J. Pediatr. (Rio J.) vol.92 número3 suppl.1 jped 92 03 s1 0S30

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www.jped.com.br

REVIEW

ARTICLE

Obesogenic

environment

---

intervention

opportunities

夽

Mauro

Fisberg

a,b,c,∗

,

Priscila

Maximino

c

,

Juliana

Kain

d

,

Irina

Kovalskys

e,f

a_{International}_Life_Sciences_Institute_(ILSI_Brasil),_Brazil

b_Escola_Paulista_de_Medicina,_Universidade_Federal_de_São_Paulo_(Unifesp),_São_Paulo,_SP,_Brazil c_Instituto_Pensi,_Fundac_¸ão_José_Luiz_Egydio_Setúbal,_Hospital_Infantil_Sabará,_São_Paulo,_SP,_Brazil

d_Instituto_de_Nutricion_y_Tecnologia_de_los_Alimentos_(INTA),_Universidad_de_Chile,_Santiago_de_Chile,_Chile e_{International}_Life_Sciences_Institute_(ILSI_Argentina),_Argentina

f_School_of_Medical_Sciences,_Universidad_Favaloro,_Buenos_Aires,_Argentina

Received18January2016;accepted5February2016 Availableonline19March2016

KEYWORDS

Schoolenvironment; Physicalactivity; Children; Adolescents; Obesity

Abstract

Objectives: Toevaluateenvironmentalobesogenic-relatedfactors,suchasphysicalactivityin neighborhoodsandschools,nutritionalbehavior,andinterventionprograms.

Sources: Criticalanalysisofliteraturewithpersonalpointofviewfrominfantobesityexperts andpoliticaladvisorsforpublicintervention.

Datasynthesis: Althoughobesityisapublichealthproblemaffectingseveralagegroups,itis amongchildrenandadolescentsthatitplaysamoreimportantrole,duetotreatment complex-ity,highlikelihoodofpersistenceintoadulthood,andassociationwithothernon-transmissible diseaseswhilestillinearlyage.Environmentisamaincomponentofthegenesisandoutcomes inthenearfutureorlongterm.Modificationofintakewithhigh-densityfood,mealskipping, andhighintakeofsaturatedfat,sugar,andsalt,associatedtohighlevelsofsedentarismare maincausesofobesity.

Conclusion: Interventionopportunitiesarerelatedtomodificationsinpolitical,environmental, andindividualsettings.Schoolandphysicalactivitiesintheeducationalenvironmentare inter-twinedwithnutritioninterventionincontinuouseducation.Acriticalreviewofsomedifferent scenariosinLatinAmericancountriesispresented.

夽

Pleasecitethisarticleas:FisbergM,MaximinoP,KainJ,KovalskysI.Obesogenicenvironment---interventionopportunities.JPediatr (RioJ).2016;92(3Suppl1):S30---9.

∗_{Corresponding}_author.

E-mails:[email protected],[email protected](M.Fisberg).

http://dx.doi.org/10.1016/j.jped.2016.02.007

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PALAVRAS-CHAVE

Ambienteescolar; Atividadefísica; Crianc¸as; Adolescentes; Obesidade

Ambienteobesogênico---oportunidadesdeintervenc¸ão

Resumo

Objetivos: Avaliarosfatoresrelacionadosaoambienteobesogênico,comoatividadefísicanos bairrosenasescolas,comportamentonutricionaleprogramasdeintervenc¸ão.

Fontes: Análisecríticadaliteraturacompontodevistadeespecialistasemobesidadeinfantil econselheirospolíticosdeintervenc¸õespúblicas.

Resumodosdados: Emboraaobesidadesejaumproblemadesaúdepúblicaqueafetadiversas faixasetárias,éentrecriançaseadolescentesqueeladesempenhaumpapelmaisimportante devido àcomplexidade do tratamento, àalta probabilidade de persistência navidaadulta eàassociaçãocomoutrasdoenças nãotransmissíveiscominícioprecoce.Oambienteéum componenteprincipaldagêneseedosresultadosnofuturopróximoouemumprazomaislongo. Amodificaçãodoconsumodealimentosdealtadensidade,pularrefeiçõeseoaltoconsumode gordurasaturada,açúcaresal,associadosaosaltosníveisdesedentarismo,sãoasprincipais causasdaobesidade.

