S YS T E M AT I C R E V I E W P R O T O C O L
Effectiveness of family-based weight management interventions in childhood obesity: an umbrella review protocol Li Kheng Chai 1 Tracy Burrows 1 Chris May 2 Katherine Brain 1 Denise Wong See 3 Clare Collins 1,4,5 1 School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia, 2Family Action Centre, The University of Newcastle, Callaghan, New South Wales, Australia, 3Department of Nutrition and Dietetics, John Hunter Children’s Hospital, Newcastle, New South Wales, Australia, 4Priority Research Centre in Physical Activity and Nutrition, The University of Newcastle, Callaghan, New South Wales, Australia, and 5University of Newcastle Centre for Evidence Based Health Care Informing Research (CEBHIR): a Joanna Briggs Institute Centre of Excellence
Review question/objective: The main objective of this umbrella review is to identify the effectiveness of familybased interventions that target overweight or obesity in children aged 18 years and under. The umbrella review intends to compare and summarize existing systematic reviews of experimental studies that address a range of family-based interventions for overweight children. Family-based is defined as the involvement of first- or seconddegree relatives or carers who are cohabiting under one roof.1 The second objective of this umbrella review is to identify strategies that are effective in improving children’s body weight or body mass index (primary outcomes) and, where applicable, changes in child/family behavior, including dietary intake or physical activity. The review questions are as follows: What is the effectiveness of family-based behavioral or lifestyle weight management interventions for overweight children? What are the strategies or characteristics of effective interventions in combating child obesity? Keywords Children; family; intervention; obesity; overweight
Background n the last few decades, childhood obesity has become a public health crisis worldwide and has a higher prevalence, especially in developed countries, including the United States, United Kingdom and Australia.2 It is estimated that 42 million children under the age of five were overweight or obese in 2013, across the world.3 A report of the International Obesity Task Force in the year 2000 estimated that, globally, approximately 155 million children aged five to 17 years were overweight, of whom 30-45 million were obese.4,5 Overweight or obese children have an increased risk of both childhood cardiovascular risk factors, including elevated low-density lipoprotein, cholesterol and blood pressure,6-8 as well as longer term health conditions including type 2 diabetes and heart disease.9-11 In addition, obesity carries a social stigma that adversely affects children as well as their families.12
I
Correspondence: Tracy Burrows, [email protected] There is no conflict of interest in this project. DOI: 10.11124/JBISRIR-2016-003082 JBI Database of Systematic Reviews and Implementation Reports
Many obese children suffer from significant emotional problems ranging from overt depression to disturbed eating behavior.12 Obesity primarily develops from a prolonged excessive energy imbalance caused by calorie consumption that exceeds an individual’s energy requirements.13 Risk factors include genetic predispositions to obesity, obesogenic environment and increased sedentary behaviors.13 Extensive research has been conducted examining both obesity prevention and treatment in children and adolescents, with a number of systematic reviews completed in recent years.14-18 Despite advances in obesity research, the prevalence of overweight and obesity remains on the rise in almost all countries during the last decade.2 The American Medical Association officially recognized obesity as a disease in June 2013 and it is anticipated that this decision will lead to a more focused approach around the world regarding an individual’s access to treatment and in relation to the type of treatment that they receive.19,20 In 2014, the World Health Organization (WHO) established the Commission on Ending Childhood Obesity to better inform and develop a ß 2016 THE JOANNA BRIGGS INSTITUTE
©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
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comprehensive response to childhood obesity.3 The Commision on Ending Childhood Obesity aims to review and address gaps in current strategies and to advocate and raise awareness for action to halt childhood obesity.3 Homes and schools have commonly been targeted as settings for child obesity interventions, while evidence suggests that parental involvement has resulted in effective interventions.21,22 Parents’ attitudes, beliefs and behaviors can influence their child’s risk of being overweight. Parental characteristics such as high body mass index (BMI), regular smoking, high alcohol intake, low education level and low socio-economic status have all been associated with increased likelihood of their children being overweight.23 Although children are known to influence food choices in many families, parents are the key mediators of the obesogenic family environments. Parents make the final decision on the food provided and meal preparation methods at home, hence impacting their children’s food preferences. The presence of parents at family meals can promote a positive atmosphere and model appropriate foodrelated behaviors and healthy food choices. Combined, these factors are associated with improved child diet quality. In order to reduce the prevalence of childhood obesity, it is essential to identify the elements that underpin effective interventions including prevention, weight management and treatment. As parental influences are closely associated with child weight or weight-related outcome, the parental role in the treatment of childhood obesity is likely to be a critical element for effective interventions.17,24 Family-based interventions for childhood obesity are not uncommon; however, it remains a challenge for healthcare professionals aiming to treat childhood obesity to work effectively with both parents as a collective unit. Yet, the ability to work effectively with both parents is likely to be important when aiming to influence the complex dynamics of family systems.25 There is an abundance of literature on childhood obesity interventions with parental involvement.14,17,26 Yet, systematic reviews of childhood obesity interventions have reported difficulties in assessing the effectiveness of family-based interventions on children’s weight and weight-related behavior due to both the scarcity of quality programs27,28 and the diversity of existing strategies.16 A Cochrane review28 acknowledged that research in JBI Database of Systematic Reviews and Implementation Reports
L.K. Chai et al.
