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Introduction to summaries of chapters and other contents sub headings: Chapter one: This chapter discuss the main background of the study also summaries the reasons why obesity is a problem to children especially from Asian countries communities living in UK. It summaries the main rationale of the study and establish a base for the purpose of improving the nutritional stature of children and physical activities in promoting their life expectancy.

Chapter Two: This chapter explores the main themes of the study and provides literatures regarding previous studies that explain and answered the research question regarding childhood obesity and its management. It also looks at certain studies that involved management of the problem inform of comparison and look at some other studies in certain countries of the world. Chapter Three: This chapter explores the main inclusion and exclusion criteria for the study and explain the search strategies employed for the identification of the articles relevant to the population of interest and main method for collection of data synthesis. Chapter Four: These chapter summaries the main articles used for the review as contain in chapter three of the study fig 1, and identified all the dependent and independent variables of the study. It also shows the themes of the study and explains how they were related to the systematic review for the study. Chapter Five: The findings of the studies were discussed in this chapter; it as well identifies the limitation bias and examines the ethical considerations with over roll quality assessment of the study. The chapter makes possible conclusions and recommendations for the purpose of improving the well being of the public and implementation by the health care providers. Similarly, ways by which results of the dissertation will be disseminated are as well suggested and a brief reflection about current practices and any indication of what is new, from the authors point of view. CHAPTER ONE: 1.1 INTRODUCTION: According to the British Medical Association (BMA 2005) , there were approximately 1 million obese children under the age of 16 in the United Kingdom (UK) in 2005. However, estimates of the incidence of childhood obesity within the UK vary for a variety of reasons. (Hillier, Pedula et al. 2007) noted that it may be underestimated and under-reported due to the unwillingness of children and possibly their parents to participate in measuring their weight. As well as this, there are different ways of defining childhood obesity: Obesity is not easy to define in children due to variations in the ratio between weight gain and height gain during normal childhood growth. The best way to define Childhood obesity and overweight is by considering the body mass index of the affected child. When the body mass index (BMI) is above a normal weight as described by the Centre for Disease Control and Prevention, the individual is said to be overweight and have a greater tendency of becoming obese (Etelson, Brand et al. 2003). Similarly, another factor that defines obese and overweight is the differences in body fat between boys and girls and differences in body fats according to ages ranges among boys and girls. Childhood obesity and overweight are defined using (BMI) by calculating the weight and height of the child since BMI do not measure body fat directly, it only gives a reasonable indication of body fatness in some children and teens (Prevention 2011). Weight statuses of a child are determined by age and sex of the child at a specific percentile of BMI as described by the CDC growth chart (Index 2009).Therefore a child can be described as an overweight when BMI are at or above the 85th percentile and lower than the 95th

percentile specific to children of the same age and gender (Barlow, Bobra et al. 2007). Similarly, an obese child is one that attains BMI at 95th percentile for children of the same age and gender (Barlow, 2007). Obesity can be also be defined as a condition where an individuals body fat stores are enlarged to an extent that impairs health (Garrow&Summerbell, 2000). John Mclennan argues that the there is more than 85th percentile of children who are overweight and abut more than 95th percentile are obese. There are many reasons of child obesity and it occurs in almost every country. And it directly affects the bones and is the cause of many heart diseases. The most important is the asthma attacks which are caused in the over weighted children (Hughes anr Railly 2008). One of the major issue behind this is that parents are too much ignorant about their children health issues. Regular checkups are not conducted properly and they give less importance to the regularly checking of the childs weight. Obesity is usually measured by the Body Mass Index (BMI). It is the ratio of weight and height. Weight (kg)/height (2/m). When BMI becomes higher than the normal average rate then we say that child is overweight and can become obese. Arch Pediatr Adolesc Med (1996) says that watching television and the advancement in the technology is the main reason of child obesity. Computers, play stations, video games and such indoor games has increased the positive impact on the relationship of obesity and technology. Moller and Berger (2003) says that obesity is easily handled by some proper measures and care especially by parents, the regularity of physical exercise, maintaining proper and healthy eating habits as the obesity after effects are so much dangerous.( Reilly Armstrong et al.2005)

Rony Caryn Robin (Feb 2010) says that child obesity is the reason of early deaths even below the age of 55 in adults because of the diseases like high blood pressure and diabetes in children. In U.S.A, the

campaign is started in order to vanish the factor of obesity among the children thus creating the better new generation as the disease is causing everyone to disqualify from the armed forces, nonetheless these extra healthy children will be considered as the dead soldiers of the U.S army. The important reason behind this is the use of artificial preservatives and colors in the food. This is the case of those families who have the finances from the ownership, not from the wages. This occurs in case of highly developed countries but the same problem also arises in developed as well as the under developed countries. And the reason here is the poverty and also the illiteracy. The poverty of opportunities is analyzed primarily in relation to access to corresponding inputs such as health care, sanitation facilities and starvation issues. Amartya Sen has explained the many dimension of poverty as the lack of capability the capability to overcome violence, starvation, ignorance, diseases, disparity and voicelesness.

1.2 BACKGROUND: The concept of childhood obesity involved environment, agents and host, as well as the interactions that exist between those factors, this help in understanding the epidemic of the diseases (Guillermo & Melendez, 2011).In the popular media both in the UK and worldwide, a variety of claims about the causes of childhood obesity can be found, for example blaming childhood obesity on parents neglect (Martin, 2008 #508), lack of childrens exercise (Hawkes, 2007 #507), and ineffective Government intervention (Rogers, #510). Many of these claims appear to be emotive and simplistic, however, and careful scrutiny is required to assess the validity of these. A broader search is therefore required in order to gain a more balanced and evidence-based perspective on the causes of childhood obesity. Whiting (2008) provides a useful summary of the causes of childhood obesity, suggesting that the majority of children who become obese do so as a result of an inappropriate diet and a lack of physical exercise. Interestingly, Lempert (Lempert, 2002 #509) suggests that marketing by food companies may be a factor in causing the rise of childhood obesity. It should be noted that although he is writing from a US perspective, his comments may nevertheless be relevant in the UK. Why is childhood obesity and overweight a problem in UK? In UK Almost 67% of the populations are overweight or obese, so there is a dire need to look into the matter on how to combat the problem among children for sustainable life (Edmunds, 2001 #511).The scale of the epidemic, outlined in a health select committee report last month, may have come as a shock to many, but for pediatrics physiotherapists all around the UK, the gloomy picture it paints is all too familiar (Allison et al., 2008).

According to the final report of the committee, the number of obese people in England has multiplied for about 400 times when compared to the last 25 years. Currently about 3.7 billion pounds are spent yearly for obesity only and about 3.8 billon for overweight yearly. This amount to 7.4 billion pounds spent for both obesity and overweight. It seriously affects the economy of England greatly (Martel, 2011). The rising figure of obesity among the young is of more particular concern, with the committees report citing the case of a three-year-old girl who died at a London hospital of heart failure. Extreme obesity, exacerbated by a genetic defect, has been cited as a contributory factor for the girl (Edmunds, 2001 #511). In order to look in to the problem of childhood obesity and overweight among UK communities, an investigatory advisory committee was set up recently in order to bring necessary advice on how to tackle the problem through collaborative effort of health professionals, educational sectors and to work together for the alarming rise in the number of overweight and obese children (Edmunds, 2001 #511). The problem of obesity has been shown to be due to lack of proper monitoring of the affected child when start to manifest the sign of overweight. This problem equally lies in hands of the parents due to lack of necessary monitoring which resulted into overweight and obese children and could have been avoided if tackled at the early age (Gortmaker, 1993 #512).If this problem is not checked, there is greater tendency to have more blind people, people demanding for amputation and more demand of kidney dialysis (Edmunds, 2001 #511).Likewise, the life expectancy of children will also drop drastically. Similarly, if the trend continues; obesity may surpass smoking as the greatest cause of premature death. It is therefore very necessary to look in to new initiatives for the government to convert the deadly diseases (Gortmaker, 1993 #512).

