Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors

One-year predictors of smoking initiation and of continued smoking among elementary schoolchildren in multiethnic, low-income, inner-city neighbourhoods

OBJECTIVE

To identify one-year predictors of smoking initiation among never-smokers, and of continued smoking among ever-smokers.

DESIGN

Two sequential cohorts of grade 4 and 5 children. Data were collected as part of Coeur en sante St Louis du Parc, a non-randomised controlled trial to evaluate the impact of a school-based heart health promotion programme.

SETTING

24 inner-city elementary schools located in multiethnic, low-income neighbourhoods in Montreal.

SUBJECT

1824 schoolchildren aged 9-12 years with baseline and one-year follow-up data.

MAIN OUTCOME MEASURES

Changes in smoking behaviour over a year; the ability of baseline data to predict smoking initiation and continued smoking a year later was investigated in logistic regression analyses.

RESULTS

The prevalence of ever-smoking was 21.1% at baseline and 30.2% at one-year follow up. One in six never-smokers initiated smoking; one in three ever-smokers continued smoking. Predictors of initiation included age (odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3 to 2.0), male gender (OR = 1.5 (95% CI = 1.1 to 2.0)), friends who smoke (OR = 2.3 (95% CI = 1.7 to 3.3)), sibling(s) who smoke (OR = 1.9 (95% CI = 1.2 to 3.1)), father/mother who smokes (OR = 2.2 (95% CI = 1.6 to 3.0)), and frequent high fat/"junk food" consumption (OR = 1.6 (95% CI = 1.1 to 2.1)). Age and friends who smoke were also independent predictors of continued smoking in both genders. In addition, in boys, current smokers at baseline were 2.6 times (95% CI = 1.4 to 5.0) more likely to continue smoking than past smokers. In girls, being overweight was associated with continued smoking (OR = 3.5 (95% CI = 1.6 to 7.6)).

CONCLUSIONS

Smoking prevention programmes should address parental and sibling influences on smoking, in addition to refusal skills training. Among girls, weight-related issues may also be important.

School-based interventions improve heart health in children with multiple cardiovascular disease risk factors

OBJECTIVE

To determine the immediate effects of two types of elementary school-based interventions on children with multiple cardiovascular disease (CVD) risk factors.

DESIGN

Randomized, controlled field trial.

SETTING

Conducted in 18 randomly selected elementary schools across North Carolina.

STUDY PARTICIPANTS

Four hundred twenty-two children age 9 +/- 0.8 years with at least two risk factors at baseline: low aerobic power and either high serum cholesterol or obesity.

INTERVENTION

Both 8-week interventions consisted of a knowledge and attitude program and an adaptation of physical education. The classroom-based intervention was given by regular teachers to all children in the 3rd and 4th grades. The risk-based intervention was given in small groups only to children with identified risk factors. Children in the control group received usual teaching and physical education.

OUTCOME MEASURES

The primary outcome measure was cholesterol; additional measures were blood pressure, body mass index, body fat, eating and activity habits, and health knowledge.

RESULTS

Both interventions produced large reductions in cholesterol (-10.1 mg/dL and -11.7 mg/dL) compared with a small drop (-2.3 mg/dL) in the controls. There was a trend for systolic blood pressure to increase less in both intervention groups than in the controls. Both intervention groups had a small reduction in body fat and higher health knowledge than the control group.

CONCLUSIONS

Both brief interventions can improve the CVD risk profile of children with multiple risk factors. The classroom-based approach was easier to implement and used fewer resources. This population approach should be considered as one means of early primary prevention of CVD.

Parental smoking and risk factors for cardiovascular disease in 10- to 12-year-old children

OBJECTIVE

Smokers have multiple adverse health-related behaviors and an increased risk of cardiovascular disease. We examined whether health behaviors in parents who smoke may influence children's health behaviors.

STUDY DESIGN

Cross-sectional data from 10- to 12-year-olds (n = 800) entering a trial of health promotion programs.

RESULTS

Smoking in children was independently associated with maternal (odds ratio 2.1, confidence interval 1.2, 3.8) and paternal smoking (odds ratio 2.1, confidence interval 1.2, 3.7) and was less likely in girls (odds ratio 0.4, confidence interval 0.2, 0.6). Maternal smoking and paternal smoking were additive predictors in children of lower physical activity (P = .0013 for mothers; P = .0476 for fathers) and more television watching (P = .0335 for mothers; P = .0241 for fathers). Children's fat intake was significantly greater if either parent smoked. Children's body mass index (P = .0183) and waist-to-hip ratio (P = .0009) were significantly greater if mothers smoked.

