined at Israeli kindergartens (preschools) with different socioeconomic status and ethnic groups, including Arab Israeli children.30–32 Additionally, a French study reported subgroup comparisons between underprivileged areas and non-underprivileged areas.33 There was a great deal of variety in the intervention strategies applied in these 15 studies. Five studies explicitly identified the theoretical frameworks underpinning the interventions, including social cognitive theory (social learning theory),26,34,35 Zajonc’s exposure effect,35 health belief model,29 competence motivational theory,29 reinforced learning theory,33 and selfdetermination theory.26 The rest of the studies only briefly described the intervention approaches that were implemented. Among the studies that assessed nutrition intervention components, the intervention strategies included structured, in-class sessions of ageappropriate nutritional education for the children, such as games with food themes,24–26,28–33,35 healthy cooking classes,28,29,35,36 healthy snack or meal tasting,28,29,35,37–39 or book reading.30–32,36 Seven interventions provided physical activity education sessions to children,24–26,28,29,33,37–40 whereas six other interventions engaged children in playful games.28–32,34,37–39 In addition to education for children, several interventions included a parent education component, such as education sessions,28–32,35–39 home assignments,40 Internet-based modules,34 printed informational materials,24–26,28,29,36–43 or cooking classes with children.35 Eleven studies reportedly involved training for facility staff to deliver the interventions.28–32,34,37–39 The studies varied in terms of intervention duration and length of follow-up. Among the 15 studies, seven had short-term intervention duration (6 months or less),24–26,30,35,40,43 another five studies applied mediumterm intervention (9 to 18 months),28,29,31,32,36–39 and the other three used a long-term intervention approach (2 years).33,34,41,42 Length of


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Table 2 Obesity Prevention Intervention Studies in Childcare Settings: Interventions with Both Nutrition and Physical Activity Components† Reference, Design, Intervention Duration, Location ‘‘Hip Hop to Health Jr.,’’ Fitzgibbon et al.24 Cluster RCT) Duration: 14 wk 2 y follow-up Chicago, IL, USA ‘‘Hip Hop to Health Jr.,’’ Fitzgibbon et al.25 Cluster RCT Duration: 14 wk 2 y follow-up Chicago, IL, USA ‘‘Hip Hop to Health Jr.,’’ Fitzgibbon et al.26 Cluster RCT Duration: 14 wk 14-wk follow-up Chicago, IL, USA

Sample Size, Participants, Setting

Jouret et al.33 Cluster RCT Duration: 2 school y 2-y follow-up Haute-Garonne Department, France

‘‘Tiger Kids,’’ Bayer et al.34 Cluster RCT Duration: 2 school y Sample 1: 12- to 20-mo follow-up; Sample 2: 3- to 9mo follow-up Bavarian regions, Germany

‘‘Tooty Footy Vegie,’’ Zask et al.28, Adams et al.29 Cluster RCT Duration: 10 mo 10-mo follow-up New South Wales, Australia

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Study Results Intervention Description

Significant Findings*

Difference or Odds Ratio (OR)*

(N ¼ 409) baseline (N ¼ 261) y 2 follow-up 3 to 5 y old Head Start preschool programs Predominantly AfricanAmerican

Children: 40-min education session 3 d/wk (20 min for nutrition, 20 min for aerobic activity) Parents: Weekly newsletters and take-home assignments Control: General health intervention

Adiposity: Lower mean BMI Diet: Lower % of calories from saturated fat PA

Y 1: 0.53 kg/m2‡ Y 2: 0.54 kg/m2‡ Y 1: 1.2 percentage points NS

(N ¼ 401) baseline (N ¼ 341) y 2 follow-up 3 to 5 y old Head Start preschool programs Predominantly Latino American

Same intervention design as the study in Bond et al.16

Adiposity Diet PA

NS NS NS

Adiposity Diet PA: Higher mean minutes daily PA Lower mean minutes daily screen time

