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Intergenerational interventions targeting obesity: a review

Authors Melanie Rimmer [1], Stuart Parker [2], Paul Bissell [3], Sheila Kennedy [4], Anna Cantrell [5]

[1], [3], [4], [5] School of Health and Related Research, The University of Sheffield

[2] Institute for Ageing and Health, Newcastle University

Keywords Obesity, overweight, intergenerational, interventions

Corresponding author Professor Stuart Parker Institute for Ageing and Health Newcastle University Campus for Ageing and Vitality Newcastle upon Tyne NE4 5PL United Kingdom Stuart.Parker@newcastle.ac.uk

Potential Conflicts of Interest None

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Intergenerational interventions targeting obesity: a review

Authors M. Rimmer, S. Parker, P. Bissell, S. Kennedy, A. Cantrell

Abstract Intergenerational exchange is an effective source of support for older people and their families and is a potentially useful resource in the prevention and management of obesity and its complications. Intergenerational interventions are increasingly seen as an effective way to reduce or prevent childhood obesity. It is possible that they may also be used to provide benefit for older generations. The purpose of this review was to analyse the characteristics and effectiveness of intergenerational interventions targeting overweight and obesity in order to inform the development of social interventions which aim to harness or expand the potential of intergenerational exchange as a resource in the prevention or management of obesity in older age. A search of eleven electronic databases was carried out. The search and selection process resulted in 19 studies which met the inclusion criteria. These studies included 4 systematic literature reviews, 2 randomised controlled trials, 4 quasi experimental studies and 9 other study designs.

It is concluded that there is a paucity of evidence around intergenerational interventions with children/seniors, while most research focuses on children/parents. There is a great deal of variation in the studies reviewed making it difficult to draw firm conclusions. However in general the impact of intergenerational interventions on BMI or z-scores was small, and tended to vanish on follow-up.

Keywords Obesity, overweight, intergenerational, interventions

Introduction Population ageing and obesity are two of this century’s megatrends1 2. In Europe, between 2010 and 2060, the proportion of the population aged over-65 years is projected to increase from 17% to 30%. The proportion over 80 years is expected to increase from 5% to 12%3. Global obesity nearly doubled between 1980 and 2013. It is likely that these two trends will combine to give rise to increasing numbers of older people with problematic obesity and associated medical conditions. It is estimated that at present obesity accounts for as much as 8% of healthcare costs in Europe, and it has been suggested that lack of exercise and poor diets are amongst the leading causes of avoidable deaths in Europe4. It is therefore an urgent matter to find ways to reduce the number of people who reach old age with problematic obesity. The achievement of such a goal might reasonably be expected to impact favourably on the magnitude and duration of disability in later life.

There are links between health and social connectedness. In Europe, older people still have close links with their families and intergenerational exchange of resources is from older to younger for all but the oldest old people1.

It is possible that intergenerational interventions may be developed to address the issue of preventing and managing overweight and obesity in older people in ways that have not previously been attempted. The primary research question for this review was “What intergenerational innovations have been attempted to reduce obesity?” - with the aim of identifying features of

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successful and unsuccessful interventions. This information will be used to inform the development of novel intergenerational interventions for children and seniors.

Methods To address the research question the search strategy was developed to retrieve studies on intergenerational innovations to reduce obesity and comprised the following elements:

• searching of electronic databases

• scrutiny of bibliographies of retrieved papers and previous reviews

The following databases were searched:

• MEDLINE(R) In-Process & Other Non-Indexed Citations and MEDLINE(R) (Ovid) (1946 to April

2013)

• Cochrane Database of Systematic Reviews (Wiley Interscience) 1996 to April 2013

• Cochrane Central Register of Controlled Trials (Wiley Interscience) 1898 to April 2013

• Health Technology Assessment Database (Wiley Interscience) 1995 to April 2013

• Database of Abstracts of Review of Effects (Wiley Interscience) 1995 to April 2013

• Cumulative Index to Nursing and Allied Health Literature (EBSCO) 1982 to April 2013

• Social Sciences Citation Index (Web of Knowledge) 1956 to April 2013

• Science Citation Index (Web of Knowledge) 1900 to April 2013

• ASSIA (ProQuest) 1987 to April 2013

• Social Care Online 1986 to April 2013

• UK clinical research network (UKCRN) study portfolio 2007 to April 2013 (to find ongoing

clinical research studies)

The search strategy was developed on Medline and then translated to the other databases. It was conducted in March 2013 and limited to papers in English about humans. The following Medline search strategy illustrates our approach to retrieve studies on intergenerational innovations to influence obesity:

Database: Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R) <1946 to Present>

Search Strategy:

--------------------------------------------------------------------------------

1. Health Promotion/ 2. social innovation$.tw. 3. social intervention$.tw. 4. Inventions/ 5. technological innovation$.tw. 6. technological intervention$.tw.

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7. Computers/ 8. Telemedicine/ 9. Biomedical Technology/ 10. Wireless Technology/ 11. or/1-10 12. exp Obesity/ 13. Overweight/ 14. (obes$ or overweight or fat$).tw. 15. or/12-14 16. 11 and 15 17. intergenerational relations/ or exp parent-child relations/ 18. intergenerational.tw. 19. inter-generational.tw. 20. crossgenerational.tw. 21. cross-generational.tw. 22. or/17-21 23. 16 and 22 24. limit 23 to (english language and humans)

The search terms were refined as appropriate to conform with the syntax required by each database

Studies were included if they met the following criteria:

(i) they contained an intervention or interventions

(ii) the intervention(s) had an intergenerational component

(iii) the intervention targeted obesity/overweight

We included (iv) reviews of intergenerational interventions targeting obesity.

