Evidence-based recommendations

for the development of obesity

prevention programs targeted at
preschool children
Summary
TheToyBoxinterventionwasdevelopedusinganevidencebasedapproach,usingthe
findingsoffourreviews.Thesereviewsincludedthreecriticalandnarrativereviewsof
educational strategies and psychological approaches explaining young childrens
acquisitionandformationofenergybalancerelatedbehaviours,andthemanagementof
these behaviours, and also a systematic review of behavioural models underpinning
schoolbasedinterventionsinpreschoolandschoolsettingsforthepreventionofobesity
inchildrenaged46years.
This paper summarises and translates the findings from these reviews into practical
evidencebasedrecommendationsforresearchersandpolicymakerstoconsiderwhen
developingandimplementinginterventionsforthepreventionofoverweightandobesity
inyoung(aged46years)children.
The recommendations focus on two behaviours, physical activity and sedentary
behaviour, and healthy eating, and include general recommendations, intervention
approaches, interventions content, and simple messages. The review also briefly
examinestherolethatthecommercialsectorplaysinhinderingorfacilitatingattemptsto
createhealthyfoodenvironmentsforchildren.Thispaperalsorecognisesthatchildhood
obesityisnotanissuefortheeducationsectoralone;itneedstobetackledatamulti
sectoral level, recognizing the particularly important role of local governments,
nongovernmentorganizationsandthemedia.
Keywords:Children,evidencebasedrecommendations,obesityprevention,preschool.
As previously discussed in other papers in this Supplement of Obesity Reviews, the
ToyBox intervention was developed using an evidencebased approach, and refined
throughpilottesting.Aspartofthatevidencebase,twopiecesofworkwerecarriedout.
First,aseriesofnarrativereviewsofeducationalstrategiesandpsychologicalapproaches
explaining young childrens acquisition and formation of energybalance related
behaviours,andfacilitatingtheirmanagement(Gibson etal.(1);Gibson etal.(2),all
published in this supplement). Second, a systematic review to identify behavioural

modelsunderpinningschoolbasedinterventionsinpreschoolandschoolsettingsforthe
preventionofobesityinchildren aged46years (Nixon et al.(3); publishedin this
supplement).
Theaimofthisshortpaperistosummarizeandtranslatethefindingsfromthesetwo
reviews into practical evidencebased recommendations for researchers and policy
makerstoconsiderwhendevelopingandimplementinginterventionsfortheprevention
of overweight and obesity in young (aged 46) children. We have divided these
recommendations into sections for ease of reading: (i) general considerations; (ii)
interventionapproaches;(iii)interventioncontent;and(iv)simplemessages.Theauthors
ofthispaperhopethattherecommendationslistedbelowwillhelppolicymakers,bothin
Europeandothercountries,whoaredevelopingandimplementinginterventions,which
aimtopreventoverweightandobesityinyoungchildren.
1. General considerations when developing interventions for the prevention of
obesityinpreschool(aged46)children.
a)Asmostsuccessfulinterventionshaveparentalcomponents,parentalengagementthat
includesrolemodellingshouldbeakeypartofanyinterventioninthisagegroup,and
mere provision of knowledge and information although distribution of letters and
newsletterstoparentsisnotsufficient.Thereisparticularlygoodevidencetosuggestthat
increasingthephysicalactivitylevelsoffathers/malecarers(asrolemodels)increasesthe
physical activity levels of young children. Where parents attempts to increase their
physical activity levels are limited because of a lack of local opportunities, local
authoritiesshouldprovideappropriatesupport,forexample,throughfreeorincentivized
play and activity areas and schemes. If the intervention takes place only in the
school/kindergartensetting,andattemptstoengageparentsfail,thenteacherscouldbe
consideredasrolemodels.
b) A limited number of clear and simple messages (strategies), which aim to effect
positivebehaviourchangeinyoungchildren,underpinnedbytheoreticalknowledge,are
requiredforparentsandteachers.
c) When considering the resource materials for interventions, the literacy levels of
parents should be taken into account, alongside the acceptability of the intervention
materialforparents,teachersandchildren.Unlessthematerialsareeasilyaccessibleto
all members of that community, only those who are more literate will feel able to
participateintheintervention.Usabilityoftestingofneworexistingmaterialsinthe
targetpopulationbeforeimplementingtheinterventionisaprudentmove(4).Ifthisis
notcarriedout,theinterventionmay,inadvertently,increasehealthinequalitiesinthe
targetpopulation.
d)Parentsandcaregiversshouldbethemajortargetoftheintervention,butoutcomesfor
evaluation (change in body mass index, change in physical activity and dietary
behaviours)shouldbefocusedonchildren(5).