CONCLUSIONS

Poor health behaviors associated with smoking in parents, particularly mothers, are likely to influence children's long-term risk of having lifestyle diseases. The results may also explain some of the apparent effects attributed to passive smoking in families.

Prevalence and correlates of early smoking among elementary schoolchildren in multiethnic, low-income inner-city neighborhoods

PURPOSE

The prevalence and correlates of early smoking were investigated among schoolchildren in grades 4-6 living in multiethnic, low-income neighborhoods in Montreal.

METHODS

As part of the evaluation of a school-based heart health promotion program, baseline data on the prevalence of early smoking were collected from 2285 students aged 9-13 years in 24 inner-city elementary schools during May-June 1993.

RESULTS

Overall, 28.7% of boys and 20.3% of girls had smoked. Girls began trying later than boys, but by age 13 the prevalence of experimental or regular smoking by girls overtook that of boys. Univariately, ever smoking varied considerably by family origin, from 2.1% among Vietnamese girls, to 35.8% among Portuguese boys. In multivariate analysis, age, perceived smoking habits of friends, and smoking by family members, were strong correlates of smoking. Being of Asian family origin was negatively associated with smoking. None of the indicators of social class were significantly associated with ever smoking.

CONCLUSIONS

Smoking prevention should begin with children even younger than age 9 in multiethnic, low-income, inner-city neighborhoods. With the exception of a lower prevalence of smoking among Asian children, ethnicity and social class were not strong influences on early smoking behavior in this population.

2-year tracking of children's fruit and vegetable intake

OBJECTIVE

To evaluate the tracking of children's fruit and vegetable intake over 2 years.

DESIGN

Children in the control group from the Gimme 5 nutrition education intervention trial completed three 7-day food diaries once a year in 1994, 1995, and 1996, beginning when they were in third grade.

SUBJECTS

Five hundred sixty-one students from public elementary schools.

STATISTICAL ANALYSES PERFORMED

Tracking was examined through correlation of fruit and vegetable servings over the 2 years as well as the percent of subjects remaining in the same or adjacent quintiles of fruit and vegetable intake, using the kappa statistic.

RESULTS

Tracking of fruit and vegetable intake was fair to moderate over the 2 years. One-year correlations for total fruit and vegetable servings were .37 for boys and .46 for girls; 2-year correlations were .48 for boys and .40 for girls. kappa values for remaining in the same quintile generally exceeded chance rates only for the top and bottom quintiles. No values exceeded .50. APPLICATION/CONCLUSION: The drift in ranking may have been a result of true changes in fruit and vegetable intake or measurement error (i.e., inability to accurately assess actual intake). If this drift reflects true change, it may be difficult for nutrition education programs targeting this age group to demonstrate long-term behavioral effects on fruit and vegetable intake. If the drift is the result of measurement limitations, improved dietary assessment may yield stronger tracking.

Australian Students' Preferences for School-Based Smoking Cessation Programs

Estimates of daily smoking as high as 15 percent by Year 10 students (average age 15) suggest there is an urgent need to focus attention on the formulation of school-based cessation programs for young smokers, as an adjunct to existing prevention focused programs which serve the majority of young non-smokers. The purpose of this study was to gather recommendations from student smokers (in the middle high school years, about 15 years of age) which may be used in the design of school-based smoking cessation programs. This study investigated the opinions of 2865 smoking and nonsmoking Year 10 students drawn from twenty-one metropolitan high schools in Brisbane, Australia. The majority of students, including smokers, were supportive of school-based smoking cessation programs. Smokers reported a preference for the program to be voluntary, to be accessible during school time, and facilitated by other students or non-teaching personnel. A clear preference for individualized attempts to quit over more structured or group programs was evident. The majority of smokers reported that they preferred to quit on their own. They, however, also recognized the value of assistance from a supportive friend or being in a group of students who helped one other. In general, male and female students expressed the same preferences regarding methods of quitting. Males, however, appeared more difficult to motivate and more skeptical of quitting programs. Specific ideas for identifying students who may have higher support needs when quitting are provided.

Validity and reliability in a Flemish population of the WHO-MONICA Optional Study of Physical Activity Questionnaire

PURPOSE

This study assessed the validity and reliability of a self-administered physical activity questionnaire used in the WHO-MONICA project.

METHODS

Subjects (N = 167) were physical education and physical therapy alumni. The questionnaire (MOSPA-Q) covers a 1-yr period and measures the average weekly time and energy expenditure spent in one's occupation, transport-related activities, household chores, and leisure time activities. Test-retest reliability was reported as the intra-class correlation between calculated time or energy expenditure in different questionnaire items determined from two MOSPA-Q administrations. Validity was assessed using biometrical and physiological parameters as criterion measures.

