Preventing Overweight and Obesity - Practice Resource Section 2: What works? (only)
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Preventing
Overweight and
Obesity
Practice Resource
Section 2: What works?
(only)
Downloaded from www.rch.org.au/ccchPractice Resource: Preventing Overweight and Obesity Table of Contents Overview ................................................................................................................... 2 Glossary.................................................................................................................... 6 Section 1: Introduction Setting the scene ..................................................................................................... 7 Prevalence of overweight and obesity................................................................... 8 Impact of obesity...................................................................................................... 9 Factors found to influence overweight and obesity ............................................. 9 Section 2: What works? Introduction ............................................................................................................ 10 Understanding healthy weight promotion strategies ......................................... 11 School-based healthy weight promotion programs ............................................. 11 Individual family-based prevention programs ...................................................... 12 Group family-based prevention programs ........................................................... 13 What you can do .................................................................................................... 14 Information for parents.......................................................................................... 18 Key Messages for Professionals .......................................................................... 19 Key Messages for Managers................................................................................. 20 Section 3: What the research shows Summary of the evidence on overweight and obesity ....................................... 21 Key research findings............................................................................................ 22 About overweight and obesity ............................................................................. 22 About interventions for overweight and obesity................................................... 25 Key points about tertiary clinic-based interventions ............................................ 26 Annotated summary of intervention studies....................................................... 30 Summary of intervention studies ......................................................................... 30 Obesity prevention strategies .............................................................................. 31 Obesity intervention strategies ............................................................................ 34 References.............................................................................................................. 36 Appendix 1: Centre for Community Child Health................................................ 39 Appendix 2: Telstra Foundation ........................................................................... 40 Appendix 3: Criteria for selecting topics ............................................................. 41 Appendix 4: NHMRC Guidelines for Levels of Evidence.................................... 42 Appendix 5: Glossary of Terms – Research Methodology ................................ 43 © Centre for Community Child Health 2006 1
Glossary
Adiposity A measure of fatness.
PREVENTING OVERWEIGHT AND OBESITY
APPLES Active Programme Promoting Lifestyle in
Schools – a school-based program in the
United Kingdom for children seven to
twelve years that promotes healthy eating
and physical activity.
Body mass index Ratio of weight in kilograms to the square
(BMI) of height in metres.
KOPS Kiel Obesity Prevention Study – an eight-
hour course of nutrition education for
children aged five to seven years that
operates in the United Kingdom, is school
based and includes breaks for activity.
LEAP The Live, Eat and Play study – an
Australian-based universal prevention
program in which general practitioners are
trained to assess and address overweight
and obesity in children.
Obesity When the BMI is above the 95th percentile
(based on BMI for age percentile charts
recommended for use in Australia and
developed by the Center for Disease
Control).
Overweight When the BMI is above the 85th percentile
(based on BMI for age percentile charts
recommended for use in Australia and
developed by the Center for Disease
Control).
Planet Health A comprehensive school-based program in
the United States for children 11 to 12 years
old that involves teachers giving lessons on
healthy eating, increasing exercise and
reducing television watching.
Primary Efforts that target all children, educating
prevention them about how to avoid overweight and
obesity.
Secondary Efforts aimed at children who are already
prevention overweight in order to prevent them from
becoming obese.
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Tertiary Efforts targeting obese children in the
intervention clinical setting in order to increase healthy
behaviours, decrease unhealthy
behaviours, and ultimately reduce BMI
ratios.
Refer to Appendix 5 for a glossary of terms related to research
methodology terminology.
© Centre for Community Child Health 2006 6Section 2: What works?
Introduction
PREVENTING OVERWEIGHT AND OBESITY
A variety of healthy weight promotion strategies for children
have been trialled. Some have targeted children’s overweight or
obesity, while others have taken an early intervention approach,
targeting all children with messages about how to avoid
overweight and obesity. Children who are obese require a
medical assessment by a general practitioner or paediatrician.
The range of healthy weight promotion programs that have
been trialled can be categorised in the following way:
Universal healthy weight promotion (primary prevention)
programs
• School-based programs
Obesity prevention programs (secondary prevention)
• Individual family-based programs
• Group family-based programs
These programs are aimed at children who are already
overweight in order to prevent them from becoming obese.