NS NS 7.46 min/d moderate to vigorous PA‡ 27.8 min/day screen time‡

(N ¼ 618) baseline Same intervention design as the study (N ¼ 589) 14-wk follow-up in Bond et al.16 3 to 5 y old Facility staff: Trained to deliver education sessions Head Start preschool programs Predominantly AfricanAmerican (N ¼ 1780) baseline (N ¼ 1253) y 2 follow-up 3 to 4 y old Kindergartens (prior to primary school)

Children: INT B: 20-min education sessions 5 Adiposity: Lower % INT A 5.2 points; INT of BMI 90th B 6.5 points times/y (nutrition, PA, sedentary behaviors) percentile Not measured Parents: INT A & B: Printed info on Diet Not measured overweight and health PA Facility staff: INT A & B: Trained to deliver education sessions (frequency not reported) Control: Historical data from comparable kindergartens

Sample 1 (N ¼ 1340); Sample 2 (N ¼ 1318) baseline Sample 1 (N ¼ 1340); Sample 2 (N ¼ 1318) follow-up 3 to 6 y old Kindergartens (prior to primary school)

Children: Fresh F/V for snacks; served water and other nonsugared drinks; 30þ min/d PA Parents: Two information sessions, Internet platform Facility staff: Trained to deliver intervention in class (two workshops, information hotline) Control: No intervention

Adiposity Diet: Higher % high fruit consumption Higher % high vegetable consumption Lower % consumption high caloric drinks PA

Sample Sample Sample Sample Sample Sample Sample Sample NS

(N ¼ 537) baseline (N ¼ 468) 10-mo followup 3 to 6 y old Preschools

Children: Games with food themes and new food tasting; games-based fundamental movement skills program 2 times/wk; home gardening and healthy cooking classes Parents: Workshop on PA and sedentary behaviors; workshops on healthy eating (frequency not reported); monthly newsletters Facility staff: Trained to provide movement skills program Environment: Altered playground environment Control: No intervention

Adiposity: Lower BMI z scores Lower waist circumference Diet: Higher F/V servings in lunch box Lower % with 2þ junk food items in lunch box PA: Higher gross motor skills quotient

0.15‡ 0.80 cm‡ 0.61 servings‡ 24.5 points‡ 14.79 units‡


1: 2: 1: 2: 1: 2: 1: 2:

NS NS OR ¼ 1.59‡ OR ¼ 1.64‡ OR ¼ 1.48‡ NS NS 1.66‡



Table 2, Continued Reference, Design, Intervention Duration, Location Burgi et al.37, Puder et al.38, Niederer et al.39 Cluster RCT Duration: 1 school y 10-mo follow-up St. Gallen and Lausanne, Switzerland

Study Results


Eliakim et al.30 Cluster RCT Duration: 4 mo 4-mo follow-up Oranit community, Israel

Nemet et al.31 Cluster RCT Duration: 1 school y 9-mo follow-up Sharon area, Israel

Nemet et al.32 Cluster RCT Duration: 1 school y 9-mo follow-up Central Israel


Intervention Description

(N ¼ 652) baseline (N ¼ 626) 10 mo followup 4- to 6 y old Preschools

Children: 45-min PA sessions 4 d/wk; 22 sessions on nutrition, media use, sleep; healthy snacks, and treats Parents: 3 educational sessions (PA, healthy food, screen time, sleep); printed info Facility staff: Trained to deliver intervention in class (3 training sessions, individual support) Environment: Fixed and mobile equipment installed or provided in and around classrooms Control: Usual curriculum with one 45-min PA lesson per wk (N ¼ 101) baseline Children: Educational sessions with games, (N ¼ 101) 4-mo follow-up books, printed info; 45 min PA sessions 6 d/wk 5 to 6 y old Middle and high Parents: 2 educational sessions socioeconomic Facility staff: Trained to deliver intervention in preschools class (frequency not reported) Control: 2 parent educational sessions; usual curriculum (N ¼ 795) baseline Children: Educational sessions with games, (N ¼ 725) 9-mo follow up books, printed info; 45 min PA sessions 6 3.8 to 6.8 y old d/wk Low socioeconomic Parents: 2 educational sessions preschools Facility staff: Trained to deliver intervention in class (3 all-day sessions) Control: Usual curriculum (N ¼ 342) baseline Same intervention design as in Giraudeau (N ¼ 297) 9-mo follow-up and Ravaud23 4.2 to 6.5 y old Arab-Israeli preschools


