RESEARCH ARTICLE Open Access
E ec i eness and p ocess e alua ion in
obesi y and ype 2 diabe es p e en ion
p og ams in child en: a sys ema ic e iew
and me a-analysis
M. Se al-Co es
1,2
, P. De Miguel-E ayo
1,3*
, P. Zapa a
1,4
, M. L. Miguel-Be ges
1,2
and L. A. Mo eno
1,2,3
Abs ac
Backg ound: Obesi y in child en is one o he mos se e e public heal h challenges o he cu en cen u y and
Type 2 Diabe es Melli us (T2DM) equency is also escala ing. Mo e so, he impo ance o p ocess e alua ion (PE) in
complex in e en ions is inc easingly ecognized. The p esen e iew, aims o iden i y he e ec i eness in e ms o
body composi ion pa ame e s in a gene a ion o a icles o p e en obesi y and T2DM in child en. We hypo hesise
ha hose s udies epo ing PE applying he la es implemen a ion guidelines sugges ed by he esea che s would
po en ially show posi i e changes in body composi ion compa ed o hose no epo ing i . Addi ionally, we will
e alua e he implemen a ion deg ee o PE in hose a icles conside ing i and desc ibe he PE subcomponen s.
Las ly, we aim o assess he in e en ion a ge used and i s esul s.
Me hods: A li e a u e e iew was pe o med in pa allel by 2 independen e iewe s. A inal numbe o 41 s udies
we e selec ed o inclusion c i e ia.
Resul s: Me a-analysis o BMI and zBMI ound non-signi ican e ec s o he p oposed in e en ions. Sub-g oup
analysis e ealed only a signi ican e ec in s udies which pe o med PE. Mo eo e , PE was epo ed in 42%
e ec i e s udies and 57% non-e ec i e s udies. Fideli y and sa is ac ion we e he mos implemen ed PE
subcomponen s, al hough he e was a gene ally low g ade o PE use (7/41). The highes p opo ion o e ec i eness
(83%) was shown in in e en ions o physical ac i i y alone while he in e en ion mos used was 3-a m a ge (die ,
PA and BS).
(Con inued on nex page)
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* Co espondence: pila dm@uniza .es
1
G ow h, Exe cise, NU i ion and De elopmen (GENUD) Resea ch G oup,
Ins i u o Ag oalimen a io de A agón (IA2), Ins i u o de In es igación Sani a ia,
A agón (IIS A agón), Uni e sidad de Za agoza, 50009 Za agoza, Spain
3
CIBER Fisiopa ología de la Obesidad y Nu ición (CIBERobn), Ins i u o de
Salud Ca los III, Mad id, Spain
Full lis o au ho in o ma ion is a ailable a he end o he a icle
Se al-Co es e al. BMC Public Heal h (2021) 21:348
h ps://doi.o g/10.1186/s12889-021-10297-8
(Con inued om p e ious page)
Conclusions: O e all, obesi y and T2DM p e en ion s udies included in his e iew a e no e ec i e in e ms o BMI
and zBMI. Those s udies pe o ming PE epo ed o be e ec i e in e ms o BMI, while s udies no epo ing PE did
no ha e posi i e esul s in e ms o BMI and zBMI. In addi ion, none o he in e en ion s udies included all PE
indica o s and mos s udies, which included PE in hei in e en ions, did no p o ide ull epo o he PE
componen s, acco ding o he guidelines used o he p esen e iew. PROSPERO egis a ion numbe :
CRD42018093667.
Keywo ds: P ocess e alua ion, Obesi y, Type 2 diabe es melli us, Body composi ion, Heal h plan implemen a ion,
P ima y p e en ion
Backg ound
Obesi y has impo an e ec s on heal h in he sho ,
medium and long e ms whe e me abolic complica ions
a e common [1]. In child en, o e weigh and obesi y’s
p e alence has inc eased in e e y con inen o he wo ld
in ecen decades [2]. Cu en ly o e 1.5 billion adul s
and 170 million child en a e o e weigh o obese [3].
Obesi y in child en is one o he mos se e e global pub-
lic heal h challenges o he cu en cen u y [4]. Type 2
diabe es melli us (T2DM) equency is apidly escala ing,
wi h i al implica ions o mo bidi y and mo ali y.