1.3 Rationale of the study: There has been an increasing prevalence of overweight and obesity among children and adolescents in the European Union (EU) for the last 20 years (James, 2001 #513).According to health survey an estimated number of cases regarding childhood obesity and overweight just within the UK aloneis around three in ten boys and girls aged 2 to 15 and were classed as either overweight or obese 31% and 29% respectively, which is very similar to the HSE 2007 findings 31% for both boys and girls. The NHS Information Centre, Lifestyles Statistics in 2010 (Ogden, #514).More recent 10 years records indicate that about 18% of European school children are overweight, with an annual rise to about 2% yearly (Lobstein, 2004 #486). Similarly, among the overweight children, more than 2.99 million are estimated to be obese with an increase of 85000 cases yearly (Cole, 2007 #515). The associated risk factors of overweight and obese children are fatty liver disease, type 2 diabetes and endocrine and orthopaedic disorders (Lobstein, 2004 #486). Overweight children may enters adulthood with a raised risk of cardiovascular diseases, adult obesity, and a range of other disorders including psychiatric problems (Ells, 2005 #516) with an increased rate of mortality among those adults that were obese during their adolescent years (Must, 1999 #517). The evidence base for effective prevention of child obesity is Poor as reported by several studies (Campbell, 2002 #496).

1.4.1 AIMs:

This systematic review will gather the current evidence base outlining the interventions to manage and prevent the further progression of diseases that may arise as a result of childhood obesity and overweight problems in adulthood.

1.4.2 Objectives: To collect the evidence based data in order to find out the most suitable approach that can be employed in the prevention and management of childhood obesity and overweight. To synthesize the recommendations proposed by selected studies to help policy makers and health professionals on how to control the risk factors of childhood obesity and overweight. To develop recommendations with reference to the selected studies as outlined that will assist parents about the possible relationship that exists between childhood obesity and overweight.

Review Questions This review aimed to address the following research questions: What role do physical activities and diet play in prevention and control of obesity and overweight among children? Is there any relationship between childhood obesity and overweight regarding dietary behaviour?

Chapter: Two (Literature Review): 2.1 REVIEW OF LITERATURE METHODOLOGY 2.1.1 METHODOLOGY: Literature review has been defined as a process of gathering information, documenting, evaluating, and presenting the information in a systematic manner for the purpose of exploring relevance work done in a specific field of interest. It is a research article that identifies relevant studies, appraises their quality and summarizes their result using a scientific methodology (Modell, 2008 #518).It gives the supervisor an idea on the knowledge of the students towards the research field of interest. This will enable the supervisor to be able to critically analyze and interprets the students performance in a piece of research. Therefore, literature review allows a researcher to critically evaluate previous research and summarised the findings, evaluate and present it in a simple and direct form. This will enable anyone else reading the paper is able to acknowledge and establish the possible reasons of pursuing the particular research. In general, good literature review should be able to expand upon the reasons behind selecting a particular research question (Shuttle& Worth, 2009). For the purpose of evaluating the different interventional approach employed for controlling and managing childhood obesity and overweight among UK communities, difference preventive and control approaches will be systematically reviewed. Different data base source will be used in searching for relevance information related to childhood obesity and overweight, this will include PUB MED, Med Line, Cochran library, yahoo search engine, and CINAL will be used. Similarly, printed copies of articles from journals, online journals, relevance interventional programmes regarding obesity and overweight for schools children will be obtain, government documents and policies regarding management and prevention of childhood obesity and overweight were accessed, other documents regarding feeding behaviour were accessed, publications from printed journals were used. Other means are through nongovernmental organisations reports such as WHO, UNICEP, AVERT, and many other control programmes targeting childhood obesity and overweight were used. Term used in accessing the articles in the search engine are: childhood obesity management, overweight and obesity, prevention of obesity in children, relationship between childhood obesity and overweight, long term effect of obesity, complication of obesity in children, risk of overweight and obesity, factors responsible for childhood obesity and many others. The research is mainly focused on the prevention and management of childhood obesity and overweight with particular reference to UK.

2.2 Justification of the research Obesity has been reported to rise at an alarming rate. Already, about one-third of children with two thirds of adults in England are overweight or obese. If trends continue as forecast, by 2050 only one out of ten adults will be a healthy weight. In response to the rising reported cases of obesity, the Government has set out strategies aimed at reducing the level of obesity among children and all individuals and maintain be able to maintain healthy weight. The focus was aimed at children at age of 11 in which the Governments target at reducing the percentage of obese children to about 2000 levels within the period of 2020. There is a unique opportunity to influence the lifestyles of these children and the environment in which they are raised from birth. Healthy Lives, Healthy Weight: A CrossGovernment Strategy for England has been announced targeted at reducing the level of obesity among children and adolescent and budgeted about 372 million for a major programme of measures, including increased funding for pregnancy and early years, promoting a culture of healthy eating in

schools, the development of Healthy Towns and building more cycle lanes and safe places to play. Healthy Weight, Healthy Lives similarly announced 75 million for a three-year social marketing campaign. The focus of the campaign was on prevention and it sets out to change the behaviours and circumstances that lead to weight gain, rather than being a weight-loss programme for the already obese. At the same time, it will of course influence the behaviours of todays children, leading to a gradual decrease in the prevalence of obesity among the children and adolescent. It is therefore very important to look at the best strategic way at which health in equalities are overcome among different population for the purpose of maintaining good being of children and avoiding adult obese from childhood. 2.2. Literature review: Aetiology: Obesity results from an increase in number or size of adipocyte cells. This is caused by a positive energy balance, i.e. more energy is ingested than is used by the body. Obesity causes can be split into primary or secondary causes. Primary obesity has no underlying medical condition associated with it and is caused by an interplay of genetic and environmental factors. Secondary obesity is rare and is associated with a number of syndromes and endocrine disorders (Chu, 2007 #522). Prevalence: According to a study the level of obesity is continuously rising within the United Kingdom. The prevalence has increased from 6% within male and 8% in females during the year 1980 as reported by (Lustig, 2003 #523) to 23.6% in male and 23.8% in females in 2004 in Health Survey for England (Sproston, 2006 #524). Similarly, between 1995 and 2003 obesity prevalence among children aged 2 to 10 years old increased from 9.9% to 13.7% (Webber, #525). Previous data documented during the period of 1997 and 2003 in UK regarding childhood obesity and overweight revealed that, children from low economic background shows higher prevalence increase risk of obesity compared to these children from higher income background (Stamatakis, 2005 #526). However it is documented that in most of the European countries like Scandinavia parts, the prevalence of childhood obesity is low compared to Mediterranean parts where the prevalence of childhood obesity is high, all alone; childhood obesity is continually rising (Livingstone, 2001 #527). Similarly, in all Eastern, Central and Middle East of Europe, childhood obesity prevalence is high (James, 2004 #528). Furthermore, proportion of overweight children shows a higher percentage of girls than boys in both developed and developing countries especially among adolescent (Dehghan, 2005 #529). 1.2.1 Epidemiology of childhood obesity and overweight worldwide trends: The recognition of the obesity epidemic took some time before the world perceives it as a global health concern. Only during 1997 when WHO recognized that, obesity was a major public health problem worldwide (James, 2004 #505).A study documented school age children trends towards obesity in some 60 countries around the world using IOTF criteria, the result shows that prevalence of childhood overweight had increased in almost all countries for which data was available, with only exception from countries like Poland and Russia within 1990s (Lobstein, 2004 #486). Similarly, there has been an increase in overweight and obesity among more economically developed countries and in urbanized locations (Lobstein, 2004 #486). The prevalence has shown to be more in countries like North America, Europe, and Western Pacific (approximately 20-30%). Similarly, South and Central America, Northern Africa and Middle Eastern countries fell in between and South East Asia and much of sub-Saharan Africa appeared to have the lowest prevalence (Lobstein, 2004 #486).