the area of childhood obesity treatment is challenging as it is difficult to suggest that one intervention component is more effective than the other given the heterogeneity of current literature. Therefore, it is warranted to address this gap through a comprehensive review of current systematic reviews summarizing existing strategies that have been reported to be effective in supporting parents with an overweight child to better manage their child’s weight. The current study aims to systematically review the literature, including existing systematic reviews to identify the key strategies employed in effective family-based weight management programs for overweight children that result in weight loss and/or behavior change. This review would therefore address current gaps in the literature concerning this area of research by summarizing the strategies that could effectively facilitate parents in managing their child’s weight. A search of the systematic review repositories (PROSPERO, the JBI Database of Systematic Reviews and Implementation Reports) has shown that there is no current umbrella review or overview underway for this topic.
Inclusion criteria Types of participants Systematic reviews in which study populations have included children and adolescents aged 18 years and under who were classified as overweight or obese at baseline, based on WHO Child Growth Standards, Centers for Disease Control and Prevention Growth Charts or Cole’s LMS method, will be included.29-31
Types of intervention(s)/phenomena of interest This umbrella review will include reviews considering family-based behavioral or lifestyle interventions for child weight management. For the purpose of this review, ‘‘family-based’’ is defined as the involvement of first- or second-degree relatives or carers cohabiting under one roof.1 Interventions that involve parents only, the parent and child separately or the parent and child together will be included, regardless of the setting (home environment, schools, clinical sites and community settings). Interventions of interest are those that aim for weight loss as a primary outcome through changes to behavioral or lifestyle habits, including, but not limited to, dietary intake, physical activity, sedentary behavior, mealtime patterns and sleep. Comparison groups ß 2016 THE JOANNA BRIGGS INSTITUTE
©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
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may include usual care, other interventions or no intervention control.
Outcomes The primary outcome of interest is children’s body weight or BMI. Existing reviews that reported synthesis of children’s body weight or BMI change, measured from baseline to intervention-end or post-intervention follow-up, will be considered for this review. Where available, ‘‘behavior change’’ such as dietary intake or physical activity may be included as secondary outcomes of interest. Behavior change outcomes could be measured using various methods including, but not limited to, the food frequency questionnaire, weighed food record (food diary), diet history, 24-hour recall, accelerometer, pedometer and physical activity questionnaire. Other outcomes, such as waist circumference, adiposity, blood glucose levels or blood lipid levels, which may be of interest in relation to change in weight or behavior will also be reported in the same way as the included reviews. Adverse outcomes that have resulted from interventions such as deterioration of disordered eating, depression or anxiety will be documented if reported within the reviews.28
Types of studies Systematic reviews (both quantitative and mixed methods) and meta-analyses of intervention studies will be included in this review. Systematic reviews of solely qualitative studies or reviews of nonexperimental studies (such as cohort study, case study and cross-sectional study) or narrative reviews will be excluded. Where mixed method reviews are available, only quantitative results will be extracted for inclusion in the umbrella review, qualitative results will be excluded. For reviews that include both experimental and nonexperimental studies, only results from experimental studies will be extracted for inclusion in the umbrella review. If results are not reported or not separable between experimental and nonexperimental studies, the review will be excluded.
Search strategy The search strategy is designed to identify syntheses of research evidence such as systematic reviews and meta-analyses exclusively. As there were limited systematic reviews published prior to 1990,32 the
JBI Database of Systematic Reviews and Implementation Reports
L.K. Chai et al.
current review aims to focus on reports available from 1990 to present that were published in the English language. A three-stage search method will be used in this review. Initial keywords will be identified in MEDLINE first, the text words contained in the title and abstract will be analyzed subsequently, and then the index terms used to describe related reviews. Second, a search will be performed in the following databases – MEDLINE, EMBASE, CINAHL, PsycInfo, Scopus, Database of Abstracts of Reviews of Effects and the Cochrane Database of Systematic Reviews using a search strategy (Appendix I), which comprises all identified keywords and index terms, reviewed by an experienced academic librarian. The third phase will include manually searching reference lists of all included reviews for additional studies.33 Two independent reviewers, with experience in the field, will examine titles and abstracts of all identified reviews. Relevant reviews will be obtained in the form of full articles and assessed against the inclusion and study quality criteria as described in the protocol. Any disagreements that arise will be resolved through discussion or with a third reviewer, who will perform an additional independent evaluation.
Assessment of methodological quality All included systematic reviews will be critically appraised by two reviewers individually using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses (Appendix II).33 When consensus cannot be reached between the two reviewers, a third reviewer will perform an additional appraisal independently.
Data extraction The JBI Data Extraction Form for Review for Systematic Reviews and Research Syntheses (Appendix III) will be used for data extraction from the studies included in the review.33 Characteristics of studies will be included in the Table of Included Study Characteristics to be attached to the review report. Review characteristics: author/year, objectives, participants (characteristics/total number), setting/context (cultural factors: ethnicity/socioeconomic status/minority group), interventions of interest, number of databases/sources searched, date range of included studies, detailed
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description of the included studies (number/type/ country of origin of included studies), appraisal instrument and rating, type of review/method of analysis and outcomes. Results: significant findings/outcomes of the review and comments.