Wo ldwide p e alence igu es o T2DM in 2019 es i-
ma es 463 million (9.3%) people a ec ed, escala ing o
578 million (10.2%) by 2030 and 700 million (10.9%) by
2045 [5]. As a esul o he inc easing a es o obesi y
and seden a y li es yle, younge popula ions a e
p omp ly diagnosed wi h T2DM [6] co esponding o
he ex ensi e sp ead o childhood obesi y [7].
Li es yle in e en ion p og ams o he ea men o
child en and adolescen s wi h obesi y had a long- e m
success a e lowe han 10% [8]. The ine iciency o p e-
en ion p og ams o li es yle in e en ion comp ehends
se e al ac o s including lack o mul idisciplina y ap-
p oaches, inc easing men al heal h ela ed issues o in-
su icien in ol emen o he pa en s, which migh
in e ac wi h he p og am’s adhe ence [9]. As T2DM is
one o he mos equen me abolic complica ions o
obesi y wi h impo an long- e m e ec s, combined ac-
ions o p e en bo h obesi y and T2DM could be
de eloped.
A numbe o esea ch ac i i ies aim o build and
e alua e e idence-based p og ams o p e en childhood
obesi y [10]. The school is usually ega ded as a sui able
and e ec i e se ing o ca y ou obesi y p e en ion p o-
g ams aiming o e alua e s uden s’ene gy balance-
ela ed beha io s (EBRBs) [11]. Howe e , mos o sys-
ema ic e iews conduc ed in Uni ed s a es and Eu ope
o school-based in e en ions p e en ing obesi y, p o-
mo e physical ac i i y (PA) and dec ease seden a y be-
ha io s, show mode a e e idence o e ec i eness [12,
13]. Mos o he obesi y p e en ion p og ams a e di i-
cul o implemen and e alua e due o he mul iple
in e ac ing componen s ha exis . Randomized con-
olled ials (RCT) o hese p og ams a e o en known
o i s di icul ies o ind ou he eason why he p o-
g am wo ked o did no wo k wi hou examining unde -
lying p ocesses [11]. Wi h public heal h depending on
he impac o hese p og ams and hei implemen a ion
in p ac ice, i is essen ial o in e p e whe he a p og am
was implemen ed as in ended, o wha ex end and how
hese concep s could modula e he e ec i eness o he
p og am [14]. Ve i ying ha he in e en ions a e deli -
e ed as planned as well as ac o s a ec ing implemen a-
ion, allows an accu a e in e p e a ion o in e en ion
ou comes and con ex by he esea che s and policy
make s in o de o op imize u he implemen a ion o
in e en ions in he u u e [15].
The impo ance o p ocess e alua ion (PE) in public
heal h in e en ion esea ch is g adually ecognized [16].
The use o PE is o obse e and eco d p og am imple-
men a ion as well as helping o unde s and he connec-
ion be ween speci ic p og am elemen s and p og am
ou comes. Se e al p ac ical amewo ks and models a e
a ailable o lead di e en p o essionals o he de elop-
men o an e alua ion plan wi h wide scope, including
PE. The e a e comp ehensi e and sys ema ic app oaches
o de eloping a PE plan o assess he implemen a ion o
a pa icula p e en ion p og am in e en ion. These ap-
p oaches a e di ided in di e en indica o s including e-
c ui men , each, ideli y, dose and sa is ac ion [16].
Howe e , he e is no ag eemen on wha is he ideal
s anda d o classi y he s udy o implemen a ion in o key
pa s, o ins ance dose and each, and i is no possible
o p oduce a de ini e s anda d among he a ious ame-
wo ks used a p esen . Wi hou he p esence o PE, i is
challenging o di e en ia e be ween ou comes ha a e,
in heo y, ela ed o a lack o ideli y and hose ones a -
ibu ed o he incompe ence o he in e en ion o
achie e he expec ed esul s. Unsuccess ul a emp s o
pe o m an in e en ion as in ended p omp s o mis-
leading esul s and conclusions abou he e ec i eness
o he in e en ion and is conside ed no alid o epli-
ca e o use in u u e in es iga ions in he scien i ic com-
muni y. Mul icomponen p e en ion p og ams a e
Se al-Co es e al. BMC Public Heal h (2021) 21:348 Page 2 o 17
complex in e en ions, designed o wo k syne gis ically.
Fo his eason, PE con ibu es o in e p e complex ou -
come e ec s and helps o unde s and he analysis o he
in e en ion deli e ed [17,18].