1.2.2 Consequences of childhood obesity: From the report on National Centre for Health Statistics, about 35% of children and adolescents in US were obese or overweight just within 2004 (Ogden, 2006 #514). As a result of this compounding issue, it was reported that physical activity trends have shown that adolescents and children are less fit, less active and less healthy when compared with the previous passed generations (DH, 2009 #487). Due to the combinations of factors like body mass increase and decrease in physical activity, it was suggested that imbalance in energy may be the central determinant of obesity epidemic affecting the youth of developed countries (Llorens-Martin, 2008 #530). Other associated issues related to imbalance include; colon cancer, metabolic syndrome and type 2 diabetes (Rosenstock, 2005 #531). Similarly, more recent data suggested that certain mental health issues may be related to poor health status of the children (Ludwig, 2007 #532). Childhood obesity and overweight are also associated with certain co-morbidities, including cardiovascular disease (CVD), type 2 diabetes and other cancers types (NHS, 2010). Thus the rising prevalence of childhood obesity has become a major global public health concern in both developed and developing countries. About 30% of coronary heart disease (CHD) and ischemic stroke with almost 60% of hypertensive disease in developed countries attributable to excess body mass index (Ogden, 2006 #514). It was reported that about 32% of children and adolescents in the United States are above the percentile of 85th percentile of BMI as represented in the body mass index growth chart ((Hedley, 2004 #533) and (Ogden, 2006 #514). Additionally, in the UK, records of 2004 indicate about 29% of childhood obesity within children of age 5-17 years old according to British Health Foundation in 2008 (Whitaker, 1997 #534). Excess adiposity has been reported to transfer from childhood into adult life with the risk of developing obesity at adult age (Singh, 2008 #535). This relationship has been shown to be complex however, with the likelihood of obesity persistence related to gender, the severity of obesity and the age at which it is first present. There has been much assumption that childhood obesity is a major risk factor for cardiovascular diseases during adulthood (James, 2004 #505). Moreover, some studies have presented a positive relationship between childhood obesity and cardiovascular diseases risk factors during adult life (Freedman et al., 2004) there is still argument whether childhood obesity exerts an independent effect on adult cardiovascular health. Similarly, there has been much evidence to suggest that childhood obesity is a moderate risk factor for adult obesity, but association that exists between cardiovascular disease risks at later adult stage is still unclear (Chu, 2007 #536). Last but not the least, the childhood obesity has both physical and psychological health impacts. It is associated with hypertension, infertility, hyperlipidaemia and abnormal glucose tolerance. They carry a greater risk ofhavingdigestiveand cardiovascular diseases and are more likely to die at early age (Daniels, 2008 #537). What are the health consequences of childhood obesity tracking into adulthood? For the past few years there has been an increasing prevalence of childhood obesity affecting both developed and the developing countries of the world (Lobstein, 2004 #486). Certain health risks factors such as asthmas, type 2 diabetes and other related health illnesses has been linked to excess adiposity during young age and may continue to persist up to adulthood (Stamatakis, 2005 #538). Similarly, an increase in middle-age mortality and morbidity irrespective of adult weight status and socioeconomic background are linked to adiposity but it varies with gender, population, ethnic origin and age (Engelandet al., 2003; Wang & Zhang, 2006; Shrewsbury & Wardle, 2008).

The common well established risk factors for childhood obesity into adulthood are heart and circulatory diseases, raised blood pressure, cholesterol levels increase in insulin resistance (also known as collectively metabolic syndrome). More recent studies conducted in US suggested that nearly 35% of overweight and obese adolescents show an evidence of metabolic syndrome, this has greatly increases the risk of diabetes, heart disease, stroke and other forms of cancers during adulthood (Must, 1992 #539). Another serious condition is type2 diabetes among children and this condition is associated with middle aged obese adults, and it gives a strong association between diabetes and kidney failure, retina damage which can lead to blindness, cardiovascular diseases and limb amputation (Must, 1992 #539). The population of diabetic patients in the UK currently is amounting 2.4 million and is expected to double within the next 10 to 15 years and majority of the newly diagnosed cases will occur in children (NHS, 2011). In a study involving 730 children conducted at Otago, New Zealand which was aimed at assessing the effectiveness of programmes as an intervention in preventing excessive weight gain among children for reducing childhood obesity and overweight. The study was a two years community based obesity prevention programmes for healthy lifestyle and exercise and a non-randomized design. The participants were 5 to 12 years old children through encouraging opportunities on healthy and noncircular activity. Four intervention and three control schools were exposed to the measurements of their heights, waist circumference, weight, diet, physical activity and blood pressure within 1 to 2 years. Interventions used were nutritional education that alters their consumption of sweetened drinks, and improving their fruit and vegetable intake and introducing a community activity that promote walking as physical activity. The result of the study indicates that BMI value was significantly lowered among the intervention group than in the control group with a mean of 0.09 (95% confidence interval: 0.01, 0.18) after the first year and 0.26 at (95% confidence interval: 0.21, 0.32) at the second year, but prevalent of overweight shows no difference. There was low significance in the Waist circumference at 2 year (1 cm), and significance reduction in systolic blood pressure to about (2.9 mm Hg) at 1 year. This shows an interaction between intervention group and the overweight status at (p_0.029), with mean BMI Z score reducing to (_0.29; 95% confidence interval; _0.38, _0.21) at normal weight, but did not observed in overweight (_0.02; 95% confidence interval _0.16, 0.12) as intervention children relative to controls. Similarly it was observed that consumption of carbonated beverages was very low in intervention children with (67% control intake; P_0.04) and in the fruit and juice drinks (70% P_0.03) and more fruit (0.8 servings/3 d; P_0.01). The study conclusively suggested that provision of basic nutritional education and coordinating physical activity in schools significantly reduces the rate of (Savoye, 2007 #540). But the researcher suggested for more new studies in order to bring new approaches in this field. In another study conducted at South West of England involving schools children aimed at assessing the long term effects of an obesity prevention programme targeted at school children within the age range of 7 to 11 years. Total samples participants was 644 children out of which 511 children were tracked. A total of 434 children were measured after three years baseline. Over one year, the intervention was conducted among the children focusing on four sessions regarding health education in promoting healthy diet and discouraging the consumption of carbonated drinks. The outcome was measured using the Anthropometric measures of weight, waist circumference and height. Conversion of BMI body mass index to z scores at (SD scores) Standard Deviation and centile values and growth reference curve. Similarly, Waist circumference was converted to Standard Deviation values scores z (SD score). The results after three years baseline with respect to age and sex specific Body Mass Index z scores Standard Deviation shows an increase in the control group with 0.10 (Standard Deviation 0.53) but decreases with _0.01(Standard Deviation 0.58) in the control group at a mean difference of 0.01 (95% CI -0.00 to

