Given the increasing prevalence of pediatric obesity, we evaluated two kindergarten-based strategies for reducing overweight in preschool children in the Haute-Garonne Department in France.
Kindergartens (n=79) were randomly assigned to one of the two strategies and followed for 2 years. In the first group (Epidémiologie et prévention de l’obésité infantile, EPIPOI-1), parents and teachers received basic information on overweight and health, and children underwent screening to identify those with overweight (body mass index (BMI) ⩾90th percentile) or at risk for overweight (BMI between 75 and 90th percentile), who were then followed up by their physicians. EPIPOI-2 children, in addition, received kindergarten-based education to promote healthy practices related to nutrition, physical activity and sedentary behaviors. Data on control children from non-intervention kindergartens (n=40) were retrieved from medical records at the Division of School Health.
At baseline, groups differed significantly on age and school area (underprivileged/ not). Owing to a significant interaction between school area and group, analyses were stratified by school area. At baseline, groups did not differ on overweight prevalence and BMI z-scores for any school area. After intervention, prevalence of overweight, BMI z-score and change in BMI z-score were significantly lower in intervention groups compared with controls in underprivileged areas. Using multilevel analysis adjusted for potential confounders, a significant effect on overweight prevalence at the end of the study was noted for EPIPOI-1 in underprivileged areas only (odds ratio and 95% confidence interval: 0.18 (0.07–0.51). In non-underprivileged areas, the gain in BMI z-score was lower in EPIPOI-2 group compared with control and EPIPOI-1.
Our results suggest that simple measures involving increasing awareness on overweight and health, and periodic monitoring of weight and height with follow-up care when indicated, could be useful to reduce overweight in young children from underprivileged areas. A reinforced strategy with an education component, in addition, may be indicated in children in non-underprivileged areas.
The epidemic of obesity and associated diseases poses a serious public health challenge worldwide.1 A major concern is the dramatic and continuing increase in the prevalence of overweight and obesity in children in most developed countries. The prevalence of overweight in school aged children is estimated to be between 10 and 20% in most West European countries and 25% in the United States.2 Of concern is the fact that overweight and obesity are also increasing at an alarming rate at younger ages.3 Overweight and obesity in childhood have significant effect on both physical and psychosocial health with both short- and long-term adverse effects.4, 5, 6 Indeed, many of the cardiovascular consequences seen in adulthood are preceded by abnormalities that begin in childhood.7, 8 In addition, obesity in childhood is considered a risk factor for adult obesity.9, 10 In response to these alarming trends, many international organizations and national governments have initiated obesity prevention programs. The French government also identified reducing childhood obesity as a key objective in its national policy concerning nutrition and health.11
Prevention of pediatric obesity involves targeting at least one of the six areas: family, institutions (kindergarten, school and after school programs), health professionals, government, media and industries.12 The interventions for preventing childhood obesity can be directed either at the whole population or at high-risk individuals, or at individuals facing the problem.1, 10 Several intervention studies have been conducted at schools to reduce overweight and obesity in children. Majority of these studies involved children over 7 years of age, with interventions focused on increased physical activity, improved nutrition practices and/or reducing television watching, and have yielded mixed results (summarized by Summerbell et al.13). Few randomized controlled studies aiming at reducing overweight have been carried out with children <7 years of age.13, 14, 15, 16, 17, 18, 19, 20, 21 In recent years, preschool age has been identified as a critical period for targeting interventions against obesity prevention.22 Our goal was to evaluate interventions with young children that could be incorporated into existing schools, community and health-care programs, with physicians and community involvement, to optimize effectiveness and resources. Therefore, we implemented a kindergarten-based study in young children (3–4 years old), to test two strategies with the primary objective of reducing the prevalence of childhood overweight at 5–6 years of age.
