Waters Et Al-2011-The Cochrane Library

Cochrane Database of Systematic Reviews
Interventions for preventing obesity in children (Review)

Waters E, de Silva-Sanigorski A, Burford BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L,
Summerbell CD
Waters E, de Silva-Sanigorski A, Burford BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD.
Interventions for preventing obesity in children.
Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD001871.
DOI: 10.1002/14651858.CD001871.pub3.
www.cochranelibrary.com

Copyright 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1.
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Figure 2.
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Figure 3.
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Figure 4.
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Figure 5.
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Figure 6.
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Figure 7.
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Figure 8.
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DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
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REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Childhood obesity interventions versus control by age groups 0-5, 6-12 and 13-18 years,
Outcome 1 Standardised mean change in Body Mass Index (BMI/zBMI) from baseline to postintervention. .
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
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8
9
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47
160
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[Intervention Review]
Interventions for preventing obesity in children

Elizabeth Waters1 , Andrea de Silva-Sanigorski2 , Belinda J Burford3 , Tamara Brown4 , Karen J Campbell5 , Yang Gao6 , Rebecca Armstrong
2 , Lauren Prosser7 , Carolyn D Summerbell8
1 Jack
Brockhoff Child Health and Wellbeing Program, The McCaughey Centre, Melbourne School of Population and Global Health,
The University of Melbourne, Carlton, Australia. 2 Jack Brockhoff Child Health and Wellbeing Program, The McCaughey Centre,
Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia. 3 The Jack Brockhoff Child
Health and Wellbeing Program, The McCaughey Centre, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia. 4 Liverpool Reviews and Implementation Group, Division of Clinical Effectiveness, School of Population,
Community and Behavioural Sciences, University of Liverpool, Liverpool, UK. 5 Centre for Physical Activity and Nutrition Research,
School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia. 6 School of Public Health and Primary Care,
The Chinese University of Hong Kong, Hong Kong, Hong Kong. 7 Dental Health Services Victoria, Carlton, Australia. 8 School of
Medicine and Health, Wolfson Research Institute, Queens Campus, Durham University, Stockton-on-Tees, UK
Contact address: Elizabeth Waters, Jack Brockhoff Child Health and Wellbeing Program, The McCaughey Centre, Melbourne
School of Population and Global Health, The University of Melbourne, Level 5/207 Bouverie St, Carlton, VIC, 3010, Australia.
[email protected].
Editorial group: Cochrane Heart Group.
Publication status and date: Edited (no change to conclusions), published in Issue 12, 2011.
Review content assessed as up-to-date: 22 September 2010.
Citation: Waters E, de Silva-Sanigorski A, Burford BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD.
Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD001871. DOI:
10.1002/14651858.CD001871.pub3.
ABSTRACT
Background
Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic
diseases, general health, development and well-being. The international evidence base for strategies that governments, communities
and families can implement to prevent obesity, and promote health, has been accumulating but remains unclear.
Objectives
This review primarily aims to update the previous Cochrane review of childhood obesity prevention research and determine the
effectiveness of evaluated interventions intended to prevent obesity in children, assessed by change in Body Mass Index (BMI). Secondary
aims were to examine the characteristics of the programs and strategies to answer the questions What works for whom, why and for
what cost?
Search methods
The searches were re-run in CENTRAL, MEDLINE, EMBASE, PsychINFO and CINAHL in March 2010 and searched relevant
websites. Non-English language papers were included and experts were contacted.
Selection criteria
The review includes data from childhood obesity prevention studies that used a controlled study design (with or without randomisation).
Studies were included if they evaluated interventions, policies or programs in place for twelve weeks or more. If studies were randomised
at a cluster level, 6 clusters were required.
Data collection and analysis

Two review authors independently extracted data and assessed the risk of bias of included studies. Data was extracted on intervention
implementation, cost, equity and outcomes. Outcome measures were grouped according to whether they measured adiposity, physical
activity (PA)-related behaviours or diet-related behaviours. Adverse outcomes were recorded. A meta-analysis was conducted using
available BMI or standardised BMI (zBMI) score data with subgroup analysis by age group (0-5, 6-12, 13-18 years, corresponding to
stages of developmental and childhood settings).
Main results
This review includes 55 studies (an additional 36 studies found for this update). The majority of studies targeted children aged 612 years. The meta-analysis included 37 studies of 27,946 children and demonstrated that programmes were effective at reducing
adiposity, although not all individual interventions were effective, and there was a high level of observed heterogeneity (I2 =82%).
Overall, children in the intervention group had a standardised mean difference in adiposity (measured as BMI or zBMI) of -0.15kg/
m2 (95% confidence interval (CI): -0.21 to -0.09). Intervention effects by age subgroups were -0.26kg/m2 (95% CI:-0.53 to 0.00) (05 years), -0.15kg/m2 (95% CI -0.23 to -0.08) (6-12 years), and -0.09kg/m2 (95% CI -0.20 to 0.03) (13-18 years). Heterogeneity was
apparent in all three age groups and could not explained by randomisation status or the type, duration or setting of the intervention.
Only eight studies reported on adverse effects and no evidence of adverse outcomes such as unhealthy dieting practices, increased
prevalence of underweight or body image sensitivities was found. Interventions did not appear to increase health inequalities although
this was examined in fewer studies.
Authors conclusions
We found strong evidence to support beneficial effects of child obesity prevention programmes on BMI, particularly for programmes
targeted to children aged six to 12 years. However, given the unexplained heterogeneity and the likelihood of small study bias, these
findings must be interpreted cautiously. A broad range of programme components were used in these studies and whilst it is not possible
to distinguish which of these components contributed most to the beneficial effects observed, our synthesis indicates the following to
be promising policies and strategies:
school curriculum that includes healthy eating, physical activity and body image
increased sessions for physical activity and the development of fundamental movement skills throughout the school week
improvements in nutritional quality of the food supply in schools
environments and cultural practices that support children eating healthier foods and being active throughout each day
support for teachers and other staff to implement health promotion strategies and activities (e.g. professional development,
capacity building activities)
parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in
screen based activities
However, study and evaluation designs need to be strengthened, and reporting extended to capture process and implementation factors,
outcomes in relation to measures of equity, longer term outcomes, potential harms and costs.
Childhood obesity prevention research must now move towards identifying how effective intervention components can be embedded
within health, education and care systems and achieve long term sustainable impacts.
PLAIN LANGUAGE SUMMARY

Childhood obesity can cause social, psychological and health problems, and is linked to obesity later in life and poor health outcomes
as an adult. Obesity development is related to physical activity and nutrition. To prevent obesity, 55 studies conducted internationally
have looked at programmes aiming to improve either or both of these behaviours. Although many studies were able to improve
childrens nutrition or physical activity to some extent, only some studies were able to see an effect of the programme on childrens
levels of fatness. When we combined the studies, we were able to see that these programmes made a positive difference, but there
was much variation between the study findings which we could not explain. Also, it appeared that the findings may be biased by
missing small studies with negative findings. We also tried to work out why some programmes work better than others, and whether
there was potential harm associated with children being involved in the programmes. Although only a few studies looked at whether
programmes were harmful, the results suggest that those obesity prevention strategies do not increase body image concerns, unhealthy
dieting practices, level of underweight, or unhealthy attitudes to weight, and that all children can benefit. It is important that more
studies in very young children and adolescents are conducted to find out more about obesity prevention in these age groups, and also
that we assess how long the intervention effects last. Also, we need to develop ways of ensuring that research findings benefit all children
by embedding the successful programme activities into everyday practices in homes, schools, child care settings, the health system and
the wider community.
BACKGROUND
Obesity prevention is an international public health priority and
there is growing evidence of the impact of overweight and obesity on short- and long-term functioning, health and well being. In children, adolescents and adults in a wide range of countries (including more recently, middle- and low-income countries) high and increasing rates of overweight and obesity have
been reported over the last 20 to 30 years (Lobstein 2004; Popkin
2004; Wang 2001; Wang 2006a). Internationally, childhood obesity rates continue to rise in some countries (e.g. Mexico, India,
China, Canada), although there is emerging evidence of a slowing
of this increase or a plateauing in some age groups across European
countries, the US (Rokholm 2010) and Australia (Nichols 2011;
Olds 2010). The evidence is strong however, that once obesity
is established, it is both difficult to reverse through interventions
(Luttikhuis 2009), and tracks through to adulthood (Singh 2008;
Whitaker 1997), strengthening the case for primary prevention.
Governments internationally are acting to implement strategies
for obesity prevention and, behaviour change relating to diet and
physical activity is an integral component of any such strategy.
However, behaviour change interventions cannot operate in isolation from the context and the interplay between the obesogenic
environment and the child is an important consideration.
Childhood obesity has been described as the primary childhood
health problem in developed nations (Ebbeling 2002), having been
linked to many serious physical, social and psychological consequences. These include increased risk of cardiovascular dysfunction (Freedman 1999), type 2 diabetes (Fagot-Campagna 2000),
and pulmonary (Figueroa-Muoz 2001), hepatic (Strauss 2000),
renal (Adelman 2001) and musculoskeletal (Chan 2009) complications; lower health-related quality of life (Tsiros 2009); negative emotional states such as sadness, loneliness, and nervousness,
and increased likelihood of engagement in high-risk behaviours
(Strauss 2000a); and undesirable stereotyping including perceptions of poor health, academic and social ineptness, poor hygiene
and laziness (Hill 1995).
Obesity prevalence is also inextricably linked to the degree of relative social inequality, with greater social inequality associated with
a higher risk of obesity in most developed countries but in most developing countries the reverse relationship is observed (Monteiro
2004). It is therefore critical that in preventing obesity we are also
reducing the associated gap in health inequalities, ensuring that
interventions do not inadvertently have more favourable outcomes
in those with a more socio-economically advantaged position in
society. The available knowledge base on which to develop a platform of obesity prevention action and base decisions about appropriate public health interventions to reduce the risk of obesity
across the whole population, or targeted towards those at greatest
risk, still remains limited (Gortmaker 2011). The impact of interventions on preventing obesity, the extent that they work equitably, their safety and how they work, remains poorly understood.
Description of the condition

Overweight and obesity are terms used to describe an excess of
adiposity (or fatness) above the ideal for good health. Current
expert opinion supports the use of body mass index (BMI) cutoff
points to determine weight status (as healthy weight, overweight or
obese) for children and adolescents and several standard BMI cutoffs have been developed (Cole 2000; Cole 2007; de Onis 2004; de
Onis 2007). Despite this, there is no consistent application of this
methodology by experts and a variety of percentile based methods
are also used, which can make it difficult to compare studies that
have used different measures and weight outcomes.
Overweight and obesity in childhood are known to have significant impact on both physical and psychosocial health (reviewed in
Lobstein 2004). Indeed, many of the cardiovascular consequences
that characterise adult-onset obesity are preceded by abnormalities
that begin in childhood. Hyperlipidaemia, hypertension and abnormal glucose tolerance occur with increased frequency in obese
children and adolescents (Freedman 1999) and children with type
2 diabetes have also been identified (Arslanian 2002). In addition,
obesity in childhood and adolescence are known to be indepen-

dent risk factors for adult obesity (Must 1992; Must 1999; Power
1997; Singh 2008; Whitaker 1997), underpinning the importance
of obesity prevention efforts.
Modifiable determinants of childhood obesity

Obesity develops from a sustained positive energy imbalance and
a variety of genetic, behavioural, cultural, environmental and economic factors have been implicated in its development (reviewed
in Lobstein 2004).The interplay of these factors is complex and
has been the focus of considerable research, however, the burden
of obesity is not experienced uniformly across a population, with
the highest levels of the condition experienced by those most disadvantaged. In developed countries there is a significant trend observed between obesity and lower socio-economic status, while in
some developing countries the contrary is found, with children
from relatively affluent families more vulnerable to obesity.
Description of the intervention

This review involves assessing educational, behavioural and health
promotion interventions. The terms intervention and programme are used interchangeably throughout this review. The
Ottawa Charter defines four action areas for health promotion: 1)
Actions to develop personal skills, which are actions targeted at
individual skills, behaviours, or knowledge and beliefs; 2) Actions
to strengthen community actions, which are actions targeted at
communities and include environmental and settings-based approaches to health promotion; 3) Actions to reorient health services, which are actions within the health sector and relate to the
delivery of services; and 4) Actions to build healthy public policy
and create supportive environments, which are inter-sectoral in
nature and relate to creating physical, social and policy environments that promote health.
Why it is important to do this review

Governments internationally are being urged to take action to
prevent childhood obesity and to address the underlying determinants of the condition. To provide decision-makers with high
quality research evidence to inform their planning and resource
allocation, this review aims to provide an update of the evidence
from studies designed to compare the effect of interventions to
prevent childhood obesity with the effect of receiving an alternative intervention or no intervention. We aimed to update the previous review (Summerbell 2005) which concluded that many diet
and exercise interventions to prevent obesity in children appeared
ineffective in preventing weight gain, but could be effective in promoting a healthy diet and increased levels of physical activity. The
previous review also urged reconsideration of the appropriateness
of study durations, designs and intervention intensity as well as
making recommendations in relation to comprehensive reporting of studies. Overall however, although there was insufficient
evidence to determine that any one particular programme could
prevent obesity in children, the evidence suggested that comprehensive strategies to increase the healthiness of childrens diets and
their physical activity levels, coupled with psycho-social support
and environmental change were most promising. We incorporated
research evidence that has been published since that time and is
also consistent with emerging issues in relation to evidence reviews
and synthesis (Doak 2009; Tugwell 2010). In addition, to meet
the growing demand from public health and health promotion
practitioners and decision makers, we have attempted to include
information related to not only the impact of interventions on
preventing obesity, but also information related to how outcomes
were achieved, how interventions were implemented, the context
in which they were implemented (Wang 2006) and the extent to
which they work equitably (Tugwell 2010). This new aspect of
the review was partly guided by the Systematic Reviews of Health
Promotion and Public Health Interventions (Armstrong 2007),
more recent recommendations for complex reviews and useful evidence for decision makers (Waters 2011), and informed by expert
opinion.
OBJECTIVES
The main objective of the review is to update the previous review and determine the effectiveness of educational, health promotion and/or psychological/family/behavioural therapy/counselling/management interventions which focus on diet, physical
activity or lifestyle support, or both and were designed, or had
an underlying intention to prevent obesity/further weight gain, in
children. Specific objectives include:
Evaluation of the effect of dietary educational interventions
versus control on changes in BMI, prevalence of obesity, rate of
weight gain and other outcomes among children under 18 years
Evaluation of the effect of physical activity interventions
versus control on changes in BMI, prevalence of obesity and rate
of weight gain and other outcomes among children under 18
years
Evaluation of the effect of dietary educational interventions
versus physical activity intervention on changes in BMI,
prevalence of obesity and rate of weight gain and other outcomes
among children under 18 years
Evaluation of combined effects of dietary educational
interventions and physical activity interventions versus control
on changes in BMI, prevalence of obesity and rate of weight gain
and other outcomes among children under 18 years

Evaluation of demographic characteristics of participants

(socio-economic status, gender, age, ethnicity, geographical
location, etc.)
study. Studies that only enrolled children who were obese at baseline were considered to be focused toward treatment rather than
prevention and were therefore excluded. Interventions for treating
obesity in children have been reviewed in another Cochrane review
(Luttikhuis 2009). We excluded studies of interventions designed
to prevent obesity in pregnant women and studies designed for
children with a critical illness or severe co-morbidities.
Evaluation of particular process indicators (i.e. those that

describe why and how a particular intervention has worked)
Types of interventions
Secondary aims are to describe the interventions in order to identify the characteristics of the interventions that are related to the
reported outcomes. Specific objectives include:
Evaluation of contextual factors contributing to the

performance of the intervention
Evaluation of the maintenance of short-term changes
beyond 12 weeks
Strategies
We included educational, health promotion (this would include community-based interventions), psychological/family/
behavioural therapy/counselling/management strategies.
METHODS
Interventions included
Criteria for considering studies for this review
We included studies of interventions or programmes that involved

diet and nutrition, exercise and physical activity, lifestyle and social
support.
Types of studies
Setting
We included data from controlled trials (with or without randomisation), with a minimum duration of 12 weeks, that were designed,
or had an underlying intention to prevent obesity. The terms research studies and trials also represent programme/demonstration project evaluations and are used interchangeably throughout
this review. In the previous version of this review, studies were
categorised into long-term (at least one year) and short-term (at
least 12 weeks), referring to the length of the intervention itself or
to a combination of the intervention with a follow-up phase. For
this review update, studies were required to have minimum intervention duration of 12 weeks and we categorised studies based
on target age group rather than study duration, though length of
duration has been captured and integrated into the analysis.
We accepted studies in which individuals or groups of individuals
were randomised, however, for those with group randomisation
we accepted only studies with six or more groups.
Interventions within the community, school and out of school

hours care, home, childcare or preschool/nursery/kindergarten
were eligible.
Types of comparison
We included studies that compared diet or physical activity interventions, or both with a non-intervention control group who received usual care or another active intervention (i.e. head-to-head
comparisons).
Intervention personnel
There was no restriction on who delivered the interventions, for

example, researchers, primary care physicians (general practitioners), nutrition/diet professionals, teachers, physical activity professionals, health promotion agencies, health departments, or others.
Types of participants
We included studies of children less than 18 years at the commencement of the study, including studies where children were
part of a family group receiving the intervention if data could be extracted separately for the children. Studies with interventions that
included children who were already obese were included to reflect
a public health approach that recognises the prevalence of a range
of weight within the general population of children, provided that
obesity was not a requirement for children to be included in the
Indicators of theory and process
We collected data on indicators of intervention process and evaluation, health promotion theory underpinning intervention design, modes of strategies and attrition rates from these trials. We
compared where possible, whether the effect of the intervention
varied according to these factors. This information was included
in descriptive analyses and used to guide the interpretation of findings and recommendations.

Interventions excluded
We excluded studies of interventions designed specifically for the

treatment of childhood obesity and studies designed to treat eating
disorders such as anorexia and bulimia nervosa.
Types of outcome measures
To be included, studies had to report one or more of the following
primary review outcomes, presenting a baseline and a post-intervention measurement. These data were used to evaluate change
from baseline if not reported within the study.
Primary outcomes
weight and height

per cent fat content
BMI
ponderal index
skin-fold thickness
prevalence of overweight and obesity
Secondary outcomes
activity levels
dietary intake (using validated measures such as diaries etc)
change in knowledge
environment change (such as food provision service)
stakeholders views of the intervention and other evaluation
findings
measures of self-esteem, health status and well being,
quality of life
harm associated with the process or outcomes of the
intervention
cost effectiveness/costs of the intervention
Search methods for identification of studies
Searching other resources
Websites searched
We searched the following websites during March 2010 to identify

other systematic reviews or studies that may have been missed in
the database searches.
The Campbell Library
The Centre for Reviews and Dissemination (CRD)
The Cochrane Library, including DARE
Health evidence, Canada, http://www.health-evidence.ca/
NHS Evidence
The Evidence for Policy and Practice Information and Coordinating Centre (EPPI Centre) database of health promotion
research
World Health Organization International Clinical Trials
Registry Platform (ICTRP)
Google (included to increase the potential for identifying
relevant grey literature for inclusion)
Combinations of key words relating to population (child*, infant*, young children, adolescen*, teenag*, school* children,
youth), intervention (obesity prevention, prevention of obesity, diet, health promotion, nutrition, exerci*, physical activity, intervention) and outcomes (weight, height, fat content,
body mass index, ponderal index, skinfold thickness) informed the searching.
Contacting experts (advisory group)
A Review Advisory Group was formed to aid in the decisions made

for the progression of revising the scope of the protocol and the
subsequent review, as well as hallmarks for useful review components to aid its relevance to policy and programme decision making. This group consists of six members who are, and have contact
with, experts from the research, advocacy and policy sectors in the
field of obesity prevention. Advisory group members are named
in the Acknowledgements section.
Electronic searches
Reference lists checked
For this updated search in March 2010 and searches for previous
versions of this review, we searched the following databases:
Cochrane Central register of controlled trials (CENTRAL)
MEDLINE
EMBASE
PsycINFO
CINAHL
We scanned the reference lists of systematic reviews (identified

from searches detailed above) that included information on interventions for the prevention of childhood obesity to identify potential additional studies for inclusion.
Studies were not excluded on the basis of language. Complete

search strategies and search dates for each database can be found
in the Appendices. The search strategies used for this update (
Appendix 1), as well as those used for the previous published
version of this review, (Appendix 2) are both included.
Data collection and analysis
Selection of studies
For this update of the review, we included studies published during
or after 2005. Included and excluded studies published between

1990 and 2005 that were identified for previous versions of this
review were carried forward to this review. Articles were rejected
on initial screen when the review author determined from the title
and abstract that the article was not a report of a controlled trial
(randomised or non-randomised); or the trial did not address an
intervention which aims to improve food intake, physical activity
and/or prevent obesity; or the trial was exclusively in individuals
older than 18 years, pregnant women/young adults, or the critically ill; or the trial was of less than 12 weeks duration; or the
intervention was concerned with the treatment of eating disorders
such as anorexia nervosa and bulimia nervosa.
When a title or abstract could not be rejected with certainty, we
obtained the full text of the article for further evaluation. Two
review authors independently assessed the studies for inclusion
and resolved differences between their assessments by discussion
and, when necessary, in consultation with a third review author.
Data extraction and management
We developed a data extraction form, based on the Effective Public
Health Practice Project Quality Assessment Tool for quantitative
studies (Thomas 2003).
This review update introduced additional data extraction items
specifically related to implementation. These have now been included in the Characteristics of included studies tables grouped
under the category of implementation-related factors. We included
quality criteria questions relating to randomised controlled trials
(RCTs), as well as non-randomised controlled trials in the data
extraction form. We used the PROGRESS checklist to collect data
relevant for equity (Ueffing 2009). We extracted data from related
publications that reported findings on the process evaluation or
the design of the intervention. Two review authors independently
extracted data from included papers into the data extraction form
for each study and managed numerical data for analysis in an Excel
spreadsheet.
Assessment of risk of bias in included studies
We assessed the risk of bias of included studies using the Risk
of bias tool developed by The Cochrane Collaboration (Higgins
2008). This includes five domains of bias: selection, performance,
attrition, detection and reporting, as well as an other bias category to capture other potential threats to validity. The guidance
provided with the EPOC (Effective Practice and Organisation of
Care) Risk of bias tool for studies with a separate control group
(Cochrane EPOC 2009) was also used to guide assessments for
non-randomised studies. At least two review authors assessed the
risk of bias for each study. Review authors were not blinded with
respect to study authors, institution or journal as they were familiar with the literature. We used discussion and consensus to resolve
any disagreements.
Selection bias included an assessment of adequate sequence generation as well as allocation concealment. We assessed sequence gen-
eration to be at low risk when studies clearly specified a method for

generating a truly random sequence. We assessed allocation concealment to be at low risk for RCTs if the method used to ensure
that investigators enrolling participants could not predict group
assignment was described. Cluster RCTs received a rating of low
risk of bias for this domain if the unit of allocation was by institution or community and allocation was performed on all units at
the start of the study, as recommended by the EPOC Risk of bias
tool for studies with a separate control group. We assessed all non
randomised studies as high risk of bias for both sequence generation and allocation concealment. Performance and detection bias
was incorporated under the one domain in the Risk of bias tool:
blinding. We assessed this to be low risk for studies that reported
blinding of outcome assessors, and high risk for studies reporting
that outcome assessors were not blinded. We assessed studies as
low risk for attrition bias if an adequate description of participant
flow through the study was provided, the proportion of missing
outcome data was relatively balanced between groups and the reasons for missing outcome data were provided, relatively balanced
between groups and considered unlikely to bias the results. We
assessed studies as low risk of reporting bias when a published protocol was available and all specified outcomes were included in the
study report; studies without a published protocol, we assessed as
unclear. When an outcome measure was specified and the results
were not reported either at baseline or at follow-up, we considered
that study as being at high risk of reporting bias.
Measures of treatment effect

All reported outcomes were taken directly from studies. We conducted a to investigate the impact of included interventions on
BMI. When considering the most appropriate metric for metaanalysis, we found that BMI or zBMI (standardised body mass
index) were the most consistently reported measures. We did not
undertake a meta-analysis of the effects of the interventions on
prevalence of overweight or obesity due to two factors:it was not
reported in the majority of the studies, and there were highly variable methods used for the classification of overweight and obesity
(e.g. overweight variably classified as BMI 90th percentile or
BMI 90th < BMI <97th percentile, or overweight classified as BMI
> 85% for age and sex; obesity classified using 95th percentile National Center for Health Statistics triceps-skinfold thickness cutoffs; percentage of overweight classified by comparing the BMI of
the participant with the relevant 50th BMI percentile based on
the gender and age of the participant; prevalence of overweight/
obesity classified as BMI > 85th percentile; overweight or obese
classified as > 91st centile; obesity classified as BMI > 95th percentile; obesity classified as BMI > 97th percentile; weight status classified using the IOTF (International Obesity Task Force)
BMI cut-offs), and also variability in the reporting of prevalence
rates. Given that different methods of classification of weight status in children produce very different prevalence estimates, and

limit comparisons between studies, we therefore, did not perform

a meta-analysis of this outcome. The data are however included
in the narrative synthesis.
For the meta-analysis on BMI/zBMI, we did not perform any
re-calculations of means. If it was not reported, we derived the
standard deviation (SD) from the reported standard error (SE) of
the mean, or 95% confidence intervals (CIs) using the equations
provided in Chapter 9 of the Cochrane Handbook for Systematic
Reviews of Interventions (Deeks 2008). We then used means and
SDs to determine standardised mean differences (SMDs) between
groups for use in the meta-analysis. Where no SE was provided
for follow-up data, we imputed the SD from either the baseline
values or other included studies of similar size and target population (one occasion only). For studies which reported more than
one intervention arm, we presented the data for each intervention
arm compared with the control arm, with the number of participants in the control arm halved to ensure no double counting.
Where the trial reported data immediately post-intervention and
at a subsequent follow-up time point, only the data immediately
post-intervention is included in the meta-analysis. Analysis was
conducted stratified by age group and we used the I2 statistic to
provide a measure of heterogeneity. Analyses were conducted using
Review Manager (RevMan) 5.1 software. For studies not included
in the meta-analyses, findings are described in tables and in the
text. Unless otherwise stated, all data are presented in the format of
mean and SD 95% CIs. Results with P > 0.05 are reported as not
significant (ns) and P values are not given if they were unreported
in the original study.
We also sought factors related to intervention development, implementation process, equity and sustainability. These included
methods of stakeholder engagement, descriptions of formative research, pilot studies and on-going evaluation; modification of the
programme, programme reach, completeness of the implementation of the intervention, outcomes against PROGRESS categories,
and maintenance of the programme after the intervention ceased.
This information is presented in the Characteristics of included
studies tables and summarised in the results section.

Data synthesis
We grouped studies primarily according to target age group (05 years, 6-12 years and 13-18 years). Within these categories, we
summarised studies in relation to effectiveness, implementation,
and maintenance or sustainability of effects. We summarised effectiveness results according to outcomes (measures of adiposity,
behaviour, impact on equity and adverse/unintended effects), as
well as the design and theoretical basis of studies. We summarised
implementation information according to whether process evaluations were conducted, reporting of the resources and other factors
needed for implementation, and whether specific strategies were
included to address disadvantage or diversity.
Subgroup analysis and investigation of heterogeneity
We explored heterogeneity by age group, setting of intervention,
risk of bias, duration of intervention (12 weeks versus >12 weeks)
and by randomisation. Studies did not report intervention intensity or complexity at the level required to be able to explore heterogeneity by these factors in a meaningful way.
RESULTS
Description of studies
Results of the search

Figure 1 describes how the references identified through the
searches were processed for this update as well as previous versions
of the review.

Figure 1. Quorom statement flow diagram - Interventions for preventing obesity in children

In summary, for this review update, the hits identified from the
searches of electronic databases (MEDLINE 7,194, CINAHL
1,459, PsycINFO 783, EMBASE 6,772 CENTRAL 1,201) were
combined (n = 17,409) and de-duplicated (n = 13,734). These
list hits were then de-duplicated against the hits identified for the
previous version of this review. This reduced list of hits were then
screened on titles and abstracts (review author initials: LP). Articles were rejected on initial screen if the review author could determine from the title and abstract that the article did not meet
the inclusion criteria for this review.
The review authors (EW, KC, LP, RA, GY, CS, BH, AdS-S) independently assessed full-text copies of 117 papers against the inclusion criteria. Thirty six new studies have been included in this
version of the review, giving a total number of 55 included studies
(Amaro 2006; Coleman 2005; Donnelly 2009; Ebbeling 2006;
Fernandes 2009; Fitzgibbon 2005; Fitzgibbon 2006; Foster 2008;
Gentile 2009; Gutin 2008; Haerens 2006; Hamelink-Basteen
2008; Harrison 2006; Jouret 2009; Keller 2009; Kipping 2008;
Lazaar 2007; Macias-Cervantes 2009; Marcus 2009; Paineau
2008; Pate 2005; Patrick 2006; Peralta 2009; Reed 2008; Reilly
2006; Robbins 2006; Rodearmel 2006; Salmon 2008; Sanigorski
2008; Sichieri 2009; Simon 2008; Singh 2009; Spiegel 2006;
Taylor 2008; Vizcaino 2008; Webber 2008).
The excluded studies included those that did not meet the minimum duration of 12 weeks, studies with a cluster allocation of
fewer than six groups, those that were studies of treatment for
obesity rather than prevention, studies recruiting only obese participants, and those not reporting at least one of the primary outcomes of interest for this review (weight and height, per cent fat
content, BMI, ponderal index, skin-fold thickness or prevalence
of overweight and obesity). In a change to the inclusion criteria
for this review update, we excluded studies with an intervention
period of less than 12 weeks, even if the follow-up period extended
beyond 12 weeks (Danielzik 2005). The last published version of
this review included 22 studies, however, three of these studies
have now been excluded (Donnelly 1996; Flores 1995; Robinson
1999) because they were studies with a cluster allocation of fewer
than six groups, and therefore should not have been included in
the last version of this review. Therefore, only 19 of the 22 previously included studies were carried forward into this review. Studies identified that were ongoing at the time of the search have
been listed under Characteristics of ongoing studies. While some
studies appear to have completed based on dates listed in study
records, studies with no available outcome data published at the
time of the search remain classified as ongoing studies to ensure
this information is available to end-users of this review.
Included studies
Fifty of the 55 included studies were set in high-income countries,

as classified by the World Bank economic classification. Of these,
26 studies were conducted in the USA, two in Canada, six in the
United Kingdom, four in France, two in Germany, two in the
Netherlands, one each in Belgium, Sweden, Italy and Spain, and
four in Australia/New Zealand. Four studies were conducted in
upper-middle-income countries (two in Brazil, one each in Chile
and Mexico), and one study was conducted in Thailand, a lowermiddle-income country. Of the included studies, eight targeted
children aged 0-5 years, 39 targeted children aged 6 to -12 years,
and eight studies targeted children aged 13-18 years (Table 1). Of
the 55 included studies, 41 were interventions implemented for 12
months or less, seven for 1 to 2 years, and seven were implemented
for more than two years. We remain mindful of the potential
weaknesses (and bias) of data derived from short-term behaviour
change studies and this will be a consideration in the Risk of
bias assessment and during interpretation of findings. Due to the
range of interventions included in this review, descriptive details
will be integrated into the results section and details by study can
be found in the Characteristics of included studies tables, as well
as the Study Design Table (Table 1). Details of outcomes reported
in studies can be found in Table 2 for 0-5 year olds, Table 3 for 612 year olds and Table 4 for 13-18 year olds. No head to head
comparisons fulfilling our inclusion criteria were found.
Risk of bias in included studies

All included studies were assessed for their risk of bias across a
number of domains known to be important for internal validity,
that is, the extent to which results of included studies should be
believed. This was conducted using The Cochrane Collaborations
Risk of bias tool, a domain-based evaluation in which assessments
are made separately for each domain (Higgins 2008). The domains of interest are sequence generation, allocation concealment,
blinding, incomplete outcome data, selective outcome reporting
and other sources of bias.
Thirty studies had a high risk of bias for one or more domains.
Across all domains, most studies were rated as either low or unclear
risk of bias, with the proportion of studies rated in these categories
for each domain ranging from approximately 70% to 90% (Figure
2). Unclear risk of bias was the most common rating for all but
two domains (incomplete outcome data and other bias). Studies
received a rating of unclear for a domain when there was insufficient information included in the relevant papers for this to determined. This highlights the ongoing need for diligent reporting
of research methods, which is vital for transparency and to maximise the potential utility of results. End-users of research must
have adequate information to enable informed decisions about the
internal and external validity of research findings.

10
Figure 2. Risk of bias graph: review authors judgements about each risk of bias item presented as
percentages across all included studies.
Selection bias (sequence generation and allocation

concealment)
Eleven studies were rated as having a high risk of bias for sequence
generation and 10 studies were rated as having a high risk of bias
for allocation concealment. The majority of these (n = 9) were nonrandomised studies (Fernandes 2009; Hamelink-Basteen 2008;
Harrison 2006; Jouret 2009; Kain 2004; Mller 2001; Sanigorski
2008; Taylor 2008; Pangrazi 2003), which were all rated as having a high risk of bias for both domains relating to selection bias.
Selection bias is an inherent risk in non-randomised studies. This
does not mean that this risk would always be likely to seriously
affect the outcomes of the study. There will be differing degrees
to which this could be the case. Some non randomised studies in
this review sought to address the potential for selection bias with
strategies such as selecting control groups that were matched for
known confounders, or including all eligible participants within
an entire community or setting to receive an intervention (for example, all schools in a given area) rather than selecting a particular
subset of the community. Others however, selected intervention
sites based on existing programmes or prevalence of obesity which
may have confounded the results.
One cluster RCT was rated as high risk of bias for sequence generation since schools were randomly assigned to three experimental
conditions, however, an additional school was recruited and added
to the control group after this process was conducted (Sallis 1993).
Another cluster RCT was rated as high risk of bias for this domain
since, despite stating that schools were chosen randomly, the design
is described by the study authors as quasi-experimental (Coleman
2005). Two cluster RCTs were assessed as high risk of bias for allocation concealment. One recruited participants after the schools
were randomised and potential participants knew about the in-
terventions that they were enrolling in (NeumarkSztainer 2003).

The other performed recruitment over two periods and during
the second recruitment period, parents/students were informed
of the intervention assignment of the school (Gutin 2008). This
may have affected the characteristics of participants who agreed to
participate in these studies.
The remaining study designs were RCTs or cluster RCTs and of
these, we rated 18 studies low risk of bias for sequence generation
and 16 studies as low risk of bias for allocation concealment. This
means that 18 studies clearly specified a method for generating
a truly random sequence. We rated the remainder of studies as
having an unclear risk of bias. Allocation concealment was often
not clearly specified in the study report, however, cluster RCTs
received a rating of low risk of bias for this domain if the unit
of allocation was by institution or community and allocation was
performed on all units at the start of the study, as recommended
by the EPOC Risk of bias tool for studies with a separate control
group (Cochrane EPOC 2009).
Performance and Detection bias (blinding)

We judged 11 studies as having a low risk of performance bias
based on the blinding of outcome assessors. Most studies did not
blind participants or staff delivering the intervention as it is often
not possible to blind interventions of this nature. This means that
there may be differences in the way that participants were treated
in the intervention and control groups, perhaps exposing them
to factors that might be considered external to the particular intervention of interest. However, obesity prevention interventions,
like many public health interventions, will often involve important implementation or contextual factors that cannot always be

11
separated from the intervention itself such as who delivered the

intervention, setting, resources available. For this reason, it is important that as much information as possible is captured about
these potential factors so they can be taken into account by anyone exploring the outcomes of the intervention and considering
replication in another setting.
Ten studies were judged as having a high risk of bias, and this was
usually as a result of this information about the study not being
blinded being clearly reported in the study paper. The remainder
of studies were rated as unclear because blinding information was
not reported, although it was likely that most of these did not
implement blinding. It is probably more meaningful to consider
blinding at the outcome measurement level (detection bias), since
some outcomes would be more likely to be affected by lack of
blinding than others. This is discussed below for BMI, the outcome
included in the meta-analysis for this review.
Attrition bias (incomplete outcome data)
We assessed more than half of the included studies as being at
low risk of attrition bias (Amaro 2006; Beech 2003; Caballero
2003; Coleman 2005; Dennison 2004; Donnelly 2009; Ebbeling
2006; Epstein 2001; Fernandes 2009; Foster 2008; Gortmaker
1999a; Harvey-Berino 2003; Kain 2004; Lazaar 2007; MaciasCervantes 2009; Mo-Suwan 1998; NeumarkSztainer 2003; Pate
2005; Patrick 2006; Reed 2008; Reilly 2006; Robbins 2006;
Robinson 2003; Sahota 2001; Sanigorski 2008; Sichieri 2009;
Simon 2008; Singh 2009; Spiegel 2006; Story 2003a; Vizcaino
2008; Warren 2003; Webber 2008). Decisions were based on the
provision of an adequate description of participant flow through
the study with missing outcome data relatively balanced between
groups and judged to be unlikely to be related to the outcomes of
interest.
We assessed four studies as being at high risk of attrition bias
for the following reasons: unbalanced completion rates in study
groups and reasons for missing data not provided; missing data not
provided by study group; differences in characteristics related to
study outcomes between completers and non-completers (Haerens
2006; Mller 2001; Sallis 1993; Stolley 1997).
Reporting bias (selective reporting)
Most studies had an unclear risk of reporting bias, with three
assessed as being at low risk (Harrison 2006; Sanigorski 2008;
Singh 2009) and seven at high risk of reporting bias. According
to the Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2008), it is likely that most studies fall into the category of
unclear for this domain, due to the difficulty in establishing what
outcomes may have been collected and not reported. Publishing of
study protocols prior to study commencement or at least prior to
study completion, has contributed significantly to increasing our
ability to detect selective outcome reporting, however publication
of study protocols is still relatively uncommon in public health.
We assessed studies with a published protocol that confirmed all

specified outcomes were included in the study report as low risk of
reporting bias. Studies without a published protocol, we assessed as
unclear. We assessed studies as being at high risk of reporting bias
when an outcome measure was specified and results not reported
either at baseline or at follow-up. Of the seven studies, four studies
were following a common protocol which noted percentage body
fat as an outcome measure of interest. All four studies reported
this at baseline and not at follow-up so it is not clear what changes
occurred in this outcome measure as a result of the intervention
(Baranowski 2003; Beech 2003; Robinson 2003; Story 2003a).
Other bias
Most studies (n = 35) were assessed as being at low risk of other
sources of bias and 17 were assessed as being at high risk for other
sources of bias. Of the studies we assessed as being at high risk of
bias, a common issue was that the units of analyses were inadequately addressed, with randomisation at a group level, but analysis conducted at an individual level without clearly identifying
if, or how, the effects of clustering were accounted for. Other issues included significant differences in outcome measures between
groups at baseline and likely contamination between intervention groups. One study implemented a cross-over study design in
which every alternating year, intervention schools became control
schools and vice versa (Mller 2001). Given obesity prevention
interventions seek to change behaviour, this type of study design
is compromised due to the carry-over effects of the intervention.
This study remained included in the overall narrative because it
met inclusion criteria, however, it was not included in the metaanalysis.
Risk of bias for studies included in the meta-analysis

The meta-analysis for this review included all 49 studies reporting
BMI/zBMI data and reporting a mean and associated measure of
variance. BMI was the most common measure of adiposity reported. Six studies that were assessed as being at high risk for selection bias were included in the meta-analysis. In terms of blinding,
seven studies assessed as at a high risk of bias were included in the
meta-analysis, with six studies assessed as at a low risk of bias, and
the remainder unclear. Since BMI was measured and can be viewed
as an objective measure (rather than self-reported measures), it is
less likely to be affected by the lack of allocation concealment or
blinding, so probably had little effect on the meta-analysis results.
Three of the six studies assessed as high risk for reporting bias were
included in the meta-analysis. Although studies were not excluded
from the meta-analysis on the basis of Risk of bias assessments,
it is important to note that three of the four studies identified as
being at high risk for attrition bias did not appear in the metaanalysis. Also, the study identified as a cross-over design (Mller
2001) leading to significant concern for potential biases was not

12
included in the meta-analysis. A funnel plot was also generated

to examine potential publication bias (Figure 3). The funnel plot
shows an uneven distribution of studies, indicating that there may
be small study bias occurring. Bias of this type may lead to an
inflated assessment of the intervention effectiveness as small negative studies appear to be under-represented.
Figure 3. Funnel plot of comparison: 1 Childhood obesity interventions versus control by age groups 0-5, 612 and 13-18 years, outcome: 1.1 Standardised mean change in Body Mass Index (BMI/zBMI) from baseline to
post-intervention.
Effects of interventions
A meta-analysis was conducted to investigate the impact of included interventions on BMI or zBMI, the most common measures of adiposity reported, as a measure of effectiveness (Analysis
1.1). The meta-analysis revealed significant heterogeneity which
was explored by age group (Figure 4), type of intervention (Figure
5), setting of intervention (Figure 6), duration of intervention (12
weeks versus >12 weeks) (Figure 7) and by randomisation (Figure

8). The heterogeneity was not explained by any of these factors,
other than setting in the 0-5 age group. For this reason, the studies were organised into subgroups based on the age group of the
child participants (0-5, 6-12, 13-18 years) and this decision was
based on what would be meaningful for decision makers. Further
breakdown by age was not possible given the number of studies in
the 0-5 and 13-18 groups.

13
Figure 4. Forest plot of comparison: 1 Childhood obesity interventions versus control by age groups 0-5, 612 and 13-18 years, outcome: 1.1 Standardised mean change in Body Mass Index (BMI/zBMI) from baseline to
post intervention.

14
Figure 5. Forest plot of the standardised mean change in body mass index (BMI/zBMI) from baseline to post
intervention for childhood obesity interventions versus control grouped by intervention type (physical activity,
dietary, combined physical activity/dietary)

15
intervention for childhood obesity interventions versus control grouped by setting

16
intervention for childhood obesity interventions versus control grouped by duration of intervention (short
term and long term)

17
intervention for childhood obesity interventions versus control grouped by risk of bias based on randomisation
(high risk=non-randomised; unclear risk=method of randomisation or sequence generation unclear; low
risk=randomisation occurred appropriately)

18
Study outcomes are presented by target age groups, with three

categories: 0-5 years, 6-12 years, 13-18 years. In all cases, the
outcome data are summarised or reported using the determination
of the study authors as to primary and secondary outcomes, to
ensure consistency with the design of the studies and published
results.
Outcome measures
Adiposity
Measures of adiposity include direct measures and proxy measures

and each measure has limitations. The most direct method of
adiposity used in the included studies was DEXA (Dual Energy Xray Absorptiometry). (Mei 2002) This method is highly sensitive,
precise and accurate and allows the determination of the amount of
fat mass and fat-free mass, as well as the distribution of the fatness.
The method, however, is expensive and requires participants to
attend a clinic-type setting for the DEXA scan, therefore, this
method is often not feasible for trials or routine measurement.
A more commonly used method of measuring body fatness is
by measuring skinfold thickness at a variety of sites (e.g. bicep,
tricep, subscapular, suprailliac, medial calf ). Standard equations
are then used which sum the thickness of various sites to determine
percentage body fat. Fat distribution may also be determined using
this method. Although this measurement is simple, inexpensive
and quick, poor reliability is often a limitation. Reliability can
be improved through operator training, and taking duplicate or
triplicate measurements.
Measurement of waist and hip circumference are also commonly
used measures of adiposity. However, several sites can be used
to measure these circumferences (e.g. waist circumference can be
measured at the umbilicus, mid-point between the lowest rib and
iliac crest, or a point 2 cm below the lowest rib), which can limit
the ability to compare measures across studies. Waist and hip circumferences provide a measure of fat distribution (central and peripheral adiposity), rather than amount of overall adiposity. Measurement is simple, inexpensive and quick, although again, reliability is a problem. Reliability can be improved through operator
training, and taking duplicate or triplicate measurements.
The most commonly used method for estimating body fatness is
BMI (body mass index). BMI is derived from measures of height
and weight, and calculated by dividing weight (in kilograms) by
the square of height (in metres). BMI is a proxy measure of adiposity, which has been shown to correlate well with fat mass measured
by DEXA (ref ), although it does not always provide an accurate
indicator of fatness at an individual level. It is widely used as it
is simple, inexpensive and quick. BMI is also used to calculate
standardised BMI (zBMI) score, which is BMI standardised on
age and gender against a reference population. There are a num-
ber of quality reference populations in use internationally (e.g.

