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Review Article

Effectiveness of Lifestyle Interventions in Child Obesity: Systematic Review With Meta-analysis

Mandy Ho, Sarah P. Garnett, Louise Baur, Tracy Burrows, Laura Stewart, Melinda Neve and Clare Collins
Pediatrics December 2012, 130 (6) e1647-e1671; DOI: https://doi.org/10.1542/peds.2012-1176
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Abstract

BACKGROUND AND OBJECTIVES: The effects of lifestyle interventions on cardio-metabolic outcomes in overweight children have not been reviewed systematically. The objective of the study was to examine the impact of lifestyle interventions incorporating a dietary component on both weight change and cardio-metabolic risks in overweight/obese children.

METHODS: English-language articles from 1975 to 2010, available from 7 databases, were used as data sources. Two independent reviewers assessed articles against the following eligibility criteria: randomized controlled trial, participants overweight/obese and ≤18 years, comparing lifestyle interventions to no treatment/wait-list control, usual care, or written education materials. Study quality was critically appraised by 2 reviewers using established criteria; Review Manager 5.1 was used for meta-analyses.

RESULTS: Of 38 eligible studies, 33 had complete data for meta-analysis on weight change; 15 reported serum lipids, fasting insulin, or blood pressure. Lifestyle interventions produced significant weight loss compared with no-treatment control conditions: BMI (−1.25kg/m2, 95% confidence interval [CI] −2.18 to −0.32) and BMI z score (−0.10, 95% CI −0.18 to −0.02). Studies comparing lifestyle interventions to usual care also resulted in significant immediate (−1.30kg/m2, 95% CI −1.58 to −1.03) and posttreatment effects (−0.92 kg/m2, 95% CI −1.31 to −0.54) on BMI up to 1 year from baseline. Lifestyle interventions led to significant improvements in low-density lipoprotein cholesterol (−0.30 mmol/L, 95% CI −0.45 to −0.15), triglycerides (−0.15 mmol/L, 95% CI −0.24 to −0.07), fasting insulin (−55.1 pmol/L, 95% CI −71.2 to −39.1) and blood pressure up to 1 year from baseline. No differences were found for high-density lipoprotein cholesterol.

CONCLUSIONS: Lifestyle interventions can lead to improvements in weight and cardio-metabolic outcomes. Further research is needed to determine the optimal length, intensity, and long-term effectiveness of lifestyle interventions.

KEY WORDS
  • Abbreviations:
    CI —
    confidence interval
    HDL —
    high-density lipoprotein
    HOMA-IR —
    homeostasis model assessment of insulin resistance
    LDL —
    low-density lipoprotein
    WMD —
    weighted mean difference

    • Obesity in children and adolescents is a global public health concern and is associated with a range of short- and long-term health complications.1–4 Although prevention of obesity is important, so too are effective treatments for those already affected. Lifestyle interventions, involving a combination of diet, exercise, and/or behavior modification, are an essential element of obesity management.5–7 Several systematic reviews of childhood obesity have been published and lifestyle interventions targeting treatment of child and adolescent obesity are reported as efficacious in weight loss in the short to medium term.8–12 The first specific review of dietary interventions, published in 2006,13,14 included studies published up to 2003, and found positive effects of interventions that included a dietary component.14,15

    The previously mentioned systematic reviews and others have all presented data on weight change outcomes; however, obese children and adolescents also carry an increased risk for cardio-metabolic complications, including dyslipidemia, insulin resistance, and hypertension.15–20 To our knowledge, no systematic review has examined the effects of lifestyle interventions on cardio-metabolic outcomes in overweight children and adolescents. Therefore, the aim of this review was to present the best available evidence from randomized controlled studies of lifestyle interventions incorporating a dietary component to assess their impact on both weight loss and cardio-metabolic risks. This review covers literature published between 1975 and 2010.

    Methods

    The protocol and search strategy for this systematic review was based on the previous peer-reviewed protocol13 registered with the Joanna Briggs Institute. It involved a 2-stage process. First, a detailed literature search was conducted in September 2010 to identify studies published between 2003 and 2010. Eligible studies from the previous review13 covering 1975 and 2003 were then combined in the data synthesis with those from the current search.

