PREVENT TOGETHER

“A PRospEctive randomized parallel controlled, open-label, multicentre trial of interVENTional sTrategies prOmotinG hEalTHy diEt and physical activity among childRen and their families”

Il PROGETTO

Il tasso di obesità nell’età evolutiva in Italia è tra i più alti d’Europa ed è in crescita (Istituto Auxiologico Italiano, IRCCS e dati OMS, 2022). Nonostante sia più diffusa che in passato una maggiore consapevolezza circa l’importanza di scegliere stili di vita sani, i dati sono molto preoccupanti. I rischi non riguardano solo l’insorgenza di malattie non trasmissibili, che riducono le aspettative di vita oltre che la qualità della vita, ma anche lo sviluppo delle capacità cognitive.

Il progetto di ricerca PREVENT TOGETHER è stato ideato dall’Università di Brescia e dalla Scuola Superiore di Studi Avanzati della Sapienza di Roma, coinvolgendo esperti nel campo medico, pedagogico, psico-sociale e dell’urbanistica, con l’obiettivo di misurare, attraverso la raccolta di alcuni parametri corporei, gli effetti di azioni di promozione di stili di vita più sani rivolte a giovani dagli 11 ai 14 anni e di valutare possibili fattori che determinano condizioni di obesità.

Il progetto PREVENT TOGETHER è stato condotto nel periodo tra aprile 2023 e marzo 2026, grazie al finanziamento di Fondazione Cariplo Cibo e Salute. Ricerche sull'obesità nell'età evolutiva per la promozione di stili di vita più sani.

Background

Cardiovascular diseases (CVD) are the leading cause of morbidity and mortality in developed countries and worldwide (Roth et al, 2021; Timmis et al., 2020). Although science has deciphered the natural course of atherosclerosis, heart failure and most CVD, discovered their causal risk factors and developed effective means to intervene, we are still faced with an ongoing global pandemic of CVD. Evidence linking exposure to risk factors in early life with cardiovascular outcomes has begun to emerge. Moreover, cohort studies have shown that childhood exposure to risk factors, such as dyslipidaemia, obesity and tobacco smoking,

are associated with adult preclinical CVD. Importantly, these long-term effects are substantially reduced if the individual

becomes free from the risk factor by adulthood (Raitakari et al., 2022). Data from the Bogalusa Study in Louisiana have

shown that being overweight during adolescence was associated with an increased risk of 8.5-fold of developing high

blood pressure, 2.4-fold for hypercholesterolemia, three-fold for an increase in low density lipoprotein. (Srinivasan et al.)

In Italy, 2019 data from the National Health system, underline that 20.4% of children are overweight and 9.4% are obese

(https://www.epicentro.iss.it/okkioallasalute/indagine-2019-dati).

The most recently published Italian data from IRCCS Istituto Auxologico Italiano showed that the prevalence of obesity

and overweight is 18% in children and 19% in adolescence. Also, geographical differences have been highlighted: 34.1%

in the South, 20% in the North-West, 22.4% in the North-East, 23.9% in the Centre and 28.4% in the Islands. The black

jersey regions are Campania (37.8%), Molise (33.5%), Basilicata (32.4%), Abruzzo and Puglia (31.2%). It is estimated that

more than one third of patients with obesity and overweight in childhood and adolescence will be also in adulthood.

Multiple factors may contribute to obesity, including a familial predisposition and socio-economic factors. Obesity is also

tightly linked to the composition of the gut microbiota in multiple ways: diet shapes the microbiota composition, and in

turn bacteria and their metabolites can contribute to nutrient absorption, inflammatory status, and dietary habits of the

host, also through the gut-brain axis (Torres-Fuentes et al. 2017). Environmental exposure to airborne microbes can

shape the microbial communities colonising humans especially at early age, as shown in experimental models. (Liddicoat

et al., 2019) Different microbiotas can characterise different indoor and outdoor environments, also depending on

human occupancy as it occurs in a classroom (Rook, 2013; Qian et al., 2012; Lee et al. 2021). Furthermore, obese and

overweight children are consistently at higher risk of developing negative psychological outcomes. They are more likely

to experience stigmatization, social isolation, physical and verbal bullying compared to the healthy-weight peers. These

experiences have a significant impact on the emotional well-being and can often lead to the development of poor body

image and low self-esteem (Sanders et al., 2015). Also, family stressors are positively related to overweight and obesity

in children. Living in households lacking cognitive stimulation and emotional support is positively associated with being

overweight and obese (Garasky et al., 2009). There is additional evidence that individuals who are overweight and/or

obese in their childhood have significantly higher risk of developing psychological comorbidities when they become

adults (Wardle & Cook, 2005).