Center for Disease Control (CDC), World Health Organization
(WHO)), although country-specific reference populations are also
sometimes used.
To determine weight/nutritional status (e.g. underweight, healthy
weight, overweight, obese) a number of methods are available.
Commonly used methods include using BMI cut-offs that are age
and gender specific such as those developed by the IOTF (Cole
2000; Cole 2007). The IOTF cut-offs were generated from pooled
international child anthropometric data, with age and gender specific BMI cut-offs established for determining the childs weight
status (Cole 2000). In more recent times, the WHO has developed
a new growth reference and associated cut-off points for schoolaged children and adolescents that are closely aligned to the WHO
Child Growth Standards produced in 2006 (de Onis 2004; de
Onis 2007), and the recommended adult cut-offs for overweight
and obesity at 19 years. Another method is using percentile based
cut-offs for BMI-for-age percentiles or weight-for-age percentiles
of a reference population (e.g. CDC).
In all cases, the prevalence of these categories can easily be determined as a percentage of the measured population, and change in
weight status (e.g. remission or incidence of obesity) can be determined longitudinally. It should be noted however, that terminology is not consistent internationally, with obese, overweight, and
at risk-of-overweight all being used to refer to levels of adiposity
that are associated with increased disease risk.
Behaviours
A variety of behavioural measures have been reported in the included studies. The behaviour itself can be measured (minutes
spent in moderate-to-vigorous physical activity) or an indicator
related to the behaviour can be measured (number of occasions
of organised sports per week). The choice of measure is often determined by cost, equipment requirements, feasibility, acceptability to participants, scale (number of participants), access to participants, and also the objective of the intervention and therefore
evaluation requirements. Behaviours may also be objectively measured (accelerometry, observation) or subjectively measured (selfreport, parent-report). Behavioural data that are reported by parents, children or others are subject to social desirability bias and recall bias. Reliability and accuracy may also be affected by comprehension and literacy skills of children where survey-based methods
are used. This can be partly overcome by a run-in period. The process of data collection can also lead to changes in behaviour (e.g.
increased activity or changed diet) which can produce data that do
not reflect usual patterns of the behaviour. A further source of bias
can be introduced by non-blinding of data collectors who may
inadvertently introduce artificial differences in measurements be-

19
tween groups. Given the difficulty of measuring behavioural data,

it is recommended to use measures that have been validated and
psychometric properties assessed, to ensure that the data collected
accurately and reliably measure the behaviours of interest. In the
Characteristics of included studies, we have reported whether or
not studies have assessed the reliability of the outcome measures
used.
Section 1: 0-5 years

This section describes studies targeting young children, delimited
as those aged 0-5 years. It should be noted however, that of the eight
studies targeting this age group, all but one study (Harvey-Berino
2003), includes children with a mean age greater than three years
at baseline, and one of these (Keller 2009) recruited children aged
four to seven years.
(difference in zBMI of -0.19) schools (Jouret 2009). Therefore,

although Jouret was not included in the meta-analysis, the size of
the effects for participants recruited from underprivileged schools
are consistent with those in the meta-analysis, which further supports the findings.
Alternative sub-group analysis of those studies conducted in an
education-type setting also reduced heterogeneity considerably (I
2 = 27%) but revealed a non-significant intervention effect of 0.03 (-0.15, 0.09; P = 0.58), with n = 796 and n = 799 children in
intervention and control groups, respectively. These results suggest
that for children aged 0-5 years, interventions set outside education
settings are more effective, which may relate to a number of factors
including the level of parent engagement.
Outcomes from individual studies
Adiposity
Effectiveness
Of the eight studies targeting young children, two tested the same
intervention design with different target groups (Hip Hop to
Health Jnr (Fitzgibbon 2005; Fitzgibbon 2006).
All but one study (Jouret 2009), provided appropriate BMI or
zBMI data for inclusion in the meta-analysis, which showed an
effect size of -0.26 (-0.53 to 0.00), see Analysis 1.1. This can be
interpreted to mean that children in the intervention group had a
change in BMI/zBMI from pre- to post-intervention that was 0.26
units less than what was observed in the control group. Although
the studies are heterogeneous and the analysis only just failed to
reach statistical significance (P = 0.05), there is a trend towards a
positive intervention effect. With subgroup analysis of those studies that were either home-based or involved a healthcare setting
(Harvey-Berino 2003; Keller 2009), heterogeneity was removed
and a highly significant effect size of -1.08 (-1.39 to -0.77) was
observed (P = 0.0001), although the sample size is small (Intervention: 66, Control: 154). This analysis did not include all interventions set outside the education setting, as the study by Jouret 2009
reported only medians and interquartile ranges and therefore could
not be included in the analysis. Jouret found that after the two-year
intervention period, children in both the basic intervention group
(health-service-based; EPIPOI-1) and the reinforced intervention
group (health-service-based + kindergarten-based; EPIPOI-2) had
significantly lower prevalence of overweight (BMI 90th percentile) than the control group. In this study, subgroup analysis
revealed there were differences in effects if the schools were in
underprivileged areas. Specifically, testing the EPIPOI-1 intervention, median change in zBMI was significantly lower in the intervention group (compared with controls) only in underprivileged
schools (difference in zBMI in intervention group from control
group of -1.0 units), while the median change in zBMI was significantly lower in the EPIPOI-2 intervention group in both underprivileged (difference in zBMI -0.85) and non-underprivileged
Results for outcomes measured in each study for this age group
are presented in Table 2. Of the outcomes measuring adiposity
or prevalence of overweight or obesity, only two studies reported
significant differences between groups immediately post-intervention; these were also the longest studies in this group. Keller 2009
reported a stabilisation of zBMI in the intervention group after the
12-month intervention period, which was significantly different
to the increase observed in the control group. Jouret found that
after the two-year intervention period, children in both the basic
intervention group (health-service-based; EPIPOI-1) and the reinforced intervention group (health-service-based + kindergartenbased; EPIPOI-2) had significantly lower prevalence of overweight
(BMI 90th percentile) than the control group. Subgroup analysis revealed there was only a significant difference between groups
if the schools were in underprivileged areas. The effects of the intervention on zBMI are described above.
Behaviours
On balance, only modest behavioural impacts were achieved from

the interventions in this age group.
Diet-related
Five of the eight interventions targeted both dietary and physical activity related behaviours combined. Dietary changes were
reported in only two studies, with Fitzgibbon 2005 reporting a
significantly lower intake of saturated fat in intervention children
at one-year follow-up (P = 0.002), but not post-intervention or at
two-year follow-up. Interestingly, this impact in the African American participants was not observed with the same intervention in
the Latino participants (Fitzgibbon 2006). Keller 2009 reported
significantly lower energy intake and percentage protein intake in
the intervention group post-intervention.

20
Physical Activity-related
Three of the eight interventions targeted physical activity related
behaviours only. Of the range of physical activity related measures
captured, the only positive impact was in one study that reported
children in the intervention group had significantly higher performance in movement skills tests than children in the control group
at six-month follow-up (95% CI: 0.3 to 1.3; P = 0.003) after adjustment for sex and baseline performance (Reilly 2006).
Sedentary-related
Dennison 2004 reported that television viewing was significantly
reduced by the 12-week intervention (the number of children
watching more than two hours of television/day was significantly
lower in the intervention group, as was total number of hours
watched), although time spent playing computer games was not
different between groups.
Cardiovascular disease risk factors

In relation to the impact of the interventions on cardiovascular
disease risk factors other than adiposity, no studies measured effects
on blood pressure, heart rate, blood lipids, or cardiovascular fitness.
units in intervention children and 0.70 units in control children

(P = 0.34), and the BMI z score change was -0.13 and 0.00 for intervention and control children, respectively (P = 0.34). Diet and
physical activity-related measures were also not different between
groups. Reilly 2006 showed that at follow-up six months postintervention, there were no differences in BMI/zBMI or activity
and diet-related behaviours, although children in the intervention
group had significantly higher performance in movement skills
tests than control children at six-month follow-up (P = 0.003; 95%
CI 0.3 to 1.3) after adjustment for sex and baseline performance.
Mo-Suwan 1998 reported that six months post-intervention, the
prevalence of obesity in the control group decreased from 12.2%
at baseline to 9.4% after the intervention at 29.6 weeks and was
10.8% at 29.6 weeks plus six months. In the exercise intervention
group, the prevalence of obesity was 12.9% at baseline, 8.8% at
29.6 weeks and 10.2% six months later. It is not known (information not available) if the changes at 29.6 weeks plus six months
are statistically significant, although only non-significant changes
in prevalence were observed immediately post-intervention.
In summary, follow-up after the completion of these short-term
interventions revealed a lack of further impact on child adiposity
and obesity-related behaviours,
Equity
Assessment of outcomes by gender

Outcomes were reported by gender in three studies. Mo-Suwan
1998 reported that girls in the intervention group had a lower
likelihood of having an increasing BMI slope than the control
girls (odds ratio (OR): 0.32; 95% CI: 0.18 to 0.56). Reilly 2006
reported the change in score for fundamental movement skills was
improved more in females than males, with the average difference
in improvement being 0.7 units (95% CI: 0.3 to 1.1; P = 0.001).
Keller 2009 reported that there were no differences in outcomes
by gender. In summary therefore, there is insufficient evidence
from these studies to determine if either gender benefits more from
interventions in young children, although there is some evidence
that females tend to do better.
Maintenance/Sustainability of effects
Four studies assessed maintenance or sustainability of impacts

(Fitzgibbon 2005; Fitzgibbon 2006; Mo-Suwan 1998; Reilly
2006). In the Fitzgibbon studies, the lack of effects observed postintervention were maintained one and two years later (Fitzgibbon
2006). After one-year follow-up, the increase in BMI for children
in intervention was 0.33 units (P = 0.46), and the mean increase
for children in control schools was 0.48 units (P = 0.46). Similar to the results in BMI, the change in BMI z score was also
not significantly different between the intervention and control
groups at one-year follow-up (0.00 and 0.07, respectively; P =
0.56). At two-year follow-up, the mean increase in BMI was 0.46
This review sought to identify studies which had reported on socio-demographic characteristics known to be important from an
equity perspective. For this process, the PROGRESS (Place, Race,
Occupation, Gender, Religion, Education, Socio-economic status (SES), Social status) framework was utilised (Ueffing 2009).
All studies reported the gender of participants at baseline. Four
studies reported the race of participants and the level of education
of parents (Dennison 2004; Fitzgibbon 2005; Fitzgibbon 2006;
Harvey-Berino 2003) and two studies included information about
the employment status of parents at baseline (Dennison 2004;
Harvey-Berino 2003). Mo-Suwan 1998 included information on
SES of participants at baseline based on parental income. Jouret
2009 reported some indicators related to place (the proportion
of participating schools in a rural or urban region) and SES (the
proportion of participating schools in an urban region which were
also in an area considered to be underprivileged). When analysing
data on outcomes, only three studies analysed results by any of
the PROGRESS items. Mo-Suwan 1998 and Reilly 2006 analysed
outcomes by gender and Jouret 2009 analysed outcomes by the
same indicators of place and SES that were collected at baseline
(these data are discussed above).
Of the eight studies targeting this age group, only Jouret 2009
attempted to analyse the outcomes of the intervention by a
PROGRESS category other than gender, showing differential impacts of the intervention in underprivileged schools. The lack of
analysis by a measure of equity or SES limits our ability to assess
the effectiveness of the interventions in reducing health inequities,

21
however, it should be noted that the participants in most of the

studies were from high risk, underprivileged communities. In this
sub-set of studies, participants are from Thailand, USA (African
American, Native American, Latino), France and Scotland, allowing us to assess the utility of approaches in a variety of contexts.
Harm-adverse/unintended effects
It is critical that measures of harm or unintended consequences

are included in evaluations targeting eating and activity-related
behaviours, to ensure that interventions are safe and appropriate.
This is particularly important in very young children, as this is an
important growth period and adequate nutrition is critical. Also,
given the short intervention periods of most of the studies targeting
this age group, any impacts on diet, weight and fatness need to be
carefully considered. None of the eight studies targeting 0-5 year
olds explicitly reported unintended outcomes or measures of harm,
however, Fitzgibbon 2006 reported there were no adverse events
during the trial, although no data were provided or information
on what measures were used.
Implementation Factors
In order to fully understand the outcomes of the intervention,

an understanding of the development and implementation is required. This allows interpretation of the findings in an appropriate
context and also an assessment of the applicability, transferability
and appropriateness of the intervention for similar or different
population groups. The reporting of the theoretical basis, implementation factors and process evaluation are discussed below.
Design and theoretical basis
Five of the eight studies were both diet and physical activity combined, three were physical activity interventions only. All but one
of the studies had short intervention periods (< one year; six studies
24 weeks), with only Jouret 2009 having a longer intervention
period (two years). Of the seven study designs, theoretical basis
was only explicitly reported in one (Fitzgibbon 2006). Despite
this, we can surmise that behaviour change theory informed the
design of five of the studies (Dennison 2004; Fitzgibbon 2005;
Fitzgibbon 2006; Harvey-Berino 2003; Jouret 2009; Keller 2009),
while environmental change models seemed to inform the design
of two of the studies (Mo-Suwan 1998; Reilly 2006).
for the face-to-face component of the intervention, from which

staff hours could be extrapolated, however, five studies provided
more specific information about resources required for implementation (Dennison 2004; Fitzgibbon 2005; Fitzgibbon 2006;
Harvey-Berino 2003; Reilly 2006). Four of these studies described
the materials used to deliver the intervention, for example, materials required to teach particular lesson topics within the classroom setting or resources that were sent home with children, or
both. Dennison 2004 mentioned examples of additional community resources that could be mobilised to enhance the intervention.
Harvey-Berino 2003 included staff hours required for training in
order to deliver the intervention. While no studies included a formal economic evaluation, Reilly 2006 reported estimated costs of
both the nursery-based and home-based component of their intervention. The nursery element of the intervention was intended
to be inexpensive and therefore generalisable (capital cost < 200,
EURO297, USD377). For the home-based component, each participating family received a resource pack of materials costing 16
(EURO24, $30) (Reilly 2006). The cost of maintaining the usual
curriculum in the control group was not estimated.
Strategies to address disadvantage/diversity

Of the eight studies targeted towards the 0-5 year age group,
three incorporated strategies to address disadvantage or diversity (Fitzgibbon 2005; Fitzgibbon 2006; Harvey-Berino 2003).
Harvey-Berino 2003 conducted a pilot study targeting motherchild pairs within a Native-American community. Study personnel delivering the intervention received training from a family
therapist/parenting consultant from the tribe within which the
intervention was delivered. Hip Hop to Health Jr was a combined dietary and physical activity intervention targeted towards
preschool minority children, with one study to be conducted
in sites which serviced primarily African American communities
(Fitzgibbon 2005) and a repeat study conducted in sites which
service primarily Latino communities (Fitzgibbon 2006). For the
Latino communities, this intervention was delivered in both English and Spanish. In reporting the design of Hip Hop to Health Jr,
a number of components have been highlighted as important considerations for any culturally-specific intervention including: safe
and easy access to the programme; fostering identification between
interventionists and participants; addressing cognitive and environmental barriers to exercise and adoption of a healthier diet; emphasis on behavioural demonstrations to facilitate lifestyle changes
and consideration for all levels of literacy (Fitzgibbon 2005).
Resources needed
All studies reported on who delivered the intervention. All interventions were delivered by trained study personnel with the exception of one physical activity intervention which was delivered
by two members of staff from each intervention nursery who had
attended three training sessions with the study personnel (Reilly
2006). Most studies included information about the length of time
Process evaluation
Attempts were made to capture programme reach (i.e. to all the
target population), programme acceptability (to the target population) and programme integrity (i.e. programme implemented as
planned). A comprehensive process evaluation allows variability

22
in context and delivery to be monitored, and the identification of

barriers and facilitators to implementation. These factors can then
be related to the variability in intervention impact and programme
outcomes.
Of the eight studies targeted towards children between the ages
of 0 and 5 years, half of them reported some elements that might
be considered part of a process evaluation (Fitzgibbon 2005;
Fitzgibbon 2006; Harvey-Berino 2003; Reilly 2006). All four of
these studies recorded either hours of attendance of participants or
number of sessions completed to provide some confidence about
the actual dose delivered. Two studies were based on one design that was conducted twice, once in sites servicing primarily
African American communities and repeated in sites servicing primarily Latino communities (Fitzgibbon 2005; Fitzgibbon 2006).
Fitzgibbon 2005 described the development of their intervention
in significant detail which involved an initial pilot to explore feasibility and acceptability. This report provided information about
optimal class length, childrens ability to grasp the curriculum and
reasons for poor attendance of parents, all of which could be used
to adapt their intervention accordingly.
Section 2: six to12 year olds
Effectiveness
are presented in Table 3. Of the 39 intervention studies targeted
towards children between the ages of six and 12 years, 27 studies provided appropriate BMI or zBMI data for inclusion in the
meta-analysis. Of those included in the meta-analysis, a statistically significant mean effect size of -0.15 (95% CI: -0.23 to -0.08)
was found (see Analysis 1.1), although the heterogeneity of the
studies, and small sample sizes of several studies are both limitations, meaning inferences should be made with caution. Analysing
only those interventions conducted solely in an education setting
did not reduce heterogeneity and resulted in a similar effect size
as the whole group (-0.17, 95% CI: -0.25 to -0.09; P < 0.001).
Conversely, analysing those studies conducted either in multiple
settings (n = 4 of 27 studies), or outside education settings (e.g.
home, community) (n = 3 of 27 studies) reduced heterogeneity
and resulted in a non-significant mean effect size of -0.07 (-0.24 to
0.10), although the majority of these were small studies. Of those
studies not included in the meta-analysis due to the lack of appropriate data being reported, Sahota 2001 reported a weighted mean
difference in zBMI between groups from baseline to follow-up of
0 (-0.1 to 0.1). The majority of the other studies reported changes
in prevalence of overweight or obesity or percentage body fat and
in some cases a significant intervention effect was observed overall
or in subgroups (Foster 2008; Gortmaker 1999a; Mller 2001;
described below), while non-significant differences were reported
in other studies (Fernandes 2009; Kipping 2008; Warren 2003).
In total, only seven of the 39 studies were conducted outside of an

education setting (Baranowski 2003; Beech 2003; Epstein 2001;
Macias-Cervantes 2009; Robinson 2003; Rodearmel 2006; Stolley
1997).
Outcomes from individual studies
Adiposity
Eighteen of the 39 studies targeting this age group reported a

significant intervention effect on any measure of adiposity. Thirteen studies reported intervention effects on continuous measures
of adiposity (BMI, zBMI, weight, skinfold thickness, percentage
body fat, or BMI percentiles) and five studies reported intervention effects on only categorical measures of fatness (weight status
e.g. overweight). The effective interventions are summarised below in chronological order.
Gortmaker 1999a reported that after the long-term Planet Health
intervention the prevalence of obesity among females in intervention schools was reduced compared with controls, however, there
were no differences in male participants. There was also greater
remission of obesity among intervention females compared with
control females. Mller 2001 reported a significantly smaller increase in triceps skinfold in the intervention group after the 12month intervention period. In addition, there were positive intervention effects on percentage fat mass of overweight children
(increased by 3.6% per year versus 0.4% per year in control and
intervention groups, respectively). In the study by Kain 2004, the
only measure of fatness that was decreased significantly in intervention group was waist circumference (reduced by a mean of 0.9
cm in the intervention group and increased in controls by same
amount). In the study by James 2004, there were no differences
between intervention and control groups in change in BMI from
baseline after the 12-month intervention, however, there was a
significant difference in the change from baseline in the prevalence
of overweight and obesity in favour of the intervention group (increased by 7.5% in the control clusters, and decreased by 0.2%
in intervention clusters). This difference was not maintained after
three years from baseline. Coleman 2005 explored the effects of
the El Paso CATCH programme in schools and found that, although the percentage of children who were at risk of overweight,
or overweight did not significantly differ from year to year between
intervention and control schools, the rates of increase were higher
in control schools. Rates of increase from 3rd to 5th grades were
13% in girls and 9% in boys in control schools, compared with
2% in girls and 1% in boys in intervention schools.
Rodearmel 2006 reported significant differences between intervention and control groups after the 13-week intervention in the
mean change of all measures of child fatness (percentage BMI-forage, percentage body fat) and parent adiposity (weight, BMI and
percentage body fat). Given the short-term nature of the intervention, and time between measurements (13 weeks), this effect may

23
be spurious. The five to six-month intervention by Spiegel 2006

was associated with a reduced BMI in the intervention group and
a correlation between the change in BMI from baseline to postintervention. BMI-for-age data showed no significant shift in the
comparison group, but a reduction in the intervention group in
overweight and at risk for overweight classification, which was
most significant in the at risk for overweight (BMI-for-age between 85% to 95%) level. There was a 2% reduction in overweight (BMI > 85% for age and sex) in the intervention group.
However, there was a 16% attrition rate in the comparison group
(N = 479 matched measures between baseline to post-data) and a
14% attrition rate in the intervention group (N = 534 matched).
The long-term New Zealand study by Taylor 2008 reported the
adjusted mean zBMI score post-intervention as significantly lower
in the intervention group compared with control group children
after the first year of the study. After two years, mean zBMI score
remained significantly lower in children the whole group and in
those who were in the intervention for at least one year 1 (n = 389;
-0.19 (95%CI: -0.24 to -0.13)) or 2 (n = 256; -0.21 (95%CI: 0.29 to -0.14)) years. Although the risk of being overweight or
obese at year-end in intervention compared with the children in
the control group (OR 0.55; 95% CI: 0.19 to 1.48) did not achieve
statistical significance, children in the intervention group were less
likely to be overweight post-intervention, but only in those who
were present for the full intervention. During the two years postintervention, a lower proportion of children in the intervention
group became overweight; more intervention children who were
overweight at baseline were not overweight at follow-up, a lower
proportion of children in the intervention group became overweight, and a higher proportion of children in the intervention
group became normal weight, compared with children in the control group.
A French study (Lazaar 2007) reported post-intervention that the
intervention group had a significantly higher rate of remission of
obesity (to overweight) and less incidence of obesity. Subgroup
analysis revealed effects only in female participants, and larger
effects of the intervention were observed in obese (compared with
non-obese children) regardless of measure. In male participants,
The zBMIz score decreased more in the intervention group than
the control group.
Foster 2008 implemented a school nutrition policy-based intervention and found that the unadjusted incidence of overweight was
reduced by 50% as a result of the intervention, with a significantly
lower percentage of children in the intervention group (7.5%) becoming overweight after two years compared with children in the
control schools (15%). The unadjusted incidence of obesity was
not different between groups. After controlling for gender, race/
ethnicity and age, the adjusted (predicted) odds of becoming overweight during the intervention period (incidence of overweight)
were 33% lower for the intervention group (P < 0.05). There were
no differences in the incidence of obesity. When collapsing the
overweight and obese categories, the predicted odds of incidence
of overweight/obesity (becoming overweight or obese during the

study period) were 15% lower for the intervention group (P <
0.05). In relation to the prevalence of overweight, after controlling for age, race/ethnicity, gender and prevalence at baseline the
predicted odds of being overweight post-intervention (overweight
prevalence) were 35% lower in the intervention group post-intervention. In contrast, after two years there were no differences
in the prevalence of obesity, or in the prevalence of overweight/
obesity combined (although there was a non-significant trend; P
= 0.07). The predicted odds of remission of overweight or obesity
(moving from being overweight or obese at baseline to not overweight or obese at post-intervention assessment) were 32% higher
for the intervention group (P 0.01).
Gutin 2008 (The Medical College of Georgia Fitkid Project)
reported various results. When using intention-to-treat analysis
there were no significant differences between groups, but with
higher programme attendance there were significantly greater reductions in percent body fat. During the intervention period,
the intervention group significantly reduced their body fat during
school months, however, this effect was lost during school vacation (after the summer months). Fat-free soft tissue also showed a
significant group by time interaction in favour of the intervention
(P < 0.01). However, BMI increased significantly more in the intervention group by the end of the three intervention periods.
The Australian study reported by Salmon 2008 tested three interventions, and found significant reductions in BMI immediately after the six-month intervention in the Behaviour Modification and
Fundamental Movement Skills (BM/FMS) group only compared
with control. This effect was maintained at six and 12 months follow-up. This reduction was not observed in with the BM or FMS
alone intervention groups. Also, those in the BM/FMS intervention group were > 60% less likely to be overweight or obese on
average between baseline and post intervention and over the four
time points of the study compared with control (P <0.05). This
effect was maintained at six- and 12- month follow-up. Another
Australian study, reported by Sanigorski 2008 found that the three
year Be Active Eat Well intervention was associated with significantly smaller increases in weight, waist circumference, waist-toheight ratio and zBMI in the intervention group, compared with
children in the control group.
Sichieri 2009 reported no significant differences between intervention and control groups in BMI or weight as a result of the intervention conducted in Brazil, however, subgroup analysis revealed
that for participants overweight at baseline, the intervention group
had a greater BMI reduction than the control group, although this
difference was only statistically significant among girls. It should
be acknowledged that these subgroup findings could be spurious
as they were likely to be derived from the data post-hoc and involve relatively small sample sizes, so should be interpreted with
caution.
The long-term French study by Simon 2008 reported that postintervention participants had a smaller increase in BMI (P - 0.01)

24
over time than those in the control group. The significant differences in change in BMI between groups were evident at three
years and at four years. The cumulative incidence of overweight
was also lower in the intervention group than in the control group
at four years.
Vizcaino 2008 reported the Spanish intervention resulted in a
significant reduction in triceps skinfold thickness in intervention
children compared with controls for both boys and girls. There
was also a significant reduction in percentage body fat in girls but
not boys, compared with the comparison group.
The long-term study by Donnelly 2009 reported various results.
Using intention-to-treat analysis showed no intervention effect on
BMI, however analysis of schools (n = 9) with > 75mins of the
PAAC intervention activities delivered per week showed significantly less increase in BMI at three years compared to schools (n
= 5) with < 75min/week. Marcus 2009 reported that the fouryear Swedish intervention was associated with a reduction in the
prevalence of overweight/obesity by 3.2% in intervention schools
compared with an increase of 2.8% in control schools (P < 0.05).
There was also a higher rate of remission of overweight children
to healthy weight in the intervention group (14%) compared with
the control group (7.5%).
Summary: Of the 39 studies that targeted children aged six to
12 years, 18 were effective on some indicator of adiposity. Ten
studies involved long-term intervention periods (> 12 months),
one had an intervention period of 12 months, five had intervention
periods approximately six months, and two involved very shortterm intervention periods. Seven studies were conducted in the
USA, two in Australia, two in France, one in each of New Zealand,
UK, Germany, Sweden, Chile, Brazil and Spain. Of the 21 studies
not effective on any indicator of adiposity, only three studies had
an intervention period greater than 12 months (> one to two years:
Sallis 1993; Warren 2003; > two years: Caballero 2003).
Behaviours
As seen in Table 1, of the 39 studies, six studies targeted dietary

factors only, 21 targeted diet and physical activity related factors
combined and 12 targeted factors related to promoting physical
activity only. On balance, a variety of modest behavioural impacts
have been achieved in most of the interventions in this age group.
Diet-related
Diet-related factors were significantly positively altered in 20
studies. A variety of indicators have been used, however, nutrition knowledge was increased in four studies (Amaro 2006;
Mller 2001; Sahota 2001; Story 2003a), eating practices were
improved in one study (Robinson 2003), food preparation practices were improved in two studies (Beech 2003; Story 2003a),
higher levels of fruit and vegetable consumption was reported
in five studies (Amaro 2006; Gentile 2009; Gortmaker 1999a;
Hamelink-Basteen 2008; Mller 2001), reductions in energy

dense snack foods in one study (Fernandes 2009), reduced intake of sweetened/carbonated drinks in five studies (Beech 2003;
Hamelink-Basteen 2008; James 2004; Marcus 2009; Sichieri
2009), reduced intake of sweet foods was reported in two studies (Hamelink-Basteen 2008; Marcus 2009), reduction in total
energy, energy from fat or total fat intake were reported in five
studies (Caballero 2003; Gortmaker 1999a; Paineau 2008; Stolley
1997; Story 2003a) and other indicators of better diets were reported in four studies (Fernandes 2009; Marcus 2009; Mller
2001; Rodearmel 2006).
Physical activity-related
Physical activity-related factors were significantly positively impacted in 21 studies, with a variety of indicators and measures used.
Higher levels of physical activity self-efficacy were reported in four
studies (Caballero 2003; Harrison 2006; Salmon 2008; Simon
2008), better cardiovascular fitness in three studies (Gutin 2008;
Kain 2004; Reed 2008), higher levels of physical activity in nine
studies (Hamelink-Basteen 2008, Harrison 2006; Pangrazi 2003;
Donnelly 2009, Mller 2001; Rodearmel 2006; Salmon 2008;
Spiegel 2006; Taylor 2008), more time spent in organised physical
activity in one study (Simon 2008), and decreased sedentary behaviours (predominantly screen time, and television viewing) were
reported in eight studies (Foster 2008; Gentile 2009; Gortmaker
1999a; Hamelink-Basteen 2008; Mller 2001; Robinson 2003;
Simon 2008; Taylor 2008).

Only eight studies reported the impact of the interventions on
cardiovascular disease risk factors other than adiposity. Significant
beneficial effects on blood pressure, heart rate, blood lipids, and
cardiovascular fitness were reported in four studies (Gutin 2008;
Reed 2008; Simon 2008; Vizcaino 2008).

Nineteen studies analysed the effects of the intervention by gender. Of those, eight reported no difference in outcomes by gender
(Caballero 2003; Coleman 2005; Donnelly 2009; Epstein 2001;
Foster 2008; James 2004; Sallis 1993; Simon 2008), four reported
more pronounced intervention effects in male participants (Kain
2004, Kipping 2008; Marcus 2009; Salmon 2008) and seven reported more pronounced intervention effects in female participants (Gentile 2009; Gortmaker 1999a; Lazaar 2007; Pangrazi
2003; Rodearmel 2006; Sichieri 2009; Vizcaino 2008). Of the
studies that did not undertake this analysis, five were female-only
studies (Baranowski 2003; Beech 2003; Robbins 2006; Robinson
2003; Story 2003a).

25
Maintenance/Sustainability of effects
The sustainability of these effects on behaviours was assessed in

only four studies (Donnelly 2009; Gentile 2009; James 2004;
Salmon 2008). Gentile 2009 reported a significantly lower level
of parent-reported TV/computer screen time post-intervention in
the intervention group and this effect was maintained at six months
follow-up (a reduction of about two hours/week). The intervention group also had a significant increase in parent- and child-reported fruit and vegetable consumption immediately post-intervention and this was also maintained at the six-month follow-up.
Salmon 2008 reported that all impacts achieved post-intervention
(increased level of physical activity and physical activity-related
self efficacy) were maintained six and 12 months post-intervention. Donnelly 2009 reported on the Physical Activity Across the
Curriculum intervention which promoted 90 min/wk of moderate to vigorous intensity physically active academic lessons delivered by classroom teachers. Teachers were surveyed nine months
after the completion of the intervention and it was found that
approximately 95% of teachers were using PAAC lessons on at
least one day/week, approximately 55% of teachers indicated that
they were using PAAC two to four days/week, 35% were using
PAAC on most days or every day. James 2004 observed a significant
difference in favour of the intervention group in the proportion
of children who were overweight or obese following a 12-month
intervention aimed at encouraging a healthy diet and reducing
carbonated drink consumption, however this difference was not
maintained at two years after the intervention had ended.
Equity
With the exception of Robbins 2006, all studies reported one or

more items of the PROGRESS framework at baseline. Most studies reported gender of participants at baseline (n = 32). Socioeconomic status (SES) (n = 16) and race (n = 15) were the next
most commonly reported items at baseline, followed by education
level of parents (n = 11), place (n = 6), occupation or employment
status of parents (n = 4) and social status (n = 2). When analysing
outcome data, 17 studies did not analyse by any of the items in the
PROGRESS framework. Of the 22 studies that did analyse by at
least one item on the PROGRESS framework, the majority analysed outcomes by gender (n = 21). A total of six studies included
analysis of outcome data by PROGRESS items other than gender (Foster 2008; Gortmaker 1999a; Gutin 2008; Marcus 2009;
Sanigorski 2008; Simon 2008). These included race (n = 3), SES
(n = 3) and education level of parents (n = 2).
Foster 2008 used subgroup analysis (by participant ethnicity) to
determine that in addition to the main effect of the intervention
on the prevalence of overweight and obesity, the interventions
effect on the prevalence of overweight was particularly effective
for African American participants (OR: 0.59; 95% CI: 0.38 to
0.92; P < 0 .05), after the two-year intervention, with control for
gender, age, and baseline prevalence. Overall, after controlling for
gender, race/ethnicity, age, and baseline prevalence, the predicted

odds of overweight prevalence were 35% lower for the intervention
group (OR: 0.65; 95% CI: 0.54 to 0.79; P < 0.0001). There were
no interaction effects between the intervention and race/ethnicity,
gender, or age on the level of inactivity or television viewing.
Gortmaker 1999a analysed the impacts of the Planet Health intervention on changes in obesity by ethnic group. The largest intervention effects were observed in African American girls, with
obesity prevalence significantly reduced in intervention (n = 28)
versus control (n = 51) participants (OR 0.14; 95% CI: 0.04-0.48;
P = 0.007). Among white girls (intervention n = 223; control n
= 200), the intervention effect was similar to the overall result
(OR 0.46; 95% CI: 0.19-1.12; P = 0.08), while for Hispanic girls
(intervention n = 31; control n = 48), results did not reach statistical significance (OR, 0.38; 95% CI: 0.03-5.3; P=0.42). The
findings in African American girls and Hispanic girls should be
treated with caution due to the small sample size in those groups.
No differences were found for boys.
In the Swedish STOP study reported by Marcus 2009, a significant interaction effect was observed between parental education
level and the impact of the intervention on reported intake of
dairy products and fast food. For children in families with low
parental education background, the odds ratio (OR) was 3.58 for
healthy choice behaviour for dairy products in the intervention
group compared with the control group (OR = 1.0), whereas for
children in families with high parental education background the
corresponding ORs for the intervention group and the control
group were 1.65 and 1.18, respectively (P for interaction = 0.02).
A similar pattern was observed for the healthy choice behaviour
in relation to fast foods, where ORs were 2.5 in the intervention
group compared with 1.0 in the control group in children in families with low parental education, and 2.1 and 3.2 in families with
a high parental education, for intervention and control groups,
respectively (P for interaction = 0.0005).
Sanigorski 2008 reported a flattening of the gradient between measures of fatness and SES after the intervention period in the intervention group, which was not apparent in the control group.
Associations between the adjusted changes in the five anthropometric measures and the four individual- and area-level indicators
of socio-economic status were tested post-intervention. In the
comparison population, all regression coefficients were negative
and 19 of 20 analyses were statistically significant (lower SES associated with a greater weight gain). In the intervention group, all
coefficients were also negative, but none were statistically significant and the association was less strong than in the comparison
group.
Simon 2008 reported impacts on fatness and physical activity related factors, however they also tested the interaction of outcomes
with gender and SES status (based on highest parental occupation category), and found no significant interactions, suggesting
no difference in outcomes by these factors.
Summary: All studies which assessed outcomes by a PROGRESS

26
measure of equity, reported either no association between the outcomes of the intervention and the PROGRESS measure, or positive impacts for groups of lower SES. The possibility of a bias
towards reporting favourable equity effects cannot be excluded.
Eight studies assessed adverse or unintended consequences of the

interventions. A variety of measures were used to assess adverse effects, including prevalence of underweight, unhealthy eating practices, teasing, stigmatisation, body image perceptions, satisfaction
and self-worth. In all studies either very few (Beech 2003) or no
adverse outcomes were reported (Foster 2008; Gortmaker 1999a;
Marcus 2009; Sahota 2001; Salmon 2008; Sanigorski 2008; Story
2003a). Based on the available studies, there is no evidence of adverse effects of obesity prevention interventions in this age group,
however it must be acknowledged that only a minority of the 39
studies reported that adverse effects were assessed.
Implementation
Design and theoretical basis

Twenty one of the 39 studies targeted both diet and physical activity. Twelve studies targeted physical activity alone and six studies
targeted diet alone. The majority of studies had short intervention
periods (< one year; 27 studies). Five studies had an intervention
period of one to two years and seven studies had intervention periods of longer than two years.
Of the 39 studies targeting children aged six to 12 years, the theoretical basis of the intervention design was explicitly reported in
24 studies. The predominant theories were behavioural, although
a variety of other theories such as environmental change, socioecological, social learning theory, health promotion, the Transtheoretical Model and youth development and resiliency based approaches are also represented. In a number of studies, where theories were not reported they could be surmised based on the details
provided (see Table 1).
Process evaluation
Of the 39 studies, 26 reported some elements of process evaluation. Many studies recorded programme attendance or number
of sessions completed in order to estimate exposure (Baranowski
2003; Beech 2003; Caballero 2003; Donnelly 2009; Gortmaker
1999a; Gutin 2008; Harrison 2006; Kain 2004; Kipping 2008;
Robinson 2003; Sahota 2001; Salmon 2008; Sanigorski 2008;
Simon 2008; Stolley 1997; Story 2003a; Vizcaino 2008). In addition to attendance or participation, it is also possible to assess
the intensity of intervention delivery. Lazaar 2007 implemented
a physical activity intervention and estimated intensity of the exercise sessions by randomly selecting two participants from each
intervention group and monitoring their physical activity levels.

Donnelly 2009 reported intensity of lesson delivery and also investigated the effect of teacher participation in classroom physical
activity. They found that teacher participation appeared to influence student activity levels in the study, so that teachers who were
more physically active tended to have students who were more
physically active as well.
A related concept measured is adherence to the intervention programme, often assessed from the perspective of those delivering
the intervention. Marcus 2009 reported that research staff performed both regular and random compliance checks at participating schools, documenting deviations and discussing them with
headmasters in order to address them as the study progressed.
Adherence to the programme by participants was also measured
in two studies, with physical activity levels monitored to determine if participants were following the intervention guidelines
(Macias-Cervantes 2009; Rodearmel 2006).
Many studies also explored satisfaction with the programme from
the perspective of either participants or those who delivered the intervention, or both (Beech 2003; Caballero 2003; Coleman 2005;
Gortmaker 1999a; Kain 2004; Kipping 2008; Robbins 2006;
Robinson 2003; Salmon 2008; Sanigorski 2008; Spiegel 2006;
Story 2003a; Vizcaino 2008; Warren 2003). Measures included
levels of enjoyment, ease of implementation (barriers and facilitators) and general impressions about the intervention. Information
was collected using a variety of methods including surveys, focus
groups and interviews. For example, in Kipping 2008, teachers
reportedly found it difficult to adhere to the intervention requirements as intervention lessons were difficult to accommodate into
the school timetable. Robbins 2006, similarly identified important barriers to increasing physical activity in some girls, with lack
of suitable places, resources and social support for physical activity
limiting compliance with the intervention programme. The process evaluation therefore identified important environmental barriers that need to be addressed to increase the potential for the intervention to be implemented fully. Robinson 2003 also explored
barriers to attendance and found transportation to be an important factor. Coleman 2005 published implementation-related information in a separate paper and provided recommendations to
practitioners covering some of the contextual factors to consider
when adapting the programme to their own context (Heath 2002).
Beyond exposure, barriers to attendance, ease of implementation
and satisfaction with the programme, a number of studies employed more sophisticated process evaluation measures to investigate programme fidelity (Donnelly 2009; Gutin 2008; Kain 2004;
Reed 2008; Sahota 2001; Salmon 2008; Sanigorski 2008). For
example, Gutin 2008 assessed programme fidelity by evaluating
programme variability, participant variability and site variability
(Yin 2005; Yin 2005a; Yin 2005b). A detailed process evaluation
linked to the study by Sanigorski 2008 summarises the results of
a number of process measures covering potential impact, barriers encountered and the likely sustainability for each intervention

27
component (Simmons 2008).
Resources needed
All studies reported who delivered the intervention. Approximately half of the interventions were delivered primarily by trained
study personnel (Baranowski 2003; Beech 2003; Epstein 2001;
James 2004; Kain 2004; Lazaar 2007; Macias-Cervantes 2009;
Mller 2001; Robinson 2003; Rodearmel 2006; Sahota 2001;
Sallis 1993; Salmon 2008; Sanigorski 2008; Sichieri 2009; Simon
2008; Stolley 1997; Story 2003a, Taylor 2008, Vizcaino 2008;
Warren 2003). The remaining interventions were delivered primarily by school-based staff, usually teachers, after receiving training and materials from the study team (Amaro 2006; Caballero
2003; Coleman 2005; Donnelly 2009; Fernandes 2009; Foster
2008; Gentile 2009; Gortmaker 1999a; Gutin 2008; Harrison
2006; Kipping 2008; Marcus 2009; Paineau 2008; Pangrazi 2003;
Reed 2008; Robbins 2006; Spiegel 2006). Sallis 1993 included
two intervention groups, one led by specialists from the study team
and one led by teachers trained by study team.
Twenty-eight of the 39 studies included information about the
resources required to deliver the intervention, however the level
of detail varied considerably. Many studies included information about the length of time required for the face-to-face intervention components, however some studies also included information about time required for staff training in order to deliver the intervention and/or additional support and consultation offered by study team members (Caballero 2003, Donnelly
2009, Foster 2008, Gutin 2008, Kain 2004, Sahota 2001, Sallis
1993, Sanigorski 2008, Sichieri 2009, Story 2003a; Taylor 2008;
Vizcaino 2008). Many studies included descriptions (to varying
levels of detail) of the materials used to deliver the intervention, such as lesson topics, materials used within the classroom
or sent home with children, curricula and planning guides provided to teachers, resources provided for families, as well as items
provided as incentives for participation and achievement (Amaro
2006; Beech 2003; Caballero 2003; Coleman 2005; Epstein
2001; Gortmaker 1999a; Gutin 2008; Harrison 2006; Kain 2004;
Kipping 2008; Paineau 2008; Pangrazi 2003; Reed 2008; Robbins
2006; Robinson 2003; Rodearmel 2006; Sahota 2001; Salmon
2008; Sanigorski 2008; Sichieri 2009; Spiegel 2006; Story 2003a;
Warren 2003). One study estimated the total number of personhours required to implement the intervention (Sanigorski 2008)
and Mller 2001 reported the availability of intervention materials for purchase by education and counselling services.
The Medical College of Georgia Fitkid Project (Gutin 2008) published information not only about the rationale, design and components of their physical activity intervention, but also included
information about contextual factors that the study authors believe may have been important for implementation within their
study setting (Yin 2005). This included assessment of feasibility,
based on the facilities available within schools such as indoor and
outdoor sporting facilities and play areas, and suitably large classrooms within which to hold academic enrichment sessions. Transportation, funded by the research project, was also provided for
study participants, minimising an important barrier to participation in after-school programmes. Action Schools! BC evaluated
an active school model for elementary school-based physical activity promotion (Reed 2008). Reports on this intervention included an implementation model to depict the various intervention components, including materials provided, and support and
liaison roles to implement the programme (Naylor 2006; Naylor
2006a).
While no studies included a formal economic evaluation, Kipping
2008 included the cost of materials and teacher training (110 per
teacher and 2 per pupil), Coleman 2005 included the amount of
funding provided for evaluation, funding for co-ordinators, facility
overhead, copying, incentives, and translation services (USD4.2
million over four years), Vizcaino 2008 reported the cost (28 euros)
per child per month and Sanigorski 2008 included the amount of
funding provided to implement the intervention (AUD100 000
per year for four years). Intervention costs in the studies mentioned
above were not compared with costs in the control groups since
these consisted of either no intervention or maintaining usual curriculum/practice. In the studies authored by Kipping 2008 and
Vizcaino 2008, costs were reported for the purpose of emphasising
feasibility and generalisability with both considering their interventions to be relatively inexpensive and so, from a cost perspective, feasible to scale up.

Of the 39 studies, 15 incorporated strategies to address disadvantage or diversity. Seven interventions included components tailored for African American children, four of these were part of
the GEMS (Girls health Enrichment Multi-site Studies) project,
targeting African American girls (Baranowski 2003, Beech 2003,
Robinson 2003, Story 2003a). Of these, three specifically targeted low-income participants (Beech 2003, Robinson 2003,
Story 2003a), while the fourth included participants of a middle- and upper-income demographic (Baranowski 2003). All four
GEMS studies conducted formative evaluation including focus
groups, interviews and surveys with African American girls and
their families to inform the intervention design. Two of the GEMS
studies reported culturally matching providers of lessons, ensuring
that interventions were delivered by African American instructors
(Robinson 2003, Story 2003a). Robinson 2003 also describes the
incorporation of African and African American history and cultural themes into the intervention lessons. Stolley 1997 developed
a culturally specific curriculum for African American girls and
their mothers that included education about food labels, shopping
and food preparation using foods and recipes identified by participants. Culturally relevant music and dance were utilised for a
physical activity component and the curriculum was adapted to

28
suit the needs of their inner-city population, for example, ensuring the venue was within walking distance for participants. Gutin
2008 implemented a culturally sensitive physical activity intervention to predominantly African American students. Strategies used
to deliver an a culturally appropriate intervention programme included engaging African American teachers/personnel to implement the programme, an emphasis on collective goals, interpersonal rather than individualistic influences, and distinctiveness in
dress and verbal expressions were considered when deciding on
various aspects of the intervention.
Caballero 2003 targeted a combined dietary and physical activity
intervention toward American Indian schoolchildren. Formative
research and approval by tribal health authorities were used to ensure culturally appropriate classroom curriculum. Coleman 2005
translated a school health curriculum that had been tested in a
national trial into community low-income school settings in an
area with a population of predominately Mexican descent, so the
curriculum was designed to reflect this. Robbins 2006 described
the development of an individually tailored physical activity computer-based intervention which enabled the inclusion of culturally sensitive and developmentally appropriate strategies for participants from diverse ethnic backgrounds. Spiegel 2006 administered survey measures that were available in English and Spanish.
The remaining five studies were conducted in areas of social disadvantage (Harrison 2006; Salmon 2008, Kain 2004), or in a rural
setting (Vizcaino 2008, Sanigorski 2008).
Section 3: 13 to 18 year olds
Effectiveness
are presented in Table 4. Of the eight included studies targeting
adolescents, six provided appropriate BMI or zBMI data for inclusion in the meta-analysis (NeumarkSztainer 2003; Ebbeling 2006;
Haerens 2006; Webber 2008; Singh 2009; Peralta 2009). Of those
included in the meta-analysis a mean standardised difference between change in BMI/zBMI from baseline to post-intervention
between intervention and control groups was -0.09 units (95% CI:
-0.20 to 0.03) (see Analysis 1.1). Although this was not statistically
significant, and the heterogeneity of the studies is a limitation, the
results show there was a trend for intervention children to have
smaller increases in these measures of adiposity over time. The
two studies not included in the meta-analysis (Patrick 2006, Pate
2005) did not report appropriate BMI or zBMI data; however it
was reported that the prevalence of overweight or obesity was not
different between groups post-intervention in the Pate 2005 study,
and it was reported that BMI z scores were not different between
groups post-intervention in the Patrick 2006 study, although the
subgroup of children with a BMI at or above the 95th percentile
tended to have a lower BMI z score (P = 0.10). The small number
of studies and observed heterogeneity of the studies in the metaanalysis limits our ability to determine with confidence the effectiveness of interventions in adolescents, although these results are
promising.
Outcomes in individual studies
Adiposity
Of the eight studies included in this subgroup, only Ebbeling 2006

and Singh 2009 reported a significant intervention effect on any
measure of adiposity. Many studies had only small sample sizes
which limits their power to detect significant changes. Immediately after the eight-month intervention (the DoiT programme),
Singh 2009 reported significant reductions in hip circumference
(mean difference, 0.53 cm; 95% CI, 0.07 to 0.98) and sum of
skinfolds among females (mean difference -2.31 mm; 95% CI, 4.34 to 0.28). In males, the intervention resulted in a significant
difference in waist circumference (mean difference, -0.57 cm; 95%
CI, -1.10 to -0.05). A follow-up assessment conducted at 12 and
20 months found no intervention impacts on BMI, however, there
were impacts on fatness (measured by skin fold thickness). Intervention males showed significantly lower triceps (-0.7mm; 95%
CI: -1.2 to -0.1 mm), biceps (-0.4 mm; 95% CI: -0.8 to -0.1 mm)
and subscapular (-0.5 mm; 95% CI: -1.0 to -0.1 mm) skinfold
thickness at 20 months. In female participants there was a significant intervention effect on biceps skinfold thickness (-0.7 mm;
95% CI: -1.3 to -0.04 mm) and the sum of skinfold thickness (2.0 mm; 95% CI: -3.9 to -0.1 mm) at 20 months. Ebbeling 2006
did not report any overall differences in BMI between intervention and control groups, however there was a significant difference
in BMI change in favour of the intervention group among those
with baseline BMI > 30 kg/m2 (-0.63 - 0.23 kg/m2 versus +0.12
0.26 kg/m2 ).
Behaviours
On balance, a variety of modest behavioural impacts have been

achieved from the interventions in this age group.
Diet-related
Although a number of dietary behaviours were targeted by all but
two interventions, and a range of measures of dietary intake were
utilised, significant positive dietary changes were reported in only
three studies. The two-year Belgium study of Haerens 2006 reported a significantly lower intake of fat and percentage of energy from fat in intervention children compared with the control
group. Ebbeling 2006 reported a significantly greater decrease in
energy intake from sugar-sweetened beverages along with an increase in noncaloric beverage intake in intervention participants

29
compared with control participants. Singh 2009 also reported significant positive impacts of the intervention on consumption of
sugar-sweetened beverages, soft drinks, and fruit juices. These
positive intervention impacts were sustained at the 12-month follow-up assessment (four months post-intervention), but had dissipated at the 20-month follow-up assessment. Patrick 2006, while
not finding an overall intervention effect, did observe that more
females in the intervention group met the guideline for maximum
percentage of daily calories from saturated fat at 12 months.
Physical Activity-related
Physical activity-related behaviours were measured in all studies,
and five studies report at least one indicator of significant positive
intervention impacts on physical activity. After one full academic
year of the LEAP (Lifestyle Education for Activity programme) intervention, Pate 2005 report that 45% of girls in the intervention
schools and 36% of girls in the control schools reported vigorous physical activity during an average of one or more 30-minute
time blocks per day over a three-day period (P = 0.05). When
missing data at follow-up were imputed by applying a regression
method, this prevalence difference increased in statistical significance (P < 0.05). This rigorous study reported that a school-based
intervention can increase regular participation in vigorous physical activity among high-school girls however the short time frame
(< 12 months) may have limited the impact of this intervention
given the approach taken (socio-ecological model). The study by
Haerens 2006 reported that in males, the intervention significantly
increased school-related physical activity, reduced the decrease in
light intensity physical activity and stabilised time in moderate-tovigorous physical activity compared with changes in the control
group (Haerens 2006). In females, the intervention reduced the
decrease in light intensity physical activity. Peralta 2009 found
that after the six-month intervention period, intervention males
had significantly less weekend vigorous physical activity than comparison males. Patrick 2006 found that boys in the intervention
group increased their number of active days per week compared
with boys in the control group, however this effect was not observed in girls. During a three-year intervention in girls, Webber
2008 found no intervention impacts on physical activity at two
years, however at three years, girls in intervention schools had 10.9
more MET-weighted minutes of moderate-vigorous physical activity (MVPA) than those in control schools. The same study also
found a smaller decrease in physical activity from 6th grade to 8th
grade in girls from intervention schools compared with those from
control schools. There was a differential effect by ethnicity in this
study, with higher physical activity levels reported for white girls
compared with African American girls or Hispanic girls at both
two years and three years.
Sedentary-related
Only one study reported positive intervention impacts on sedentary behaviours, with Patrick 2006 observing a change in sedentary behaviours in favour of the intervention group compared with
control (changes from baseline to endpoint: 4.3 3.4 to 3.4 2.6
h/d vs 4.2 3.4 to 4.4 3.7 h/d for girls, [P =. 001]; 4.2 3.7
to 3.2 2.6 h/d versus 4.2 2.8 to 4.3 3.5 h/d for boys, [P =
. 001]). This corresponds to a percentage change for intervention
versus control of -21% versus + 4.8% in girls and -24% versus +
2.4% in boys To measure this, participants completed a self-report measure of recent school day and non-school day time spent
watching television, playing computer/video games, sitting talking on the telephone, and sitting listening to music. A composite
score of sedentary behaviour was calculated from a weighted sum
of the school day and non-school day responses.

