Prevention and interventional strategies of adolescent obesity / overweight

Автор: Munusamy G., Shanmugam R.

Статья в выпуске: 23, 2022 года.

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Purpose: It’s a known factor that obesity and overweight among adolescentsare major emerging global health problems associated with morbidityand mortality throughout their life in developed and developing countries. There is evidence that reducing overweight and obesity by increasing awareness, self-efficacy, and contemplation to adopt a health-promoting lifestyle.The aim of this review how the theory and model used to reduce this burden through vicarious interventional activities among adolescence (10-19 years)in a school setting. Methods: A literature search was performed in four databases to identify published studies between January 2009 and December 2019. Randomized control trial exploring the multiple interventional effects on obesity and overweight by utilization of with or without theoretical constructs and outcome on body mass index. Results: Originally references searched were 2112 abstracts and full-text articles. The total population was 34,846 adolescents. Most of the multiple interventionshad little positive effect onphysical activity, dietary intake, and sedentary behavior changes directly on BMI. Only three studies show changes in behavior through theory. Minimal studies reported the involvement and motivation of parents, friends, and teachers for themselves and adolescents. Conclusion: The contemporary review to visualizemultiple interventions, and how models and theory focused on various pragmatic activities in the delivery and outcome in school settings among adolescents.

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Adolescent, body mass index, obesity, overweight, schools

Короткий адрес: https://sciup.org/148326564

IDR: 148326564 | DOI: 10.18137/cardiometry.2022.23.133147

Текст научной статьи Prevention and interventional strategies of adolescent obesity / overweight

Gomathi Munusamy, Ramesh Shanmugam. Prevention and Interventional Strategies of Adolescent Obesity / Overweight. Cardiometry; Issue 23; August 2022; p. 133-147; DOI: 10.18137/ cardiometry.2022.23.133147; Available from:

Overweight and the obesity problem has been dramatically rising in all the countries, both rural and urban settings [1]. Globally from1975 to 2016, an increase in trends of obesity prevalence among children and adolescents which needs to create challenges for preventive and interventional strategies [2]. An adolescent may consider as an individual in the 10-19 years and categorized age group into three stages: early (~10-14 years), middle (~15 - 17 years), and late adolescence (~18 - 21 years). Currently, major trends of modernization and urbanization, factors that contributed to a negative change in living habits, as adolescents became more exposed to intake of less healthy foods, low-nutrient-densityfoods, increased in sugary beverages, changes in away-from-home eating, consumption of fast and packaged food items, and snacking, lack of regular and energy expenditure physical activity (PA), increases in sedentary lifestyles due to computer games and electronic media. Nowadays adolescent obesity is considered an international health problem and a powerful predictor of morbidity and mortality, it needs amenable to modify behaviours [3]. The lifestyle behavior learned and adopted during adolescence will influence the positive spectrum of health in both present and future [4]; longterm health risks of adolescent obesity prevention in children to prevent obesity-related diseases in adulthood [5].

Obesity may be defined as an abnormal accumulation of the adipose tissue in a cell or an increased number of fat cells or a combination of both. Adolescent overweight is a BMI between the 85th and 95th percentiles and BMI ator above the 95th percentile is called obesity [3]. The greatest increases in BMI occur in childhood and adolescence and are associated with higher chances of obesity, premature death, and disability in adulthood. Besides, it is also linked to increasing major future risk of breathing difficulties, cardiovascular disease, diabetes, cancers, asthma, kidney diseases, fracture, hepatobiliary diseases, dementia, and psychological effects, thereby decreasing the quality and expectancy of life [5].

Prevention of obesity/overweight should begin in childhood than in adulthood because it is harder to treat. This can be achieved by regular PA,di-etary changes, and targeting behavioral change to reduce sedentary activityis critical for intervention. Health-promoting strategies intended for adolescents must make every effort to understand and address their perspectives to aid in preventing them. Adults who interact with adolescents are important stakeholders to be consulted and involved in the development of adolescents’ health [4]. Interventions that can be delivered at home, school, and in the community are required to empower teens to increase PA, healthy dietary behavior, and reduce sedentary activity [6]. Previous reviews evidenced that obesity prevention among adolescents delivered through a school-based integrated curriculum for the promotion of healthy dietary habits, PA behavior, and reduce screen time by active commuting [7]. However, multiple interventional approaches have been documented with the outcome.

Therefore, this review aimed to recognize possible strategies, summarize the characteristics of prevention and interventions pointing to obesity and adolescents that are effective in reducing BMI/ BMI-z score, effective theory constructs, discuss the implications of these findings, and identify gaps between interventions and its findings to our existing knowledge.

Methods

Systematic Search

A systematic search was to identify studies published between January 2009 and December 2019. The search strategy was created to identify intervention, and prevention studies in adolescents which used analysis for outcomes of PA, dietary, sedentary be-havior,and effects on BMI. Search terms included the following: adolescent OR teenage OR teen, PA OR exercise, nutrition OR diet, BMI, intervention/preven-tion,schools,and randomized controlled trial (RCTs). The electronic databases used for the literature search were Pub Med, Science Direct, Sci hub, and Google Scholar.

Eligibility criteria

Inclusion criteria:

• study participants were adolescents with a mean age of 10-19 years
• the article was written in the English language
• study settings must be in school
• feasibility and pilot studies
• RCTs/Quasi-experimental/cluster controlled studies • BMI/BMI-z score as a primary or secondary outcome.

