Energy balance-related behaviours associated with overweight and obesity in preschool children: a...

Energy balance-related behaviours associated withoverweight and obesity in preschool children:a systematic review of prospective studies

S. J. te Velde1, F. van Nassau2, L. Uijtdewilligen2, M. M. van Stralen2, G. Cardon3, M. De Craemer3,Y. Manios4, J. Brug1 and M. J. M. Chinapaw2 on behalf of the ToyBox-study group

1EMGO Institute for Health and Care

Research and the Department of

Epidemiology and Biostatistics, VU University

Medical Center, Amsterdam, The Netherlands;2EMGO Institute for Health and Care

Research, Department of Public and

Occupational Health, VU University Medical

Center, Amsterdam, The Netherlands; 3Ghent

University, Department of Movement and

Sports Sciences, Ghent, Belgium;4Department of Nutrition and Dietetics,

Harokopio University, Athens, Greece

Received 16 May 2011; accepted 7 October

2011

Address for correspondence: Saskia te Velde,

EMGO Institute for Health and Care Research

and the Department of Epidemiology and

Biostatistics, VU University Medical Center,

Van der Boechorststraat 7, 1081 BT

Amsterdam, The Netherlands.

E-mail: [email protected]

SummaryThe current review aimed to systematically identify dietary, physical activity andsedentary behaviours in preschool children (4–6 years of age) that are prospec-tively related to overweight or obesity later in childhood. Prospective studiespublished between January 1990 and June 2010 were selected from searches inPubMed, EMBASE, PsycINFO, CINAHL and Cochrane Library. Studies exam-ining the prospective association between at least one relevant behaviour mea-sured during preschool period (children aged 4–6 years at baseline) in relation toat least one anthropometric measurement at follow-up (age <18 years) wereincluded. Harvest plots were used to summarize the results and draw conclusionsfrom the evidence.Of the 8,718 retrieved papers, 23 papers reporting on 15 different study sampleswere included in this review. Strong evidence was found for an inverse associa-tion between total physical activity and overweight. Moderate evidence wasobserved for a positive association between television viewing and overweight.Because of the heterogeneity in the assessed dietary behaviours, insufficient evi-dence was found for an association between dietary intake or specific dietarybehaviours and overweight. These results suggest that interventions aiming toprevent overweight among preschool children should focus on promotion oftotal physical activity and limitation of screen time and that further research isneeded to establish whether and which dietary behaviours are important forobesity prevention in this age group. However, despite the lack of evidence fordietary behaviours from the present review, future interventions may alreadytarget specific dietary behaviours that are highly prevalent and for which there aclear rationale as well as preliminary evidence that these behaviours are associ-ated with overweight.

Keywords: BMI, dietary behaviour, physical activity, preschoolers.

obesity reviews (2012) 13 (Suppl. 1), 56–74

Introduction

The still-increasing prevalence of overweight and obesity inchildren worldwide is a threat to public health (1). Even

among children below 5 years old, the prevalence rates ofoverweight increased from 7.9% in 1990 to 10.6% in 2005in developed countries, and it was predicted that thisrate will further increase to 14.1% in 2020 (2). Effective

obesity reviews doi: 10.1111/j.1467-789X.2011.00960.x

56 © 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74

interventions are needed to reverse these anticipated trends.Especially, because childhood obesity is associated withserious adverse psychological (3), social and physical healthconsequences in childhood (4) and has also been associatedwith increased comorbidities in adulthood (5,6). Earlychildhood may be a critical period for preventing over-weight and obesity (7). During this period children learnwhat, when and how much to eat and develop their foodpreferences (8,9). At this age, children also refine theirmotor skills in a wide variety of activities, and motor skillproficiency has been shown to predict adolescent physicalactivity (10).

Although it is known that both sides of the energybalance, i.e. energy intake and energy expenditure, areimportant for weight management, it is not known whatspecific behaviours play the most important role in pre-school children. Previous studies suggest that short sleepduration, insufficient physical activity, excessive television(TV) viewing and high intakes of sugar-sweetened bever-ages are associated with the development of overweight(11,12). In a narrative review, Reilly also concluded thatphysical activity may protect against overweight, while sed-entary behaviour is obesogenic in preschool children (13).However, the evidence for associations of specific physicalactivity, sedentary and dietary behaviours during youngchildhood and the development of overweight later inchildhood has never been systematically and simulta-neously reviewed.

Therefore, one of the aims of the European Commission-funded ToyBox study (14) was to systematically reviewprospective studies addressing the relationship betweenenergy balance-related behaviours and overweight among4–6-year-old children. Evidence on what behaviours areprospectively associated with childhood overweight iscrucial for the development of effective overweight preven-tion strategies. The current review summarizes the existingevidence on this topic and provides recommendations forfuture intervention development.

Methods

Literature search

A systematic search was carried out in five electronic data-bases (PubMed, EMBASE, PsycINFO, CINAHL andCochrane Library) to identify relevant studies from January1990 up to June 2010. The search strategy focused onsearch terms standing for population (e.g. ‘preschool’), inAND combination with terms for overweight/obesity (e.g.‘body composition’, ‘overweight’), in AND-combinationwith terms for at least one energy balance-related behav-iour (e.g. ‘screen time’ OR ‘physical activity’ OR ‘eating’).These terms were used as MeSH headings and as free text

words. The search strategy for the database of PubMed isshown in Table 1.

Eligibility criteria

The current review was restricted to: (i) prospectivestudies – observational cohorts and intervention studies;(ii) examining the relation between at least one energybalance-related behaviour measured during the preschoolperiod (children aged 4–6 years at baseline) in relationto (iii) at least one anthropometric measurement atfollow-up (age <18 years). Anthropometric measurementscould include categorical or continuous markers of bodycomposition such as body mass index (BMI) or skinfoldthickness. Only full-text papers published in English wereincluded.

The following exclusion criteria were applied: (i) studiesaddressing nutrition disorders, malnutrition or dentalhealth; (ii) studies only reporting parental behaviours (e.g.feeding practices); and (iii) studies including a selectedgroup of children with a specific disease or health problemonly.

Selection process

Two reviewers (FN, GC) independently checked allretrieved titles and abstracts. Selected abstracts werereviewed by FN and LU, independently, and full paperswere retrieved subsequently. A third reviewer (MC)checked for inconsistencies.

Data extraction

FN and LU independently performed data extraction usinga structured form including author, year of publication,study sample, follow-up period, type of energy balance-related behaviour, type of measures (objective, valid/reliable method or report) and main findings. Disagreementbetween the reviewers with regard to the extracted datawas discussed until consensus was reached.

Quality assessment

The methodological quality of each study was scored usinga 12-item quality assessment scale derived from previouslyused quality assessments in systematic reviews (15,16). Ascan be seen in Table 2, this scale is categorized in fourdimensions: (i) study population and participation at base-line (3 items); (ii) study attrition (4 items); (iii) data collec-tion (2 items); and (iv) data analysis (3 items). Further, thecriteria distinguish between informativeness (I, n = 5) andvalidity/precision (V/P, n = 7) of the study. Criteria have a‘yes’ (‘+’), ‘no’ (‘-’) or ‘don’t know’ (‘?’) answer format. Apaper received a positive score when it met the quality

obesity reviews Review of energy balance behaviours in preschool children S. J. te Velde et al. 57

© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74

criterion for a specific item. A negative score was given ifthe paper did not meet the specific quality criterion. Aquestion mark was given in case of none or unclear/incomplete description of the item. If the study referred toanother publication describing the design or other relevantinformation about the study in question, the additionalpublication was read to score the criterion of concern. Ifnecessary, authors were contacted by email to ask for addi-tional information to score the criterion of concern. Twoindependent reviewers (FN and LU) performed the meth-odological quality assessment, reaching an agreement of>90%. Disagreements were discussed and resolved. Foreach study, a total methodological quality score was calcu-lated by counting the number of items scored positively onthe V/P criteria. A quality score (percentage of positiveratings) was assigned to each study, resulting in a possiblescore of 0–100%. A study was considered to have highmethodological quality if the methodological quality scorewas >70%. A lower score was defined as low methodologi-cal quality.

