Interventions to prevent obesity in children aged 5 to 11 years old.

BACKGROUND: Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review. OBJECTIVES: To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was February 2023. SELECTION CRITERIA: Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS: This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability. AUTHORS' CONCLUSIONS: The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

Interventions to prevent obesity in children aged 12 to 18 years old.

BACKGROUND: Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review. OBJECTIVES: To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was February 2023. SELECTION CRITERIA: Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS: This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI slightly at medium-term (MD -0.32, 95% CI -0.53 to -0.11; 3 studies, 2143 participants) and long-term (MD -0.28, 95% CI -0.51 to -0.05; 1 study, 985 participants) follow-up; both low-certainty evidence. Seven studies (5428 participants; low-certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short-term follow-up (MD 0.03, 95% CI -0.07 to 0.13; 11 studies, 3429 participants; high-certainty evidence), and probably do not reduce BMI at medium-term (MD 0.01, 95% CI -0.09 to 0.11; 8 studies, 5612 participants; moderate-certainty evidence) or long-term (MD 0.06, 95% CI -0.04 to 0.16; 6 studies, 8736 participants; moderate-certainty evidence) follow-up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD -0.09, 95% CI -0.2 to 0.02; 3 studies, 515 participants; very low-certainty evidence), and they may not reduce zBMI at medium-term (MD -0.05, 95% CI -0.1 to 0.01; 6 studies, 3511 participants; low-certainty evidence) or long-term (MD -0.02, 95% CI -0.05 to 0.01; 7 studies, 8430 participants; low-certainty evidence) follow-up. Four studies (2394 participants) reported data on serious adverse events (very low-certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect. AUTHORS' CONCLUSIONS: The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low-certainty evidence that activity interventions may have a small beneficial effect on BMI at medium- and long-term follow-up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples.

Childhood obesity prevention trials: A systematic review and meta-analysis on trial design and the impact of type 1 error.

Effect sizes from previously reported trials are often used to determine the meaningful change in weight in childhood obesity prevention interventions because information on clinically meaningful differences is lacking. Estimates from previous trials may be influenced by statistical significance; therefore, it is important that they have a low risk of type 1 error. A systematic review and meta-analysis were conducted to report on the design of child obesity prevention randomized controlled trials and effectiveness according to risk of type 1 error. Eighty-four randomized controlled trials were identified. A large range of assumptions were applied in the sample size calculations. The most common primary outcome was BMI, with detectable effect size differences used in sample size calculations ranging from 0.25 kg/m2 (followed up at 2 years) to 1.1 kg/m2 (at 9 months) and BMI z-score ranging from 0.1 (at 4 years) to 0.67 (at 3 years). There was no consistent relationship between low risk of type 1 error and reports of higher or lower effectiveness. Further clarity of the size of a meaningful difference in weight in childhood obesity prevention trials is required to support evaluation design and decision-making for intervention and policy. Type 1 error risk does not appear to impact effect sizes in a consistent direction.

Young people's experiences of physical activity insecurity: a qualitative study highlighting intersectional disadvantage in the UK.

BACKGROUND: Intersecting socioeconomic and demographic reasons for physical activity (PA) inequalities are not well understood for young people at risk of experiencing marginalisation and living with disadvantage. This study explored young people's experiences of PA in their local area, and the associated impacts on opportunities for good physical and emotional health and wellbeing. METHODS: Seven local youth groups were purposefully sampled from disadvantaged areas across urban, rural and coastal areas of England, including two that were specifically for LGBTQ + young people. Each group engaged in three interlinked focus groups which explored young people's perceptions and lived experience of PA inequalities. Data were analysed using an inductive, reflexive thematic approach to allow for flexibility in coding. RESULTS: Fifty five young people aged 12-21 years of different sexualities, gender and ethnicity took part. Analysis yielded four themes: PA experiences across spaces; resigned to a lack of inclusivity and 'belonging'; safety first; complexities in access and accessibility. Young people felt more comfortable to be active in spaces that were simpler to navigate, particularly outdoor locations largely based in nature. In contrast, local gyms and sports clubs, and the school environment in general, were spoken about often in negative terms and as spaces where they experienced insecurity, unsafety or discomfort. It was common for these young people to feel excluded from PA, often linked to their gender and sexuality. Lived experiences or fears of being bullied and harassed in many activity spaces was a powerful message, but in contrast, young people perceived their local youth club as a safe space. Intersecting barriers related to deprivation, gender and sexuality, accessibility, disability, Covid-19, affordability, ethnicity, and proximity of social networks. A need emerged for safe spaces in which young people can come together, within the local community and choose to be active. CONCLUSIONS: The overarching concept of 'physical activity insecurity' emerged as a significant concern for the young people in this study. We posit that PA insecurity in this context can be described as a limited or restricted ability to be active, reinforced by worries and lived experiences of feeling uncomfortable, insecure, or unsafe.

