Introduction to the Active Living Research Reference List 2007

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R. S. Levine, R. G. Feltbower, A. M. Connor, M. Robinson and M. C. Rudolf. (2007). Monitoring trends in childhood obesity: A simple school-based model. Public Health.

BACKGROUND: The UK Government has set a target of halting the rise in childhood obesity by 2010. However, at the time the target was set, no monitoring process existed. The English Department of Health has now issued guidelines to primary care trusts for the annual weighing and measuring of all children on entry to primary school and in year 6. AIM: Development of an inexpensive school-based monitoring scheme for trends in childhood obesity suitable for national implementation. METHOD: The methodology was developed in 10 pilot schools in 2004 and implemented in 25 primary schools and three secondary schools in 2005. Specially trained healthcare support workers (HCSWs) recorded height and weight measurements of primary school children in reception and year 4, and secondary school children in year 8 (aged 5, 8 and 13 years, respectively, on average). The ethnic and socio-economic profile of the sample was compared with census data, and the levels of obesity were calculated using standard age cut-offs. RESULTS: While monitoring in primary schools was achieved with no evidence of disruption to the schools or distress to the subjects, monitoring in secondary schools was deemed to be impractical. Cost analysis indicated an estimated cost of less than pound1.50 per primary school child measured. CONCLUSIONS: The model provides a viable means of monitoring childhood obesity trends. Monitoring should be confined to primary schools and should be conducted by specially trained HCSWs rather than school nurses.

T. Lob-Corzilius. (2007). Overweight and obesity in childhood--a special challenge for public health. International Journal of Hygiene and Environmental Health.

The prevalence and incidence of overweight or even obese children and adolescents is significantly on the increase worldwide. According to the German Children and Adolescent Health Survey (KIGGS) conducted in 2006, 15% of all children and adolescents in Germany aged 3 through 17 years are overweight, and 6.3% of these children and adolescents are obese. On account of the long-term consequences, such as the metabolic syndrome, it can be expected that this "crisis in public health" will lead to a significantly higher expenditure of economic resources in the health care sector. Therefore it is important that public health prevention strategies analyse the key causes of overweight and obesity, and that they not only incorporate individual behaviours regarding nutrition and physical activity, but also take environmental factors, such as the residential area and traffic situation, as well as political circumstances regarding the nutrition and social aspects, into account. Even though the definition of body-mass index (BMI) has been widely accepted, the epidemiological data and the drawn percentiles are in need of a solid interpretation. There are several causes for the rising prevalence in overweight and obesity which are currently being focused on and discussed. On the individual level, the focus is on the genetic disposition and the changes in the behaviour regarding nutrition and physical exercise. Additional key influential factors like the increase in urbanisation and motorisation, the respective changes in the living environment of children and their families, and migration with its specific biosocial and cultural implications are discussed from the environmental and sociomedical, as well as the public health perspective. The article concludes with a discussion on the consequences of effective prevention strategies with reference to the Cochrane analysis from 2005. In order to be effective and successful, interventions for the prevention of overweight and obesity have to look at the structures and the environment of the person, as well as at the behavioural aspects of the individual. Such elements will be outlined based on the German "Platform Physical Activity and Nutrition".

T. Lobstein and R. Jackson-Leach. (2007). Child overweight and obesity in the USA: prevalence rates according to IOTF definitions. International Journal of Pediatric Obesity.

AIMS: To establish the prevalence of child overweight and obesity in the USA using IOTF-recommended definitions. METHODS: Original data from the NHANES surveys for 1999-2000 and 2003-2004 were analysed using the IOTF cut-offs and prevalence levels calculated using sample weightings provided. RESULTS: In 1999-2000, overweight (including obesity) was affecting 29% of school-age children. By 2003-2004 this figure had risen above 35%. Obesity alone was affecting 10% of school children in the 1999-2000, and over 13% in 2003-2004. CONCLUSION: The United States is experiencing levels of child overweight and obesity that are among the highest recorded in any country in the world.

E. Milne, J. A. Simpson, R. Johnston, B. Giles-Corti and D. R. English. (2007). Time spent outdoors at midday and children's body mass index. American Journal of Public Health.