Conclusão: Asoportunidadesdeintervençãoestãorelacionadasamodificações noscenários político,ambiental eindividual. Atividadesescolaresefísicasnoambienteeducacional são intercaladascomintervençãoalimentarem umaeducaçãocontínua.Uma análisecríticade algunscenáriosdiferenteséapresentadaempaíseslatino-americanos.

Introduction

Obesity is defined as excessivebody adiposity, above the ideallevelsforgoodhealth.Itdevelopsfromachronic, posi-tiveenergybalance,undertheinfluenceofmultiplefactors of social,behavioral, andenvironmentalorigin.1_Although obesity is a public health problem affecting several age groups, it isamongchildren and adolescentsthatit plays amoreimportantrole,duetotreatment complexity,high likelihood of persistence into adulthood, and association withother non-transmissiblediseases starting at an early age.2,3 _Between ₁₉₉₀ _and _2010, _childhood _obesity _in _the worldincreasedfrom4.2%to6.7%,beinghigher in devel-opedcountries(7.9---11.7%)ascomparedtodevelopingones (3.7---6.1%).4_It _is_estimated_that_in _Latin_America,_7.1%_of childrenbelowtheageof5yearsareobese.Obesity preva-lencebetweentheagesof5and11yearsrangesfrom18.9% to36.9%,whereasamongadolescents(12---19yearsofage) itvariesfrom16.6%to35.8%.5

InBrazil,intheyearsencompassedbetweentheNational StudyofFamilyExpense(EstudoNacionaldeDespesa Famil-iar[ENDEF])of1974/75andtheResearchofFamilyBudget (PesquisadeOrc¸amentosFamiliares[POF])6_of_1996/97,_the obesity prevalence observed amongchildren of the coun-tryincreasedfrom4.9%to17.4%.7_{Nevertheless,}_an_analysis by age bracket shows that obesity amongchildren below the age of 2 years decreased 2.5%. Currently it affects 6.5% of this age group, having increased among children betweentheagesof2and5yearsfrom3.0%to7.7%.8 Obe-sityincreasedsix-foldamongschoolchildrenbetween the agesof5and9years,affecting16.8%and11.8%ofboysand girls, respectively. Among adolescents,this condition was estimatedat5.9%amongboysandat4.0%amonggirls.9

An obesogenic environment includes all aspects that have been shown to be related to possible cause-effects

of generingobesity. Based onthe concept that obesity is agenetic-metabolicdiseasemodifiedbyenvironmental fac-tors,thepresentstudyfocuses onphysicalandnutritional issuesthatcouldmodifyorberelatedtoinfantobesity res-olution.Anon-systematicreviewofintervention programs wasperformed,basedonacriticalapproachandthe expe-rienceof internationalorganizationsfor thepreventionof infantobesity.

Intervention

Onemeasurealoneisnotenoughtoimprovethenutritional profileofthepopulationbecauseoftheepidemiologic com-plexityofchildobesity.Interventionsshouldencompass:

- Incentive measures: disseminate information and moti-vateindividualstoadoptahealthylifestyle;

- Support:facilitate healthy optionsamongalready moti-vatedpeople;

- Healthprotection:preventexposureofindividualsto fac-torsthatstimulatenon-healthyhabits.10

Brazilian

politics

regarding

obesity

prevention

and

intervention

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BeforethesignatureofthePlan,policiesaimingat mak-ing individuals aware of the importance of healthy life styles,includingtheadoptionofhealthyfoodhabitsandan activelifestyle,hadbeen alreadypublishedinBraziland hadimpactedchildobesity.AnexampleistheNational Pol-icyonFoodandNutrition(PolíticaNacionaldeAlimentac¸ãoe Nutric¸ão[PNAN]),thefirstnationalpolicytoproposeactions thataimatrespecting,protecting,promoting,and provid-inghumanrightsrelatedtohealth andfood,aswellasto emphasizethe importanceofoverweightand obesityasa nationalpublichealthproblem.12

Recently, the Intersectorial Plan of Obesity Prevention and Control in Brazil (Plano Intersetorial de Prevenc¸ão e ControledaObesidade doBrasil) wasalsopublished. The actionsprovidedbythisplanaimatimprovingthe popula-tion’sconsumptionstandards,promotingthepracticeofPA, andorganizingthetreatmentservicesforthiscondition.13