No studies measured the impact of the interventions on cardiovascular disease risk factors other than adiposity.

Of the eight studies in this section, three were conducted with
female participants only (NeumarkSztainer 2003; Pate 2005;
Webber 2008) and one was conducted with male participants
only (Peralta 2009). The remaining four studies included both
males and females and examined differences in outcomes by gender (Ebbeling 2006; Haerens 2006; Patrick 2006; Singh 2009).
Ebbeling 2006 found no significant differences in outcomes between males and females. While observing no gender differences
in most outcomes, Patrick 2006 reported one dietary measure
and one physical activity measure where there were gender-specific
differences in favour of the intervention group for females and
males respectively. Haerens 2006 reported different intervention
impacts between male and female participants, with the intervention seeming to bring about more activity-related changes in males
(no impact on diet), and more dietary related impacts in females,
although some impacts on physical activity were also observed for
females. Haerens 2006 also reported that for females in the intervention with parental support group, there was a smaller increase
in BMI compared with the control group after two years, an effect
not observed for males in the equivalent group. This gender difference was not present in the group receiving intervention alone
(without parental support). Immediately after an eight-month intervention (the DoiT programme), Singh 2009 reported significant reductions in hip circumference and sum of skinfolds among
females. In males, the intervention resulted in a significant difference in waist circumference. At 20 months, intervention males
showed significantly lower triceps, biceps and subscapular skinfold thickness, while in female participants there was a significant
intervention effect on biceps skinfold thickness and the sum of
skinfold thickness. Given the limited evidence, there is no clear

30
picture of how gender may influence effectiveness of the interventions in adolescents.
Maintenance / Sustainability of effects
Post-intervention follow-up was reported for two studies (

NeumarkSztainer 2003, Singh 2009). Follow-up data from the
Singh 2009 study are reported above. A follow-up assessment was
also performed in the NeumarkSztainer 2003 study, eight months
after the end of the 16-week intervention and eight-week maintenance periods. For the majority of outcome variables, differences between intervention and control schools post-intervention
and at follow-up were not statistically significant, except change
in Physical Activity Stage, which was significantly increased in the
intervention group at follow-up, compared with control children.
In summary, although obesity-related behaviours were not different at the end of the follow-up periods of either study, the Singh
2009 study, with an eight-month intervention period, was associated with reduced body fatness in adolescents even 12 months
post-intervention, with the largest effects observed in female participants.
Equity
All studies reported at least one item from the PROGRESS framework at baseline. Most studies reported gender (Ebbeling 2006;
Haerens 2006; NeumarkSztainer 2003; Peralta 2009; Singh 2009)
and/or race (Ebbeling 2006; Pate 2005; NeumarkSztainer 2003;
Patrick 2006; Singh 2009; Webber 2008) of participants. Two
studies included information about the socio-economic status of
participants (Ebbeling 2006; Haerens 2006), and one study included information about the highest household education level
(Patrick 2006). When analysing outcome data, only four of the
eight studies analysed results by any of the PROGRESS items.
Four studies analysed results by gender (Ebbeling 2006; Haerens
2006; Patrick 2006; Singh 2009; for results refer to section on
gender above) and two studies by race (Pate 2005; Webber 2008).
Webber 2008 found a differential effect by race, with higher physical activity levels reported for white girls compared with African
American girls or Hispanic girls at both two years and three years
after baseline. Singh 2009 analysed results by both gender (results
reported above) and race and, although the data for race was not
provided, it was reported that there was no group by ethnicity
interaction (Singh 2009). The lack of analysis by a measure of equity or socio-economic status limits our ability to assess the effectiveness of the interventions in reducing health inequities, however it should be noted that most of the studies targeted settings
or families of low socio-economic status. The studies in this age
group were conducted in four different countries (USA (five studies), Belgium, Netherlands and Australia) allowing us to assess the
utility of the approaches in a variety of contexts.
It is critical that measures of harm or unintended consequences

are included in evaluations targeting eating and activity related
behaviours, to ensure that interventions are safe and appropriate.
This is particularly important in adolescents, where body image
sensitivities are wide spread and there is the real possibility of causing unintended consequences such as stigmatisation, low self-esteem or unhealthy dieting practices. This is also particularly important in short-term studies and the implications of any impacts
on diet, weight and fatness should be carefully considered. None
of the eight studies targeting adolescents explicitly reported unintended outcomes or measures of harm, however, NeumarkSztainer
2003 reported measures of unhealthy weight control, self-acceptance and self-worth, which were not different between groups
immediately after the New Moves intervention or at the eightmonth follow-up assessment.
Implementation
Intervention design and theoretical basis

Five of eight studies targeted both diet and physical activity. Pate
2005 and Webber 2008 targeted physical activity alone, while
Ebbeling 2006 targeted diet alone. All but two studies had short
intervention periods (< 1 year), with Haerens 2006 having an intervention period of two school years and Webber 2008 including
a two-year staff-directed intervention followed by one-year Programme Champion component.
Of the eight study designs, theoretical basis was reported in all
but one (Ebbeling 2006). A range of behaviour change theories informed the design of five of the studies (Haerens 2006;
NeumarkSztainer 2003; Patrick 2006; Peralta 2009; Singh 2009),
while a socio-ecological framework was used by Pate 2005, Webber
2008 and possibly also Singh 2009.
Process evaluation
Of the eight studies targeting children aged 13 to 18 years, six
studies reported some elements of process evaluation (Ebbeling
2006; Haerens 2006; NeumarkSztainer 2003; Peralta 2009; Singh
2009; Webber 2008). These studies recorded programme attendance and/or adherence to instructions by participants . These
are measures of dose delivered or exposure to the intervention.
Haerens 2006 also reported a working group meeting at regular
intervals to evaluate implementation of their intervention, and reported that BMI z-score increased significantly more in schools
with low levels of implementation, when compared with schools
with medium and high levels of implementation. Four studies
planned a more detailed process evaluation into their measures
for their intervention. These included measures of intervention
fidelity, feasibility of implementation, satisfaction and acceptability for participants and relevant stakeholders and suggestions for

31
programme modification (NeumarkSztainer 2003; Peralta 2009,

Singh 2009; Webber 2008).
Resources needed
All studies reported on who delivered the intervention. The majority of the interventions were delivered by school staff with
varying levels of support from research staff, usually involving
training, materials and consultation as needed (Haerens 2006,
NeumarkSztainer 2003; Pate 2005, Peralta 2009, Singh 2009;
Webber 2008). Singh 2009 implemented an intervention that included a classroom-based component, delivered by regular teachers, as well as an environmental intervention at the school level,
facilitated by the research team. Ebbeling 2006 and Patrick 2006
both delivered home-based intervention provided by research staff.
Five of the eight studies provided varying levels of information
about resources required for implementation. Singh 2009 provided a list of tools and materials for each of their intervention
components. Haerens 2006 detailed sports equipment provided
to schools, in addition to educational materials for teachers and
students. NeumarkSztainer 2003 provided a detailed description
of intervention activities including information on resources and
staff training. Links with the community were also utilised with
community guest instructors facilitating some of the physical activity sessions. Webber 2008 included information about linking
school and community agencies to develop programmes as well as
the cost of providing a stipend for a Programme Champion. No
studies included a formal economic evaluation, however, Ebbeling
2006 estimated that the costs involved in delivering their intervention was approximately 35 USD per student over 25 weeks.
However, the unexplained heterogeneity of effects observed, potential attrition bias in many studies, and the likelihood of small
study bias may have inflated our estimate of effect, so these findings should be interpreted with caution. The majority of the included studies targeted children aged six to12 years, with interventions predominantly based on behaviour change theories and
implemented in education settings. Further, analysis by age group
indicates the strongest evidence of effectiveness is in six to 12 year
olds (primarily due to the larger number of studies in this age
group), with promising findings also in 0-5 year olds, particularly
for interventions conducted in home or healthcare settings. The
interventions were developed to prevent obesity through strategies
aimed at altering dietary or physical activity related factors, or both
combined. These types of interventions represent only some of
the factors that are important in tackling childhood obesity and
should be considered as part of a suite of interventions including population and targeted measures with action across a range
of areas that may include advertising, obesogenic environments
and government and school policy (Foresight 2007). The variety
of approaches used in the interventions in this review, combined
with heterogeneous measures used to assess intervention impacts,
limits our ability to draw firm conclusions about the best interventions for effective behaviour change. Further, although a variety of
positive intervention impacts were reported on behavioural measures, only a limited number of studies reported post-intervention
follow-up, which makes it difficult for us to have confidence that
the outcomes of often short-term interventions are sustained over
the longer term. Despite this, the interventions which report on
potential adverse effects and outcomes by indicators of equity provide evidence that childhood obesity prevention interventions can
be both safe and equitable.

Of the eight studies only one incorporated strategies to address disadvantage or diversity. Singh 2009 targeted adolescents with lower
socio-economic and educational level. Pre-testing of the materials allowed the research team to adapt workbooks and worksheets
that was appropriate, easy to understand and included practical
assignments over theoretical assignments (Singh 2009).
DISCUSSION
Summary of main results
This updated review now includes 55 studies of programmes
aimed at preventing obesity in children aged 0 to 18 years, and
across the age range we present evidence indicating that childhood obesity prevention may be effective at reducing adiposity in
children. The best estimate of effect on BMI was of a 0.15kg/
m2 reduction which would correspond to a small but clinically
important shift in population BMI if sustained over several years.
Effectiveness
Our review includes a meta-analysis of 37 studies with a combined
sample of 27,946 children. This analysis reveals these interventions may be effective in reducing the magnitude of the change in
BMI/zBMI from pre- to post-intervention by -0.15 units, relative
to the change in the control group. Subgroup analysis by age group
revealed that the effectiveness of interventions in young children
and adolescents is less clear, and more studies in these age groups
are needed. The analysis in children age six to 12 years includes
the majority of the studies and provides the clearest indication
that obesity prevention interventions can be effective at reducing
adiposity.
In an attempt to examine the clinical significance of the effect size
seen, we have applied these to the BMI of an average Australian
child of preschool, elementary school and secondary school age.
For a preschool child aged 3.7 years with a BMI 16.3 kg/m2 , an
effect size of -0.26 would represent reducing average BMI by 1.6%.
For a child aged 9.5 years with a BMI 18.2 kg/m2 , an effect size
of -0.15 would represent reducing average BMI by 0.8%. For a

32
child aged 14 years with a BMI 16.3 kg/m2 , an effect size of -0.09
would represent reducing average BMI by 0.4%.
While these effect sizes may appear small they represent important
reductions at a population level if sustained over several years.
A study of Australian adults shows that a 1.4kg/m2 increase in
BMI in men and 2.1 kg/m2 increase in BMI in women over a 20
year period (1980-2000; average increase of 0.07-0.105 kg/m2 per
year) was associated with a doubling of the population prevalence
of obesity, and a four-fold increase in the prevalence of obesity
class III (BMI40 kg/m2 ) Walls 2009. The effect sizes seen in
the meta-analysis across all groups are comparable (-0.09) or larger
(-0.15 and -0.26) then the increases which were associated with
these substantial increases in obesity prevalence.
In addition, it should be noted that these effect sizes were demonstrated with predominantly non-overweight children, and in trials
of prevention interventions-rather than treatment interventions,
and with children, over mainly short (12 months) intervention
periods. As such we would expect small effect sizes.
Although the sample size for the meta-analysis is large, 18 studies
were not able to be included. This was due to a lack of appropriate BMI data reported, and is a limitation given the intended
purpose of the review to reflect the findings on effectiveness across
the evidence base. Of those not included in the meta-analysis, six
studies reported significant intervention impacts on the incidence,
remission or prevalence of overweight or obesity (Coleman 2005;
Gortmaker 1999a; Jouret 2009; Mller 2001; Rodearmel 2006;
Salmon 2008). The other studies did not report significant intervention impacts on any indicator of adiposity. When reviewing
the evidence, it is apparent that many individual studies are underpowered to detect small differences between groups, particularly on adiposity outcomes. We did not exclude studies from the
meta-analysis for any other reason apart from the data not being
available. Some may view this as a limitation since studies of varying quality were inevitably included. However, given the heterogeneity in the designs of included studies as well as the variability
in reporting, it was not feasible to define a clear quality threshold
for studies to meet in order to be included. Including all studies
that reported BMI data was determined to be the most transparent
way to present the findings of this review. Further, the funnel plot
suggests there is evidence of the under-reporting of small studies
with negative findings in the published literature, which may inflate our assessments of effectiveness.
Applicability of the evidence

This review included studies from high income countries as well
as lower-middle- and upper-middle-income countries, with five
studies conducted in countries within the latter two groupings
(Thailand, Brazil, Chile and Mexico). This means that, while predominantly conducted within high-income settings, the findings
from this review may be generalisable to a number of settings. A
total of nineteen studies specifically reported incorporating strate-
gies to target socio-economic and/or cultural diversity or disadvantage. One such study was conducted outside of the high-income country setting, in Chile, an upper-middle-income country.
Of the remaining eighteen studies, seven studies conducted in the
USA were of interventions targeting African American children
and their communities and another two studies targeted Native
American communities. Other studies targeted participants of low
socio-economic status, or were implemented in areas of social disadvantage. By far the most common setting for interventions included in this review were schools (43 studies). Other interventions were (or included) home-based (14 studies), communitybased (six studies), or were set in a health service (two studies) or
care setting (two studies). Eleven studies incorporated interventions across multiple settings. Most interventions took a combined
dietary and physical activity approach to obesity prevention (31
studies). As a single strategy, targeting physical activity alone was
more popular (17 studies) than targeting diet alone (seven studies).
The predominant theoretical basis for interventions in this review
was behaviour change theory. Other theories represented include
environmental change strategies, the socio-ecological framework,
social learning theory, health promotion theory, transtheoretical
models, and youth development and resiliency based approaches.
The theoretical basis for interventions was explicitly reported in
approximately half of the included studies.
Quality of the evidence

Where reporting was sufficient, the overall quality of studies in
this review was reasonable as assessed by The Cochrane Collaborations Risk of bias tool. Many studies were assessed as having a
low risk of bias across a number of domains. This review includes
non-randomised studies, meaning that selection bias is a potential
concern. However, many of the non-randomised studies in this
review sought to minimise the impact of potential selection bias.
Contamination is another important consideration for the interventions studied in this review. While some studies acknowledged
the susceptibility of their findings to this issue, most studies mentioned recruiting groups in different locations to minimise this,
and of note, the majority of studies in this review were cluster
RCTs. It is important to acknowledge that some cluster RCTs did
not report addressing unit of analysis issues, despite randomising at
a cluster level and analysing outcomes at the individual level. The
validity of outcome measures continues to be an important consideration for this evidence base, given the variety of tools utilised.
While many studies reported the validity of their measurement
tools, many studies did not. Also, many studies included measures
of behaviour change relying on self-report, which can lead to estimates that are less accurate. However, all studies in this review
included an objective measure of adiposity such as BMI, waist circumference or percentage body fat. Having an objective measure
increases the potential to limit the impact of outcome assessors not
being blinded.. Most studies included clear reporting of partici-

33
pant flow through the study, describing the extent of missing data,
with some studies attempting to analyse the potential impact of
missing data on their outcomes and providing information about
the characteristics of participants that did not complete post-intervention assessments. Importantly, many papers provided insufficient information to make an informed judgement about the
risk of bias, highlighting the need for more careful reporting of
research methods. Informed decisions based on research evidence
rely on comprehensive and transparent reporting. Publishing complete study protocols will increase the level of comprehensive reporting in obesity prevention research. This will make it easier for
readers to assess whether a study has measured and reported all
outcomes as intended in the study protocol, which is an important
consideration in assessing the risk of bias of a study.
What is new in this review?

This review update includes 36 new studies. To provide useful evidence to decision makers, and those wishing to replicate effective
interventions, we have attempted to provide a synthesis of a variety
of implementation factors. We believe this information is required to move beyond simply the question of what works in obesity prevention, to the other important questions of how it worked,
will it work in another context or under different conditions, and
is it feasible or appropriate for others to implement. Although
we have summarised available evidence from the included studies
in this review, often the detail required to answer these questions
is not available in the published papers. This leaves practitioners and policy-makers without the critical information needed to
achieve successful implementation of the effective interventions,
which may in turn compromise the integrity of the intervention
and result in different outcomes.
As in previous reviews, there continues to be considerable variability in the approaches and intervention components tested for
childhood obesity prevention, primarily because the interventions
attempt to reduce adiposity through various combinations of targeted behaviours and environments. The methods of implementation are less varied, with the interventions delivered by settings
staff, teachers, academics, investigators, or via an electronic media such as the Internet, or a combination of these methods. The
majority of included studies were of interventions conducted in
educational settings and the majority were implemented for less
than 12 months. Thus, the evidence of short-term effectiveness
may now be established and further new short-term trials testing
similar interventions to those evaluated in this review appear to
be no longer warranted. Further, long-term follow-up of trial participants could yield very valuable information on sustainability
of effects and we encourage researchers to collect such data. The
review has also revealed significant gaps in the available evidence
in relation to younger and older children, as the majority of the
research included in this review was focused on behavioural and
individual level interventions for children aged six to 12 years. Fu-
ture reviews should now also determine the effectiveness of environmental and population level interventions, such as those which
target changes in infrastructure and policies, to develop a clearer
picture of the best possible portfolio of interventions with which
to address this public health issue at a population level.
AUTHORS CONCLUSIONS
Implications for practice
The body of evidence in this review provides some support for the
hypothesis that obesity prevention interventions in children can
be effective, and where examined, have not caused adverse outcomes or increased health inequalities. To this end, the direction of
research and evaluation must move into how to implement effectively to scale, sustain the impacts over time and ensure equitable
outcomes. In addition, interventions need to be developed that
can be embedded into ongoing practice and operating systems,
rather than implementing interventions that are resource intensive
and cannot be maintained long-term.
This review also highlights that although we may now have a good
sense of the range of interventions feasible for use in reducing the
risk of childhood obesity, we lack the knowledge of which specific
intervention components are most effective and what is affordable
and cost-effective. Being able to answer these question is of critical
importance to decision makers, and economic evaluations must
feature in future obesity prevention research if we are to enable
well informed decisions about which interventions warrant population-wide implementation.
Also of particular interest is the safety of obesity prevention efforts
in children. Although measured in only a minority of studies and
using a variety of indicators, the studies which measured adverse
outcomes or harms reported no adverse intervention effects, even
with the intensely individual focus of most of the interventions.
However, significant impacts on adiposity reported from shortterm interventions do raise concerns and we recommend that all
studies monitor the potential occurrence of unhealthy practices.
In relation to equity and the incorporation of PROGRESS (Place,
Race, Occupation, Gender, Religion, Education, Socio-economic
status, Social status), only a minority of studies reported outcomes
by any such indicators, and of those that did, the majority focused
on SES, followed by race. The review however provides evidence
of significant positive outcomes for the more disadvantaged, and
thus those of higher morbidity. There was no evidence for a widening of health inequalities as a result of obesity prevention interventions. In addition, the relatively large numbers of studies either of
interventions targeting disadvantaged population groups, or conducted in low- to middle- income countries, also provide useful information about the implementation strategies needed for obesity

34
prevention efforts targeting these high risk groups. We advocate

for assessment of outcomes by measures of equity, such as those
indicated by PROGRESS, if a general population is targeted.
In relation to which interventions should now be implemented
more widely, the findings of this review cannot distinguish which
specific components of intervention programmes are necessary to
achieve beneficial impacts on obesity in children. As a guide to
policy makers planning programmes, the following activities have
been included in beneficial programmes:
Curriculum on healthy eating, physical activity and body
image integrated into regular curriculum
More sessions for physical activity and the development of
fundamental movement skills throughout the school week
Improved nutritional quality of foods made available to
students
Creating an environment and culture that support children
eating nutritious foods and being active throughout each day
Providing support for teachers and other staff to implement
health promotion strategies and activities (e.g. professional
development, capacity building activities)
Engaging with parents to support activities in the home
setting to encourage children to be more active, eat more
nutritious foods and spend less time in screen-based activities
Implications for research

This review demonstrates wide variation in the effectiveness of
individual level and behavioural interventions for childhood obesity prevention conducted under trial conditions. On balance, it
appears that a variety of interventions can impact on either behaviours or adiposity and shift child outcomes in the desired direction. Given the large number of studies already published, and
those currently in the process of being conducted or reported, it
seems unnecessary to continue to test short-term interventions that
are predominantly individually focused, behavioural interventions
in children aged six to 12 years and implemented in schools. To
further enhance the evidence base for this age group, we now need
to determine which of the approaches and intervention components comprise the optimal package for scaling up for population
level implementation. In addition, the research gaps evident from
this review relate to effective interventions for children aged 0-5
years (particularly 0-3 years), and for adolescents. Further, more
studies testing interventions guided by theories such as the socioecological model are warranted. This needs to be coupled with
better reporting of the impacts on the environment and setting,
and the sustainability of the impacts measured.
In relation to reporting adiposity outcomes, BMI (or zBMI) and
prevalence of overweight should both be measured and reported.
To enable systematic reviewers to undertake meta-analyses, reporting the mean and standard deviation for each outcome, as well
as the number of participants assessed at each time point in each
group are needed. Process data should also be measured and reported, including data on appropriateness, implementation, feasibility, acceptability, sustainability and context. Economic data
are urgently needed and costs relating to conducting the intervention should be measured and reported, with formal economic
evaluations undertaken where possible. In relation to nutritionand activity-related behaviours, using valid and reliable measures
is always the best practice.
Trial designs continue to be compromised by non-random allocation, and investigators should randomise wherever possible. However, randomisation and allocation concealment may not always
be possible, and blinded analysis of outcomes should be used as a
means of minimising bias. In future, we recommend larger, longer
term studies powered to detect the small changes that are likely
to be found, with assessments of potential harm, equity impacts,
implementation factors and sustainability, to enable translation of
research findings into effective public health approaches for preventing childhood obesity.
Key points
Obesity prevention interventions show beneficial effects on
BMI in a meta-analysis but substantial unexplained heterogeneity
of effects and the likelihood of publication bias exist.
Testing short-term, behaviourally focused school-based
interventions for 6-12 year old children may no longer be
warranted
More evidence is needed to determine effective
interventions in young children, particularly those aged 0-3
years, and adolescents
There is a continued need to strengthen trial design,
measurement approaches of physical activity and diet-related
behaviours, and reporting of process, impact and outcomes
Future trials should be larger, longer term and include
assessments of costs, harm, equity impacts, implementation
factors and sustainability
Translational research is required to embed effective
interventions into standard practice across childrens settings
ACKNOWLEDGEMENTS
The authors would like to thank the Review Advisory Group: Liz
Bickerdike (Cochrane Heart Group, Bristol, UK), Margaret Burke
(Cochrane Heart Group, Bristol, UK), Tim Lobstein (International Obesity Taskforce, UK), Kellie-Ann Jolley (Director of Active Communities and Healthy Eating Unit, VicHealth), The Par-

35
ents Jury, Melbourne, Australia. The authors would particularly

like to thank Tahna Pettman, Rachel Clark, Shayne Zang, Priscilla
Lai Han Lunn, Jodie Doyle, Rebecca Conning and Alana Pirrone
for their contributions and assistance with searching, data extraction and knowledge translation recommendations. The authors
would also like to thank Nicole Martin (Cochrane Heart Review
Group Trials Search Coordinator), Fleur van de Wetering (Dutch
Cochrane Centre) and Rob Scholten (Dutch Cochrane Centre)
for their help with translation of papers in German and Dutch for
inclusion in this review.
REFERENCES
References to studies included in this review

Amaro 2006 {published data only}
Amaro S, Viggiano A, Di Costanzo A, Madeo I, Viggiano A,
Baccari ME, et al. Kaldo, a new educational board-game,
gives nutritional rudiments and encourages healthy eating in
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Caballero 2003 {published data only}
Caballero B, Clay T, Davis SM, Ethelbah B, Rock BH,

Lohman T, et al. Pathways: a school-based, randomized
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Donnelly 2009 {published data only}
Donnelly JE, Greene JL, Gibson CA, Smith BK,

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Fitzgibbon 2005 {published data only}

Fitzgibbon ML, Stolley MR, Dyer AR, VanHorn L,
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Fitzgibbon 2006 {published data only}
Fitzgibbon ML, Stolley MR, Schiffer L, Van Horn L,
KauferChristoffel K, Dyer A. Hip-Hop to Health Jr. for
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Foster GD, Sherman S, Borradaile KE, Grundy KM,
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James 2004 {published data only}
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Macias-Cervantes 2009 {published data only}
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admin.nsf/Images/ssop6report6baewfinal.pdf/$File/
ssop6report6baewfinal.pdf 2008.
Sichieri 2009 {published data only}
Sichieri R, Paula Trotte A, de Souza RA, Veiga GV. School
randomised trial on prevention of excessive weight gain by
discouraging students from drinking sodas. Public Health
Nutrition. 2008/06/19 2009; Vol. 12, issue 2:197202.
[13689800: (Print)]
Simon 2008 {published data only}
Simon C, Schweitzer B, Oujaa M, Wagner A, Arveiler

D, Triby E, et al. Successful overweight prevention
in adolescents by increasing physical activity: a 4-year
randomized controlled intervention. International Journal
of Obesity (Lond). 2008/07/16 2008; Vol. 32, issue 10:
148998. [14765497: (Electronic)]
Simon C, Wagner A, DiVita C, Rauscher E, Klein-Platat
C, Arveiler D, et al. Intervention centred on adolescents
physical activity and sedentary behaviour (ICAPS): concept
and 6-month results. International Journal of Obesity 2004;
28:S96S103.
Singh 2009 {published data only}

Singh AS, Chin A Paw MJ, Brug J, Van Mechelen W. Shortterm effects of school-based weight gain prevention among
adolescents. Archives of Pediatrics & Adolescent Medicine
2007;161:56571.
Singh AS, Chin APMJ, Brug J, Van Mechelen W. Dutch

obesity intervention in teenagers: effectiveness of a schoolbased program on body composition and behavior. Archives
of Pediatrics & Adolescent Medicine. 2009/04/08 2009;
Vol. 163, issue 4:30917. [15383628: (Electronic)]
Singh AS, Paw MJMCA, Kremers SPJ, Visscher TLS,
Brug J, Van Mechelen W. Study Protocol: Design of the
Dutch Obesity Intervention in Teenagers (NRG-DOiT):
systematic development, imlementation and evaluation of
a school-based intervention aimed at the prevention of
excessive weight gain in adolescents. BMC Public Health
2006;6:304.
Spiegel 2006 {published data only}
Spiegel SA, Foulk D. Reducing overweight through a
multidisciplinary school-based intervention. Obesity 2006;
14(1):8896.
Stolley 1997 {published data only}
Stolley MR, Fitzgibbon ML. Effects of an obesity prevention
program on the eating behaviour of African American
mothers and daughters. Health Education and Behaviour
1997;24(2):15264.
Story 2003a {published data only}
Rochon J, Klesges RC, Story M, Robinson TN, Baranowski
T, Obarzanek E, et al. Common design elements of the
Girls health Enrichment Multi-site Studies (GEMS).
Ethnicity and Disease 2003;13(Suppl 1):S6S14.
Story M, Sherwood NE, Himes JH, Davis M, Jacobs DR
Jr, Cartwright Y, et al. An after-school obesity prevention
program for African-American girls: the Minnesota GEMS
pilot study. Ethnicity and Disease 2003;13(Suppl 1):
S5464.
Story M, Sherwood NE, Obarzanek E, Beech BM,
Baranowski JC, Thompson NS, et al. Recruitment of
African-American pre-adolescent girls into an obesity
prevention trial: the GEMS pilot studies. Ethnicity and
Disease 2003;13(Suppl 1):S78S87.
Taylor 2008 {published data only}
Taylor RW. Two-year follow-up of an obesity prevention

initiative in children: the APPLE project. The American
Journal of Clinical Nutrition 2008; Vol. 88, issue 5:13717.
[: 00029165]
Taylor RW, McAuley KA, Barbezat W, Strong A, Williams
SM, Mann JI. APPLE Project: 2-y findings of a communitybased obesity prevention program in primary school-age
children. The American Journal of Clinical Nutrition 2007;
86:73542.
Taylor RW, Mcauley KA, Williams SM, Barbezat W, Nielsen
G, Mann JI. Reducing weight gain in children through
enhancing physical activity and nutrition: the APPLE
project. International Journal of Pediatric Obesity 2006;1(3):
14652.

39
Vizcaino 2008 {published data only}

Vizcano VM, Aguilar FS, Gutirrez RF, Martnez MS,
Lpez MS, Martnez SS, et al. Assessment of an after-school
physical activity program to prevent obesity among 9- to 10year-oldchildren: a cluster randomized trial. International
Journal of Obesity 2008;32:1222.
Warren 2003 {published data only}
Warren JM, Henry CJK, Lightowler HJ, Bradshaw SM,
Perwaiz S. Evaluation of a pilot school programme aimed
at the prevention of obesity in children. Health Promotion
International 2003;18(4):28796.
Webber 2008 {published data only}
Webber LS, Catellier DJ, Lytle LA, Murray DM, Pratt CA,
Young DR, et al. Promoting physical activity in middle
school girls: Trial of Activity for Adolescent Girls. American
Journal of Preventive Medicine. 2008/03/04 2008; Vol. 34,
issue 3:17384. [07493797: (Print)]
References to studies excluded from this review

Al-Nakeeb 2007 {published data only}
Al-Nakeeb Y, Duncan MJ, Lyons M, Woodfield L. Body
fatness and physical activity levels of young children. Annals
of Human Biology. 2007/06/01 2007; Vol. 34, issue 1:
112. [03014460: (Print)]
Alves 2008 {published data only}
Alves JG, Gal CR, Souza E, Batty GD. Effect of
physical exercise on bodyweight in overweight children: a
randomized controlled trial in a Brazilian slum. [Article in
Portuguese]. Cad Saude Publica 2008;24(Suppl 2):S3539.
Ara 2006 {published data only}
Ara I, Vicente-Rodriguez G, Perez-Gomez J, JimenezRamirez J, Serrano-Sanchez JA, Dorado C, et al. Influence
of extracurricular sport activities on body composition
and physical fitness in boys: a 3-year longitudinal study.
International Journal of Obesity (Lond). 2006/06/28 2006;
Vol. 30, issue 7:106271. [03070565: (Print)]
Arbeit 1992 {published data only}
Arbeit ML, Johnson CC, Mott DS, Harsha DW, Nicklas
TA, Webber LS, et al. The Heart Smart cardiovascular
school health promotion: behavior correlates of risk factor
change. Preventive Medicine 1992;21(1):1832.
Ask 2006 {published data only}
Ask AS, Hernes S, Aarek I, Johannessen G, Haugen M.
Changes in dietary pattern in 15 year old adolescents
following a 4 month dietary intervention with school
breakfast--a pilot study. Nutrition Journal 2006;5:33.
Bollela 1999b {published data only}

Bollella MC, Spark A, Boccia LA, Nicklas TA, Pittman
BP, Williams CL. Nutrient intake of Head Start children:
Home vs. school. Journal of the American College of
Nutrition 1999;18(2):10814.
Borys 2000 {published data only}
Borys J-M, Lafay L. Nutritional education of children to
influence the dietary habits of all the family [Linformation
nutritionelle des enfants pour modifier les habitudes
alimentaires de toute la famille]. Revue Medicale de la Suisse
Romande 2000;120:2079.
Burke 1998 {published data only}
Burke V, Milligan RA, Thompson C, Taggart AC, Dunbar
DL, Spencer MJ, et al. A controlled trial of health
promotion programs in 11-year-olds using physical activity
enrichment for higher risk children. Journal of Pediatrics
1998;132(5):8408.
Cairella 1998 {published data only}
Cairella G, Romagnoli F, Cantarelli P, Valentini P, Tarsitani
G. School oriented intervention on dietary education:
results of phase 1. International Journal of Obesity 1998;22:
S254 (Abstract).
Carrel 2005 {published data only}
Carrel AL, Clark RR, Peterson S, Eickhoff J, Allen DB.
School-based fitness changes are lost during the Summer
vacation. Archives of Pediatrics and Adolescent Medicine
2007;161:5614.
Carrel AL, Clark RR, Peterson SE, Nemeth BA, Sullivan

J, Allen DB. Improvement of fitness, body composition,
and insulin sensitivity in overweight children in a schoolbased exercise program. Archives of Pediatrics and Adolescent
Medicine 2005;159:9638.
Casazza 2006 {published data only}
Casazza K, Ciccazzo M. The method of delivery of nutrition
and physical activity information may play a role in eliciting
behavior changes in adolescents. Eating Behaviours 2007;8:
7382.
Chomitz 2003 {published data only}
Chomitz VR, Collins J, Kim J, Kramer E, McGowan
R. Promoting healthy weight among elementary school
children via a health report card approach. Promoting
healthy weight among elementary school children via
a health report card approach. Archives of Pediatrics &
Adolescent Medicine 2003;157(8):76572.
Berry 2007 {published data only}

Berry D, Savoye M, Melkus G, Grey M. An intervention for
multiethnic obese parents and overweight children. Applied
Nursing Research 2007;20(2):6371.
Cullen 1996 {published data only}

Cullen KJ, Cullen AM. Long-term follow-up of the
Busselton six-year controlled trial of prevention of childrens
behaviour disorders. Journal of Pediatrics 1996;129(1):
1369.
Bollela 1999a {published data only}

Bollella MC, Boccia LA, Nicklas TA, Lefkowitz KB,
Pittman BP, Zang EA, et al. Assessing dietary intake in
preschool children: The Healthy Start Project - New York.
Nutrition Research 1999;19(1):3748.
DAgostino 1999 {published data only}

DAgostino CD, DAndrea T, Talbot -Nix S, Williams CL.
Increasing nutrition knowledge in preschool children: The
Healthy Start Project, Year 1. Journal of Health Education
1999;30(4):21721.

40
Daley 2006 {published data only}

Daley AJ, Copeland RJ, Wright NP, Roalfe A, Wales
JKH. Exercise therapy as a treatment for psychopathologic
conditions in oese and morbidly obese adolescents: a
randomized, controlled trial. Pediatrics 2006; Vol. 118,
issue 5:212634.
Danielzik 2005 {published data only}
Danielzik S, Pust S, Landsberg B, Mller MJ. First
lessons from the Kiel Obesity Prevention Study (KOPS).
International Journal of Obesity 2005;29 (S2):S7883.
Dixon 2000 {published data only}
Dixon LB, Tershakovec AM, McKenzie J, Shannon B. Diet
quality of young children who received nutrition education
promoting lower dietary fat. Public Health Nutr 2000;3(4):
4116.
Donnelly 1996 {published data only}
Donnelly JE, Jacobsen DJ, Whatley JE, Hill JO, Swift
LL, Cherrington A, et al. Nutrition and physical activity
program to attenuate obesity and promote physical and
metabolic fitness in elementary school children. Obesity
Research 1996;4(3):22943.
Economos 2007 {published data only}
Economos CD, Hyatt RR, Goldberg JP, Must A, Naumova
EN, Collins JJ, et al. A community intervention reduces
BMI z-score in children: Shape Up Somerville first year
results. Obesity 2007;15(5):132536.
Flodmark 1993 {published data only}
Flodmark CE, Ohlsson T, Ryden O, Sveger T. Prevention
of progression to severe obesity in a group of obese school
children treated with family therapy. Pediatrics 1993;91(5):
8804.
Florea 2005 {published data only}
Florea IM. The Goodbodies Program: Physical activity and
motor skill performance influences on fitness, and body
composition in overweight children. University of South
Carolina. United States - South Carolina: University of
South Carolina, 2005; Vol. AAT 3181946:by Florea, Ioana
Madalina,.
Flores 1995 {published data only}
Flores R. Dance for health: improving fitness in African
American and Hispanic adolescents. Public Health Reports
1995;110(2):18993.
Fonseca 2007 {published data only}
Fonseca H, Matos MG. 39: Obesity, overweight and
lifestyle/psychosocial associated factors: A comparative
study in a four year time. Journal of Adolescent Health
2007; Vol. 40, issue 2, Supplement 1:S356.
Gately 2005 {published data only}
Gately PJ, Cooke CB, Barth JH, Bewick BM, Radley D,
Hill AJ. Childrens residential weight-loss programs can
work: a prospective cohort study of short-term outcomes
for overweight and obese children. Pediatrics. 2005/07/05
2005; Vol. 116, issue 1:737. [10984275: (Electronic)]
Goldfield 2006 {published data only}
Goldfield, G. S.Mallory, R.Parker, T.Cunningham, T.Legg,
C.Lumb, A.Parker, K.Prudhomme, D.Gaboury, I.Adamo,
K. B. Effects of open-loop feedback on physical activity

and television viewing in overweight and obese children:
a randomized, controlled trial. Pediatrics 2006;118(1):
e15766.
Goldfield 2007 {published data only}
Goldfield GS, Mallory R, Parker T, Cunningham T, Legg
C, Lumb A, et al. Effects of modifying physical activity
and sedentary behavior on psychosocial adjustment in
overweight/obese children. Journal of Pediatric Psychology
2007;32(7):78393.
Gortmaker 1999b {published data only}
Gortmaker SL, Cheung LWY, Peterson KE, Chomitz
G, Cradle JH, Dart H, et al. Impact of a school-based
interdisciplinary intervention on diet and physical activity
among urban primary school children. Archives of Pediatrics
and Adolescent Medicine 1999;153:97583.
Harrell 1998 {published data only}
Harrell JS, Gansky SA, McMurray RG, Bangdiwala SI,
Frauman AC, Bradley CB. School-based interventions
improve heart health in children with multiple cardiovascular
disease risk factors. Pediatrics 1998;102(2 Pt 1):37180.
Harrell 1999 {published data only}
Harrell JS, McMurray RG, Gansky SA, Bangdiwala SI,
Bradley CB. A public health vs a risk-based intervention
to improve cardiovascular health in elementary school
children: the Cardiovascular Health in Children Study.
American Journal of Public Health 1999;89(10):152935.
He 2004 {published data only}
He Yi-Feng, Wang Wen-yuan, Fu Ping, Sun Yun, Yu
Shuang-yu, Chen Ru, et al. Effects of a comprehensive
intervention programme on simple obesity of children in
kindergarten. Chinese Journal of Pediatrics 2004;42(5):16.
Hopper 1996 {published data only}
Hopper CA, Gruber MB, Munoz KD, MacConnie SE.
School-based cardiovascular exercise and nutrition programs
with parent participation. Journal of Health Education 1996;
27(5):S32S39.
Horodynski 2004 {published data only}
Horodynski MAO, Hoerr S, Coleman G. Nutrition
education aimed at toddlers: A pilot program for rural
low-income families. Family and Community 2004;27(4):
10313.
Howard 1996 {published data only}
Howard JKH, Bindler RM, Synoground G, Van Gemet FC.
A cardiovascular risk reduction program for the classroom.
Journal of School Nursing 1996;12(4):411.
Ildiko 2007 {published data only}
Ildik V, Zsfia M, Jnos M, Andreas P, Dra NE, Andrs
P, et al. Activity-related changes of body fat and motor
performance in obese seven-year-old boys. Journal of
Physiological Anthropology 2007;26(3):3337.
Jago 2006 {published data only}
Jago R, Jonker ML, Missaghian M, Baranowski T. Effect of
4 weeks of Pilates on the body composition of young girls.
Preventive Medicine 2006;42(3):17780.

41
Jiang 2006 {published data only}

Jiang J, Xia X, Greiner T, Wu G, Lian G, Rosenqvist U. The
effects of a 3-year obesity intervention in schoolchildren in
Beijing. Child Care Health Development 2007;33(5):6416.
Jurg 2006 {published data only}
Jurg ME, Kremers SP, Candel MJ, Van der Wal MF, De
Meij JS. A controlled trial of a school-based environmental
intervention to improve physical activity in Dutch children:
JUMP-in, kids in motion. Health Promotion International
2006;21(4):32030.
Koblinsky 1992 {published data only}
Koblinsky SA, Guthrie JF, Lynch L. Evaluation of a
nutrition education program for Head Start parents. Society
for Nutrition Education 1992;24:No 1.
Lagstrom 1997 {published data only}
Lagstrom H, Jokienen E, Seppanen R, Ronnemaa T, Viikari
J, Valimaki I, et al. Nutrient intakes by young children
in a prospective randomized trial of a low-saturated fat,
low-cholesterol diet. Archives of Pediatric and Adolescence
Medicine 1997;151:1818.
Lionis 1991 {published data only}
Lionis C, Kafatos A, Vlachonikolis J, Vakaki M, Tzortzi M,
Petraki A. The effects of a health education intervention
program among Cretan adolescents. Preventive Medicine
1991;20(6):68599.
Luepker 1996 {published data only}
Luepker RV, Perry CL, McKinlay SM, Nader PR, Parcel
GS, Stone EJ, et al. Outcomes of a field trial to improve
childrens dietary patterns and physical activity: the child
and adolescent trial for cardiovascular health (CATCH).
JAMA 1999;275(10):76876.
Lytle 2006 {published data only}
Lytle LA, Kubik MY, Perry C, Story M, Birnbaum AS,
Murray DM. Influencing healthful food choices in school
and home environments: results from the TEENS study.
Preventative Medicine 2006;43(1):813.
Manios 1998 {published data only}
Manios Y, Kafatos A, Mamalakis G. The effects of a health
education intervention initiated at first grade over a 3
year period: physical activity and fitness indices. Health
Education Research 1998;13(4):593606.
Manios 1999 {published data only}
Manios Y, Moschandreas J, Hatzis C, Kafatos A. Evaluation
of a health and nutrition education program in primary
school children of Crete over a three-year period. Preventive
Medicine 1999;28:14959.
McCallum 2007 {published data only}
McCallum Z, Wake M, Gerner B, Baur L A, Gibbons K,
Gold L, et al. Outcome data from the LEAP (Live, Eat
and Play) trial: a randomized controlled trial of a primary
care intervention for childhood overweight/mild obesity.
International Journal of Obesity 2007;31:6306.
McCallum Z, Wake M, Gerner B, Harris C, Gibbons K,
Gunn J, et al. Can Australian general practitioners tackle
childhood overweight/obesity? Methods and processes from
the LEAP (Live, Eat and Play) randomized controlled trial.

Journal of Paediatrics and Child Health 2005;41:48894.
McGarvey 2004 {published data only}
McGarvey E, Keller A, Forrester M, Williams R, Seward
D, Suttle DE. Feasibility and benefits of a parent-focused
preschool child obesity intervention. American Journal of
Public Health 2004;94(9):1490.
McMurray 2002 {published data only}
McMurray RG, Harrell JS, Bangdiwala SI, Bradley CB,
Deng S, Levine A. A school-based intervention can reduce
body fat and blood pressure in young adolescents. Journal
of Adolescent Health 2002;31(2):12532.
Melnyk 2007 {published data only}
Melnyk BM, Small L, Morrison-Beedy D, Strasser A, Spath
L, Kreipe R, et al. The COPE Healthy Lifestyles TEEN
program: feasibility, preliminary efficacy, & lessons learned
from an after school group intervention with overweight
adolescents. Journal of Pediatric Health Care. 2007/09/11
2007; Vol. 21, issue 5:31522. [08915245: (Print)]
Niinikoski 1997 {published data only}
Niinikoski H, Viikari V, Ronnemaa T, Helenius H, Jokinen
E, Lapinleimu H, et al. Regulation of growth of 7- to
36- month-old children by energy and fat intake in the
prospective, randomized STRIP baby trial. Pediatrics 1997;
100(5):8106.
Obarzanek 1997 {published data only}
Obarzanek E, Hunsberger SA, Van Horn L, Hartmuller
VV, Barton BA, Stevens VJ, et al. Safety of a fat-reduced
diet: The Dietary Intervention Study in Children (DISC).
Pediatrics 1997;100(1):519.
Oehrig 2001 {published data only}
Oehrig E, Geiss HC, Haas G-M, Schwandt P. The
prevention education program (PEP) Nuremberg: design
and baseline data of a family oriented intervention study.
International Journal of Obesity 2001;25(Suppl 1):S89S92.
Rask-Nissila 2000 {published data only}
Rask-Nissila L, Jokinen E, Terho P, Tammi A, Lapinleimu
H, Ronnemaa T, et al. Neurological development of 5 year
old children receiving a low-saturated fat, low-cholesterol
diet since infancy: A randomized controlled trail. JAMA
2000;284(8):9931000.
Reinehr 2007 {published data only}
Reinehr T, Temmesfeld M, Kersting M, de Sousa G,
Toschke AM. Four-year follow-up of children and
adolescents participating in an obesity intervention
program. International Journal of Obesity (Lond) 2007;
Vol. 31, issue 7:10747. [03070565: (Print)]
Resnicow 2005 {published data only}
Resnicow K, Taylor R, Baskin M, McCarty F. Results of Go
Girls: A weight control program for overweight AfricanAmerican adolescent females. Obesity Research 2005;13(10):
173948.