0.21, P=0.06). During the three years period there was an increase in overweight in both control and the intervention group. Similarly, there was significance difference among those seen at 12 months which shows that it is no longer evident. Body Mass Index also increases in the control group with 2.14 (Standard Deviation 1.64) and in the intervention group by 1.88 (Standard Deviation 1.71), and the mean difference of 0.26 (-0.07 to 0.58, P= 0.12). After three years, the waist circumference increases in both control and intervention groups with 0.09 mean difference (-0.06 to 0.26, P=0.25). In conclusion these longitudinal results show that after a simple yearlong intervention the difference in prevalence of overweight in children seen at 12 months was not sustained at three years. This shows that success of a school based intervention was not maintained two years after the end of the first year project. Finally the study suggested that, for any school based intervention programme to be successful evaluated the intervention in question should be continuous for the period of the programme (Janet et al., 2007). In another study conducted aimed at examining the effects of multi component school policy on nutrition for the prevention of overweight (85.0th percentile to 94.9th percentile) and obesity (95.0th percentile) among school children using nutritional policy initiatives among children in grades 4 to 6 over a 2 years period. The study involved 1349 schools children in grades 4 through 6 within 10 schools in the US at the Mid-Atlantic region. Schools were marched considering the size of each school and type of food to be given. Randomized control design was used for the study in which both the intervention and the control group were assigned randomly. Students were assessed at baseline for the first and after 2 years. The policy used during the study includes school self-assessment, nutrition education, social marketing and parent outreach and nutrition policy. At the end of the study incidence of obesity and overweight after 2 years of the intervention were primary outcomes. While remission of obesity and overweight prevalence on the Body Mass Index z score, fruit and vegetable intake, body dissatisfaction, hours of activity and inactivity and total energy and fat intake were all secondary outcomes of the study. At the end, about 50% reductions were recorded in the incidence of overweight. Similarly, fewer children shows significance within the intervention schools (7.5%) when compared with the control schools with (14.9%) that became overweight after the 2 years. Prevalence of overweight was found to be low in the intervention schools and no difference was observed in the prevalence or incidence of obesity in the remission of obesity or overweight during the 2 years period. In conclusion, the study suggested that promoting multi component intervention programme involving school children can be very effective in the prevention of overweight development among school children in grades 4 through 6 within urban public schools at a high proportion of children eligible for free and reduced price school meals (Gary et al., 2007). In a study conducted to determine whether paediatricians and dieticians can have influence in implementing an office based obesity prevention programme by the use of motivational interview as primary interventions. A non-randomized clinical trial were used during the study, a total of 15 paediatric research in office settings were involved, 5 registered dieticians were assigned to one of the 3 groups as follows: 1.minimal intervention group (paediatrician); or 2.intensive intervention (both paediatrician and dietician); 3. Control group. Primary care paediatric office was used as the setting. A total of ninety-one children Participated that met the criteria for eligibility for being within the age of 3 to 7 years and attain a body mass index at 85th percentile or greater but lower than 95th percentile for the age or having a normal weight and parents with BMI of 30 or greater. Training was given to both paediatrician and registered dieticians among the intervention group as a motivational interviewing training. In the minimal intervention group parents of children received one motivational interviewing session from the physician and among intensive intervention group parents of children received two motivational interview sessions both paediatrician and the registered dietician. The major outcomes

measures used were change in BMI for age percentile. At the end of the project during the 6 month period of follow up, a decrease BMI percentile in the control group was observed at 0.6, 1.9 and 2.6. The main difference of BMI percentile changes among the 3 groups were non- significant (P=85). Participants dropout rates were 2 representing 10%, 13representing 32% and 15 representing 50% among the control, minimal and intensive groups. Similarly 95% of the parents 15 give good recommendations for being helped by the intervention on how to think of changing their eating behaviours within the family. On the basis of the study it was suggested that in preventing childhood obesity motivational interviewing by paediatrician and dietician should be encouraged as an officebased preventive measures against childhood obesity management. But there in need for additional studies to be conducted, in order to demonstrate the efficacy of such interventions in larger settings (Rogers, #510). Grouping of the studies: The following main themes emerged on searching relevant literature and this formed the criteria method for grouping the studies. Studies were classified according to their relevance to the aim and objectives of the review in terms of overweight and obesity among children and adolescents. The author performed a full critical appraisal using a systematic framework (appendix 1) and screened relevant the titles and abstracts, examined full text of relevant documents and eventually identified 10 relevant studies that met the inclusion criteria. 1. Physical activity 2. Nutrition and Diet 3. Combined approaches 4. Behavourial strategies Out 10 total studies, 6 were the intervention studies .Two of them utilized combined physical activity and dietary programs, two studies exclusively utilized educational models and behaviour modification strategies, while the other two studies utilized programs based on government policies based on diet and physical activity. In addition, 3 were systematic review studies. One of the systematic reviewsinclude 11 studies which focused on physical activity for the prevention of obesity in children. Other focused on all approaches to childhood obesity prevention .It include total of 22 studies and writer split the results into long and short-term outcomes and again into dietary interventions, physical activity interventions, and combined approaches.The other literature review include 51 studies and 16 studies exclusively utilized educational models and behaviour modification strategies, and 20 studies utilized both. In addition, 31 studies utilized exclusively quantitative variables like body mass indices and waist-to-hip ratios to measure the efficacy of the intervention programs, and another 20 studies utilized a combination of quantitative and qualitative measures that included self-reported physical activity and attitude toward physical activity and the tested knowledge of nutrition, cardiovascular health, and physical fitness.

CHAPTER 3 This chapter covered the research designs, approaches and went on to describe the techniques undertaken in the data collection and data analysis. The methodological frameworks applied in this study were described in this section. 3.1 METHODS OF REVIEW 3.1.1 Study design A systematic review has been conducted to examine published literature to identify the prevention of childhood overweight and obesity in UK.This method is turning out to be a progressively widespread and recognized research method in public health (Petticrew 2003).It is now broadly contemplated to be a very good method of constructing research evidence manageable to use(Bambra 2009). The UK government has emphasized the significance of systematic review in offering vigorous and trustworthy evidence on the efficacy of interventions (Wanless, 2004). Likewise, the approach helps as a main factor in the designing of binding recommendations build by the National Institute for Health and clinical Excellence (NICE 2009) for the National Health Service. Systematic reviews are carried out by putting together the finest existing research on particular question by integrating findings of numerous studies following an precise and explicit framework to ascertain reliability in scientific results and their generalizability among all populations (Higgins and Green 2008). The benefit of employing a systematic literature review is that it permits the practice of explicit approaches to assess and evaluate studies to check bias and thus anticipated to develop trustworthiness and precision of conclusions (Parahoo 2006) where studies with unreliable results can be recognized to create new hypothesis regarding specific subgroups (Bambra,2009). Nonetheless, it should be documented that it is not likely to respond all clinically related questions using systematic reviews with trouble to assimilate recognized research conclusions in practice (Campbell collaboration Library, 2008). There is also substantial risk if organization of data is haphazard and this can lead into misrepresenting and all the more harmful results. To check for this possible bias, all involved participants must be recommended and offered appropriate training in order to implement effective and valuable systematic reviews which can apply conclusions in practice. 3.2.0 Types of studies The author begin with detecting research papers those relating to children from age group5 to 14 years to examine factors related with childhood obesity. Maximum outcomes emerged were showing a substantial sum of valuable studies carried out in other countries such as the USA, Germany, Ireland and the Scandinavian. This could possibly be for the reason that not enough has been worked out on the subject due to dearth of data to manifest exact prevalence of the dilemma. Thus, in order to provide a global and comprehensive viewpoint of an area, these studies were judged to be suitable and hence incorporated in the research if they meet the inclusion and exclusion criteria. In order to alleviate bias on generalisability, a rigorous and explicit inclusion and exclusion criteria have been applied to confirm standard method for the studies to enhance the external reliability. The review engaged systematic, qualitative and qualitative studies regarding to intervention strategies being employed for the prevention of childhood obesity. The benefit of making use of mixed methods in a research is that it leads to the extraction of diverse nature of data. There are apprehensions from researchers on possible danger of dispute due to philosophical incongruence between qualitative and quantitative approaches. Regardless of this limitation, this approach is believed as a beneficial suitable mode to augment the types of information and knowledge acquired from participants to generate a complete holistic picture. (Gerrish and Lacey 2010). All research studies were in English language and this might be due to a