Exclusion criteria:

• analysis of cross-sectional data
• children <10 years and >19 years
• study protocol with single/multiple components
• interventions were laboratory blood analysis, pharmacological or surgical
• studies have not included an intervention or prevention
• studies other than the English language.

Study selection

The 45 relevant full-text articles were screened and analyzed and in which 19 were eliminated by the authors based on inclusion criteria. All included studies will be summarized in tables that tabulate the study populations, study design, settings, duration, inter-vention/prevention strategies, obesity/overweight measures, and major findings of the studies.

Risk of bias assessment

Studies were assessed for risk of bias using a modified tool8 Mixed Studies Review (MSR appropriate for quantitative RCTs and out come measures on BMI, overweight and obesity, PA, DB, and sedentary behavior. This adapted assessment tool used a 1-4 scoring system (i.e., 1=weak, 2= moderate, 3= strong, and 4= very strong) at the study level as a combined risk of bias score. A higher score desired better methodological quality with a lower score indicating poorer methodological quality. The score has based on the presence or absence of each criterion respectively (sequence generation and/or randomization, concealment and/or blinding, low withdrawal/drop-out (<20%), intervention integrity. Studies were scored on what was reported in the existing article that was examined for further information.

ResultsStudy characteristics

Participant characteristics

The participant and general study characteristics are shown in Table 1. Overall study participants were aged 10-19 years, in that, studies girls only: aged 12-18 years, boys only: aged 12-15 years. Seventeen studies showed participant numbers <1000, with the minimal sample size being 37 [9], Eight studies contained 1000 to 3000 adolescents; four studies were >3000 participants [10–13], with the highest sample of 6371 [11].

Table 1

General study characteristics of Multi-level Obesity Intervention

First author (yr), country	Design, study name, theory basis	Schools randomized I:C	Participants, age/ mean age (SD)	Studyperiod, intervention duration	Sample size (n) BA = I:C FA = I:C
Neumark-Sztainer (2010), USA ¹⁴	Group RCT, NMP, SCT / TTM	6:6	Girls, 15.8 (±1.2) yrs	2007 - 2009, 9 months	n = 356 182:174 9^th month 177:159
Millar (2011), Australia¹⁰	Quasi-experimental design, IYM, Nil	5:7	Boys & girls, 13 – 19 yrs	2005 - 2008, 3 yrs	n = 3040 1852:1188 3^rdyr 1276:778
Lubans (2011), Australia⁹	RCT, PALs, Bandura’s SCT	4	Low-active boys,14.3 (0.6) yrs	Jun to Dec 2009, 6 months	n = 100 50:50 6^th month 37:45
Bjelland (2011), Norway¹⁵	Cluster randomized controlled pre-post design, HEIA, Nil	12:25	Boys & girls, 11 – 12 yrs/11.2 (0.26) yrs	Sep 2007 - May 2008 8 month	n = 2165 784:1381 8^th month 542:970
Lubans (2012), Australia¹⁶	Group RCT, PALs, SCT	4	Low-active boys, 14.3 (0.6) yrs	Jun to Dec 2009, 6 months	n= 100 50:50 6^th month 37:45
Toulabi (2012), Iran¹⁷	Quasi -experimental study, Nil	12	Obese boys & girls, 14 - 19 yrs/15.87 (± 1) yrs	2004 - 2006, 6 months	n = 152 76:76 6^th month 76:76
Melnyk (2013), USA¹⁸	Prospective, blinded,cluster RCT, COPE TEEN, Cognitivetheory	11	Boys & girls, 14-16yrs/14.74 (0.73) yrs	2010 - 2012, 15 wks	n = 779 358:421 6^th month 286:341
Dewar (2013), Australia¹⁹	Group RCT, NEAT girls, Bandura’s SCT	6:6	Girls, 13.2 (± 0.5) yrs	2010 - 2012, 12-24 months	n = 357 178:179 24^th month 113:121
Bonsergent (2013), France¹¹	Stratified factorial cluster RCT, PRALIMAP, Nil	12:12	Boys & girls, 15.6 (±0.7)yrs	2006 – 2010, 2 yrs	n = 6,371 3,191:3,180 2^ndyr 1,851:1,687
Grydeland (2013), Norway²⁰	Cluster RCT, HEIA, Nil	12:25	Boys & girls, 11 – 12 yrs/11.2 (0.3) yrs	2007 - 2009, 20 months	n = 2165 784:1381 20^th month 519:945
Bonsergent (2013), France¹²	Stratified factorial cluster RCT, PRALIMAP, Nil	12 high schools	Boys & girls, 15.6 (±0.6)yrs	2006 - 2010, 2 yrs	n = 3191 2^ndyr 1,804
Collins (2014), Australia²¹	Cluster RCT, NEAT Girls, Bandura’s SCT	6:6	Girls, 13.2 (± 0.5) yrs	12 months, 10 wks	n = 357 178:179 12^th month 111:153
Simon (2014), France²²	Cluster RCT, ICAPS, Nil	8	Boys & girls, 12 yrs	Sep 2002 – Aug 2006, 4yrs	n = 954 479:475 30^th month 275:256
Grydeland (2014), Norway²³	Cluster RCT, HEIA, Nil	12:25	Boys & girls, 11 – 12 yrs/11.2 (0.3) yrs	2007 - 2009, 20 months	n = 2165 784:1381 20^th month 491:870

Study design

Thirteen studies were cluster RCTs [15, 20, 33, 35, 36, 21–23, 25, 26, 28, 30, 31]; four group RCTs [14, 16, 19, 24]; three stratified factorial RCTs 2x2x2 [11–13]; two RCTs [9, 37]; two quasi-experimental studies [10, 17]; two matched-pair cluster RCTs [29]; cluster randomized community trial [34]; 2 – group randomized with repeated measure design [27]; prospective blinded cluster RCTs [18]; 2x3 within subject design [32].

