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Childhood obesity is becoming increasingly prolific and problematic. Contributors to childhood obesity include decreased levels of physical activity and increased sedentary behavior. Screen-based entertainment may be an important factor in the development of childhood obesity as children and adolescents prefer to spend time using electronic devices than exercising. While it is difficult to encourage children to cease playing video games, it is possible to change these passive screens to active ones. Information and Communication Technologies (ICTs) have been utilized by academics and researchers to promote levels of physical activity among young people. This paper is part of our continuous research into the use of technology in the facilitation and motivation of children to be more physically active. This paper presents the "MySteps " framework that has been developed to manage youth screen time and exercise performance statistics. By developing technology-based solutions, we intend to increase children and adolescents awareness of their levels of physical activity and screen time. Consequently, self-monitoring and management of screen time and physical activity levels may lead to more active living beginning at an early age and continuing throughout life.

The home learning environment is a potential correlate of childhood obesity and obesity-related factors. We examined relationships between the home learning environment and weight status and the home learning environment and dietary intake, in a sample of 303 preschool-aged children from Australia. We measured their height and weight, and their parents completed a questionnaire that included questions related to demographics, dietary intake, and the home learning environment. Parents reported their children’s usual consumption of foods from each food group, the frequency of their discretionary food intake, and the frequency of home activities that might support cognitive stimulation. We analysed relationships using regression, adjusting for parents’ education level, and household income. We found no significant associations between the home learning environment and BMI or weight category. We found a significant inverse relationship between the overall home learning environment and discretionary food intake scores, but when stratified by income, this result was significant for children from lower-income families only. Regarding specific elements of the home learning environment, we found significant inverse relationships between discretionary food intake and both reading to children, and teaching them the alphabet. While reading was significant across all income levels, teaching the alphabet was only significant in children from higher-income families. We also found significant inverse relationships between discretionary food intake and: visiting a library, teaching numbers or counting, and teaching songs, poems and nursery rhymes in lower-income families only. There was no association between the home learning environment and meeting individual dietary guidelines. This area requires further research to explore broader home environment factors that may influence these relationships. We also suggest that interventions explore the use of strategies to improve the home learning environment to determine its efficacy in improving healthy eating behaviors.

Background Prenatal factors might have some health impacts later in life. This study aims to systematically review the current literature on the association between season and month of birth with birth weight as well as with weight status in childhood. Methods The search process was conducted in electronic databases, including papers published until April 2019 in ISI Web of Science, PubMed, Scopus, and Google Scholar. The following search strategy was used with MeSH terms: ("Seasons"[Mesh]) AND ("Obesity"[Mesh] OR "Pediatric Obesity"[Mesh] OR "Obesity, Abdominal"[Mesh] OR "Overweight"[Mesh] OR "Birth Weight"[Mesh] OR "Body Height"[Mesh]). After the selection process, 50 papers were included in this systematic review. Results This review showed that individuals who are born in cold season (winter month) have higher body mass index (BMI) and weight in childhood. Birth in March was associated with lower weight and BMI in boys according to most studies. All studies, except one of them, showed that season/month of birth was not associated with birth weight. Conclusions This systematic review confirms a relationship between season and month of birth with birth weight and body size in childhood; however, the impact of confounding factors, for example, vitamin D status, should be considered in the underlying pathway of this association. Impact The results provide evidence for the effect of season and month of birth on body size in childhood. Our systematic review suggests that there is no pattern between birth weight and season/month of birth, and the occurrence of low birth weight was more frequent among infants who were born in summer than others. Further research should focus on identifying the impact of confounding factors, for example, vitamin D status in the underlying pathway of this association. There was response to the controversial findings about the effect of environment factors, such as season and month of birth, and future anthropometric indices, such as obesity, weight, height, and birth weight. Obesity is a complex and multifactorial disorder; the findings of the current study would be useful in determining the relationship pathway between the season and the month of birth with other underlying factors for childhood obesity.

Purpose Despite public health efforts to reduce childhood obesity, there remains an unequal distribution of obesity among rural and urban children, with higher rates in rural areas. However, few studies have compared differences in program delivery. This paper aims to describe differences between an urban and rural program delivery of a family-focused, community-based intervention program to prevent and reduce obesity among children. Methods This paper uses a case study format to provide a descriptive analysis of similar obesity prevention programs, designed by the same research team, implemented in Minnesota in different settings (i.e., an urban and rural setting) with significant community engagement in the adaptation process. The rural NU-HOME program is compared to HOME-Plus, an urban family-based obesity prevention program for school-aged children. Results Community engagement in the adaptation process of an urban program to a rural program confirmed some anticipated program content and delivery similarities while identifying key differences that were necessary for adaptation related to engagement with the community, recruitment and data collection, and intervention delivery. Discussion When adapting research-tested programs from urban to rural areas, it is important to identify the modifiable behavioral, social, and environmental factors associated with obesity to ensure the content of effective childhood obesity prevention programs is relevant. Customizing a program to meet the needs of the community may increase reach, engagement, and sustainability. In addition, long-term dissemination of a tailored program may significantly reduce childhood obesity in rural communities and be implemented in other rural settings nationally.

Background This study examines the relationships between childhood food allergy and parental unhealthy food choices for their children across attitudes towards childhood obesity as mediators and parental gender, income and education as potential moderators. Methods We surveyed parents with at least one child between the ages of 6 and 12 living in Canada and the United States. We received 483 valid responses that were analysed using structural equation modelling approach with bootstrapping to test the hypothetical path model and its invariance across the moderators. Results The analysis revealed that pressure to eat fully mediated the effects of childhood food allergy and restriction on parental unhealthy food choices for their children. Finally, we found that parental gender moderated the relationship between childhood food allergy and the pressure to eat. Conclusions The paper contributes to the literature on food allergies among children and the marginalisation of families with allergies. Our explorative model is a first of its kind and offers a fresh perspective on complex relationships between variables under consideration. Although our data collection took place prior to Covid-19 outbreak, this paper bears yet particular significance as it casts light on how families with allergies should be part of the priority groups to have access to food supply during crisis periods.

Background Childhood obesity remains a significant global problem with immediate and long-term individual health and societal consequences. Targets for change should include the most potent and predictive factors for obesity at all levels of the personal, social and physical environments. The Michael & Susan Dell Center for Healthy Living (‘the Center’) is a public-private partnership that was developed to address child health issues through research, service, and education. This overview paper introduces a special issue of seven articles on childhood obesity from the Center, and the implications of this research for obesity prevention. Methods and results A review of the literature on public-private partnerships was undertaken and key components of the partnership between the Michael & Susan Dell Foundation and the Center were compared for compatibility. The conceptual framework for Center research, based on social cognitive theory and the social-ecological model, is explained. An overview of papers in this special issue, relative to the conceptual framework, and the implications of this research for childhood obesity prevention, are provided. Conclusions The public-private partnership that created the Michael & Susan Dell Center for Healthy Living has been instrumental in motivating the Center’s academic faculty to focus their research on improvements in child, family and community health through etiologic, epidemiologic, methodologic and intervention research. This special issue extends this work and places particular emphasis on socioeconomic inequalities in addressing the obesity problem in the U.S. and worldwide.