RCTs a e conside ed he bes s udy design o es ablish
he e ec i eness o in e en ions wi h ce ain deg ee o
complexi y. Howe e , he e is no in o ma ion a p esen
o how an in e en ion migh be ep oduced in a pa -
icula con ex , o whe he ial ou comes will be epli-
ca ed. To ou knowledge, he e is no sys ema ic e iew
and me a-analysis ocusing on he e alua ion o e ec -
i eness and he de elopmen and epo o PE o in e -
en ions in heal h p og ams p e en ing obesi y and
T2DM in child en. The p esen e iew, aims o iden i y
he e ec i eness in e ms o body composi ion pa ame-
e s in a gene a ion o a icles o p e en obesi y and
T2DM in child en. We hypo hesise ha hose s udies
epo ing PE applying he la es implemen a ion guide-
lines sugges ed by he esea che s [19,20] would po en-
ially be mo e e ec i e in e ms o changes in body
composi ion compa ed o hose no epo ing i . Add-
i ionally, we will e alua e he implemen a ion deg ee o
PE in hose a icles conside ing i and desc ibe he PE
subcomponen s. Las ly, we aim o assess he in e en ion
a ge used and i s esul s.
Me hods
Li e a u e sea ch
A li e a u e e iew was pe o med in pa allel by 2 inde-
penden e iewe s and a hi d independen e iewe was
in ol ed when inconsis ency o disag eemen wi h he
selec ion o a icles was iden i ied. The p o ocol was de-
eloped acco ding o he p e e ed epo ing i ems o
sys ema ic e iews and me a-analysis (PRISMA) guide-
lines adap ed o he design o he p esen s udy [21].
Mo eo e , he sys ema ic li e a u e sea ch was egis e ed
on he In e na ional P ospec i e Regis e o Sys ema ic
Re iews (PROSPERO, egis a ion numbe :
CRD42018093667). An in-dep h sea ch o elec onic da-
abases was conduc ed in he PubMed, Scopus and
Embase. (Mesh®) e ms we e used du ing he sea ch
s a egy in PUBMED, based on medical subjec headings
and ex wo ds o pee pape s iden i ied. Sea ch e ms
and ex wo ds a e desc ibed in ull epo as ollows:
((((((“Diabe es Melli us, Type 2”[Mesh]) OR “Risk”[-
Mesh]) OR (“Obesi y”[Mesh] OR “Pedia ic Obesi y”[-
Mesh] OR “Obesi y, Abdominal”[Mesh] OR “Obesi y
Managemen ”[Mesh])) AND “Heal h Plan Implemen a-
ion”[Mesh]) OR (“p e en ion and con ol”[Subheading]
OR “P ima y P e en ion”[Mesh])) OR (“Ou come and
P ocess Assessmen (Heal h Ca e)”[Mesh] OR “P ocess
Assessmen (Heal h Ca e)”[Mesh])) AND “Body Compo-
si ion”[Mesh])))))). The e e ence lis s o all included pa-
pe s we e doublechecked o iden i y po en ial missing
a icles ha migh ha e been missed du ing he ini ial
sea ch. The ocus was on he s udies assessing he e ec -
i eness on changes in body composi ion: zBMI (body
mass index z sco e) and/o BMI (body mass index) and/
o wais ci cum e ence as well as he conside a ion o
any o he PE subcomponen s in he heal h p og am
in e en ion.
O he isk ac o s such as high and inc eased blood
p essu e, high and inc eased blood glucose le el, insulin
le el, a - ee mass, pe cen age o and oid mass and pe -
cen age obesi y a we e also conside ed in he selec ion
o a icles as seconda y ou comes. A icles we e also
conside ed i any o he p ima y ou comes we e e e ed
as seconda y ou come and ice e sa.
Da a ex ac ion and quali y assessmen
The sys ema ic selec ion p ocess was pe o med in 3
phases (Fig. 1). Final esul s a e p esen ed in he desc ip-
ion o pape s. The inclusion c i e ia we e 1) p esence o
obesi y and/o T2DM pa ame e s as p ima y o second-
a y ou comes, 2) die , physical ac i i y (PA) and beha -
io al suppo (BS) alone o combined wi h o he kind o
in e en ion, 3) popula ion child en age 6–12 yea s old,
4) w i en in English, 5) published om 2008 and 6) ex-
clusi ely andomized con ol ials. Any disc epancies
wi h he inclusion c i e ia be ween e iewe s was dis-
cussed o each a common inal consensus.