Strength of the evidence

Based on the best evidence synthesis (15), the evidence forthe relationship between measured energy balance-relatedbehaviours and overweight was rated as:

• Strong evidence: consistent findings in multiple (�2)high methodological quality studies.

• Moderate evidence: consistent findings in one highquality and at least one low methodological quality studyor consistent findings in multiple low methodologicalquality studies.

• Insufficient evidence: only one study available orinconsistent findings in multiple (�2) studies.

Similar to other reviews applying the best evidence syn-thesis, results were considered to be consistent when atleast 75% of the studies showed results in the same direc-tion. If two or more high-quality studies were available, thestudies of low methodological quality were disregarded inthe evidence synthesis.

Table 1 Search strategy for the database of PubMed

Search

#1 ‘Child, Preschool’[Mesh] OR young children[tiab] OR toddler*[tiab] OR early child*[tiab] OR preschool*[tiab]#2 ‘Body Weights and Measures’[Mesh] OR ‘Body Composition’[Mesh] OR obes*[tiab] OR BMI[tiab] OR body mass[tiab] OR weight[tiab] OR

overweight[tiab] OR adipos*[tiab] OR body composition[tiab]#3 energy balance*[tiab]#4 ‘Television’[Mesh] OR ‘Leisure Activities’[Mesh] OR ‘Computers’[Mesh] OR ‘Internet’[Mesh] OR ‘Sedentary Lifestyle’[Mesh] OR

‘Reading’[Mesh] OR sedentary[tiab] OR screen time[tiab] OR television[tiab] OR TV[tiab] OR game*[tiab] OR gaming[tiab] OR video[tiab]OR DVD[tiab] OR computer*[tiab] OR sitting[tiab] OR (physical*[tiab] AND inactiv*[tiab])

#5 ‘Exercise’[Mesh] OR ‘Motor Activity’[Mesh] OR ‘Sports’[Mesh] OR (physical*[tiab] AND active[tiab]) OR (physical*[tiab] AND activity[tiab])OR (physical*[tiab] AND activities[tiab]) OR exercis*[tiab] OR walking[tiab] OR cycling[tiab] OR sport*[tiab]

#6 ‘Feeding Behavior’[Mesh] OR ‘Energy Intake’[Mesh] OR ‘Eating’[Mesh] OR beverage*[tiab] OR snack*[tiab] OR softdrink*[tiab] OR softdrink*[tiab] OR fruit*[tiab] OR vegetable*[tiab] OR drink*[tiab] OR soda*[tiab] OR breakfast[tiab] OR supper[tiab] OR lunch*[tiab] ORmeal*[tiab] OR dinner*[tiab] OR tea[tiab] OR juice*[tiab] OR milk[tiab] OR eating[tiab] OR energy intake[tiab]

#7 Humans, English, Publication Date from 1990End search: #1 AND #2 AND #3 AND (#4 OR #5 OR #6) AND #7

((((‘Child, Preschool’[Mesh]) OR (young children[tiab] OR toddler*[tiab] OR early child*[tiab] OR preschool*[tiab])) AND ((‘Body Weights andMeasures’[Mesh] OR ‘Body Composition’[Mesh]) OR (obes*[tiab] OR BMI[tiab] OR body mass[tiab] OR weight[tiab] OR overweight[tiab] ORadipos*[tiab] OR body composition[tiab]))) AND (energy balance*[tiab])) OR ((((‘Child, Preschool’[Mesh]) OR (young children[tiab] OR toddler*[tiab]OR early child*[tiab] OR preschool*[tiab])) AND ((‘Body Weights and Measures’[Mesh] OR ‘Body Composition’[Mesh]) OR (obes*[tiab] OR BMI[tiab]OR body mass[tiab] OR weight[tiab] OR overweight[tiab] OR adipos*[tiab] OR body composition[tiab]))) AND ((‘Television’[Mesh] OR ‘LeisureActivities’[Mesh] OR ‘Computers’[Mesh] OR ‘Internet’[Mesh] OR ‘Sedentary Lifestyle’[Mesh] OR ‘Reading’[Mesh]) OR (sedentary[tiab] OR screentime[tiab] OR television[tiab] OR TV[tiab] OR game*[tiab] OR gaming[tiab] OR video[tiab] OR DVD[tiab] OR computer*[tiab] OR sitting[tiab] OR(physical*[tiab] AND inactiv*[tiab])))) OR ((((‘Child, Preschool’[Mesh]) OR (young children[tiab] OR toddler*[tiab] OR early child*[tiab] ORpreschool*[tiab])) AND ((‘Body Weights and Measures’[Mesh] OR ‘Body Composition’[Mesh]) OR (obes*[tiab] OR BMI[tiab] OR body mass[tiab] ORweight[tiab] OR overweight[tiab] OR adipos*[tiab] OR body composition[tiab]))) AND ((‘Exercise’[Mesh] OR ‘Motor Activity’[Mesh] OR ‘Sports’[Mesh])OR ((physical*[tiab] AND active[tiab]) OR (physical*[tiab] AND activity[tiab]) OR (physical*[tiab] AND activities[tiab]) OR exercis*[tiab] ORwalking[tiab] OR cycling[tiab] OR sport*[tiab]))) OR ((((‘Child, Preschool’[Mesh]) OR (young children[tiab] OR toddler*[tiab] OR early child*[tiab] ORpreschool*[tiab])) AND ((‘Body Weights and Measures’[Mesh] OR ‘Body Composition’[Mesh]) OR (obes*[tiab] OR BMI[tiab] OR body mass[tiab] ORweight[tiab] OR overweight[tiab] OR adipos*[tiab] OR body composition[tiab]))) AND ((‘Feeding Behavior’[Mesh] OR ‘Energy Intake’[Mesh] OR‘Eating’[Mesh]) OR (beverage*[tiab] OR snack*[tiab] OR softdrink*[tiab] OR soft drink*[tiab] OR fruit*[tiab] OR vegetable*[tiab] OR drink*[tiab] ORsoda*[tiab] OR breakfast[tiab] OR supper[tiab] OR lunch*[tiab] OR meal*[tiab] OR dinner*[tiab] OR tea[tiab] OR juice*[tiab] OR milk[tiab] OReating[tiab] OR energy intake[tiab]))).

58 Review of energy balance behaviours in preschool children S. J. te Velde et al. obesity reviews


Plotting

Studies were quite heterogeneous in terms of type andmeasurement of energy balance-related behaviours. As aresult, the statistical analysis applied varied, and thereforethe reported types of effect sizes (e.g. odds ratios or regres-sion coefficients) varied, which made statistical poolingimpossible. Therefore, the harvest plot method (17) wasapplied to present the results. This method combines thevisual immediacy of the conventional forest plot with amuch more inclusive hypothesis testing approach summa-rizing the distribution of the best available evidence acrossa heterogeneous group of studies (17).

For each energy balance-related behaviour (e.g. TVviewing), a bar chart depicts the distribution of the evi-dence. Each bar chart consists of three sections (one for anegative association, one for no association and one for apositive association). Each study is presented by one bar. Inaddition, the following three characteristics are presentedin the bar charts: (i) the methodological quality of the studyby the height of the bar; (ii) the number of participantsannotated on the top of the respective bar; and (iii) studieswith objective or valid/reliable measures of the specific

energy balance-related behaviour indicated with full-tone(black), and studies with self-report of unknown or inad-equate validity/reliability measures with half-tone (grey)bars.

Results

In total 8,718 papers of potential interest were retrieved(3,749 in PubMed, 3,199 in Embase, 823 in CINAHL, 529in PsychINFO and 418 in Cochrane). After further selec-tion based on first the title and abstract and subsequentlythe full paper, 23 published papers (18–40) reporting on 15different study samples, were included. All studies wereobservational cohorts, except for one intervention study(39). Reasons for excluding papers are reported in Fig. 1.

Sample characteristics

Dietary behaviour was studied in 13 papers (18–28,32,40),physical activity in 11 papers (19,20,22,30,33–38,40) andsedentary behaviour in seven papers (19,20,29,31,33,38,39). Table 3 shows the characteristics of the 23 includedpapers, divided over these three behavioural categories.