Study duration

Four were of 3 to 4 years duration [10, 12, 13, 18], nine studies 2 to <3 years of duration [11, 14, 17, 19, 22, 24, 26, 31, 37], seven studies duration of 1 to <2 years [20, 21, 23, 25, 30, 34, 36], eight studies were < 1-year duration [9, 16, 27–29, 32, 33, 35] and one study in 8 month mid-way assessment [15].

PA intervention duration

Five studies had PA measurement periods of 24 to 36 months [10–13, 26], nine studies had PA measurement periods of 12 to ≤ 24 months [19–21, 23–25, 29, 31, 36], eight studies had PA measurement periods of 6 to ≤ 12 months [9, 16, 18, 28, 32, 33, 35, 37], one study had PA measurement periods in 8-months mid way assessment [15], four studies had PA measurement periods of ≤ 6 months [14, 17, 30, 34], one study 30 months follow-up after the 4-year study period, PA measurement not clear [22], one study not associated with PA [27].

Behavior change theories

Theoretical framework/models used to develop their intervention: one study stated that they used a Social Cognitive Theory(SCT)/Trans theoretical Model [14]; eight studies stated that Bandura’s SCT [9, 19, 21, 24, 28, 29, 33, 34]; three studies stated that SCT [16, 32, 37]; one study stated Cognitive Theory [18]; one study stated Self Determination Theory (SDT) and SCT [30]; two studies stated SCT and Social Ecologic Theory [26, 31]; one study stated Information-Motivation-Behavioral-Skills Theory [27]; one study stated Integrating Behavioral Theory-driven Content [35]; one study stated Food, Health, & Choices theory Model blended with SCT and SDT [36]; ten studies not stated any theoretical framework or models [10–13, 15, 17, 20, 22, 23, 25].

Intervention delivery

PA intervention

Ten were delivered by the school staff including physical education (PE) teachers [11–13, 17, 21, 26,

29–32], four were by the school teachers and research team members [9, 24, 28, 36], two were by the PE teachers and research team members [16, 37], seven were by the school teachers [15, 18, 20, 23, 25, 33, 35], two were by the trained research assistant [19, 34], one study by school PE teachers and community guest instructor [14]; school project officer and student am-bassadors10; trained professionals and interviewers [22]; research staff [27].

Dietary intervention

Three studies were delivered by the school staff including PE teachers [11–13], three were by the research staff [27, 32, 37], two were by the dietician and psychologist [14, 34], four were by the research team [9, 16, 19, 24], and six were by the trained/ school teachers [15, 18, 20, 23, 25, 36], intervention delivered by the dietician or final year U.G. dietetic students, school staff and PE teachers [21]; nursing expert [17]; accredited dietician [28]; school project officer and student ambassadors [10]; facilitator [29]; nutrition and dietetic students [33]; five studies were not measured and not delivered [22, 26, 30, 31, 35].

Anthropometric measurements

Studies used to measure obesity and overweight by height, weight, BMI, BMI-z score, waist circumference, high waist circumference, waist-hip circumference, waist-hip ratio, waist-to-height ratio, body fat %, muscular fitness, and skinfold thickness. Three studies were measured by the school nurses [11, 12, 17], fifteen studies were measured by the trained research assistant/staff [9, 10, 28, 30, 31, 33, 37, 14, 16, 19–23, 26], and three studies were measured by the research team as a self-report [25, 27, 34], the study measured by the clinical research nurses [13]; trained research coordinator [29]; trained nutritionist [32], five studies were not cleared [15, 18, 24, 35, 36].

Blinding

Four were blinded to group allocation researcher / research assistants / trained research assistants [24, 26, 28]; trained U.G. and graduate students [33], two were investigator and participants blinded for conditions [20, 23], one was trained nutritionist blinded to study allocation [32], four studies not blinded to group allocation research assistants and participants [9, 34]; research team [25]; research staff [37], eighteen studies not mentioned about blinding [10, 11, 21, 22, 27, 29–31, 35, 36, 12–19].