While a number of well-controlled studies from the United
States and the United Kingdom have been conducted to test the
effectiveness of school-based and family-based interventions, to
date only minimal success has been achieved in actually
reducing rates of childhood overweight and obesity. For
example, in some of these studies attitude change may be
evident but corresponding changes in BMI have not been found.
However, what has been learned from these studies has been
used to design more recent interventions such as group family-
based interventions, for example PEACHES (Parenting Eating
and Activity for Child Health) and HIKCUPS (Hunter and
Illawarra Kids Challenge Using Parental Support) and the
individual family-based intervention LEAP (Live, Eat and Play).
To date there is not strong evidence for recommending any one
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specific strategy for promoting healthy weight and preventing
obesity, over others.
Children who are obese
require a medical assessment
by a general practitioner or
paediatrician
© Centre for Community Child Health 2006 10Section 2: What works?
Understanding healthy weight promotion
PREVENTING OVERWEIGHT AND OBESITY
strategies
The healthy weight promotion strategies that are outlined in
more detail below includes:
• School-base healthy weight promotion programs (primary
prevention)
• Individual family-based prevention programs (secondary
prevention)
• Group family-based prevention programs (secondary
prevention)
School-based healthy weight promotion programs
Key points
• School-based interventions focus on promoting physical
activity and healthy eating and reducing sedentary
behaviour for all children.
• Teachers are trained by program staff and they deliver the
program in short sessions over a few weeks.
• School-based programs have generally been carried out
with primary school-age children (aged 5–12 years).
• In addition to delivering core messages about increasing
physical activity, eating healthily and reducing sedentary
behaviour, some school-based programs have also included
lessons on diet and nutrition, some have involved practical
sessions requiring children to do exercise and others have
included school-wide initiatives to promote healthy
behaviours, for example, modifying the tuckshop menu.
• School-based programs have generally not focused on
behavioural approaches to addressing overweight and
obesity such as children’s readiness to change their
behaviour and children’s attitudes towards nutrition and
physical activity.
• School-based programs have had some success in
changing attitudes of children and minor success in reducing
sedentary behaviour and increasing physical activity.
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Generally, however, school-based programs have not
resulted in significant changes in BMI ratios.
• There is evidence to suggest that school-based
interventions may have differential effects on girls and boys
(that is, girls are more likely to adopt a positive attitude to
themselves as a result, while boys are more likely to
increase physical activity).
© Centre for Community Child Health 2006 11Section 2: What works?
Individual family-based prevention programs
PREVENTING OVERWEIGHT AND OBESITY
Key points
• Individual family-based interventions occur in a primary care
setting, that is, a setting accessed by all families, such as
the local GP’s clinic and involves training primary care
professionals to assess and address overweight and obesity
in children over a small number of regularly scheduled
sessions.
• These interventions are based on the understanding that
universal prevention and tertiary management approaches
have yet to halt the rising prevalence of childhood
overweight and obesity and that therefore the primary care
sector is an increasingly important forum for secondary
prevention of obesity.
• Practitioners are trained to help parents adopt a healthier
lifestyle for the family by offering specific strategies. Families
receive a set of purpose-designed materials to support the
changes.
• There is some early evidence from the Live, Eat and Play
(LEAP) pilot project to suggest that children who receive this
intervention show some positive change in nutrition and
physical activity, but no change in BMI compared to those
who do not receive the intervention. A larger trial (LEAP2) is
now underway.
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© Centre for Community Child Health 2006 12Section 2: What works?
Group family-based prevention programs
PREVENTING OVERWEIGHT AND OBESITY
Key points
• Family-based interventions have been carried out with
children aged five to nine years and involve a combination of
child-centred physical activity, dietary modification and
parental education and support.
• In group family-based programs children are brought
together over a number of weeks for a couple of hours at a
time to engage in a range of physical activities that will
develop their movement skills.
• Parents sign children up for the program.
• Family-based interventions have been based on key
findings from past research trials about what does and does
not work in preventing overweight and obesity.
