School-based interventions promoting both physical activity and healthy eating in Europe: a systematic review within the HOPE project

A systematic review on economic evaluations of school-based lifestyle interventions targeting weight-related behaviours among 4-12 year olds: Issues and ways forward

Current guidelines for economic evaluations do not provide specific recommendations for the evaluation of school-based lifestyle interventions. This study examined and discussed the key aspects in the design of economic evaluations on school-based interventions targeting weight-related behaviours among 4-12 year olds. The PubMed and CRD databases (NHS EED) were searched. Grey literature was identified from reference lists and websites of relevant organizations. Full economic evaluations on school-based interventions targeting physical activity, sedentariness, or diet were selected. Key aspects included the objective, audience, intervention, comparator, population, type of analysis, perspective, costs, outcomes, and time horizon. Information was also extracted on measuring and valuing costs and outcomes, linking and extrapolating outcomes, and the maintenance of intervention effects. The 23 included studies reported on cost-effectiveness (CEAs) (N = 12), cost-utility (CUAs) (N = 9), social cost benefit (SCBA) (N = 2), and social return on investment (SROI) (N = 1) analysis. The usual practice comparator was generally not clearly defined. The SROI analysis was the single study that included outcomes in other persons than the child. Healthcare costs (N = 14), productivity costs (N = 4), and costs to the household (N = 3), or education (N = 2) sector were examined. The outcome in trial-based CEAs consisted of a variety of weight-related measures. Seven distinctive models were used to extrapolate health and/or productivity costs. To enhance the usefulness of economic evaluations on school-based lifestyle interventions in allocating public health budgets, transparent reporting on key aspects, broadening the scope of economic evaluations, and standardizing the measurement, valuation, and extrapolation of costs and outcomes should be improved. This study was conducted in Maastricht, the Netherlands.

A cluster randomised controlled trial of a sugar-sweetened beverage intervention in secondary schools: Pilot study protocol

BACKGROUND

Due to the rising prevalence of overweight and obesity in children and adolescents, reducing childhood overweight and obesity rates is a public-health priority. A significant source of excess sugar and energy in children's diets comes from sugar-sweetened beverages (SSB), with adolescents having the highest intake of all age groups. However, existing interventions targeting SSB intake in adolescents have multiple limitations. Schools have proven to be an appropriate setting for improving student health.

AIM

To assess the effectiveness of a school-based SSB intervention in reducing daily SSB consumption and daily percentage energy from SSBs of secondary-school students.

METHODS

A pilot study ( switchURsip) was designed based on the Health Promoting Schools framework components. A convenience sample of schools in New South Wales, Australia will be used to recruit six schools (three intervention; three control). The study incorporates strategies that focus on factors associated with SSB intake in adolescents. These strategies include: lesson plans on SSB; communication with students and parents; school challenge to build peer support; and school nutrition environment modifications. Support strategies to facilitate implementation are executive leadership and school committees, auditing and feedback, providing resources, staff professional learning and communication and marketing.

CONCLUSION

The high intake of SSB in adolescents has been consistently linked to having overweight and obesity, hence, interventions in this area should be prioritised. This pilot study intends to address identified evidence gaps by piloting the first intervention in Australia of its kind to reduce SSB intake in adolescents.

Feasibility and impact study of a reward-based mobile application to improve adolescents' snacking habits

OBJECTIVE

Adolescents' snacking habits are driven by both explicit reflective and implicit hedonic processes. Hedonic pathways and differences in sensitivity to food rewards in addition to reflective determinants should be considered. The present study evaluated the feasibility and impact of a mobile phone-delivered intervention, incorporating explicit reflective and implicit rewarding strategies, on adolescents' snack intake.

DESIGN

Adolescents (n 988; mean age 14·9 (sd 0·70) years, 59·4 % boys) completed a non-randomized clustered controlled trial. Adolescents (n 416) in the intervention schools (n 3) were provided with the intervention application for four weeks, while adolescents (n 572) in the control schools (n 3) followed the regular curriculum. Outcomes were differences in healthy snacking ratio and key determinants (awareness, intention, attitude, self-efficacy, habits and knowledge). Process evaluation data were collected via questionnaires and through log data of the app.

RESULTS

No significant positive intervention effects on the healthy snack ratio (b=-3·52 (se 1·82), P>0·05) or targeted determinants were observed. Only 268 adolescents started using the app, of whom only fifty-five (20·5 %) still logged in after four weeks. Within the group of users, higher exposure to the app was not significantly associated with positive intervention effects. App satisfaction ratings were low in both high and low user groups. Moderation analyses revealed small positive intervention effects on the healthy snack ratio in high compared with low reward-sensitive boys (b=1·38 (se 0·59), P<0·05).

CONCLUSIONS

The intervention was not able to improve adolescents' snack choices, due to low reach and exposure. Future interventions should consider multicomponent interventions, teacher engagement, exhaustive participatory app content development and tailoring.

Effects of School-based Health Promotion Intervention on Health Behaviors among School Adolescents in North Lima and Callao, Peru

Background

Multicomponent interventions that include both school and family or community involvements have the potential to cause significant changes in the levels of health in adolescents. To this end, KOICA and Yonsei Global Health Center implemented a school-based health promotion program from 2015 to 2016 in Northern Lima and Callao, Peru. The present study aimed to evaluate the effects of a school-based health promotion intervention on the health behaviors of school adolescents in Peru.

Methods

Health behaviors were measured using a standard self-administered questionnaire before and after the introduction of a school-based health promotion intervention in 2014 and 2016. The intervention was executed in secondary schools, specifically two schools from Lima and two from Callao, from April 2015 to November 2016. Two schools (one from each area) were selected as control schools. The interventions included health education, screening, and psychological counseling of vulnerable individuals as well as education for teachers and workshops with parents.

Results

Descriptive statistics, chi-square test results, and logistic regression values were computed. Sample sizes were 332 and 255 in 2014 and 933 and 599 in 2016 in the intervention and control schools, respectively. Logistic regression analysis revealed significant improvement in the consumption of vegetables and in depression in the intervention schools. Suicide attempts, television-watching, video game use, Internet use, consumption of chips and sugary drinks, and being in fights did not decrease in the intervention group but did increase in the control group. Thus, the intervention might have prevented the worsening of these behaviors in the intervention schools.

Conclusion

The intervention had a positive effect on vegetable consumption and feeling depressed as well as on preventing the increase in sedentary behaviors, fighting, and suicide attempts.

Project SoL-A Community-Based, Multi-Component Health Promotion Intervention to Improve Healthy Eating and Physical Activity Practices among Danish Families with Young Children Part 2: Evaluation

Project SoL is implemented over a period of four years with the aim to promote healthy eating and physical activity among children aged 3⁻8 years by targeting the families in a Danish municipality based on the multi-component, supersetting strategy. Interventions are implemented in childcare centres, schools and supermarkets in three local communities as well as in local mass media and social media during a 19 months period in the Municipality of Bornholm. The matching Municipality of Odsherred serves as a control site based on its similarity to Bornholm regarding several socio-demographic and health indicators. The present paper gives an account of the design used for the summative and formative evaluation based on a realistic evaluation and a mixed methods approach combining qualitative and quantitative methods. Summative studies are conducted on changes of health behaviours among the involved families and within the municipalities in general, changes in community awareness of the project, changes in purchase patterns, changes in overweight and obesity among the targeted children and changes in knowledge and preferences among children due to sensory education workshops. The formative research comprises studies on children's perceptions of health, perceptions of staff at supermarkets and media professionals on their roles in supporting the health promotion agenda, and motivations and barriers of community stakeholders to engage in health promotion at community level. The paper discusses operational issues and lessons learnt related to studying complex community interventions, cross-disciplinarily, interfaces between practice and research and research capacity strengthening; and suggests areas for future research. The development and implementation of the intervention and its theoretical foundation is described in a separate paper.

