12/9/2019 Dr Zaidah Rizidah Binti Murang

https://expert.ubd.edu.bn/zaidah.murang 1/6

(https://scholar.google.com/citations?hl=en&user=0WUCE-cAAAAJ)     

(https://www.scopus.com/authid/detail.uri?authorId=57190811091)     

Zaidah Rizidah is a lecturer in Public Health at PAPRSB Institute of Health Sciences, Universiti Brunei

Darussalam. At the institute, she is a convener for various Master of Public Health modules. She has been

appointed as a member for Institute of Health Sciences Research and Ethics committee (IHSREC) until 2022.

She also holds an administrative position as a visit coordinator at the institute.

Her research interest is mostly in the area of health promotion and non-communicable diseases. She is

currently working on 3 projects which are on 1) Improving oral care for terminally-ill patients in Brunei

Darussalam, 2) Health literacy among diabetic patients in Brunei Darussalam, which is a collaborative project

between Health Promotion Centre (HPC) and Universiti Brunei Darussalam, and 3) Health insurance

coverage among documented migrant workers in Brunei Darussalam.

EDUCATION

DR ZAIDAH RIZIDAH BINTI MURANGzaidah.murang@ubd.edu.bn

Lecturer, Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences

https://scholar.google.com/citations?hl=en&user=0WUCE-cAAAAJhttps://www.scopus.com/authid/detail.uri?authorId=57190811091

The Effectiveness of Team-based Tailored Health Education (‘THE’) among Overweight and Obese Primary-school Children: a Randomized Controlled Trial

Zaidah Rizidah Binti Murang1,*

1PAPRSB Institute of Health Science, Universiti Brunei Darussalam, Brunei

*Corresponding Author: zaidah.murang@ubd.edu.bn

ABSTRACT

Objectives: Effective intervention to curb the rising childhood obesity is urgently needed. This study

examined the effectiveness of ‘THE’ intervention by comparing the anthropometric changes in overweight

and obese children, and health-related knowledge and behaviour changes among these children and their

parents through a randomized controlled trial.

Methods: Intervention group received four sessions of tailored health education and healthier food options at

their school canteen whereas control group received the usual care.

Results: Children in the intervention group significantly decreased their BMI (p

their diet and physical activity (Golley et al. 2011; Kalarchian et al. 2009; Robertson et al. 2008, 2012; West

et al. 2010), and their perceptions have been shown to have significant impact on the development of

childhood obesity (van der Kruk et al. 2013). In Brunei, parents were found to believe that childhood obesity

is caused by ‘inheritance’ and ‘genetics’, and they also believe that their children were in their ‘ideal’ weight

despite not knowing the cut off values for childhood obesity (Z. Murang, Tuah, and Naing 2017). Also,

84.2% of Bruneian children were reported to lack in knowledge on the required daily servings of fruits and

vegetables (Z. R. Murang, Tuah, and Naing 2017). These findings emphasized that the most effective

strategies to manage childhood obesity in Brunei is urgently needed.

Therefore, Team-based Health Education (‘THE’) was designed to be a novel and effective childhood obesity

intervention in Brunei which aimed to reduce the excess weight of overweight and obese Bruneian children

by addressing parents’ and their children’s specific needs. Specifically, our objectives were to:

• To compare the anthropometric changes [body mass index (BMI) and waist circumference (WC)]

among overweight and obese children between intervention and control group

• To compare health-related knowledge and behavioural changes among overweight and obese

children and their parents between intervention and control group

Methods

Study design

This study was a randomized controlled trial (RCT). Six primary schools (n=1125) were selected randomly

by computer generated simple random sampling from a list of nine primary schools in Mukim Gadong of

Brunei, three were randomly assigned to the intervention group (n=90) and three to a control group (n=90).

The control group was given printed materials on health after the completion of the study. Outcomes were

assessed at baseline at week 0 (T1), end of intervention at week 12 (T2) and a follow-up at week 24 (T3), to

evaluate both the short-term and sustained effects. Figure 1 shows the flow of study.