As a as exclusion c i e ia is conce ned i was ex-
cluded om he e iew 1) clinical popula ions (diso de s,
disabled, ins i u ionalized) o p esence o Type 1 dia-
be es melli us and o he ypes o diabe es (E.g. insulin-
dependen -diabe es, p egnancy diabe es, ges a ional dia-
be es), 2) no in e en ion applied, 3) child en younge
han 6 yea s and olde popula ions han 12 yea s old, 4)
no w o e in English language, 5) published be o e 2008
and 6) non andomized con ol ials and unpublished
s udies.
S udies we e classi ied depending on an es ablished
p ocess acco ding o he QUALYST (S anda d Quali y
Assessmen C i e ia o e alua ing p ima y esea ch pa-
pe s om a a ie y o ields) checklis o measu ing
quali y by 2 independen e iewe s. The men ioned
checklis has 14 ques ions which ha e o be answe ed
wi h “yes”,“pa ial”,“no”o “no applicable”depending
on he quali y o each a icle. The summa y sco e is he
o al o he accumula ed answe s ansc ibed in o a
numbe be ween 0 and 1 indica ing he quali y o each
publica ion, being 1 he highes possible esul . When
compa ing he me hodological sco e be ween he 2 e-
iewe s, a hi d e iewe in e ened in he e en o a nu-
me ical di e ence o mo e han 0.2 wi hin he same
publica ion e alua ed.
The Coch ane Collabo a ions Tool o assessing isk
o bias in andomized ials [22] and he Coch ane
Se al-Co es e al. BMC Public Heal h (2021) 21:348 Page 3 o 17
Fig. 1 PRISMA low cha o sea ch s a egy p ocess
Se al-Co es e al. BMC Public Heal h (2021) 21:348 Page 4 o 17
Handbook o Sys ema ic Re iews o In e en ions [23]
we e used o assess me hodological isk o bias o an-
domized con ol ials, which ecommend he explici
epo ing o he ollowing domains: andom sequence
gene a ion, alloca ion sequence concealmen , blinding
(pa icipan s and pe sonnel), blinding (ou come assess-
men ), comple eness o ou come da a, selec i e epo ing
and o he sou ces o bias. Each i em was gi en a sco e
as being a high, low o unclea isk o bias as pe c i-
e ia p o ided [23].
Me a-analysis
Wi hin included e iews, a me a-analysis o 30 s udies
epo ing BMI and 16 s udies epo ing zBMI in an
in e en ion popula ion e sus a compa a o popula ion
we e unde aken. Me a-analysis o subg oups acco ding
o PE epo ing was pe o med in o de o iden i y dis-
pa i ies in s udies be ween he 2 g oups including PE o
no and he epo o i s e ec i eness. Wi hin included
s udies o me a-analysis, G eening e al. [24] and Kala-
ainen e al. [25] we e no included on BMI and Lison
e al. [26] was no conside ed as no mee ing he inclu-
sion c i e ia o BMI and zBMI.
S anda dized mean di e ence was he app op ia e
me ic o he da a ype. The in e en ions compa ed
in me a-analysis we e changes in BMI and zBMI in
he in e en ion g oup e sus changes in BMI and
zBMI in he con ol g oup. Sub-g oup analysis we e
ca ied ou in each ou come s udying PE as ac o co-
a ia e o obse e po en ial di e ences be ween he
g oups implemen ing PE e sus hose no implemen -
ing i .
Da a on mean di e ence in BMI and zBMI be ween
in e en ion and compa a o g oups and s anda d de i-
a ion o he di e ence om s udies ha epo ed da a in
a compa able way we e analyzed in OpenMe aAnalys
so wa e using in e se a iance andom-e ec s me a-
analysis. Con inuous andom-e ec s De Simonian-Lai d
analysis we e selec ed o e lec di e en s udy g oups,
se ing, and age among he included s udies.
The con idence le el used was 95.0. I2 s a is ic was
used o assess he he e ogenei y o he s udies [23]. This
s a is ic explains he a iance wi hin s udies as a p opo -
ion o he o al a iance. < 25% alue showed low he -
e ogenei y, 25 o 50% alue showed mode a e
he e ogenei y, > 50 o 75% alue showed high he e ogen-
ei y and > 75% alue indica ed e y high he e ogenei y.