2. Intervention approaches to consider when developing interventions for the

preventionofobesityinyoung(aged46)children.
a)Physicalactivityanddietarybehavioursshouldbetargetedtogetherinacombined
intervention,althoughthisshouldbemadeassimpleaspossible.
b)Rewardsforchildren(whichcanincludepraise,butnotfood)foruptakeofdesired
energybalancebehaviourshouldbeincludedintheintervention.
c) The key elements of successful approaches are modelling (through older peers,
teachersandparents)andtechniquestofacilitateskilldevelopment.Theseapproaches
increasethesuccessofaninterventionbecausetheyincreaselevelsofselfefficacyin
parents,teachersandchildren.
d)Theinterventionshouldhaveacommonframework,andwithinthisthereshouldbe
enoughflexibilityfortailoringittothetargetpopulation.Inschoolbasedinterventions,
theteachersmustbeallowedtoadaptthemodulestotheirdifferentclasses,andthey
shouldbeencouragedtoincludecountryandculturalspecificactivities(basedonthe
sametheoreticalunderpinning).
Physicalactivityandsedentarybehaviour
a)Thephysicalactivityelementoftheinterventionshouldtakeintoaccountthefactthat
there may be children in the target population who would have problems, or feel
uncomfortable,followingcertainphysicalactivityregimes.
b)Inschoolbasedinterventions,thephysicalactivityelementoftheinterventionshould
beincorporatedintothedailycurriculum,whereverpossible,withoutaffectingthepreor
postschoolprogram.
c)Promotionofatleast120180min/dofphysicalactivityforchildrenatbothweekdays
andweekendsshouldbeincludedintheintervention.ParticipationinPhysicalEducation
classesandactiveplaytimeatschoolcount,asdoallphysicalactivitiesofallintensities,
towards this goal.Itis importanttosuggestwaysinwhichchildrencanachievethe
recommendedlevelsofphysicalactivityatweekends,forexample,byparticipatingin
organizedphysicalactivitieswithlocalclubsandsocieties,orvisitstoplaygroundareas.
d)Limitationofleisurescreentimeto 1h/d(ortheamountoftimerecommendedby
appropriatenationalguidelines,iflessthan1h/d)shouldbeincludedintheintervention.
e)Theactivitiesthataimtoincreaselevelsofphysicalactivityshouldbeplayful,andbe
abletobeperformedinmanyenvironmentsandhaveachanceofbeingfeasibleforall
children; forced participation in competitive sports or activities which some children
cannot(orfeeltheycannot)succeedincancausemoreharmthangood.
Healthyeating

