Early Obesity Prevention – the Role of Life Style. Experience from Toybox and

Other Intervention Trials Zbigniew Kułaga

Public Health Department The Children’s Memorial Health Institute

Warszawa

The Power of Programming – Developmental Origins of Adiposity and Long-Term Health Munich 13-15 Oct. 2016

Note: for non-commercial purposes only

Dr John Snow; London 1854, Broad Street cholera outbreak

water pump intervention

Aims • The aim of ToyBox-study was to prevent obesity in

early childhood (3.5-5.5 years old)

• Create a supportive social and physical environment at kindergartens and home to facilitate desired behaviour

• At a potentially effective, low-cost, scalable-approach

Mulitfactorial evidence based approach using behavioural models in understanding and promoting fun, healthy food, play and policy for the prevention of obesity in early childhood: ToyBox

http://www.toybox-study.eu/

ToyBox-study Academic Research Institutes

Harokopio University, HUA (GR)

Ludwig-Maximilians University of Munich, LMU (DE)

State Institute of Early Childhood Research, IFP (DE)

Ghent University, Ugent (BE)

VU University Medical Centre, Vumc (NL)

University of Zaragoza, UniZar (ES)

Akershus University College, HIAK (NO)

Durham University, UDUR (UK)

Roehampton University, RoU (UK)

Children’s Memorial Health Institute, CMHI (PL)

Medical University of Varna, MUV (BG)

University of Luxembourg (ULU) (LUX)

International / Health Promotion Organisations

International Association for the Study of Obesity, IASO (UK) CBO B.V., (CBO) (NL)

SME

AOK- Verlag GmbH (DE) GREECE

SPAIN BULGARIA

UK

NORWAY

POLAND GERMANY HOLLAND

BELGIUM LUXEMBURG

April 2010 2011 2012 2013 2014

ToyBox-study

2010 2011 2012-2013 2014

M

ay-Ju

ne 2

012

Base

line

Mea

sure

men

ts

Academic year 2012-2013

Implementation

of ToyBox-intervention

M

ay-Ju

ne 2

013

Follo

w-u

p M

easu

rem

ents

Development of the ToyBox-intervention

Sample – Baseline: May/June 2012

GERMANY

GREECE

BULGARIA

POLAND

SPAIN

BELGIUM

Country Kindergartens Children/ Parents

Belgium 26 1327

Bulgaria 34 964

Germany 58 1217

Greece 110 1229

Poland 49 1430

Spain 32 889

Total 309 7056

Measurements

• Anthropometric – Weight – Height – Waist

• Parental questionnaire incl. FFQ

• Pedometers • Accelerometers (only

Belgian sub-sample)

• Baseline (May-June 2012)

• Follow-up (May- June 2013)

8.0% 9.5% 10.4% 11.0% 11.9%

14.0%

1.9%

2.1% 2.4%

4.2% 4.1%

5.7%

0%

5%

10%

15%

20%

25%

Germany Belgium Poland Bulgaria Spain Greece

Obese

Overweight

Prevalence of overweight*/obesity* by country

p < 0.001

*Cole TJ, Lobstein T. Pediatr Obes. 2012;7:284-94

Toybox study intervention Targeted behaviours • Water consumption • Snacking • Physical activity • Sedentary behaviour

Aiming to:

• Changes kindergarten environment • Implement the behaviours • Conduct interactive activities • Target/Involve parents via

newsletters/tip-cards/posters

Training of teachers

1st Behaviour: Water consumption

Change of kindergarten environment – water station

Implementation of behaviour

2nd Behaviour: Snacking

Change of kindergarten environment: fruits and vegetable

snacks Implementation of behaviour

3rd Behaviour: Physical activity

Change of kindergarten environment – ensure enough space

for PA Implementation of behaviour

4th Behaviour: Sedentary behaviour

Change of kindergarten environment – enable more

acitivities standing instead of sitting

Implementation of behaviour

Complete data May/June 2012 & May/June 2013

GERMANY

GREECE

BULGARIA

POLAND

SPAIN

BELGIUM

Country Kindergartens Children/ Parents

Belgium 26 1032

Bulgaria 19 792

Germany 55 954

Greece 92 854

Poland 49 1065

Spain 30 853

Total 271 5550

WATER CONSUMPTION AND EATING HABITS

PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR

Results: targeted lifestyles

Table 2. Intervention effects for total water and all beverages in the total sample (adjusted for age, sex, SES and country).