Table 2 Criteria list for assessment of the methodological quality of prospective studies and proportion of studies meeting the criteria

Criteria: I, V/P (rating of criteria: + = yes, - = no or insufficient information) I, V/P Criterionmet (%)

Study population and participation (baseline): the study sample represents the population of interest on key characteristics1. Adequate* description of sampling frame, recruitment methods, period of recruitment and place of recruitment

(geographical location).†I 61

2. Participation rate at baseline at least 80%, or the non-response was not selective (shows that baseline studysample does not significantly differ from population of eligible subjects).

V 17

3. Adequate* description of baseline study sample (i.e. individuals entering the study) for key characteristics (numberof participants, age, gender and measured energy balance-related behaviours).†

I 57

Study attrition: loss to follow-up is not associated with key characteristics (i.e. the study data adequately represent the study sample)4. Provision of the exact number of participants at each follow-up measurement I 575. Provision of exact information on follow-up duration. I 916. Response at long-term follow-up (>12 months) was at least 70% of the number of participants at baseline. V 617. Not selective non-response during follow-up measurement(s).‡ V/P 17

Data collection8. Measurement of energy balance-related behaviours using objective (i.e. accelerometry, heart rate monitoring,

food-weighed record or observation) or valid and reliable measures.§V 22

9. Measurement of overweight indices using objective measures V 100

Data analyses10. The statistical model used was appropriate.¶ V/P 6111. The number of cases was at least 10 times the number of the independent variables. V/P 9112. Presentation of point estimates and measures of variability (confidence interval or standard error) I 65

*Adequate = sufficient information to be able to repeat the study.†‘+’ is given only if adequate information is given in the text or related papers on all items.‡‘+’ is given only if non-selective dropout study sample does not significantly differ from study population on key characteristics or results areadjusted for selective non-response.§(+ = only objective or valid/reliable measurements, +/- = not all behaviours by means of objective or valid/reliable measurements, - = onlyproxy- report).¶‘+’ is given only if a multivariate regression model was used including more than one predicting variable (e.g. measured behaviour, energy intake).I, criterion on informativeness; V/P, criterion on validity/precision.



8,718 retrieved

PubMed 3,749

Embase 3,199

CINAHL 823

PsychINFO 529

Cochrane 418

Duplicates:3,141 excluded

5,577 articles

Title-abstract:4,944 excluded

633 articles

610 excluded

450 no prospective study design

57 no longitudinal analysis relation EBRB

and overweight

48 not meeting age inclusion

24 wrong subject

21 only parental behaviors reported

7 only overweight subjects

2 duplicate publication

1 no full text available

23 articles included

11 articles reportingphysical activity

7 articles reportingsedentary behavior

13 articles reportingdietary behavior

Figure 1 Flow chart of paper search and study selection. EBRB, energy balance-related behaviours.



Tab

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Cha

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eris

tics

ofin

clud

edst

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sort

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0.23

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Tab

le3

Con

tinue

d

Aut

hor

(yea

r)q

ualit

ysc

ore

Stu

dy

pop

ulat

ion

FUTy

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(mea

sure

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Moo

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(23)

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6)57

%

US

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ing

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rye

ars

also

self-

rep

ort)

BM

Ian

dsu

mof

four

skin

fold

s(o

bje

ctiv

e)C

hild

ren

inth

elo

wes

tse

x-sp

ecifi

cte

rtile

ofd

iary

inta

ke(i.

e.<1

.25

serv

ing

sp

erd

ayfo

rg

irls

and

<1.7

0se

rvin

gp

erd

ayfo

rb

oys)

dur

ing

pre

scho

olha

dsi

gni

fican

tg

reat

erg

ains

inb

ody

fat

dur

ing

child

hood

.Th

ese

child

ren

with

low

dai

ryin

take

sg

aine

dm

ore

than

anad

diti

onal

3m

mof

sub

cuta

neou

sfa

tp

erye

arin

the

sum

offo

ursk

info

ldm

easu

res.

By

the

time

ofea

rlyad

oles

cenc

e,th

ose

inth

elo

wes

tte

rtile

ofd

iary

inta

keha

da

BM

Ith

atw

asap

pro

xim

atel

ytw

oun

itshi

ghe

ran

dan

extr

a25

mm

ofsu

bcu

tane

ous

fat.

Lee

etal

.(2

4)(2

001)

57%

US

A(P

enns

ylva

nia)

;n

=19

799

%w

hite

;10

0%g

irls;

mea

n5

year

s2

year

sTh

ree

24-h

reca

lls(2

-wee

kan

don

ew

eeke

ndd

ayra

ndom

over

a2-

wee

kp

erio

dd

urin

gsu

mm

er),

com

bin

edw

ithH

EI

tom

easu

red

iet

qua

lity

(mot

her

rep

ort

inp

rese

nce

ofd

aug

hter

)

BM

I;su

mof

tric

eps

and

sub

cuta

neou

ssk

info

ld(o

bje

ctiv

e)C

hang

ein

BM

Ian

dsu

mof

skin

fold

thic

knes

sfro

m5

to7

year

sw

assi

gni

fican

tlyg

reat

erfo

rg

irls

onH

Fd

iets

(P<

0.05

);fa

tin

take

was

pos

itive

lyco

rrel

ated

toch

ang

ein

BM

I(r

=4.

14,

P<

0.05

);ca

rboh

ydra

tein

take

was

neg

ativ

ely

corr

elat

edto

BM

I(r

=-0

.19,

P<

0.01

).

John

son

etal

.(2

7)(2

008a

)43

%

UK

(ALS

PAC

coho

rt);

n=

521

for

5-ye

ar-o

lds;

21%

boy

s;m

ean

5.2

�0.

1ye

ar

4ye

ars

(die

tco

mp

ositi

onat

age

5or

7an

db

ody

com

pos

ition

atag

e9)

Thre

e-d

ayun

wei

ghe

dd

iet

dia

ry(2

wee

ksan

don

ew

eeke

ndd

ay)

rep

ort

ofD

ED

(par

enta

lrep

ort)

DE

XA

and

BM

I(o

bje

ctiv

e)N

osi

gni

fican

tas

soci

atio

nb

etw

een

DE

Dat

age

5an

dex

cess

adip

osity

atag

e9

OR

=1.

12(C

I0.

90–1

.40)

.

John

son

etal

.(2

5)(2

008b

)43

%

UK

(ALS

PAC

coho

rt);

n=

521;

21%

boy

s;m

ean

5.2

�0.

1ye

ar4

year

s(d

iet

com

pos

ition

atag

e5

or7

and

bod

yco

mp

ositi

onat

age

9)

Thre

e-d

ayun

wei

ghe

dd

iet

dia

ry(2

wee

ksan

don

ew

eeke

ndd

ay)

rep

ort

(par

enta

lrep

ort)

DE

XA

and

BM

I(o

bje

ctiv

e)Th

ead

just

edod

ds

ofex

cess

adip

osity

atag

e9

year

sfo

rch

ildre

nin

qui

ntile

5co

mp

ared

with

qui

ntile

1of

die

tary

pat

tern

scor

e(lo

wco

nsum

ptio

nof

fresh

frui

tan

dve

get

able

san

dhi

gh

cons

ump

tion

ofcr

isp

s,sn

acks

,ch

ocol

ate

and

conf

ectio

nery

)at

ages

5ye

ars

was

2.52

(CI

1.13

–6.0

8).



Tab

le3

Con

tinue

d

Aut

hor

(yea

r)q

ualit

ysc

ore

Stu

dy

pop

ulat

ion

FUTy

pe

ofd

ieta

ryb

ehav

iour

(mea

sure

)M

easu

res

ofov

erw

eig

htR

esul

ts

John

son

etal

.(2

1)(2

007)

43%

UK

(ALS

PAC

coho

rt);

n=

521;

21%

boy

s;m

ean

5.2

�0.