Gamification of nutrition: A preliminary study on the impact of gamification on nutrition knowledge, attitude, and behaviour of adolescents in Nigeria

BACKGROUND:

In Nigeria and many parts of sub-Saharan Africa, the availability of foods that are high in salt, sugar, and saturated fat is steadily increasing. This has led to an increase in the consumption of such foods among Nigerians, particularly among adolescents.

AIM:

This pilot study was undertaken to understand whether, and how, gamification of nutrition can have an impact on addressing the problem of unhealthy eating among Nigerian adolescents.

METHODS:

Gamification of nutrition through board games, clubs and vouchers was introduced in three secondary schools in Abuja, Nigeria over a span of three to four months. Semi-structured focus groups were conducted with grade 11 and 12 students in the three secondary schools. Participants were asked about their perceptions of the intervention and how it influenced their eating behaviour, attitudes and knowledge about nutrition.

RESULTS:

A total of 31 students participated in four focus groups. Participants reported that the intervention shifted their perceptions and preferences, leading them to alter their behaviour by incorporating more nutritious foods (such as fruits and vegetables) into their diet and engaging in more physical activity. Five themes emerged from the analyses: improved eating behaviour; increased physical activity; improved overall well-being; increased nutrition knowledge; and influencing others.

CONCLUSIONS:

The results from the focus groups suggest that gamification of nutrition can lead to improvements in dietary behaviour among adolescents over the short-term. More studies are needed to evaluate the long-term effects of nutrition interventions that use gamification techniques.

Effectiveness of mother and daughter interventions targeting physical activity, fitness, nutrition and adiposity: A systematic review

BACKGROUND

Physical inactivity and poor dietary habits in women pose a clear public health burden. Mothers are generally the main female role model for daughters, therefore, targeting intergenerational females simultaneously may be a novel approach. However, the effectiveness of this approach to improve physical activity, fitness, nutrition and adiposity has not been systematically examined.

OBJECTIVES

To assess the effectiveness of physical activity, fitness and nutrition interventions targeting mothers and their daughters.

DATA SOURCES

PubMed, Psychinfo, EMBASE, Ovid Medline, SCOPUS, CINAHL, Sportdiscus and Informit were searched for English language studies (1980-2015).

STUDY SELECTION

Randomized controlled trials (RCTS), non-randomized experimental trials and pre-post studies of physical activity, fitness, nutrition and adiposity interventions targeting mothers and daughters were eligible if they reported changes in physical activity, fitness, dietary intake or adiposity.

DATA EXTRACTION

Data were extracted using a standardized template and checked by a second author.

DATA SYNTHESIS

3577 articles were screened and 14 unique studies (7 RCTs, 1 pseudo-randomized, 1 non-randomized, 5 pre-post) met the inclusion criteria. The majority of studies were conducted in the US (n=11) and most were limited by methodological concerns. Of the RCTs that targeted each outcome exclusively, ≤20%, ≤20% ≤21% and 0% were successful for improving physical activity, fitness, nutrition and adiposity respectively.

CONCLUSIONS

Overall, evidence for the effectiveness of mother-daughter interventions to improve physical activity, fitness, nutrition and adiposity is inconclusive. The diversity of study designs, exposures and outcomes used, along with methodological weaknesses means that well-designed and reported RCTs are warranted.

Systematic review of interventions for promoting active school transport

Active commuting to school has been recognized as a potential avenue to increase physical activity in children and adolescents. However, active commuting to school has declined over time, and interventions are needed to reverse this trend. The main aim in the current study was to update a previous systematic review on interventions focused on active travel to school, following the same methodology and addressing the quality and effectiveness of new studies detected in the more recent scientific literature. A systematic review was conducted to identify intervention studies of active commuting to school published from February 2010 to December 2016. Five electronic databases and a manual search were conducted. Detailed information was extracted, including a quantitative assessment comparing the effect sizes, with Cohen's d, and a qualitative assessment using the Evaluation of Public Health Practice Projects tool. We identified 23 interventions that focused on active commuting to school. Among the 23 interventions, three were randomized control trials, 22 had a pre/post design, and 12 used control groups. Most interventions reported a small effect size on active commuting to school (14/23) (d: from -1.45 to 2.37). The quality assessment was rated as weak in most studies (21/23). Government funding continues investing in public policies to promote active commuting to school. However, even though seven years have passed since the last systematic review, research with high quality designs with randomization, greater sample size, and the use of valid and reliable instruments are needed.

Project SoL-A Community-Based, Multi-Component Health Promotion Intervention to Improve Eating Habits and Physical Activity among Danish Families with Young Children. Part 1: Intervention Development and Implementation

Project SoL was implemented over a period of four years from 2012–2015 with the aim to promote healthy eating and physical activity among families with children aged 3–8 years, living in selected communities in two Danish municipalities. This was done by applying the supersetting approach to implement complex multi-component interventions in a participatory, coordinated, and integrated manner in childcare centres, schools, and supermarkets in three local communities, as well as in local media during a 19-month period in the Regional Municipality of Bornholm, which served as the intervention site. The matching municipality of Odsherred served as a control site based on its similarity to Bornholm regarding several socio-demographic and health indicators. The present paper describes the design of Project SoL as well as the processes of developing and implementing its complex interventions. Moreover, the theoretical and conceptual framework of the project is described together with its organisational structure, concrete activities, and sustainability measures. The paper discusses some of the key lessons learned related to participatory development and the implementation of a multi-component intervention. The paper concludes that coordinated and integrated health promotion activities that are implemented together with multiple stakeholders and across multiple settings in the local community are much more powerful than individual activities carried out in single settings. The supersetting approach was a useful conceptual framework for developing and implementing a complex multi-component health promotion intervention and for fostering ownership and sustainability of the intervention in the local community. The research and evaluation approach of the project is described in a separate paper (Part 2).

Adherence to Canada's Food Guide recommendations among Alberta's multi-ethnic youths is a major concern: findings from the WHY ACT NOW project

BACKGROUND

Dietary habits formed during youth may result in the development of obesity and chronic diseases in adulthood. We aimed to determine the frequency of the consumption of foods and beverages and the degree of adherence to Canada's Food Guide recommendations among multi-ethnic youths.

METHODS

Participants were recruited from 12 schools in the Edmonton, Alberta area by use of posters, school newsletters and advertisements. A 30-item food frequency questionnaire was administered by a trained interviewer to assess dietary intake in a convenience sample of 557 (328 females and 229 males) youths aged 11-23 years; for the purpose of the present study, only the 14-18 years age group was considered in the analysis. Participants were divided by sex and self-identified ethnicity into four groups [Indigenous, African & Middle Eastern (AME), Asian, and European]. Statistical analysis of the data was undertaken using t-tests, Welch's analysis of variance and Games-Howell tests. P < 0.05 was considered statistically significant.

RESULTS

Vegetables and Fruit recommendations were the least likely to be followed, with 90.7-96.8% of participants in all groups not consuming the recommended number of servings day^-1 . The mean frequency of fruit consumption was lower among Indigenous youths compared to Asian youths (0.90 versus 1.37 times day^-1 ). A greater proportion of males than females (55.9% versus 44.3%) did not meet the minimum recommendations for Meat and Alternatives (P = 0.016). The percentage of youths not adhering to recommendations for Milk and Alternatives was 81.7% for Indigenous, 73.3% for AME, 78.6% for Asian and 63.5% for European youths. Indigenous youths more frequently consumed potato chips and soft drinks compared to other ethnic youths. The most frequently consumed beverage was milk (1.25 times day^-1 ).