Adiposity: Lower % body fat Lower waist circumference Diet PA: Higher aerobic fitness Higher motor agility (obstacle course)

1.1 points 1.0 cm not measured 0.32 units 0.54 s

Adiposity: Lower BMI percentile Lower % body fat Diet PA: Higher daily steps Higher fitness (endurance time) Adiposity: Lower % overweight (85 percentile) Diet PA: Greater improvement in fitness test score Adiposity: Greater decrease in BMI Greater decrease in BMI percentile Diet PA: Greater improvement in fitness test score

6.7 2.29 points Not measured 1438 steps 6.71 units

3.7 points Not measured 20 units

0.3 kg/m2 6.2 Not measured 21.8 units

† RCT indicates randomized controlled trial; INT, intervention; NS, not significant; PA, physical activity; F/V, fruit and vegetable. ‡ Adjusted value * Intervention group vs. control group, p , 0.05.

follow-up of the 15 studies ranged from short-term (less than 1 school year),30,34,40 to medium-term (approximately 1 school year or 1 calendar year) in the majority of the studies,28,29,31,32,34–39,41,42 to long-term (2 years) in four studies.24,25,33,41,42 Risk of Bias and Quality of Evidence Table 5 summarizes the results of the assessment of risk of bias in the individual studies. Fourteen of the 15 studies included in the current review were cluster randomized controlled


trials (cluster RCT), with the childcare facility as the cluster. Only one study used a cluster controlled design but with nonrandom assignment of the control sites,41,42 which was rated high in selection bias. Because of the nature of these behavioral intervention studies, it was not possible to blind intervention staff or participants; thus, the risk of performance bias is high across all of the included studies. Two studies were rated high in detection bias because the research staff collecting data were not blinded to group as-

signment,24,33 and one study each was rated as high for potential attrition bias35 or recruitment bias.33 However, notably, about half of the included studies did not provide sufficient information for the authors to assess possible risk of detection bias,25,26,28–30,34,36,40–42 attrition bias (such as reasons for attrition or use of intention to treat analysis),24,25,34,36,40–43 or recruitment bias.28–32,35,37–40 Some other methodological issues that can impact the quality of evi-


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Table 3 Obesity Prevention Intervention Studies in Preschool and Childcare Settings: Interventions with Nutrition Components Only† Reference, Design, Intervention Duration, Location Hu et al.36 Cluster RCT Duration: 10 mo 1-y follow-up Anhui, China

De Bock et al.35 Cluster RCT Duration: 6 mo 12-mo follow-up South Germany

‘‘Healthy Start,’’ Williams et al.41, Williams et al.42 Cluster controlled trial Duration: 2 school y 9-mo follow-up Upstate New York

Efficacy Outcomes





(N ¼ 2068) baseline (N ¼ 1755) 1-y follow-up 4 to 6 y old Kindergartens (prior to primary school)

Children: 8þ monthly education sessions on Adiposity Diet: Greater decrease nutrition, food preparation; book with in % eating nutritional theme; posters unhealthy snack Parents: 8þ monthly education sessions; Greater decrease in % printed info, posters eating dinner while Facility staff: Assisted with storytelling watching TV Control: Book of general stories Greater increase in % eating breakfast

(N ¼ 377) baseline (N ¼ 348) 1-y follow-up 3 to 6 y old Preschools

NS Children: 12 weekly 2-h sessions on nutrition Adiposity Diet: Greater increase 0.22 and healthy eating; healthy snacks and 0.15 in intake of fruit water were offered portions Parents: 5 weekly 2-h sessions on nutrition; Greater increase in participating children’s cooking practices intake of vegetable Facility staff: Assisted the delivery of portions education sessions Control: Wait-list control (same intervention 6 mo after baseline)

(N ¼ 748) baseline (N ¼ 745) 1-y follow-up (adiposity) (N ¼ 567) 1-y follow-up (diet) (N ¼ 144) 2-y follow-up (diet) 2 to 5 y old Head Start centers

