the epidemic of childhood obesity is no more limited to high - income countries , and has become as one of the most important global health problems of the 21 century . the world health organization ( who ) experts have estimated that there are 43 million overweight children under the age of 5 and by 2020 more than 60% of global disease burden will be the result of obesity related disorders . childhood obesity is associated with several short term and long - term health hazards as cardiovascular diseases , hypertension , type 2 diabetes , fatty liver disease , orthopedic problems , low self - esteem , etc . although both genes and environment have a role in an obesity epidemic , gene defects needs to time to show their phenotype ; so obesogenic environment is responsible for obesity . primordial / primary prevention of pediatrics obesity and establishment of a healthy lifestyle behaviors from early life are the favored against the epidemic of obesity at the global level . effective interventions for prevention and control of childhood obesity should be considered for different aspects . experts recommend specific eating and physical activity ( pa ) behaviors through counseling . along with clinic - based interventions , researchers have attempted to manage obesity by virtue of family , community , school , and after school programs . based on cochrane review of obesity prevention programs in children , most of the well - designed interventions had positive results especially in 6 - 12-year - old children . clearly targeted interventions for children and population - based approach for adolescents may be useful and make economic sense . the purpose of this investigation was to systematically review the effects of various clinical- , family- , and community - based interventions targeting the control of childhood obesity and make a suggestion for future interventions . relevant literature reporting the interventions for controlling excess weight in children and adolescents was identified through electronic search of papers published from 2000 to 2012 in medline , pubmed , isi web of science , and scopus . keywords such as  childhood obesity  ,  overweight ,   weight disorder ,   intervention ,   treatment ,   management ,   control , nutrition ,   behavior therapy ,  and  diet therapy  were used . the relevant papers were selected in three phases . in the first and second phases , titles and abstracts of papers were screened and irrelevant papers were excluded . in the last phase , the full text of recruited papers was explored deeply to select only relevant papers . all these three screening phases were done by two independent reviewers ( rk and fa ) . studies were included if they met the following criteria : studies on 2 - 18-year - old children ; community , family , school , and clinic interventions or a combination of them ; english language ; and conducted among obese or overweight children and adolescents . the required information that was extracted from all eligible papers was as follow : 
 ( i)general characteristics of the study ( first author 's name , publication year , study year , study design , sampling method,(ii)characteristics of the study population ( age and sex of studied participants and sample size , follow - up),(iii)type and duration of the intervention , measure(s ) used to assess child weight , and(iv)main finding . one reviewer ( fa ) extracted the data while another ( rk ) randomly selected 10% of them and checked their extracted data . general characteristics of the study ( first author 's name , publication year , study year , study design , sampling method , characteristics of the study population ( age and sex of studied participants and sample size , follow - up ) , type and duration of the intervention , measure(s ) used to assess child weight , and main finding . one reviewer ( fa ) extracted the data while another ( rk ) randomly selected 10% of them and checked their extracted data . relevant literature reporting the interventions for controlling excess weight in children and adolescents was identified through electronic search of papers published from 2000 to 2012 in medline , pubmed , isi web of science , and scopus . keywords such as  childhood obesity  ,  overweight ,   weight disorder ,   intervention ,   treatment ,   management ,   control , nutrition ,   behavior therapy ,  and  diet therapy  were used . having removed duplicates , the relevant papers were selected in three phases . in the first and second phases , titles and abstracts of papers were screened and irrelevant papers were excluded . in the last phase , all these three screening phases were done by two independent reviewers ( rk and fa ) . studies were included if they met the following criteria : studies on 2 - 18-year - old children ; community , family , school , and clinic interventions or a combination of them ; english language ; and conducted among obese or overweight children and adolescents . the required information that was extracted from all eligible papers was as follow : 
 ( i)general characteristics of the study ( first author 's name , publication year , study year , study design , sampling method,(ii)characteristics of the study population ( age and sex of studied participants and sample size , follow - up),(iii)type and duration of the intervention , measure(s ) used to assess child weight , and(iv)main finding . one reviewer ( fa ) extracted the data while another ( rk ) randomly selected 10% of them and checked their extracted data . general characteristics of the study ( first author 's name , publication year , study year , study design , sampling method , characteristics of the study population ( age and sex of studied participants and sample size , follow - up ) , type and duration of the intervention , measure(s ) used to assess child weight , and main finding . one reviewer ( fa ) extracted the data while another ( rk ) randomly selected 10% of them and checked their extracted data . the interventions were categorized as school - based , family - based , and clinic - based programs as described below : a summary of the school - based obesity prevention and control programs is presented in table 1 . in brief , such interventions are suggested to be feasible and effective ; because students spend a considerable part of their time in school , moreover teachers and peers can be engaged in such programs . they are characterized by nutritional education and changes in dietary habits , as well as increase in pa through structured programs . findings of various studies proposed that the effects of such interventions will be preserved for several years after intervention . this effect has been of special concern about consuming fruits and vegetables , and healthy snacks , as well as increased pa . nevertheless , the impact of school - based programs on obesity prevention is controversial and remains to be determined by large studies with long - term follow - up research . some studies have not evaluated the effect of intervention on anthropometric measures , but they have shown positive impacts on eating and activity behaviors . the most common limitation of these studies is presenting self - reported data , non - randomized selection of schools , short duration of study , and not masking the interventional groups . school - based weight control studies reaching a healthy weight is not successful unless children have support for making healthy behavior choices ; obviously , providers of this support are families . family - based intervention programs are considered as one of the most successful methods for obesity treatment or prevention . engaging parents in childhood obesity prevention programs may make weight loss easier for children ; because they can provide confirmatory conditions to help their children to choose healthy behaviors , furthermore they are important role models for their children . it is difficult for parents to know and accept that their child has excess weight , and that recommended diets would not have adverse health effect for their children ; therefore , they often do not comprehend the necessity of obesity prevention . families are able to construct children 's lifestyle habits , perhaps through their  parenting style  and management of  family functioning . table 2 shows family - based interventions for management of childhood obesity . as it demonstrates , most of these programs were successful in decreasing body mass index ( bmi ) z - score and some health consequences of overweight . after participation of parents in these kinds of programs , their children consumed more fiber and were less sedentary . in some cases , significant decrease in fat mass is documented , as well . it has shown that low parental confidence predicts dropout rate from family - based behavioral treatment . the main limitation of family - based studies is the small sample size , high dropout rate , no follow - up data , and selection of motivated families . family - based studies for controlling childhood obesity table 3 presents a summary of clinic - based weight management programs conducted in the pediatric age group . although most researchers have tried low calorie - low fat diets for treating obesity , experts have recommended to consider a diet with balanced macronutrients . nevertheless , different dietary changes have been tried to control excess weight in children and adolescents . high protein ( hp ) diets seems to make more satiety , but two studies did not confirm their advantage versus standard diets . clinic - based weight control studies for children and adolescents in studies in which diet , exercise or both of them were taken into account , nutrition plus pa had more effect on anthropometric indices . one study showed that combination of aerobic and strength training along with diet therapy results in bmi decrease in comparison with strength training plus diet recommendation . a successful experience is reported about the favorable effects of zinc supplementation on anthropometric and metabolic indices . obesity behavioral therapy has different parts such as motivational interviewing , goal setting , positive reinforcement , monitoring , and cognitive restructuring . most of behavioral therapies had positive consequences on weight , bmi , or dietary and pa habits . all interventions that consisted of nutrition , exercise , and counseling had significant effects on body weight or other obesity - related factors except for a study , which had beneficial effects only on obesity related behaviors . the main limitation of some of these studies is lack of comparison with the control group , and short - term follow - up of participants , and the uncertain sustainability of such kinds of interventions . a summary of the school - based obesity prevention and control programs is presented in table 1 . in brief , such interventions are suggested to be feasible and effective ; because students spend a considerable part of their time in school , moreover teachers and peers can be engaged in such programs . they are characterized by nutritional education and changes in dietary habits , as well as increase in pa through structured programs . findings of various studies proposed that the effects of such interventions will be preserved for several years after intervention . this effect has been of special concern about consuming fruits and vegetables , and healthy snacks , as well as increased pa . nevertheless , the impact of school - based programs on obesity prevention is controversial and remains to be determined by large studies with long - term follow - up research . some studies have not evaluated the effect of intervention on anthropometric measures , but they have shown positive impacts on eating and activity behaviors . the most common limitation of these studies is presenting self - reported data , non - randomized selection of schools , short duration of study , and not masking the interventional groups . reaching a healthy weight is not successful unless children have support for making healthy behavior choices ; obviously , providers of this support are families . family - based intervention programs are considered as one of the most successful methods for obesity treatment or prevention . engaging parents in childhood obesity prevention programs may make weight loss easier for children ; because they can provide confirmatory conditions to help their children to choose healthy behaviors , furthermore they are important role models for their children . it is difficult for parents to know and accept that their child has excess weight , and that recommended diets would not have adverse health effect for their children ; therefore , they often do not comprehend the necessity of obesity prevention . families are able to construct children 's lifestyle habits , perhaps through their  parenting style  and management of  family functioning . table 2 shows family - based interventions for management of childhood obesity . as it demonstrates , most of these programs were successful in decreasing body mass index ( bmi ) z - score and some health consequences of overweight . after participation of parents in these kinds of programs , their children consumed more fiber and were less sedentary . in some cases , significant decrease in fat mass is documented , as well . it has shown that low parental confidence predicts dropout rate from family - based behavioral treatment . the main limitation of family - based studies is the small sample size , high dropout rate , no follow - up data , and selection of motivated families . table 3 presents a summary of clinic - based weight management programs conducted in the pediatric age group . although most researchers have tried low calorie - low fat diets for treating obesity , experts have recommended to consider a diet with balanced macronutrients . nevertheless , different dietary changes have been tried to control excess weight in children and adolescents . high protein ( hp ) diets seems to make more satiety , but two studies did not confirm their advantage versus standard diets . clinic - based weight control studies for children and adolescents in studies in which diet , exercise or both of them were taken into account , nutrition plus pa had more effect on anthropometric indices . one study showed that combination of aerobic and strength training along with