The objective of the National Policy of School Food (PolíticaNacional deAlimentac¸ão Escolar [PNAE]), imple-mented in 1955, is to cater to the nutritional needs of studentswhiletheyareintheclassroom.Accordingtothe policy,schoolfoodshouldofferthreeservingsoffruitsand vegetableseachweek,andamaximumof10%ofenergyfrom simplesugar,15---30%fromtotalfats,10%fromsaturatedfat, and1%fromtransfat.Purchasingoflownutritionalcontent drinksisforbiddenandisrestrictedforsemi-ready prepara-tions,aswell asfor concentratedfoodwithhighlevelsof sodiumorsaturatedfat.Moreover,instateschoolfacilities thesaleofsnacksanddrinkswithproductsand/or prepara-tions,whetherindustrializedornot,containinghighcontent ofcalories,saturatedfat,transfat,freesugars,salt, alco-holcontent,andlownutritionalcontentisforbidden.10_The Health Department published, for the private schools, a manualforhealthyschoolcafeterias, withessential infor-mationregardingwhatrepresentsahealthysnackandhow topromoteit.9

Astoadvertisementandmarketingoffood,theNational Agencyof Sanitary Surveillance(Agência Nacional de Vig-ilânciaSanitária [ANVISA])publishedRDC#24/2010,which regulates the supply, advertising, information, and other similarpracticeswhoseobjectiveistodisseminateand com-merciallypromotefoodswithhighlevelsofsugar,saturated fat, trans fat, sodium, and low nutritional content bev-erages.This Resolution representedamajoradvance, but wassuspended,byan injunctionof theFederal Justiceof Brasília, filed by the Brazilian Association of Food Indus-tries (Associac¸ão Brasileira das Indústrias daAlimentac¸ão [ABIA]),whichquestionedANVISA’scompetencetoregulate theissue.14

Healthy

eating

initiatives

In the field of support and incentive for healthy eating, somestudieswereconductedinBrazilfocusingonpromoting breastfeedingandguidancerelatedtothe introductionof supplementaryfood.Interventionswerefocusedon updat-ing the training of professionals regarding feeding in the first year of life and educational activities with infants’ mothersandgrandmothers.Themostusedtheoretical ref-erence in those actions was the ‘‘Ten steps for healthy feeding of children under2 years of age.’’ By and large,

resultspointedtoimprovementinfoodconsumption,such aslonger durationof breastfeeding,less earlyfood intro-duction,delayinintroducing processedfoodtothechild’s diet, and higher frequency in meat consumption without alteringthe nutritionalstatus.15---17 _The_authors _praise _the positive and protective results for child’shealth and sug-gestthatother etiologicalfactorsshouldbeconsidered in interventionsaimingatobtainingfavorableresultsregarding nutritionalstatus.

Consideringtheeducationalactionstoincentiveand sup-port healthyfoodsin schools,a reviewstudy showedthat mostoftheactionsconductedinBrazilwereimplementedin thelastfiveyears,andanincrementinknowledgeon nutri-tionandchangesinfoodhabitsinchildrenwereobserved.18 However,regardingthenutritionalstatus,andsimilarlyto whatwasidentifiedinactionsgearedtoinfants,thestudies didnot findanystatisticallysignificant changes.This may beexplainedbytheacknowledgmentthatchangesinbody massdonotoccurinashortperiod.19

School-based

intervention

programs

In a nine-month, controlled intervention study conducted amongadolescents(10---11 yearsofage)ofDuquede Cax-ias(RJ),monthlyone-hoursessionsonnutritionaleducation promotedtheconsumptionoffruitandhomemade prepara-tionsinsteadofsugarybeveragesandotherultra-processed foods. Theresults showedareductionintheconsumption of industrializedcookiesandsoftdrinks, togetherwithan increaseinfruitconsumption,withnoimpactonbodymass index(BMI)andonobesityprevalence.19

InTeresina(PI),arandomized,quasi-experimentalstudy withadolescentsof10---14yearsofage,frompublicschools, andwithnineweeklymeetings,showedasignificant reduc-tionintheconsumptionofsoftdrinksandprocessedjuices, aswellasalowerfrequencyofconsumptionofcoldcutsand friedfood.20

Thus, the success of intervention actions with the pediatricgroupisevident,relatedtochangesinfood con-sumptionandtheneedforlongerstudiestoevaluatethereal effectivenessofthechangesinnutritionalstatus.Moreover, thereis a need for studies todecreasethe prevalence of childhoodobesitythat evaluatetheimpactofpublic poli-cies.

