Effect of Childhood Obesity Prevention Programs
on Blood Pressure
A Systematic Review and Meta-Analysis
Li Cai, MD; Yang Wu, MS; Renee F. Wilson, MS; Jodi B. Segal, MD; Miyong T. Kim, PhD;
Youfa Wang, MD
Downloaded from http://circ.ahajournals.org/ by guest on June 14, 2017
Background—Childhood overweight and obesity are associated with elevated blood pressure (BP). However, little is known
about how childhood obesity lifestyle prevention programs affect BP. We assessed the effects of childhood obesity
prevention programs on BP in children in developed countries.
Methods and Results—We searched databases up to April 22, 2013, for relevant randomized, controlled trials, q­ uasiexperimental studies, and natural experiments. Studies were included if they applied a diet or physical activity
intervention(s) and were followed for ≥1 year (or ≥6 months for school-based intervention studies); they were excluded if
they targeted only overweight/obese subjects or those with a medical condition. In our meta-analysis, intervention effects
were calculated for systolic BP and diastolic BP with the use of weighted random-effects models. Of the 23 included
intervention studies (involving 18 925 participants), 21 involved a school setting. Our meta-analysis included 19 studies
reporting on systolic BP and 18 on diastolic BP. The pooled intervention effect was −1.64 mm Hg (95% confidence
interval, −2.56 to −0.71; P=0.001) for systolic BP and −1.44 mm Hg (95% confidence interval, −2.28 to −0.60; P=0.001)
for diastolic BP. The combined diet and physical activity interventions led to a significantly greater reduction in both
systolic BP and diastolic BP than the diet-only or physical activity–only intervention. Thirteen interventions (46%) had a
similar effect on both adiposity-related outcomes and BP, whereas 11 interventions (39%) showed a significant desirable
effect on BP but not on adiposity-related outcomes.
Conclusions—Obesity prevention programs have a moderate effect on reducing BP, and those targeting both diet and
physical activity seem to be more effective. (Circulation. 2014;129:1832-1839.)
Key Words: blood pressure ◼ meta-analysis ◼ obesity ◼ pediatrics ◼ prevention
E
levated blood pressure (BP) during childhood, recognized
as an important health issue in children over the past several decades,1 is associated with premature death risk in Native
Americans2 and elevated BP later in life.3 Recent research indicates that even modest elevations in BP pose a risk to health.4
A cohort study on 1 207 141 Swedish male conscripts also
showed that elevated BP during late adolescence contributed
to cardiovascular mortality over a median of 24 years.5
shown that weight loss can help to treat hypertension; this can
be achieved through health behavior modifications.8 A previous meta-analysis estimating the effect of weight reduction on
BP showed significantly larger BP reductions in adults with
an average weight loss of >5 kg than in those with less weight
loss.9 Another systematic review focusing on overweight and
obese children suggested that lifestyle interventions incorporating a dietary component along with an exercise or behavioral therapy component can lead to improvements in both
weight and cardiometabolic outcomes, including BP.10
However, little is known about how childhood obesity prevention programs on lifestyle modification may affect BP and
whether the effect is modified by changes in weight status and
the type of intervention in the general child population.
Clinical Perspective on p 1839
Childhood overweight and obesity are associated with
elevated BP.6 As childhood obesity prevalence has increased
dramatically worldwide,7 numerous intervention studies have
been conducted to fight the epidemic. Some research has
Received August 13, 2013; accepted February 7, 2014.
From the Johns Hopkins Global Center on Childhood Obesity, Department of International Health, Bloomberg School of Public Health, Baltimore, MD
(L.C., Y. Wu, Y. Wang); Department of Nutrition and Food Hygiene, School of Public Health, Peking University Health Science Center, Beijing, China
(L.C.); Departments of Health, Behavior, and Society (Y. Wu) and Health Policy and Management (R.F.W., J.B.S.), Johns Hopkins Bloomberg School
of Public Health, Baltimore, MD; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (J.B.S.); School of Nursing,
University of Texas at Austin (M.T.K.); and Department of Epidemiology and Environmental Health, School of Public Health and Health Professions,
University at Buffalo, State University of New York (Y. Wang).
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.
113.005666/-/DC1.
Correspondence to Youfa Wang, MD, PhD, Department of Epidemiology and Environmental Health (former Department of Social and Preventive Medicine),
School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, NY 14214. E-mail [email protected]
© 2014 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.005666
1832
Cai et al Childhood Obesity Prevention Programs and BP 1833
The present study was part of a larger, comprehensive project that sought to assess the effectiveness of childhood obesity
prevention programs in various settings in developed countries;
this project examined multiple outcomes, although results on BP
were not reported.11 The present study sought to (1) evaluate the
effects of childhood obesity prevention programs on BP in developed countries and (2) examine the potential differential effects
of the interventions on a­ diposity-related and BP outcomes.