Studies were excluded if

(i)the focus was on neonates and infants,

(ii) they did not feature an intervention,

(iii) there was no intergenerational component,

(iv) the intervention(s) did not target obesity/overweight or the causes of obesity/overweight,

and (v) and which were not indexed in at least one of the databases named

Searches of grey literature were not included.

Two researchers (M.R. and S.P.) obtained and read the full text of all potentially relevant papers, and agreed those that matched the inclusion criteria (unresolved disputes would have been resolved by arbitration by another research team member, but there were none). The process is illustrated in Figure 1.

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Phase 1: Boolean Logic Health promotion OR social innovation$ OR social intervention$ OR

Inventions OR technological innovation OR technological intervention$ OR Computers OR Telemedicine OR Biomedical Technology OR Wireless

Technology AND

Obesity OR Overweight (OR Obes$ OR Overweight OR fat$ AND

(intergenerational relations OR parent/child relations) OR intergenerational OR inter-generational limited to (english language and

humans)

Total Articles returned (n=206)

Phase 2: Distillation 152 Articles excluded after

Title/Abstract review

54 full papers reviewed

Phase 3: Manuscript review 35 rejected after detailed

review: 27 were not interventions

2 were not intergenerational 4 were not focused on

obesity 2 exclusively studied infants

19 articles included in the review

Systematic reviews (n=4) Randomised Control Trials (n=2) Quasi-experimental designs (n=4) Miscellaneous other designs (n=9)

Figure 1 Selection of papers for review

Quality assessment was performed using Critical Appraisal Skills Programme (CASP) checklists appropriate to the study design including systematic reviews, randomised controlled trials, quasi

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experimental studies and cohort studies5. The templates were used to extract data on the focus of the studies, the population, intervention and outcomes, assessment of bias.

Results The initial search yielded 206 articles. After screening the titles and abstracts of candidate studies, 54 papers were retrieved and the full article reviewed. Of these 56 articles, 19 papers met the inclusion criteria (Figure 1). The 19 papers are listed in Table 1.

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Systematic Reviews

Hingle et al

Parental involvement in interventions to improve child dietary intake: a systematic review

Preventive Medicine

2010

Vol.51(2), pp.103-111

Knowlden and Sharma

Systematic review of family and home-based interventions targeting paediatric overweight and obesity

Obesity Reviews

2012

Vol.13(6), pp.499-508

Niemeier et al

Parent Participation in weight-related health interventions for children and adolescents: A systematic review and meta-analysis

Preventive Medicine

2012

Vol. 55, pp.3-13

Swanson et al

Intergenerational energy balance interventions: a systematic literature review

Health Education & Behavior

2011

Vol.38(2), pp.171-197

Randomised controlled trials

Golan Parents as agents of change in childhood obesity – from research to practice

International Journal Of Pediatric Obesity

2006

Vol.1(2), pp.66-76

Hopper et al

The effects of a family fitness program on the physical activity and nutrition behaviors of third-grade children

Research Quarterly For Exercise And Sport

2005

Vol.76(2), pp.130-139

Quasi experimental designs

Chomitz et al

Promoting healthy weight among elementary school children via a health report card approach

Archives Of Pediatrics & Adolescent Medicine

2003

Vol.157(8), pp.765-772

Kubik et al

Providing obesity counselling to children during a primary care clinic visit: results from a pilot study

Journal Of The American Dietetic Association

2008

Vol.108(11), pp.1902-1906

Olvera et al

BOUNCE: a community-based mother-daughter healthy lifestyle intervention for low-income Latino families

Obesity 2010

Vol.18, pp.S102-S104

Olvera et al

A healthy lifestyle program for Latino daughters and mothers: the BOUNCE overview and process evaluation

American Journal of Health

2008

Vol.39(5), p.283-295

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Education

Miscellaneous designs

Cronk et al

Effects of a culturally tailored intervention on changes in body mass index and health related quality of life in Latino children and their parents

American Journal of Health Promotion

2011

Vol 25, No. 4 pp e1-e11

Jacobson and Melnyk

A primary care intervention program for overweight and obese school-age children and their parents

Journal of Pediatric Health Care

2012

Vol 26, No. 2, pp.126-138

Janicke Treatment of Pediatric Obesity Using a Parent-Only Approach: A Case Example

Health Psychology

2013

Vol.32(3), pp.345-350

Kicklighter et al

A home-based nutrition and physical activity intervention for grandparents raising grandchildren: a pilot study

Journal of Nutrition for the Elderly

2009

Vol 28, pp.188-199

Olvera et al

BOUNCE: an exploratory healthy lifestyle summer intervention for girls

American Journal of Health Behavior

2010

Mar-Apr;34(2):144-55

Robertson et al

Pilot of “families for health”: community-based family intervention for obesity

Archives of Disease in Childhood

2008

Vol 93, pp.921-926

Simson et al

Humor your way to good health: an intergenerational program to address a critical public health issue: the epidemic of overweight and obesity among children

Journal of Intergenerational Relationships

2008

Vol 6(1), pp.83-100

St Jeor et al

Family-based interventions for the treatment of childhood obesity

Journal Of The American Dietetic Association

2002

Vol.102(5), pp.640-644

Werner et al

Active generations: an intergenerational approach to preventing childhood obesity

Journal of School Health

2012

Aug;82(8):380-6

Table 1 Table of All Papers Included in This Review

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Four of the papers were systematic reviews, two were randomised control trials, four used a quasi-experimental design and nine were of miscellaneous research design (Table 1). Both of the randomised controlled trials were already included in the systematic literature reviews6,7 so their data was not extracted for reporting separately. Here we summarise the evidence from the four systematic reviews and the quasi experimental studies. The findings from the other designs will be discussed briefly.

