Liane B. Azevedo1; Jonathan Ling2; Istvan Soos2; Louisa Ells1; Shannon Robalino3; Greg Atkinson1 1Teesside University; 2Sunderland University; 3Newcastle University

Effectiveness of sedentary behaviour interventions on BMI reduction in children and adolescents: a meta-analysis

Introduction Ø Sedentary behaviour definition:

Activities that do not increase energy expenditure substantially above the resting level (1.0 to 1.5 METs) and includes activities such as sitting, lying down, and watching television and other forms of screen-based entertainment1.

1: Pate et al. (2008) Exerc Sport Sci Rev.

Department of Health, 20111

Early years (under 5s):

Ø  All under 5s should minimise the amount of time spent being sedentary (being restrained or sitting) for extended periods (except time spent sleeping).

Children and young people:

Ø  People should minimise the amount of time spent being sedentary (sitting) for extended periods.

ACSM recommendation: limit television viewing and video game playing to less than two hours per day2,3.

Public Health Recommendations

1: Department of Health (2011). Start Active, Stay Active: A report on physical activity from the four home countries’ Chief Medical Officers. 2: Tremblay et al. (2011) Int J Behav Nutr Phys Act. 3: Strasburger & Hogan (2013) American Academy of Pediatrics Committee on Public Education. Children, adolescents, and the media. Pediatrics 2013

Introduction

High levels of sedentary behaviour in children are associated with:

Ø Increased risk of obesity (i.e. TV viewing) 1,2 Ø Low self-esteem2

Ø Decrease in academic achievement2

Ø Lower fitness levels2 Ø Poor motor coordination3 Ø Poor mental health4 Ø Unhealthy diet5

1: Rey-López et al. (2008). Nutrition, Metabolism and Cardiovascular Diseases; Lee et al (2014) Int J Environ Res Public Health. 2014 2: Tremblay et al. (2011). IJBNPA 3: Smith et al (2015). Int J Behav Nutr Phys Act. 4: Asare & Danquah (2015). Child Adolesc Psychiatry Ment Health. 5: Hobbs et al (2015). Br J Sports Med.

Why focus on BMI

Ø Strong relationship between screen time and weight gain1

Ø Sedentary behaviour might be associated with increase energy intake (e.g. snacking)1,2

Ø Most common measurement of sedentary behaviour interventions in children.

Introduction

1. Monteiro & Victora (2005); Rey-López et al. (2008); Lee et al (2014) 2. Must et al. (2009) 3: Borghese et al. (2015): J Nutr Sci. ; Borghese et al. (2014) Appl Physiol Nutr Met; De Craemer et al. (2012), Obesity Review

Davison & Birch (2001). Childhood overweight: a contextual model and recommendations for future research. Obesity Reviews 2(3):159-171

Ecological model of predictors of childhood overweight

Wahi et al., 2011 N=6

Van Grieken et al., 2012 N=14

Liao et al., 2014 N=25

Why another one? Ø Latest update July 2012 Ø 21 new studies have been published since the

last review Ø 19 studies before July 2012 were not included

in previous reviews. Ø Different inclusion criteria Ø Van Grieken et al., 2011 not included studies

with overweight and obese participants Ø Liao et al., 2014 excluded studies in which BMI

was adjusted for covariates

AimPrimary aim:

Ø The aim of this meta-analysis is to summarize and compare the effect of interventions that target sedentary behavior (e.g. TV viewing, video game) on BMI in children.

Secondary aim:

Ø Explore the impact of several moderator variables on intervention effectiveness to reduce BMI:

• Child age range: pre-school (0 to 4 years old); children (4 to 10 years old) and adolescents (11 to 17 years old).

