child obesity final

8/3/2019 Child Obesity Final

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SHERMEEN KHAN

CONTACT

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[email protected]

SKYPE ID:shermeen35

Introduction to summaries of chapters and other contents sub headings:

Chapter one:

This chapter discuss the main background of the study also summaries the reasons why obesity is a

problem to children especially from Asian countries communities living in UK. It summaries the main

rationale of the study and establish a base for the purpose of improving the nutritional stature of

children and physical activities in promoting their life expectancy.
mailto:[email protected]:[email protected]


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Chapter Two:

This chapter explores the main themes of the study and provides literatures regarding previous studies

that explain and answered the research question regarding childhood obesity and its management. It

also looks at certain studies that involved management of the problem inform of comparison and look at

some other studies in certain countries of the world.

Chapter Three:

This chapter explores the main inclusion and exclusion criteria for the study and explain the search

strategies employed for the identification of the articles relevant to the population of interest and main

method for collection of data synthesis.

Chapter Four:

These chapter summaries the main articles used for the review as contain in chapter three of the study

fig 1, and identified all the dependent and independent variables of the study. It also shows the themes

of the study and explains how they were related to the systematic review for the study.

Chapter Five:

The findings of the studies were discussed in this chapter; it as well identifies the limitation bias and

examines the ethical considerations with over roll quality assessment of the study. The chapter makes

possible conclusions and recommendations for the purpose of improving the well being of the public

and implementation by the health care providers. Similarly, ways by which results of the dissertation will

be disseminated are as well suggested and a brief reflection about current practices and any indication

of what is new, from the authors point of view.

CHAPTER ONE:

1.1 INTRODUCTION:According to the British Medical Association (BMA 2005) , there were approximately 1 million obese

children under the age of 16 in the United Kingdom (UK) in 2005. However, estimates of the incidence of

childhood obesity within the UK vary for a variety of reasons. (Hillier, Pedula et al. 2007) noted that it

may be underestimated and under-reported due to the unwillingness of children and possibly their

parents to participate in measuring their weight. As well as this, there are different ways of defining

childhood obesity: Obesity is not easy to define in children due to variations in the ratio between weight

gain and height gain during normal childhood growth. The best way to define Childhood obesity and

overweight is by considering the body mass index of the affected child. When the body mass index (BMI)

is above a normal weight as described by the Centre for Disease Control and Prevention, the individual is

said to be overweight and have a greater tendency of becoming obese (Etelson, Brand et al. 2003).Similarly, another factor that defines obese and overweight is the differences in body fat between boys

and girls and differences in body fats according to ages ranges among boys and girls. Childhood obesity

and overweight are defined using (BMI) by calculating the weight and height of the child since BMI do

not measure body fat directly, it only gives a reasonable indication of body fatness in some children and

teens (Prevention 2011). Weight statuses of a child are determined by age and sex of the child at a

specific percentile of BMI as described by the CDC growth chart (Index 2009).Therefore a child can be

described as an overweight when BMI are at or above the 85th percentile and lower than the 95th


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percentile specific to children of the same age and gender (Barlow, Bobra et al. 2007). Similarly, an

obese child is one that attains BMI at 95th percentile for children of the same age and gender (Barlow,

2007). Obesity can be also be defined as a condition where an individuals body fat stores are enlarged

to an extent that impairs health (Garrow&Summerbell, 2000).

John Mclennan argues that the there is more than 85th percentile of children who are overweight and

abut more than 95th percentile are obese. There are many reasons of child obesity and it occurs in

almost every country. And it directly affects the bones and is the cause of many heart diseases. The

most important is the asthma attacks which are caused in the over weighted children (Hughes anr Railly

2008).

One of the major issue behind this is that parents are too much ignorant about their children health

issues. Regular checkups are not conducted properly and they give less importance to the regularly

checking of the childs weight.

Obesity is usually measured by the Body Mass Index (BMI). It is the ratio of weight and height.

Weight (kg)/height (2/m). When BMI becomes higher than the normal average rate then we say that

child is overweight and can become obese.

Arch Pediatr Adolesc Med (1996) says that watching television and the advancement in the technology

is the main reason of child obesity. Computers, play stations, video games and such indoor games has

increased the positive impact on the relationship of obesity and technology. Moller and Berger (2003)

says that obesity is easily handled by some proper measures and care especially by parents, the

regularity of physical exercise, maintaining proper and healthy eating habits as the obesity after effects

are so much dangerous.( Reilly Armstrong et al.2005)

Rony Caryn Robin (Feb 2010) says that child obesity is the reason of early deaths even below the age of

55 in adults because of the diseases like high blood pressure and diabetes in children. In U.S.A, the


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campaign is started in order to vanish the factor of obesity among the children thus creating the better

new generation as the disease is causing everyone to disqualify from the armed forces, nonetheless

these extra healthy children will be considered as the dead soldiers of the U.S army. The important

reason behind this is the use of artificial preservatives and colors in the food. This is the case of those

families who have the finances from the ownership, not from the wages. This occurs in case of highly

developed countries but the same problem also arises in developed as well as the under developed

countries. And the reason here is the poverty and also the illiteracy. The poverty of opportunities is

analyzed primarily in relation to access to corresponding inputs such as health care, sanitation facilities

and starvation issues. Amartya Sen has explained the many dimension of poverty as the lack of

capability the capability to overcome violence, starvation, ignorance, diseases, disparity and

voicelesness.

1.2 BACKGROUND:

The concept of childhood obesity involved environment, agents and host, as well as the interactions that

exist between those factors, this help in understanding the epidemic of the diseases (Guillermo &

Melendez, 2011).In the popular media both in the UK and worldwide, a variety of claims about thecauses of childhood obesity can be found, for example blaming childhood obesity on parents neglect

(Martin, 2008 #508), lack of childrens exercise (Hawkes, 2007 #507), and ineffective Government

intervention (Rogers, #510). Many of these claims appear to be emotive and simplistic, however, and

careful scrutiny is required to assess the validity of these. A broader search is therefore required in order

to gain a more balanced and evidence-based perspective on the causes of childhood obesity. Whiting

(2008) provides a useful summary of the causes of childhood obesity, suggesting that the majority of

children who become obese do so as a result of an inappropriate diet and a lack of physical exercise.

Interestingly, Lempert (Lempert, 2002 #509) suggests that marketing by food companies may be a factor

in causing the rise of childhood obesity. It should be noted that although he is writing from a US

perspective, his comments may nevertheless be relevant in the UK.

Why is childhood obesity and overweight a problem in UK?

In UK Almost 67% of the populations are overweight or obese, so there is a dire need to look into the

matter on how to combat the problem among children for sustainable life (Edmunds, 2001 #511).The

scale of the epidemic, outlined in a health select committee report last month, may have come as a

shock to many, but for pediatrics physiotherapists all around the UK, the gloomy picture it paints is all

too familiar (Allison et al., 2008).


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According to the final report of the committee, the number of obese people in England has multiplied

for about 400 times when compared to the last 25 years. Currently about 3.7 billion pounds are spent

yearly for obesity only and about 3.8 billon for overweight yearly. This amount to 7.4 billion pounds

spent for both obesity and overweight. It seriously affects the economy of England greatly (Martel,

2011). The rising figure of obesity among the young is of more particular concern, with the committees

report citing the case of a three-year-old girl who died at a London hospital of heart failure. Extreme

obesity, exacerbated by a genetic defect, has been cited as a contributory factor for the girl (Edmunds,

2001 #511).

In order to look in to the problem of childhood obesity and overweight among UK communities, an

investigatory advisory committee was set up recently in order to bring necessary advice on how to

tackle the problem through collaborative effort of health professionals, educational sectors and to work

together for the alarming rise in the number of overweight and obese children (Edmunds, 2001 #511).

The problem of obesity has been shown to be due to lack of proper monitoring of the affected child

when start to manifest the sign of overweight. This problem equally lies in hands of the parents due to

lack of necessary monitoring which resulted into overweight and obese children and could have been

avoided if tackled at the early age (Gortmaker, 1993 #512).If this problem is not checked, there is

greater tendency to have more blind people, people demanding for amputation and more demand of

kidney dialysis (Edmunds, 2001 #511).Likewise, the life expectancy of children will also drop drastically.