Systematic Reviews Our searches found 4 systematic reviews8,9,10,11. The systematic reviews are detailed in Table 2

Hingle et al (2010) Hingle et al8 reviewed 24 randomised controlled trials in which parents supported children or adolescents to improve dietary intake. These trials included approximately 35316 participants. They used the CONSORT checklist for non-pharmacologic randomized controlled trials12 to evaluate the quality of the papers reviewed. CONSORT is a 26-item checklist of items which comprises an evidence-based, minimum set of recommendations for reporting RCTs. The authors found that the quality of the included papers varied widely. Only four studies (out of 24 included RTCs) met more than 70% of the CONSORT checklist. The most common weaknesses were failure to provide details on how adherence to protocol was assessed, failure to provide information about how sample size was determined, failure to provide information about randomization methods, failure to provide information about blinding, failure to provide information about flow of participants through the study and failure to provide information about adverse events during the study. They reviewed 24 interventions and found insufficient research comparing intergenerational with non-intergenerational interventions to be able to compare the effectiveness of the two approaches. By comparing the outcomes of studies which used direct methods to engage parents with those using more indirect the authors concluded that amongst intergenerational interventions (which were exclusively in the direction of parental support for change in the child), the most effective involve the parents much more than the least effective. Interventions which simply involve sending home information sheets, for example, aren’t highly effective. However, interventions in which parents are more involved, for example attending diet and exercise sessions with their children, are much more effective.

Knowlden and Sharma (2012) Knowlden and Sharma9 systematically reviewed 9 family and home-based randomised control trials aimed at the prevention or treatment of over- weight and obesity in children ages 2–7 years. To be included, studies had to be tertiary prevention studies which targeted overweight children and included at least one care giver and had a home based component. They did not report the use of a standard method for assessing the quality of included studies. They included 10 randomised controlled trials of 9 interventions (644 participants). Seven of the interventions targeted parents as the exclusive agents of change. Only 2 included home visits and only 2 of the interventions incorporated process evaluations, and none evaluated fidelity to the intervention. The authors concluded that interventions to reduce childhood obesity should focus on parents as the main agent of change, but they recognised that attrition rates could be high due to time constraints on busy parents. They also conjectured that these time constraints are likely to intensify in the current economic climate. They therefore proposed that alternative modes of intervention delivery be explored, such as online learning.

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Swanson et al (2011) Swanson et al10 reviewed 37 papers about intergenerational interventions aimed at improving energy balance (the balance between calorie intake and calorie expenditure). The total number of participants was at least 19940. Their thematic analysis identified themes including the nature of the intergenerational component, the theoretical basis (if any) for the interventions, differences in the target populations, location where the intervention is delivered, intervention structure, intensity, and duration, research designs, and outcomes and measures . They concluded that “...intergenerational intervention approaches to enhance energy balance use a broad array of designs, target populations and theoretical models, making results difficult to compare and ‘best practices’ challenging to identify”.

Niemeier et al (2012) Niemeier et al11 reviewed 42 interventions across 36 papers to investigate the role of parental influence on the success of child and adolescent weight-related health interventions. The combined sample size was 7455 children and adolescents. Because they only included interventions which reported pre- and post-test BMI scores, they were able to perform data synthesis and calculate effect sizes. They then compared effect sizes across different levels of parental participation, and found that interventions with mandatory parent participation more effectively reduce BMI of children and adolescent participants than those with optional parent participation, or no parent participation at all. Niemeier et al also found that the duration of the intervention positively predicted the intervention effectiveness, and that the linear combination of parent participation and intervention duration predicted intervention effectiveness with a significance of p=0.001. They did not compare parent-only interventions (with no direct child participation) as part of their analysis but they consider the issue in the discussion.

Characteristics of the reviews. Between them, these systematic reviews reported on a total of 102 articles. The total number of participants was at least 44,000. Five articles13,14,15,16,17) were reported in more than one review. Caballero et al13 and Lytle et al16 were included in both Hingle et alError! Bookmark not defined. and Swanson et al10. Fitzgibbon et al14 and Paineau et al17 were reported in both Niemeier et al11 and Hingle et alError! Bookmark not defined.. Kalavainen et al15 was reported in both Niemeier et al11 and Swanson et al10.

The CASP quality scores for Hingle et alError! Bookmark not defined., Knowlden and Sharma9 and Swanson et al10 were all 87.5%. The CASP quality score for Niemeier et al11 was 75%. Knowlden and Sharma9 and Niemeier et al11 both lost points because they failed to assess the quality of the included studies. Niemeier et al11 scored zero on item 8 of the CASP schedule: “Can the results be applied to the local population?” but this does not reflect on the quality of their research so much as whether their findings are helpful to our target population. Hingle et alError! Bookmark not defined. and Swanson et al10 both scored zero on item 10: “Are the benefits worth the harms and costs?” but again this is not a reflection of the rigour of their reviews; it reflects the fact that the studies in the reviews had small and often statistically insignificant effect sizes. Nevertheless their work provides insights into how to design interventions with larger and more significant effects.