42
Robinson 1999 {published data only}

Robinson TN. Can a school-based intervention to reduce
television use decrease adiposity in children in grades 3 and
4. Western Journal of Medicine 2000;173(1):40.
Robinson TN. Reducing childrens television viewing to
prevent obesity: A randomised controlled trial. JAMA
1999;282(16):15617.
Sadowsky 1999 {published data only}
Sadowsky HS, Sawdon JM, Scheiner ME, Sticklin AM.
Eight week moderate intensity exercise intervention elicits
body composition change in adolescents. Cardiopulmonary
Physical Therapy Journal 1999;10 (2):3844.
Simonetti 1986 {published data only}
Simonetti DArca A, Tarsitani G, Cairella M, Siani V, De
Filippis S, Mancinelli S, et al. Prevention of obesity in
elementary and nursery school children. Public Health
1986;100:166173.
Spark 1998 {published data only}
Spark A, Pfau J, Nicklas TA, Williams CL. Reducing fat in
preschool meals: Description of the foodservice intervention
component of Healthy Start. Journal of Nutrition Education
1998;30(3):170.
Stenevi-Lundgren 2009 {published data only}
Stenevi-Lundgren S, Daly RM, Linden C, Gardsell P,
Karlsson MK. Effects of a daily school based physical
activity intervention program on muscle development in
prepubertal girls. European Journal of Applied Physiology.
2008/11/20 2009; Vol. 105, issue 4:53341. [14396327:
(Electronic)]
Stephens 1998 {published data only}
Stephens MB, Wentz SW. Supplemental fitness activities
and fitness in urban elementary school classrooms. Family
Medicine 1998;30(3):2203.
Stewart 1995 {published data only}
Stewart KJ, Lipis PH, Seemans CM, McFarland, Weinhofer
JJ, Brown CS. Heart Healthy Knowledge, food patterns,
fatness and cardiac risk factors in children receiving
nutrition education. Journal of Health Education 1995;26
(6):38190.
Stock 2007 {published data only}
Stock S, Miranda C, Evans S, Plessis S, Ridley J, Yeh S, et
al. Healthy Buddies: a novel, peer-led health promotion
program for the prevention of obesity and eating disorders
in children in elementary school. Pediatrics 2007;120(4):
e1059e1068.
Talvia 2004 {published data only}
Talvia S, Lagstrom H, Rasanen M, Salminen M, Rasanen
L, Salo P, et al. A randomized intervention since infancy
to reduce intake of saturated fat. Archives of Pediatrics &
Adolescent Medicine 2004;158(1):41.
Tamir 1990 {published data only}
Tamir D, Feurstein A, Brunner S, Halfon S, Reshef A,
Palti H. Primary prevention of cardiovascular diseases
in childhood: changes in serum total cholesterol, high
density lipoprotein, and body mass index after 2 years of
intervention in Jerusalem schoolchildren age 7-9 years.

Preventive Medicine 1990;19:2230.
Taylor 2005 {published data only}
Taylor MJ, Mazzone M, Wrotniak BH. Outcome of an
exercise and educational intervention for children who are
overweight. Pediatric Physical Therapy 2005; Vol. 17, issue
3:1808. [08985669: (Print)]
Tershakovec 1998 {published data only}
Tershakovec AM, Jawad AF, Stallings VA, Zemel
BS, McKenzie JM, Stolley PD, et al. Growth of
hypercholesterolemic children completing physicianinitiated low-fat dietary intervention. The Journal of
Pediatrics 1998;133(1):2834.
Treuth 2007 {published data only}
Treuth MS, Catellier DJ, Schmitz KH, Pate RR, Elder
JP, McMurray RG, et al. Weekend and weekday patterns
of physical activity in overweight and normal-weight
adolescent girls. Obesity 2007;15(7):17828.
Trudeau 2000 {published data only}
Trudeau F, Espindola R, Laurencelle L, Dulac F, Rajic M,
Shephard RJ. Follow-up of participants in the Trois-Rivieres
growth and development study: Examining their healthrelated fitness and risk factors as adults. American Journal of
Human Biology 2000;12:20713.
Trudeau F, Shephard RJ, Arsenault F, Laurencelle L.
Changes in adiposity and body mass index from late
childhood to adult life in the Trois-Rivieres study. American
Journal of Human Biology 2001;13(3):34955.
Vandongen 1995 {published data only}
Vandongen R, Jenner DA, Thompson C, Taggart AC,
Spickett EE, Burke V, et al. A controlled evaluation of a
fitness and nutrition intervention program on cardiovascular
health in 10- to 12-year-old children. Preventive Medicine
1995;24(1):922.
Williams 1998 {published data only}
Williams CL, Spark A, Strobino BA, Bollella MC, DAgostio
CA, Brotanek J, et al. Cardiovascular risk reduction in a
preschool population: The Healthy Start Project. Preventive
Cardiology 1998;2:4555.
Williams CL, Squillace MM, Bollella MC, Brotanek J,
Campanaro L, DAgostino C, et al. Healthy Start: A
comprehensive health education program for preschool
children. Preventive Medicine 1998;27:21623.
Williams CL, Strobino BA, Bollella M, Brotanek J.
Cardiovascular risk reduction in preschool children: The
Healthy Start Project. Journal of the American College of
Nutrition 2004;23(2):11723.
Williamson 2006 {published data only}
Williamson DA, Walden HM, White MA, York-Crowe E,
Newton RL Jr, Alfonso A, et al. Two-year internet-based
randomized controlled trial for weight loss in AfricanAmerican girls. Obesity 2006;14(7):123143.
Williamson DA, Copeland AL, Anton SD, Champagne
C, Han H, Lewis L, et al. Wise Mind project: a school-

43
based environmental approach for preventing weight gain

in children. Obesity 2007;15(4):90617.
References to ongoing studies

Adab 2008 {published data only}
Adab. Birmingham Healthy Eating and Active Lifestyle
for Children Study (BEACHeS). http://www.controlledtrials.com/ISRCTN51016370. [: ISRCTN51016370]
Adams 2009 {published data only}
Adams J, Zask A, Dietrich U. Tooty Fruity Vegie in
preschools: an obesity prevention intervention in preschools
targeting childrens movement skills and eating behaviours.
Health Promotion Journal of Australia 2009;20(2):1129.
Barlow 2008 {unpublished data only}
Barlow J. Empowering Mothers to Prevent Obesity at
Weaning. http://tcru.ioe.ac.uk/nsf/Default.aspx?tabid=336.
Campbell 2008 {published data only}
Campbell K, Hesketh K, Crawford D, Salmon J, Ball K,
McCallum Z. Study Protocol: The Infant Feeding Activity
and Nutrition Trial (INFANT) an early intervention to
prevent childhood obesity: Cluster-randomised controlled
trial. BMC Public Health 2008;8:103. [DOI: 10.1186/
1471-2458-8-103]
Daniels 2008 {published data only}
Daniels L. Positive feeding practices and food preferences
in very early childhood: an innovative approach to obesity
prevention. http://apps.who.int/trialsearch/Trial.aspx?
TrialID=ACTRN12608000056392.
Haby 2009 {unpublished data only}
Haby. Go for your life Health Promoting Communities:
Being Active Eating Well HPC: BAEW. http://apps.who.int/
trialsearch/Trial.aspx?TrialID=ACTRN12609000892213
2009.
Jansen 2008 {published data only}
Jansen W, Raat H, Joosten-van Zwanenburg E, Reuvers
I, Van Walsem R, Brug J. A school-based intervention to
reduce overweight and inactivity in children aged 6-12 years:
study design of a randomized controlled trial. BMC Public
Health 2008;8:257. [DOI: 10.1186/1471-2458-8-257]
Jones 2007 {published data only}
Jones RA, Okely AD, Collins CE, Morgan PJ, Steele
JR, Warren JM, et al. The HIKCUPS trial: a multi-site
randomized controlled trial of a combined physical activity
skill-development and dietary modification program in
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Roberts 2008a {unpublished data only}
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44
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Indicates the major publication for the study

47
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Amaro 2006
Methods
Trial design: Cluster randomised controlled trial

Intervention period: 24 weeks
Follow-up period (post-intervention): Nil
Differences in baseline characteristics: Reported
Reliable outcomes: Reported
Protection against contamination: Not Reported
Unit of allocation: Classrooms
Unit of analysis: Child (controlling for clustering effect of classroom)
Participants
N (controls baseline) = 103

N (controls follow-up) = 88
N (interventions baseline) = 188
N (interventions follow-up) = 153
Setting: Schools (n = 3; Intervention: 10 classrooms, Control: 6 classrooms)
Recruitment: Middle school students in Naples
Geographic Region: Italy
Percentage of eligible population enrolled: 95%
Mean Age: Intervention: 12.3 0.8; Control: 12.5 0.7
Sex: Males and females
Interventions
Board game Kaledo to increase nutrition knowledge:

1 play session per week lasting 15-30 minutes with 2 players on each team
Players match difference between the total energy intake given by the nutrition
cards and the total energy expenditure given by the activity cards
At the end of the game the player with the least difference between energy intake
and expenditure is the winner
Dietary intervention versus control
Outcomes
Height, weight
Physical activity
Nutrition knowledge
Dietary Intake
Process evaluation: Not reported
Implementation related factors
Theoretical basis: Not Reported

Resources for intervention implementation (e.g. funding needed or staff hours required)
: Reported
Who delivered the intervention: Reported
PROGRESS categories assessed at baseline: Reported (Race)
PROGRESS categories analysed at outcome: Not Reported
Outcomes relating to harms/unintended effects: Not Reported
Intervention included strategies to address diversity or disadvantage: Not Reported
Economic evaluation: Not Reported

48
Amaro 2006
(Continued)
Notes
Risk of bias
Bias
Authors judgement
Support for judgement
Random sequence generation (selection Unclear risk

bias)
Cannot be determined
Allocation concealment (selection bias)
Unclear risk
Blinding (performance bias and detection Unclear risk

bias)
All outcomes
Incomplete outcome data (attrition bias)

All outcomes
Low risk
Selective reporting (reporting bias)
Unclear risk
Protocol not available
Other bias
Low risk
Analysis controlled for clustering effect of

classroom
Baranowski 2003
Methods
Trial Design: Randomised controlled trial

Follow-up: Twelve weeks.
Differences in baseline characteristics: Reported.
Reliable outcomes: Yes for anthropometry and accelerometry.
Protection against contamination: Not reported, but set in two camps.
Unit of allocation: Child
Unit of analysis: Child
All analyses were performed according to intention to treat principles
Participants
Recruitment: all consenting 8-year old, African American girls = 50th percentile for age
and gender BMI, with a parent willing to be involved. Set in Texas, US
Proportion of eligibles participating: Not stated, but children needed access to Internet
Mean Age: Intervention: 8.3 (SD 0.3); Controls: 8.4 (SD 0.3) years.
Sex: girls only.
Interventions
Set in summer camps and homes, the intervention was delivered by trained personnel
in camp and researchers via a website. The intervention was designed to prevent obesity
and aimed to increase fruit, vegetable and water consumption, and enhance physical
activity. Intervention continued via a website with weekly visits. The pilot also evaluated

49
Baranowski 2003
(Continued)
the feasibility of a larger trial.

Controls received usual camp activities and asked to visit control website once a month
[Combined effects of dietary interventions and physical activity interventions versus
control]
Outcomes
BMI
Waist circumference
Physical maturation
Dual X-Ray Absorptiometry (DEXA) for % Body fat
Physical activity: CSA accelerometer,
a modification of the Self-Administered Physical Activity Checklist (SAPAC),
GEMS Activity Questionnaire (GAQ) computerised
Dietary intake measured by two 24 hour recalls using Nutrition Data System computer
programme (NDS-R)
Monitoring website usage.
Process Evaluation: Reported
Theoretical basis: Social cognitive theory and family systems theory

: Not Reported
PROGRESS categories assessed at baseline: Reported (Race, Education, SES)
Intervention included strategies to address diversity or disadvantage: Reported
Notes
Risk of bias
Bias
Authors judgement
Random sequence generation (selection Low risk

bias)
Random assignment was conducted in

an urn randomisation procedure, through
telephone contact to the coordinating centre
Unclear risk

bias)
All outcomes

All outcomes
Unclear risk
High risk
Did not report % body fat at follow-up despite noting this as a measure and recording

50
Baranowski 2003
(Continued)
at baseline
Other bias
High risk
Statistically significant differences between

groups in BMI at baseline
Beech 2003
Methods

Intervention period: Twelve weeks
Protection against contamination: Not reported
Participants
Interventions
Outcomes
Body Mass Index

Waist circumference
Physical maturation
Blood samples for insulin
Physical activity: accelerometer CSA,
a modification of the Self-Administered Physical Activity Checklist (SAPAC),
GEMS Activity Questionnaire (GAQ) computerised.
Dietary intake measured by two 24 hour recalls using Nutrition Data System computer
programme (NDS-R)
Psychological variables:
Body image using modified (Stunkard 1983) body silhouettes. Weight control behaviours
using McKnight Risk Factor Survey.
Parental food preparation practices
Self-Perception Profile for Children
Healthy Growth Study for physical activity expectations, and a self-efficacy measure
Process evaluation: Reported

Notes
Risk of bias
Bias
Authors judgement

bias)

...urn randomization procedure was used
to generate the treatment allocation se51
Beech 2003
(Continued)
quences. The different sequences were

stored on a computer at the CC, and accessed using an interactive voice-response
telephone system. (Rochon 2003)
Unclear risk

bias)
All outcomes

All outcomes
Low risk
no missing outcome data
High risk
Did not report % body fat at endpoint despite noting this as a measure and recording
at baseline
Other bias
Low risk
Caballero 2003
Methods
Trial Design: Cluster randomised controlled trial

Intervention period: Three years
Follow-up (post-intervention): Nil
Reliable outcomes: Yes
Protection against contamination: Adequately addressed.
Unit of allocation: School
Unit of analysis: Child.
Unit of analysis errors addressed
Primary analysis applied the intention to treat principle and missing data at follow-up
was imputed based on a prediction equation developed using control school data and
Rubins multiple imputation method
Participants

N of schools: 41
Recruitment: all consenting American Indian students in grades 3 to 5 (8 to 11years)
from schools in Arizona, New Mexico, South Dakota, US
Proportion of eligibles participating: Not stated, but schools had to provide: >15 3rd
graders; 90% American Indian; retention of 3-5 grades over 70% in past 3 years; school
meals prepared on site; facilities for PA programme; approval of study by school, community and tribal authorities
Mean Age: 7.6 (SD 0.6) years
Sex: both sexes included but no figures given

52
Caballero 2003
(Continued)
Interventions
School-based multi-component trial utilising school curriculum and existing staff resources trained by licensed SPARK (Sports, Play and active Recreation for Kids, see
Sallis et al. 1993) instructors and Pathways personnel who also acted as mentors. The
intervention aimed to attenuate obesity and reduce percentage body fat.
Four components included improved physical activity, food service, class-room curriculum and family involvement programme.
Control programme not reported, presumably usual curriculum
Combined effects of dietary interventions and physical activity interventions versus
control
Outcomes
BMI
Triceps and subscapular Skinfolds.
Bioelectrical impedance.
Physical activity: TriTrac R3D accelerometer, and checklist standardised from pilot work
was used as a 24-recall questionnaire.
Knowledge attitudes and beliefs: self report questionnaires developed in pilot.
Dietary intake measured by modified 24-hour recall
Observations of school meals.
Analysis of school menus for energy, protein, carbohydrate, fat, sodium and fibre using
the Nutrition Data System computer programme
Theoretical basis: Social learning theory and principles of American Indian culture and
practice
: Reported
PROGRESS categories assessed at baseline: Reported (Gender)
PROGRESS categories analysed at outcome: Reported (Gender)
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk
Blinding (performance bias and detection Low risk

bias)
All outcomes

Assessors were not involved in delivering intervention so as a result were likely

blinded
53
Caballero 2003
(Continued)

All outcomes
Low risk
Missing data balanced across groups and

imputation method given
Unclear risk
Other bias
Low risk
Unit of analysis issues addressed
Coleman 2005
Methods

Intervention period: 4 years
Unit of analysis: School
Participants

Setting [and number by trial group]: 8 schools (n = 4 intervention; n = 4 control)
Recruitment: Intervention schools chosen randomly from schools that had applied to
participate in the programme in 1999. Control schools matched by district and geographic location. All children in 3rd grade invited to participate
Geographic Region: El Paso, Texas - along US-Mexico border region
Mean Age:
Control: 8.3 0.5 years (boys); 8.3 0.5 years (girls)
Intervention: 8.3 0.5 years (boys); 8.2 0.45 years (girls)
Sex
Intervention: 47% female
Control: 47% female
Interventions
Intervention schools: received money ($3500 in first year, $2500 in second year, $1500
for third year and $1000 for fourth year) for purchasing equipment and paying substitutes
so that PE teachers and food service staff could attend training, and for promotion of
CATCH programme at each school. Classroom materials were also subsidised (CATCH
PE guidebook, PE activity box for grades 3 through 5, curriculum material for grades 3
through 5 and the EATSMART manual)
Control schools: did not receive any of the El Paso CATCH programme materials and
did not attend any training for the programme. Received $1000 at the start of each
school year to encourage participation
Also received some data i.e. at start of 4th grade, the 3rd grade summary results were
provided to both intervention and control schools
control

54
Coleman 2005
(Continued)
Outcomes
Risk of overweight or overweight

Anthropometry (height, weight, waist to hip ratio, BMI)
Aerobic fitness
PE outcomes (time spent in moderate physical activity (goal greater than or equal
to 50%), time spent in vigorous physical activity (goal greater than or equal to 20%))
Cafeteria outcomes (fat in school lunches (greater than or equal to 30%), sodium
in school lunches (goal = 600-1000mg))
Theoretical basis: Not reported

: Reported
PROGRESS categories assessed at baseline: Reported (Race, Gender, SES)
Notes
Risk of bias
Bias
Authors judgement
Random sequence generation (selection High risk

bias)
Participant schools were chosen randomly

from those schools that had completed an
application to participate in CATCH programme. Not clear how this was done.
Control schools matched and assigned,
probably not using randomly generated sequence. Authors describe design as quasiexperimental
Allocation may have been concealed but it

is not clear. There was cluster allocation
Unclear risk
Blinding (performance bias and detection High risk

bias)
All outcomes
blinding probably not carried out for participants or outcome assessors

All outcomes
Low risk
Intention to treat analysis conducted
High risk
Incomplete reporting of outcome data. No

anthropometry data at endpoint (authors
state no effect but no data provided)

55
Coleman 2005
(Continued)
Other bias
Low risk
School-level dependent measures were

analysed by group and time
Dennison 2004
Methods

Follow-up (Post-intervention): Nil
Differences in baseline characteristics: Not reported.
Reliable outcomes: Reported.
Protection against contamination: Reported
Unit of allocation: Nursery
Unit of analysis: Unclear
Participants
Setting: School (8 intervention and 8 control)
Geographic Region: New York State, US
Proportion of eligibles participating: Not stated
Mean Age: 4.0 years
Sex: both sexes included but no figures given
Interventions
Preschool and day care centre based intervention delivered by one early childhood teacher
and a music teacher. This was part of larger Brocodile the Crocodile health promotion
programme which lasted for 39 weeks for 1 hour each week including 32 sessions on
healthy eating. Seven educational sessions assessed intervention to encourage reduction
of TV viewing for both parents and children.
Controls received materials and activities about health and safety
Physical activity interventions versus control
Outcomes
BMI
Triceps Skinfolds
Parental estimates of childs sedentary activity in previous week in hours, and to estimate
number of hours usually spent in these activities for each weekend day and each week
day
Alternate activities as a result of reduced TV viewing were not stated/measured
Process Evaluation: Not Reported
Theortetical basis: Not Reported

: Reported
PROGRESS categories assessed at baseline: Reported (Race, Occupation, )

56
Dennison 2004
(Continued)

Notes
Risk of bias
Bias
Authors judgement

bias)
Randomisation performed in random

permutations of the numbers 1 and 2
Centres agreed to participate, then randomisation was performed at the centre

level on all centres at the start of the study
Low risk

bias)
All outcomes
Not blinded

All outcomes
Low risk
Participant flow through study provided

and reasons given for missing data
Unclear risk
Other bias
High risk
Unit of analysis issues not addressed
Donnelly 2009
Methods
Trial design: cluster randomised controlled trial

Follow-up period (post-intervention): Teachers surveyed 9 months after completion
Unit of analysis: Individual; School (correlation between BMI change and weekly PAAC
minutes)
Participants

Setting [and number by trial group]: Schools (n = 14 intervention, n = 10 control)
Recruitment: All students in grades 2 and 3 at baseline in participating schools (since it
was adopted as a curriculum)
Geographic Region: Northeast Kansas, USA

57
Donnelly 2009
(Continued)
Mean Age:
Grade 2: Female (C: 7.8, 0.4; I: 7.7, 0.3); Male (C: 7.8, 0.3; I: 7.7, 0.4)
Grade 3: Female (C: 8.7, 0.4; I: 8.7, 0.4); Male (C: 8.8, 0.4; I: 8.7, 0.3)
Sex: Both Males and Females
Interventions
programme promoted 90 min/wk of moderate-to-vigorous physically active

academic lessons delivered to children intermittently throughout school day. This is in
addition to the existing 60 min/wk PE which would result in a total of 150 min of PA/
wk
Teacher training: Teacher training was provided as a traditional in-service to
teachers in the intervention group at the beginning of the first year, and reviewed in the
second and third year. Each in-service comprised a 6-hour day and provided teachers
with skills to implement PA fully into the classroom and incorporate PA into their
lesson plans. Training also covered organisation and management techniques,
observation of student behaviours, safety procedures, active teaching techniques,
motivational techniques, and understanding moderate-intensity PA.
Outcomes
BMI
Accelerometry (sub-sample only)
Learning outcomes

: Reported
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

RAs blinded to condition for measurement

of primary and secondary outcomes and
data entry. RA who conducted classroom
visitations not blinded
58
Donnelly 2009
(Continued)

All outcomes
Low risk
Unclear risk
Other bias
Low risk
Analysis conducted at both individual and

school level
Ebbeling 2006
Methods
Trial Design: randomised controlled trial

Participants
Setting [and number by trial group]: Home (intervention n = 53; control n = 50)
Recruitment: Local high school provided mailing lists. Adolescents ages 13-18 years who
reported consuming at least one serving per day of sugar-sweetened beverage (SSB) and
lived predominately in one household were eligible
Geographic Region: USA
Mean Age:
Control: 15.8 1.1 years
Intervention: 16.0 1.1 years
Sex:
Control: 54% female
Interventions
Intervention
Weekly home deliveries of noncaloric beverages for 25 weeks: the target number
of individual beverage servings (i.e., 360 mL or 12 fl oz per referent serving) delivered
to each home was based on household size: 4 servings per day for the subject and 2
servings per day for each additional member of the household. Beverage preferences
selected from a wide variety of options (e.g., bottled water and diet beverages
including soft drinks, iced teas, lemonades, and punches). A regional supermarket
delivery service filled the orders and delivered the beverages, with research staff
coordinating and monitoring the process
Monthly telephone calls to reinforce instructions, provide education and
counselling, etc
Refrigerator magnets with messages under the theme of Think Before You Drink

59
Ebbeling 2006
(Continued)
and an additional message cautioned subjects to beware of misleading beverage labels

and advertisements
Control
Subjects in control group asked to continue their usual beverage consumption
habits throughout the 25-week intervention period
Received weekly home deliveries of noncaloric beverages for 4 weeks after
completion of follow-up measurements, as a benefit for having participated in the study
Dietary interventions vs control
Outcomes
BMI
Energy intake from sugar-sweetened beverages
Noncaloric beverage intake (ml)
Physical activity (MET)
Television viewing (hours)
Total media time (hours)

: Reported
Notes
Risk of bias
Bias
Authors judgement

bias)
Eligible subjects were entered sequentially

onto a list of random group assignments
prepared in advance by the study statistician, stratified by gender and BMI. Sequence of random assignments was permutated within stratum in blocks of 2, 4 and
6
To avoid any bias in the enrolment procedure, personnel conducting recruitment

were masked to the sequence
Low risk

bias)
All outcomes

Interviewer for dietary and PA recall interviews was masked to group assignment. Not clear whether people conducting BMI measures (primary endpoint) were
60
Ebbeling 2006
(Continued)
masked to group assignment. Participants

not masked
All outcomes
Low risk
All participants completed study
Unclear risk
Other bias
Low risk
Epstein 2001
Methods

Intervention period: one year
Protection against contamination: Not clear
Participants
For percentage of overweight (height and weight measured but not reported)
N (controls baseline) = 13 (low fat/sugar)
N (controls follow-up) =13
N (interventions baseline) =13 (fruit and veg)
Two interventions, 13 children in each intervention group. 30 started but only 26
children provided baseline data
Geographic region: New York State, US.
Mean Age: 8.8 (1.8) (low fat/sugar); 8.6 (1.9) (fruit/veg)
Sex: both sexes included (boys/girls 6/7 (low fat/sugar); 3/10 (fruit/veg))
Interventions
Families with obese parents and non-obese children were randomized to groups in
which parents were provided a comprehensive behavioural weight-control programme
and were encouraged to increase fruit and vegetable intake.
Comparison groups were encouraged to decrease intake of high fat/high sugar
foods
Dietary interventions versus control
Outcomes
Percentage of overweight
Servings per day of fruits and vegetables
Servings per day of high fat/high sugar foods

: Reported

61
Epstein 2001
(Continued)

Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

All outcomes
Low risk
No missing outcome data
Unclear risk
Other bias
Low risk
Fernandes 2009
Methods
Trial design: controlled before and after study

Reliable outcomes: Reported (anthropometric, dietary intake)
Protection against contamination: Contamination likely as there were control and intervention classes within the same school. Teachers of control classes were instructed not
to teach about diet and nutrition during the study period
Unit of allocation: Class
Unit of analysis: Individual
Participants
Setting [and number by trial group]: 9 classes within 2 schools (n = 4 classes, intervention;
n = 5 classes control)
Recruitment: All schoolchildren enrolled in the 2nd grade at the 2 schools whose parents
gave consent and who attended on both data collection days

62
Fernandes 2009
(Continued)
Geographic Region: Florianpolis, Brazil

Mean Age:
Interventions
Nutritional education programme delivered via 8 fortnightly meetings (each 50 mins)

and taught using learning-through-play teaching methods
Outcomes
Prevalence overweight/obese (i.e. BMI <85th percentile)

Number of days on which children ate prohibited foods (0-1 day or 2-3 days) over two
dietary recalls
Distribution of children eating certain foods over the two dietary recalls
Theoretical basis: learning-through-play

: Not Reported
Notes
Risk of bias
Bias
Authors judgement

bias)

Not randomised
High risk

bias)
All outcomes
All outcomes
Low risk
Unclear risk

No BMI/zBMI presented
63
Fernandes 2009
Other bias
(Continued)
High risk
Foods provided in schools available to all

students and outside of control of students.
Different food environment between the 2
schools (public, private). For the food recall
results, there are important differences between the results recorded in the text compared with that in the tables (values from
the tables have been used for this review
where possible)
Fitzgibbon 2005
Methods

Follow-up period (post-intervention): 2 years
Unit of allocation: preschool
To assess possible bias in results because of children leaving school or missing anthropometric data at a specific follow-up, two additional analyses were conducted in which
authors imputed BMI 1 and 2 years post-intervention from prior (baseline, post-intervention, or Year 1) or subsequent (Year 2) values of BMI
Participants

N (controls follow-up) = post-intervention (n = 183); 1-year follow-up (n = 146); 2-year
follow-up (n = 154)
N (interventions follow-up) = post-intervention (n = 179); 1-year follow-up (n = 143);
2-year follow-up (n = 146)
Setting [and number by trial group]: Preschools (intervention n = 6; control n = 6)
Recruitment: Twelve Head Start sites administered through the Archdiocese of Chicago
and that served primarily African-American children were recruited to participate. All
children at these sites were eligible to participate
Geographic Region: Chicago, USA
Percentage of eligible population enrolled: Not reported
Mean Age: Intervention: 48.6 7.6 months; Control: 50.8 6.4 months
Sex: Intervention: 49.7% female; Control: 50.5% female
Interventions
Child intervention:
14 weeks (three times weekly) of a diet/physical activity intervention delivered by
trained early childhood educators.
Each session included:
20min nutrition activity reflecting the food pyramid
20min aerobic activity based on overall moderate/vigorous movement
Parent intervention:
Received weekly newsletters that mirrored the childrens curriculum

64
Fitzgibbon 2005
(Continued)
Accompanying homework assignments (n=12) designed to be an interactive

activity between children and parents. Parents received a small monetary incentive for
completing and returning homework.
Control intervention:
14 week (one time weekly) curriculum that taught general health concepts such as
seat belt safety, immunisation and dental health.
Parents received weekly newsletters that mirrored the curriculum, but no
homework assignments
control
Outcomes
Primary: Change in BMI from baseline to Year 1 post-intervention and Year 2 postintervention
Secondary:
Dietary intake
Physical activity
Television viewing
Theoretical basis: Reported (social cognitive theory as the primary framework,

and concepts from self-determination theory)
: Reported
PROGRESS categories assessed at baseline: Reported (Gender, Race, Education)
Outcomes relating to harms/unintended effects: Reported
Notes
Intervention design reported in Fitzgibbon et al Prev Med. 2002;34:289-97

This study is linked with results reported for another 12 preschools servicing Latino
communities in Fitzgibbon et al. Obesity 2006;14:1616-1625
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

65
Fitzgibbon 2005
(Continued)

All outcomes
Low risk
Performed adjusted analysis using two different approaches for imputation of missing data and reported both results
Unclear risk
Other bias
Low risk
Analysis accounted for clustering by

preschool
Fitzgibbon 2006
Methods

Follow-up period (post-intervention): 2 years
Unit of allocation: Preschool
Participants

N (controls follow-up) = post-intervention (n = 193); 1-year follow-up (n = 165); 2-year
follow-up (n = 165)
N (interventions follow-up) = post-intervention (n = 196); 1-year follow-up (n = 178);
2-year follow-up (n =176)
Setting [and number by trial group]: Preschools (intervention n=6; control n=6)
Recruitment: Twelve Head Start sites administered through the Archdiocese of Chicago
and that served primarily Latino children were recruited to participate. All children at
these sites were eligible to participate
Geographic Region: Chicago, USA
Percentage of eligible population enrolled: Not reported
Mean Age:
Intervention: 50.8 7.3 months
Control: 51.0 7.0 months
Sex:
Intervention: 47.5% female
Control: 51.3% female
Interventions
Child intervention:
14 weeks (three times weekly) of a diet/physical activity intervention delivered by
trained early childhood educators.
Each session included:
20min nutrition activity reflecting the food pyramid
20min aerobic activity based on overall moderate/vigorous movement
Curriculum was linguistically and culturally appropriate and delivered in both
Spanish and English

66
Fitzgibbon 2006
(Continued)
Parent intervention:
Received weekly newsletters that mirrored the childrens curriculum
Accompanying homework assignments (n=12) designed to be an interactive
activity between children and parents. Parents received a small monetary incentive for
completing and returning homework.
Control intervention:
14 week (one time weekly) curriculum that taught general health concepts such as
seat belt safety, immunisation and dental health.
Parents received weekly newsletters that mirrored the curriculum, but no
homework assignments
control
Outcomes
Primary: Change in BMI from baseline to Year 1 post-intervention and Year 2 postintervention
Secondary:
Dietary intake
Physical activity
Television viewing
Theoretical basis: Reported

: Reported
PROGRESS categories assessed at baseline: Reported (Gender, Race, Education)
Notes
Intervention design reported in Fitzgibbon et al Prev Med. 2002;34:289-97

This study is linked with results reported for another 12 preschools primarily servicing
African-American children in Fitzgibbon et al. J Pediatr 2005;146:618-25
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

67
Fitzgibbon 2006
(Continued)

All outcomes
Low risk
Participant flow provided with numbers

missing similar between intervention and
control groups
Unclear risk
Other bias
Low risk
Analysis accounted for clustering by

preschool
Foster 2008
Methods

Reliable outcomes: Reported (anthropometry, dietary intake, PA and sedentary behaviour)
Protection against contamination: All schools were under the direction of the districts
Food Service Division, which agreed to make the necessary changes in intervention
schools, while making no changes to the control schools
Missing data was imputed using the multiple imputation procedure with the Markov
chain Monte Carlo algorithm as well as the last observation carried forward method for
comparison
Participants

Setting [and number by trial group]: Schools (n = 5 intervention, n = 5 control)
Recruitment: Within schools, written parental consent and child assent required
Geographic Region: Philadelphia, USA
Percentage of eligible population enrolled: School level: 83%. Across participating
schools, consent rate was 70 15%
Mean Age: Intervention: 11.13 1 years; Control: 11.2 1 years
Sex: Intervention: 52% female; control: 55% female
Interventions
SNPI-School Nutrition Policy Initiative - 5 components

school self assessment
Assessed environments using the CDC School Health Index
School formed a Nutrition Advisory Group to guide assessment
Schools subsequently developed an action plan for change with a variety of
strategies-eg limiting use of food as reward/punishment, fundraising etc
nutrition education
50 hours of food and nutrition education per student per school year-based on
NCES guidelines
Integrated into classroom subjects; integrative and interdisciplinary

68
Foster 2008
(Continued)
nutrition policy
All food sold and served in the schools was changed to meet the nutritional
standards-based on DG for Americans
social marketing
Several techniques-raffle tickets; slogan and character development
Family/parent outreach
Home and school association meetings, report card nights, parent education
meetings,weekly nutrition workshops. Parent challenges re PA and HE.
Schools encouraged parents to send healthy foods and discouraged unhealthy
foods
Staff training
all school staff offered ~10 hours/yr of training in nutrition education to receive
curricula and supporting materials e.g. Planet Health and Know your body, and
curriculum lesson packets etc
control
Outcomes
Incidence of overweight and obesity

Prevalence and remission of overweight and obesity
Dietary intake and Physical Activity
Sedentary behaviours
Potential adverse effects
Theoretical basis: Settings-based approach; CDC Guidelines to Promote Lifelong

Healthy Eating and Physical Activity
: Not Reported
PROGRESS categories analysed at outcome: Reported (Race, Gender)
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

69
Foster 2008
(Continued)

All outcomes
Low risk
Unclear risk
Other bias
Low risk
Analysis accounting for clustering within

schools
Gentile 2009
Methods
Trial design: Cluster randomised Controlled Trial

Intervention period: 8 months (1 academic year)
Follow-up period (post-intervention): 6 months
Unit of analysis: Individual (with adjustment for school)
Participants

N (controls follow-up) = 619 (post-intervention), 587 (follow-up)
N (interventions follow-up) = 582 (post-intervention), 529 (follow-up)
Setting: School (intervention n = 5, Control n = 5)
Recruitment: Students in 3rd - 5th grade from 10 schools in two States
Geographic Region: USA
Mean Age:
Intervention: 9.6 (0.9) years
Control: 9.6 (0.9) years
Sex: Both males and females
Interventions
The Switch programme promoted healthy active lifestyles by encouraging

students to Switch what you Do, Chew, and View. The specific DO, VIEW, and
CHEW goals were to be active for 60 minutes or more per day, to limit total screen
time to 2 hours or less per day, and to eat five fruits/vegetables or more per day. The
intervention utilized overlapping behavioural and environmental strategies employed at
multiple ecological levels.
Social Marketing: The community component was designed to promote
awareness of the importance of healthy lifestyles and the prevention of childhood
obesity in the targeted communities, and included paid advertising, (for example,
billboards) and unpaid media emphasizing the key messages.
Curriculum: The school curriculum component was designed to reinforce the
Switch messages and facilitate the family component of the intervention. Teachers were
provided with materials and ways to integrate key concepts into their existing curricula.
Family: The family component was designed to provide parents (and children)
with materials and resources via monthly resource packs sent home to facilitate the
adoption of the healthy target behaviours by the family.

70
Gentile 2009
(Continued)

control
Outcomes
Height and weight, Screen time, fruit and vegetable intake, physical activity (steps)
Theoretical basis: Socio-ecological theory

: Not Reported
PROGRESS categories assessed at baseline: Reported (Race, Gender)
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

All outcomes
Unclear risk
Unclear risk
Other bias
Low risk
Analysis adjusted for clustering within

schools

71
Gortmaker 1999a
Methods
Trial Design: cluster randomised controlled trial

Follow-up: Over two school years (18 months).
Differences in baseline characteristics:
Reported.
Reliable outcomes: Self report outcome measures were developed or modified from
existing measures. If not designed for youth sample the measures were validated for use
in this sample.
Protection against contamination: Not clear.
Unit of analysis errors addressed
All analyses were performed according to intention to treat principles. Also used indicator
variables with mean substitution to control for missing behavioural data and re-estimated
regressions that excluded observations with missing data for sensitivity analyses
Participants
N (intervention follow-up) = 641

N (control follow-up) = 654
Outcome data collected for: 82% of baseline N enrolled: (81% Intervention and 82%
Controls)
65% of eligible population = 1560.
N participants: 1295
N of schools: 10
Setting: School
Geographic Region: Massachusetts, US
Age: mean age 11.7 years
Sex: 48% girls.
Interventions
School-based interdisciplinary intervention utilising the school curriculum and existing

school teachers to promote four major subjects and physical education. Sessions focused
on decreasing television viewing, decreasing consumption of high-fat foods, increasing
fruit and vegetable consumption and increasing moderate and vigorous physical activity.
Control programme not reported, presumably usual school curriculum
control
Outcomes
Body Mass Index

Triceps Skinfold.
Food and activity survey
11-item TV and video Measure
Youth Activity Questionnaire used to measure moderate and vigorous physical activity
Food Frequency Questionnaire used to measure aspects of dietary intake including %
energy from fat and saturated fat, fruit and vegetable intake and total energy intake
Theoretical basis: Behavioural choice and Social Cognitive Theory

: Reported
PROGRESS categories analysed at outcome: Reported (Race, Gender)

72
Gortmaker 1999a
(Continued)

Notes
Risk of bias
Bias
Authors judgement

bias)
were randomly assigned (using a random number table)
Randomisation was conducted at school

level and all were randomised at start of
study. Student intervention status was assigned based on school enrolment
Low risk

bias)
All outcomes
Outcome assessors were blinded

All outcomes
Low risk
Missing data balanced across groups and

reasons for missing data given
Unclear risk
Other bias
Low risk
Gutin 2008
Methods

Participants

N (controls 1 year follow-up) = 265 (for analysis, N = 265)
N (controls 3 year follow-up) = 168 (for analysis, N = 168)
N (interventions 1 year follow-up) = 260 (for analysis, N = 182)
N (interventions 3 year follow-up) = 148 (for analysis, N = 42)
Setting [and number by trial group]: School (n = 9 intervention; n = 9 control)

73
Gutin 2008
(Continued)
Recruitment: All consenting students in participating schools who would be beginning

3rd grade at the start of the intervention.
Geographic Region: Augusta/Richmond County, Georgia, USA
Mean Age: 8.5 0.6 years
Sex: 52% female
Interventions
2-hour after-school intervention sessions were offered 5 days/wk on school days for 3
school years, however students did not have to attend every day to continue in the
programme. The programme included:
40 min of academic enrichment activities, during which healthy snacks were
provided (healthy snacks could be construed as a modest dietary intervention) followed
by:
80 min of moderate-to-vigorous PA (MVPA), which a variety of activities
designed to improve sport skills, aerobic fitness, strength, and flexibility and 40 min
were devoted to vigorous PA. The activities were designed to be mastery-oriented
rather than competitive.
Control group received regular health screenings and diet/PA information
Outcomes
Percent body fat (%BF), bone density, fat mass, fat-free soft tissue (FFST), BMI, waist circumference, cardiovascular (CV) fitness, CV risk factors (total cholesterol, HDL cholesterol, resting blood pressure), self-reported free-living PA, PA enjoyment, motivation for
PA, perceived competence, goal orientation
For reported outcomes at 1 year and 3 years, participants who stayed in the same schools
for the intervention period and who returned for all measurements were included. Of
these, control participants were compared with intervention participants who had an
adequate exposure to the intervention, as indicated by ?40% attendance at the after
school sessions (N for analysis reported above)
Theoretical basis: Environmental change

: Reported
PROGRESS categories assessed at baseline: Reported (Race, Gender, Education, SES)
Notes
Data extracted from 4 publications:

Yin et al. Eval Health Prof 2005;28:67 (intervention rationale, design, process and implementation factors)
Yin et al. Obes Res 2005;13:2153 (1 year outcomes)
Yin et al. Int J Obes 2005;29:S40 (1 year outcomes: post-hoc analysis of dose response
relationship between outcomes and level of programme attendance)
Gutin et al. Int J Ped Obes 2008 (3 year outcomes)

74
Gutin 2008
(Continued)
Risk of bias
Bias
Authors judgement

bias)
Sequence generated using random number

table
Performed recruitment over two periods.

During the second recruitment period, parents/students were informed of intervention assignment of school. Found no interaction effect of time of consent on primary
outcome variables
High risk

bias)
All outcomes
All outcomes
Unclear risk
Unclear risk
Other bias
High risk
Analysis was not intention to treat.

Analysis conducting taking clustering into
account.
Haerens 2006
Methods

Intervention period: Two school years
Participants
N (baseline) = 2840 (not available by condition)

Setting: Schools (Intervention: 10 (5 standard intervention, 5 standard intervention +
parent support), Control: 5)
Recruitment: Students in seventh and eighth grades from schools with technical and
vocational education in West-Flanders
Geographic Region: Belgium
Mean Age: 13.1(0.8) years (no breakdown by condition)

75
Haerens 2006
(Continued)

Interventions
Two intervention groups:

Standard intervention
Standard intervention + Parent involvement
The standard intervention comprised:
School work group
Received background information and guidelines on how to address intervention
topics
Inervention manual and educational materials
Planning and review meetings every 3 months (1-hour)
Schools promoted students being physically active during breaks, at noon or
during after school hours
Resources and sports equipment made available for students
Child physical fitness test
Computer tailored intervention advice for physical activity and reducing fat
intake
School promotions, social marketing and educational strategies which focused on
three behavioural changes
increasing fruit consumption to at least two pieces a day
reducing soft drink consumption and increasing water consumption to 1.
5L/day
reducing fat intake
Parent involvement comprised:
Social marketing and educational materials via school papers and newsletters
CD with the adult computer-tailored intervention for fat intake and physical
activity
Encouraged to discuss intervention with children and create supportive home
environment for behaviour change
control
Outcomes
BMI z-scores
Physical activity (questionnaire and accelerometry for a subset of students)
Diet (fat intake, fruit, water and soft drinks; questionnaire)
Theoretical basis: Reported (Theory of Planned Behaviour, transtheoretical model)

: Reported
PROGRESS categories assessed at baseline: Reported (Gender, SES)
Notes

76
Haerens 2006
(Continued)
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

All outcomes
High risk
Pupils not participating at follow-up were

significantly older and consumed significantly more soft drinks than pupils participating at follow-up.
Unclear risk
Other bias
High risk
Hamelink-Basteen 2008
Methods
Trial design: Controlled clinical trial/cohort analytic

Intervention period: 12 months
Differences in baseline characteristics: Not Reported
Reliable outcomes: Not Reported
Participants
Setting: School (Intervention: 8 , Control:1)
Recruitment: Primary school children from Rhenen (intervention schools) and Elst (control school)
Geographic Region: Netherlands
Percentage of eligible population enrolled: Intervention: 89%, Control: 96%
Mean Age: children aged 5-6 years (class group 2-3) and aged 9-10 years (class group 67)

77
(Continued)
Interventions
Educational programme led by schoolteacher stimulating consumption of healthy

foods (fruit & vegetables) (duration 3 months to 1 year)
Educational programme (for schoolchildren, teachers and parents) led by
schoolteacher focusing on prevention of overweight. Main themes: breakfast, healthy
snacks and exercise (duration 5 wks)
Educational programme led by schoolteacher. Main aim to stimulate an active
healthy lifestyle and participating in sports (duration 3 wks)
Educational programme led by schoolteacher involving a (food) shopping game.
Aim is to familiarize healthy food shopping (duration: 4 wks)
Information evenings (on healthy lifestyle/healthy weight) led by the
multidisciplinary project team for both parents and teachers (one eve per school)
Weight control course, a preventive educational programme for overweight kids
(9 ? 12 yrs only) and their parents. Course consisted of dietary supervision and exercise
instructions (instructed by GP/primary care)
control)
Outcomes
Height, Weight
Nutrition knowledge, diet, behaviours and lifestyle
Process evaluation: Not Reported

: Not Reported
PROGRESS categories assessed at baseline: Reported (Place. Gender)
Notes
Risk of bias
Bias
Authors judgement

bias)

Not randomised
High risk

bias)
All outcomes

All outcomes
Unclear risk

78
(Continued)
Unclear risk
Other bias
Unclear risk
Harrison 2006
Methods
Trial design: Controlled clinical trial/cohort analytic

Participants

N (controls follow-up) = Not reported (91% successfully followed up)
N (interventions follow-up) = Not reported (91% successfully followed up)
Setting: School (Intervention: 5, Control: 4)
Recruitment: Children aged 9-11 years from schools in towns and rural areas of the
South-East region (disadvantaged)
Geographic Region: Ireland
Mean Age: Intervention: 10.2 (1.2), Control: 10.3 (0.8) years
Interventions
10 (30 minute) teacher-led lessons on how children may spend their leisure time
and realistic alternatives to TV viewing & computer games usage
emphasised self-monitoring, budgeting of time and selective viewing
Points system for activity and viewing time.
Teacher resources, pupil workbooks and diaries provided, teachers supported by
visits every two weeks and parents encouraged in writing to support children
Outcomes
Height, weight
Physical activity and Screen time (measured using a one-day Previous Day Physical
Activity Recall (PDPAR)
Physical activity self-efficacy
Aerobic fitness (20m shuttle test)
Theoretical basis: Social cognitive theory

: Reported

79
Harrison 2006
(Continued)

Notes
Risk of bias
Bias
Authors judgement

bias)

Not randomised
High risk

bias)
All outcomes

All outcomes
Unclear risk
Low risk
Other bias
Low risk
Analysis conducted taking clustering into

account
Harvey-Berino 2003
Methods

Intervention Period: 16 weeks
Follow-Up (Post-intervention): Nil
Protection against contamination: Not reported.
Participants
N (controls baseline) =20

N (intervention baseline) =20
N (intervention follow-up) =20
Recruitment: Child between the ages of 9 months and 3 years, child was walking, mother
BMI >25, mother agreed to keep all appointments. Set in Northern New York State,
US, Quebec and Ontario, Canada
Mean Age: 21 months (no SD reported).
Sex: both sexes included; 54% boys.