Similarly, if the trend continues; obesity may surpass smoking as the greatest cause of premature death.

It is therefore very necessary to look in to new initiatives for the government to convert the deadly

diseases (Gortmaker, 1993 #512).

1.3 Rationale of the study:

There has been an increasing prevalence of overweight and obesity among children and adolescents in

the European Union (EU) for the last 20 years (James, 2001 #513).According to health survey an

estimated number of cases regarding childhood obesity and overweight just within the UK aloneisaround three in ten boys and girls aged 2 to 15 and were classed as either overweight or obese 31% and

29% respectively, which is very similar to the HSE 2007 findings 31% for both boys and girls. The NHS

Information Centre, Lifestyles Statistics in 2010 (Ogden, #514).More recent 10 years records indicate

that about 18% of European school children are overweight, with an annual rise to about 2% yearly

(Lobstein, 2004 #486). Similarly, among the overweight children, more than 2.99 million are estimated

to be obese with an increase of 85000 cases yearly (Cole, 2007 #515). The associated risk factors of

overweight and obese children are fatty liver disease, type 2 diabetes and endocrine and orthopaedic

disorders (Lobstein, 2004 #486). Overweight children may enters adulthood with a raised risk of

cardiovascular diseases, adult obesity, and a range of other disorders including psychiatric problems

(Ells, 2005 #516) with an increased rate of mortality among those adults that were obese during their

adolescent years (Must, 1999 #517). The evidence base for effective prevention of child obesity is Pooras reported by several studies (Campbell, 2002 #496).

1.4.1 AIMs:


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This systematic review will gather the current evidence base outlining the interventions to manage and

prevent the further progression of diseases that may arise as a result of childhood obesity and

overweight problems in adulthood.

1.4.2 Objectives:

To collect the evidence based data in order to find out the most suitable approach that can be

employed in the prevention and management of childhood obesity and overweight.

To synthesize the recommendations proposed by selected studies to help policy makers and

health professionals on how to control the risk factors of childhood obesity and overweight.

To develop recommendations with reference to the selected studies as outlined that will assist

parents about the possible relationship that exists between childhood obesity and overweight.

Review Questions

This review aimed to address the following research questions:

What role do physical activities and diet play in prevention and control of obesity and

overweight among children?

Is there any relationship between childhood obesity and overweight regarding dietary

behaviour?


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Chapter: Two (Literature Review):

2.1 REVIEW OF LITERATURE METHODOLOGY

2.1.1 METHODOLOGY:

Literature review has been defined as a process of gathering information, documenting, evaluating,and presenting the information in a systematic manner for the purpose of exploring relevance work

done in a specific field of interest. It is a research article that identifies relevant studies, appraises their

quality and summarizes their result using a scientific methodology (Modell, 2008 #518).It gives the

supervisor an idea on the knowledge of the students towards the research field of interest. This will

enable the supervisor to be able to critically analyze and interprets the students performance in a piece

of research. Therefore, literature review allows a researcher to critically evaluate previous research and

summarised the findings, evaluate and present it in a simple and direct form. This will enable anyone

else reading the paper is able to acknowledge and establish the possible reasons of pursuing the

particular research. In general, good literature review should be able to expand upon the reasons behind

selecting a particular research question (Shuttle& Worth, 2009). For the purpose of evaluating the

different interventional approach employed for controlling and managing childhood obesity and

overweight among UK communities, difference preventive and control approaches will be systematically

reviewed. Different data base source will be used in searching for relevance information related to

childhood obesity and overweight, this will include PUB MED, Med Line, Cochran library, yahoo search

engine, and CINAL will be used. Similarly, printed copies of articles from journals, online journals,

relevance interventional programmes regarding obesity and overweight for schools children will be

obtain, government documents and policies regarding management and prevention of childhood

obesity and overweight were accessed, other documents regarding feeding behaviour were accessed,

publications from printed journals were used. Other means are through nongovernmental organisations

reports such as WHO, UNICEP, AVERT, and many other control programmes targeting childhood obesity

and overweight were used. Term used in accessing the articles in the search engine are: childhood

obesity management, overweight and obesity, prevention of obesity in children, relationship between

childhood obesity and overweight, long term effect of obesity, complication of obesity in children, risk ofoverweight and obesity, factors responsible for childhood obesity and many others. The research is

mainly focused on the prevention and management of childhood obesity and overweight with particular

reference to UK.

2.2 Justification of the research

Obesity has been reported to rise at an alarming rate. Already, about one-third of children with two

thirds of adults in England are overweight or obese. If trends continue as forecast, by 2050 only one out

of ten adults will be a healthy weight. In response to the rising reported cases of obesity, the

Government has set out strategies aimed at reducing the level of obesity among children and allindividuals and maintain be able to maintain healthy weight. The focus was aimed at children at age of

11 in which the Governments target at reducing the percentage of obese children to about 2000 levels

within the period of 2020. There is a unique opportunity to influence the lifestyles of these children and

the environment in which they are raised from birth. Healthy Lives, Healthy Weight: A Cross-

Government Strategy for England has been announced targeted at reducing the level of obesity among

children and adolescent and budgeted about 372 million for a major programme of measures,

including increased funding for pregnancy and early years, promoting a culture of healthy eating in


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schools, the development of Healthy Towns and building more cycle lanes and safe places to play.

Healthy Weight, Healthy Lives similarly announced 75 million for a three-year social marketing

campaign. The focus of the campaign was on prevention and it sets out to change the behaviours and

circumstances that lead to weight gain, rather than being a weight-loss programme for the already

obese. At the same time, it will of course influence the behaviours of todays children, leading to a

gradual decrease in the prevalence of obesity among the children and adolescent. It is therefore very

important to look at the best strategic way at which health in equalities are overcome among different

population for the purpose of maintaining good being of children and avoiding adult obese from

childhood.

2.2. Literature review:

Aetiology:

Obesity results from an increase in number or size of adipocyte cells. This is caused by a positive energy

balance, i.e. more energy is ingested than is used by the body. Obesity causes can be split into primary

or secondary causes. Primary obesity has no underlying medical condition associated with it and is

caused by an interplay of genetic and environmental factors. Secondary obesity is rare and is associated

with a number of syndromes and endocrine disorders (Chu, 2007 #522).

Prevalence:

According to a study the level of obesity is continuously rising within the United Kingdom. The

prevalence has increased from 6% within male and 8% in females during the year 1980 as reported by

(Lustig, 2003 #523) to 23.6% in male and 23.8% in females in 2004 in Health Survey for England

(Sproston, 2006 #524). Similarly, between 1995 and 2003 obesity prevalence among children aged 2 to

10 years old increased from 9.9% to 13.7% (Webber, #525). Previous data documented during the

period of 1997 and 2003 in UK regarding childhood obesity and overweight revealed that, children from

low economic background shows higher prevalence increase risk of obesity compared to these children

from higher income background (Stamatakis, 2005 #526).

However it is documented that in most of the European countries like Scandinavia parts, the prevalence

of childhood obesity is low compared to Mediterranean parts where the prevalence of childhood obesity

is high, all alone; childhood obesity is continually rising (Livingstone, 2001 #527). Similarly, in all Eastern,

Central and Middle East of Europe, childhood obesity prevalence is high (James, 2004 #528).

Furthermore, proportion of overweight children shows a higher percentage of girls than boys in both

developed and developing countries especially among adolescent (Dehghan, 2005 #529).

