Education to Improve Overweight and Obesity in Children

Introduction
Overweight and obesity are significant health concerns in Australia, with these conditions increasing a person’s risk of developing other serious health concerns, such as type two diabetes, cancer, cardiovascular disease and musculoskeletal conditions (Australian Institute of Health and Welfare 2018). Being overweight or obese as a child increases an individual’s risk of being overweight or obese as an adult, and therefore the risk of developing such conditions is increased (Pérez-Escamilla et al. 2012). Approximately one in four Australian children are overweight or obese (Australian Institute of Health and Welfare 2018); there is a strong need to address weight concerns in children in order to reduce body fat, improve overall health, reduce the risk of disease and increase the chance of better health throughout life. Many interventions focus on caloric restriction and exercise to promote weight loss in children; however, it appears that education on such topics would be likely to produce a greater long-term effect (Dhuper, Buddhe & Patel 2013). Teaching a child how to manage exercise and diet and make healthier lifestyle choices is more likely to equip them with the required knowledge and skills to maintain a healthy weight throughout life, as opposed to just enrolling them in a temporary diet and exercise program without education.

As such, the PICO question that was formed around the topic included, “for overweight children, does providing daily diet and exercise education compared to no education provide a greater reduction in body mass?” This is an important question to establish the effectiveness of education in weight loss in children in order to address population health concerns (Williamson 2017). This paper will summarise the current use of evidence-based practice in Australian health care in relation to this issue and will synthesise the available literature on the topic, including comparing and contrasting findings. Finally, a rationale for decision-making in relation to the use of education to manage overweight and obesity in children will be provided along with recommendations for practice.

Summary of the Current Use of Evidence-Based Practice in Australian Health Care

The current practice in Australia for obesity management generally includes a doctor prescribing a child physical activity and nutrition recommendations (Schultz 2012). Paediatricians are commonly the main professionals that families will seek out with regard to a child’s weight, and thus the majority of health recommendations come from this professional in regard to weight maintenance (Wake et al. 2012). A referral to a dietician is also common practice in Australia, as this helps the family understand the caloric needs of the child and provides diet support and recommendations (Turner, Harris & Mazza 2015). Additionally, it is common practice to promote a whole family approach, meaning health care professionals encourage the entire family to make lifestyle changes so that weight improves as a group. This is because overweight or obese children frequently have parents and siblings who are also overweight or obese; families often share a similar lifestyle pattern of eating and level of physical activity (Laws et al. 2015). As such, a whole family approach can help to make positive lifestyle changes for all involved, and thus produces a greater reduction in weight (Ho et al. 2012). These findings indicate that a whole family approach is likely to produce greater results for weight loss compared to only involving the child in interventions.

Other studies have looked into the effects of adding in or modifying particular foods or elements of a person’s diet as part of weight management. This evidence-based research is used less frequently in Australia, but may be part of dietician practices when recommending meal plans for weight loss. Alisi et al. (2014) investigated the effects of gut microbiota modifiers in managing fat distribution and liver disease in children. The results indicated that gut microbiota modifier supplements are beneficial in reducing fatty liver disease in children (Alisi et al. 2014). Additionally, Te Morenga, Mallard and Mann (2012) reviewed the effects of dietary sugar intake on the body weight of children and adults. The findings from this systematic review and meta-analysis indicated that dietary sugar intake, particularly sugary beverages, impacted weight, and thus a reduction in these can lead to a reduction in body weight (Te Morenga, Mallard & Mann 2012). Other studies quizzed Australian students to work out what foods were low in the diets of overweight and obese children, which indicated mainly fruits and vegetables; the goal was to identify the association between food groups and overweight and obesity in these children (Valery et al. 2012). These studies indicate that certain modifications to diet may help to reduce the other health concerns that people are often at risk of when they are overweight or obese but have not really addressed key weight management principles and techniques to inform the current investigation.

