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From the studies presented in this paper, all but one occurred in a school-based setting.

Presumably, schools are universal recruitment site of child subjects, for attendance is compulsory
in most countries.

However, schools are only one setting in which children spend their time. Effective and
sustainable childhood obesity prevention efforts may need to be comprehensive in their target
settings, across schools, family/homes and in the community (39).

Evidence has shown that while programmes in schools have positive effects on health behaviour,
these changes are not reliably maintained (40,41).

Flodmark and colleagues point out that the difficulties of sustaining health behaviour change may
be due, in part, to the limited interventions found only in schools (40).

As such, Wofford suggests that behaviour change interventions should consider a whole-systems
approach to include communities and policies, in addition to targeting parents, a s well as the
children (41).

Recognizing that the evidence for intervention effectiveness across all identified studies was
fairly mixed, this appears to lend some support for programmes in multiple settings. However,
rigorously designed studies of more comprehensive obesity prevention strategies across various
settings are warranted to confirm this hypothesis in Asia.

In comparison to other previously published systematic reviews on childhood obesity prevention,


this is the first to highlight programmes found in Asia.
Other reviews have included studies originating from Europe and the US, arguably where
childhood obesity rates are more prevalent than in Asia.

The studies included in this review share many similarities with those published studies from
Europe and the US, such as having multiple components and/or often targeting more than one
EBRB (17).
The evidence suggests that targeting components of both diet and physical activity may be more
effective at preventing weight gain in children than a single-component intervention in one
setting (42).
In our included studies, a combined approach to target diet and activity behaviours was
commonly seen.
For example, if the main focus of the programme was on increasing physical activity, there was
usually an additional lecture or class component that incorporated messages on healthy diets.
Yet, in order to assess the effectiveness of individual or clusters of programme components or
specific behavioural change techniques, more rigorous evaluations are needed.

At the least, studies should perform and report on process evaluation measures to establish,
among others, implementation fidelity.
The majority of studies recruited and enrolled primary school-aged children.
It has been noted in several previously published articles that shifting the focus to prevention in
younger children may be more effective (41,43). Preschool-aged children, between 2 and 5years,
are at a critical development point of building their foundation for healthy behaviours and habits.
Therefore, early intervention in this age group may be key to lifelong obesity prevention (43).
In line with this idea, European countries have increased their research efforts related to obesity
prevention in pre-schoolers over the last few years (44).
Four of the studies included in this review focused on such a young population in the Asian con-
text; hence, it may be beneficial to continue to explore this target group.

Although there appears to be a paucity of scientifically published studies on childhood obesity


prevention in Asia, this may not accurately reflect the current status of implemented prevention
programmes. In our initial search, we noted at least four articles published in China (45), Sri
Lanka (46) and Singapore (47,48) that thoroughly described obesity prevention programmes, but
did not report on programme effects.
For China and Sri Lanka, the studies were protocol/design papers published in 2011 and 2012.
Although we could not identify any articles following the implementation of these programmes,
it may be possible that programme effects will be reported on in the upcoming years.
With regard to Singapore, a broad overview of obesity prevention initiatives was presented,
including, but not limited to, the development of public policies and guidelines, promotion of
healthy lifestyles in schools across all age ranges and the realization of increased accessibility
and affordability to make healthier choices

Intervention programmes and effects

16 used school/child care facility as their main setting for intervention implementation. 1 use
Community

3 study used The HAPPY 10 programme, in which children received at least


one 10-min physical activity sessions on a school day

Others- behavioural modification through nutrition/health education lectures/lessons and


physical activity sessions were most frequently reported.

The majority of programmes was delivered by teachers or trained research


staff, with some studies also mentioning parents and/or student ambassadors as delivery
agents

The programme duration ranged from 12 weeks to 3 years, with a majority of the
programmes (N= 13) running between 3 months to 1 year.

Some intervention overlap with other program during intervention period.

The primary outcome measures were overweight/obesity prevalence incidence and remission,
anthropometrics (e.g. weight and BMI) or body composition (e.g. %body fat and %fat free
mass) with several studies also measuring performed health behaviours and psychological
constructs for behaviour change.
Participants of five studies were very likely to be representative of the target population, with
a high participation rate of 80%.