Background Childhood obesity has become an alarming worldwide increasing public health problem. The earlier adiposity rebound occurs, the greater the risk of becoming obese during puberty and adolescence. It has been speculated about the potential influence of vigorous physical activity on modifying the age of onset of adiposity rebound. Moreover, studies aimed to evaluate the effectiveness of physical activity interventions programs on reducing adiposity and other cardiovascular risk factors in children younger than 6 years are scarce. This paper describes the rationale and methods of a study aimed to test the effectiveness of a two-years multidimensional pre-school intervention on preventing obesity and improving physical fitness during the adiposity rebound period. Methods/Design Twenty-one schools from the provinces of Cuenca and Ciudad Real, Spain, were randomised to an intervention and a control arm. In the first academic year, children in third grade of pre-school and first grade of primary school in the intervention group received the physical activity intervention (MOVI-KIDS). After an academic year schools were crossed over to the alternative arm. According to the socio-ecological model, the intervention included children, their parents and teachers, and the school environment where MOVI-KIDS was conducted. MOVI-KIDS consisted of: i) three-h/week sessions of recreational non-competitive physical activity in after-school time; ii) educational materials to parents and teachers about physical activity benefits and sedentary lifestyle risks; and iii) modifications in the playground to promote physical activity during recess. Baseline and post-intervention outcomes are going to be measured in both arms three times, at the beginning and at the end of first academic year, and at the end of the second academic year. Primary outcomes included body mass index, waist circumference, triceps skinfold thickness, percentage of both body fat and fat-free mass, and blood pressure. Secondary end points were physical activity, fitness, and carotid intima-media thickness. Discussion This paper reports the design of a randomised cross-over cluster trial aimed at assessing the effectiveness of the multidimensional physical activity intervention (MOVI-KIDS) during two years in pre-school children. Trial registration Clinical trials.gov: NCT01971840. (Date of registration: Initial Release: 10/07/2013; Record Verification: 23/10/2013).

Pediatric overweight/obesity has assumed epidemic proportions in India. It is associated with several significant complications and tracks into adulthood. The mainstay of management is a holistic lifestyle modification that must be adopted by the family as a whole. It involves dietary changes, regular physical activity, and behavioral changes that favor a healthy way of life. Regular follow-up, and attention to keeping up the motivation of the child and family achieves good results. In the present paper, a stepwise approach to prevention and management of childhood obesity is presented along with the recommendations for screening and management of associated complications and the role of pharmacotherapy and bariatric surgery.

Methods An appraisal framework, based on relevant items from existing tools (i.e. COSMIN, FDA, EMPRO, SAC) was developed. Initial testing was conducted as part of a systematic review, in which data were extracted from 100 papers describing parental feeding practices measures (HomeSTEAD). Next, the framework was expanded to include a scoring system for items related to conceptual framework, reliability, validity and responsiveness testing. The expanded framework was then used in a systematic review of 353 papers describing outcome measures used in childhood obesity treatment evaluations (CoOR).

The objectives of this paper are to present the conclusions from the workshop ‘Education for childhood obesity prevention:a life-course approach’, coordinated by the Pan-American Health Organization and the Pan-American Health and EducationFoundation, and held on 14 June 2012 in Aruba, as part of the II Pan-American Conference on Childhood Obesity(http://www.paco.aw/). This workshop focused on the need to recognize the life-course framework and education as a socialdeterminant of health to address the childhood obesity epidemic through diverse education-based initiatives. Workshopparticipants agreed that both education per se and the education sector are key for obesity prevention and must form part ofmultidisciplinary interventions and collaboration between schools, families and the entire society. Capacity building in obesityprevention is required and should include the entire learning community, teachers, leaders, health-care providers, relatedservices personnel, university professors and other interested community members. Obesity prevention initiatives should alsoengage key community institutions outside the formal education system, including early childhood centers, churches, pediatric/family medicine clinics, among others, to support family nutrition education, healthy food access and daily physical activity---allof which are key to promote a child’s ‘healthy weight’.International Journal of Obesity Supplements (2013) 3, S18--S19; doi:10.1038/ijosup.2013.7Keywords: life-course; education; prevention; childhood obesityINTRODUCTIONThe objectives of this paper are to present the conclusions fromthe workshop ‘Education for childhood obesity prevention: alife-course approach’, coordinated by the Pan-American HealthOrganization and the Pan-American Health and EducationFoundation, and held on 14 June 2012 in Aruba, as part of the IIPan-American Conference on Childhood Obesity (http://www.paco.aw/).This workshop focused on the need to recognize the life-courseframework to address the child hood obesity epidemic. Thisframework posits

Background/objective The European Childhood Obesity Project is a multi-centre double-blind randomised clinical trial in five countries testing whether protein intake in early life is related to later obesity risk. We use electronic data capture (EDC) in this trial and report here on our experience with the method. Subjects/methods Data capture for the first two study years was done with 10 notebooks, which were installed with the RDE (Remote Data Entry) programme Clindoc. Results We here exemplary report our experiences in 1 of the 11 study centres. A total of 205 of 760 visits (27.0%) were documented with interim paper-based case report forms, whereas 555 (73.0%) visits were recorded with electronic case report forms (eCRF). The need for after-trial plausibility checks of anthropometric data is significantly reduced in visits done by eCRF in comparison with visits done by paper-based CRFs (14.05% versus 35.61%). Conclusion EDC reduces significantly the need for after-trial data checks but the planning and implementation process before starting the trial is more time-consuming.

Many children growing up in cities are spending less time outdoors to escape the heat. This is contributing to childhood obesity and the prospect of a range of diseases in adulthood. When landscape architects and urban designers use a human thermal comfort model to test their designs for children's comfort, they would have to use a model essentially designed to simulate healthy adults. Yet there are many differences between the body of a child and an adult. The aim of this paper was to modify the thermal comfort model COMFA into a children's energy budget model through the consideration of the heat exchange of a child. The energy budget of a child can be up to 21 W/m2 higher than adults in hot summertime conditions, and 26 W/m2 lower in cold conditions. The model was validated through field studies of 65 children (32 boys and 33 girls) aged from 7-12 years old in 9 days from March to June in 2019, in 68 different microclimates ranging from cool to hot. A 5-point thermal comfort scale of energy budget for children was created using multinomial logistic regression, which revealed that children have a different range of thermal acceptability than adults. The frequency distribution of the actual thermal sensation and the predicted thermal comfort was improved using the new scale. The actual thermal sensation responses from children and the predicted thermal sensation using the model was determined to be positively significantly related. The accuracy of the model was 93.26%. This study has provided an effective children's energy budget model to predict children's thermal comfort. Its application can contribute to the design of thermally comfortable children's outdoor play areas by landscape architects and urban designers.

BackgroundChildhood obesity prevention initiatives emphasize healthy eating within the family. However, family-focused initiatives may not benefit children whose families lack economic and/or social resources for home cooking and shared meals. The aim of this paper is to examine how adults talk about and make sense of childhood memories of food and eating, with particular attention to understandings of family life and socioeconomic conditions.MethodsSemi-structured interviews with 49 adults in 16 families (22 parents and 27 grandparents of young children) were conducted in Oregon, United States. Most participants had experienced socioeconomically disadvantaged childhoods. The interviews were analyzed using thematic analysis, with a focus on the participants’ memories of food provision, preparation, and consumption in their childhood homes.ResultsTwo main themes were developed: (1) “Food and cohesion”, with the subthemes “Care and nurturance” and “Virtue transmission through shared meals”, and (2) “Food and adversity”, with the subthemes “Lack and neglect” and “Restriction and dominance”. The first theme captures idealized notions of food in the family, with participants recounting memories of care, nurturance, and culinary pleasure. The second theme captures how participants’ recollections of neglectful or rigidly restrictive feeding, as well as food discipline tipping over into dominance, upend such idealized images. Notably, the participants alternately identified poverty as a source of lack and as an instigator of creative and caring, if not always nutritionally-ideal, feeding. Thus, they remembered food they deemed unhealthy as a symbol of both neglect and care, depending on the context in which it was provided.ConclusionsChildhood memories of food and eating may express both family cohesion and family adversity, and are deeply affected by experiences of socioeconomic disadvantage. The connection between memories of food the participants deemed unhealthy and memories of care suggests that, in the context of socioeconomic disadvantage, unhealthy feeding and eating may become a form of caregiving, with nutrition considered only one aspect of well-being. This has implications for public health initiatives directed at lower-income families.

