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
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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.
obesity reviews Review of energy balance behaviours in preschool children S. J. te Velde et al. 59
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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.
60 Review of energy balance behaviours in preschool children S. J. te Velde et al. obesity reviews
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
Tab
le3
Cha
ract
eris
tics
ofin
clud
edst
udie
s,b
yb
ehav
iour
alca
teg
ory
and
sort
edb
yq
ualit
ysc
ore
and
dat
eof
pub
licat
ion
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
Die
tary
beh
avio
urLi
met
al.
(18)
(200
9)86
%U
SA
(NH
AN
ES
);n
=36
5hi
ghe
stp
rop
ortio
nof
low
-inco
me
resi
den
tsin
Det
roit;
48.4
%b
oys
2ye
ars
Kid
sFF
Qre
por
tof
SS
Bs
(par
enta
lre
por
t)B
MI
z-sc
ores
(ob
ject
ive)
The
odd
sof
bec
omin
gov
erw
eig
htin
crea
sed
by
1.04
(CI
1.01
–1.0
7)p
erou
nce
offr
uit
drin
k(<
100%
)co
nsum
ptio
np
erd
ayan
d1.
04(C
I1.
01–1
.07)
per
ounc
eof
allS
SB
cons
ump
tion
per
day
,ad
just
edfo
rb
asel
ine
SS
Bin
take
,B
MI,
age,
gen
der
,S
ES
,b
asel
ine
DI,
par
enta
lB
MI.
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
sd
ieta
ryin
take
(cal
orie
san
dp
erce
ntca
lorie
sfro
mfa
t)w
ritte
non
24-h
reca
ll(o
bse
rvat
ion)
BM
I(o
bje
ctiv
e)D
ieta
ryfa
ctor
sw
ere
not
asso
ciat
edw
ithB
MI
acro
ssth
eth
ree
stud
yye
ars.
Kle
sges
etal
.(4
0)(1
995)
71%
US
A;
n=
203;
54%
boy
s;m
ean
4.4
year
s3
year
sR
ecal
lsof
EI
by
Will
ett
FFQ
(par
enta
lan
dse
lf-re
por
t)B
MI
(ob
ject
ive)
Hig
her
bas
elin
ep
erce
ntag
eof
kcal
from
fat
wer
eas
soci
ated
with
gre
ater
incr
ease
sin
BM
I(t
=1.
962,
P=
0.05
2,1)
.A
sw
ella
sd
ecre
ases
infa
tin
take
wer
ere
late
dto
dec
reas
esin
BM
I(t
=2.
584,
P=
0.01
1).
Sig
nific
ance
set
onP
�0.
15.
Fior
itoet
al.
(32)
(200
9)57
%U
SA
(Pen
nsyl
vani
a);
n=
166
only
non-
His
pan
icw
hite
girl
s;ag
e5
year
s10
year
s(F
Uat
age
7,9,
11,
13,
15)
Thre
e24
-hre
calls
(ran
dom
2w
eeks
and
one
wee
kend
day
over
2–3-
wee
kp
erio
dd
urin
gsu
mm
er)
rep
ort
ofm
ilk,
100%
frui
tju
ice
and
swee
tene
db
ever
age
i.e.
sug
ar-s
wee
tene
d,
spor
tsd
rink,
<100
%fr
uit,
sod
aan
dsu
gar
edte
aor
coffe
e(m
othe
rre
por
tov
erte
lep
hone
,en
sure
dco
mp
lete
ness
by
dau
ght
er)
Wei
ght
stat
usb
yB
MI;
adip
osity
by
wai
stci
rcum
fere
nce;
tric
eps
and
sub
scap
ular
skin
fold
;an
dD
EX
A(o
bje
ctiv
e)
Con
sum
ptio
nof
swee
tene
db
ever
age
(not
milk
and
100%
frui
tju
ice)
at5
year
sw
asp
ositi
vely
asso
ciat
edw
ithad
ipos
ityat
each
follo
w-u
p:
(r=
0.27
(7ye
ars)
,0.
