A multicomponent household intervention, mixed with salt discount for kids with obesity_ a factorial randomized examine protocol



Main goal

Decide whether or not a factorial design of dietary intervention primarily based on the PHD mixed with bodily workout routines carried out with members of the family reduces extreme weight achieve in youngsters with weight problems.

Secondary aims

1) Decide whether or not using low-sodium salt added to anti-inflammatory herbs reduces the blood strain of child-guardian pairs. 2) Decide if the household intervention promoted weight lack of the child-guardians. 3) Examine the impact of the intervention on whole bodily exercise and sedentary time in youngsters and guardians.

Design of the examine


Factorial randomized medical trial for the therapy of weight problems with youngsters between 7 and 12 years of age. Youngsters and one in every of their guardians shall be randomized to intervention with steerage relating to food regimen primarily based on the PHD, on portion dimension discount and a bodily train program or management with basic wholesome consuming steerage for a interval of three months. The rules shall be directed to all members of the family. Moreover, pairs in every arm will cross-receive a low-sodium salt added anti-inflammatory spices in comparison with a placebo salt (regular sodium content material). The teams shall be randomly subdivided into 4 teams of 27 people: 1 subgroup of the intervention group and 1 subgroup of the management group will obtain hyposodium natural salt, and the opposite 2 teams will obtain placebo for 1 month. After 1 month of washout, the teams will obtain the salt cross-label (Fig. 1). The protocol is reported in keeping with the Customary Protocol Objects: Suggestions for Interventional Trials (SPIRIT) [25].

Fig. 1 Flowchart of the examine Full dimension picture

Recruitment and choice

Inclusion and exclusion standards

Recruitment for the examine shall be performed via varied channels, together with colleges in Rio de Janeiro, a public college’s banner and radio, and social media platforms. contributors can register by emailing their info primarily based on the eligibility standards. As soon as chosen, contributors shall be scheduled for an preliminary face-to-face session the place they’ll obtain all related details about the undertaking and supply their knowledgeable consent.

Households with not less than one baby aged 7 to 12 years with obese or weight problems (Z rating 1.5) and who make not less than 1 meal at house per day shall be included within the examine.

The exclusion criterion shall be primarily based on the identified preexistence of genetic problems or endocrine problems related to weight problems, in addition to youngsters with some incapacity that stops anthropometric measurements. Sufferers utilizing weight reduction medicines and in steady corticosteroid use and households which have not less than one member who has an allergy or another restriction to some ingredient in hyposodium natural salt shall be excluded. All this info shall be obtained via a questionnaire accomplished by the guardian and the kid.

Pattern dimension and randomization process

The pattern dimension of 48 pairs (baby and one guardian) per group was calculated from a normal deviation for BMI equal to three.0 and an anticipated distinction of 1.72 models of BMI within the baby [26] between the teams, contemplating a statistical energy of 80% and significance degree of 5%. This pattern dimension of 96 pairs, 192 people plus an anticipated dropout of 10% of the contributors make a remaining pattern of 108 pairs (54 pairs in every group). After the recruitment part, contributors thought of eligible shall be randomly allotted to the management group or intervention group. The randomization shall be carried out in blocks of 8 people utilizing a sequence of random numbers generated by a pc.

The mandatory pattern dimension for modifications in blood strain was primarily based on information for adults (the guardians) of the DASH (Dietary Approaches to Cease Hypertension (Sacks et al.) and a Brazilian dietary intervention trial for adults [27]. The Brazilian trial targeted on salt consumption discount, and after 6 months, systolic blood strain was decreased by 14·4 mmHg and diastolic blood strain by 9·7 mmHg within the experimental group in contrast with 6·7 and 4·6 mmHg, respectively, within the management group. A pattern dimension of thirty-one topics per arm (whole 62) assumed a discount in systolic blood strain of seven·1 mmHg and a normal deviation of 10 mmHg [28] with a significance degree of 5% and 80% energy.

Due to this fact, the pattern dimension for the change in BMI additionally allowed us to guage modifications in blood strain, not less than for adults.


We used sequentially numbered, opaque paper baggage with the salt and utensils given to the kids´s household to protect allocation concealment.


The intervention will happen via face-to-face consultations in a reserved room on the State College of Rio de Janeiro by a workforce of nutritionists and bodily schooling lecturers. There shall be 6 consultations. The primary and the final with a 15-day break. The others had been carried out month-to-month. The timeline of the interventions and the devices used within the preliminary measurement and follow-up are described beneath within the SPIRIT timetable of the examine introduced in Fig. 2.