diet therapy results in bmi decrease in comparison with strength training plus diet recommendation . a successful experience is reported about the favorable effects of zinc supplementation on anthropometric and metabolic indices . obesity behavioral therapy has different parts such as motivational interviewing , goal setting , positive reinforcement , monitoring , and cognitive restructuring . most of behavioral therapies had positive consequences on weight , bmi , or dietary and pa habits . all interventions that consisted of nutrition , exercise , and counseling had significant effects on body weight or other obesity - related factors except for a study , which had beneficial effects only on obesity related behaviors . the main limitation of some of these studies is lack of comparison with the control group , and short - term follow - up of participants , and the uncertain sustainability of such kinds of interventions . the design of most studies is a clinical trial , it makes their comparison easier . most ( 29/32 ) of the papers reported a positive effect of school - based intervention on dietary habits or anthropometric measures . this may persuade them to get involved in healthier lifestyle or might have opposite results . all of the studies conducted in the family setting ( n = 26 ) , had favorable results on obesity criteria . although some of them had negligible effects . one explanation for this can be self - reported dietary intake and pa data . on the other words , children may not pay attention to the instruction they were given . teachers can train students how to choose nutritious and low - calorie foods . in addition most students with excess weight prefer to eat fatty , sweetened , and salty snacks ; they also choose fast foods as their first meal preference . if attendants get involved in obesity prevention programs , they can provide an environment for children to purchase healthy snacks and foods . furthermore , if parents recognize the importance of weight control , they will be motivated to persuade their children for weight control . families , especially mothers , are the best paradigm for children to learn a healthful eating pattern and activity habits . through family meals , children can eat more whole grains , fruits , vegetables , low fat milk , and consume less sweets and unhealthy fats . parents should involve kids in preparing food to make a positive effect on their attitudes toward obesity prevention . it seems that the family has a key role in long - term weight control . it has been shown that if family confidence is low , rate of dropout from weight loss programs will increase . in this regard , providing parenting styles and skills as well as child management strategies are really critical . principally clinic - setting programs have brought nutrition , pa , and education or counseling together to achieve their goals and they have demonstrated long lasting results . most experts advise a low calorie low fat diet for obesity management ; but they may have side - effects such as binge eating . actually weight loss is allowed in severe obesity and in other cases weight maintenance is an appropriate policy . a review article revealed that low carbohydrate ad libitum diets are as effective as calorie restricted diets . in addition , a cochrane review showed that low fat diets have no extra advantages in comparison with other diets with calorie restriction . clearly , pa is efficient when lasts for more than 60 min , is moderate to vigorous , and is done in all weekdays . as low calorie diets are harmful for growth , and complying with them is difficult , some studies suggested that vigorous exercise can be a suitable substitute for diet therapy . as always emphasized , to be effective , pa should be considered as an enjoyable fun , and should be integrated into daily lifestyle . obesity causes mental problems in children and adolescents , so behavior therapy seems to be vital . it sounds that group treatment is more successful than individual ones ; specifically when parents are engaged . counselors should persuade children and adolescents to eat breakfast , to have structured meal plan to increase consumption of fruits , vegetables , and family meals , as well as to decrease the intake of sweetened beverages , calorie - dense foods , and eating out , as well as reducing the sedentary behaviors and the screen time . unfortunately , most studies did not show favorable effects , many of them had small sample sizes or had short - term follow - up or lacked of the control group . managing extra group support sessions or using technologies such as e - mail or sms for monitoring weight losers can be a good idea . the findings suggest that among different types of interventional programs for management of childhood obesity , a multidisciplinary approach in schools in which children 's family are involved , can be the most feasible and effective approach . as teachers and parents are the best role models , it will be easier to accustom children with healthy dietary , pa , and behavioral habits . future studies are needed to determine the long - term effects and sustainability of different programs . fas contributed in the conception of the work , conducting the review , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work . rk contributed in the conception and design of the work , drafting and revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work .
background : childhood obesity is a global health problem with short- and long - term health consequences . 
 this systematic review presents a summary of the experiences on different family- , school- , and clinic - based interventions.materials and methods : electronic search was conducted in medline , pubmed , isi web of science , and scopus scientific databases . 
 we included those studies conducted among obese individuals aged up to 18 years . 
 our search yielded 105 relevant papers , 70 of them were conducted as high quality clinical trials.results:our findings propose that school - based programs can have long - term effects in a large target group . 
 this can be related to this fact that children spend a considerable part of their time in school , and adopt some parts of lifestyle there . 
 they have remarkable consequences on health behaviors , but as there are some common limitations , their effects on anthropometric measures are not clear . due to the crucial role of parents in development of children 's behaviors , family - based interventions are reported to have successful effects in some aspects ; but selection bias and high dropout rate can confound their results . 
 clinic - based interventions revealed favorable effects . 
 they include dietary or other lifestyle changes like increasing physical activity or behavior therapy . 
 it seems that a comprehensive intervention including diet and exercise are more practical . 
 when they have different designs , results are controversial.conclusion:we suggest that among different types of interventional programs , a multidisciplinary approach in schools in which children 's family are involved , can be the best and most sustainable approach for management of childhood obesity .