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Meta-Analysis
. 2020 Jan 5;1(1):CD012547.
doi: 10.1002/14651858.CD012547.pub2.

Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors

Emily H Morgan  1 , Anel Schoonees  2 , Urshila Sriram  3   4 , Marlyn Faure  5 , Rebecca A Seguin-Fowler  4   6
Affiliations
Meta-Analysis

Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors

Emily H Morgan et al. Cochrane Database Syst Rev. .

Abstract

Background: Poor diet and insufficient physical activity are major risk factors for non-communicable diseases. Developing healthy diet and physical activity behaviors early in life is important as these behaviors track between childhood and adulthood. Parents and other adult caregivers have important influences on children's health behaviors, but whether their involvement in children's nutrition and physical activity interventions contributes to intervention effectiveness is not known.

Objectives: • To assess effects of caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors, including those intended to prevent overweight and obesity • To describe intervention content and behavior change techniques employed, drawing from a behavior change technique taxonomy developed and advanced by Abraham, Michie, and colleagues (Abraham 2008; Michie 2011; Michie 2013; Michie 2015) • To identify content and techniques related to reported outcomes when such information was reported in included studies SEARCH METHODS: In January 2019, we searched CENTRAL, MEDLINE, Embase, 11 other databases, and three trials registers. We also searched the references lists of relevant reports and systematic reviews.

Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs evaluating the effects of interventions to improve children's dietary intake or physical activity behavior, or both, with children aged 2 to 18 years as active participants and at least one component involving caregivers versus the same interventions but without the caregiver component(s). We excluded interventions meant as treatment or targeting children with pre-existing conditions, as well as caregiver-child units residing in orphanages and school hostel environments.

Data collection and analysis: We used standard methodological procedures outlined by Cochrane.

Main results: We included 23 trials with approximately 12,192 children in eligible intervention arms. With the exception of two studies, all were conducted in high-income countries, with more than half performed in North America. Most studies were school-based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The specific intervention strategies used were not always reported completely. However, based on available reports, the behavior change techniques used most commonly in the child-only arm were "shaping knowledge," "comparison of behavior," "feedback and monitoring," and "repetition and substitution." In the child + caregiver arm, the strategies used most commonly included additional "shaping knowledge" or "feedback and monitoring" techniques, as well as "social support" and "natural consequences." We considered all trials to be at high risk of bias for at least one design factor. Seven trials did not contribute any data to analyses. The quality of reporting of intervention content varied between studies, and there was limited scope for meta-analysis. Both validated and non-validated instruments were used to measure outcomes of interest. Outcomes measured and reported differed between studies, with 16 studies contributing data to the meta-analyses. About three-quarters of studies reported their funding sources; no studies reported industry funding. We assessed the quality of evidence to be low or very low. Dietary behavior change interventions with a caregiver component versus interventions without a caregiver component Seven studies compared dietary behavior change interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (mean difference [MD] -0.42%, 95% confidence interval [CI] -1.25 to 0.41, 1 study, n = 207; low-quality evidence) or from sodium intake (MD -0.12 g/d, 95% CI -0.36 to 0.12, 1 study, n = 207; low-quality evidence). No trial in this comparison reported data for children's combined fruit and vegetable intake, sugar-sweetened beverage (SSB) intake, or physical activity levels, nor for adverse effects of interventions. Physical activity interventions with a caregiver component versus interventions without a caregiver component Six studies compared physical activity interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's total physical activity (MD 0.20 min/h, 95% CI -1.19 to 1.59, 1 study, n = 54; low-quality evidence) or moderate to vigorous physical activity (MVPA) (standard mean difference [SMD] 0.04, 95% CI -0.41 to 0.49, 2 studies, n = 80; moderate-quality evidence). No trial in this comparison reported data for percentage of children's total energy intake from saturated fat, sodium intake, fruit and vegetable intake, or SSB intake, nor for adverse effects of interventions. Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component Ten studies compared dietary and physical activity interventions with and without a caregiver component. At the end of the intervention, we detected a small positive impact of a caregiver component on children's SSB intake (SMD -0.28, 95% CI -0.44 to -0.12, 3 studies, n = 651; moderate-quality evidence). We did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (MD 0.06%, 95% CI -0.67 to 0.80, 2 studies, n = 216; very low-quality evidence), sodium intake (MD 35.94 mg/d, 95% CI -322.60 to 394.47, 2 studies, n = 315; very low-quality evidence), fruit and vegetable intake (MD 0.38 servings/d, 95% CI -0.51 to 1.27, 1 study, n = 134; very low-quality evidence), total physical activity (MD 1.81 min/d, 95% CI -15.18 to 18.80, 2 studies, n = 573; low-quality evidence), or MVPA (MD -0.05 min/d, 95% CI -18.57 to 18.47, 1 study, n = 622; very low-quality evidence). One trial indicated that no adverse events were reported by study participants but did not provide data.