Figure 1 Flow of participants through the trial and analyzed for the outcomes

Participants

Participants were overweight and obese children and their parents. Eligibility criteria were: 1) overweight or

obese children, 2) aged 9 to 12 years old, and 3) have at least one parent or guardian willing to participate.

Children with a food allergy, metabolic illness which can interact with their weight or are undergoing obesity

treatment were excluded.

Intervention

Intervention design

‘THE’ intervention was a team-based childhood obesity intervention involving a team-work of certified

health professionals, school authorities, parents and children. It was a tailored intervention developed based

on the findings of a mixed-method sequential exploratory study which was conducted prior to the

intervention study, and consisted of a qualitative study through focus group discussions (Phase 1) to explore

all the possible contributors to childhood obesity among children and their parents by giving room to

unprecedented answers, and a quantitative cross sectional study (Phase 2) to quantify and rank the importance

of contributors to childhood obesity, and to produce a representative set of results. The exploratory study

revealed poor eating habits, insufficient physical activity and parental misperception, as the main contributing

factors for childhood obesity in Brunei (Figure 2).

Figure 2 Findings of exploratory study: contributing factors for childhood obesity in Brunei

The development of the ‘THE’ intervention was guided by the concept of ‘contextual fit’, which was based

on the premise that the match between an intervention and local context affects both the quality of

intervention implementation, and whether the intervention actually produces the desired outcomes for the

targeted participants (Horner and Ross 2014). To guide behaviour change, ‘THE’ intervention was

underpinned by Social Cognitive theory, which was based on the concept that dynamic interplay exists

between personal factors, behaviours and the environment, and changing one of these will change them all

(Bandura 2004).

Intervention components

The components were designed based on the expectation that children will make healthier choices when

equipped with knowledge, and when introduced to supportive environment. The two components were:

A. Tailored group educational sessions

Four weekly group educational sessions (each lasted for 2 hours 30 minutes) were delivered by certified

health professionals in a community setting (University’s seminar room) where children and their parents

were required to attend. Topics of the group sessions were tailored following the findings of our exploratory

study (Figure 2), which generated four specific topics in order to address the specific needs of the children

and their parents, namely: 1) food and nutrition, 2) physical activity and 3) risks factors of childhood obesity,

and 4) enabling environment. At the end of each session, a question and answer session was conducted, and

discussions were led by the same health professionals.

B. Healthy canteen

Canteens in the intervention primary schools were requested to prepare affordable (BND 1) healthier food

options in the canteen, which was according to the typical amount of pocket money given to children by their

parents for school meal in Brunei. All children (study and non-study participants) have access to the healthier

menu changes which was prepared five days a week (every day except Friday and Sunday) by the canteen.

The menu changes were following the guideline menus listed on ‘Contoh Menu Sihat Kantin Sekolah’

(‘Suggested Healthy Menu for Canteens in Schools’) booklet as released by the Community Nutrition

Division. The booklet consisted of a list of various healthy menus for different school days, which included

low-fat food such as potato or macaroni salad, steamed corn, chicken sandwich with low-fat mayonnaise and

tuna bun. Other energy dense foods such as rice, noodles or burgers were only allowed to be offered twice a

week. Visits were done regularly to monitor the compliance of schools.

Sample size calculation

The study sample size was calculated using Power and Sample Size Calculator (Dupont and Plummer 1990).

The required sample size was 36 participants in each group to detect a difference of 0.5 kg/m2 in BMI

change between the two study groups [SD was estimated as 1.06 (Croker et al. 2012)] with 80% certainty

(power) and alpha 0.05. With a design effect of two to account for the cluster effect, and 25% attrition rate,

the final calculated sample was 90. Six primary schools were included and approximately 30 participants

from each primary school were selected.

Randomization, allocation concealment and blinding

To ensure allocation concealment, the six primary schools were randomly assigned by computer generated

simple random sampling to either intervention or control group. Children at either group that met the

eligibility criteria were further randomized using a computer-generated randomization. Children and their

parents cannot be blinded to treatment allocation.

Outcome measures

The primary outcome was the change in anthropometric measurements in children. Health-related knowledge

and behavioural changes in children and their parents were the secondary outcomes. Data of participants were

collected at their respective primary schools.

