Women’s survival, health, and well-being are among the focusses for achieving Sustainable Development Goals (SDGs) [1], with SDG target 3.1 being to reduce the global maternal mortality ratio (MMR) to less than 70 maternal deaths per 100 000 live births by 2030, with no country having an MMR greater than 140 per 100 000 live births. According […]

Background/Objectives: Identifying the factors influencing compliance is essential to improve the effectiveness of interventions. However, no study has examined factors that influence the longitudinal patterns of obesity intervention compliance. We aim to identify the longitudinal trajectories of parental and child compliance using group-based trajectory modeling (GBTM) and assess the influencing factors. Methods: The Diet, ExerCIse, and CarDiovascular hEalth Children (DECIDE-Children) was a 9-month app-assisted obesity prevention intervention targeted 8–10-year-old children. Altogether, 684 child–parent pairs from the intervention group were included. Parents were required to use the mobile app to learn health knowledge, monitor children’s diet and exercise behaviors, manage children’s weight, and received the assessment results. Parental compliance was assessed as the monthly usage times and duration of the mobile app. For child compliance, we used data recorded by parents in the “behavior monitoring” module. We employed group-based trajectory modeling (GBTM) to identify distinct trajectories of parental and child compliance and examined their associations with childhood obesity outcomes. Univariate and multivariate logistic regressions were performed to identify the influencing factors associated with the identified compliance groups. Results: Distinct trajectory groups of parental and child compliance were identified. The compliance trajectories of parents and children are related to the extent of changes in the child’s obesity-related outcomes (waist circumference, waist-to-hip ratio, and body fat percentage. p < 0.05). A majority of parents were classified into the “relatively low compliance” group. Parents in this group was associated with having a daughter (OR: 1.95, 95% CI: 1.17, 3.31) and the father having a higher education level (OR: 1.65, 95% CI: 1.05, 2.60). For children, 20.2% were assigned to the “decreasing compliance” group. Children in this group were more likely to have a younger mother (OR: 1.05, 95% CI: 1.01, 1.10) and parents with poorer compliance (OR: 2.36, 95% CI: 1.16, 5.47). Conclusions: Both student and parental compliance were shown to influence the effectiveness of childhood obesity interventions, highlighting the need to prioritize the assessment and promotion of compliance in such interventions. Child sex, paternal educational level, and maternal age were identified as significant factors associated with compliance, while the level of family involvement was found to play a pivotal role in fostering healthy behaviors in children. These findings suggest that future intervention strategies should place greater emphasis on engaging families and providing targeted supervision and support for populations at risk of lower compliance in order to enhance intervention outcomes.

Behavioral interventions have been shown to be effective in improving dietary behavior and reducing childhood obesity. There is limited evidence on how concurrent changes in dietary behavior from intervention studies affect childhood obesity. The present study aimed to evaluate the mediating effect of concurrent changes in dietary behaviors between the intervention and changes in adiposity indicators. This study included 1180 children from the DECIDE-Children study, which was conducted across three areas in China, aiming to promote children’s healthy diet and physical activity, while also engaging schools and families to support children’s behavioral changes. Dietary behaviors were collected by a revised version of the Food Frequency Questionnaire and a self-designed questionnaire. Adiposity outcomes were objectively measured by trained personnel. Generalized linear mixed models were used to estimate the association between scores of dietary behavioral changes and adiposity indicator changes. Mediation analyses were used to evaluate how scores of dietary behavioral changes mediated the effect of intervention on adiposity indicator changes. Six hundred children in the intervention group and five hundred and eight in the control group with both baseline and follow-up data were included. Each increase in dietary behavioral change score was associated with a 0.06 (p = 0.016) decrease in changes in BMI and other adiposity indicators. Scores of dietary behavioral changes mediated 13.87% (p < 0.001), 11.81% (p < 0.001), 17.60% (p = 0.024), and 16.78% (p = 0.032) of the association between intervention and changes in body mass index (BMI), BMI z-score, body fat percentage, and waist circumference, respectively. Scores of dietary behavioral changes mediated the intervention effect on adiposity indicator changes. Future interventions targeting childhood obesity should incorporate promoting multiple dietary behaviors simultaneously.