As the global prevalence of childhood obesity continues to rise, researchers and clinicians have sought to develop more effective and personalized intervention techniques. In doing so, obesity interventions have expanded beyond the traditional context of nutrition to address several facets of a child’s life, including their psychological state. While the consideration of psychological features has significantly advanced the view of obesity as a holistic condition, attempts to associate such features with outcomes of treatment have been inconclusive. We posit that such uncertainty may arise from the univariate manner in which features are evaluated, focusing on a particular aspect such as loneliness or insecurity, but failing to account for the impact of co-occurring psychological characteristics. Moreover, co-occurrence of psychological characteristics (both child and parent/guardian) have not been studied from the perspective of their relationship with nutritional intervention outcomes. To that end, this work looks to broaden the prevailing view: laying the foundation for the existence of complex interactions among psychological features. In collaboration with a non-profit nutritional clinic in Brazil, this paper demonstrates and models these interactions and their associations with the outcomes of a nutritional intervention.

Background Systems science methods such as dynamic simulation modelling are well suited to address questions about public health policy as they consider the complexity, context and dynamic nature of system-wide behaviours. Advances in technology have led to increased accessibility and interest in systems methods to address complex health policy issues. However, the involvement of policy decision makers in health-related simulation model development has been lacking. Where end-users have been included, there has been limited examination of their experience of the participatory modelling process and their views about the utility of the findings. This paper reports the experience of end-user decision makers, including senior public health policy makers and health service providers, who participated in three participatory simulation modelling for health policy case studies (alcohol related harm, childhood obesity prevention, diabetes in pregnancy), and their perceptions of the value and efficacy of this method in an applied health sector context. Methods Semi-structured interviews were conducted with end-user participants from three participatory simulation modelling case studies in Australian real-world policy settings. Interviewees were employees of government agencies with jurisdiction over policy and program decisions and were purposively selected to include perspectives at different stages of model development. Results The ‘co-production’ aspect of the participatory approach was highly valued. It was reported as an essential component of building understanding of the modelling process, and thus trust in the model and its outputs as a decision-support tool. The unique benefits of simulation modelling included its capacity to explore interactions of risk factors and combined interventions, and the impact of scaling up interventions. Participants also valued simulating new interventions prior to implementation in the real world, and the comprehensive mapping of evidence and its gaps to prioritise future research. The participatory aspect of simulation modelling was time and resource intensive and therefore most suited to high priority complex topics with contested options for intervening. Conclusion These findings highlight the value of a participatory approach to dynamic simulation modelling to support its utility in applied health policy settings. Electronic supplementary material The online version of this article (10.1186/s12911-018-0707-6) contains supplementary material, which is available to authorized users.

This paper describes the epidemiologic evidence linking parent-child relationships, self-regulation, and weight status with a focus on early childhood. The emotional quality of parent-child interactions may influence children’s risk for obesity through multiple pathways. Prospective studies linking observer ratings of young children’s self-regulation, particularly inhibitory control, to future weight status are discussed. Although findings are preliminary, promoting positive relationships between parents/caregivers and young children holds promise as a component of efforts to prevent childhood obesity. Multi-disciplinary collaborations between researchers with training in developmental science and child health should be encouraged.

OBJECTIVES: Public health concern about increasing levels of child/youth overweight and obesity has resulted in initiatives to address this issue. In 2012, the Ontario Ministry of Health and Long-Term Care (MOHLTC) established a target to reduce childhood obesity by 20% within five years. In this paper, we examine trends and establish baseline levels of overweight/obesity to assess the impacts of population-level interventions. METHODS: We analyzed 10 years (2003–2013) of data accumulated from six cycles of the Ontario Student Drug Use and Health Survey using logistic regression to assess trends in the prevalence of overweight/obesity among middle and high school students. The 2013 data are used to begin monitoring progress toward achieving the MOHLTC target. RESULTS: From 2003 through 2013, the prevalence of overweight/obesity among middle school students in the province remained stable overall and among all subgroups except 7th-grade females, who showed a significant linear decline. Among high school students, the prevalence of overweight/obesity showed a significant linear increase and an increase among 11th graders, females, and 10th- and 11th-grade females specifically. The prevalence remained stable but elevated among 9th- and 12th-grade females as well as among males in all grades. In 2013 (baseline for the MOHLTC target), 25.1% of students in grades 7–12 were overweight or obese, implying a presumed 2018 target of 20.1%. CONCLUSION: Ten-year trends in overweight/obesity indicate stability among males and significant linear increases in some female subgroups. Also, baseline data (2013) will facilitate the monitoring of future interventions aimed at achieving the 2018 MOHLTC target.

Background Recruitment of pregnant women into trials is a challenge exacerbated by a number of factors, including strict eligibility criteria. There has been little in-depth examination of the recruitment process to trials involving pregnant women. This paper presents the findings of a study conducted to identify facilitators and challenges in recruiting pregnant women to the Communicating Healthy Beginnings Advice by Telephone (CHAT) randomised controlled trial, which aims to reduce the prevalence of infant and childhood obesity. Methods Data were collected from (1) administration of a short questionnaire to women at the time of recruitment exploring women’s reasons for consent and non-consent; (2) interviews with recruiters to capture recruiters’ experiences of the recruitment process; and (3) analysis of field notes taken by recruiters on the number of women approached/recruited and reasons as to why they did not consent to participate. Data obtained were triangulated to gain insights into the process of recruiting pregnant women. Results A total of 1155 pregnant women (mean gestational age 31.5 weeks) were enrolled over 5 months. The main reasons for women consenting to participate in the study were convenience in programme delivery mode via telephone calls or text messages, altruism and because the programme was free of charge. The main reasons for women not consenting were lack of interest, language challenges/difficulty speaking English and some felt they did not need information and support due to prior experience as a mother. Facilitators included organisational support, rapport with recruiters and some women with no other children who needed advice. Despite the challenges, the mode of delivery of intervention via telephone calls or text messages, the minimal effort required of women to participate, organisational support from the lead site and recruiters’ knowledge of and commitment towards the trial contributed towards successful recruitment. Conclusion Despite some challenges in recruiting pregnant women to an infant obesity prevention programme, some of the facilitators in recruitment included mode of delivery of the intervention programme via telephone calls or text messages, the minimal effort required for women to participate, organisational support from the lead site, and recruiters’ knowledge of and commitment towards the trial. Trial registration The CHAT RCT is registered with the Australian Clinical Trial Registry (ACTRN12616001470482p); Ethics Review Committee of Sydney Local Health District (Protocol No. X16–0360 & LNR/16/RPAH/495).

Background Child obesity is a major public health challenge, increasing the risk of chronic medical conditions such as type 2 diabetes, metabolic syndrome, and hypertension. Among U.S. states, Tennessee has one of the highest rates of child obesity. Emerging communication technologies can help to deliver highly disseminable population-level interventions to improve health behavior. The aim of this paper is to report the implementation and the evaluation of the reach of Memphis FitKids, a web-based application, intended to promote healthy behaviors for families and children. Methods A community-level demonstration project, Memphis FitKids, was developed and implemented in Tennessee’s Greater Memphis Area. This application (www.memphisfitkids.org) was designed for parents to assess their children’s obesity risk through determinants such as weight, diet, physical activity, screen time, and sleep adequacy. A built-in “FitCheck” tool used this collected information to create a report with tailored recommendations on how to make healthy changes. A Geographic Information Systems component was implemented to suggest low-cost neighborhood resources that support a healthy lifestyle. A social marketing framework was used to develop and implement FitKids, and a Community Advisory Board with representatives from community partners (e.g., the YMCA of Memphis, the Pink Palace Family of Museums, and the Memphis Public Library) supported the implementation of the project. Five kiosks distributed in the community served as public access points to provide a broad reach across socioeconomic strata. Presentations at community events and the use of Facebook facilitated the promotion of FitKids. Website traffic and Facebook usage were evaluated with Google Analytics and Facebook Insights, respectively. Results In Tennessee, 33,505 users completed 38,429 FitCheck sessions between July 2014 and December 2016. Among these, 6763 sessions were completed at the five kiosks in the community. FitKids was presented at 112 community events and the social media posts reached 23,767 unique Facebook users. Conclusions The Memphis FitKids demonstration project showed that web-based health tools may be a viable strategy to increase access to information about healthy weight and lifestyle options for families. Mobile-friendly web-based applications like Memphis FitKids may also serve health professionals in their efforts to support their clients in adopting healthy behaviors. Electronic supplementary material The online version of this article (10.1186/s12889-018-5968-6) contains supplementary material, which is available to authorized users.