Associa ed p- alues we e also displayed, and signi icance
le el was se a p< 0.05, showing he e ogenei y when p-
alues we e below 0.05.
P ocess e alua ion indica o s and c i e ia
The p esen sys ema ic e iew has e alua ed he PE
implemen a ion based on he guidelines p o ided by
Saunde s e al. [19] and Moo e e al. [20]. In sho ,
bo h guidelines sha e he ele ance o assessing idel-
i y, dose and each indica o s. Saunde s e al. p o ides
a mo e de ailed lis o indica o s and i s use, consid-
e ing ec ui men and con ex and 2 dose ca ego ies
(deli e ed and ecei ed). Moo e e al. desc ibed a
amewo k o PE buil on 3 hemes desc ibed in he
2008 MRC guidance (implemen a ion, mechanisms
and con ex ) [27]. When applying he c i e ia o hese
guidelines in ou a icles, we obse ed ha ideli y
was conside ed mainly om he ca egi e s eedback
o assess he ex en o he in e en ion implemen a-
ion acco ding o he ini ial s udy p og am; mo eo e ,
dose was epo ed o see he mode o he p og am
deli e y in e ms o aining, in e en ion compo-
nen s, ma e ials and con en h ough con ol sessions
om he s a (deli e ed), and also in e ms o use
and eac ion o child en and pa en s o he ac i i ies
deli e ed h ough ques ionnai es ( ecei ed). Finally,
each e alua ed he pa icipan s a endance and o as-
sess he p og am’s e ec on he a ge ed g oup, also
h ough ques ionnai es. Howe e , he e migh be di -
e en e ec s depending on which con ex he in e -
en ion is pe o med.
Resul s
Desc ip ion o pape s
The selec ion p ocess is displayed in Fig. 1. In summa y,
he sc eening p ocess was di ided in 3 s ages: iden i ica-
ion, eligibili y and inclusion. Fi s , a e dele ing 24 du-
plica es, iden i ica ion s age le 273 a icles o
inclusion. A e i le and abs ac sc eening, 46 a icles
we e included. Finally, he inclusion s age showed, a e
ull ex eading, a inal 41 (15%) a icles [24–26,28–65]
which main cha ac e is ics a e summa ized in Table 1.
F om he selec ed a icles, 39 o hem ocused on obesi y
and 2 a icles on T2DM, al hough 7 a icles om obesi y
included glucose and insulin le els in hei main e-
sea ch pa ame e s.
E ec i eness in body composi ion pa ame e s
Table 2shows he e ec i e pa ame e s whe e some
deg ee o imp o emen was epo ed. The analysis
shows 26/41 (63%) s udies epo ed o be e ec i e;
F om hose 26 e ec i e a icles, 3/26 (11%) included
PE in hei in e en ions, meaning ha , a leas , 1
o he PE subcomponen s has been used and e-
po ed as pa o he PE implemen a ion. The mos
epea ed s udied ou comes when epo ing e ec i e-
ness we e BMI and zBMI alone (12/26) o combined
o one ano he o wi h o he body composi ion pa-
ame e s (9/26). Tha is 81% o he o al e ec i e
a icles.
