early obesity prevention – the role of life style...
TRANSCRIPT
![Page 1: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/1.jpg)
Early Obesity Prevention – the Role of Life Style. Experience from Toybox and
Other Intervention Trials Zbigniew Kułaga
Public Health Department The Children’s Memorial Health Institute
Warszawa
The Power of Programming – Developmental Origins of Adiposity and Long-Term Health Munich 13-15 Oct. 2016
Note: for non-commercial purposes only
![Page 2: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/2.jpg)
Dr John Snow; London 1854, Broad Street cholera outbreak
water pump intervention
![Page 3: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/3.jpg)
Aims • The aim of ToyBox-study was to prevent obesity in
early childhood (3.5-5.5 years old)
• Create a supportive social and physical environment at kindergartens and home to facilitate desired behaviour
• At a potentially effective, low-cost, scalable-approach
Mulitfactorial evidence based approach using behavioural models in understanding and promoting fun, healthy food, play and policy for the prevention of obesity in early childhood: ToyBox
http://www.toybox-study.eu/
![Page 4: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/4.jpg)
ToyBox-study Academic Research Institutes
Harokopio University, HUA (GR)
Ludwig-Maximilians University of Munich, LMU (DE)
State Institute of Early Childhood Research, IFP (DE)
Ghent University, Ugent (BE)
VU University Medical Centre, Vumc (NL)
University of Zaragoza, UniZar (ES)
Akershus University College, HIAK (NO)
Durham University, UDUR (UK)
Roehampton University, RoU (UK)
Children’s Memorial Health Institute, CMHI (PL)
Medical University of Varna, MUV (BG)
University of Luxembourg (ULU) (LUX)
International / Health Promotion Organisations
International Association for the Study of Obesity, IASO (UK) CBO B.V., (CBO) (NL)
SME
AOK- Verlag GmbH (DE) GREECE
SPAIN BULGARIA
UK
NORWAY
POLAND GERMANY HOLLAND
BELGIUM LUXEMBURG
April 2010 2011 2012 2013 2014
![Page 5: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/5.jpg)
ToyBox-study
2010 2011 2012-2013 2014
M
ay-Ju
ne 2
012
Base
line
Mea
sure
men
ts
Academic year 2012-2013
Implementation
of ToyBox-intervention
M
ay-Ju
ne 2
013
Follo
w-u
p M
easu
rem
ents
Development of the ToyBox-intervention
![Page 6: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/6.jpg)
Sample – Baseline: May/June 2012
GERMANY
GREECE
BULGARIA
POLAND
SPAIN
BELGIUM
Country Kindergartens Children/ Parents
Belgium 26 1327
Bulgaria 34 964
Germany 58 1217
Greece 110 1229
Poland 49 1430
Spain 32 889
Total 309 7056
![Page 7: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/7.jpg)
Measurements
• Anthropometric – Weight – Height – Waist
• Parental questionnaire incl. FFQ
• Pedometers • Accelerometers (only
Belgian sub-sample)
• Baseline (May-June 2012)
• Follow-up (May- June 2013)
![Page 8: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/8.jpg)
8.0% 9.5% 10.4% 11.0% 11.9%
14.0%
1.9%
2.1% 2.4%
4.2% 4.1%
5.7%
0%
5%
10%
15%
20%
25%
Germany Belgium Poland Bulgaria Spain Greece
Obese
Overweight
Prevalence of overweight*/obesity* by country
p < 0.001
*Cole TJ, Lobstein T. Pediatr Obes. 2012;7:284-94
![Page 9: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/9.jpg)
Toybox study intervention Targeted behaviours • Water consumption • Snacking • Physical activity • Sedentary behaviour
Aiming to:
• Changes kindergarten environment • Implement the behaviours • Conduct interactive activities • Target/Involve parents via
newsletters/tip-cards/posters
![Page 10: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/10.jpg)
Training of teachers
![Page 11: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/11.jpg)
1st Behaviour: Water consumption
Change of kindergarten environment – water station
Implementation of behaviour
![Page 12: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/12.jpg)
2nd Behaviour: Snacking
Change of kindergarten environment: fruits and vegetable
snacks Implementation of behaviour
![Page 13: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/13.jpg)
3rd Behaviour: Physical activity
Change of kindergarten environment – ensure enough space
for PA Implementation of behaviour
![Page 14: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/14.jpg)
4th Behaviour: Sedentary behaviour
Change of kindergarten environment – enable more
acitivities standing instead of sitting
Implementation of behaviour
![Page 15: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/15.jpg)
Complete data May/June 2012 & May/June 2013
GERMANY
GREECE
BULGARIA
POLAND
SPAIN
BELGIUM
Country Kindergartens Children/ Parents
Belgium 26 1032
Bulgaria 19 792
Germany 55 954
Greece 92 854
Poland 49 1065
Spain 30 853
Total 271 5550
![Page 16: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/16.jpg)
WATER CONSUMPTION AND EATING HABITS
PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR
Results: targeted lifestyles
![Page 17: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/17.jpg)
Table 2. Intervention effects for total water and all beverages in the total sample (adjusted for age, sex, SES and country).