    Eligibility Criteria

    Eligible studies were randomized controlled trials of treatment of overweight and obesity in children and adolescents ≤18 years of age comparing the effectiveness of lifestyle intervention programs incorporating a nutrition or dietary component with no treatment or wait-list control, usual care, or minimal advice or written diet and physical activity education materials. Programs that involved the whole family or were directed exclusively at parents of overweight or obese children and adolescents were also included. Additional inclusion criteria were a follow-up period from baseline of at least 2 months, and inclusion of the outcome measures of body weight or body composition. Participants were free living or attending obesity clinical units, community programs, camps, schools, or one-off programs. Studies were excluded if they were targeted at obesity prevention or maintenance of weight loss, were drug trials or interventions that dealt with eating disorders, or if they focused on children with obesity attributable to a secondary or syndromal cause. Studies that were not written in English, or included children who were within the healthy weight range at baseline, were excluded. No restrictions were placed on intervention settings or who delivered the interventions.

    Data Source and Search Strategy

    The search strategy involved a literature search conducted by a medical librarian of published literature in the English language through CINAHL, Cochrane Reviews, Current Concepts, DARE, Embase, Premedline, and Medline. The Medical Subject Headings of the National Library of Medicine keyword search terms used were dietetic, paediatric (pediatric), child, adolescent, family, parent, school, overweight, obesity, intervention, weight control, weight management, weight loss, and healthy weight (Supplemental Appendix 1). In addition, the reference lists of retrieved articles and key systematic reviews of childhood obesity treatments were scanned for relevant references.8,9,11,12

    Study Selection

    All studies identified in the database search were assessed for relevance from the title and abstract by 2 independent reviewers. Articles that met, or appeared to meet, the inclusion criteria were retrieved. All retrieved studies were assessed for relevance by 2 independent reviewers. In case of disagreement, a third independent reviewer made the final decision.

    Quality Assessment

    Full copies of all included studies were assessed for methodological quality by 2 independent reviewers using the Joanna Briggs Institute critical appraisal of study quality tool (Supplemental Appendix 2). Studies were rated as positive, negative, or neutral based on responses to 10 items. Discrepancies were resolved by discussion or consultation with a third reviewer to achieve consensus.

    Data Extraction

    Data in relation to methodology, intervention effect, compliance, and intensity were extracted by the first reviewer by using a standardized form developed specifically for this review. This was verified by a second reviewer for accuracy and a consensus reached where disagreement existed. Data describing interventions that were reported in more than 1 article were extracted together.

    Data Synthesis

    Review Manager (RevMan5.1, The Cochrane Collaboration, Oxford, England) was used for meta-analyses. All the outcomes in this review were continuous outcomes and a weighted mean difference (WMD) was calculated if the same measurement scale was used. When different outcome measurement scales were reported, we conducted the meta-analysis by using the standardized mean difference approach. Heterogeneity was assessed by I2 statistics. Heterogeneity is considered to be low if I2 is ≤40%, and high if I2 is ≥75%.21 We used a random effects model for meta-analysis if there was significant heterogeneity (I2 >40%), and fixed effects for homogeneous (I2 ≤ 40%). BMI and BMI z score were used as the primary weight loss outcomes. We also examined the effects of interventions on body composition by using percentage body fat. By using the last time point of weight loss measurement for each study, we performed meta-analyses among subgroups by age (child defined as mean age at baseline ≤12 years and adolescent as >12 years), and the length of the follow-up from baseline. Where key details or data were missing, authors were contacted, or data imputed based on methods described in the Cochrane Handbook.21 The following cardio-metabolic outcomes were examined:

    • serum lipids, including total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides;

    • fasting glucose, fasting insulin, and insulin resistance as determined by the homeostasis model assessment of insulin resistance (HOMA-IR); and

    • systolic and diastolic blood pressures.

    Where outcomes could not be quantitatively combined in a meta-analysis, they are described in a narrative summary. For forest plots with sufficient studies included (>10), we generated funnel plots to examine for the publication bias.

    Results

    Search Result

    The literature search identified 4713 references (Fig 1), and 434 full articles were retrieved. Forty-one articles relating to 30 different studies met all inclusion criteria.22–62 Eight additional studies (12 articles) from the previous review that met the comparison criteria were also included.63–74 The total number of studies included in this review is 38.

    FIGURE 1
    FIGURE 1

    Flowchart for identification of trials for inclusion in a systematic review of lifestyle interventions incorporating a dietary component in overweight and obese children and adolescents. aCollins CE, Warren JM, Neve M, McCoy P, Stokes B. Systematic review of interventions in the management of overweight and obese children which include a dietary component. International Journal of Evidence-Based Healthcare. 2007;5(1):2–53.