RESULTS

Test-retest reliability ranged from 0.45 to 0.92 with the highest correlation coefficients obtained for the leisure time physical activities. The correlation between calculated daily total energy expenditure (TEE, Kcal.d-1) and lean body mass was 0.53 (P < 0.001). The correlation between energy expenditure in leisure time activities (Kcal.wk-1) and VO2peak was 0.44.

CONCLUSIONS

The MOSPA-Q provides a relatively valid and reliable estimate of physical activity.

The association between anger and hostility and risk factors for coronary heart disease in children and adolescents: a review

We reviewed the published literature on the association between anger and hostility and risk factors, both physiologic and behavioral, for coronary heart disease (CHD) in youth. The rationale for this review is based on observations that pathology and risk factors associated with CHD in adults, as well as patterns of expressing anger and hostility, often begin in childhood and adolescence; hence, it is imperative that we better understand the relationship between anger and CHD risk factors in young people if we are to develop interventions to change risk factor profiles. The first section discusses development of CHD risk factors and describes studies of the pathologic precursors of CHD that demonstrate the early age of onset for pathologic changes, the tracking of physiologic and behavioral risk factors from youth to adulthood, and the young age of initiation of behavioral risk factors associated with CHD. The second section discusses both the development and tracking of the constructs of anger and hostility. The third section provides a review of the epidemiologic studies that assess the association between anger or hostility and both physiologic and behavioral CHD risk factors among school-age children. The final section provides an analysis and synthesis of the preceding sections and makes suggestions for further research.

Exercise and its role in the prevention and rehabilitation of cardiovascular disease

The purpose of this article is to review the beneficial effects of regular exercise in the primary and secondary prevention of coronary artery disease (CAD). Epidemiologic studies indicate that a physically inactive life-style is associated with twice the risk of developing CAD. The magnitude of risk is similar to that of other modifiable risk factors. Meta-analysis of studies of cardiac rehabilitation after myocardial infarction demonstrate that cardiac rehabilitation participants lower their risk of death by 20% to 25% compared to controls. Exercise training results in several beneficial physiological changes including an increase in exercise endurance, higher resting and exercise stroke volumes, lower resting and submaximal exercise heart rates, and increased capillary density and oxidative enzyme capacity in skeletal muscle. In patients with established CAD, exercise training improves symptoms of angina and congestive heart failure and attenuates the severity of exercise-induced ischemia. Regular exercise can favorably modify other risk factors, but the benefits are modest. Reductions in systolic and diastolic blood pressure readings average 6 to 9 mm Hg; decreases in total and low-density lipoprotein (LDL) cholesterol approximate 5 to 10 mg/dL; and increases in high-density lipoprotein (HDL) cholesterol approximate 2 mg/dL. Exercise training as a sole intervention does not appear to enhance smoking cessation. Regular exercise does improve psychosocial well-being. Most studies of physical activity have enrolled predominantly middle-aged men; however, available evidence suggests similar cardiovascular benefits for women, the elderly, and children and youth. Physical activity levels decrease substantially during the school-age-adolescent transition in both males and females. More than half of the adult population is sedentary or inactive. Collectively, accumulated data suggest the need for both individualized/high-risk and population-based approaches to increasing physical activity across the life span.

Cigarette smoking predicts development of depressive symptoms among U.S. adolescents

To examine whether adolescent cigarette smoking predicts the development of depressive symptoms, we used a longitudinal follow-up survey of 6,863 adolescents ages 12 to 18 in the U.S. who did not report notable depressive symptoms at baseline. This study used a self-report measure of six depressive symptoms experienced within the past twelve months at follow-up as the outcome of interest. Results indicated that 11.5% developed notable depressive symptoms at follow-up. There were marked gender differences with 15.3% of girls developing notable depressive symptoms compared to 8.1% of boys. Gender differences in depressive symptoms were consistent across all age groups and were apparent by the age of twelve. For both genders, smoking status was the most significant predictor of developing notable depressive symptoms. Several other risk factors including involvement in organized athletics, availability of social support, and personality characteristics were also found to be associated with development of depressive symptoms. Adolescent cigarette smoking may have marked health consequences in terms of depressive symptoms. The reduction of cigarette smoking among adolescents should be a focus of depression prevention interventions. In addition, the development of gender-specific components of prevention interventions may be warranted.

A controlled trial of health promotion programs in 11-year-olds using physical activity "enrichment" for higher risk children

OBJECTIVE

To evaluate the short and long term benefits of a school and home based physical activity "enrichment" program for children at higher risk of cardiovascular disease as identified by cluster analysis.