Children: Modified school meals with reduced Adiposity Diet: Greater decrease total and saturated fat in % of calories Parents: Printed info, 3 to 4 parent meetings from saturated fat at half of intervention sites consumed in school Facility staff: Food service staff trained to meals purchase and prepare healthy meals and snacks (1-d session) Control: No change in food services

NS 11.7 points 1.5 points 5.2 points

Y 1: NS Y 2: Not reported Y 1: 2.87 percentage points Y 2: 5.15 percentage points

† RCT indicates randomized controlled trial; NS, not significant; PA, physical activity. * Intervention group vs. control group, p , 0.05.

dence were also noted. Some interventions recruited the preschools from the same community or geographically area, but did not discuss the issue of possible contamination across facilities and study arms.30 Furthermore, all the interventions were randomized at the preschool level, therefore clustering effect at school level should have been tested and, if significant, adjusted for using multilevel or mixed models. Three of the 15 studies did not test for or adjust for a clustering effect.30,36,41,42 Seven of the 15 studies reported that they calculated the minimum sample size to achieve statistical power before starting recruitment and/or calculated power of the actual detected effect sizes during analysis.* The other eight justified their sample size and recruitment strategy based on a vari-

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ety of considerations such as feasibility, convenience samples, or experience from previous or pilot studies. For these studies, it is possible that some statistically insignificant results could be due to underpowered samples. Synthesis of Study Results The 15 studies reported mixed results on the efficacy of the obesity prevention interventions. Seven studies found that the intervention resulted in a relative improvement in adiposity outcomes, the primary outcome of interest. Specifically, the intervention group experienced lower BMI or BMI z scores,24,28–30,32,33 lower body fat percentage or waist circumference,28–30,37–39 or lower prevalence of overweight compared to the control group.31 All seven of

these studies tested interventions that included both nutrition and physical activity components. Secondary outcomes were diet- and physical activity–related behaviors, with substantial variety in measurement of these outcomes. Six of the 13 studies with a nutrition component reported an improvement in dietary intake and a variety of eating habits in the intervention groups versus control groups, including lower percentage of calories from saturated fat,24 higher intake of fruit and vegetables,28,29,34,35 fewer unhealthy lunch items,28,36 and increased frequency of eating breakfast.36 This included three of the 10 studies with combined nutrition and physical activity interventions and all three of the nutrition-only interventions. In addition, eight of the 12 studies with physical activity interven-



Table 4 Obesity Prevention Intervention Studies in Preschool and Childcare Settings: Interventions with Physical Activity Components Only† Reference, Design, Intervention Duration, Location Dennison et al.40 Cluster RCT Duration: 10 wk 6- to 9-mo follow-up Rural upstate New York

Reilly43 Cluster RCT Duration: 24 wk 12-mo follow-up Glasgow, Scotland

Efficacy Outcomes




Difference or Odds Ratio (OR)*‡

(N ¼ 102) baseline (N ¼ 77) 7-wk follow-up 2 to 5 y old Preschools and daycare centers

Adiposity NS Children: 6 weekly 1-h sessions and final PA: Greater decrease 4.7 h/wk session 1 mo later (30 min musical in TV time 21.5 percentage activities, 10 min snack, and 20 min Greater decrease in % points educational session) children watching Parents: Printed info and activities sent home TV 2 h/d Facility staff: Printed info and activities given to staff Control: 8 monthly sessions and printed info on health and safety

(N ¼ 545) baseline (N ¼ 504) 12-mo followup Age range not reported; mean 4.2 y (SD 0.2) Nurseries

Children: 30-min enhanced PA program, 3 d/ Adiposity wk; posters PA: Greater increase Parents: Printed info; posters in fundamental Facility staff: Trained to deliver intervention (3 movement skills sessions) Control: Usual curriculum

6 mo: NS 12 mo: NS 6 mo: 0.8 units

† RCT indicates randomized controlled trial; NS, not significant; PA, physical activity; SD, standard deviation. ‡ Adjusted value * Intervention group vs. control group, p , 0.05.