In addition to family lifestyle modifications, current use of evidence-based practice is often seen in Australian schools; it is becoming more popular for schools to implement diet and exercise programs for children to manage weight (Parente et al. 2015). Sobol-Golderg, Rabinowitz and Gross (2013) found that school-based interventions are mildly effective in reducing overweight and obesity in children when delivered in schools; however, it was determined that it is more effective when interventions are long-term and have parental support included. Many of the studies have strengths, in that they are systematic reviews or randomised controlled trials—meaning they are of high-quality evidence (Sanders 2018). Some studies only had small sample sizes or were short-term studies—meaning that the results and findings may not be comparable to the general population (Mamaril 2017; Sanders 2018). All of these findings clearly indicate that there are benefits to diet and exercise programs, yet parental inclusion is crucial to ensuring long-term benefits (Millstein 2014). The current inquiry looks at the effectiveness of education, rather than actual diet and exercise interventions.

Synthesis of Available Literature

There have been numerous studies that have evaluated the effectiveness of education regarding diet and exercise either in combination or as a stand-alone; many of these studies have been directed at adults—meaning the results may be considered for children—and many have been delivered with a combination of children and parents (Leech, McNaughton & Timperio 2014). A summary of the following evidence can be found in Appendix 1. Berry et al. (2017) conducted a randomised controlled trial for child and parent weight management; this study aimed to determine the effectiveness of a nutrition and exercise program in reducing adiposity in children and their parents. Over eighteen months, children and parents attended education sessions: the results indicated that education about nutrition and exercise significantly reduced adiposity in both the children and their parents (Berry et al. 2017). The outcome of this study indicates that education is effective in helping to teach children and parents how to make healthier choices, which in turn has a positive impact on weight; however, it is unclear from these findings if children are able to implement education on their own, or if parental inclusion and guidance is essential.

Another study investigated the impact of educating mothers on their children’s body weight, because it was determined that the knowledge a mother has regarding home food availability and nutrition impacts the child’s food intake and the weight of the child. Campbell et al. (2013) conducted a study where Australian mothers were provided with nutrition on their child’s diet as well as nutrition knowledge. The results indicated that the nutrition education had a positive influence over the mother’s food choices and, in turn, the child’s food intake (Campbell et al. 2013). This study had a very large sample size of over four thousand participants; however, the study was limited in that it only reviewed mothers’ nutritional knowledge and did not consider the impact of other parents and guardians and how they could be included in an education program to influence child food intake. This study clearly demonstrates the strong influence that parental knowledge can have over a child’s food intake and therefore the child’s weight. The study makes it clear that there is a need to include parents in interventions and education relating to childhood overweight and obesity.

Telford et al. (2012) performed a study to assess the effectiveness of physical education on the prevention of obesity in children. Additionally, the researchers assessed the effectiveness of providing education to children on academic development in the areas of health and nutrition. The results from this study indicated that commonly practiced education about physical health was associated with a reduction in body fat (Telford et al. 2012). A strength of this study was that it was a longitudinal study conducted over a two-year period; this really allowed the researchers to support their conclusions with strong evidence over a longer period of time. The findings clearly indicate that ongoing education produces effective results. A limitation of this study is that the description of the education is not provided in much detail, so it may be difficult to replicate the study or utilise the findings in clinical practice (McCusker & Gunaydin 2014).

Cawley, Frisvold and Meyerhoefer (2013) conducted a systematic review to assess the effectiveness of physical education on reducing obesity in school aged children. The study found that there was a positive association between physical education and weight loss. The study also demonstrated that male students were more likely to obtain greater benefits and reductions in obesity compared to female students (Cawley, Frisvold & Meyerhoefer 2013). A strength of this study was that the researchers reviewed a variety of data from different age groups, thus enhancing the pool of research relating to education for children and overweight and obesity. A limitation of this study was that the systematic review included results from both physical exercise programs and physical education; it is impossible to distinguish the effects of either exercise or education and it can only be determined that the combination of these produces the effect discussed.