Background Obesity in childhood appears often during the toddler years. The prenatal environment influences obesity risk. Maternal gestational diabetes, the child’s diet, and physical activity in the first few years have an important role in subsequent weight gain. A study was conducted to evaluate effectiveness of a primary health-care lifestyle counselling intervention in prevention of childhood obesity up to 6 years of age. Methods The study was a controlled pragmatic trial to prevent childhood obesity and was implemented at maternity and child health-care clinics. The participants (n = 185) were mothers at risk of gestational diabetes mellitus with their offspring born between 2008 and 2010. The prenatal intervention, started at the end of the first trimester of pregnancy, consisted of counselling on diet and physical activity by municipal health-care staff. The intervention continued at yearly appointments with a public health-nurse at child health-care clinics. The paper reports the offspring weight gain results for 2–6 years of age. Weight gain up to 6 years of age was assessed as BMI standard deviation scores (SDS) via a mixed-effect linear regression model. The proportion of children at 6 years with overweight/obesity was assessed as weight-for-height percentage and ISO-BMI. Priority was not given to power calculations, because of the study’s pragmatic nature. Results One hundred forty seven children’s (control n = 76/85% and intervention n = 71/56%) weight and height scores were available for analysis at 6 years of age. There was no significant difference in weight gain or overweight/obesity proportions between the groups at 6 years of age, but the proportion of children with obesity in both groups was high (assessed as ISO-BMI 9.9% and 11.8%) relative to prevalence in this age group in Finland. Conclusion As the authors previously reported, the intervention-group mothers had lower prevalence of gestational diabetes mellitus, but a decrease in obesity incidence before school age among their offspring was not found. The authors believe that an effective intervention should start before conception, continuing during pregnancy and the postpartum period through the developmentally unique child’s first years. Trial registration ClinicalTrials.gov NCT00970710. Registered 1 September 2009. Retrospectively registered.

The prevention of obesity in children with DD is a pressing public health issue, with implications for health status, independent living, and quality of life. Substantial evidence suggests that children with developmental disabilities (DD), including those with intellectual disabilities (ID) and autism spectrum disorder (ASD), have a prevalence of obesity at least as high if not higher than their typically developing peers. The paper reviews what is known about the classic and unique risk factors for childhood obesity in these groups of children, including dietary, physical activity, sedentary behavior, and family factors, as well as medication use. We use evidence from the literature to make the case that primary prevention at the individual/family, school and community levels will require tailoring of strategies and adapting existing intervention approaches.

Overweight and obesity have risen substantially in the last few decades. Recently, food addiction has gained attention as a possible explanation for this increase. The purpose of this paper is to review the evidence for food addiction and its role in the rise of overweight and obesity in youth. Diagnostic symptoms, prevalence, and neurobiology of food addiction are reviewed. An overview of treatment options for youth is provided. Additional research on the nature of food addiction in youth as well as continued investigation of factors related to the rise in obesity is warranted.

Childhood obesity rates have risen dramatically over the past few decades. Although obesity has been linked to poorer neurocognitive functioning in adults, much less is known about this relationship in children and adolescents. Therefore, we conducted a systematic review to examine the relationship between obesity and obesity-related behaviors with neurocognitive functioning in youth. We reviewed articles from 1976 to 2013 using PsycInfo, PubMed, Medline and Google Scholar. Search terms included cognitive function, neurocognitive function/performance, executive function, impulsivity, self-regulation, effortful control, cognitive control, inhibition, delayed gratification, memory, attention, language, motor, visuo-spatial, academic achievement, obesity, overweight, body mass index, waist-hip ratio, adiposity and body fat. Articles were excluded if participants had health problems known to affect cognitive functioning, the study used imaging as the only outcome measure, they were non-peer-reviewed dissertations, theses, review papers, commentaries, or they were non-English articles. Sixty-seven studies met inclusion criteria for this review. Overall, we found data that support a negative relationship between obesity and various aspects of neurocognitive functioning, such as executive functioning, attention, visuo-spatial performance, and motor skill. The existing literature is mixed on the effects among obesity, general cognitive functioning, language, learning, memory, and academic achievement. Executive dysfunction is associated with obesity-related behaviors, such as increased intake, disinhibited eating, and less physical activity. Physical activity is positively linked with motor skill. More longitudinal research is needed to determine the directionality of such relationships, to point towards crucial intervention time periods in the development of children, and to inform effective treatment programs. © 2014 Macmillan Publishers Limited All rights reserved.

With the modernization of societies, daily living, school, chores and work tasks are less energy demanding and sedentary behaviors such as television viewing and video game playing are pervasive, particularly in children and adolescents. This sedentary behavior constellation has contributed to the progression of overweight and obesity. The low energy expenditure associated to daily sedentary behaviors has been postulated as the primary mechanism to explain population weight gain; however, recent evidence reveals that many sedentary behaviors also promote overconsumption of food. The present paper summarizes the available literature about the impact of sedentary behaviors on energy intake and appetite sensations in children and adolescents. Overall, screen-based sedentary behaviors (e.g., television viewing and video game playing) stimulate food intake in children and youth, while the influence of non-screen sedentary behaviors on feeding behavior remains largely unexplored. As in adults, insufficient sleep and waked resting positions (sitting or bed rest) are associated with increased energy consumption. Because all of these activities increase energy intake in the absence of hunger, the hedonic (rewarding) component of eating behavior seems to play an important role. At present, public health recommendations focus on increasing physical activity energy expenditure and reducing sedentary time in children and youth. From an energy balance standpoint, the impact of modern sedentary behaviors on food consumption should also be considered if we want to curb childhood obesity. A better understanding of the physiological, psychological and sociological mechanisms involved in the nutritional adaptations to sedentary activities is needed to more adequately elucidate the interplay between sedentary behaviors, feeding behaviors and obesity.

Background This paper presents design and findings from the process evaluation of a randomized controlled trial (RCT) testing the effectiveness of Smarter Lunchrooms Movement (SLM) interventions to encourage consumption of either fruit, vegetables, or unflavored milk in middle school cafeterias (grades 6–8, typically children ages 10–14 years). Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework adapted for environmental interventions, the process evaluation monitored fidelity to SLM protocol, determined barriers and facilitators influencing fidelity, and identified the training and support needs of implementers. Methods Under research team guidance, community partners (interventionists) assisted school food service staff (providers) with a six week implementation of protocol items in 13 public middle school cafeterias (two milk treatment, three vegetable treatment, four fruit treatment, and four control) in New York State during the 2013–2014 academic year. Process evaluation measures included semi-quantitative measures of implementation and maintenance (lunchroom audits) and qualitative data (environmental assessments and semi-structured interviews with school food service staff). Analyses identified challenges and opportunities for improving intervention delivery. Results Approximately 75 % of enrolled students participated in school lunch programs and thus were exposed to the SLM intervention. Findings indicated potential contamination by other nutrition-related activities in the lunchroom and larger school environment may have affected the intervention impact. Modest implementation fidelity scores were observed for intervention treatments. Providers reported treatments were acceptable and feasible, however interventionists confirmed motivation and perceived effectiveness varied among schools. Post-intervention audits revealed limited maintenance of intervention protocols. Strategies to enhance buy-in and communication among providers and increased interventionist support are recommended. Conclusions RE-AIM was a valuable framework for this process evaluation. Results highlighted implementation barriers and facilitators, and findings will enhance interpretation of forthcoming outcome data. Results will inform future iterations of the SLM RCT and provide valuable insights for those designing environmental interventions in school cafeterias.

