Article
Reference
Primary care prevention of cardiovascular risk behaviors in adolescents: a systematic review
TISSOT, Hervé, PFARRWALLER, Eva, HALLER, Dagmar M.
Abstract
Adolescence is associated with behavioral changes offering opportunities for prevention of cardiovascular risk behaviors. Primary care physicians are ideally placed to deliver preventive interventions to adolescents. The objective was to systematically review the evidence about effectiveness of primary care-led interventions addressing the main cardiovascular risk behaviors in adolescents: physical activity, sedentary behaviors, diet and smoking. PubMed, Embase, PsycINFO, CINAHL, Cochrane, ClinicalTrials.gov, and ISRCTN registry were searched from January 1990 to April 2020. Randomized controlled trials of interventions in primary care contexts on at least one of the cardiovascular behaviors were included, targeting 10–19-year old adolescents, according to the World Health Organization's definition. Two authors independently assessed risk of bias. Twenty-two papers were included in the narrative synthesis, reporting on 18 different studies. Interventions targeting smoking uptake seemed more effective than interventions targeting established smoking or the three other risk behaviors. Intervention components or intensity [...]
TISSOT, Hervé, PFARRWALLER, Eva, HALLER, Dagmar M. Primary care prevention of
cardiovascular risk behaviors in adolescents: a systematic review. Preventive Medicine , 2020, vol. 142, p. 106346
PMID : 33275966
DOI : 10.1016/j.ypmed.2020.106346
Available at:
http://archive-ouverte.unige.ch/unige:147405
Disclaimer: layout of this document may differ from the published version.
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Appendix C: Outcomes Reported in Studies Included in a Systematic Review of Primary Care Interventions to Reduce Cardiovascular Risk Behaviors in Adolescents, by Primary Outcome of the Review
Table C1: Outcome Measures and Effect of Interventions on Physical Activity
Study Outcome Measure(s) Instrument(s) Timing of Outcome
Measure(s) Relative to Baseline
Main Findings
Studies showing some effectiveness on the outcome
Oreskovic 2016
[32] • Objectively measured mean daily MVPA.
• Proportion of adolescents meeting guidelines of 60 minutes/day of MVPA.
Accelerometer worn for 7 days (Global Positioning System data measured, but only used to inform counselling).
0 months (after first part of intervention) and at 3-4 months (end of intervention)
Mean daily MVPA significantly higher in IG at follow-up, due to an increase in IG (+ 7.7 minutes) but not in CG (+ 0.5 minutes, p = 0.02).
18% of IG and 7% of CG adolescents met the recommendations of 60 minutes/day of MVPA at follow-up.
Ortega-Sanchez
2004 [33] Self-reported PA:
• Proportion of active vs non-active adolescents
• Mean duration (min/week)
• Frequency (days/week)
• Intensity of exercise (mild, moderate or vigorous)
Questionnaire (self-constructed and non- validated), administered face-to-face by the PCP delivering the intervention.
0 months (after first intervention session) and 6 months (after second intervention session)
In the IG, significant increase in the proportion of adolescents classified as active, as well as in mean duration, frequency and intensity of PA, compared to CG.
Patrick 2006 [26]
Rosenberg 2007 [34]
1. Self-reported physical activity:
• MVPA (minutes/week)
• Active days/week (≥ 30 min of vigorous PA or ≥ 60 min of moderate PA)
• Meeting PA guidelines (≥ 5 active days/week)
2. Objectively measured MVPA (min/day)
1. Telephone interview: 7-day Physical Activity Recall 2. Accelerometer worn over 7 days
12 months (intervention end) Boys in the IG significantly increased number of mean active days/week (from 4.1 to 4.4 days/week) compared to CG (no change at 3.8 days/week, p = 0.01). In girls, no significant difference between groups.
More boys in the IG than in the CG met the PA guidelines (RR, 1.47; 95%
CI, 1.19-1.75).
No significant differences between groups for MVPA (recall and accelerometer data).
No covariation of PA with sedentary behaviors or diet.
Studies showing no or unclear effectiveness on the outcome
Chen 2017 [35]
Chen 2019 [24]a Self-reported PA: Days per week of being
physically active (≥ 60 minutes of PA). Self-administered online questionnaire (one question from the California Health Interview Survey).
6 months (intervention end) No significant difference in PA time between groups.