The study entitled ‘Epidémiologie et prévention de l’obésité infantile’ (EPIPOI) comprised interventions lasting 2 years with two groups of children (EPIPOI-1 and EPIPOI-2). Children in the intervention kindergartens were randomly assigned to one of the two intervention strategies. Both groups followed the ‘basic strategy’ and the EPIPOI-2 group received a reinforced strategy consisting of an education program, in addition. The effectiveness of the strategies was evaluated in terms of prevalence of overweight and change in body mass index (BMI) z-score, and compared with reference data obtained from children of same age from kindergartens that were not involved in any intervention.
This study was conducted after obtaining permission from the Inspector of Academy, Ministry of Education, responsible for the Haute-Garonne Department (there are 96 departments in France; Haute-Garonne department falls in the South-West France, with Toulouse as its capital). The project was submitted to the Ethical Committee for Biomedical Research (‘Comité Consultatif de Protection des Personnes dans la Recherche Biomédicale’), Toulouse, France, and was forwarded to the National Committee for Information and Liberty (‘Commission Nationale de l’Informatique et des Libertés’) for approval. The study protocol and informed consent documents were approved by this committee.
Both intervention groups (EPIPOI-1 and EPIPOI-2) followed the basic strategy that comprised information dissemination to parents and teachers, as well as screening for overweight at baseline and follow-up care by family practitioners for overweight, if indicated.
Parents or legal guardians of children in the first and second section of the kindergarten, corresponding to >2.5 and <5 years of age, in the intervention kindergartens were sent flyers explaining the study and the importance of overweight in children and its consequences, as well as a letter of invitation for participation in the study through kindergarten teachers. The letter informed the parents of the study protocol involving the surveillance of weight and height of their children during the study. At the kindergarten level ,teachers were informed of the public health significance of overweight through sessions held by the study physician and a dietician. Posters emphasizing the prevention of obesity and the association of physical activity and health eating habits in child development and prevention of overweight in young children were placed at strategic points in all kindergartens, such as the entry hall where parents picked up their children, to reinforce the intervention messages.
At baseline, parents were requested to provide child's medical record and contact information for the child's general practitioner/pediatrician. Children underwent a medical visit whereby anthropometric measurements were taken by the study physician.23 Weight was determined for children in minimal clothing without shoes to the nearest 0.5 kg using a Seca scale (Hamburg, Germany), and height to the nearest 0.5 cm with a stadiometer fixed to the wall (Seca) using standardized techniques. Children were classified by the study physician using French reference curves for BMI;24 those with BMI value between 75th and 90th percentiles (z-score between 0.67 and 1.28) were considered at risk for overweight and those with BMI ⩾90th percentile (z-score ⩾1.28) were considered overweight. Parents of overweight or at risk for overweight children were mailed a letter, explaining the importance of bringing the child to the family physician. At the same time, physicians of these children were contacted by the study coordinating physician (BJ) to encourage follow-up care. The physicians were also proposed to join the health professionals network for the prevention and treatment of pediatric obesity (‘Réseau ville-hôpital pour la prévention et la prise en charge de l’obésité pédiatrique’, RePPOP) for receiving further training for treatment of obesity, if they were not already participating. Height and weight were obtained at the end of the study (two academic years later) following the methods described above.
The reinforced strategy was provided to children in EPIPOI-2 group. It consisted of a kindergarten-based education program, in addition to the basic strategy. The education program focused on promoting healthy nutrition habits and physical activity, as well as to reducing television watching. The study team, comprising a dietician and an education aide, conducted ten 20-min sessions (five sessions per year) in the classroom. These sessions incorporated learning activities and games around the following themes: improved knowledge of food groups and their role in health; and importance of eating balanced meals and snacks, having breakfast, drinking water, limiting sugar-sweetened beverages, practicing physical activity, as well as reducing sedentary behavior. In addition, children received an audio cassette and a story book to reinforce these educational messages, whereas their parents were provided packets containing information on nutrition and physical activity in relation to health and well-being, as well as morbidity associated with obesity.
At the end of the second academic year of intervention, children underwent a final medical examination whereby weight and height were measured by the study physician, following the same procedures as at baseline.