Effects/Outcome Measures

BMI

Table 2

Characteristics of Physical Activity and Findings on BMI/BMIz- score

Study	PA/session/ Intensity	Physical educa-tion/session	Outcome measures	Findings
Neumark-sztainer¹⁴	Lifestyle activities include walking, dancing, yoga, strength training, kickboxing, pilates for 4 days/wk; MVPA 30 min blocks/day	~ 16 wks	BMI, body fat percentage, 3-day PA recall survey	Significant stage of change for PA (p=.039), goal setting and self-efficacy for PA (p=.021, p=.003); support for PA by friends (p=.045), by teachers (p=.034), and by families (p= .016)
Millar¹⁰	Active commuting to school 30 min × 10 trip/wk, LTPA for 231 hours for 3 yrs, sport recess, sports-related excursion	Capacity building	BMI, BMIz- score	Significant reductions in weight (p< .04), and BMI-z score (p< .03) Significant increase in PA: walk/cycle to school ≥5 times/wk (p=.01), active after school 3–5 days (p= .01)
Lubans⁹	School sports sessions include resistance training 10 × 90 min, LTPA 8 × 30 min, steps count/dayfor 5days × 6 months	Handbooks × 9 wks, interactive seminars/3 × 30 min	BMI, BMIz- score, Body fat, muscular fitness, WC,pedometer, NSW Schools PA and nutrition survey	Significant group-by-time interaction effects on BMI (p<.001), BMI z-score (p<.001), and body fat (p< .05)
Lubans¹⁶	School sports sessions include resistance training 10 × 90 min, LTPA8 × 30 min, steps count/day for 5 days × 6 months	Interactive seminars/3 × 30 min, PA leadership session 6 × 30 min	BMI, pedometer	Significant stronger intervention effects on BMI(p = .04), changes in BMI (p = .001), resistance training self - efficacy (p < .001), PA behavioral strategies (p = .018), and resistance training self-efficacy (p < .001)
Toulabi¹⁷	Aerobic exercises60 min/day for 3 days× 6 wks; Vigorous PA	PE instruction / 8 × 45 min twice a wk	BMI, WC, hip circumference, waist-hip ratio	Significant reduction in BMI (p < .001), body weight (p < .003), WC (p < .003), hip circumfer-ence(p <.001), and improvement in resistance training skill competency (p < .001)
Melnyk¹⁸	Regular PA (walking, dancing, kickboxing) 15 – 20 min, steps count/day for 1^st and 16^thwk	PA information for 1 wk	BMI, pedometer, Healthy Lifestyles Behavior Scale	Significant effect on greater number of steps per day (p = .03) and a lower BMI(p = .01), and changes in proportion of overweight (p= .03)
Dewar¹⁹	school sport sessions, steps count ≥600 min/day for 3 days, LTPA min/day; MVPA	Interactive seminar	BMI, BMI-z score, body fat percentage, accelerometer	No significant intervention effects on BMI (p = .353) and BMI z-score (p = .178). Significant effect on group-by-time interaction for body fat percentage (p = .006)
Bonsergent¹¹	Fun PA, games	PA lecture	BMI, BMIz- score, WC	Significantly decreased in mean BMI z-score (p < .0001), decreased prevalence of overweight and obesity (p=.042), and decreased mean BMI z-score (p<.0001) for all strategy group
Grydeland²⁰	PA break10 min of PA in regular classes/wk, active commuting campaigns5 × 3 wks, steps counts/dayfor 5 days, awareness on leisure time activity, sports equipment for recess activities; Sedentary PA, light PA, and MVPA	PE lesson	BMI, accelerometer	Increased net effect of 50 cpm in intervention group (p = .05). Significant effect among girls 65 cpm(p = .03) and participants in the low-activity group 92 cpm (p < .001), than boys and high activity group. Significant effect on sedentary activity for girls of 22 minutes (p = .03) than boys
Bonsergent¹²	Fun PA games 1 hour/day	PA guidelines	BMI, WC	Greater decrease in prevalence of overweight and obesity (p = .039, -0.6 vs -2.3 %)
Simon²²	LPA>30 min / wk (%), active commuting home/school/work site< or > 20 min/day (%)	PE sessions in class / 3×50 min	BMI, modifiable activity questionnaire	Significant increased active commuting changes (p = .001, >20 min/day) and regular LPA lower in intervention than control group (p = .001, -14.4% vs -26.5%)
Grydeland²³	PA break in regular classes 10 min of PA/wk, active commuting campaigns 5× 3 wks, awareness on leisure time activity, step counts/day, sports recess activities	PE class	BMI, BMI z- score, WC, Waist-to-height ratio, pedometer	Significant effect on BMI (p = .02) and BMI z-score (p=.003) in girls, but not in boys. Effect on BMI (p = .03) in participants of parents with a high level of education