OBJECTIVES: We investigated whether the Kidskin sun protection intervention increased children's body mass index by reducing the time spent outdoors at midday. METHODS: The Kidskin sun protection intervention involved 1614 Australian school children assigned to 1 of 3 groups: a control group, a moderate-intervention group, or a high-intervention group. Schools in the control group received the standard health curriculum and schools in the intervention groups received a multicomponent intervention. Outcomes included time spent outdoors and nevus development (a marker of melanoma risk). Height and weight were measured at 3 time points. Body mass index was transformed into age- and gender-specific z scores; z scores at each age were modeled simultaneously. Time spent outdoors at ages 10 and 12 years was analyzed using a linear mixed effects modeling. RESULTS: The proportion of children who were overweight or obese increased with age. The moderate-intervention and control groups had a minimal increase in z score over time, and the z score for the high-intervention group decreased over time. There were no differences among groups with respect to total time outdoors at any age. CONCLUSIONS: It is possible to reduce the time children spend outdoors when ultraviolet radiation is high without producing an unfavorable effect on the children's body mass index.

P. M. Minihan, S. N. Fitch and A. Must. (2007). What does the epidemic of childhood obesity mean for children with special health care needs? Journal Of Law Medicine & Ethics.

Bringing the 12.8% of children with special healthcare needs into the national response to the childhood obesity epidemic will require new information, a view of health promotion beyond that which occurs within healthcare systems, and services and supports in addition to the multi-sectoral strategies presently designed for children overall. These efforts are necessary to protect the health of the nation's 9.4 million children with special health care needs now and long-term.

R. T. Mitchell, C. M. McDougall and J. E. Crum. (2007). Decreasing prevalence of obesity in primary schoolchildren. Archives Of Disease In Childhood.

The prevalence of obesity in a cohort of Scottish primary schoolchildren was assessed and compared with previous cohorts taken from the same geographical area. The prevalence of obesity has declined over the three time periods studied, from 14.7% to 10.2%. Body mass index (BMI) centiles and BMI standard deviation scores have also declined considerably over time.

J. M. Mond, H. Stich, P. J. Hay, A. Kraemer and B. T. Baune. (2007). Associations between obesity and developmental functioning in pre-school children: a population-based study. International Journal Of Obesity.

Objective: To examine associations between obesity and impairment in developmental functioning in a general population sample of pre-school children. Method: Standardized medical examinations were conducted in nine consecutive cohorts of male and female children (n=9415) aged between 4.4 and 8.6 years (mean=6.0, s.d.=0.37) residing in the Lower Bavaria region of Germany. Tests designed to assess performance in subdivisions representing four broad developmental domains, namely, motor development, speech development, cognitive development and psycho-social development, were completed by all participants. Results: Boys had significantly higher rates of impairment than girls. The prevalence of obesity in boys was 2.4%, whereas in girls it was 4.3% (x(2)=21.51, P<0.01). After controlling for age, gender, year of recruitment and other potential covariates, the prevalence of impairment in gross motor skills was higher among obese male children than normal-weight male children (adjusted odds ratio=1.76, 95% confidence interval (CI)=1.02, 3.01, P<0.05), whereas the prevalence of impairment in the ability to focus attention was higher in obese female children than normal-weight female children (adjusted odds ratio=1.86, 95% CI=1.00, 3.44, P<0.05). Conclusions: The findings suggest that gender-specific associations between obesity and impairment in specific aspects of developmental functioning may be evident in younger children.

M. Murphy and B. Polivka. (2007). Parental perceptions of the schools' role in addressing childhood obesity. The Journal of School Nursing.

As childhood obesity has increased, schools have struggled with their role in this epidemic. Parents with a school-age child in a suburban latchkey program were surveyed regarding their perceptions of childhood obesity, body mass index, and the school's role in prevention and treatment of obesity. More than 80% of participants identified inactivity, poor eating behavior, lack of parental control in what children eat, and eating too much as the main causes of childhood obesity. Parents preferred receiving information about their child's body mass index from the school via a letter from the school nurse. Participants agreed that physical education classes, as well as units on nutrition and weight control, should be present in schools. Parents also supported eliminating junk food machines and offering special low-calorie meals. By supporting these strategies, parents indicated that schools should have a role in childhood obesity. School nurses can advocate for parental preferences in their school district.