• Duration of intervention (<6 months; >6 months)

•  Intervention setting (educational, non-educational, combined)

• Type of intervention (single or multiple intervention)

• Population (mixed or overweight/obese)

• Study quality

MethodsØ Inclusion criteria:

•  Intervention studies (randomised and non-randomised) with a control group

• Children aged 0 to 17 years old

•  Intervention should targeting sedentary activities but also included if they target other behaviours (e.g. diet and physical activity)

• Objectively measured weight and height

Methods Search strategy Ø Databases: • Medline (Ovid); Cochrane (includes DARE, CDSR,

CENTRAL); Embase (Ovid); CINAHL (Ebsco); PsycInfo (Ovid); ERIC (ProQuest); SPORTDiscus (Ebsco)

Ø Searches in June and July 2013 followed by two update searches – October 2013 and March 2015

Data extraction Ø Study design Ø Population Ø Intervention (e.g. type,duration, frequency, delivery

setting…); Ø Outcome (e.g. BMI, SB, PA) Risk of bias assessment Ø Cochrane Collaboration tool for Assessing Risk of Bias

Ø 7 domains: sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting and 'other'.

Methods Ø Data analysis:

Ø Means and standard deviations (SD) of BMI or BMI z-score were used for continuous outcomes.

Ø Standardised mean difference (SMD)

SMD = Difference in mean outcome between groups Standard deviation of outcome among

Ø In case the study reported data for boys and girls they were entered separately into the meta-analysis.

Ø Studies with more than one intervention arm the data was combined using pair-wise comparison with control group.