Children's experiences of care on walking and cycling journeys between home and school in Healthy New Towns: Reframing active school travel.

The Healthy New Town programme in England set out to 'put health into place' by supporting the design and construction of healthy places to live, including by creating safe environments for active travel. To explore the impact of this approach, this study examined how children and their families experienced school journeys in two contrasting Healthy New Towns in England, one an affluent new town in the early stages of construction and the other more economically deprived and established. We undertook photo-elicitation and go-along interviews with 24 children aged 7-12 years and semi-structured interviews with 17 caregivers. We found that experiences of care were important for children's school travel. In the 'deprived' town, opportunities for children to care and to be cared for were enjoyed, facilitated by routes with limited traffic, pockets of 'nature', and possibilities to encounter meaningful others. For families living in a town under construction, the need to negotiate unfinished travel infrastructure, and a sense of being 'in limbo', was experienced as an absence of care by planners and developers. Interventions to promote children's active travel should consider the role of care-full planning in facilitating walking and cycling journeys.

This needs to be a journey that we're actually on together'-the introduction of integrated care systems for children and young people in England: a qualitative study of the views of local system stakeholders during winter 2021/22.

BACKGROUND: Integrated care has become a central feature of health system reform worldwide. In England, Integrated Care Systems (ICS) are intended to improve integration across public health, the National Health Service (NHS), education and social care. By April 2021, England had been divided into 42 geographical areas, each tasked with developing local ICS provision. However, it was not clear how ICSs would address the specific needs of children and young people (CYP). This study elicited the views of senior professional stakeholders in the first year of the ICS national roll out, to learn how integrated care for CYP was being implemented within the ICSs and future plans for service provision. METHODS: A qualitative analysis of in-depth interviews with stakeholders, including healthcare professionals, NHS managers and local authority leaders (n = 25) selected from a diverse sample of ICSs (n = 7) across England, conducted during winter 2021/22. Reflexive thematic analysis involving a collaborative coding approach was used to analyse interview transcripts. RESULTS: Four themes were identified, indicating challenges and opportunities for ICSs in relation to the health of CYP: 1) Best start in life (a more holistic approach to health afforded by integrated care); 2) Local and national contexts (tensions between local and national settings and priorities); 3) Funding and planning (instituting innovative, long-term plans using limited existing CYP funding streams); 4) Organisational complexities (integrating the work of diverse organisations). CONCLUSIONS: The views of stakeholders, provided at the beginning of the journey towards developing local ICS CYP provision, revealed a common aspiration to change focus from provision of acute, largely adult-orientated services towards one with a broader, population health remit, including prevention and early intervention. This would be delivered by integration of a range of local services, including health, education, housing and social care, to set CYP on a life-long path towards improved health and wellbeing. Yet there was an awareness that change would take place over time within existing national policy and funding frameworks, and would require overcoming organisational barriers through further developing local collaborations and partnerships. As ICSs mature, the experiences of stakeholders should continue to be canvassed to identify practical lessons for successful CYP integrated care.

A qualitative exploration of food portion size practices and awareness of food portion size guidance in first-time parents of one- to two-year-olds living in the UK.