Data summary Findings of included reviews will be presented with overall effect size evaluations extracted from the reports. Quantitative data will be presented by reporting the number of studies that inform the outcome, the number of participants from included studies, and the heterogeneity of the results of included reviews. In the cases of included reviews reporting a high level of homogeneity, pooled estimates will be presented. Any overlap of original research studies in all included reviews (e.g. one study is included in multiple included reviews) will be clearly indicated in the report. The results of the umbrella review will be summarized in the ‘‘Summary of Evidence’’ table, presenting information including the intervention names, the included systematic reviews, and a simple visual indicator of the intervention effectiveness using the JBI ‘‘stop-light’’ indicator, where green indicates an effective or beneficial intervention, amber indicates no intervention effect or no difference when compared to the comparator and red indicates a detrimental or less-effective intervention when compared to the comparator.33 An overall assessment of the quality of evidence for each intervention of interest will be performed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.34 The GRADE framework includes evaluation of the following criteria: quality of primary studies, design of primary studies, consistency and directness.
Acknowledgements The current systematic literature review will form part of the theses work for PhD candidate Li Kheng Chai from The University of Newcastle, Australia.
References 1. McLean N, Griffin S, Toney K, Hardeman W. Family involvement in weight control, weight maintenance and weight-loss interventions: a systematic review of randomised trials. Int J Obes Relat Metab Disord 2003;27(9):987–1005.
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2. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384(9945):766–81. 3. World Health Organisation. Interim report of the commission on ending childhood obesity. Geneva, Switzerland: World Health Organization; 2015. 4. Ahmad QI, Ahmad CB, Ahmad SM. Childhood obesity. Indian J Endocrinol Metab 2010;14(1):19–25. 5. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obes Rev 2004;5(Suppl 1): 4–104. 6. Bridger T. Childhood obesity and cardiovascular disease. Paediatr Child Health 2009;14(3):177–82. 7. Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander D, Stewart L, et al. Health consequences of obesity. Arch Dis Child 2003;88(9):748–52. 8. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics 1998;101(3 Pt 2):518–25. 9. Jing L, Friday CM, Suever JD, Umasankar N, Haggerty CM, Wehner GJ, et al. Abstract 15439: obese children with concentric hypertrophy and impaired cardiac strain: a potentially high-risk subgroup identified with cardiac magnetic resonance. Circulation 2015;132(Suppl 3):A15439. 10. Li C, Ford ES, Zhao G, Mokdad AH. Prevalence of prediabetes and its association with clustering of cardiometabolic risk factors and hyperinsulinemia among U.S. adolescents: National Health and Nutrition Examination Survey 2005-2006. Diabetes Care 2009;32(2):342–7. 11. Reilly JJ, Kelly J. Long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review. Int J Obes (Lond) 2011;35(7):891–8. 12. Holm JC, Nowicka P, Farpour-Lambert NJ, O’Malley G, Hassapidou M, Weiss R, et al. The ethics of childhood obesity treatment – from the Childhood Obesity Task Force (COTF) of European Association for the Study of Obesity (EASO). Obes Facts 2014;7(4):274–81. 13. Vos MB, Welsh J. Childhood obesity: update on predisposing factors and prevention strategies. Curr Gastroenterol Rep 2010;12(4):280–7. 14. Gerards SM, Sleddens EF, Dagnelie PC, de Vries NK, Kremers SP. Interventions addressing general parenting to prevent or treat childhood obesity. Int J Pediatr Obes 2011;6(2-2): e28–45. 15. Khambalia AZ, Dickinson S, Hardy LL, Gill T, Baur LA. A synthesis of existing systematic reviews and meta-analyses of school-based behavioral interventions for controlling and preventing obesity. Obes Rev 2012;13(3):214–33. 16. Showell NN, Fawole O, Segal J, Wilson RF, Cheskin LJ, Bleich SN, et al. A systematic review of home-based childhood obesity prevention studies. Pediatrics 2013;132(1):e193–200.
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©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
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17. van der Kruk JJ, Kortekaas F, Lucas C, Jager-Wittenaar H. Obesity: a systematic review on parental involvement in long-term European childhood weight control interventions with a nutritional focus. Obes Rev 2013;14(9):745–60. 18. Wang Y, Cai L, Wu Y, Wilson RF, Weston C, Fawole O, et al. What childhood obesity prevention programmes work? A systematic review and meta-analysis. Obes Rev 2015; 16(7):547–65. 19. American Medical Association. AMA adopts new policies on second day of voting at annual meeting.2015; Available from: http://www.ama-assn.org/ama/pub/news/ news/2013/2013–06–18-new-ama-policies-annualmeeting.page [updated 2013 June 18; cited 2015 Nov 25]; [Internet]. 20. European Association for the Study of Obesity. Obesity facts & figures.2013; Available from: http://easo.org/educationportal/obesity-facts-figures/ [cited 2015 Nov 25]; [Internet]. 21. Huffman FG, Kanikireddy S, Patel M. Parenthood – a contributing factor to childhood obesity. Int J Environ Res Public Health 2010;7(7):2800–10. 22. Norton DE, Froelicher ES, Waters CM, Carrieri-Kohlman V. Parental influence on models of primary prevention of cardiovascular disease in children. Eur J Cardiovasc Nurs 2003;2(4):311–22. 23. Walsh B, Cullinan J. Decomposing socioeconomic inequalities in childhood obesity: evidence from Ireland. Econ Hum Biol 2015;16:60–72. 24. Epstein LH, Paluch RA, Roemmich JN, Beecher MD. Familybased obesity treatment, then and now: twenty-five years of pediatric obesity treatment. Health Psychol 2007;26(4): 381–91. 25. Skelton JA, Buehler C, Irby MB, Grzywacz JG. Where are family theories in family-based obesity treatment?: conceptualizing the study of families in pediatric weight management. Int J Obes (Lond) 2012;36(7):891–900.