CONCLUSIONS

The majority of youths did not consume minimum daily recommended servings of Vegetables and Fruit, Milk and Alternatives, and/or Meat and Alternatives food groups. Evidence-based dietary interventions and public health strategies are needed.

School-based lifestyle education involving parents for reducing subjective psychosomatic symptoms in Japanese adolescents: study protocol for a cluster randomised controlled trial

INTRODUCTION

Severe subjective psychosomatic symptoms (SPS) in adolescents are a major public health concern, and lifestyle modification interventions for reducing SPS are important topics. Recently, we developed a school-based lifestyle education involving parents for reducing SPS of adolescents (SPRAT), an improved version of the programme from our previous study Programme for adolescent of lifestyle education in Kumamoto (PADOK). This study aimed to evaluate the effectiveness of SPRAT in reducing SPS among adolescents.

METHODS AND ANALYSIS

This is a 6-month, cluster randomised clinical trial with two intervention arms (SPRAT vs usual school education). The study population will be composed of middle school students (aged 12-14 years) with their parents/guardians in Japan. SPRAT is expected to be a more powerful programme than PADOK as it reinforces the role of parent participation. The primary endpoint will be the change from baseline SPS scores to those obtained after 6 months. Between-group differences will be analysed following the intention-to-treat principle. Crude and multivariate adjusted effects will be examined using a general linear mixed-effects model for continuous variables and a logistic regression model for dichotomous variables. The sample size required was determined based on the information needed to detect a difference in the primary outcome with a significance level of 5% and power of 80% under the assumptions of 40 students per cluster (assuming the same sample size for each cluster), an effect size of 0.3 and an intraclass correlation coefficient of 0.02. In total, participation by 28 schools (14 schools in each arm) (students: n=1120) will be needed.

ETHICS AND DISSEMINATION

This study was approved by the Medical Ethical Committee of Minami Kyushu University in 2017 (number 137). The findings will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

UMIN000026715; Pre-results.

Does the distribution frequency matter? A subgroup specific analysis of the effectiveness of the EU School Fruit and Vegetable Scheme in Germany comparing twice and thrice weekly deliveries

OBJECTIVE

The present study aimed to examine the effectiveness of two different implementation forms of the EU School Fruit and Vegetable Scheme (SFVS).

DESIGN

A quasi-experimental design was applied including a thrice as well as a twice weekly intervention group. Repeated 24 h dietary recalls were used to measure children's fruit and vegetable (F&V) intake. Effects were analysed on days with and without F&V deliveries using hierarchical linear regression models.

SETTING

Twelve primary schools in North Rhine-Westphalia, Germany.

SUBJECTS

Third and fourth graders (n 664).

RESULTS

Average daily F&V intake at pre-intervention was 0·84 frequencies in the thrice weekly intervention group, 0·90 frequencies in the twice weekly intervention group and 1·25 frequencies in the control group. Providing children thrice weekly with F&V increased children's F&V intake on average by 0·96 (P<0·001) frequencies/d. The effects were higher on days with (1·07; P<0·001) than on days without (0·75; P<0·001) F&V deliveries. Distributing F&V twice weekly resulted in an increase of 0·75 (P<0·001) frequencies/d on average, again with higher effects on days with (1·30; P<0·001) than without (0·48; P<0·003) F&V deliveries. Subgroup analysis revealed some indications for differential effectiveness only in the twice weekly intervention group.

CONCLUSIONS

The SFVS with thrice or twice weekly deliveries of F&V led to a significant increase in children's F&V intake on days with and without deliveries. The latter might provide an indication of positive long-term effects of the scheme. The scheme shows equal efficiency for almost all subgroups.

Evaluation of a program of physical activities adapted to the morphological, physiological and body composition parameters of overweight and obese adolescents of the Lukunga sports club of Kinshasa, Democratic Republic of Congo

Objective. To study the effects of regular physical activity on the morphological, physiological and body composition parameters of overweight and obese adolescents. Methods. We conducted an experimental study with30 adolescents divided in two according to their body mass index. The group 1 was composed of overweight subjects with a body mass index between 25-29.9 kg/m2 , and group 2 obese subjects with a body mass index 30 kg/m2 subjected to a program of adapted physical activity associated with a low-calorie nutrition education low in cholesterol and in saturated fatty acids (bad fats), low-fat rich in vegetables, fruits and vitamins for a period of six months. Results. This study reveals that after six months of intervention, overweight subjects significantly decreased waist circumference (82.9 ± 4.2 cm before versus 77.6 ± 4.6 cm after), heart rate (86.8 ± 3.6 beat/min before versus 81.4 ± 3.8 beat/min after), total fat (32.2 ± 1.8% before versus 27.2 ± 1.5% after), visceral fat (16.6 ± 2.3% before versus 11.1 ± 2.5% after), and decreased muscle (15.6 ± 2.7% before versus 19.4 ± 4.1% after), while obese subjects significantly decreased waist circumference (88.9 ± 6.2 cm before versus 85.8 ± 5.9 cm after), visceral fat (17.4 ± 3.2% before versus 14.1 ± 3.1% after), respiratory capacity (61.1 ± 2.7% before versus 65 ± 2.1%). In addition this study reveals that overweight subjects compared to obese subjects more changed their waist circumference (77.6 ± 4.6 cm for overweight versus 85.8 ± 5.9 cm for obese), body mass index (24.9 ± 4.1 kg/m2 for overweight versus 28.8 ± 1.2 kg/m2 for obese), heart rate (81.4 ± 3.8 beat/min for overweight versus 28.8 ± 1.2 beat/min for obese), visceral fat (11.1 ± 2.5% for overweight versus 14.1 ± 3.1% for obese), and muscle (19.4 ± 4.1% for overweight versus 17.1 ± 2.1%). Conclusion. Obese adolescents have by means of regular activity significantly changed their morphological, physiological and body composition parameters of overweight and obese

Effectiveness of a Kindergarten-Based Intervention for Preventing Childhood Obesity

BACKGROUND AND OBJECTIVES

Interventions to prevent childhood obesity targeting school age children have mostly reported limited effectiveness, suggesting such prevention programs may need to start at an earlier age, but evidence has been scarce. We reported a pilot study aiming to demonstrate the feasibility of a multifaceted intervention for preschool children and to provide a preliminary assessment of the effectiveness.

METHODS

This nonrandomized controlled trial recruited children aged 3 to 6 years from 6 kindergartens in Guangzhou, China. Based on the preference of the School and Parents Committees, 4 kindergartens (648 children) received a 3-component intervention (training of kindergarten staff, initiating healthy curriculum for children, and close collaboration between families and kindergartens) over 12 months, while the other 2 kindergartens (336 children), serving as controls, received routine health care provision. Outcome measures were the changes in BMI z score between baseline and the end of 12 months, and the prevalence of postintervention children who were overweight or obese.

RESULTS

By 12 months, children within the intervention group had a smaller BMI z score increase (0.24) compared to the control (0.41), with a difference of -0.31 (95% CI -0.47 to -0.15). The prevalence of overweight or obesity was also lower among the intervention group at the end of the study (OR: 0.43, 95% CI 0.19 to 0.96), adjusted for baseline status.

CONCLUSIONS

Our results indicated a multicomponent health behavior intervention might be effective in reducing the prevalence of obesity, but the longer term effects will need confirmation from randomized controlled trials.

Pilot evaluation of a school-based health education intervention in the UK: Facts4Life

Background

This study assessed short-term changes in children's health and illness attitudes and health status following Facts4Life, a school-based health education intervention.