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Author(s), year

Hingle et al (2010)

Knowlden and Sharma (2012)

Niemeier et al (2012)

Swanson et al (2011)

# of Articles 26 10 36 37

Focus

Parental involvement in interventions to improve child dietary intake

Family and home-based interventions targeting paediatric overweight and obesity

Parent participation in weight-related health interventions for children and adolescents

Intergenerational energy balance interventions

Included Designs

Randomised controlled trials

Randomised controlled trials

Randomised controlled trials

Randomised controlled trials, pilot and feasibility studies

Intervention Aim

Improved dietary intake in adolescents

Treatment of childhood obesity

BMI reduction Improved energy balance

Search Strategy

PubMed, Medline, Psych Info and Cochrane Library databases. Search terms provided. English language only.

CINAHL, Medline, ERIC, Psychology and Behavioural Sciences Collection, Cochrane CENTRAL. Search terms provided. English language only.

EBSCOhost used to search Academic Search Premier, Alt Health Watch, EBSCO MegaFILE, MasterFILE Premier, ERIC, Health Source: Consumer Edition, Health Source: Nursing/Academic Edition,

PubMed, AGELINE, CINAHL, PsycInfo and Web of Science databases. Search terms provided. English language only.

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MEDLINE, Professional Development Collection, PsycARTICLES, PsycINFO, Science Reference Center, CINAHL Plus, and others. Search terms provided. English language only.

Number and Type of Participants

At least 16,000* Parents, children and adolescents

644 overweight children and care giver(s)

7455 children and adolescents

At least 19,940*

Intervention Types

Parents supporting children or adolescents

Tertiary prevention studies with a home based component

Original interventions targeting weight-related health and health behaviors of children or adolescents

Intergenerational energy balance interventions

Outcomes Reported

Dietary outcomes: 24 hour food recalls, food frequency questionnaires, observational

Changes in: BMI, Z-score, % overweight, waist circumference, children and family

Changes in BMI

Diet, physical activity, physical fitness, anthropometrics, psychosocial constructs.

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, participant reported, parent reported.

eating behaviours, parenting behaviours, blood pressure, metabolic profile

Quality Score 87.50% 87.50% 75% 87.50%

Table 2 Table of Systematic Reviews

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Randomised Controlled Trials Our searches found two randomised controlled trials6,7. Both had been already included in the systematic reviews so their data has not been extracted for reporting separately.

Quasi-Experimental Studies Three quasi-experimental studies were found by our searches, described in four papers. The studies are summarised as Table 3.

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Authors Chomitz et al (2003)

Kubik et al (2008)

Olvera et al (2008)

Olvera et al (2010)a

Title Promoting healthy weight among elementary school children via a health report card approach

Providing obesity counselling to children during a primary care clinic visit: results from a pilot study

A healthy lifestyle program for Latino daughters and mothers: the BOUNCE overview and process evaluation

BOUNCE: a community-based mother-daughter healthy lifestyle intervention for low-income Latino families

Quality Score

44.4% 33.3% 66.6%

Table 3 Table of Quasi-Experimental Designs

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Chomitz et al (2003) Chomitz et al18 investigated ways of persuading parents to make changes to their child’s diet and lifestyle by sending either a personalised report on their child’s health, general information about healthy diets and lifestyles or no intervention. The study was carried out in Cambridge, Massachusetts and tested an intervention which involved a health report card being sent home to the parents of 1396 elementary school children (ages 5-11 years). Pupils were randomly assigned to the 3 experimental groups which differed in terms of the information mailed to them -personalised weight and fitness information about their child, general health and fitness information, or no intervention. The authors concluded that among overweight children, the health report card was associated with increased parental awareness of their child’s weight status.

The data from Chomitz et al18 is presented as Table 4.

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Design Cohort study with embedded controlled evaluation Setting 4 urban elementary schools Intervention A health report card, General information, or no

intervention (control) Target Parents Population 1131 families of 1396 students Outcomes Measured

Parental awareness of child’s weight status. Concern about weight status, Weight control planning, preventive behaviours.

Main results 1131 families randomised to one of three groups 793 families surveyed 1-4 weeks after intervention (stratified by weight status of children) 399 (50%) response rate to phone interview surveys PI = Health report card. GI = general information Proportions in each group reporting specific behaviours:

1. Preventive behaviour. No effect 2. Weight control planning:

a. Physical activity planning: 24(42%) vs 9 (13%) P<0.001. 13(20%) vs 0, P=0.02

b. Medical service seeking 14 (25%) vs 6 (8%) overweight P=0.004. 5(8%) vs 0, healthy weight P=0.004

3. Awareness of child weight status In both bivariate and multivariate logistic regression analyses, allocation to either of the intervention groups was associated with increased parental awareness of the child’s weight status in overweight children by multivariate logistic regression: PI vs control odds ratio 3.08 (1.35-7.01) GI vs control odds ratio 2.61 (1.19-5.75) But not in the healthy weight children: PI vs control odds ratio 0.86 (0.27-2.76) GI vs control odds ratio 0.75 (0.24-2.37) The analysis was stratified by the child’s weight status post hoc

Authors conclusions

Among overweight children, the health report card was associated with increased parental awareness of their child’s weight status. The study demonstrates that a health report card approach may be an important tool for schools interested in informing and motivating parents about their overweight children. Although most parents wanted personalized information on their children, more research is needed to ascertain the impact of this approach on children’s discomfort, self-esteem, and plans to initiate weight controlling activities.

Reviewers remarks

Interesting design which included randomisation of the receipt of the intervention, and a non specific alternative and no-intervention control group. Post hoc stratification of the analysis by child’s weight status. Essentially a parent targeted intervention with outcomes of parental knowledge and reported behaviour related to the child’s

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weight status. No measures of impact on child’s weight status, food intake or activity levels.