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26. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child 2006;16(1):169–86. 27. Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, Waters E. Interventions for treating obesity in children. Cochrane Database Syst Rev (3):2003:CD001872. 28. Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O’Malley C, Stolk RP, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev (1):2009:CD001872. 29. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320(7244):1240–3. 30. Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatr Obes 2012;7(4):284–94. 31. Harvard T.H. Chan School of Public Health. Obesity prevention source: obesity definition: defining childhood obesity2015; Available from: http://www.hsph.harvard.edu/ obesity-prevention-source/obesity-definition/definingchildhood-obesity/ [cited 2015 Nov 25]; [Internet]. 32. Smith V, Devane D, Begley CM, Clarke M. Methodology in conducting a systematic review of systematic reviews of healthcare interventions. BMC Med Res Methodol 2011;11(1):15. 33. Aromataris E, Fernandez R, Godfrey C, Holly C, Kahlil H, Tungpunkom P. Methodology for JBI umbrella reviews. Joanna Briggs Institute Reviewer’s Manual 2014. Adelaide: The Joanna Briggs Institute; 2014 ; Available from: http:// joannabriggs.org/assets/docs/sumari/ReviewersManualMethodology-JBI_Umbrella%20Reviews-2014.pdf [cited 2015 Nov 25]. 34. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, AlonsoCoello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924–6.
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©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
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Appendix I: Search strategy Platform: OVID Database(s): MEDLINE 1946 to Present with Daily Update No.
Searches
(Continued)
1
systematic review.mp,pt.
2
systematic.mp,pt.
28
kid .mp.
3
review.mp,pt.
29
toddler.mp.
No.
Searches
4
meta analys .mp,pt.
30
(preschooler or pre-schooler).mp.
5
metaanalys.mp,pt.
31
adolescent.mp.
6
meta-analys .mp,pt
32
teenager.mp.
7
1 or 2 or 3 or 4 or 5 or 6
33
youth.mp.
8
lifestyle.mp.
34
youngster.mp.
9
behavio?r.mp.
35
10
family.mp.
26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34
11
families.mp.
36
overweight.mp.
12
family-based.mp.
37
obese.mp.
13
parents.mp.
38
obes.mp.
14
parent.mp.
39
weight manag.mp.
15
mother.mp.
40
weight loss.mp.
16
father.mp.
41
weight control.mp.
17
carer.mp.
42
(overweight adj5 intervention).mp.
18
guardian.mp.
43
(overweight adj5 treatment).mp.
19
grandparent.mp.
44
(overweight adj5 program).mp.
20
grandfather.mp.
45
(weight adj5 intervention).mp.
21
grandmother.mp.
46
(weight adj5 treatment).mp.
22
sibling.mp.
47
(weight adj5 program).mp.
23
coparent.mp.
48
(obes adj5 intervention).mp.
24
co-parent.mp.
49
(obes adj5 treatment).mp.
25
8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24
50
(obes adj5 program).mp.
51
36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50
52
7 and 25 and 35 and 51
53
limit 52 to (English language and yr ¼ ‘‘1990-Current’’)
26
p?ediatric..mp.
27
child.mp.
JBI Database of Systematic Reviews and Implementation Reports
ß 2016 THE JOANNA BRIGGS INSTITUTE
©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
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Appendix II: JBI critical appraisal checklist for systematic reviews and research syntheses Reviewer
Date
Author
Year
Record Number Yes
1.
Is the review question clearly and explicitly stated?
2.
Were the inclusion criteria appropriate for the review question?
3.
Was the search strategy appropriate?
4.
Were the sources and resources used to search for studies adequate?
5.
Were the criteria for appraising studies appropriate?
6.
Was critical appraisal conducted or more reviewers independently?
7.
Were errors
8.
Were the methods used to combine studies appropriate?
9.
Was the likelihood of publication bias assessed?
there methods to in data extraction?
recommendations for policy practice supported by the reported data? the specific directives research appropriate?