tion components reported physical activity–related behavior changes in the intervention groups compared to the control groups, including increased active play or higher levels of physical activity,26,30 improved movement skills,28,29,37,38,43 improved aerobic fitness,30–32,37,38 and reduced screen time.26,40 This included six of the 10 studies with combined nutrition and physical activity interventions and both of the two physical activity–only interventions. Long-Term Efficacy and Sustainability Only four of the 15 studies evaluated long-term efficacy by following children for 2 years. Two of these were Hip Hop to Health Jr. studies. One of them reported beneficial effects on BMI in a sample of African-American children, but the other two studies in a sample of Latino children did not produce similar results.24,25 A favorable change of BMI percentile in the intervention groups was noted in a French study after a 2-year follow-up,33 but not in a nutrition intervention in Head Start centers in New York state.41,42 However, turnover of children at the childcare facility is a challenge that


researchers will face, with some children moving on to primary school each year and others moving to different childcare facilities at any time, which could impact both intervention exposure and loss to follow-up. Five studies addressed the potential for intervention sustainability after conclusion of the research. The Tooty Fruity Vegie study evaluated the potential sustainability of the intervention components.44 The authors concluded that the sustainable intervention activities had the following features: children enjoyed them; they were easy for the preschools to implement without much extra time, money, or staff capacity; they were embedded into the preschools’ environment; and they provided newsletters for parents and children. Interventions that involve institutional changes to the physical activity or nutrition environment are potentially sustainable. The Tooty Fruity Vegie28 study and a Swiss study37,38 assessed the impact of changes in the physical activity environment by altering the preschools’ playground or installing mobile equipment in the classrooms. Improvements in children’s anthropo-

metric measures were reported in both of these studies. One study in Head Start centers in the United States implemented changes in the centers’ food service menus served to children, which represents an institutional change in the nutrition environment and was associated with lower saturated fat in the dietary intake of children during meals consumed at the center.41,42

DISCUSSION Summary of Review Findings Based on numerous literature searches, to our knowledge the current study is the only in-depth review published to date that exclusively examined interventions for obesity prevention implemented in preschool childcare settings, which included 15 English publications since 2000 that reported both intermediate outcomes of behavior changes and final outcomes of adiposity. Nearly all of these interventions were tested in high-income countries and targeted a variety of populations from different ethnic groups or socioeconomic levels. The studies used a wide variety of interven-


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Table 5 Risk of Bias Assessment

Study ‘‘Hip Hop to Health Jr.,’’ Fitzgibbon et al.24 ‘‘Hip Hop to Health Jr.,’’ Fitzgibbon et al.25 ‘‘Hip Hop to Health Jr.,’’ Fitzgibbon et al.26 Jouret et al.33 ‘‘Tiger Kids,’’ Bayer et al.34 ‘‘Tooty Footy Vegie,’’ Zask et al.28, Adams et al.29 Burgi et al.37, Puder et al.38, Niederer et al.39 Eliakim et al.30 Nemet et al.31 Nemet et al.32 Hu et al.36 De Bock et al.35 ‘‘Healthy Start,’’ Williams et al.41, Williams et al.42 Dennison et al.40 Reilly43

Selection Bias (Allocation Concealment)

Detection Bias (Blinding of Outcome Assessment)

Attrition Bias (Incomplete Outcome Data)

Reporting Bias

Recruitment Bias

Low

High

High

Unclear

Low

Low

Low

High

Unclear

Unclear

Low

Low

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tion approaches and outcome measures. Evidence from these studies suggested that childhood obesity prevention interventions were variably effective in improving adiposity, dietary behaviors, and/or physical activity levels. Seven out of the 15 studies included in the current review demonstrated both desirable intermediate outcomes (i.e., changes in dietary and/or physical behavior) and desirable final outcomes (i.e., adiposity measures). These seven studies all included both dietary and physical activity–intervention components. At the same time, the five studies that focused exclusively on diet or physical activity found significant intervention effects on these targeted behaviors. Among the 10 combined nutrition and physical activity interventions, more had a significant impact on physical activity than on dietary behaviors. Three interventions implemented modifications to the nutrition and physical activity environment within the childcare setting that could be sustainable as institutional changes,