1.2.1 Epidemiology of childhood obesity and overweight worldwide trends:

The recognition of the obesity epidemic took some time before the world perceives it as a global health

concern. Only during 1997 when WHO recognized that, obesity was a major public health problem

worldwide (James, 2004 #505).A study documented school age children trends towards obesity in some

60 countries around the world using IOTF criteria, the result shows that prevalence of childhood

overweight had increased in almost all countries for which data was available, with only exception from

countries like Poland and Russia within 1990s (Lobstein, 2004 #486). Similarly, there has been an

increase in overweight and obesity among more economically developed countries and in urbanized

locations (Lobstein, 2004 #486). The prevalence has shown to be more in countries like North America,

Europe, and Western Pacific (approximately 20-30%). Similarly, South and Central America, Northern

Africa and Middle Eastern countries fell in between and South East Asia and much of sub-Saharan Africa

appeared to have the lowest prevalence (Lobstein, 2004 #486).


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1.2.2 Consequences of childhood obesity:

From the report on National Centre for Health Statistics, about 35% of children and adolescents in US

were obese or overweight just within 2004 (Ogden, 2006 #514). As a result of this compounding issue, it

was reported that physical activity trends have shown that adolescents and children are less fit, less

active and less healthy when compared with the previous passed generations (DH, 2009 #487). Due to

the combinations of factors like body mass increase and decrease in physical activity, it was suggested

that imbalance in energy may be the central determinant of obesity epidemic affecting the youth of

developed countries (Llorens-Martin, 2008 #530). Other associated issues related to imbalance include;

colon cancer, metabolic syndrome and type 2 diabetes (Rosenstock, 2005 #531). Similarly, more recent

data suggested that certain mental health issues may be related to poor health status of the children

(Ludwig, 2007 #532). Childhood obesity and overweight are also associated with certain co-morbidities,

including cardiovascular disease (CVD), type 2 diabetes and other cancers types (NHS, 2010).

Thus the rising prevalence of childhood obesity has become a major global public health concern in both

developed and developing countries. About 30% of coronary heart disease (CHD) and ischemic stroke

with almost 60% of hypertensive disease in developed countries attributable to excess body mass index

(Ogden, 2006 #514). It was reported that about 32% of children and adolescents in the United States areabove the percentile of 85th percentile of BMI as represented in the body mass index growth chart

((Hedley, 2004 #533) and (Ogden, 2006 #514). Additionally, in the UK, records of 2004 indicate about

29% of childhood obesity within children of age 5-17 years old according to British Health Foundation in

2008 (Whitaker, 1997 #534). Excess adiposity has been reported to transfer from childhood into adult

life with the risk of developing obesity at adult age (Singh, 2008 #535). This relationship has been shown

to be complex however, with the likelihood of obesity persistence related to gender, the severity of

obesity and the age at which it is first present. There has been much assumption that childhood obesity

is a major risk factor for cardiovascular diseases during adulthood (James, 2004 #505).

Moreover, some studies have presented a positive relationship between childhood obesity and

cardiovascular diseases risk factors during adult life (Freedman et al., 2004) there is still argument

whether childhood obesity exerts an independent effect on adult cardiovascular health. Similarly, therehas been much evidence to suggest that childhood obesity is a moderate risk factor for adult obesity,

but association that exists between cardiovascular disease risks at later adult stage is still unclear (Chu,

2007 #536).

Last but not the least, the childhood obesity has both physical and psychological health impacts. It is

associated with hypertension, infertility, hyperlipidaemia and abnormal glucose tolerance. They carry a

greater risk ofhavingdigestiveand cardiovascular diseases and are more likely to die at early age (Daniels,

2008 #537).

What are the health consequences of childhood obesity tracking into adulthood?

For the past few years there has been an increasing prevalence of childhood obesity affecting bothdeveloped and the developing countries of the world (Lobstein, 2004 #486). Certain health risks factors

such as asthmas, type 2 diabetes and other related health illnesses has been linked to excess adiposity

during young age and may continue to persist up to adulthood (Stamatakis, 2005 #538). Similarly, an

increase in middle-age mortality and morbidity irrespective of adult weight status and socioeconomic

background are linked to adiposity but it varies with gender, population, ethnic origin and age

(Engelandet al., 2003; Wang & Zhang, 2006; Shrewsbury & Wardle, 2008).


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The common well established risk factors for childhood obesity into adulthood are heart and circulatory

diseases, raised blood pressure, cholesterol levels increase in insulin resistance (also known as

collectively metabolic syndrome). More recent studies conducted in US suggested that nearly 35% of

overweight and obese adolescents show an evidence of metabolic syndrome, this has greatly increases

the risk of diabetes, heart disease, stroke and other forms of cancers during adulthood (Must, 1992

#539).

Another serious condition is type2 diabetes among children and this condition is associated with middle

aged obese adults, and it gives a strong association between diabetes and kidney failure, retina damage

which can lead to blindness, cardiovascular diseases and limb amputation (Must, 1992 #539). The

population of diabetic patients in the UK currently is amounting 2.4 million and is expected to double

within the next 10 to 15 years and majority of the newly diagnosed cases will occur in children (NHS,

2011).

In a study involving 730 children conducted at Otago, New Zealand which was aimed at assessing the

effectiveness of programmes as an intervention in preventing excessive weight gain among children for

reducing childhood obesity and overweight. The study was a two years community based obesity

prevention programmes for healthy lifestyle and exercise and a non-randomized design. Theparticipants were 5 to 12 years old children through encouraging opportunities on healthy and non-

circular activity. Four intervention and three control schools were exposed to the measurements of their

heights, waist circumference, weight, diet, physical activity and blood pressure within 1 to 2 years.

Interventions used were nutritional education that alters their consumption of sweetened drinks, and

improving their fruit and vegetable intake and introducing a community activity that promote walking as

physical activity. The result of the study indicates that BMI value was significantly lowered among the

intervention group than in the control group with a mean of 0.09 (95% confidence interval: 0.01, 0.18)

after the first year and 0.26 at (95% confidence interval: 0.21, 0.32) at the second year, but prevalent of

overweight shows no difference. There was low significance in the Waist circumference at 2 year (1 cm),

and significance reduction in systolic blood pressure to about (2.9 mm Hg) at 1 year. This shows an

interaction between intervention group and the overweight status at (p_0.029), with mean BMIZscore

reducing to (_0.29; 95% confidence interval; _0.38, _0.21) at normal weight, but did not observed inoverweight (_0.02; 95% confidence interval _0.16, 0.12) as intervention children relative to controls.

Similarly it was observed that consumption of carbonated beverages was very low in intervention

children with (67% control intake; P_0.04) and in the fruit and juice drinks (70% P_0.03) and more fruit

(0.8 servings/3 d; P_0.01). The study conclusively suggested that provision of basic nutritional education

and coordinating physical activity in schools significantly reduces the rate of (Savoye, 2007 #540). But

the researcher suggested for more new studies in order to bring new approaches in this field.

In another study conducted at South West of England involving schools children aimed at assessing the

long term effects of an obesity prevention programme targeted at school children within the age range

of 7 to 11 years. Total samples participants was 644 children out of which 511 children were tracked. A

total of 434 children were measured after three years baseline. Over one year, the intervention was

conducted among the children focusing on four sessions regarding health education in promoting

healthy diet and discouraging the consumption of carbonated drinks. The outcome was measured using

the Anthropometric measures of weight, waist circumference and height. Conversion of BMI body mass

index to z scores at (SD scores) Standard Deviation and centile values and growth reference curve.

Similarly, Waist circumference was converted to Standard Deviation values scores z (SD score). The

results after three years baseline with respect to age and sex specific Body Mass Index z scores Standard

Deviation shows an increase in the control group with 0.10 (Standard Deviation 0.53) but decreases

with _0.01(Standard Deviation 0.58) in the control group at a mean difference of 0.01 (95% CI -0.00 to


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0.21, P=0.06). During the three years period there was an increase in overweight in both control and the

intervention group. Similarly, there was significance difference among those seen at 12 months which

shows that it is no longer evident. Body Mass Index also increases in the control group with 2.14

(Standard Deviation 1.64) and in the intervention group by 1.88 (Standard Deviation 1.71), and the mean

difference of 0.26 (-0.07 to 0.58, P= 0.12). After three years, the waist circumference increases in both

control and intervention groups with 0.09 mean difference (-0.06 to 0.26, P=0.25).