32(9
year
s),
0.23
(11
year
s),
0.2
(13
year
s),
0.18
(15
year
s);
gre
ater
cons
ump
tion
swee
tene
db
ever
ages
at5
year
s(�
2se
rvin
gs
per
day
)w
asp
ositi
vely
asso
ciat
edw
ithhi
ghe
r%
bod
yfa
tat
5–15
year
s,
wai
stci
rcum
fere
nce,
and
wei
ght
stat
usfro
mag
e5
to15
year
s.
Gab
leet
al.
(20)
(200
7)57
%U
SA
(EC
LS-K
);n
=80
00;
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
)
Freq
uenc
yof
eatin
gfa
mily
mea
lsto
get
her
(bre
akfa
stan
dd
inne
r)m
ean
ofT2
and
T3(in
terc
orre
late
dm
ean
r=
0.44
,P
<0.
000,
1)(p
aren
talr
epor
t)
BM
I(o
bje
ctiv
e)O
verw
eig
hton
set
atth
irdg
rad
eis
pre
dic
ted
eatin
gm
eals
with
fam
ily(O
R=
0.93
,C
I0.
90–0
.97)
.P
ersi
sten
tov
erw
eig
htis
also
pre
dic
ted
by
eatin
gm
eals
with
fam
ily(O
R=
0.92
,C
I0.
90–0
.94)
.
obesity reviews Review of energy balance behaviours in preschool children S. J. te Velde et al. 61
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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.
(23)
(200
6)57
%
US
A(F
ram
ing
ham
Chi
ldre
n’s
Stu
dy)
;n
=10
3;61
%b
oys;
age
3–6
year
sA
nnua
llyFU
for
12ye
ars
Four
sets
of3-
dre
cord
sd
urin
gb
asel
ine,
FUon
eor
two
sets
rep
ortin
gd
airy
inta
ke(m
ilk,
yog
hurt
and
chee
se)
(par
enta
lrep
ort,
late
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).
62 Review of energy balance behaviours in preschool children S. J. te Velde et al. obesity reviews
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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.
obesity reviews Review of energy balance behaviours in preschool children S. J. te Velde et al. 63
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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)
.
64 Review of energy balance behaviours in preschool children S. J. te Velde et al. obesity reviews
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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.
obesity reviews Review of energy balance behaviours in preschool children S. J. te Velde et al. 65
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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)
.
66 Review of energy balance behaviours in preschool children S. J. te Velde et al. obesity reviews
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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
.
obesity reviews Review of energy balance behaviours in preschool children S. J. te Velde et al. 67
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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;
68 Review of energy balance behaviours in preschool children S. J. te Velde et al. obesity reviews
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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
esp
onse
rate
atfo
llow
-up
Not
sele
ctiv
eno
n-re
spon
seM
easu
reE
BR
BM
easu
reov
erw
eig
htin
dic
es
Ap
pro
pria
test
atis
tical
mod
el
#ca
sus
atle
ast
10*
#in
dep
end
ent
varia
ble
s
Poi
ntes
timat
esan
dm
easu
res
ofva
riab
ility
Jag
oet
al.
(200
5)(1
9)+
++
++
+-
++
++
+86
Lim
etal
.(2
009)
(18)
++
++
++
+-
++
++
86Ja
nzet
al.
(200
9)(3
0)+
++
-+
--
++
++
+71
Kle
sges
etal
.(1
995)
(40)
--
++
++
+-
++
+-
71M
oore
etal
.(1
995)
(34)
+-
++
-+
-+
++
++
71Fi
orito
etal
.(2
009)
(32)
--
--
++
--
++
+-
57G
able
etal
.(2
007)
(20)
+-
++
+-
+-
++
++
57H
anco
xan
dP
oulto
n(2
006)
(29)
-+
-+
++
--
+-
++
57Le
eet
al.