BACKGROUND: Food portion size guidance resources aimed at parents of young children in the UK are freely available from a number of credible sources. However, little is known about whether parents are aware of, and use, any of these resources to guide their food portioning practices. OBJECTIVES: We aimed to explore the food portion size practices used by first-time parents living in the UK when feeding their one- to two-year-old child, and their awareness of and views on six food portion size guidance resources. METHODS: Participants were recruited via parent Facebook groups and online parent forums. Online 1-1 semi-structured interviews were conducted, during which parents were shown images of six food portion size guidance resources to facilitate discussion. Data was analysed in NVivo 11 using a Reflexive Thematic Analysis approach. RESULTS: Of the 27 participants, most were women (n = 25), white (n = 18), and educated to first degree level or higher (n = 24). First-time parents mostly relied on their own judgement and "instinct" to portion foods, based on their learned experience of how much their child ate on a day-to-day basis. This experience was used alongside physical indicators of food portion size, such as the size of children's dishware and food packaging. Most participants were unaware of any of the six food portion size guidance resources we showed them; only four had read any of the resources. Parents suggested they had previously sought advice about weaning from a range of sources (e.g. online, friends, community groups) but would be unlikely to seek out specific food portion size guidance. Parents suggested recommendations on food portion size should acknowledge and highlight parents' perception that "every child is different". CONCLUSIONS: Existing food portion size guidance resources for parents of young children in the UK are ineffective as they have poor reach and impact. We suggest parents should be involved in developing novel strategies to promote age-appropriate consumption and healthy weight gain in young children.

From ToyBox Study to eToyBox: Advancing Childhood Obesity Reduction in Malaysian Kindergartens.

Prevention and treatment of childhood obesity is a global concern, and in Malaysia, it is considered a national public health priority. Determinants of childhood obesity are multifactorial and include factors that directly and indirectly influence energy balance-related behaviours, including energy intake and energy expenditure. Interventions to address childhood obesity that have multiple components at different levels have been shown to be the most influential. The ToyBox-study is a childhood obesity intervention aimed at preschool-aged children and their families that had been shown to be effective in several European countries and so was chosen for adaption for the Malaysian setting. Materials were translated and adjusted for the Malaysian context and audience and implemented in kindergartens in Peninsular Malaysia and Sarawak. However, during the COVID-19 pandemic and lockdown, teaching transitioned to being online. This brought an opportunity to reach a wider audience and consider the long-term sustainability of the intervention, and thus eToybox was born. eToybox aims to bring support for healthy energy balance behaviours directly to the teachers, into kindergartens and homes, to encourage families to be active and eat healthily, and prevent or reduce obesity. Through online innovation, the Toybox Study Malaysia programme has been expanded to enhance its potential to impact the promotion of healthy lifestyles among preschoolers and their families, highlighting the importance of a holistic approach to preventing and treating childhood obesity in Malaysia.

Characterizing restrictions on commercial advertising and sponsorship of harmful commodities in local government policies: a nationwide study in England.

BACKGROUND: Commercial advertising and sponsorship drive the consumption of harmful commodities. Local authorities (LAs) have considerable powers to reduce such exposures. This study aimed to characterize local commercial policies across all English LAs. METHODS: We conducted a census of all English LAs (n = 333) to identify local commercial policies concerning advertising and sponsorship of tobacco, alcohol, less healthy foods and gambling, through online searches and Freedom of Information requests. We explored policy presence, commodity frequency and type, and associations with LA characteristics (region, urban/rural and deprivation). RESULTS: Only a third (106) of LAs in England had a relevant policy (32%). These included restrictions on tobacco (91%), gambling (79%), alcohol (74%) and/or less healthy foods (24%). Policy prevalence was lowest in the East of England (22%), North East (25%) and North West (27%), higher in urban areas (36%) than rural areas (28%) and lower in the least (27%) compared with the most (38%) deprived areas. Definitions in policies varied, particularly for alcohol and less healthy foods. CONCLUSIONS: English LAs currently underutilize their levers to reduce the negative impacts of harmful commodity industry marketing, particularly concerning less healthy foods. Standardized guidance, including clarity on definitions and application, could inform local policy development.

Co-design and content validity of the movement measurement in the early years (MoveMEY) tool for assessing movement behaviour of pre-school aged children.