Fig. 2 Overview of the examine interval (SPIRIT Fig. 2013) Full dimension picture

Dietary pointers on the wholesome planetary food regimen

The dietary pointers shall be primarily based on the gadgets that make up the Planetary Food plan Index. They’re nuts and peanuts; greens, fruits, and greens; entire grains; eggs; fish; tubers; milk and dairy merchandise; vegetable oils; purple meat; hen; animal fats and added sugar. An adaptation of the proposal that shall be used will be seen in Fig. 3.

Fig. 3 Tailored plan of the Planetary Wholesome Food plan for the Brazilian food regimen Full dimension picture

As an incentive, the intervention group will obtain all through the intervention interval a cookbook, a calendar of meals objectives, a booklet of steerage in relation to meals, steerage relating to the acquisition of wholesome meals produced domestically, the significance of shopping for meals from the crop, and lowering loss and waste and studying labels.

By means of a Meals Frequency Questionnaire (FFQ), we will higher perceive the every day lifetime of the household and thus set up objectives that the household should obtain, which can assist adherence to PHD. Every month, the kid and his household shall be inspired to decide on one of many following objectives: 1) cut back the consumption of ultra-processed meals, 2) improve the consumption of nuts, 3) attempt recipes with full use of meals, 4) cut back the consumption of purple meat, 5) improve the consumption of entire grains, 6) improve the consumption of fruits, and seven) improve the consumption of greens and greens. A calendar shall be offered each month, and stickers shall be offered for the household to fill the times they will obtain the objectives proposed by the professionals. It’s a playful means for the kid and their guardian to be inspired to observe the proposed pointers.

Along with the objectives, every assembly shall be held as an academic exercise with the kid and their guardian. The primary has already been examined by the analysis group in a earlier examine and is predicated on the diploma of meals processing and encouragement to buy meals at road markets [29]. The second exercise goals to extend and diversify the consumption of contemporary meals bought at road markets, encouraging a extra energetic participation of youngsters of their food regimen. The third exercise is expounded to the consumption of entire grains. As well as, recipes and ludic actions to be carried out at house shall be delivered to the contributors.

The management group will obtain basic wholesome consuming pointers primarily based on these promoted in major care for kids with weight problems and also will obtain hyposodium natural salt within the crossover design. Supplies developed for the experimental group shall be given to the management group on the finish of the examine.

Hyposodium salt

Natural salt consists of 25% potassium chloride (KCl) and 10% a combination of rosemary, turmeric, basil, mint and oregano and shall be delivered together with info on how one can apply it to the day of the primary appointment. The placebo salt is a mixture of standard salt and pink Himalaya salt.


Discount of portion sizes

Youngsters within the intervention group shall be supplied with utensils that encourage them to scale back the scale of their parts: a soup plate with a coloured border, a protracted and slim glass and a bowl of decreased dimension [7]. Youngsters shall be instructed to eat all meals, when doable, on the utensils obtained.

Each the provide of salt and utensils goal to stimulate the home manufacturing of meals, and, periodically, easy recipes shall be supplied to households.

Bodily exercise and sedentary habits

The contributors within the intervention group will obtain a dance choreography video plus two or three fitness center class hyperlinks accessible on YouTube every week to extend moderate-to-vigorous bodily exercise. On common, the length of the video courses is 45 min. Firstly of the intervention, a equipment of sports activities supplies containing ropes and balls and a booklet with details about the rules on bodily exercise and sedentary habits for kids and adolescents shall be offered.

To enhance adherence to the intervention, a set of motivational messages shall be despatched every week through WhatsApp, encouraging youngsters to carry out the actions. Moreover, youngsters and their guardians will obtain an inventory of objectives to scale back sedentary time and improve bodily exercise all through the analysis interval, and they’ll select two of them to attain every week.

Information evaluation

The speed of change within the major and secondary outcomes over time shall be investigated by intention-to-treat evaluation utilizing mixed-effects fashions, which permit us to contemplate incomplete follow-up information and the correlation of repeated measures. The verification of the adequacy of the fashions shall be finished graphically via the analysis of the residues [30]. SAS software program, model 9.4 (SAS Institute, Cary, NC, USA) shall be used. In secondary analyses, with measurements of a couple of member of the family, the correlation of the household cluster within the change estimates shall be thought of.