Study	PA/session/ Intensity	Physical educa-tion/session	Outcome measures	Findings
Dewar²⁴	School sports sessions include aerobic exercises and resistance training 40 × 90 min, LTPA 30 × 30 min, step counts ≥600 min/day for 3 days; Sedentary PA, MPA, VPA and MVPA	Interactive seminars/3 × 30 min,	Accelerometer, social cognitive scales on PA	No group-by-time effects on MPA (p = .24), VPA (p = .87), MVPA (p = .37)
van Nassau²⁵	Active transport to school-min/day, sports participation	PE lesson	BMI, BMI z-score, skin fold thickness, WC, PA questionnaire	No significant intervention effect on BMI z-score (B = .03), WC (B = .52), sum of skin folds thickness (B = .98). Adverse intervention effect on educationon BMI z-scores(B = .09)
Omorou¹³	Walking 1 hour MET -min/wk; MPA, VPA	PA guidelines	BMI, BMIz-score, International physical activityquestionnaire	Decreased effect size adjusted for PA on BMI (β = –.07) and BMI z-score (β = –.01) Increased global PA (p < .0001, 58 min/wk), a MPA (p < .0001, 43 min/wk) in intervention group
Sutherland²⁶	School sports program includes lifelong PA skills for 10 wks, recess and LTPA for 2 days/wk, step counts/min; MVPA, MPA, VPA	PE lesson	BMI, accelerometer	Significant effect on MVPA adjusted mean difference in intervention group 7.0 minutes (p<.005) Increased effect on MVPA and MPA among boys (p<.01and p<.015) and girls (p<.05and p<.047) in the intervention
Leme²⁸	Lifelong PA includes walking, dance, resistance training and yoga, school break PA	PE lesson	BMI, BMI z-score, WC, Godin- Shephard LTPA Questionnaire	Non-significant effect on BMI (p = .076), and BMI z-score (p=.14)in intervention group. Significant intervention effects on WC (p = .01). Decreased in overweight (20.4% vs. 19.0%) and obesity (11.3% vs. 9.9%)
Pbert²⁹	After-school exercise program includes games, walking, and dance 3 sessions/wk, step counts/day 1 hour for the last 7-day period; Light PA, VPA, MVPA	PE class	BMI, WC, body fat, accelerometer	Increased PA mean number of days in intervention schools at follow-up, adjusted mean 4.53 days (p = .007)
Lubans³⁰	Sport session includes aerobic exercises and resistance training 6 × 20 min, sport re-cess1 pack/school, LTPA, step counts ≥ 480 min/day for at least 3days × 17 wks; MVPA	PE class/20 × ~90 min, researcher-led seminars (3 × 20 min	BMI, BMI z-score, WC, muscular fitness, pedometer, resistance training skills battery	Small reduction on BMI z-score (p = .013) among intervention group. Significant for resistance training skill competency (p < .001)
Hollis³¹	School sports programme 10 wks, step counts ≥600 min/ day on ≥3 days/wk, recess and LTPA for 2 days/wk; MVPA	PE lesson	BMI, BMIz- score , accelerometer	Group-by-time effects for weight (p = .01), BMI (p = .01), BMI z-score (p = .02) in the intervention group
Leme³³	Lifetime PA≤ 30 min/wk to ≥90 min/wk; Inactive PA, MPA, extensive PA	PE lesson	BMI, BMIz- score, WC, Godin - Shephard LTPA Questionnaire	No significant effect on BMI (p = .426) Effect size is small (d=.102)
Dunker³⁴	Lifetime PA	PE sessions / 2 per wk for 9 wks	BMI percentiles	No significant effect on BMI (p = .084), BMI percentiles for obese (9.2%) and overweight (19.8%).
Aittasalo³⁵	Active commuting to school < 1 km to >5 km, recesses and LPA for ≤1 wk to ≥4 wks, step counts/min/day for 7-day; Light, moderate to vigorous	PE lesson, homework leaflet	BMI, accelerometer, 7 day activity dairy, questionnaire	Significant effects found for self-reported data on brisk LPA at least 1 hour/day (p = .05), proportion of students meeting PA recommendations (p = .05), the students intended to do LPA (p = .05) in the intervention group
Koch³⁶	Dance break for 10 min daily, regular short bouts of PA (wellness class)	PE lesson(curric-ulum class)	BMI, questionnaire	Significant reduction in obesity found for boys (p = .04, 4.0%) and girls(p = .10, 2.4%) in curriculum condition.
Arlinghaus³⁷	Circuit based PA for 1 day (32 min) / wk, 3 day (96 min) / wk and 5 day (160 min) / wk for 2 years	PE class 32min/ session	BMI, BMI z-score	Significant effects found by time interaction(p< .001) at 1 year and greater decreases in BMI z-score (p< .001) 3 or 5d/wk in the intervention group at 1 year

Note. β = effect size, B = regression coefficient, BMI = body mass index, CI = confidence interval, cpm = counts per minute, d = effect size, LPA = leisure physical activity, LTPA = lunch time physical activity, MET = metabolic equivalent of task, min = minutes, MPA=moderate physical activity, MVPA= moderate-to-vigorous-physical activity, PA = physical activity, PE=physical education, VPA=vigorous physical activity, WC = waist circumference, wk = week

PA behavior

Ten studies with combined interventions found significant effect on PA (Table 2): Walk/cycle to school (≥5 times per week) (1.49, p=.01)+Active after school (3-5 d): (.75 odds ratio, P = .01) 10 ; PA behavioral strategies and resistance training self-efficacy¹⁶;PA fitness with daily pedometer steps¹⁸; increase PA p= .05 with a net effect of 50 cpm (95% CI -.4, 100)²⁰; regular leisure PA (-14.4% vs -26.5%) odds ratio = 1.7 (95% CI: 1.2 –2.4) lower in intervention than control group and increased active commuting changes [(>20 minutes/day: +11.7% vs - 4.8%)]²²; Increased global PA (58 minutes/ week), a moderate PA (43 minutes/week), adherence to the French PA guidelines (OR = 1.3)¹³; MVPA adjusted mean difference 7.0 minutes (95% CI =2.7, 11.4, p<.005)²⁶; increased mean number of days (adjusted mean difference .89 days; 95% CI .25–1.53)²⁹; resistance training skill competency^17,30; brisk leisure PA time³⁵.

Dietary behavior

Nine studies with diet and combined interventions reported significant effects on one or more dietary behaviors; one study found increased eating pattern control behaviors (p=.014) and decreased using unhealthy weight control behaviors 13.7% (p=.021)14; study reduced their intake of sugar-containing/sugar sweetened beverages (SSB)9; less intake of SSB on weekend days (p=.04) among girls only but not in boys15includ-ing fact sheets to parents and classroom components, on intake of sugar-sweetened beverages (SSB; group-by-time (p=.052), reduction in consuming prepackaged snacks > 3 times/day (from 44.9% to 28.8%)21; study reported by gender was effective in reducing sugar-containing beverage consumption in girls (B=-188.2 ml/day) and effect on breakfast frequency (B = .29 days / week) in boys25; study reported that group-by time effects for vegetable and fruit intake (1.16, .26 servings/day, p = .01)28; study found significant dietary or lifestyle factor change in BMI at follow-up was less soda intake29; nutritional behaviors and psychological variables such as self-efficacy, social support, intention, and situation were significant in comparison (p<.05)32 than control group; study reported that positive changes for sweetened beverages frequency and size, processed packaged snacks size, candy frequency, baked food frequency, fast food frequency and combo meals36; (Table 3). Most studies were multi-component with theory construct. Emphasized nutrition ed-