STUDY DESIGN

During two 10-week school terms, 800 11-year-olds took part in a randomized controlled trial with the standard physical activity and nutrition program in six schools, the standard program in a further seven schools but with the addition of physical activity enrichment for higher risk children in those schools, and no program in five control schools. Cluster analysis identifying the 29% or so highest risk children used systolic blood pressure, percent body fat, physical fitness, and blood cholesterol.

RESULTS

Fitness improved significantly in program schools, particularly with enrichment in higher risk boys. Substantial improvements persisted 6 months later in girls from program schools. At "Enrichment" schools, cholesterol showed significant benefits in higher risk girls and, 6 months later, in both boys and higher risk girls. Sodium intake and, in girls, subscapular skinfolds were lower in "Enrichment" schools when the program ended, but not 6 months later.

CONCLUSION

Two-semester health programs with physical activity enrichment for higher risk children can produce benefits sustained for at least 6 months. Improvements extend to lower risk children exposed indirectly to the enrichment. Attenuation of effects on diet and body composition in the longer-term suggest the need for on-going programs.

Stability of dental health behavior: a 3-year prospective cohort study of 15-, 16- and 18-year-old Norwegian adolescents

There is a need for a descriptive epidemiology of patterns of dental health behavior through adolescence.

OBJECTIVES

The purpose of this study was to assess the tracking (degree of stability) of several categories of self-reported dental health behavior in adolescence over a 3-year period.

METHODS

In 1992, a representative sample of 970 15-year-old adolescents of Hordaland county, Norway, completed questionnaires under supervision at school. Postal follow-up studies 1 and 3 years later provided 709 and 781 answers, respectively. The present analyses included 581 adolescents who participated on all three occasions and 670 adolescents who replied in 1992 and 1995. Paired sample t-tests, cross-tabulations and Pearson's correlation coefficients were used to assess stability. For use in the cross-tabulations all variables were transformed into binary categories (active and inactive).

RESULTS

A substantial proportion of adolescents remained consistently in the same behavioral category for all 3 survey years. Toothbrushing (80%) and use of dental floss (64%) were the most stable activities, while consumption of sugared mineral water (53%), intake of chocolate/sweets (52%) and use of F-rinse (54%) were less stable. However, Pearson's correlations between corresponding behaviors assessed in 1992 and 1995 were moderate and varied from 0.59 (toothbrushing) to 0.22 (F-rinse) (P<0.001).

CONCLUSION

The results do not conclusively indicate a pattern of tracking. The tendency is, however, clear enough to support the assumption that dental health behavior continues during adolescence into adulthood.

Changing fruit and vegetable consumption among children: the 5-a-Day Power Plus program in St. Paul, Minnesota

OBJECTIVES

A randomized school based trial sought to increase fruit and vegetable consumption among children using a multicomponent approach.

METHODS

The intervention, conducted in 20 elementary schools in St. Paul, targeted a multiethnic group of children who were in the fourth grade in spring 1995 and the fifth grade in fall 1995. The intervention consisted of behavioral curricula in classrooms, parental involvement, school food service changes, and industry support and involvement. Lunchroom observations and 24-hour food recalls measured food consumption. Parent telephone surveys and a health behavior questionnaire measured psychosocial factors.

RESULTS

The intervention increased lunchtime fruit consumption and combined fruit and vegetable consumption, lunchtime vegetable consumption among girls, and daily fruit consumption as well as the proportion of total daily calories attributable to fruits and vegetables.

CONCLUSIONS

Multicomponent school-based programs can increase fruit and vegetable consumption among children. Greater involvement of parents and more attention to increasing vegetable consumption, especially among boys, remain challenges in future intervention research.

Lessons from the Child and Adolescent Trial for Cardiovascular Health (CATCH): interventions with children

School-based, primary prevention programs can be effective in improving children's dietary intake of fat and saturated fat and in increasing their self-reported levels of physical activity. School environments can be modified to provide healthier food options in the school cafeteria and to increase the amount of moderate to vigorous physical activity occurring during physical education class.