    Description of Included Studies

    Study characteristics and weight-related outcomes are summarized in Table 1. Nearly half of the studies were conducted in the United States (n = 18),22,24,29,33,41,46–49,50,56,63,64,66–69,71 5 in Australia,25,30,35–37 and the others in Israel (n = 3),39,43,44 Germany (n = 2),32,51 the United Kingdom (n = 2),34,40 Belgium,65 China,28 Finland,42 Iran,45 Korea,31 Mexico,38 Taiwan,26 and Tunisia.23 Eighteen studies targeted obese children exclusively,22,23,26,28,29,31,34,38,40–42,44,46,51,64–66,71 whereas the others targeted both overweight and obese children. Most studies (n = 14) were conducted in a hospital environment,22,25,29,32,36,38,40–41,43–44,46,63,65,68 followed by the community (n = 6),23,27,33–35,51 school (n = 6),26,42,48–50,64 and primary care setting (n = 6).30,37,39,47,67,69 Thirteen studies were conducted in children,25,30,33–35,37,40–42,44,47,50,66 7 in adolescents,22–24,28,29,31,36 and others enrolled both children and adolescents.26,27,32,38,39,43,45,46,48,49,51 Only 1 study included children aged <5 years.35 Four adolescent studies specifically targeted girls.24,29,31,45 The sample size of included studies ranged from 16 to 258, with a median of 72 participants per study. Twenty-seven studies had 2 study arms, 9 had 3 study arms, and 2 had 4 study arms (Table 1). Among the no treatment or wait-list control comparisons (n = 22) (Table 1), the intervention lengths varied from 1 month (n = 1) to 2 years. Twelve studies did not follow the participants after the intervention program ended.22–24,26,28,29,31,32,36,63,64,68 For the comparison of lifestyle intervention with usual care (n = 11), the intervention lengths varied from 3 months to 1 year, and 6 studies conducted subsequent follow-up,41–43,45,65,69 ranging from 2 months to 4 years from the end of the active intervention component. Among the 5 written information studies, 1 had a varied intervention length, 2 had an intervention length of 6 months,48,49 and another 2 were 1-year50,51 intervention programs with the outcome evaluation at the end of the intervention.

    View this table:
    TABLE 1

    Study Characteristics and Weight-Related Outcomes (Structured by Year of Publication)

    Methodological Quality

    No studies fulfilled all requirements listed in the study quality critical appraisal tool, although 8 studies met 8 of the 10 requirements25,27,30,32,37,40,49,69 (Table 2). Twenty-four studies did not specify the method of randomization.22–24,26,28,29,31,33,36,39,42,45,46,48–51,63–68,71 Details of allocation concealment23,24,26,28,29,31,33–36,41,43–46,50,51,63,66–68,71 and study blinding24,27–31,33,36,37,39,41–43,45,48,50,51,63–69,71 were not adequately reported for most studies. Blinding of participants in dietary and lifestyle interventions is usually not possible. Only 5 studies reported that outcome assessors were blinded to participants’ treatment allocation.25,30,37,38,40 Overall, retention rates for all included studies ranged from 38% to 100%. Most studies (29/38) had a retention rate of ≥70% at 6 months or >60% at 1 year. Only 9 studies used intention-to-treat analysis.32,41,44,46,47,62,67–69 Six studies did not report dropout rates and it was therefore not clear if they used an intention-to-treat analysis.23,26,35,45,48,63

    View this table:
    TABLE 2

    Selected Methodological Quality of Included Studies: Results Are Presented as Number of Studies (%)

    Dietary Interventions

    Ten studies used the Traffic Light or modified Traffic Light diet as their dietary intervention.27,28,32,38,40,41,48,49,66,69 The Traffic Light diet is a calorie-controlled approach in which foods in each category are color-coded according to their calorie density per average serving: green for low-calorie foods that can be eaten freely; yellow for moderate-calorie foods that can be eaten occasionally; and red for high-calorie foods that should be eaten rarely. Four studies used a hypocaloric diet or a calorie restriction approach. Two aimed for a 30% of reported energy intake deficit or 15% less than estimated daily requirements.43,44 One study targeted 500 kcal less than the reported baseline energy intake,23 and another imposed caloric restrictions on snacks and beverages.22 One-fifth of the included studies inadequately described the details of dietary interventions.31,33,36,39,48,50,71 Other studies provided general healthy eating advice (Table 1). A dietitian was reported to be involved in the delivery of the dietary interventions in 13 studies.25,35,38,40,42–47,51,63,67