Pinket AS, Van Lippevelde W, De Bourdeaudhuij I, Deforche B, Cardon G, et al. (2016) Effect and Process Evaluation of a Cluster Randomized Control Trial on Water Intake and Beverage Consumption in Preschoolers from Six European Countries: The ToyBox-Study. PLoS ONE 11(4): e0152928. doi:10.1371/journal.pone.0152928 http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0152928

Children’s sweets consumption (portions/day) p<0.001

p=0.055 2,16

1,94

2,12

2,05

1,8

1,85

1,9

1,95

2

2,05

2,1

2,15

2,2

baseline follow-up

port

ion

/ day

intervention control

% Children >10.000steps/day (pedometers)

62,3% 62,4%

44,0%

38,4%

49,8% 50,5%

42,1%

35,0%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

Baseline Follow up Baseline Follow up

Weekdays Weekend

Intervention

Control

p<0.002

p<0.004

Sedentary behaviour accelerometer data

0

5

10

15

20

25

30

35

40

45

50

SB weekdays (% / day) SB weekends (% / day)

% o

f day

intervention control

De Craemer M et al; ToyBox-study group. The effect of a cluster randomised control trial on objectively measured sedentary time and parental reports of time spent in sedentary activities in Belgian preschoolers: the ToyBox-study.Int J Behav Nutr Phys Act. 2016 5;13:1.

Toybox children BMI kg/m2 (BMI z-score*)

2012 2013 boys intervention 15.9 (0.16) 16.0 (0.25) boys control 15.9 (0.16) 15.9 (0.25) girls intervention 15.9 (0.30) 16.0 (0.36) girls control 15.8 (0.25) 15.8 (0.28)

*Cole TJ, Lobstein T. Pediatr Obes. 2012;7:284-94

p=0.04

Overweight incl. obesity among Toybox study children

14,4 15,5 13,4 14,3

0

2

4

6

8

10

12

14

16

baseline follow-up

Ove

rwei

ght p

reva

lenc

e (%

)

Intervention Control

Overweight incl. obesity among Toybox study children

12,7 13,7 11,9

13,8

0

2

4

6

8

10

12

14

16

18

baseline follow-up

Prev

alen

ce (%

)

boys

intervention control

16,2 17,3 15,2 15,0

baseline follow-up

girls

intervention control

Toybox overweight incl. obesity after the intervention (follow-up) according to the body mass category before intervention (baseline)

Body mass category pre intervention (baseline 2012)

Intervention (% of overweight 2013)

Control (% of overweight 2013)

non-overweight boys+girls 4.9 4.6

non-overweight boys 5.0 5.0

non-overweight girls 4.8 4.2

overweight boys+girls 77.6 76.9

overweight boys 73.5 → 78.7

overweight girls 81.2 ← 75.3

Wen LM et al. Effectiveness of home based early intervention on children’s BMI at age 2: randomised

controlled trial. BMJ. 2012;26;344:e3732

Intervention • Randomized 1:1 (I:C); 667 mothers • Home visits in the antenatal

period, and at 1, 3, 5, 9, 12, 18 and 24 months after birth; trained community nurses

• Key intervention messages: – Breast is best – No solids for me until 6 months – I eat a variety of fruit and vegetables

every day – Only water in my cup – I am part of an active family

Results Intervention vs Control • Improved:

– vegetable servings (mother and child),

– TV viewing during meal – TV>60 min/day; – mother total activity time>150

min/week • No difference:

– fruit servings, water, salty snacks, soft drinks intake

• BMI at the age 2 years: 16.49 vs 16.87 (p=0.01)

The ‘‘TigerKids’’ behavioral intervention program. Bayer O et al. Short- and mid-term effects of a setting based prevention program to reduce obesity

risk factors in children: A cluster-randomized trial. Clinical Nutrition 2009;28:122–128.