Methods
Search Strategy and Selection Criteria
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Details of methods have been documented in a protocol.11 In brief,
we searched MEDLINE, EMBASE, PsychInfo, CINAHL, and the
Cochrane Library for relevant studies from their inception through
April 22, 2013. We developed a search strategy for MEDLINE based
on MeSH (Medical Subject Headings) terms and text words of key
articles that we identified a priori. We reviewed the reference lists of
all included articles and relevant review articles to identify articles
that the database searches might have missed. We uploaded the articles into DistillerSR (Evidence Partners, Ottawa, Ontario, Canada),
a Web-based software package developed for systematic review and
data management. We also conducted a gray literature search in
http://www.ClinicalTrials.gov to identify unpublished research that
was relevant to our review up to July 23, 2012.
We identified studies conducted in developed countries (ie, those
with a very high Human Development Index)12 that described the
effects of interventions to prevent obesity (or “excessive weight
gain”) in children and adolescents aged 2 to 18 years. We used the
definitions of overweight and obesity/excess weight defined in the
original articles. Studies needed to include adiposity-related outcomes, although the interventions might not necessarily have focused
specifically on obesity but rather on other outcomes such as cardiovascular risk reduction. We included only randomized, controlled
trials, quasi-experimental studies,13 and natural experiments. The
studies needed to test interventions targeting diet, physical activity
(PA), or the combination of the 2 in any setting or combinations of
settings (eg, school, home, community, primary care, and child care)
for at least 1 year or for at least 6 months for school-based intervention studies (considering the length of the school year). We included
only articles published in English but reviewed the abstracts of non–
English language articles to assess agreement with the results published in English.
Studies were excluded if they did not report on the attained differences between the intervention and control groups in BP or if they
targeted only overweight or obese subjects or those with a medical
condition, such as diabetes mellitus or heart disease.
Data Extraction and Quality Assessment
Two independent reviewers each conducted title scans and abstract
reviews, and they reviewed the full articles to assess their eligibility for inclusion. Standardized forms were created for data extraction. Each article also received a double review for data abstraction;
the second reviewer confirmed the first reviewer’s data abstraction
for completeness and accuracy. Reviewers extracted information on
study characteristics, study participants, eligibility criteria, intervention components, outcome measures, method of ascertainment, and
outcomes. A third reviewer (the first author) double-checked the
­adiposity-related and BP outcomes of all included studies.
Two independent reviewers applied the Downs and Black Checklist
for Measuring Quality to assess the quality of the included studies.14 We
categorized studies as having low, moderate, or high risk of bias (ROB).
We classified a study as having a low ROB only when it fulfilled all of
the following: stated the objective clearly, described the characteristics
of the enrolled subjects, described the intervention clearly, described
the main findings, described the main outcomes, randomized the subjects to the intervention group, and concealed the intervention assignment until recruitment was complete. In addition, the study must have
at least partially described the distributions of (potential) confounders
in each treatment group. If any one of these items was not fulfilled by a
study or its fulfillment could not be verified, the study was rated as having a moderate ROB; if a study did not fulfill >1 of the aforementioned
items, it was rated as having a high ROB.
Data Synthesis and Meta-Analysis
We conducted 2 types of data synthesis: (1) comparison of intervention effects on adiposity and BP outcomes for all of the included studies and (2) performance of meta-analyses for BP.
The primary outcome measures in the meta-analysis were mean
changes in systolic BP (SBP) and diastolic BP (DBP). Studies were
included in the meta-analysis if sufficient data were available to calculate the net change in BP and its variance in each group. For each
study, we calculated the net change as the difference in the mean
changes in BP, which equaled mean change in BP in the intervention
group minus the mean change in the control group. The variances
for net changes in BP were not reported directly in some studies.
Therefore, they were calculated from confidence intervals (CIs) for
intervention and control groups with the use of standard methods.15
For studies that reported BP data before and after the intervention, we
calculated the variance in the mean changes in BP using correlation
coefficient methods.15 We combined the subgroups of boys and girls
into a single group.16 In 1 study,17 3 nutritional intervention approaches
were implemented in 3 different groups, respectively. We combined
these 3 groups into a single group. When studies had >1 intervention
group and 1 control group,17,18 we chose only 1 intervention group
and the control group for the meta-analysis to avoid d­ ouble-counting
the control group. Meta-analyses results were similar when different
intervention groups were chosen from these 2 studies.
To calculate the pooled mean net change in BP, each comparison
was assigned a weight equal to the reciprocal of its variance. The I2
statistic and χ2 test were used to assess the heterogeneity of effect
size across interventions. I2>50% or P<0.10 from the χ2 test was considered evidence of heterogeneity. The random-effects model was
Records identified
Total: 48844
Titles:
42221
Abstracts:
7392
Full-text articles:
677
Studies included in
qualitative synthesis:
23
Eligible for metaanalysis:
SBP=19; DBP=18
Duplicates removed:
6623
Excluded:
34829
Excluded*: 6715
Insufficient follow-up time: 701
Study included ONLY overweight/obese children or
population is defined by a disease: 741
Study of adults only: 517
Study does not take place in setting of interest: 63
No intervention: 2512
No human data reported: 84
Does not measure weight as an outcome: 964
Insufficient data: 1581
Qualitative study: 448
Other: 2542
Excluded*: 654
Insufficient follow-up time: 67
Study included ONLY overweight/obese children or
population is defined by a disease: 96
Study of adults only: 7
Study does not take place in setting/country of interest: 17
No intervention: 80
No human data reported: 1
Does not report weight as an outcome: 78
Does not report blood pressure as outcomes: 129 Insufficient
data: 182
Qualitative study: 11
Other: 120
Figure 1. Flow diagram of childhood obesity prevention studies
identified and evaluated in the review regarding the intervention
effects on blood pressure. *Sum of excluded abstracts exceeds
6715 or 654 because reviewers were not required to agree on
reasons for exclusion. DBP indicates diastolic blood pressure;
and SBP, systolic blood pressure.