    Exercise Interventions

    Nineteen studies conducted supervised physical activity sessions or exercise training as part of the intervention,22–26,31,32,34,42–46,48,49,51,63,64,68 although the intensity and variety varied. The total duration of physical activity sessions ranged from 20 minutes per month25 to 6 hours per week,23 most providing ∼1.5 to 2.0 hours of training each week (Table 1). Three studies used pedometers to promote physical activity.27,33,36

    Effects of Lifestyle Intervention Compared With No Treatment or Wait-Listed Control

    Eighteen of the 22 studies that compared lifestyle intervention with no treatment or a wait-listed control group reported a positive effect on weight loss22,23,25–28,31,32,34–36,63,64,66–69,71 (Table 1). In the meta-analysis, which included 19 studies (24 comparisons) and 1234 participants, there was a significantly larger effect on weight and body composition (standardized mean difference −0.97, 95% confidence interval (CI) −1.39 to −0.55) for lifestyle interventions compared with control over 2 years (Supplemental Fig 8). However, the studies were significantly heterogeneous (I2 = 90%) and the effect size varied by age and length of study. There was no evidence of publication bias or small-study effects with visual inspection of the funnel plot.

    We also conducted meta-analyses of 12 studies (899 participants) that reported BMI (Fig 2A) and 7 studies (493 participants) that reported BMI z score (Fig 2B). There was a pooled BMI reduction of 1.25 kg/m2 (95% CI: 0.32–2.18, I2 = 98%) and a 0.10 BMI z score reduction (95% CI: 0.02–0.18, I2 = 0%–50%) greater for the lifestyle intervention compared with the control condition.

    FIGURE 2
    FIGURE 2

    Meta-analysis of studies comparing lifestyle intervention with no-treatment or wait-list controls.

    The short-term study of children with the greatest postintervention effect was a 6-month community-based program (mean BMI difference = 2.10 kg/m2) in which parents and children attended eighteen 2-hour group education and exercise sessions held twice weekly in sports centers and schools, followed by a 12-week free family swimming pass (Table 1).34 However, the greatest BMI reduction in the studies of adolescents (mean BMI difference 4.30 kg/m2) was in a 2-month community-based intensive exercise training program (4 times per week, 90 minutes each) combined with dietary restriction (500 kcal/d less than the reported baseline energy intake).23

    Effects of Lifestyle Intervention Program Compared With Usual Care or Minimal Intervention

    Eight of the 11 studies reported a positive effect of the lifestyle intervention as compared with usual care or minimal interventions.38,41–46,69 The overall effect size in the meta-analysis, which included 7 studies (586 participants),38,41–44,46,69 was a decrease in BMI of 1.30 kg/m2 at the end of active intervention (95% CI: 1.03–1.58, I2 = 0% to 48%) (Fig 3A). Studies with longer intervention periods (>6 months)41,42 showed greater weight loss than shorter term interventions.41–44,69 Four studies followed up participants at 7 months to 1 year from baseline and the pooled results indicate that weight loss was sustained after program completion (Fig 3B). Similar observations were obtained for percentage body fat change, with the lifestyle intervention group losing 3.2% more body fat (95% CI: 1.39–5.01) than the usual care group at the end of active intervention (Supplemental Fig 9A).The fat loss effect was sustained at 1 year follow-up (Supplemental Fig 9B). Four studies38–40,42 reported BMI z score change after the active intervention, with the pooled weight loss being 0.09 BMI z score greater (0.02 to 0.15, I2 < 40%) in the lifestyle intervention compared with usual care (Supplemental Fig 9C).

    FIGURE 3
    FIGURE 3

    Meta-analysis studies comparing lifestyle program to usual care or minimal intervention conditions.

    Effects of Lifestyle Intervention Program Compared With Written Educational Materials

    Two of the 5 studies reported BMI and 3 reported BMI z score. There was a 2.52 kg/m2 greater reduction in pooled BMI (95% CI: 0.91–5.95, I2 = 97%) and 0.06 greater reduction in pooled BMI z score (95% CI: 0.02–0.10, I2 = 99%) for the lifestyle intervention programs compared with written educational materials only over 1 year (Fig 4A and B).

