ABSTRACT
Diet-related behavioral modification for healthy eating and lifestyle is required to improve childhood obesity. The present study aimed to develop customized nutritional intervention protocol and education program to find barriers to adhere healthy diet and lifestyle for moderate to severe obese children and adolescents and their families. Theoretical framework approaches can be used to change behavior and achieve goals. Previous studies that described the relationship between behavioral modification and nutrition education theory were reviewed. The social cognitive theory and transtheoretical model were employed with behavioral changes to target a healthful diet and lifestyle. The nutrition care process (NCP) model was adopted to customize nutrition care for the participants. Customized nutritional intervention protocol was developed following as the four steps of the NCP. Firstly, nutrition status of the participants was assessed by the nutrition expert. Nutrition problems were described as “inadequate energy intake,” “overweight/obesity,” or “food and nutrition-related knowledge deficit.” All nutrition sessions were designed for nutrition intervention to give nutritional knowledge and a practical mission in real life for individual goal setting and self-control. Meal planning, portion control, healthy snack selection and cooking with fruits and vegetables were consisted of five components of the nutrition education session. During each session, the participants and their families were interviewed by a nutrition expert for monitoring and evaluating diet-related goal setting and achievement. A theoretical and evidence-based nutritional intervention was developed for the secondary to tertiary prevention of childhood obesity. This nutrition intervention protocol and program might be helpful for the further research on childhood obesity.
-
Trial Registration
Clinical Research Information Service Identifier:
KCT0002111
-
Keywords: Behavior therapy; Childhood obesity; Nutrition assessment; Nutrition care process
INTRODUCTION
An unprecedented increase in the prevalence of childhood obesity has occurred worldwide during the last few decades [
1,
2]. In South Korea, the prevalence of childhood obesity steadily increased from 11.6% to 16.5% between 2006 and 2016 [
3]. To tackle these trends in childhood obesity, unhealthy eating behaviors including individual, familial and environmental risk factors are considered the key modifiable factors [
4]. Dietary modification and nutritional education are essential elements of nutrition interventions [
5].
Behavioral change theory-based studies [
6,
7,
8,
9] have established successful nutrition intervention implementation. Social cognitive theory (SCT) [
10] and transtheoretical model (TTM) [
11] have been widely used as theoretical frameworks in childhood obesity. In particular, nutrition education combined with behavior change counselling was effective in childhood obesity for weight control and dietary modification [
12].
Traditionally, school-based nutrition education [
13] for the primary prevention of childhood obesity has been implemented. The secondary to tertiary prevention of childhood obesity requires more structured and comprehensive treatments including a healthier diet and weight [
14]. Furthermore, evidence-based [
15], customized nutritional intervention that considers obesity-related genetic, environmental, family, and community factors is powerful strategy for treating childhood obesity. The nutrition care process (NCP) [
16] model is a well-known, systematic, problem-solving method that may allow the modification of diet-related behaviors and lifestyles in childhood obesity. None of studies have been treated and documented by using NCP according to nutrition and health status for childhood obesity.
Therefore, this study aimed to develop a theory- and evidence-based nutritional intervention to change the dietary habits of moderate to severe obese children and adolescents.
METHODS
Literature review
As shown in
Figure 1, relevant research papers conducted in children and adolescents aged 10–18 from 2006 to 2016 were reviewed by a trained nutrition expert team. A search for theory-based scientific articles was reviewed in MEDLINE
®, ClinicalTrials.gov and Google Scholar. Various terminologies were used such as ‘childhood obesity,’ ‘nutrition intervention,’ ‘theory-based,’ ‘study protocol’ and ‘nutrition education.’ Effective intervention components were reviewed and analyzed from a previous childhood-obesity intervention. We identified studies [
17,
18,
19,
20,
21,
22,
23,
24,
25,
26,
27,
28,
29,
30,
31,
32,
33,
34,
35,
36,
37] with SCT- based or TTM, to consider theoretical background, contents of nutrition education session and intervention components development.
Figure 1The flowchart of literature review for the theoretical framework of nutritional intervention development.
Theoretical background
This protocol was designed to focus on a theoretical framework-employed SCT [
10] and TTM [
11]. SCT is widely used to design intervention programs that emphasize behavioral change strategies between personal and environmental factors [
38]. SCT constructs including environments, behavioral capacity, self-control, observational learning, reinforcements, and self-efficacy have been applied in nutrition education curricula [
39]. For development of this protocol, SCT was employed to address what factors affect unhealthy eating behaviors related to socio-environmental factors in moderate to severe obese children and adolescents in order to improve behavioral change to target healthy dietary habits and lifestyle modification. This conceptual framework nutritional intervention delivered based on the TTM stages of participants. TTM evaluates the stages of change in diet-related behaviors and lifestyle modification in moderate to severe obese children and adolescents.