Fairclough et al. (2013) also investigated the effects of education programs in schools on promoting a healthy weight in children; however, the focus was on nutrition education compared to physical education as seen in order studies. The findings of the study found that a twenty-week nutrition education intervention program produced significantly positive body outcomes including waist circumference reductions and increases in the level of physical activity that children engaged in (Fairclough et al. 2013). A strength of this study is that a variety of different outcome measures were included so the impact of the program could be assessed at various levels and aspects of a person’s health. A limitation of this study was that only students aged between ten and eleven were included; this means there is a gap, in that it is unclear if the program is effective for school children of other ages. However, this is an area for future research.

Wake et al. (2013) conducted a study to determine the effectiveness of general practice consultations and advice from health professionals in reducing body fat in children. The results from this study clearly demonstrated that consultations did not impact body weight or reduce overweight and obesity (Wake et al. 2013). The findings of this study are important as they demonstrate that casual visits to a health professional accompanied by casual education and advice is not sufficient to promote and produce lifestyle changes that lead to reductions in body mass. This demonstrates a need for more ongoing education and advice to ensure consistency. A limitation of this study was the small sample size, meaning results may not be able to be generalised to the greater population. Additionally, there was no blinding in this study, so bias may have been apparent (Hróbjartsson et al. 2014).

Comparison of Findings

The findings from all of the studies were relatively similar in that they all agreed that education about diet and exercise or nutrition education in general supported weight loss and healthy weight management in children. Some studies agreed that parental involvement was crucial in this, given that it is often the parents who are in charge of the child’s food preparation and food intake (Campbell et al. 2013). Cawley, Frisvold and Meyerhoefer (2013) had a strength in that various age groups were investigated, demonstrating that education can be effective in reducing body fat across a variety of age groups and should not just be restricted to older children. Some studies were limited in that they did not completely explain the education programs provided. There is a need for comprehensive education programs to be created and evaluated based off study results in order to ensure comprehensive education is provided to children and parents and guardians, and thus interventions will be effective.

Rationale for Decision Making

Based on the review of the evidence, it is clear that implementing an education program that focuses on teaching diet and exercise education to children would be effective in reducing overweight and obesity. It is clear from the evidence that such programs allow children to be more knowledgeable about health and able to make better choices in relation to diet and exercise, which has a positive impact on weight. The evidence also indicates that such a program would be beneficial with parental input, as the parents are often in control of the child’s diet and schedule, and thus parental inclusion would promote greater weight loss in children (Berry et al. 2017). A diet and exercise education program should be implemented both in a clinical and regulatory manner.

The evidence has thoroughly reviewed the effectiveness of diet and exercise interventions as well as educational-only interventions. However, there is a gap in the research with regard to the long-term effects of such interventions in children. It is well-documented that programs for children are more effective with parental involvement, but there is a need to establish what ongoing effects, if any, there are once the child is older and no longer has parental influence (Sanders 2018). Future research could focus on conducting a longitudinal study into children and the long-term effects of diet and exercise education. Longitudinal studies could provide interventions in childhood with parental involvement and then assess the ongoing effects every year as the child becomes older. This would determine if education early on is sufficient to teach someone healthy lifestyle management long-term, or if there is a greater need for ongoing education to ensure that weight can be effectively managed into adulthood.   

Conclusion 

An educational program focused on delivering diet and exercise education to children is likely to be effective in reducing overweight and obesity in this population group. Such a program would be useful with parental inclusion and would likely promote better weight management, thus reducing the risk of developing overweight and obesity related health complications throughout life. This program should be implemented at both a clinical and regulatory level; it should be mandatory for such education programs to be included in schools in order to promote better health education and health management in this population. Future research should investigate the long-term impact of such educational programs to determine if early education is sufficient for weight management or if there is a need for such education to be ongoing and long-term.

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Appendix 1:

Table 1. Included Studies in Summary