possible language and country bias linked to a greater amount of English language literature accessible in the d 3.2.2 Types of participants The participants in chosen studies comprised ofchildren from the age range from 5 t0 14 years to allow children in initialphases of adolescence. They were mostly employed through community set ups likeschools. Other than childrenthe participants included mothers, fathers and some grandparents and health staff with the majority of participants being mothers, which reflects the position of women as primary child-carerin most societies (Table 2).Study participants came from a range of socioeconomic backgrounds. The selection of participants was not limited on race, ethnicity, setting. A precise and accurate sample strategy in a study is vital and essential section for analysis and interpretation of material. Absence of transparency in selection processes could result possibly jeopardize the representativeness of the sample. 3.3.0 Types of outcome measures The main outcome measure in this review is to establish the evidence base for successful interventions regarding prevention of child hood obesity. There are a wide range of factors that may contribute to the reasons why children are gaining weight leading to obesity. This study considered factors if they were relating to nutrition, physical activity, family dynamics, social or cultural factors and demographic background. These included any preventive outcomes as well as any possible adverse effects and any rectifications where applicable. 3.3.1 Inclusion criteria: Based on the literature review, childhood obesity is a topic of importance but carry a very wide scope. To have focus on the primary trigger factors and prevention of childhood obesity, this review will accept research that include the interventions related to physical activity and dietary patterns to overcome problem of obesity and overweight among children. However, in order not to omit relevant evidence, some studies related to other contributing factors are also included such as educational and behavioral interventions .In addition systematic reviews are also selected as involving these reviews have a great advantage of exploring relevant studies which are primarily aimed at improving the quality of control measures and moreover it is an outcome of several primary studies with different inclusion and exclusion criteria. The studies which were included in the review should be published in between 2002 and 2011 to avail the most recent literature in the study. The age limit for children in studies participants in the study is 5-14yrs old as indicated earlier. Most studies used population samples which may or may not have included overweight or obese children. This review focuses on childhood obesity and how it relates different practices and factors and how they can be avoided. Although many studies have linked childhood obesity PA or eating disorders, this review will also include studies that contain other information and knowledge. In my view, the relationship between childhood obesity and different contributing factors, demands more rigorous investigations to explore than this review would acknowledge. 3.3.2 Exclusion criteria Studies mainly focused on obesity related to adults Studies with no clear aim and objectives about childhood obesity

Studies outside the western countries Letters, editorials, news, Language other than English Studies which include research on childhood obesity associated with some diseases

3.4.0 SEARCH METHODS FOR IDENTIFICATION OF STUDIES Searches were performed and accomplished using different standard databases including Cochrane library, MEDLINE, CINAHL, EMBASE, PSYCH-INFO Campbell collaboration library. Studies published from 1990 to-date were looked at to integrate and bring in useful background information. The search was accomplished using the combination of following keywords obesity* OR obese* OR overweight* OR * OR overweight and obesity* combined with childhood or children or adolescents OR teen* OR * OR youth*. This was then combined with physical activity OR exercise OR dietary behaviour* OR nutrition*OR *. Apart from it subject titles headings and captions were employed from the thesaurus of databases to broaden the search to expand possibility to retract related articles which we were unable to reach at with the keyword search. Internet searches were carried outthrough websites such as goggle scholar, and the grey literature. The search was restricted to English studies and studies involving children of 5 to 14 years to allow inclusion for those in possible adiposity rebound period. 3.4.1 Study selection process: The purpose of selection is to confirm and make sure that all applicable studies are counted in the review by the Centre for Reviews and Dissemination (CRD 2009). The process of selection was comprised of two stages. Initially the titles and abstracts of the studies are examined against the inclusion criteria in order to categorize and distinguish studies that are relevant and research articles which do not match the inclusion criteria were skipped. Following this step author approached a further thorough screening by carrying out a complete critical appraisal using systematic framework and scrutinized a detailed script of detailed and related documents and finally spotted and mainstreamed 10 studies as a final selection for the review. The critical appraisal of studies during selection procedure is to lessen selection biasin a systematic review. The duplicate studies are also checked to avoid replication. They were then sorted out into themes with regard to the aim and objectives of the review in relation to the role of physical activity, dietary patterns and other factors as discussed in chapter two of this review. 3.4.2 Dealing with duplication Identified duplicates of selected publications of research results were equally looked at in order to avoid treating them as separate studies in the review. However, Von Elm et al (2004) highlighted that it was difficult in identifying such replicas especially where they are not cross referenced. Their studies estimated that incidences of replica publications range between 1.4% and 28%, and duplicated articles can be as many as five.

Fig 1.

Process of selection of studies

Initial screening arrived at 1100 studies

240 studies were finalized after abstract screening

115 eliminated on the basis of unrelated aims and objectives

135 Remaining studies were assessed according to the inclusion criteria

60 studies excluded not being research articles

65 studies were thoroughly read for review final selection

Out of them 10 studies were finalized

3.5.0 Data extraction: The process of data extraction comprised of drawing out of information appropriate to study findings and characteristics from selected studies (CRD 2009). The information from each qualified study related to thedescriptions and qualities on interventions related to the childhood obesity were extracted. This extraction of data depends upon study methodology, design, findings and relevant conclusions. The assembled data will be summarized through a narrative synthesis. This type of synthesis is proper and right for this review because included studies will not deliver consistent and uniform quantitative results to carry out a meta-analysis (Hemingway and Brereton 2009). Data extraction forms were employed in order to gather information for integration of evenness and consistency in the research. (Higgins and Green 2008). 3.6.1 Managing lack of information The results from articles where possible could be tested employing a sensitivity analysis. In order to do this we need time and were not been practical in this case. 3.6.2 Data Synthesis Data analysis is a systematic process of bringing together and summarizing of the results of individual studies included in a systematic review to answer a research question or test research hypothesis (Polit and Beck 2010). In quantitative research data is summarized using formal statistical techniques such as meta-analysis, whereas qualitative research tends to involve a less informal process through a narrative approach, where data is analysed so trends and patterns can be detected. There are various approaches to data analysis and this is dependent on the research design and nature of data collected (Gerrish and Lacey 2010). In this study data was analysed through narrative approach. This involved a documentary approach that provides an investigation of the relationships within and between studies and an overall rigor of evidence (CRD, 2009). This approach was considered more appropriate for this review as studies involved in the systematic review were too diverse to combine in a meta-analysis. To overcome potential bias due to the subjective nature of this review, the author ensured strict and transparent process. 3.6.3 Narrative Sysnthesis: Hence as emphasized by CRD (2009), narrative synthesis offers clarity and rigorousness to reduce any possible bias through the following; Elaborates a theory in relation to the interventions work, screening factors that have made them to function and whom they are meant for. Builds initial synthesis explained from articles that have met the inclusion criteria. discovers how the studies can be related to one another and Assesses the strength of the synthesis

3.6.4 Assessment of study quality Quality assessment is a significant segment of the systematic review progression to avoid the chance and possibility of bias in involved studies due to insufficiencies in study design, conduct or analysis (CRD, 2009).These errors and weaknesses in design or conduct of a study can lead to bias, even in some cases can have as much influence on outcome of the study (CRD, 2009; James et al., 2008). The author

evaluated all studies that are according to the inclusion criteria for the selection of primary research to ensure validity and reliability in the study.(Higgins and Green, 2008). The quality appraisal checklists (Appendix 1) were employed for explanatory and descriptive purpose to emphasize and underline variations in the characteristics of studies. Both qualitative and quantitative studies were dealt different criteria. The practice and suggestion of using scales with summary scores in order to differentiate superior and low quality studies is questionable and not recommended (Colle, Rannou et al. 2002).Quality score was not measured and thus reviews were not eliminated and dismissed on their basis of quality (CRD, 2009; Birch et al., 2007).There is no single approach for the calculation of methodological quality which suitable to all systematic reviews. The best approach will be determined by contextual, pragmatic and methodological considerations (Green et al., 2008; CRD, 2009 8).Paratoo (2006) proposes that assessment of every single study should be carried out by more than one evaluator exercising completely the similar standards and measures. It is useful for assessors to be blinded to the identity of the authors of the studies. To alleviate and lessen bias an assessment needs to be evaluated and contemplated by a second person and if there is any inconsistencies should be worked out by consensus and if required should be accessed by another person 3.7.0 Methodological quality It is essential to evaluate the methodological quality of studies in systematic review (CRD 2009). Research may significantly vary according to the methods used; identifying mistakes in research design or conducting a study could be resulted into biased results and possibly have an effect on the findings of the interventions. As documented by CRD (2009) anticipation of strength and weakness of included studies will help to develop suggestion on whether results have been unduly and excessively affected and biased by quality and descriptions of the study design. Successively, gauging value of study will reflect the strength and weakness of evidence of results revealing in the systematic review as well specifying support and guidelines for further research. Finally, quality assessment will channelize and direct to authenticate about selected studies whether they are vigorous enough and can be appliedas a guide for upcoming interventions in prevention, and policy execution.