The NCP model [
16] is a well-known, systematic, problem-solving method that allows nutrition experts to care for their patients individually using a structured and standardized language. Four distinct, interrelated steps, nutrition assessment, diagnosis, intervention and monitoring/evaluation of NCP were adopted for the present study protocol. Prior to nutrition assessment of the participants, anthropometrics, biochemical data, self-reported questionnaires and 3-day food diaries were assessed. After analyzing the recorded data, diet-related problems were identified by a problem (P), etiology (E), and sign/symptom (S) form, which the NCP adopted (Academy of Nutrition and Dietetics, 2016). A nutrition diagnosis was documented by writing a PES statement after communication and collaboration with other providers and professionals. The customized nutritional intervention program comprised four monthly appointments that aim to identify barriers to healthy eating behaviors and inform the nutritional knowledge of a balanced diet in moderate to severe obese children and adolescents.
Moderate to severe obese children and adolescents from ages 7 to 16 with body mass index (BMI) ≥ 95th percentile and their family were included. One hundred three participants and their families were recruited through posted flyers, newspaper advertisements, email, and social media. The sample size was calculated for our project based on changes in BMI-z score between groups. The study had 80% power with a two-sided significance level set at 0.05 to detect differences of 0.1 between usual care and physical activity (PA) groups. PA sessions were randomly assigned by senior researcher who is not blinded because of regional and individual time differences.
The questionnaire packets were sent to families who contacted the intervention team manager to join this study. The packets for participants contained a project brochure, a welcome letter, a detailed list for initial assessment, consent forms and a survey (clinical, PA and food & nutritional).
The study was conducted according to the guidelines laid down in the Declaration of Helsinki, with ethical approval from the Hallym University Sacred Heart Hospital's Institutional Review Board (approval number: 2015-I134) and all participants provided informed consent. This study was registered at cris.nih.go.kr (identifier:
KCT0002111).
RESULTS
Nutritional intervention protocol and program development
Supplementary Table 1 describes the 16-week nutritional intervention protocol. For a baseline, the consent form, questionnaires for participants and parents, and 3-day food records were assessed by nutrition team. Anthropometric measurements and a biochemical assessment were performed by trained nurses. The nutritional intervention program included education and counselling, nutrition assessment, phone contact, text messages, online cooking recipes, and a compliance assessment (
Supplementary Table 1).
The SCT components of nutritional intervention
The SCT components and objectives of the nutrition session are described in
Table 1. All sessions aimed to provide nutritional knowledge and a practical mission in real life for individual dietary goal setting and self-control. Nutrition education (NE), skill building (SB), goal setting (GS), outcome expectation (OE), overcoming barriers (OB) and social support (SS) were applied to perform the monthly practical missions, individual goal setting to change dietary habits, and to seek environmental barriers in moderate to severe obese children and adolescents (
Table 1).
Table 1An overview of SCT components and objectives
Table 1
|
Components |
Objectives |
Actions |
|
Nutrition education |
• Awareness-raising of healthy weight & eating (nutrition knowledge and health benefits) |
• Nutritional assessment review with parents |
|
Skill building |
• Energy-balanced diet based on five food groups |
• Monthly practical poster & food diary hand-out |
|
• Individual food guide (nutrients, serving size & meal frequency) |
• Knowing about five food groups |
|
• Portion control |
• Estimate individual daily calories by using KDRIs |
|
• Estimate dietary requirements |
• Reading food labels |
|
• Cook healthy snacks |
• Cooking healthy snack |
|
Goal setting |
• Reduce |
• Individual goal setting to change dietary habits |
|
Outcome expectation |
|
- High-fat protein food intake |
• Assess healthy weight loss |
|
- Unhealthy snack (high fat, SSB, and fast food) intake |
• Overview health benefits |
|
- Late-night snacking |
• Suggest a healthy diet plan |
|
• Increase |
• Eating out & lifestyle modification |
|
- Fruit & vegetable consumption |
|
- Lean protein intake |
|
- Having breakfast |
|
Overcoming barriers |
• Maintain healthy weight & dietary habits |
• Face-to-face interview to determine environmental barriers |
|
Social support |
• Promoting self-efficacy |
• Phone counseling & text messages |
|
• Remind of goals & appointment check |
• Web-based recipes for cooking breakfast & healthy snacks |
Customized nutrition care process
Dietary, clinical assessment components and tools
An evidence-based nutritional intervention protocol was developed to adopt the NCP model to care for and manage childhood obesity. To assess the nutritional status of the participants, dietary habits, nutritional intake, medication and supplement history, life and social history, medical/health history, anthropometrics and biochemical markers were used by a nutrition expert. In this step, nutrition-related metabolic risk factors, dietary problems, nutritional knowledge, stages of change and the nutritional status based on an individual Dietary Reference Intake (DRI) were evaluated (
Table 2).