Table 4 Results from Chomitz et al (2003)

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Kubik et al (2008) Kubik et al19 reported on a pilot study involving giving parents information about obesity prevention during visits to one of two primary care clinics in the American Midwest (intervention and control). Parents attending the intervention clinic with 5-10 year old children were given a brochure, interactive activities in the waiting area, the child’s BMI was calculated and the parents offered weight-related behaviour counselling. Outcomes measured included the parent’s intention to change the child’s physical activity, fruit and vegetable intake, sweetened beverage intake and screen-time behaviours. A significantly higher proportion of intervention parents compared to control parents reported intentions to change their child’s fruit and vegetable intake during the next thirty days. Intentions to change the child’s physical activity, sweetened beverage intake and screen-time behaviours did not show a significant difference between the two groups. There was no follow-up which could determine whether the intention to change the child’s fruit and vegetable intake became actual practice, nor whether this had any influence on the child’s BMI or z-score. The authors describe the results as “promising”. The data from this study is presented in Table 5.

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Logistic regression analyses of parent-reported pediatric provider counseling about child's lifestyle practices during a clinic visit Visit Physical activitya (n=103) Fruit and Vegetable Intakea

(n=104) Sweetened Beverage Intakea

(n=104) Screen Timea (n=104)

Orb 95% CIc

P value

Orb 95% CIc P value Orb 95% CIc P value

Orb

95% CIc P value

Intervention clinic

3.69 1.41, 9.65

0.0008

3.23 1.21, 8.64

0.019 5.07 1.56, 16.43

0.007 7.72

2.39, 24.96

0.0006

Control clinic (referent)

- - - - - - - - - - - -

Well child visit 4.01 1.65, 9.75

0.002

3.03 1.24, 7.41

0.015 3.41 1.28, 9.05 0.014 3.64

1.41, 9.38

0.008

Nonwell child visitd (referent)

- - - - - - - - - - - -

aChild year of birth and sex not included in models because no significant differences across treatment condition were identified bOR=odds ratio cCI-confidence interval dNonwell child visits include acute nonemergent and chronic care visits

Table 5 Results from Kubik et al (2008)

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The BOUNCE Study (Olvera et al 2008, 2010a) Two papers by Olvera et al20,21 give an overview and process evaluation of BOUNCE, a community-based intervention for low-income Latino mothers and daughters, reporting effects on physical fitness, physical activity levels, intake of high fat foods, sweetened beverages and fruits and vegetables. Participants were 46 Latino mother-daughter dyads where the daughters were in 3rd-6th grades (8 -12 years). Dyads in both control and intervention groups received a 12-week program of nutrition education, counselling and physical exercise for 3 sessions a week. Those in control group received one session a week of the same intervention. At the end of the intervention, daughters in the intervention group had significantly higher levels of physical fitness than control group daughters. There was no significant difference in the levels of physical fitness of the mothers. Levels of physical activity of mothers and daughters in the intervention group were not significantly different than the control group. There were no significant differences between the two groups for consumption of high fat food, sweetened beverages or fruit and vegetables. There was no follow-up post intervention. There was no control group which received no intervention making the presence and magnitude of effects difficult to interpret.

The results from this study are presented in Table 6.

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Pre- and post-intervention changes in outcome variables

Variable Means ± s.d.a

Experimental group Comparison group

Pre Post Pre Post F P value

Effect size (Cohen's d)

Daughter

Physical fitness and activity

20-Meter Shuttle (number of laps)

14.9±4.9 20.7±8.4 11.2±5.3 13.1±5.5 4.49 0.044b 0.78

Average daily counts (cpm) 340941.1± 86,005.7

368045.2± 131802.8

229751.5± 93890.8

266717.1± 56508.3

1.14 0.295 0.39

MVPA (min) 64.3±23.9 70.7±31.5 35.4±21.9 38.0±13.1 4.22 0.049b 0.75

Dietary intake

High fat foods 2.2±1.4 1.9±1.6 1.9±1.9 2.6±1.9 1.32 0.26 0.4

Sweetened beverages 2.0±1.3 1.4±1.4 1.1±1.1 1.7±1.0 1.06 0.312 0.36

Fruit/vegetables 3.1±1.6 4.1±2.6 3.1±2.0 2.9±2.3 0.93 0.343 0.34

Mother

Physical fitness and activity

Exercise HR (bpm) 124.1±19.3 129.8±21.6 136.0±12.5 140.7±12.9 7.76 0.012b 1.09

VO2peak; ml/kg/min 36.4±8.1 36.9±5.1 42.9.4±9.0 42.9.4±6.7 1.84 0.188 0.4

Physical activity rating 1.4±0.9 2.1±1.6 1.2±1.5 1.2±0.9 1.35 0.257 0.4

cpm, counts per minute; HR, heart rate. aAdjusted for baseline value. bRelative size of Cohen's d; negligible effect (≥-0.15 to <0.15); small effect (>0.15 and <0.40); medium effect (>0.40 and <0.75); large effect (>0.75 and <1.10).

Table 6 Results from Olvera et al (2010a)

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Characteristics of the Quasi-Experimental Studies Chomitz et al18 reported on 399 participants, Kubik et al19 had 117 participants. Olvera et al2020,21

had a total of 92 participants (46 mother-daughter dyads). The total number of participants in these three studies was 608.