In conclusion these longitudinal results show that after a simple yearlong intervention the difference in

prevalence of overweight in children seen at 12 months was not sustained at three years. This shows

that success of a school based intervention was not maintained two years after the end of the first year

project. Finally the study suggested that, for any school based intervention programme to be successful

evaluated the intervention in question should be continuous for the period of the programme (Janet et

al., 2007).

In another study conducted aimed at examining the effects of multi component school policy on

nutrition for the prevention of overweight (85.0th percentile to 94.9th percentile) and obesity (95.0th

percentile) among school children using nutritional policy initiatives among children in grades 4 to 6

over a 2 years period. The study involved 1349 schools children in grades 4 through 6 within 10 schools

in the US at the Mid-Atlantic region. Schools were marched considering the size of each school and typeof food to be given. Randomized control design was used for the study in which both the intervention

and the control group were assigned randomly. Students were assessed at baseline for the first and

after 2 years. The policy used during the study includes school self-assessment, nutrition education,

social marketing and parent outreach and nutrition policy. At the end of the study incidence of obesity

and overweight after 2 years of the intervention were primary outcomes. While remission of obesity and

overweight prevalence on the Body Mass Index z score, fruit and vegetable intake, body dissatisfaction,

hours of activity and inactivity and total energy and fat intake were all secondary outcomes of the study.

At the end, about 50% reductions were recorded in the incidence of overweight. Similarly, fewer

children shows significance within the intervention schools (7.5%) when compared with the control

schools with (14.9%) that became overweight after the 2 years. Prevalence of overweight was found to

be low in the intervention schools and no difference was observed in the prevalence or incidence ofobesity in the remission of obesity or overweight during the 2 years period. In conclusion, the study

suggested that promoting multi component intervention programme involving school children can be

very effective in the prevention of overweight development among school children in grades 4 through

6 within urban public schools at a high proportion of children eligible for free and reduced price school

meals (Gary et al., 2007).

In a study conducted to determine whether paediatricians and dieticians can have influence in

implementing an office based obesity prevention programme by the use of motivational interview as

primary interventions. A non-randomized clinical trial were used during the study, a total of 15

paediatric research in office settings were involved, 5 registered dieticians were assigned to one of the 3

groups as follows: 1.minimal intervention group (paediatrician); or 2.intensive intervention (both

paediatrician and dietician); 3. Control group. Primary care paediatric office was used as the setting. Atotal of ninety-one children Participated that met the criteria for eligibility for being within the age of 3

to 7 years and attain a body mass index at 85th percentile or greater but lower than 95th percentile for

the age or having a normal weight and parents with BMI of 30 or greater. Training was given to both

paediatrician and registered dieticians among the intervention group as a motivational interviewing

training. In the minimal intervention group parents of children received one motivational interviewing

session from the physician and among intensive intervention group parents of children received two

motivational interview sessions both paediatrician and the registered dietician. The major outcomes


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measures used were change in BMI for age percentile. At the end of the project during the 6 month

period of follow up, a decrease BMI percentile in the control group was observed at 0.6, 1.9 and 2.6.

The main difference of BMI percentile changes among the 3 groups were non- significant (P=85).

Participants dropout rates were 2 representing 10%, 13representing 32% and 15 representing 50%

among the control, minimal and intensive groups. Similarly 95% of the parents 15 give good

recommendations for being helped by the intervention on how to think of changing their eating

behaviours within the family. On the basis of the study it was suggested that in preventing childhood

obesity motivational interviewing by paediatrician and dietician should be encouraged as an office-

based preventive measures against childhood obesity management. But there in need for additional

studies to be conducted, in order to demonstrate the efficacy of such interventions in larger settings

(Rogers, #510).

Grouping of the studies:

The following main themes emerged on searching relevant literature and this formed the criteria

method for grouping the studies. Studies were classified according to their relevance to the aim and

objectives of the review in terms of overweight and obesity among children and adolescents. The author

performed a full critical appraisal using a systematic framework (appendix 1) and screened relevant thetitles and abstracts, examined full text of relevant documents and eventually identified 10 relevant

studies that met the inclusion criteria.

1. Physical activity

2. Nutrition and Diet

3. Combined approaches

4. Behavourial strategies

Out 10 total studies, 6 were the intervention studies .Two of them utilized combined physical activity

and dietary programs, two studies exclusively utilized educational models and behaviour modificationstrategies, while the other two studies utilized programs based on government policies based on diet

and physical activity. In addition, 3 were systematic review studies. One of the systematic

reviewsinclude 11 studies which focused on physical activity for the prevention of obesity in children.

Other focused on all approaches to childhood obesity prevention .It include total of 22 studies and

writer split the results into long and short-term outcomes and again into dietary interventions, physical

activity interventions, and combined approaches.The other literature review include 51 studies and 16

studies exclusively utilized educational models and behaviour modification strategies, and 20 studies

utilized both. In addition, 31 studies utilized exclusively quantitative variables like body mass indices and

waist-to-hip ratios to measure the efficacy of the intervention programs, and another 20 studies utilized

a combination of quantitative and qualitative measures that included self-reported physical activity and

attitude toward physical activity and the tested knowledge of nutrition, cardiovascular health, and

physical fitness.


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CHAPTER 3

This chapter covered the research designs, approaches and went on to describe the techniques

undertaken in the data collection and data analysis. The methodological frameworks applied in this

study were described in this section.

3.1 METHODS OF REVIEW

3.1.1 Study design

A systematic review has been conducted to examine published literature to identify the prevention of

childhood overweight and obesity in UK.This method is turning out to be a progressively widespread and

recognized research method in public health (Petticrew 2003).It is now broadly contemplated to be a

very good method of constructing research evidence manageable to use(Bambra 2009). The UK

government has emphasized the significance of systematic review in offering vigorous and trustworthy

evidence on the efficacy of interventions (Wanless, 2004). Likewise, the approach helps as a main factor

in the designing of binding recommendations build by the National Institute for Health and clinical

Excellence (NICE 2009) for the National Health Service. Systematic reviews are carried out by putting

together the finest existing research on particular question by integrating findings of numerous studiesfollowing an precise and explicit framework to ascertain reliability in scientific results and their

generalizability among all populations (Higgins and Green 2008). The benefit of employing a systematic

literature review is that it permits the practice of explicit approaches to assess and evaluate studies to

check bias and thus anticipated to develop trustworthiness and precision of conclusions (Parahoo 2006)

where studies with unreliable results can be recognized to create new hypothesis regarding specific sub-

groups (Bambra,2009). Nonetheless, it should be documented that it is not likely to respond all clinically

related questions using systematic reviews with trouble to assimilate recognized research conclusions in

practice (Campbell collaboration Library, 2008). There is also substantial risk if organization of data is

haphazard and this can lead into misrepresenting and all the more harmful results. To check for this

possible bias, all involved participants must be recommended and offered appropriate training in order

to implement effective and valuable systematic reviews which can apply conclusions in practice.

3.2.0 Types of studies

The author begin with detecting research papers those relating to children from age group5 to 14 years

to examine factors related with childhood obesity. Maximum outcomes emerged were showing a

substantial sum of valuable studies carried out in other countries such as the USA, Germany, Ireland and

the Scandinavian. This could possibly be for the reason that not enough has been worked out on the

subject due to dearth of data to manifest exact prevalence of the dilemma. Thus, in order to provide a

global and comprehensive viewpoint of an area, these studies were judged to be suitable and hence

incorporated in the research if they meet the inclusion and exclusion criteria. In order to alleviate bias

on generalisability, a rigorous and explicit inclusion and exclusion criteria have been applied to confirm

standard method for the studies to enhance the external reliability. The review engaged systematic,qualitative and qualitative studies regarding to intervention strategies being employed for the

prevention of childhood obesity. The benefit of making use of mixed methods in a research is that it

leads to the extraction of diverse nature of data. There are apprehensions from researchers on possible

danger of dispute due to philosophical incongruence between qualitative and quantitative approaches.

Regardless of this limitation, this approach is believed as a beneficial suitable mode to augment the

types of information and knowledge acquired from participants to generate a complete holistic picture.