BACKGROUND: Movement behaviours (physical activity, sedentary behaviour, and sleep) are important for pre-school children's health and development. Currently, no tools with appropriate content validity exist that concurrently capture these movement behaviours in young children. The aim of this study was to co-design and assess the content validity of a novel tool to concurrently measure movement behaviours in pre-school aged children (aged 3-4 years). METHODS: We followed four distinct steps to develop and assess the content validity of Movement Measurement in the Early Years (MoveMEY): (1) We conducted an extensive literature search, to identify pre-existing proxy measurement tools (questionnaires and diaries) to inform the design of a novel tool, which aimed to effectively capture movement behaviour guidelines of pre-school aged children. (2) We facilitated focus group discussions with parents and carers of pre-school aged children (n = 11) and (3) a qualitative survey with free text responses was completed by topic relevant researchers (n = 6), to co-design the measurement tool. (4) We assessed the content validity of the developed tool, MoveMEY, through interviews with parents of pre-school aged children (n = 12) following piloting of the tool. RESULTS: We developed an initial version of MoveMEY based on the format of an existing questionnaire and by mapping the content of questions to the guidelines. Co-design of MoveMEY resulted in changes to the format (e.g. short questionnaire to a seven-day diary) and content (e.g. inclusion of 'general information' questions on illness, disabilities and sleep disturbances; question on screen time before bed). Content validity assessment demonstrated that the items of MoveMEY were relevant and comprehensive for the assessment of children's movement behaviours. MoveMEY was felt to be comprehensible, however, parental suggestions were implemented to finalise and improve MoveMEY (e.g. adding examples to questions aiming to detect moderate to vigorous physical activity). CONCLUSION: MoveMEY is the first co-designed measurement tool that has relevance for assessing the movement behaviour guidelines of pre-school aged children. Parent/carer and topic relevant researcher involvement throughout the development process resulted in a seven-day daily reported activity diary that is comprehensive of children's movement behaviours and comprehensible to parents and carers.

Child and adolescent obesity.

The prevalence of child and adolescent obesity has plateaued at high levels in most high-income countries and is increasing in many low-income and middle-income countries. Obesity arises when a mix of genetic and epigenetic factors, behavioural risk patterns and broader environmental and sociocultural influences affect the two body weight regulation systems: energy homeostasis, including leptin and gastrointestinal tract signals, operating predominantly at an unconscious level, and cognitive-emotional control that is regulated by higher brain centres, operating at a conscious level. Health-related quality of life is reduced in those with obesity. Comorbidities of obesity, including type 2 diabetes mellitus, fatty liver disease and depression, are more likely in adolescents and in those with severe obesity. Treatment incorporates a respectful, stigma-free and family-based approach involving multiple components, and addresses dietary, physical activity, sedentary and sleep behaviours. In adolescents in particular, adjunctive therapies can be valuable, such as more intensive dietary therapies, pharmacotherapy and bariatric surgery. Prevention of obesity requires a whole-system approach and joined-up policy initiatives across government departments. Development and implementation of interventions to prevent paediatric obesity in children should focus on interventions that are feasible, effective and likely to reduce gaps in health inequalities.

Measurement Instruments for Integration within Children and Young People Healthcare Systems and Networks: A Rapid Review of the International Literature.

Introduction: Robust measures of integration are essential for assessment of the development, design and implementation of integration within healthcare systems. This review aimed to identify measurement instruments for integration within children and young people's (CYP) healthcare systems (PROSPERO registration number CRD42021235383). Methods: We searched electronic databases (PubMED and Ovid Embase) using three main concepts: '(integrated care) AND (child population) AND (measurement)', along with additional searches. Results: Fifteen studies describing 16 measurement instruments were eligible for inclusion. The majority of studies were conducted in the USA. There was a diversity of health conditions included in the studies. The most frequent type of assessment used was a questionnaire (11 identified), but interviews, patient data and healthcare records, and focus groups were also used. Integration outcomes assessed were quality of care coordination, quality of collaboration, continuity of care, completeness of care, structure of care, quality of communication, and local implementation of integrated care. Conclusion: A variety of instruments for the measurement of integration within CYP healthcare systems were identified. Further work on the standardisation of integrated care measures would be valuable; however, it is important that instruments and measures meet the needs of specific settings, populations and conditions being studied.