Pinket AS, Van Lippevelde W, De Bourdeaudhuij I, Deforche B, Cardon G, et al. (2016) Effect and Process Evaluation of a Cluster Randomized Control Trial on Water Intake and Beverage Consumption in Preschoolers from Six European Countries: The ToyBox-Study. PLoS ONE 11(4): e0152928. doi:10.1371/journal.pone.0152928 http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0152928
![Page 18: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/18.jpg)
Children’s sweets consumption (portions/day) p<0.001
p=0.055 2,16
1,94
2,12
2,05
1,8
1,85
1,9
1,95
2
2,05
2,1
2,15
2,2
baseline follow-up
port
ion
/ day
intervention control
![Page 19: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/19.jpg)
% Children >10.000steps/day (pedometers)
62,3% 62,4%
44,0%
38,4%
49,8% 50,5%
42,1%
35,0%
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
70,0%
Baseline Follow up Baseline Follow up
Weekdays Weekend
Intervention
Control
p<0.002
p<0.004
![Page 20: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/20.jpg)
Sedentary behaviour accelerometer data
0
5
10
15
20
25
30
35
40
45
50
SB weekdays (% / day) SB weekends (% / day)
% o
f day
intervention control
De Craemer M et al; ToyBox-study group. The effect of a cluster randomised control trial on objectively measured sedentary time and parental reports of time spent in sedentary activities in Belgian preschoolers: the ToyBox-study.Int J Behav Nutr Phys Act. 2016 5;13:1.
![Page 21: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/21.jpg)
Toybox children BMI kg/m2 (BMI z-score*)
2012 2013 boys intervention 15.9 (0.16) 16.0 (0.25) boys control 15.9 (0.16) 15.9 (0.25) girls intervention 15.9 (0.30) 16.0 (0.36) girls control 15.8 (0.25) 15.8 (0.28)
*Cole TJ, Lobstein T. Pediatr Obes. 2012;7:284-94
p=0.04
![Page 22: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/22.jpg)
Overweight incl. obesity among Toybox study children
14,4 15,5 13,4 14,3
0
2
4
6
8
10
12
14
16
baseline follow-up
Ove
rwei
ght p
reva
lenc
e (%
)
Intervention Control
![Page 23: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/23.jpg)
Overweight incl. obesity among Toybox study children
12,7 13,7 11,9
13,8
0
2
4
6
8
10
12
14
16
18
baseline follow-up
Prev
alen
ce (%
)
boys
intervention control
16,2 17,3 15,2 15,0
baseline follow-up
girls
intervention control
![Page 24: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/24.jpg)
Toybox overweight incl. obesity after the intervention (follow-up) according to the body mass category before intervention (baseline)
Body mass category pre intervention (baseline 2012)
Intervention (% of overweight 2013)
Control (% of overweight 2013)
non-overweight boys+girls 4.9 4.6
non-overweight boys 5.0 5.0
non-overweight girls 4.8 4.2
overweight boys+girls 77.6 76.9
overweight boys 73.5 → 78.7
overweight girls 81.2 ← 75.3
![Page 25: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/25.jpg)
Wen LM et al. Effectiveness of home based early intervention on children’s BMI at age 2: randomised
controlled trial. BMJ. 2012;26;344:e3732
Intervention • Randomized 1:1 (I:C); 667 mothers • Home visits in the antenatal
period, and at 1, 3, 5, 9, 12, 18 and 24 months after birth; trained community nurses
• Key intervention messages: – Breast is best – No solids for me until 6 months – I eat a variety of fruit and vegetables
every day – Only water in my cup – I am part of an active family
Results Intervention vs Control • Improved:
– vegetable servings (mother and child),
– TV viewing during meal – TV>60 min/day; – mother total activity time>150
min/week • No difference:
– fruit servings, water, salty snacks, soft drinks intake
• BMI at the age 2 years: 16.49 vs 16.87 (p=0.01)
![Page 26: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/26.jpg)
The ‘‘TigerKids’’ behavioral intervention program. Bayer O et al. Short- and mid-term effects of a setting based prevention program to reduce obesity
risk factors in children: A cluster-randomized trial. Clinical Nutrition 2009;28:122–128.