Implementation of preventive strategies from childhood is therefore warranted. Prevention of childhood obesity, with

strategies aimed at contrasting negative food choices and sedentary behaviour, is especially important now that the

coronavirus disease 2019 (COVID-19) pandemic still imposes social isolation, semi-lockdown and “stay at home” orders

whose consequences negatively impact on children and adolescent’s wellbeing, food choices and lifestyle (Nogueira-de-

Almeida et al., 2020; Cena et al., 2021).

Furthermore, the investigation of both genetic and environmental factors related to obesity (e.g. parents' working

conditions, school and demographic policies) represents the sine qua non for future interventions.

Recently, the importance of a multidisciplinary approach has been proposed. Childhood obesity is often perceived as a

personal "failure" by both children and their parents. However, it is often connected to the economic, health, family, and

housing context, namely the availability of accessible spaces and/or opportunities for socializing and game.

Consequently, in recent years has seen an increase in the phenomenon of obesity especially in the most degraded areas

and in the most fragile social groups of the country.

Therefore, obesity must be framed in an interdisciplinary context, not being simply linked to poor eating habits, but also

to poor relationships, isolation, poor health care, lack of services, educational opportunities, and non-formal learning,

which operate in integration with the formal educational pathways of the school.

In this interdisciplinary frame, recent studies have shown the effectiveness of urban planning and urban projects in

reducing childhood obesity, in particular stimulating outdoor physical activity. The spatial organization of services and

green areas is a context factor that favours physical activity, because it can affect, at different levels, the organization

of the daily life of children and adolescents. Moreover, it can modify the environmental exposure to airborne bacterial

communities, which can shape human commensal bacteria composition and thus susceptibility to obesity.

In the early 1990s, in the United Kingdom has been published the first reports correlating food, physical activity, and

body weight to the area of residence (Ellaway & Macintyre 2000). The routine of the family, the activities promoted inthe school environment and the opportunities in free time are therefore related to the dislocation and provision of

services.

The World Health Organization's reports (WHO 2016, 2017) provide a review of existing projects aimed at increasing

physical activity in cities, with the goal of moving these projects forward. It also focuses on recent case studies of urban

planning to promote physical activity, demonstrating how common principles and concepts in urban planning can be

utilized to encourage an increase in physical activity.

In particular, outdoor physical activity should be encouraged, as it is considered of higher quality than that carried out

in enclosed spaces for the simultaneous production of vitamin D by the body, whose deficiency is often found in obese

patients (Zakharova et.al., 2019).

Outdoor physical activity, for example, can be achieved by promoting sustainable travel modality on home-school paths

or by reaching certain neighbourhood services. (Brolli & Tiboni, 2008; Giuliani & Maternini, 2017; Pezzagno, Richiedei,

Tiboni, 2021). This must also be achieved through the improving of safety on the routes most used in walking or cycling

and improving synergy with public transport (AA.VV. 2017, Pezzagno, Richiedei, Tiboni, 2021). What can be obtained is

a child-friendly city, in which the little ones can move alone, a city that rediscovers the spaces of proximity, the quality

of public space, sustainable mobility, green and play spaces, walkability (Tiboni & Rossetti, 2012). Moreover, a child-

friendly city stimulates social relationships which increase the involvement of children in physical activities (D’Onofrio &

Truisani, 2018).

Awareness of childhood obesity in developed countries is growing. However, preventive strategies are still scarce and

unsuccessful. Preschool and school-based interventions offer promise to instil healthy behaviours in children, which can

be a strategy to reduce the burden of cardiovascular disease later. (Paul et al., 2018) (Dobbins et al., 2009) The cluster-

randomized controlled FAMILIA (Family-Based Approach in a Minority Community Integrating Systems-Biology for

Promotion of Health) trial involved 562 subjects from 15 Head Start preschools in Harlem, New York. Compared with the

control group, the mean relative change from baseline in the overall KAH score was 2.2 fold higher in the intervention

group, suggesting that multidimensional school-based educational intervention may be an effective strategy for

establishing healthy behaviours among pre-schoolers from a diverse and socioeconomically disadvantaged community.

Several data have been published also regarding the impact of interventive strategies in primary school children. On the

other hand, data are lacking about the possible beneficial effect of an educational intervention in the specific age group

of 11-14 years; a multidisciplinary approach, involving several specialties, has been recently proposed. Therefore, we

sought to investigate the effect of this innovative approach in this setting of preadolescents.

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