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Performance Bias (Blinding of Participants and Personnel)


and they showed significant impacts on adiposity and/or behavior changes. Strengths and Limitations This systematic review had several strengths. We chose a variety of key words for the electronic database search to reduce the chances of missing eligible studies. We included studies with controlled designs to assess efficacy of the interventions. In order to examine the efficacy of interventions for prevention of obesity, we excluded interventions that did not report changes in adiposity, the primary outcome. Because of the limited number of interventions published in this area, we included interventions with varied sample sizes, intervention durations, intervention strategies, and outcome measures. A limitation of the review was the inability to perform quantitative synthesis using meta-analysis because of this substantial variability among the studies. The wide eligibility criteria allowed us to include more studies and more accurately assess the state of the literature in this area. The review excluded only two interventions owing

to not reporting adiposity outcomes, and these two studies had relatively short intervention duration, 6 weeks and 20 weeks, respectively. Therefore, their exclusion likely did not have a substantial impact on our overall findings. In the future, as more randomized controlled trials of childhood obesity interventions in childcare settings become available, it will be useful to apply more narrow eligibility criteria and conduct meta-analysis among relatively homogenous studies to compare the efficacy of different intervention strategies in this setting. The reviewed studies had several notable strengths and limitations. All but one of the studies used a cluster RCT design, which represents a high level of evidence. The exception was a Head Start demonstration study in which it was not feasible to randomly assign sites to the control condition with no intervention.41 All of the studies used at least one anthropometric measure of adiposity in addition to at least one behavior outcome measure. Anthropometric measures are objective indicators that can be


For individual use only. Duplication or distribution prohibited by law. measured accurately and reliably with standardized protocols. However, several studies had short intervention duration and a short follow-up time period, which may have limited their ability to achieve sufficient intervention exposure and/or sufficient followup time to be able to detect changes in adiposity beyond any intermediate behavioral changes. Another limitation of the studies was the use of a large variety of measures for the secondary outcomes of dietary or physical activity behaviors. Some of these were objective measures, such as accelerometry or fitness tests, whereas others relied on self-reports by parents or teachers, such as dietary recall. Also, all 10 interventions comprising both nutrition and physical activity components addressed the effect modification of the strategies and approaches applied in their studies through conduction of subgroup analysis33,34,37–39 or testing multiple populations.24–32 The diversity of the ethnic and socioeconomic backgrounds of the study populations is a strength. However, one must also be cautious about the comparability and transferability of specific interventions to different populations. What Recommendations Can Be Made for Future Studies From the Current Review? More controlled trials of childhood obesity interventions in childcare settings are needed. These studies should measure both intermediate behavioral outcomes (dietary intake and/or physical activity) as well as the ultimate outcome of interest, adiposity. More consistency across studies is needed in terms of which measures are used for these outcomes, and objective measures should be used whenever possible. Preferably, a variety of valid adiposity measures should be used to enhance comparability across studies. Interventions that incorporate institutional changes are important for sustainability, such as policies that support healthy eating and activity, ageappropriate health promotion education curricula, and professional training of preschool staff. For example, the Healthy Start study implemented changes in the nutrition environment of Head Start centers by training the food service staff to modify the menus