Overall appraisal:
Include
Unclear
Not Applicable
two
minimize
10. Were
11. Were
by
No
for
and/or
new
Exclude
JBI Database of Systematic Reviews and Implementation Reports
Seek further info
ß 2016 THE JOANNA BRIGGS INSTITUTE
©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
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Appendix III: JBI data extraction form for review for systematic reviews and research syntheses Study details Author/year Objectives Participants (characteristics/total number) Setting/context Description of interventions/phenomena of interest Search details Sources searched Range (years) of included studies Number of studies included I Types of studies included Country of origin of included studies Appraisal Appraisal instruments used Appraisal rating Analysis Method of analysis Outcome assessed Results/findings Significance/direction Heterogeneity Comments
JBI Database of Systematic Reviews and Implementation Reports
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©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
39
Effectiveness of family-based weight management interventions in childhood obesity: an umbrella review protocol Li Kheng Chai 1 Tracy Burrows 1 Chris May 2 Katherine Brain 1 Denise Wong See 3 Clare Collins 1,4,5 1 School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia, 2Family Action Centre, The University of Newcastle, Callaghan, New South Wales, Australia, 3Department of Nutrition and Dietetics, John Hunter Children’s Hospital, Newcastle, New South Wales, Australia, 4Priority Research Centre in Physical Activity and Nutrition, The University of Newcastle, Callaghan, New South Wales, Australia, and 5University of Newcastle Centre for Evidence Based Health Care Informing Research (CEBHIR): a Joanna Briggs Institute Centre of Excellence
Review question/objective: The main objective of this umbrella review is to identify the effectiveness of familybased interventions that target overweight or obesity in children aged 18 years and under. The umbrella review intends to compare and summarize existing systematic reviews of experimental studies that address a range of family-based interventions for overweight children. Family-based is defined as the involvement of first- or seconddegree relatives or carers who are cohabiting under one roof.1 The second objective of this umbrella review is to identify strategies that are effective in improving children’s body weight or body mass index (primary outcomes) and, where applicable, changes in child/family behavior, including dietary intake or physical activity. The review questions are as follows: What is the effectiveness of family-based behavioral or lifestyle weight management interventions for overweight children? What are the strategies or characteristics of effective interventions in combating child obesity? Keywords Children; family; intervention; obesity; overweight
Background n the last few decades, childhood obesity has become a public health crisis worldwide and has a higher prevalence, especially in developed countries, including the United States, United Kingdom and Australia.2 It is estimated that 42 million children under the age of five were overweight or obese in 2013, across the world.3 A report of the International Obesity Task Force in the year 2000 estimated that, globally, approximately 155 million children aged five to 17 years were overweight, of whom 30-45 million were obese.4,5 Overweight or obese children have an increased risk of both childhood cardiovascular risk factors, including elevated low-density lipoprotein, cholesterol and blood pressure,6-8 as well as longer term health conditions including type 2 diabetes and heart disease.9-11 In addition, obesity carries a social stigma that adversely affects children as well as their families.12
I
Correspondence: Tracy Burrows, [email protected] There is no conflict of interest in this project. DOI: 10.11124/JBISRIR-2016-003082 JBI Database of Systematic Reviews and Implementation Reports
Many obese children suffer from significant emotional problems ranging from overt depression to disturbed eating behavior.12 Obesity primarily develops from a prolonged excessive energy imbalance caused by calorie consumption that exceeds an individual’s energy requirements.13 Risk factors include genetic predispositions to obesity, obesogenic environment and increased sedentary behaviors.13 Extensive research has been conducted examining both obesity prevention and treatment in children and adolescents, with a number of systematic reviews completed in recent years.14-18 Despite advances in obesity research, the prevalence of overweight and obesity remains on the rise in almost all countries during the last decade.2 The American Medical Association officially recognized obesity as a disease in June 2013 and it is anticipated that this decision will lead to a more focused approach around the world regarding an individual’s access to treatment and in relation to the type of treatment that they receive.19,20 In 2014, the World Health Organization (WHO) established the Commission on Ending Childhood Obesity to better inform and develop a ß 2016 THE JOANNA BRIGGS INSTITUTE
©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
32
SYSTEMATIC REVIEW PROTOCOL
comprehensive response to childhood obesity.3 The Commision on Ending Childhood Obesity aims to review and address gaps in current strategies and to advocate and raise awareness for action to halt childhood obesity.3 Homes and schools have commonly been targeted as settings for child obesity interventions, while evidence suggests that parental involvement has resulted in effective interventions.21,22 Parents’ attitudes, beliefs and behaviors can influence their child’s risk of being overweight. Parental characteristics such as high body mass index (BMI), regular smoking, high alcohol intake, low education level and low socio-economic status have all been associated with increased likelihood of their children being overweight.23 Although children are known to influence food choices in many families, parents are the key mediators of the obesogenic family environments. Parents make the final decision on the food provided and meal preparation methods at home, hence impacting their children’s food preferences. The presence of parents at family meals can promote a positive atmosphere and model appropriate foodrelated behaviors and healthy food choices. Combined, these factors are associated with improved child diet quality. In order to reduce the prevalence of childhood obesity, it is essential to identify the elements that underpin effective interventions including prevention, weight management and treatment. As parental influences are closely associated with child weight or weight-related outcome, the parental role in the treatment of childhood obesity is likely to be a critical element for effective interventions.17,24 Family-based interventions for childhood obesity are not uncommon; however, it remains a challenge for healthcare professionals aiming to treat childhood obesity to work effectively with both parents as a collective unit. Yet, the ability to work effectively with both parents is likely to be important when aiming to influence the complex dynamics of family systems.25 There is an abundance of literature on childhood obesity interventions with parental involvement.14,17,26 Yet, systematic reviews of childhood obesity interventions have reported difficulties in assessing the effectiveness of family-based interventions on children’s weight and weight-related behavior due to both the scarcity of quality programs27,28 and the diversity of existing strategies.16 A Cochrane review28 acknowledged that research in JBI Database of Systematic Reviews and Implementation Reports
L.K. Chai et al.