Background Weight loss improves cardiovascular risk factors and “quality of life”. Most therapeutic approaches fail to induce a sustained weight loss and most individuals undergo weight regain. In this paper the comprehensive design of the “MAINTAIN” study, all assessments as well as the one year lifestyle intervention will be outlined in detail. Methods/Design One-center randomized controlled trial with seven assessment time points conducted 2009-2015. For the randomization eight groups were distinguished in a list to allocate intervention or control group: Females and males either pre-pubertal or pubertal and with a BMI-SDS under or over 2.5. Setting: Weight loss at a residential weight reduction programme Berlin/Brandenburg and intervention at a paediatric outpatient clinic; Participants: 137 children and adolescents (10 to 17 years). Intervention: Participants were randomized after an initial weight loss at a residential weight reduction programme and allocated to intervention (n=65) and control (n=72) conditions. The intervention group received an one-year group multi-professional lifestyle intervention with monthly meetings at the paediatric outpatient obesity clinic. The control group had a free living phase for one year and both groups 48 months follow up. Main outcome measures: Participants who are engaged in monthly intervention meetings will benefit in terms of a sustained weight maintenance. The primary aim is to describe the dynamic of hormonal and metabolic mechanisms counter-balancing sustained weight loss during puberty and adolescence. The secondary aim is to investigate the effect of an intensive family based lifestyle intervention during the weight maintenance period on the endogenous counter-regulation as well as on health related quality of life. The third aim is to establish predictors for successful weight maintenance and risk factors for weight regain in obese children and adolescents. Discussion Weight maintenance after induced weight loss is one of the most important therapeutic challenges as long as most patients fail to maintain their weight loss. MAINTAIN is the first paediatric RCT addressing in parallel to a RCT in obese adults the course of weight regain after induced weight loss and is embedded in an experimental research consortium in order to also address several molecular mechanisms of weight regain. Trial registration ClinicalTrials NCT00850629, first registration 17 February 2009, verified January 2012, Paediatric part of the interventional study. Ethic proposal approved at 08.04.2009 Electronic supplementary material The online version of this article (doi:10.1186/s40608-016-0110-8) contains supplementary material, which is available to authorized users.

Background In recent years, childhood overweight and obesity have become an increasing and challenging phenomenon in Western cities. A lot of studies have focused on the analysis of factors such as individual dispositions and nutrition balances, among others. However, little is known about the intra-urban spatial patterns of childhood overweight and its associations with influencing factors that stretch from an individual to a neighbourhood level. The aim of this paper is to analyse the spatial patterns of childhood obesity in Berlin, and also to explore and test for associations with a complex set of risk factors at the individual, household and neighbourhood levels. Methods We use data from a survey of 5–6 year-olds that includes health status, height, and weight, as well as several socioeconomic and other risk variables. In addition, we use a set of neighbourhood variables, such as distance, and density measures of parks or fast food restaurants. Our outcome variable is the percentage of children of 5–6 years who were reported overweight or obese in 2012. The aggregated data is available for 60 areas in Berlin. We first analyse the outcome and risk factor data descriptively, and subsequently apply a set of regression analyses to test for associations between reported overweight and obesity, and also individual, household and neighbourhood characteristics. Results Our analysis returned a distinct spatial distribution of childhood overweight in Berlin with highest shares in the city centre. Moreover, we were able to identify significant effects regarding the social index, and the percentage of non-German children being obese or overweight; additionally, we identified fast food restaurant density as a possible influencing factor. For the other variables, including the neighbourhood variables, we could not identify a significant association on this aggregated level of analysis. Conclusions Our findings confirm the results of earlier studies, in which the social status and percentage of non-German children is very important in terms of the association with childhood overweight and obesity. Unlike many studies conducted in North America, this study did not reveal an influence of neighbourhood variables. We argue that European urban structures differ from North American structures and highlight the need for a more detailed analysis of the association between the neighbourhood environment and the physical activity of children in urban setting. Electronic supplementary material The online version of this article (doi:10.1186/s12942-016-0041-0) contains supplementary material, which is available to authorized users.

School travel is becoming increasingly car-based and this is leading to many environmental and health implications for children all over the world. One of several reasons for this is that journey to school distances have increased over time. This is a trend that has been reinforced in some countries by the adoption of so-called ‘school choice’ policies, whereby parents can apply on behalf of their child(ren) to attend any school, and not only the school they live closest to. This paper examines the traffic and environmental impacts of the school choice policy in England. It achieves this by analysing School Census data from 2009 from the Department for Education. Multinomial logit modelling and mixed multinomial logit modelling are used to illustrate the current travel behaviour of English children in their journey to school and examine how there can be a significant reduction in vehicle miles travelled, CO2 emissions and fuel consumption if the ‘school choice’ policy is removed. The model shows that when school choice was replaced by a policy where each child only travelled to their ‘nearest school’ several changes occurred in English school travel. Vehicle Miles Travelled (VMT) by motorised transport fell by 1 % for car travel and 10 % for bus travel per day. The reduction in vehicle miles travelled could lead to less congestion on the roads during the morning rush hour and less cars driving near school gates. Mode choice changed in the modelled scenario. Car use fell from 32 to 22 %. Bus use fell from 12 to 7 %, whilst NMT saw a rise of 17 %. With more children travelling to school by walking or cycling the current epidemic of childhood obesity could also be reduced through active travel.

This is an Open Access article Background: While many studies have demonstrated positive associations between childhood obesity and adult metabolic risk, important questions remain as to the nature of the relationship. In particular, it is unclear whether the associations reflect the tracking of body mass index (BMI) from childhood to adulthood or an independent level of risk. This systematic review aimed to investigate the relationship between childhood obesity and a range of metabolic risk factors during adult life. Objective: To perform an unbiased systematic review to investigate the association between childhood BMI and risk of developing components of metabolic disease in adulthood, and whether the associations observed are independent of adult BMI. Design: Electronic databases were searched from inception until July 2010 for studies investigating the association between childhood BMI and adult metabolic risk. Two investigators independently reviewed studies for eligibility according to the inclusion/exclusion criteria, extracted the data and assessed study quality using the Newcastle–Ottawa Scale. Results: The search process identified 11 articles that fulfilled the inclusion and exclusion criteria. Although several identified weak positive associations between childhood BMI and adult total cholesterol, low-density lipo protein-cholesterol, triglyceride and insulin concentrations, these associations were ameliorated or inversed when adjusted for adult BMI or body fatness. Of the four papers that considered metabolic syndrome as an end point, none showed evidence of an independent association with childhood obesity. Conclusions: Little evidence was found to support the view that childhood obesity is an independent risk factor for adult blood lipid status, insulin levels, metabolic syndrome or type 2 diabetes. The majority of studies failed to adjust for adult BMI and therefore the associations observed may reflect the tracking of BMI across the lifespan. Interestingly, where adult BMI was adjusted for, the data showed a weak negative association between childhood BMI and metabolic variables, with those at the lower end of the BMI range in childhood, but obese during adulthood at particular risk.

Obesity and other eating-related problems are widespread and are associated with harmful physical, psychological, and social problems. The dramatic increases in rates of pediatric obesity has created a mounting need for psychologists and other mental health care providers to play a significant role in the assessment and treatment of youth with eating- and weight-related problems. Therefore, it is imperative for providers to be aware of the causes and consequences of eating- and weight-related problems and to be familiar with evidence-based assessment and intervention approaches. Currently, the most well-established intervention approaches are family-based behavioral treatments, and weight loss maintenance treatments with a socio-ecological focus are promising. This paper provides a comprehensive review of these topics and highlights the important roles that mental health care providers can have. Medical settings are often the patient’s first point of contact within the healthcare system, making mental health care providers in such settings uniquely suited to assess for a broad range of eating- and weight-related problems and associated comorbidities, to deliver relevant evidence-based interventions, and to make appropriate referrals. Moving forward, providers and researchers must work together to address key questions related to the nature of eating- and weight-related problems in youth and to achieve breakthroughs in the prevention and treatment of such problems in this vulnerable population.

Most childhood obesity prevention efforts have focused on school-age children and adolescents and have had limited success. We argue that the first years of life, including the prenatal period, the postnatal suckling period and the transition to the modified adult diet, may provide opportunities for preventive interventions. These early periods are characterized by high plasticity and rapid transitions, and parents have a high degree of control over children's environments and experiences. Observational and experimental evidence reveal persistent effects of early environments on eating behavior and obesity risk, suggesting that interventions should be tested during these early periods. The central task parents have in early development points to their potential as key targets and agents of change in early preventive interventions. In this paper, we review evidence of early environmental effects on children's eating and obesity risk, highlighting ways that parental feeding practices and parents' own behaviors impact these outcomes and calling for further experimental research to elucidate whether these factors are indeed promising targets for childhood obesity preventive interventions.