Initial database search n= 7607

Duplication removed n= 1842

Abstracts screened N=5765

Full- text assessed for eligibility N= 187

Articles selected for data extraction N= 67

Abstracts excluded: met one of the exclusion criteria: n= 5578

Papers excluded after evaluation of full text N= 120

Results

Risk of Bias

0% 10% 20% 30% 40% 50% 60%

Unclear

High risk of bias

Low risk of bias

Study name Statistics for each study Mean and 95% CI

Standard Weight Lower Upper Mean error (Random) limit limit p-Value

Andrade et al.2014 -0.010 0.008 256.99 -0.025 0.005 0.191Bacardi- Gascon et al.2012-0.740 0.194 24.14 -1.120 -0.360 0.000Backlund et al.2011 -0.300 0.371 7.07 -1.027 0.427 0.419Birken et al.2012 0.010 0.117 56.81 -0.220 0.240 0.932Breslin et al. 201; boys 0.130 0.187 25.85 -0.236 0.496 0.486Breslin et al. 2012; girls0.210 0.192 24.53 -0.167 0.587 0.275Campbell et al.2013 -0.020 0.082 95.27 -0.180 0.140 0.806De Coen et al.2011 -0.030 0.037 193.44 -0.102 0.042 0.412Dennison et al. 2004 -0.360 0.440 5.07 -1.222 0.502 0.413Dzewaltowski et al.2010-0.100 0.073 109.74 -0.242 0.042 0.169Elder et al.2013 0.000 0.195 23.86 -0.382 0.382 1.000Epstein et al. 2008 -0.110 0.510 3.79 -1.110 0.890 0.829Esfarjani et al. 2012 -0.400 0.252 14.86 -0.894 0.094 0.112Ezendam et al.2013 0.160 0.145 40.08 -0.125 0.445 0.271Faith et al. 2001 -1.300 1.252 0.64 -3.753 1.153 0.299Fitzgibbon et al. 2006 -0.020 0.179 28.00 -0.370 0.330 0.911Fitzgibbon et al. 2010 -0.110 0.079 99.14 -0.265 0.045 0.164Fitzgibbon et al. 2012 0.070 0.156 35.65 -0.235 0.375 0.653Fitzgibbon et al.2004 -0.090 0.084 91.58 -0.255 0.075 0.285Folta et al.2013 -0.057 0.010 254.01 -0.077 -0.037 0.000French et al. 2010 0.064 0.100 72.29 -0.132 0.260 0.523Gentile et al. 2009 0.100 0.161 33.50 -0.216 0.416 0.535Goldfield et al. 2013 -0.900 0.504 3.88 -1.887 0.087 0.074Goran et al.2005; boys 0.150 0.028 216.37 0.095 0.205 0.000Goran et al.2005; girls -0.070 0.028 215.65 -0.126 -0.014 0.014Grydeland et al.2014 -0.100 0.057 141.11 -0.212 0.012 0.080Habib-Mourad et al.20140.180 0.158 34.89 -0.129 0.489 0.253Haines et al. 2013 -0.400 0.202 22.50 -0.795 -0.005 0.047Harrison et al. 2006 -0.080 0.041 181.86 -0.160 -0.000 0.050Hughes et al.2008 0.030 0.041 181.86 -0.050 0.110 0.462Kalarchian et al. 2013 -1.220 0.360 7.49 -1.926 -0.514 0.001Kipping et al.2008 0.100 0.186 25.97 -0.265 0.465 0.591Lawlor et al. 2011 -0.020 0.028 216.44 -0.075 0.035 0.476Lloyd et al. 2012 -0.950 1.452 0.47 -3.795 1.895 0.513Lubans et al. 2012 -0.190 0.263 13.72 -0.705 0.325 0.470Martínez-Andrade et al. 20140.230 0.156 35.65 -0.075 0.535 0.139McCallum et al. 2006 -0.200 0.383 6.66 -0.950 0.550 0.601Nemet et al.2013 -0.970 0.200 22.81 -1.362 -0.578 0.000Neumark-Sztainer et al. 2010-0.080 0.122 53.52 -0.319 0.159 0.512Ni Mhurchu et al.2009 0.050 0.166 31.93 -0.275 0.375 0.763O'Connor et al. 2011 0.090 0.506 3.85 -0.902 1.082 0.859Ostbye et al. 2012 -0.010 0.071 113.22 -0.149 0.129 0.888Patrick et al.2013 -0.133 0.059 137.68 -0.248 -0.019 0.023Pbert et al.2013 -0.090 0.380 6.76 -0.834 0.654 0.813Peralta et al.2009 -0.200 0.306 10.25 -0.800 0.400 0.514Puder et al. 2011 -0.070 0.064 126.58 -0.195 0.055 0.272Reilly et al. 2006 0.050 0.059 136.15 -0.066 0.166 0.399Reinehr et al. 2010 -1.700 0.276 12.51 -2.241 -1.159 0.000Robinson et al. 2003 -0.320 0.227 18.06 -0.765 0.125 0.159Robinson et al.1999 -0.450 0.143 41.25 -0.730 -0.170 0.002Robinson et al.2010 0.040 0.115 58.79 -0.185 0.265 0.728Roemmich et al. 2004 -0.080 0.075 105.79 -0.227 0.067 0.286Saelens et al. 2002 -0.100 0.016 244.95 -0.131 -0.069 0.000Salmon et al. 2008 -1.037 0.326 9.07 -1.676 -0.397 0.001Shelton et al. 2007 -1.160 0.724 1.90 -2.578 0.258 0.109Simon et al. 2008 -0.260 0.089 84.71 -0.435 -0.085 0.004Singh et al. 2009; boys 0.000 0.077 103.20 -0.150 0.150 1.000Singh et al. 2009; girls -0.100 0.077 103.20 -0.250 0.050 0.191Smith et al. 2014 0.000 0.120 54.85 -0.235 0.235 1.000Spruijt-Metz et al. 2008 -0.020 0.007 257.58 -0.034 -0.006 0.005Taveras et al.2010 -0.260 0.335 8.62 -0.917 0.397 0.438Taveras et al.2011 -0.210 0.145 40.04 -0.495 0.075 0.149Todd et al. 2008 -0.440 0.145 40.04 -0.725 -0.155 0.002Toruner et al. 2010 -0.300 0.319 9.49 -0.925 0.325 0.346van Nassau et al.2014 0.030 0.028 216.33 -0.025 0.085 0.286Veldhuis et al.2009 -0.160 0.222 18.84 -0.595 0.275 0.471Verbestel et al.2012 -0.560 0.101 71.07 -0.758 -0.362 0.000Wafa et al. 2011 -0.090 0.158 34.66 -0.400 0.220 0.569Wen et al.2012 -0.290 0.135 45.22 -0.555 -0.025 0.032Williamson et al. 2012; boys-0.034 0.040 185.34 -0.111 0.043 0.390Williamson et al. 2012; girls-0.035 0.016 244.37 -0.067 -0.003 0.030