Typology of how 'harmful commodity industries' interact with local governments in England: a critical interpretive synthesis.

INTRODUCTION: Industries that produce and market potentially harmful commodities or services (eg, tobacco, alcohol, gambling, less healthy foods and beverages) are a major influence on the drivers of behavioural risk factors for non-communicable diseases. The nature and impact of interactions between public bodies and 'harmful commodity industries' (HCIs) has been widely recognised and discussed at national and international levels, but to date little is known about such interactions at local or regional government levels. This study aimed to identify and characterise actual and potential interactions and proposes a typology of interactions between HCIs and English local authorities (LAs). METHODS: Five electronic databases covering international literature (PubMed, EBSCO, OVID, Scopus and Web of Science) were searched up to June 2021. We also performed online searches for publicly available, web-based grey literature and documented examples of interactions in an English LA context. We conducted a critical interpretive synthesis of the published and grey literature to integrate and conceptualise the data in the context of English LAs. RESULTS: We included 47 published papers to provide the frame for the typology, which was refined and contextualised for English LAs through the available grey literature. Three categories were developed, describing the medium through which interactions occur: (1) direct involvement with LAs, (2) involvement through intermediaries and (3) involvement through the local knowledge space. Within these, we grouped interactions into 10 themes defining their nature and identified illustrative examples. CONCLUSION: Our typology identifies complex inter-relationships and characterises interactions between HCIs and LAs, with illustrative examples from English LAs. Drawn from well-established theories and frameworks in combination with contextual information on English LAs, this typology explores the LA perspective and could help local decision-makers to maximise population health while minimising negative impacts of HCIs. PROSPERO REGISTRATION NUMBER: CRD42021257311.

Interventions to prevent obesity in school-aged children 6-18 years: An update of a Cochrane systematic review and meta-analysis including studies from 2015-2021.

Background: Childhood obesity remains a global public health priority due to the enormous burden it generates. Recent surveillance data suggests there has been a sharp increase in the prevalence of childhood obesity during the COVID-19 pandemic. The Cochrane review of childhood obesity prevention interventions (0-18 years) updated to 2015 is the most rigorous and comprehensive review of randomised controlled trials (RCTs) on this topic. A burgeoning number of high quality studies have been published since that are yet to be synthesised. Methods: An update of the Cochrane systematic review was conducted to include RCT studies in school-aged children (6-18 years) published to 30 June 2021 that assessed effectiveness on child weight (PROSPERO registration: CRD42020218928). Available cost-effectiveness and adverse effect data were extracted. Intervention effects on body mass index (BMI) were synthesised in random effects meta-analyses by setting (school, after-school program, community, home), and meta-regression examined the association of study characteristics with intervention effect. Findings: Meta-analysis of 140 of 195 included studies (183,063 participants) found a very small positive effect on body mass index for school-based studies (SMD -0·03, 95%CI -0·06,-0·01; trials = 93; participants = 131,443; moderate certainty evidence) but not after-school programs, community or home-based studies. Subgroup analysis by age (6-12 years; 13-18 years) found no differential effects in any setting. Meta-regression found no associations between study characteristics (including setting, income level) and intervention effect. Ten of 53 studies assessing adverse effects reported presence of an adverse event. Insufficient data was available to draw conclusions on cost-effectiveness. Interpretation: This updated synthesis of obesity prevention interventions for children aged 6-18 years, found a small beneficial impact on child BMI for school-based obesity prevention interventions. A more comprehensive assessment of interventions is required to identify mechanisms of effective interventions to inform future obesity prevention public health policy, which may be particularly salient in for COVID-19 recovery planning. Funding: This research was funded by the National Health and Medical Research Council (NHMRC), Australia (Application No APP1153479).

Children's experiences of the journey between home and school: A qualitative synthesis using meta-ethnography.