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gradestudentsaftertwoyearsofinterventionrevealedthat childrenin APPLESschools consumedmorefruitsand veg-etables,consumedlesscalories,andwerelesslikelytobe obese.22

Afewexamplesofpolicy-basedinterventionstochange the school food environment are briefly described here. ‘‘The Healthy Options for Nutrition Environments in Schools’’(HealthyONES)23_is_based_on_a_model_which_focuses onorganizationalchange byusingspecificimplementation cycles designed to build capacity within an organization. Thisapproachwasusedinsomelow-incomeschoolsinthe US.Theintervention,whichlastedtwoyears,included elim-inatingthesaleofunhealthyfoodsandthetrainingofschool staffinhealthyeating.Thenutritionenvironmentwasused to determine the amount of foods and beverages avail-able at the schools. Observations were made monthly in eachtargetedschoolenvironment.Resultswerepromising; theunhealthyfoodandbeverageitemsperchildperweek decreasedovertimeininterventionschools,whileincontrol schoolstheyincreased.24,25

The Nutrition Policy Initiative (www.thefoodtrust.org) also was implemented in US schools, but only in those withmorethan50%ofchildreneligibleforfederally subsi-dized,free,orreduced-pricemeals.In2008,Fosteretal.26 includedthefollowingcomponents:schoolself-assessment, nutritioneducation,nutritionpolicy,socialmarketing,and parentoutreach.Arecentevaluationexaminedtheeffects onobesityratesamongfourthtosixthgradestudents.Overa two-yearperiod,itshoweda50%reductionintheincidence ofoverweight,i.e.,significantlyfewerchildreninthe inter-vention schools(7.5%) than inthe control schools (14.9%) becameoverweight;however,nodifferenceswereobserved intheincidenceorprevalenceofobesityaftertwoyears.

Nutrition detectives (www.nutritiondetectives.com),27 whichisactiveinhundredsofschoolsintheUnitedStates and Canada, includes teaching children andtheir parents how to read food labels and detect deceptive marketing strategies, while learning to identify healthful foods. An initial evaluationof thisprogramshowed thatthird grade studentsandparentsininterventionschoolsshoweda signif-icantincreaseinnutritionlabelliteracy,whiletotalcalories, sodium,andsugardecreasednon-significantly,andasfound inmostinterventions,BMIdidnotchange.

Constant28 _reviewed _the_evidence _on_the _{effectiveness} of school-based nutrition policy on the food environ-ment, student’s dietary intake, and BMI. The author found that although several policies have been imple-mentedinbothdevelopedasindevelopingcountries,very few have been evaluated. In some countries nutritional standards have already been established for competitive foods,while inother countriesthesewillbeimplemented soon.

Establishing

social

healthy

habits

Becausepreferencesandpurchasingrequestsareinfluenced byculturalandsocialaspectsaswell asmarketing strate-gies, which include advertisements on TV, the Internet, and advergames, schools should take advantage of these strategiestopromotetheappealofhealthierfoodsand bev-erages in variousways (Institute ofMedicine, 2006-online

http://iom.nationalacademies.org/Reports/2005/Food-Marketing-to-Children-and-Youth-Threat-or-Opportunity. aspx).Tastetestinginimaginativeformsprovidesstudents an opportunity to try healthy foods especially fruits and vegetables. Older children can be involved in making changes in order to improve food habits. In the United States,theActionforHealthyKids,StudentsTakingCharge program(http://www.studentstakingcharge.org)29 _and_the Alliance for a Healthier Generation’s empowerME@school toolkit (http://www.empowerme2b.org) are resources that provide examples in this area. Social marketing can be especially useful in targeting unhealthy behaviors.30 It is defined as the application of commercial marketing principles (i.e., the four ‘‘Ps’’ of place, price, product, andpromotion) tobenefit society andthe intended audi-enceratherthanthemarketer (Task ForceonCommunity PreventiveServices). Physicalactivity: increasing physical activity through information approaches, behavioral and socialapproaches,environmentalandpolicyapproaches.31 These ‘‘P’’ principles can change community norms by delivering health messages, as well as encouraging indi-vidual behavior change. For example, social marketing can encourage parents to adopt protective behaviors by demonstrating positive parental role models in order to createahealthyhomeenvironment,whichalsoinfluences whatchildrenbuyat school.Socialmarketingcanbeused to promote engagement and positive role modeling, and canalsoinfluencehealthpolicybycreatingandpromoting positivesocialimagesofhealthybehaviors(i.e.,showthat ahealthy option, suchas eatingfruits andvegetables, is superiortoeatingjunkfood).32