Methods

Children aged 7-11 years (School Years 3-6) recruited from 10 schools in the UK participated in this study. A quasi-experimental design was utilized with 187 children participating in the intervention, and 108 forming a control condition. Children in both conditions completed measures of health and illness attitudes and health status at baseline and at immediate follow-up. Intervention effects were examined using mixed between-within subjects analysis of variance.

Results

Analysis revealed significant baseline to follow-up improvements in intervention group responses to 'When I feel unwell I need to take medicine to feel better' (Years 3 and 4: P = 0.05, η2p = 0.02; Years 5 and 6: P = 0.004, η2p = 0.07). For intervention group children in Years 5 and 6 there was an improvement in response to 'When I am ill, I always need to see a doctor' (P = 0.01, η2p = 0.07). There was no evidence that Facts4Life had an impact upon health status.

Conclusions

This study identified some positive intervention effects and results suggest that Facts4Life has potential as a school-based health education intervention.

Determinants of diet and physical activity (DEDIPAC): a summary of findings

The establishment of the Determinants of Diet and Physical Activity (DEDIPAC) Knowledge Hub, 2013-2016, was the first action taken by the 'Healthy Diet for a Healthy Life' European Joint Programming Initiative. DEDIPAC aimed to provide better insight into the determinants of diet, physical activity and sedentary behaviour across the life course, i.e. insight into the causes of the causes of important, non-communicable diseases across Europe and beyond. DEDIPAC was launched in late 2013, and delivered its final report in late 2016. In this paper we give an overview of what was achieved in terms of furthering measurement and monitoring, providing overviews of the state-of-the-art in the field, and building toolboxes for further research and practice. Additionally, we propose some of the next steps that are now required to move forward in this field, arguing in favour of 1) sustaining the Knowledge Hub and developing it into a European virtual research institute and knowledge centre for determinants of behavioural nutrition and physical activity with close links to other parts of the world; 2) establishing a cohort study of families across all regions of Europe focusing specifically on the individual and contextual determinants of major, non-communicable disease; and 3) furthering DEDIPAC's work on nutrition, physical activity, and sedentary behaviour policy evaluation and benchmarking across Europe by aligning with other international initiatives and by supporting harmonisation of pan-European surveillance.

Evaluating for impact: what type of data can assist a health promoting school approach?

There is debate within the health promoting school (HPS) movement on whether schools should monitor health behaviour outcomes as part of an evaluation or rely more on process type measures, such as changes to school policies and the physical and social environment which yield information about (in)effective implementation. The debate is often framed around ideological considerations of the role of schools and there is little empirical work on how these indicators of effective implementation can influence change at a policy and practice level in real world settings. Information has potentially powerful effects in motivating a change process, but this will vary according to the type of information and the type of organizational culture into which it is presented. The current predominant model relies on process data, policy and environmental audit monitoring and benchmarking approaches, and there is little evidence of whether this engages school communities. Theoretical assertions on the importance of monitoring data to motivate change need to be empirically tested and, in doing so, we can learn which types of data influence adoption of HPS in which types of school and policy contexts.

Delphi Survey for Designing a Intervention Research Study on Childhood Obesity Prevention

Background

The prevalence of childhood obesity in South Korea has increased owing to economic improvement and the prevailing Westernized dietary pattern. As the incidence of chronic diseases caused by obesity is also expected to increase, effective interventions to prevent childhood obesity are needed. Therefore, we conducted a Delphi study to determine the priorities of a potential intervention research on childhood obesity prevention and its adequacy and feasibility.

Methods

The two-round Delphi technique was used with a panel of 10 childhood obesity experts. The panelists were asked to rate “priority populations,” “methods of intervention,” “measurement of outcomes,” “future intervention settings,” and “duration of intervention” by using a structured questionnaire. Finally, a portfolio analysis was performed with the adequacy and feasibility indexes as the two axes.

Results

For priority populations, the panel favored “elementary,” “preschool,” and “middle and high school” students in this order. Regarding intervention settings, the panelists assigned high adequacy and feasibility to “childcare centers” and “home” for preschool children, “school” and “home” for elementary school children, and “school” for adolescents in middle and high school. As the age of the target population increased, the panelists scored increasing numbers of anthropometric, clinical, and intermediate outcomes as highly adequate and feasible for assessing the effectiveness of the intervention.

Conclusion

According to the results of the Delphi survey, the highest-priority population for the research on childhood obesity prevention was that of elementary school students. Various settings, methods, outcome measures, and durations for the different age groups were also suggested.

Effect and process evaluation of a kindergarten-based, family-involved cluster randomised controlled trial in six European countries on four- to six-year-old children's steps per day: the ToyBox-study

BACKGROUND

The ToyBox-intervention is a theory- and evidence-based intervention delivered in kindergartens to improve four- to six-year-old children's energy balance-related behaviours and prevent obesity. The current study aimed to (1) examine the effect of the ToyBox-intervention on increasing European four- to six-year-old children' steps per day, and (2) examine if a higher process evaluation score from teachers and parents was related to a more favourable effect on steps per day.

METHODS

A sample of 2438 four- to six-year-old children (51.9% boys, mean age 4.75 ± 0.43 years) from 6 European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain) wore a motion sensor (pedometer or accelerometer) for a minimum of two weekdays and one weekend day both at baseline and follow-up to objectively measure their steps per day. Kindergarten teachers implemented the physical activity component of the ToyBox-intervention for 6 weeks in total, with a focus on (1) environmental changes in the classroom, (2) the child performing the actual behaviour and (3) classroom activities. Children's parents received newsletters, tip cards and posters. To assess intervention effects, multilevel repeated measures analyses were conducted for the total sample and the six intervention countries separately. In addition, process evaluation questionnaires were used to calculate a total process evaluation score (with implementation and satisfaction as a part of the overall score) for teachers and parents which was then linked with the physical activity outcomes.

RESULTS

No significant intervention effects on four- to six-year-old children' steps per weekday, steps per weekend day and steps per average day were found, both in the total sample and in the country-specific samples (all p > 0.05). In general, the intervention effects on steps per day were least favourable in four- to six-year-old children with a low teachers process evaluation score and most favourable in four- to six-year-old children with a high teachers process evaluation score. No differences in intervention effects were found for a low, medium or high parents' process evaluation score.

CONCLUSION

The physical activity component of the ToyBox-intervention had no overall effect on four- to six-year-old children' steps per day. However, the process evaluation scores showed that kindergarten teachers that implemented the physical activity component of the ToyBox-intervention as planned and were satisfied with the physical activity component led to favourable effects on children's steps per day. Strategies to motivate, actively involve and engage the kindergarten teachers and parents/caregivers are needed to induce larger effects.

Effect and process evaluation of a kindergarten-based, family-involved intervention with a randomized cluster design on sedentary behaviour in 4- to 6- year old European preschool children: The ToyBox-study

Background

The aim of the present study evaluated the effect and process of the ToyBox-intervention on proxy-reported sedentary behaviours in 4- to 6-year-old preschoolers from six European countries.

Methods

In total, 2434 preschoolers’ parents/primary caregivers (mean age: 4.7±0.4 years, 52.2% boys) filled out a questionnaire, assessing preschoolers’ sedentary behaviours (TV/DVD/video viewing, computer/video games use and quiet play) on weekdays and weekend days. Multilevel repeated measures analyses were conducted to measure the intervention effects. Additionally, process evaluation data were included to better understand the intervention effects.

