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      Are school‐based physical activity interventions effective and equitable? A meta‐analysis of cluster randomized controlled trials with accelerometer‐assessed activity


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          The prevalence of childhood obesity is increasing at epidemic rates globally, with widening inequalities between advantaged and disadvantaged groups. Despite the promise of schools as a universal context to access and influence all children, the potential of school‐based interventions to positively impact children's physical activity behaviour, and obesity risk, remains uncertain. We searched six electronic databases to February 2017 for cluster randomized trials of school‐based physical activity interventions. Following data extraction, authors were sent re‐analysis requests. For each trial, a mean change score from baseline to follow‐up was calculated for daily minutes of accelerometer‐assessed moderate‐to‐vigorous physical activity (MVPA), for the main effect, by gender, and by socio‐economic position (SEP). Twenty‐five trials met the inclusion criteria; 17 trials provided relevant data for inclusion in the meta‐analyses. The pooled main effect for daily minutes of MVPA was nonexistent and nonsignificant. There was no evidence of differential effectiveness by gender or SEP. This review provides the strongest evidence to date that current school‐based efforts do not positively impact young people's physical activity across the full day, with no difference in effect across gender and SEP. Further assessment and maximization of implementation fidelity is required before it can be concluded that these interventions have no contribution to make.

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          Socioeconomic status and child development.

          Socioeconomic status (SES) is one of the most widely studied constructs in the social sciences. Several ways of measuring SES have been proposed, but most include some quantification of family income, parental education, and occupational status. Research shows that SES is associated with a wide array of health, cognitive, and socioemotional outcomes in children, with effects beginning prior to birth and continuing into adulthood. A variety of mechanisms linking SES to child well-being have been proposed, with most involving differences in access to material and social resources or reactions to stress-inducing conditions by both the children themselves and their parents. For children, SES impacts well-being at multiple levels, including both family and neighborhood. Its effects are moderated by children's own characteristics, family characteristics, and external support systems.
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            School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18.

            The World Health Organization (WHO) estimates that 1.9 million deaths worldwide are attributable to physical inactivity and at least 2.6 million deaths are a result of being overweight or obese. In addition, WHO estimates that physical inactivity causes 10% to 16% of cases each of breast cancer, colon, and rectal cancers as well as type 2 diabetes, and 22% of coronary heart disease and the burden of these and other chronic diseases has rapidly increased in recent decades. The purpose of this systematic review was to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents. The search strategy included searching several databases to October 2011. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information. To be included, the intervention had to be relevant to public health practice (focused on health promotion activities), not conducted by physicians, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, included all school-attending children, and be implemented for a minimum of 12 weeks. In addition, the review was limited to randomized controlled trials and those that reported on outcomes for children and adolescents (aged 6 to 18 years). Primary outcomes included: rates of moderate to vigorous physical activity during the school day, time engaged in moderate to vigorous physical activity during the school day, and time spent watching television. Secondary outcomes related to physical health status measures including: systolic and diastolic blood pressure, blood cholesterol, body mass index (BMI), maximal oxygen uptake (VO2max), and pulse rate. Standardized tools were used by two independent reviewers to assess each study for relevance and for data extraction. In addition, each study was assessed for risk of bias as specified in the Cochrane Handbook for Systematic Reviews of Interventions. Where discrepancies existed, discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated, and outcomes measured. In the original review, 13,841 records were identified and screened, 302 studies were assessed for eligibility, and 26 studies were included in the review. There was some evidence that school-based physical activity interventions had a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally, school-based interventions had little effect on physical activity rates, systolic and diastolic blood pressure, BMI, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity resulted in positive effects.In this update, given the addition of three new inclusion criteria (randomized design, all school-attending children invited to participate, minimum 12-week intervention) 12 of the original 26 studies were excluded. In addition, studies published between July 2007 and October 2011 evaluating the effectiveness of school-based physical interventions were identified and if relevant included. In total an additional 2378 titles were screened of which 285 unique studies were deemed potentially relevant. Of those 30 met all relevance criteria and have been included in this update. This update includes 44 studies and represents complete data for 36,593 study participants. Duration of interventions ranged from 12 weeks to six years.Generally, the majority of studies included in this update, despite being randomized controlled trials, are, at a minimum, at moderate risk of bias. The results therefore must be interpreted with caution. Few changes in outcomes were observed in this update with the exception of blood cholesterol and physical activity rates. For example blood cholesterol was no longer positively impacted upon by school-based physical activity interventions. However, there was some evidence to suggest that school-based physical activity interventions led to an improvement in the proportion of children who engaged in moderate to vigorous physical activity during school hours (odds ratio (OR) 2.74, 95% confidence interval (CI), 2.01 to 3.75). Improvements in physical activity rates were not observed in the original review. Children and adolescents exposed to the intervention also spent more time engaged in moderate to vigorous physical activity (with results across studies ranging from five to 45 min more), spent less time watching television (results range from five to 60 min less per day), and had improved VO2max (results across studies ranged from 1.6 to 3.7 mL/kg per min). However, the overall conclusions of this update do not differ significantly from those reported in the original review. The evidence suggests the ongoing implementation of school-based physical activity interventions at this time, given the positive effects on behavior and one physical health status measure. However, given these studies are at a minimum of moderate risk of bias, and the magnitude of effect is generally small, these results should be interpreted cautiously. Additional research on the long-term impact of these interventions is needed.
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              Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns.