Intervention • Kindergarten setting, children aged 6 y; • Key targets to be reached by children:

– at least 30 min/day vigorous physical activity games at the Kindergarten,

– regular consumption of fresh fruit and vegetables as a snack, aiming at replacing high energy density snack,

– regular consumption of water and other non-sugared drinks aiming at replacing sugared beverages and reaching a habitual consumption of not more than one glass/day of sugared drinks and juices

• Simple messages on health related behavior for parents

• Randomization (kindergartens) 2:1 (I:C) • Assesment after 6 and 18 months

Intervention effects OR, controls as reference

Outcome OR (CI)

Overweight 0.73 (0.51–1.04)

Obesity 0.58 (0.31–1.10)

High fruit consumption 1.64 (1.26–2.12)

High vegetable consumption

1.26 (0.98–1.61)

Low consumption of high caloric drinks

1.66 (1.16–2.38)

Lifestyle Education

• four clinics (232 infants) were randomized to control or intervention

• intervention delivered by health care provider at each of 7–9 wellbaby visits over 2 years

• advice on infant feeding practices, physical activity, and developmental milestones related to eating patterns

• no difference in body size (BMI) but significant change of feeding practices

27

Schroeder N et al. J Obes. 2015;2015:795859

Intervention Control Soda Sweetened tea

Cow’s milk Punch

Other interventions studies LIMIT study

• Dietary, exercise and behavioural strategies adressed to pregnant woman to limit GWG

• Limited impact of lifestyle intervention on primary outcome: infant large for gestational age

Dodd J, Plenary Session II, 13.10.2016 Munich

Systematic review: Redsell SA, Maternal Child Nutr 2016; 12: 24–38.

• randomised controlled trials of interventions that aim to reduce the risk of overweight and obesity in infancy and early childhood

• 12 trials with lifestyle intervetion and weight outcome: – no difference in weight outcome: 7 studies – intervention heavier: 2 studies – BMI lower in comparison to controls: 3

studies

Acknowledgements The ToyBox-study was funded by the Seventh Framework Programme (CORDIS FP7) of the European Commission The ToyBox-study group consists of: Co-ordinator: Yannis Manios; Steering Committee: Yannis Manios, Berthold Koletzko, Ilse De Bourdeaudhuij, Mai Chin A Paw, Luis Moreno, Carolyn Summerbell, Tim Lobstein, Lieven Annemans, Goof Buijs; External Advisors: John Reilly, Boyd Swinburn, Dianne Ward; Harokopio University (Greece): Yannis Manios, Odysseas Androutsos, Eva Grammatikaki, Christina Katsarou, Eftychia Apostolidou, Eirini Efstathopoulou, Paraskevi-Eirini Siatitska, Angeliki Giannopoulou, Effie Argyri, Konstantina Maragkopoulou, Athanasios Douligeris; Ludwig Maximilians Universitaet Muenchen (Germany): Berthold Koletzko, Kristin Duvinage, Sabine Ibrügger, Angelika Strauß, Birgit Herbert, Julia Birnbaum, Annette Payr, Christine Geyer; Ghent University (Belgium): Department of Movement and Sports Sciences: Ilse De Bourdeaudhuij, Greet Cardon, Marieke De Craemer, Ellen De Decker and Department of Public Health: Lieven Annemans, Stefaan De Henauw, Lea Maes, Carine Vereecken, Jo Van Assche, Lore Pil; VU University Medical Center EMGO Institute for Health and Care Research (the Netherlands): EMGO Institute for Health and Care Research: Mai Chin A Paw, Saskia te Velde; University of Zaragoza (Spain): Luis Moreno, Theodora Mouratidou, Juan Fernandez, Maribel Mesana, Pilar De Miguel-Etayo, Esther González, Luis Gracia-Marco, Beatriz Oves; Oslo and Akershus University College of Applied Sciences (Norway): Agneta Yngve, Susanna Kugelberg, Christel Lynch, Annhild Mosdøl; University of Durham (UK): Carolyn Summerbell, Helen Moore, Wayne Douthwaite, Catherine Nixon; State Institute of Early Childhood Research (Germany): Susanne Kreichauf, Andreas Wildgruber; Children’s Memorial Health Institute (Poland): Piotr Socha, Kamila Zych, Magdalena Góźdź, Beata Gurzkowska, Katarzyna Szott; Medical University of Varna (Bulgaria): Violeta Iotova, Mina Lateva, Natalya Usheva, Sonya Galcheva, Vanya Marinova, Zhaneta Radkova, Nevyana Feschieva; International Association for the Study of Obesity (UK): Tim Lobstein, Andrea Aikenhead; National Institute for Health Promotion and Disease Prevention (the Netherlands): Goof Buijs, Annemiek Dorgelo, Aviva Nethe, Jan Jansen; AOK- Verlag (Germany): Otto Gmeiner, Jutta Retterath, Julia Wildeis, Axel Günthersberger; Roehampton University (UK): Leigh Gibson; University of Luxembourg (Luxembourg): Claus Voegele.