Chapter: Four 4.0 Review of studies 4.1 Summary of selected studies as shown in fig 1 chapter three above: Introduction: It was suggested by Loke (2004) that provision of relevant information that will be of benefit to interventions for patients are very important on decision making. Prior knowledge of patients for any unpleasant effects that will result in the intervention encouragement is very important and need prompt acknowledgment. In order to acquire good knowledge the systematic review make use of research that demonstrated the benefit of appropriate intervention measures for the treatment and control of childhood obesity and overweight and at the same time recognized other adverse effect of the problems and interventions into childhood obesity. The chapter focused on the specific issues responsible for childhood obesity prevention, control and management (Holcomb, 2009 #506). 4.4. Reviews: STUDY 1: The first study, Preventing obesity by reducing consumption of carbonated drinks: cluster randomized controlled trial (James, 2004 #505) aimed at reducing the consumption of carbonated drinks in 615 children aged 7-11 years old via the delivery of a focused educational programme on nutrition in schools. According to the findings of this study, a targeted, school based education programme produced a modest reduction in the number of carbonated drinks consumed, which was associated with a reduction in the number of overweight and obese children. The researchers carried out a cluster randomized 7-11 years, with the intervention being a focused educational programme on nutrition over one school year. The programme was delivered to all classes. The main objective was to discourage the consumption of "fizzy" drinks (sweetened and unsweetened) with positive affirmation of a balanced healthy diet. The main outcome measures used in the study were drink consumption and number of overweight and obese children. The results of the study found Consumption of carbonated drinks over three days decreased by 0.6 glasses (average glass size 250 ml) in the intervention group but increased by 0.2 glasses in the control group (meandifference0.7,95%confidenceinterva0.1to1.3).At 12 months the percentage of overweight and obese children increased in the control group by 7.5%, compared with a decrease in the intervention group of 0.2% (mean difference 7.7%, 2.2% to 13.1%). it is not clear precisely how much time and method of delivery was devoted to each component; discouragement of fizzy drinks, affirmation of a balanced healthy diet, drinking water, presenting art, writing songs/raps outlining healthy messages. And as a result of this it is impossible to identify which aspects were actually effective and which were unnecessary. One problem with the sampling, which the researchers point out, is that school s contained classes both in the experimental and the control group and therefore it is possible that transfer of knowledge may have taken place outside the classroom with participants discussing the different conditions amongst themselves The participants were asked to keep a three day diary both at the beginning and at the end of the intervention (over one school year) and keep record of the drinks that they consumed. It is doubtful whether this could be regarded an appropriate method of collecting data considering the sample used.

Is it feasible to ask a 7 year old to keep an accurate diary indicative of the complete beverages they have consumed? This is a poor method of measurement with participants as young as this and indeed this was reflected in the low number of completed diaries they received both at baseline and the climax of the intervention It has some interesting methods of engaging the children and because it is multi- faceted it seems to bombard the messages and the results seem to suggest that the do influence the participants eating and drinking behaviour. STUDY2: MEND: A family based community intervention for childhood obesity. It was aimed at to evaluate the effectiveness of the mind, exercise, nutrition, Do it programme. The design was a randomized control trial designed to assess the effectiveness of 6 month intervention with nine week MEND programme followed by 12 week free family swim passes. It was a multicomponent intervention focusing on healthy lifestyles based on the principals of nutrition and sports sciences and from psychology learning and social cognitive theory and study of therapeutic processes. The intervention strategies include nutrition and behaviour change sessions targeted on both parents and children and exercise sessions which only focused on children. The programme was delivered at five different sites by separate teams of health, social and educational professionals. The researchers included 116 children aged 8 to 12 years with BMI >98th percentile and randomly assigned them to either participate in intervention or wait six months for intervention. They took measurements at baseline, six and 12 months. Mean attendance was 86%. At six months, children assigned to the MEND program had a reduced waist circumference z score (0.37) and a BMI z score that compared with children assigned to wait six months for intervention (0.24; P<.0001 for both). At 12 months, children in the intervention group had reduced their waist circumference z score by 0.47 and BMI z score by 0.23 (P<.0001 for both).This study explored the effects of the intervention on three indicators of adiposity .These three indicators are: A waist circumference, MI and body composition. Among these waist circumference was considered as a primary outcome measure, which is a quite different from other childhood intervention studies. Secondary outcome measures include BMI and cardio vascular fitness. The waist circumference at the end of the programme was decreased by 4.1 cm among intervention children. This result favours the two other randomized control trials which comprised of life style intervention. (Thomas, 1995 #504). As a secondary outcome measure BMI was also significantly reduced .This also favours the previous studies(30,31,32,33).Another similar study has even showed a more significant results with decrease in BMI of 3.1kg/m. Apart from it the decrease in body composition has also been showed although slight, which may need more time to show. Another contribution which was reflected through this study was its contribution in showing that there are no psychological consequences of such weight management programs by showing that participation was associated with psychological benefits rather than harm. These findings of the study favours the other growing body of literature which supports that weight management may improve emotional health of obese young people (41).The benefits of programme sustained following 12 months as described by researchers which shows favourable consistency. The technique used to measure physical activity is important to determine the effectiveness of intervention. Subjective intervention measurement e.g. self-report may not record the true picture. Moreover the intensive nature of the programme could have been the cause for the positive short term changes that were recorded, however this may not be sustainable for a long term In short this study has showed those child weight loss programmes which involve the whole family are scientifically proven and sustainable solution to childhood obesity crisis. Although the programme was

limited by a small number of participants and having no control group, it showed a favorable tendency of success. In short, this programme was accepted by families and produced a significant improvement in range of risk factors associated with obesity. In addition children also benefited from the social aspect of the programme and had fun making new friends, felt better about them and enjoyed the company of children having similar weight situations. STUDY 3: A 4 year, cluster randomized controlled childhood obesity prevention study: STOPP by Marcus et al (Marcus, 2009 #503) was a school based intervention randomized control trial which aimed to assess whether a school based prevention programme, focused on reducing unhealthy eating and increased physical activity during school time over a four year period could reduce the prevalence of overweight and obesity among 6 to 10 year old children. It was a school based policy intervention focusing on changing the school environment. School staff was encouraged to promote healthy eating and physical activity. Additionally policies were put in place to promote healthy eating and physical activity which include 1 hour and 30 minutes daily physical activity time was added to daily school curriculum. Moreover to reduce sedentary behaviour, children were not allowed to bring toys that bring that might increase this behaviour such as hand held computer games to schools and after care school centers. The teachers were instructed to encourage the children to increase the intake of vegetables during the school lunch. To facilitate this all intervention schools agreed to offer a variety of vegetables and food was arranged so that the children first served themselves vegetables and thereafter the main course. The products include a wide amount of dietary fibers. The sugar content in school lunches and in the snacks was reduced. Skimmed milk, low fat butter, cheese and yogurt were also provided. Intervention school was encouraged to eliminate sweets, sweet buns and ice-creams in association with festivities. Parents were also asked not to provide such stuff during school and after school care centers for celebrating birthdays. They were also instructed not to provide sweetened drinks sweets and other unhealthy products in packed lunch during school excursions and ports days. A STOPP newsletter was distributed to parents and school staff of intervention schools twice annually aimed to increase the awareness of the intervention. Furthermore the research staff had meetings with school personnel once every term aimed at increasing the awareness of intervention. The programme was carried out with the help of routine school staff. Training for the staff was updated twice a year. Measurements for Height and weight were measured using the standard transportable harpenden stadiometer, The physical activity was assessed using acti watch accelerometer.AT the end food questionnaire regarding eating habits at home was distributed by school staff to the parents of the all children of third and fourth grade and eating attitudes were assessed by Swedish version of CHEAT(childrens eating attitude test .Long term impact showed that prevalence of overweight and obesity decreased by 3.2% in intervention schools compared with an increase of 2.8% in control group. This study showed that intervention was more pronounced among boys than girls whichis not in line with most of previous educational based prevention programmes(ref).Moreover this study showed better results from previous studies (ref).A possible approach would be that there was a restricted access for children to sweetened products and beverages. The study has limitations as during a period from 1 to 4 years only 311 children participated for the full duration of intervention. Moreover there is no control over physical activity and dietary behaviours during the summer holidays and this can affect the long term effect of intervention as summer periods have been shown to be associated with an increase of the body fat in children (ref).Apart from it the family food questionnaire has not been validated which could have implications on the result .The results of the study showed that including healthy school lunches and after care school snacks as well as strict rules against unhealthy eating can reduce the prevalence of overweight and positively influence eating habits at home .This study has also revealed that physical activity intervention did not