The increasing prevalence and severity of obesity in children and adolescents has provided greater emphasis on the wide variety of comorbid conditions and complications that can be experienced as a consequence of obesity. These complications can occur both in the short term and in the long term. Some complications, earlier thought to be long-term issues, which would only occur in adulthood, have now been shown to occur in children and adolescents. These findings have raised concerns about the overall health experience of those who develop obesity early in life and have even raised questions about whether the obesity epidemic might shorten the life span of the current generation of children. In this paper, I will examine current knowledge regarding the different organ systems that may be impacted by childhood obesity.

This paper investigates the channels through which maternal employment affects childhood obesity. We use time diaries and interview responses from the Child Development Supplement of the Panel Study of Income Dynamics which combine information on children’s time allocation and mother’s labor force participation. Our empirical strategy involves estimating the effect of children’s activities and meal routines on BMI, estimating the effect of maternal employment on these activities and routines and then combining these two estimates. We find that maternal employment affects child weight through two main mechanisms – supervision and nutrition, however, the particular channels vary by mother’s education.

The epidemiological question of concern here is "can young children at risk of obesity be identified from their early growth records?" Pilot work using logistic regression to predict overweight and obese children demonstrated relatively limited success. Hence we investigate the incorporation of non-linear interactions to help improve accuracy of prediction; by comparing the result of logistic regression with those of six mature data mining techniques. The contributions of this paper are as follows: a) a comparison of logistic regression with six data mining techniques: specifically, for the prediction of overweight and obese children at 3 years using data recorded at birth, 6 weeks, 8 months and 2 years respectively; b) improved accuracy of prediction: prediction at 8 months accuracy is improved very slightly, in this case by using neural networks, whereas for prediction at 2 years obtained accuracy is improved by over 10%, in this case by using Bayesian methods. It has also been shown that incorporation of non-linear interactions could be important in epidemiological prediction, and that data mining techniques are becoming sufficiently well established to offer the medical research community a valid alternative to logistic regression.

Understanding parents’ feeding control practices and their associations with various factors is useful for prevention of childhood obesity, an emerging problem in low- and middle-income countries. The aim of this paper is to describe the control practices used by parents of preschool children in Vietnam and factors associated with these. Two cross-sectional studies were conducted in urban DodaLab (n = 1364) and rural FilaBavi (n = 1313), Health and Demographic Surveillance Sites (HDSS), Hanoi, Vietnam. For 94.9 % of the children, both parents answered the Child Feeding Questionnaire and additional questions about nutritional practices. Children’s and parents’ weight and height were measured. Simple Pearson correlation coefficients, multiple regression and exploratory factor analysis were used for the statistical analysis. Mothers reported the use of more restriction, pressure to eat and monitoring than the fathers. The measured child’s body mass index (BMI) and the mother’s perception of the child’s weight were negatively associated with pressure to eat and positively associated with monitoring. A positive association was found between restriction and the mother’s perception of the child’s weight. In the rural area, high consumption of fatty food, sweets and snacks was associated with high use of restriction and monitoring. The amount of food consumed was negatively associated with the use of pressure to eat. In the urban area, consumption of fatty food and sweets was positively correlated both with restriction and pressure to eat. Monitoring was negatively associated with consumption of fatty food and snacks and positively with the amount of food. Higher education of the mothers was associated with higher use of monitoring, restriction (in the urban area) and pressure to eat (in the rural area). While feeding practices in Vietnam differed between mothers and fathers and between urban and rural areas, the associations with children’s BMI and socioeconomic factors were weak. This implies that parental roles as well as sociodemographic factors should be considered when designing programs for prevention of childhood overweight and obesity.

Background: Childhood obesity is an increasing health problem globally. Overweight and obesity may be established as early as 2–5 years of age, highlighting the need for evidence-based effective prevention and treatment programs early in life. In adults, mobile phone based interventions for weight management (mHealth) have demonstrated positive effects on body mass, however, their use in child populations has yet to be examined. The aim of this paper is to report the study design and methodology of the MINSTOP (Mobile-based Intervention Intended to Stop Obesity in Preschoolers) trial., Methods/Design: A two-arm, parallel design randomized controlled trial in 300 healthy Swedish 4-year-olds is conducted. After baseline measures, parents are allocated to either an intervention- or control group. The 6- month mHealth intervention consists of a web-based application (the MINSTOP app) to help parents promote healthy eating and physical activity in children. MINISTOP is based on the Social Cognitive Theory and involves the delivery of a comprehensive, personalized program of information and text messages based on existing guidelines for a healthy diet and active lifestyle in pre-school children. Parents also register physical activity and intakes of candy, soft drinks, vegetables as well as fruits of their child and receive feedback through the application. Primary outcomes include body fatness and energy intake, while secondary outcomes are time spent in sedentary, moderate, and vigorous physical activity, physical fitness and intakes of fruits and vegetables, snacks, soft drinks and candy. Food and energy intake (Tool for Energy balance in Children, TECH), body fatness (pediatric option for BodPod), physical activity (Actigraph wGT3x-BT) and physical fitness (the PREFIT battery of five fitness tests) are measured at baseline, after the intervention (six months after baseline) and at follow-up (12 months after baseline)., Discussion: This novel study will evaluate the effectiveness of a mHealth program for mitigating gain in body fatness among 4-year-old children. If the intervention proves effective it has great potential to be implemented in child-health care to counteract childhood overweight and obesity., This work is supported by grants from the Swedish Research Council, the Swedish Research Council for Health, Working life and Welfare, Karolinska Institute, and Bo and Vera Ax:son Johnssons’ foundation (all ML). FO and JR are supported by grants from the Spanish Ministry of Economy and Competitiveness [RYC–2010–05957; RYC–2011–09011].

Existing systematic reviews aimed at comparing effectiveness of childhood obesity treatment interventions are limited by a lack of quality in the conduct and reporting of trials in this area. This study aimed to identify the number and types of primary and secondary outcomes used within trials of childhood obesity treatments and to determine the degree to which these trials correctly report their use of outcome measures. A systematic literature review was conducted to identify phase II (i.e. pilot and feasibility studies) and phase III (e.g. determining effectiveness) trials of childhood obesity treatments across 11 databases. Data were extracted from eligible manuscripts pertaining to the number and type of outcome measures used, in addition to details of citations provided for these measures. 145 different outcome measures were reported to be used within 200 identified eligible trial manuscripts. Citations were provided to indicate the provenance for 417 measures, but only 13% of these were correctly linked to papers describing the development and/or evaluation of measures. This study identified inconsistencies and inaccuracies in the use and reporting of outcome measures used by eligible trials. Researchers in this area are urged to consider guidelines such as CONSORT and the National Obesity Observatory Standard Evaluation Framework in the design and reporting of future trials.

Background The prevalence of childhood obesity, which has seen a rapid increase over the last decade, is now considered a major public health problem. Current treatment options are based on the two important frameworks of school- and family-based interventions; however, most research has yet to compare the two frameworks in the treatment of childhood obesity. The objective of this review is to compare the effectiveness of school-based intervention with family-based intervention in the treatment of childhood obesity. Methods Databases such as Medline, Pub med, CINAHL, and Science Direct were used to execute the search for primary research papers according to inclusion criteria. The review included a randomised controlled trial and quasi-randomised controlled trials based on family- and school-based intervention frameworks on the treatment of childhood obesity. Results The review identified 1231 articles of which 13 met the criteria. Out of the thirteen studies, eight were family-based interventions (n = 8) and five were school-based interventions (n = 5) with total participants (n = 2067). The participants were aged between 6 and 17 with the study duration ranging between one month and three years. Family-based interventions demonstrated effectiveness for children under the age of twelve and school-based intervention was most effective for those aged between 12 and 17 with differences for both long-term and short-term results. Conclusions The evidence shows that family- and school-based interventions have a considerable effect on treating childhood obesity. However, the effectiveness of the interventional frameworks depends on factors such as age, short- or long-term outcome, and methodological quality of the trials. Further research studies are required to determine the effectiveness of family- and school-based interventions using primary outcomes such as weight, BMI, percentage overweight and waist circumference in addition to the aforementioned factors.