1. Anthropometric measurements

Anthropometric measurements which included the BMI and WC of children were carried out using

standardized techniques and calibrated wall mounted stadiometre (Seca 200). All measurements were taken

in the morning before break time (10 am) during all assessments.

a. BMI measures

Weight was measured to the nearest 0.1 kg and height was measured to the nearest 0.5 cm. The

measurements of weight were obtained when the children were bare-footed or with socks/stockings,

directly from the digital scale of the stadiometre which was placed on a hard, even surface. Children

wore a light layer of clothing (i.e. school uniform) and were asked to remove any items from their

pockets before standing squarely on the scales, arms hanging loosely by their side, looking forward

and remaining still until asked to move. To obtain the height measurements, the horizontal bar was

lowered so that it was horizontal to the floor when rested flat on the top of the child’s head. They

were also asked to remove their shoes before standing in an erect position on the equipment, back as

straight as possible, arms hanging loosely by their side and head looking forward with feet together.

The BMI was determined by using the formula: BMI = Weight (kg)/[Height (m) x Height (m)].

Classification of the children’s BMI were according to the WHO’s BMI-for-age (5-19 years) (WHO |

BMI-for-age (5-19 years) 2015), which used children’s weight in relation to their height for a specific

age and gender.

b. WC measures

WC measurements of the children were taken using a non-resistant measuring tape, performed by the

researcher and recorded to the nearest 0.5 cm. The WC was measured at the end of several

consecutive breaths with the child standing erect, midpoint between the top of the iliac crest and the

lower margin of the last palpable rib in the mid axillary line. This was typically at the level of the

umbilicus, midway point between the 10th rib and the iliac crest (Roockley 2014). The measurement

was taken over a light layer of clothing, with children being asked to breathe normally. If a child was

wearing a jacket or cardigan, the WC measurement was taken under it.

2. Health-related knowledge and behavioural measures

The health-related knowledge and behavioural measures of children and their parents were obtained through

separate questionnaires. The questionnaires comprised of four sections for children (personal information,

knowledge about childhood obesity, eating habits and physical activity), and an additional section for parents

(perception on the contributors of childhood obesity). Scores were obtained in order to detect any significant

changes in health-related knowledge and behaviours of the participants. The questionnaires were pretested

and pilot-tested. Cronbach’s alpha coefficient to assess the internal consistency reliability of the

questionnaires was found to range between 0.705 to 0.980, where an alpha of ≥0.7 was considered reliable

(Spek et al. 2013).

Statistical analysis

Data were analyzed using IBM SPSS (Version 21). Repeated Measures ANOVA and Independent t test were

used to compare and analyze the gathered data at two and three time-points. The demographic characteristics

of the participants were displayed using mean (SD) and percentages (n %). Prior to statistical analysis,

normality and distribution of all the variables were examined. All analyses were two-sided, and conducted

using an intention-to-treat (ITT) protocol.

Ethical considerations

Permission to conduct the study was obtained from PAPRSB Institute of Health Science Research and Ethics

Committee (UBD/IHS/B3/8), which was based on commonly agreed standards of good practice, such as

those outlined in the Declaration of Helsinki Ethical Principles for Medical Research Involving Human

Subjects. Participation in the study was through the process of informed consent and identities of participants

were kept confidential.

Results

Demographic characteristics of children according to group

Table 1 Characteristics of study children according to group

Characteristic Intervention (n = 82)

Control (n = 87)

Demographic Age (years) 9 10 11

30 31 21

41 20 26

Gender n (%) Boys Girls

38 (46.3) 44 (53.7)

43 (49.4) 44 (50.6)

Race n (%) Melayu Brunei Dusun Kedayan Chinese Others

70 (85.4)

1 (1.2) 3 (3.7) 2 (2.4) 6 (7.3)

82 (94.3)

0 (0) 2 (2.3) 2 (2.3) 1 (1.1)

Nationality n (%) Citizens PR

67 (81.7) 15 (18.3)

66 (75.9) 21 (24.1)

In total, there were eighty-two (n=82) children in the intervention group and eighty-seven (n=87) children in

the control group. For both groups, the age of children ranged from 9 to 11 years old, there were more

participation from girls than boys, and the majority were of Melayu Brunei race and citizens of Brunei

Darussalam (Table 1).