Table 2Dietary and clinical components and tools of the NCP
Table 2
|
Steps |
Dietary components |
Clinical components |
Tools |
|
Assessment |
- Dietary habits |
- Anthropometric measurements |
- Questionnaires |
|
- Nutritional history |
|
: Height, weight, BMI, BMI-z score, WC, WHR, LBM, body fat, SBP, DBP |
|
: Sociodemographics |
|
- Nutritional status assessment |
- Biochemical markers |
|
: Health & diet related |
|
: HOMA-IR, hs-CRP, LDL-C, HDL-C, triglycerides, creatinine, AST, ALT, glucose, insulin, leptin |
|
: Nutrient quotient |
|
- Three-day food diary |
|
- Face-to-face interview with family |
|
Diagnosis |
- Intake |
- Clinical |
- IDNT |
|
- Behavioral & environmental related PES statement |
|
Intervention |
- Skill building |
|
- Nutritional assessment sheet |
|
- Elevating self-control & self-efficacy |
- Phone contact |
|
- Goal setting, overcoming barriers |
- Text messages |
|
- Online cooking recipes |
|
- Toolkit |
|
Monitoring/evaluation |
- Intervention monitoring & evaluation |
- Anthropometric measurements: |
- Three-day food diary |
|
: Height, weight, WC, SBP, DBP |
- Face-to-face interview with family |
Dietary problems and employed nutrition diagnosis
A specific nutrition problem was identified by a PES statement from the nutrition assessment data for nutrition diagnosis. In this critical step, a nutrition problem was described by using standardized nutrition diagnosis language such as “inadequate energy intake,” “overweight/obesity,” and “food and nutrition-related knowledge deficit.” A nutrition expert team analyzed the terminology to label the nutritional diagnosis by using three main domains for treatment: intake, clinical and behavioral. Each selected International Dietetics and Nutrition Terminology (IDNT, 2015) were labeled for the three domains from the initial screening of the participants' dietary problems (data not shown).
Nutrition intervention and monitoring & evaluation
All consenting participants underwent 30 minutes of individual nutrition education and counselling throughout the 16-week intervention. A face-to-face diet-related interview was performed by a nutrition expert to find the barriers to healthy eating habits of the participants and their families for customized nutritional education and counselling. In every counselling session, a nutrition assessment sheet was provided based on the 3-day food diary of the participants. From the assessment sheet completed by a nutrition expert, each participant reviewed their problematic eating behaviors such as excessive fat intake or frequent sugar-sweetened beverage (SSB) consumption. During each session, theme-based nutrition education was taught to the participants. Monthly goal setting was discussed with the participants and their families at the end of each individual counselling session. Monthly phone contact and text messages were provided for the social support along with online food recipes to emphasize consuming vegetables and fruit and having the breakfast (
Table 3).
Table 3Nutrition intervention components by using IDNT
Table 3
|
Nutrition Diagnosis |
Intervention |
Goals/Expected Outcomes |
|
Excessive oral intake |
- E-1.1: Initial/brief E, Purpose of E |
- Choose lean & red meat |
|
NI-2.2*
|
- ND-1.2: Nutrition intervention: recommend, implement, or order the modification of meals and snacks |
- Changes to high-quality protein foods such as fish, beans and tofu |
|
- Choose fruit & low-fat milk for healthy snacks |
|
Overweight/obesity |
- E-1.2: Priority modifications |
- Diet for weight management & ready for physical activity |
|
NC-3.3†
|
- Goal setting for weight loss: −3 kg/month |
|
Not ready for diet/lifestyle change |
- Appropriate meal plan |
- Healthy food preparation & cooking |
|
NB-1.3‡
|
- Theoretical Basis/ Strategies |
|
- C-1.1: Social cognitive theory |
- Motivation for appropriate nutrient intake, goal setting, self-monitoring, problem solving, social support |
|
- C-1.4: Transtheoretical Model/ Stages of Change |
|
- C-2.1/ C-2.2/ C-2.3/ C-2.4/ C-2.5/ C-2.10 |
|
Nutritional prescription |
- 50%–60% carbohydrates, 20%–25% protein, 20%–25% fat, depending on activity level |
|
Provided handouts |
- Anthropometric measurement assessment sheet |
|
- Nutritional assessment sheet |
|
- Project book |
|
- Practical poster |
|
- Three-day food diary |
|
Follow-up |
- MM/DD/YY AM/PM |
Monitoring and evaluation were overlapped to evaluate nutrition care outcomes (behavioral, physical, and environmental), food intake and individual goal achievements. Nutritional adherence was evaluated that TTM compliance with the intervention program (completed all nutrition and counseling sessions) by a nutrition professional using four nutritional diagnosis categories: intake (NI) problem, clinical (NC) problem, or behavioral (NB) problem, and TTM.