1ye

ar4

year

s(d

iet

com

pos

ition

atag

e5

or7

and

bod

yco

mp

ositi

onat

age

9)

Thre

e-d

ayun

wei

ghe

dd

iet

dia

ry(2

wee

ksan

d1

wee

kend

day

)re

por

tof

SS

B,

milk

,fr

uit

juic

e,lo

wen

erg

yan

dw

ater

(par

enta

lrep

ort)

DE

XA

and

BM

I(o

bje

ctiv

e)N

oas

soci

atio

nb

etw

een

SS

Bco

nsum

ptio

nat

age

5an

dfa

tnes

sat

age

9ye

ars.

Con

sum

ptio

nlo

w-e

nerg

yd

rinks

atag

e5

year

s(r

educ

edsu

gar

orsu

gar

-fre

efr

uit

squa

shes

,co

rdia

lsan

dd

iet

fizzy

drin

k)is

asso

ciat

edw

ith0.

26kg

(CI

-0.0

04–0

.52)

chan

ge

infa

tm

ass

atag

e9

year

s(P

<0.

05).

Con

sum

ptio

nof

milk

atag

e5

year

s(a

llm

ilkco

nsum

edd

urin

gth

ed

ayan

dm

ilkad

ded

toce

real

,te

a,co

ffee,

hot

choc

olat

ean

dm

ilksh

akes

)is

neg

ativ

eas

soci

ated

with

-0.5

1kg

(CI-

0.86

to-0

.16)

chan

ge

infa

tm

ass

(P<

0.01

),b

oth

adju

sted

for

sex,

heig

htat

age

9,b

asel

ine

BM

I,TV

view

ing

,m

ater

nale

duc

atio

nan

dB

MI,

pat

erna

lcla

ssan

dB

MI,

mis

rep

ortin

g,

DE

D,

%fa

tin

take

and

fibre

inta

ke.

No

asso

ciat

ion

bet

wee

nw

ater

cons

ump

tion

of10

0%fr

uit

juic

eat

age

5an

d7

year

san

dfa

tnes

sat

age

9ye

ars.

She

aet

al.

(26)

(199

3)43

%U

SA

(Col

umb

iaU

nive

rsity

Stu

dy

ofC

hild

hood

Act

ivity

and

Nut

ritio

n);

n=

215

92.1

%H

isp

anic

,7.

9%A

fric

an-A

mer

ican

;49

%b

oys;

52.2

�4.

2m

onth

s

FUat

leas

t12

mon

ths

Four

times

24-h

die

tary

reca

llan

dth

ree

times

adap

ted

Will

ett

sem

i-qua

ntita

tive

FFQ

(ad

just

edfo

rth

isst

udy)

with

inte

rval

of6

mon

ths

by

reca

ll(p

aren

talr

epor

t)

BM

I(o

bje

ctiv

e)N

osi

gni

fican

tlo

ngitu

din

alre

latio

nshi

ps

bet

wee

nfa

tin

take

and

stat

ure.

Mac

Farla

neet

al.

(28)

(200

9)29

%

Aus

tral

ia(H

EA

PS

);n

=16

1d

ivid

edov

erS

ES

,49

.7%

boy

s,ag

e5–

6ye

ars

3.0

�0.

15ye

ars

Food

envi

ronm

ent

varia

ble

s:b

reak

fast

atho

me,

eatin

gw

hile

view

ing

TV,

take

away

food

;en

erg

y-d

ense

snac

kfo

od(p

aren

tal

rep

ort)

BM

Iz-

scor

es(o

bje

ctiv

e)N

osi

gni

fican

tlo

ngitu

din

alas

soci

atio

nsb

etw

een

fam

ilyfo

oden

viro

nmen

t(d

aily

bre

akfa

st,

din

ner

whi

lew

atch

ing

TV,

snac

king

whi

lew

atch

ing

TV,

eatin

gfa

stfo

odat

oraw

ayfro

mho

me)

and

over

wei

ght

atFU

,ad

just

edfo

rw

eig

htst

atus

atb

asel

ine,

sex,

mat

erna

led

ucat

ion,

TVvi

ewin

g,

PA,

mat

erna

lBM

Ian

dcl

uste

ring

by

scho

ol.



Tab

le3

Con

tinue

d

Aut

hor

(yea

r)q

ualit

ysc

ore

Stu

dy

pop

ulat

ion

FUTy

pe

ofd

ieta

ryb

ehav

iour

(mea

sure

)M

easu

res

ofov

erw

eig

htR

esul

ts

Dav

ison

and

Birc

h(2

2)(2

001)

29%

US

A(P

enns

ylva

nia)

;n

=19

7on

lyno

n-H

isp

anic

whi

teg

irls;

mea

n5.

4�

0.4

year

2ye

ars

Thre

e24

-hre

calls

(ran

dom

2-w

eek

and

one

wee

kend

day

over

a2–

3-w

eek

per

iod

dur

ing

sum

mer

)re

por

tof

tota

lEI

and

%fa

tin

take

adju

sted

for

bod

yw

eig

ht(m

othe

rre

por

tov

erte

lep

hone

,en

sure

dco

mp

lete

ness

by

dau

ght

er)

BM

I(o

bje

ctiv

e)H

R:

exp

lain

edva

rianc

eof

final

mod

elis

26%

.G

irls

with

gre

ater

incr

ease

sin

BM

Ib

etw

een

ages

5an

d7,

had

ahi

ghe

rB

MI

atag

e5,

ahi

ghe

rp

erce

ntag

eof

ener

gy

from

fat

atag

e5,

ahi

ghe

rfa

mili

alris

kof

over

wei

ght

and

had

fath

ers

who

enjo

yed

activ

ityle

ss(a

ndha

da

hig

her

ener

gy

inta

ke).

Phy

sica

lact

ivity

Jag

oet

al.

(19)

(200

5)86

%U

SA

(SC

AN

);n

=13

8A

ngel

o,A

fric

anan

dH

isp

anic

;47

–49%

boy

s;m

ean

4.4

�0.

6ye

ar

3ye

ars

Four

day

sC

AR

Sob

serv

atio

n6–

12h

d-1

:fiv

e-le

velr

atin

gsy

stem

–st

atio

nary

non-

mov

ing

,no

ntr

unk

mov

emen

t,sl

oww

alk,

fast

wal

kan

dru

nnin

g(o

bse

rvat

ion)

.4

dp

erye

arPA

mea

sure

db

yQ

uant

umX

Lte

lem

etry

hear

tra

tem

onito

r(o

bse

rvat

ion)

BM

I(o

bje

ctiv

e)B

MI

acro

ssal

l3ye

ars:

HR

PA/H

*yea

r1:

b=

-9.0

98,

SE

=2.

959,

P=

0.00

2.

HR

PA/H

*yea

r2:

b=

-5.6

64,

SE

=2.

926,

P=

0.05

4.

Janz

etal

.(3

0)(2

009)

71%

US

A(I

BD

S);

n=

333;

44.4

%b

oys;

mea

n5.

3ye

ars

6ye

ars

(FU

atag

e5,

8an

d11

)S

umm

ary

MV

PAw

ithcu

t-p

oint

thre

shol

dof

3,00

0co

unt

(thr

eew

eekd

ays,

one

wee

kend

day

dur

ing

autu

mn

mon

ths)

by

Act

iGra

ph

unia

xial

acce

lero

met

ers

1-m

inin

terv

al(o

bje

ctiv

e)

DE

XA

(ob

ject

ive)

Gen

der

spec

ific

reg

ress

ion

mod

els.

For

boy

s(b

=-0

.02,

P<

0.00

5)an

dg

irls

(b=

-0.0

2,P

<0.

025)

,M

VPA

atag

e5

year

sw

asa

pre

dic

tor

ofad

just

edfa

tm

ass

atag

e8

year

san

dag

e11

year

s.In

girl

s,th

eef

fect

ofM

VPA

atag

e5

year

sw

asno

tsi

gni

fican

tw

hen

fat

mas

sat

age

5ye

ars

was

incl

uded

.B

oys

and

girl

sin

the

hig

hest

qua

rtile

ofM

VPA

atag

e5

year

sha

da

low

erfa

tm

ass

atag

e8

year

san

dag

e11

year

sth

anch

ildre

nin

the

low

est

MV

PAq

uart

ileat

age

5ye

ars.