1834 Circulation May 6, 2014
Table 1. Main Characteristics of Childhood Obesity Interventions and Their Effects on BP in Developed Countries
Intervention
Setting(s)
Type of
Intervention
Walter, 1985
School
Combined
Follow-Up
Time, mo
12
Effect of Intervention
on Adiposity-Related
Outcome
Effect of Intervention
on BP*
Index
Effect*
SBP
TSF
(−), NS
(−)
DBP
Direction of
Adiposity-Related
and BP Outcomes†
(−)
→↓
→↓
Bush, 1989
School
Combined
24
TSF
(+), NS
(−)
(−)
Nader, 1989
School/home
Combined
24
BMI
(−), NS
(−)
(−)
→↓
Lionis, 1991
School/home
Diet only
12
BMI
(−)
(+), NS
(−), NS
↓→
Vandongen,
1995a
School
PA only
9
BMI
(+), NS
(+), NS
(−), NS
→→
Vandongen,
1995b
School
Combined
9
BMI
(+), NS
(−), NS
(+), NS
→→
Vandongen,
1995c
School/hom
Diet only
9
BMI
(+), NS
(+), NS
(+), NS
→→
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Nader, 1999
School/home
Combined
36
BMI
(+), NS
0, NS
(+), NS
→→
Skybo, 2002
School
Combined
9
% Body fat
0, NS
(−)
(−)
→↓
Yin, 2005
School
Combined
8
BMI
(−), NS
(−)
(+)
→↓
Child care
PA only
24
BMI
(+), NS
NR
(−)
→↓
→↓
Scheffler, 2007
Stock, 2007a
School
Combined
12
BMI
0, NS
(−)
(+), NS
Stock, 2007b
School
Combined
12
BMI
(+)
(−)
(−), NS
↑↓
Taylor, 2007
Community/ school
Combined
24
BMI Z score
(−)
(−)
(−)
↓↓
Reed, 2008
School
PA only
9
BMI
(−), NS
(−)
(−)
→↓
Simon, 2008
School/home
PA only
48
BMI
(−)
(−), NS
Angelopoulos,
2009
School/home/
community
Combined
12
BMI
(−)
(−)
Salcedo, 2010
(−), NS
↓→
(−)
↓↓
→↑
School
PA only
21
BMI
(−), NS
(+)
(+)
Hatzis, 2010
School/home
Combined
120
BMI
(−)
(+)
(+)
↓↑
Hollar, 2010
School/home
Combined
16
BMI Z score
(−)
(−)
(−)
↓↓
Kriemler, 2010
School/home
PA only
9
BMI
(−)
(−)
(−)
↓↓
Robinson, 2010
Community/home
PA only
24
BMI Z score
(+), NS
(+), NS
(−), NS
→→
Burguera, 2011a
School
Combined
6
BMI Z score
0, NS
(+), NS
(+), NS
→→
Burguera, 2011b
School
Combined
6
BMI Z score
(+), NS
(−), NS
(+), NS
→→
Resaland, 2011
School
PA only
24
BMI
0, NS
(−)
(−)
→↓
Rush, 2012b
School
Combined
24
BMI Z score
(+), NS
(−)
(−), NS
→↓
Rush, 2012a
School
Combined
24
BMI Z score
0, NS
(+), NS
(+), NS
→→
Tomlin, 2012
School/home/
community
Combined
7
BMI Z score
(−), NS
(+), NS
(−), NS
→→
BMI indicates body mass index; BP, blood pressure; Combined, combined diet and physical activity (PA) intervention; DBP, diastolic blood pressure; NS, nonsignificant;
SBP, systolic blood pressure; and TSF, triceps skinfold thickness.
*(−) or (+) indicates reduction or increase in outcome in intervention group compared with control group, respectively.
†There are 2 arrows in each cell; the first one represents the adiposity-related outcome, and the second one represents blood pressure outcomes. → indicates no
significant differences between changes in intervention and control groups; ↓ or ↑, significant reduction or increase in outcome in intervention group compared with
control group, respectively.
applied. The between-studies variance, τ2, was estimated. Prespecified
stratified analyses were performed to assess the impacts of various
study designs, including setting(s), type of intervention, follow-up
time, and publication year, on outcomes. A sensitivity analysis was
conducted to investigate the influence of a single study on the overall
pooled estimate by omitting 1 study at a time.
Potential publication bias was examined by the funnel plot, Egger’s
linear regression test, and Begg’s rank correlation test. When publication bias was identified, a nonparametric trim-and-fill method
was performed to adjust the publication bias.19 All meta-analyses
were conducted in STATA (version 11.0; Stata Corporation, College
Station, TX).