Anthropometric changes

Table 2 shows the reduction in BMI in the intervention group from 27.1 kg/m2 to 26.6 kg/m2 was

significant (p

3.1 and eating habits from 42.5 to 42.0 were also significant (p

Variable T1 T2 T3

F statistic (df)a

P value

Post hoc testsb (mean difference)

Mean (SD)

Mean (SD)

Mean (SD)

T1-T2 T2-T3 T1-T3

Knowledge Intervention Control

1.1 (1.12) 1.0 (0.59)

1.5 (0.73) 1.0 (0.66)

1.6 (1.56) 1.0 (0.65)

9.72 (2) 3.37 (1)

have influenced a child’s weight status over time. In contrast, a childhood obesity intervention

which focused on school-wide food environmental changes among American children aged 12 to 15

did not exhibit significant effects on BMI after 5 weeks, although the intervention was expected to

produce significant reductions after 2 years (Bogart et al. 2016).

Our study also found a decrease in intervention children’s WC from 81.1 cm to 80.8 cm after 24

weeks, although it was not statistically significant (p=0.079), but was significantly increasing from

83.1 cm to 84.8 cm in the control group (p12 months) are effective to significantly reduce

some indicators of adiposity such as WC (Swedish Council on Health Technology Assessment.

2005). The statistically insignificant result in the waist reduction within the intervention children

was therefore probably due to the short duration of the intervention and time between

measurements. For example, ‘APPLE’ project, a childhood obesity intervention which focused on

healthy eating and physical activity among primary-school children in New Zealand, found a

significant decrease of 1.0 cm in WC of the intervention children after 2 years (Taylor et al. 2007).

Another similar intervention, ‘Be Active Eat Well’ found a significant reduction of 3.14 cm

(p=0.01) in their WC of intervention children after 3 years (Sanigorski et al. 2008).

Our study also indicated that children who had undergone the intervention experienced a significant

increase in knowledge (p

conclusions of a motivational intervention counseling among Italian parents to tackle childhood

obesity which found a non-significant reduction in unhealthy dietary intake in the intervention group

(Davoli et al. 2013). However, the same study found that the children in the intervention group

showed increased physical activity, a result which was similar to the present study, and was also

supported by a parenting intervention to encourage health behaviours among overweight and obese

children through praise, active support and positive role-modeling (Patrick et al. 2006). A 1-year

follow-up intervention among parents of preschool age children which focused on motivational

intervention produced non-significant trend towards decreasing intake of unhealthy food in the

intervention group compared to the control group, however, this study only used parental report of

behaviours rather than objective measures (Taveras et al. 2011).

Similarly, the present study found that the intervention was successful in increasing parental health-

related knowledge (p

parents could possibly be explained by their increase in knowledge and awareness of factors

associated with childhood obesity following intervention, as revealed by the present study.

Strength of the current study lies in its design where RCT is the most reliable in providing the

evidence of effectiveness of interventions by minimizing confounding factors and selection bias

through a control group and randomization process, generating results that are likely to be closer to

the true effect. In addition, the study was powered to detect changes in the primary outcome

measures. The outcome measures of the study include a range of both self-reported (participant-

reported) and objectively assessed (researcher-reported) which contributed to internal validity of the

study. This study was also designed to include a follow-up at 6th month post-randomization to

ascertain the outcomes for participants completely.

However, the study was limited by the inclusion of a narrow age range of children and the setting of

research which only focused in Mukim Gadong of Brunei impacted the generalizability of the study

to other age groups and geographical locations. It was also not possible to blind assessors to group

allocation due to the modes of delivery. The use of questionnaires in the study was also susceptible

to misclassification and difficulties with recalling past behaviours, especially among children. We

were also unable to evaluate the effectiveness of the intervention beyond 6 months due of time

constraints.

Conclusions

‘THE’ intervention proved to be effective in reducing the BMI of overweight and obese children in

Brunei. We hypothesized that a tailored, team-based, contextually fit and theory-based childhood

obesity intervention had an impact on the children’s energy balance-related behaviours. Future

studies could assess the impact of the intervention at a longer period of follow up to test its

sustainability.