the area of childhood obesity treatment is challenging as it is difficult to suggest that one intervention component is more effective than the other given the heterogeneity of current literature. Therefore, it is warranted to address this gap through a comprehensive review of current systematic reviews summarizing existing strategies that have been reported to be effective in supporting parents with an overweight child to better manage their child’s weight. The current study aims to systematically review the literature, including existing systematic reviews to identify the key strategies employed in effective family-based weight management programs for overweight children that result in weight loss and/or behavior change. This review would therefore address current gaps in the literature concerning this area of research by summarizing the strategies that could effectively facilitate parents in managing their child’s weight. A search of the systematic review repositories (PROSPERO, the JBI Database of Systematic Reviews and Implementation Reports) has shown that there is no current umbrella review or overview underway for this topic.
Inclusion criteria Types of participants Systematic reviews in which study populations have included children and adolescents aged 18 years and under who were classified as overweight or obese at baseline, based on WHO Child Growth Standards, Centers for Disease Control and Prevention Growth Charts or Cole’s LMS method, will be included.29-31
Types of intervention(s)/phenomena of interest This umbrella review will include reviews considering family-based behavioral or lifestyle interventions for child weight management. For the purpose of this review, ‘‘family-based’’ is defined as the involvement of first- or second-degree relatives or carers cohabiting under one roof.1 Interventions that involve parents only, the parent and child separately or the parent and child together will be included, regardless of the setting (home environment, schools, clinical sites and community settings). Interventions of interest are those that aim for weight loss as a primary outcome through changes to behavioral or lifestyle habits, including, but not limited to, dietary intake, physical activity, sedentary behavior, mealtime patterns and sleep. Comparison groups ß 2016 THE JOANNA BRIGGS INSTITUTE
©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
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may include usual care, other interventions or no intervention control.
Outcomes The primary outcome of interest is children’s body weight or BMI. Existing reviews that reported synthesis of children’s body weight or BMI change, measured from baseline to intervention-end or post-intervention follow-up, will be considered for this review. Where available, ‘‘behavior change’’ such as dietary intake or physical activity may be included as secondary outcomes of interest. Behavior change outcomes could be measured using various methods including, but not limited to, the food frequency questionnaire, weighed food record (food diary), diet history, 24-hour recall, accelerometer, pedometer and physical activity questionnaire. Other outcomes, such as waist circumference, adiposity, blood glucose levels or blood lipid levels, which may be of interest in relation to change in weight or behavior will also be reported in the same way as the included reviews. Adverse outcomes that have resulted from interventions such as deterioration of disordered eating, depression or anxiety will be documented if reported within the reviews.28
Types of studies Systematic reviews (both quantitative and mixed methods) and meta-analyses of intervention studies will be included in this review. Systematic reviews of solely qualitative studies or reviews of nonexperimental studies (such as cohort study, case study and cross-sectional study) or narrative reviews will be excluded. Where mixed method reviews are available, only quantitative results will be extracted for inclusion in the umbrella review, qualitative results will be excluded. For reviews that include both experimental and nonexperimental studies, only results from experimental studies will be extracted for inclusion in the umbrella review. If results are not reported or not separable between experimental and nonexperimental studies, the review will be excluded.
Search strategy The search strategy is designed to identify syntheses of research evidence such as systematic reviews and meta-analyses exclusively. As there were limited systematic reviews published prior to 1990,32 the
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current review aims to focus on reports available from 1990 to present that were published in the English language. A three-stage search method will be used in this review. Initial keywords will be identified in MEDLINE first, the text words contained in the title and abstract will be analyzed subsequently, and then the index terms used to describe related reviews. Second, a search will be performed in the following databases – MEDLINE, EMBASE, CINAHL, PsycInfo, Scopus, Database of Abstracts of Reviews of Effects and the Cochrane Database of Systematic Reviews using a search strategy (Appendix I), which comprises all identified keywords and index terms, reviewed by an experienced academic librarian. The third phase will include manually searching reference lists of all included reviews for additional studies.33 Two independent reviewers, with experience in the field, will examine titles and abstracts of all identified reviews. Relevant reviews will be obtained in the form of full articles and assessed against the inclusion and study quality criteria as described in the protocol. Any disagreements that arise will be resolved through discussion or with a third reviewer, who will perform an additional independent evaluation.
Assessment of methodological quality All included systematic reviews will be critically appraised by two reviewers individually using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses (Appendix II).33 When consensus cannot be reached between the two reviewers, a third reviewer will perform an additional appraisal independently.
Data extraction The JBI Data Extraction Form for Review for Systematic Reviews and Research Syntheses (Appendix III) will be used for data extraction from the studies included in the review.33 Characteristics of studies will be included in the Table of Included Study Characteristics to be attached to the review report. Review characteristics: author/year, objectives, participants (characteristics/total number), setting/context (cultural factors: ethnicity/socioeconomic status/minority group), interventions of interest, number of databases/sources searched, date range of included studies, detailed
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description of the included studies (number/type/ country of origin of included studies), appraisal instrument and rating, type of review/method of analysis and outcomes. Results: significant findings/outcomes of the review and comments.