(Gerrish and Lacey 2010). All research studies were in English language and this might be due to a


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possible language and country bias linked to a greater amount of English language literature accessible

in the d

3.2.2 Types of participants

The participants in chosen studies comprised ofchildren from the age range from 5 t0 14 years to allow

children in initialphases of adolescence. They were mostly employed through community set ups

likeschools. Other than childrenthe participants included mothers, fathers and some grandparents and

health staff with the majority of participants being mothers, which reflects the position of women as

primary child-carerin most societies (Table 2).Study participants came from a range of socioeconomic

backgrounds. The selection of participants was not limited on race, ethnicity, setting. A precise and

accurate sample strategy in a study is vital and essential section for analysis and interpretation of

material. Absence of transparency in selection processes could result possibly jeopardize the

representativeness of the sample.

3.3.0 Types of outcome measures

The main outcome measure in this review is to establish the evidence base for successful interventionsregarding prevention of child hood obesity. There are a wide range of factors that may contribute to the

reasons why children are gaining weight leading to obesity. This study considered factors if they were

relating to nutrition, physical activity, family dynamics, social or cultural factors and demographic

background. These included any preventive outcomes as well as any possible adverse effects and any

rectifications where applicable.

3.3.1 Inclusion criteria:

Based on the literature review, childhood obesity is a topic of importance but carry a very wide scope.

To have focus on the primary trigger factors and prevention of childhood obesity, this review will accept

research that include the interventions related to physical activity and dietary patterns to overcome

problem of obesity and overweight among children. However, in order not to omit relevant evidence,

some studies related to other contributing factors are also included such as educational and behavioral

interventions .In addition systematic reviews are also selected as involving these reviews have a great

advantage of exploring relevant studies which are primarily aimed at improving the quality of control

measures and moreover it is an outcome of several primary studies with different inclusion and

exclusion criteria. The studies which were included in the review should be published in between 2002

and 2011 to avail the most recent literature in the study. The age limit for children in studies

participants in the study is 5-14yrs old as indicated earlier. Most studies used population samples which

may or may not have included overweight or obese children. This review focuses on childhood obesity

and how it relates different practices and factors and how they can be avoided. Although many studies

have linked childhood obesity PA or eating disorders, this review will also include studies that contain

other information and knowledge. In my view, the relationship between childhood obesity and differentcontributing factors, demands more rigorous investigations to explore than this review would

acknowledge.

3.3.2 Exclusion criteria

Studies mainly focused on obesity related to adults

Studies with no clear aim and objectives about childhood obesity


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Studies outside the western countries

Letters, editorials, news,

Language other than English

Studies which include research on childhood obesity associated with some diseases

3.4.0 SEARCH METHODS FOR IDENTIFICATION OF STUDIES

Searches were performed and accomplished using different standard databases including Cochrane

library, MEDLINE, CINAHL, EMBASE, PSYCH-INFO Campbell collaboration library. Studies published from

1990 to-date were looked at to integrate and bring in useful background information. The search was

accomplished using the combination of following keywords obesity* OR obese* OR overweight*

OR * OR overweight and obesity* combined with childhood or children or adolescents OR

teen* OR * OR youth*. This was then combined with physical activity OR exercise OR dietary

behaviour* OR nutrition*OR *. Apart from it subject titles headings and captions were employed

from the thesaurus of databases to broaden the search to expand possibility to retract related articles

which we were unable to reach at with the keyword search. Internet searches were carried outthrough

websites such as goggle scholar, and the grey literature. The search was restricted to English studies and

studies involving children of 5 to 14 years to allow inclusion for those in possible adiposity rebound

period.

3.4.1 Study selection process:The purpose of selection is to confirm and make sure that all applicable studies are counted in the

review by the Centre for Reviews and Dissemination (CRD 2009). The process of selection was

comprised of two stages. Initially the titles and abstracts of the studies are examined against the

inclusion criteria in order to categorize and distinguish studies that are relevant and research articles

which do not match the inclusion criteria were skipped. Following this step author approached a further

thorough screening by carrying out a complete critical appraisal using systematic framework and

scrutinized a detailed script of detailed and related documents and finally spotted and mainstreamed 10

studies as a final selection for the review. The critical appraisal of studies during selection procedure is

to lessen selection biasin a systematic review. The duplicate studies are also checked to avoidreplication. They were then sorted out into themes with regard to the aim and objectives of the review

in relation to the role of physical activity, dietary patterns and other factors as discussed in chapter two

of this review.

3.4.2 Dealing with duplication

Identified duplicates of selected publications of research results were equally looked at in order to avoid

treating them as separate studies in the review. However, Von Elm et al (2004) highlighted that it was

difficult in identifying such replicas especially where they are not cross referenced. Their studies

estimated that incidences of replica publications range between 1.4% and 28%, and duplicated articles

can be as many as five.


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Fig 1.

Initial screening arrived at 1100 studies

Process of selection of studies

240 studies were finalized after abstract

screening

115 eliminated on the basis of unrelated aims and objectives

135 Remaining studies were assessed according to

the inclusion criteria

60 studies excluded not being research articles

65 studies were thoroughly read for review final

selection

Out of them 10 studies were finalized


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3.5.0 Data extraction:

The process of data extraction comprised of drawing out of information appropriate to study findings

and characteristics from selected studies (CRD 2009). The information from each qualified study related

to thedescriptions and qualities on interventions related to the childhood obesity were extracted. This

extraction of data depends upon study methodology, design, findings and relevant conclusions. The

assembled data will be summarized through a narrative synthesis. This type of synthesis is proper and

right for this review because included studies will not deliver consistent and uniform quantitative

results to carry out a meta-analysis (Hemingway and Brereton 2009). Data extraction forms were

employed in order to gather information for integration of evenness and consistency in the research.

(Higgins and Green 2008).

3.6.1 Managing lack of information

The results from articles where possible could be tested employing a sensitivity analysis. In order to do

this we need time and were not been practical in this case.

3.6.2 Data Synthesis

Data analysis is a systematic process of bringing together and summarizing of the results of individual

studies included in a systematic review to answer a research question or test research hypothesis (Polit

and Beck 2010). In quantitative research data is summarized using formal statistical techniques such as

meta-analysis, whereas qualitative research tends to involve a less informal process through a narrative

approach, where data is analysed so trends and patterns can be detected. There are various approaches

to data analysis and this is dependent on the research design and nature of data collected (Gerrish and

Lacey 2010). In this study data was analysed through narrative approach. This involved a documentary

approach that provides an investigation of the relationships within and between studies and an overall

rigor of evidence (CRD, 2009). This approach was considered more appropriate for this review as studies

involved in the systematic review were too diverse to combine in a meta-analysis. To overcome

potential bias due to the subjective nature of this review, the author ensured strict and transparent

process.

3.6.3 Narrative Sysnthesis:

Hence as emphasized by CRD (2009), narrative synthesis offers clarity and rigorousness to reduce any

possible bias through the following;

Elaborates a theory in relation to the interventions work, screening factors that have made

them to function and whom they are meant for.

Builds initial synthesis explained from articles that have met the inclusion criteria.

discovers how the studies can be related to one another and

Assesses the strength of the synthesis

3.6.4 Assessment of study quality

Quality assessment is a significant segment of the systematic review progression to avoid the chance

and possibility of bias in involved studies due to insufficiencies in study design, conduct or analysis (CRD,

2009).These errors and weaknesses in design or conduct of a study can lead to bias, even in some cases

can have as much influence on outcome of the study (CRD, 2009; James et al., 2008). The author


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evaluated all studies that are according to the inclusion criteria for the selection of primary research to

ensure validity and reliability in the study.(Higgins and Green, 2008). The quality appraisal checklists

(Appendix 1) were employed for explanatory and descriptive purpose to emphasize and underline

variations in the characteristics of studies. Both qualitative and quantitative studies were dealt different

criteria. The practice and suggestion of using scales with summary scores in order to differentiate

superior and low quality studies is questionable and not recommended (Colle, Rannou et al.