    FIGURE 4
    FIGURE 4

    Meta-analysis of studies comparing lifestyle intervention program with written education materials.

    Effects of Lifestyle Interventions on Cardio-metabolic Outcomes

    Table 3 summarizes the metabolic outcomes reported by each study. Fifteen of the 38 studies reported at least 1 cardio-metabolic outcome.22,24,26,28,31,32,34,39,41,43,46,49,51,63,68 All except 2 small studies (with 7 to 15 participants in each study arm)24,39 reported a positive weight loss effect of lifestyle interventions compared with control groups. Eight studies reported blood lipids results26,28,31,39,43,46,49,63; 6 studies reported results of fasting glucose, fasting insulin, or HOMA-IR,22,24,26,31,46,49; and 12 studies reported blood pressure findings.26,28,31,32,34,41,43,46,49,51,63,68

    View this table:
    TABLE 3

    Effects of Lifestyle Interventions on Anthropometric and Metabolic Outcomes (Structured by Year of Publication)

    Total Cholesterol and Triglycerides

    Meta-analysis of 5 studies including 440 participants between 8 and 16 years old (Supplemental Fig 10) showed that lifestyle intervention had a significantly greater impact on total cholesterol improvement compared with no treatment/wait-list control, usual care, or written educational materials, both in the short-term (WMD −0.40 mmol/L, 95% CI: −0.51 to −0.30; I2 = 0%; study length: 4 to 6 months)26,31,49 and the longer-term studies (WMD −0.24 mmol/L, 95% CI: −0.30 to −0.17; I2 = 0%; study period: 1 to 2 years).28,46 The pooled intervention effect on triglycerides for the same group of studies (Fig 5A) was −0.20 mmol/L in the short-term studies (95% CI: −0.35 to −0.05, I2 = 59%) and −0.09 mmol/L in the longer-term studies (95% CI: −0.11 to −0.07, I2 = 0%).

    FIGURE 5
    FIGURE 5

    a, Forest plot of mean differences in triglycerides concentrations (mmol/L). B, Forest plot of mean differences in LDL cholesterol concentrations (LDL, mmol/L). C, Forest plot of mean differences in HDL concentrations (HDL, mmol/L).

    Low-Density Lipoprotein and High-Density Lipoprotein Cholesterol

    Meta-analysis of 4 studies including 372 participants with study length between 4 and 12 months showed a significant improvement in LDL cholesterol (−0.30 mmol/L, 95% CI: −0.45 to −0.15, I2 = 59%) favoring lifestyle intervention (Fig 5B). No differences were found for HDL cholesterol (P = .22) (Fig 5C).

    Fasting Glucose, Fasting Insulin, and HOMA-IR

    Meta-analyses of 4 studies including 372 participants showed a significant improvement in fasting insulin (−55.1 pmol/L, 95% CI: −71.2 to −39.1, I2 = 0%) in favor of lifestyle interventions over 1 year (Fig 6A) and no differences was found for fasting glucose (P = .08) (Supplemental Fig 11). The pooled difference for HOMA-IR was −2.32 (95% CI: −3.25 to −1.39) in favor of lifestyle intervention over 1 year; however, the heterogeneity was high (I2 = 79%) (Fig 6C).

    FIGURE 6
    FIGURE 6

    a, Forest plot of differences in mean fasting insulin (pmol/L). B, Forest plot of mean differences in homeostasis model assessment of insulin resistance (HOMA-IR).

    Blood Pressure

    Meta-analyses of 7 studies (554 participants) showed that lifestyle interventions led to a significantly greater improvement in diastolic blood pressure in the short-term studies (WMD −1.69 mm Hg, 95% CI: −3.15 to −0.24, I2 = 26%, study length: 6 months or less) but there was no difference in the longer-term studies (Fig 7A). On the contrary, a significantly greater improvement in systolic blood pressure was shown only in the studies with a study length of 1 year or more (WMD −3.72 mm Hg, 95% CI: −4.74 to −2.69, I2 = 0%) (Fig 7B). Five studies were not included in the meta-analyses, as they reported the absolute values only at baseline and follow-up.34,43,51,63,68 These studies reported a similar trend as those included in the meta-analyses.

    FIGURE 7
    FIGURE 7

    a, Forest plot of differences in mean diastolic blood pressure (mmcHg). B, Forest plot of differences in mean systolic blood pressure (mmcHg).

