Project objectives

Aim

To systematically map and  review the quantitative and qualitative literature on the determinants/correlates of

1.  Fruit and vegetable intake
2. Sugar sweetened beverage and other unhealthy diet intake and<
3. Physical activity and sedentary behaviours in young children.

With the aim of informing interventions to change these behaviours in this age group.

Search Strategy

• Searches conducted in eight electronic databases (Medline, Embase, Cinhal, Psychinfo, Web of Knowledge, BNI, ASSIA and Sociological Abstracts) using a refined search strategy.
• This will be supplemented by checking references, citation tracking and contacting authors of included studies.

Inclusion criteria:

• Quantitative (prospective & intervention) and Qualitative studies in developed countries that examine the factors associated with these behaviours in children aged 0-6 years (at baseline) will be included.
• No language or period restrictions will be applied

Review stages:

Stage 1: Studies will be mapped descriptively

Stage 2: Refining of inclusion criteria for study selection, in-depth data extraction and synthesis

Stage 3: Integration of qualitative studies with quantitative evidence to provide a deeper understanding of effective strategies to influence these energy balance related behaviours.

Data analyses

Data from quantitative non-intervention studies will be summarised using forest plots and/or harvest plots and narrative synthesis, intervention studies using forest plots (where no significant heterogeneity is found) and qualitative studies using thematic analysis.

Changes to project objectives

1. Cross-sectional studies: Initially the plan was to include cross-sectional studies but as this could potentially involve inclusion of over 2000 papers, which would make the project unfeasible, these studies will not be included in the detailed data extraction but will be used for the descriptive mapping.
2. PhD theses: To minimise procurement costs, it has been decided that relevant papers published from PhD research work would be ordered if required rather than procuring PhD theses.
3. Papers in foreign languages: To minimise translation costs, it has been decided to seek help from colleagues at Cambridge and Durham Universities to help identify studies that meet our inclusion criteria, so a further pragmatic solution could be arranged if any of these studies are to be included in the review.
4. Prospective quantitative evidence is very poor on behaviours related to sugar sweetened beverage and other unhealthy diet intake. It has therefore been decided that cross sectional studies will be included only for these behaviours.
5. Inclusion of a mapping stage: due to the large number of studies identified.

Brief summary

Methods

Following an iterative scoping stage, a combined search strategy with terms related to population (preschool children aged 0-6 years), exposure (observational, intervention, qualitative studies and review articles) and outcome (1. physical activity (PA) and sedentary behaviours (Sed), 2. fruit and vegetable intake (F&V), 3. sugar sweetened beverage (SSB) and other obesogenic diet (OD) intake was used to identify papers from eight electronic databases (Medline, Embase (via OVID), Cinhal, Psychinfo (via Ebsco), Web of Knowledge (via Thomson Reuters), British Nursing Index (BNI), Applied Social Sciences Index and Abstracts (ASSIA) and Sociological Abstracts (via Proquest)). No language or period restrictions were applied. Titles and abstracts of 37,686 retrieved articles were screened by three reviewers. Full texts of articles appearing to meet the inclusion criteria were retrieved for further review and their status recorded in a pre-piloted IN/OUT spread sheet, along with specific study details and reasons for exclusion (for excluded studies). Studies in clinical populations, in children over the age of 6 years at baseline, and laboratory-based studies were excluded. Study inclusion, quality assessment, and data extraction were independently validated by two researchers. Quantitative data were synthesised in harvest plots or tables to demonstrate strength and direction of association and quality of study. Thematic analysis was used for qualitative studies.

The reviews for 1) PA and Sed behaviour and 2) F&V intake followed a similar methodology and synthesised evidence from intervention, prospective and qualitative studies. The reviews for 3) SSB and Obesogenic diet intake synthesised the quantitative (intervention, prospective and cross-sectional) and qualitative evidence separately. 

Overall Conclusions

Multi-level interventions, including parental modelling of healthy behaviours, show promise in changing EBRBs in young children. However, few conclusions could be drawn regarding other specific modifiable determinants. Furthermore, qualitative evidence indicates that future interventions should also target the barriers to behaviour change. Long-term sustainability, impact on inequalities and potential for implementation in routine practice of interventions should be considered.

Further conclusions will be drawn following consideration of findings of updated searches and from the critical revision of arising full scientific reports.

Main further conclusions are that parental modelling and environmental factors are important modifiable intervention targets; however parental modelling has not been included in previous interventions.