contributed significantly to the result as no difference in physical activity levels between intervention and control schools was observed despite the school level intervention. Further research is needed to establish whether physical activity intervention can further improve the outcome. STUDY4: The Fit Kid project by Yin et al was designed to determine whether adiposity and fitness can be improved in children who are exposed to fitogenic versus an obesogenic environment .This programme was initiated a motivation from an ecological approach to the obesity pandemic by Eagger and Swinburg (Egger, 1997 #502) which was focused on the observation that obesity is increasing due to the exposure of youths towards more obesogenic environment. The population included was elementary 3 rd to 5th grade children in Richmond country Georgia in after school settings. This programme consisted of healthy snack, academic enhancement and physical activity .It was comprised of 2 hours programme which included 40 minutes of minimum exercise for 5 days a week and was based on socio ecological perspective. Staff and volunteers included certified teachers and paraprofessionals, United States department of agriculture (USDA) after school snack programme, after school transportation programme. Moreover pre-programme workshops and the three mandatory staff meetings were also organized. The evaluation measurements were done by x- ray, YCMA step test, portable scales, cholestec LDS.The school physical activity and nutrition project questionnaire, physical activity questionnaire for children(PAQ-C),physical-activity enjoyment scale(PACES),Pictorial Motivation Scale(PMS),Self Perception Profile for Children(SPPC) and the Task and Ego orientation in sports questionnaire. Resources of the programme included certified teachers and professionals, United States department of agriculture (USDA) after school snack programme and after school transportation programme. The settings in the programme included gymnasium, large outdoor fields suitable for games and sports and large class rooms. Participants were recruited through letters to parents and at school registration for both intervention and non-intervention schools. All participants were given pre, mid and post intervention physical assessments including body composition, non-fasting blood samples, blood pressure, step test for cardiovascular fitness and psychosocial survey. The fit kid programme was offered free of charge to third grade participants at intervention schools including after school programme, USDA healthy snack and transportation. All these programmes were conducted in participants schools. First year results showed significant beneficial results for % body fat, bone mineral density and cardiovascular fitness for those with 40% or greater attendance. There was also a relative reduction of body fats among participants. There are no long-term impacts as study is still in progress. It is learned from the programme that as the fit-kid is built on infra-structure of elementary schools, it can be potentially implemented on a large scale if deemed acceptable by schools and communities. Moreover kids cannot be relied on to bring home information, therefore participant recruitment is best done at mandatory events like school registrations. Moreover, these results of the study are in line with previous findings (ref) that demonstrated that effects of physical training and physical activity on body composition. Thus it is found that 30 -60 min/day of moderate vigorous physical activity is capable of improving body composition .The study has demonstrated that it is possible to engage children in 70-80 MVPA when they are placed in a supportive environment and were motivated which is never done by any other previous studies and as in line with other studies (37) the findings of this study support that the extra time spent in physical activity does not have a detrimental effect on academic achievements. STUDY 5: Title of the article: Developing obesity prevention interventions among minority ethnic children in schools and places of worship by Maria et al., (Maynard, 2009 #499).The DEAL (Diet and Active living) study by Maria et al (Maynard, 2009 #499).The study was conducted in Dundee united Kingdom aimed at assessing the feasibility, efficacy and cultural acceptability of child and family based interventions to reduce risk factors for children and adolescent obesity among ethnic minorities .The data obtained as

continued process for the period of study .Data was collected from focus group discussions and interviews. Children were also interviewed in the absence of parents and teachers. Grandparents were as well interviewed among Asian children due to their influence on dietary behaviour. A topic guide was distributed among the parents, teachers and grandparents for measuring dietary levels. The study was conducted in school based settings and places of worship and in schools teachers were recruited on the basis of ethnicity. In order to improve on the efficacy for facilitating behavioural changes, it is important to explore motivational strategies as suggested by Sallis (Sallis, 1996 #500),which is in line with the study objectives Assessment of self -efficacy for changing perceptions on dietary behaviours and physical activity as suggested by Molt et al (Trost, 2003 #501) which is applicable to this study using a questionnaire based on a 5 point linkert scale. Similarly, Timper et al(2006) emphasized on the same method for improving motivational behaviours as a means of reducing childhood obesity. In order to improve a dietary and physical exercise as a means of preventing childhood obesity and overweight among children age 7-13 years, it is advisable to apply school and places of worships that involved both qualitative and quantitative approach .It also suggested there should be the involvement of religious leaders, cultural leaders, teachers, children and parents. This study approach has been supported by several studies with demonstration of good outcome (Sallis, 1996 #500). Article 6. Wareham et al (2005) This is among the recent systematic review which consider role of physical activity for the prevention of obesity in children which was conducted in Irish during the period of 2005. The research was shown to be part of the moderate research with quality assessment when compared with primary research due to uncertainty and was conducted within the period of 2000 to 2004 that included 11 studies with outcome measures of body composition, body weight gain and issues regarding increase in physical activity by self report. The majority of studies reviewed therein used the school setting (8). They varied in who carried out the interventions, including parents, teachers and trained personnel. Of the eleven trials, only three showed a significant treatment effect in terms of anthropometric measurements. Gender differences in the results were indicated, with two of the three studies showing an effect only in boys. Some of the other trials showed an improvement in physical activity levels but these were not converted into improvements in body weight or composition. (Wareham, 2005 #497) The authors concluded that there was limited good quality data on which to draw conclusions in the area of obesity prevention in children and adolescents. However, they suggested that perhaps there was enough evidence to indicate that school-based interventions may be more promising than family-based trials. Article 7. Summerbell et al (2005) There was one systematic review that looked at all approaches to obesity prevention in children and was conducted by the Cochrane Group. The initial review, published in 2001 was then updated in 2005. This was the strongest review in our included publications in terms of its quality. (Campbell, 2002 #496)