Intervention • Kindergarten setting, children aged 6 y; • Key targets to be reached by children:
– at least 30 min/day vigorous physical activity games at the Kindergarten,
– regular consumption of fresh fruit and vegetables as a snack, aiming at replacing high energy density snack,
– regular consumption of water and other non-sugared drinks aiming at replacing sugared beverages and reaching a habitual consumption of not more than one glass/day of sugared drinks and juices
• Simple messages on health related behavior for parents
• Randomization (kindergartens) 2:1 (I:C) • Assesment after 6 and 18 months
Intervention effects OR, controls as reference
Outcome OR (CI)
Overweight 0.73 (0.51–1.04)
Obesity 0.58 (0.31–1.10)
High fruit consumption 1.64 (1.26–2.12)
High vegetable consumption
1.26 (0.98–1.61)
Low consumption of high caloric drinks
1.66 (1.16–2.38)
![Page 27: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/27.jpg)
Lifestyle Education
• four clinics (232 infants) were randomized to control or intervention
• intervention delivered by health care provider at each of 7–9 wellbaby visits over 2 years
• advice on infant feeding practices, physical activity, and developmental milestones related to eating patterns
• no difference in body size (BMI) but significant change of feeding practices
27
Schroeder N et al. J Obes. 2015;2015:795859
Intervention Control Soda Sweetened tea
Cow’s milk Punch
![Page 28: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/28.jpg)
Other interventions studies LIMIT study
• Dietary, exercise and behavioural strategies adressed to pregnant woman to limit GWG
• Limited impact of lifestyle intervention on primary outcome: infant large for gestational age
Dodd J, Plenary Session II, 13.10.2016 Munich
Systematic review: Redsell SA, Maternal Child Nutr 2016; 12: 24–38.
• randomised controlled trials of interventions that aim to reduce the risk of overweight and obesity in infancy and early childhood
• 12 trials with lifestyle intervetion and weight outcome: – no difference in weight outcome: 7 studies – intervention heavier: 2 studies – BMI lower in comparison to controls: 3
studies
![Page 29: Early Obesity Prevention – the Role of Life Style ...munich2016.project-earlynutrition.eu/pdf/B6_1_Kulaga.pdf · Life Style. Experience from Toybox and Other Intervention Trials](https://reader030.vdocuments.mx/reader030/viewer/2022011721/5f44758df2a19c28da0e32e6/html5/thumbnails/29.jpg)
Acknowledgements The ToyBox-study was funded by the Seventh Framework Programme (CORDIS FP7) of the European Commission The ToyBox-study group consists of: Co-ordinator: Yannis Manios; Steering Committee: Yannis Manios, Berthold Koletzko, Ilse De Bourdeaudhuij, Mai Chin A Paw, Luis Moreno, Carolyn Summerbell, Tim Lobstein, Lieven Annemans, Goof Buijs; External Advisors: John Reilly, Boyd Swinburn, Dianne Ward; Harokopio University (Greece): Yannis Manios, Odysseas Androutsos, Eva Grammatikaki, Christina Katsarou, Eftychia Apostolidou, Eirini Efstathopoulou, Paraskevi-Eirini Siatitska, Angeliki Giannopoulou, Effie Argyri, Konstantina Maragkopoulou, Athanasios Douligeris; Ludwig Maximilians Universitaet Muenchen (Germany): Berthold Koletzko, Kristin Duvinage, Sabine Ibrügger, Angelika Strauß, Birgit Herbert, Julia Birnbaum, Annette Payr, Christine Geyer; Ghent University (Belgium): Department of Movement and Sports Sciences: Ilse De Bourdeaudhuij, Greet Cardon, Marieke De Craemer, Ellen De Decker and Department of Public Health: Lieven Annemans, Stefaan De Henauw, Lea Maes, Carine Vereecken, Jo Van Assche, Lore Pil; VU University Medical Center EMGO Institute for Health and Care Research (the Netherlands): EMGO Institute for Health and Care Research: Mai Chin A Paw, Saskia te Velde; University of Zaragoza (Spain): Luis Moreno, Theodora Mouratidou, Juan Fernandez, Maribel Mesana, Pilar De Miguel-Etayo, Esther González, Luis Gracia-Marco, Beatriz Oves; Oslo and Akershus University College of Applied Sciences (Norway): Agneta Yngve, Susanna Kugelberg, Christel Lynch, Annhild Mosdøl; University of Durham (UK): Carolyn Summerbell, Helen Moore, Wayne Douthwaite, Catherine Nixon; State Institute of Early Childhood Research (Germany): Susanne Kreichauf, Andreas Wildgruber; Children’s Memorial Health Institute (Poland): Piotr Socha, Kamila Zych, Magdalena Góźdź, Beata Gurzkowska, Katarzyna Szott; Medical University of Varna (Bulgaria): Violeta Iotova, Mina Lateva, Natalya Usheva, Sonya Galcheva, Vanya Marinova, Zhaneta Radkova, Nevyana Feschieva; International Association for the Study of Obesity (UK): Tim Lobstein, Andrea Aikenhead; National Institute for Health Promotion and Disease Prevention (the Netherlands): Goof Buijs, Annemiek Dorgelo, Aviva Nethe, Jan Jansen; AOK- Verlag (Germany): Otto Gmeiner, Jutta Retterath, Julia Wildeis, Axel Günthersberger; Roehampton University (UK): Leigh Gibson; University of Luxembourg (Luxembourg): Claus Voegele.