-0.064 0.014 -0.091 -0.038 0.000-4.00 -2.00 0.00 2.00 4.00

Favours A Favours B

Meta Analysis

Favours intervention Favours comparator

67 studies 71 entries N=30,116

Study name Statistics for each study Mean and 95% CI

Standard Weight Lower Upper Mean error (Random) limit limit p-Value

Bacardi- Gascon et al.2012 -0.740 0.194 14.74 -1.120 -0.360 0.000Backlund et al.2011 -0.300 0.371 5.95 -1.027 0.427 0.419Breslin et al. 2012 boys 0.130 0.187 15.36 -0.236 0.496 0.486Breslin et al. 2012 girls 0.210 0.192 14.88 -0.167 0.587 0.275Dennison et al. 2004 -0.360 0.440 4.47 -1.222 0.502 0.413Dzewaltowski et al.2010 -0.100 0.073 28.14 -0.242 0.042 0.169Elder et al.2013 0.000 0.195 14.63 -0.382 0.382 1.000Esfarjani et al. 2012 -0.400 0.252 10.67 -0.894 0.094 0.112Ezendam et al.2013 0.160 0.145 19.46 -0.125 0.445 0.271Faith et al. 2001 -1.300 1.252 0.63 -3.753 1.153 0.299Fitzgibbon et al. 2006 -0.020 0.179 16.09 -0.370 0.330 0.911Fitzgibbon et al. 2010 -0.110 0.079 27.39 -0.265 0.045 0.164Fitzgibbon et al. 2012 0.070 0.156 18.36 -0.235 0.375 0.653Fitzgibbon et al.2004 -0.090 0.084 26.77 -0.255 0.075 0.285Gentile et al. 2009 0.100 0.161 17.77 -0.216 0.416 0.535Goldfield et al. 2013 -0.900 0.504 3.52 -1.887 0.087 0.074Goran et al.2005; boys 0.150 0.028 32.21 0.095 0.205 0.000Goran et al.2005; girls -0.070 0.028 32.19 -0.126 -0.014 0.014Grydeland et al.2014 -0.100 0.057 29.84 -0.212 0.012 0.080Habib-Mourad et al.2014 0.180 0.158 18.15 -0.129 0.489 0.253Haines et al. 2013 -0.400 0.202 14.11 -0.795 -0.005 0.047Harrison et al. 2006 -0.080 0.041 31.32 -0.160 -0.000 0.050Kalarchian et al. 2013 -1.220 0.360 6.26 -1.926 -0.514 0.001Kipping et al.2008 0.100 0.186 15.40 -0.265 0.465 0.591Lloyd et al. 2012 -0.950 1.452 0.47 -3.795 1.895 0.513Lubans et al. 2012 -0.190 0.263 10.07 -0.705 0.325 0.470Martínez-Andrade et al. 2014 0.230 0.156 18.36 -0.075 0.535 0.139McCallum et al. 2006 -0.200 0.383 5.66 -0.950 0.550 0.601Nemet et al.2013 -0.970 0.200 14.23 -1.362 -0.578 0.000Neumark-Sztainer et al. 2010 -0.080 0.122 22.17 -0.319 0.159 0.512Ni Mhurchu et al.2009 0.050 0.166 17.32 -0.275 0.375 0.763Pbert et al.2013 -0.090 0.380 5.73 -0.834 0.654 0.813Peralta et al.2009 -0.200 0.306 8.07 -0.800 0.400 0.514Puder et al. 2011 -0.070 0.064 29.13 -0.195 0.055 0.272Reinehr et al. 2010 -1.700 0.276 9.40 -2.241 -1.159 0.000Robinson et al. 2003 -0.320 0.227 12.22 -0.765 0.125 0.159Robinson et al.1999 -0.450 0.143 19.74 -0.730 -0.170 0.002Robinson et al.2010 0.040 0.115 23.02 -0.185 0.265 0.728Salmon et al. 2008 -1.037 0.326 7.32 -1.676 -0.397 0.001Shelton et al. 2007 -1.160 0.724 1.81 -2.578 0.258 0.109Simon et al. 2008 -0.260 0.089 26.15 -0.435 -0.085 0.004Singh et al. 2009; boys 0.000 0.077 27.69 -0.150 0.150 1.000Singh et al. 2009; girls -0.100 0.077 27.69 -0.250 0.050 0.191Smith et al. 2014 0.000 0.120 22.39 -0.235 0.235 1.000Taveras et al.2010 -0.260 0.335 7.02 -0.917 0.397 0.438Todd et al. 2008 -0.440 0.145 19.45 -0.725 -0.155 0.002Toruner et al. 2010 -0.300 0.319 7.59 -0.925 0.325 0.346Veldhuis et al.2009 -0.160 0.222 12.58 -0.595 0.275 0.471Wen et al.2012 -0.290 0.135 20.60 -0.555 -0.025 0.032

