Evidence-based recommendations for the development of obesity prevention programs targeted at preschool children

Summary

The ToyBox intervention was developed using an evidence-based approach, using the findings of four reviews. These reviews included three critical and narrative reviews of educational strategies and psychological approaches explaining young children’s acquisition and formation of energy-balance related behaviours, and the management of these behaviours, and also a systematic review of behavioural models underpinning school-based interventions in preschool and school settings for the prevention of obesity in children aged 4–6 years.

This paper summarises and translates the findings from these reviews into practical evidence based recommendations for researchers and policy-makers to consider when developing and implementing interventions for the prevention of overweight and obesity in young (aged 4–6 years) children.

The recommendations focus on two behaviours, physical activity and sedentary behaviour, and healthy eating, and include general recommendations, intervention approaches, interventions content, and simple messages. The review also briefly examines the role that the commercial sector plays in hindering or facilitating attempts to create healthy food environments for children. This paper also recognises that childhood obesity is not an issue for the education sector alone; it needs to be tackled at a multi sectoral level, recognizing the particularly important role of local governments, nongovernment organizations and the media.

Keywords: Children, evidence-based recommendations, obesity prevention, preschool.

As previously discussed in other papers in this Supplement of Obesity Reviews, the ToyBox intervention was developed using an evidence-based approach, and refined through pilot testing. As part of that evidence base, two pieces of work were carried out. First, a series of narrative reviews of educational strategies and psychological approaches explaining young children’s acquisition and formation of energy-balance related behaviours, and facilitating their management (Gibson et al. (1); Gibson etal. (2), all published in this supplement). Second, a systematic review to identify behavioural models underpinning school-based interventions in preschool and school settings for the prevention of obesity in children aged 4–6 years (Nixon et al. (3); published in this supplement).

The aim of this short paper is to summarize and translate the findings from these two reviews into practical evidence-based recommendations for researchers and policy-makers to consider when developing and implementing interventions for the prevention of overweight and obesity in young (aged 4–6) children. We have divided these recommendations into sections for ease of reading: (i) general considerations; (ii) intervention approaches; (iii) intervention content; and (iv) simple messages. The authors of this paper hope that the recommendations listed below will help policy-makers, both in Europe and other countries, who are developing and implementing interventions, which aim to prevent overweight and obesity in young children.

1. General considerations when developing interventions for the prevention of obesity in preschool (aged 4–6) children.

a) As most successful interventions have parental components, parental engagement that includes role modelling should be a key part of any intervention in this age group, and mere provision of knowledge and information although distribution of letters and newsletters to parents is not sufficient. There is particularly good evidence to suggest that increasing the physical activity levels of fathers/male carers (as role models) increases the physical activity levels of young children. Where parents’ attempts to increase their physical activity levels are limited because of a lack of local opportunities, local authorities should provide appropriate support, for example, through free or incentivized play and activity areas and schemes. If the intervention takes place only in the school/kindergarten setting, and attempts to engage parents fail, then teachers could be considered as role models.

b) A limited number of clear and simple messages (strategies), which aim to effect positive behaviour change in young children, underpinned by theoretical knowledge, are required for parents and teachers.

c) When considering the resource materials for interventions, the literacy levels of parents should be taken into account, alongside the acceptability of the intervention material for parents, teachers and children. Unless the materials are easily accessible to all members of that community, only those who are more literate will feel able to participate in the intervention. Usability of testing of new or existing materials in the target population before implementing the intervention is a prudent move (4). If this is not carried out, the intervention may, inadvertently, increase health inequalities in the target population.

d) Parents and caregivers should be the major target of the intervention, but outcomes for evaluation (change in body mass index, change in physical activity and dietary behaviours) should be focused on children (5).

2. Intervention approaches to consider when developing interventions for the prevention of obesity in young (aged 4–6) children.

a) Physical activity and dietary behaviours should be targeted together in a combined intervention, although this should be made as simple as possible.

b) Rewards for children (which can include praise, but not food) for uptake of desired energy-balance behaviour should be included in the intervention.

c) The key elements of successful approaches are ‘modelling’ (through older peers, teachers and parents) and techniques to facilitate skill development. These approaches increase the success of an intervention because they increase levels of self-efficacy in parents, teachers and children.

d) The intervention should have a common framework, and within this there should be enough flexibility for tailoring it to the target population. In school-based interventions, the teachers must be allowed to adapt the modules to their different classes, and they should be encouraged to include country- and cultural-specific activities (based on the same theoretical underpinning).