80
Harvey-Berino 2003
(Continued)
Interventions
Home visiting programme delivered by an indigenous peer educator who was extensively
trained. The intervention was an adaptation of the Active Parenting Curriculum where
11 parenting topics were covered in 16 weeks. The focus for the treatment group was
exclusively on how to improve parenting skills to develop appropriate eating and exercise
behaviours to prevent obesity.
Controls received the usual parenting support programme
control
Outcomes
Maternal BMI
N classified >85th and 95th weight for height z (WHZ) centile scores
Diet: 3 day food records analysed for total calorie and fat intake using Nutritionist IV
computer programme.
Physical activity:
Tritrac R3D accelerometer (mother and child)
Outcomes Expectations
Self-efficacy
Intentions
Child Feeding Questionnaire

: Reported
PROGRESS categories assessed at baseline: Reported (Race, Occupation, Gender, Education)
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

81
Harvey-Berino 2003
(Continued)

All outcomes
Low risk
Reasons reported for missing data
Unclear risk
Other bias
Low risk
James 2004
Methods
Trial Design: cluster randomised controlled trial

Intervention period: One year
Follow-up (Post-intervention): Two years
Unit of analysis: Class
Participants
N (intervention baseline and post-intervention follow-up) 325 (15 classes)

N (intervention 2-year follow-up) = 219
N (control baseline and post-intervention follow-up) = 319 (14 classes)
N (control 2-year follow-up) = 215
No of classes: 29
Outcome data collected for: 100% of sample post-intervention; 67% of sample at 2 year
follow-up
% of eligible population enrolled: Not stated
Setting: School
Geographic Region: Southern UK
Age: 8.7 years (range 7 to 10.9 years)
Sex: both sexes included; Controls: 51% girls; Intervention: 48% girls
Interventions
School-based educational intervention aiming to prevent obesity by reducing consumption of carbonated drinks, delivered by the author and supported by existing staff. Three
sessions, one per term, promoted drinking water and a reduction of carbonated drinks.
Dietary intervention versus controls
Outcomes
Body Mass Index

Proportion of children overweight or obese (based on converting BMI values to centile
values and measuring the proportion above the 91st centile)
Carbonated drink consumption and water consumption using a drinks diary
Theoretical Basis: Not Reported

: Not Reported

82
James 2004
(Continued)

Notes
2-year follow-up data reported in:

James et al. Preventing childhood obesity: two-year follow-up results from the
Chirstchurch obesity prevention programme in schools (CHOPPS). BMJ 2007;335
(7623):762
Risk of bias
Bias
Authors judgement

bias)

clusters were randomised according to a
random number table, with blinding to
schools or classes
Low risk

bias)
All outcomes

All outcomes
Unclear risk
Low return rate of drink diaries at baseline

and completion
Unclear risk
Other bias
Low risk
No unit of analysis issues
Jouret 2009
Methods
Trial design: Controlled before and after study/Cohort analytic

Unit of allocation: Kindergarten
Participants
N (controls baseline) = 410 (retrospective data)

N (interventions baseline) = EPIPOI-1: 750; EPIPOI-2: 1030
N (interventions follow-up) = EPIPOI-1: 556; EPIPOI-2: 697
Setting: Kindergartens (79 randomised to either intervention 1 (EPIPOI-1) or intervention 2 (EPIPOI-2) group; 40 matched control kindergartens selected)

83
Jouret 2009
(Continued)
Recruitment: Preschool children in Haute-Garonne Department

Geographic Region: France
Mean Age (mean, SD EPIPOI-1 (3.8, 0.4); EPIPOI-2 (3.7, 0.3); Control (3.9, 0.3)
Interventions
This study involved two levels of intervention EPIPOI-1 Basic strategy only; EPIPOI-2
Basic plus Education-based reinforcement
Basic strategy
Children were assessed (anthropometric measurements) by a physician to identify
overweight (BMI 90th percentile) and at risk for overweight (BMI between 75th and
90th percentile) children.
Parents of overweight and at risk children were advised to take their children to
the family physician for treatment.
Physicians of these children were notified to encourage follow-up care and
training for obesity treatment was offered to physicians
Parents were provided with resources on the consequences of overweight
Study physician and a dietician provided information session at participating
kindergartens
Posters were placed in all participating kindergartens to reinforce the message
Reinforced strategy (provided to intervention group 2; EPIPOI-2)
An additional education programme focused on promoting healthy nutrition
habits and physical activity and on reducing television watching.
A dietician and an education aide conducted ten 20-min sessions of learning
activity and games (5 sessions per year) in the classrooms of participating kindergartens.
Families were given resources to reinforce the messages and assist with achieving
behaviour change
control
Outcomes
Prevalence of overweight (BMI 90 percentile); weight, height; change in BMI Z-score

in relation to age and sex using the French curves

: Not reported
PROGRESS categories assessed at baseline: Reported (Place, Gender, S-for SES)
PROGRESS categories analysed at outcome: Reported (Place, S-for SES)
Notes
Risk of bias
Bias
Authors judgement


84
Jouret 2009
(Continued)

bias)
Not randomised - used historic control

group
High risk

bias)
All outcomes
Historic control group

All outcomes
Unclear risk
Unclear risk
Other bias
Low risk
Unit of analysis issues were addressed
Kain 2004
Methods
Trial Design: CCT (cluster case controlled trial)

Intervention period: Six months
Unit of analysis: Unclear
Participants
N (Intervention and control at baseline) = 2375 N (intervention follow-up) = 2141;

N (control follow-up) =945.
N of schools: 5
(Authorities assigned schools to intervention on basis of need; boys had higher BMIs in
intervention schools at baseline).
Outcome data collected for: 100% of sample.
% of eligible population enrolled: Not stated.
Setting: School
Geographic Region: Chile.
Age: 10.6 (SD 2.6)
Sex: both sexes included; Controls: 52% boys; Intervention: 53.5% boys
Interventions
School-based multi-component intervention aimed to change adiposity and physical

activity levels, delivered by a nutritionist and a Physical Education (PE) teacher. Nutrition
education was available for children and parents supported by healthier food kiosks.
Sessions included 90 minutes additional physical activity weekly for 3rd to 8th grade for
6 months and 15minutes of activity in recess per day, for last 3 months.
control

85
Kain 2004
(Continued)
Outcomes
Body Mass Index

Triceps Skinfolds
Waist Circumference
Fitness:
Shuttle run test (20m Leger and Lambert test)
Sit and reach for lower back flexibility
Theoretical Basis: Not Reported

: Reported
Notes
Risk of bias
Bias
Authors judgement

bias)

Not randomised
High risk

bias)
All outcomes
Not blinded

All outcomes
Low risk
Reasons for missing data given
Unclear risk
Other bias
High risk
Group assignment was made according to

perception of overweight prevalence and
willingness of the schools director to accept a research study. Boys in intervention
schools had higher BMIs at baseline

86
Keller 2009
Methods
Trial design: Randomised Controlled Trial

Differences in baseline characteristics: N/A
Reliable outcomes: N/A
Protection against contamination: N/A
Unit of allocation: Individual
Participants

Setting: Home
Recruitment: The network CrescNet collected data (patient height and weight) from
more than 300,000 children and 365 were selected at risk of obesity (age 4 to 7 years)
to participate
Geographic Region: Germany
Mean Age: Intervention: 5.9 1.4; control: 5.6 1.2
Interventions
The paediatrician carried out a low threshold intervention which consisted of an

age-adapted nutrition and exercise programme to inspire the awareness of the adequate
nourishment and motion
Three-monthly measurement of height and weight by paediatrician and
consultation about aims to change life style (diet and exercise) and progress to targets
based on results of questionnaire (physical activity) and food diaries
Three food diaries over period of 12 months, each for 5 days including one
weekend. Dietician passed recommendations for dietary change (based on food
diaries) to paediatrician for consultation with family and child
control
Outcomes
Height, weight
Diet
Process evaluation: N/A

: N/A
Notes

87
Keller 2009
(Continued)
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

All outcomes
Unclear risk
Unclear risk
Other bias
Unclear risk
Kipping 2008
Methods
Trial design: pilot cluster randomised controlled trial

Unit of analysis: Individual (analysed both with and without taking clustering within
schools into account)
Participants
N (controls baseline) = 256 (for BMI)

N (controls follow-up) = 223 (for BMI)
N (interventions baseline) = 275 (for BMI)
N (interventions follow-up) = 249 (for BMI)
Setting [and number by trial group]: Schools (n=10 intervention; n = 9 control)
Recruitment: Children were recruited from year 5 classes in 19 primary schools
Geographic Region: South Gloucestershire, England
Percentage of eligible population enrolled: 70% of invited schools; 78% of eligible children within participating schools
Mean Age:
Intervention 9.4 (0.5) years
Control 9.4 (0.49) years
Sex:
Intervention 49.6% female
Control 54.7% female

88
Kipping 2008
(Continued)
Interventions
The programme was adapted from the Eat Well Keep Moving programme implemented
in the US
16 lessons on healthy eating, increasing PA and reducing TV viewing
Changes from original programme included shortening the lesson plans, change
US phrasing or references and change pyramid structure of food groups to the balance
of good health. The pilot also did not include two staff meetings.
Two teachers provided a training session for 10 teachers who would be delivering
the sessions.
Materials provided to the schools, including lesson plans for 9 PA lessons, 6
nutrition lessons and one screen viewing sessio
control
Outcomes
Primary outcome: reduction in time spent doing screen-based activities

Other outcomes:
BMI
Obesity
Walks/cycles to and from school also included since there was a difference
between groups at baseline.
Numbers included in final analysis:
Intervention: BMI 75%, screen questionnaire 48% and activity
questionnaire 51%
Control: BMI 64%, screen questionnaire 47% and activity questionnaire
61%
Theoretical basis: Social cognitive theory and behavioural choice theories

: Reported
Economic evaluation: Not reported (however cost of intervention materials was included)
Notes
Risk of bias
Bias
Authors judgement

bias)
Allocation was at the school level and all

schools allocated at the start of the study,
after schools were invited to participate and
notified that they would be allocated to ei-
Low risk

89
Kipping 2008
(Continued)
ther intervention or control groups

bias)
All outcomes
Outcome assessors and analysts were

blinded

All outcomes
Unclear risk
Unclear risk
Other bias
Low risk
Clustering taken into account in analyses
Lazaar 2007
Methods

Participants
N (obese: controls baseline) = 41

N (obese: controls follow-up) = Not Reported*
N (non obese: controls baseline) = 187
N (non obese: controls follow-up) = Not Reported*
N (obese: interventions baseline) = 59
N (obese: interventions follow-up) = Not Reported*
N (non obese: interventions baseline) = 138
N (non obese: interventions follow-up) = Not Reported*
*Data at 6 months collected from 98.9% of study participants overall. Numbers are not
reported by group
Setting [and number by trial group]: School (intervention n = 14; control n = 5). Intervention and control groups were further divided into obese (BMI>97th percentile) and
non obese children to give a total of 4 trial groups (2 x intervention and 2 x control)
Recruitment: Children from participating local state schools were eligible if they were
in their first or second grade of elementary school, participating in the scheduled school
physical education classes, participating in less than 3h of extra-school sports activity per
week, free of any known disease and not participating in other studies
Percentage of eligible population enrolled: Not Reported
Mean Age: 7.40.8 years (not reported by group)
Sex: 50% female (not reported by group)
Interventions
Control: All children took part in scheduled school physical education (SPE) classes:
Two 1-hour sessions each week held within the school timetable
Aimed at providing children with a rational basis for their activity programmes

90
Lazaar 2007
(Continued)
and for exercise in general

Various combinations of 5min exercises: exercises on coordination, exercises
devoted to posture and balance, relaxation techniques, rhythm and music, exercises
devoted to creative movement, games relating to group participation etc.
Activities increased in intensity and duration throughout the study
Intervention: children in the intervention group were required to follow an additional
physical activity (PA) programme:
Two 1-hour sessions each week held after class
Objective: a playful physical practice and 45min of dynamic exercise within the
hour
Exercise programme designed to enhance the joy of movement, body awareness
and team spirit
Based on traditional games aimed at minimising childrens inactivity
During a session, two children were randomly selected to monitor their energy
expenditure and estimate the average intensity of the sessions and quantify the total
duration of PA
Outcomes
Primary: Obesity status

Secondary:
BMI
BMI z-score
Waist circumference
Skinfold thickness
Fat free mass

: Not Reported
Notes
Risk of bias
Bias
Authors judgement

bias)
A draw was carried out to choose intervention schools
All eligible children from within schools

were automatically assigned to groups
based according to school assignment and
Low risk

91
Lazaar 2007
(Continued)
based on their individual BMI

bias)
All outcomes

All outcomes
Low risk
Unclear risk
No protocol available
Other bias
High risk
Macias-Cervantes 2009
Methods

Participants
N (interventions follow-up) =32
Setting: Home
Recruitment: Children aged 6-9 years attending public schools in four neighbourhoods
in Len, Guanajuato, Mexico
Geographic Region: Mexico
Median Age: Control: 7.5 (6.9-8.4); Intervention: 8 (6.1-9.1)
Interventions
Intervention children were instructed to modify their physical activity to obtain an

increase of at least 2,500 steps per day over the baseline level. To attain this, two strategies
were used:
(a) to increase incidental physical activity (i.e., walk to school, to accompany their parents
at shopping and to help in the domestic work at home
(b) involvement in recreational activities three times per week in a Municipal Sport
Center (60 min sessions of age-appropriate recreational activities)
Outcomes
Anthropometric measurements: height, weight, waist circumference, triceps skinfold

Laboratory measurements: glucose, triglycerides, cholesterol, HDL-C, LDL-C, HOMAIR
Basal physical activity (steps/day, by pedometer)

92
(Continued)
Cardiovascular fitness (VO2 max): by treadmill

Food intake

: Not Reported
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes
All outcomes
Low risk
Unclear risk
Other bias
High risk

Not blinded but unlikely to influence results
93
Marcus 2009
Methods
Trial design: Cluster Randomised Controlled Trial

Reliable outcomes: Reported (anthropometry and accelerometry)
Primary analysis used observed cases, but sensitivity analyses were carried out using
FAS population (evaluated with replacement for missing data by last observation carried
forward)
Participants

Setting: Schools (n = 5 intervention, n = 5 control)
Recruitment: All consenting students in selected schools up to 4th school year
Geographic Region: Sweden
Percentage of eligible population enrolled: 90% to 100%
Mean Age: Control: 7.5 (1.3) years; Intervention: 7.4 (1.3) years
Sex: both sexes included
Interventions
Intervention was designed to change the school environment to promote healthy

eating and physical activity during school and in after school care.
Daily physical activity (30 min per child) was integrated into regular school
curriculum and facilitated by classroom teachers
Classroom teachers encouraged healthy eating, eating less sweetened foods, and
to chose healthy items for school lunch and afternoon snack (provided by schools)
School changes in items provided to increase healthiness (lower sugar, more fibre,
lower fat etc), eliminate unhealthy celebration foods and restrict foods for excursions
and sports days
Awareness raising activities included STOPP newsletter to parents and schools
twice a year
School nurses were also trained in obesity-related problems
control
Outcomes
Prevalence overweight/obese
Physical Activity, accelerometer
Eating habits

: Not reported
PROGRESS categories assessed at baseline: Reported (Place, Race, Occupation, Gender,
Education, Social status)
PROGRESS categories analysed at outcome: Reported (Gender. Education)

94
Marcus 2009
(Continued)

Intervention included strategies to address diversity or disadvantage: Not reported
Economic evaluation: Not reported
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

All outcomes
Unclear risk
Unclear risk
Other bias
Low risk
Unit of analysis issues addressed.
Mo-Suwan 1998
Methods

Intervention period: 29.6 weeks
Follow-up (post-intervention): 6 months
Reliable outcomes: All measures validated in children over 6 years of age.
Unit of analysis errors addressed.
Participants
Follow-up at 6 months:
N (intervention baseline) = 158
N (control baseline) =152
N of classes: 10
Outcome data collected for:
94% of baseline N followed up
75% of eligible population enrolled = 310
Geographic setting: Thailand.

95
Mo-Suwan 1998
(Continued)
Age: 4.5 (SD 0.4) years

Sex: both sexes included; Controls: 61% boys; Intervention: 56% boys
Interventions
Kindergarten-based physical activity programme conducted by specially trained staff and

including a 15 minute walk and a twenty minute aerobic dance session 3-times a week.
Study objective was to evaluate the effect of a school-based aerobic exercise programme
on the obesity indexes of preschool children.
Outcomes
Body Mass Index

Triceps Skinfold (TSF)
WHCU (ratio of wt in kg divided by ht cubed in meters)
Computation of BMI, WHCU and TSF slopes

: Not Reported
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

All outcomes
Low risk
Loss to follow-up was minimal and reasons

given for 2 exclusions from analysis
Unclear risk
Other bias
Low risk

96
Mller 2001
Methods

Intervention period: 1 school year
Follow-up (post-intervention): unclear (still ongoing - further follow-up to be done at
4 and 8 years)
Protection against contamination: Not done (Every alternating year schools change and
control schools become intervention schools and intervention schools become control
schools).
Not known if unit of analysis errors addressed.
Participants
For weight, height and TSF

N of schools: 6
Recruitment: all consenting school pupils aged 5-7 years. General recruitment took place
as part of health examinations by the school physicians
Geographical setting: Kiel, Germany.
Proportion of eligibles participating: 30.2 %
Mean Age:
Not reported (children aged 5-7 years)
Sex: both sexes included but not reported for the 297 (136 + 161) children followed up
for weight, height and skin fold thickness
Interventions
School-based intervention which included an 8 hour course of nutrition education including active breaks was given by a skilled nutritionist and a trained teacher. The course
included the following messages: eat fruit and vegetables each day, reduce intake of
high fat foods, keep active at least 1 hour each day, decrease TV consumption to less
than 1 hour per day.
(In addition a family-based intervention plus a structured sports programme were offered
to families with overweight or obese children and to families with normal weight children
but obese parents).
The controls received usual schooling during this time period but will cross-over every
alternate year
control
Outcomes
Body Mass Index

Triceps skinfold thickness
% fat mass of overweight children
Nutrition knowledge
Daily physical activities
Daily fruit and vegetable consumption
Daily intake of low fat food

97
Mller 2001
(Continued)

: Reported
PROGRESS categories assessed at baseline: Reported (Race, Occupation, Gender, Education, Social status)
Notes
Risk of bias
Bias
Authors judgement

bias)

Not reported for school intervention. Family intervention was not randomised
High risk

bias)
All outcomes

All outcomes
High risk
Low completion rate for family intervention (25%) with no reasons given or exploration of differences between completers
and non-completers
Unclear risk
Other bias
High risk
Every alternating year schools changed

and the control schools became intervention schools and vice versa. This will affect all outcome measures due to carryover
effects of the intervention. Unit of analysis
issues not addressed

98
NeumarkSztainer 2003
Methods

Intervention period: 16 weeks + 8 weeks maintenance
Follow-up: Eight months
Reliable outcomes: Yes for weight, height, TSF (but method of measurement not reported).
Protection against contamination: Not done.
Participants
(3 high schools)
N (control baseline) = 112
(3 high schools)
Outcome data collected for all those enrolled i.e. 100% follow-up
% of eligible population enrolled = 86.8% of intervention school, 83.6% of control
school
Geographical setting;
Minnesota, US.
Mean Age: Intervention: 14.9 (SD0.9) years: Controls: 15.8 (SD1.1).
Sex: girls only
Interventions
High-school based girls only, intervention with priority given to girls with BMI at or
above 75th percentile and who did less than 30 minutes per day 3 times per week
physical activity (eating disorders excluded). Delivery was by school staff and research
team, with local guest instructors. Intervention addressed socio-environmental, personal
and behavioural factors, with physical activity four times per week, nutrition and social
support session every other week for total of 16 weeks with an 8 week maintenance
component of lunch time meetings.
control
Outcomes
Body Mass Index

Physical activity Stages of change (based on the Stages of Change Model)
Participation in physical activity based on Godin and Sheppard
Dietary intake adapted from Youth and Adolescent Food Frequency
Questionnaire
Binge eating adapted from the Minnesota Adolescent Health Survey
Personal Factors
Harters Self Perception Profile for Children
Media internalisation
Self-efficacy to be active
Socio-environmental support

99
(Continued)
Theoretical basis:Reported (Social Cognitive Theory)

: Reported
Notes
Risk of bias
Bias
Authors judgement

bias)
Girls were recruited after the schools were

randomised. Girls in intervention schools
knew they were enrolling in an alternative
physical education class. Girls in control
schools were recruited to participate in a research study about eating and exercise patterns of teens
High risk

bias)
All outcomes

All outcomes
Low risk
Reasons for missing data given and missing

data balanced across groups and with similar baseline characteristics to completers
Unclear risk
Other bias
High risk
Girls in the intervention group had higher

BMI values than girls in control group, although not statistically significant
Unit of analysis issues not addressed.

100
Paineau 2008
Methods
Trial design: Cluster randomised Controlled Trial

Unit of analysis: Family/Individual
All analyses were performed according to intention to treat principles. Missing data for
BMI were imputed using the mean value in the whole cohort
Participants
N (controls baseline) = 418 families

N (controls follow-up) = 393 children 394 adults
N (intervention A [reduce fat, increase high-complex carbohydrates] baseline) = 297
families
N (intervention A follow-up) = 280 children 280 adults
N (intervention B [reduce both fat and sugar and to increase complex carbohydrates]
baseline) = 298 families
N (intervention B follow-up) = 274 children 275 adults
Setting [and number by trial group]: School ( intervention, control)
Recruitment: Particpants recruited from 54 schools. In each family, one second- or
third-grade pupil (aged 7-9 years) and one of his or her parents participated
Percentage of eligible population enrolled: <10%
Mean Age:
Children: Intervention A 7.7 (0.6) , Intervention B 7.8 (0.6), Control 7.6 (0.6)
Parents: Intervention A 40.4 (5.3), Intervention B 40.3 (5.4) , Control 40.6 (5.4)
Interventions
Intervention group A received advice on how to reduce dietary fats (<35% of total
energy intake) and how to increase complex carbohydrates (>50% of total energy intake)
;Intervention group B received advice on how to reduce both dietary fats (<35% of total
energy intake) and sugars (-25% of initial crude intake) and how to increase complex
carbohydrates (>50% of total energy intake)
Computer based interventions: through the ELPAS website, participant families
can access to self-administered questionnaires (diet, PA, meal preparation, and quality
of life) along with updated information, an individual and interactive agenda, an email
address, and various other functions. They also performed 3-day dietary records
Monthly telephone counselling and internet-based monitoring to families (30
min/month) by a trained dietician for 8 months. The telephone calls were dedicated to
analyzing food habits and providing advice on reaching their specific dietary targets
Monthly newsletters, to both children and parents
Series of events (e.g., conferences, museum visits), and 3 school-based lessons on
nutritional education were programmed in participating schools
Outcomes
Dietary intake: total energy intake, fats, sugars, complex carbohydrates; Anthropometric
measures: height, weight, BMI, z BMI, chest, waist, hip and knee circumferences, blood
pressure, heart rate, fat mass, fat free mass, overall physical activity: daily screen viewing

101
Paineau 2008
(Continued)
and activities for clubs


: Reported
PROGRESS categories assessed at baseline: Not Reported (Occupation, Gender, Race,
Education, S for SES)
Notes
Risk of bias
Bias
Authors judgement

bias)
Randomisation performed according to a

computer-generated randomisation list
Randomisation occurred at the school level

and performed on all units at start of study
Low risk

bias)
All outcomes

All outcomes
Unclear risk
Unclear risk
No protocol available
Other bias
High risk

102
Pangrazi 2003
Methods
Controlled before and after study (CBA)

Differences in baseline characteristics: Not reported.
Protection against contamination: Adequately addressed
Unit of analysis: Group
Not known if unit of analysis errors addressed
Participants
N at baseline 606
N of controls and treatment group not reported
Recruitment: all consenting 4th grade children in 35 schools in Arizona, New Mexico,
US
Proportion of eligibles participating: Not stated, but restricted to 4th graders (9 to10
years) as they would not know about PLAY
Mean Age: 9.8 (SD 0.6) years
Sex: both sexes included (Controls: 57% girls; Intervention: 50.5% girls)
Interventions
School based intervention aimed at increased physical activity with a secondary intention
of preventing obesity and delivered by school staff who were specially trained. There were
three conditions and a control: 1) PLAY (9 schools); 2) PLAY and PE (10 schools); 3)
PE only (10 schools). The intervention has three elements: to promote play behaviour,
followed by teacher directed activities and then self-directed activity was encouraged.
This was achieved by incorporating 15 minutes of daily activity in the school day and
encouraging 30 minutes of out of school play by the end of the intervention.
Controls attended schools (N = 6) with no PE provision
Outcomes
Body Mass Index

Physical activity: CSA accelerometer

: Reported
Notes
Risk of bias
Bias
Authors judgement

103
Pangrazi 2003
(Continued)

bias)
Not randomised
High risk

bias)
All outcomes
Not blinded

All outcomes
Unclear risk
Baseline data not reported, Group Ns not

reported
High risk
Baseline data not reported, Group Ns not

reported
Other bias
High risk
Schools were stratified into groups based on

their participation in PLAY and/or the existence of a PE programme (the intervention
groups of interest). Participating schools
were selected from within these groups, so
they were already motivated and participating in the program, and were followed over
time. The No Treatment group (control)
was comprised of schools who did not have
PLAY or a PE programme already in place
Pate 2005
Methods

Missing data at follow-up were imputed by applying a regression method
Participants

N (controls follow-up) = 712-741
N (interventions follow-up) = 827-863
Setting [and number by trial group]: School (intervention n = 12; control n = 12)
Recruitment: All eighth-grade girls who attended 1 of the 31 middle schools that fed
students to the 24 participating high schools were invited to complete the measures
Geographic Region: 14 South Carolina counties

104
Pate 2005
(Continued)
Mean Age:
Intervention: 13.60.6 years
Control: 13.60.6 years
Sex: 100% female
Interventions
LEAP (Lifestyle Education for Activity Programme)

Designed to change both instructional practices and school environment to increase
support for PA among girls
Instructional:
Changes in content and delivery of physical education and health education
Included a gender-specific , girl-friendly, choice-based instructional programme
designed to build activity skills and reinforce participation in PA, both inside and
outside of class
Health education lessons to teach skills necessary for adopting and maintaining a
physically active lifestyle
Environmental:
Role modelling by faculty and staff
Increased communication about PA
Promotion of PA by the school nurse
Family- and community-based activities
Outcomes
Primary outcome: % of girls in who reported participating in vigorous physical activity

Secondary outcomes: prevalence of overweight and at-risk for overweight
Theoretical basis: Reported (Socio-ecological model drawn from Social Cognitive Theory)
: Not Reported
PROGRESS categories analysed at outcome: Reported (Race)
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

105
Pate 2005
(Continued)

bias)
All outcomes

All outcomes
Low risk
Unclear risk
Other bias
Low risk
Patrick 2006
Methods
Trial design: Randomised controlled trial

Analyses were conducted under the intent-to-treat assumption by replacing missing
values at the 12-month end point with the most recent available data from either the 6month or baseline assessment
Participants

Setting [and number by trial group]: Community (intervention n = 424; control n =
395)
Recruitment: Healthy adolescents scheduled for a well child visit were recruited through
their primary care providers (n = 45 primary care providers) from 6 private clinic sites
Geographic Region: San Diego County, California, USA
Mean Age:
Intervention: 12.8 1.3 years (girls); 12.6 1.4 years (boys)
Control: 12.6 1.4 years (girls); 12.8 1.3 years (boys)
Sex: 53% female
Interventions
PACE+ intervention: designed to promote adoption and maintenance of improved eating

and PA behaviours
computer-supported intervention initiated in primary health care settings
printed manual to take home
12 months of stage-matched telephone calls and mail contact
parent intervention to help parents encourage behaviour change
Control
adaptation of SunSmart sun protection behaviour programme developed at the

106
Patrick 2006
(Continued)
University of Rhode Island, Kingston

control
Outcomes
Primary outcomes
Minutes per week of moderate plus vigorous physical activity measured by selfreport and accelerometer
self-report of days per week of physical activity and sedentary behaviours
percentage of energy from fat and servings per day of fruits and vegetables (24-hr
diet recalls)
Secondary outcomes
BMI
Theoretical basis: Reported (Behavioural determinants model; Social Cognitive Theory;

Transtheoretical model behaviour of change)
: Not Reported
PROGRESS categories assessed at baseline: Reported (Race, Gender. Education)
Notes
Risk of bias
Bias
Authors judgement

bias)
Method for sequence generation not reported
Unclear risk
Method for allocation concealment not reported

bias)
All outcomes
Participants were not blinded. Not reported whether or not outcome assessors
were blinded

All outcomes
Low risk
Participant flow through study reported

and similar rates of attrition across groups
Unclear risk
Other bias
Low risk

107
Peralta 2009
Methods

Participants
N (interventions baseline) =16
Setting [and number by trial group]: Secondary school (n = 1)
Recruitment: 7th Graders completing less than 49 laps using Multistage Fitness Test
Geographic Region: Australia
Mean Age: 12.5 0.4 years
Sex: Males only
Interventions
Curriculum component: 1 x 60-min minute curriculum session and two2x 20minminute lunchtime physical activity sessions per week, and for 16 programme weeks;
Each 60-min curriculum session included practical and/or theoretical components
Practical component: comprised of modified games and activities.
Theoretical components: focused on promoting physical activity through
increasing physical self-esteem and, self-efficacy, reducing time spent in small screen
recreation at weekends, decreasing sweetened beverage consumption, and increasing
fruit consumption and the, acquisition and practice of self-regulatory behaviours such
as goal setting, time management, and identifying and overcoming barriers.
Behaviour modification techniques (e.g. group goals converting time spent in
physical activity to kilometres to reach a specified destination, and the use of incentives
such as small footballs) were used throughout the programme behaviours.
Practical components: modified games and activities.
School staff, PE teacher,Facilitated by researcher but included programme
champion who also chose peer facilitators (11th graders), one 20-min training session)
and 6x newsletters sent to parents were also involved except for researchers.
[Combined effects of dietary interventions and physical activity interventions versus
control]
Outcomes
Height and weight, Waist circumference, percentage body fat, cardiorespiratory fitness,
physical activity using accelerometry, time spent using small screen recreation and sweetened beverage and fruit consumption
Theoretical basis: Reported (Social Cognitive Theory)

: Not Reported

108
Peralta 2009
(Continued)

Notes
All analyses performed according to intention to treat principles
Risk of bias
Bias
Authors judgement

bias)
randomised using a computer-based number producing algorithm...
Unclear risk

bias)
All outcomes
Assessors blinded

All outcomes
Unclear risk
Unclear risk
Other bias
Low risk
Intervention conducted in one school with

an absence of a true control group since it
was compulsory for all boys to participate
in physical activity
Reed 2008
Methods
Trial design: Cluster randomized Controlled Trial

Intervention period: 1 school year
Participants
Setting: 10 participating schools randomised, 3 assigned to usual practice and 7 assigned
to intervention. Of the 10 schools, 2 from the usual practice group and 6 from the
intervention group took part in cardiovascular assessment

109
Reed 2008
(Continued)
Recruitment: Elementary schools in Vancouver and Richmond school districts, British

Colombia, Canada; 4th and 5th grade children
Geographic Region: Canada
Mean Age: 9-11 years
Interventions
The goal of the programme (Action Schools! BC) was to provide 150 min of
physical activity per week (2x40 min PE classes and 15x5 min/day of extra physical
activity in class throughout the day)
The model emphasised a whole-school approach that targeted 6 Action Zones: i)
school environment, ii) scheduled physical education, iii) extra-curricular activities, iv)
school spirit, v) family and community, and vi) classroom action.
Classroom Action was the only prescriptive component and required teachers in
the intervention group to deliver 15 min of moderate to intensive physical activity daily
to achieve the 75 min of extra physical activity per week in addition to the PE classes.
An intervention facilitator worked with the school Action Team (comprised of the
school principal and/or teachers) to design a programme that included activities across
all 6 Action Zones.
A Support Team conducted a 1-day training workshop for teachers in the
intervention group to support their action plan. Intervention teachers were also
provided a Classroom Action Bin with resources to support their Action Plan.
Teachers in both intervention and usual practice (control) groups were asked to
record the minutes of physical activity per day in Activity Logs.
Outcomes
Outcome measures: Cardiovascular fitness (measured by 20-m shuttle run test), blood
pressure (systolic and diastolic), BMI, total cholesterol, HDL, LDL, Apo B, C-reactive
protein and fibrinogen at the end of the intervention period
Theoretical basis: Reported (Social Ecological model)

: Reported
PROGRESS categories assessed at baseline: Place, Race, Gender
Notes
Risk of bias
Bias
Authors judgement

bias)

110
Reed 2008
(Continued)
Unclear risk

bias)
All outcomes

All outcomes
Low risk
Unclear risk
Other bias
High risk
Unit of analysis not addressed
Reilly 2006
Methods

Follow-up period (post-intervention): 6 months
Unit of allocation: Nursery
Participants

N (controls follow-up) = 259 (at 12 months)
N (interventions follow-up) = 245 (at 12 months)
Setting [and number by trial group]: Nurseries (intervention n = 18; control n = 18)
Recruitment: 36 nurseries were randomly selected from a total of 104 nurseries that
were willing to participate (124 nurseries in total were initially invited). All families with
children in their preschool year attending the 36 nurseries were eligible to participate
Geographic Region: Glasgow, Scotland
Percentage of eligible population enrolled: 47% (from original 124 invited nurseries)
Mean Age:
Sex:
Control: 48% female
Interventions
Nursery element:
Enhanced physical activity programme consisting of three 30 minute sessions of
PA each week over 24 weeks.
Two members of staff from each intervention nursery attended 3 training sessions
to deliver the intervention
For 6 weeks during the intervention, each intervention nursery displayed posters
focusing on increasing PA through walking and play

111
Reilly 2006
(Continued)
Capital cost < 200 pounds

Home element:
Each participating family received a resource pack of materials (cost = 16 pounds)
with guidance on linking physical play at nursery and at home, and two health
education leaflets
Control:
Usual curriculum and headteachers agreed not to enhance their physical
development and movement curriculum
Outcomes
Primary outcome: BMI, expressed as a standard deviation score relative to UK 1990

reference data
Secondary outcomes: physical activity; sedentary behaviour; fundamental movement
skills; process evaluation

: Reported
Economic evaluation: No formal evaluation, however costs of materials provided
Notes
Risk of bias
Bias
Authors judgement

bias)
Low risk
Allocation was by nursery and allocations

were concealed by carrying out randomisation of the 36 nurseries at the same time...

bias)
All outcomes
Researchers who made the outcome measures were blinded to nursery allocation
with the exception of the statistician who
carried out the allocation and the contact
between the research team and the nurseries. Nurseries were made aware of their
allocation status

112
Reilly 2006
(Continued)

All outcomes
Low risk
Participant flow provided and similar proportion of missing data from both groups
Unclear risk
Other bias
Low risk
Analysis conducted at the individual and

nursery level.
Robbins 2006
Methods

Unit of allocation: Grade
Participants
Setting: School (n=2, Intervention: 3 grades; Control: 3 grades)
Recruitment: Girls who were inactive most days of the week and had no health condition
limiting physical activity in grades 6, 7 and 8 from two middle schools in low socioeconomic areas in the Midwest
Geographic Region: United States of America
Percentage of eligible population enrolled: 100% of eligible
Mean Age:
Intervention Grade 6: 11.45 (0.80), Grade 7: 12.37 (0.50), Grade 8: 13.00 (0.00)
Control Grade 6: 11.25 (0.46), Grade 7: 12.27 (0.59), Grade 8: 13.44 (0.53)
Sex: Girls only
Interventions
To encourage physical activity each girl in the intervention group received

computerized, individually tailored feedback messages based on their responses to the
baseline questionnaires
Individual counselling (10 minutes) from the schools paediatric nurse practitioner
(PNP) to discuss, and negotiate individual physical activity targets to be achieved
Telephone calls and mailings to participants and parents
Outcomes
Height, Weight
Physical activity frequency, intensity, duration, and readiness
Physical activity determinants: interpersonal influences, activity-related affect (physical
activity enjoyment), self efficacy, and perceived benefits and barriers of physical activity

113
Robbins 2006
(Continued)
Theoretical basis: Health Promotion Model and Transtheoretical Model

: Reported
PROGRESS categories assessed at baseline: Not Reported
Notes
Risk of bias
Bias
Authors judgement

bias)
Computer assignment to either an intervention or control group was based upon a

numerical code that included school group
and grade. Flip-of-a-coin randomisation
identified the grade and school assigned to
each condition
Randomisation was at school level and was

performed on all units at the start of the
study
Low risk

bias)
All outcomes
All outcomes
Low risk
High risk
Other bias
High risk

114
Robinson 2003
Methods

Participants
N (controls- baseline) = 33
N (controls- follow-up) = 33
N (interventions- baseline) = 28
N (interventions-follow-up) = 26
Recruitment: all consenting 8-10 year old, African American girls with BMI >=50th
percentile for age and gender, and a parent with a BMI = 25. Set in Oakland and Palo
Alto, California, US
Proportion of eligibles participating: Not stated, but criteria kept broad. Intended to
recruit 50 and 61 were enrolled
Mean Age: Intervention: 9.5 (SD 0.8) years; Controls: 9.5 (SD 0.9)
Sex: girls only.
Interventions
After school dance classes set in community centers designed to improve physical activity, reduce sedentary behaviours and enhance diet. The intervention called START
(sisters taking action to reduce television) was delivered by trained university based dance
instructors and a female African American intervention specialist. The programme consisted daily dance classes during school weeks and reducing television was covered in five
home based lessons. Four community lectures were also provided.
Controls received newsletters and health education lectures
control
Outcomes
Body Mass Index

Waist circumference
Physical maturation
Physical activity:
CSA accelerometer,
a modification of the Self-Administered Physical Activity Checklist (SAPAC)
,
GEMS Activity Questionnaire(GAQ) computerised
Dietary intake measured by two 24 hour recalls using Nutrition Data System
computer programme (NDS-R)
Theoretical basis: Social cognitive theory

: Reported
PROGRESS categories assessed at baseline: Reported (Education, SES)

115
Robinson 2003
(Continued)

Notes
Risk of bias
Bias
Authors judgement

bias)

to generate the treatment allocation sequences. The different sequences were
Unclear risk

bias)
All outcomes

All outcomes
Low risk
Missing data minimal and reasons given
High risk
at baseline
Other bias
Low risk
Rodearmel 2006
Methods

Unit of allocation: Family
Participants
N (controls baseline):
Families n=23
Target girls n = 14; Target boys n = 11
Other girls n = 9; Other boys n = 10
N (controls follow-up): Families n = 19; Target girls n = 12; Target boys n = 8; Other

116
Rodearmel 2006
(Continued)
girls n = 6; Other boys n = 6

N (interventions baseline): Families n = 82; Target girls n = 40; Target boys n = 53;
N (interventions follow-up): Families n = 62; Target girls n = 29; Target boys n = 39;
Setting [and number by trial group]: Families (intervention n = 82; control n = 23)
Recruitment: Families from Fort Collins, CO area with at least one 8- to 12-year old
child who was at-risk-for-overweight or overweight (?85th percentile BMI-for-age) (target child) who would participate with at least one parent or guardian were recruited.
Recruitment by printed flyers and email advertising
Geographic Region: Fort Collins, Colorado, USA
Mean Age:
Intervention:
Target girls 10.10.2
Target boys 9.80.2
Other girls 12.80.7
Other boys 11.80.4
Control:
Target girls 9.90.4
Target boys 9.90.2
Other girls 11.80.8
Other boys 12.00.7
Sex: Intervention 55% female; Control 56% female
Interventions
Outcomes
Intervention group:
Families asked to maintain their usual eating and step patterns for the first week
of the study to establish baseline, then asked to make two small lifestyle changes
consisting of:
increasing their daily walking by 2000 steps/day above baseline levels and
consuming 2 servings/day of ready-to-eat cereal, one at breakfast and one for
a snack.
Provided with a step counter and a group-specific step and cereal log and free
cereal
Control group:
Asked to maintain their usual eating and step patterns throughout the study.
Provided with a step counter and a group-specific step and cereal log
Both groups:
All family members asked to record their daily steps and cereal servings consumed
Attended three group meetings throughout study period for measurement and
data collection
Given magnets and stickers with written reminders to record daily data. Also
provided with calculators
control
Steps
Cereal servings consumed
Food intake
Body weight/adiposity

117
Rodearmel 2006
(Continued)
For adults:
Body weight
BMI
% body fat
For children:
% BMI-for-age
% body fat

: Reported
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

All outcomes
Unclear risk
Higher proportion of drop outs in intervention group. Not clear how this may have
affected results
Unclear risk
Other bias
High risk
This study chose to enrol more families into

the intervention group then control, so as
a result the numbers of participants in the
control group are very small, limiting the
power for comparison
Not known if unit of analysis issues were
addressed

118
Sahota 2001
Methods

Intervention period: one year
Follow-up (Post-intervention): Nil
Protection against contamination: Not done. (schools which were controls one year
received the intervention the following year).
Unit of analysis errors addressed.
Participants
For weight and height:

N of schools: 10
Recruitment: Not clear
Geographical setting: Northern UK.
Proportion of eligibles participating: For weight and height: control 97%, intervention
96%
Mean Age:
Control: 8.42 (0.63) years
Intervention: 8.36 (0.63) years
Sex: both sexes included
Control: 59% boys Intervention: 51% boys.
Interventions
School-based intervention - Active Programme Promoting Lifestyle in Schools (APPLES)

. The programme was designed to influence diet and physical activity and not simply
knowledge. Targeted at the whole school community including parents, teachers and
catering staff. The programme consisted of teacher training, modifications of school
meals and the development and implementation of school action plans designed to
promote healthy eating and physical activity.
Control schools received usual curriculum
control
Outcomes
Body Mass Index

Dietary intake - 24 hour recall and 3 day food diaries
Physical activity - frequency of physical activity and sedentary behaviour was measured
by questionnaire.
Psychological measures - three validated measures including a Self-Perception Profile
for Children, a questionnaire to distinguish global self-worth from competence and a
measure of dietary restraint
Theoretical basis: multicomponent health promotion programme, based on the Health

Promoting Schools concept
: Reported

119
Sahota 2001
(Continued)

Notes
Risk of bias
Bias
Authors judgement

bias)
We randomised them to receive the intervention or to serve as the comparison

school using the toss of a coin.
Schools were recruited, then all were randomised at the same time at the start of the
study and interventions were implemented
throughout participating schools
Low risk

bias)
All outcomes
Outcome assessment was not blinded

All outcomes
Low risk
Participant flow provided and completion

rate by outcome measure given
Unclear risk
Other bias
Low risk
Sallis 1993
Methods

Intervention period: Two years
Protection against contamination: Unclear
Participants
N (controls and intervention not reported separately ) = 740

N (follow-up) = 549 (data presented for these.) From graphs: Controls = 198; teacher
intervention = 200 and specialist intervention = 98.

120
Sallis 1993
(Continued)
N of schools: 6 (one school added to control group, 7 schools in total)

Setting: School
Geographic Region: California, US.
Age range (mean) 9.25 years
Sex: both sexes included; 55.5% boys.
Interventions
School-based intervention. Followed the (Sports, Play and Active Recreation for Kids)
SPARK intervention, incorporating physical education and self-management into the
school curriculum. Two intervention schools, led by either 1) certified physical education
specialists or 2) classroom teachers evaluated against a control.
Controls received usual PE curriculum.
Outcomes
Weight Status: BMI presented at fall 1990, spring 1991, fall 1991 and spring 1992
Theoretical basis: Behaviour change and self-management

: Reported
Notes
Risk of bias
Bias
Authors judgement

bias)
12 schools were randomly assigned to the

3 experimental conditions, however an additional school was recruited and added to
the control group after this process was conducted
Unclear risk

bias)
All outcomes

All outcomes
High risk
Missing data (26%) not provided by study

group and reasons for attrition not given
Unclear risk

121
Sallis 1993
Other bias
(Continued)
High risk
Salmon 2008
Methods

Follow-up period (post-intervention): 1 year (assessments at 6, 12 months post-intervention)
Participants
N (controls 12 month follow-up) = 55
N (behavioural modification (BM) intervention baseline) = 66
N (BM 12 month follow-up) = 60
N (fundamental motor skills (FMS) intervention baseline) = 74
N (FMS 12 month follow-up) = 69
N (BM/FMS baseline) = 93
N (BM/FMS 12 month follow-up) = 84
Setting [and number by trial group]: 17 classes across 3 schools. Number of classes in
each trial group not reported
Recruitment: All Grade 5 students within 3 selected government schools located across
4 campuses in low SES areas
Geographic Region: Melbourne, Australia
Mean Age:
Male 10 years 8 months 5 months
Female 10 years 8 months 4 months
Sex: 51% female
Interventions
Three intervention groups:

Behaviour Modification (BM) group: In addition to the usual physical education
and sports classes, 19 lessons (40-50 min each) were delivered in classroom by one
qualified physical education teacher for 1 school year. Lessons incorporated selfmonitoring time spent in physical activity and screen behaviours, health benefits of
physical activity, sedentary behaviour environments, decision-making and identifying
alternatives to screen behaviours, intelligent TV viewing and reducing viewing time,
advocacy of reduced screen time, use of pedometers and group games.
Fundamental Motor Skills (FMS) group: In addition to the usual physical
education and sports classes, 19 lessons (40-50 min each) were delivered either in the
indoor or outdoor physical activity facilities at each school for 1 school year. Lessons
focused on mastery of six fundamental movement skills (run, throw, dodge, strike,
vertical jump, and kick). The interventionist taught the skills with an emphasis on
enjoyment and fun through games and maximum involvement for all the children.
BM/FMS group: children in this group received both BM and FMS lessons.