Table 3

Characteristics of Dietary, Sedentary Behaviorand Findings on Multi-level Obesity Intervention

Study	DB content/education session	SB/Screen time	Outcome measures	Findings
Neumark-sztainer¹⁴	Increase f/v intake, limit SSB, breakfast consumption every day, pay attention to signs of hunger and satiety, avoid unhealthy weight control behaviors/educa-tion 1day/wk× 16 wks	Sedentary activity, TV30 min blocks/ day	24-hour dietary recall	Significant decreased in SB 130 minutes block a day (p=.05); increased eating pattern control behaviors (p= .014); stage of change for fruits and vegetable intake (p=.033); breakfast (p = .028); goal setting for healthy eating (p= .002); changes in unhealthy weight control behaviors (p=.021, 13.7%)
Millar¹⁰	Breakfast consumption, home lunches, f/v consumption, limiting soft drinks, cordial and snack foods/lesson, practical class, assignment for 26 wks, healthy eating practice	TV/videos/DVD/ electronic games/ day	Self - report	Significant reduction in average time watching TV, videos, DVDs/day (p = .001, %≤2 hours) and average time playing video games,electronic games or using computer(not for homework) per day (p = .001, %≤1 hour)
Lubans⁹	f/v intake, limit SSB, water intake/ handbooks × 9 wks, 3 interactive seminars× 30 min	Nil	NSW Schools PA and nutrition survey	Significantly decreasedconsumption of SCB (p=.02, β=-1.17)
Bjelland¹⁵	f/v intake, SSB/Lesson, booklet, and posters	TV/DVD/computer games hours/day for wk and weekend	Questionnaire	Significant changes in time spent on TV/DVD for wk and weekend (p = .001 and p = .03), computer/ game-use for wk and weekend(p = .004 and p < .001). Changes in less intake of SSB on weekend days (p = .04)
Toulabi¹⁷	Dietary modification/eight 45 min for twice a wk	Nil	24-hour diet record, questionnaire	Significant changes on increased nutrition knowledge among students’ and parents’ (p = < .046)
Melnyk¹⁸	Influence of feelings on eating, social eating, snacks eating out/ nutrition information × 5wks	Nil	Healthy lifestyles behavior scale	No significant changes in healthy lifestyles behavior scale (p = .48)
Dewar¹⁹	Energy intake kcal per day/nutri-tion workshops, handbook, interactive seminar	Screen time min/ day	ACAES food frequency questionnaire, ASAQ	No significant effect on group-by-time interaction on energy intake kcal/day (p = .291) and screen time min/day (p = .159)

Study	DB content/education session	SB/Screen time	Outcome measures	Findings
Bonsergent¹¹	Increase availability of f/v, water intake, limit sugary drinks and snacks, eating habits, tasting of food/dietary lecture	Nil	Eating Attitudes Test 40	Significant changes in BMI, BMI z- score (p = .03, p= .017)
Bonsergent¹²	Dietary choices and practices, nutritional change / dietary lessons, and guidelines	Nil	Eating Attitudes Test 40	Significant changes in prevalence of overweight and obesity (p = .039)
Collins²¹	Increase f/v consumption, daily breakfast, eating meals at a dinner table, monitoring portion size, drinking water, reducing SSB and energy-dense nutrients and poor snacks/handbook, messages for 10 wks, 3 - practical workshops	Nil	ACAES food frequency questionnaire	Significant changes in water intake (p = .052, 54%), SSB consumption < one sweetened beverage/day(p = .057) among girls, and effect on group-by-time (p = .052) reduction in consuming pre-packaged snacksin the intervention group (p = .052)
Simon²²	Nil	TV, TVT min/day	Self-report	Significant decrease in BMI - .98 kgm^-2 (p = .01) with high baseline TVT (>2 h per day) vs - .05 kgm^-2(p = .79) with low baseline TVT, and effect on lower TVT(p = .02, -14.0 min/day)
Dewar²⁴	Healthy eating/workshop, Interactive seminar, text message	TV/DVD/ recreational computer use min/day, interactive seminar 3 × 30 min, handbook with home challenges × 10wks, text messages/wk	ASAQ, self-report	Significant effect on intervention group for self-reported recreational computer use (p < .05) and sedentary activities (p < .05)
van Nassau²⁵	Reducing intake of SCB and high-energy snacks/sweets, daily breakfast consumption/ Lesson, booklet	TV, computer use min/day	Questionnaire	Significant effect on reducing SCB consumption in girls (p < .05) and positive intervention effect on breakfast frequency (p < .05) in boys.
Omorou¹³	Eating pattern, dietary intake/ lecture, dietary guidelines, group personal work on nutritional rhythms	Sitting time min/wk	Boire Manger Bouger self-reported questionnaire	Decreased effect size adjusted for SB on BMI(β = –.06) and BMI z-score (β = –.01) and decreased SB sitting time (p < .05, -198 min/wk) in intervention group.
Daly²⁷	Eating skills practice, mindful eating concept, satiety awareness exercise/Mind-fullness meditation for 3 min, nutritional information, instruction, discussion 90-min sessions for 6 wks	Nil	Mindful attention awareness scale	Significant reduction on BMIinMEIgroup1.1kg/m² (p = .019) at 6 wks, continue to decline 1.4kg/ m²(p = .019) by 10 wks than comparison group.
Leme²⁸	Healthy eating, low-cost healthy dietary choices / Handbook, interactive seminars, nutrition workshops, messages/wk	TV, computer for wk, weekend hours/ day	Food frequency questionnaire, self-report for SB	Significant reduction in weekend computer screen time (p=.02), and total sedentary activities(p < .01) Significant group-by-time effects for vegetable intake (p = .01),fruit intake (p = .01)
Pbert²⁹	Increase f/v, limit consumption of soda, SSB, fast food, and unhealthy snacks, hunger and appetite/ counseling on nutrition 30 min × 6 wks, booklet, food and tracking log	TV/computer/game use for the average school day in the past 7 days	24-hour dietary recall, youth risk behaviorsurvey	The significant effect found on eating breakfast days/wk (p = .024) and change in BMI on less soda intake past 7 days (p = .001)
Lubans³⁰	SSB consumption	Recreational screen time min/day	ASAQ, NSW schools PA and nutrition survey	Significant group-by-time interaction effect for recreational screen time (p = .003)
Bagherniya³²	Dietary intake, self-efficacy, social support, situation, and intention/ practical nutrition workshops and interactive seminarstwice a month x 60 min ×14 sessions, monthly diet consulting sessions	Nil	Questionnaire	No significant effect on mean of BMI (p = .127) and WC(P = .504) Significant effect on nutritional behaviors and social cognitive theory construct (p<.001)
Leme³³	Healthy food choices, dietary intake, estimate energy intake	TV/computer use, SB for wk, weekend (hours/day),	BFFQ, selfreport for SB	Significant effect found for time spent on TV/ weekdays (p=.01),TV/weekends (p=.01) and SB/ weekdays (p=.04)
Dunker³⁴	Unhealthy weight control behav-iors/wk inter-active group educational sessions x 1 hour × 8 wks, girl’s pages, recipes book	Nil	Questionnaire	No significant effect on BMI (p = .084)
Aittasalo³⁵	Nil	Screen time >2 hours for last 7 days	Self-report, questionnaire	Significant group changes in the family set limitations for screen time (p < .05)