The detailed findings are available in the following publications:

Hesketh, K., Lakshman, R., & Van Sluijs, E. Barriers and Facilitators to Young Children’s Physical Activity and Sedentary Behaviour: A Systematic Review and Synthesis of Qualitative Literature. Obesity Reviews https://doi.org/10.17863/CAM.8786 https://goo.gl/oN1GBZ

Hesketh, K. R., O'Malley, C., Paes, V. M., Moore, H., Summerbell, C., Ong, K. K., Lakshman, R., van Sluijs, E. M. F. (2016). Determinants of Change in Physical Activity in Children 0-6 years of Age: A Systematic Review of Quantitative Literature. Sports Med. doi:10.1007/s40279-016-0656-0 https://goo.gl/inT9Wq

Mazarello Paes, V., Hesketh, K., O'Malley, C., Moore, H., Summerbell, C., Griffin, S., Lakshman, R. (2015). Determinants of sugar-sweetened beverage consumption in young children: a systematic review. Obes Rev, 16(11), 903-913. doi:10.1111/obr.12310 https://goo.gl/jCLaVD

Mazarello Paes, V., Ong, K. K., & Lakshman, R. (2015). Factors influencing obesogenic dietary intake in young children (0-6 years): systematic review of qualitative evidence. BMJ Open, 5(9), e007396. doi:10.1136/bmjopen-2014-007396 https://goo.gl/ZT3nHG

Lakshman, R., Mazarello Paes, V., Hesketh, K., O'Malley, C., Moore, H., Ong, K., Summerbell, C. (2013). Protocol for systematic reviews of determinants/correlates of obesity-related dietary and physical activity behaviors in young children (preschool 0 to 6 years): evidence mapping and syntheses. Syst Rev, 2, 28. doi:10.1186/2046-4053-2-28 https://goo.gl/tmm2RV 

Table 1: Number of full text articles and studies included in the reviews.

Behaviour	Full text articles	Quantitative			Qualitative	Total
		Intervention	Cohort	X-section
Physical activity and sedentary behaviour	164	16	6	-	21	49
Fruit and vegetable intake	337	29	7	-	13	49
Quantitative: Sugar sweetened beverage intake	286	13	6	23		39 (+3)
Quantitative: Obesogenic food intake	286	19	6	36		57 (+4)
Qualitative: SSB and Obesogenic food intake	286	-	-	-	20	20

1) Systematic review of quantitative and qualitative evidence of determinants of change in, and barriers and facilitators to, physical activity in children, aged 6 years and under

Lead analyst

Kathryn Hesketh

Results

A total of 43 articles were included (prospective cohort studies=6; intervention studies=16; qualitative studies=21). All studies were conducted in North America, Australasia and Europe, and 42 were published after 2004. 27 determinants of change in activity were identified in 19 distinct quantitative studies (3 prospective; 16 intervention) across individual, interpersonal and organisational domains. Two determinants (sex, enhanced school curriculum) were assessed in four or more studies, with only an enhanced curriculum showing a consistent positive association with change in activity. A total of 51 barriers and facilitators to preschool-aged children’s physical activity were identified in 13 distinct qualitative studies, across all 5 socio-ecological domains (individual; interpersonal; organisational; community; policy). Parents, childcare providers and children themselves most frequently (in four or more studies) mentioned the role of parents; the role of teachers, childcare as an initiation; children’s perceived safety; and the weather as important positive and negative influences on preschool-aged children’s physical activity.

Conclusions

Few of the determinants studied were consistently associated with change in preschoolers’ physical activity, although similarities between determinants assessed and the barriers and facilitators to activity identifıed in qualitative studies were seen. Across all study types, the most frequently explored determinants, barriers and facilitators to activity were in the interpersonal and organisational domains (i.e. the role of other people and the child’s immediate environment on their activity), with little research conducted in the individual, community and policy domains. Heterogeneity in study samples, outcome measures and method of data collection limit the ability to draw firm conclusions about prospective influences on change in preschool-aged children’s activity. This review highlights the potential utility of qualitative research to inform where interventions may be best targeted to change young children’s activity, but further quantitative evidence is required to identify determinants of change in preschool-aged children’s physical activity.