Physical activity and sedentary behaviour

a) The physical activity element of the intervention should take into account the fact that there may be children in the target population who would have problems, or feel uncomfortable, following certain physical activity regimes.

b) In school-based interventions, the physical activity element of the intervention should be incorporated into the daily curriculum, wherever possible, without affecting the pre- or post-school program.

c) Promotion of at least 120–180 min/d of physical activity for children at both weekdays and weekends should be included in the intervention. Participation in Physical Education classes and active play time at school count, as do all physical activities of all intensities, towards this goal. It is important to suggest ways in which children can achieve the recommended levels of physical activity at weekends, for example, by participating in organized physical activities with local clubs and societies, or visits to playground areas.

d) Limitation of leisure screen time to 1 h/d (or the amount of time recommended by appropriate national guidelines, if less than 1 h/d) should be included in the intervention.

e) The activities that aim to increase levels of physical activity should be playful, and be able to be performed in many environments and have a chance of being feasible for all children; forced participation in competitive sports or activities which some children cannot (or feel they cannot) succeed in can cause more harm than good.

Healthy eating

a) Thehealthyeatingelementoftheinterventionshould raise awareness in parents, carers and teachers about how children can vary in their reluctance to try new foods, and the importance of familiarization with new healthy foods at a young age.

b) Healthy food and drink items, including fruits and vegetables, should be made available and accessible for children, both at school and home. Conversely, children should have limited exposure and availability to unhealthy foods and drinks such as

sweetened soft drinks and energy- dense snacks.

c) Teachers should discuss with children what barriers exist for them in choosing healthy foods and having a well-balanced diet, and how these might be overcome (e.g. vegetables with a favourite sauce, fruit with pudding). Tasting sessions that involve new healthy foods and drinks are particularly useful. Another useful strategy is to allow children to get involved in the menu choices, preparation and service of their food, both at home and at school.

3. Simple messages to consider when developing interventions for the prevention of obesity in young (aged 4–6) children.

Physical activity and sedentary behaviour

a) Encourage the use of active transport (walking and cycling) for short distances.

b) Encourage visiting places where children can be active.

c) Discourage the provision of a screen in the bedroom (television [TV], computer or PlayStation).

d) Encourage the provision of non-competitive participation in physical activity.

e) Encourage parents to provide their children with appropriate clothing for indoor and outdoor activities.

f) Encourage the development of a large, active play enhancing all weather play areas in kindergartens and schools.

g) Provide game equipment during lesson breaks, and encourage children to be active.

h) Decrease total sedentary time in the classroom and at home by changing activities from passive to active.

Healthy eating

a) Encourage eating together with others, and as a family unit when at home.

b) Encourage the provision of a broad variety of healthy foods especially fruits and vegetables, and discourage the provision of unhealthy foods such as sweetened soft drinks and energy-dense snacks.

c) Discourage the behaviour of eating while watching TV or using game consoles, etc.

There is also strong evidence that the current activities of parts of the commercial sector are actively undermining attempts to create healthy food environments for children (6,7), and it is therefore recognized that the setting-based approach to preventing childhood obesity described in this paper needs to be complemented by policies to reduce the negative influences of the commercial sector on children’s diets. We believe that the

commercial sector has a potentially important role in helping young children and families consume a healthy diet that they enjoy, at a price they can afford (8).

Policy-makers and service providers should feel confident that there are effective strategies, as listed above, for preventing obesity in young children. However, it is also important to consider how these strategies (which focus on improving diet and physical activity behaviours) are incorporated with other critical aspects of an intervention program, if that program is to be effective. World Health Organisation has stated that the greatest challenge in tackling childhood obesity is the need to sensitize and mobilize all sectors of society, and to involve all levels of government in joint efforts with ministries of health (9). Childhood obesity is not an issue for the education sector alone; it needs to be tackled at a multisectoral level, recognizing the particularly important role of local governments, non-government organizations and the media. Indeed, any effective intervention program will need to include components for which there is little specific efficacy evidence, for example, leadership support, coordination, workforce development, communications, network development, monitoring feedback, appropriate cultural adaptation, and policy development and implementation.

As suggested in a recent Cochrane review of interventions to prevent childhood obesity (10), further research in this area should focus on translational research, and assess how best to implement interventions which can be embedded into ongoing practice and operating systems, be effectively scaled up, be sustained over time and ensure equitable outcomes.

Conflict of Interest Statement

None of the authors have any conflicts of interests to declare.

Acknowledgements

The ToyBox-study is funded by the Seventh Framework Programme (CORDIS FP7) of the European Commission under Grant agreement No. 245200. The content of this article reflects only the authors’ views, and the European Community is not liable for any use that may be made of the information contained therein.