R. Murray. (2007). Response to "Parents' perceptions of curricular issues affecting children's weight in elementary schools". Journal of School Health.

P. K. Newby. (2007). Are dietary intakes and eating behaviors related to childhood obesity? A comprehensive review of the evidence. Journal of Law, Medicine & Ethics.

The purpose of this article is to comprehensively review studies that have examined the relation between diet and childhood obesity. The review specifically considers the roles of total energy intake and energy density; dietary composition; individual foods, food groups, and dietary patterns; beverage consumption; and eating behaviors. The paper also discusses methodological considerations and future research directions and concludes by summarizing the evidence presented and highlighting the ethical issues surrounding providing dietary advice.

P. Nowicka and C. E. Flodmark. (2007). Physical activity-key issues in treatment of childhood obesity. Acta Paediatrica Supplementum.

Changes in physical activity with the aim of increasing energy expenditure are usually an important component of childhood obesity treatment. Physical activity also has several other aspects that are positive for the obese child's health, such as improving the metabolic profile and psychological well being. The aim of this paper is to give a short review of what we know about physical activity in paediatric obesity treatment. In addition, practical recommendations will be presented which a health care provider can suggest to obese children and their families with a special focus on daily activity, participation in physical education classes and sports, sedentary behaviours, active commuting to school and how to get family and friends involved in supporting the child.

C. O. Nwobu and C. C. Johnson. (2007). Targeting obesity to reduce the risk for type 2 diabetes and other co-morbidities in African American youth: a review of the literature and recommendations for prevention. Diabetes and Vascular Disease Research.

Over the last decade, the prevalence of obesity has continued to rise within the adolescent population of the US. Data show that African American youth are disproportionately affected by the obesity epidemic due to their higher risk for obesity-related co-morbidities, such as type 2 diabetes. Interventions that target risk factors for obesity at the individual, family and community levels are needed in order to prevent the onset of type 2 diabetes and related complications. This article provides an overview of the prevalence of obesity and type 2 diabetes in African American youth, the pathophysiology of the disease, and the behavioural risk factors that have contributed to its high prevalence within the African American adolescent population. Successful intervention strategies that target modifiable risk factors, such as diet and physical activity, will be identified. Finally, recommendations for programmes to prevent the onset of type 2 diabetes within the African American adolescent population are presented.

M. O'Brien, P. R. Nader, R. M. Houts, R. Bradley, S. L. Friedman, J. Belsky and E. Susman. (2007). The ecology of childhood overweight: a 12-year longitudinal analysis. International Journal of Obesity (London).

OBJECTIVE: To investigate ecological correlates of the development of overweight in a multisite study sample of children followed from age 2 to 12. DESIGN: Longitudinal examination of covariates of overweight status throughout childhood, with covariates drawn from three ecological levels: sociocultural or demographic, quality of the child's home environment, and proximal child experience that could directly affect the balance between energy intake and energy expenditure. SUBJECTS: A total of 960 children participating in a long-term longitudinal study provided growth data at least once; 653 of the children had complete data on covariates. MEASUREMENTS: Height and weight measured seven times between ages 2 and 12 were converted to a body mass index (BMI) and entered into a latent transition analysis to identify patterns of overweight across childhood. Ecological correlates measured longitudinally included demographic characteristics obtained by maternal report, home environment quality obtained by observation and maternal report, and proximal child experience factors obtained by observation, maternal report and child report. RESULTS: Four patterns of overweight were found: never overweight, overweight beginning at preschool age, overweight beginning in elementary school, and return to normal weight after being overweight at preschool age. The weight status groups differed on home environment quality and proximal child experience factors but not on demographics. Children overweight at preschool had less sensitive mothers than never overweight children. Children overweight at school age had fewer opportunities for productive activity at home than did never overweight children. School-age overweight children also watched the most TV after school. Multivariate logistic regression analyses further indicated the significance to children's weight status of proximal child experience variables. Less physically active children and those who watched more television after school were more likely to become overweight. Results did not vary by child sex. CONCLUSION: The results support the idea that childhood overweight is multiply determined. The one potentially important and changeable factor identified as a target for intervention centers on how children spend their time, especially their after-school time. Children who are more physically active and spend less time watching TV after school are less likely to become overweight by age 12.