• As a result, family-based interventions include such
strategies as making physical activity fun and enjoyable
rather than a chore and teaching children to recognise non-
hungry versus hungry eating, rather than using a ‘dieting’
approach.
• Parents are closely involved in the interventions; for
example, facilitators assist parents to identify barriers to
promoting physical activity and reducing sedentary
behaviours and help them figure out ways that they might
overcome these barriers. Information sessions on healthy
lifestyles may be part of the interventions. g
• While information on the effectiveness of the family-based
interventions is not yet available, the interventions appear to
be promising because of their grounding in principles
coming out of the research literature and clinical best
practice.
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© Centre for Community Child Health 2006 13Section 2: What works?
What you can do
PREVENTING OVERWEIGHT AND OBESITY
Assessing a child’s weight
The Body Mass Index (BMI) ratio is used to categorise an
individual’s weight. It is the ratio of weight in kilograms to the
square of height in metres (see below) and is relative to age
and sex, using sex- and age-specific cut-off points.
Weight in Kilograms
BMI = (Height in Meters) x (Height in Meters)
BMI rises in the first year of life, and then falls before rising
again at around 4-6 years of age. This rise continues into
adolescence and is referred to as ‘adiposity rebound’.
The following definitions of overweight and obesity are based on
BMI for age percentile charts recommended for use in Australia
and developed in the United States by the Center for Disease
Control:
• Overweight: BMI above the 85th percentile
• Obesity: BMI above the 95th percentile
While the BMI is useful in a clinical sense as a measure of body
fatness, it should be noted that it does not discriminate between
body fat and muscle mass. In practice this means that people
with much muscle but little fat, such as bodybuilders, may have
the same BMI as a person with much more body fat. Thus, it is
important to be aware that the BMI ratio has some limitations in
its use. It should also be noted that there are no definitions of
obesity and overweight for children under two years of age.
For BMI for age and gender specific percentile charts, see the
following links:
• For girls:
www.health.vic.gov.au/childhealthrecord/growth_details/char
t_girls4.htm
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• For boys
www.health.vic.gov.au/childhealthrecord/growth_details/char
t_boys4.htm
• To access a BMI calculator see the following link:
nhlbisupport.com/bmi/bminojs.htm
© Centre for Community Child Health 2006 14Section 2: What works?
Strategies to use in individual family-based programs
PREVENTING OVERWEIGHT AND OBESITY
In LEAP, an individual family-based program, discussing a
child’s weight in a sensitive and respectful way is considered as
important as providing practical strategies for behaviour change.
Outlined below are principles that reflect the approach of
individual family-based programs.
Principles for discussing overweight and obesity:
When discussing a child’s weight, a good place to start is by
asking the child and their parents about their views. This is likely
to help with the rapport between the professional and family and
also provide direction about the best course of action to take.
When the child or parents openly express concern about the
child’s weight, the professional can discuss ideas for changing
behaviour with the family and organise follow-up with another
professional, for example, a local GP or paediatrician.
When the child or parents do not see the child’s overweight or
obesity as a problem, it is likely to be more effective to work on
raising awareness of the issue rather than moving to
discussions about how to solve the problem. In such cases, it is
important that discussions are framed in a light and positive
way. One way to achieve this is to talk about the child’s health
rather than specifically about his or her weight.
When discussing a child’s
weight, a good place to start
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is by asking the child and
parents about their views.
© Centre for Community Child Health 2006 15Section 2: What works?
Principles for behaviour change:
PREVENTING OVERWEIGHT AND OBESITY
When working with families, it is important to address attitudes
towards change to ensure the family is ready to show the level
of commitment required to address overweight and obesity. One
way to do this is to raise parents’ awareness that addressing
overweight and obesity requires a long-term commitment from
them and may involve a number of lifestyle-related changes, for
example, walking rather than taking the car or dedicating time
each week to planning for physical activities.