Se al-Co es e al. BMC Public Heal h (2021) 21:348 Page 5 o 17

Table 1 Main cha ac e is ics o he included s udies
Au ho /Yea Coun y Sample
Size
Gende Mean
Age
Se ing In e en ion
du a ion
C oke e al. 2012 [28] UK 72 No epo ed 10.3 ± 1.6 Hospi al 12 mon hs
Danielsen e al. 2011 [29] No way 49 24 male; 25 emale 10.6 ± 1.2 Family based/p ima y ca e 12 mon hs
Da is e al. 2012 [30] USA 222 93 male; 129 emale 9.4 ± 1.1 School 10–15 weeks
Ea he e al. 2013 [31] Aus alia 213 108 male; 105 emale 10.7 ± 0.6 School 8 weeks
Elde e al. 2013 [32] UK 541 243 male; 298 emale 6.6 ± 0.7 Rec ea ion Cen e 2 yea s
Foley e al. 2016 [33] New Zealand 251 142 male; 109 emale 11.25 Family based/Home 6 mon hs
Ge a ds e al. 2015 [34] Ne he lands 86 38 male; 48 emale 7.2 ± 1.4 School 14 weeks
Hollis e al. 2016 [35] Aus alia 1150 male 543; emale 583 12.0 School 24 mon hs
Jones e al. 2015 [36] Aus alia 37 male 20; emale 17 9.7 ± 0.8 School 7 mon hs
Kala chian e al. 2009 [37] USA 192 83 male; 109 emale 10.2 ± 1.2 Medical Cen e 18 mon hs
Ko acs e al. 2009 [38] Hunga y 51 23 male; 28 emale 9.9 ± 1.3 School 15 weeks
La sen e al. 2016 [39] Denma k 115 51 male; 64 emale 12.0 ± 0.4 Day camp 1 yea
Li e al. 2010 [40] China 4700 2242 emale; 2458 male 9.3 ± 0.7 School 2 yea s
Lison e al. 2012 [26] Spain 110 no epo ed 11.9 ± 2.2 Hospi al 6 mon hs
Maddison e al. 2011 [41] New Zealand 322 male 235; emale 87 11.6 ± 1.1 School 6 mon hs
Maddison e al. 2012 [42] New Zealand 322 male 235; emale 87 11.6 ± 1.1 School 24 weeks
Maddison e al. 2014 [43] New Zealand 251 male 142; 109 emale 11.2 School/Communi y cen e 24 weeks
Magnusson e al. 2012 [44] Iceland 321 173 male; emale 148 7.3 ± 0.3 School 2 yea
Mon ei o e al. 2015 [45] B azil 32 16 emale; 18 male 11.0 ± 1.5 Family based/Communi y 20 weeks
Neme e al. 2008 [46] Is ael 22 14 emales; 8 males 10.2 ± 0.5 Heal h cen e and nu i ional clinic 3 mon hs
Neme e al. 2011 [47] Is ael 795 437 male; 358 emale 5.2 ± 0.3 Kinde ga ens 12 weeks
Nowicka e al. 2009 [48] Sweden 76 40 male; 36 emale 10.5 Obesi y Clinic 6 mon hs
Sa die e al. 2013 [49] Mexico 830 415 male; 415 emale 9.7 ± 0.7 School 18 mon hs
Simon e al. 2008 [51] F ance 954 527 males; 527 emale 11.7 ± 0.7 School 4 yea s
Sighn e al. 2009 [50] Ne he lands 1108 549 male, 559 emale 12.7 School 20 mon h
Wa e s e al. 2018 [52] Aus alia 2965 No epo ed 8.5 School 3.5 yea s
Williamson e al. 2012 [53] USA 2060 male 854; Female 1206 10.5 ± 1.2 School 28 mon hs
Yackobo i ch Ga an e al. 2009 [54] Is ael 162 81 male; 81 emale 8.3 ± 1.6 Medical Cen e 12 weeks
Yin e al. 2012 [55] USA 574 270 male; 304 emale 8.7 ± 0.5 School 3 yea s
Casazza e al. 2012 [56] USA 26 26 emale 12.4 ± 0.3 Family based 16 weeks
Copeland e al. 2013 [57] USA 699 No epo ed 13.5 No epo ed 24 mon hs
G eening e al. 2011 [24] USA 450 234 male; 216 emale 8.34 ± 1.3 School 9 mon hs
Gu in e al. 2008 [58] USA 206 97 male; 109 emale 8.5 ± −0.6 School 3 yea
Johns on e al. 2009 [59] USA 60 33 male; 27 emale 12.3 ± 0.7 School 2 yea s
Kala ainen e al. 2011 [25] Finland 70 28 male; 42 emale 8.1 ± 0.8 Family o ien ed 6 mon hs
Khan e al. 2014 [60] USA 220 117 male; 103 emale 8.8 ± 0.5 School 9 mon h
Lau e al. 2014 [61] Hong Kong 48 36 male; 12 emale 10.4 ± 0.9 School 6 weeks
Meye e al. 2014 [62] Swi ze land 289 153 male; 136 emale 10.6 ± 0.3 School 3 yea
Ma ild e al. 2012 [63] Sweden 66 28 male; 38 emale 10.8 ± 1.1 School 12 mon h
Rush e al. 2011 [64] New Zealand 1348 686 male; 662 emale 7.5 School 2 yea s
Velazquez Lopez e al. 2014 [65] Mexico 49 23 male; 26 emale 11.2 ± 2.7 Family medicine Uni 16 weeks