Background and objectives: The objective of this study was to test the effects of objectively measured screen time using wearable cameras, along with dietary intake and physical activity level (and their interaction), on obesity among Chinese school-aged children. Methods: This study was conducted among 52 fourth-grade children (age: 9.76 ± 0.44; 50% boy) in Beijing, including children with obesity and age- and sex-matched normal-weight controls. Screen time (min/day) was coded from wearable camera images collected over one week using image recognition, physical activity measured using accelerometers, and dietary intake via camera-assisted 3-day 24 h dietary recalls. Logistic regression and generalized additive models assessed associations with obesity indicators, including general (obesity; percentage of body fat, BF%) and central (waist circumference; weight-to-height ratio). The combined effects of screen time with dietary and physical activity factors were also analyzed. Results: Children with obesity had longer daily screen time (94.91 ± 35.44 vs. 83.15 ± 36.86 min). Longer screen time was associated with higher energy and carbohydrate intake, more average duration per meal, a higher proportion of meals with screen, increased sedentary time, and a lower proportion of time spent in moderate-to-vigorous physical activity (MVPA). After adjusting for dietary intake and demographic covariates, longer screen time (≥1.3 h/day) was linked to higher odds of obesity (OR = 4.25, 95% CI = 1.09, 16.53) and BF% (OR = 6.14, 95% CI = 1.29, 29.10). Less protein intake (OR = 9.57, 95% CI = 1.31, 70.14), more proportion of meals with screen (OR = 6.40, 95% CI: 1.22, 33.61), less proportion of meals with social interaction (OR = 5.90, 95% CI: 1.01, 34.59), and less MVPA (OR = 5.21, 95% CI = 1.11, 24.43) with more screen time increased obesity risk. Conclusions: Objectively measured screen time was positively associated with the risk of childhood obesity. Longer screen time combined with lower protein intake, a higher proportion of meals consumed while watching screens, less meals with social interaction, and lower MVPA may collectively increase obesity risk. These findings call for efforts to reduce screen exposure, promote MVPA, and increase dietary protein intake. Additionally, encouraging children to avoid screen use during meals and promoting parent or peer companionship during eating may help reduce the risk of childhood obesity.

Background: Childhood obesity remains a major public health challenge. Mobile health (mHealth) interventions offer a scalable approach to support behavior change, but their effectiveness may depend on participant adherence. While both caregiver and child adherence are important, few studies have jointly examined caregiver app-use adherence and child behavioral adherence within digital obesity interventions. Objective: This study aimed to evaluate the independent and joint associations of caregiver app-use adherence and child behavioral adherence with obesity-related outcomes in a school-based mHealth intervention. Methods: We conducted a secondary analysis of 684 child-caregiver dyads in the intervention arm of the diet, exercise, and cardiovascular health—children cluster-randomized trial, implemented across 3 socioeconomically diverse regions in China. Caregiver app-use adherence was measured using app-recorded app-use frequency and total usage duration. Child behavioral adherence was assessed through weekly behavior monitoring scores covering diet, screen time, and physical activity. Linear mixed models estimated associations between adherence levels and changes in anthropometric and physical fitness outcomes over 9 months. Results: Higher caregiver app-use frequency and duration were both significantly associated with reductions in children’s obesity-related indicators, such as BMI (β=−0.19; P =.005), BMI z -score (β=−0.08; P =.006), and body fat percentage (BFP) (β=−0.70; P =.005) for frequency. Greater child behavioral adherence was associated with lower BFP (β=−0.63; P =.01) and better physical fitness, including shorter shuttle run time (β=−3.63; P <.001) and longer standing long jump distance (β=2.88; P =.005). App-use frequency and duration showed a significant interaction for rope-skipping performance ( P =.05). In joint adherence analyses, children in the high caregiver-high child adherence group showed the most favorable changes, including lower BMI (β=−0.22; P =.02), lower BFP (β=−1.18 percentage points; P =.001), and 7.45 additional rope-skipping repetitions ( P =.003), compared with the low caregiver-low child adherence group. Conclusions: In this secondary analysis of an mHealth app-assisted childhood obesity intervention, higher caregiver app-use adherence and child behavioral adherence were associated with more favorable changes in weight status and physical fitness. These findings underscore the importance of coengagement in digital health programs and highlight the potential of app-supported, family-engaged strategies for childhood obesity prevention.

Background/Objectives: Few paediatric obesity trials have examined behavioural mediators of intervention effects on detailed body composition outcomes beyond body mass index (BMI). Given the complexity of multiple correlated body composition indicators, this study aimed to employ principal component analysis (PCA) to derive a composite adiposity factor and to apply mediation analysis to identify whether changes in dietary behaviours and physical activity mediated the effects of the DECIDE-Children intervention on body composition. Methods: This study included 1180 children from a 9-month cluster-randomised controlled trial that delivered a multifaceted, digitally assisted intervention targeting children (health education, physical activity reinforcement, and app-based BMI monitoring/feedback) and their environments (school food policies and family engagement). Outcomes were changes in body composition (whole-body and trunk fat mass, fat-free mass, and muscle mass indices measured by bioelectrical impedance analysis). Potential mediators included changes in dietary behaviour, screen time, and moderate-to-vigorous physical activity (MVPA), assessed via validated questionnaires. PCA was used to reduce the dimensionality of body composition variables and to derive a composite adiposity factor (PCA_1), with higher values indicating greater adiposity and lower muscle mass. Mediation was tested using linear mixed-effects models adjusted for age, sex, and region. Results: The intervention significantly reduced adiposity indicators (e.g., whole-body and trunk fat mass percentage decreased by 1.003%, and PCA_1 decreased by 0.942 SD) and concurrently increased fat-free mass percentage and muscle mass percentage at both whole-body and trunk levels. Dietary behaviour significantly mediated the intervention effects on all body composition outcomes (e.g., mediating 16.1% of the effect on PCA_1), whereas physical activity (both screen time and MVPA) showed no mediation. Sensitivity analyses supported the primary findings. Conclusions: The DECIDE-Children intervention improved body composition by reducing adiposity and increasing fat-free and muscle mass percentage, effects primarily mediated by dietary behaviour. These findings highlight dietary behaviour as a key component in paediatric obesity intervention.