C. L. Ogden, S. Z. Yanovski, M. D. Carroll and K. M. Flegal. (2007). The epidemiology of obesity. Gastroenterology.

In the United States, obesity among adults and overweight among children and adolescents have increased markedly since 1980. Among adults, obesity is defined as a body mass index of 30 or greater. Among children and adolescents, overweight is defined as a body mass index for age at or above the 95th percentile of a specified reference population. In 2003-2004, 32.9% of adults 20-74 years old were obese and more than 17% of teenagers (age, 12-19 y) were overweight. Obesity varies by age and sex, and by race-ethnic group among adult women. A higher body weight is associated with an increased incidence of a number of conditions, including diabetes mellitus, cardiovascular disease, and nonalcoholic fatty liver disease, and with an increased risk of disability. Obesity is associated with a modestly increased risk of all-cause mortality. However, the net effect of overweight and obesity on morbidity and mortality is difficult to quantify. It is likely that a gene-environment interaction, in which genetically susceptible individuals respond to an environment with increased availability of palatable energy-dense foods and reduced opportunities for energy expenditure, contributes to the current high prevalence of obesity. Evidence suggests that even without reaching an ideal weight, a moderate amount of weight loss can be beneficial in terms of reducing levels of some risk factors, such as blood pressure. Many studies of dietary and behavioral treatments, however, have shown that maintenance of weight loss is difficult. The social and economic costs of obesity and of attempts to prevent or to treat obesity are high.

D. L. Pagnini, R. L. Wilkenfeld, L. A. King, M. L. Booth and S. L. Booth. (2007). Mothers of pre-school children talk about childhood overweight and obesity: The Weight of Opinion study. Journal Of Paediatrics And Child Health.

To investigate the perceptions of parents of young children aged 2-5 years regarding childhood overweight and obesity. Parents with children in seven pre-schools and long day-care centres from diverse socio-economic areas across metropolitan Sydney and one rural area were recruited for focus groups. Focus group transcripts were analysed using content analysis. Providing food was an emotional issue for the mothers in this study. They were more concerned about their young children being underweight than overweight, and this increased their stress around children's eating. Food treats were perceived as entitlements. Mothers did believe that they were responsible for their children's eating, but acknowledged the influence of other environmental factors related to food retail and marketing. Practical and safety issues limited opportunities for their children to be physically active beyond the formal child-care setting. Parents had practical suggestions for solutions to some of the barriers they experienced, and wanted support for their role. The emotional intensity of the mothers' perceptions about their children's eating and weight status suggests that interventions, including communications, need to go beyond information and engage with parents' emotions. Some food concerns were actually related to broader parenting issues and indicate the potential value for interventions to focus on behavioural parenting techniques. Preventive interventions need to acknowledge the issues faced by parents and support their role directly, such as through making healthy and active behaviours easily available, and indirectly, through providing local services, including early childhood services.

K. A. Pfeiffer, M. Dowda, R. K. Dishman, J. R. Sirard and R. R. Pate. (2007). Cardiorespiratory fitness in girls - Change from middle to high school. Medicine And Science In Sports And Exercise.