Main final result

The first final result of the examine would be the variation within the youngsters’s physique mass index (BMI). Physique weight shall be measured on a conveyable digital scale (Tanita BC-558). Top shall be measured in duplicate with using a conveyable anthropometer of the model Altura Exata. Each measurements shall be measured with the assessed, barefoot, sporting gentle clothes, with out props within the hair, with the arms prolonged to the aspect of the physique, positioned by the horizontal airplane of Frankfurt. The classification of dietary standing shall be carried out primarily based on BMI/age values, in z scores, utilizing the brand new curves of the World Well being Group with using the software program WHO-Anthro Plus 2007 [31]. The values obtained shall be labeled in keeping with the cutoff factors beneficial by the WHO for kids over 5 years of age, being underweight: beneath –2Z; eutrophy: between –2 and + 1Z; obese: between + 1 and + 2Z; weight problems between + 2Z and + 3Z and extreme weight problems above 3Z of the reference median. This classification shall be carried out at baseline to substantiate the inclusion standards.

Secondary outcomes

Blood strain shall be measured with an digital and digital gadget Omron® Hem 742, beforehand validated to be used in youngsters [32]. Earlier than taking the measurement, it will likely be licensed that the kid or adolescent doesn’t have a full bladder, has not ingested medicines and/or espresso, has not eaten as much as 30 min earlier than the process and/or practiced bodily workout routines as much as 1 h earlier than. The measurement shall be carried out on the suitable arm, on the similar degree as the center, supported on a desk with a flat floor, with the palm of the hand going through up and the elbow barely flexed. The person ought to be seated, with toes in touch with the ground or flat floor platform, and stay on this place for five min at relaxation earlier than the measurement [33]. Two BP measurements shall be carried out, with a minimal interval of two min, and the imply of the two measurements shall be calculated. If the distinction between the two measurements is bigger than or equal to five mmHg, a brand new measurement shall be taken.

The opposite secondary outcomes of the examine investigated shall be variations within the BMI of the accountable particular person, waist circumference (WC), waist top ratio (WHtR), and urinary sodium/potassium.

The grownup BMI is obtained via weight (kg) divided by top (m) squared. The values obtained shall be labeled in keeping with the cutoff factors beneficial by the WHO for adults over 18 years of age, being underweight: beneath 18.5; eutrophy: between 18.6 and 24.9; obese: between 25.0 and 29.9; grade I weight problems: between 30.0 and 34.9; grade II weight problems: between 35.0 and 39.9 and grade III weight problems: above 40.0.

For the measurement of WC, a versatile and inelastic tape measure shall be used, with an amplitude of 150 cm and a variation of 0.1 mm. WC shall be measured with tape positioned horizontally on the midpoint between the decrease fringe of the final rib and the iliac crest. The measurements shall be carried out with the tape agency on the pores and skin, nonetheless, with out compression of the tissues, being the evaluated standing with relaxed stomach and with the arms prolonged to the aspect of the physique. For the QC, the tape measure shall be positioned horizontally across the hip in probably the most protruding a part of the buttocks [34]. The WHtR shall be obtained by the ratio between WC and top, each in centimeters.

To measure urinary sodium and potassium, the spot urine technique shall be used [35]. A clear and sterile bottle shall be offered. The participant shall be instructed to open the bottle solely on the time of assortment to keep away from contamination. The pot with the urine collected at any time of the day shall be packed in Styrofoam and brought to the laboratory.

Measures of adherence to intervention


Meals consumption shall be evaluated by the Meals Frequency Questionnaire administered at baseline and on the finish of the examine. Based mostly on the responses, particular person objectives shall be created, and the intervention group will obtain a calendar that goals to watch the achievement of those established objectives.

The bodily exercise of the guardians shall be assessed utilizing the IPAQ-SF [36] and kids utilizing the PAQ-C [37]. As well as, moderate-to-vigorous bodily exercise and sedentary time for kids shall be assessed utilizing triaxial accelerometers (ActiGraph GT3x-BT, Pensacola, FL, USA) [38] positioned on the nondominant wrist for 7 consecutive days at baseline and after the intervention interval. The adherence to the train protocol shall be evaluated via a questionnaire on the finish of the intervention, the place contributors ought to report what number of courses per week had been carried out.

Moral points

This examine was reviewed and accredited by the Analysis Ethics Committee of the Instituto de Medicina Social Hésio Cordeiro, State College of Rio de Janeiro (CAAE 59008422.8.0000.5260). That is an IRB (institutional evaluate board). Knowledgeable consent shall be obtained from all contributors and their authorized guardians by signing the consent type of guardians and kids’s consent, pursuant to Decision nº 466/2012.

The examine protocol is registered within the digital platform of free entry for registration of experimental and nonexperimental research performed in people and performed in Brazilian territory, the Brazilian Registry of Scientific Trials (RBR-10 mm62vs). The outcomes of the examine shall be introduced in keeping with the rules of the consolidated report for medical research – CONSORT (Consolidated Requirements of Reporting Trials) [39].