The CASP quality score for Chomitz et al18 was 44.4%. Kubik et al19 scored 33.3%. Olvera et al20,21

scored 66.6%. All the studies scored zero on item 4: “Were patients, health workers and study personnel ‘blind’ to treatment?” as blinding is not possible in this type of intervention. They also all scored zero on item 11: “Are the benefits worth the harms and costs?” because none of them demonstrated a reduction in overweight or obesity. None of the studies in this section reported as an outcome weight, BMI, z-score or any other measure of overweight or obesity. This alone makes it difficult to draw any conclusions from these studies about how one might design an effective intergenerational intervention to reduce overweight/obesity in seniors.

Miscellaneous Research Design Nine papers in this review were categorised as miscellaneous research design. These are listed in Table 7.

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Authors Title Journal Year Pages

Cronk et al Effects of a culturally tailored intervention on changes in body mass index and health related quality of life in Latino children and their parents

American Journal of Health Promotion

2011 Vol 25, No. 4 pp e1-e11

Jacobson and Melnyk

A primary care intervention program for overweight and obese school-age children and their parents

Journal of Pediatric Health Care

2012 Vol 26, No. 2, pp.126-138

Janicke Treatment of Pediatric Obesity Using a Parent-Only Approach: A Case Example

Health Psychology

2013 Vol.32(3), pp.345-350

Kicklighter et al

A home-based nutrition and physical activity intervention for grandparents raising grandchildren: a pilot study

Journal of Nutrition for the Elderly

2009 Vol 28, pp.188-199

Olvera et al BOUNCE: an exploratory healthy lifestyle summer intervention for girls

American Journal of Health Behavior

2010 Mar-Apr;34(2):144-55

Robertson et al

Pilot of “families for health”: community-based family intervention for obesity

Archives of Disease in Childhood

2008 Vol 93, pp.921-926

Simson et al Humor your way to good health: an intergenerational program to address a critical public health issue: the epidemic of overweight and obesity among children

Journal of Intergenerational Relationships

2008 Vol 6(1), pp.83-100

St Jeor et al Family-based interventions for the treatment of childhood obesity

Journal Of The American Dietetic Association

2002 Vol.102(5), pp.640-644

Werner et al Active generations: an intergenerational approach to preventing childhood obesity

Journal of School Health

2012 Aug;82(8):380-6

Table 7 Table of Miscellaneous Research Designs

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Cronk et al (2011) Cronk et al22 evaluated the effects of a multicomponent, family-based, culturally tailored intervention for overweight Latina children and their parents. The intervention was called Familias Sanas y Activas (Healthy and Active Families). Participants were 54 parent-child dyads from Spanish-speaking families with at least one overweight child aged 8-11 years. The intervention took place at a local community centre and comprised six weekly sessions which included nutrition education, education about the importance of increasing physical activity and decreasing sedentary behaviours. There were also supplementary activities such as family fun night, a walking club and canoeing. Pedometers were distributed and used as a tool for self-awareness, but step count data was not gathered for analysis. The study found a small but statistically significant reduction in the children’s BMI z-scores between baseline and 12-months follow-up, while a comparison group of children showed an increase in z-scores over the same time period. However, there were significant differences in BMI z-scores between the comparison and intervention group at baseline, which makes the post-intervention data harder to interpret. The intervention group parents’ BMIs decreased but the change was non-significant. Health-related quality of life was significantly increased for both parents and children.

Jacobson and Melnyk (2012) Jacobson and Melnyk23 reported on a feasibility study for a Healthy Choices Intervention based on cognitive theory. Participants were fifteen 9-12 year old overweight children and their parents. The intervention took place in a primary care setting and comprised four personalised face-to-face clinic sessions alternating with three telephone sessions. Sessions included cognitive-behavioural guidance (e.g. identifying and modifying negative thinking and emotion patterns) as well as nutrition education and education about physical activity. Children and parents were given a pedometer and asked to keep a food diary. The children’s BMI z-scores decreased by a small but significant amount between baseline and the 7-week post-test measurements. Parents lost a non-significant amount of weight.

Janicke (2013) Janicke24 reported on a single case study of an obese pre-teen girl who was treated using a parent-only approach. The intervention included nutritional, physical activity and sedentary behaviour approaches, the use of a pedometer, goal-setting and self-monitoring activities. The child’s z-score fell from 2.06 at baseline to 1.63 post-treatment, and fell further to 1.38 at 6-month follow-up. Her mean daily kilocalories fell from 2,066 at baseline to 1,664 at 6 months follow-up. And her average daily energy expenditure increased by 263 kilojoules between baseline and follow-up. In this case study, a parent-only approach seemed to be highly effective.

Kicklighter et al (2009) The only study found by our searches to feature grandparents was Kicklighter et al25. This was a pilot study to evaluate a home-based nutrition and physical activity intervention with five African-American grandparents raising their grandchildren. The purpose of the intervention was to increase the nutrition and physical activity knowledge of the grandparents, and to increase the physical activity of the grandparents and the grandchildren. The intervention was based on social cognitive theory and comprised four modules, each lasting one to two hours. Three of the modules took place in the grandparents’ home and one was a field-trip to a grocery store. Modules included nutrition education and education about physical activity. Grandparents and grandchildren were given talking

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pedometers and asked to complete physical activity diaries. A small decrease in the grandparents’ BMI was reported within three months after the intervention, but the significance was not reported. BMI scores are not reported for the children.