The increasing prevalence of childhood obesity and its concomitant health risks justify widespread efforts toward prevention. Although both diet and physical activity have been emphasized as appropriate interventions, the current paper focuses on the role of physical activity in obesity prevention. Children's levels of physical activity are highly variable, and may be influenced by a multitude of factors including physiological, psychological, sociocultural and environmental determinants. Although the relationship between physical activity and obesity is controversial and the protective mechanism unclear, physical activity is hypothesized to protect individuals from the development of obesity by increasing energy expenditure and resting metabolic rate (RMR) and leading to a favourable fuel utilization. The beneficial effect of physical activity in children is supported by controlled exercise intervention programs. Several broad-based public health interventions designed to increase children's levels of physical activity have been implemented in schools, families and communities, with results suggesting promising strategies for the prevention of childhood obesity. It is likely that successful prevention of childhood obesity through physical activity promotion will involve theory-based, culturally appropriate school, family and community interventions. Through policy changes, environmental planning and educational efforts in schools and communities, increased opportunities and encouragement for physical activity can be provided.

This report reviews the risks and consequences associated with childhood and adolescent obesity. Although no consensus definition of childhood obesity exists, the various measures encountered in the literature are moderately well correlated. The paper is organized in three parts. The first section reviews childhood obesity sequelae that occur during childhood. These short-term risks, for orthopedic, neurological, pulmonary, gasteroenterological, and endocrine conditions, although largely limited to severely overweight children, are becoming more common as the prevalence of severe overweight rises. The social burden of pediatric obesity, especially during middle childhood and adolescence, may have lasting effects on self-esteem, body image and economic mobility. The second section examines the intermediate consequences, such as the development of cardiovascular risk factors and persistence of obesity into adulthood. These mid-range effects of early obesity presage later adult disease and premature mortality. In the final section, the small body of research on the long-term morbidity and mortality associated with childhood obesity is reviewed. These studies suggest that risk of cardiovascular disease and all-cause mortality is elevated among those who were overweight during childhood. The high prevalence and dramatic secular trend toward increasing childhood obesity suggest that without aggressive approaches to prevention and treatment, the attendant health and social consequences will be both substantial and long-lasting.

The state of childhood obesity in Canada and many countries worldwide has reached epidemic proportions. The Canadian prevalence has tripled from 1981-1996. A stunning 40% of obese children and 70% of obese youth continue this trend into adulthood. This has led to higher rates of adult obesity and associated conditions such as type 2 diabetes and cardiovascular disease. A chronically positive energy balance causes obesity, where energy intake exceeds expenditure. Although genetic heritability may account for 25-40% of childhood obesity, it would be hard to imagine that recent mutations have accounted for the epidemic rise in rates over the past 20 years. Clearly, environmental factors must play a significant role. Most important among these are inappropriate nutrition and inadequate physical activity. Canadians ingest large amounts of refined sugar and fat-containing foods. The most popular Canadian beverage is the soft drink with greater than 110 litres consumed per person per year. With their busy schedules, families rely more readily on meals from fast food restaurants where large portions of fatty foods are consumed. Eating while watching television is also associated with weight gain, and excessive sedentary activities, such as television watching and playing video and computer games are more prominent than ever. Recent statistics show that children and youth watch up to14 hours per week of television and spend an average of 6-7 hours per day viewing various media. Eighty percent of Canadian children have Internet access at home and almost 50% are online for at least an hour per day. In addition, children are not engaged in sufficient amounts of regular physical activity. At least half of Canadian children are not physically active enough for optimal growth, and development and levels of activity drop as they get older. Adolescents are on average 10% less physically active than children 2-12 years of age. Girls are less active, and do less physically intense activities than boys. The reduction in physical activity levels begins 2 years earlier in girls (14-15 vs 16-17 years) compared with boys. Hypoactivity is even more prevalent in obese children and youth, which results in less energy expenditure and more weight gain. Unfortunately, obese children and youth are not just “out of shape”. Over the last 10-20 years, these individuals have developed a number of chronic illnesses including type 2 diabetes, hypertension, hyperlipidemia, respiratory disorders, gallbladder disease, orthopaedic problems and, not inconsequentially, psychological illness. Obesity is associated with poor self-esteem and depression, and when depression is noted in non-obese youth there is a two-fold increase in risk of obesity within one year. Body image and “fitting in” with perceived norms of weight, height and sexual development are important concerns for adolescents. Heavy-set youth in a state of poor self-worth frequently try to lose weight by adopting various calorie-restricted diets, which are ultimately ineffective and usually result in greater weight gain. This leads to a vicious circle of inadequate self-esteem, high levels of physique anxiety and unhealthy behaviours. In this issue of the Canadian Journal of Public Health, Peter Crocker’s article entitled “Predicting Change in Physical Activity, Dietary Restraint, and Physique Anxiety in Adolescent Girls: Examining Covariance in Physical Self-Perceptions” looked at the relationship between changes in these elements prospectively over a one-year period using several questionnaires. There are a number of limitations to this study including the lack of objective measurements of height, weight and physical activity. Also, there was a 10% drop out of subjects, which might have an impact on data analysis. In addition, the paper is exploratory in nature and as such, causation cannot truly be determined. However, a number of interesting associations were reported. Statistically significant small increases in mean body mass index (BMI) and social physique anxiety were noted in this study. Intriguingly, rising BMI values over the 12 months did not predict a change in physical activity, social physique anxiety, physical self-perceptions or dietary restraint. A reduction in physical activity was associated with changes in all self-perceptions except BMI. However, worsening of perceived physical conditioning was the only significant predictor. Body appearance, especially perceived physical conditioning, was linked to increases in social physique anxiety and dietary restraint, independent of BMI. This implies that factors other than actual height, weight and percent body fat may play a role in the development of negative self-perceptions resulting in significant aberrations in nutritional intake. One of these factors is likely the media in today’s society. Research has shown that in girls, the development of a negative body image appears to be strongly linked to media images of the thin female role model. Interestingly, young people are often unaware that the fashion industry uses digital enhancement and airbrush techniques to make these models look “perfect”. It is no wonder that obese teens become increasingly frustrated trying to achieve these unrealistic standards by ineffective and potentially harmful weight-losing behaviours. If we hope to stop the epidemic of obesity in Canada, fad diets are undoubtedly not the answer. Instead, a focus on healthy active living within families, schools, communities, and all levels of government must be adopted. Healthy food choices should be promoted. These include restricting soft drink and juice intake in childhood, increasing the intake of carboFaculty of Medicine, University of Ottawa Correspondence: Dr. Claire M.A. LeBlanc, Department of Pediatrics, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1

Background There is an urgent need to develop and evaluate weight management interventions to address childhood obesity. Recent research suggests that interventions designed for parents exclusively, which have been named parents as agents of change (PAC) approaches, have yielded positive outcomes for managing pediatric obesity. To date, no research has combined a PAC intervention approach with cognitive behavioural therapy (CBT) to examine whether these combined elements enhance intervention effectiveness. This paper describes the protocol our team is using to examine two PAC-based interventions for pediatric weight management. We hypothesize that children with obesity whose parents complete a CBT-based PAC intervention will achieve greater reductions in adiposity and improvements in cardiometabolic risk factors, lifestyle behaviours, and psychosocial outcomes than children whose parents complete a psycho-education-based PAC intervention (PEP). Methods/Design This study is a pragmatic, two-armed, parallel, single-blinded, superiority, randomized clinical trial. The primary objective is to examine the differential effects of a CBT-based PAC vs PEP-based PAC intervention on children’s BMI z-score (primary outcome). Secondary objectives are to assess intervention-mediated changes in cardiometabolic, lifestyle, and psychosocial variables in children and parents. Both interventions are similar in frequency of contact, session duration, group facilitation, lifestyle behaviour goals, and educational content. However, the interventions differ insofar as the CBT-based intervention incorporates theory-based concepts to help parents link their thoughts, feelings, and behaviours; these cognitive activities are enabled by group leaders who possess formal training in CBT. Mothers and fathers of children (8–12 years of age; BMI ≥85th percentile) are eligible to participate if they are proficient in English (written and spoken) and agree for at least one parent to attend group-based sessions on a weekly basis. Anthropometry, cardiometabolic risk factors, lifestyle behaviours, and psychosocial health of children and parents are assessed at pre-intervention, post-intervention, 6-, and 12-months follow-up. Discussion This study is designed to extend findings from earlier efficacy studies and provide data on the effect of a CBT-based PAC intervention for managing pediatric obesity in a real-world, outpatient clinical setting. Trial Registration ClinicalTrials.gov identifier: NCT01267097