De Bar 2012 [36] Self-reported PA:
• Minutes/day of PA
• Average MET/day
Telephone interview: 24-hour Physical
Activity Recall 6 months (1 month after
intervention end) No significant differences between groups.
Eddy Ives 2012
[37] Self-reported PA: Time spent doing sports
(minutes/week) Self-administered questionnaire
(unvalidated) 12 months (intervention end) No significant differences between groups.
Fleischman 2016
[38] Self-reported PA: MET/day Telephone interview: 24-hour Physical
Activity Recall 6 months (intervention end)
and 12 months No significant change in PA.
2
Kong 2013 [25] 1. Self-reported PA: Number of 30-minute blocks per day spent in MVPA 2. Objectively measured MVPA (min/day)
1. Questionnaire: 3-Day Physical Activity Recall (form of administration not described) 2. Accelerometer worn over one
week
8 months (intervention end) No significant differences between groups.
Love-Osborne
2014 [39] Fitness test score Fitnessgram Progressive Aerobic
Cardiovascular Endurance Run (PACER) test.
6-8 months (intervention end) Unclear significance of findings: Fitness testing was done only in IG, and only 23% of IG completed both baseline and follow-up tests. 80% of them improved their test score (scores not reported).
Patrick 2001 [29] Self-reported PA:
• Days/week with ≥ 20 minutes of vigorous PA
• Days/week with ≥ 30 minutes of moderate PA
Validated questionnaire (self- administered on computer at baseline, conducted by trained telephone interviewers at follow-up).
4 months (intervention end) No significant effect of the type of intervention on PA.
Patrick 2013 [27] 1. Self-reported PA: Minutes/week of MVPA
2. Self-reported PA behavior change strategies
1. Interview: 7-day Physical Activity Recall
2. Behavior change skills questionnaire
12 months (intervention end) No significant effect on MVPA and behavior change strategies.
Saelens 2002 [28] Self-reported PA: daily PA-related energy
expenditure in kcal/kg/day) 7-Day Physical Activity Recall
(administration method not stated) 4 months (intervention end)
and 7 months No significant difference in PA-related energy expenditure between groups and no significant change over time.
Walker 2002 [40] Self-reported health damaging behaviors: “not
exercising regularly” Self-administered postal questionnaire 3 months and 12 months No differences between groups in self-reported exercise behavior, and no significant change of behavior over time.
a
Study reported in two different publications with partly different outcomes. Therefore, only the results reported in the more recent paper are reported in this review.
Abbreviations: PA = Physical activity, IG = Intervention group, CG = Control group, MVPA = Moderate to vigorous physical activity, PCP = Primary care
physician, MET = Metabolic equivalent
3 Table C2: Outcome Measures and Effect of Interventions on Sedentary Behaviors
Study Outcome Measure(s) Instrument(s) Timing of Outcome
Measure(s) Relative to Baseline
Main Findings
Studies showing some effectiveness on the outcome Chen 2017 [35]
Chen 2019 [24]a Self-reported time (hours/day) spent with sedentary activities: television viewing or video games, recreational computer use.
Self-administered online questionnaire (3 questions from the California Health Interview Survey)
6 months (intervention end) Significant decrease of television and computer time in IG (3.22 to 2.43 hours/day) compared to CG (3.51 to 3.42 hours/day).
Kong 2013 [25] Self-reported television viewing time
(weekday and weekend, hours/day) 11-item Television and Video Measure
(form of administration not described) 8 months (intervention end) Significant difference in weekday television viewing time between groups (- 0.4 hours/day in IG, + 0.2 hours/day in CG, p = 0.03).
No significant difference between groups in weekend television viewing.
Patrick 2006 [26]
Rosenberg 2007 [34]
Self-reported time (hours/day) spent watching television, playing computer or video games, sitting talking on the phone, and sitting listening to music.
Telephone interview modified from a
validated survey 12 months (intervention end) Significant decrease in mean sedentary time in IG compared to CG (p = 0.001).
No covariation found between changes in time spent in sedentary behaviors and engaging in physical activity, and between sedentary behaviors and diet.
Patrick 2013 [27] 1. Self-reported time spent doing various sedentary behaviors during school and non-school days (hours/day).