Olvera et al (2010b) Olvera et al26 reported on a summer intervention styled after summer camps. The participants were 37 Latino and African-American parent-daughter dyads. Daughters attended the programme from 9am-5pm, five days a week for three weeks during the summer. The setting was a university campus. Daughters’ sessions included physical activity, nutrition education and behavioural counselling. Parents attended one 2-hour session each week in which they received advice about their daughters’ nutrition and physical activity, and how to enhance their daughters’ self-esteem. Between baseline and the end of the three-week intervention, daughters had a small but statistically significant reduction in BMI. There was no follow-up reported.

Robertson et al (2008) Robertson et al27 described a community-based intervention called Families for Health. The participants were 27 overweight or obese children aged between 7-13 years. Sessions took place in a leisure centre, and the programme comprised twelve weekly 2 ½ hour sessions. Parents and children had separate sessions but met mid-session to share an activity and a healthy snack. The children’s BMI z-scores were reduced by a small but statistically significant amount by the end of the 12-week programme. Parents’ BMIs were not reported. There was no follow-up.

Simson et al (2008) Simson et al28 was one of the few studies found by our searches which included older people. They described an intervention for children, led by trained volunteers aged 50+. The participants were seventeen multicultural children aged between 9-11 years. The intervention comprised five weeks of 1-hour sessions in which humour was used to deliver nutrition education. Seven of the children continued with an additional five week program on other health topics. Post-test the children scored more highly on a nutrition quiz compared to pre-test. Qualitative feedback was also collected which seemed to indicate that children enjoyed the intervention. No quantitative data was collected about the children’s weight, BMI, z-score, adiposity, fitness or anything else.

St Jeor et al (2002) St Jeor et al29 described a program called HOPSCOTCH (Health Opportunities for Pre-School Children to Optimize their Cardiovascular Health), a family-based obesity prevention program developed by the University of Nevada. Most of the interventions in this review are aimed either at overweight children (obesity treatment programs) or at all children regardless of weight status (obesity prevention programs). Typically the goal of the intervention is to prevent or treat obesity in the child, and parent is only there as an agent of change. But HOPSCOTCH is an obesity prevention program targeted at overweight parents with pre-school children, and the goal of the intervention is to treat the parent’s obesity and also to prevent or treat obesity in the child. Parent-child dyads were assigned to an intervention group or a control group. Dyads in the intervention group attended sessions together although after an initial parent-and-child session the adults were divided from the children for separate activities and then brought back together at the end of each session. The paper does not discuss the content of the sessions in much detail. The children’s sessions included play, education, and the preparation of a healthy snack which was eaten with the parents at the end. The

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adults’ sessions (described as “group treatment sessions”) incorporated cognitive behaviour theory, social learning theory, ecological theory and nurturing theory and were designed to enhance parenting skills and better manage their own weight. However this paper is a commentary paper, combining a narrative review of family-based interventions for the treatment of childhood obesity with a descriptive account of the HOPSCOTCH study. Outcomes and results of the study are not reported.

Werner et al (2012) Werner et al30 (like Simson et al2828) investigated an intervention for children led by older people. Participants were 760 children in third- to fifth-grade (8 to 11 years old). The programme comprised ten 90-minute sessions over a 4- to 10-week period. Sessions include nutrition education, physical activity and discussions and were led by trained older volunteers. After the intervention children had significantly higher self-reported fruit and vegetable consumption compared to baseline, were more likely to report reading nutritional information labels, reported greater confidence that they would participate in physical activity, and decreased the self-reported time spent watching TV or playing video games.

Characteristics of the Miscellaneous Design Studies The total number of participants in the miscellaneous design studies was at least 916. The uncertainty is because St Jeor et al29 did not report the number of participants.

Discussion Given the urgent need to reduce the number of people in Europe who reach old age with problematic obesity, this review asked the question “What intergenerational innovations have been attempted to reduce obesity”? The aim was to identify the features of successful and unsuccessful intergenerational interventions in order to inform the development of novel intergenerational interventions for children and seniors.

This article reviewed the literature up to 2013 on intergenerational interventions to address obesity. Intergenerational interventions involve more than one generation of the same family e.g. children, parents, grandparents. Both therapeutic and preventative interventions were included. The interventions reviewed involved mechanisms such as reducing caloric intake, increasing physical activity, or decreasing sedentary behaviours, but most typically included all of these.

Intergenerational Component Our results found a dearth of research about grandparents/grandchildren. Of the included systematic reviews, Hingle et alError! Bookmark not defined. and Niemeier et al11 focused specifically on parental involvement. Knowlden and Sharma9 and Swanson et al10 reviewed family or intergenerational interventions, which could include grandparents or seniors. But all 10 studies reviewed in Knowlden and Sharma9 were about parents. The majority of the 37 papers reviewed in Swanson et al10 were also about parents, but a few specified only “families”31,32 which could involve grandparents. One of the studies reviewed in Swanson et al10 specifically targeted mother-daughter-grandmother triads33. But this is only one paper focusing on grandparents out of 102 papers across the 4 systematic reviews.

Our searches only found one study which included grandparents2525, and two which included seniors and children28,30. The majority of the studies investigated parents and children. Some20,21

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included specifically mothers and daughters. Even those which were open to parents of any gender typically had more mothers than fathers responding18 although some had close to an equal ratio of mothers to fathers19.

Direction of Effect Most of the articles reviewed investigated the effect of the intervention on the child i.e. the direction of influence was down the generations. Of the included systematic reviews, Hingle et alError! Bookmark not defined., Knowlden and Sharma9 and Niemeier11 all focused specifically on the outcomes for the children. Swanson et al10 looked more broadly at intergenerational energy balance interventions which could include outcomes for parents or grandparents. The majority of studies in Swanson et al10 focused on the outcomes for the children but a small number also sought to influence the behaviour of the adults34,35.