Hawkes C. et al.33 _recently _proposed _a _novel _way _of understanding food policy for obesity prevention, iden-tifying four mechanisms, namely: providing an enabling environment for healthy preference, overcoming barri-ers,encouragingindividualstore-evaluatetheirunhealthy choices,andstimulatingafoodsystemsresponse.The evi-dence presented by the authors show that food policies canaffectdietaryintakefromthreeareas:economictools (taxes,subsidies), school settings, and nutritionlabeling. Withrespecttoschools, theimplementationofarangeof activities, mostly nutrition education and changes to the environment,haveproducedmoresignificantandsustained changes. Regarding nutrition education, Kain J. et al.34 showed in a series of interventions in Chile that it had minimaleffects,duetoproblemswithadequate implemen-tation,pre-existingunhealthypreferencesamongchildren, parents, and teachers, as well as lack of changes to the environment. Yet, other studies have shown that nutri-tion education-only interventions have been effective in changing intake of certain foods. Although policies that influence the school environment for obesity prevention are very important, the behavior of parents related to food, nutrition, and physical activity are probably more relevant.Thereisevidencethattherearebarriersfor par-ents to adopting healthy lifestyles, as demonstrated by somestudiesbasedonfocusgroups.Thesebarriersinclude the number of siblings, lack of time and money, neigh-borhood safety,and the child’spreferences for sedentary activities.35---37

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recommendations for obesity prevention of sweetened drinks and snacks chips in schools was shown ineffective by Cullenet al.39 _because_in _some _schools _students com-pensated by purchasing unhealthy ‘‘non-banned foods.’’ However,anotherstudythatassessed theimpactofa dis-trictlevelnutritionpolicyinLosAngeles(US),whichbanned soft-drinksandsnackswithlimitednutritionalvaluethrough vending machines and direct sales to all students during schooldays,showedthat 55.5% ofstudents reducedtheir softdrinkconsumptionand52.6% reducedsnackintakein school.40

Programs

targeting

the

environment

Reductioninpriceofhealthierfoods,suchaslow-fatsnacks and fruit and vegetables, might increase their sales, as wasshown first by French S., in 2003.41 _In _addition, ini-tiatives to promote fruit and vegetables consumption at schools have been proven successful42_; _however, _it _is _not realistic to expect that students will continue to adopt healthy diet behavior at school if the school environ-mentdoes not supportthesebehaviorscontinually, which requires investigating whether students return to their former behavior when the intervention is no longer in place.

Astudypublishedin 2008thatdeterminedtheefficacy of behavioral interventions to prevent childhood obesity throughameta-analysesofrandomizedtrialsconcludedthat the effect on target behaviors was small, while that on BMIwasnon-significant.Longerinterventions,greaterthan sixmonths,yieldedmarginallybetter effectsthanshorter ones.43

Becausein general, most childhoodobesity prevention interventionshave not proved to besufficiently effective to be sustainable in the long run and obesity in most countrieshaseitherincreasedor remainedstable,buthas not declined, several highly respected researchers have recentlyproposeda ‘‘systemsframework’’toaddressthis problem.Thesystemapproachfocusesontherelationships between different aspects of the environment and inter-actions between individuals with the environment.44 _It _is importanttodistinguishitfromamulticomponentmodel, theinteractionsamongallsectorsrequiredtoproduce sus-tainablechangesthatcanbescalable.Thiscanbeespecially importantto supportmodifications tothe school environ-ment that can make it easier to adopt healthy choices withintheschoolpremises.Theseissues,whichareunique ineach school,arecriticalwhendesigninganintervention anddeterminingitseffectiveness.