Se al-Co es e al. BMC Public Heal h (2021) 21:348 Page 6 o 17
Table 2 Type o in e en ion applied, s udied ou come and e ec i eness
In e en ion applied S udied Ou come E ec i e E ec i e Ou come
PA,D and BS PA and BS PA and D D and BS D PA BS
C oke e al. 2012 [28]√BMI, WC, %BF X
Danielsen e al. 2011 [29]√BMI √BMI
Da is e al. 2012 [30]√zBMI, %BF, BG, IL √zBMI, %BF, BG, IL
Ea he e al. 2013 [31]√zBMI, BMI √zBMI, BMI
Elde e al. 2013 [32]√zBMI,BMI,WC,%BF X
Foley e al. 2016 [33]√zBMI,BMI X
Ge a ds e al. 2015 [34]√zBMI,WC X
Hollis e al. 2016 [35]√zBMI,BMI √zBMI,BMI
Jones e al. 2015 [36]√zBMI,BMI,WC,%BF √zBMI,BMI,WC,%BF
Kala chian e al. 2009 [37]√BMI,WC √BMI, WC
Ko acs e al. 2009 [38]√BMI,WC,BP √BMI,WC,BP
La sen e al. 2016 [39]√zBMI,BMI,WC,BG √zBMI,BMI,WC BG
Li e al. 2010 [40]√zBMI,BMI,%BF √zBMI,BMI,%BF
Lison e al. 2012 [26]√zBMI,BMI,WC,%BF √zBMI,BMI, WC, %BF
Maddison e al. 2011 [41]√zBMI,BMI,WC,%BF √zBMI,BMI,WC,%BF
Maddison e al. 2012 [42]√BMI,%BF √BMI,%BF
Maddison e al. 2014 [43]√zBMI,BMI,WC,%BF X
Magnusson e al. 2012 [44]√BMI,WC,%BF X
Mon ei o e al. 2015 [45]√%BF,FFM,%AF √%BF,FFM;%AF
Neme e al. 2008 [46]√BMI,%BF √BMI, %BF
Neme e al. 2011 [47]√BMI X
Nowicka e al. 2009 [48]√zBMI,BMI X
Sa die e al. 2013 [49]√BMI √BMI
Simon e al. 2008 [51]√BMI √BMI
Sighn e al. 2009 [50]√BMI,WC X
Wa e s e al. 2018 [52]√zBMI,BMI X
Williamson e al. 2012 [53]√zBMI,%BF √%BF
Yackobo i ch Ga an e al. 2009 [54]√BMI,%BF √BMI,%BF
Yin e al. 2012 [55]√%BF √%BF
Casazza e al. 2012 [56]√zBMI,BMI,%BF,BG X
Copeland e al. 2013 [57]√BMI,WC,%BF X
G eening e al. 2011 [24]√BMI,WC,%BF √BMI,%BF
Gu in e al. 2008 [58]√%BF √%BF
Johns on e al. 2009 [59]√zBMI,BMI √zBMI,BMI
Kala ainen e al. 2011 [25]√BMI, WC √BMI,WC
Khan e al. 2014 [60]√zBMI,BMI,%BF √zBMI,BMI,%BF
Lau e al. 2014 [61]√BMI X
Meye e al. 2014 [62]√%BF X
Ma ild e al. 2012 [63]√BMI √BMI
Rush e al. 2011 [64]√BMI,%BF,BP X
Velazquez Lopez e al. 2014 [65]√BMI,%BF,BG √BMI,%BF,BG
*BMI body mass index, *BP Blood p essu e, *BG Blood glucose, *FFM a - ee mass, *IL insulin le els, *WC wais ci cum e ence *%BF pe cen age o body
a , *%AF pe cen age o and oid a
Se al-Co es e al. BMC Public Heal h (2021) 21:348 Page 7 o 17
zBMI and BMI me a-analysis and sub-g oups analysis
conside ing PE
Figu e 2shows he o e all s udy esul s and plo he glo-
bal e ec o changes in BMI. Figu e 3shows he sub-
g oup s udies acco ding o he pe o mance o PE. Fig-
u es 4and 5show he same o e all and sub-g oup ana-
lysis, in his case, wi h zBMI. Me a-analysis o he 30
s udies which epo ed changes om baseline o ollow
up in BMI ound non-signi ican e ec s be ween con ol
and in e en ion g oups (O e all mean di e ence in
BMI: −0.055; 95% CI, −0.116 o 0.006). The esul s
main ained he e y high he e ogenei y in BMI s udies
(I2 = 90.27%, p< 0.001). Sub-g oup analysis o zBMI e-
sul s showed signi icance when compa ing s udies in-
cluding PE (−0.301 (−0.531, −0.071)) e sus no PE
(0.064 (−0.086, 0.214)). He e ogenei y wi hin s udies
was e y high (I2=. 90.27%; p< 0.001). Me a-analysis o
he 16 s udies which epo ed changes om baseline o
ollow up in zBMI ound non-signi ican e ec be ween
s udies (O e all mean di e ence in zBMI: −0.055; 95%
CI, −0.116 o 0.006). He e ogenei y among s udies was
high (I2 = 61.18%, p< 0.001). The sub- g oup analysis e-
sul s e ealed non-signi ican di e ences in PE (No PE:
−0.038 (−0.097, 0.021); PE -0.115 (−0.361, −0.132). In
sub-g oup analysis, he esul s main ained he high he -
e ogenei y in he PE s udies (sub-g oup No PE: I2 =
56.23%, p= 0.009; sub-g oup PE: I2 = 75.77%, p= 0.006).