The same was true of the studies returned by our searches. Most were specifically focused on the influence on the child. A few looked at the effect on both generations20, 21, 22,24. None focused on the influence up the generations, including the one study to include grandparents25.

Outcome Measures A surprisingly large proportion of the articles didn’t measure the weight, BMI, z-score, body fat percentage, skinfold measurements or any other anthropometric measure of overweight/obesity at all, despite having an explicit focus on overweight/obesity25,28,30. These tended to be pilot or feasibility studies whose focus was on the design, delivery and acceptability rather than the efficacy of the interventions. BMI in children is correlated with age therefore z-scores are a better way of evaluating adiposity although still not perfect36.

Of the included systematic reviews, Niemeier et al11 only reviewed studies which reported pre- and post-intervention BMI, as this was a specific inclusion criterion. Knowlden and Sharma9 had no inclusion criteria about outcome measures, but nonetheless all the reviewed studies included an anthropometric overweight/obesity measure of some kind. Hingle et alError! Bookmark not defined. and Swanson et al10 included studies which used a variety of different outcome measures, so some of the reviewed studies reported anthropometric measures of overweight/obesity but others did not.

The studies returned by our searches used a variety of outcome measures. Four reported BMI 22,23,24,26 and one reported z-score27. Frustratingly, Chomitz et al18 collected data about weight and BMI of participants but only used it to stratify the results, not as an outcome measure.

Effect Sizes The uneven reporting of anthropometric overweight/obesity measures made it very difficult to assemble meaningful data about effect sizes. This difficulty was further compounded because some of the studies focused on treatment of pre-existing overweight/obesity whilst others focused on preventing the development of overweight/obesity in healthy-weight children.

Typical effect sizes were very small. Where there was follow up (and very often there was none) the effects invariably diminished or vanished. This is in line with previous research; meta-analysis has demonstrated that children’s weight loss associated with interventions shows rebound at 6 and 12 months from baseline37.

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Implications The purpose of carrying out this review was to inform the future development of intergenerational interventions for the prevention or management of overweight or obesity in older age. Our searches found no previous evaluations of this type of intervention, which suggests that there is a need for such research. The development of these interventions must therefore be informed by other types of interventions which have some similarities, such as intergenerational interventions for the prevention or treatment of overweight/obesity in children.

Of the included systematic reviews, Hingle et alError! Bookmark not defined. suggests that interventions which are personalised and which actively involve the participants are more likely to be effective than those which are not personalised or which require little involvement from participants. Niemeier et al11 found that intergenerational interventions were more effective than non-intergenerational interventions, and also that longer interventions are more effective. Swanson et al10 emphasised the need for theoretical grounding of intergenerational interventions. These findings could be useful in planning novel interventions with older adults.

Of the studies returned by our searches, Chomitz et al18 and Kubik et al19 support the conclusion of Hingle et alError! Bookmark not defined. that personalised interventions are more beneficial than those which are not personalised. Olvera et al20,21 supports the conclusion of Hingle et alError! Bookmark not defined. that the more actively participants are involved the more effective the intervention is likely to be.

We therefore recommend that future interventions for the treatment or prevention of obesity in older age should be intergenerational, personalised and should seek to actively involve participants, as there is evidence that these factors increase the efficacy of interventions with other population groups.

Study Strengths and Limitations Our searches did not find any intergenerational interventions to manage weight in older people. As a result we have had to draw such conclusions as we can from interventions with children instead. There are obvious differences between the population of children and older adults which are likely to influence the way they manage their weight. For example, children are most often dependent on their parents to buy and prepare meals, but older adults are more likely to buy and prepare their own meals. Therefore our conclusions and recommendations are subject to the caveat that they are based on a different population.

It is interesting that there was little overlap between the four systematic reviews and our own searches. In total there were 122 articles in the four reviews plus the primary studies returned by our own searches. Of these only 7 articles appeared twice.Further investigation found that studies not found in our search were generally in the same databases searched for this review but were missing terms for one of the 3 searchfacets: health promotion and synonyms, obesity and synonyms, and intergenerational and synonyms. The majority of papers in the 4 systematic reviews not found by our search did not include search terms for intergenerational. Terms for Health promotion were the next most common term to be missing, followed by terms for obesity. Papers that didn't focus on obesity would have been excluded by our criteria, but papers that lacked our specific terms for health promotion or intergenerational could potentially have been relevant. One keyword which might have been beneficial to include in the intergenerational facet was family health, but even this

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would not have returned all of the papers in the 4 systematic reviews. Furthermore, it does not explain why the 4 systematic reviews had so little overlap between themselves. This is a poorly-defined area; the keywords for this area are not generally agreed or widely used.

A strength of this review is that it is the first review we are aware of to address the question of how to design an intergenerational intervention for weight management in older adults. Not only are there no reviews about this specific topic but neither did we find any primary studies. Our review therefore identifies a gap in the literature, and is a useful contribution to literature in this important area.

Recommendations On the basis of a thorough review of intergenerational interventions for the treatment and prevention of overweight and obesity, we recommend that future interventions for older adults be intergenerational, be personalised and involve the participants to a high degree. There is evidence that these features characterise the most effective interventions. However there is a paucity of research about intergenerational interventions for weight management with older adults, so these conclusions are drawn from evidence based on a different population, children and adolescents. It seems likely that this population may have significant differences from the population of older adults in the way they manage their weight. We therefore recommend that more research is necessary into intergenerational interventions for weight management with older people.

Conflict of Interest Statement The authors report no potential conflicts of interest.

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