Constitution of groups
Sample size was estimated based on two hypotheses. Assuming a prevalence of overweight of 20% at 6 years, hypothesis 1 was that, compared with the control group, EPIPOI-1 strategy would lead to 30% reduction in overweight at the end of the study. It was calculated that 480 subjects in each group would provide statistical power of 0.80 (α=0.05; one-tailed test). Hypothesis 2 was that, compared with EPIPOI-1, EPIPOI-2 strategy would yield a reduction of overweight by 30%. Sample size estimates indicated that 820 subjects in each intervention group would provide statistical power of 0.80 (α=0.05; one-tailed test). Therefore, the objective was to have 480 subjects in the control and 820 in each of the two intervention groups. Assuming an acceptance rate of 60% and an attrition rate of 25% between baseline and end of the study, we needed to start with 1820 children, corresponding to 40 kindergartens, in each intervention group.
Of the 344 kindergartens in Haute-Garonne Department, we randomly contacted 156 kindergartens to potentially participate in the intervention study (Figure 1). Seventy-nine kindergartens agreed to participate in the intervention study and were randomly assigned to EPIPOI-1 or EPIPOI-2 groups. Randomization took into account two variables related to kindergarten location: region (rural/urban) and for kindergartens in urban area, schooling in underprivileged area (yes/no). Kindergartens in Toulouse and its suburbs were considered as urban. We used the French Ministry of National Education's definition of ‘zones for prioritizing education’ that is based on socioeconomic indicators and kindergarten environment, to identify the kindergartens in underprivileged area with the assistance of the administration at the Department level (Mayor of Haute-Garonne).
Data for the control group were obtained retrospectively from 40 non-contacted kindergartens during the study duration from the classes of 5to 6 year-old children (Figure 1) that were selected considering the same sociodemographic distribution as the intervention kindergartens in terms of region and location of kindergarten in underprivileged area. Data on weight and height for control children at 3–4 and 5–6 years of age, corresponding to the beginning and end of the intervention study period, were retrieved from the school medical records. As part of National health policy, anthropometric data (height, weight) are collected routinely at kindergarten by physicians of the Well Child program ‘Protection Maternelle et Infantile’ at 3–4 years of age, and by school physicians, Division of School Health, Department of National Education at 5–6 years of age. Before the implementation of the intervention study, the physicians in these institutions were trained to take anthropometric measurements and informed on the importance of precision in these measures, by the Principal Investigator and her team from the Division of Endocrinology and Pediatrics, Toulouse University Hospital. The access to these data allowed us to build a comparative control group without specific examination of children in a study setting. This process offered the advantage of avoiding a potential placebo effect that can arise from measuring height and weight of subjects13 that can be present in a classical randomized-controlled design.
Body mass index was expressed as z-score (s.d. score) in relation to age and sex for each subject using French reference curves.24 Comparisons of BMI and BMI change were performed using the Mann–Whitney U-test. Univariate analyses for others variables were conducted using Student's t-test or χ2-test, as appropriate. In order to account both for intra-class correlation because of clustering of children within kindergartens and for potential confounders, the intervention effect on the prevalence of overweight at the end of the study was assessed by multilevel logistic regression analyses. Interactions between independent variables were examined and models run separately when a significant interaction was observed. The odds ratios and 95% confidence intervals are presented. Owing to multiple group comparisons and multiple statistical tests conducted in the present analyses, we used a more conservative level of significance (P<0.01) for all analyses. Statistical analyses were conducted using STATA version 8.2 (College Station, TX, USA).
Of 3736 parents or legal guardians of all 3 to 4-year-old children in 79 kindergartens contacted, 1910 (51%) indicated an interest for their child to participate in the study and provided signed informed consent (Figure 1); 1780 (93%) children presented for the baseline examination. Thirty per cent subjects were lost to follow-up, leaving 1253 children in the two EPIPOI groups at the end of the study. Therefore, we compared subjects with data at both baseline and end of study with those with data at baseline only in both intervention groups. There were no significant differences on sex ratio, school area (underprivileged/not) and BMI status at baseline; however, children with missing data at the end of the study were slightly older (by ∼2 months) than those with data before and after intervention (data not shown). To constitute the control group, school medical records of 1295 children were examined; complete data (height, weight and age) at both 3–4 and 5–6 years of age were available for 410 children that served as controls.The three groups (EPIPOI-1, EPIPOI-2, and control) did not differ significantly at baseline on sociodemographic variables (region, sex ratio) and anthropometric variables, except age and school area (underprivileged or not) (Table 1). The difference in age between groups was small at baseline (∼2 months), but more important at the end of intervention (∼5 months) between the control and the EPIPOI groups. To account for these differences in age and school area, we examined the prevalence of overweight at the end of the study in regression models that adjusted for these variables. However, a significant interaction was observed between school area and group; thus all analyses were stratified by school area.