Five components of the nutrition education session
Five components of nutrition education were designed by a nutrition expert team; these aimed to promote healthy dietary habits by reducing unhealthy eating behaviors and a sedentary lifestyle. The first session, ‘My meal planning,’ aimed to assess children's problematic meal patterns through the food bicycle and five food groups. In the second session, ‘My meal portion,’ an individual DRI was calculated to control personal portions by using Dietary Reference Intakes for Korean [
40]. For the third session, food labels were used to ‘Choose healthy (good vs. bad) snacks.’ The fourth session was ‘Cook with fruits and vegetables’ to practice healthy cooking and increase fruit and vegetable (F&V) intake for participants. The follow-up session was to ‘Maintain a healthy diet and weight’ and consisted of a certificate to cheer on and reward the participants (
Table 4). As monthly content, customized dietary goal setting was attained by every participant with their family.
Table 4The contents of nutrition education book and practice posters
Table 4
|
Session |
Contents |
Goals |
Handout*
|
Theme-based tools†
|
|
1 |
My meal planning |
Balanced diet |
Poster 1 |
Food bicycle |
|
2 |
My meal portion |
Portion control |
Poster 2 |
Hand & plate portion |
|
3 |
Choose healthy snacks |
Choose healthy snacks |
Poster 3 |
Food label |
|
4 |
Cook with fruits and vegetables |
Intake fruits and vegetables |
Healthy recipe contest |
Cooking recipe |
|
5 |
Maintain my healthy diet |
Healthy diet and weight maintenance |
Certificate |
Reward |
Development of the nutritional intervention program toolkit
All content in the nutritional intervention toolkit was developed by a nutrition expert team. Based on the study protocol, an educational toolkit was provided to the participants at the first nutrition education and counselling session (Visit 1). The program book and posters were able to be displayed at home where families who participate in the nutritional intervention program could support and help each other. The contents of each page consisted of the monthly title, a poster with an illustrated guideline for a practical mission, and a goal-setting space. Three different mission posters were handed out at the baseline, and fourth and eighth weeks of the nutrition session. After tracking each monthly poster, the participants and their families were encouraged to upload the completed posters on the community website.
The logotype was designed to consider community movement and cooperation to overcome stigmatization for participants and their families. Resources for promoting healthy eating practices including a program book, practice posters, food diaries and a water bottle were provided to all participants to motivate their healthy eating and lifestyle.
DISCUSSION
To intervene systemically, strengthened evidence and continuous care were required in the secondary and tertiary prevention of childhood obesity in a community setting. Little is known about studies that have been adopted to customize the nutrition care process (NCP) model in childhood obesity. This is the first study to develop a nutritional intervention protocol for South Korean children and adolescents with moderate to severe obesity. The present theoretical framework and customized NCP approach protocol were designed with integrated strategies for participants and their families to evaluate unhealthy dietary behaviors and lifestyles. In addition, five healthy diet-related education programs with the social cognitive theory (SCT) components were developed to treat childhood obesity. An educational toolkit for a nutrition program was designed to cheer on and support the participants.
A theoretical framework has been carried out in several previous studies [
6,
7,
8,
9]. SCT offered a theoretical underpinning for the behavior changes in previous childhood obesity nutritional interventions [
6]. Improved culinary skills increased the consumption of fruits and vegetable (F& V), which affected participants' long-term health [
41]. Furthermore, applied nutrition education (e.g., fruit-flavored water) supported the behavioral changes in participants' diets. An ongoing cohort study [
7] provided nutrition education sessions for participants, which encouraged more healthful foods instead of sugar-sweetened beverage (SSB), processed foods and fast foods. In addition, a round-table session for their families was helpful to build strategies for overcoming barriers. Familial involving intervention enhanced emotional and psychosocial health improvements in obese Latino youth with prediabetes [
8] by fostering social support components [
42,
43]. These elements could assist with building self-efficacy in this critical age as a ‘gold-standard’ for sustainable health-related behavioral change [
44]. A systematic review reported positive dietary outcomes (reduced fat intake or increased F&V consumption) and significant changes in stage actions and maintenance from the previous transtheoretical model (TTM)-based interventions [
9]. In the present study, the constructs of SCT were applied to the nutritional intervention protocol development. This protocol aimed to increase awareness of healthy eating behaviors, customize food guidance (nutrients, serving size, and snack & meal frequency), reduce unhealthy snacking and maintain healthy dietary habits in moderate to severe obese children and adolescents. During the intervention, the SCT components (nutrition education [NE], skill building [SB], goal setting [GS], outcome expectation [OE], overcoming barriers [OB] and social support [SS]) of the program helped set individual goals for changing the dietary habits, and building the skills (portion control, nutrition label reading and cooking healthy snacks) of participants with their families. Furthermore, TTM-based customized face-to-face nutrition counselling, phone contact with families, and text messages were implemented to continuously support participants.