Health-related behaviours and psycho-social characteristics of 18 year-old Australians

Psychosocial variables associated with health-related behaviours for diet, physical activity, alcohol consumption and smoking were examined in 18 year-old Australian men (n = 301) and women (n = 282). These psychosocial variables included Type A behaviour and depression, perceived self-efficacy for engaging in healthy behaviours and perceived barriers to performing these behaviours. Self-efficacy for following a healthy diet and moderating alcohol intake was greater in females but males had higher self-efficacy for physical activity. Self-efficacy for smoking did not differ according to gender. Lack of willpower was perceived as a barrier to desirable dietary, smoking and physical activity behaviours. Other perceived diet-related barriers included buying suitable foods when eating out, ignorance about appropriate foods and, in young women, perceived expense. Barriers for desirable levels of physical activity included planning time, tiredness, limiting social life and lack of social support. Social occasions were the main perceived barriers preventing both alcohol moderation and quitting smoking. Lack of family support, stress and concerns about weight gain, particularly in women, were perceived barriers to smoking cessation. Type A behaviour was associated with smoking and "unsafe" drinking in both men and women, generally unhealthy dietary choices in young women but with greater physical activity in young men. Depressive affect was significantly higher in female smokers and "unsafe" drinkers and tended to have an inverse relationship with physical activity in men and women. Depressive affect was inversely related to self-efficacy in both men and women for each of the health behaviours examined. Health promotion in young adults should therefore attempt to increase self-efficacy and address perceived barriers to change, taking into account gender-related differences in attitudes and the influence of depression and Type A characteristics on health-related behaviours.

Transitions out of high school: time of increased cancer risk?

BACKGROUND

The effectiveness of lifestyle behavior interventions with children to reduce chronic disease risks in adulthood assumes stability in the lifestyle behaviors across time. The transition out of high school is a time when many changes occur in social roles, e.g., changing schools, leaving the parents' home, changing peers, finding employment, getting married, and becoming a parent. Cancer risk behaviors may increase as a result of some of these social role changes.

METHODS

Concepts relevant to the stability or change in lifestyle behaviors through the transition out of high school are presented. Literature concerning diet, smoking, smokeless tobacco, alcohol, physical activity, sexual practices, and sun exposure behaviors through the transition is reviewed.

RESULTS

Most lifestyle behaviors display increasing cancer risk around the transition out of high school. Different levels of change were associated with different pathways through the transition. Inconsistent findings were obtained in the pattern of co-occurrence of these behaviors.

CONCLUSION

Priority research includes establishing the pattern of co-occurrence of lifestyle behaviors through the transition, identifying the pattern of tracking of each behavior through the transition, and identifying the primary influences on the group values and tracking of the behaviors. Longitudinal research is needed to control for preexisting differences between pathways through the transition.

Associations of health-related behaviors, school type and health status to physical activity patterns in 16 year old boys and girls

Sedentary behavior often begins in childhood and is associated with the development of risk factors for many chronic diseases in adulthood. Physical activity is considered important in the prevention of unfavorable changes in the risk factors. We investigated whether health-related behaviors, school type and health status are associated to physical activity among adolescents. A questionnaire was sent to all Finnish 16-year-old twins in 1991-93. A total of 3,254 twins responded. The response rate was 88%. Physical activity was classified into five categories (very active, active, moderately active, hardly active, inactive) based on self-reported frequency and intensity of physical activity. The analysis considered all subjects as individuals. Smoking was strongly associated with physical activity among girls and boys. Those who smoked regularly were less active. The type of school was also associated with physical activity. In general, those who attended comprehensive school or high school were physically more active, while those in vocational schools, particularly boys, were less active. Girls in lower physical activity groups reported more psychosomatic symptoms. Associations of self-reported health-related behaviors, school type and health status to physical activity seem to be the same among boys and girls. However, as the more active students are in comprehensive school or high school and the less active in vocational school, and physical inactivity is related to smoking and use of alcohol, health education should be tailored by school type.

Guidelines for school and community programs to promote lifelong physical activity among young people. National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and prevention

Regular physical activity is linked to enhanced health and to reduced risk for all-cause mortality and the development of many chronic diseases in adults. However, many U.S. adults are either sedentary of less physically active than recommended. Children and adolescents are more physically active than adults, but participation in physical activity declines in adolescence. School and community programs have the potential to help children and adolescents establish lifelong, healthy physical activity patterns. This report summarizes recommendations for encouraging physical activity among young people so that they will continue to engage in physical activity in adulthood and obtain the benefits of physical activity throughout life. These guidelines were developed by CDC in collaboration with experts from universities and from national, federal, and voluntary agencies and organizations. They are based on an in-depth review of research, theory, and current practice in physical education, exercise science, health education, and public health. The guidelines include recommendations about 10 aspects of school and community programs to promote lifelong physical activity among young people policies that promote enjoyable physical activity and social environments that encourage and enable physical activity; physical education curricula and instruction; health education curricula and instruction; extracurricular physical activity programs that meet the needs and interests of students; involvement of parents and guardians on physical activity instruction and programs for young people; personnel training; health services for children and adolescents; developmentally appropriate community sports and recreation programs that are attractive to young people; and regular evaluation of physical activity instruction, programs, and facilities.