Results
Literature Search and Study Characteristics
We identified 48 844 potentially relevant articles, and 677 full
articles were retrieved (Figure 1). In total, 23 were included in
this review.16–18,20–39
Table I in the online-only Data Supplement shows the characteristics of the 23 studies. Thirteen (57%) were randomized, controlled trials, and 1 was a natural experiment study.
Nine were conducted in Europe, 8 in the United States, 3 in
Cai et al Childhood Obesity Prevention Programs and BP 1835
Canada, and another 3 in Australasia. The studies varied in
sample size, ranging from 58 to 3714, with a median of 601
and a total number of 18 925. One study included only girls;
the others included both sexes. Subjects’ mean ages ranged
from 3.0 to 13.7 years. Eighteen studies reported the baseline mean body mass index (BMI), ranging from 16.0 to 23.3
kg/m2, with a sample size-weighted mean BMI of 18.1 kg/
m2. Four studies16,18,31,37 reported baseline prevalence of overweight and obesity, ranging from 23% to 40%. Four studies
had low ROB, 13 had moderate ROB, and 6 had high ROB.
Interventions
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As shown in Table 1, 28 interventions were identified in these
23 studies (some studies had >1 intervention group). Fifteen
interventions were conducted in a school-only setting and 8
in a combined school and home setting. Four interventions
involved a community setting; only 1 was conducted in a child
care setting. The interventions reported in the included studies sought to prevent children from gaining excessive body
weight and reduce their risk of developing obesity. They generally sought to improve dietary intake, increase PA, reduce
sedentary activity, or a combination of these. Most (18 [64%])
of them used combined diet and PA interventions, 8 applied a
PA-only intervention, and only 2 interventions evaluated the
effect of a diet-only intervention. The follow-up time varied
widely, ranging from 6 to 120 months, with a median of 12
months.
Comparison of Effects of Interventions on Adiposity
and BP Outcomes
Seven interventions showed significantly desirable effects, and
1 showed significantly undesirable effects on a­ diposity-related
outcomes (Table 1). Fourteen and 11 interventions had significantly desirable intervention effects on SBP and DBP.
Thirteen interventions (46%) had a similar effect on
­adiposity-related outcome and BP, as 4 of them showed significantly desirable effects (Tables 1 and 2). Eleven interventions
(39%) showed a significantly desirable effect on BP (10 for
SBP and 7 for DBP) but not on adiposity-related outcomes.
Two interventions having nonsignificant effects and another
one having significantly undesirable effects on BP showed
significantly desirable effects on adiposity-related outcomes.
Meta-Analysis: Intervention Effects on BP
Nineteen studies (20 interventions) reporting on SBP
and18 studies (18 interventions) on DBP were included our
­meta-analysis (Figure 2). Tests for heterogeneity indicated
that the effect was significantly different across interventions.
The interventions resulted in an average reduction of −1.64
mm Hg (95% CI, −2.56 to −0.71; P=0.001) for SBP and −1.44
mm Hg (95% CI, −2.28 to −0.60; P=0.001) for DBP.
Stratified Analyses and Sensitivity Analysis
Interventions taking place in a school-only setting had a significant effect on SBP but not on DBP (Table 3). The opposite results were observed in those interventions in multiple
settings. The combined diet and PA interventions had significant effects on both SBP (−2.11 mm Hg) and DBP (−1.51
mm Hg). The significant decreases in SBP were observed in
Table 2. Comparison of Effect of Childhood Obesity
Prevention Programs on Adiposity and BP Outcomes
Reduced Adiposity
Outcome*
Reduced BP
(systolic or
diastolic)*
Yes
No
Total
Yes
4 (14.3)
11 (39.3)
15 (53.6)
No
3 (10.7)
10 (35.7)
13 (46.4)
7 (25.0)
21 (75.0)
28
Total
Values in parentheses are percentages. BP indicates blood pressure.
*Significant reduction in outcome in intervention group compared with
control group.
the interventions with a follow-up of ≤12 months, and the corresponding reductions in DBP were observed in those interventions with a follow-up of >12 months. Only interventions
published between 2000 and 2009 had a significant effect on
SBP (net change= −3.73 mm Hg; 95% CI, −5.37 to −2.09
mm Hg; P<0.001). No overall time trend was observed.
In the sensitivity analyses in which a random-effects model
was used, none of the interventions omitted in each turn
seemed to substantially influence the intervention effect (data
not presented).
Publication Bias
There was no sign of publication bias when the funnel plots
were examined (data not presented). Results from Begg’s
and Egger’s tests yielded similar results, except that Egger’s
test indicated the evidence of publication bias for SBP (SBP:
Begg P=0.626, Egger P=0.001; DBP: Begg P=0.081, Egger
P=0.339). The trim-and-fill method was used to correct the
publication bias for SBP. Results showed that no trimming
was needed, and the data were unchanged.
Discussion
To our knowledge, this is the first systematic, quantitative
analysis evaluating the effect of childhood obesity prevention
programs on BP, comparing their effects on adiposity and BP,
and testing how the effect may vary by type of intervention in
the general child population. We found that childhood obesity prevention programs incorporating a diet or PA component significantly improved BP in children, with an average
reduction of −1.64 mm Hg in SBP and −1.44 mm Hg in DBP.