This paper uses meta-ethnography to synthesise qualitative and ethnographic studies of children's (aged 5-13) experiences of socio-material environments on their school journey. Most of the 21 papers (18 studies) identified from the systematic search were from high-income countries and used self-report qualitative methods. Our synthesis shows children can feel vulnerable, but also negotiate journeys and manage risks, enjoy shared and solitary mobility, and explore their material environments. School journeys offer children a place to learn and develop agency within their socio-material environments. Attending to these wider benefits of school journeys, alongside supporting children to develop active modes attuned to the risks associated with these journeys, could improve the reach and impact of active school travel initiatives.

An analysis of English national policy approaches to health inequalities: 'transforming children and young people's mental health provision' and its consultation process.

BACKGROUND: A national policy for England, published in 2017, entitled 'Transforming Children and Young People's Mental Health Provision' aimed to address the increasing prevalence mental health problems in children and tackle inequalities. In the context of this policy's implementation as ongoing and the effects of the Covid-19 pandemic, the need for appropriate, timely and ongoing national government commitment is vital. METHODS: A narrative review using a problem representation evaluation [1], we critiqued the policy and related consultation documents using a social determinants of health perspective. We also reviewed wider policy discourses through engaging with stakeholder responses, providing an innovative methodological contribution to scholarship on public health policy and health inequalities. RESULTS: We found absences and oversights in relation to inequalities (most notably the lack of acknowledgement that mental health can cause inequalities), access, workforce capacity, and the impacts of cuts and austerity on service provision. We suggest these inadequacies may have been avoided if stakeholder responses to the consultation process had been more meaningfully addressed. We illustrate how 'problems' are discursively created through the process of policy development, justified using specific types of evidence, and that this process is politically motivated. Local policy makers have a critical role in translating and adapting national policy for their communities but are constrained by absences and oversights in relation to health inequalities. CONCLUSIONS: This narrative review illustrates how policy discourse frames and produces 'problems', and how the evidence used is selected and justified politically. This review contributes to the existing transdisciplinary field of knowledge about how using methods from political and social science disciplines can reveal new insights when critiquing and influencing policy approaches to health inequalities.

'It All Kind of Links Really': Young People's Perspectives on the Relationship between Socioeconomic Circumstances and Health.

Meaningful inclusion of young people's perceptions and experiences of inequalities is argued to be critical in the development of pro-equity policies. Our study explored young people's perceptions of what influences their opportunities to be healthy within their local area and their understandings of health inequalities. Three interlinked qualitative focus group discussions, each lasting 90 to 100 min, with the same six groups of young people (n = 42) aged 13-21, were conducted between February and June 2021. Participants were recruited from six youth groups in areas of high deprivation across three geographical locations in England (South Yorkshire, the North East and London). Our study demonstrates that young people understand that health inequalities are generated by social determinants of health, which in turn influence behaviours. They highlight a complex interweaving of pathways between social determinants and health outcomes. However, they do not tend to think in terms of the social determinants and their distribution as resulting from the power and influence of those who create and benefit from health and social inequalities. An informed understanding of the causes of health inequalities, influenced by their own unique generational experiences, is important to help young people contribute to the development of pro-equity policies of the future.

Parental Views on the Acceptability and Feasibility of Measurement Tools Used to Assess Movement Behaviour of Pre-School Children: A Qualitative Study.

Movement behaviours (physical activity, sedentary behaviour, and sleep) are important for the health and development of pre-school children (aged 3-4 years). There is limited qualitative research examining the acceptability and feasibility of tools used to assess movement behaviours in pre-schoolers. This study explored parental views on various measurement tools in three deprived areas in England, UK (West Yorkshire, County Durham and Northumberland). The study consisted of a demonstration of the different tools (accelerometers, a diary and a questionnaire), directly followed by focus group discussions. Three focus group discussions with a total of eleven parents and carers were transcribed verbatim and analysed using thematic analysis. Findings revealed four main themes: (1) importance of contextual information when using any measurement tool (e.g., child illness, capturing different routines); (2) practical issues associated with devices (e.g., aversion to devices being attached directly to the skin of their child; concern of larger devices during sleep time); (3) encouraging children to wear a device (e.g., making devices attractive to children-'superpowers'); and (4) presentation of diaries and questionnaires (e.g., age-appropriate movement activities, preference for real-time recording over recall). Practical recommendations for the use of the tools to measure movement behaviours of pre-school children are provided.