Kle

sges

etal

.(4

0)(1

995)

71%

US

A;

n=

203;

54%

boy

s;m

ean

4.4

year

s3

year

sPA

ofch

ild’s

stru

ctur

ed,

leis

ure

and

aero

bic

activ

ityco

mp

ared

toot

her

child

ren

(par

enta

lrep

ort:

aver

age

ofb

oth

par

ents

)

BM

I(o

bje

ctiv

e)A

thi

ghe

rle

vels

ofb

asel

ine

aero

bic

activ

ity,

sub

seq

uent

chan

ges

inB

MI

dec

reas

ed(t

=-2

.153

,P

=0.

033,

3).

Incr

ease

sin

child

ren’

sle

isur

eac

tivity

was

asso

ciat

edw

ithd

ecre

ases

insu

bse

que

ntw

eig

htg

ain

(t=

-1.7

27,

P=

0.08

6,7)

.



Tab

le3

Con

tinue

d

Aut

hor

(yea

r)q

ualit

ysc

ore

Stu

dy

pop

ulat

ion

FUTy

pe

ofd

ieta

ryb

ehav

iour

(mea

sure

)M

easu

res

ofov

erw

eig

htR

esul

ts

Moo

reet

al.

(34)

(199

5)71

%U

SA

(Fra

min

gha

mC

hild

ren’

sS

tud

y);

n=

97;

61%

boy

s;m

ean

4.0

year

sA

nnua

llyFU

PAw

ithC

altr

acac

cele

rom

eter

aver

age

coun

tsp

erho

urfo

r5

dtw

ice

per

year

;av

erag

eac

tivity

scor

eav

erag

edd

ata

ofal

lpre

scho

olm

onito

ring

per

iod

s(o

bje

ctiv

e)

Tric

eps

and

sub

scap

ular

skin

fold

san

dB

MI

(ob

ject

ive)

The

effe

ctof

activ

ityw

asst

rong

erfo

rsl

ope

oftr

icep

sth

anfo

rot

her

outc

omes

.W

hen

age,

TVvi

ewin

g,

ener

gy

inta

ke,

bas

elin

etr

icep

san

dp

aren

ts’B

MI

wer

eco

ntro

lled

for,

inac

tive

pre

scho

oler

sw

ere

3.8

(CI

1.4–

10.6

)tim

esas

likel

yas

activ

ep

resc

hool

ers

toha

vean

incr

easi

ngtr

icep

ssl

ope

dur

ing

FU.

This

rela

tive

risk

estim

ate

was

slig

htly

hig

her

(OR

=5.

8,C

I1.

1–31

.3)

for

child

ren

with

mor

eb

ody

fat

atb

asel

ine.

Met

calf

etal

.(3

5)(2

008)

57%

UK

(Ear

lyb

ird37

);n

=21

298

%C

auca

sian

s;53

%b

oys,

mea

n4.

92ye

ars

(4.8

7–4.

98),

47%

girl

s,m

ean

4.92

year

s(4

.88–

4.97

)

3ye

ars

(FU

atag

e6,

7,8

year

s�

1m

onth

)PA

7d

by

Act

iGra

ph

acce

lero

met

err

=0.

70in

dep

end

ent

ofb

ody

wei

ght

,r

=0.

92d

epen

den

ton

bod

yw

eig

ht,

1-m

inep

ochs

;PA

set

atav

erag

e�

60m

ind

-1at

�2,

500

coun

tsp

erm

inut

e(3

ME

Ts);

year

onye

arre

liab

ility

for

4ye

ars

=90

%(o

bje

ctiv

e)

BM

IS

DS

;su

mof

skin

fold

and

wai

stci

rcum

fere

nce

(ob

ject

ive)

Ther

ew

ere

nosi

gni

fican

tas

soci

atio

nsb

etw

een

phy

sica

lac

tivity

and

chan

ges

inan

ym

easu

rem

ent

ofb

ody

mas

sor

fatn

ess

over

time

inei

ther

sex

(ind

epen

den

tof

age,

time

toFU

,b

asel

ine

mea

sure

men

ts,

seas

onal

ityan

dac

cele

rom

eter

sens

itivi

ty).

Gab

leet

al.

(20)

(200

7)57

%U

SA

(EC

LS-K

);n

=8,

000;

63%

non-

His

pan

ic;

48%

boy

s;m

ean

68.4

�4.

1m

onth

s

3.5

year

s(b

asel

ine

fall

kind

erg

arte

nT1

,FU

sprin

gki

nder

gar

ten

T2,

first

-gra

de

sprin

gT3

and

third

-gra

de

sprin

gT4

)

Aer

obic

exer

cise

and

opp

ortu

nitie

sfo

rac

tivity

atT2

(par

enta

lrep

ort)

BM

I(o

bje

ctiv

e)Fo

rb

oth

onse

tan

dp

ersi

sten

tov

erw

eig

ht,

noas

soci

atio

nw

ithch

ildae

rob

icex

erci

se/d

ays

per

wee

k.

Moo

reet

al.

(36)

(200

3)57

%U

SA

(Fra

min

gha

mC

hild

ren’

sS

tud

y);

n=

103;

61%

boy

s;m

ean

4.0

year

sA

nnua

llyFU

for

8ye

ars

PAw

ithC

altr

acac

cele

rom

eter

aver

age

coun

tsp

erho

urfo

r3–

5d

twic

ep

erye

ar;

aver

age

activ

itysc

ore

tert

ilera

nkin

gof

mea

nco

unts

per

hour

from

4–11

year

s(o

bje

ctiv

e)

BM

I;tr

icep

san

dsu

mof

five

skin

fold

s(o

bje

ctiv

e)C

hild

ren

inth

ehi

ghe

stte

rtile

ofav

erag

ed

aily

activ

ityfro

mag

es4

to11

year

sha

dco

nsis

tent

lysm

alle

rg

ains

inB

MI,

tric

eps,

and

sum

offiv

esk

info

lds

thro

ugho

utch

ildho

od.

This

pro

tect

ive

effe

ctof

activ

ityw

asev

iden

tfo

rb

oth

girl

san

db

oys,

but

stro

nger

ing

irls.



Tab

le3

Con

tinue

d

Aut

hor

(yea

r)q

ualit

ysc

ore

Stu

dy

pop

ulat

ion

FUTy

pe

ofd

ieta

ryb

ehav

iour

(mea

sure

)M

easu

res

ofov

erw

eig

htR

esul

ts

Janz

etal

.(3

3)(2

005)

50%

US

A(I

BD

S);

n=

378

95%

whi

tech

ildre

n;45

.5%

boy

s;m

ean

5.6

�0.

5ye

ar

3ye

ars

Four

day

sd

urin

gau

tum

nPA

by

Act

iGra

ph

acce

lero

met

erre

por

ting

sum

ofal

lmov

emen

tsd

ivid

edb

ym

inut

es;

calc

ulat

edp

erp

art

ofd

ay;

inac

tivity

set

as1.

4M

ETs

,m

oder

ate

PAse

tat

3M

ETs

and

vig

orou

sat

6M

ETs

;ac

tivity

load

calc

ulat

edov

ertim

e(o

bje

ctiv

e)

DE

XA

and

BM

I(o

bje

ctiv

e)C

hild

ren

mai

ntai

ning

ahi

gh

deg

ree

ofvi

gor

ous

activ

ityan

dov

eral

lac

tivity

wer

ele

sslik

ely

than

pee

rsto

be

inth

eup

per

qua

rtile

for

adip

osity

atFU

.

Cle

land

etal

.(3

7)(2

008)

43%

Aus

tral

ia(C

LAN

);n

=18

8;52

,7%

boy

s;ag

e5–

6ye

ars

3ye

ars

Hou

rssp

ent

outs

ide

dur

ing

war

mer

/coo

ler

mon

ths

dur

ing

wee

kday

and

wee

kend

day

(par

enta

lre

por

t)

BM

Iz-

scor

es(o

bje

ctiv

e)Ve

rylit

tleev

iden

ceof

anas

soci

atio

nb

etw

een

time

spen

tou

tdoo

rsan

dB

MI

z-sc

ores

.