The BP reduction was more pronounced in those studies in
which combined diet and PA interventions were used. Nearly
half (46%) of the interventions had similar effects on adiposity and BP outcome, but 39% of the interventions showing no
significant effect on adiposity outcome showed a significant
desirable effect on BP. This important finding indicates that
if only adiposity measures are assessed, the benefits of such
interventions would be underestimated.
In general, our results concerning the beneficial effect on
BP are consistent with those of a recent 2012 meta-analysis,10 which tested the effects of lifestyle interventions in
overweight or obese children. It included only 7 studies
for the meta-analysis of BP, reporting that lifestyle interventions led to a significant reduction in both SBP (−3.4
mm Hg; 95% CI, −5.19 to −1.61) and DBP (−1.78 mm Hg;
1836 Circulation May 6, 2014
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Study
ID
WMD (95% CI)
%
Weight
Walter (1985)
Bush (1989)
Lionis (1991)
Vandongen (1995b)
Nader (1999)
Skybo (2002)
Yin (2005)
Stock (2007a)
Stock (2007b)
Taylor (2007)
Reed (2008)
Simon (2008)
Angelopoulos (2009)
Salcedo (2010)
Hatzis (2010)
Hollar (2010)
Kriemler (2010)
Robinson (2010)
Burguera (2011b)
Resaland (2011)
Overall (I-squared = 91.7%, p = 0.000)
-2.40 (-3.55, -1.25)
-3.19 (-5.38, -1.00)
0.11 (-2.86, 3.08)
-0.10 (-2.17, 1.97)
0.00 (-0.55, 0.55)
-8.00 (-12.60, -3.40)
-1.90 (-3.68, -0.12)
-4.40 (-7.80, -1.00)
-4.00 (-7.67, -0.33)
-4.00 (-7.00, -1.00)
-7.00 (-9.79, -4.21)
-0.42 (-2.01, 1.17)
-3.50 (-4.91, -2.09)
4.57 (3.38, 5.76)
0.70 (0.56, 0.84)
-1.27 (-2.30, -0.24)
-2.00 (-3.55, -0.45)
0.21 (-1.03, 1.45)
-4.90 (-14.08, 4.28)
-2.57 (-4.28, -0.86)
-1.64 (-2.56, -0.71)
6.25
4.98
4.04
5.14
6.75
2.55
5.51
3.58
3.32
4.01
4.25
5.75
5.96
6.21
6.91
6.37
5.79
6.16
0.89
5.60
100.00
NOTE: Weights are from random effects analysis
-15
Favor intervention
0
Favor control
10
Study
ID
WMD (95% CI)
%
Weight
Walter (1985)
Bush (1989)
Lionis (1991)
Vandongen (1995b)
Nader (1999)
Skybo (2002)
Yin (2005)
Taylor (2007)
Reed (2008)
Simon (2008)
Angelopoulos (2009)
Salcedo (2010)
Hatzis (2010)
Hollar (2010)
Kriemler (2010)
Robinson (2010)
Burguera (2011b)
Resaland (2011)
Overall (I-squared = 94.3%, p = 0.000)
-1.50 (-2.56, -0.44)
-6.78 (-8.92, -4.64)
-2.47 (-5.19, 0.25)
0.20 (-1.06, 1.46)
0.30 (-0.09, 0.69)
-4.00 (-7.87, -0.13)
2.20 (1.15, 3.25)
-3.00 (-4.75, -1.25)
-5.00 (-8.55, -1.45)
-2.31 (-4.91, 0.29)
-2.80 (-3.89, -1.71)
2.14 (1.25, 3.03)
-2.00 (-2.13, -1.87)
-1.21 (-1.86, -0.56)
-2.00 (-3.34, -0.66)
-0.27 (-1.08, 0.54)
1.90 (-7.12, 10.92)
-2.20 (-3.59, -0.81)
-1.44 (-2.28, -0.60)
6.61
5.00
4.18
6.35
7.27
2.89
6.62
5.61
3.20
4.34
6.57
6.82
7.37
7.07
6.22
6.92
0.78
6.16
100.00
Figure 2. Meta-analysis of effect of childhood
obesity prevention interventions on changes
in blood pressures. A, Systolic blood pressure
(mm Hg) based on 19 studies. B, Diastolic blood
pressure (mm Hg) based on 18 studies. CI indicates
confidence interval; and WMD, weighted mean
difference.
NOTE: Weights are from random effects analysis
-11
0
11
Favor intervention
Favor control
WMD=weighted mean difference.
95% CI, −2.88 to −0.67). Our results extended the evidence
that childhood obesity prevention programs are effective in
BP reduction in the general child population, regardless of
weight status.
A recent study has shown that elevated BP in childhood
increases the risk of developing hypertension during adolescence.40 Many children with newly diagnosed hypertension
already have evidence of cardiovascular damage.41 Because
the prevalence of elevated BP in children has been increasing dramatically, a more aggressive approach is needed to
screen and diagnose elevated BP, even in early childhood.1
Although the BP reductions we found here are small at the
individual level, the BP tracking phenomenon suggests that a
lower BP value in childhood represents a lower risk of hypertension in adult life.3,4 In addition, every mm Hg decrease in
BP decreases the risk of cardiovascular mortality in adults.42
These facts indicate that our findings have important public
health implications.