122
Salmon 2008
(Continued)

Outcomes
BMI
Overweight/Obesity
Objectively assessed physical activity (accelerometer) - physical activity measured
for 8 days during waking hours, except when bathing or swimming
Self-reported screen behaviours
Self-reported enjoyment of physical activity (five-point Likert scale)
Mastery of fundamental movement skills
Body Image (five-point Likert scale) - rate their satisfaction with their body
weight and body shape
Food intake: Children were asked to complete a 22 item food-frequency
questionnaire to determine the energy density of their diet
Theoretical basis: Social cognitive theory and behavioural choice theory

: Reported
PROGRESS categories assessed at baseline: Reported (Place, Gender, Education, SES)
Notes
Risk of bias
Bias
Authors judgement

bias)
Randomised by withdrawing a ticket from

a container
Low risk
Allocation was by class and all classes were

randomised at the start of the study

bias)
All outcomes
The five specialist evaluators who examined

video tapes of children performing the fundamental movement skills to assess the childrens mastery of these skills were blind to
the group assignment

All outcomes
Unclear risk
Unclear risk

123
Salmon 2008
(Continued)
Other bias
Low risk
Adjusting for clustering by class
Sanigorski 2008
Methods
Trial design: Cohort Analytic

Participants

Setting [and number by trial group]: preschools and primary schools (n=10 intervention)
Recruitment: All preschools (n = 4, age 4 years) and primary schools (n = 6, age 5-12
years) in Colac with ?20 enrolled children were included in sample frame. Comparison
group sampled from a regionally representative population
Geographic Region: Colac, Australia
Percentage of eligible population enrolled: 49.5%
Mean Age:
Intervention 8.21 (2.26) years
Control 8.34 (2.22) years
Sex:
Intervention 54% female
Control 50% female
Interventions
Nutrition strategies
School-appointed dietitian for support
School nutrition policies
Training for canteen staff
Canteen menu changes
Lunch pack
Professional development for teachers about healthy eating curriculum
One-off class sessions conducted by dietitians
Fresh taste programme (Melbourne Markets) and Healthy breakfast days
Interactive, childrens newsletters/teacher fliers
Promotional materials
Happy healthy families programme (small groups, 6 weeks)
Parent tips sheets (set of 10)
Healthy lunchbox tip sheets
Community garden
Choice chips programme (7 hot chip outlets in Colac)
Fruit shop displays (3 shops involved)
Physical activity strategies

124
Sanigorski 2008
(Continued)
After-school activities programme

Be Active Arts programme
Walking school buses
Walk to school days
Promotional materials
Sporting club coach training
Sporting club equipment
Pedometers
Screen time
TV power-down week, including a 2-week curriculum
Interactive, childrens newsletters / Teacher fliers
Across all strategies
Sponsorship of the Colac Kana festival 2004
Sponsorship of kids day out 2003
Broad media coverage over 4 years (57 newspaper articles, 21 paid adverts)
Incorporation of BAEW strategies on Municipal Early Years Plan Colac
Otway Shire
Incorporation of BAEW strategies into Integrated Health Promotion Plan
(Colac Area Health) and Municipal Public Health Plan (Colac Otway Shire)
Social marketing training; Obesity-prevention training
control
Outcomes
Body weight (kg)

Waist circumference (cm)
BMI (kg/m2)
Waist/height
BMI-z score
Prevalence/incidence of overweight/obesity
Relationship between baseline indicators of childrens household SES and changes
in childrens anthropometry
Process evaluation: Reported (www.goforyourlife.vic.gov.au/hav/articles.nsf/pracpages/
BeActiveEatWell)
Theoretical basis: Reported

: Reported
PROGRESS categories analysed at outcome: Reported (Education, SES)
Notes
Risk of bias
Bias
Authors judgement


125
Sanigorski 2008
(Continued)

bias)
Not randomised
Not randomised
High risk

bias)
All outcomes
All outcomes
Low risk
Low risk
Other bias
Low risk
Blinding not feasible, however primary

outcomes were objective and not likely to
be affected
Sichieri 2009
Methods

Intervention period: 7 months of 1 school year
Unit of analysis: Individual with clustering by class
Participants

Setting [and number by trial group]: 47 classes (n = 23 intervention; n = 24 control) in
22 schools
Recruitment: All fourth graders from 22 public schools in metropolitan city of Niteroi
were invited to participate
Geographic Region: Niteroi, Rio de Janeiro, Brazil
Mean Age: (intervention + control)
Intervention: 10.9 0.81
Control: 10.9 0.75
Sex: Intervention: 53.1% female; Control: 52.6% female
Interventions
Focus on the reduction in consumption of sugar-sweetened carbonated beverages by

students:
Healthy lifestyle education programme, social marketing
Simple messages encouraging water instead of SSB
Formative and developmental work performed prior

126
Sichieri 2009
(Continued)
Classroom quizzes, games, activities to promote water over SSB

Children make drawings and songs
10x 1 hr sessions of activities facilitated by 4 trained researchers who were
assigned for each class
Activities required 20-30 min and teachers encouraged to reinforce the messages
during their lessons
Printed materials provided to RAs and music teachers to facilitate sessions
Outcomes
Outcome measures:
Primary outcome: change in BMI, carbonated SSB and juice intake
Secondary outcomes: overweight and obesity

: Reported
PROGRESS categories assessed at baseline: Reported (Gender, Race)
Notes
Risk of bias
Bias
Authors judgement

bias)
Randomisation at school level and all

schools randomised at start of study
Low risk

bias)
All outcomes

All outcomes
Low risk
Unclear risk
Other bias
Low risk
ITT analysis performed taking into account clustering by class

127
Simon 2008
Methods

Unit of analysis: School, Individual
Sensitvity analysis conducted using intention to treat population to compare this with
analysis using data from only those participants who completed the study
Participants
N (controls baseline) = 479 (blood samples n=326)

N (interventions baseline) = 475 (blood samples n=304)
Setting [and number by trial group]: 8 schools (4 in each group)
Recruitment: Four pairs of matched schools randomly selected out of 77 public middle
schools of the Department of Bas-Rhin. All six-graders in randomised schools were
eligible
Geographic Region: Eastern France
Percentage of eligible population enrolled: 91% (surveys); 73% (blood samples)
Mean Age:
Intervention: 11.7 0.7
Control: 11.6 0.6
Sex:
Intervention: 52.6% female
Interventions
programme began during first school year and ran until end of fourth school year
Educational component focusing on physical activity and sedentary behaviours
New opportunities for PA offered in lunchtime, breaks and after school hours
taking account of barriers to PA
Activities organised by formal physical educators, no competitive aspect
Enjoyment highlighted to help less confident children
Sporting events and cycling to school days
Parents and educators encouraged to support PA through regular meetings
[Physical activity interventions versus control]
Outcomes
Primary Outcome: BMI

Secondary Outcomes:
Self-reported leisure physical activity ? assessed with the Modifiable Activity
Questionnaire for adolescents.
Time spent in front of TV/video and in active commuting between home and
school
Self-efficacy and intention toward physical activity (lower scores indicating better
outcomes) were assessed with the Stanford Adolescent Heart Health Programmes
questionnaire
Cardiovascular risk factors

128
Simon 2008
(Continued)
Theoretical basis: Behaviour change and socio-ecological model

: Not Reported
PROGRESS categories assessed at baseline: Reported (Gender,, SES)
PROGRESS categories analysed at outcome: Reported (Gender,, SES)
Notes
Study rationale, research design, intervention programme and process evaluation described in additional papers (Simon et al. Int J Obes Relat Metab Disord 2004; 28 (Suppl
3):S96-S103; Simon et al. Diabetes Metab 2006;32:41-49)
Risk of bias
Bias
Authors judgement

bias)
Randomised at the school level and all

schools randomised at start of study
Low risk

bias)
All outcomes

All outcomes
Low risk
Unclear risk
Other bias
Low risk
Analysis at school and individual level

129
Singh 2009
Methods

Follow-up period (post-intervention): 4 months and 12 months post-intervention (12
and 20 month observations respectively)
Unit of analysis: Individual with multilevel analysis that included student, class, school
Participants

N (controls follow-up) = Not reported by group
N (interventions follow-up) = Not reported by group
Setting [and number by trial group]: schools (n = 10 intervention; n = 8 control). Three
classes in each school were included
Recruitment: Participating schools were asked to select 3 classes of first-year students.
Selection of classes was based on practical reasons
Geographic Region: The Netherlands
Mean Age:
Intervention: Boys = 12.80.5; Girls = 12.6 0.5
Control: Boys = 12.90.5; Girls = 12.7 0.5
Sex:
Control: 47% female
Interventions
Aim was to increase awareness and induce behavioural changes:

Reduction in consumption of sugar-sweetened beverages
Reduction in consumption of high-sugar, high-fat-content snacks
Reduction in sedentary behaviour
Increase in active transport behaviour
Maintenance of level of sports participation
Individual component:
educational programme covering 11 biology and physical education lessons.
Environmental component:
School-specific advice on selection of school canteen and possible change
options
Financial encouragement of schools to offer additional physical activity
options
Utilised the Intervention Mapping Protocol which facilitates a systematic process
of designing health promotion interventions and based on theory and empirical
evidence
Behaviour change methods used:
Self-monitoring, self-evaluation
Reward
Increasing skills
Goal setting

130
Singh 2009
(Continued)
Environmental changes
Social encouragement
Social support
Information regarding behaviour
Personalised messages
control
Outcomes
Outcome measures
Primary Outcome:
Changes in body composition (i.e. waist circumference, skinfold thickness
and BMI)
Secondary Outcomes:
Changes in dietary and physical activity behaviour (EBRBs)
Consumption of sugar-containing beverages (i.e. consumption of soft drinks
and fruit juices)
Consumption of high-energy snacks (i.e., consumption of savoury snacks
and sweet snacks)
Screen-viewing behaviour (i.e., time spent on television viewing and
computer use)
Active commuting to school
Theoretical basis: Reported (Intervention mapping protocol, behaviour change and environmental frameworks)
: Reported
PROGRESS categories assessed at baseline: Reported (Gender, Race)
PROGRESS categories analysed at outcome: Reported (Gender, Race)
Notes
Protocol published separately. Refer to: Singh et al. BMC Public Health 2006, 6:304 doi:
10.1186/1471-2458-6-304
This also includes 8-month outcome data published in Singh et al. Arch Pediatr Adolesc
Med 2007;161:565-571
Risk of bias
Bias
Authors judgement

bias)
Low risk


and was performed on all units at the start
of the study
131
Singh 2009
(Continued)

bias)
All outcomes
Research assistants involved in conducting

measurements and delivering intervention
materials were not blinded. Other members
of the research team who helped with the
measurements were blinded

All outcomes
Low risk
Low risk
Study protocol published
Other bias
Low risk
Multilevel analysis included student, class,

school
Spiegel 2006
Methods

Intervention period: 5-6 months
Unit of allocation: Classroom
Unit of analysis: Individual (not adjusted for clustering by classroom)
Participants

Setting: Classrooms in Schools
Recruitment: Fourth and fifth graders from 16 schools (69 classes) in four states
(Delaware, Florida, Kansas, and North Carolina)
Geographic Region: United States of America
Mean Age: Not Reported (fourth and fifth graders)
Interventions
The WAY intervention programme was teacher led

Intervention teachers participated in workshops & received programme materials.
The programme was integrated throughout the school year with activities ranging
in engagement time from 20 minutes to more extensive activities that require 1 hour or
more
Students were engaged in multidisciplinary activities in language arts,
mathematics, science, and health content, building their academic skills while
developing their health attitudes, behavioural intent, and, ultimately, behaviour
Used directed-reflective journaling and class discussions with students that were
reinforced over time
Students were provided with an orientation to the programme and activities

132
Spiegel 2006
(Continued)
through video and print resources

Intervention classes followed a 10-minute aerobic exercise routine each day
during class time. The video provided a common baseline exercise routine for all
intervention classes
The programme activities were organized into seven discrete modules.
Module 1 orients students to the programme and the concept of wellness
and has them record a baseline description of their understanding, interpretations, and
attitudes of themselves and wellness.
Module 2 is where the students learn how to collect, report, and analyze data
about themselves and their health and reflect on their attitudes and beliefs related to
the data
and their health behaviorus.
Module 3 focuses on physical activity and fitness. Students learn about the F.
I.T.T. (Frequency, Intensity, Time, and Technique) principles, how to design a basic
workout
routine, and how to incorporate physical activity into their daily routine
Module 4 addresses nutrition and diet
Module 5 is where students learn more about their bodies (how they move,
the parts and systems of their bodies); how their behaviours influence their bodies; how
researchers learn about their bodies (medical technology and research); how to be a
good consumer of health information; and basic information and attitudes about
disease transmission.
Module 6 provides an orientation to genetics and family health history as a
resource to examining personal health.
Module 7 is where students practice the information and skills they learned
in class. They conclude the year with a review of their personal goals and a personal
assessment of their progress toward the goal
control
Outcomes
Height, Weight
Diet (survey)
Physical activity levels (survey)
Theoretical basis: Reported (Theory of Reasoned Action, Constructivism)

: Reported
PROGRESS categories assessed at baseline: Reported (Place, SES)
Notes
Risk of bias

133
Spiegel 2006
(Continued)
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

All outcomes
Low risk
Unclear risk
Other bias
High risk
Analysis not adjusted for clustering by

classroom
Stolley 1997
Methods

Protection against contamination: Not possible
Participants
N (intervention baseline) = 32mothers and 32 daughters

N (control baseline) = 30 mothers and 33 daughters
N (intervention follow-up) = 20 mothers and 23 daughters have dietary data reported
however, stated that in all 51 mothers (78%) and 54 daughters (83%) had data collected
Unable to separate intervention from control figures with data provided.
Geographical setting: Chicago, US.
Age: 7 to 12 years, mean age Intervention 9.9 (SD I.3); Controls 10.0 (SD 1.5) years
Sex: girls only.
Interventions
Set up within a community based tutoring programme this intervention examined the
effectiveness of a culturally specific obesity prevention programme for low-income, innercity African American, preadolescent girls and their mothers.
Programme focused on adopting a low-fat, low-calorie diet and increased activity.
Controls were offered a general health programme.
control

134
Stolley 1997
(Continued)
Outcomes
Mother and daughters:

Body weight and height
% overweight
Daily caloric intake, total fat gram intake, % calories from fat, sat fat, dietary cholesterol
assessed by Quick Check for Fat (QCF) and analysed with Quick Check Diet (QCD)
Parental completion of a self-report measure of parental support and role modelling
around food

:Not Reported
PROGRESS categories assessed at baseline: Reported (Occupation, Gnder, Education,
SES)
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

All outcomes
High risk
78% of mothers completed the study with

a difference in weight between completers
and dropouts. Thinner mothers were more
likely to drop out (p<0.05)
Unclear risk
Other bias
Low risk

135
Story 2003a
Methods

Follow-up: Twelve weeks.
Participants
Proportion of eligibles participating: Not stated, but criteria kept broad. Intended to
recruit 50 and 61 were enrolled
Geographical setting: Minnesota, US.
Mean Age: Intervention 9.4 (SD 0.9); Controls 9.1 (SD 0.8) years
Sex: girls only.
Interventions
After school classes set in schools designed to improve skill building and practice
in support of health behaviour messages in the programme.
Included drinking water, eating more fruit, vegetables and low fat foods,
increasing physical activity reducing TV watching and enhancing self-esteem.
The intervention was delivered by African American GEMS staff. Family contact
and activities supported the intervention.
Controls received a 12 week programme unrelated to nutrition and physical
activity (enhancing self-esteem and cultural enrichment).
control
Outcomes
Body Mass Index

Waist circumference
Physical maturation
Physical activity: CSA accelerometer, a modification of the Self-Administered
Physical Activity Checklist (SAPAC), GEMS Activity Questionnaire(GAQ)
computerised
Dietary intake measured by two 24 hour recalls using Nutrition Data System
computer programme (NDS-R).
Body silhouettes McKnight Risk Factor Survey, and Stunkard et al. 1983.
Healthy choice Behavioural Intentions (diet)
Self-Efficacy for Healthy Eating
Physical Activity Outcomes Expectations, and a self-efficacy measure.
Theoretical basis: Social cognitive theory, youth development, and resiliency based approach
: Reported

136
Story 2003a
(Continued)
PROGRESS categories assessed at baseline: Reported (Race, Education, SES)

Notes
Risk of bias
Bias
Authors judgement

bias)

to generate the treatment allocation sequences. The different sequences were
Unclear risk

bias)
All outcomes

All outcomes
Low risk
Missing data minimal (1 participant).
High risk
at baseline
Other bias
Low risk
Taylor 2008
Methods
Trial design: Controlled clinical trial

Follow-up period (post-intervention): two years
Unit of allocation: Community
Participants

N (controls post-intervention) = 207

137
Taylor 2008
(Continued)
N (intervention post-intervention) = 177

Setting: Primary schools (4 intervention, 3 control)
Recruitment: Children aged 5-12 years from 7 primary schools from 2 geographic regions
Geographic Region: New Zealand
Percentage of eligible population enrolled: Intervention: 92%, Control: 87%
Mean Age: Intervention: 8.0 (1.7) years; Control: 7.9 (1.5) years
Interventions
A community activity co-ordinator was employed at each school in the

intervention area for 20 hours per week to increase non-curricular activity at recess,
lunchtime, and after school. (provided 8 hours of activity programming in the school)
Specific activities varied by school but resources facilitating short bursts of activity
in class were developed and sports equipment were made available to encourage free
play
In the second year of the project, intervention initiatives were nutrition-based,
and included provision of cooled water filters in each school, science lessons
highlighting the adverse health effects of sugary drinks, a community-based healthy
eating resource, an interactive card game, and the provision of free fruit for 6 months
control
Outcomes
Height, weight, waist circumference

Blood pressure heart rate
Physical activity (accelerometer and 7-day recall)
Television viewing time (recall)

: Reported
PROGRESS categories assessed at baseline: Reported (Place, Race, Gender)
Notes
Taylor 2006, 2007 & 2008
Risk of bias
Bias
Authors judgement

bias)
Not Randomised
Not Randomised
Unclear risk

138
Taylor 2008
(Continued)

bias)
All outcomes

All outcomes
Low risk
Reasons given for missing data and demographic characteristics of those lost to follow-up were similar to those remaining in
the study
Unclear risk
Other bias
Unclear risk
Vizcaino 2008
Methods

Intervention period: 24 weeks (during the 2004-2005 academic year)
Participants

Setting [and number by trial group]: Schools (n = 10 intervention; n = 10 control)
Recruitment: Selected 20 schools in 20 towns in the Province of Cuenca, Spain. Fourth
and fifth-grade children in participating schools were invited to participate
Geographic Region: Cuenca, Spain
Mean Age:
Intervention: boys = 9.4 0.7 years; girls = 9.4 0.7 years
Control: boys = 9.5 0.7 years; girls = 9.4 0.6 years
Sex:
Intervention : 48.9% female
Interventions
Implemented during the 2004/2005 academic year, consisted of 3 x 90-min

sessions per week for 24 weeks. These were held after school.
90-min session included 15 min of stretching, 60 min of aerobic resistance and 15
min of muscular strength/resistance exercise
Non-competitive recreational physical activity programme (Movi) adapted to
childrens age and held at the schools athletic facilities ? usually children went home
after class then returned to school for programme.

139
Vizcaino 2008
(Continued)
Physical activity sessions planned by two qualified physical education teachers and
supervised by sports instructors
Sessions included sports with alternative equipment (pogo sticks, Frisbees,
jumping balls, parachutes, etc, cooperative games, dance and recreational athletics
Sports instructors had 2-day training programme and written plan of activities for
each session was developed for standardisation
Standard physical education curriculum continued in both intervention and
control schools.
Further details at www.movidavida.org
Physical activity intervention versus control
Outcomes
BMI
Triceps skin-fold thickness
Percentage body fat
Blood pressure
12 hour fasting blood samples to measure: total cholesterol, triglycerides, apo A
and apo B

: Reported
Outcomes relating to harms/unintended effects: Not reported
Economic evaluation: No formal evaluation, however average cost per child was provided
(28 euros per child per month)
Notes
Risk of bias
Bias
Authors judgement

bias)
used a computer-generated procedure

and Schools were informed of the result
of randomisation after they agreed to participate in the study
Low risk

bias)
All outcomes

Nurses who made the anthropometric and

blood pressure measurements were not
blinded to intervention allocation. Laboratory analysts who determined blood lipids
were blinded to school allocation
140
Vizcaino 2008
(Continued)

All outcomes
Low risk
Low rates of attrition between groups
Unclear risk
Other bias
Low risk
Analysis conducted taking clustering into

account
Warren 2003
Methods
RCT
Intervention period: Fourteen moths
Participants
N (controls and interventions - baseline) = 218

N (3 interventions follow-up) = 164
Recruitment: all consenting 5-7 year-olds from 3 primary schools. Set in central UK
Mean Age: all groups 6.1 (SD 0.6) years;
Sex: both sexes; 51% boys.
Interventions
School and family-based interventions focusing on nutrition, physical activity, or

both, upon the prevalence of overweight/obesity.
The setting was lunchtime clubs where an interactive and age-appropriate
nutrition and/or physical activity curriculum was delivered by the project team.
Controls received an education programme covering the non-nutritional aspects
of food and human biology.
control
Outcomes
Body Mass Index

Skinfolds measured at five sites (biceps, triceps, subscapular, supra-iliac, calf ).
Nutrition knowledge: validated questionnaire .
Physical activity: children and parents completed basic questions about habitual
activity (not validated).
Diet: parents reported on behalf of children a 24h recall and a food frequency
questionnaire
Theoretical basis: Social learning theory

: Reported

141
Warren 2003
(Continued)

PROGRESS categories assessed at baseline: Reported (Gender, Education)
Notes
Risk of bias
Bias
Authors judgement

bias)
Unclear risk

bias)
All outcomes

All outcomes
Low risk
Similar numbers missing from each group.

Reasons for withdrawal given and characteristics of withdrawals investigated
Unclear risk
Other bias
Low risk
Webber 2008
Methods
Trial design: Repeated cross-sectional design (cluster randomisation to determine intervention allocation)
Intervention period: 2 year staff-directed intervention followed by 1 year Programme
Champion component
Unit of analysis: Individual with group randomisation and the nesting of students within
schools, sites and conditions taken into account
Participants
N* (baseline) = 1721 (intervention + control)

N* (follow-up; primary outcome) = 3504 (intervention + control)
*Note: The larger N at follow-up was possible due to the cross-sectional sampling design
and the study team decision to recruit twice as many participants at follow-up compared
with baseline

142
Webber 2008
(Continued)
Setting [and number by trial group]: School (intervention n = 18; control n = 18)
Recruitment: Public middle schools in which a majority of students lived in the surrounding community, with enrolment of at least 90 8th-grade girls at least one semester
of PE in each grade were eligible to participate. Student and parental consent obtained
prior to each measurement period during which cross-sectional, random samples of girls
were recruited for measurement
Geographic Region: Louisiana and South Carolina, USA
Percentage of eligible population sampled at baseline: 79.7%
Mean Age:
Intervention = 11.9 years
Control: boys = 12.0 years
Sex: 100% female
Interventions
Intervention activities targeted to create:

environmental and organisational changes supportive of physical activity
cues, messages and incentives to be more physically active
Activities included:
linking schools and community agencies to develop and promote physical activity
programmes for girls delivered both on an off school property
health education including 6 lessons in each grade to enhance behavioural skills
known to influence PA participation
After the 2-year staff-directed intervention, a Programme Champion component
was conducted for an additional year to foster sustainability. Programme Champions
continued existing intervention activities and developed new programmes were
possible.
Control schools received a delayed intervention after all measurements were obtained
Physical activity intervention vs control
Outcomes
Physical activity measured by accelerometry

Body composition
Theoretical basis:
Operant learning theory
social cognitive theory
organisational theory
diffusion of innovation theory
socio-ecological framework
: Reported
PROGRESS categories analysed at outcome: Reported (Race)
Notes

143
Webber 2008
(Continued)
Risk of bias
Bias
Authors judgement

bias)
Method of sequence generation not reported
Allocation at the school level and all schools

were allocated at the start of the study
Low risk

bias)
All outcomes
Blinding not reported. Separate intervention and measurement staff were employed,
however it is not clear whether measurement staff were blinded

All outcomes
Low risk
Due to repeated cross-sectional design,

the same participants were not followed
throughout the study, however all girls in
participating schools received the intervention. This design was used to assess intervention effects in the entire population of
girls enrolled in participating schools
Unclear risk
Could not be determined
Other bias
Low risk
Glossary
BMI, Body Mass Index
CSA accelerometer, COmputer Sciences Applicvations accelerometer
GEMS, Acronym for Girlsl health Enrichment Multi site Studies
SD, standard deviation
TSF, Triceps Skinfold
WHCU weight/height cubed.
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Al-Nakeeb 2007
Longitudinal cohort study-No intervention
Alves 2008
Intervention designed for the treatment of childhood obesity
Ara 2006
Longitudinal cohort study-No intervention

144
(Continued)
Arbeit 1992
Aim of the trial was to prevent cardiovascular disease
Ask 2006
Cluster allocation with fewer than six groups
Berry 2007
Parent-targeted intervention designed specifically for the treatment of obesity
Bollela 1999a
Aim of the trial was to improve nutritional intake
Bollela 1999b
Borys 2000
Aim was to improve dietary habits of families
Burke 1998
Aim was to improve physical activity
Cairella 1998
Aim was to improve nutritional intake
Carrel 2005
Intervention recruited only overweight or obese participants so considered treatment for the purposes of
this review
Casazza 2006
Intervention was less than 12 weeks
Chomitz 2003
Aim was to increase parent awareness of child weight status
Cullen 1996
Aim of the trial was to prevent childrens behaviour disorders
DAgostino 1999
Daley 2006
Intervention designed specifically for the treatment of obesity
Danielzik 2005
Dixon 2000
Donnelly 1996
Economos 2007
Flodmark 1993
Florea 2005
Flores 1995
Fonseca 2007
Comparative study-No intervention
Gately 2005
Intervention duration less than 12 weeks

145
(Continued)
Goldfield 2006
Goldfield 2007
Intervention duration was less than 12 weeks
Gortmaker 1999b
Study did not report to be measuring any of the primary outcomes of the review
Harrell 1998
Intervention less than 12 weeks duration
Harrell 1999
He 2004
Hopper 1996
Horodynski 2004
Howard 1996
Ildiko 2007
Jago 2006
Jiang 2006
Jurg 2006
Study did not report to be measuring any of the primary outcomes of the review
Koblinsky 1992
Lagstrom 1997
Lionis 1991
Aim of the trial was to assess the effects of a health education intervention aimed at reducing risk for CVD
and cancer
Luepker 1996
Lytle 2006
Aim of the trial was to improve nutritional intake.
Manios 1998
Aim of the trial was to improve physical activity and fitness
Manios 1999
McCallum 2007
McGarvey 2004
McMurray 2002

146
(Continued)
Melnyk 2007
Niinikoski 1997
Obarzanek 1997
Oehrig 2001
Aim of trial was to improve cardiovascular risk factors
Rask-Nissila 2000
Aim of trial was to examine neurological development
Reinehr 2007
Resnicow 2005
Robinson 1999
Sadowsky 1999
Simonetti 1986
This trial was conducted before 1990 and so had been excluded from this review
Spark 1998
Stenevi-Lundgren 2009
Aim of the trial was to improve bone health outcomes
Stephens 1998
Aim of the trial was to improve fitness levels.
Stewart 1995
Stock 2007
Talvia 2004
Aim of trial was to improve nutritional intake.
Tamir 1990
Taylor 2005
Tershakovec 1998
Trial conducted in hypercholesterolaemic children
Treuth 2007
Cross-sectional study design. Not evaluating the intervention
Trudeau 2000
This was not an intervention study
Vandongen 1995
Williams 1998

147
(Continued)
Williamson 2006
Intervention recruited only overweight or obese participants so considered treatment for the purposes of
this review
Williamson 2007
Cluster allocation with fewer than 6 groups
Characteristics of ongoing studies [ordered by study ID]

Adab 2008
Trial name or title
Birmingham Healthy Eating and Active Lifestyle for Children Study (BEACHES)
Methods
Participants
School children aged 6 to 8 years particularly focusing on South Asians
Interventions
Intervention still in development phase. Baseline data is being analysed along with reviewing evidence base
and receiving expert input. Baseline data consisted of focus groups undertaken with a range of stakeholders to
gauge views of childhood obesity and potential prevention interventions explored. Baseline measurements were
also taken from participants including: height, weight, waist circumference, skinfolds, BIA, Blood Pressure,
Physical Activity assessment, Dietary Assessment, HRQoL, Self concept, Body Image, Demographics (each
involved follow-up measures)
Outcomes
Starting date
TBC
Contact information
Adab Peymane, University of Birmingham
Notes
Communication with the lead author (Adab) has confirmed that no outcomes from this study have been
published yet
ISRCTN51016370
Adams 2009
Trial name or title
Tooty Fruity Vegie in Preschools (TFV)
Methods
Controlled before and after study evaluating a one-year intervention conducted during 2006-2007 in 18
preschools (matched with 13 control preschools)
Participants
Recruited from preschools in NSW, Australia. Those in towns with a high proportion of disadvantaged
populations were prioritised
Interventions
Intervention strategies included skills development and awareness-raising for parents, staff and children, and
social support for parents to foster behaviour changes in their children through feedback and reinforcement.
Included healthy eating and physical activity strategies

148
Adams 2009
(Continued)
Outcomes
Primary outcome measures were BMI and waist circumference. Intermediary impact indicators include FMS
proficiency, access to and consumption of fruits and vegetables, EDNP food and sweet drinks, time spent in
screen-based activities and outdoors. Outcome measures assessed at baseline and 10 months
Starting date
2007
Contact information
Jillian Adams, North Coast Area Health Service. [email protected]
Notes
Barlow 2008
Trial name or title
Empowering Mothers to Prevent Obesity at Weaning
Methods
Participants
Women with pre-pregnancy obesity (BMI >35).
Interventions
Feasibility RCT of the effectiveness of an intervention aimed at empowering mothers to prevent obesity at
weaning
Outcomes
Starting date
01/04/2007 Project End Date: 31/08/2009
Contact information
Jane Barlow, Professor of Public Health in the Early Years, University of Warwick, Conventary.
[email protected]
Notes
Campbell 2008
Trial name or title
The Infant Food Activity and Nutrition Trial (INFANT) an early intervention to prevent childhood obesity:
cluster-randomised controlled trial
Methods
Cluster RCT (with first-time parent groups as the unit of randomisation) to be conducted with a sample of
600 first-time parents and their newborn children who attend the first-time parents group at Maternal and
Child Health Centres in Victoria, Australia. Groups randomly allocated to intervention or control groups
Participants
First-time parents and their new born children who attend first-time parents groups
Interventions
The INFANT project will employ an anticipatory guidance approach to support first-time parents in skilled
approaches to their infants emerging dietary, physical activity and sedentary behaviours. The intervention
will be delivered by an experienced dietician during infants first 18 months of life at first-time parents groups
within Maternal and Chid Health (MCH) centers

149
Campbell 2008
(Continued)
Outcomes
Early health promotion programme delivered to first-time parents in their existing social groups promotes
healthy eating, physical activity and reduced sedentary behaviour
Starting date
TBC
Contact information
Dr Karen Campbell
[email protected]
Notes
ISRCTN81847050
Daniels 2008
Trial name or title
Positive feeding practices and food preferences in very early childhood: an innovative approach to obesity
prevention
Methods
Participants
First time mothers of healthy infants 4-7 months at enrolment
Interventions
Will provide anticipatory guidance via 2 x 12 week parent education and peer support modules (6x1.5 hours
sessions), each followed by 6 x monthly maintenance contact (choice support phone/email) The modules
will commence at ages 4-7m and 13-16m to coincide with establishment of solid feeding and development
of autonomy and independence
Outcomes
assessed at baseline (age 4-7m), 9 m (age 13-16 m) and 18 m (final, age 2y)
Starting date
Contact information
Professor Lynn Daniels, Institute of Healthand Biomedical Innovation (IHBI), School of Public Health (SPH)
, Queensland University of Technology [email protected]
Notes
Haby 2009
Trial name or title
Go for your life Health Promoting Communities: Being Active Eating Well
HPC: BAEW
Methods
A quasi-experimental multi-level intervention demonstration project with comparison group to increase

community capacity to promote healthy eating and physical activity, measured by changes in community
capacity, environments, health behaviours and anthropometry
Participants
Inclusion criteria: Each project has a primary and secondary target group, with comparison groups selected to
match primary targets. Target groups include children 0-12, adolescents 12-18, young people newly arrived
to Australia, families, carers, working adults, older adults, seniors and an indigenous community
Exclusion criteria: None
Age minimum: 0 No limit

150
Haby 2009
(Continued)
Age maximum: 0 No limit

Gender: Both males and females
Interventions
Intervention groups: multiple strategies in schools, workplaces and community organisations to promote
healthy eating and physical activity. Examples of strategies include school and workplace food policies, community kitchens and gardens, walking groups, parent education programs, social marketing, training of local
professionals and promoting active transport. The duration of the trial is approximately 4 years
Outcomes
Primary: BMI z-score

Secondary:
BMI
Community capacity to effect behaviour change around overweight and obesity, as evidenced by the development of new structures and partnerships, staff development, community awareness etc (measured by expert
assessment)
Prevalence of overweight and obesity, measured by BMI and waist circumference
School and workplace environmental changes, as measured by school/workplace environmental audits and
expert assessment
Waist circumference
Starting date
2006
Contact information
Michelle Haby: [email protected]
Notes
ACTRN12609000892213
Jansen 2008
Trial name or title
Lekker Fit!
Methods
Cluster RCT in 20 primary schools comparing intervention with control
Participants
Children aged 6-12 years in grades 3 through to 8 within primary schools in Rotterdam with large populations
of foreign ethnicity
Interventions
Main components of the intervention are the re-establishment of a professional physical education teacher;
three (instead of two) PE classes per week; additional sport and play activities outside school hours; fitness
testing; classroom education on health nutrition, active living and healthy lifestyle choices; and the involvement
of parents
Outcomes
Primary outcome measures are BMI, waist circumference and fitness. Secondary outcomes are assessed in
a subgroup of grade 6-8 pupils and consist of nutrition and physical activity behaviours and behavioural
determinants
Starting date
Contact information
Wilma Jansen: [email protected]
Notes
ISRCTN84383524

151
Jones 2007
Trial name or title
The HIKCUPS trial: a multi-site ramdomised controlled trial of a combined physical activity skill-development and dietary modification programme in overweight and obese children
Methods
Multi-site randomised controlled trial in overweight/obese children comparing the efficacy of three interventions: 1) a parent-centered dietary modification programme; 2) a child-centered physical activity skilldevelopment programme; and 3) a programme combining both 1 and 2 above
Participants
Overweight/obese 5-9 year old children. Approximately 200 families are being recruited, three cohorts during
2005 and one cohort during 2006 from the Hunter and Illawarra regions of New South Wales, Australia
Interventions
Each intervention consists of three components: i) 10-weekly face-to-face group sessions; ii) a weekly homework component, completed between each face-to-face session and iii) three telephone calls at monthly intervals following completion of the 10-week programme
Outcomes
The primary outcome measures are BMI z-score and waist circumference. The secondary outcomes include:
metabolic profile, dietary intake, Child Feeding Questionnaire, fundamental movement skill proficiency and
perceived competence, objectively measured physical activity, time spent in sedentary activities, proficiency
in performing an activity of daily living, and health-related quality of life. Outcome measures are assessed at
baseline and at 6-, 12- and 24-months
Starting date
Contact information
Rachel Jones: [email protected]
Notes
Maddison 2009
Trial name or title
The electronic games to aid motivation to exercise study (eGAME)
Methods
Standard 2-arm parallel RCT. 330 participants will be randomised to receive either an active video game
upgrade package or to a control group
Participants
Children aged 10-14 years living in the greater metropolitan Auckland area, who are overweight and play>=
two hours of video games per week
Interventions
Intervention involves an upgrade of childrens existing gaming technology to enable them to play active video
games at home
Outcomes
Primary outcome: change in BMI from baseline to 12 and 24 weeks

Secondary outcomes: changes in % body fat, waist circumference, physical fitness, physical activity (time
spent), psychological variables
Starting date
Contact information
Louise Foley: [email protected]

152
Maddison 2009
(Continued)
Notes
Mastersson 2006
Trial name or title
eat well be active Community Programs
Methods
Controlled before and after study evaluating a five-year intervention conducted during 2006-2010 in 18
preschools, 27 schools and 20 additional community settings (matched with similar numbers of comparison
settings by non-random allocation)
Participants
Recruited from preschools, schools and community settings in two geographically distinct communities in
SA, Australia. All communities were more socio-economic disadvantaged than the State average
Interventions
Intervention strategies included workforce development and peer education for staff, healthy eating and
physical activity policy, infrastructure (such as drinking water facilities and canteen improvements), resources
and programs, local marketing and promotion of key messages (fruit and vegetables, water, active play and
breastfeeding), and community development via the establishment of local stakeholder action groups
Outcomes
Primary outcome measures included BMI of preschool children, and BMI and waist circumference of primary
school children. Impact indicators included primary school childrens behaviours, attitudes and knowledge;
and environments of preschools, primary school and high schools via staff surveys of policy, access, attitudes
and knowledge relating to healthy eating, breastfeeding, physical activity and sedentary time. Evaluation
measures assessed at baseline and 5 years
Starting date
2005
Contact information
Nadia Mastersson, SA Health [email protected]
Notes
Intervention implementation concluded June 2010. Final evaluation report released February 2011. http://
www.health.sa.gov.au/pehs/branches/health-promotion/ewba/publications.htm
Niederer 2009
Trial name or title
Methods
Cluster RCT conducted in preschools to test a multidisciplinary lifestyle intervention versus control
Participants
Twenty preschool classes in the German and another 20 in the French part of Switzerland (areas with a high
migrant population) were selected to participate
Interventions
The multidisciplinary lifestyle intervention aimed to increase physical activity and sleep duration, to reinforce
healthy nutrition and eating behaviour and to reduce media use. It included children, their parents and the
teachers. The intervention included physical activity lessons, adaptation of the built infrastructure, promotion
of regional extracurricular physical activity, as well as lessons about nutrition, media use and sleep. It lasted
one school year

153
Niederer 2009
(Continued)
Outcomes
Primary outcomes: BMI and aerobic fitness. Secondary outcomes: total and central body fat, motor abilities,
physical activity and sleep duration, nutritional behaviour and food intake, media use, quality of life and signs
of hyperactivity, attention and spatial working memory ability
Starting date
Contact information
Iris Niederer: [email protected]
Notes
NCT00674544
Roberts 2008
Trial name or title
Healthy Youths, Healthy Communities; A community based obesity prevention study in secondary school
students
Methods
A 3-year study in secondary school children of a multi-strategy, community intervention promoting healthy
eating and physical activity compared to no specific interventions on changes in body size and composition
Participants
Inclusion criteria: Inclusion for measurement: male and female students in Forms 3-6 in selected schools in
intervention and comparison areas. Minimum age: 12 years, maximum age: 19 years. Inclusion Criteria of
schools and community: sample size and ethnic composition, convenience and relevance of location
Exclusion criteria: Age of student (between 13 years to 19 years)
Age minimum: 13 Years
Age maximum: 19 Years
Interventions
Interventions are multiple strategies over 3 years within secondary schools and the community to build the
communitys capacity to promote healthy eating and physical activity. Examples include school food policies,
improving school food service, within school and after school physical activity programs, training of teachers,
students and community leaders as coordinators, curriculum on healthy eating and physical activities, social
marketing, incorporating programs into local government strategic plans
Outcomes
Primary: Percent body fat

Secondary: BMI measured by BMI z-score.
Prevalence of overweight and obesity assessed by waist circumference
Quality of life measured using the modified AQol tool.
Starting date
2005
Contact information
Graham Roberts: [email protected]
Notes
ACTRN12608000345381

154
Roberts 2008a
Trial name or title
Maalahi Youth Project; The effects of a community based intervention promoting healthy eating and physical
activity in secondary school students on changes in body size and composition
Methods
A 3-year study in secondary school children of a multi-strategy, community driven intervention promoting
healthy eating and physical activity compared to no specific interventions on changes in body size and
composition
Participants
Inclusion criteria: Inclusion for measurement: male and female students in Forms 1-6 in selected schools in
intervention and comparison areas. Inclusion Criteria for schools and communities: Sample size of students
and convenience and relevance of location
Exclusion criteria: Age of student (between 12 years to 19 years)
Interventions
Interventions are multiple strategies over 3 years within the communities and selected schools to build
the communitys capacity to promote healthy eating and physical activity. The promotional strategies are
implemented by the Obesity Prevention In Community (OPIC) Intervention Officers and National Health
Promotion Officers from the Ministry of Health. Promotional materials used are social marketing (e.g.
Billboards, radio programmes, Radio and TV spots), community based sports competition, leaflet distribution
on importance / composition of healthy breakfast, helping in the set up of vegetable gardens through seedling
distribution and implementing the National Canteen Guidelines in school canteens. Aerobics sessions and
competitions are also promoted both in schools and village communities
Outcomes
Primary: Percent body fatSecondary: BMI measured by BMI z-score.Prevalence of overweight and obesity
assessed by waist circumference.Quality of life measured using the modified AQol tool
Starting date
2005
Contact information
Graham Roberts: [email protected]
Notes
ACTRN12608000346370
Shrewsbury 2009
Trial name or title
The Loozit Study
Methods
RCT with two arms. One arm receives the Loozit group weight management programme and the other arm
received the same Loozit group weight management programme plus additional therapeutic contact
Participants
Aim is to recruit 168 overweight and obese 13-16 year olds in Sydney, Australia. Recruitment via schools,
media coverage, health professionals and several community organisations
Interventions
The group weight management programme consists of two phases. Phase 1 involved seven weekly group
session held separately for adolescents and their parents. Phase 2 involves a further seven group sessions held
regularly, for adolescents only, until two years follow-up. Additional therapeutic contact is provided to one of
the study groups approximately once per fortnight during phase 2 only

155
Shrewsbury 2009
(Continued)
Outcomes
Assessed at 2, 12, and 24 months. BMI z-score, waist z-score, metabolic profile indicators, physical activity,
sedentary behaviour, eating patterns and psychosocial well being
Starting date
Recruitment began: May 2006. 24 month follow-up to be completed by July 2011
Contact information
Vanessa Shrewsbury: [email protected]
Notes
Swinburn 2007
Trial name or title
Its Your Move! A community-based obesity prevention study in secondary school children
Methods
A 3-year study in secondary school children of a multi-strategy, community intervention promoting healthy
eating and physical activity compared to no specific interventions on changes in body size and composition
Participants
Inclusion criteria: Students in Years 7-11 in selected schools in intervention and comparison areas
Exclusion criteria: Nil
Interventions
Interventions are multiple strategies over 3 years within secondary schools and the community to build
the communitys capacity to promote healthy eating and physical activity. Examples include school food
policies, improving school food service, within school and after school physical activity programs, training
for coordinators and student ambassadors, curriculum on healthy eating and healthy bodies, activities around
avoiding fad diets and creating body size acceptance, social marketing, incorporating programs into local
government strategic plans
Outcomes
Primary: percent body fat

Secondary: BMI, BMI z-score, prevalence of overweight and obesity, waist circumference, behavioural indicators of healthy eating and physical activity, quality of life, and knowledge indicators
Starting date
2005
Contact information
Boyd Swinburn: [email protected]
Notes
ACTRN12607000257460
Swinburn 2007a
Trial name or title
Romp & Chomp: A community-based intervention programme to promote healthy eating and physical
activity in under 5s in the City of Greater Geelong
Methods
A study in pre-school children of multiple strategies to increase the communitys capacity to promote healthy
eating and physical activity compared to no specific interventions on the prevalence of overweight and obesity

156
Swinburn 2007a
(Continued)
Participants
Inclusion criteria: Inclusion for anthropometry: All children attending Maternal and Child Health (MCH)
Key Age and Stages visits for 2 and 3.5 years Inclusion for behaviours: Parents attending MCH 2 and 3.5
year Age and Stage visits within the data collection time period. Inclusions for Settings audits: Kindergartens,
long daycare, family daycare settings in the intervention and comparison areas
Exclusion criteria: Exclusion for anthropometry: participants with missing data and outlying data indicating
data entry errors. Exclusions for audits: nil
Interventions
Intervention: Multiple strategies over 3 years (2005-2008) to increase community capacity to increase healthy
eating and physical activity in pre-school children. Examples of strategies include food policies in child care
settings, active play programs, social marketing, promotion of water, training of early childhood professionals,
and parent education
Outcomes
Primary: Change in the prevalence of overweight and obesity calculated from measured height and weight
from routinely collected anthropometry in 2 and 3.5 year olds
Starting date
2005
Contact information
Boyd Swinburn: [email protected]
Notes
ACTRN12607000374460
Veldhuis 2009
Trial name or title
Be active, eat right
Methods
Cluster RCT to assess a prevention protocol developed within Youth Health Care in 2005
Participants
5-year-old children included by 44 Youth Health Care teams randomised within 9 Municipal Health Services
in The Netherlands
Interventions
When a child in the intervention group is detected with overweight according to BMI cut-offs, the prevention
protocol is applied. According to the protocol, parents of overweight children are invited for up to three
counselling session during which they receive personal advice about a healthy lifestyle, and are assisted with
behavioural change
Outcomes
Primary outcomes are BMI and waist circumference of the children. Parents complete questionnaires to assess
secondary outcome measures: levels of overweight inducing/reducing behaviours, parenting styles/practices/
attitudes, health-related quality of life of children, possible adverse effects. Data collected at baseline, 12 and
24 months follow-up. Process and cost-effectiveness evaluation will also be conducted
Starting date
Contact information
Lydian Veldhuis: [email protected]

157
Veldhuis 2009
(Continued)
Notes
ISRCTN04965410
Waters 2007
Trial name or title
Fun n healthy in Moreland
Methods
Participants
Primary School Children in 24 Schools in Moreland, an inner city suburb of Melbourne, Australia
Interventions
Intervention is a facilitated approach to supporting school to implement an evidence based approach with
interventions based on priorities within the school, ensuring focus on diet, physical activity and child health
and well being
Outcomes
BMI, child health and well being,
Starting date
2004-2010
Contact information
http://www.mchs.org.au/
Notes
Victorian Government Departments of Sport and Recreation and Human Services

ACTRN12607000385448
Wen 2008
Trial name or title
Early intervention of multiple home visits to prevent childhood obesity in a disadvantaged population: a
home-based randomised controlled trial (Healthy Beginnings Trial)
Methods
Participants
First time mothers who are 24 to 34 weeks pregnant.
Interventions
Comprises of eight home visits from a specially trained community nurse over two years and pro-active
telephone support between the visits
Outcomes
a) duration of breastfeeding measured at 6-12 months b) introduction of solids measured at 4 and 6 months
c) nutrition, physical activity and television viewing measured at 24 months, and d) overweight/obesity status
at age 2 and 5 years
Starting date
TBC
Contact information
Li Ming Wen: [email protected]
Notes

158
Williamson 2008
Trial name or title
Louisiana (LA) Health
Methods
Three treatment arms will be compared in a cluster RCT design. A fourth treatment arm will serve as a
nonrandomised control condition
Participants
23 school systems in Louisiana, USA were invited to participate and students were recruited from participating
schools
Interventions
Primary Prevention: based on Social Learning Theory with an emphasis on modification of environmental
cues, enhancement of social support and promotion of self-efficacy for health behaviour change
Secondary Prevention: relies in intentional efforts to change behaviour as opposed to latering the environment
to prompt behaviour change. Designed to increase healthy eating habits, increase physical activity and decrease
sedentary behaviour
Outcomes
Primary outcomes are BMI z-scores and percentile. Secondary outcomes: successful weight gain prevention,
body fat, food selections and food intake, physical activity, questionnaires to assess dietary social support,
physical activity social support, mood, eating attitudes
Starting date
Contact information
Donald Williamson: [email protected]
Notes
BMI: body mas index

BMIz: standatdised body mss index
FMS: Fundamental Movement Skills
RCT: randomised contorlled trial

159
DATA AND ANALYSES
Comparison 1. Childhood obesity interventions versus control by age groups 0-5, 6-12 and 13-18 years
Outcome or subgroup title
No. of
studies
No. of
participants
Statistical method
Effect size
37
27946
Std. Mean Difference (IV, Random, 95% CI)
-0.15 [-0.21, -0.09]
7
24
6
1815
18983
7148

-0.26 [-0.53, 0.00]

-0.15 [-0.23, -0.08]
-0.09 [-0.20, 0.03]
1 Standardised mean change

in Body Mass Index
(BMI/zBMI) from baseline to
postintervention
1.1 0-5 years
1.2 6-12 years
1.3 13-18 years
Analysis 1.1. Comparison 1 Childhood obesity interventions versus control by age groups 0-5, 6-12 and 1318 years, Outcome 1 Standardised mean change in Body Mass Index (BMI/zBMI) from baseline to
postintervention.
Review:
Comparison: 1 Childhood obesity interventions versus control by age groups 0-5, 6-12 and 13-18 years
Outcome: 1 Standardised mean change in Body Mass Index (BMI/zBMI) from baseline to postintervention
Study or subgroup
Experimental
Std.
Mean
Difference
Control
Weight
IV,Random,95% CI
Std.
Mean
Difference
Mean(SD)
Mean(SD)
IV,Random,95% CI
Mo-Suwan 1998 (1)
65
-0.67 (0.85)
57
-0.39 (0.99)
1.5 %
-0.30 [ -0.66, 0.05 ]
Mo-Suwan 1998 (2)
82
-0.33 (1.23)
88
-0.44 (1.06)
1.8 %
0.10 [ -0.21, 0.40 ]
Harvey-Berino 2003 (3)
17
-0.27 (0.52)
20
0.31 (0.7)
0.6 %
-0.91 [ -1.59, -0.23 ]
Dennison 2004
43
-0.24 (1.64)
34
0.12 (1.75)
1.1 %
-0.21 [ -0.66, 0.24 ]
Fitzgibbon 2005
179
0.05 (0.67)
183
0.14 (0.68)
2.3 %
-0.13 [ -0.34, 0.07 ]
Reilly 2006
231
0.07 (0.45)
250
0.02 (0.46)
2.5 %
0.11 [ -0.07, 0.29 ]
Fitzgibbon 2006
196
0.11 (1.54)
187
0.13 (1.5)
2.3 %
-0.01 [ -0.21, 0.19 ]
49
-0.15 (0.23)
134
0.11 (0.23)
1.5 %
-1.13 [ -1.47, -0.78 ]
13.7 %
-0.26 [ -0.53, 0.00 ]
1 0-5 years
Keller 2009
Subtotal (95% CI)
862
953
-1
-0.5
Favours experimental
0.5
Favours control
(Continued . . . )

160
(. . .
Study or subgroup
Experimental
N
Heterogeneity:
Tau2
= 0.12;
Chi2
Std.
Mean
Difference
Control
Mean(SD)
= 47.90, df = 7 (P<0.00001);
N
I2
Mean(SD)
Weight
IV,Random,95% CI
Continued)
Std.
Mean
Difference
IV,Random,95% CI
=85%
Test for overall effect: Z = 1.94 (P = 0.052)