Cigarette smoking attitudes and first use among third- through sixth-grade students: the Bogalusa Heart Study

OBJECTIVES

This study examined cigarette smoking attitudes, peer and parental influence, and first use among children in southeastern Louisiana.

METHODS

Data from 933 children in grades 3 through 6 in the Bogalusa Heart Study (1993 through 1994) were analyzed.

RESULTS

Fifteen percent of the children had tried smoking. Of these, 40% first smoked with a family member, and 46% obtained their first cigarette from a family member or from home. Correlates of ever having smoked were race, sex, having a best friend or family member who smoked, and attitudes that smoking is disgusting and that nonsmokers get better grades.

CONCLUSIONS

Prevention programs should begin early and focus on family and peer influences as well as attitudes.

Food preferences predict eating behavior of very young Mohawk children

OBJECTIVE

To collect baseline data on energy and nutrient intake and nutrition knowledge, attitudes, and behavior of very young Mohawk children to assist the community in planning an appropriate, targeted nutrition and exercise intervention.

DESIGN

Energy and nutrient intake data were collected from 24-hour recalls conducted in the children's homes. Nutrition knowledge, attitudes, and behavior were assessed using a 38-item questionnaire that asked children to report on what foods they like the best, eat most of the time, and think are healthful. The questionnaire was completed in an elementary school on the reservation. Before data collection, we hypothesized that the average diet of the Mohawk children would not meet national dietary recommendations.

SUBJECTS

One hundred forty-three children, prekindergarten through third grade (aged 4 to 9 years), completed the 24-hour recalls and the questionnaire. An additional 136 children, also prekindergarten through third grade, completed the questionnaire (n = 279).

STATISTICS

Analysis of variance with a Scheffe's multiple-comparison test was used to test for differences among grades and genders for energy and nutrient intake and questionnaire scores. Multiple regression analysis was used to assess the relationship between eating behavior and selected variables.

RESULTS

A mean daily energy intake of 1,980 kcal consisted of 34% fat, 13% protein, and 52% carbohydrate with 13 g fiber and 235 mg cholesterol. Food preferences were the strongest predictor of behavior, they explained 71% of the variation in the behavior score.

APPLICATIONS

The major finding of this study, that food preferences are the strongest predictor of reported eating behavior in very young Mohawk children, has implications for behavior change interventions. Focusing on changing what children like to eat, through repeated exposure to new foods in a positive social context, is more likely to change what foods they choose than is simple nutrition education.

A rational approach to treating hypercholesterolaemia in children. Weighing the risks and benefits

Because atherosclerosis is a continuous process throughout life, expert panels have suggested guidelines to reduce the risk of cardiovascular disease, starting from childhood. The guidelines focus on population-based measures and on treating hypercholesterolaemia in individual children. Low-fat diets in children have been widely debated. There is little evidence that growth is stunted or that nutritional deficiencies arise if the energy that is lost by limiting fat intake is substituted with other nutrients. Dietary fibre, plant sterols and fish oils have been used to modify lipid levels in children; however, the efficacy of these dietary adjuncts is limited. Bile acid-binding resins are the only approved drugs to lower cholesterol levels in children and appear to be well tolerated. However, compliance with resins is low because of unpalatability, so low dosages are preferred and vitamin supplementation is prudent. Data on HMG CoA reductase inhibitors and fibrates are insufficient to recommend these drugs at present. Drug treatment should be restricted to children who are at exceptionally high risk of disease, usually those with genetic dyslipidaemias.

Do children eat what they say? Validity of intended food choices among Native American school children

OBJECTIVE

To examine the agreement between school children's intended food choices and observed food choices.

DESIGN

Native American students in the second through fifth grade completed a questionnaire that asked them to select from 10 paired food choices for a given meal or snack. Three weeks later students chose among foods identical to those on the questionnaire as part of their usual school lunch or breakfast over three consecutive days; afternoon snacks were also offered.

RESULTS

Agreement between students' intended food choices and observed food choices was examined across 10 food pairs. The composite kappa coefficient between intended and observed food choices was 0.09 (95% confidence interval 0.06, 0.012), including virtually no agreement above that expected by chance. There were no differences in agreement by sex or grade.

CONCLUSIONS

Intended food choices were not significantly associated with observed food choices. It is unclear whether intended food choices reflect nutrition knowledge, socially desirable responses, food preferences, or some other dimension of eating behavior. Although responsive to school-based nutrition interventions, the interpretation of changes in intended food choices must be clarified in future research.