The observed favorable effect of childhood obesity prevention programs on BP is biologically plausible. BP has been
shown to be strongly correlated with BMI in children.43 In this
review, nearly half of the interventions had similar effects on
adiposity-related outcome and BP, and 4 showed significant
desirable effects on both BMI/BMI Z score and BP. All 4 of
Cai et al Childhood Obesity Prevention Programs and BP 1837
Table 3. Meta-Analyses of Effect of Childhood Obesity Prevention Programs on BP by Intervention Characteristics
Systolic BP, mm Hg
No. of
Interventions
Net Change
(95% CI)
20
Diastolic BP, mm Hg
Heterogeneity
I2, %*
χ2
P Value*
τ2
No. of
Interventions
Net Change
(95% CI)
−1.64
(−2.56 to −0.71)§
91.7
229.5
<0.001
3.2
18
11
−2.75
(−5.09 to −0.42)§
92.4
132.3
<0.001
13.1
9
−0.92
(−1.84 to 0.00)
89.0
73.0
<0.001
Diet only
1
0.11
(−2.86 to 3.08)
…
0.0
PA only
6
−1.07
(−3.83 to 1.70)
94.8
13
−2.11
(−3.19 to −1.03)§
≤12 mo
11
>12 mo
Heterogeneity
I2, %*
χ2
P Value*
τ2
−1.44
(−2.28 to −0.60)§
94.3
299.8
<0.001
2.5
9
−1.44
(−3.37 to 0.48)
92.5
106.6
<0.001
6.9
1.4
9
−1.59
(−2.52 to −0.66)§
94.3
140.8
<0.001
1.6
…
0.0
1
−2.47
(−5.19 to 0.25)
…
0.0
…
0.0
95.7
<0.001
11.2
6
−1.28
(−3.05 to 0.48)
90.2
50.8
<0.001
4.0
91.0
133.0
<0.001
2.6
11
−1.51
(−2.55 to −0.47)§
95.3
213.7
<0.001
2.4
−2.92
(−4.09 to −1.74)§
64.8
28.4
0.002
2.1
9
−1.50
(−3.05 to 0.05)
86.9
60.9
<0.001
4.1
9
−0.32
(−1.34 to 0.70)
91.8
97.5
<0.001
1.9
9
−1.47
(−2.59 to −0.34)§
96.5
229.7
<0.001
2.5
1985–2000
5
−1.14
(−2.60 to 0.32)
79.7
19.7
0.001
1.9
5
−1.82
(−3.69 to 0.05)
92.2
51.2
<0.001
3.9
2000–2009
8
−3.73
(−5.37 to −2.09)§
73.0
25.9
0.001
3.7
6
−2.28
(−4.81 to 0.25)
91.5
59.1
<0.001
8.5
2010–2012
7
−0.11
(−1.63 to 1.42)
92.7
82.2
<0.001
3.3
7
−0.85
(−2.07 to 0.36)
94.0
100.8
<0.001
2.1
Total
Setting(s)
School-only
setting†
Multiple settings
Type of intervention
Combined
Downloaded from http://circ.ahajournals.org/ by guest on June 14, 2017
Follow-up‡
Publication year
BP indicates blood pressure; CI, confidence interval; and Combined, combined diet and physical activity (PA) intervention.
*I2>50% or P<0.10 was considered evidence of heterogeneity.
†The Scheffler (2007) intervention was conducted in a single setting (child care) but did not have adequate data for meta-analysis.
‡Follow-up of data collection after intervention was initiated. In many studies, it was the duration of the intervention.
§Significant difference.
these interventions took place in multiple settings, with a large
mean sample size (n=1001).
Eleven of the 28 childhood obesity interventions included
in our review had a significant desirable effect on SBP or DBP
but not on adiposity-related outcomes. An unhealthy lifestyle,
including unhealthy eating and a lack of PA, plays a key role
in the development of hypertension. The association between
reduced salt intake and lower BP has been well established.
There is a significant association between salt intake and total
fluid intake, including sugar-sweetened soft drinks,44 which
are often consumed in large amounts by children.45 In addition, studies have confirmed the effect of fruits and vegetables
on lowering BP. 1 Exercise also lowers BP in both normotensive and hypertensive subjects, even in children.46 Our study
shows that obesity prevention programs can favorably affect
BP in children, regardless of changes in adiposity outcomes.
Such findings demonstrate the merits of promoting childhood
obesity prevention programs in general populations. These
findings also suggest using alternate outcome assessments
to evaluate the effectiveness of childhood obesity prevention
programs instead of focusing solely on adiposity outcomes.
Our study showed that the BP-lowering effect was significant and more prominent in studies in which a combination of
diet and PA interventions was used. The PA-only interventions
showed a slight, although not significant, reduction in both SBP
and DBP. The absence of a significant effect in those PA-only
interventions may be explained partly by their failure to increase
PA. Another recent systematic review concluded that PA interventions had only a small effect on children’s overall activity
levels.47 Our results regarding diet-only interventions should be
interpreted cautiously because only 2 studies were included in
this category and had a nonsignificant effect on BP.