2002).Quality score was not measured and thus reviews were not eliminated and dismissed on their

basis of quality (CRD, 2009; Birch et al., 2007).There is no single approach for the calculation of

methodological quality which suitable to all systematic reviews. The best approach will be determined

by contextual, pragmatic and methodological considerations (Green et al., 2008; CRD, 2009 8).Paratoo

(2006) proposes that assessment of every single study should be carried out by more than one evaluator

exercising completely the similar standards and measures. It is useful for assessors to be blinded to the

identity of the authors of the studies. To alleviate and lessen bias an assessment needs to be evaluated

and contemplated by a second person and if there is any inconsistencies should be worked out by

consensus and if required should be accessed by another person

3.7.0 Methodological quality

It is essential to evaluate the methodological quality of studies in systematic review (CRD 2009).Research may significantly vary according to the methods used; identifying mistakes in research design

or conducting a study could be resulted into biased results and possibly have an effect on the findings of

the interventions. As documented by CRD (2009) anticipation of strength and weakness of included

studies will help to develop suggestion on whether results have been unduly and excessively affected

and biased by quality and descriptions of the study design. Successively, gauging value of study will

reflect the strength and weakness of evidence of results revealing in the systematic review as well

specifying support and guidelines for further research. Finally, quality assessment will channelize and

direct to authenticate about selected studies whether they are vigorous enough and can be appliedas a

guide for upcoming interventions in prevention, and policy execution.


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Chapter: Four

4.0 Review of studies

4.1 Summary of selected studies as shown in fig 1 chapter three above:

Introduction:

It was suggested by Loke (2004) that provision of relevant information that will be of benefit to

interventions for patients are very important on decision making. Prior knowledge of patients for any

unpleasant effects that will result in the intervention encouragement is very important and need prompt

acknowledgment. In order to acquire good knowledge the systematic review make use of research that

demonstrated the benefit of appropriate intervention measures for the treatment and control of

childhood obesity and overweight and at the same time recognized other adverse effect of the problems

and interventions into childhood obesity. The chapter focused on the specific issues responsible for

childhood obesity prevention, control and management (Holcomb, 2009 #506).

4.4. Reviews:

STUDY 1:

The first study, Preventing obesity by reducing consumption of carbonated drinks: cluster randomized

controlled trial (James, 2004 #505) aimed at reducing the consumption of carbonated drinks in 615

children aged 7-11 years old via the delivery of a focused educational programme on nutrition in

schools.

According to the findings of this study, a targeted, school based education programme produced a

modest reduction in the number of carbonated drinks consumed, which was associated with a reduction

in the number of overweight and obese children. The researchers carried out a cluster randomized 7-11

years, with the intervention being a focused educational programme on nutrition over one school year.

The programme was delivered to all classes. The main objective was to discourage the consumption of"fizzy" drinks (sweetened and unsweetened) with positive affirmation of a balanced healthy diet. The

main outcome measures used in the study were drink consumption and number of overweight and

obese children. The results of the study found Consumption of carbonated drinks over three days

decreased by 0.6 glasses (average glass size 250 ml) in the intervention group but increased by 0.2

glasses in the control group (meandifference0.7,95%confidenceinterva0.1to1.3).At 12 months the

percentage of overweight and obese children increased in the control group by 7.5%, compared with a

decrease in the intervention group of 0.2% (mean difference 7.7%, 2.2% to 13.1%).

it is not clear precisely how much time and method of delivery was devoted to each component;

discouragement of fizzy drinks, affirmation of a balanced healthy diet, drinking water, presenting art,

writing songs/raps outlining healthy messages. And as a result of this it is impossible to identify whichaspects were actually effective and which were unnecessary. One problem with the sampling, which the

researchers point out, is that school s contained classes both in the experimental and the control group

and therefore it is possible that transfer of knowledge may have taken place outside the classroom

with participants discussing the different conditions amongst themselves

The participants were asked to keep a three day diary both at the beginning and at the end of the

intervention (over one school year) and keep record of the drinks that they consumed. It is doubtful

whether this could be regarded an appropriate method of collecting data considering the sample used.


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Is it feasible to ask a 7 year old to keep an accurate diary indicative of the complete beverages they have

consumed? This is a poor method of measurement with participants as young as this and indeed this

was reflected in the low number of completed diaries they received both at baseline and the climax of

the intervention

It has some interesting methods of engaging the children and because it is multi- faceted it seems to

bombard the messages and the results seem to suggest that the do influence the participants eatingand drinking behaviour.

STUDY2:

MEND: A family based community intervention for childhood obesity. It was aimed at to evaluate the

effectiveness of the mind, exercise, nutrition, Do it programme. The design was a randomized control

trial designed to assess the effectiveness of 6 month intervention with nine week MEND programme

followed by 12 week free family swim passes. It was a multicomponent intervention focusing on healthy

lifestyles based on the principals of nutrition and sports sciences and from psychology learning and

social cognitive theory and study of therapeutic processes. The intervention strategies include nutrition

and behaviour change sessions targeted on both parents and children and exercise sessions which onlyfocused on children. The programme was delivered at five different sites by separate teams of health,

social and educational professionals. The researchers included 116 children aged 8 to 12 years with BMI

>98th percentile and randomly assigned them to either participate in intervention or wait six months for

intervention. They took measurements at baseline, six and 12 months. Mean attendance was 86%. At six

months, children assigned to the MEND program had a reduced waist circumference z score (0.37) and

a BMI z score that compared with children assigned to wait six months for intervention (0.24; P


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limited by a small number of participants and having no control group, it showed a favorable tendency

of success. In short, this programme was accepted by families and produced a significant improvement

in range of risk factors associated with obesity. In addition children also benefited from the social aspect

of the programme and had fun making new friends, felt better about them and enjoyed the company of

children having similar weight situations.

STUDY 3:

A 4 year, cluster randomized controlled childhood obesity prevention study: STOPP by Marcus et al

(Marcus, 2009 #503) was a school based intervention randomized control trial which aimed to assess

whether a school based prevention programme, focused on reducing unhealthy eating and increased

physical activity during school time over a four year period could reduce the prevalence of overweight

and obesity among 6 to 10 year old children. It was a school based policy intervention focusing on

changing the school environment. School staff was encouraged to promote healthy eating and physical

activity. Additionally policies were put in place to promote healthy eating and physical activity which

include 1 hour and 30 minutes daily physical activity time was added to daily school curriculum.

Moreover to reduce sedentary behaviour, children were not allowed to bring toys that bring that might

increase this behaviour such as hand held computer games to schools and after care school centers. The

teachers were instructed to encourage the children to increase the intake of vegetables during theschool lunch. To facilitate this all intervention schools agreed to offer a variety of vegetables and food

was arranged so that the children first served themselves vegetables and thereafter the main course.

The products include a wide amount of dietary fibers. The sugar content in school lunches and in the

snacks was reduced. Skimmed milk, low fat butter, cheese and yogurt were also provided. Intervention

school was encouraged to eliminate sweets, sweet buns and ice-creams in association with festivities.

Parents were also asked not to provide such stuff during school and after school care centers for

celebrating birthdays. They were also instructed not to provide sweetened drinks sweets and other

unhealthy products in packed lunch during school excursions and ports days. A STOPP newsletter was

distributed to parents and school staff of intervention schools twice annually aimed to increase the

awareness of the intervention. Furthermore the research staff had meetings with school personnel once

every term aimed at increasing the awareness of intervention. The programme was carried out with the

help of routine school staff. Training for the staff was updated twice a year. Measurements for Height

and weight were measured using the standard transportable harpenden stadiometer, The physical

activity was assessed using acti watch accelerometer.AT the end food questionnaire regarding eating

habits at home was distributed by school staff to the parents of the all children of third and fourth grade

and eating attitudes were assessed by Swedish version of CHEAT(childrens eating attitude test .Long

term impact showed that prevalence of overweight and obesity decreased by 3.2% in intervention

schools compared with an increase of 2.8% in control group. This study showed that intervention was

more pronounced among boys than girls whichis not in line with most of previous educational based

prevention programmes(ref).Moreover this study showed better results from previous studies (ref).A

possible approach would be that there was a restricted access for children to sweetened products and

beverages.