(200
1)(2
4)-
--
++
+-
-+
++
+57
Met
calf
etal
.(2
008)
(35)
--
--
++
-+
+-
++
57M
oore
etal
.(2
003)
(36)
+-
+-
++
-+
+-
+-
57M
oore
etal
.(2
006)
(23)
+-
--
++
--
++
++
57P
roct
oret
al.
(200
3)(3
1)+
-+
++
+-
-+
++
+57
Janz
etal
.(2
005)
(33)
+-
++
++
-+/
-+
-+
-50
Cle
land
etal
.(2
008)
(37)
+-
-+
+-
+-
+-
++
43Jo
hnso
net
al.
(200
7)(2
1)+
--
-+
--
-+
++
+43
John
son
(200
8a)
(27)
+-
+-
+-
--
++
++
43Jo
hnso
n(2
008b
)(2
5)+
--
-+
--
-+
++
+43
She
aet
al.
(199
3)(2
6)-
-+
--
--
-+
++
-43
Dav
ison
and
Birc
h(2
001)
(22)
--
++
++
--
+-
--
29E
pst
ein
etal
.(2
008)
(39)
--
++
++
--
+-
--
29M
acFa
rlane
etal
.(2
009)
(28)
+-
-+
+-
--
+-
++
29S
alb
eet
al.
(200
2)(3
8)-
--
-+
--
-+
-+
-29
*=
valid
ity/p
reci
sion
crite
ria;
+=
pub
licat
ion
pro
vid
edan
info
rmat
ive
des
crip
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ofth
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iterio
nat
issu
ean
dm
etth
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n;-
=th
ep
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atio
nd
idno
tm
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the
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lity
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rion;
+/-
=p
ublic
atio
np
rovi
ded
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form
ativ
ed
escr
iptio
nfo
ron
lyon
em
easu
red
EB
RB
;%
scor
e=
tota
lmet
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olog
ical
qua
lity
scor
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lcul
ated
by
coun
ting
the
num
ber
ofite
ms
scor
edp
ositi
vely
onth
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/Pcr
iteria
.E
BR
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ener
gy
bal
ance
-rel
ated
beh
avio
urs.
obesity reviews Review of energy balance behaviours in preschool children S. J. te Velde et al. 69
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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
Negative
0102030405060708090
100
0102030405060708090
100
0102030405060708090
100
0102030405060708090
100
0102030405060708090
100
0102030405060708090
100
Negative
Negative Negative
Negative
NegativeNo
No No
No
No No
Positive Positive
Positive Positive
Positive Positive
Qua
lity
sco
reQ
uali
ty s
core
Qua
lity
sco
re
Qua
lity
sco
reQ
uali
ty s
core
Qua
lity
sco
re
138
161
166* 166*
166*
521 521
521 521
521
365
203
197*
197*
138
215
103
197*
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.
70 Review of energy balance behaviours in preschool children S. J. te Velde et al. obesity reviews
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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
Negative Negative
NegativeNegative
0102030405060708090
100
0102030405060708090
100
0102030405060708090
100
0102030405060708090
100
No No
NoNo
Positive Positive
PositivePositive
Qua
lity
sco
reQ
uali
ty s
core
Qua
lity
sco
reQ
uali
ty s
core
138
333
378 212
203
8000
203
188
138
138103
378 97
197*
Total physical acticity
Aerobic exercise Leisure activity
Moderate and vigorous physical activity
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.
Negative
0102030405060708090
100
No Positive
Qua
lity
sco
re
138
878378
70138
103 8000
Television viewing/computer use
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.
obesity reviews Review of energy balance behaviours in preschool children S. J. te Velde et al. 71
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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.
72 Review of energy balance behaviours in preschool children S. J. te Velde et al. obesity reviews
© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 13 (Suppl. 1), 56–74
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