    The study that achieved the greatest improvement across all cardio-metabolic outcome measures, including blood lipids, fasting glucose and insulin, HOMA-IR, and blood pressure, was a 12-week intensive school-based lifestyle intervention program targeting 10- to 13-year-old obese students.26 The participants received 30-minutes of nutrition instruction twice per week at school plus 40-minutes of classroom-based noncompetitive aerobic activity 3 times per week. The mean BMI and body fat percentage difference between the intervention group and the no-treatment control at the end of active intervention was −1.5 kg/m2 and −1.2% respectively.

    Discussion

    This systematic review reports on lifestyle intervention trials incorporating a dietary component aimed at treating overweight and obesity in children and adolescents published between 1975 and September 2010 (n = 38). It is the first review to summarize the effects of lifestyle interventions on cardio-metabolic outcomes in this age group and provides an improved understanding of the effects of lifestyle interventions on weight loss and cardio-metabolic outcomes. The results support the importance of lifestyle interventions incorporating a dietary component as a critical part of treatment of childhood obesity.

    The meta-analyses indicate that lifestyle interventions incorporating a dietary component led to significant weight loss when compared with no treatment. These results support previous reviews,8,9,11–14 and extend the evidence base on the use of lifestyle interventions in the treatment of childhood obesity, as this review includes more trials, uses clearly defined no-treatment, or wait-list controls, and extends ascertainment to September 2010. Studies comparing lifestyle interventions with usual care also resulted in significant immediate and posttreatment effects on BMI up to 1 year from baseline. The meta-analysis shows that weight loss was greater when the duration of treatment was longer than 6 months. Lifestyle interventions also produced significant treatment effects on BMI and BMI z score, compared with written information only, over a 6- to 12-month intervention period.

    Meta-analyses showed that lifestyle interventions resulted in significant improvements in total cholesterol and triglycerides up to 2 years from baseline, as well as improvements in fasting insulin and HOMA-IR up to 1 year from baseline; however, the improvements were not uniformly associated with the extent of weight loss or body fat reduction. It is uncertain whether the positive effects were attributable to weight loss per se or attributable to aspects of the lifestyle intervention that were independent of weight loss, such as reduction in saturated fat intake or increased physical activity. Some studies have reported that lifestyle intervention resulted in improvement in plasma lipid concentrations, insulin sensitivity, and blood pressure in obese children, even in the absence of weight loss or body composition change.75,76 The absence of individual participants’ data on weight and cardio-metabolic outcome changes makes it impossible to characterize the relationship between the extent of weight loss and changes in various cardio-metabolic outcomes. Although most studies showed a significant improvement in total cholesterol (6/7)26,28,31,43,46,49 or LDL cholesterol,26,31,43,49 fewer than half demonstrated significant improvements in triglycerides26,28,31 or HDL cholesterol.26,63 High triglycerides and low HDL cholesterol levels are the important risk factors of cardiovascular disease. Future studies should explore effective strategies to improve triglycerides and HDL cholesterol concentrations.

    The impact of lifestyle interventions on blood pressure is less certain from the included studies. Most overweight or obese children are likely to be normotensive. In addition, blood pressure is strongly related to age and height77–79 in children and adolescents, and therefore direct comparison of blood pressure reading possibly underestimates the intervention effects and limits our ability to draw definitive conclusions on the effects of lifestyle interventions on blood pressure.

    Features of Effective Interventions

    The heterogeneity of the included studies makes it difficult to give definitive recommendations for practice. However, the studies provide evidence to support a variety of dietary and lifestyle components in treating childhood obesity across a wide range of treatment settings, age groups, and severity of obesity.

    Family Involvement

    Family involvement in treatment of childhood obesity is widely advocated and discussed.9,80,81 Our review demonstrated that almost all effective interventions (particularly in studies that enrolled children <12 years of age) reported including a family component, including separate education sessions for parent and child,25,27,32,41,42,44,48,49,51,66 targeted parents as the sole agent of change,35 encouraged parents to lose weight if they were overweight,38,66 or provided a free family swim pass to participants.34

    Dietary Intervention

    We found that dietary interventions were rarely evaluated as a sole component of treatment in comparison with a waited-list or no-treatment control group. Dietary interventions were usually part of a broader lifestyle intervention program. Not all studies adequately described the dietary intervention. The most commonly reported dietary interventions were the modified Stop/Traffic Light approach and a hypocaloric diet/calorie restriction approach. Both dietary approaches were demonstrated to achieve effective relative weight loss across different age groups, settings, and countries.22,23,27,32,38,41–44,66 The influences on weight were sustained up to 1 year from baseline.27,41–43

    Exercise Intervention

    Another frequent feature of effective studies is involvement of a structured exercise training component.22,31,43,46,48,49,64,68 Again, the varied strategies, intensity, and duration of intervention make it difficult to conduct direct comparisons and to identify the most effective exercise intervention for weight loss in this age group.

