Ausgewählte Einflussfaktoren für die Entstehung von Übergewicht und Adipositas im Kindes- und Jugendalter - Ansätze für die Prävention: Analyse ausgewählter (ambulanter) Programme aus dem Raum NRW

Introduction: Overweight and obesity in children and adolescents in Germany amounts to about 15% of the population and is therefore highly prevalent. The risk is not averted yet. Even though it appears to be leveling since about 2004, there still happens to be an increase among high risk target groups. Overweight and obesity can lead to serious co-morbidities and secondary diseases even at a young age. Furthermore, many adipose children remain obese as grown- ups while the associated health risks further increase with age. Therefore, being overweight or obese amounts to serious problems for the people concerned. In addi- tion, the developing co-morbidities and secondary diseases cause considerable costs in the healthcare system. Besides a genetic predisposition and sociodemographic factors an unhealthy diet and lack of physical activity are particular root causes. Overweight and insufficient activity lead to deficits in motor skills which in turn lead to frustration and ongoing physical inactivity. A vicious circle ensues. Nationwide, there are a lot of prevention programs to counteract overweight and obesity in children and adolescents. Evaluated and publicized prevention programs do show positive effects on nutrition-related outcomes and activity levels while show- ing almost no effects on anthropometric measures. There are few positive results that do not proof consistent. When it comes to preventing overweight and obesity, espe- cially the first years of life prove to play a vital role. Major risk factors are being mold- ed during these early years and many of them can only be averted during this phase of life. Methods: The analyzed data was collected from 10 outpatient prevention and inter- vention programs led by German Sport University of Cologne, and two more data collections. All in all there were about 13.000 data sets. Besides the factors influenc- ing the BMI (BMI-SDS) they tested those influencing cross-sectional and longitudinal motor skills. Results: Determinants already described in literature, such as migrant background and weight of the parents (particularly that of the mother), highlighted a clear influ- 433 ence on the status of the BMI/BMI-SDS. The influence of SES, the amount of media use and physical activity was rather heterogeneous, however, literature available for the latter two reflects a high divergence. Usually, methodical definitions are found to interpret these divergences. Weight had the biggest influence on motor ability (the latter is seen a marker of fitness). This shows how the determinants influence each other while making it more difficult to clearly assign cause and effect. The data showed that overweight or even obesity during preschool age does not influence mo- tor ability to a large extent - with increasing age, however, this influence intensifies, depicting a so-called scissor effect. According to the data analysis of the Cologne programs in the intervention groups (Ball & Birne, Kita fit and KiMo), preschool children were able to maintain their weight while that of children in control groups increased significantly. The interventions for children in primary school (CHILT I, Gesundheit macht Schule, StEP TWO, FOG) showed a significantly lower weight increase in percentage than in those of the con- trol groups. This has to be emphasized particularly because literature shows almost no information about interventions with (positive) influence on anthropometric data. During the evaluation period, development of motor ability correlated notably with weight, which means the more overweight the children, the worse proved their motor development during the time of the study. All children were able to improve their mo- tor skills, however, in most intervention groups they showed significantly better re- sults. Particularly overweight and obese children benefitted more than the younger children. Thus, children participating in the kindergarten programs were able to adjust their motor deficits within a short time span. Even obese children who initially showed slightly worse results than their normal-weight counterparts managed almost to catch up and achieve similar results during this half year long intervention. The older the children, the more difficult it proved for them to adjust to the motor deficits they had in comparison to their normal-weight counterparts. The already existing scissor effect increased disproportionately during the course of the study. Discussion: The positive effect of physical activity was clearly showcased by eval- uation of the programs of German Sport University of Cologne. Through this, signifi- cant evidence for forming prevention programs is gained: Lack of exercise is one of the main reasons for childhood/adolescent overweight and obesity and leads to mo- tor deficits. Resulting from these two conditions, lack of exercise increases and leads 434 to a vicious circle which is to be prevented or broken as early as possible. Results of children in preschool age are proof that early intervention is worth the effort. In order for prevention to be effective enough before the onset of overweight, it is also vital to focus on the living environment of the children. First and foremost, the parents have to become aware of their responsibility, for instance due to an epigenet- ic imprint and their influence as role models. On the one hand, it is possible to achieve weight reduction in women before motherhood during times of family plan- ning when the issue is addressed by a primary care physician or a gynecologist. On the other hand, it is important to consider a multi-modal approach and involve the parents in the programs. Families with migration backgrounds should be addressed in a way that is considering their culture so it makes it easier for them to access pre- ventive measures. The lifestyle of the children is being shaped early on. Therefore, prevention is an ob- ligations as well as an opportunity. If elements like healthy nutrition and physical ac- tivity or reduction of sitting time are being implemented in the lives of children at an early age, there is a big chance of them maintaining this behavior. Universal preven- tion measures like the ones examined by the Cologne programs would work well. They took place in preschool (not later than primary school) because irrespective of the childrens’ social backgrounds they can be addressed early. Physical activity proved to be a successful component, because the instructions were purposefully directed by exercise instructors. The instructors were able to make the children feel successful about their motor skills which translated into fun - a vital component for sustainability. In comparison, a simple increase of physical activity of one hour per week was not successful. The goal must be to increase physical activity of children and adolescents on a daily basis. Increasing instructed movement units, for instance in preschool during sports class, would be a solution. There should also be the goal of greater activity during everyday life. Sports club memberships had, according to the studies, an additional positive effect on the weight of the children. A co-operation between preschools and schools with sports clubs is therefore recommended. Since a modified living environment favors developing overweight and obesity, it is also necessary to take social and structural prevention measures. This implies that national, state and local levels of government have to be held accountable. 435 Limitations: Development of childhood obesity is complex and many (important) determinants could not be incorporated into the analyses, because they were not collected in all programs in the same way (for example nutrition, body fat index) or the results were presented in different formats (for example intensity of exercise ac- tivity). To encompass the complexity and especially the interaction between the de- terminants within a context is still difficult and will remain one of biggest challenges in future research endeavors. Conclusion: Despite many conducted prevention programs, quality evaluations and conclusive studies are still non existent. The reason for insufficient study data (be- sides missing standards) is also found in the complexity and interaction of the deter- minants that cause and facilitate overweight and obesity. Besides, it has to be brought into question if the reduction of BMI/BMI-SDS is indeed the correct outcome parameter for measuring success of future prevention programs. Possibly, body composition assessment (BFP) should rather be more in focus. The benefit of pre- vention per se is undeniable and present data show remarkable success, particularly when children are being led purposefully to physical exercise at an early age. With every year passing without prevention measures, the chance of becoming older in a healthy way decreases for the children at risk. The studies are particularly impressive in demonstrating that once overweight or obesity has developed, it is almost impos- sible for older children or adolescents to achieve a stable, normal weight.