2) Systematic review on the determinants of fruit and vegetable intake in young children (aged 0-6 years)

Lead analyst

Claire O’Malley

Results are presented separately for qualitative, intervention and prospective studies

Qualitative studies

13 qualitative studies were identified. The majority involved interviews/focus groups with parents/caregivers of young children (n=10), two examined the child’s perspective and one, related to the opinions of a childcare management team. Most commonly identified barriers/facilitators to fruit and vegetable intake included; accessibility, costs of food, behaviours of child (demanding food, reluctance to try fruits and vegetables etc.), lack of transport, convenience of unhealthy food, time constraints, convenience of cheap unhealthy food. Interestingly, given that the children are so young, in one study children also highlighted the availability of fast food preventing them from eating fruits and vegetables.

Intervention studies

Evidence from 29 studies, which were published between 1992 and 2012 were identified. Eleven studies were set in the Americas (USA n=10 and Brazil n=1), twelve in Europe (UK n=7, Germany n=2, Belgium n=1, Netherlands n=1 and Finland n=1) and 2 in Asia (Thailand n=2). Children’s ages ranged from infancy to 6 years. Duration of intervention ranged from 12 weeks to 2 years with post-intervention follow-up ranging from immediately to 4 years. Twenty of the studies targeted multi-level determinants of fruit and vegetable intake with the most frequently occurring being a combination of the following; school, family, community and individual (either parent and/or child). Sixteen interventions were underpinned by theory (Social Learning n=6, Socio ecological n=1, Health belief model n=1, other stated behavioural change models n=8).

Significant increases in F&V consumption and/behaviour were reported in 13 studies. The remaining studies reported non-significant beneficial increases or no effect (n=15). Those studies relating to policy change in nursery school (n=2) showed no improvements in fruit and/or vegetable consumption with one having a seemingly detrimental effect, reporting a reduction in fruit consumption following the implementation of a school policy intervention.Increased parental knowledge, education, higher SES status and Children’s liking/preference for specific F&V were all positively associated with an increase in F&V consumption.

Prospective studies

Seven prospective cohort studies published between 1999 and 2012 were included in this review. Four studies were set in the Americas (USA n=3 and Brazil n=1), two in Europe (Germany n=1 and Finland n=1), and one in Australia.Maternal feeding practices were investigated by one study which found significantly positive associations between maternal modelling of a healthy diet and an increase in fruit and vegetable intake. Conversely this study also found that using pressure to eat and restricting food had a detrimental effect on fruit and vegetable consumption. Inverse associations were found between age and fruit and vegetable intake in four of the studies, however these were deemed non-significant.

Two studies reported no correlations with fruit and vegetable consumption. One examined fruit juice intake as a determinant and the other gender, birth weight, maternal schooling, annual family income, maternal employment and maternal overweight.

Conclusions

There is minimal prospective evidence on the determinants of fruit and vegetable intake in very young children. However parental feeding practices, in particular modelling of healthful behaviour shows promise. This was also seen to be true in those intervention studies which included similar behavioural components. Interventions which were most successful in terms of increasing fruit and vegetable consumption/behaviour were those which targeted both family/parent and child, included an educational component and were underpinned by a theoretical framework/theory.An updated search was carried out for this review on July 24th 2014. It identified 1217 new hits which are currently being screened for inclusion. Any new evidence will be included in future publications.

3) Systematic review of qualitative and quantitative evidence on the correlates and determinants of obesogenic dietary behaviours in preschool children (0-6 years)

Lead analyst

Veena Mazarello Paes

Results are presented separately for qualitative, intervention, prospective and cross-sectional studies.

Qualitative evidence on SSB and obesogenic food intake

Twenty qualitative studies involving 879 parents (mainly mothers), 99 teachers and 15 children were included. Study designs were-16 focus groups, 5 individual interviews and 1 ethnographic study (2 studies used more than 1 study design). Eighteen studies were published after 2004, 9 were conducted in America, 6 in Europe, 4 in Australia and 1 in Canada. We identified 15 broad themes around parental, child and environmental factors. Parental factors influencing young children’s diets were- time pressures (n=13 studies), cost/affordability (n=10), knowledge (n=13), modelling (n=10), concerns about child’s health (n=9) and use of food as a reward (n=10). Child preferences also influence feeding decisions (n=14 studies). Environmental factors include- availability (n=10 studies), advertising & packaging (n=10), school/childcare (n=9), family& peers (n=14) and societal & cultural (n=5) influences. Other themes identified in 1-3 studies were parenting, cooking skills and involving children in cooking.