PA

opportunities

at

school

Thereisacommonagreementthatduringthelastdecades, there has been a displacement of time from playing, engagingsports,andrecreationalgamestowardsacademic activities. Even some of the after-school programs must competewithtechnologicaloptions.Additionally, physical education(PE)classesdonotalwaysinfluenceenergy bal-ance with moderate to vigorous physical activity (MVPA). The Center for Disease Control and Prevention of the UnitedStatesrecommends thatMVPA shouldtakeat least

50% of lesson time. A global review, published by Hol-lis, including studies from nine countries and published between 2005and2014, analyzed theproportionofMVPA during PE lessons.45 _The _authors _concluded _that _studies based on direct observations report that children spent 57.6%ofthePElessonperformingMVPA,comparedto stud-ies based on accelerometers in which only 32.6% of the time was spent on MVPA. It is clear that although there arestilllimitations onPA evaluationmethods in children, interventions aimed at increasing MVPA in PE lessons are needed.

Schoolbreaks arean excellentopportunity todevelop motivational and recreational activities that improve the PAlevelandfairplay. ComparedtoPEclasses, breaksare usually full of non-competitive activities based onfun. A quasi-experimental intervention study conducted in three schools in Californiatested the timespent onMVFA after teachers’ social prompting of PA during recess. Findings from this study indicate that when a teacher prompted a child to engage in MVPA, it had a significant impact on the amount of MVPA while modeled by a competent adult.46

Unfortunately,whenthesetypesofinterventionsare ana-lyzedregardingobesityprevention,thesizeeffectonBMIis toosmallornull.Mostofthecurrentstudiesarefocusedon demonstratingresultsassociatedwithchronicdisease pre-vention; however, undera more qualitative standpoint of theintervention,itispossiblethatinthelongrun,thereis impactfromsustainablehealthybehaviorlinkedtoPA.

‘‘TAKE10!’’isanotherexample ofaprogramaimedat addressingthebarriersagainstsedentarybehavioratschool. It takesadvantage of theaccumulation of tenminutes of PAduringregularclasses, integratingmovementwith aca-demics in elementary schools. Up to August 2010, more than 40,000 schools in the United Sates had participated inTAKE10!fortheprevious tenyears.Theanalysisofthe programs influence onenergybalance suggests incremen-talexpenditureattributedTAKE10!activities,whichrange from24to43kcalper10-minute session.Thelonger-term studies reportedby Kibbe etal. suggest thatBMI mainte-nanceisachievedininterventionstudentswhenexposureis sustained.47

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Effectiveness

of

PA

in

obesity

prevention

interventions

Generallyspeaking,pediatricobesity preventionprograms havebeenfoundtocausesmallchangesintargetbehaviors andsmallornosignificanteffectonchildren’sactivitylevel andBMI.43,49_On_the_other_hand,_demonstrated_by_the_same methodology(systematicreviewandmeta-analysis)within similarperiodsofsearch,anotherstudyshowedthe impor-tanceofthePAcomponentinschool-basedinterventionsto beeffectiveinreducingBMIinchildren.50

The bias associated to these differences could be attributed to the measurement of variables of energy expenditure (accelerometer, observational, and/or ques-tionnaires), and/or cut offs of anthropometric measure-ments,andalso,theselectionofthestudies(randomizedor non-randomized).Allareprobablycausesofthedifferences inassessmentsand,consequently,intheconclusions.

TwoCochranereviewsongeneralinterventionsfor pre-ventingobesityinchildrenandspecificallyonschool-based PAprogramshavedemonstratedmorepositive results.51,52 The first, which assessed educational, behavioral, and health promotion interventions, reported the success of interventions at preventing childhood obesity with no adverse outcomes, by improving both dietary and PA behavior.53,54

SpecificallyrelatedtoPA,inallagegroups(0---5,6---12, and 13---18 years), individual studies that met inclusion criteriademonstrateasignificantinterventioneffecton PA-relatedfactors(three, 21, andfivestudies, respectively), andsomeofthemintermsofadiposity.Thesecondreview publishedbyDobbinswasfocusedonprogramspromotingPA andfitnessinchildren.Afteranalyzing26studiesfrom302 eligibleones,therewasevidencethatschool-basedPA inter-ventionshadapositiveimpactonfourofthenineoutcome measures:durationofPA,televisionviewing,VO2max,and bloodcholesterol.

These results indicate that despite BMI not being an effective primary outcome measure, some other positive healthoutcomescouldbeconsideredaspartofthevariables thatdeterminepreventionofchronicdiseases.

OpportunitiesforPAinschools,interventionstoincrease duration and recreational PA, and capacity building for teachers appear to be critical to determine and sustain healthy habits. Sincethese behaviorsareoften promoted byenvironmentalcues,currentfindingssuggestvalueofthis typeofintervention,especiallyinproposingchange strate-giesthatfavorPA(Table1).