2. Self-reported behavior change strategies.
1. 8-item survey based on validated survey (administration method not stated)
2. Behavior change skills questionnaire
12 months (intervention end) Significant decrease in mean sedentary time (from 4.9 to 2.8 hours/day) in the website-only intervention arm compared with CG (p = 0.006). No significant effects in other intervention arms.
No significant effects on sedentary behavior change strategy.
Studies showing no or unclear effectiveness on the outcome
De Bar 2012 [36] Self-reported screen time (hours/week) Telephone questionnaire (adapted from
the Youth Risk Behavior Survey) 6 months (1 month after intervention end) and 12 months
No significant differences between groups.
The authors argue that the reduction of screen time between baseline and the 6-month follow-up in the IG (- 5 hours/week) is consistent with changes considered clinically significant.
Eddy Ives 2012
[37] Self-reported time of recreational screen use (television, video games, computer) in minutes/day
Self-administered questionnaire
(unvalidated) 12 months (intervention end) No significant differences between groups.
Oreskovic 2016
[32] Objectively measured mean daily sedentary
time (minutes/day) Accelerometer worn for 7 days (Global Positioning System data measured, but only used to inform counselling).
0 months (after first part of intervention) and at 3-4 months (end of intervention)
No significant differences between groups.
Saelens 2002 [28] Self-reported time spent with various
sedentary behaviors (minutes/day) Questionnaire about several sedentary behaviors in the last 7 days
(administration method not stated)
4 months (intervention end)
and 7 months No significant differences in sedentary behaviors between groups, and no significant change over time.
a
Study reported in two different publications with partly different outcomes. Therefore, only the results reported in the more recent paper are reported in this review.
Abbreviations: IG = Intervention group, CG = Control group
4 Table C3: Outcome Measures and Effect of Interventions on Diet
Study Outcome Measure(s) Instrument(s) Timing of Outcome
Measure(s) Relative to Baseline
Main Findings
Studies showing some effectiveness on the outcome
Chen 2017 [35]
Chen 2019 [24]a Self-reported dietary intake:
• Fruit and vegetables (number of servings on previous day)
• Sweetened drinks (number of glasses or cans on previous day)
• Breakfast
• Fast food consumption (occurrences in past 7 days)
Self-administered online questionnaire (questions from the California Health Interview Survey)
6 months (intervention end) In IG, significant decrease in sweetened drinks consumption (-1.08 glasses/day) compared to CG.
No significant differences in breakfast, fast food consumption, and vegetable and fruit consumption.
De Bar 2012 [36] 1. Self-reported dietary intake: total kcal/day, % of calories from fat 2. Self-reported dietary habits: eating
breakfast (days/week), family meals (times/week), eating fast-food (times/week), sweetened beverages (times/week)
Telephone interview:
1. 24-hour dietary recall 2. Questionnaire adapted from the
Youth Risk Behavior Survey
1. 6 months (1 month after intervention end) 2. 6 months (1 month after
intervention end) and 12 months
Significant differences between groups for frequency of family meals (less reduction in the frequency of family meals in IG compared to CG) and fast- food consumption (less fast-food intake in IG than in CG), but not for other outcomes.
Studies showing no or unclear effectiveness on the outcome
Eddy Ives 2012
[37] Self-reported dietary habits Self-administered questionnaire
(unvalidated) with 15 items 12 months (intervention end) No significant differences between groups.
In both groups, there was an overall decrease in the proportion of adolescents who ate faster than others and those who ate when bored, an overall increase in fruit and vegetable intake, and an overall decrease in the consumption of sweets.
Fleischman 2016
[38] Self-reported dietary intake: total kcal/day, % of calories from carbohydrates, fat and protein, glycemic index, glycemic load, fiber intake (g/1000 kcal)
Telephone interview: 24-hour dietary
recall 3 months, 6 months
(intervention end), 9 months and 12 months
No significant differences between groups.
There was an overall significant decrease in dietary glycemic load and carbohydrate intake in both groups.
Kong 2013 [25] Self-reported dietary intake: calories/day, sweetened drinks (glasses/day), fruits and vegetables (servings/day)
Youth/Adolescent Questionnaire food frequency survey (form of
administration not described)
8 months (intervention end) No significant differences between groups.
Patrick 2001 [29] Self-reported dietary intake:
• Fruit and vegetables (servings/day)
• High fat foods (servings/day)
Validated questionnaire (modified food frequency survey), self-administered by computer (baseline) and conducted by trained telephone interviewers (intervention end).