These authors had strict inclusion criteria and limited their search to studies published from 1990 onwards. All included studies had to have outcome measures relating to the following: body weight/height, body fat percentage, body mass index, ponderal index and/or skinfold thickness. They included 22 studies in their review and split them into long-term follow up (i.e. greater than 12 months) and short-term follow-up (i.e. between 3 and 12 months) and included only randomised controlled trials or controlled trials. The settings of theses interventions included school, community and clinic bases and the intervention was delivered by a variety of personnel including teachers, researchers and trained individuals. The authors split the results into long and short-term outcomes and again into dietary interventions, physical activity interventions, and combined approaches. Of the 10 long-term studies, two focused on Physical activity (PA), two focused on diet and the other 6 focused on a combination of PA and diet. In the long-term studies there was no treatment effect that could be attributed to dietary interventions alone. In terms of physical activity, one study found a significant effect on the BMI of girls, however, the other study in this group similarly showed no effect. Consideration of combined approaches of physical activity and diet together was also disappointing, with 4 studies showing no treatment effect, although one study had a significant effect on skin fold thickness, but not BMI. There were no studies that compared dietary intervention to a PA intervention. Of the 12 short-term studies, none considered diet alone. Four studies looked physical activity, two of which showed significant effects on BMI; with one of these also showing an effect on skin fold thickness. The other eight studies looked at the combination of diet and physical activity with no significant positive results. The authors of the review conclude that overall, the interventions to date have not impacted on the weight status of children and thus there needs to be further high quality research to examine these issues more fully. Article 8.The study was conducted by Fadia et al., (Gonzalez-Suarez, 2009 #495) Titled School-Based Obesity Interventions: A Literature Review. Childhood obesity is an impending epidemic. The article describe an overview of many interventions conducted within certain schools settings that act as a guide for the management of obesity among children in order to minimise the risk of being obese at adult and other related complication. The study was conducted within the period 1986 to 2006 with participants age range 7 years to 19 years with 51 interventions and involved both qualitative and quantitative studies. The interventions ranged from 4 weeks in length to as long as 8 continuing Years. Out 51 total studies, 15 of the intervention studies exclusively utilized physical activity programs, 16 studies exclusively utilized educational models and behaviour modification strategies, and 20 studies utilized both. In addition, 31 studies utilized exclusively quantitative variables like body mass indices and waist-to-hip ratios to measure the efficacy of the intervention programs, and another 20 studies utilized a combination of quantitative and qualitative measures that included self-reported physical activity and attitude toward physical activity and the tested knowledge of nutrition, cardiovascular health, and physical fitness. A total of 40 studies achieved positive statistically significant results between the baseline and the follow-up quantitative measurements. CONCLUSIONS: No persistence of positive results in reducing obesity in school-age children has been observed. Studies employing long-term follow-up of quantitative and qualitative measurements of short-term interventions in particular are warranted. Article 9. The study was conducted by Gary Foster et al. (Foster, 2008 #494) Titled A Policy-Based School Intervention to Prevent Overweight and Obesity. The study was conducted for the purpose of the prevalence and seriousness of childhood obesity which has prompted in the public health concern

showing high demand for the urgent need of intervention measures. The aim of the study was to examine the effectiveness of school nutritional programme policy for the prevention of overweight and obesity among children. The study was conducted for the period of two year. A total of 1349 students were involved involving 10 schools US city in the Mid-Atlantic region with _50% of students eligible for free school nutritional reduced-price meals. Schools were matched on school size and type of food service and randomly assigned to intervention or control. Students were assessed at baseline and again after 2 years. The School Nutrition Policy Initiative included the following components: school selfassessment, nutrition education, nutrition policy, social marketing, and parent outreach. The incidences of overweight and obesity after 2 years were primary outcomes. The prevalence and remission of overweight and obesity, BMI zscore, totalenergy and fat intake, fruit and vegetable consumption, body dissatisfaction, and hours of activity and inactivity were secondary outcomes. The intervention resulted in a 50% reduction in the incidence of overweight. Significantly fewer children in the intervention schools (7.5%) than in the control schools (14.9%) became overweight after 2 years. The prevalence of overweight was lower in the intervention schools. No differences were observed in the incidence or prevalence of obesity or in the remission of overweight or obesity at 2 years. CONCLUSION: A multicomponent school-based intervention can be effective in preventing the development of overweight among children in grades 4 through 6 in urban public schools with a high proportion of children eligible forfree and reduced-priced school meals. Article 10. Ten Years of TAKE 10 integrating physical activity with academic concepts in elementary school classrooms. The study was conducted by Debra Etelson (Etelson, 2003 #477). The study was aimed at conducting reviewing articles that support the use of physical activity, fitness and use of classroombased programme with relevant programmes organised by the federal government in promoting policies that will help in reducing obesity in children and adolescent. Evidence from journal articles, published abstracts, and reports were examined to summarize the impact of TAKE 10 on student health and other outcomes. This paper reviews 10 years of TAKE 10studies and makes recommendations for future research. Teachers are willing and able to implement classroom-based PA integrated with gradespecific lessons (4.2 days/wk). Children participating in the TAKE 10! program experience higher PA levels (13%>), reduced time-off-task (20.5%), and improved reading, math, spelling and composite scores (pb0.01).Furthermore, students achieved moderate energy expenditure levels (6.16 to 6.42 METs) and studies suggest that BMI may be positively impacted (decreases in BMI z score over 2 years [Pb0.01]). Conclusion:TAKE 10 demonstrates that integrating movement with academics in elementary school classrooms is feasible, helps students focus on learning, and enables them to realize improved PA levels while also helping schools achieve wellness policies.

Quality of articles: Considering the nature of research questions, the number of articles was not large. The intervention quality that was put in place has helped in the process of carrying out the research. There is the need for conducting further research in order to establish a basic fact on how such interventions can be of benefit to the society in converting obesity among children this will help in improving the wellbeing of the community at risk.

Chapter: Five Discussion: Overweight and obesity among children has been one of the major threats for health care providers and affect almost all the industrialized countries of the world. Obesity and under nutrition are among the conditions that contribute to the world global burden of illness/diseases with dual nature affecting the developing countries. Obesity is considered as a threat for health. Taking the example of a single country, in U.S.A the increase in obesity is creating a cost of $ 344 billion per year on the health issues.( Nanchi Helmich, 2009) and it is estimated that more than 50% population will be striving from this disease till the year 2018. The reason behind this is the use of junk food which is so much popular and too much unhealthy. In addition to this the carbonated drinks are also ruining the health and especially of children, these should be banned from the school canteens. Children keep on liking such a tasty but unhealthy junk food and above this the outdoor gaming fashion is also reducing. They become so much lazy to go outside and swimming, jogging, walking and exercises are not preferred. Nutrition counseling sessions should be undertaken after a certain periods and especially mothers should be invited to maintain a special healthy diet for their children and those should be arranged by health care professionals and nutritionist, as the healthy kids are the bright future of the state. The physical activities should be encouraged and parents as well as teachers should involve in such activities. School/ college trips should be arranged for hiking or certain area where children can easily enjoy and exercise.
Congresswoman Kay Granger says that special knowledge about eating and how to eat should be given to children and healthy life style should be encouraged properly. In America, about 23 million children are overweight and this ratio goes on increasing day by day and the main cause is the use of technology. A small research shows that comparing the year 2000 and 2005, the youth and the children are so much used to of the technology and this can be seen from the following few ratios: The ratio of using internet increases from 73 % to 87 % The ratio of going online per day increases from 42 % to 51 % The ratio of using mobile phones increases from 68 % to 89 % The ratio of using instant messages increases from 40 % to 65 %

The physical activities do not mean always going outside. The parents should be concerned and after every 2-3 days a plan should be made that all the family members will do the house chores and some exercise needed house chores should be distributed by the family head. And this will surely keeps the family healthier and stronger. Eliminating the food is never healthier. It means that food should be included which is healthy, examples are fruits, fresh vegetables instead of snacks and fried items. There should be discipline in eating habits and this should be watched by parents. With the help of little care this problem can be easily solved. Recommendations: For being healthy, it is strongly recommended that proper check ups and proper appointments from the doctors, physicians and nutritionists should be taken and the weight should always be checked and is compared with the average Body Mass Index. When the child is obessed, there always comes some medical problems such as weak kidneys, high cholesterol or heart or asthma problem. And no doubt that these diseases are very much common in children and youngsters nowadays.

The precautions should be made and this is always preferable as compared to the treatment when the water goes above the head. Liposuction is never recommended for children as it causes many side effects and is too much unhealthy for less aged people. The children should be more active and it is the responsibility of parents as well as the teachers to provide them such opportunities and give them such responsibilities so that they try to be active and responsible. As the development of the body of the child depends on the physical exercise so the sportsman spirit should be indulged in them in order to be active and healthy. Fat and unhealthy children are always lazy and lack behind not only in such activities but also in the studies and mentality. Favorite sports should be a part of daily school period and on the other hand children should be made habitual to eat the home cooked food instead of eating chips, carbonated drinks, chocolates and burgers. Chocolates and sweets are also very unhealthy and are the reason of high weight. Parents should be given proper knowledge and parents teacher meeting in the schools should have a proper session that is related to the diet of the students and the lunch which the parents give to students while going to school. No doubt that the little effort will be too much healthier in building the nation and making it strong and stronger.

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