Interventional evidence on SSB intake

Thirteen studies were published between 2007- 2013 and were conducted in America (n=4), Europe (n=4), Australia (n=4) and Asia (n=1). Seven studies tested interventions targeting multi-level determinants of SSB intake (community, school/centre environment, parents and/or child) and four studies reported statistically significant beneficial effects on SSB intake. Two out of four studies testing interventions targeting only parental determinants (knowledge, food and parenting skills, self-efficacy, goal setting and motivation, social support), reported statistically significant beneficial effects on SSB intake. No study tested interventions targeting exclusively child determinants of SSB intake. Almost all effective studies were set outside of Europe (Australia n=3, Asia n=1, USA n=1, UK=1). There was no apparent relationship between study setting (home, school or healthcare) or the types of determinants targeted and the intervention effectiveness.

Interventional evidence on obesogenic food intake

Nineteen intervention studies, published between 2003 and 2013 came from Americas (n=6), Asia (n=2), Australia (n=6) and Europe (n=5). The study setting were clinic/home-based (n=11), school-based (n=7) and community-level (n=1). Eleven interventions were based on theoretical models of behaviour change. Interventional evidence on obesogenic dietary behaviour were categorised into a) sweet, b) savoury and c) obesogenic meals consumption. Eight out of nineteen included studies were in non-representative population and six of these interventions targeted parental determinants (nutritional knowledge, infant feeding, parenting skills). Twelve interventions targeted multi-level (child, parent environment), parental (n=6) and environmental (n=1) determinants and most reduced obesogenic food behaviours.

Determinants of SSB intake

Six prospective cohort studies, mainly in non-representative populations, reported seven determinants. Of these child’s age, maternal high pre-pregnancy BMI, maternal SSB consumption/negative modelling and early introduction of SSB/solids in infants were associated with higher SSB consumption in children whereas socio-economic status was not.

Correlates of SSB intake

Twenty-three cross-sectional studies identified 79 correlates. Of these socio-demographic (low maternal age, low education, low income, ethnicity and child’s age), child-behavioural (obesogenic food consumption and TV viewing), parental (maternal obesogenic diet and early weaning/introduction of solids) and environmental (availability) correlates were studied more extensively than others and were associated with increased SSB consumption in children.

Determinants of obesogenic food intake

Observational evidence from six prospective cohort studies (one in non-representative population) identified eight determinants. Two socio-demographic (child’s age and gender), four parental (maternal restriction, pressure to eat, negative modelling and early introduction of non-core foods in infants) and one environmental (food availability) determinants were associated with higher obesogenic food consumption in children.

Correlates of obesogenic food intake

Thirty six cross sectional studies reported on 115 correlates of obesogenic food behaviours. Most studies investigated correlates of obesogenic sweet foods and/or meals. Socio-demographic correlates (low household-income, maternal age & education, parent ethnicity, family size, child’s age and male-child), child behavioural correlates (eating patterns & preferences and TV viewing), parental correlates (not breast feeding/early weaning, smoking and obesogenic-dietary habits) and environmental correlates (food-availability and food-security) were associated with higher levels of obesogenic-food consumption in young children.

Conclusions

Multi-level interventions targeting parents/family, children and school/childcare environments appear to be effective in changing obesogenic dietary behaviours in young children. However, few conclusions could be drawn regarding specific modifiable determinants. Qualitative evidence indicates that future interventions should also target the barriers, especially at the family and preschool levels simultaneously by promoting healthy dietary behaviours at home and in preschools.

An updated search was carried out using the original search strategy (as described in the published protocol) in eight electronic databases on 10th June 2014. This search identified 8124 articles (after de-duplication) which are currently being screened for inclusion. Any new evidence will be included in future publications.

Plain English summary

The aim of this project is to inform the design and content of interventions to reduce obesity in young children. Over the past few years the focus of obesity prevention has shifted to preschool children because of the high prevalence of obesity at school entry and recognition that habits formed in early life often persist into later life. In order to develop effective interventions and change behaviour, it is important to understand the factors that are associated with those behaviours. The energy-balance related behaviours (EBRB) associated with obesity are 1) intake of sugary drinks 2) intake of high calorie foods 3) less fruit and vegetable intake and 4) sedentary behaviour and low levels of physical activity.

We searched through almost 40,000 papers and identified studies describing interventions to change the four behaviours we were interested in, studies that describe which factors are associated with these behaviours and studies that asked children and caregivers their opinions on changing these behaviours.