References

Bandura, Albert. 2004. “Health Promotion by Social Cognitive Means.” Health Education & Behavior 31(2): 143–64. http://www.ncbi.nlm.nih.gov/pubmed/15090118 (September 16, 2017).

Bogart, L M et al. 2016. “Two-Year BMI Outcomes From a School-Based Intervention for Nutrition and Exercise: A Randomized Trial.” Pediatrics 137(5).

Cadzow, Renee B., Meghan K. Chambers, and Angela M. D. Sandell. 2015. “School-Based Obesity Intervention Associated with Three Year Decrease in Student Weight Status in a Low-Income School District.” Journal of Community Health 40(4): 709–13. http://link.springer.com/10.1007/s10900-015-9989-0 (September 7, 2017).

Croker, H et al. 2012. “Family-Based Behavioural Treatment of Childhood Obesity in a UK National Health Service Setting: Randomized Controlled Trial.” International journal of obesity (2005) 36(1): 16–26. http://www.ncbi.nlm.nih.gov/pubmed/21931327 (December 24, 2016).

Davoli, Anna Maria et al. 2013. “Pediatrician-Led Motivational Interviewing to Treat Overweight Children: An RCT.” Pediatrics 132(5): e1236-46. http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2013-1738 (September 9, 2017).

Dupont, W D, and W D Plummer. 1990. “Power and Sample Size Calculations. A Review and Computer Program.” Controlled clinical trials 11(2): 116–28. http://www.ncbi.nlm.nih.gov/pubmed/2161310 (May 18, 2017).

Gerards, Sanne M P L et al. 2012. “Lifestyle Triple P: A Parenting Intervention for Childhood Obesity.” BMC public health 12: 267. http://www.ncbi.nlm.nih.gov/pubmed/22471971 (December 15, 2016).

Gerards SM, Dagnelie PC, Gubbels JS, van Buuren S, Hamers FJ, Jansen MW, van der Goot OH, de Vries NK, Sanders MR7, Kremers SP. 2015. “The Effectiveness of Lifestyle Triple P in the Netherlands: A Randomized Controlled Trial.” PloS one 10(4): e0122240. http://www.ncbi.nlm.nih.gov/pubmed/25849523 (September 12, 2017).

Golley, R. K., G. A. Hendrie, A. Slater, and N. Corsini. 2011. “Interventions That Involve Parents to Improve Children’s Weight-Related Nutrition Intake and Activity Patterns - What Nutrition and Activity Targets and Behaviour Change Techniques Are Associated with Intervention Effectiveness?” Obesity Reviews 12(2): 114–30. http://www.ncbi.nlm.nih.gov/pubmed/20406416 (December 15, 2016).

Heelan, Kate A, R Todd Bartee, Allison Nihiser, and Bettylou Sherry. 2015. “Healthier School Environment Leads to Decreases in Childhood Obesity: The Kearney Nebraska Story.” Childhood obesity (Print) 11(5): 600–607. http://www.ncbi.nlm.nih.gov/pubmed/26440386 (September 7, 2017).

Horner, Rob, and Scott W Ross. 2014. “THE IMPORTANCE OF CONTEXTUAL FIT WHEN IMPLEMENTING EVIDENCE-BASED INTERVENTIONS.” https://youth.gov/docs/Contextual_IssueBrief_508.pdf (December 9, 2017).

Kader, Manzur, Elinor Sundblom, and Liselotte Schäfer Elinder. 2015. “Effectiveness of Universal Parental Support Interventions Addressing Children’s Dietary Habits, Physical Activity and Bodyweight: A Systematic Review.” Preventive medicine 77: 52–67. http://linkinghub.elsevier.com/retrieve/pii/S0091743515001577 (September 9, 2017).