Guidelines for school health programs to promote lifelong healthy eating

Healthy eating patterns in childhood and adolescence promote optimal childhood health, growth, and intellectual development; prevent immediate health problems, such as iron deficiency anemia, obesity, eating disorders, and dental caries; and may prevent long-term health problems, such as coronary heart disease, cancer, and stroke. School health programs can help children and adolescents attain full educational potential and good health by providing them with the skills, social support, and environmental reinforcement they need to adopt long-term, healthy eating behaviors. This report summarizes strategies most likely to be effective in promoting healthy eating among school-age youths and provides nutrition education guidelines for a comprehensive school health program. These guidelines are based on a review of research, theory, and current practice, and they were developed by CDC in collaboration with experts from universities and from national, federal, and voluntary agencies. The guidelines include recommendations on seven aspects of a school-based program to promote healthy eating: school policy on nutrition, a sequential, coordinated curriculum, appropriate instruction for students, integration of school food service and nutrition education, staff training, family and community involvement, and program evaluation.

Tracking of physical activity and physical fitness across the lifespan

Although different indicators of physical activity and different methods of analysis are used, it appears that physical activity tracks at low to moderate levels during adolescence, from adolescence into adulthood, and across various ages in adulthood. Tracking of inactivity is less often studied. Measures of performance- and health-related physical fitness (strength, flexibility, motor fitness, aerobic power) track significantly across childhood and adolescence, but correlations are low to moderate. Limited data that span adolescence into adulthood indicate somewhat higher interage correlations for flexibility, static strength, and power. Data for different periods in adulthood are not available. Presently, it is common to criticize focus on motor and sport skills in physical education and competitive sports as contrary to health and fitness goals (e.g., James, 1995; Livingstone, 1994; Simons-Morton et al., 1988). There is a need, however, to distinguish between youth or community sports and highly specialized sport for the elite. Sports activities, be they competitive or recreational, are probably the major form of physical activity during childhood and adolescence, and perhaps in young adulthood. Though low to moderate, the tracking of various activity indicators, most of which include sport participation, suggests that sport activities during childhood and youth may form the foundation for activity habits in the future.

Nutritional status outcomes for children: ethnic, cultural, and environmental contexts

The objective of this literature review was to explore the relationship between nutritional status outcomes among ethnically diverse children and cultural and environmental contexts. Articles form the literature on anthropometric/body composition measure, diet, and physiologic outcomes among ethnically diverse children were identified through on-line literature searches and references from articles reviewed. These studies were critically reviewed and selected if they reported findings resulting from use of accepted methodologies. Explanations consistent with evaluation of results from the studies and reports were developed by synthesis of the findings. Children from underserved, ethnically diverse population groups were at increased risk for obesity, increased serum lipid levels, and dietary consumption patterns that do not meet the Dietary Guidelines for Americans. More than 80% of all US children consume more than the recommended amount of total fat and saturated fat. These factors, which were noted during childhood, may track into adolescence, placing these children at increased risk for the early onset of chronic diseases such as non-insulin-dependent diabetes mellitus, cardiovascular disease, hypertension, and some forms of cancer. Although federally funded food assistance programs are changing rapidly, currently they provide foods that, when eaten as recommended, exceed the Dietary Guidelines for these children. Future interventions to improve the health and nutritional status of our nation's children, especially those from underserved, ethnically diverse groups, should be culturally appropriate and implemented at the levels of individuals, families, and communities.

Project Northland: outcomes of a communitywide alcohol use prevention program during early adolescence

OBJECTIVES

Project Northland is an efficacy trial with the goal of preventing or reducing alcohol use among young adolescents by using a multilevel, communitywide approach.

METHODS

Conducted in 24 school districts and adjacent communities in northeastern Minnesota since 1991, the intervention targets the class of 1998 (sixth-grade students in 1991) and has been implemented for 3 school years (1991 to 1994). The intervention consists of social-behavioral curricula in schools, peer leadership, parental involvement/education, and communitywide task force activities. Annual surveys of the class of 1998 measure alcohol use, tobacco use, and psychosocial factors.

RESULTS

At the end of 3 years, students in the intervention school districts report less onset and prevalence of alcohol use than students in the reference districts. The differences were particularly notable among those who were nonusers at baseline.

CONCLUSIONS

The results of Project Northland suggest that multilevel, targeted prevention programs for young adolescents are effective in reducing alcohol use.