2 6-12 years
Robinson 2003 (4)
28
0.5 (2.43)
33
0.71 (2.47)
1.0 %
-0.08 [ -0.59, 0.42 ]
Caballero 2003
727
3 (2.05)
682
3.1 (2.05)
2.9 %
-0.05 [ -0.15, 0.06 ]
Beech 2003 (5)
21
-1.2 (6.58)
2.1 (4.85)
0.5 %
-0.52 [ -1.32, 0.27 ]
Beech 2003 (6)
21
-1.2 (6.58)
2.1 (4.85)
0.5 %
-0.52 [ -1.32, 0.27 ]
Story 2003a (7)
26
-0.2 (5)
27
2 (2.41)
0.9 %
-0.56 [ -1.11, -0.01 ]
Baranowski 2003 (8)
17
3.2 (3.53)
14
-2.2 (6.93)
0.5 %
0.99 [ 0.23, 1.74 ]
Kain 2004 (9)
996
0.3 (1.72)
454
0.2 (1.7)
2.9 %
0.06 [ -0.05, 0.17 ]
Kain 2004 (10)
1145
0 (1.62)
491
0.3 (1.44)
2.9 %
-0.19 [ -0.30, -0.09 ]
James 2004
297
0.7 (0.2)
277
0.8 (0.3)
2.6 %
-0.39 [ -0.56, -0.23 ]
Spiegel 2006
534
0.16 (0.89)
479
0.52 (1.02)
2.8 %
-0.38 [ -0.50, -0.25 ]
Harrison 2006
175
-0.2 (1.3)
118
0.1 (2)
2.1 %
-0.18 [ -0.42, 0.05 ]
Amaro 2006
153
0.13 (0.68)
88
0.26 (0.64)
2.0 %
-0.19 [ -0.46, 0.07 ]
Lazaar 2007 (11)
69
-0.1 (0.54)
94
0.2 (0.49)
1.7 %
-0.58 [ -0.90, -0.27 ]
Lazaar 2007 (12)
30
-0.1 (1.13)
21
0.3 (0.92)
0.8 %
-0.38 [ -0.94, 0.19 ]
Lazaar 2007 (13)
30
-0.2 (1.4)
21
0.4 (0.97)
0.8 %
-0.48 [ -1.04, 0.09 ]
Lazaar 2007 (14)
69
-0.1 (0.54)
94
0.3 (0.52)
1.7 %
-0.75 [ -1.07, -0.43 ]
Reed 2008
156
0.4 (2.42)
81
0.3 (2.92)
1.9 %
0.04 [ -0.23, 0.31 ]
Vizcaino 2008 (15)
234
0.4 (1.64)
280
0.4 (1.52)
2.5 %
0.0 [ -0.17, 0.17 ]
349
0.83 (1.03)
77
0.95 (0.73)
2.1 %
-0.12 [ -0.37, 0.13 ]
Paineau 2008 (16)
280
0.05 (0.94)
197
0.12 (0.91)
2.5 %
-0.08 [ -0.26, 0.11 ]
Simon 2008
479
2.38 (2.2)
475
2.42 (2.14)
2.8 %
-0.02 [ -0.15, 0.11 ]
Sanigorski 2008
833
-0.09 (0.42)
974
-0.02 (0.39)
3.0 %
-0.17 [ -0.27, -0.08 ]
Foster 2008
479
1.99 (1.9)
364
2.1 (1.9)
2.7 %
-0.06 [ -0.19, 0.08 ]
Taylor 2008
201
0.8 (1.32)
188
1.4 (1.77)
2.3 %
-0.39 [ -0.59, -0.18 ]
Paineau 2008 (17)
274
0.1 (1.1)
197
0.12 (0.91)
2.5 %
-0.02 [ -0.20, 0.16 ]
Vizcaino 2008 (18)
231
0.2 (1.61)
299
0.3 (1.61)
2.5 %
-0.06 [ -0.23, 0.11 ]
Gutin 2008
182
0.1 (2.1)
265
0.3 (1.99)
2.4 %
-0.10 [ -0.29, 0.09 ]
Donnelly 2009
792
2 (1.9)
698
2 (1.9)
2.9 %
0.0 [ -0.10, 0.10 ]
-1
-0.5
0.5
Favours control
(Continued . . . )

161
(. . .
Study or subgroup
Experimental
Std.
Mean
Difference
Control
Weight
Std.
Mean
Difference
Mean(SD)
Mean(SD)
Marcus 2009
591
-0.01 (0.73)
430
0.3 (0.73)
2.8 %
-0.42 [ -0.55, -0.30 ]
Gentile 2009
582
0.6 (2.9)
619
0.5 (2.8)
2.9 %
0.04 [ -0.08, 0.15 ]
Sichieri 2009
434
0.32 (1.43)
493
0.22 (1.08)
2.8 %
0.08 [ -0.05, 0.21 ]
Subtotal (95% CI)
10435
IV,Random,95% CI
Continued)
IV,Random,95% CI
8548
65.1 % -0.15 [ -0.23, -0.08 ]
Heterogeneity: Tau2 = 0.03; Chi2 = 139.70, df = 30 (P<0.00001); I2 =79%

3 13-18 years
Ebbeling 2006
53
0.07 (1.02)
50
0.21 (1.06)
1.4 %
-0.13 [ -0.52, 0.25 ]
NeumarkSztainer 2003 (19)
84
-0.96 (3.22)
106
0.75 (2.59)
1.8 %
-0.59 [ -0.88, -0.30 ]
Haerens 2006 (20)
611
1.48 (1.55)
120
1.22 (1.29)
2.4 %
0.17 [ -0.02, 0.37 ]
Haerens 2006 (21)
381
1.11 (1.74)
176
1.66 (1.61)
2.5 %
-0.32 [ -0.50, -0.14 ]
Haerens 2006 (22)
590
1.31 (1.63)
119
1.22 (1.29)
2.4 %
0.06 [ -0.14, 0.25 ]
Haerens 2006 (23)
118
1.42 (1.62)
176
1.66 (1.61)
2.1 %
-0.15 [ -0.38, 0.09 ]
1751
2 (2.05)
1751
2 (2.05)
3.1 %
0.0 [ -0.07, 0.07 ]
Singh 2009 (24)
312
0.5 (1.37)
208
0.5 (1.55)
2.5 %
0.0 [ -0.18, 0.18 ]
Singh 2009 (25)
276
0.4 (1.22)
234
0.4 (1.3)
2.5 %
0.0 [ -0.17, 0.17 ]
Peralta 2009 (26)
16
0.3 (1.86)
16
0.6 (1.83)
0.6 %
-0.16 [ -0.85, 0.54 ]
21.2 %
-0.09 [ -0.20, 0.03 ]
Webber 2008
Subtotal (95% CI)
4192
2956
Heterogeneity: Tau2 = 0.02; Chi2 = 31.50, df = 9 (P = 0.00024); I2 =71%

Total (95% CI)
15489
100.0 % -0.15 [ -0.21, -0.09 ]
12457
Heterogeneity: Tau2 = 0.03; Chi2 = 227.83, df = 48 (P<0.00001); I2 =79%

Test for overall effect: Z = 4.92 (P < 0.00001)
Test for subgroup differences: Chi2 = 1.81, df = 2 (P = 0.40), I2 =0.0%
-1
-0.5

0.5
Favours control
162
(1) Females
(2) Males
(3) Weight-for-height z score
(4) Females only
(5) Child-targeted intervention (females only)
(6) Parent-targeted intervention (females only)
(7) Females only
(8) Females only
(9) Females
(10) Males
(11) Non-obese males
(12) Obese males
(13) Obese females
(14) Non-obese females
(15) Males
(16) Intervention A vs Control
(17) Intervention B vs Control
(18) Females
(19) Females only
(20) Intervention only; males
(21) Intervention + Parents; females
(22) Intervention + Parents; males
(23) Intervention only; females
(24) Females
(25) Males
(26) Males only

163
ADDITIONAL TABLES
Table 1. Study Design
Study
Type
Coun- Guid- Setting

try
ing
theoretical
frameworks
Care
Dennison
2004
PA
USA
Child age (at Baseline)
Education
ComHealth munity
Service
Home 0-5
years
6-12
years
13-18
years
Intervention period
12
>1
weeks- year-2
1 year years
NRX
behaviour
change
Diet
USA
Fitzgib& PA
bon
com2005
bined
SCT
Diet
USA
Fitzgib& PA
bon
com2006
bined
SCT
Harvey-
NRbehaviour
change
Diet
USA
& PA
comBerino bined
2003
Jouret
2009
Diet
NR& PA France becomhaviour
bined
change
theory
Keller
2009
Diet
Ger& PA many
combined
NRbehaviour
change
Mo-
PA
NRenvironmen-
Suwan
1998
Thailand

>2
years
164
(Continued)
tal
change
Reilly
2006
Amaro
2006
PA
Scotland
NRX
environmental
change
& behavioural
Diet
Italy
NR
Bara- Diet
USA
nowski & PA
2003 combined
SCT
and
family systems
theory
X
(summer
camp)
Beech
2003
Diet
USA
& PA
combined
SCT
and
family systems
theory
Diet
USA
Caballero & PA
2003 combined
Social
learning
theory
&
principles
of
American
Indian
culture
and
practice
NR
Coleman
2005
Diet
USA
& PA
com-

165
(Continued)
bined
Donnelly
2009
PA
USA
NRenvironmental
model
Epstein
2001
Diet
USA
NR
Fernandes
2009
Diet
Brazil
Learning
through
play
Foster
2008
Diet
USA
& PA
combined
Gentile
2009
Settings
based,
CDC
guidelines
to
promote
lifelong
HE
and
PA
Diet
USA
& PA
combined
Socioecological
theory
Gortmaker
1999a
Diet
USA
& PA
combined
SCT
Gutin
2008
PA
Environmental
change
USA

166
(Continued)
Diet
NR
Hamelink& PA Nethercom- lands
Basbined
teen
2008
Harrison
2006
PA
Ireland
SCT
James
2004
Diet
UK
NR
Kain
2004
Diet
Chile
& PA
combined
NR
Kipping
2008
Diet
UK
& PA
combined
SCT
& behavioural
choice
NR
Lazaar PA
2007
France
MaciasCervantes
2009
PA
Mexico
NR
Marcus
2009
Diet
Swe& PA den
combined
NR
Diet
GerMller
& PA many
2001
combined
NR
Diet
NR
Behavioural
Paineau
2008
Pangrazi
2003
France
PA
Mexico

167
(Continued)
Reed
2008
PA
socioCanada ecological
model
Robbins
2006
PA
USA
The
Health
Promotion
Model
and
the
Transtheoretical
Model
Diet
USA
Robin& PA
son
com2003
bined
Social
cognitive
theory
Diet
USA
Rodearmel
& PA
2006
combined
NR
Sahota
2001
Diet
UK
& PA
combined
Multicomponent
health
promotion
programme,
based
on the
Health
Promoting
Schools
concept

168
Sallis
1993
Salmon
2008
Sanigorski
2008
Sichieri
2009
PA
USA
Behaviour
change
and
selfmanagement
PA
Australia
SCT
and
behavioural
choice
theory
Diet
Aus& PA tralia
combined
Socioecological
model
Diet
NR
Simon PA
2008
Brazil
BeFrance haviour
change
and
socioecological
model
Diet
USA
Spiegel
& PA
2006
combined
Stolley
1997
(Continued)
Diet
USA
& PA
combined
Theory
of reasoned
action,
constructivism
NR

169
Story
2003a
Diet
USA
& PA
combined
(Continued)
SCT,
youth
development,
and
resiliency
Taylor Diet
New
NR
2008 & PA Zealand
combined
Vizcaino
2008
PA
NR
Warren
2003
Diet
Eng& PA land
combined
Social
learning
theory
Ebbel- Diet
ing
2006
Spain
USA
NR
Diet
BelHaerens
& PA gium
2006
combined
Theory of
planned
behaviours
&
transtheoretical
model
NeumarkSztainer
2003
Diet
USA
& PA
combined
SCT
Pate
2005
PA
Socioecological
model
&
USA

170
(Continued)
SCT
Diet
USA
Patrick
& PA
2006
combined
Behavioural
determinants
model,
SCT
&
transtheoretical
model
Peralta
2009
Diet
Aus& PA tralia
combined
SCT
Singh
2009
Diet
and
PA
combined
Webber
2008
PA
TOTALS
InterNether- venlands tion

mapping
protocol,
behaviour
change
& environmental
USA
Socioecological
framework
2
43
14

39
40
171
Table 2. Results 0-5 years
Study ID
Primary Outcomes
Secondary Outcomes
Dennison 2004
1. Fatness assessed by repeat measures of height and

weight (and calculated BMI) at baseline and after 1
year (end of intervention):
OUTCOME: No differences between intervention
and control.
2. Skinfolds:
and control.
3. Waist circumference:
and control.
4. Television Viewing:
OUTCOME: television viewing was significantly reduced in intervention group on weekdays and Sundays. The percentage of children watching > 2h per
day was also significantly decreased in intervention
group
1. Computer games playing:

and control.
2. Dietary assessment:
OUTCOME: No significant changes or differences
between intervention and control groups in the frequency of snacking whilst watching TV or the number of days family ate dinner together or watched TV
during dinner (actual data not reported)
Fitzgibbon 2005
MEASURES: BMI
OUTCOMES:
Immediately post-intervention, changes in BMI and
BMI z score were not significantly different between
intervention and control children
Intervention children had significantly smaller increases in BMI compared with control children at 1year follow-up (0.06 vs 0.59 kg/m2; difference -0.53
kg/m2 (95%CI: -0.91 to -0.14), P = 0.01), and at
2-year follow-up (0.54 vs 1.08 kg/m2; difference -0.
54 kg/m2 (95% CI: -0.98 to -0.10), P = 0.02), with
adjustment for baseline age and BMI
MEASURES: dietary intake

OUTCOMES: Reported intake of total fat and dietary fibre was similar between children in the control
and intervention groups at all assessment points
Saturated fat intake was significantly lower in intervention children at Year 1 (P = 0.002) but not postintervention or at Year-2 follow-up
MEASURES: Physical activity
OUTCOMES: No significant differences between
groups in reported frequency and intensity of exercise
MEASURES: Television viewing
groups in TV viewing at any assessment point
Fitzgibbon 2006
MEASURES: BMI
OUTCOMES: Post-intervention changes in BMI
and BMI z score were not significantly different between intervention and control children
MEASURES: dietary intake

OUTCOMES: Reported intake of total and saturated
fat and dietary fibre was similar between children in
the control and intervention groups at Year 2 followup
groups in reported frequency and intensity of exercise
MEASURES: Television viewing
groups in TV viewing at any assessment point
Harvey-Berino 2003
1. Maternal fatness assessed by repeat measures of 1. Diet 3-day food records:

height and weight (and calculated BMI) at baseline OUTCOME: No differences between intervention

172
(Continued)
and end of pilot:

and control.
2. % WHP scores > 85th and 95th percentile:
and control.
3. % WHZ scores > 85th and 95th percentile:
Jouret 2009
MEASURES: Weight, height

OUTCOMES:
Prevalence of overweight (BMI 90th percentile)
1
At end of study, 12.6% in EPIPOI-1 group was
overweight, 11.3% in EPIPOI-2 group, and 17.8%
in control (EPIPOI-1 vs control P = 0.02; EPIPOI-2
vs control P =0.003)
2
There was no difference between groups if
the schools were not in underprivileged areas, however
there was a significant intervention effect in school s
in underprivileged areas
At end of study, 12.2% in EPIPOI-1 group was overweight, 17.0% in EPIPOI-2 group, and 36.8% in
control (EPIPOI-1 vs control P <0.01; EPIPOI-2 vs
control P = 0.001)
BMI z-score
1
At end of study and among schools not in
underprivileged areas, median change in BMI z-score
in EPIPOI-1 group was +0.39, +0.22 in EPIPOI-2
group, +0.41 in control (EPIPOI-2 vs control P = 0.
01)
3
At end of study and among schools in underprivileged areas, median change in BMI z-score
in EPIPOI-1 group was +0.35, +0.50 in EPIPOI-2
group, and +1.35 in control (EPIPOI-1 vs control P
< 0.001; EPIPOI-2 vs control P < 0.001)
Keller 2009
MEASURES: Height, Weight

OUTCOMES: This study population stabilized their
BMI SDS (P < 0.025). The children randomised
in the intervention group who were not interested to
participate, and the children of the control group increased their BMI SDS within the observation period
of one year (P < 0.001, P = 0.002)
MEASURES: Diet
OUTCOMES: According to nutrition diaries a decrease energy intake of the participants of the inter-
and control.
2. Physical activity: CSA accelerometer,
and control.
3. Psychological variables: Outcomes Expectations
Self-efficacy
Intentions
Child Feeding Questionnaire
and control.

173
(Continued)
vention group was detected. The percentage of protein intake was particularly remarkable, amounting to
363% fulfilment of demand at the beginning of the
study and 274% at the end
Mo-Suwan 1998
1. Fatness assessed by weight, height (BMI, WHCU None reported

weight (kg)/height cubed), and triceps skinfold thickness at baseline, twice during intervention and at 29.
6 weeks (end of intervention).
OUTCOME: No statistically significant change between intervention and control at 29.6 weeks (end of
intervention). The prevalence of obesity, using 95th
percentile National Center for Health Statistics triceps skinfold-thickness cutoffs, of both the intervention and control groups decreased. The intervention
group decreased from 12.2% at baseline to 8.8% (P =
0.058) and the control group decreased from 11.7%
to 9.7% (P = 0.179). A sex difference in the response
of BMI to exercise was observed. Girls in the exercise
group had a lower likelihood of having an increasing
BMI slope than the control girls did (odds ratio: 0.
32; 95% CI: 0.18 to 0.56).
Follow-up data on (overall prevalence of obesity, using
95th percentile National Center for Health Statistics
triceps-skinfold thickness cut-offs in the control group
)
Prevalence of obesity
Baseline Intervention 12.9 Control 12.2
Post-intervention (29.6 wks) Intervention 8.8 Control 9.4
Six months later Intervention 10.2 Control 10.8
Data for follow-up 29.6 wks + 6 months.
School I
Six months later Intervention 13.5 Control 8.3.
School II
Six months later Intervention Intervention 9.1 Con-

174
(Continued)
trol 12.1.
It is not known (information not available) if the
changes at 29.6 weeks plus 6 months are statistically
significant . But small changes are unlikely to be clinically significant
Reilly 2006
MEASURES: BMI
MEASURES: physical activity and sedentary beOUTCOMES: No significant differences between in- haviour by accelerometry
tervention and control groups
OUTCOxMES: No significant differences between
intervention and control groups
MEASURES: fundamental movement skills
OUTCOMES: Children in the intervention group
had significantly higher performance in movement
skills tests than control children at 6 month follow-up
(i.e. immediately post-intervention) after adjustment
for sex and baseline performance
BMI: body mass index

BMIz: standardised body mass index
CI: confidence interval
Study ID
Primary Outcomes
Amaro 2006
MEASURES: Height, weight

OUTCOMES: No significant difference OUTCOMES: No significant difference
in zBMI between treated group and con- between groups post-intervention
trol group at post-assessment controlling
for baseline values. Adjusted means were 0.
345 (95% CI 0.299 to 0.390) for the intervention group and 0.405 (95% CI 0.345
to 0.465) for the control group.
MEASURES: Nutrition knowledge
OUTCOMES: Intervention group had
significant increase in nutrition knowledge
(P < 0.05) compared to control. Adjusted
means were 11.24 (95%CI 10.68 to 11.80)
for the intervention group and 9.24 (95%
CI 8.50 to 9.98) for the control group
MEASURES: Dietary Intake
OUTCOMES: Intervention group had
significant increase in weekly vegetable intake (P < 0.01) compared with control. Adjusted mean number of servings per week
was 3.7 (95% CI 3.5 to 4.1) for the intervention group and 2.8 (95% CI 2.4 to 3.

Secondary Outcomes
175
(Continued)
3) for the control group

Baranowski 2003
1. Fatness assessed by repeat measures of

height and weight (and calculated BMI) at
baseline and end of pilot:
OUTCOME: No differences between intervention and control.
3. Dual X-Ray Absorptiometry (DEXA)
for % Body fat
OUTCOME: Not reported.
1. Participation in summer camp

OUTCOME: I: 91.5% and C: 80.5%
2. Monitoring website usage (log-on rates)
.
OUTCOME: Intervention: child mean
48%, parent mean 47%; Control: child
mean 25%, parent mean 16%

OUTCOME: No differences between I
and C.
5. a modification of the Self-Administered
Physical Activity Checklist (SAPAC),
6. GEMS Activity Questionnaire (GAQ)
computerised
7. Dietary intake measured by two 24 hour
recalls using Nutrition Data System computer programme (NDS-R).
Beech 2003

for % Body fat
1. Psychological variables:
Body silhouettes McKnight Risk Factor
Survey, and Stunkard et al. 1983.
OUTCOME: No differences between intervention and control
2. Over concern with weight or shape:
OUTCOME: Intervention significantly
better than control.
3. Parental food preparation practices
4. Self-Perception Profile for Children
OUTCOME: No differences between in4. Physical activity: accelerometer CSA,
OUTCOME: No differences between intervention and control
5. Healthy Growth Study for physical actervention and control.
5. a modification of the Self-Administered tivity expectations, and a self-efficacy measure.

176
(Continued)

OUTCOME: No differences between in6. GEMS Activity Questionnaire(GAQ) tervention and control.
computerised
OUTCOME: Intervention parent group
significantly lower for sweetened drinks
compared with intervention child group
and controls
Caballero 2003

height and weight (and calculated BMI), at
baseline and after 3 years (end of intervention):
2. Triceps and subscapular Skinfolds.
3. Bioelectrical impedance.
1. Lunch Programme:
OUTCOME:
Intervention
schools
lunches had significantly less energy from
fat (4%), P = 0.005. 24 hour dietary records
showed significant reduction in energy P =
0.003 and total fat P = 0.001.
2. Physical Activity
OUTCOME: Tri Trac R3D accelerometer showed no significant differences, but
trends were in the desired direction. 24
hour recalls were significantly higher in I P
= 0.001.
3. Knowledge, attitudes and beliefs:
OUTCOME: significant improvements
were found in I, especially in the 3rd grade
(8-9 years), but Self efficacy to be physically
active was higher in I schools but choosing
healthy foods was not.
4. Family Programme
OUTCOME: families attending events
was 58%.
Coleman 2005
MEASURE: Risk of overweight and overweight

OUTCOME: The rate of increase in the
percentage of students at risk of overweight
or overweight from 3rd to 5th grades was
13% in control girls compared with 2% in
intervention girls and 9% in control boys
compared with 1% in intervention boys
MEASURE: Anthropometry
OUTCOME: No effect of intervention on
height, weight, waist-to-hip ratio or BMI.
All children had increases in these measures
from year to year
MEASURE: PE outcomes
OUTCOME: For part of the 3rd and
4th grades, intervention schools had higher
MVPA than control schools. By the end of
the 4th grade, control schools had reached
similar values to intervention schools, with
a similar pattern for the 5th grade
Intervention schools has higher vigorous physical activity (VPA) than control
schools in the fall of 4th grade and for both
5th grade semesters
MEASURE: Cafeteria outcomes
OUTCOME: At the beginning and end

177
(Continued)
MEASURE: Aerobic fitness

OUTCOME: Results for passing Fitnessgram standards were similar between intervention and control schools for the 3rd
grade. In the 4th grade, control schools
had higher rates than intervention schools,
while in the 5th grade, intervention schools
had higher rates than control schools
of the 4th grade, intervention schools had

a lower percentage of fat than control
schools. This difference disappeared by the
5th grade. Intervention schools met programme goals for fat content in school
lunches during the 2nd year of the programme, while control schools did not at
any time
No schools reached programme sodium
recommendations.
Donnelly 2009
MEASURES: BMI
OUTCOMES: No significant differences
for change in BMI or BMI percentile (baseline to 3 year) for intervention vs control
(not influenced by gender)
Schools (n = 9) with 75min of PAAC/wk
showed significantly less increase in BMI at
3 years compared to schools (n = 5) with <
75min (1.8 1.8 vs 2.4 2.0; P = 0.02)
MEASURES: Daily PA (accelerometer)

OUTCOMES: Over a 4-day average (consecutive), children in PAAC schools had
greater levels of PA (13%>) compared to
children in control schools (P = 0.007)
Children in PAAC schools had greater levels of PA during the school day (12%>; 0.
01) and on weekends (17%>; 0.001) compared with children in control schools
Children in PAAC schools exhibited 27%
higher levels of moderate to vigorous intensity PA (?4 METS) compared with children
in control schools (P = 0.001)
MEASURES: Academic achievement measured using Weschler Individual Achievement Test 2nd edition.
OUTCOMES: significant improvement in
academic achievement from baseline to 3
years were observed in the PAAC compared
with the control schools for the composite,
reading, math and spelling scores (all P <
0.01)
Epstein 2001
1. Fatness assessed by percentage of overweight (established by comparing the BMI

of the subject with the relevant 50th BMI
percentile based on the gender and age of
the subject) at baseline and at one year (end
of intervention).
OUTCOME: Children showed no significant differences in percentage of overweight with either intervention: increase
fruit and vegetable intervention (-1.10 + 5.
29) or decrease high fat/high sugar intervention (-2.40 + 5.39).
2. Dietary intake:
OUTCOME: High fat/high sugar in-

178
(Continued)
take significantly decreased across all children independent of group. Children also
showed trends toward greater increases in
fruit and vegetable intake for the Increase
Fruit and Vegetable group through the one
year study
Fernandes 2009
MEASURES: Nutritional status defined

on the basis of BMI for age and sex
OUTCOMES: No significant changes
from baseline in the prevalence of overweight/obesity (BMI?85th percentile) were
observed in either group (both p=1.0) with
no difference between groups. The percentage of overweight/obese children increased
from 21.8 to 23.6% in the intervention
group and from 33.7 to 35.0% in the nointervention group (P > 0.05)
MEASURES: Frequency of eating foods

(either 0-1 day or 2-3 days) prohibited by
School Canteens Act by self-report for two
3-day dietary recalls
OUTCOMES: The percentage of children
who ate foods prohibited by the Act on 23 days decreased in both intervention and
control groups (not significant)
MEASURES: Distribution of children eating certain foods on the two 3-day dietary
recalls
OUTCOMES: In the control group, the
percentage eating mass-produced snacks
increased (P = 0.008), while in the intervention group, this decreased (p=0.016)
In both groups, there was a significant reduction in the intake of artificial juice (P <
0.001) and chocolate (I: P < 0.001; C: P =
0.031)
There was an increase in the percentage of
children drinking soda in both intervention
and control groups (P = 0.002 and P = 0.
016)
For the percentage of children eating yoghurt, there was an increase in the intervention group (P = 0.016) and a decrease
in the control group (P = 0.016)
There was a decrease in the percentage of
children drinking natural juice in the control group (P < 0.001) and a numerical increase in the intervention group (P = 0.063)
There was an increase in the percentage
of children eating fruit in both groups,
but this was only significant in the control
group (P = 0.016 vs P = 0.25)
Foster 2008
MEASURES: Incidence of overweight and

obesity
OUTCOMES: Fewer children in the intervention schools (7.5% [unadjusted mean])
than in the control schools (14.9% [unadjusted mean]) became overweight after 2
MEASURES: Prevalence and remission of

overweight and obesity
OUTCOMES: After 2 years, the predicted
odds of overweight prevalence were 35%
lower for in the intervention group (odds
ratio: 0.65 [0.54 to 0.79]; P < 0.0001 [ad-

179
(Continued)
years (adjusted odds ratio: 0.67 [0.47 to 0.

96]; P = 0.03 [adjusted for gender, race/
ethnicity and age])
No differences between control and intervention groups in the incidence of obesity
at 2 years (P = 0.99)
The predicted odds of incidence of either
overweight or obesity were 15% lower for
the intervention group (odds ratio: 0.85 [0.
74 to 0.99]; P <0.05)
Gentile 2009
justed for gender, race/ethnicity, age])

Effect was slightly greater in black students
who, if receiving the intervention, were
41% less likely to be overweight than those
in control schools after 2 years (after controlling for gender, age and baseline prevalence)
No differences between intervention and
control groups in the prevalence of obesity
after 2 years (P = 0.48)
No difference between intervention and
control groups for combined prevalence of
overweight and obesity (P = 0.07)
No differences between groups with respect
to the remission of overweight or obese after 2 years
MEASURES: Dietary intake and physical
activity sedentary behaviours, potential adverse effects
OUTCOMES: Reported decreases in both
intervention and control schools in selfreported consumption of energy, fat, and
fruits and vegetables over 2 years with no
differences between groups
Decreases in self-reported amounts of physical activity in both intervention and control groups with no differences between
groups
MEASURES: Sedentary behaviours
OUTCOMES: Inactivity was 4% lower after 2 years in the intervention group compared with the control group after adjusting for gender, age, race/ethnicity and baseline inactivity (odds ratio: 0.96 [0.94 to 0.
99]; P < 0.01)
Weekday television watching was 5% lower
in the intervention group than in the control group (odds ratio: 0.95 [0.93 to 0.97];
P < 0.0001) after 2 years
MEASURES: Potential adverse effects
OUTCOMES: The intervention showed
no evidence of an adverse impact with respect to a worsening body image or changes
in incidence, prevalence and remission of
underweight
MEASURES: Height and Weight

OUTCOMES: No significant difference in
BMI between groups post-intervention or

180
(Continued)
at 6 months follow-up
MEASURES: Screen time
OUTCOMES: Child report (hours/week)
: No significant difference between groups
post-intervention or at 6 months follow-up
Parent report (hours/week) Significantly
lower in intervention group post-intervention (I: 22.8(0.7), C: 24.6(0.3), P <0.05)
and at 6 months follow-up (I: 23.7(0.5), C:
25.7(0.5), P <0.05) ) compared with control group
MEASURES: Fruit and vegetable consumption
OUTCOMES: Child report (servings/
week): Significantly lower in intervention
group post-intervention (I: 4.4(0.2), C: 4.
2(0.1), P < 0.05) and at 6 months followup (I: 4.1(0.2), C: 4.0(0.1), P < 0.05) compared with control group
Parent report (servings/week) Significantly
lower in intervention group post-intervention (I: 24.9(0.7), C: 22.6(0.4), P < 0.05)
and at 6 months follow-up (I: 22.5(0.7),
C: 21.3(0.3), P < 0.05) ) compared with
control group
MEASURES: Physical activity (steps/day)
OUTCOMES: No significant difference
on pedometer measures of physical activity
Gortmaker 1999a
Gutin 2008
(see Notes in Included Studies table)

height, weight, (and calculated BMI), and
triceps skinfold thickness, at baseline and
after 18 months (end of intervention) :
OUTCOME: The prevalence of obesity
among girls in intervention schools was
reduced compared with controls, controlling for baseline obesity (odds ratio, 0.47;
95% confidence interval, 0.24-0.93; P =
0.03), with no differences found among
boys. There was greater remission of obesity
among intervention girls vs control girls
(odds ratio, 2.16; 95% confidence interval,
1.07-4.35; P = 0.04)
Reestimated regressions that excluded observations with missing data and got similar results with both approaches
1. Television viewing time:

OUTCOME: Both girls and boys in the
intervention group spent less time viewing
television.
2. Dietary intake:
OUTCOME: Intervention girls reported
eating more fruit and vegetables and reduced their increase in dietary energy over
the two years of the intervention.
MEASURES: Percent body fat (%BF)

OUTCOMES:
MEASURES: Bone Mineral Density

(BMD)

Behavioural variables as explanations for

intervention effect: Regression indicated
that only change in television viewing mediated the intervention effect
181
(Continued)
1 year: %BF decreased in intervention participants with no change in control participants (adjusted change: -0.76 [-1.42, -0.
09]; P = 0.027). No significant differences
between groups for ITT analysis
Significant relationship between level of
programme attendance and change in %BF
in intervention group, with greater decreases in %BF observed with higher programme attendance (P = 0.0004)
3 year: Significant group by time interaction (P < 0.05). Intervention group reduced
their body fat during school months and
this returned to levels similar to those of
the control group after the summer months
(school vacation)

OUTCOMES:
1 year: Compared with control, intervention participants showed significantly
greater gains in BMD (adjusted change: 0.
008 [0.001, 0.015]; P = 0.023)
In intervention group greater increases in
BMD were observed with higher programme attendance (P = 0.029)
3 year: Significant group by time interaction in favour of intervention participants
(P < 0.01)
MEASURES: Fat mass
OUTCOMES:
1 year: No significant differences between
groups post-intervention
In intervention group greater decreases in
fat mass were observed with higher programme attendance (P = 0.0004)
3 year: No significant differences between groups post-intervention (data not
reported)
MEASURES: Fat-free soft tissue (FFST)
OUTCOMES:
3 year: Significant group by time interaction in favour of intervention participants
(P < 0.01)
MEASURES: cardiovascular fitness (CVF)
OUTCOMES:
1 year: Compared with control, intervention participants showed significantly
greater gains in CVF (adjusted change: -4.
4 [-8.2 to -0.6]; P = 0.025)
In intervention group greater increases
in CVF were observed with higher programme attendance (P = 0.029)
3 year: Significant group by time interactions in favour of intervention participants
(P < 0.01). The intervention group improved in fitness during school months and
this returned to levels similar to those of the
control group after the summer months
MEASURES: BMI
OUTCOMES:
3 year: Significant group by time interac-
182
(Continued)
tion, with the increase in BMI being greater

in the intervention group than in the control group (P < 0.05)
MEASURES: waist circumference
OUTCOMES:
MEASURES: CV risk factors
OUTCOMES:

OUTCOMES: BMI increase did not differ
between groups post-intervention
MEASURES: Obesity
OUTCOMES: Prevalence of obesity did
not differ between groups post-intervention
Harrison 2006

OUTCOMES: MVPA in 30 min blocks
was significantly higher (by 0.84 blocks;
95%CI 0.11, 1.57) in the intervention
group post-intervention (P = 0.03)
MEASURES: Screen time
MEASURES: Physical activity self-efficacy
OUTCOMES: Significantly higher self efficacy (by 0.86 units; 95%CI: 0.16, 1.56)
post-intervention (P = 0.03)
MEASURES: Aerobic fitness (20m shuttle
test)
James 2004
MEASURE: BMI at 1 year (end of intervention) and 3 years post-baseline (or 2year follow-up)
OUTCOME: No differences between intervention and control in the change in
BMI from baseline
MEASURE: Proportion of children over-

MEASURES: Nutrition knowledge

OUTCOMES: Higher level of knowledge
about importance of vegetables and fruit
and a healthy diet
MEASURES: Lifestyle and behaviours
OUTCOMES: Intervention group walked
more frequently to school, watched less
television, drank less soft drinks and ate less
sweets than control group
MEASURE: Carbonated drink consumption at 1 year (end of intervention):

OUTCOME: Children in intervention
classes reported fewer carbonated drinks (0.
6 glasses fewer compared with an increase
in controls of 0.2 (95% CI: 0.1 to 1.3).
MEASURE: Water consumption at 1 year
183
(Continued)
weight or obese at 1 year (end of interven- (end of intervention)

tion) and 3 years post-baseline (or 2-year OUTCOME: No differences between infollow-up), based on proportion above 91st tervention and control.
centile
OUTCOME: At 1 year, the mean percentage of overweight and obese children increased in the control clusters by 7.5%,
compared with a decrease in the intervention group of 0.2% (mean difference 7.7%,
95%CI: 2.2% to 13.1%). At 3 years, this
difference was smaller and no longer significant (Odds ratio: 0.79 (95%CI: 0.52 to 1.
21))
Kain 2004
Fatness assessed by repeat measures of

baseline and after 1 year (end of intervention):
Skinfolds:
Waist circumference:
OUTCOME: decreased significantly in intervention group by a mean of 0.9cm and
increased in controls by same amount.
Physical Fitness:
OUTCOME: Shuttle run test and lower
back flexibility both improved for boys and
girls in the intervention group compared
with controls
1. Dietary assessment: food frequency

questionnaire of 16 key items:
2. Attitudes and behaviours (14 questions
about physical activity and some about fruit
and vegetable consumption):
Kipping 2008
MEASURES: Time spent doing screenbased activities

OUTCOMES: No statistically significant
differences between intervention and control groups
MEASURES: BMI
MEASURES: Obesity (BMI > 95th percentile)
differences between intervention and control groups. However, subgroup analysis by
gender showed that the odds of being overweight post-intervention were higher in females (1.52; 95%CI: 0.37 to 6.25) than
males (0.28; 95% CI: 0.06 to 1.33)
MEASURES: Walks/cycles to and from
school

184
(Continued)

Lazaar 2007
MEASURES: Obesity status

OUTCOMES: A larger proportion of
obese children (BMI > 97th percentile) became overweight (90th <BMI <97th percentile) in the intervention group compared with control (16.3%, P < 0.05 versus
9.3%, P < 0.05)
The proportion of non obese children becoming obese or overweight was greater in
controls than in the intervention group (14.
8%, P < 0.05 versus 2.6%, P= ns)
MEASURES
OUTCOMES

MEASURES: BMI
OUTCOMES: Average BMI remained unchanged over time in both groups overall
In girls, there was a significant group*time
interaction (P < 0.01) and a significant effect of PA intervention between intervention and control in obese (-1.4% vs 0.9%;
P < 0.05) and non obese (-0.2% vs 2.1%;
P < 0.001) girls
MEASURES: BMI z-score
OUTCOMES: In boys, BMI z-score declined significantly over time only in the intervention group and was significantly different compared with controls (P < 0.001)
. In boys, there was also a significant difference between intervention and control
groups in both obese (-2.8% vs 1.5%; P <
0.05) and non obese boys (-2.4% vs 2.6%;
P < 0.01)
In girls, BMI z-score declined significantly
in all groups except for obese controls.
The decrease was higher in the intervention groups compared with control groups
for both obese (-6.8% vs -2.4%; P < 0.001)
and non obese (-3.1% vs -1.8%; P < 0.01)
girls. Changes were greater in obese compared with non obese girls (P < 0.001)
MEASURES: Waist circumference
OUTCOMES: In girls, waist circumference was affected over time, decreasing in
the intervention group and increasing in
the control group (-3.3% vs 2.8%; P < 0.
001)
In boys, waist circumference was not significantly affected over time
MEASURES: Skinfold thickness
OUTCOMES: In girls, the sum of skinfolds was significantly decreased over time
in the intervention groups in both obese (4.4%, P < 0.05) and non obese (-3.2%, P
< 0.001) girls, with a significant difference
between obese and non obese girls (P < 0.
05) and no significant changes in controls
In boys, the sum of skinfolds was not significantly altered over time
185
(Continued)
MEASURES: Fat-free mass

OUTCOMES: In girls, fat-free mass increased over time, with greater increases in
intervention children compared with controls for both obese (5.2% vs 2.4%, P < 0.
001) and non obese (4.0% vs 0.6%, P < 0.
05) girls
In boys, fat-free mass improved over time
with higher changes in the intervention
groups (obese = 6.4%, P < 0.001 and non
obese = 3.4%, P < 0.001) compared with
control groups (obese = 1.3%, P = ns and
non obese = 0.7%, P = ns), and a higher
increases in obese boys compared with non
obese boys (P < 0.01)
MEASURES: Anthropometric measure- MEASURES: Food intake

ments: height, weight, BMI, waist circum- OUTCOMES: Not reported
ference, triceps skinfold
OUTCOMES: Differences between
groups post-intervention were not tested
MEASURES: Glucose, triglycerides,
cholesterol, HDL-C, LDL-C, HOMA-IR
OUTCOMES: Intervention group decreased insulin (P < 0.001) and HOMA index (4.36 vs. 2.39, P <0.001) from baseline
to follow-up, but no difference in control
group. No other differences were reported.
Differences between groups post-intervention were not tested
MEASURES: Physical activity (steps/day,
by pedometer)
OUTCOMES: Intervention group increased their median daily steps from baseline to follow-up (15,329 to 19,910). Differences between groups post-intervention
were not tested
Marcus 2009
MEASURES: Height and weight

OUTCOMES: Prevalence of overweight/
obesity decreased by 3.2% (from 20.3 to
17.1) in intervention schools compared
with an increase of 2.8% (from 16.1 to 18.
9) in control schools (P < 0.05)
No difference between intervention and
control groups in change in zBMI
(BMIsds) post-intervention
A larger proportion of the children who

MEASURES: Physical activity measured

by accelerometry
MEASUREs: Eating habits at home measured by parental report.
OUTCOMES: Post-intervention eating
habits at home were healthier among intervention families. Significant differences
between children in intervention and con186
Mller 2001
(Continued)
were initially overweight reached normal

weight in the intervention group (14%)
compared with the control group (7.5%),
P < 0.017
trol schools were found for high-fat dairy

products (P < 0.001), sweetened cereals
(P<0.02) and sweet products (P < 0.002)
MEASURES: Eating disorders measured
by self-report.

height and weight.
OUTCOME: No significant difference between I and C from BMI data available at
baseline and 1 year. The median of the BMI
was 15.2 (intervention school) and 15.4 for
children in control schools. At one-year follow-up the corresponding data were 16.1
and 16.3 respectively.
1. Nutrition knowledge
OUTCOME: significant increase from
48% to 60% of the children.
2. Daily physical activities
OUTCOME: significant increase from 58
to 65% of the children.
3. Daily fruit and vegetable consumption
OUTCOME: significant increase from 40
to 60% of the children.
4. Daily intake of low fat food
OUTCOME: significant increase in frequency of daily intake of low fat food from
20 to 50%.
5. Decrease in TV watching
OUTCOME: significant decrease from 1.
9 to 1.6 h/day.
2. Triceps skinfold thickness

OUTCOME: Significant difference in
favour of the intervention group at oneyear follow-up (age-dependent increases in
median triceps skinfolds of the whole group
(from 10.9 to 11.3mm in intervention
schools vs from 10.7 to 13.0mm in control schools, P < 0.01). Also positive intervention impacts on percentage fat mass
of overweight children (increase by 3.6 vs
0.4% per year without and with intervention, respectively; P < 0.05)
Paineau 2008
MEASURES: Nutritional intake

OUTCOMES: Compared with controls,
participants in the intervention groups
achieved their nutritional targets for fat intake and for sugar and complex carbohydrate intake, leading to a decrease in energy
intake (children, P<0.001; parents, P = 0.
02)
MEASURES: height and weight
were found between groups in BMI or
zBMI, with a trend toward negative
changes in zBMI in all 3 groups
BMI differed in parents (group A, +0.13,
95% CI, ?0.01, 0.27; group B, ?0.02, 95%
CI, ?0.14, 0.11; control group,+ 0.24, 95%
CI, 0.13, 0.34; P =.001), with a significant
difference between group B and the control


OUTCOMES: In children, changes in
physical activity throughout the study did
not differ between groups, either for daily
screen viewing or for activities in clubs
MEASURES: Food-related quality of life
OUTCOMES: In parents, food-related
quality of life did not change differently between groups throughout the study
187
(Continued)
group (P = 0.01)
Pangrazi 2003
1. Fatness assessed by repeat measures of None reported.