Kalarchian, Melissa A et al. 2009. “Family-Based Treatment of Severe Pediatric Obesity: Randomized, Controlled Trial.” Pediatrics 124(4): 1060–68. http://www.ncbi.nlm.nih.gov/pubmed/19786444 (December 19, 2016).

van der Kruk, J J, F Kortekaas, C Lucas, and H Jager-Wittenaar. 2013. “Obesity: A Systematic Review on Parental Involvement in Long-Term European Childhood Weight Control Interventions with a Nutritional Focus.” Obesity reviews : an official journal of the International Association for the Study of Obesity 14(9): 745–60. http://www.ncbi.nlm.nih.gov/pubmed/23734625 (December 9, 2017).

Lloyd, Adam B., David R. Lubans, Ronald C. Plotnikoff, and Philip J. Morgan. 2015. “Paternal Lifestyle-Related Parenting Practices Mediate Changes in Children’s Dietary and Physical Activity Behaviors: Findings from the Healthy Dads, Healthy Kids Community Randomized Controlled Trial.” Journal of Physical Activity and Health 12(9): 1327–35. http://www.ncbi.nlm.nih.gov/pubmed/25526517 (September 12, 2017).

Ministry of Health. 2016. “Theme: Ending Childhood Obesity.” http://www.moh.gov.bn/Lists/CO_Announcements/NewDispForm.aspx?ID=37 (December 15, 2016).

Murang, Zaidah Rizidah, NAA Tuah, and Lin Naing. 2017. “Knowledge, Attitude and Practice towards Eating and Physical Activity among Primary School Children in Brunei: A Cross-Sectional Study.” International Journal of Adolescent Medicine and Health 0(0). http://www.ncbi.nlm.nih.gov/pubmed/29190212 (April 4, 2019).

Murang, Zaidah, Nik Tuah, and Lin Naing. 2017. “Parental Perceptions of Factors in-Fluencing the Development of Child-Hood Obesity in Brunei Darussalam: A Cross-Sectional Study.” Brunei International Medical Journal 13(1): 20–26. https://pdfs.semanticscholar.org/d40b/079f5eda03b0270e24fb60f80e09aff20c6c.pdf (April 4, 2019).

Nyberg, Gisela et al. 2016. “Effectiveness of a Universal Parental Support Programme to Promote Health Behaviours and Prevent Overweight and Obesity in 6-Year-Old Children in Disadvantaged Areas, the Healthy School Start Study II, a Cluster-Randomised Controlled Trial.” The international journal of behavioral nutrition and physical activity 13: 4. http://www.ncbi.nlm.nih.gov/pubmed/26795378 (September 7, 2017).

Patrick, Kevin et al. 2006. “Randomized Controlled Trial of a Primary Care and Home-Based Intervention for Physical Activity and Nutrition Behaviors: PACE+ for Adolescents.” Archives of pediatrics & adolescent medicine 160(2): 128–36. http://archpedi.jamanetwork.com/article.aspx?doi=10.1001/archpedi.160.2.128 (September 11, 2017).

Robertson, W et al. 2008. “Pilot of "Families for Health": Community-Based Family Intervention for

https://www.ncbi.nlm.nih.gov/pubmed/?term=Gerards%20SM%5BAuthor%5D&cauthor=true&cauthor_uid=25849523https://www.ncbi.nlm.nih.gov/pubmed/?term=Dagnelie%20PC%5BAuthor%5D&cauthor=true&cauthor_uid=25849523https://www.ncbi.nlm.nih.gov/pubmed/?term=Gubbels%20JS%5BAuthor%5D&cauthor=true&cauthor_uid=25849523https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20Buuren%20S%5BAuthor%5D&cauthor=true&cauthor_uid=25849523https://www.ncbi.nlm.nih.gov/pubmed/?term=Hamers%20FJ%5BAuthor%5D&cauthor=true&cauthor_uid=25849523https://www.ncbi.nlm.nih.gov/pubmed/?term=Jansen%20MW%5BAuthor%5D&cauthor=true&cauthor_uid=25849523https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20der%20Goot%20OH%5BAuthor%5D&cauthor=true&cauthor_uid=25849523https://www.ncbi.nlm.nih.gov/pubmed/?term=de%20Vries%20NK%5BAuthor%5D&cauthor=true&cauthor_uid=25849523https://www.ncbi.nlm.nih.gov/pubmed/?term=Sanders%20MR%5BAuthor%5D&cauthor=true&cauthor_uid=25849523https://www.ncbi.nlm.nih.gov/pubmed/?term=Sanders%20MR%5BAuthor%5D&cauthor=true&cauthor_uid=25849523https://www.ncbi.nlm.nih.gov/pubmed/?term=Kremers%20SP%5BAuthor%5D&cauthor=true&cauthor_uid=25849523

Obesity.” Archives of Disease in Childhood 93(11): 921–28. http://www.ncbi.nlm.nih.gov/pubmed/18463121 (December 19, 2016).