4 months (intervention end) No significant differences between groups.
Overall increase in fruit and vegetables intake and decrease in fat intake in both groups.
Patrick 2006 [26]
Rosenberg 2007 [34]
Self-reported dietary intake:
• Percentage of calories from fat
• Fruit and vegetables intake (servings/day)
• Fiber intake (grams/day)
Telephone interview: 24-hour dietary recall for 2 weekdays and 1 weekend day, using food portion models.
12 months (intervention end) Significantly more girls in the IG met the guideline for daily calories from saturated fat, compared to CG girls (RR, 1.33; 95% CI, 1.01-1.68), but there were no other significant differences between groups.
No covariation was found between diet and physical activity and between diet and sedentary behavior.
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• Meeting national dietary guidelines (%
of calories from total fat and saturated fat, number of daily fruit and vegetables servings, amount of dietary fiber) Patrick 2013 [27] 1. Self-reported dietary intake: Percentage
of calories from fat, fruit and vegetables intake (number of servings per 1000 kcal)
2. Self-reported dietary behavior change strategies
1. Self-administered validated food frequency questionnaire 2. Behavior change skills
questionnaire
12 months (intervention end) No significant difference between groups in fruit and vegetable consumption and percentage of calories from fat.
In the website + group sessions intervention arm only, there was a significant treatment effect for behavior change strategies concerning fruit and vegetable intake.
Saelens 2002 [28] Self-reported dietary intake:
• Kcal/day
• Percentage of kcal from fat
Interview; 2-day dietary recall 4 months (intervention end)
and 7 months No significant differences between groups.
Walker 2002 [40] Self-reported health damaging behavior: “not
eating healthily”. Self-administered postal questionnaire 3 months and 12 months No significant difference between groups.
a
Study reported in two different publications with partly different outcomes. Therefore, only the results reported in the more recent paper are reported in this review.
Abbreviations: IG = Intervention group, CG = Control group
6 Table C4: Outcome Measures and Effect of Interventions on Cigarette Smoking
Study Outcome Measure(s) Instrument(s) Timing of Outcome
Measure(s) Relative to Baseline
Main Findings
Studies showing some effectiveness on the outcome
De Micheli 2004
[30] Self-reported frequency of use of tobacco products in the last month
Telephone questionnaire (Drug
Use Screening Inventory) 6 months Change in prevalence of tobacco use in the last 30 days between baseline and follow-up, categorized into light (1-2 times), medium (3-9 times) and heavy (10 or more times) use.
Significant decrease in the percentage of heavy smokers in IG.
Significant increase in the percentage of heavy smokers in CG (non-smokers at baseline) Significant increase in light smoking in IG (non-smokers at baseline)
Fidler 2001 [41] Self-reported frequency of cigarette smoking (“how often do you smoke?”)
Self-administered postal
questionnaire 12 months
(intervention end) Smoking uptake was significantly lower in IG (5.1%) than in CG (7.8%, p-value 0.006).
The intervention effect was more pronounced in boys than in girls and in those defined as “definite non- smokers” at baseline. Among those defined as “potential smokers” at baseline, the intervention was effective in boys, but not in girls.
Hollis 2005 [42]
Huang 2005 [43] Self-reported cigarette smoking in
last 30 days Self-administered postal
questionnaire or telephone interview
12 months
(intervention end) and 24 months
Significantly higher proportion of non-smokers in IG (72.8%) compared to CG (68.6%; OR 1.23, 95%
CI 1.03-1.47).
In non-smokers at baseline, the intervention significantly reduced smoking onset at the 12-month assessment only. In smokers at baseline, the intervention had a significant effect at 24 months (23.9%
smoke-free in IG versus 11.4% in CG, OR 2.42, 95% CI 1.40-4.16).
Risk for smoking uptake at 24 months was predicted by susceptibility to smoking and stages of acquisition.
Pbert 2008 [31] Self-reported cigarette smoking in
past year and last 30 days Self-administered questionnaire (format not detailed)
6 and 12 months Nonsmokers in IG had higher odds of remaining abstinent compared to nonsmokers in the CG (at 12 months: OR 1.64, 95% CI: 1.01-2.67).
Smokers in IG had higher odds of being abstinent compared to smokers in the CG only at the 6-month follow-up (OR 1.59, 95% CI: 1.06-2.4), but not at the 12-month follow-up.