Sal

be

etal

.(3

8)(2

002)

29%

US

A(A

rizon

a);

n=

138

full

Ind

ian

and

atle

ast

75%

Pim

a-P

apag

ohe

ritag

e;47

%b

oys;

mea

n5

year

s

5ye

ars

PAre

por

ting

spor

tsan

dre

crea

tiona

lb

yq

uest

ionn

aire

aver

age

hour

sov

erp

ast

year

(par

enta

lrep

ort)

Bod

yco

mp

ositi

onb

y18

Od

ilutio

nsp

aces

orD

EX

Aan

dB

MI

(ob

ject

ive)

Min

imal

sig

nific

ant

pos

itive

rela

tions

hip

bet

wee

np

hysi

cala

ctiv

ityat

bas

elin

ean

dp

erce

ntag

eof

bod

yfa

tan

db

ody

wei

ght

atFU

.Th

enu

mb

erof

recr

eatio

nala

ctiv

ities

atb

asel

ine

was

neg

ativ

ely

corr

elat

edw

ithp

erce

ntag

eof

bod

yfa

tan

db

ody

wei

ght

atFU

.In

reg

ress

ion

mod

elth

eac

tivity

que

stio

nnai

reva

riab

les

wer

eno

tsi

gni

fican

tp

red

icto

rsof

adip

osity

orw

eig

ht.

Dav

ison

and

Birc

h(2

2)(2

001)

29%

US

A(P

enns

ylva

nia)

;n

=19

7on

lyno

n-H

isp

anic

whi

teg

irls;

mea

n5.

4�

0.4

year

2ye

ars

Rec

allo

fch

ildPA

com

par

edto

othe

rch

ildre

n(p

aren

talr

epor

t)B

MI

(ob

ject

ive)

No

sig

nific

ant

effe

ctw

asfo

und

for

PA.

Sed

enta

ryb

ehav

iour

Jag

oet

al.

(19)

(200

5)86

%U

SA

(SC

AN

);n

=13

8A

ngel

o,A

fric

anan

dH

isp

anic

;47

–49%

boy

s;m

ean

4.4

�0.

6ye

ars

3ye

ars

Four

day

sC

AR

Sob

serv

atio

nsof

TVvi

ewin

g(o

bse

rvat

ion

ofch

ildp

ayin

gat

tent

ion

toTV

)

BM

I(o

bje

ctiv

e)B

MI

acro

ssal

l3ye

ars:

TV/H

*yea

r1:

b=

-0.0

41,

SE

=0.

017,

P=

0.01

7.TV

/H*y

ear

2:b

=-0

.044

,S

E=

0.01

7,P

=0.

009.

Gab

leet

al.

(20)

(200

7)57

%U

SA

(EC

LS-K

);n

=8,

000;

63%

non-

His

pan

icC

auca

sian

;48

%b

oys;

mea

n68

.4�

4.1

mon

ths

3.5

year

s(b

asel

ine

fall

kind

erg

ard

enT1

,FU

sprin

gki

nder

gar

den

T2,

first

-gra

de

sprin

gT3

and

third

-gra

de

sprin

gT4

)

Mea

nho

urs

TVan

dvi

deo

view

ing

(sep

arat

ew

eek

and

wee

kend

day

s)of

T2an

dT3

(inte

rcor

rela

ted

mea

nr

=0.

45,

P<

0.00

0,1)

(par

enta

lrep

ort)

BM

I(o

bje

ctiv

e)O

verw

eig

hton

set

atth

irdg

rad

eis

pre

dic

ted

by

child

TVvi

ewin

gat

kind

erg

ard

enan

dfir

stg

rad

e(O

R=

1.02

,C

I1.

00–1

.04)

.P

ersi

sten

tov

erw

eig

htis

pre

dic

ted

by

child

TVho

urs

per

wee

k(O

R=

1.03

,C

I1.

01–1

.05)

.



Tab

le3

Con

tinue

d

Aut

hor

(yea

r)q

ualit

ysc

ore

Stu

dy

pop

ulat

ion

FUTy

pe

ofd

ieta

ryb

ehav

iour

(mea

sure

)M

easu

res

ofov

erw

eig

htR

esul

ts

Han

cox

and

Pou

lton

(29)

(200

6)57

%

New

Zea

land

;n

=87

8re

pre

sent

full

rang

eof

SE

San

det

hnic

ity;

51.5

%b

oys;

5ye

ars

10ye

ars

(FU

ever

y2

year

s)Ti

me

spen

tw

atch

ing

TVon

wee

kday

s(p

aren

talr

epor

tat

age

5–11

,se

lf-re

por

tat

age

13–1

5)

BM

I(o

bje

ctiv

e)In

crea

sein

odd

sof

bei

ngov

erw

eig

htfo

rea

chho

urof

wee

knig

htTV

view

ing

upto

and

incl

udin

gth

atag

e;7

year

s(O

R=

1.61

,C

I1.

38–2

.02)

;11

year

s(O

R=

1.44

,C

I1.

04–2

.00)

;15

year

s(O

R=

1.48

,C

I1.

17–1

.88)

;Th

ese

asso

ciat

ions

wer

est

rong

erin

girl

sth

anb

oys.

Pro

spec

tive

corr

elat

ion

bet

wee

nB

MI

and

mea

nho

urs

ofTV

view

ing

bef

ore

that

age;

7ye

ars

r=

0.14

;9

year

sr

=0.

08;

13ye

ars

r=

0.10

;15

year

sr

=0.

10.

Pro

ctor

etal

.(3

6)(2

003)

57%

US

A(F

ram

ing

ham

Chi

ldre

n’s

Stu

dy)

;n

=10

3;61

%b

oys;

mea

n4.

0ye

ars

Ann

ually

FUfo

r7

year

sQ

uest

ionn

aire

time

spen

tvi

ewin

gTV

and

vid

eog

ames

.In

anal

yses

,ho

urs

ofTV

wat

ched

per

day

clas

sifie

din

toth

ree

cate

gor

ies:

<1.7

5h;

1.75

to<3

.0h;

�3.

0h

(par

enta

lrep

ort)

BM

I;tr

icep

ssk

info

ldan

dsu

mof

five

skin

fold

s(o

bje

ctiv

e)C

hild

ren

view

ing

�3

hd

-1TV

had

stat

istic

ally

sig

nific

ant

hig

her

BM

I,tr

icep

san

dsu

mof

five

skin

fold

sth

anch

ildre

nvi

ewin

g<1

.75

hd

-1

cont

rolle

dfo

rp

aren

talb

ody

fat,

PAan

dd

ieta

ryva

riab

les.

Janz

etal

.(3

3)(2

005)

50%

US

A(I

BD

S);

n=

378

95%

whi

tech

ildre

n;45

.5%

boy

s;m

ean

5.6

�0.

5ye

ars

3ye

ars

Que

stio

nnai

rere

por

ting

TVvi

ewin

gan

dvi

deo

/com

put

erg

ame

pla

ying

(par

enta

lpro

xyre

por

t)

DE

XA

and

BM

I(o

bje

ctiv

e)C

hild

ren

mai

ntai

ning

low

leve

lsof

TVvi

ewin

g(>

120

min

d-1

)w

ere

less

likel

yth

anp

eers

tob

ein

the

upp

erq

uart

ilefo

rad

ipos

ityat

FUan

dw

ere

less

likel

yto

gai

nad

ipos

ityd

urin

gth

est

udy

per

iod

.

Ep

stei

net

al.

(39)

(200

8)29

%U

SA

(inte

rven

tion

stud

y);

n=

70w

ithB

MI�

75th

per

cent

ile(8

0%�

85th

ofw

hich

44%

�95

th);

I=34

,53

%b

oys,

mea

n6.

1�

1.3

year

s;C

=36

,53

%b

oys,

mea

n5.

8�

1.2

year

s

2ye

ars

(FU

ever

y6

mon

ths)

TVan

dco

mp

uter

time

dur

ing

3-w

eek

per

iod

(ob

ject

ive

by

mon

itorin

gd

evic

e)

BM

Iz-

scor

e(o

bje

ctiv

e)TV

and

com

put

erus

em

edia

ted

the

effe

ctof

the

inte

rven

tion

onB

MI

z-sc

ore

valu

esov

ertim

e.