Results

Positive intervention effects were found for computer/video games use. In the total sample, the intervention group showed a smaller increase in computer/video games use on weekdays (ß = -3.40, p = 0.06; intervention: +5.48 min/day, control: +8.89 min/day) and on weekend days (ß = -5.97, p = 0.05; intervention: +9.46 min/day, control: +15.43 min/day) from baseline to follow-up, compared to the control group. Country-specific analyses showed similar effects in Belgium and Bulgaria, while no significant intervention effects were found in the other countries. Process evaluation data showed relatively low teachers’ and low parents’ process evaluation scores for the sedentary behaviour component of the intervention (mean: 15.6/24, range: 2.5–23.5 and mean: 8.7/17, range: 0–17, respectively). Higher parents’ process evaluation scores were related to a larger intervention effect, but higher teachers’ process evaluation scores were not.

Conclusions

The ToyBox-intervention had a small, positive effect on European preschoolers’ computer/video games use on both weekdays and weekend days, but not on TV/DVD/video viewing or quiet play. The lack of larger effects can possibly be due to the fact that parents were only passively involved in the intervention and to the fact that the intervention was too demanding for the teachers. Future interventions targeting preschoolers' behaviours should involve parents more actively in both the development and the implementation of the intervention and, when involving schools, less demanding activities for teachers should be developed.

Trial registration

clinicaltrials.gov NCT02116296

Protocol for systematic review of school-based interventions to prevent and control obesity in African learners

INTRODUCTION

The increasing prevalence of obesity and overweight in childhood in developing countries is a public health concern to many governments. Schools play a significant role in the obesity epidemic as well as provide favourable environments for change in behaviours in childhood which can be carried on into adulthood. There is dearth of information on intervention studies in poor-resource settings. This review will summarise the available evidence on school-based interventions that focused on promoting healthy eating and physical activity among learners aged 6-15 years in Africa and to identify factors that lead to successful interventions or potential barriers to success of these programmes within the African context.

METHODS AND ANALYSIS

This protocol is developed following the guidelines of PRIMSA-P 2015. Relevant search terms and keywords generated from the subject headings and the African search filter will be used to conduct a comprehensive search of MEDLINE (PubMed), MEDLINE (EbscoHost), CINAHL (EbscoHost), Register Academic Search Complete (EbscoHost) and ISI Web of Science (Science Citation Index) for published literature on school-based interventions to prevent and control obesity in learners in Africa. Grey literature will be also be obtained. The searches will cover 1 January 2000 to 30 June 2016. No language limitations will be applied. Full-text articles of eligible studies will be screened. Risk of bias and quality of reporting will be assessed. Data will be extracted, synthesised and presented by country and major regional groupings. Meta-analysis will be conducted for identical variables across studies, where data allow. This protocol is developed following the guidelines of PRISMA-P 2015.

ETHICS AND DISSEMINATION

No primary data will be collected hence ethics is not a requirement. The findings will be submitted for publication in peer-reviewed journals, in conferences and in policy documents for decision-making, where needed.

Classroom Nutrition Education Combined With Fruit and Vegetable Taste Testing Improves Children's Dietary Intake

BACKGROUND

We tested the effectiveness of the Go Wild With Fruits and Veggies! (GWWFV) Extension curriculum on increasing fruit and vegetable (FV) intake of third graders.

METHODS

An intervention study was used testing self-reported FV intake pre/post GWWFV. Recruited schools were randomized to control (12 schools, N = 369, third grade children) or intervention (14 schools, N = 378, third grade children). Measures included items from a validated FV food frequency survey. Access to the federal Fresh Fruit and Vegetable Snack Program (FFVSP), and taste testing within GWWFV were also measured. Between-group differences in FV intake were evaluated using 1-way ANOVA for unadjusted models and 1-way ANCOVA for baseline adjusted models. The Tukey-Kramer test was employed for post hoc comparisons.

RESULTS

Students with access to the FFVSP consumed more fruits (p < .01) and vegetables (p < .0001). Students who participated in the FFVSP and GWWFV with taste testing consumed more fruits and vegetables (p < .05) compared with students who participated in the FFVSP and GWWFV without taste testing, along with the control group.

CONCLUSIONS

The FFVSP and GWWFV with taste testing demonstrated a positive influence on FV intake in third grade children. Leveraging environmental approaches with interactive learning experiences create desired outcomes.

Recommendations and Improvements for the Evaluation of Integrated Community-Wide Interventions Approaches

Background. Integrated community-wide intervention approaches (ICIAs) are implemented to prevent childhood obesity. Programme evaluation improves these ICIAs, but professionals involved often struggle with performance. Evaluation tools have been developed to support Dutch professionals involved in ICIAs. It is unclear how useful these tools are to intended users. We therefore researched the facilitators of and barriers to ICIA programme evaluation as perceived by professionals and their experiences of the evaluation tools. Methods. Focus groups and interviews with 33 public health professionals. Data were analysed using a thematic content approach. Findings. Evaluation is hampered by insufficient time, budget, and experience with ICIAs, lack of leadership, and limited advocacy for evaluation. Epidemiologists are regarded as responsible for evaluation but feel incompetent to perform evaluation or advocate its need in a political environment. Managers did not prioritise process evaluations, involvement of stakeholders, and capacity building. The evaluation tools are perceived as valuable but too comprehensive considering limited resources. Conclusion. Evaluating ICIAs is important but most professionals are unfamiliar with it and management does not prioritise process evaluation nor incentivize professionals to evaluate. To optimise programme evaluation, more resources and coaching are required to improve professionals' evaluation capabilities and specifically the use of evaluation.

Efficacy of interventions that use apps to improve diet, physical activity and sedentary behaviour: a systematic review

BACKGROUND

Health and fitness applications (apps) have gained popularity in interventions to improve diet, physical activity and sedentary behaviours but their efficacy is unclear. This systematic review examined the efficacy of interventions that use apps to improve diet, physical activity and sedentary behaviour in children and adults.

METHODS

Systematic literature searches were conducted in five databases to identify papers published between 2006 and 2016. Studies were included if they used a smartphone app in an intervention to improve diet, physical activity and/or sedentary behaviour for prevention. Interventions could be stand-alone interventions using an app only, or multi-component interventions including an app as one of several intervention components. Outcomes measured were changes in the health behaviours and related health outcomes (i.e., fitness, body weight, blood pressure, glucose, cholesterol, quality of life). Study inclusion and methodological quality were independently assessed by two reviewers.

RESULTS

Twenty-seven studies were included, most were randomised controlled trials (n = 19; 70%). Twenty-three studies targeted adults (17 showed significant health improvements) and four studies targeted children (two demonstrated significant health improvements). Twenty-one studies targeted physical activity (14 showed significant health improvements), 13 studies targeted diet (seven showed significant health improvements) and five studies targeted sedentary behaviour (two showed significant health improvements). More studies (n = 12; 63%) of those reporting significant effects detected between-group improvements in the health behaviour or related health outcomes, whilst fewer studies (n = 8; 42%) reported significant within-group improvements. A larger proportion of multi-component interventions (8 out of 13; 62%) showed significant between-group improvements compared to stand-alone app interventions (5 out of 14; 36%). Eleven studies reported app usage statistics, and three of them demonstrated that higher app usage was associated with improved health outcomes.

CONCLUSIONS

This review provided modest evidence that app-based interventions to improve diet, physical activity and sedentary behaviours can be effective. Multi-component interventions appear to be more effective than stand-alone app interventions, however, this remains to be confirmed in controlled trials. Future research is needed on the optimal number and combination of app features, behaviour change techniques, and level of participant contact needed to maximise user engagement and intervention efficacy.

