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Childhood Obesity Prevention Programs: Comparative Effectiveness. Prepared for: Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov. Outline of Material. Introduction to childhood obesity and the various programs designed to prevent it Systematic review methods

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Childhood Obesity Prevention Programs: Comparative Effectiveness


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    1. Childhood Obesity Prevention Programs: Comparative Effectiveness Prepared for: Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov

    2. Outline of Material • Introduction to childhood obesity and the various programs designed to prevent it • Systematic review methods • The clinical questions addressed by the comparative effectiveness review • Results of the review and evidence-based conclusions about the relative effectiveness of currently available programs to prevent childhood obesity • Gaps in knowledge and future research needs • What to discuss with patients and their caregivers Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    3. Background: Prevalence of Childhood Obesity • Childhood overweight and obesity are highly prevalent in the United States, affecting one-third of children and adolescents. • Since 1980, the rates of obesity have tripled for children aged 2 to 19 years. • The risk of obesity is higher among minority and low-income populations. Ogden CL, Carroll MD, Kit BK, et al. JAMA. 2012;307(5):483-490. PMID: 22253364. Wang Y, Beydoun M. Epidemiol Rev. 2007;29:6-28. PMID: 17510091. Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    4. Background:Health Consequences of Childhood Obesity • Overweight children and adolescents are at greater risk for health problems when compared with their normal-weight peers and are more likely to become obese adults. • Obese children and adolescents are more likely to have serious illnesses such as type 2 diabetes, hypertension, high cholesterol, stroke, heart disease, nonalcoholic fatty liver disease, certain types of cancer, and arthritis. • Other reported health consequences of childhood obesity include eating disorders and mental health issues such as depression and low self-esteem Centers for Disease Control and Prevention. Available at www.cdc.gov/obesity/childhood/index.html. Reilly JJ, Kelly J. Int J Obes (Lond). 2011 Jul;35(7):891-8. PMID: 20975725. Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    5. Background:Factors Contributing to Childhood Obesity • Many factors interact to contribute to obesogenic environments and affect children’s weight. These include: • Genetic and individual factors • Home influences • The school environment • Factors in the local community • Policies implemented at the regional and national levels Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    6. Background: Preventing Childhood Obesity • Obesity is difficult to treat, and prevention of childhood obesity has been identified as a key to fight the growing obesity epidemic. • Leading health organizations, including the World Health Organization and an Institute of Medicine expert panel, have recommended comprehensive interventions to fight obesity. • The main goal of most childhood obesity prevention interventions is to prevent children who are not overweight from becoming overweight or obese. • Interventions designed for obesity prevention may also help overweight or obese children lose excess weight or stabilize their weight. Koplan JP, Liverman CT, Kraak VA, eds. Preventing Childhood Obesity: Health in the Balance. Available at www.nap.edu/catalog.php?record_id=11015. Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm. World Health Organization. www.who.int/dietphysicalactivity/childhood_what_can_be_done/ en/index.html.

    7. Background: Objectives of This Comparative Effectiveness Review • This review aimed to compare the effectiveness of obesity prevention programs for children and adolescents conducted in the United States and other high-income countries. • All studies of children that tested interventions of diet, physical activity, or any combination of these in any of the following settings were included in this review. • School • Home • Primary care clinic • Childcare center • Community setting • A combination of the above • The authors of this review also assessed consumer health informatics interventions. Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    8. Settings of Obesity Prevention Interventions Assessed in This Comparative Effectiveness Review (1 of 2) Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    9. Settings of Obesity Prevention Interventions Assessed in This Comparative Effectiveness Review (2 of 2) Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    10. Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Review (CER) Development • Topics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, members of the public, and others. • A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the select clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment. • The results of these reviews are summarized into Clinician Research Summaries and Consumer Research Summaries for use in decisionmaking and in discussions with patients and/or caregivers. • The Research Summaries and the full report, with references for included and excluded studies, are available at www.effectivehealthcare.ahrq.gov/ child-obesity-prevention.cfm. Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    11. Clinical Questions Addressed by This Comparative Effectiveness Review (1 of 2) • Key Question 1. What is the comparative effectiveness of school-based interventions for the prevention of obesity or overweight in children? • Key Question 2. What is the comparative effectiveness of home-based interventions for the prevention of obesity or overweight in children? • Key Question 3. What is the comparative effectiveness of primary care-based interventions for the prevention of obesity or overweight in children? • Key Question 4. What is the comparative effectiveness of childcare setting-based interventions for the prevention of obesity or overweight in children? Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    12. Clinical Questions Addressed by This Comparative Effectiveness Review (2 of 2) • Key Question 5. What is the comparative effectiveness of community-based or environment-level interventions for the prevention of obesity or overweight in children? • Key Question 6. What is the comparative effectiveness of consumer health informatics applications for the prevention of obesity or overweight in children? • Key Question 7. What is the comparative effectiveness of multisetting interventions for the prevention of obesity or overweight in children? • Key Question 7 was addressed as part of the other six Key Questions. Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    13. Rating the Strength of Evidence From the Comparative Effectiveness Review • The strength of evidence was classified into four broad categories: Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    14. Evidence for the Benefits of School-Based Interventions in Preventing Obesity or Overweight in Children (1 of 3) • School-Based Interventions Only • School-based diet or physical activity interventions prevent obesity or overweight in children. ˜˜™ Strength of Evidence: Moderate • „„School-based combination diet and physical activity interventions prevent obesity or overweight in children. Strength of Evidence: Insufficient • School-Based Interventions With a Home Component • Physical activity interventions within school-based settings with a home component prevent obesity or overweight in children. Strength of Evidence: High • Combined diet and physical activity interventions in a school-based setting with a home component prevent obesity or overweight in children. Strength of Evidence: Moderate Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    15. Meta-analysis of Change in Body Mass Index Between the Control Group and Combined Diet and Physical Activity Interventions in a School Setting With a Home Component Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm. Study ID WMD (95% CI) % Weight Burke, 1998 Burke, 1998 Dzewaltowski, 2010 Siegrist, 2011 Story, 2012 Hatzis, 2010 Mihas, 2010 Llargues, 2011 Overall (I-squared = 99.1%, p = 0.000) 0.00 (-0.16, 0.16) 12.49 0.10 (-0.05, 0.25) 12.51 -0.10 (-0.18, -0.02) 12.67 0.10 (0.06, 0.14) 12.71 0.34 (0.15, 0.53) 12.36 1.00 (0.80, 1.20) 12.34 -1.20 (-1.32, -1.08) 12.59 -1.60 (-1.80, -1.40) 12.33 -0.17 (-0.57, 0.23) 100.00 NOTE: Weights are from random effects analysis -1.9 0 1.4 Intervention Control WMD = weighted mean difference