Sal

be

etal

.(3

8)(2

002)

29%

US

A(A

rizon

a);

n=

138

full

Ind

ian

and

atle

ast

75%

Pim

a-P

apag

ohe

ritag

e;47

%b

oys;

mea

n5

year

s

5ye

ars

Sed

enta

ryac

tiviti

esre

por

ting

nap

pin

g,

slee

pin

g,

TVvi

ewin

g,

pla

yco

mp

uter

/vid

eog

ames

over

pas

tye

ar(p

aren

talr

epor

t)

Bod

yco

mp

ositi

onb

y18

Od

ilutio

nsp

aces

orD

EX

Aan

dB

MI

(ob

ject

ive)

The

num

ber

ofho

urs

spen

tw

atch

ing

TVw

asp

ositi

vely

corr

elat

edw

ithFU

per

cent

age

ofb

ody

fat

and

bod

yw

eig

ht.

Inre

gre

ssio

nm

odel

the

activ

ityq

uest

ionn

aire

varia

ble

sw

ere

not

sig

nific

ant

pre

dic

tors

ofad

ipos

ityor

wei

ght

.

ALS

PAC

,A

von

Long

itud

inal

Stu

dy

ofP

aren

tsan

dC

hild

ren;

BM

I,b

ody

mas

sin

dex

;C

AR

S,

Chi

ldre

n’s

Act

ivity

Rat

ing

Sca

le;

CI,

confi

den

cein

terv

al;

CLA

N,

Chi

ldre

n’s

Livi

ngin

Act

ive

Nei

ghb

ourh

ood

s;D

ED

,d

ieta

ryen

erg

yd

ensi

ty;

DI,

Die

tary

inta

ke;

DE

XA

,d

ual-e

nerg

yX

-ray

abso

rptio

met

ry;

EC

LS-K

,E

arly

Chi

ldho

odLo

ngitu

din

alS

tud

y,K

ind

erg

arte

n–Fi

rst

Gra

de

Wav

es;

EI,

ener

gy

inta

ke;

FFQ

,fo

odfre

que

ncy

que

stio

nnai

re;

FU,

follo

w-u

p;

HE

I,H

ealth

yE

atin

gIn

dex

;H

F,H

igh

Fat;

HR

,hi

erar

chic

alre

gre

ssio

n;M

ET,

Met

abol

iceq

uiva

lent

;M

VPA

,m

oder

ate

tovi

gor

ous

phy

sica

lact

ivity

;n,

num

ber

ofp

artic

ipan

ts;

NH

AN

ES

,N

atio

nalH

ealth

and

Nut

ritio

nE

xam

inat

ion

Sur

vey;

OR

,od

ds

ratio

;PA

,p

hysi

cala

ctiv

ity;

r,re

gre

ssio

nco

effic

ient

;S

CA

N,

Stu

die

sof

Chi

ldA

ctiv

ityan

dN

utrit

ion;

SD

S,

Sta

ndar

dD

evia

tion

Sco

res;

SE

,st

and

ard

erro

r;S

ES

,so

cial

econ

omic

stat

us;

SS

B,

sug

ar-s

wee

tene

db

ever

ages

;TV

,te

levi

sion

.



The papers included 15 different study samples (10 USA, 2UK, 2 Australia and 1 New Zealand). One study sample(described in three papers) consisted of girls only(22,24,32). Sample sizes ranged from 70 to 8,000 partici-pants. At baseline, nine studies reported a mean age of 4years (4.0–4.9) and 14 studies a mean age of 5 years (5.0–5.9). Follow-up duration varied from 2 to 12 years.

All studies, except Janz et al. (30), used BMI as anindicator of body composition or overweight. Other indi-cators used were sum of skinfolds (23,24,31,32,34–36),fat mass assessed by dual-energy X-ray absorptiometry(21,25,27,30,32,33,38), waist circumference (32,35) andfat mass assessed by 18O dilution (38).

Methodological quality

The methodological quality of the studies ranged from 29to 86% (Table 4). Five studies were rated as high method-ological quality, with a methodological quality score >70%(18,19,30,34,40); all studies met the criteria for appro-priate statistical analysis and described their sampleappropriately. All high- and low-quality studies used objec-tive measures to assess body composition and/or over-weight status. As can be seen in Table 4, most of the 18low-quality studies did not meet the criteria regardingparticipation rate (17 out of the 18 papers), non-selectiveresponse (16/18) and objective or valid measure of behav-iour (16/18).

Dietary behaviour

All studies except for one used parental report of the child’sdietary behaviour. Jago et al. (19) assessed dietary behav-iour by a 4-d observation by trained researchers.

Association between dietary behaviour and overweightFigure 2 shows harvest plots of the association betweendietary behaviours and overweight, except for the sub-behaviours that were examined only once (family behav-iour [28], eating meals together with the family [20], fruitand vegetable intake [25], low-energy drink [21], and waterconsumption [21]). Insufficient evidence was found for anassociation between dietary intake or dietary behaviours,and overweight, generally because most intake levels orsub-behaviours were reported in one single study or inlow-quality studies only. Although three studies (2 low, 1high quality) showed a positive association between pro-portion of total energy intake from fat and overweight(22,24,40), two other studies (1 low, 1 high quality)showed no association (19,26), resulting in inconsistentevidence. Whereas a positive association for consumptionof sugar-sweetened beverages with overweight was foundin two studies (1 low, 1 high quality) (18,32), incoherentfindings were found in another low-quality study (21). Two

low-quality studies reported an inverse association for milkconsumption with overweight (21,23), but no significantassociation was found in another low-quality study (32).

Physical activity

Among the 13 studies that focused on physical activitybehaviour, six studies used objective measures such asaccelerometers (30,33–36), heart rate monitors (19) orobservation (19) (see Table 3).

Association between physical activity and overweightFigure 3 shows that strong evidence was found for aninverse association between total physical activity and over-weight. For the specific sub-behaviours moderate to vigor-ous physical activity, aerobic exercise and leisure activityinsufficient evidence was found (20,30,35,37,38,40).

Sedentary behaviour

Seven studies examined TV viewing (19,20,29,31,33,38,39) and one additionally examined computer use (39)Although three studies (31,33,38) assessed computer/videogaming, only one study actually analysed the prospectiverelationship between playing computer games and bodycomposition or overweight indicators (33). Five studiesused parent-reported sedentary time (20,29,31,33,38),while one study (19) used observation by trained research-ers to measure time spent sitting and TV viewing. Anotherstudy (39) used an automated device controlling and moni-toring the use of TV or computer monitors.

Association between sedentary behaviourand overweightFigure 4 shows the evidence for the association betweensedentary behaviour and overweight. We found moderateevidence for a positive association between TV/video/computer time and overweight, because one high-qualitystudy (19) and five low-quality studies (20,29,33,36,39)reported a significant positive association. One low-qualitystudy found no significant associations between TV timeand adiposity (38).

Discussion

Our systematic review is the first that aimed to summarizeand appraise the evidence regarding the prospectiveassociation between energy balance-related behaviours inpreschool children and their weight status later in child-hood. Results showed strong evidence for an inverse asso-ciation between total physical activity and overweight;moderate evidence for a positive association between sed-entary behaviour – mainly TV viewing – and overweight;



Tab

le4

Qua

lity

asse

ssm

ent

ofp

rosp

ectiv

est

udie

son

ener

gy

bal

ance

-rel

ated

beh

avio

urs

and

bod

yco

mp

ositi

onor

over

wei

ght

inp

resc

hool

child

ren

sort

edb

yq

ualit

ysc

ore

Qua

lity

crite

ria1

2*3

45

6*7*

8*9*

10*

11*

12Q

ualit

ysc

ore

(%)

Aut

hor

(yea

r)R

ecru

itmen

tP

artic

ipat

ion

rate

Des

crip

tion

bas

elin

esa

mp

le

Num

ber

sat

follo

w-u

pFo

llow

-up

dur

atio

nR

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but insufficient evidence for an association between dietarybehaviours and overweight was found.