Caregivers' perception of factors associated with a healthy diet among people with intellectual disability living in community residences: A Concept mapping method

BACKGROUND

Many people with intellectual disabilities (ID) living in community-based residences have been found to have unhealthy diet and weight disturbances. In Norway, a majority of people with ID live in such residences.

AIMS

The aim of the study was to examine factors affecting the caregivers' opportunity to promote a healthy diet among the residents.

METHODS AND PROCEDURES

A concept mapping methodology was adopted, including group-based brainstorming, idea synthesising, sorting, rating and analysis of the results. Informants were caregivers in four different community residences for people with mild to moderate ID in the southeast of Norway. A total of 13 informants were recruited (12 females and 1 male), and 10 informants completed two sessions.

RESULTS

Eight clusters were identified as affecting the caregivers' ability to promote a healthy diet: "Availability and accessibility", "Guidance and autonomy", "Competence among staff", "Planning and involvement", "Customization", "External conditions affecting staff", "Legislation, rules and structure" and "Everyday challenges", each including both barriers and facilitators.

CONCLUSIONS AND IMPLICATIONS

Multiple factors affect the caregivers' ability to promote a healthy diet. Caregivers' opportunity to promote a healthy diet is complex. Availability and accessibility of healthy food is crucial, but a healthy diet also requires time and competence among the caregivers.

Associations of specific types of sports and exercise with all-cause and cardiovascular-disease mortality: a cohort study of 80 306 British adults

BACKGROUND/AIM

Evidence for the long-term health effects of specific sport disciplines is scarce. Therefore, we examined the associations of six different types of sport/exercise with all-cause and cardiovascular disease (CVD) mortality risk in a large pooled Scottish and English population-based cohort.

METHODS

Cox proportional hazards regression was used to investigate the associations between each exposure and all-cause and CVD mortality with adjustment for potential confounders in 80 306 individuals (54% women; mean±SD age: 52±14 years).

RESULTS

Significant reductions in all-cause mortality were observed for participation in cycling (HR=0.85, 95% CI 0.76 to 0.95), swimming (HR=0.72, 95% CI 0.65 to 0.80), racquet sports (HR=0.53, 95% CI 0.40 to 0.69) and aerobics (HR=0.73, 95% CI 0.63 to 0.85). No significant associations were found for participation in football and running. A significant reduction in CVD mortality was observed for participation in swimming (HR=0.59, 95% CI 0.46 to 0.75), racquet sports (HR=0.44, 95% CI 0.24 to 0.83) and aerobics (HR=0.64, 95% CI 0.45 to 0.92), but there were no significant associations for cycling, running and football. Variable dose-response patterns between the exposure and the outcomes were found across the sport disciplines.

CONCLUSIONS

These findings demonstrate that participation in specific sports may have significant benefits for public health. Future research should aim to further strengthen the sport-specific epidemiological evidence base and understanding of how to promote greater sports participation.

Chinese women health ambassadors programme: A process evaluation

AIMS AND OBJECTIVES

The aim of this study was to assess a community-women health ambassadors programme and report the areas that were successful and those that required improvement. The objectives were to assess the feasibility, effectiveness, implementation and sustainability of the programme.

BACKGROUND

Health promotion for the prevention of chronic diseases has always been the top priority in the health sector. To ensure that the relevant health messages are well received in local communities, a health promotion programme must be accessible, acceptable and culturally relevant.

DESIGN

We conducted and evaluated a women health ambassador programme based on the lay health advisor model for health promotion in Hong Kong during November 2014 to February 2015. Health needs and the subsequent focus of the programme were determined by underprivileged Chinese women.

METHODS

University health educators from different disciplines trained the women (N = 80) to be health ambassadors through mini-lectures and training workshops. The trained women raised awareness about the importance of health within their families and social networks. The programme was evaluated through attendance rates, questionnaires and quizzes, changes in knowledge and behaviour, as well as qualitative discussion.

RESULTS

While the majority of participants found the programme valuable and useful, retention rates were unideal. A statistically significant improvement was found in eating habits, but no significant change was identified for other knowledge and behaviour assessments.

CONCLUSIONS

The programme empowered underprivileged women to reflect on the importance of health, take responsibility for their own health and actively promote health to their families and personal communities.

RELEVANCE TO CLINICAL PRACTICE

Our study supports that health promotion programmes based on the lay health advisor model are effective and encourage large-scale programmes of this nature. Our results also support that future health promotion efforts should deliver brief, clear and simple content as opposed to intricate information.

Environmental components of childhood obesity prevention interventions: an overview of systematic reviews

Childhood obesity has a complex multi-factorial aetiology grounded in environmental and individual level factors that affect behaviour and outcomes. An ecological, systems-based approach to addressing childhood obesity is increasingly being advocated. The primary aim of this review is to summarize the evidence reported in systematic reviews on the effectiveness of population-level childhood obesity prevention interventions that have an environmental component. We conducted a systematic review of reviews published since 1995, employing a standardized search strategy in nine databases. Inclusion criteria required that reviews be systematic and evaluated at least one population-level, environmental intervention in any setting aimed at preventing or reducing obesity in children (5-18 years). Sixty-three reviews were included, ten of which were of high quality. Results show modest impact of a broad range of environmental strategies on anthropometric outcomes. Systematic reviews vary in methodological quality, and not all relevant primary studies may be included in each review. To ensure relevance of our findings to practice, we also report on relevant underlying primary studies, providing policy-relevant recommendations based on the evidence reviewed. Greater standardization of review methods and reporting structures will benefit policymakers and public health professionals seeking informed decision-making.

A quasi-experimental cross-disciplinary evaluation of the impacts of education outside the classroom on pupils' physical activity, well-being and learning: the TEACHOUT study protocol

Background

Education Outside the Classroom (EOTC) is a teaching method that aims to promote schoolchildren’s learning, physical activity (PA), social relations, motivation, and well-being. EOTC activities are characterized by teachers using the local environment in their teaching, and involve innovative teaching methods, child-led approaches to problem-solving, experimentation, cooperation, PA, and play. EOTC has become common practice for many teachers in Scandinavia; however, only case studies have evaluated its impacts.

The TEACHOUT study aims to evaluate the impacts of EOTC on Danish schoolchildren’s PA, social relations, motivation, well-being, and learning.

Methods

TEACHOUT is a quasi-experimental, cross-disciplinary study. Sixteen schools participated, containing 19 EOTC school classes and 19 parallel non-EOTC classes, with a total of 834 children aged 9 to 13 years. Measures of the children’s social relations, motivation for school, well-being, and academic performance were collected at the beginning and end of the school year. Data on PA levels were collected over ten-day periods during the school year using accelerometers. The amount and characteristics of the actual EOTC provided in both EOTC and non-EOTC classes were monitored day-to-day throughout the school year, using an online teacher survey platform. The effects of EOTC are mainly analysed by comparing EOTC pupils to non-EOTC (i.e. control) pupils based on their scores on the outcome variables (i.e. school performance, well-being, motivation, and social relations) at the end of the school year, adjusting for the baseline values (from the beginning of the year). The impacts of EOTC on PA are evaluated by comparing the total as well as context-specific amounts of PA of children participating in EOTC to those of children in their parallel non-EOTC classes. Furthermore, the interdependencies between PA, social relations, well-being, motivation, and learning are explored using path analysis. To help describe and understand the processes that have led to the quantitative outcomes, qualitative case observations of children’s practices and interactions in EOTC as well as classroom teaching were carried out and combined with qualitative interviews about children’s perceptions of these practices.