We found that multi-level interventions (child, parents, school, community), including parental modelling of healthy behaviours, show promise in changing EBRBs in young children. However, few conclusions could be drawn regarding other specific modifiable factors associated with these behaviours. Furthermore, qualitative evidence indicates that future interventions should also target the barriers to behaviour change. Long-term sustainability, impact on inequalities and potential for implementation in routine practice of interventions should be considered.

The findings can be used by policy makers and researchers to develop and test interventions to prevent childhood obesity.

Dissemination

Articles and reports

1. Hesketh KR, O’Malley C, Mazarello Paes V, Moore H, Summerbell C, Ong KK, Lakshman R, van Sluijs EMF. Determinants of Change in Physical Activity in Children 0–6 years of Age: A Systematic Review of Quantitative Literature. Sports Medicine (2016). DOI: 10.1007/s40279-016-0656-0 
   https://goo.gl/rSZJuQ
2. Mazarello Paes V, Hesketh K, O'Malley C, Moore H, Summerbell C, Griffin S, van Sluijs EM, Ong KK, Lakshman R. Determinants of sugar-sweetened beverage consumption in young children: a systematic review. Obesity Review. 2015 Aug 7. doi: 10.1111/obr.12310. 
   http://www.ncbi.nlm.nih.gov/pubmed/26252417
3. Mazarello Paes V, Ong KK, Lakshman R. Factors influencing obesogenic dietary intake in young children (0–6 years): systematic review of qualitative evidence. BMJ Open 2015;5: e007396. doi:10.1136/bmjopen-2014-007396. 
   http://bmjopen.bmj.com/content/5/9/e007396.full.pdf+html 
4. The review protocol is registered with the PROSPERO International Prospective Register of Systematic Reviews (registration number CRD42012002881).
5. Lakshman R, Paes V, Hesketh K, O’Malley C, Moore H, Ong K, Griffin S, van Sluijs E, Summerbell C. (2013) Protocol for systematic reviews of determinants/correlates of obesity-related dietary and physical activity behaviours in young children (preschool 0 to 6 years): evidence mapping and syntheses. Systematic Reviews 2013 2:28. doi:10.1186/2046-4053-2-28 
   http://www.systematicreviewsjournal.com/content/2/1/28 