Although 13 papers addressed dietary intakes or behav-iours, a range of different specific dietary intakes or behav-iours were assessed, making it impossible to draw definiteconclusions about dietary intake or behaviour. Only a fewstudies focused on similar dietary intakes or behaviours,such as fat intake, intake of sugar-sweetened beverages andmilk consumption, but results were inconsistent. Moreover,most of the studies on dietary intake or behaviour were oflow methodological quality. The diversity in types andmeasures of dietary intake or behaviour shows the com-plexity of studying behaviours related to energy balance.Furthermore, this inconsistency may also be explained bythe fact that studies on intake of macronutrients, e.g. car-

bohydrate intake, included intake of ‘healthy’ foods such asfruit and vegetables, as well as ‘unhealthy’ foods, such asbiscuits. The lack of evidence for an association betweendietary intakes or behaviours and overweight does notmean that there is evidence for absence of such an associa-tion. In order to extend our understanding of the role ofdietary intake or behaviours in the development of over-weight, future studies should use similar indicators andmeasures, ensure a high-quality design and use measuresfor which at least validity and reliability have been estab-lished. The latter is especially important because the lack ofevidence may be caused by the use of inaccurate measures.

Most studies on physical activity used total physicalactivity as a predictor in the analyses, which gives no indi-cation on what specific physical activity behaviours may be

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Carbohydrate/sucrose intake

High energydensity intake

Fat intake

100% fruit juice intake Milk intake

Sugar-sweetened beverage intake(sports drink,< 100% fruit juice, soda, sugared tea/coffee)

Figure 2 Harvest plots for the evidence for the association between dietary behaviours and overweight. Height of the bar: methodological quality ofstudy; x-axis, direction of the association; bar colour, use of objective (black) or self-reported (grey) measures; number above bar, number ofincluded study participants; SBB, sugar-sweetened beverages; *, study only conducted in girls.



related to overweight. Using accelerometers to assess phy-sical activity has the advantage of being an objectivemeasure, not influenced by recall bias, but accelerometersusually do not provide insight in what specific activities arerelated to overweight. Only a few studies addressed morespecific sub-behaviours. Probably, future studies shouldalso examine the setting where those physical activities takeplace in order to find the best setting for promoting physi-cal activity. Hesketh and Campbell (41) recently showed

that many overweight prevention interventions amongpreschoolers do indeed promote physical activity (42), butonly one of the interventions in their review increasedphysical activity (43); its efficacy with respect to overweightprevention was not tested.

Contrary to studies on dietary and physical activitybehaviours, all studies on sedentary behaviours measuredthe same sub-behaviour, namely TV viewing (19,20,29,31,33,38,39). Some studies additionally assessed computertime or gaming (31,33,38,39). All but one (38) found apositive prospective association between TV time andindices of overweight, but because only one study was ofhigh methodological quality (19), the evidence was moder-ate. Future studies should use valid and reliable measuresand apply appropriate statistical models. More impor-tantly, sedentary behaviour comprises more than screentime alone, and total screen time may not be representativefor all sedentary activities that occur throughout the day(44). Moreover, TV time and other sedentary activities mayhave distinct associations with overweight; TV time hasbeen associated with reduced resting metabolic rate(45,46), while seated and active video game play increasesenergy expenditure above the resting level (47). In addition,it appears that all sedentary activities, particularly TVwatching, promote overconsumption (48,49), which mayadditionally explain its association with overweight. There-fore, future studies should also focus on sedentary activities

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Figure 3 Harvest plots for the evidence for the association between physical activity behaviours and overweight. Height of the bar, methodologicalquality of study; x-axis, direction of the association; bar colour, use of objective (black) or self-reported (grey) measures; number above bar: numberof included study participants; *, study only conducted in girls.

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Figure 4 Harvest plots for the evidence for the association betweensedentary behaviour and overweight. Height of the bar, methodologicalquality of study; x-axis, direction of the association; bar colour, use ofobjective (black) or self-reported (grey) measures; number above bar,number of included study participants; *, study only conducted in girls.



other than screen time, e.g. sitting at preschool, in order toextend our knowledge and the evidence with regard to theassociation between sedentary behaviour and overweightamong preschool children.

In general, the results from our systematic reviewsupport Reilly’s observation that physical activity and sed-entary behaviours contribute to the energy imbalanceamong preschool children (13). In addition, a recent review(50) on the relative contribution of energy intake andenergy expenditure to childhood obesity concluded thatthere is insufficient evidence and therefore no consensus onthe main drivers of the development of overweight amongchildren and adolescents. Although that review did notinclude studies among preschool children, it is anotherindication of the lack of good quality studies that provideevidence on what behaviours contribute most to the devel-opment of overweight in young people.

In addition to the prevention of the development ofoverweight, promoting physical activity does also improvemotor skills, physical fitness and psychological develop-ment (51). Moreover, increased physical activity will resultin more lean tissue, which has a higher metabolic rate (52).Furthermore, physical activity has many additional healthbenefits (53,54). Unfortunately, most studies used BMI,which cannot distinguish between fat and lean mass, as anindicator of overweight. Therefore, if feasible, futurestudies should include more sensitive measures such aswaist circumference or skinfold thicknesses to evaluatewhether promoting physical activity, energy restriction or acombined approach is most effective in preventing thedevelopment of excessive fat mass.

Some limitations of this review have to be considered.Despite the extensive search, only 23 papers were includedin the current review, of which some reported on the samestudy population. Moreover, only a few were rated as highmethodological quality (18,19,30,34,40) or used valid andreliable measures for the energy balance-related behav-iours, and a range of different measurement instrumentsand methods were used, making comparison and poolingof results difficult. The harvest plotting method was usedto summarize the results in the clearest way. The plotsimmediately show the direction – i.e. negative, no or posi-tive – of the association and what their methodologicalquality was. It further showed that for some sub-behaviours, only a few studies were available. All but fiveincluded studies were conducted in the USA, and it istherefore uncertain if results can be generalized to othercountries or regions.

Strengths of the current review were the systematic pro-cedure, the quality scoring and applying the best evidencesynthesis. Moreover, by using the harvest plots (17), it waspossible to display the results in a systematic way despitethe fact that a meta analysis was not possible. Moreover,the current review only included prospective studies and

thus provides stronger evidence about the direction ofthe relationships found than if cross-sectional studieswere included. Nevertheless, some associations can bebi-directional. For instance, spending little time physicallyactive can lead to excess weight gain, which in turn can leadto less physical activity, and thus inducing a vicious cycle.However, it needs to be mentioned that in some of theincluded studies, the follow-up periods were quite long (e.g.>3 years), and that especially in children and adolescents,the current behaviour may be more strongly associatedwith overweight than the baseline behaviour. Some studiestherefore adjusted for the current levels of the specificbehaviours (e.g. [32]), applied longitudinal analyses includ-ing all repeated measures (e.g. [19]) or compared changesin behaviour with changes in overweight indices during thesame time period (e.g. [40] and [18]).

Based on the results presented, it can be recommendedthat future overweight prevention interventions targetingpreschool children should focus on the promotion ofphysical activity and the limitation of screen time. Moreresearch is necessary to identify whether and which spe-cific dietary behaviours are associated with overweightand could potentially be included in future preventioninterventions targeting this age group. Despite the lackof evidence for dietary behaviours from the presentreview, future interventions may already target specificdietary behaviours that are highly prevalent and for whichthere a clear rationale as well as preliminary evidence, orevidence from other age groups that these behaviours areassociated with overweight, e.g. sugar-sweetened beverageintake (32,55). Future research should apply high-qualitydesigns, use valid and reliable measures to assess energybalance-related behaviours, may focus on identification ofmore specific sub-behaviours for physical activity, andinclude other measures than screen time to assess seden-tary time.

Conflict of interest statement

None declared.

Acknowledgements

This study is part of the ToyBox study. The ToyBox studyis funded by the Seventh Framework Programme (CORDISFP7) of the European Commission under grant agreementn°245200. The content of this paper reflects only theauthors’ views and the European community is not liablefor any use that may be made of the information containedtherein.

In addition, we would like to thank René HJ Otten fromthe VU University Medical Center, for his support in per-forming the literature searches for this review.



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