Study	DB content/education session	SB/Screen time	Outcome measures	Findings
Koch³⁶	Fruits and vegetable intake, limit SSB, processed packaged foods, and fast food, food choices/cur-riculum, and wellness class	TV/video games	Food, health,&choic-es questionnaire	Significant changes for SSB frequency (p = .05) and size (p = .006); processed packaged snacks size (p = .01); candy frequency (p = .04); baked good frequency (p = .05); and fast food frequency (p = .003), size (p = .01), and combo meals (p = .002) No significant effects found on overweight/obesity (p = .55).
Arlinghaus³⁷	Dietary modification/ nutrition lesson 1 day (8 min)/wk, 3 day (24 min)/wk and 5 day (40 min)/wk	Nil	BMI, BMI z-score	Significant time by condition interaction (p < .001).

Note. ACAES =Australian Child and Adolescent Eating Survey, ASAQ = adolescent sedentary activity questionnaire, BMI = body mass index,β = effect size, BFFQ = Brazilian food frequency questionnaire, B = regression coefficient, DB = dietary behavior, f/v = fruit and vegetable, MEI = Mindful Eating Intervention, min = minutes, NSW = New South Wales, SB = sedentary behavior, SCB = sugar containing beverages, SSB = sugar sweetened beverages, TVT = TV/video time, WC = waist circumference,wk = week ucation or nutrition, PA/PA education, and sedentary activity as the intervention strategy implemented by the teachers.

Overweight and obesity prevalence

Sedentary Behavior

Eleven studies with multi-component interventions found significant decreased sedentary behavior such as computer screen time (not for homework), television viewing time, and recreational screen time (videos, DVDs)10, 13–15, 22, 24, 28, 30, 33, 35; a study showed a significant effect on girls (22 minutes, p = .03) than boys20 (Table 3).

Parental/Teacher/ Friends support

Four studies showed an effect on BMI for parents23; support for PA and well balanced healthy diet and eating from teacher/parents/friends14; parental aware-ness15; and parents nutritional knowledge17 (Table 3).

Effectiveness of studies measuring a primary and secondary outcome

Out of 29 studies, 12 were significant with the primary outcome on BMI and BMI-z score. 9 studies found more effects on BMI/BMI-z score; a larger number of studies influenced by PA (PE, resistance training, pedometer/ accelerometer, MVPA, leisure PA, active commuting), dietary behavior(nutritional education, dietary intake, handbook/booklet, 24-hour diet record, parental in- 142 | Cardiometry | Issue 23. August 2022

Behavior change theories

Three studies found a small effect on the utilization of theory, PA (.039), fruits and vegetable intake (p=.033); Goal setting and self-efficacy for PA (p=.021, .003); Goal setting for healthy eating (p=.002)¹⁴; resistance training self-efficacy ( r =.42, p <.001) and PA behavioral strategies ( r =.26, p =.018)¹⁶; increased self-efficacy, goal setting for change and social support, situation and intention to enhance diet(p<.001)³²(Table 2 & 3).

Risk of Bias

Only one study received a ‘very strong’ risk of bias score³²; ten studies received a ‘strong’ risk of bias score^{14, 17, 20, 23, 24, 26–29, 33}; eighteen studies received a ‘moderate’ risk of bias score 9, 10, 22, 25, 30, 31, 34–37, 11–13, 15, 16, 18, 19, 21 .

Discussion

This existing review analyzed the effect of schoolbased obesity multiple prevention interventions on BMI and /or BMI-z score outcomes among adolescents both boys and girls. The past review reported that combined education on PA and nutrition had more positive effects in the reduction of BMI among school-age students than the single component38.