Problematic eating behaviors were prevalent in obesity-related dietary patterns in numerous previous studies. It also has been reported from several studies that high quantities of fat, sugar, and calories can lead to various obesity-related health problems. In particular, dietary patterns such as eating out and consuming fast food, SSB, portion size and energy-dense foods, F&V intake, skipping breakfast, and unhealthy snacking habit [
45] were important key eating behaviors for obtaining a qualitative dietary assessment of childhood obesity. Data from the 2017 Korean Youth Risk Behavior survey indicates a lower intake of fruit and milk vs. a higher consumption of fast food and SSB in Korean youth [
46]. Consistent with these reports, this study protocol was designed to identify obesity-related dietary behaviors and modify the key factors of diet and lifestyle through a customized NCP in moderate to severe obese children and adolescents. At the beginning of the intervention, assessed individual dietary problems of the participants were labeled with selected International Dietetics and Nutrition Terminology in this study. All participants were individually counseled to overcome diet-related problems and barriers based on their nutritional status and readiness. Over 16 weeks, a nutrition expert taught all participants monthly theme-based nutrition education and developed nutritional knowledge and skills (e.g., portion control and reading food labels) to adapt to their real life.
The Childhood Obesity Research Demonstration project [
34] in the U.S. is a well-established real-world implementation of evidence-based intervention among numerous childhood obesity studies. The project teams built in each community aimed to improve healthy weight and growth among children by increasing the obesity-related nutritional and physical knowledge and skills of the parents, providers, teachers and organizations. The Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infants (IDEFICS) [
35] study is a community-oriented intervention that aims to prevent childhood obesity in eight European countries. From the baseline survey (n = 11,674), high levels of sedentary behavior, low F&V and SSB consumption and low PA were presented as obesogenic factors. Even the week effects were reported over the 2-year follow-up [
36], however, lower consuming sugar were observed after six years further follow-up from the families and children who participated in the intervention when compared with the control group [
37].
The present nutrition education content and program toolkit were consistently designed to target all family members, so that siblings and peers could join the participants in focusing on healthy eating and F&V consumption not only during the intervention also maintaining healthy habits in diet and lifestyle after the intervention. Such advantageous properties of the education content and program toolkit might be useful in the childhood obesity weight management field to overcome stigmatization and build social support. It can also be generalized and scaled to other populations and communities for easy access. Another strong point of the present study is a theory-based framework that adopts an evidence-based NCP approach in childhood obesity. With this approach, it might be possible to find obesity-related behavioral and environmental factors surrounding moderate to severe obese children and adolescents. Additional strengths of the study include the educational resources and individual nutrition sessions. These methods help with engagement and support to build a ‘rapport’ between participants and their families with nutritional experts as mediators during the intervention. Additionally, the participants' use of a unique toolkit for individual strategies and goal setting that is based on the constructs of the SCT could interplay a role for participation.
Nevertheless, some limitations exist due to the lack of previous research for guiding the study protocol focused on this population. Therefore, the latest published formative research and childhood obesity guideline 28 were reviewed to develop the present study protocol. Secondly, a customized NCP requires sufficient time to accurately assess each participant. Therefore, a more systematic procedure (e.g., electronic or internet-based) and well-trained nutrition staff would be needed to utilize this protocol in a real setting.
A theory-based framework and evidence-based NCP study protocol were developed in the present study. In the study protocol, the obesity-related, modifiable risk factors of the participants were treated through diet and eating behaviors during the intervention. A unique project toolkit and nutrition sessions were used to improve the eating behaviors of moderate to severe obese children and adolescents by changing their unhealthy dietary habits. This nutritional intervention protocol and program might assist with implementing and disseminating further research in childhood obesity.
Korea Centers for Disease Control & Preventionhttps://doi.org/10.13039/5011000036692015-ER6401-00
NOTES
-
Funding: This study was funded by Korea Centers for Disease Control and Prevention Grant 2015-ER6401-00.
-
Conflict of Interest: The authors declare that they have no competing interests.
SUPPLEMENTARY MATERIAL
Supplementary Table 1
Nutritional intervention protocol and program development
cnr-8-184-s001.xls
REFERENCES
- 1. World Health Organization. Report of the commission on ending childhood obesity. Geneva: World Health Organization; 2016.