Three key elements of behaviour change to recommend that
parents focus on to promote healthy weight include:
1. Increasing physical activity
2. Maintaining a healthy level of consumption of nutritious
foods and drinks
3. Being aware of what constitutes nutritious food and drink
and what can help to encourage a healthy lifestyle. An
example of a positive practice for increasing awareness of
nutritious foods is reading food labels to ensure food is low
in both fat and sugar and therefore low in calories overall
Families should be encouraged to incorporate exercise into the
normal routine of the family to make it more feasible and fun.
General principles of behaviour management can be used in
managing children’s activity levels and eating and drinking
patterns. One such principle is that parents should focus on
reinforcing positive behaviour, such as an increase in physical
activity, rather than paying a lot of attention to negative
behaviour, for example, punishing a child for not engaging in an
activity.
For a specific outline of the approach endorsed as best practice
for primary care professionals in programs such as LEAP, see
the following link:
www.racgp.org.au/document.asp?id=18131
For information on the nutrition requirements of Australian
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children for use in discussions with parents, see the following
site:
www7.health.gov.au/nhmrc/publications
© Centre for Community Child Health 2006 16Section 2: What works?
Strategies to use in group family-based programs
PREVENTING OVERWEIGHT AND OBESITY
Suggestions for group family-based interventions include the
following:
• Use a group setting to promote physical activity with
children.
• Make the activities varied and fun for the children involved.
• Develop a learning environment that is based on increasing
self-esteem and feelings of mastery over physical activity.
The acronym TARGET is used to describe this approach:
- T: Ensure variety in the tasks children engage in and
opportunities to be challenged.
- A: Encourage a feeling of authority or autonomy over
the activity by giving children choices and engaging
in shared decision-making with the group.
- R: Recognise children’s efforts and signs of
improvement.
- G: Include small-group problem-solving tasks.
- E: Evaluate how the child is doing according to criteria
that are suitable for each individual.
- T: Provide adequate time for learning and
demonstrating the skills learned.
• Include challenges for the home environment which
encourage family participation and support.
• De-emphasise being overly restrictive about the child’s
eating and replace with a positive, skills-based approach.
For example:
- Encourage eating in response to true hunger.
- Teach recognition of non-hungry eating.
- Encourage positive attitudes to food.
• Empower parents to change the family’s usual food habits.
• Empower parents to use positive reinforcement and
incentives when the child shows positive eating behaviours.
Strategies to use in school-based programs
Many of the messages promoted in the individual and group
family-based interventions can be applied to the school-based
programs also. Some of the specific messages that have been
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promoted in school-based interventions include:
• Eat fruit and vegetables every day.
• Reduce intake of high-fat foods.
• Be active for at least one hour each day.
• Decrease television viewing to less than one hour each day.
• Self-monitor television watching and video game playing.
© Centre for Community Child Health 2006 17Section 2: What works?
Information for parents
PREVENTING OVERWEIGHT AND OBESITY
Parents can be directed to the following sites for helpful tips and
information on healthy eating and exercise:
• Children’s Hospital at Westmead: A healthy lifestyle for a
healthy weight
www.chw.edu.au/parents/factsheets/fohealj.htm
• Victorian Government: Ideas to increase levels of physical
activity and healthy eating for the whole family
www.goforyourlife.vic.gov.au/
www.health.vic.gov.au/nutrition/child_nutrition/schoolchild.htm
www.kidshealth.org/parent/nutrition_fit/index.html
• Kaz Cooke: Body image issues
www.completelygorgeous.com.au
• Rick Kausman: If not dieting
www.ifnotdieting.com.au/cpa/htm/htm_home.asp
• Dieticians Association of Australia: Information on Nutrition –
recipes, questions, and answers
www.daa.asn.au
• The Raising Children website is a one-stop resource for
parenting information with all the basics on raising children
0-8 years, quality-assured by Australian experts, and
supported by the Australian Government.
www.raisingchildren.net.au
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© Centre for Community Child Health 2006 18Section 2: What works?
Key Messages for Professionals
PREVENTING OVERWEIGHT AND OBESITY
In Australia from 1985 to 1995 the level of combined overweight
and obesity in Australian children more than doubled, and the level
of obesity tripled in all age groups and for both sexes. The
likelihood of an obese child becoming an obese adult is high: at
four years of age the probability is 20 per cent and by adolescence
it is closer to 80 per cent. Childhood obesity in particular has
possible immediate and long-term effects. As well as psychological
effects such as depression and low self-esteem, it can have effects
on various systems within the body, such as the cardiovascular
system.