Roles of diet and physical activity in the prevention of osteoporosis

In recent years, much attention has been directed toward the prevention of osteoporosis, since this disease has become a leading cause of morbidity and mortality in elderly women. Research has demonstrated that the prevention of osteoporosis and osteoporosis-related fractures may best be achieved by initiating sound health behaviors early in life and continuing them throughout life. Evidence suggests that osteoporosis is easier to prevent than to treat. In fact, healthy early life practices, including the adequate consumption of most nutrients, regular physical activity, and other health behaviors, contribute to greater bone mineral measurements and optimal peak bone mass by the fourth decade of life of females, and, perhaps, also of males. Several reports have shown that the adequate consumption of nutrients, calcium in particular, during the pre-pubertal and early post-pubertal years of females contribute to increased peak bone mass. Indeed, skeletal benefits from long-term calcium supplementation have been reported for females at practically every period of the life cycle. Vitamin D, which may be either consumed or produced endogenously through the action of sunlight, promotes calcium absorption and thereby enhances bone mineralization. Thus, the adequate consumption of calcium, in conjunction with vitamin D, in early life will likely optimize peak bone mass, and adequate intakes of these two nutrients should continue through the remainder of life to help maintain bone mass. On the other hand, excess phosphorus consumption may deter bone mineral accrual because of the resultant elevation of serum parathyroid hormone levels. Additionally, high intakes of protein, sodium, and caffeine may decrease bone mineral mass through increased urinary excretion of calcium. Vitamin K may also have an important positive effect on the development and maintenance of bone through its role in promoting carboxylations of the matrix protein, osteocalcin. In conclusion, the prevention of osteoporosis needs to begin during the pre-pubertal years and it should be continued throughout life. Bone mass can better be maintained later in life through adequate consumption of several nutrients with specific roles in calcium and bone metabolism, regular physical activity, and the practice of a healthy lifestyle. Mechanisms through which the nutrients and exercise affect bone mass will be explored.

[The distribution of selected cardiac risk factors in employed and studying youths in the rural region of Steiermark (Austria)]

Demographic data, components of lifestyles such as risk behavior, health complaints, illnesses and utilization of preventive and curative services were surveyed through a health survey conducted in 79 selected rural communities of Styria between 1989 and 1933. Our research focussed on the stratification of cardiovascular risk factors such as smoking, high blood pressure, unhealthy nutrition, low physical activity and obesity in adolescents employed or attending school. The sample comprises 1239 adolescents divided into two groups: 651 were employed and 588 were in school. We could show that even at such a young age significant differences occur in the distribution of cardiovascular risk factors between these two groups. The employed adolescents were far more stressed than those of their age group attending school. Generally, the females are less strained than the males. Our results suggest that efficient programs to prevent cardiovascular disease need to specifically focus on the various life contexts of young people. Such programs should start at an early date.

Measuring nicotine dependence among high-risk adolescent smokers

In the present study we tested our hypothesis that because of the higher prevalence and greater intensity of cigarette smoking among vocational-technical students (N = 110; 51.8% males; mean age 17 years), adolescents might demonstrate the nicotine dependence patterns comparable to those measured in a similar fashion in a group of adult smokers (N = 173; 50% males; mean age 42 years). A modified version of the Fagerström Tolerance Questionnaire (FTQ) utilized in the adolescent sample was coded to make it comparable to the original FTQ used in the adult sample. The tests of item structure and internal consistency of the modified FTQ for adolescents were satisfactory; the overall mean FTQ score correlated significantly with the intensity and duration of smoking. Although the FTQ values were generally lower in the adolescent sample, 20% of students had an overall FTQ score of 6 and above, indicating substantial nicotine dependence (compared to 49% in adults). Reasons for failure of the existing adolescent smoking cessation programs as well as the rationale for adding a nicotine replacement option to the behavioral smoking cessation treatment for a subset of high-risk nicotine-dependent adolescents are discussed.

The tracking of nutrient intake in young children: the Framingham Children's Study

OBJECTIVES

This study compared the nutrient intake of children at 3 through 4 years of age with that in subsequent years to determine whether nutrient intake tracked over time.

METHODS

Intakes of 10 nutrients were estimated by means of multiple days of food diaries collected over a span of up to 6 years of follow-up for 95 children in the Framingham Children's Study. All diaries collected during each of three age periods (age 3 through 4, age 5 through 6, and age 7 through 8) were averaged. Nutrient density intakes at each age period were compared.

RESULTS

Nutrient-specific correlations ranged from .37 to .63 between nutrient density intakes at age 3-4 and age 5-6. Correlations between intakes at age 3-4 and age 7-8 ranged from .35 to .62. Consistency of classification was strong; 35.7% to 57.1% of children in the highest quintile of intake at age 3-4 remained in that quintile at age 5-6, and 57.1% to 85.7% remained in the top two quintiles. At age 7-8, 40.0% to 66.7% of those with the highest intake at baseline were still in the top quintile, and 60.0% to 93.3% remained in the top two quintiles. Results were similar in the lowest quintile of intake. Extreme misclassification was rare.

CONCLUSIONS

This study suggests that tracking of nutrient intake begins as young as 3-4 years of age.