The Validity, Reliability, and Feasibility of Measurement Tools Used to Assess Sleep of Pre-school Aged Children: A Systematic Rapid Review.

Background: Sleep of pre-school aged children is important for their health and development, but there are currently no standards for measuring sleep in this age group. We aimed to examine the validity, reliability and feasibility of tools used to assess sleep of pre-school aged children. Methods: Studies were eligible for inclusion if they examined the validity and/or reliability and/or feasibility of a measurement tool used to examine sleep of pre-school aged children (aged 3-7 years). We systematically searched six electronic databases, grey literature and trial registries. We manually searched topic specific journals, reference and citations of included studies, and reference lists of existing reviews. We extracted data and conducted a risk of bias assessment on the included studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist. We used a narrative synthesis to present the results. Results: Sixteen studies met the inclusion criteria: these explored accelerometers (n = 3) and parental reported tools (n = 13; nine questionnaires, six diaries). Studies assessed construct validity (n = 3), criterion validity (n = 1), convergent validity (n = 13), test-retest reliability (n = 2), internal consistency (n = 4) and feasibility (n = 12). Most studies assessed the convergent validity of questionnaires and diaries compared with accelerometers, but the validity of accelerometers for sleep in this age group is unknown. Of studies with a low risk of bias, one sleep diary was shown to be valid for measuring sleep duration. No measurement tools were appropriate for determining sleep quality. Reporting of reliability and feasibility was minimal. Discussion: The evidence base in this field is limited, and most studies had high risk of bias. Future research on sleep in pre-school aged children should focus on assessing the validity, reliability and feasibility of accelerometers, which in turn will improve the quality of studies that assess questionnaires and diaries against accelerometers. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021230900; PROSPERO: CRD42021230900.

A critique of the English national policy from a social determinants of health perspective using a realist and problem representation approach: the 'Childhood Obesity: a plan for action' (2016, 2018, 2019).

BACKGROUND: The UK government released Chapter 1 of the 'Childhood Obesity: a plan for action' (2016), followed by Chapter 2 (2018) and preliminary Chapter 3 was published for consultation in 2019 (hereon collectively 'The Policy'). The stated policy aims were to reduce the prevalence of childhood obesity in England, addressing disparities in health by reducing the gap (approximately two-fold) in childhood obesity between those from the most and least deprived areas. METHODS: Combining a realist approach with an analysis of policy discourses, we analysed the policies using a social determinants of health (SDH) perspective (focusing on socio-economic inequalities). This novel approach reveals how the framing of policy 'problems' leads to particular approaches and interventions. RESULTS: While recognising a social gradient in relation to obesity measures, we critique obesity problem narratives. The Policy included some upstream, structural approaches (e.g. restrictions in food advertising and the soft-drinks industry levy). However, the focus on downstream individual-level behavioural approaches to reduce calorie intake and increase physical activity does not account for the SDH and the complexity and contestedness of 'obesity' and pays insufficient attention to how proposals will help to reduce inequalities. Our findings illustrate that individualising of responsibility to respond to what wider evidence shows is structural inequalities, can perpetuate damaging narratives and lead to ineffective interventions, providing caution to academics, practitioners and policy makers (local and national), of the power of problem representation. Our findings also show that the problem framing in The Policy risks reducing important public health aims to encourage healthy diets and increase opportunities for physical activity (and the physical and mental health benefits of both) for children to weight management with a focus on particular children. CONCLUSIONS: We propose an alternative conceptualisation of the policy 'problem', that obesity rates are illustrative of inequality, arguing there needs to be policy focus on the structural and factors that maintain health inequalities, including poverty and food insecurity. We hope that our findings can be used to challenge and strengthen future policy development, leading to more effective action against health inequalities and intervention-generated inequalities in health.