    16. Evidence for the Benefits of School-Based Interventions in Preventing Obesity or Overweight in Children (2 of 3) • School-Based Interventions With a Community Component • Combined diet and physical activity interventions in a school-community setting prevent obesity or overweight in children. ˜˜™ Strength of Evidence: Moderate • School-Based Interventions With Home and Community Components • Combined diet and physical activity interventions in a school-home-community setting prevent obesity or overweight in children. ˜˜™ Strength of Evidence: High Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    17. Evidence for the Benefits of School-Based Interventions in Preventing Obesity or Overweight in Children (3 of 3) • School-Based Interventions With a Consumer Health Informatics Component • Evidence is insufficient to determine if physical activity or combined diet and physical activity interventions in a school setting with a consumer health informatics component prevent childhood obesity or overweight.˜˜™ Strength of Evidence: Insufficient Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    18. Evidence for the Benefits of Home-Based or Childcare Center-Based Interventions in Preventing Obesity or Overweight in Children • Home-Based Interventions Only • Home-based combination (diet and physical activity) interventions prevent obesity or overweight in children. Strength of Evidence: Low • Childcare Center-Based Interventions Only • Combined diet and physical activity interventions in a childcare center setting showed no beneficial effect on childhood obesity or overweight prevention. ˜˜™ Strength of Evidence: Low Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    19. Evidence for the Benefits of Community-Based or Primary Care–Based Interventions in Preventing Obesity or Overweight in Children • Community-Based Interventions With a School Component • Combined diet and physical activity interventions in a community setting with some school involvement prevent childhood obesity or overweight.˜˜™ Strength of Evidence: Moderate • Primary Care-Based Interventions Only • Evidence is insufficient to determine if combined diet and physical activity interventions in a primary care setting prevent obesity or overweight in children.˜˜™ Strength of Evidence: Insufficient • This does not mean that interventions do not work in the primary care setting, but more research is needed. Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    20. Conclusions (1 of 2) • School-based programs involving dietary or physical activity interventions are effective in preventing childhood obesity. • Combining a home or community component with a school-based program also works. • The magnitude of effects appears to be modest, although the heterogeneity in study interventions, outcomes, and duration make it difficult to estimate a precise effect size. Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    21. Conclusions (2 of 2) • Evidence is limited regarding the effectiveness of interventions in other settings including those in primary care. • This does not mean that such interventions do not work but that more research is needed. Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    22. Gaps in Knowledge (1 of 2) Several gaps in knowledge were identified in the evidence base reviewed for this report: • „„A lack of sufficient information on the effectiveness of the following types of obesity and overweight prevention interventions • Interventions tested in the primary care or childcare settings • ††Environment-based and policy-based interventions (e.g., agriculture policies and regulations on food retailing and distribution) • Consumer health informatics interventions Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    23. Gaps in Knowledge (2 of 2) • The need for an improved understanding of the contexts and challenges associated with implementing prevention programs in different settings • A paucity of information on the effects of various interventions in preventing childhood obesity in populations stratified by sex, age, ethnicity, demographics, or socioeconomic status • Limited information on the effectiveness of obesity prevention programs in adolescents Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    24. What To Discuss With Your Patients andTheir Caregivers (1 of 2) • That clinicians are concerned about childhood obesity and the welfare of their patients • „The patient’s body mass index and how to diagnose overweight/ obesity in children • „„The possible factors contributing to overweight and obesity in children, including less physical activity, more sedentary/screen time, increased empty and liquid calories in the diet, and inappropriate use of food rewards or eating when not hungry • „„What constitutes an appropriate serving size • „„The importance of monitoring total daily caloric intake as opposed to total daily food intake • „„Important things that can be done at home to keep children at a healthy weight Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.

    25. What To Discuss With Your Patients andTheir Caregivers (2 of 2) • The potential health consequences of overweight and obesity in children • „„The relative effectiveness of the various interventions in preventing overweight and obesity • „„The programs and resources that help children maintain a healthy weight that are available at school or in the community • If a list of such resources could not be obtained, encourage parents and caregivers to explore schools, school district offices, and community centers for the available resources. • „„What can be done if healthy food or safe locations for physical activity are not easily accessible to patients and their families Wang Y, Wu Y, Wilson RF, et al. AHRQ Comparative Effectiveness Review No. 115. Available at www.effectivehealthcare.ahrq.gov/child-obesity-prevention.cfm.