Recommendations

Despitedifferencesinsizeeffectofpositiveoutcomesfrom PAinterventions,thereisnodoubtaboutthegeneral ben-eficialeffectof PAduringgrowth anddevelopment.From psychological tobiological issues, thereare awide range ofhealthoutcomesthathaveprovedtobebeneficialfora healthylife.RecommendationofPAduringchildhoodisthus aconsensusamongscientistsandresearchers.55

Oneofthekeypointsincludesstartingasearlyas possi-bletofavoralinkbetweenearly-lifeexperiencesandlater healthoutcomes,creatingapatternofPAbehaviorsthrough

life.AnotheraspectisthatcurrentlevelsofPAareverypoor, andbothdevelopedanddevelopingcountriesdonotmeet PArecommendations,despitetheexistentguidelines.Asa generalrule,recommendationsinclude,type,andduration ofPA,andlevelofintensity.

The environmentplaysa criticalrolein infancy, favor-ingordiscouraging engagementin recreationalmovement activities, PA, and sports. The role of education through messages,or academiccontentswithinthecurricula, con-troversially does not influence behaviors if they are not supportedbyanincreaseinopportunitiesandmoreaccessto facilitiesandactivities.Educationaloneislesseffectivefor preventionthantreatmentprograms,incontrastto encour-agingteachersandtheentireschoolstafftobecomedrivers ofphysicalandhealthliteracyandbehaviorchange,andalso forbeingthemselvesmorephysicallyactive.56

Summaryofrecommendations

• Time:Elementaryschools150/minutes/week.Secondary

schools225---300minutes/week.

• Intensity in PE classes: Students are physically active

(MVPA)foratleast50%ofthePElessontime.

• Quality: Enjoyable classes while teaching and children

developappropriateskillsforageandgender.

• Duringschool time:Increase opportunities tobeactive

duringrecessandlunchtime.ConsiderintegratingPAinto classroomactivities.

• Schoolsshouldprovideadequateenvironments,including

equipmentandplaygrounds,andalsoorganizeactivities duringbreaks.

• Encourageandofferafterschoolactivities,both

compet-itive andnon-competitive, in orderto include asmany studentsaspossible.

• Engage teachers and familythroughevents, education,

messages,andmarketingfavoringPA,workingpositively tocreateanactiveschoolcommunity.

Barriers

and

conclusions

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Table1 Summaryofreviewsand/ormeta-analysisforphysicalactivityintervention.

Author&aim Kindofstudy Criteriafor consideringstudies

Mainoutcomes Finalconclusions

Jaime,PC 2009---Effectivenessof schoolnutrition policies. SystematicReview UptoNov.2007 Primaryand SecondarySchools 18Studies USA-Europe

Policyassessed Moreefficacyin: -Implementationof recommendationsand priceinterventions -Regulationofaccess tofoodsand

beverages

Somepolicieshave beeneffectivein improvingfood environmentand dietaryintake Littleevaluationof impactonIMC

Morelongterm studiesarenecessary

Khambalia,A 2012---Effectivenessof Schoolbased obesity interventions SystematicReview 1990---2010 8studies:,3 meta-analysisand5 systematicreviews AllinEnglish

School-based Reviewsthat consideredindividual studieswhich examinedbehavioural interventionsfor preventingor controlling

overweightorobesity (PA,dietorboth).

Themeta-analyses concludedthat school-basedobesity interventionshada significant,albeit modest,effectin achievingweight reductioninschool settings

Littleevidence. Morehighquality Studiesareneeded

Lobelo,F 2013---School-Based ProgramsAimedat thePreventionand Treatmentof Obesity Systematicreview 1965---2010 10studies LatinAmerica School-based Evaluatedanobesity relatedoutcome (bodymassindex [BMI],weight,%body fat,waist

circumference,BMI z-score),

-Comparative (exposedvsnot exposed) Mostsuccessful interventionswere focusedon: Prevention Longerfollow-ups Multidisciplinaryteam, Fewerlimitationsin execution

5/10Positiveoutcomes

Sufficientevidenceto recommend

school-based interventionsto preventobesity amongyouthinLatin America. Lavelle,H 2012---Effectivenessof school-based interventionsto reduceBMI

Systematicreview& meta-analysis 1991---2010 43studies Population=<18y. Europe-US-Brazil

Stratifiedanalysis 26%studiesPAonly 7%educationalone 69%combinedPA interventionswith nutrition

PAaloneandorPAplus nutrition,was

associatedwith significant

improvementsinBMI

School-based interventionsthat containaphysical activitycomponent maybetoreduceBMI

Metcalf 2012---2013 Effectivenessof interventionon physicalactivityof children

Systematicreview& Meta-analysis 2003---2011 30Studies

16yearsoryounger

Randomized controlledtrialsor controlledclinical trials

Studiesdesignedto increasethephysical activityof

children/adolescents. Atleastfourweek.