Table 2 shows the prevalence of overweight. Globally, at baseline, no differences were noted between groups. At the end of the study, there was no difference between the two intervention groups as well, but a significant difference was noted between EPIPOI-2 and the control group. In stratified analyses, for kindergartens not in underprivileged areas, no differences were seen either at baseline or at the end of the study between groups. In contrast, for kindergartens in underprivileged areas, the prevalence of overweight in the two intervention groups was significantly lower than that in the control group at the end of the study. Importantly there were no differences between the EPIPOI-1 and EPIPOI-2 interventions. Table 3 shows the evolution of BMI z-score examined by group and school area. At the end of the study, BMI z-score and change in BMI z-score were lower in both intervention groups compared with controls in underprivileged areas; however, again no differences were noted between the two intervention groups. For kindergartens not in underprivileged areas, change in BMI z-score was lower only in EPIPOI-2 compared with control children. In addition, change in BMI z-score in EPIPOI-2 was significantly lower than EPIPOI-1 in this school area.
The results of multilevel logistic regression analyses stratified by school area (Table 4) showed similar patterns as observed in the univariate analyses (Table 2); there was a significant intervention effect on the prevalence of overweight at the end of the study in EPIPOI-1 group as compared with the control group for kindergartens in underprivileged areas only.
Our study was designed to test two strategies for reducing the prevalence of overweight and obesity in young children. The basic strategy (EPIPOI-1) provided information on overweight and health, as well as screening at kindergarten to identify overweight or at risk for overweight children combined with follow-up care performed by their physicians. The reinforced strategy (EPIPOI-2) included an education component at kindergarten in addition.
The results at the end of 2 years of intervention did not confirm our initial hypotheses that the basic level intervention (EPIPOI-1) would be effective at reducing overweight compared with controls, nor of reinforced strategy (EPIPOI-2) being more effective than the basic strategy alone (EPIPOI-1) when the entire study group was considered as a whole, collapsing over all school areas (underprivileged or not). However, owing to a significant difference in the EPIPOI and control groups on localization of kindergartens in underprivileged areas or not, and a significant interaction effect between school area and group on prevalence of overweight, stratified analyses based on school area (underprivileged or not) had to be conducted that yielded interesting findings related to intervention effects in kindergartens in different socioeconomic areas. This difference in school area between control and intervention groups was unexpected, as the control group of 5–6 year olds was constituted from kindergartens with similar distribution on school area and region as the intervention kindergartens. The significant difference in school area in the control groups arose because of more missing data at 3–4 years of age for control children in kindergartens in not underprivileged areas, as school physicians prioritize their visits to kindergartens in underprivileged areas.
We chose to constitute the control group in a retrospective fashion (although data were collected prospectively by school physicians) rather than conducting a three-arm randomized-controlled study (two intervention strategies EPIPOI-1 and EPIPOI-2, and a control group), to avoid a potential placebo effect. In fact, if the control group were to be constituted at the same time as the intervention groups, and measurements for height and weight taken, this assessment in itself could sensitize the control group children and could result in underestimation of the intervention effect.13
At baseline, no differences in BMI status and sex ratio were observed between the three groups; however, a slight difference in age was noted. In particular, the control group was older than the EPIPOI groups (by ∼2 months at baseline and ∼5 months at the end of the study). This is related to the fact that children in the EPIPOI groups began baseline assessment in the first part of the academic year and were reassessed 2 years later. In fact, weight and height for control group children were measured all along the entire academic year by physicians from the Division of School Health, leading to the difference in age for control versus intervention children. Importantly, when age at the end of the study was also taken into account in the multilevel regression models, the significant effect of EPIPOI-1 strategy on overweight compared with the control group persisted in the kindergartens in the underprivileged areas.