- 2. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, Abraham JP, Abu-Rmeileh NM, Achoki T, AlBuhairan FS, Alemu ZA, Alfonso R, Ali MK, Ali R, Guzman NA, Ammar W, Anwari P, Banerjee A, Barquera S, Basu S, Bennett DA, Bhutta Z, Blore J, Cabral N, Nonato IC, Chang JC, Chowdhury R, Courville KJ, Criqui MH, Cundiff DK, Dabhadkar KC, Dandona L, Davis A, Dayama A, Dharmaratne SD, Ding EL, Durrani AM, Esteghamati A, Farzadfar F, Fay DF, Feigin VL, Flaxman A, Forouzanfar MH, Goto A, Green MA, Gupta R, Hafezi-Nejad N, Hankey GJ, Harewood HC, Havmoeller R, Hay S, Hernandez L, Husseini A, Idrisov BT, Ikeda N, Islami F, Jahangir E, Jassal SK, Jee SH, Jeffreys M, Jonas JB, Kabagambe EK, Khalifa SE, Kengne AP, Khader YS, Khang YH, Kim D, Kimokoti RW, Kinge JM, Kokubo Y, Kosen S, Kwan G, Lai T, Leinsalu M, Li Y, Liang X, Liu S, Logroscino G, Lotufo PA, Lu Y, Ma J, Mainoo NK, Mensah GA, Merriman TR, Mokdad AH, Moschandreas J, Naghavi M, Naheed A, Nand D, Narayan KM, Nelson EL, Neuhouser ML, Nisar MI, Ohkubo T, Oti SO, Pedroza A, Prabhakaran D, Roy N, Sampson U, Seo H, Sepanlou SG, Shibuya K, Shiri R, Shiue I, Singh GM, Singh JA, Skirbekk V, Stapelberg NJ, Sturua L, Sykes BL, Tobias M, Tran BX, Trasande L, Toyoshima H, van de Vijver S, Vasankari TJ, Veerman JL, Velasquez-Melendez G, Vlassov VV, Vollset SE, Vos T, Wang C, Wang X, Weiderpass E, Werdecker A, Wright JL, Yang YC, Yatsuya H, Yoon J, Yoon SJ, Zhao Y, Zhou M, Zhu S, Lopez AD, Murray CJ, Gakidou E. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384:766-781.
- 3. Korean Ministry of Education. A sample survey from school health examination. Sejong: Korean Ministry of Education; 2015.
- 4. Ben-Sefer E, Ben-Natan M, Ehrenfeld M. Childhood obesity: current literature, policy and implications for practice. Int Nurs Rev 2009;56:166-173.
- 5. Kirk S, Scott BJ, Daniels SR. Pediatric obesity epidemic: treatment options. J Am Diet Assoc 2005;105(Suppl 1):S44-S51.
- 6. Gittelsohn J, Trude AC, Poirier L, Ross A, Ruggiero C, Schwendler T, Anderson Steeves E. The impact of a multi-level multi-component childhood obesity prevention intervention on healthy food availability, sales, and purchasing in a low-income urban area. Int J Environ Res Public Health 2017;14:1371.
- 7. Xu F, Marchand S, Corcoran C, DiBiasio H, Clough R, Dyer CS, Nobles J, White J, Greaney ML, Greene GW. A community-based nutrition and physical activity intervention for children who are overweight or obese and their caregivers. J Obes 2017;2017:2746595.
- 8. Soltero EG, Konopken YP, Olson ML, Keller CS, Castro FG, Williams AN, Patrick DL, Ayers S, Hu HH, Sandoval M, Pimentel J, Knowler WC, Frick KD, Shaibi GQ. Preventing diabetes in obese Latino youth with prediabetes: a study protocol for a randomized controlled trial. BMC Public Health 2017;17:261.
- 9. Carvalho de Menezes M, Bedeschi LB, Santos LC, Lopes AC. Interventions directed at eating habits and physical activity using the Transtheoretical Model: a systematic review. Nutr Hosp 2016;33:586.
- 10. Bandura A. Social foundations of thought and action: a social cognitive theory. 1986. cited 2019 January 17. Available from: https://www.uky.edu/~eushe2/Bandura/Bandura1989ACD.pdf
- 11. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38-48.
- 12. Contento IR. Nutrition education: linking research, theory, and practice. Asia Pac J Clin Nutr 2008;17(Suppl 1):176-179.
- 13. Wang Y, Cai L, Wu Y, Wilson RF, Weston C, Fawole O, Bleich SN, Cheskin LJ, Showell NN, Lau BD, Chiu DT, Zhang A, Segal J. What childhood obesity prevention programmes work? A systematic review and meta-analysis. Obes Rev 2015;16:547-565.
- 14. Hoelscher DM, Kirk S, Ritchie L, Cunningham-Sabo L. Academy Positions Committee. Position of the Academy of Nutrition and Dietetics: interventions for the prevention and treatment of pediatric overweight and obesity. J Acad Nutr Diet 2013;113:1375-1394.