Authors' conclusions: Current evidence is insufficient to support the inclusion of caregiver involvement in interventions to improve children's dietary intake or physical activity behavior, or both. For most outcomes, the quality of the evidence is adversely impacted by the small number of studies with available data, limited effective sample sizes, risk of bias, and imprecision. To establish the value of caregiver involvement, additional studies measuring clinically important outcomes using valid and reliable measures, employing appropriate design and power, and following established reporting guidelines are needed, as is evidence on how such interventions might contribute to health equity.

PubMed Disclaimer

Conflict of interest statement

Emily H Morgan (EHM) received funding from Cornell University to attend the World Health Organization (WHO)/Cochrane/Cornell University Summer Institute for Systematic Reviews in Nutrition for Global Policy Making, hosted by the Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA, July 27 to August 7, 2015. Additionally, EHM was partially supported by a Fellowship from Cochrane South Africa, South African Medical Research Council, which is funded by the Effective Health Care Research Consortium. This Consortium is funded by UK aid from the UK Government for the benefit of developing countries (Grant 5242). This Fellowship financed EHM's travel to Stellenbosch University for two weeks in 2018 to facilitate collaboration. Additionally, EHM declares that she is part owner of a small business that sells hearing aids. EHM does not believe this poses any conflict but declares it as an interest in the medical/health field.

Anel Schoonees (AS) received a Developing Country Stipend in 2018 from Cochrane to attend the Cochrane Colloquium in Edinburgh, UK. This was not related to this review, but AS declares it in the interest of transparency.

Urshila Sriram—none known.

Marlyn Faure—none known.

Rebecca A Seguin—none known.

Disclaimer: the views expressed in this publication are those of the authors and do not necessarily reflect UK government policy.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgments about each risk of bias item for each included study.
4
4
Forest plot of comparison: 3 Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component, outcome: 3.21 Children's dietary intake—sugar‐sweetened beverage intake: all intervention time points.
5
5
Forest plot of comparison: 3 Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component, outcome: 3.42 Children's body mass index or weight‐for‐height parameter—body mass index: all intervention time points.
6
6
Forest plot of comparison: 3 Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component, outcome: 3.43 Children's body mass index or weight‐for‐height parameter—body mass index: follow‐up time point.
See this image and copyright information in PMC

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    1. NCT03075085. Developing and testing implementation strategies for evidence‐based obesity prevention in childcare. clinicaltrials.gov/ct2/show/NCT03075085 (first received February 20, 2017).
    1. Swindle T, Johnson SL, Whiteside‐Mansell L, Curran GM. A mixed methods protocol for developing and testing implementation strategies for evidence‐based obesity prevention in childcare: a cluster randomized hybrid type III trial. Implemention Science 2017;12(1):90. [DOI: 10.1186/s13012-017-0624-6; PMC5516351 ; PUBMED: 28720140] - DOI - PMC - PubMed