For kindergartens in underprivileged areas, both intervention strategies showed a significant reduction in the prevalence of overweight as compared with the prevalence in 5 to 6-year-old controls in Haute-Garonne area, on the basis of the data available from the Division of School Health. The analysis of the evolution of BMI z-score also showed that the increase in BMI z-score over the study period was lower in the EPIPOI groups compared with the control group in this school area. There was no significant difference between the two intervention groups. In contrast, in kindergartens not in underprivileged areas, no effect was seen on prevalence of overweight with either intervention; however, the increase in BMI z-score is reduced only with EPIPOI-2 strategy in this school area.
The interesting finding of the differential impact of interventions as a function of socio economic status (SES), seen in this study, has not been examined in most studies and mixed findings have been reported in few recent studies.18, 25 In the Kiel Obesity Prevention Study,25 the effect of an education program involving nutrition education and increased activity at school on prevalence of overweight at 4-year follow-up was significant in children from families with high SES. In contrast, Epstein et al.18 found that with an intervention targeting only television viewing and computer use over a 2-year period, change in BMI z-score was significant only in children from families of low SES. Similarly, Foster et al.26 showed that a multi-component school-based intervention for 2 years involving older children (mean age 11 years) from low SES, resulted in marked reduction in the prevalence of overweight; odds ratios and 95% confidence interval were 0.65 (0.54–0.79).
The observation that the basic strategy (EPIPOI-1) is effective in children from kindergartens in underprivileged areas, a proxy for lower SES is important because overweight and obesity are more prevalent in low SES groups27, 28, 29, 30, 31 and because children of low SES are at a greater risk of becoming obese in adulthood compared with children of higher SES.32 It is likely that the families of children in the underprivileged areas were more sensitive to interventions addressed to their children because they may be generally less exposed to information on overweight prevention, and may less utilize the health-care system. Even the mere act of observing and measuring height and weight has been shown to be associated with healthier behaviors.13 On the other hand, the parents of children from Kindergartens not in underprivileged areas were probably more aware of general health messages; thus, the impact in overweight prevalence was not noted with the simpler EPIPOI-1 approach. Nevertheless, the smaller increase in BMI z-score with the reinforced EPIPOI-2 intervention, that involved in addition an education component at kindergarten, is noteworthy in children in not underprivileged areas.
The current study targeting whole population of young children at kindergarten offers encouraging results and contributes to the limited literature in this age group.15, 16, 17, 20, 21 In the study (n=545) by Reilly et al.15 involving a 1-year intervention focused on reducing TV watching and increasing physical activity, no change in BMI z-score was observed in the intervention compared with the control group. In another small study, Dennisson et al.21 also did not find any significant effect of intervention targeting reduced television watching on BMI z-score compared with controls. However, in the study by Mo-Suwan et al.16 with 4 year olds, involving an intervention focused on increasing physical activity, a trend of reduction in prevalence of overweight was noted in the exercise versus control group. Furthermore, in that study, the school-based exercise program significantly prevented BMI gain in girls. In slightly older children (5–7 year olds; n=218) intervention targeting improved nutrition, increased physical activity, or a combination resulted in improved nutrition knowledge but no effect on prevalence of overweight was noted.17 Similarly, in the ‘Hip-Hop to Health Jr’ randomized-controlled trial, an intervention targeting improved nutrition and physical activity in preschool children a smaller increase in BMI at 1- and 2-year follow-up was noted with the intervention.20
The multidimensional nature of the intervention in this study whereby several risk factors were targeted simultaneously might have contributed to the promising findings seen in the current study. These results may be explained by the fact that the interventions not only involved parents, teachers and children, but also involved the physicians at school, thus linking several systems/persons involved in child health and child care that could have reinforced the study messages.