- 15. Lobstein T, Jackson-Leach R, Moodie ML, Hall KD, Gortmaker SL, Swinburn BA, James WP, Wang Y, McPherson K. Child and adolescent obesity: part of a bigger picture. Lancet 2015;385:2510-2520.
- 16. Electronic Nutrition Care Process Terminology. Nutrition terminology reference manual: dietetics language for nutrition care. 2016. cited 2019 January 17. Available from: http://ncpt.webauthor.com
- 17. Stea TH, Haugen T, Berntsen S, Guttormsen V, Øverby NC, Haraldstad K, Meland E, Abildsnes E. Using the Intervention Mapping protocol to develop a family-based intervention for improving lifestyle habits among overweight and obese children: study protocol for a quasi-experimental trial. BMC Public Health 2016;16:1092.
- 18. Cunningham-Sabo L, Lohse B, Smith S, Browning R, Strutz E, Nigg C, Balgopal M, Kelly K, Ruder E. Fuel for Fun: a cluster-randomized controlled study of cooking skills, eating behaviors, and physical activity of 4th graders and their families. BMC Public Health 2016;16:444.
- 19. Lohse B, Smith S, Cunningham-Sabo L. Fuel for fun impact study affirms positive effect on fruit & vegetable preference and approach to cooking in school age youth. Poster presented at: Annual Meeting of the Society for Nutrition Education and Behavior. July 2015; Pittsburgh (PA): Fort Collins (CO): Colorado State University, College of Health and Human Sciences; 2015.
- 20. Partridge SR, McGeechan K, Hebden L, Balestracci K, Wong AT, Denney-Wilson E, Harris MF, Phongsavan P, Bauman A, Allman-Farinelli M. Effectiveness of a mHealth lifestyle program with telephone support (TXT2BFiT) to prevent unhealthy weight gain in young adults: randomized controlled trial. JMIR Mhealth Uhealth 2015;3:e66.
- 21. Sawesi S, Rashrash M, Phalakornkule K, Carpenter JS, Jones JF. The impact of information technology on patient engagement and health behavior change: a systematic review of the literature. JMIR Med Inform 2016;4:e1.
- 22. Spook J, Paulussen T, Kok G, van Empelen P. Evaluation of a serious self-regulation game intervention for overweight-related behaviors (“Balance It”): a pilot study. J Med Internet Res 2016;18:e225.
- 23. Taveras EM, Marshall R, Horan CM, Gillman MW, Hacker K, Kleinman KP, Koziol R, Price S, Simon SR. Rationale and design of the STAR randomized controlled trial to accelerate adoption of childhood obesity comparative effectiveness research. Contemp Clin Trials 2013;34:101-108.
- 24. Taveras EM, Marshall R, Kleinman KP, Gillman MW, Hacker K, Horan CM, Smith RL, Price S, Sharifi M, Rifas-Shiman SL, Simon SR. Comparative effectiveness of childhood obesity interventions in pediatric primary care: a cluster-randomized clinical trial. JAMA Pediatr 2015;169:535-542.
- 25. Brug J, te Velde SJ, Chinapaw MJ, Bere E, de Bourdeaudhuij I, Moore H, Maes L, Jensen J, Manios Y, Lien N, Klepp KI, Lobstein T, Martens M, Salmon J, Singh AS. Evidence-based development of school-based and family-involved prevention of overweight across Europe: the ENERGY-project's design and conceptual framework. BMC Public Health 2010;10:276.
- 26. Bush NR, Allison AL, Miller AL, Deardorff J, Adler NE, Boyce WT. Socioeconomic disparities in childhood obesity risk: association with an oxytocin receptor polymorphism. JAMA Pediatr 2017;171:61-67.
- 27. Chen Y, Ma L, Ma Y, Wang H, Luo J, Zhang X, Luo C, Wang H, Zhao H, Pan D, Zhu Y, Cai L, Zou Z, Yang W, Ma J, Jing J. A national school-based health lifestyles interventions among Chinese children and adolescents against obesity: rationale, design and methodology of a randomized controlled trial in China. BMC Public Health 2015;15:210.
- 28. Eisenmann JC, Alaimo K, Pfeiffer K, Paek HJ, Carlson JJ, Hayes H, Thompson T, Kelleher D, Oh HJ, Orth J, Randall S, Mayfield K, Holmes D. Project FIT: rationale, design and baseline characteristics of a school- and community-based intervention to address physical activity and healthy eating among low-income elementary school children. BMC Public Health 2011;11:607.