Childhood obesity prevention programs in many countries
have focused mainly on schools. However, it has been recommended to address the broader issues of the overall food
and PA environment, including families and communities.48
In the subgroup meta-analysis, interventions taking place in
multiple settings (eg, school, home, and community) had a
significant and favorable effect on DBP. Interventions taking
place in a school-only setting had a significant desirable effect
on SBP. Optimal intervention setting(s) still need more data to
be determined.
1838 Circulation May 6, 2014
Downloaded from http://circ.ahajournals.org/ by guest on June 14, 2017
The present study has several strengths. A systematic
approach to identify the relevant literature and a sequence
of screening procedures were used. The review process also
benefited from important input from a number of experts
in the field at various stages of this review to ensure study
quality and representativeness. Only experimental studies,
natural experiments, and quasi-experimental studies were
included, and therefore confounding was minimized. We
also assessed the potential differential effects of the interventions on adiposity and BP outcomes, quantified the
effect of obesity prevention programs on BP, and tested
these effects by intervention type using stratified analysis.
This review also has limitations. First, it focused on
only developed countries. However, this choice can help to
enhance the comparability of the studies for pooled analysis. Second, some of the included studies did not focus specifically on obesity (eg, some were focused more broadly on
cardiovascular risk reduction). They were included because
they targeted diet and PA and reported both adiposity and
BP outcomes. Third, only articles published in English were
included. Publication bias should be considered when the
results are interpreted, although statistical publication bias
was not identified. Fourth, some heterogeneity was observed,
which might stem from the variety of study designs, eligibility, follow-up times, and intervention approaches (eg, intervention intensity). The effects of heterogeneity on the results
of meta-analysis were uncertain. Heterogeneous intervention
intensities and interventions with short follow-up periods
may have underestimated the effect of these prevention programs. Furthermore, methodological problems in the design,
conduct, or reporting of included studies may have affected
our meta-analysis results.
In conclusion, childhood obesity prevention programs
could effectively lower children’s BP in developed countries.
When compared with the control group, combined diet and PA
interventions performed better than the diet-only or PA-only
interventions in lowering BP. Such interventions might effectively lower BP without changes in adiposity outcomes.
Future obesity prevention studies are recommended to assess
other outcomes such as BP in addition to adiposity measures
in order to fully capture their health benefits.
Sources of Funding
This project is part of a comprehensive systematic review study funded
under contract 290-2007-10061-I from the Agency for Healthcare
Research and Quality, US Department of Health and Human
Services. The efforts of Dr Wang, Yang Wu, and Dr Cai were also
supported in part by the National Institutes of Health (research grants
1R01HD064685-01A1 and U54HD070725 from the Eunice Kennedy
Shriver National Institute of Child Health and Human Development).
The U54 project is cofunded by the National Institute of Child Health
and Human Development and the Office of Behavioral and Social
Sciences Research. Dr Cai received additional support from the
China Scholarship Council for her postdoctoral training and work
related to the present study at Johns Hopkins University.
Disclosures
None.
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Clinical Perspective
This systematic, quantitative analysis shows the beneficial effect of childhood obesity prevention programs on blood pressure. These prevention programs, in which physical activity or diet interventions were used, had a significant desirable effect
on blood pressure in children with or without favorable changes in adiposity outcomes. This indicates that evaluating only
adiposity outcomes might underestimate the benefits of these programs. Future such studies may assess blood pressure to
help to fully capture their beneficial effects.
Effect of Childhood Obesity Prevention Programs on Blood Pressure: A Systematic
Review and Meta-Analysis
Li Cai, Yang Wu, Renee F. Wilson, Jodi B. Segal, Miyong T. Kim and Youfa Wang
Downloaded from http://circ.ahajournals.org/ by guest on June 14, 2017
Circulation. 2014;129:1832-1839; originally published online February 19, 2014;
doi: 10.1161/CIRCULATIONAHA.113.005666
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2014 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circ.ahajournals.org/content/129/18/1832
Data Supplement (unedited) at:
http://circ.ahajournals.org/content/suppl/2014/02/19/CIRCULATIONAHA.113.005666.DC1
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SUPPLEMENTAL MATERIAL
Table S1. Characteristics of study populations and intervention approaches of included childhood obesity prevention studies in developed countries
Mean
Total
Study
RCT
%
Country
Baseline
age
N
Risk of
Intervention approaches*
Grade
BMI
girls
Bias
/(Range)
Walter,
Yes
US
1563
48.6
9.1
4
NR
Moderate
C
1985
Bush, 1989
Incorporated social learning strategies to encourage behavioral change
regarding diet and PA (improvement of cardiovascular fitness)
Yes
US
1041
54.0
10.5
4-6
NR
Low
C
Subjects received nutrition, exercise, anti-smoking lessons, health
screening and a “Health Passport”. Health newsletters were mailed to
parents throughout intervention
Nader, 1989
Yes
US
323
NR
12.1
5-6
19.2
Moderate
C
Children in program played soccer three days a week, engaged in
community service and/or creative writing. Training in self-monitoring
in regard to diet and sodium content along with self-monitoring for PA.
Lionis,
No
Greece
171
51.0
(13-14)
NR
20
Moderate
1991
D
School health education curriculum focused on nutrition, physical
fitness, and prevention of cigarette smoking; it
the
school
by
the
regular class teachers
with a team from a Health Center.