Discussion

The TEACHOUT study represents a holistic multidisciplinary approach to educational and school health-promotion research through its study design and combination of scientific disciplines and methods, as well as its focus on the interdependent relations between learning, PA, social relations, well-being, and motivation. This will result in a comprehensive picture of school health promotion and children’s health and well-being, which will broaden the understanding of the potential benefits of EOTC in school health promotion and primary education. These results can be used to inform and guide future policy and practice.

Multi-Level, Multi-Component Approaches to Community Based Interventions for Healthy Living-A Three Case Comparison

There is increasing interest in integrated and coordinated programs that intervene in multiple community settings/institutions at the same time and involve policy and system changes. The purpose of the paper is to analyse three comparable cases of Multi Level, Multi Component intervention programs (ML-MC) from across the world in order to give recommendations for research, policy and practice in this field. Through the comparison of three cases: Health and Local Community (SoL-program), Children's Healthy Living (CHL) and B'More Healthy Communities for Kids (BHCK), this paper examines the potential of ML-MC community-based public health nutrition interventions to create sustainable change. The paper proposes methodology, guidelines and directions for future research through analysis and examination strengths and weaknesses in the programs. Similarities are that they engage and commit local stakeholders in a structured approach to integrate intervention components in order to create dose and intensity. In that way, they all make provisions for post intervention impact sustainability. All programs target the child and family members' knowledge, attitudes, behavior, the policy level, and the environmental level. The study illustrates the diversity in communities as well as diversity in terms of which and how sites and settings such as schools, kindergartens, community groups and grocery stores became involved in the programs. Programs are also different in terms of involvement of media stakeholders. The comparison of the three cases suggests that there is a need to build collaboration and partnerships from the beginning, plan for sufficient intensity/dose, emphasize/create consistency across levels and components of the intervention, build synchronization across levels, and plan for sustainability.

Policies for promotion of physical activity and prevention of obesity in adolescence

Obesity rates among children and adolescents in developed countries have increased dramatically since the 1970s. During that same period, numerous secular changes have combined to reduce the demand for physical activity in day-to-day life, and many barriers to physical activity are now evident. As a consequence, most children and adolescents do not meet the accepted public health guidelines for physical activity. Accordingly, public health interventions are needed to increase physical activity in adolescence. Such interventions, if successfully implemented, can be expected to improve fitness and health as well as reduce the prevalence of overweight and obesity in young people. Promotion of physical activity in populations of children and adolescents will require comprehensive strategic planning and adoption of new policies in multiple societal sectors. This paper highlights nine initiatives that can address the problem of physical activity in children. The initiatives are to: establish comprehensive school physical activity programming; demand high quality physical education; require physical activity in early child care and education; require physical activity in afterschool programs; create equity in community resources; activate youth sports programs; re-normalize active transport to school; institutionalize clinic-based physical activity assessment and counseling; and build activity-friendly homes. A case will be made for comprehensive national and international strategic planning aimed at effective and large-scale implementation of these initiatives and tactics.

Using a gamified monitoring app to change adolescents' snack intake: the development of the REWARD app and evaluation design

BACKGROUND

As the snacking pattern of European adolescents is of great concern, effective interventions are necessary. Till now health promotion efforts in children and adolescents have had only limited success in changing adolescents' eating patterns and anthropometrics. Therefore, the present study proposes an innovative approach to influence dietary behaviors in youth based on new insights on effective behavior change strategies and attractive intervention channels to engage adolescents. This article describes the rationale, the development, and evaluation design of the 'Snack Track School' app. The aim of the app is to improve the snacking patterns of Flemish 14- to 16-year olds.

METHODS

The development of the app was informed by the systematic, stepwise, iterative, and collaborative principles of the Intervention Mapping protocol. A four week mHealth intervention was developed based on the dual-system model with behavioral change strategies targeting both the reflective (i.e., active learning, advance organizers, mere exposure, goal-setting, monitoring, and feedback) and automatic processes (i.e., rewards and positive reinforcement). This intervention will be evaluated via a controlled pre-post design in Flemish schools among 1400 adolescents.

DISCUSSION

When this intervention including strategies focused on both the reflective and automatic pathway proves to be effective, it will offer a new scientifically-based vision, guidelines and practical tools for public health and health promotion (i.e., incorporation of learning theories in intervention programs).

TRIAL REGISTRATION

NCT02622165 registrated November 15, 2015 on clinicaltrials.gov.

Promoting physical activity for children and adolescents in low- and middle-income countries: An umbrella systematic review: A review on promoting physical activity in LMIC

OBJECTIVE

It is unknown how much previous reviews on promoting physical activity (PA) for children and adolescents (aged 6-18years) take into account studies from low- and middle-income countries (LMIC, based on the World Bank definition) and the level of evidence of the effect of PA interventions in this population. This study aims to answer such questions using an umbrella systematic review approach.

METHODS

We searched for peer-reviewed systematic reviews and original studies in eight electronic databases, screening of reference lists and expert contacts. Information in systematic reviews on PA interventions for children and adolescents from LMIC was discussed. Original studies on PA interventions (randomized-controlled trials [RCT], cluster-RCT and non-RCT) with children and adolescents from LMIC were eligible. We assessed the methodological quality in all studies, and the evidence level of effect on PA in intervention studies.

RESULTS

Fifty systematic reviews (nine meta-analyses) and 25 original studies (20 different interventions) met eligibility criteria. Only 3.1% of mentioned studies in previous reviews were from LMIC. Strong and LMIC-specific evidence was found that school-based, multicomponent, and short-term (up to six months) interventions, focused on adolescents primarily (aged 13-18years), can promote PA in children and adolescents from LMIC. Other intervention characteristics had inconclusive evidence due to the low number of studies, low methodological quality, and/or small sample size.

CONCLUSION

A minimal part of PA interventions mentioned in previous reviews are from LMIC. Our LMIC-specific analyses showed priorities of implementation and practical implication that can be used in public policies for PA promotion in LMIC.

Obesogenic environment - intervention opportunities

OBJECTIVES

To evaluate environmental obesogenic-related factors, such as physical activity in neighborhoods and schools, nutritional behavior, and intervention programs.

SOURCES

Critical analysis of literature with personal point of view from infant obesity experts and political advisors for public intervention.

DATA SYNTHESIS

Although obesity is a public health problem affecting several age groups, it is among children and adolescents that it plays a more important role, due to treatment complexity, high likelihood of persistence into adulthood, and association with other non-transmissible diseases while still in early age. Environment is a main component of the genesis and outcomes in the near future or long term. Modification of intake with high-density food, meal skipping, and high intake of saturated fat, sugar, and salt, associated to high levels of sedentarism are main causes of obesity.

CONCLUSION

Intervention opportunities are related to modifications in political, environmental, and individual settings. School and physical activities in the educational environment are intertwined with nutrition intervention in continuous education. A critical review of some different scenarios in Latin American countries is presented.

The impact of long-term school-based physical activity interventions on body mass index of primary school children - a meta-analysis of randomized controlled trials

Background

Physical activity (PA) intervention is a commonly recommended strategy to combat childhood obesity. However, its effectiveness has long been controversial. This paper aims to examine the effectiveness of long-term (≥12 months) school-based PA interventions on body mass index (BMI) in primary school children, who are gaining BMI.

Methods

Original papers were retrieved from PubMed, Google Scholar, the Cochrane Library and Web of Science, published between 1990 and 2015. The inclusion criteria were those research studies that were: randomized controlled trials (RCTs), conducted in primary school settings, had valid data on BMI at baseline and at the final follow up (or on BMI changes), and involved PA intervention that lasted for at least 12 months.