Conference presentations

1. Hesketh K, O’Malley C, Paes V, Moore H, Ong K, Summerbell C, Lakshman R, van Sluijs E. Determinants, barriers and facilitators of change in preschool-aged children’s physical activity: a systematic review of quantitative and qualitative evidence. ISBNPA Conference, Edinburgh, 3 – 6 Jun 2015. (poster)
2. O’Malley C, Mazarello Paes V, Hesketh K, Moore H, Ong K, van Sluijs E, Lakshman R, Summerbell C. Systematic Review on the determinants of Fruit and Vegetable consumption in young children (aged 06). ISBNPA Conference, Edinburgh, 3 – 6 Jun 2015. (poster)
3. O’Malley C, Mazarello Paes V, Hesketh K, Moore H, Ong K, van Sluijs E, Lakshman R, Summerbell C. Systematic Review on the determinants of Fruit and Vegetable consumption in young children (aged 06). ECO Conference, Prague, 6 – 9 May 2015. (poster)
4. O’Malley C. Systematic Review on the determinants of Fruit and Vegetable consumption in young children (aged 0-6). Wolfson Research Colloquium, Durham, 15 Apr 2015. (presentation)
5. Lakshman R. Determinants of obesity related behaviours in preschool children. SPHR @ Cambridge Stakeholder Engagement Event, Cambridge, 25 Feb 2015. (presentation) 
6. Lakshman R, Paes V, O’Malley C, Hesketh K, Moore H, Griffin S, Van Sluijs E, Ong K, Summerbell C. Systematic reviews of determinants of energy balance related behaviours in young children (0-6yrs): Evidence from quantitative and qualitative literature. ASO (Association for the Study of Obesity) Symposium on Early life obesity (0-6): Interventions and determinants), Birmingham, 16 Sept 2014.
   http://www.kc-jones.co.uk/files/uploads/1411484878.pdf
7. O’Malley C, , Paes V, Hesketh K, Moore H, Griffin S, Van Sluijs E, Ong K, Lakshman R, Summerbell C. Determinants of Fruit and Vegetable intake in Pre-school Children (0-6 years), ASO (Association for the Study of Obesity) Symposium on Early life obesity (0-6): Interventions and determinants), Birmingham, 16 Sept 2014. 
   http://www.kc-jones.co.uk/files/uploads/1411484890.pdf
8. Hesketh K, Paes V, O’Malley C, Moore H, Griffin S, Ong K, Summerbell C, Lakshman R, Van Sluijs E. Determinants of Change in Activity in Children 0-6 years: A quantitative and qualitative synthesis, ASO (Association for the Study of Obesity) Symposium on Early life obesity (0-6): Interventions and determinants), Birmingham, 16 Sept 2014. 
   http://www.kc-jones.co.uk/files/uploads/1411484866.pdf
9. Mazarello Paes V, K. Hesketh, C. O’Malley, H. Moore, K. Ong, S. Griffin, E.  M.F. van Sluijs, C. Summerbell, R. Lakshman. Determinants of unhealthy dietary behaviours (excluding sugar sweetened beverage intake) in young children: Systematic review of quantitative evidence. Public Health@Cambridge Showcase Event. Jul 2014. (poster)
10. Mazarello Paes V, Ong K, O’Malley C, Hesketh K, Moore H, Griffin S, Summerbell C, van Sluijs E, Lakshman R. Determinants and correlates of sugar-sweetened beverage consumption in preschool children: Systematic review of quantitative evidence. Public Health@Cambridge Showcase Event. Jul 2014. (poster)
11. V. Mazarello Paes, K. Hesketh, C. O’Malley, H. Moore, K. Ong, S. Griffin, E.  M.F. van Sluijs, C. Summerbell, R. Lakshman. Determinants of unhealthy dietary behaviours (excluding sugar sweetened beverage intake) in young children: Systematic review of quantitative evidence. Faculty of Public Health Annual Public Health Conference: Glo-cal Health - Making a World of Difference. Manchester, 2 – 3 Jul 2014. (poster)
12. Mazarello Paes V, Ong K, O’Malley C, Hesketh K, Moore H, Griffin S, Summerbell C, van Sluijs E, Lakshman R. Determinants and correlates of sugar-sweetened beverage consumption in preschool children: Systematic review of quantitative evidence. Faculty of Public Health Annual Public Health Conference: Glo-cal Health - Making a World of Difference. Manchester, 2 – 3 Jul 2014. (poster)
13. Mazzarello Paes V, Summerbell C, Hesketh K, O’Malley C, Moore H, van Sluijs E, Ong K, Griffin S, Lakshman R. Systematic review of quantitative evidence on the determinants / correlates of sugar sweetened beverage intake in pre-school aged (0-6yrs) children. The Centre for Diet and Activity Research (CEDAR), Research and policy meeting: What shall we do about diet and physical activity? Cambridge, 9 Oct 2013. (poster)
14. Mazzarello Paes V, Summerbell C, Hesketh K, O’Malley C, Moore H, van Sluijs E, Ong K, Griffin S, Lakshman R. Systematic review of quantitative evidence on the determinants / correlates of sugar sweetened beverage intake in pre-school aged (0-6yrs) children. NIHR SPHR Annual Scientific Meeting, London, 8 Oct 2013. (poster)
15. Lakshman R, Hesketh K, O’Malley C, Paes V, Moore H, Van Sluijs E, Ong K, Griffin S, Summerbell C. Systematic reviews of determinants of obesity related dietary and physical activity behaviours in young children (0-6 yrs): Evidence mapping and syntheses. NIHR SPHR Annual Scientific Meeting, Sheffield, 10 Oct 2012.

Public involvement

Results of the systematic reviews were presented at the SPHR @Cambridge stakeholder event held on 25th February 2015. The event was attended by policy makers, academics, Cambridgeshire County Council Public Health Directorate team and members of the public. Evidence briefs will be produced when the final results are ready.

Impact

The reviews will guide intervention and policy development to prevent childhood obesity. It will also inform future research in this area. We have provided a summary of findings to Cambridgeshire County Obesity Group and Public Health Directorate. The ‘Early Years Nutrition in Pre-school settings’ is now a priority for the Cambridgeshire County Council where Rajalakshmi Lakshman works as a Public Health Medicine consultant lead for Children.

A summary of findings has also been provided to the NIHR’s Public Health Research Programme and the Director of Obesity at Public Health England.

This project was funded by the National Institute for Health Research School for Public Health Research (project number SPHR-CAM-PH1-PSO).

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Public Health Research, NIHR, NHS or the Department of Health.