    Strengths and Limitations

    This review comprehensively included lifestyle intervention trials published between 1975 and 2010 during which time childhood obesity became prevalent. Strengths of the study include the reporting of mean differences in BMI and percentage body fat, weight change indicators commonly used by clinicians, as well as cardio-metabolic outcomes, Also, separate meta-analyses were conducted to compare lifestyle interventions with clearly defined no-treatment or wait-list controls, usual care, or minimal advice and written diet and physical activity education materials respectively. This provides clinically meaningful information for future pediatric obesity treatment service planning.

    A number of limitations of the present analyses should be acknowledged. First, this review was confined to published literature written in English; this may have introduced publication bias and an overrepresentation of effective interventions. Second, a high degree of clinical and statistical heterogeneity among the included studies means the results should be interpreted with caution. We addressed statistical heterogeneity by using a random effects meta-analysis and by subgroup analysis. The potential sources of heterogeneity include variations in the participant populations, the intensity and duration of interventions, and the variety of diet and exercise regimens used. The review was also limited by the less than optimal methodological quality of the included studies and the lack of isolation of the effects of the dietary intervention components. In addition, there were inadequate data reported to allow inclusion of some studies in meta-analyses, and almost 40% of included studies (n = 19) reporting only absolute values of weight outcome. For these studies, we calculated weight change from absolute values and used imputation methods to estimate the SD of the change. To facilitate future systematic reviews and meta-analyses, authors should be encouraged to report both weight change and SD data. Finally, the review was also limited by the use of intermediate outcomes, such as lipoprotein and blood pressure, in the absence of longer-term cardiovascular morbidity data.

    Conclusions

    The body of research reviewed suggests that lifestyle interventions incorporating a dietary component along with an exercise and/or behavioral therapy component are effective in treating childhood obesity and improving the cardio-metabolic outcomes under a wide range of conditions at least up to 1 year. To draw firm clinical recommendations, future studies should provide details of all intervention components, participant characteristics, and the study design, including the method of randomization, blinding, allocation concealment, and attrition rates. Further work is required not only to determine the optimal length, intensity, and long-term effectiveness of lifestyle interventions, but also to determine what magnitude of weight reduction in the pediatric population is compatible with clinically significant benefits. Further, cost-effectiveness analyses need to be conducted.

    Acknowledgment

    We thank Ms Debbie Booth, librarian, Faculty of Health, The University of Newcastle, for assistance with the search-and-retrieve strategies.

    Footnotes

      • Accepted August 7, 2012.
    • Address correspondence to Ms Mandy Ho, Institute of Endocrinology and Diabetes, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail: mandy.ho{at}sydney.edu.au

    • All authors were involved in study conception and design, interpretation of data, critical revision, and final approval of the submitted manuscript; Ms Ho was involved in quality assessment, data extraction, data analysis, and manuscript preparation; Prof Collins, Dr Baur, and Dr Garnett were involved in quality assessment, data extraction and study supervision; and Drs Burrow and Steward were involved in quality assessment and data extraction.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: Ms Ho is supported by an Australian National Health and Medical Research Council Dora Lush Postgraduate Research Scholarship (APP 1017189). Dr Garnett is supported by a Cancer Institute NSW Early Career Development Fellowship Grant (10/ECF/2-11). Dr Neve is supported by a Priority Research Centre in Physical Activity and Nutrition Postdoctoral Fellowship. Prof Collins is supported by a National Health and Medical Research Council Career Development Fellowship.

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    Pediatrics
    Vol. 130, Issue 6
    1 Dec 2012
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    Effectiveness of Lifestyle Interventions in Child Obesity: Systematic Review With Meta-analysis
    Mandy Ho, Sarah P. Garnett, Louise Baur, Tracy Burrows, Laura Stewart, Melinda Neve, Clare Collins
    Pediatrics Dec 2012, 130 (6) e1647-e1671; DOI: 10.1542/peds.2012-1176
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