A secondary analysis of the childhood obesity prevention Cochrane Review through a wider determinants of health lens: implications for research funders, researchers, policymakers and practitioners

Abstract

Background Randomised controlled trials (RCTs) are often regarded as the gold standard of evidence, and subsequently go on to inform policymaking. Cochrane Reviews synthesise this type of evidence to create recommendations for practice, policy, and future research. Here, we critically appraise the RCTs included in the childhood obesity prevention Cochrane Review to understand the focus of these interventions when examined through a wider determinants of health (WDoH) lens. Methods We conducted a secondary analysis of the interventions included in the Cochrane Review on “Interventions for Preventing Obesity in Children”, published since 1993. All 153 RCTs were independently coded by two authors against the WDoH model using an adaptive framework synthesis approach. We used aspects of the Action Mapping Tool from Public Health England to facilitate our coding and to visualise our findings against the 226 perceived causes of obesity. Results The proportion of interventions which targeted downstream (e.g. individual and family behaviours) as opposed to upstream (e.g. infrastructure, environmental, policy) determinants has not changed over time (from 1993 to 2015), with most intervention efforts (57.9%) aiming to change individual lifestyle factors via education-based approaches. Almost half of the interventions (45%) targeted two or more levels of the WDoH. Where interventions targeted some of the wider determinants, this was often achieved via upskilling teachers to deliver educational content to children. No notable difference in design or implementation was observed between interventions targeting children of varying ages (0–5 years, 6–12 years, 13–18 years). Conclusions This study highlights that interventions, evaluated via RCTs, have persisted to focus on downstream, individualistic determinants of obesity over the last 25 years, despite the step change in our understanding of its complex aetiology. We hope that the findings from our analysis will challenge research funders, researchers, policymakers and practitioners to reflect upon, and critique, the evidence-based paradigm in which we operate, and call for a shift in focus of new evidence which better accounts for the complexity of obesity.

Prevention of Pediatric Overweight and Obesity: Position of the Academy of Nutrition and Dietetics Based on an Umbrella Review of Systematic Reviews

“…Most included interventions focused on individual-level interventions rather than on "upstream" determinants, such as infrastructure, environment, or policy, and this trend has not changed over time. 18 Implication for Practitioners. RDNs provide nutrition education as an essential part of pediatric obesity prevention interventions.…”

“…17 The certainty of evidence was higher among preschool children aged 0 through 5 years compared with those in elementary schools (aged 6 through 12 years) or secondary schools (aged 13 through 18 years). 11 In addition, most interventions tended to focus on individual-level behaviors rather than upstream environmental factors or social determinants of health, 18,26 which is antithetical to the premise that obesity is a complex disease. Most of the nutrition education interventions for children aged 0 through 5 years are targeted primarily at the parents rather than the children, as at that age, the parents are the primary gatekeepers for children's diets and social influences.…”

Brown Adipose Tissue: New Challenges for Prevention of Childhood Obesity. A Narrative Review

“…Pediatric obesity is a significant challenge for our society [ 1 ]. Prevalence between males and females, in school age and during adolescence, is better than previous years, but remains high [ 2 ].…”

A critique of the English national policy from a social determinants of health perspective using a realist and problem representation approach: the ‘Childhood Obesity: a plan for action’ (2016, 2018, 2019)

“…The stated aim of The Policy was to significantly reduce the prevalence of childhood obesity in England, and to address disparities in health by reducing the gap in childhood obesity between those from the most and least deprived areas. Although the creation of a policy addressing childhood obesity was generally welcomed by public health bodies at the time of publication, there is concern that they focus too heavily on individual behaviour change rather than upstream (stealth) interventions [ 4 , 5 , 10 , 11 ]. With plans underway for Chapter 3 of The Policy [ 9 ] potentially delayed due to a Government focus on Covid-19, it is our hope that government will revisit and review the aims of The Policy with a focus on the structural influences of health inequalities and poverty on health outcomes.…”

“…Traditionally, policy discourses around obesity have focused on personal responsibility and individualism, with an absence of engagement with the social determinants of health [ 20 , 21 ]. Individualistic approaches are evident in the wealth of research examining risk factors for childhood obesity, which focus on implementing changes to lifestyle behaviours [ 11 ] with minimal consideration of the wider social determinants of health. A pattern in approaches to obesity interventions lacking complexity has also been found at a local authority level in England [ 22 ].…”