a)Thehealthyeatingelementoftheinterventionshouldraiseawarenessinparents,carersand
teachers about how children can vary in their reluctance to try new foods, and the
importanceoffamiliarizationwithnewhealthyfoodsatayoungage.
b) Healthy food and drink items, including fruits and vegetables, should be made
available and accessible for children, both at school and home. Conversely, children
should have limited exposure and availability to unhealthy foods and drinks such as
sweetenedsoftdrinksandenergydensesnacks.
c)Teachersshoulddiscusswithchildrenwhatbarriersexistfortheminchoosinghealthy
foodsandhavingawellbalanceddiet,andhowthesemightbeovercome(e.g.vegetables
withafavouritesauce,fruitwithpudding).Tastingsessionsthatinvolvenewhealthy
foodsanddrinksareparticularlyuseful.Anotherusefulstrategyistoallowchildrento
getinvolvedinthemenuchoices,preparationandserviceoftheirfood,bothathomeand
atschool.
3.Simplemessagestoconsiderwhendevelopinginterventionsforthepreventionof
obesityinyoung(aged46)children.
Physicalactivityandsedentarybehaviour
a)Encouragetheuseofactivetransport(walkingandcycling)forshortdistances.
b)Encouragevisitingplaceswherechildrencanbeactive.
c)Discouragetheprovisionofascreeninthebedroom(television[TV],computeror
PlayStation).
d)Encouragetheprovisionofnoncompetitiveparticipationinphysicalactivity.
e)Encourageparentstoprovidetheirchildrenwithappropriateclothingforindoorand
outdooractivities.
f)Encouragethedevelopmentofalarge,activeplayenhancingallweatherplayareasin
kindergartensandschools.
g)Providegameequipmentduringlessonbreaks,andencouragechildrentobeactive.
h)Decreasetotalsedentarytimeintheclassroomandathomebychangingactivities
frompassivetoactive.
Healthyeating
a)Encourageeatingtogetherwithothers,andasafamilyunitwhenathome.
b) Encourage the provision of a broad variety of healthy foods especially fruits and
vegetables, and discourage the provision of unhealthy foods such as sweetened soft

drinksandenergydensesnacks.
c)DiscouragethebehaviourofeatingwhilewatchingTVorusinggameconsoles,etc.
Thereisalsostrongevidencethatthecurrentactivitiesofpartsofthecommercialsector
areactivelyunderminingattemptstocreatehealthyfoodenvironmentsforchildren(6,7),
anditisthereforerecognizedthatthesettingbasedapproachtopreventingchildhood
obesity described in this paper needs to be complemented by policies to reduce the
negativeinfluencesofthecommercialsectoronchildrensdiets.Webelievethatthe
commercialsectorhasapotentiallyimportantroleinhelpingyoungchildrenandfamilies
consumeahealthydietthattheyenjoy,atapricetheycanafford(8).
Policymakers and service providers should feel confident that there are effective
strategies,aslistedabove,forpreventingobesityinyoungchildren.However,itisalso
importanttoconsiderhowthesestrategies(whichfocusonimprovingdietandphysical
activity behaviours) are incorporated with other critical aspects of an intervention
program,ifthatprogramistobeeffective.WorldHealthOrganisationhasstatedthatthe
greatestchallengeintacklingchildhoodobesityistheneedtosensitizeandmobilizeall
sectorsofsociety,andtoinvolvealllevelsofgovernmentinjointeffortswithministries
ofhealth(9).Childhoodobesityisnotanissuefortheeducationsectoralone;itneedsto
betackledatamultisectorallevel,recognizingtheparticularlyimportantroleoflocal
governments, nongovernment organizations and the media. Indeed, any effective
interventionprogramwillneedtoincludecomponentsforwhichthereislittlespecific
efficacy evidence, for example, leadership support, coordination, workforce
development,communications,networkdevelopment,monitoringfeedback,appropriate
culturaladaptation,andpolicydevelopmentandimplementation.
AssuggestedinarecentCochranereviewofinterventionstopreventchildhoodobesity
(10),furtherresearchinthisareashouldfocusontranslationalresearch,andassesshow
best to implement interventions which can be embedded into ongoing practice and
operatingsystems,beeffectivelyscaledup,besustainedovertimeandensureequitable
outcomes.

Conflict of Interest Statement

Noneoftheauthorshaveanyconflictsofintereststodeclare.

Acknowledgements
TheToyBoxstudyisfundedbytheSeventhFrameworkProgramme(CORDISFP7)of
theEuropeanCommissionunderGrantagreementNo.245200.Thecontentofthisarticle
reflectsonlytheauthorsviews,andtheEuropeanCommunityisnotliableforanyuse
thatmaybemadeoftheinformationcontainedtherein.