-0.147 0.035 -0.217 -0.078 0.000-4.00 -2.00 0.00 2.00 4.00

Favours A Favours B

Meta Analysis

Favours intervention Favours comparator

49 studies N=17,495

Group or Subgroup

Meta-analysis (95%CI)

Heterogeneity Between group differences p value

Number of studies (entries)

Overall change SMD

-0.064 (-0.091 to -0.038)

75% <0.001 71

Overall change BMI (kg/m2)

-0.147 (-0.217 to -0.078)

76% <0.001

49

Intervention

SB -0.204 (-0.354 to -0.053)

75 % <0.05 6

SB + PA -0.030 (-0.090 to 0.03)

NS 11

SB + PA + Diet -0.074 (-0.108 to -0.041)

<0.001 54

Setting

Educational -0.022 (-0.060 to -0.015)

75% NS 27

Non- educational

-0.161 (-0.218 to -0.105)

<0.001 25

Combined -0.059 (-0.109 to -0.010)

<0.05 19

Results Ø No significant differences between groups were

found: • For different age groups (pre-school; children and

adolescents).

• Duration of intervention (<6 months; >6 months)

• Population (mixed; overweight/obese)

• Study quality

Discussion

Studies BMI SDS BMI (kg/m2) Significance

Wahi et al. 2011 N=6

-0.10 (95%CI: -0.28 to 0.09)

NS

Van Grieken et al. 2012 N= 14

-0.14 (95%CI: -0.23 to -0.05)

P<0.05

Liao et al. 2014 N= 25

-0.07 (95% CI: -0.14 to -0.01)

P<0.05

This study -0.064 (95% CI: -0.091 to -0.038) N=67

-0.147 (95% CI: -0.217 to -0.078) N=49

P<0.001

Results were statistically significant but were they clinically relevant?

Discussion Studies Reference value Health improvement

Reinehr & Andler 2004 Reinehr et al., 2004

BMI z ≥ 0.5 Improvement in insulin sensitivity and resistance and atherogenic profile

Kirk et al., 2005 BMI z ≥ 0.15 Improvement in cholesterol (total, LDL and HDL) and insulin

Ford et al., 2012 BMI z ≥ 0.25 Improvement in cardiometabolic risk

Kolsgaard et al., 2011

BMI z ≥0.0 Improvement in insulin and cholesterol levels

Goldsmith et al., 2013 Changes in weight of -7.55 kg to +3.9 kg

Sufficient from overweight or obese child to become normal weight after 1 year

9 year old children Reduce 0.25 BMIz = 0.5 BMI Kg/m2

0.15 BMI kg/m2 = 0.07 BMI z

16 year old children Reduce 0.25 BMIz = 0.39 BMI Kg/m2

0.15 BMI kg/m2 = 0.1 BMI z

Summary Ø Sedentary behaviour interventions are associated with small

but significant improvement in BMI and BMI z. Ø The clinical relevance of this findings remains unclear. Ø Interventions which target only SB or target SB + PA + diet

and delivered in non-educational (e.g. home) or combined (e.g. home and school) settings appear to be more effective.

Ø There was a high heterogeneity between studies possibly

caused by clinical or methodological differences between studies.

Conclusion Ø Child obesity is multifactorial and

involve several contexts that interact with each other1 and it is unlikely that targeting only one behaviour will promote change in child weight status.

Ø Interventions targeting child obesity

should still consider including a SB as this might:

Ø Increase total energy expenditure (TEE)1

Ø Reduce a higher consumption of unhealthy food2

Ø Be associated with improvement in other health outcomes (self-esteem, academic achievement, fitness level, motor coordination and mental health). 1: Deheeger et al. (1997) Int J Obes Relat Metab Disord

2: Diez & Gortmaker (1985) Pediatrics

Thank you for your attention