The study has limitations as during a period from 1 to 4 years only 311 children participated for the full

duration of intervention. Moreover there is no control over physical activity and dietary behaviours

during the summer holidays and this can affect the long term effect of intervention as summer periods

have been shown to be associated with an increase of the body fat in children (ref).Apart from it the

family food questionnaire has not been validated which could have implications on the result .The

results of the study showed that including healthy school lunches and after care school snacks as well as

strict rules against unhealthy eating can reduce the prevalence of overweight and positively influence

eating habits at home .This study has also revealed that physical activity intervention did not


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contributed significantly to the result as no difference in physical activity levels between intervention

and control schools was observed despite the school level intervention. Further research is needed to

establish whether physical activity intervention can further improve the outcome.

STUDY4:

The Fit Kid project by Yin et al was designed to determine whether adiposity and fitness can be

improved in children who are exposed to fitogenic versus an obesogenic environment .This programmewas initiated a motivation from an ecological approach to the obesity pandemic by Eagger and

Swinburg (Egger, 1997 #502) which was focused on the observation that obesity is increasing due to the

exposure of youths towards more obesogenic environment. The population included was elementary 3rd

to 5th grade children in Richmond country Georgia in after school settings. This programme consisted of

healthy snack, academic enhancement and physical activity .It was comprised of 2 hours programme

which included 40 minutes of minimum exercise for 5 days a week and was based on socio ecological

perspective. Staff and volunteers included certified teachers and paraprofessionals, United States

department of agriculture (USDA) after school snack programme, after school transportation

programme. Moreover pre-programme workshops and the three mandatory staff meetings were also

organized. The evaluation measurements were done by x- ray, YCMA step test, portable scales,

cholestec LDS.The school physical activity and nutrition project questionnaire, physical activityquestionnaire for children(PAQ-C),physical-activity enjoyment scale(PACES),Pictorial Motivation

Scale(PMS),Self Perception Profile for Children(SPPC) and the Task and Ego orientation in sports

questionnaire. Resources of the programme included certified teachers and professionals, United States

department of agriculture (USDA) after school snack programme and after school transportation

programme. The settings in the programme included gymnasium, large outdoor fields suitable for games

and sports and large class rooms. Participants were recruited through letters to parents and at school

registration for both intervention and non-intervention schools. All participants were given pre, mid and

post intervention physical assessments including body composition, non-fasting blood samples, blood

pressure, step test for cardiovascular fitness and psychosocial survey. The fit kid programme was offered

free of charge to third grade participants at intervention schools including after school programme,

USDA healthy snack and transportation. All these programmes were conducted in participants schools.

First year results showed significant beneficial results for % body fat, bone mineral density and

cardiovascular fitness for those with 40% or greater attendance. There was also a relative reduction of

body fats among participants. There are no long-term impacts as study is still in progress. It is learned

from the programme that as the fit-kid is built on infra-structure of elementary schools, it can be

potentially implemented on a large scale if deemed acceptable by schools and communities. Moreover

kids cannot be relied on to bring home information, therefore participant recruitment is best done at

mandatory events like school registrations. Moreover, these results of the study are in line with previous

findings (ref) that demonstrated that effects of physical training and physical activity on body

composition. Thus it is found that 30 -60 min/day of moderate vigorous physical activity is capable of

improving body composition .The study has demonstrated that it is possible to engage children in 70-80

MVPA when they are placed in a supportive environment and were motivated which is never done by

any other previous studies and as in line with other studies (37) the findings of this study support thatthe extra time spent in physical activity does not have a detrimental effect on academic achievements.

STUDY 5:

Title of the article: Developing obesity prevention interventions among minority ethnic children in

schools and places of worship by Maria et al., (Maynard, 2009 #499).The DEAL (Diet and Active living)

study by Maria et al (Maynard, 2009 #499).The study was conducted in Dundee united Kingdom aimed

at assessing the feasibility, efficacy and cultural acceptability of child and family based interventions to

reduce risk factors for children and adolescent obesity among ethnic minorities .The data obtained as


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continued process for the period of study .Data was collected from focus group discussions and

interviews. Children were also interviewed in the absence of parents and teachers. Grandparents were

as well interviewed among Asian children due to their influence on dietary behaviour. A topic guide was

distributed among the parents, teachers and grandparents for measuring dietary levels. The study was

conducted in school based settings and places of worship and in schools teachers were recruited on the

basis of ethnicity.

In order to improve on the efficacy for facilitating behavioural changes, it is important to explore

motivational strategies as suggested by Sallis (Sallis, 1996 #500),which is in line with the study objectives

Assessment of self -efficacy for changing perceptions on dietary behaviours and physical activity as

suggested by Molt et al (Trost, 2003 #501) which is applicable to this study using a questionnaire based

on a 5 point linkert scale. Similarly, Timper et al(2006) emphasized on the same method for improving

motivational behaviours as a means of reducing childhood obesity. In order to improve a dietary and

physical exercise as a means of preventing childhood obesity and overweight among children age 7-13

years, it is advisable to apply school and places of worships that involved both qualitative and

quantitative approach .It also suggested there should be the involvement of religious leaders, cultural

leaders, teachers, children and parents. This study approach has been supported by several studies with

demonstration of good outcome (Sallis, 1996 #500).

Article 6.

Wareham et al (2005)

This is among the recent systematic review which consider role of physical activity for the prevention of

obesity in children which was conducted in Irish during the period of 2005. The research was shown to

be part of the moderate research with quality assessment when compared with primary research due to

uncertainty and was conducted within the period of 2000 to 2004 that included 11 studies with outcome

measures of body composition, body weight gain and issues regarding increase in physical activity by

self report. The majority of studies reviewed therein used the school setting (8). They varied in who

carried out the interventions, including parents, teachers and trained personnel. Of the eleven trials,only three showed a significant treatment effect in terms of anthropometric measurements. Gender

differences in the results were indicated, with two of the three studies showing an effect only in boys.

Some of the other trials showed an improvement in physical activity levels but these were not converted

into improvements in body weight or composition. (Wareham, 2005 #497)

The authors concluded that there was limited good quality data on which to draw conclusions in the

area of obesity prevention in children and adolescents. However, they suggested that perhaps there was

enough evidence to indicate that school-based interventions may be more promising than family-based

trials.

Article 7.

Summerbell et al (2005)

There was one systematic review that looked at all approaches to obesity prevention in children and

was conducted by the Cochrane Group. The initial review, published in 2001 was then updated in 2005.

This was the strongest review in our included publications in terms of its quality. (Campbell, 2002 #496)


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These authors had strict inclusion criteria and limited their search to studies published from 1990

onwards. All included studies had to have outcome measures relating to the following: body

weight/height, body fat percentage, body mass index, ponderal index and/or skinfold thickness. They

included 22 studies in their review and split them into long-term follow up (i.e. greater than 12

months) and short-term follow-up (i.e. between 3 and 12 months) and included only randomised

controlled trials or controlled trials. The settings of theses interventions included school, community and

clinic bases and the intervention was delivered by a variety of personnel including teachers, researchers

and trained individuals. The authors split the results into long and short-term outcomes and again into

dietary interventions, physical activity interventions, and combined approaches. Of the 10 long-term

studies, two focused on Physical activity (PA), two focused on diet and the other 6 focused on a

combination of PA and diet. In the long-term studies there was no treatment effect that could be

attributed to dietary interventions alone. In terms of physical activity, one study found a significant

effect on the BMI of girls, however, the other study in this group similarly showed no effect.

Consideration of combined approaches of physical activity and diet together was also disappointing,

with 4 studies showing no treatment effect, although one study had a significant effect on skin fold

thickness, but not BMI. There were no studies that compared dietary intervention to a PA intervention.

Of the 12 short-term studies, none considered diet alone. Four studies looked physical activity, two of

which showed significant effects on BMI; with one of these also showing an effect on skin fold thickness.The other eight studies looked at the combination of diet and physical activity with no significant

positive results.