PFEIFFER, K. A., M. DOWDA, R. K. DISHMAN, J. R. SIRARD, and R. R. PATE. Cardiorespiratory Fitness in Girls-Change from Middle to High School. Med. Sci. Sports Exerc., Vol. 39, No. 12, pp. 2234-2241, 2007. Purpose: To determine how factors are related to change in cardiorespiratory fitness (CRF) across time in middle school girls followed through high school. Methods: Adolescent girls (N = 274, 59% African American, baseline age = 13.6 +/- 0.6 yr) performed a submaximal fitness test (PWC170) in 8th, 9th, and 12th grades. Height, weight, sports participation, and physical activity were also measured. Moderate-to-vigorous physical activity (MVPA) and vigorous physical activity (VPA) were determined by the number of blocks reported on the 3-Day Physical Activity Recall (3DPAR). Individual differences and developmental change in CRF were assessed simultaneously by calculating individual growth curves for each participant, using growth curve modeling. Results: Both weight-relative and absolute CRF increased from 8th to 9th grade and decreased from 9th to 12th grade. On average, girls lost 0.16 kg.m.min(-1).kg(-1).yr(-1) in weight-relative PWC170 scores (P < 0.01) and gained 10.3 kg.m.min(-1).kg(-1).yr(-1) in absolute PWC170 scores. Girls reporting two or more blocks of MVPA or one or more blocks of VPA at baseline showed an average increase in PWC170 scores of 0.40-0.52 kg.m.min(-1).kg(-1).yr(-1) (weight relative) and 22-28 kg.m.min(-1).kg(-1).yr(-1) (absolute) in CRF. In weight-relative models, girls with higher BMI showed lower CRF (similar to 0.37 kg.m.min(-1).kg(-1).yr(-1)), but this was not shown in absolute models. In absolute models, white girls (similar to 40 kg.m.min(-1).kg(-1).yr(-1)) and sport participants (similar to 28 kg.m.min(-1).kg(-1).yr(-1)) showed an increase in CRF over time. Conclusion: Although there were fluctuations in PWC170 scores across time, average scores decreased during 4 yr. Physical activity was related to change in CRF over time; BMI, race, and sport participation were also important factors related to change over time in CRF (depending on expression of CRF-weight-relative vs absolute). Subsequent research should focus on explaining the complex longitudinal interactions between CRF, physical activity, race, BMI, and sports participation.

L. H. Powell, J. E. Calvin and J. E. Calvin. (2007). Effective obesity treatments. American Psychologist.

To curb the epidemic of obesity in the United States, revised Medicare policy allows support for efficacious obesity treatments. This review summarizes the evidence from rigorous randomized trials (9 lifestyle trials, 5 drug trials, and 2 surgical trials) on the efficacy and risk-benefit profile of lifestyle, drug, and surgical interventions aimed at promoting sustained (>= 2 years) reductions in weight. Both lifestyle and drug interventions consistently produced an approximate 7-lb (3.2-kg) weight loss that was sustained for 2 years and was associated with improvements in diabetes, blood pressure, and/or cardiovascular risk factors. Surgical interventions have a less solid empirical base but offer promise for the promotion of significant and sustained weight reduction posttreatment in the morbidly obese but with possible significant short-term side effects. In summary, there is strong and consistent support from rigorous randomized trials that lifestyle or drug interventions result in modest weight loss with minimal risks but disproportionate clinical benefit. Combinations of lifestyle, drug, and, where appropriate, surgical interventions may be the most efficacious approach to achieving sustained weight loss for the widest diversity of patients.

M. Reznik, A. E. Blank, D. Appel and P. O. Ozuah. (2007). Relationship between obesity and grade level in inner-city school children. Acta Paediatrica.

J. L. Robinson, J. H. Fuerch, D. D. Winiewicz, S. J. Salvy, J. N. Roemmich and L. H. Epstein. (2007). Cost effectiveness of recruitment methods in an obesity prevention trial for young children. Preventive Medicine.

BACKGROUND: Recruitment of participants for clinical trials requires considerable effort and cost. There is no research on the cost effectiveness of recruitment methods for an obesity prevention trial of young children. METHODS: This study determined the cost effectiveness of recruiting 70 families with a child aged 4 to 7 (5.9+/-1.3) years in Western New York from February 2003 to November 2004, for a 2-year randomized obesity prevention trial to reduce television watching in the home. RESULTS: Of the 70 randomized families, 65.7% (n=46) were obtained through direct mailings, 24.3% (n=17) were acquired through newspaper advertisements, 7.1% (n=5) from other sources (e.g., word of mouth), and 2.9% (n=2) through posters and brochures. Costs of each recruitment method were computed by adding the cost of materials, staff time, and media expenses. Cost effectiveness (money spent per randomized participant) was US $0 for other sources, US $227.76 for direct mailing, US $546.95 for newspaper ads, and US $3,020.84 for posters and brochures. CONCLUSION: Of the methods with associated costs, direct mailing was the most cost effective in recruiting families with young children, which supports the growing literature of the effectiveness of direct mailing.

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