The results indicate that school-based interventions have only a small effect on reducing BMI and /or BMI-z score and a decrease in the prevalence of overweight/obesity with multiple interventional strategies. It was reported that interventional strategies were heterogeneous and found minimal or non-sig-nificant effects on weight or BMI and small effects on diet, physical exercise, and decrease sedentary screen time39, 40. We found significant effects on decreased sedentary behavior such as computer screen time, television viewing time, recreational screen time, and regular daily active commuting. It was reported from a previous review that school consolidated curriculum on PE and decreasing screen time on television viewing had a successful effect on BMI40.

Few included studies that involve parents to incorporate the adolescent’s PA, dietary intake, and minimize sedentary spent time and it shows more beneficial effects of transferring knowledge from children to adult/family members to integrate approaches apart from the school. The previous review stated that effectiveness in a school-based setting with the support of family members/parents at home39. The studies incorporated more and moderate effects on PE sessions/ lessons, nutritional seminars/workshop/education, and individual counseling/motivational interviews with single/multi-component interventions. This supports previous research that based on PA and/or nutrition counseling was efficient41; and evidence that nutritional interventions are effective in decreasing BMI among adolescents integral to school curricu-lum42. Most studies utilized single/multiple theories/ models only a few studies showed very little effect on goal setting, stage of change/self-efficacy in PA, intake of a healthy diet, and support from stakeholders. The recent systematic review reported that intervention linked with theory was more consistent with self-efficacy, social support, and outcome expectations with PA and dietary consumption43.

The review bias score was found very strong in the randomization process, with negative effects on the absence of allocation of concealment /blinding and low withdrawal and dropout rates (<20%), and a moderate effect on intervention integrity. Another study review also observed that fair quality evidence on decreased BMI, and moderate-quality evidence on de- creased weight, mainly in the intervention group compared with no treatment with multiple interventions. Contradictory results, risk of bias, or uncountable outcome measures used intend that the evidence must be elucidated with caution44. Sustained Development Goals(SDG)-3, 2030 agenda “Leaving no one behind” emphasizing to secure, boost, promote healthy individuals and well-being for all age groups, a 25% curtailment in the risk of early mortality from cardiovascular disease, cancer, diabetes, and 10%limiting the prevalence of insufficient PA45.

Strengths and limitations

The systematic review states to find out the efficacy of BMI/BMI-z score on school-based multi-component interventions among adolescents (10-19 years) and both gender (2009-2019).Multiple intervention components in the school setting are more feasible among adolescents than home-based to reduce risk factors due to overweight/obesity. As found in previous review adolescents <20 years are prone to get obesity due to physical inactivity and increased sedentary activity46. PA, good dietary patterns, and sedentary behavior with the support of school teachers, parents/family members, and peer groups are motivating and enhancing adolescents to avert overweight/obesity. Our review showed that follow-up in-home with parental/friends/family support increases the effect of sound dietary intake and minimizes sedentary activity5. The use of BMI/BMI-z score which provides an objective measurement for PA, dietary behavior, and sedentary activity that is conventionally known and used in research background, with well consenting reference standards, standard instruments may potentially be reducing participant bias, observer bias, and instrumentation bias.

The limitation of this review was the exclusion of studies based on a language other than English. The review stated with multi-level interventional strategies with limited significant changes in BMI/BMI-z score, and the decreasing prevalence of overweight/ obesity makes it difficult to test the effectiveness of school-based education by the intervention components. The previous review reported that training and resources are needed to support intensive multi-disciplinary teams to implement multilevel interventions and it was expensive47. This shortcoming presents opportunities for young future researchers, planners, and public health policymakers to identify which preventive approaches, considering the theoretical Frame Maker-linked directly with some interventions for ef- fective research trials. The previous review found that limited application of theories emphasizing the future ground with a theoretical base which makes multiple influences on obesity prevention48; more theoretically based studies lay a foundation for interventional strategies to enhance adolescent weight loss should be conducted to reduce BMI on overweight/obese49.

Conclusion

The present review states that there is an intervention effect on primary outcome BMI and BMI-z score among adolescents. Parents’involvement in the modification of behavior in adolescents is most important to facilitate a good lifestyle specifically for the selection of healthy food, eating time with family members, increasing physical exercise, and decreasing recreational screen time. However,the current review suggests that delivering multiple interventional strategies consciously to be applied with theory. If it should be minimal component strategies that may be more effective. It should be noted that not all of the included meta-anal-yses included subgroup analyses based on participant age; as a result, this issue should be addressed in future research to disclose potential differences in the results and identify the most effective, age-appropriate therapies. Furthermore, because BMI does not accurately represent body composition, it is not always trustworthy in pediatric groups, tall, skinny individuals, or individuals with a high percentage of muscle mass.

Recommendation

• The study is interlinked by the theory which gives a more effective with minimal component rather than multi-intervention.
• Using a standardized curve/cut-off points for BMI/ BMI-z score, objective measurement of PA with actigraph accelerometer/pedometer data, and PE classes integrated with the wellness curriculum for better results.
• Need for the involvement of parents to increase PA, decrease sedentary activity,and modification for healthy dietary behavior.
• Process evaluations must be needed for program implementation.
• Minimal intervention components are effective and feasible for future research.
• School environment as a root for decreasing or preventing overweight/obesity, risk factors, complications, and,cut-off premature mortality rate.

144 | Cardiometry | Issue 23. August 2022

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest

None declared.

Author contributions

The authors read the ICMJE criteria for authorship and approved the final manuscript.

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