2. Physical activity: accelerometer CSA,
OUTCOME: All students: PLAY & PE,
and PLAY only groups were significantly
more active than C. Girls: PLAY & PE,
and PE only groups were significantly more
active than controls
Reed 2008
MEASURES: Cardiovascular fitness (measured by 20-m shuttle run test)

OUTCOMES: The intervention group
demonstrated a significantly greater increase (20%) in fitness (20-m shuttle run)
compared with the control group (P <0.05)
MEASURES: Blood pressure (systolic and
diastolic)
OUTCOMES: Systolic blood pressure in
the intervention group decreased significantly compared with an increase in the
control group (5.7% smaller increase; P <
0.05). There was no difference for change
in diastolic blood pressure
Robbins 2006
MEASURES: Physical activity variables

(frequency, intensity, duration, and readiness)
between groups
MEASURES: Physical activity determinants (interpersonal influences, physical
activity enjoyment, self efficacy, and perceived benefits and barriers of physical activity)
OUTCOMES: The intervention group
had significantly greater social support
across time (P = 0.019). No other significant differences between groups
No other significant differences between
groups
Robinson 2003
1. Fatness assessed by repeat measures of 1. TV usage: TV, videotape and video

height and weight (and calculated BMI) at games:

MEASURES: Total cholesterol, HDL,

LDL, Apo B, C-reactive protein and fibrinogen
OUTCOMES: Although all serum variables in the intervention group decreased
more than these same variables for the control group changes failed to reach significance
MEASURES: Weight, height
OUTCOMES: BMI not different between
188
(Continued)

for % Body fat
OUTCOME: Not done

2. Total household TV usage:
less than control.
3. Ate breakfast with TV on:
4. Ate dinner with TV on:
less than control.
4. Physical activity: accelerometer CSA,

5. a modification of the Self-Administered OUTCOME: Intervention significantly
Physical Activity Checklist (SAPAC):
6. GEMS Activity Questionnaire(GAQ)
computerised
OUTCOME: Not reported
Rodearmel 2006
MEASURES: Steps per day

OUTCOMES: Steps per day increased in
all members of intervention families but
not in any members of the control families.
Intervention target girls/boys, mums and
dads, all took significantly more steps per
day on average than their control counterparts (P < 0.05)
Increases in steps/day over baseline in intervention groups approached the primary
goal of the intervention (an additional
2000 steps/day)
MEASURES: cereal consumption
OUTCOMES: Intervention families consumed approximately 1 serving of cereal/
day, double the amount consumed by control families (P < 0.05)
MEASURES: Food Intake
OUTCOMES: No significant changes in
self-reported total energy intake or in intake of any macronutrient in either group

189
(Continued)
MEASURES: Body weight/adiposity

OUTCOMES: Significant between-group
differences (P < 0.05) were found pre- to
post-study in the difference in the mean
change of all body weight/adiposity measures of primary importance for overweight
target children (%BMI-for-age, % body
fat) and their parents (weight, BMI and %
body fat). All trends were in favour of the
intervention group
When analysed by gender, significant between-group differences were found in the
difference in the mean change of both the
child- and adult-specific body weight/adiposity measures between intervention and
control for target girls and mums, but not
for target boys and dads
Sahota 2001

baseline and after 1 year (end of intervention)
OUTCOME: No differences between
groups overall (weighted mean difference
between intervention and control of 0
(95% CI: -0.1 to 0.1) overall, or when
analysed by weight status for overweight
(WMD: -0.07, 95% CI -0.22 to 0.08) or
obese (WMD: -0.05; 95% CI: -0.22 to 0.
11) children separately
2. Dietary intake:
OUTCOME: Vegetable consumption by
24 hour recall was higher in children in the
intervention group than the control group
(weighted mean difference 0.3 portions/
day, 95% CI 0.2 to 0.4). Fruit consumption was lower in obese children in the intervention group ( - 1.0, - 1.8 to - 0.2) than
those in the control group. The three-day
diary showed higher consumption of high
sugar foods (0.8, 0.1 to 1.6)) among overweight children in the intervention group
than the control
group.
3. Physical activity:
OUTCOME: Sedentary behaviour was
higher in overweight children in the intervention group (0.3, 0.0 to 0.7)
4. Psychological measures:

1. Nutrition knowledge:OUTCOME: Focus groups indicated higher levels of selfreported behaviour change, understanding
and knowledge
190
(Continued)
OUTCOME: small increase in global selfworth for obese children in the intervention
schools
Sallis 1993
1. Fatness assessed by weight, height, BMI, None reported

calf and triceps skinfold at baseline and 6,
12, 18 months.
OUTCOME: Little difference in BMI
for boys and girls between specialist and
teacher led intervention conditions (statistical significance not addressed) at 6, 12 and
18 months.
Small differences in BMI for boys and girls
between specialist-led, teacher-led conditions and usual physical education control.
(statistical significance not addressed) at 6,
12 and 18 months
Salmon 2008
MEASURES: BMI
OUTCOMES: Significant reduction in
BMI post-intervention in the BM/FMS
group compared with control (average -1.
88 BMI units less than control; P < 0.01)
. This was maintained at 6 and 12 month
follow-up
MEASURES: Weight status
OUTCOMES: On average, those in the
BM/FMS group were over 60% less likely
to be overweight or obese compared with
control (P < 0.05). This was maintained at
6 and 12 month follow-up

MEASURES: Physical activity (accelerometer)

FMS group children recorded higher levels
and greater enjoyment of PA; and BM children
recorded higher levels of PA across all four
time points.Significant average effects over
time in favour of the BM and FMS groups
compared with control (P < 0.05). This was
maintained at 6 and 12 month follow-up.
Gender was a significant moderator, with
boys showing greater increases
MEASURES: Self-reported screen behaviours
OUTCOMES: Children in the BM group
reported 229 min/week more in TV viewing on overage over time compared with
control (P < 0.05). These effects were maintained with inclusion of 6 and 12 month
follow-up data
MEASURES: Self-reported enjoyment of
physical activity (five-point Likert scale)
OUTCOMES: Children in the FMS group
reported higher average enjoyment scores
over time compared with those in the control group (P < 0.05)
MEASURES: Mastery of fundamental
movement skills
OUTCOMES: No significant intervention effects on FMS z-scores between base-
191
(Continued)
line and any of the post-intervention time

points. In girls, there was a significant effect, with those in the BM (P < 0.05) and
FMS (P < 0.01) groups recording higher
average FMS z-scores compared with those
in the control group
MEASURES: Body Image (five-point Likert scale)
OUTCOMES: No effects on childrens
happiness with their body shape and body
weight, or eating to gain weight or lose
weight in the last month. When stratified by gender, boys in the FMS group
(P = 0.003) and BM/FMS group (P = 0.
014) recorded significantly higher satisfaction with their body shape between baseline and all post-intervention time points
compared with control
Sanigorski 2008
MEASURES: Body weight

OUTCOMES: Children in intervention
population gained less weight than in the
comparison population (-0.92kg [-1.74 to
-0.11], P = 0.03)
population showed lower increases in waist
circumference than in the comparison population (-3.14cm [-5.07 to -1.22], P = 0.
01)
MEASURES: BMI-z score
population showed lower increases in BMIz score than in the comparison population
(-0.11 [-0.21 to -0.01], P = 0.04)
MEASURES: Relationship between baseline indicators of childrens household SES
and changes in childrens anthropometry
OUTCOMES: In the comparison population, lower SES was associated with a
greater weight gain (statistically significant
relationship in 19 of 20 analyses)
In the intervention population, no statistically significant relationships were observed
MEASURES: BMI
between intervention and comparison populations (P = 0.20)
MEASURES: waist/height ratio
population showed lower increases in
waist/height ratio than in the comparison
population (-0.02 [-0.03, -0.004], P = 0.
01)
MEASURES: Prevalence and incidence of
ow/ob
OUTCOMES: Prevalence of overweight/
obesity increased in both groups, and the
incidence of overweight/obesity was not
significantly different between groups
Sichieri 2009
MEASURES: change in BMI

OUTCOMES: BMI and weight increased
in both groups with no statistically significant differences between groups. Among
MEASURES: overweight and obesity

OUTCOMES: For both groups, obesity
changed from about 4 to 4.5% with no
statistically significant difference between

192
(Continued)
students overweight at baseline, the inter- groups

vention group showed greater BMI reduction and this difference was statistically significant among girls (P = 0.009)
MEASURES: carbonated SSB and juice intake
OUTCOMES: Mean intake of sodas per
class was reduced in both groups, with reduction being about four times greater in
the intervention compared with the control group (-69ml vs -13ml). Carbonated
beverage intake was significantly reduced
in the intervention group compared with
the control group (p=0.03), but fruit juice
consumption was slightly increased in the
intervention group (P = 0.08)
Simon 2008
MEASURES: BMI
OUTCOMES: intervention students
showed a lower increase in BMI (P = 0.01)
over time than control students. The differences across groups of the adjusted (by
baseline weight status) BMI changes were
-0.33 (-0.55 to -0.12) at 3 years and -0.36
(-0.60 to -0.11) at 4 years
Cumulative incidence of overweight was
lower in the intervention group than in the
control group (4.2% vs 9.8% at 4 years; P
< 0.01)
Sensitvity analyses conducted using intention to treat population to compare this
with analysis using data from only those
participants who completed the study and
similar results were observed

MEASURES: Self-reported leisure physical

activity
OUTCOMES: At 4 years, 79% of intervention students practised at least one supervised physical activity outside school PE
classes, compared with 47% of control students (P < 0.001). Supervised leisure physical activity increased in intervention students, whereas it slightly decreased in controls, with a difference across groups of
the 4-year within-group changes of 66min
(95%CI: 34 to 98) per week (P < 0.0001)
MEASURES: TV/video viewing time
OUTCOMES: Intervention students had
a greater reduction over time of TV/video
viewing than controls (P < 0.01), with a
difference in the 4-year changes of -16min
(95%CI: -29, -2) per day
MEASURES: Active commuting to/from
school
OUTCOMES: Slight increase in active
commuting observed across both groups
MEASURES: Self-efficacy and intention
towards physical activity
OUTCOMES: Intervention associated
with an increase of self-efficacy during the
first 2 years (P < 0.0001 and 0.01 at 1 and 2
years respectively) and a sustained improvement of intention toward physical activity
(P < 0.05)
MEASURES: Cardiovascular risk factors
193
(Continued)

intervention participants had a higher increase of high-density lipoprotein-cholesterol concentration at 4 years and a slight
decrease in blood pressure at 2 years. Other
biological cardiovascular risk factors were
similar between groups over time
Spiegel 2006

OUTCOMES: There were significant
shifts in BMI in the intervention group,
with a 2% reduction in overweight (BMI
> 85% for age and sex) in the intervention group. There was a significant correlation at the 0.01 level between the intervention and a reduced BMI and BMI-forage data showed that 39.4% of the comparison group and 36.4% of the intervention
group were either overweight or at risk for
overweight when measured at the baseline
interval
Significant shifts in BMI were noted in the
intervention group, with a 2% reduction
in overweight (BMI 85% for age and sex)
youth in the intervention group. Students
t test and Pearson correlations were used to
evaluate the significance of the BMI shift.
Both analyses showed a significant correlation at the 0.01 level between the intervention and a reduced BMI. Students t test
mean for the comparison group was 0.5210
(N 479; SD 1.01610, SE 0.04643)
and for the intervention group was 0.1606
(N 534, SD 0.89446, SE 0.03871).
The Pearson correlation for change in BMI
baseline to post-data measure with treatment (r 0.186; N 1013) was significant
at the 0.01 level (two-tailed).
BMI-for-age data showed that 39.4% of
the comparison group and 36.4% of the intervention group were either overweight or
at risk for overweight when measured at the
baseline interval. There was no significant
shift in the comparison group, but there
was a notable reduction in the intervention
group in overweight and at risk for overweight classification, which was most significant at the at risk for overweight (BMI-

194
(Continued)
for-age between 85% to 95%) level. There

was a 16.2% attrition rate in the comparison group (N 479 matched measures between baseline to post-data) and a 13.7%
attrition rate in the intervention group (N
534 matched).
There was no significant shift in the comparison group, but there was a reduction
in the intervention group in overweight
and at risk for overweight classification,
which was most significant at the at risk for
overweight (BMI-for-age between 85% to
95%) level
MEASURES: Fruits and Vegetable Consumption
OUTCOMES: Post-intervention, there
was an increase in fruit and vegetable consumption
in both groups from baseline levels, with a
higher increase in the intervention group
MEASURES: Physical activity levels
OUTCOMES: Physical activity levels in
the intervention group increased in both
school and home settings. Post-intervention, intervention students reported an average of 102.5 min/wk of physical activity
during the school day (up from 59min/wk
at baseline) and a mean level of 37.42 min/
d outside of the school day (up from 22.34
min/d at baseline). Physical activity levels
increased slightly in the comparison group
in reported levels of light exercise
Stolley 1997
1. Fatness assessed by weight and height at

baseline and at 12 weeks (end of the intervention):
OUTCOME: No statistically significant
change between intervention and control
1. Dietary Intake:
OUTCOME:
Significant
reductions found in intervention mothers daily
saturated fat intakes and percentage of energy from fat when compared to controls.
Also intervention girls had statistically significant reductions for percentage energy
from fat when compared to controls
Story 2003a


2. Diet: Healthy choice Behavioural Inten195
(Continued)

for % Body fat
OUTCOME: Not done.
tions:
3. Self-Efficacy for Healthy Eating
4. Diet knowledge:
OUTCOME: No differences between in- OUTCOME: Intervention significantly
tervention and control.
5. a modification of the Self-Administered
5. Physical Activity Outcomes ExpectaOUTCOME: Not reported.
tions, and a self-efficacy measure.
6. GEMS Activity Questionnaire(GAQ) OUTCOME: No differences between incomputerised
tervention and control (except physical acOUTCOME: No differences between in- tivity preference).
6. Parental reported diet
7. Dietary intake measured by two 24 hour OUTCOME: Significant differences with
recalls using Nutrition Data System com- intervention better than control: % energy
from fat and low fat food practices.
puter programme (NDS-R).
OUTCOME: No differences between in- 7. Parental reported physical activity:
Taylor 2008
MEASURES: Weight, Height

OUTCOMES:
Post-intervention: Adjusted mean BMI Zscore was lower in intervention relative to
control children by -0.12 units (95% CI: 0.22 to -0.02)
Follow-Up: Mean BMI z score (and 95%
CI) remained significantly lower in intervention children in the whole group (n =
554, -0.17; -0.25 to -0.08) and in the group
who underwent at least 1 (n = 389;-0.19;0.24 to -0.13) or 2 (n = 256;-0.21;-0.29 to
-0.14) full years of intervention
MEASURES: Prevalence Overweight and
obesity
OUTCOMES:
Post-intervention: Although the risk of
being overweight or obese (18) at yearend in intervention compared with control children (odds ratio 0.55; 95% CI: 0.
19 to 1.48) did not achieve statistical significance, more intervention children who
were overweight at baseline tended to be
classified as normal weight at year-end (12
of 49, 24%) than control children (10 of


OUTCOMES: Post-intervention average
accelerometry counts at 1 year were 28%
(95% CI: 11 to 47%) higher in intervention compared with control children after
adjusting for age, sex, baseline values and
school
Intervention children spent less time in
sedentary activity (ratio 0.91, P = 0.007)
and more time in moderate (1.07, P = 0.
001) and moderate/vigorous (1.10, P = 0.
01) activity
MEASURES: Waist circumference, blood
pressure, pulse rate
OUTCOME: No intervention effect was
observed
196
(Continued)
65, 15%). Furthermore, 10 of 158 (6%)

intervention children became overweight
during the year compared with 13 of 112
(12%) control children
Follow-up: Intervention children were less
likely to be overweight, but only in those
who were present for the full intervention
(n = 256; Relative Risk: 0.81; 95% CI: 0.
69, 0.94). 9 (10%) intervention and 10
(14%) control children became overweight
during the 2 yr after the cessation of the
intervention project. 12 (30%) intervention and 14 (25%) control children who
were overweight at baseline were not overweight at follow-up. 13 (10%) intervention and 18 (17%) control children became
overweight. 20 (30%) intervention and
20 (24%) control children became normal
weight
Vizcaino 2008
MEASURE: BMI
between intervention and control groups
MEASURES: Triceps skin-fold thickness
(TST)
OUTCOMES: Significant reduction in
TST in intervention children compared
with controls for both boys (-1.14mm;
95%CI: -1.71, -0.57; p<0.001) and girls (1.55mm; 95%CI: -2.38, -0.73; p<0.001)
MEASURES: Percentage body fat
OUTCOMES: Significant reduction in %
body fat in girls (-0.58%; 95%CI: -1.04,
-0.11; p=0.02). No significant differences
between intervention and control for boys
MEASURES: Blood pressure, total cholesterol, triglycerides, apo A and apo B

intervention children had lower apo B levels and higher apo A-1 levels
Intervention was not associated with any
significant changes in total cholesterol,
triglycerides or blood pressure, with the exception of diastolic blood pressure, which
rose in intervention versus control boys
Warren 2003

height and weight.
OUTCOME: No significant changes in
the rates of overweight and obesity were
seen as a result of the 3 different interventions (Be Smart, Eat Smart, Play Smart).
Post-intervention, the change in prevalence
of overweight from baseline was -1, +5, 0
for the Be Smart, Eat Smart, Play Smart
groups, respectively. Post-intervention, the
change in prevalence of obesity from baseline was -1, -2, 0 for the Be Smart, Eat
Smart, Play Smart groups, respectively
1. Nutrition knowledge:
OUTCOME: all conditions improved
their knowledge, I vs C not reported. No
gender differences.
2. Diet:
OUTCOME: significant increase in vegetable consumption (P<0.05) and fruit
(P<0.01). However, 24h recall showed no
significant differences between the groups
or genders at base line or at follow-up.
3. Physical activity:
OUTCOME: No intervention effect was
found in either the childrens or parents

197
(Continued)
questionnaires
Study ID
Primary Outcomes
Secondary Outcomes
Ebbeling 2006
MEASURE: BMI
OUTCOME: Change in BMI was not significantly
different between groups (mean SE: 0.07 0.14
kg/m2 for intervention group and 0.21 0.15 kg/m
2
for control group). This varied according to baseline BMI, with the intervention effect significant in
those subjects with baseline BMI > 30 kg/m2 and
a significant difference between BMI change in intervention and control subjects among those in the
upper baseline-BMI tertile (-0.63 -0.23 kg/m2 vs
+0.12 0.26 kg/m2 ).
MEASURE: Energy intake from SSB (kJ)

OUTCOME: Energy intake from SSB decreased in
intervention subjects (-1201 836 kJ) and this was
significantly different from control (-185 945 kJ)
(P < 0.0001)
MEASURE: Noncaloric beverage intake (mL)
OUTCOME: Significant increase in intervention
subjects compared with control (p=0.002)
MEASURE: Physical activity (MET)
OUTCOME: No difference between intervention
and control
MEASURE: Television viewing (hours)
and control
MEASURE: Total media time (hours)
and control
Haerens 2006; Table 3
MEASURES: BMI
OUTCOMES:
Prevalence of overweight was not different between
groups (baseline:18.5 38.8 and post-intervention:
18.6 38.9)
MALES: No significant positive intervention effects
on BMI were found
FEMALES: After 1 year of intervention, there was
a trend for a significant lower increase in BMI in
the intervention group with parental support when
compared with the control group (F = 3.04, P < 0.08)
. After 2 years of intervention, there was a significant
lower increase in BMI (F = 12.52, P < 0.05) and BMI
z-score (F = 8.61, P < 0.05) in the intervention with
parental support group compared with the control
group. There was also a significantly lower increase in
BMI z-score (F = 2.68, P = 0.05) in the intervention
with parental support group compared with in the
intervention-alone group

OUTCOMES:
MALES: school-related physical activity increased
significantly more in the intervention groups compared with the control group (P < 0.05). Using accelerometry, there were significantly lower decreases
in physical activity of light intensity in the intervention groups (-6 min/day) compared with the control
group (-39 min/day, P < 0.001). Where
time spent in MVPA remained stable in the intervention group, it significantly decreased (-18 min/
day) in the control group (P < 0.05)

FEMALES: Time spent in physical activity of light

intensity decreased significantly less in the intervention groups (-2 min/day) compared with the control
group (-20 min/day, P < 0.05)
MEASURES: fat intake, fruit, water and soft drinks
OUTCOMES:
MALES: No differences between groups
FEMALES: Decreases in fat intake and percent energy from fat were significantly higher in the intervention groups (-20 g/day) when compared with the
198
(Continued)
control group (-10g/day, P < 0.05)

In either males or females there were no positive
intervention effects on fruit, water and soft drink
consumption
Parental involvement did not increase intervention
effects
The primary outcomes were the feasibility i.e. sustainability and satisfaction of the intervention as assessed by a various satisfaction, behaviour change,
personal change and socio-environmental support
variables. All did not achieve significance except:
1. Change in Physical Activity Stage:
OUTCOME: Intervention significantly greater
than controls at 8 month follow-up only
Pate 2005
MEASURES: % of girls who reported participating MEASURES: % overweight or at-risk for overweight
in vigorous physical activity during an average of 1 OUTCOMES: No significant differences between
or more 30-minute blocks per day during the 3-day intervention and control schools at follow-up
reporting period
OUTCOMES: At follow-up, the prevalence of vigorous physical activity was greater in the LEAP intervention schools than in control schools (45% vs
36% P = 0.05) after adjusting for baseline differences. When missing data at follow-up were imputed
by applying a regression method, this prevalence difference increased in statistical significance (P < 0.05)
Patrick 2006

MEASURES: BMI
OUTCOMES: Both groups improved in all be- OUTCOMES: No differences at 12 months behaviours with no significant difference between in- tween groups for BMI z scores
tervention and control
Boys in the intervention group increased their number of active days per week (P = 0.01) compared with
control adolescents
MEASURES: Sedentary behaviours based on a composite self-report measure including time spent
watching television, playing computer/video games,
sitting talking on the telephone, and sitting listening
to music
OUTCOMES: Significant (P < 0.001) betweengroup difference for the change in sedentary behaviours (intervention -21% versus control +4.8%
in girls and intervention -24% versus control +2.4%
in boys)
MEASURES: % of energy from fat and servings per
day of fruits and vegetables
OUTCOMES: More girls in the intervention group
met the guideline for maximum % of daily calories

1. BMI
2. Diet and physical activity related behaviours
and control.
199
(Continued)
from saturated fat at 12 months. Both groups increased their daily fruit and vegetable intake with no
differences between groups
Peralta 2009
MEASURES: Height and weight
OUTCOMES: No significant differences between OUTCOMES: No significant differences between

MEASURES: Percentage body fat assessed using
Tanita body fat analyser
MEASAURES: Cardiorespiratory fitness (by 20-metre Multistage Fitness Test)
MEASURES: Physical activity measured using Actigraph accelerometers
OUTCOMES: Only significant difference was for
intervention boys to have significantly less weekend
vigorous physical activity (min/day) than comparison boys ( ?5.3; 95% CI: ?10.4, ?0.2; P = 0.045)
MEASURES: Time spent using small screen recreation measured using the Adolescent Sedentary Activities Questionnaire
MEASURES: Sweetened beverage and fruit consumption measured using a validated Food Frequency Questionnaire
Singh 2009
MEASURE: BMI
OUTCOME: No significant differences between intervention and control groups
MEASURE: Hip and waist circumference
OUTCOME: After 8 months, there were significant differences in hip circumference for intervention compared with control (mean difference in of
0.53 cm; 95% CI 0.07 to 0.98) in females. In males,
the intervention resulted in a significant difference
in waist circumference (mean difference, -0.57 cm;
95% CI, -1.10 to -0.05)
At the 20 month follow-up assessment, waist circumference in boys was significantly lower in the control

MEASURE: Aerobic Fitness

OUTCOME: No reported difference between intervention and control at 8 months
MEASURE: Consumption of sugar-containing beverages
OUTCOME: While consumption of sugar-containing beverages was significantly lower among students
of the intervention schools at both 8- and 12-month
follow-ups, there were no significant differences at
20 months
MEASURE: Consumption of high-energy snacks
OUTCOME: No significant intervention effects.
MEASURE: Screen viewing behaviour
200
Webber 2008
(Continued)
group. In girls at 20 months, there was no significant

difference between intervention and control
MEASURE: Skinfold thickness
OUTCOME: Significant difference in sum of skinfolds for intervention females compared to control
females were observed at 8 months (mean difference
-2.31cm; 95% CI -4.34 to -0.28)
In boys, there was a significant intervention effect on
triceps (-0.7mm; 95%CI: -1.2 to -0.1mm), biceps (0.4mm; 95%ci: -0.8 to -0.1mm) and subscapular (0.5mm; 95%CI: -1.0 to -0.1mm) skinfold thickness
at 20 months. In girls, there was a significant intervention effect on biceps skinfold thickness (-0.7mm;
95%CI: -1.3 to -0.04mm) and the sum of skinfold
thickness at 20 months (-2.0mm; 95%CI: -3.9 to 0.1mm)
OUTCOME: Numerical differences in screen-viewing behaviour consistently favoured students from

intervention schools at all follow-up measurements,
with statistically significant differences in favour of
boys of the intervention group at 20 months (-25
min/d; 95%CI: -50 to -0.3 min/d)
MEASURES: Active commuting to school
OUTCOMES: No significant intervention effects.

OUTCOMES: At 2 years, there was no difference
in adjusted MET-weighted minutes of MVPA between 8th-grade girls in intervention compared with
control schools. At 3 years, 8th-grade girls in intervention schools had 10.9 more MET-weighted minutes of MVPA than those in control schools (P =
0.03). The decrease in MET-weighted minutes of
MVPA in intervention schools from 6th grade to
8th grade was 6% compared with 15% in control
schools. These differences in physical activity were
seen more during weekdays than weekends
There were differences in the number of METweighted minutes of MVPA among the three largest
racial/ethnic groups. After adjusting for 6th-grade
activity differences, both MET-weighted minutes
and unweighted minutes of MVPA were higher for
white girls than for African-American and Hispanic
girls at both 2 years and 3 years
MEASURES: Body composition

OUTCOMES: Changes in triceps skinfold thickness and percent body fat were similar between intervention and control groups

201
APPENDICES
Appendix 1. Search strategies 2010
CENTRAL Issue 1, 2010

Searched 26th March 2010
Limits: CENTRAL Issue 1, 2005 - Issue 1, 2010
1. MeSH descriptor Obesity explode all trees
2. MeSH descriptor Body Weight Changes explode all trees
3. (obes*)
4. (weight gain or weight loss)
5. (overweight or over weight or overeat* or (over next eat*))
6. (weight next change*)
7. ((bmi or body mass index) near (gain or loss or change*))
8. (1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7)
9. MeSH descriptor Behavior Therapy explode all trees
10. MeSH descriptor Social Support explode all trees
11. MeSH descriptor Psychotherapy, Group explode all trees
12. ((psychological or behavio?r*) near (therapy or modif* or strateg* or intervention*))
13. (group therapy or family therapy or cognitive therapy)
14. (lifestyle or life style) near (chang* or intervention*)
15. counsel?ing
16. social support
17. (peer near2 support)
18. (children near3 parent* near3 therapy)
19. (9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18)
20. MeSH descriptor Obesity explode all trees with qualifier: DH
21. MeSH descriptor Diet Therapy explode all trees
22. MeSH descriptor Fasting, this term only
23. (diets or diet or dieting)
24. diet* near (modif* or therapy or intervention* or strateg*)
25. low calorie or (calorie next control*) or healthy eating
26. (fasting or (modified next fast*))
27. MeSH descriptor Dietary Fats explode all trees
28. (fruit or vegetable*)
29. (high next fat*) or (low next fat*) or (fatty next food*)
30. formula next diet*
31. (20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30)
32. MeSH descriptor Exercise explode all trees
33. MeSH descriptor Exercise Therapy explode all trees
34. exercis*
35. (aerobics or physical therapy or physical activity or physical inactivity)
36. fitness near (class* or regime* or program*)
37. (physical training or physical education)
38. dance therapy
39. sedentary next behavio?r*
40. (32 OR 33 OR 34 OR 35 OR 36 OR 37 OR 38 OR 39)
41. MeSH descriptor Complementary Therapies explode all trees
42. alternative medicine or (complementary next therap*) or complementary medicine
43. (hypnotism or hypnosis or hypnotherapy)
44. (acupuncture or homeopathy or homoeopathy)
202
45. (chinese medicine or indian medicine or herbal medicine or ayurvedic)

46. (41 OR 42 OR 43 OR 44 OR 45)
47. (diet* or slim*) near (club* or organi?ation)
48. (weightwatcher* or (weight next watcher*))
49. correspondence near (course* or program*)
50. (fat or diet*) next camp*
51. (47 OR 48 OR 49 OR 50)
52. MeSH descriptor Health Promotion explode all trees
53. MeSH descriptor Health Education explode all trees
54. (health promotion or health education)
55. (media intervention* or community intervention*)
56. (health next promoting next school*)
57. ((school or community) near2 program*)
58. ((school or community) near2 intervention*)
59. (family next intervention*) or (parent* next intervention*)
60. (parent* near2 (behavio?r* or involve* or control* or attitude* or educat*))
61. (52 OR 53 OR 54 OR 55 OR 56 OR 57 OR 58 OR 59 OR 60)
62. MeSH descriptor Health Policy explode all trees
63. (health next polic*) or (school next polic*) or (food next polic*) or (nutrition next polic*)
64. (62 OR 63)
65. MeSH descriptor Obesity explode all trees with qualifier: PC
66. MeSH descriptor Primary Prevention explode all trees
67. (primary prevention or secondary prevention)
68. (preventive next measure*) or (preventative next measure*)
69. (preventive care or preventative care)
70. (obesity near2 (prevent* or treat*))
71. (65 OR 66 OR 67 OR 68 OR 69 OR 70)
72. (19 OR 31 OR 40 OR 46 OR 51 OR 61 OR 64 OR 71)
73. (8 AND 72)
74. MeSH descriptor Child explode all trees
75. MeSH descriptor Infant explode all trees
76. (child* or adolescen* or infant*)
77. (teenage* or young people or young person or (young next adult*))
78. (schoolchildren or school children)
79. (pediatr* or paediatr*)
80. (boys or girls or youth or youths)
81. MeSH descriptor Adolescent, this term only
82. (74 OR 75 OR 76 OR 77 OR 78 OR 79 OR 80 OR 81)
83. (73 AND 82)
Ovid MEDLINE (1950 to March Week 2 2010)

Limits: entry date Feb 2005-search date
1. exp Obesity/
2. Weight Gain/
3. exp Weight Loss/
4. obes$.af.
5. (weight gain or weight loss).af.
6. (overweight or over weight or overeat$ or over eat$).af.
7. weight change$.af.
8. ((bmi or body mass index) adj2 (gain or loss or change)).af.
9. or/1-8
203
10. exp Behavior Therapy/

11. social support/
12. exp Psychotherapy, Group/
13. ((psychological or behavio?r$) adj (therapy or modif$ or strateg$ or intervention$)).af.
14. (group therapy or family therapy or cognitive therapy).af.
15. ((lifestyle or life style) adj (chang$ or intervention$)).af.
16. counsel?ing.af.
17. social support.af.
18. (peer adj2 support).af.
19. (children adj3 parent$ adj3 therapy).af.
20. or/10-19
21. exp OBESITY/dh [Diet Therapy]
22. exp Diet Therapy/
23. Fasting/
24. (diets or diet or dieting).af.
25. (diet$ adj (modif$ or therapy or intervention$ or strateg$)).af.
26. (low calorie or calorie control$ or healthy eating).af.
27. (fasting or modified fast$).af.
28. exp Dietary Fats/
29. (fruit or vegetable$).af.
30. (high fat$ or low fat$ or fatty food$).af.
31. formula diet$.af.
32. or/21-31
33. exp Exercise/
34. exp Exercise Therapy/
35. exercis$.af.
36. (aerobics or physical therapy or physical activity or physical inactivity).af.
37. (fitness adj (class$ or regime$ or program$)).af.
38. (aerobics or physical therapy or physical training or physical education).af.
39. dance therapy.af.
40. sedentary behavio?r.af.
41. or/33-40
42. exp Complementary Therapies/
43. (alternative medicine or complementary therap$ or complementary medicine).af.
44. (hypnotism or hypnosis or hypnotherapy).af.
45. (acupuncture or homeopathy or homoeopathy).af.
46. (chinese medicine or indian medicine or herbal medicine or ayurvedic).af.
47. or/42-46
48. ((diet or dieting or slim$) adj (club$ or organi?ation)).af.
49. (weightwatcher$ or weight watcher$).af.
50. (correspondence adj (course$ or program$)).af.
51. (fat camp$ or diet$ camp$).af.
52. or/48-51
53. exp Health Promotion/
54. exp Health Education/
55. (health promotion or health education).af.
56. (media intervention$ or community intervention$).af.
57. health promoting school$.af.
58. ((school or community) adj2 program$).af.
59. ((school or community) adj2 intervention$).af.
60. (family intervention$ or parent$ intervention).af.
61. (parent$ adj2 (behavio?r or involve$ or control$ or attitude$ or educat$)).af.
62. or/53-61
204
63. exp Health Policy/

64. (health polic$ or school polic$ or food polic$ or nutrition polic$).af.
65. 63 or 64
66. exp OBESITY/pc [Prevention & Control]
67. exp Primary Prevention/
68. (primary prevention or secondary prevention).af.
69. (preventive measure$ or preventative measure$).af.
70. (preventive care or preventative care).af.
71. (obesity adj2 (prevent$ or treat$)).af.
72. or/66-71
73. randomized controlled trial.pt.
74. controlled clinical trial.pt.
75. Random Allocation/
76. Double-Blind Method/
77. single-blind method/
78. Placebos/
79. *Research Design/
80. intervention studies/
81. evaluation studies/
82. Comparative Study/
83. exp Longitudinal Studies/
84. cross-over studies/
85. clinical trial.tw.
86. clinical trial.pt.
87. latin square.tw.
88. (time adj series).tw.
89. (before adj2 after adj3 (stud$ or trial$ or design$)).tw.
90. ((singl$ or doubl$ or trebl$ or tripl$) adj5 (blind$ or mask)).tw.
91. placebo$.tw.
92. random$.tw.
93. (matched communities or matched schools or matched populations).tw.
94. control$.tw.
95. (comparison group$ or control group$).tw.
96. matched pairs.tw.
97. (outcome study or outcome studies).tw.
98. (quasiexperimental or quasi experimental or pseudo experimental).tw.
99. (nonrandomi?ed or non randomi?ed or pseudo randomi?sed or quasi randomi?ed).tw.
100. prospectiv$.tw.
101. volunteer$.tw.
102. or/73-101
103. 20 or 32 or 41 or 47 or 52 or 62 or 65 or 72
104. 9 and 102 and 103
105. Animals/
106. exp Child/
107. Adolescent/
108. exp Infant/
109. (child$ or adolescen$ or infant$).af.
110. (teenage$ or young people or young person or young adult$).af.
111. (schoolchildren or school children).af.
112. (pediatr$ or paediatr$).af.
113. (boys or girls or youth or youths).af.
114. or/106-113
115. 104 not 105
205
116. 114 and 115

117. limit 116 to Date of Publication from 20050201-
EMBASE OVID (1980 to 2010 Week 11)

Limits: entry 2005-2010
1. exp obesity/
2. weight gain/
3. weight reduction/
4. obes$.af.
9. or/1-8
10. behavior therapy/
11. social support/
12. family therapy/
13. group therapy/
17. counsel?ing.af.
20. (children adj3 parent$ adj3 therapy).af.
21. or/10-20
22. exp diet therapy/
27. exp fat intake/
31. or/22-30
32. exp exercise/
33. exp kinesiotherapy/
34. exercis$.af.
40. or/32-39
41. exp alternative medicine/
46. or/41-45
206

51. or/47-50
52. exp health education/
60. or/52-59
61. health care policy/
63. 61 or 62
64. exp obesity/pc [Prevention]
65. primary prevention/
70. or/64-69
71. exp clinical trial/
72. exp Randomized Controlled Trial/
73. randomization/
74. exp Double-Blind procedure/
75. exp Single-Blind procedure/
76. exp Crossover procedure/
78. ((singl$ or doubl$ or treble$ or tripl$) and (mask$ or blind$)).tw.
80. placebo/
81. placebo$.tw.
82. random$.tw.
84. evaluation/
90. control$.tw.
96. prospectiv$.tw.
97. volunteer$.tw.
98. or/71-97
99. 21 or 31 or 40 or 46 or 51 or 60 or 63 or 70
207
100. 9 and 98 and 99

101. animal/
102. exp child/
103. exp ADOLESCENT/
104. exp preschool child/
105. exp infant/
111. or/102-110
112. 100 not 101
113. 111 and 112
114. 113 and [2005-2010]/py
PsycINFO 1806 to March Week 3 2010

Limits: Date Range: 2005-2010
1. exp overweight/
2. weight control/
3. obes*.tw.
4. weight gain*.tw.
5. weight loss*.tw.
6. (overweight or over weight).tw.
7. weight loss/
8. weight gain/
9. (overeat* or over eat*).tw.
10. weight change*.tw.
11. ((bmi or body mass) adj3 (gain* or loss* or change*)).tw.
12. or/1-11
13. (adolescence 13 17 yrs or childhood birth 12 yrs or infancy 2 23 mo or neonatal birth 1 mo or preschool age 2 5 yrs or school age
6 12 yrs).ag.
14. (child* or adolescen*).tw.
15. (child* or adololescen* or infant*).tw.
16. (pediatr* or paediatr*).tw.
17. (boys or girls or youth or youths).tw.
18. or/13-17
19. 12 and 18
20. exp experimental design/
21. exp clinical trials/
22. (clinical* stud* or single-blind or single blind or triple-blind or triple blind).tw.
23. (random* or clinical trial* or controlled study or double-blind or double blind).tw.
24. (matched communit* or matched school* or matched population*).tw.
25. ((control or comparison) adj group).tw.
27. matched pair*.tw.
29. prospectiv*.tw.
30. volunteer*.tw.
31. (before and after adj3 (trial* or study or studies or design*)).tw.
32. time series.tw.
208

34. or/20-33
35. 19 and 34
36. limit 35 to Date Range: 2005 to 2010
CINAHL Plus with Full Text

Limits: entry date Feb 2005 1. (MH Obesity+)
2. (MH Weight Gain)
3. (MH Weight Loss)
4. (TI obese or obesity) OR (AB obese or obesity)
5. (TI weight gain or weight loss) OR (AB weight gain or weight loss)
6. (TI weight change*) OR (AB weight change*)
7. (TI bmi N2 loss) OR (AB bmi N2 loss)
8. (TI bmi N2 gain) OR (AB bmi N2 gain)
9. (TI bmi N2 change) OR (AB bmi N2 change)
10. (TI body mass index N2 change) OR (AB body mass index N2 change)
11. (TI body mass index N2 gain) OR (AB body mass index N2 gain)
12. (TI body mass index N2 loss) OR (AB body mass index N2 loss)
13. (1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12)
14. (MH Child+)
15. (MH Child)
16. (MH Infant+)
17. (MH Adolescence)
18. (TI child* or adolescen* or infant*) OR (AB child* or adolescen* or infant*)
19. (TI teenage$ or young people or young person or young adult*) OR (AB teenage$ or young people r young person or young adult*)
20. (TI schoolchildren) OR (AB schoolchildren)
21. (14 or 15 or 16 or 17 or 18 or 19 or 20)
22. 13 and 21
23. (MH Study Design+)
24. (MH Evaluation Research+)
25. (MH Comparative Studies)
26. (MH Random Assignment)
27. (MH Random Sample+)
28. (MH Placebos)
29. (MH Clinical Trials)
30. (PT CLINICAL TRIAL)
31. clin* N25 trial*
32. clin* N25 stud*
33. latin square
34. time series
35. TX random*
36. TX matched communities or matched schools or matched populations
37. TX comparison group*
38. TX matched pair*
39. TX outcome study or outcome studies
40. TX quasiexperimental or quasi experimental or pseudo experimental
41. TX nonrandomi* or pseudorandomi* or quasirandomi*
42. TX prospectiv*
43. TX volunteer
44. (23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43)
209
45. 22 and 44
46. 45 and em 200502-
Appendix 2. Search strategies 2005
CENTRAL (on The Cochrane Library) (2005 update)

Issue 1, 2005
1. exp OBESITY/
2. exp Weight Gain/
3. exp Weight Loss/
4. obes$.af.
9. or/1-8
11. exp Social Support/
12. exp Family Therapy/
17. counsel?ing.af.
20. (children adj3 parent$ adj therapy).af.
21. or/10-20
23. exp Diet, Fat-Restricted/
24. exp Diet, Reducing/
26. exp FASTING/
35. or/22-34
36. exp EXERCISE/
38. exercis$.af.
210
44. or/36-43
50. or/45-49
55. or/51-54
65. or/56-64
67. exp Nutrition Policy/
69. or/66-68
76. or/70-75
79. exp Controlled Clinical Trials/
80. exp Random Allocation/
81. exp Double-Blind Method/
82. exp Single-Blind Method/
83. exp Placebos/
85. exp Intervention studies/
86. exp Evaluation studies/
87. exp Comparative Study/
88. exp Follow-Up Studies/
89. exp Prospective Studies/
90. exp Cross-over Studies/
211
97. placebo$.tw.
98. random$.tw.
100. control$.tw.
107. volunteer$.tw.
108. or/77-107
109. 21 or 35 or 44 or 50 or 55 or 65 or 69 or 76
110. 9 and 109 and 108
111. Animals/
112. exp CHILD/
113. exp CHILD, PRESCHOOL/ or CHILD/
114. exp INFANT/
120. or/112-119
121. 110 not 111
122. 121 and 120
MEDLINE (through Ovid) (2005 update)

Searched 12 February 2005/16 February 2005
1. exp OBESITY/
2. exp Weight Gain/
3. exp Weight Loss/
4. obes$.af.
9. or/1-8
17. counsel?ing.af.
21. or/10-20
212

26. exp FASTING/
35. or/22-34
36. exp EXERCISE/
38. exercis$.af.
44. or/36-43
50. or/45-49
55. or/51-54
65. or/56-64
69. or/66-68
76. or/70-75
213

79. exp Controlled Clinical Trials/
80. exp Random Allocation/
81. exp Double-Blind Method/
82. exp Single-Blind Method/
83. exp Placebos/
85. exp Intervention studies/
86. exp Evaluation studies/
87. exp Comparative Study/
88. exp Follow-Up Studies/
90. exp Cross-over Studies/
97. placebo$.tw.
98. random$.tw.
100. control$.tw.
107. volunteer$.tw.
108. or/77-107
109. 21 or 35 or 44 or 50 or 55 or 65 or 69 or 76
110. 9 and 109 and 108
111. Animals/
112. exp CHILD/
115. exp INFANT/
121. or/112-120
122. 110 not 111
123. 122 and 121
124. limit 123 to yr=1990-2005
EMBASE (2005 update)

Dates 1990 to 2005
1. exp OBESITY/
214
2. exp Weight Gain/

3. exp Weight Loss/
4. obes$.af.
9. or/1-8
17. counsel?ing.af.
21. or/10-20
26. exp FASTING/
35. or/22-34
36. exp EXERCISE/
38. exercis$.af.
44. or/36-43
50. or/45-49
215
55. or/51-54
65. or/56-64
69. or/66-68
76. or/70-75
77. exp Clinical Trial/
78. exp Randomized Controlled Trial/
79. exp Randomization/
80. exp Double-Blind procedure/
81. exp Single-Blind procedure/
82. exp Crossover procedure/
84. ((singl$ or doubl$ or treble$ or tripl$) and (mask$ or blind$)).tw.
86. exp PLACEBO/
87. placebo$.tw.
88. random$.tw.
90. exp Evaluation/
96. placebo$.tw.
97. random$.tw.
99. control$.tw.
106. volunteer$.tw.
107. or/77-107
216
108. 21 or 35 or 44 or 50 or 55 or 65 or 69 or 76
109. 9 and 108 and 107
110. Animals/
111. exp CHILD/
114. exp INFANT/
120. or/111-119
121. 109 not 110
122. 121 and 120
123. limit 122 to yr=1990-2005
PsycINFO (2005 update)

Date 1990 to 2005
1. exp OBESITY/
2. exp Weight Gain/
3. exp Weight Loss/
4. obes$.af.
9. or/1-8
17. counsel?ing.af.
21. or/10-20
26. exp FASTING/
217

35. or/22-34
36. exp EXERCISE/
38. exercis$.af.
44. or/36-43
50. or/45-49
55. or/51-54
65. or/56-64
69. or/66-68
76. or/70-75
77. 21 or 35 or 44 or 50 or 55 or 65 or 69 or 76
78. Animals/
84. or/79-82
85. 9 and 77 and 84
86. 85 not 78
218
CINAHL (2005 update)

Date 1990 to 2005
1. exp OBESITY/
2. exp Weight Gain/
3. exp Weight Loss/
4. obes$.af.
9. or/1-8
17. counsel?ing.af.
21. or/10-20
26. exp FASTING/
35. or/22-34
36. exp EXERCISE/
38. exercis$.af.
44. or/36-43
50. or/45-49
219

55. or/51-54
65. or/56-64
69. or/66-68
76. or/70-75
77. exp study design/
78. exp evaluation research/
79. exp comparative studies/
80. exp Random Assignment/
81. exp Random sample/
82. exp Placebos/
86. (clin$ adj25 (trial$ or stud$)).mp. [mp=title, cinahl subject headings, abstract, instrumentation]
91. placebo$.tw.
92. random$.tw.
94. control$.tw.
101. volunteer$.tw.
102. or/77-101
103. 21 or 35 or 44 or 50 or 55 or 65 or 69 or 76
220
104. Animals/
105. exp CHILD/
108. exp INFANT/
114. or/105-113
115. 9 and 103
116. 115 and 102 and 114
117. 116 not 104
WHATS NEW
Last assessed as up-to-date: 22 September 2010.
Date
Event
Description
1 August 2013
Amended
Republished under new editorial group (from Heart to Public Health Group), with no changes to the
text of the review
HISTORY
Protocol first published: Issue 4, 1999
Review first published: Issue 1, 2001
Date
Event
Description
27 May 2011
New citation required but conclusions have not changed In this update, we reran the search for studies up to March
2010 and 36 additional new studies have now been included (the previous version of this review included 22
studies, however three of the original 22 studies have now
been moved to excluded studies). A meta-analysis has
been conducted and demonstrates marked heterogeneity,
but with estimates of effects that are unlikely to be due to
chance. Data extraction has been expanded in this review
update to include a variety of implementation factors
to aid contextualisation and utilisation of findings.
3 July 2008
Amended
Converted to new review format.

221
(Continued)
1 July 2005
New search has been performed
Search strategies run in February 2005. The inclusion

criteria were changed to exclude studies published before
1990.
Twelve new studies were included. Three long-term studies of 1 year or more (Caballero 2003; James 2004; Warren
2003) and nine short-term studies of 3 months to 1 year
(Baranowski 2003; Beech 2003; Dennison 2004; Harvey-Berino 2003; Kain 2004; Neumark-Sztainer 2003;
Pangrazi 2004; Robinson 2003; Story 2003).
One study (Simonetti 1986) was excluded because it was
published before 1990. This study had been included in
earlier version of this review.
The conclusions were amended slightly, but the main direction and intent of the conclusions did not change. The
background section was updated. The methodology used
for this update was changed to include additional search
terms and information from study evaluations in keeping with the broader approach of health promotion and
public health reviews
1 April 2002
New search has been performed
Search strategies were rerun and review content updated

accordingly
CONTRIBUTIONS OF AUTHORS
Elizabeth Waters lead the review process, provided the overall structure and process, provided advice with data extraction, meta-analysis
and data synthesis decisions, helped to write the review text and contributed to previous versions of this review.
Andrea de Silva-Sanigorski lead the review process, extracted data, performed the meta-analysis, performed data synthesis, and wrote
the review text.
Belinda Hall extracted data, helped with the meta-analysis, performed data synthesis and wrote the review text.
Tamara Brown helped with data extraction, commented on the final review and contributed to previous versions of this review.
Karen Campbell helped with data extraction, commented on the final review and contributed to previous versions of this review.
Gemma Gao helped with data extraction and commented on the final review.
Rebecca Armstrong worked on the amended protocol, provided searching advice, helped to develop the extraction template and
commented on the final review.
Lauren Prosser helped with searching, data extraction and commented on the final review.
Carolyn Summerbell commented on the final review and contributed to previous versions of this review

222
DECLARATIONS OF INTEREST
There are no conflicts of interest to report.
SOURCES OF SUPPORT
Internal sources
School of Health and Social Care, University of Teesside, UK.

School of Population Health, University of Melbourne, Australia.
Centre for Physical Activity and Nutrition Research, Deakin University, Australia.
Jack Brockhoff Child Health and Wellbeing Program, Australia.
External sources
Department of Health, UK.
World Health Organisation, Switzerland.
Victorian Health Promotion Foundation (VicHealth), Victoria, Australia.
Commonwealth Department of Health and Ageing, Australia.
National Health and Medical Research Council Capacity Building Grant, Australia.
The Jack Brockhoff Foundation, Australia.
Karen Campbell is supported by a VicHealth Fellowship, Australia.
Andrea de Silva Sanigorski is funded by an NHMRC Capacity Building Program for Child and Adolescent Obesity Prevention,
Australia.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

Previous versions of this review recorded the following differences between the protocol and the review : Duration referred to the
intervention itself or to a combination of the intervention with a follow-up phase. However, in light of the very small numbers of studies
(n = 3) that met this criterion for the first version of this review (published in 2001) we changed the criteria to include shorter term
studies with minimum duration three months. We reviewed our protocol in light of the Cochrane Guidelines for Health Promotion
and Public Health Reviews (Armstrong 2007) and changed the inclusion criteria of this study to exclude studies published before 1990.
For this update, the minimum duration of 12 weeks was maintained. In previous versions of the review the 12-week duration referred
to the length of the intervention itself or to a combination of the intervention with a follow-up phase. For this review update, studies
were required to have minimum intervention duration of 12 weeks, meaning that one study that had been included in previous versions
of this review was excluded. The reviewers are aware of susceptibility of post hoc questions to bias (Alderson 2005).
In the previous version of this review, and as specified in the protocol, studies were categorised into long-term (at least one year) and
short-term (at least 12 weeks), referring to the length of the intervention itself or to a combination of the intervention with a follow-up
phase. For this review update, studies were categorised based on target age group (0-5 years, 6-12 years, and 13-18 years) rather than
study duration, to enhance utility of this review for decision makers.

223
INDEX TERMS
Medical Subject Headings (MeSH)
Adiposity [physiology]; Life Style; Obesity [ prevention & control; psychology]; Randomized Controlled Trials as Topic; Treatment
Outcome
MeSH check words

Adolescent; Child; Child, Preschool; Humans

224

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Cochrane Database of Systematic Reviews

Interventions for preventing obesity in children (Review)

Interventions for preventing obesity in children (Review)

Interventions for preventing obesity in children (Review)

Interventions for preventing obesity in children

Data collection and analysis

improvements in nutritional quality of the food supply in schools

PLAIN LANGUAGE SUMMARY

Description of the condition

Interventions for preventing obesity in children (Review)

Modifiable determinants of childhood obesity

Description of the intervention

Why it is important to do this review

Interventions for preventing obesity in children (Review)

Evaluation of demographic characteristics of participants

Evaluation of particular process indicators (i.e. those that

Evaluation of contextual factors contributing to the

Criteria for considering studies for this review

We included studies of interventions or programmes that involved

Interventions within the community, school and out of school

There was no restriction on who delivered the interventions, for

Indicators of theory and process

Interventions for preventing obesity in children (Review)

We excluded studies of interventions designed specifically for the

weight and height

Search methods for identification of studies

Searching other resources

We searched the following websites during March 2010 to identify

A Review Advisory Group was formed to aid in the decisions made

Reference lists checked

We scanned the reference lists of systematic reviews (identified

Studies were not excluded on the basis of language. Complete

Data collection and analysis

Interventions for preventing obesity in children (Review)

eration to be at low risk when studies clearly specified a method for

Measures of treatment effect

Interventions for preventing obesity in children (Review)

limit comparisons between studies, we therefore, did not perform

studies tables and summarised in the results section.

Results of the search

Interventions for preventing obesity in children (Review)

Interventions for preventing obesity in children (Review)

Fifty of the 55 included studies were set in high-income countries,

Risk of bias in included studies

Interventions for preventing obesity in children (Review)

Selection bias (sequence generation and allocation

terventions that they were enrolling in (NeumarkSztainer 2003).

Performance and Detection bias (blinding)

Interventions for preventing obesity in children (Review)

separated from the intervention itself such as who delivered the

We assessed studies with a published protocol that confirmed all

Risk of bias for studies included in the meta-analysis

Interventions for preventing obesity in children (Review)

included in the meta-analysis. A funnel plot was also generated

weeks versus >12 weeks) (Figure 7) and by randomisation (Figure

Interventions for preventing obesity in children (Review)

Interventions for preventing obesity in children (Review)

Interventions for preventing obesity in children (Review)

Interventions for preventing obesity in children (Review)

Interventions for preventing obesity in children (Review)