Physicalactivity Interventionsdonot affecttheoverall activitylevelsof children

Strongevidencethat physicalactivity interventionshave hadonlyasmall effect(approximately 4minutesmore walkingorrunning perday)onchildren’s overallactivitylevels Brown,T

2009

Interventionsthat focusonchanging dietaryintakeand physicalactivity levelstoprevent childhoodobesity

SystematicReview 38RCT

13fromNICE 7NEandPA

School-based Onlyincludesstudies thatreporteda weightoutcome. Studieswitha lifestyleintervention (diet,PA,dietplus PA)

Physicalactivity interventionsmayhelp childrenmaintaina healthyweight Theresultsare inconsistentand short-term. Physicalactivity interventionsmaybe moresuccessfulin youngerchildrenandin girls.

Usequalititaveand quantitative outcomes

Combinationofboth PAanddiet

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Table1 (Continued)

Author&aim Kindofstudy Criteriafor consideringstudies

Mainoutcomes Finalconclusions

Waters,E 2011

CochraneReview

Review& Meta-analysis Case-ControlStudies (Randomizedornot) Atleast12weeks 55Studies(37 meta-analysis) 6---12yearsold

Studieswereincluded iftheyevaluated interventions, policiesorprograms inplacefortwelve weeksormore

Programswere effectiveatreducing adiposity,althoughnot allindividual

interventionswere effective

Strongevidenceto supportbeneficial effectsofchild obesityprevention programsonBMI, Include

recommendationsand strategies

Guerra,PH 2013 School-based physicalactivity andnutritional education interventionson bodymassindex

Meta-analysis Publishedafter2000 33articles

6---18yearsold

Schoolbased RCTonPAandNE PerformedPAandNE interventionsfor childrenand adolescents DescribedtheBMI outcomeinboth interventionand controlgroups

Showednostatistically significantmean reductiononchildren’s andadolescents’BMIin normalpopulation. Littlepositiveeffect wasobservedwhen includingOWandOB

Morestudiesare neededinorderto provideaneffective frameworktobe implementedinthe schoolsetting.

RCT,randomizedcontrolledtrial;PA,physicalactivity;BMI,bodymassindex;OW,overweight;OB,obese;NE,nutritionaleducation.

facilitator,were proposed:a minimumnumber of materi-alsweredonated, playgroundswerepaintedtoencourage playing onthepainted ground, andthe teacher’straining wasadequate toincrease moderate andvigorousphysical activityduringschoolhours.57

Considering that global environmental conditions are leadingtoenergyimbalance,manyintervention opportuni-tiesappeartobeatleastpartofthesolution.Itseemsvery difficulttoarbitraryseparatethecomponentsofenergy bal-ance,butinchildren,theenergyexpenditurethroughPAis acrucialcomponentinpreventivestrategies.

Someauthorssuggestthatschool-basedinterventionsare more effective compared to home-based interventionsto preventobesityinchildrenandadolescents.De Bourdeaud-huihetal.58 _reviewed₁₁ _European_studies _and_concluded thatcombiningeducationalandenvironmentalcomponents thatfocusonbothsidesoftheenergybalancecreatebetter and morerelevant effects, suggesting that environmental interventionsmightincludePAinterventionslikeorganized PA during breaks, or before and after school; improved availability of PA opportunities in and around the school environment;andincreasedPElessontime;withoutfailing toconsidertheinterventionsonhealthyfoodoptions.

Funding

ILSI, Coca-Cola, CPW, Danone Institute International and DanoneResearch,CNPq.

Conflicts

of

interest

Mauro Fisberg is an invited speaker for Abbott, Danone, Coca-Cola,Nestle,Unilever,EMS.Theotherauthorsdeclare tohavenoconflictsofinterest.

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