Background Childhood obesity is multi-factorial and determined to a large extent by dietary habits, physical activity and sedentary behaviours. Previous research has shown that school-based programmes are effective but that their effectiveness can be improved by including a parental component. At present, there is a lack of effective parental support programmes for improvement of diet and physical activity and prevention of obesity in children. Methods/Design This paper describes the rationale and design of a parental support programme to promote healthy dietary habits and physical activity in six-year-old children starting school. The study is performed in close collaboration with the school health care and is designed as a cluster-randomised controlled trial with a mixed methods approach. In total, 14 pre-school classes are included from a municipality in Stockholm county where there is large variation in socio-economic status between the families. The school classes are randomised to intervention (n = 7) and control (n = 7) groups including a total of 242 children. The intervention is based on social cognitive theory and consists of three main components: 1) a health information brochure; 2) two motivational interviewing sessions with the parents; and 3) teacher-led classroom activities with the children. The primary outcomes are physical activity in the children measured objectively by accelerometry, children's dietary and physical activity habits measured with a parent-proxy questionnaire and parents' self-efficacy measured by a questionnaire. Secondary outcomes are height, weight and waist circumference in the children. The duration of the intervention is six months and includes baseline, post intervention and six months follow-up measurements. Linear and logistic regression models will be used to analyse differences between intervention and control groups in the outcome variables. Mediator and moderator analysis will be performed. Participants will be interviewed. Discussion The results from this study will show if it is possible to promote a healthy lifestyle and a normal weight development among children from low-income districts with relatively limited efforts involving parents. Hopefully the study will provide new insights to the further development of effective programmes to prevent overweight and obesity in children. Trial registration ISRCTN: ISRCTN32750699

Background Although several previous projects have attempted to address the issue of child obesity through school-based interventions, the overall effectiveness of school-based programs on health-related outcomes in youth has been poor. Thus, it has been suggested that multi-level interventions that aim to influence healthy lifestyle behaviors at the community, school and family levels may prove more successful in the prevention of childhood obesity. Methods/Design This paper describes the rationale, design, and implementation of a community-, school-, and family-based intervention aimed at modifying key behaviors (physical activity, screen time (Internet, television, video games), and nutrition) related to childhood obesity among third through fifth graders in two mid-western cities. The intervention involves a randomized study of 10 schools (5 intervention and 5 control schools). The intervention is being conducted during the duration of the academic year – approximately 9 months – and includes baseline and post-intervention measurements of physical activity, dietary intake, screen time and body composition. Discussion We hope this report will be useful to researchers, public health professionals, and school administrators and health professionals (nurses and physical/health educators) seeking to develop similar prevention programs. It is obvious that more collaborative, inter-disciplinary, multi-level work is needed before a proven, effective intervention package to modify behaviors related to childhood obesity can be generally recommended. It is our hope that SWITCH is a step in that direction. Trial Registration ClinicalTrials.gov NCT00685555

Correction to: International Journal of Obesity (2013) 37, 31–39; doi:10.1038/ijo.2012.168; published online 13 November 2012 Since the publication of the above paper, the authors have noticed that in referring to the weight status for 9-month-old children, the descriptor should be the CDC standard of percentile of weight-for-height, rather than the percentile of BMI.

Background:\ud Effective programs to help children manage their weight are required. Families for Health focuses on a parenting approach, designed to help parents develop their parenting skills to support lifestyle change within the family. Families for Health V1 showed sustained reductions in overweight after 2 years in a pilot evaluation, but lacks a randomized controlled trial (RCT) evidence base.\ud \ud Methods/design:\ud This is a multi-center, investigator-blind RCT, with parallel economic evaluation, with a 12-month follow-up. The trial will recruit 120 families with at least one child aged 6 to 11 years who is overweight (≥91st centile BMI) or obese (≥98th centile BMI) from three localities and assigned randomly to Families for Health V2 (60 families) or the usual care control (60 families) groups. Randomization will be stratified by locality (Coventry, Warwickshire, Wolverhampton).\ud Families for Health V2 is a family-based intervention run in a community venue. Parents/carers and children attend parallel groups for 2.5 hours weekly for 10 weeks. The usual care arm will be the usual support provided within each NHS locality.\ud A mixed-methods evaluation will be carried out. Child and parent participants will be assessed at home visits at baseline, 3-month (post-treatment) and 12-month follow-up. The primary outcome measure is the change in the children’s BMI z-scores at 12 months from the baseline. Secondary outcome measures include changes in the children’s waist circumference, percentage body fat, physical activity, fruit/vegetable consumption and quality of life. The parents’ BMI and mental well-being, family eating/activity, parent–child relationships and parenting style will also be assessed.\ud Economic components will encompass the measurement and valuation of service utilization, including the costs of running Families for Health and usual care, and the EuroQol EQ-5D health outcomes. Cost-effectiveness will be expressed in terms of incremental cost per quality-adjusted life year gained. A de novo decision-analytic model will estimate the lifetime cost-effectiveness of the Families for Health program.\ud Process evaluation will document recruitment, attendance and drop-out rates, and the fidelity of Families for Health delivery. Interviews with up to 24 parents and children from each arm will investigate perceptions and changes made.\ud \ud Discussion:\ud \ud This paper describes our protocol to assess the effectiveness and cost-effectiveness of a parenting approach for managing childhood obesity and presents challenges to implementation.\ud \ud Trial registration: Current Controlled Trials ISRCTN45032201

Background There is increasing recognition that public health strategies to prevent childhood obesity need to start early in life. Any behavioural interventions need to target maternal attitudes and infant feeding practices, This paper describes the development and preliminary validation of a questionnaire to assess maternal attitudes towards infant growth and milk feeding practices. Methods We designed a 57-item (19 questions), self-administered questionnaire to measure the following four domains- 1) type of milk feeding, decision making and sources of advice; 2) frequency and quantity of milk feeds; 3) attitudes to infant feeding and growth; and 4) theory-based beliefs about following infant feeding recommendations. Forty mothers completed the questionnaire on two occasions six days apart (to assess test-retest reliability) and then participated in a semi-structured, open-ended telephone interview covering the same domains (to assess criterion validity). Percentage agreement, Cohen's Kappas (for categorical variables) and Spearman's correlation coefficients (for continuous variables) were used to quantify reliability and validity. Internal consistency between theory-based constructs (self-efficacy, outcome expectancy and intention) was quantified by Chronbach's alpha. Results Of the 57 questionnaire items 51 (89%) had percentage agreement above 70% indicating good test-retest reliability, and the remaining 6 items had moderate or substantial levels of agreement (kappa 0.41-0.68). Comparing questionnaire with interview coding (validity), percentage agreement was above 66% for 39/57 items (68%). Of the 16 items with percentage agreement below 66%, only five had kappa values below 0.20 (two items had insufficient interview responses). Internal consistency was 0.51, 0.79 and 0.90 for self-efficacy, outcome expectancy and intention respectively. Conclusions This questionnaire could be a useful tool in understanding the determinants of infant feeding and the 'causal mechanism' of interventions that target infant feeding practices to prevent early obesity.