Robertson, W. et al. 2012. “Two-Year Follow-up of the ‘Families for Health’ Programme for the Treatment of Childhood Obesity.” Child: Care, Health and Development 38(2): 229–36. http://www.ncbi.nlm.nih.gov/pubmed/21463350 (December 19, 2016).

Roockley, Claire Ellen. 2014. “A Mixed Methods Obesity Prevention Intervention For Australian Children Aged 6-12 Years: Influence Of Parents Misperceptions About Food And Exercise On The Efficacy Of Educational Obesity Simulations.” Edith Cowan University. http://ro.ecu.edu.au/theses/1419 (May 18, 2017).

Sanigorski, A M et al. 2008. “Reducing Unhealthy Weight Gain in Children through Community Capacity-Building: Results of a Quasi-Experimental Intervention Program, Be Active Eat Well.” International journal of obesity (2005) 32(7): 1060–67. http://www.ncbi.nlm.nih.gov/pubmed/18542082 (September 18, 2017).

Singh, A. S. et al. 2008. “Tracking of Childhood Overweight into Adulthood: A Systematic Review of the Literature.” Obesity Reviews 9(5): 474–88. http://www.ncbi.nlm.nih.gov/pubmed/18331423 (December 15, 2016).

Spek, Viola et al. 2013. “Development of a Smoking Abstinence Self-Efficacy Questionnaire.” International Journal of Behavioral Medicine 20(3): 444–49. http://www.ncbi.nlm.nih.gov/pubmed/22350635 (December 23, 2017).

Swedish Council on Health Technology Assessment. 2005. “Interventions to Prevent Obesity: A Systematic Review - PubMed - NCBI.” Stockholm: Swedish Council on Health Technology Assessment (SBU). https://www.ncbi.nlm.nih.gov/pubmed/28876747 (September 18, 2017).

Taveras, Elsie M et al. 2011. “Randomized Controlled Trial to Improve Primary Care to Prevent and Manage Childhood Obesity: The High Five for Kids Study.” Archives of pediatrics & adolescent medicine 165(8): 714–22. http://archpedi.jamanetwork.com/article.aspx?doi=10.1001/archpediatrics.2011.44 (September 9, 2017).

Taylor, Rachael W et al. 2007. “APPLE Project: 2-Y Findings of a Community-Based Obesity Prevention Program in Primary School Age Children.” The American journal of clinical nutrition 86(3): 735–42. http://www.ncbi.nlm.nih.gov/pubmed/17823440 (September 18, 2017).

Wang, Youfa, and Tim Lobstein. 2006. “Worldwide Trends in Childhood Overweight and Obesity.” International journal of pediatric obesity : IJPO : an official journal of the International Association for the Study of Obesity 1(1): 11–25. http://www.ncbi.nlm.nih.gov/pubmed/17902211 (December 20, 2016).

Washington, Reginald L. 2011. “Childhood Obesity: Issues of Weight Bias.” Preventing chronic disease 8(5): A94. http://www.ncbi.nlm.nih.gov/pubmed/21843424 (December 15, 2016).

West, Felicity, Matthew R. Sanders, Geoffrey J. Cleghorn, and Peter S.W. Davies. 2010. “Randomised Clinical Trial of a Family-Based Lifestyle Intervention for Childhood Obesity Involving Parents as the Exclusive Agents of Change.” Behaviour Research and Therapy 48(12): 1170–79.

“WHO | BMI-for-Age (5-19 Years).” 2015. WHO. http://www.who.int/growthref/who2007_bmi_for_age/en/ (May 18, 2017).