The study has certain limitations that should be considered. The choice of study design whereby the control group was constituted based on data collected by school physicians in non-intervention kindergartens in parallel to the study could be considered a limitation, as data were available on a smaller sample size than previously estimated and the control group differed from the intervention group on age and school area (underprivileged or not). Although, the latter differences were accounted for in the statistical analysis, future studies could consider a randomized-controlled design to avoid baseline differences among groups. Our study had a high drop-out rate that has been reported by others as well in young children.25 The study was voluntary and involved preschoolers whose families are prone to move and change schools that could partly account for the relatively high drop-out rate. In both intervention groups, children who were identified as overweight or at risk for overweight were recommended follow-up care with their family physician. However, no further information on such follow-up visits was available in the scope of the study. The study lasted two academic years and children were not followed after that period. Therefore, the study does not allow to examine whether the effect of interventions were sustained long-term.
In conclusion, the results of this study show that simple early intervention (EPIPOI-1), consisting of regular surveillance of weight and height and follow-up of at-risk and overweight children by their physicians, as well as increased awareness of parents and teachers on overweight, reduced the risk of overweight compared with control group in underprivileged areas. Kindergarten-based education component in addition (EPIPOI-2) did not yield any improvement over this basic strategy (EPIPOI-1) in underprivileged areas. In contrast, in non-underprivileged areas the reinforced educational intervention was effective in terms of change in BMI z-score as compared with the control and the basic intervention. Our results support that simple interventions involving screening and follow-up care could be useful for reducing overweight in children in underprivileged areas, although reinforced interventions involving in addition education component may be indicated for children not in underprivileged areas. Indeed, the approaches used in this study, that is, integrated interventions that begin at early age, and that are incorporated into existing school and community infrastructure, with physicians, combined with community involvement have been recently recommended for childhood obesity prevention.33 The promising preliminary findings of this study merit to be examined in other settings with randomized-controlled designs when possible. It would also be of interest to examine in future studies whether the benefits of such interventions last over time in future.
Conflict of interest
The authors declare no conflict of interest.
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We are indebted to Pierre Machicot and Richard Cosaert, Caisse Primaire d’Assurance Maladie (social security) of Haute-Garonne region for their assistance with subject recruitment. We are thankful to Drs Francoise Collet, Danielle Augier, Danielle Leautier and Claudine Guitard, the Protection Maternelle et Infantile (Division of School Health), and Drs Marie-Françoise Delors, Fanny Delon et Dorothée Querleu (Ministry of Education), Haute-Garonne region, for their assistance in obtaining the information from children's medical records. We are grateful to Dr Nadia Lounis, Johanne Galino and Corinne Fleury for their assistance in data collection. We thank Professor Didier Concordet, Institut National de la Recherche Agronomique (National Institute for Research in Agronomy), for his guidance with multilevel regression analyses. The authors’ contributions were as follows—BJ: overseeing study and writing of the paper; NA: supervision of data analysis, and writing of the paper; MD: contributed to data analysis under the supervision of HG and NA and to the paper development; CC: contributed to data analysis under the supervision of HG and NA and to the paper development; LNP: study coordination and comments on the paper; HG: design of the study, supervision of data analysis and contributing to the paper development; MT: design of study, funding for the study, overseeing study and contributing to the paper development. This work is supported by grants from the French Social Security System.
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Jouret, B., Ahluwalia, N., Dupuy, M. et al. Prevention of overweight in preschool children: results of kindergarten-based interventions. Int J Obes 33, 1075–1083 (2009). https://doi.org/10.1038/ijo.2009.166
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Obesity Reviews (2019)
The effect of Public Health/Pediatric Obesity interventions on socioeconomic inequalities in childhood obesity: A scoping review
Obesity Reviews (2019)
A feasibility cluster randomised controlled trial of a preschool obesity prevention intervention: ToyBox-Scotland
Pilot and Feasibility Studies (2019)
School-Based Interventions in Low Socioeconomic Settings to Reduce Obesity Outcomes among Preschoolers: A Scoping Review