              The purposes of this systematic review were to present and compare recent estimates of the prevalence of overweight and obesity in school-aged youth from 34 countries and to examine associations between overweight and selected dietary and physical activity patterns. Data consisted of a cross-sectional survey of 137 593 youth (10-16 years) from the 34 (primarily European) participating countries of the 2001-2002 Health Behaviour in School-Aged Children Study. The prevalence of overweight and obesity was determined based on self-reported height and weight and the international child body mass index standards. Logistic regression was employed to examine associations between overweight status with selected dietary and physical activity patterns. The two countries with the highest prevalence of overweight (pre-obese + obese) and obese youth were Malta (25.4% and 7.9%) and the United States (25.1% and 6.8%) while the two countries with the lowest prevalence were Lithuania (5.1% and 0.4%) and Latvia (5.9% and 0.5%). Overweight and obesity prevalence was particularly high in countries located in North America, Great Britain, and south-western Europe. Within most countries physical activity levels were lower and television viewing times were higher in overweight compared to normal weight youth. In 91% of the countries examined, the frequency of sweets intake was lower in overweight than normal weight youth. Overweight status was not associated with the intake of fruits, vegetables, and soft drinks or time spent on the computer. In conclusion, the adolescent obesity epidemic is a global issue. Increasing physical activity participation and decreasing television viewing should be the focus of strategies aimed at preventing and treating overweight and obesity in youth.

                Author and article information

                Obes Rev
                Obes Rev
                Obesity Reviews
                John Wiley and Sons Inc. (Hoboken )
                09 January 2019
                June 2019
                : 20
                : 6 ( doiID: 10.1111/obr.v20.6 )
                : 859-870
                [ 1 ] Centre for Diet and Activity Research (CEDAR), MRC Epidemiology Unit University of Cambridge Cambridge UK
                Author notes
                [*] [* ] Correspondence

                Rebecca Love, MRC Epidemiology Unit and Centre for Diet and Activity Research (CEDAR), University of Cambridge School of Clinical Medicine, Box 285, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK.

                Email: rel54@ 123456medschl.cam.ac.uk

                Author information
                OBR12823 OBR-08-18-3547.R1
                © 2019 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                : 22 August 2018
                : 26 October 2018
                : 21 November 2018
                Page count
                Figures: 4, Tables: 2, Pages: 12, Words: 3838
                Funded by: Medical Research Council
                Award ID: MC_UU_12015/7
                Funded by: Gates Cambridge Scholarship
                Funded by: Wellcome Trust
                Funded by: British Heart Foundation, Department of Health, Economic and Social Research Council, Medical Research Council
                Funded by: UKCRC Public Health Research Centre of Excellence
                Award ID: RES‐590‐28‐0002
                Funded by: Centre for Diet and Activity Research (CEDAR)
                Award ID: 087636/Z/08/Z
                Award ID: ES/G007462/1
                Award ID: MR/K023187/1
                Pediatric Obesity/Obesity Prevention
                Pediatric Obesity/Obesity Prevention
                Custom metadata
                June 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.4 mode:remove_FC converted:13.06.2019

                children and adolescents,meta‐analysis,physical activity,systematic review
                children and adolescents, meta‐analysis, physical activity, systematic review


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