Data summary Findings of included reviews will be presented with overall effect size evaluations extracted from the reports. Quantitative data will be presented by reporting the number of studies that inform the outcome, the number of participants from included studies, and the heterogeneity of the results of included reviews. In the cases of included reviews reporting a high level of homogeneity, pooled estimates will be presented. Any overlap of original research studies in all included reviews (e.g. one study is included in multiple included reviews) will be clearly indicated in the report. The results of the umbrella review will be summarized in the ‘‘Summary of Evidence’’ table, presenting information including the intervention names, the included systematic reviews, and a simple visual indicator of the intervention effectiveness using the JBI ‘‘stop-light’’ indicator, where green indicates an effective or beneficial intervention, amber indicates no intervention effect or no difference when compared to the comparator and red indicates a detrimental or less-effective intervention when compared to the comparator.33 An overall assessment of the quality of evidence for each intervention of interest will be performed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.34 The GRADE framework includes evaluation of the following criteria: quality of primary studies, design of primary studies, consistency and directness.
Acknowledgements The current systematic literature review will form part of the theses work for PhD candidate Li Kheng Chai from The University of Newcastle, Australia.
References 1. McLean N, Griffin S, Toney K, Hardeman W. Family involvement in weight control, weight maintenance and weight-loss interventions: a systematic review of randomised trials. Int J Obes Relat Metab Disord 2003;27(9):987–1005.
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2. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384(9945):766–81. 3. World Health Organisation. Interim report of the commission on ending childhood obesity. Geneva, Switzerland: World Health Organization; 2015. 4. Ahmad QI, Ahmad CB, Ahmad SM. Childhood obesity. Indian J Endocrinol Metab 2010;14(1):19–25. 5. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obes Rev 2004;5(Suppl 1): 4–104. 6. Bridger T. Childhood obesity and cardiovascular disease. Paediatr Child Health 2009;14(3):177–82. 7. Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander D, Stewart L, et al. Health consequences of obesity. Arch Dis Child 2003;88(9):748–52. 8. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics 1998;101(3 Pt 2):518–25. 9. Jing L, Friday CM, Suever JD, Umasankar N, Haggerty CM, Wehner GJ, et al. Abstract 15439: obese children with concentric hypertrophy and impaired cardiac strain: a potentially high-risk subgroup identified with cardiac magnetic resonance. Circulation 2015;132(Suppl 3):A15439. 10. Li C, Ford ES, Zhao G, Mokdad AH. Prevalence of prediabetes and its association with clustering of cardiometabolic risk factors and hyperinsulinemia among U.S. adolescents: National Health and Nutrition Examination Survey 2005-2006. Diabetes Care 2009;32(2):342–7. 11. Reilly JJ, Kelly J. Long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review. Int J Obes (Lond) 2011;35(7):891–8. 12. Holm JC, Nowicka P, Farpour-Lambert NJ, O’Malley G, Hassapidou M, Weiss R, et al. The ethics of childhood obesity treatment – from the Childhood Obesity Task Force (COTF) of European Association for the Study of Obesity (EASO). Obes Facts 2014;7(4):274–81. 13. Vos MB, Welsh J. Childhood obesity: update on predisposing factors and prevention strategies. Curr Gastroenterol Rep 2010;12(4):280–7. 14. Gerards SM, Sleddens EF, Dagnelie PC, de Vries NK, Kremers SP. Interventions addressing general parenting to prevent or treat childhood obesity. Int J Pediatr Obes 2011;6(2-2): e28–45. 15. Khambalia AZ, Dickinson S, Hardy LL, Gill T, Baur LA. A synthesis of existing systematic reviews and meta-analyses of school-based behavioral interventions for controlling and preventing obesity. Obes Rev 2012;13(3):214–33. 16. Showell NN, Fawole O, Segal J, Wilson RF, Cheskin LJ, Bleich SN, et al. A systematic review of home-based childhood obesity prevention studies. Pediatrics 2013;132(1):e193–200.
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17. van der Kruk JJ, Kortekaas F, Lucas C, Jager-Wittenaar H. Obesity: a systematic review on parental involvement in long-term European childhood weight control interventions with a nutritional focus. Obes Rev 2013;14(9):745–60. 18. Wang Y, Cai L, Wu Y, Wilson RF, Weston C, Fawole O, et al. What childhood obesity prevention programmes work? A systematic review and meta-analysis. Obes Rev 2015; 16(7):547–65. 19. American Medical Association. AMA adopts new policies on second day of voting at annual meeting.2015; Available from: http://www.ama-assn.org/ama/pub/news/ news/2013/2013–06–18-new-ama-policies-annualmeeting.page [updated 2013 June 18; cited 2015 Nov 25]; [Internet]. 20. European Association for the Study of Obesity. Obesity facts & figures.2013; Available from: http://easo.org/educationportal/obesity-facts-figures/ [cited 2015 Nov 25]; [Internet]. 21. Huffman FG, Kanikireddy S, Patel M. Parenthood – a contributing factor to childhood obesity. Int J Environ Res Public Health 2010;7(7):2800–10. 22. Norton DE, Froelicher ES, Waters CM, Carrieri-Kohlman V. Parental influence on models of primary prevention of cardiovascular disease in children. Eur J Cardiovasc Nurs 2003;2(4):311–22. 23. Walsh B, Cullinan J. Decomposing socioeconomic inequalities in childhood obesity: evidence from Ireland. Econ Hum Biol 2015;16:60–72. 24. Epstein LH, Paluch RA, Roemmich JN, Beecher MD. Familybased obesity treatment, then and now: twenty-five years of pediatric obesity treatment. Health Psychol 2007;26(4): 381–91. 25. Skelton JA, Buehler C, Irby MB, Grzywacz JG. Where are family theories in family-based obesity treatment?: conceptualizing the study of families in pediatric weight management. Int J Obes (Lond) 2012;36(7):891–900.