The authors of the review conclude that overall, the interventions to date have not impacted on the

weight status of children and thus there needs to be further high quality research to examine these

issues more fully.

Article 8.The study was conducted by Fadia et al., (Gonzalez-Suarez, 2009 #495) Titled School-Based

Obesity Interventions: A Literature Review. Childhood obesity is an impending epidemic. The article

describe an overview of many interventions conducted within certain schools settings that act as a

guide for the management of obesity among children in order to minimise the risk of being obese at

adult and other related complication. The study was conducted within the period 1986 to 2006 withparticipants age range 7 years to 19 years with 51 interventions and involved both qualitative and

quantitative studies. The interventions ranged from 4 weeks in length to as long as 8 continuing Years.

Out 51 total studies, 15 of the intervention studies exclusively utilized physical activity programs, 16

studies exclusively utilized educational models and behaviour modification strategies, and 20 studies

utilized both. In addition, 31 studies utilized exclusively quantitative variables like body mass indices and

waist-to-hip ratios to measure the efficacy of the intervention programs, and another 20 studies utilized

a combination of quantitative and qualitative measures that included self-reported physical activity and

attitude toward physical activity and the tested knowledge of nutrition, cardiovascular health, and

physical fitness. A total of 40 studies achieved positive statistically significant results between the

baseline and the follow-up quantitative measurements.

CONCLUSIONS: No persistence of positive results in reducing obesity in school-age children has been

observed. Studies employing long-term follow-up of quantitative and qualitative measurements of

short-term interventions in particular are warranted.

Article 9.

The study was conducted by Gary Foster et al. (Foster, 2008 #494) Titled A Policy-Based School

Intervention to Prevent Overweight and Obesity. The study was conducted for the purpose of the

prevalence and seriousness of childhood obesity which has prompted in the public health concern


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showing high demand for the urgent need of intervention measures. The aim of the study was to

examine the effectiveness of school nutritional programme policy for the prevention of overweight and

obesity among children. The study was conducted for the period of two year. A total of 1349 students

were involved involving 10 schools US city in the Mid-Atlantic region with _50% of students eligible for

free school nutritional reduced-price meals. Schools were matched on school size and type of food

service and randomly assigned to intervention or control. Students were assessed at baseline and again

after 2 years. The School Nutrition Policy Initiative included the following components: school self-

assessment, nutrition education, nutrition policy, social marketing, and parent outreach. The incidences

of overweight and obesity after 2 years were primary outcomes. The prevalence and remission of

overweight and obesity, BMI zscore, totalenergy and fat intake, fruit and vegetable consumption, body

dissatisfaction, and hours of activity and inactivity were secondary outcomes. The intervention resulted

in a 50% reduction in the incidence of overweight. Significantly fewer children in the intervention

schools (7.5%) than in the control schools (14.9%) became overweight after 2 years. The prevalence of

overweight was lower in the intervention schools. No differences were observed in the incidence or

prevalence of obesity or in the remission of overweight or obesity at 2 years.

CONCLUSION: A multicomponent school-based intervention can be effective in preventing the

development of overweight among children in grades 4 through 6 in urban public schools with a highproportion of children eligible forfree and reduced-priced school meals.

Article 10.

Ten Years of TAKE 10 integrating physical activity with academic concepts in elementary school

classrooms. The study was conducted by Debra Etelson (Etelson, 2003 #477). The study was aimed at

conducting reviewing articles that support the use of physical activity, fitness and use of classroom-

based programme with relevant programmes organised by the federal government in promoting

policies that will help in reducing obesity in children and adolescent. Evidence from journal articles,

published abstracts, and reports were examined to summarize the impact of TAKE 10 on student health

and other outcomes. This paper reviews 10 years of TAKE 10studies and makes recommendations for

future research. Teachers are willing and able to implement classroom-based PA integrated with grade-

specific lessons (4.2 days/wk). Children participating in the TAKE 10! program experience higher PA

levels (13%>), reduced time-off-task (20.5%), and improved reading, math, spelling and composite

scores (pb0.01).Furthermore, students achieved moderate energy expenditure levels (6.16 to 6.42

METs) and studies suggest that BMI may be positively impacted (decreases in BMI z score over 2 years

[Pb0.01]).

Conclusion:TAKE 10 demonstrates that integrating movement with academics in elementary school

classrooms is feasible, helps students focus on learning, and enables them to realize improved PA levels

while also helping schools achieve wellness policies.

Quality of articles:

Considering the nature of research questions, the number of articles was not large. The intervention

quality that was put in place has helped in the process of carrying out the research. There is the need for

conducting further research in order to establish a basic fact on how such interventions can be of

benefit to the society in converting obesity among children this will help in improving the wellbeing of

the community at risk.


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Chapter: Five

Discussion:

Overweight and obesity among children has been one of the major threats for health care providers and

affect almost all the industrialized countries of the world. Obesity and under nutrition are among the

conditions that contribute to the world global burden of illness/diseases with dual nature affecting the

developing countries.

Obesity is considered as a threat for health. Taking the example of a single country, in U.S.A the increase

in obesity is creating a cost of $ 344 billion per year on the health issues.( Nanchi Helmich, 2009) and it is

estimated that more than 50% population will be striving from this disease till the year 2018. The reason

behind this is the use of junk food which is so much popular and too much unhealthy. In addition to this

the carbonated drinks are also ruining the health and especially of children, these should be banned

from the school canteens. Children keep on liking such a tasty but unhealthy junk food and above this

the outdoor gaming fashion is also reducing. They become so much lazy to go outside and swimming,

jogging, walking and exercises are not preferred.

Nutrition counseling sessions should be undertaken after a certain periods and especially mothersshould be invited to maintain a special healthy diet for their children and those should be arranged by

health care professionals and nutritionist, as the healthy kids are the bright future of the state . The

physical activities should be encouraged and parents as well as teachers should involve in such activities.

School/ college trips should be arranged for hiking or certain area where children can easily enjoy and

exercise.

Congresswoman Kay Granger says that special knowledge about eating and how to eat should begiven to children and healthy life style should be encouraged properly. In America, about 23 millionchildren are overweight and this ratio goes on increasing day by day and the main cause is the useof technology. A small research shows that comparing the year 2000 and 2005, the youth and thechildren are so much used to of the technology and this can be seen from the following few ratios:

The ratio of using internet increases from 73 % to 87 %

The ratio of going online per day increases from 42 % to 51 %

The ratio of using mobile phones increases from 68 % to 89 %

The ratio of using instant messages increases from 40 % to 65 %

The physical activities do not mean always going outside. The parents should be concerned and after

every 2-3 days a plan should be made that all the family members will do the house chores and some

exercise needed house chores should be distributed by the family head. And this will surely keeps the

family healthier and stronger. Eliminating the food is never healthier. It means that food should be

included which is healthy, examples are fruits, fresh vegetables instead of snacks and fried items. There

should be discipline in eating habits and this should be watched by parents.

With the help of little care this problem can be easily solved.

Recommendations:

For being healthy, it is strongly recommended that proper check ups and proper appointments from the

doctors, physicians and nutritionists should be taken and the weight should always be checked and is

compared with the average Body Mass Index. When the child is obessed, there always comes some

medical problems such as weak kidneys, high cholesterol or heart or asthma problem. And no doubt

that these diseases are very much common in children and youngsters nowadays.


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The precautions should be made and this is always preferable as compared to the treatment when the

water goes above the head. Liposuction is never recommended for children as it causes many side

effects and is too much unhealthy for less aged people. The children should be more active and it is the

responsibility of parents as well as the teachers to provide them such opportunities and give them such

responsibilities so that they try to be active and responsible.

As the development of the body of the child depends on the physical exercise so the sportsman spirit

should be indulged in them in order to be active and healthy. Fat and unhealthy children are always lazy

and lack behind not only in such activities but also in the studies and mentality.

Favorite sports should be a part of daily school period and on the other hand children should be made

child obesity final

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