The majority of studies (N= 11) had a methodologically rigorous study design using a
randomized controlled trial or controlled trial study design .

Most studies used validated research instruments to assess the outcome variables related to
obesity, and/or assessments were performed by trained professionals.

Programme effects on overweight/obesity prevalence, incidence or remission were mixed


with some studies reporting significant or non-significant decreased rates
and/or no change over time.

Of the studies with a controlled design, more than half reported no significant difference of
overweight/obesity prevalence, incidence or remission between groups (i.e. intervention
group(s) compared with control group). A similar trend was observed for studies reporting on
outcomes including BMI (z-scores), waist circumference or fat mass.

Most positive and significant programme effects were found for outcomes such as improved
health knowledge and/or favourable lifestyle practices (e.g. healthier diet and increased
physical activity). This was true for changes from baseline and for between group
differences.

16 but one study (37) used the school/child care facility as


their main setting for intervention implementation.

The HAPPY 10 programme, in which children received at least


one 10-min physical activity sessions on a school day, was
described in three studies (2628).

All other studies implemented different intervention programmes, in which behavioural


modification through nutrition/health education lectures or lessons and physical activity
sessions were most frequently reported.

The majority of the intervention programmes was delivered by teachers or trained research
staff, with some studies also mentioning parents and/or student ambassadors as delivery
agents (21,24,30,34).

The programme duration ranged from 12 weeks (25) to 3 years (23,32), with a majority of the
programmes (N= 13) running between 3 months to 1 year (22,2531,3337).

Among the studies, there were considerable differences with regard to programme intensity,
but with a general tendency towards weekly child/adolescent engagement and/or the
overlapping/subsequent implementation of (multiple) programme components over the
intervention period.
The primary outcome measures were overweight/obesity prevalence incidence and remission
(21,23,2528,3033), anthropometrics (e.g. weight and BMI) or body composition (e.g.
%body fat and %fat free mass) (21,22,2529,31,35,36) with several studies also measuring
performed health behaviours and psychological constructs
for behaviour change (22,24,25,27,30,3335,37).

Participants of five studies (22,23,26,28,33) were very likely to be representative of the target
population, with a high participation rate of 80%.

For the remaining studies, (i) it was less likely they had included a sample that was
representative of the target population, and/or (ii) representativeness
could not be scored based on the information
provided in the article, and/or (iii) participation rates were
lower than 80% and/or (iv) no participation rate was
reported.
The majority of studies (N= 11) had a methodologically rigorous study design using a
randomized controlled trial or controlled trial study design (2123,25
28,31,32,35,36).
Yet, in cases where a study was described as randomized, the method of randomization was
only rarely reported (21,22,28).

Most studies used validated research instruments to assess the outcome variables related to
obesity, and/or assessments were performed by trained professionals.

Programme effects on overweight/obesity prevalence, incidence or remission were mixed


with some studies reporting significant or non-significant decreased rates
and/or no change over time.

Of the studies with a controlled design, more than half reported no significant difference of
overweight/obesity prevalence, incidence or remission between groups (i.e. intervention
group(s) compared with control group). A similar trend was observed for studies reporting on
outcomes including BMI (z-scores), waist circumference or fat mass.

Most positive and significant programme effects were found for outcomes such as improved
health knowledge and/or favourable lifestyle practices (e.g. healthier diet and increased
physical activity). This was true for changes from baseline and for between group
differences.

It was not possible to identify effective programme components or sharing elements


among countries for the following reasons:

Only six studies (24,25,29,30,36,37) assessed process indicators; e.g. programme fidelity as
expressed in actual exercise classes given. None of them, however, checked whether
low/high programme fidelity influenced the programme outcomes;

Most intervention programmes included multiple components and involved multiple


delivery agents.
Yet, no separate statistical analyses were run to examine how each component influenced the
programme outcomes;
Almost all interventions were different in content; e.g. lectures versus active workshops
versus daily exercise sessions, which made them difficult to group;

Finally, no rigorous effectiveness assessment was performed as part of this review, and the
large majority of studies reported (some) positive findings. Hence, we reported little variation
among the studies in terms of effectiveness.

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