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26. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child 2006;16(1):169–86. 27. Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, Waters E. Interventions for treating obesity in children. Cochrane Database Syst Rev (3):2003:CD001872. 28. Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O’Malley C, Stolk RP, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev (1):2009:CD001872. 29. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320(7244):1240–3. 30. Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatr Obes 2012;7(4):284–94. 31. Harvard T.H. Chan School of Public Health. Obesity prevention source: obesity definition: defining childhood obesity2015; Available from: http://www.hsph.harvard.edu/ obesity-prevention-source/obesity-definition/definingchildhood-obesity/ [cited 2015 Nov 25]; [Internet]. 32. Smith V, Devane D, Begley CM, Clarke M. Methodology in conducting a systematic review of systematic reviews of healthcare interventions. BMC Med Res Methodol 2011;11(1):15. 33. Aromataris E, Fernandez R, Godfrey C, Holly C, Kahlil H, Tungpunkom P. Methodology for JBI umbrella reviews. Joanna Briggs Institute Reviewer’s Manual 2014. Adelaide: The Joanna Briggs Institute; 2014 ; Available from: http:// joannabriggs.org/assets/docs/sumari/ReviewersManualMethodology-JBI_Umbrella%20Reviews-2014.pdf [cited 2015 Nov 25]. 34. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, AlonsoCoello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924–6.
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Appendix I: Search strategy Platform: OVID Database(s): MEDLINE 1946 to Present with Daily Update No.
Searches
(Continued)
1
systematic review.mp,pt.
2
systematic.mp,pt.
28
kid .mp.
3
review.mp,pt.
29
toddler.mp.
No.
Searches
4
meta analys .mp,pt.
30
(preschooler or pre-schooler).mp.
5
metaanalys.mp,pt.
31
adolescent.mp.
6
meta-analys .mp,pt
32
teenager.mp.
7
1 or 2 or 3 or 4 or 5 or 6
33
youth.mp.
8
lifestyle.mp.
34
youngster.mp.
9
behavio?r.mp.
35
10
family.mp.
26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34
11
families.mp.
36
overweight.mp.
12
family-based.mp.
37
obese.mp.
13
parents.mp.
38
obes.mp.
14
parent.mp.
39
weight manag.mp.
15
mother.mp.
40
weight loss.mp.
16
father.mp.
41
weight control.mp.
17
carer.mp.
42
(overweight adj5 intervention).mp.
18
guardian.mp.
43
(overweight adj5 treatment).mp.
19
grandparent.mp.
44
(overweight adj5 program).mp.
20
grandfather.mp.
45
(weight adj5 intervention).mp.
21
grandmother.mp.
46
(weight adj5 treatment).mp.
22
sibling.mp.
47
(weight adj5 program).mp.
23
coparent.mp.
48
(obes adj5 intervention).mp.
24
co-parent.mp.
49
(obes adj5 treatment).mp.
25
8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24
50
(obes adj5 program).mp.
51
36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50
52
7 and 25 and 35 and 51
53
limit 52 to (English language and yr ¼ ‘‘1990-Current’’)
26
p?ediatric..mp.
27
child.mp.
JBI Database of Systematic Reviews and Implementation Reports
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Appendix II: JBI critical appraisal checklist for systematic reviews and research syntheses Reviewer
Date
Author
Year
Record Number Yes
1.
Is the review question clearly and explicitly stated?
2.
Were the inclusion criteria appropriate for the review question?
3.
Was the search strategy appropriate?
4.
Were the sources and resources used to search for studies adequate?
5.
Were the criteria for appraising studies appropriate?
6.
Was critical appraisal conducted or more reviewers independently?
7.
Were errors
8.
Were the methods used to combine studies appropriate?
9.
Was the likelihood of publication bias assessed?
there methods to in data extraction?
recommendations for policy practice supported by the reported data? the specific directives research appropriate?
Overall appraisal:
Include
Unclear
Not Applicable
two
minimize
10. Were
11. Were
by
No
for
and/or
new
Exclude
JBI Database of Systematic Reviews and Implementation Reports
Seek further info
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Appendix III: JBI data extraction form for review for systematic reviews and research syntheses Study details Author/year Objectives Participants (characteristics/total number) Setting/context Description of interventions/phenomena of interest Search details Sources searched Range (years) of included studies Number of studies included I Types of studies included Country of origin of included studies Appraisal Appraisal instruments used Appraisal rating Analysis Method of analysis Outcome assessed Results/findings Significance/direction Heterogeneity Comments
JBI Database of Systematic Reviews and Implementation Reports
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39