P ocess e alua ion inclusion and indica o s desc ip ion
In he p esen e iew all indica o s ha e been examined
and displayed in Table 3. PE was included in 17% o he
s udies (7/41). Fideli y and sa is ac ion in 4/7 (57%) s ud-
ies we e he indica o s conside ed he mos , ollowed by
dose 3/7 (43%), each 2/7 (29%) and ec ui men 1/7
(13%) espec i ely.
We also analysed how he PE indica o s we e p e-
sen ed in each pape . Ea he e al. [31] epo edPE
in a sepa a e pa ag aph wi hin he me hods sec ion
Fig. 2 Fo es plo o he o e all s udies using BMI
Se al-Co es e al. BMC Public Heal h (2021) 21:348 Page 8 o 17
and ocused on in e en ion wo ke s and pa en s e-
c ui men , e en ion, adhe ence and sa is ac ion by
comple ing e alua ion ques ionnai es by eache s and
s uden s. Rec ui men and e en ion we e again e al-
ua ed sepa a ely wi h no signi ican di e ences be-
ween s udy g oups. Elde e al. [32] desc ibed PE in
hei me hodology, examining p ocess da a associa ed
o in e en ion ideli y wi h di e en ideli y mea-
su es o each amily: “ abula ions o he numbe
and ypes o con ac s comple ed”and desc ibes i in
a able wi h no u he men ion. Foley e al. [33]
conside ed PE h oughou he a icle and akes on a
comp ehensi e analysis o a gene al implemen a ion
o PE. They ocused on PE in e en ion a 3 le els
(“ om in es iga i e eam o communi y wo ke ,
om communi y wo ke o p ima y ca egi e and
om p ima y ca e gi e o child”). Dose and sa is ac-
ion we e assessed by in e iew wi h he communi y
wo ke s which conclusions h ow ha i was a “poo
up ake o in e en ion componen s, and weak e i-
cacy o he in e en ion i sel ”. Ge a ds e al. [34]
amed PE in hei esul s. Fi s , hey measu ed pa -
en al a endance in he g oup and elephone sessions
and added PE ques ions in he 4-mon h ques ion-
nai e. Then, he pa icipa ing pa en s comple ed a
sa is ac ion ques ionnai e. The epo s showed a
“high each as majo i y o lessons which we e
planned ac ually ook place and he pa en s who did
isi a leas one g oup session, 81% (pa en s o 25
child en) we e p esen a 5 o mo e sessions”and
pa en s had a good imp ession o he p og am and
a ed i on 7.7 on a 10-poin scale. Maddison e al.
[43] epo ed ideli y sepa a ely o PE in he me hods
sec ion. Fideli y was assessed by moni o ing he ses-
sions pe o med by a esea che om he communi y
wo ke s wi h eedback o ensu e all componen s
we e deli e ed. P ima y ca egi e s also comple ed a
su ey o de e mine hei pe cep ions o he
Fig. 3 Fo es plo o p ocess e alua ion on s udies using BMI. Subg oup A No p ocess e alua ion; Subg oup B P ocess e alua ion
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Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in
published maps and ins i u ional a ilia ions.
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