Studies showing no or unclear effectiveness on the outcome Stevens 2002 [44]
Jones 2005 [45] Self-reported lifetime use of
cigarettes or smokeless tobacco Self-administered postal questionnaire (validated and piloted survey items)
12 months, 24 months, 36 months
(intervention end)
No significant differences between groups.
The effect of the intervention was not moderated by maternal/paternal positive parenting or gender of the adolescent.
Walker 2002 [40] Self-reported smoking behavior Self-administered postal
questionnaire 3 months and 12
months No significant differences between groups in the proportion of teenagers reporting positive behavior change related to smoking.
Abbreviations: IG = Intervention group, CG = Control group
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Table C5: Outcome Measures and Effect of Interventions on Secondary Outcomes of the Review
Study Outcome Measure(s) Instrument(s) Timing of Outcome
Measure(s) Relative to Baseline
Main Findings
Studies showing some effectiveness on the outcome
Chen 2017 [35]
Chen 2019 [24]a • BMI (z-score) Anthropometric measurements taken 2x
by trained research assistant. 6 months (intervention end) Both groups decreased BMI and BMI z-score significantly over time.
Adolescents in the IG reduced BMI and BMI z-score significantly more than those in the CG.
DeBar 2012 [36] • BMI (percentile and z-score)
• Blood cholesterol (total, HDL-C, LDL-
• C) Fasting glucose
Anthropometric measures obtained 3x by blinded research staff.
Blood samples drawn after 10-hour overnight fast.
6 months (1 month after intervention end) and 12 months
Significantly greater decrease in BMI z-score in IG (- 0.15) compared to CG (- 0.08), but low-to-moderate intervention effect size.
No significant differences in metabolic outcomes.
Kong 2013 [25] • BMI (percentile)
• Waist circumference
• HDL-C
• Glucose levels
• Insulin levels
• Blood pressure
Anthropometric measures obtained by a registered dietitian.
Blood samples drawn after a 10-hour overnight fast.
Blood pressure measured 3x by auscultation by a research pediatric nurse after 5 minutes of sitting.
8 months (intervention end) Significant difference in BMI percentile between groups, due to a decrease in IG (-0.3%) and an increase in CG (+ 0.2%, p = 0.04).
Significant difference in waist circumference between groups, due to an increase in CG (+ 1.7 cm, unchanged in IG, p = 0.04).
Fasting glucose increased in both groups, but the increase was significantly higher in the IG than in the CG.
No other significant differences in other parameters and blood pressure.
Saelens 2002 [28] • BMI (z-score)
• Percentage of overweight (average percentage above the 50th percentile BMI)
Anthropometric measures obtained by research staff at a university-based weight control clinic.
4 months (intervention end)
and 7 months Significant condition by time interaction for BMI z-score at both time points (p < 0.03), due to a slight decrease in IG and an increase in CG.
Studies showing no or unclear effectiveness on the outcome
Eddy Ives 2012
[37] • BMI (z-score)
• Waist circumference and associated z- score
Not described 12 months (intervention end) No significant differences between groups.
BMI and waist circumference z-scores decreased significantly in both groups.
Fleischman 2016
[38] • BMI (percentile and z-score)
• Waist circumference
• Blood pressure
Measurements by trained nurses, blinded to assignment. Blood pressure measured by auscultation.
3 months, 6 months (intervention end), 9 months and 12 months
No significant difference between groups.
Significant decrease in BMI z-score (-0.11) at 6 months in IG.
Patrick 2006 [26]
Rosenberg 2007 [34]
BMI (z-score) Measures obtained 2x by trained
research staff. 12 months (intervention end) No significant differences between groups.
Patrick 2013 [27] 1. BMI (percentile and z-score)
2. Percentage of body fat 1. Precise measure not described
2. Dual energy X-ray absorptiometry 12 months (intervention end) No significant differences between groups.
Love-Osborne
2014 [39] BMI (z-score) Measures obtained at end of intervention
visit (not described). 6-8 months (intervention end) Unclear significance of findings: BMI z-score decreased significantly (by ≥ 0.1) in 40% of the CG vs 18% of the IG (p = 0.02). Post-hoc analysis revealed that sports participation was significantly higher in CG (47%) vs the IG (28%, p = 0.02).
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a