References to ongoing studies

Armstrong 2019a {published data only}
    1. Armstrong B, Trude ACB, Johnson C, Castelo RJ, Zemanick A, Haber‐Sage S, et al. CHAMP: a cluster randomized‐control trial to prevent obesity in child care centers. Contemporary Clinical Trials 2019;86:105849. [DOI: 10.1016/j.cct.2019.105849; PUBMED: 31525490] - DOI - PMC - PubMed
    1. NCT03111264. Building blocks for healthy preschoolers [Building blocks for healthy preschoolers: child care and family models]. clinicaltrials.gov/ct2/show/NCT03111264 (first received March 27, 2017).
Cunningham Sabo 2016 {published data only}
    1. Cunningham‐Sabo L, Lohse B, Smith S, Browning R, Strutz E, Nigg C, et al. Fuel for fun: a cluster‐randomized controlled study of cooking skills, eating behaviors, and physical activity of 4th graders and their families. BMC Public Health 2016;16:444. [DOI: 10.1186/s12889-016-3118-6; PMC4882848; PUBMED: 27230565] - DOI - PMC - PubMed
    1. NCT02491294. Fuel for fun: cooking with kids plus parents and play (FFF) [Cooking with kids 2.0: plus parents and play]. clinicaltrials.gov/ct2/show/NCT02491294 (first received July 1, 2015).
Kovalskys 2017a {published data only (unpublished sought but not used)}
    1. ISRCTN58093412. More jumping and better eating at home and school [MINI SALTEN: study assessing the efficacy of a virtual intervention targeted to parents and aimed at preventing obesity in 6 year old children of public schools of Buenos Aires]. isrctn.com/ISRCTN58093412 (first received March 14, 2016).
    1. Kovalskys I, Indart Rougier P, Luciana L, Rauch Herscovici C, Gregorio MJ. MINI SALTEN: a case study on learnings from Argentina on outcomes and challenges. Annals of Nutrition & Metabolism 2017;71(Suppl 2):96‐7. [DOI: 10.1159/000480486] - DOI
    1. Kovalskys I, Rausch Herscovici C, Indart Rougier P, Gregorio MJ, Zonis L, Orellana L. Study protocol of MINI SALTEN: a technology‐based multi‐component intervention in the school environment targeting healthy habits of first grade children and their parents. BMC Public Health 2017;17(1):401. [DOI: 10.1186/s12889-017-4327-3; PMC5420097 ; PUBMED: 28477624] - DOI - PMC - PubMed
NCT00065247 {published data only (unpublished sought but not used)}
    1. Economos C. Query re: BONES [personal communication]. Email to E Morgan, October 11, 2019.
    1. NCT00065247. The BONES project: building healthy bones in children [Beat osteoporosis: nourish and exercise skeletons (BONES)]. clinicaltrials.gov/ct2/show/NCT00065247 (first received July 18, 2003).
NCT02809196 {published data only (unpublished sought but not used)}
    1. Frodi Olsen S. NCT02809196, 2014‐01, texts for healthy teens: a health education program for adolescents [personal communication]. Email to E Morgan, November 4, 2019.
    1. NCT02809196. Texts for healthy teens: a health education program for adolescents (T4HT) [A digital messaging education program for dietary behavior modification towards healthier lifestyle among Danish adolescents]. clinicaltrials.gov/ct2/show/NCT02809196 (first received June 20, 2016).
NCT02942823 {published data only (unpublished sought but not used)}
    1. Mack I. NCT02942823, KOP_2, Kids Obesity Prevention Program Part 2 [personal communication]. Email to E Morgan, October 10, 2019.
    1. NCT02942823. Kids obesity prevention program part 2 (KOP‐2). clinicaltrials.gov/ct2/show/NCT02942823 (first received October 19, 2016).
Yin 2019a {published data only (unpublished sought but not used)}
    1. NCT03590834. Míranos! program, a preschool obesity prevention RCT [Obesity prevention in Head Start: Míranos! program]. clinicaltrials.gov/ct2/show/NCT03590834 (first received June 27, 2018).
    1. Yin Z. Query re: Miranos! [personal communication]. Email to E Morgan, November 3, 2019.
    1. Yin Z, Ullevig SL, Sosa E, Liang Y, Olmstead T, Howard JT, et al. Study protocol for a cluster randomized controlled trial to test "¡Míranos! Look at Us, We Are Healthy!"—an early childhood obesity prevention program. BMC Pediatrics 2019;19(1):190. [DOI: 10.1186/s12887-019-1541-4; PMC6556954 ; PUBMED: 31179916] - DOI - PMC - PubMed

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