- 29. Evans A, Ranjit N, Hoelscher D, Jovanovic C, Lopez M, McIntosh A, Ory M, Whittlesey L, McKyer L, Kirk A, Smith C, Walton C, Heredia NI, Warren J. Impact of school-based vegetable garden and physical activity coordinated health interventions on weight status and weight-related behaviors of ethnically diverse, low-income students: study design and baseline data of the Texas, Grow! Eat! Go! (TGEG) cluster-randomized controlled trial. BMC Public Health 2016;16:973.
- 30. HaGani N, Moran MR, Caspi O, Plaut P, Endevelt R, Baron-Epel O. The relationships between adolescents' obesity and the built environment: are they city dependent? Int J Environ Res Public Health 2019;16:1579.
- 31. Irwin CC, Irwin RL, Miller ME, Somes GW, Richey PA. Get fit with the Grizzlies: a community-school-home initiative to fight childhood obesity. J Sch Health 2010;80:333-339.
- 32. Jia P, Xue H, Cheng X, Wang Y, Wang Y. Association of neighborhood built environments with childhood obesity: evidence from a 9-year longitudinal, nationally representative survey in the US. Environ Int 2019;128:158-164.
- 33. Lubans DR, Morgan PJ, Dewar D, Collins CE, Plotnikoff RC, Okely AD, Batterham MJ, Finn T, Callister R. The Nutrition and Enjoyable Activity for Teen Girls (NEAT girls) randomized controlled trial for adolescent girls from disadvantaged secondary schools: rationale, study protocol, and baseline results. BMC Public Health 2010;10:652.
- 34. Hoelscher DM, Butte NF, Barlow S, Vandewater EA, Sharma SV, Huang T, Finkelstein E, Pont S, Sacher P, Byrd-Williams C, Oluyomi AO, Durand C, Li L, Kelder SH. Incorporating primary and secondary prevention approaches to address childhood obesity prevention and treatment in a low-income, ethnically diverse population: study design and demographic data from the Texas Childhood Obesity Research Demonstration (TX CORD) study. Child Obes 2015;11:71-91.
- 35. Verbestel V, De Henauw S, Maes L, Haerens L, Mårild S, Eiben G, Lissner L, Moreno LA, Frauca NL, Barba G, Kovács E, Konstabel K, Tornaritis M, Gallois K, Hassel H, De Bourdeaudhuij I. Using the intervention mapping protocol to develop a community-based intervention for the prevention of childhood obesity in a multi-centre European project: the IDEFICS intervention. Int J Behav Nutr Phys Act 2011;8:82.
- 36. De Henauw S, Huybrechts I, De Bourdeaudhuij I, Bammann K, Barba G, Lissner L, Mårild S, Molnár D, Moreno LA, Pigeot I, Tornaritis M, Veidebaum T, Verbestel V, Ahrens W. IDEFICS consortium. Effects of a community-oriented obesity prevention programme on indicators of body fatness in preschool and primary school children. Main results from the IDEFICS study. Obes Rev 2015;16(Suppl 2):16-29.
- 37. Arvidsson L, Bogl LH, Eiben G, Hebestreit A, Nagy P, Tornaritis M, Moreno LA, Siani A, Veidebaum T, De Henauw S, Lissner L. IDEFICS and I.Family consortia. Fat, sugar and water intakes among families from the IDEFICS intervention and control groups: first observations from I.Family. Obes Rev 2015;16(Suppl 2):127-137.
- 38. Bandura A. Health promotion from the perspective of social cognitive theory. Psychol Health 1998;13:623-649.
- 39. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977;84:191-215.
- 40. Korean Nutrition Society. Dietary reference intakes for Koreans. Seoul: Korean Nutrition Society; 2015.
- 41. Larson NI, Story M, Eisenberg ME, Neumark-Sztainer D. Food preparation and purchasing roles among adolescents: associations with sociodemographic characteristics and diet quality. J Am Diet Assoc 2006;106:211-218.
- 42. Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care 2002;25:2165-2171.
- 43. Keller C, Coe K, Shaibi G. Using Rituals for Intervention Refinement. Health Cult Soc (Pittsburgh Pa) 2015;8:37-45.
- 44. Davison KK, Lawson HA, Coatsworth JD. The Family-centered Action Model of Intervention Layout and Implementation (FAMILI): the example of childhood obesity. Health Promot Pract 2012;13:454-461.
- 45. Ross MM, Kolbash S, Cohen GM, Skelton JA. Multidisciplinary treatment of pediatric obesity: nutrition evaluation and management. Nutr Clin Pract 2010;25:327-334.
- 46. Korea Centers for Disease Control and Prevention. The eleventh Korea youth risk behavior web-based survey user's guide. Cheongju: Korea Centers for Disease Control and Prevention; 2017.
, Yoon Myung Kim3, Han Byul Jang4, Hye-Ja Lee4, Sang Ick Park4, Kyung-Hee Park5