1 was taught
in
in
cooperation
Vandongen,
Yes
Australia
1147
51.3
(10-12)
6
17.9
Low
PA
1995
Arm A: Classroom sessions providing rational basis for activity
programs. Fitness program included relays, skipping and health
hustles.
C
Arm B: The fitness program as stated in Arm A and a school-based
nutrition program, which aimed to improve knowledge, attitudes
and eating habits.
D
Arm C: The school-based nutrition program and/or the home-based
nutrition program, which provide educational material for the child
and parents.
Nader, 1999
Yes
US
3714
48.0
8.7
3
17.6
Moderate
C
CATCH intervention: targeted consuming foods low in fat, saturated
fat and sodium via a multi-component program that included school
environmental changes, and a family component.
Skybo,
No
US
58
48.3
NR
3
NR
High
C
2002
American Heart Association Heart Power! Emphasized nutrition in
class discussions as well as importance of PA. Children then engaged in
PA such as jumping jacks or running in place.
Yin, 2005
Yes
US
601
52.0
8.7
3
19.4
Moderate
C
Youths were provided healthy snacks during after-school PA sessions
along with academic enrichment homework and assistance.
2 Scheffler,
No
Germany
160
NR
3.0
NR
16.0
High
PA
2007
Playful athletic exercise programs were designed. The exercises
targeted improving the pleasure of movement and training in the motor
basics like endurance, power, speed and skill.
Stock, 2007
No
Canada
360
55.3
NR
1-7
17.7
Low
C
Themes targeted exposure to nutritional information on foods and
beverages. Themes also included structured PA/aerobic fitness and
lessons on healthy body image and self-esteem.
Taylor,
No
2007
New
730
30.5
7.7
NR
17.8
Moderate
C
Zealand
APPLE: Encourage healthy eating with science lessons highlighting
adverse health effects of sugary drinks and fatty foods. Cooled water
filters installed in schools to promote drinking water. Initiatives were
set to promote more PA activity, and sports equipments were provided
for free time.
Reed, 2008
Yes
Canada
268
NR
(9-11)
4-5
18.9
Moderate
PA
Goal to deliver 15 min of moderate to intensive PA daily for 75 extra
min of PA per week in schools. Principals and teachers met with
facilitators to design program. Teachers also provided classroom
activities such as skipping, dancing, and resistance training.
Simon,
Yes
France
954
50.0
11.6
6
18.8
Moderate
2008
School education on physical activity and sedentary behaviors,
opportunities for physical activity were offered. Parents were asked to
3 PA
support the child's physical activity.
Angelopoul
Yes
Greece
646
55.7
10.3
5
20.2
Moderate
C
os, 2009
A student workbook and teacher manual, which covered themes
related to self-esteem, body image, nutrition, physical activity, fitness
and environmental issues.
Salcedo,
Yes
Spain
1044
51.5
(9-11)
4-5
18.5
Moderate
PA
2010
Activity program with sports using alternative equipment (pogo sticks,
frisbees, parachutes, etc). Primary care providers encouraged to focus
on behavioral targets for patients.
Hatzis,
No
Greece
1046
47.9
6.3
1
16.3
Moderate
C
2010
"Know Your Body" education material with major modifications to the
Mediterranean diet of Crete and the orthodox Christian church fasting
rituals.
Hollar,
No
US
2494
51
8.0
0-6
NR
Moderate
C
2010
Kriemler,
the school day.
Yes
2010
Robinson,
School provided diet, classroom curricula, and physical activity during
Switzerlan
502
51
(6-12)
d
Yes
US
1 and
17.1
Low
PA
5
261
100
9.4
NR
School-based stringent physical activity program and home daily
physical activity homework of about 10 minutes.
20.7
High
2010
PA
Daily 1-hour homework period and small snack, followed by 45 to 60
minutes of learning and practicing dance routines. Home-based screen
time reduction intervention designed to incorporate African or African
4 American history and culture.
Burguera,
No
Spain
90
59.7
13.9
7-9
22.6
High
C
2011
Subjects offered two nutrition and behavioral modification workshops.
Special emphasis on healthy lifestyle and self-responsibility.
Opportunities to participate in PA sessions if required.
Resaland,
No
Norway
256
51.2
9.2
4
17.3
High
PA
60 min/day of PA conducted by specialist PE teacher for 104 weeks
Yes
New
1348
50.2
(5-10)
NR
NR
Moderate
C
Energizer educated through information regarding replacing sugary
2011
Rush, 2012
Zealand
drinks with water and importance of eating breakfast. Canteen
makeovers were conducted to remove pastries and pies and to add
healthier options. Promotion of PA sessions with games and activities.
Tomlin,
NE
Canada
148
48.0
12.5
4-12
23.3
High
C
2012
Lessons on healthy eating and physical activity as well as extra
physical activity sessions. In addition, extra playground equipment
was provided.
*
All the studies had a concurrent control group except that the Tomlin, 2012 study used the baseline as control.
NE, natural experiment; NR, not reported; PA, physical activity; RCT, randomized control trial; US, United State; BMI, body mass index (Kg/m2); C, combined diet
and physical activity intervention; D, diet-only intervention; PA, physical activity-only intervention.
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