served to the children.41,42 After the 1year Tooty Fruity Vegie intervention study ended, the preschools sustained some of the intervention strategies for 2 more years; namely, the fun experiential activities for the children, the strategies that were easy for the preschools to implement, and the strategies that were integrated into the preschools’ environmental framework (e.g., nutrition policy and access to water fountains).44 In fact, the components and structure of Tooty Fruity Vegie were later adapted for a statewide, low-intensity obesity prevention intervention at preschools in New South Wales, Australia.45 Besides institutional changes, modification of the built environment within childcare centers should be considered because such modification represents a potentially effective intervention strategy for sustaining increased physical activity levels among preschool children; modification of the built environment has not been addressed sufficiently in available obesity intervention studies in this setting. The outdoor and indoor environment, such as the availability of space for play, play equipment, or architecture structure, can either limit or facilitate children moving around and engaging in active play.46 However, only two studies included in this review addressed this issue. The Tooty Fruity Vegie study and a Swiss study made alterations to the school equipment to provide a variety of play opportunities for the intervention.28,37 Notably, these two interventions showed significantly beneficial effects on both adiposity and physical activity–related outcomes. An Australian intervention called ‘‘The Romp & Chomp,’’ which was not included in the current review because of its community-based design, acknowledged that environmental barriers such as the active play equipment prevented researchers from observing more organized active play among children exposed to the intervention.47,48 More research needs to focus on targeting interventions to meet the needs of children from diverse cultural and socioeconomic backgrounds. A few studies targeting children from ethnic minority groups indicated that they applied culturally targeted learn-

ing materials.25,26,32 The Hip-Hop to Health Jr. program was originally designed for African-American preschoolers, then was adapted for Latino preschoolers. The authors suggested that the nonsignificant intervention outcomes in the Latino sample may have been partly because the parental component of the intervention, which included a weekly newsletter and reports of the children’s food intake, was not intensive enough for Latino parents with low acculturation.25 The Swiss study, whose study participants came from heterogeneous backgrounds, designed positive and culturally independent nutrition messages for the intervention.37 The authors suggested that the families from low socioeconomic backgrounds might set different priorities for healthy behaviors compared to groups from other socioeconomic levels. On the other hand, the French study only found significant intervention effects among children from underprivileged areas, and the authors suggested that families in this group may be more sensitive to health messages owing to a lack of resources.33 Finally, future trials in childcare settings should include cost-effectiveness analysis of the intervention strategies and outcomes. Literature searches did not reveal any cost-effectiveness analyses for this type of intervention in childcare settings, and cost data from early childhood obesity prevention interventions in general are very sparse. An elementary school– based obesity intervention study showed that with exposure to at least 40% of the intervention, a significant reduction in body fat could be achieved with a cost of approximately $300 per child per year beyond the normal after-school care expense.49 Similar cost-effectiveness evidence for interventions in childcare settings would be useful for translating efficacious obesity prevention interventions into practice in childcare facilities.

CONCLUSION This systematic review identified 15 intervention studies aimed at childhood obesity prevention in childcare settings conducted in eight different countries


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For individual use only. Duplication or distribution prohibited by law. and published in English since 2000. These studies used a variety of different intervention strategies and had variable success in improving adiposity and dietrelated and physical activity-related behaviors. The findings highlight the need for more research on interventions to improve the nutrition environment and built environment in preschool settings, as well as the need to further test multistrategy approaches and to use consistent outcome measures. As a larger number of randomized controlled trials in this setting become available, quantitative metaanalyses that combine efficacy data across relatively homogenous studies is needed. Footnote

*

References 25, 26, 28, 29, 33, 35, 37, 38, 43.

SO WHAT? Implications for Health Promotion Practitioners and Researchers What is already known on this topic? A limited number of studies have tested how obesity prevention interventions targeting preschoolers impact behavior and adiposity outcomes. Even fewer have been implemented in childcare settings, which represent an opportune location for early childhood obesity prevention interventions. What does this article add? To our knowledge, this is the first review to provide in-depth qualitative analysis of controlled studies testing obesity prevention interventions in childcare settings using both intermediate outcomes (dietary intake, physical activity) and the final outcome (adiposity). Fifteen eligible studies yielded variable efficacy on adiposity despite some desirable intermediate outcome(s). What are the implications for health promotion practice or research? More research should test changes in the nutrition and physical activity environment as potentially sustainable early prevention strategies in childcare facilities. More controlled trials are needed for quantitative analysis among studies testing similar interventions and using consistent outcome measures of both behaviors and adiposity.

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Acknowledgment This research is funded by a grant from the U.S. Department of Agriculture, USDA/AFRI/NIFA Grant no. 2011-6800130113. The views expressed do not necessarily reflect the official policies of the U.S. Department of Agriculture; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

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