Strategies to promote healthy weight need to focus on physical
activity, healthy eating and parental perception.
Research based strategies for overweight and obesity
There is a lack of strong evidence for recommending any one
specific strategy for promoting healthy weight and preventing
obesity in children. It is clear however that to be effective
interventions must focus on making exercise varied and enjoyable
and, instead of advocating overly restrictive eating, they must
promote a skills-based approach that helps a child recognise true
hunger as opposed to engaging in non-hungry eating.
Adopt a solutions-focused and respectful approach to asking
about and addressing overweight and obesity in children. When
asking about overweight and obesity an appropriate starting point
is asking the family their views about the issue. If families do not
perceive a problem with a child’s weight it is recommended that
the professional first work on raising the family’s awareness of the
issue before moving on to discuss how to address it.
Consider the following principles when recommending health-
related behaviour change strategies to parents:
• Focus on attitudes towards change to ensure the family is
ready to show the level of commitment required to address
overweight and obesity.
• Three important elements of healthy weight promotion in
children include: increasing physical activity, maintaining a
healthy level of consumption of nutritious foods and drinks,
and educating parents and children about what constitutes
nutritious foods and a healthy lifestyle.
Practice resource:
• Incorporating physical activity into the family’s normal routine
makes it more enjoyable and more likely that it will take place.
• General principles of behaviour management can be used to
manage children’s activity levels and eating and drinking
patterns, eg parents can focus on reinforcing positive healthy
behaviours rather than paying negative attention to unhealthy
behaviours.
Where a child requires further support it is recommended that the
family is referred to a local GP, paediatrician or weight
management clinic.
© Centre for Community Child Health 2006 19Section 2: What works?
Key Messages for Managers
PREVENTING OVERWEIGHT AND OBESITY
In Australia from 1985 to 1995, the level of combined overweight
and obesity in Australian children more than doubled, while the
level of obesity tripled in all age groups and for both sexes. The
likelihood of an obese child becoming an obese adult is high: at
four years of age the probability is 20 per cent and by adolescence
it is closer to 80 per cent. Childhood obesity in particular has
possible immediate and long-term effects. As well as psychological
effects such as depression and low self-esteem, it can have effects
on various physical systems within the body, particularly the
cardiovascular system.
Strategies used to promote healthy weight need to focus on
physical activity, healthy eating and parental perception.
Research based strategies for overweight and obesity
At this stage, there is a lack of strong evidence for
recommending one specific strategy for promoting healthy weight
and preventing obesity in children.
There are two types of overweight and obesity programs that
lend themselves to being run in a service for children: school-
based health promotion programs and group family-based
prevention programs. The evidence leads to the following
recommended key features for such interventions:
• Use a group setting to promote physical activity in children.
• Make the activities varied and fun for children.
• Incorporate physical activity into the family’s normal routine. It
is more enjoyable and more likely to take place.
• Educate children about healthy eating. Teach them to
recognise non-hungry versus hungry eating rather than using
a ‘dieting’ approach.
• Encourage home challenges and ‘homework’ to get the
whole family involved.
• Include separate sessions for parents where possible to
focus on assisting them to identify barriers to promoting
physical activity and reducing sedentary behaviours and how
they might overcome these barriers.
• Empower parents to change usual food habits.
• Empower parents to use positive reinforcement and
incentives when the child shows positive eating behaviours.
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Managers of children’s services can also promote healthy weight
messages by displaying posters and distributing written material.
Points to consider in designing such material include:
• Focus on attitudes to change to ensure parents are ready to
show the level of commitment required to address
overweight and obesity.
• Three important elements of healthy weight promotion in
children include: increasing physical activity, maintaining a
healthy level of consumption of nutritious foods and drinks,
and educating parents and children on what constitutes
nutritious foods and a healthy lifestyle.
© Centre for Community Child Health 2006 20You can also read