Results

Out of 11,158 potentially eligible articles, 18 papers were included in the analysis, involving 22,381 primary school children with intervention durations ranging from 12 to 72 months. Compared to the control groups, the BMI increment was 2.23 kg/m² less in the intervention groups (p < 0.05). The heterogeneity was high across the studies (99.8 %), but declined after sub-group analyses. The intervention type, intervention duration, and weekly PA intervention time were among the factors leading to the heterogeneity.

Conclusion

Long-term school-based interventions containing PA as a core component appear to be effective in achieving healthier BMI. However, the results should be interpreted with caution due to the high heterogeneity among the studies. More high quality school-based RCTs among diverse populations are needed to improve the homogeneity and to yield a more robust conclusion.

Socio-economic status and overweight or obesity among school-age children in sub-Saharan Africa - a systematic review

Childhood overweight and obesity have emerged as a public health concern in sub-Saharan Africa. We conducted a systematic review with the aim to examine the association between socio-economic status (SES) and overweight or obesity among school-age children in sub-Saharan Africa. In March 2014 we searched five electronic databases for reports which presented cross-sectional data on prevalence levels of overweight or obesity stratified by SES groups among school-age children in sub-Saharan Africa. We used a random-effect model to pool the relative indexes of inequality of the association from the individual studies. In total, 20 reports satisfied the inclusion criteria providing results of 21 datasets. The risk of overweight or obesity in children from highest SES households was 5.28 times as high as that of children from lowest SES households (95% confidence interval [CI] 2.62 to 10.66). On subgroup analysis, this association was statistically significant for household income and composite SES measures but not for parental educational attainment and occupation type. Similarly, the risk of overweight or obesity in children attending affluent (private) schools was 15.94 times as high as that of children going to either urban or rural public schools (95% CI 5.82 to 43.68). The magnitude of the association tended to be stronger for area or school-type compared with composite measures. In summary, children from higher SES households and those attending private schools tended to be overweight and obese.

Effects of a Theory-Based Education Program to Prevent Overweightness in Primary School Children

The effectiveness of the “Extra Fit!” (EF!) education program in promoting healthy diet and physical activity to prevent and reduce overweightness among primary school children aged 9 to 11 was evaluated. A randomized controlled design was carried out in 45 primary schools (n = 1112) in the Netherlands, 23 intervention and 22 control schools. The intervention schools received the education program for two successive school years in grades (U.S. system) 4, 5, and 6 (mean 7.6 h during 16 weeks per school per year). The control schools followed their usual curriculum. No positive effects of EF! were found with regard to behavior and anthropometric measures when follow-up measurements were compared to the baseline. However, from baseline to follow-up after one and two school years, the intervention group improved their knowledge score significantly compared to the control group. Moreover, an effect was observed for mean time spent inactively that increased more in the control group than in the intervention group. In conclusion, limited intervention effects were found for the intervention on knowledge and inactivity. To improve the effectiveness of education programs, we advise focusing on parental involvement, attractive lessons to enlarge the acceptability of the program, and multi-component environmental strategies.

Physical activity and nutrition education at the school environment aimed at preventing childhood obesity: evidence from systematic reviews

OBJECTIVE

To organize the main findings and list the most frequent recommendations from systematic reviews of interventions developed at the school environment aimed at reducing overweight in children and adolescents.

DATA SOURCE

Searches for systematic reviews available until December 31, 2014 were conducted in five electronic databases: Cochrane, PubMed, SciELO, SPORTDiscus, and Web of Science. Manual search for cross-references were also performed.

SUMMARY OF THE FINDINGS

Of the initial 2139 references, 33 systematic reviews adequately met the inclusion criteria and were included in the descriptive summary. In this set, interventions with periods of time greater than six months in duration (nine reviews), and parental involvement in the content and/or planned actions (six reviews) were identified as the most frequent and effective recommendations. Additionally, it was observed that boys respond more effectively to structural interventions, whereas girls respond to behavioral interventions. None of the included reviews was able to make inferences about the theoretical basis used in interventions as, apparently, those in charge of the interventions disregarded this component in their preparation.

CONCLUSIONS

Although the summary identified evidence with important applications in terms of public health, there are still gaps to be filled in this field of knowledge, such as the effectiveness of different theoretical models, the identification of the best strategies in relation to gender and age of participants and, finally, the identification of moderating variables to maximize the benefits provided by the interventions.

Evaluation of a comprehensive intervention with a behavioural modification strategy for childhood obesity prevention: a nonrandomized cluster controlled trial

Background

With regard to the global childhood obesity epidemic, it is imperative that effective lifestyle interventions are devised to combat childhood obesity. This paper describes the development and implementation of a comprehensive (a combination of diet and physical activity (PA)), social cognitive behaviour modification intervention using accelerometry and a dietary diary to tackle child overweight and obesity. The comprehensive intervention effect was evaluated in a comparison with diet only, PA only and a no-treatment control group.

Methods

A pilot study was conducted with a non-randomized cluster design. Four hundred thirty-eight overweight and obese children aged 7–12 years from ten primary schools in Beijing were recruited to receive a one-year intervention. Participants were allocated into one of four groups: the comprehensive intervention group; the PA only group (Happy 10 program); the diet only group (nutrition education program); and a control group. The effects of intervention on adiposity, blood pressure, and biochemical indicators were assessed by examining 2-way interactions (time × intervention) in linear mixed models. Means and 95 % confidence intervals (CI) for the adjusted changes between post-intervention and baseline relative to changes in the control group were calculated and reported as effect sizes.

Results

The percentage of body fat in the comprehensive intervention group showed a significant relative decrease (adjusted change: −1.01 %, 95 % CI: (−1.81, −0.20) %) compared with the PA only, diet only or control groups (P < 0.001). Systolic blood pressure significantly decreased in the comprehensive intervention group (adjusted change: −4.37 mmHg, 95 % CI: (−8.42, −0.33) mmHg), as did diastolic blood pressure (adjusted change: −5.50 mmHg, 95 % CI (−8.81, −2.19) mmHg) (P < 0.05). Compared with the other two intervention groups and the control group, positive adjusted changes in fasting glucose in the comprehensive group were found, although not for the biochemical lipid metabolism indicators. Positive but non-significant adjusted changes in body mass index and waist circumference were observed.

Conclusions

Compared with the diet or PA only intervention groups, the current comprehensive program had superior positive effects on body fat percentage and blood pressure but not on the biochemical lipid metabolism indicators in Chinese overweight and obese children. Future randomized controlled trials and long-term follow-up studies are required to elaborate the findings of the current intervention.

Trial registration

ClinicalTrials.gov identifier: NCT02228434

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2535-2) contains supplementary material, which is available to authorized users.

Assessing the usefulness of systematic reviews for policymakers in public health: A case study of overweight and obesity prevention interventions

OBJECTIVE

Systematic reviews (SRs) should include policy-relevant information in order to more readily inform policy and practice. We investigated whether SRs of overweight and obesity prevention interventions are framed in such a way that maximises their usefulness for policymakers.

METHOD

We conducted a systematic review of SRs of overweight and obesity prevention interventions published in 4 databases any time up to December 2014. We analysed the SRs for their usefulness to policymakers, using a coding frame developed based on literature around what policymakers want and need from systematic reviews. Systematic reviews were assessed for a) policy links and framing; b) quality assessment and conflict of interest statements: and c) discussion of policy implications.

RESULTS

Of the 153 SRs that met the inclusion criteria, very few (7%) had authors from policy-based organisations, 48% had funding from such organisations, and almost a third (31%) framed their introduction or aims around policy. Most (69%) discussed issues affecting generalisability of the SR findings but only a quarter (24%) discussed cost or cost-effectiveness of the intervention under investigation. Less than a third (29%) of SRs discussed the policy implications of their findings. SRs that were policy-framed were significantly more likely to discuss costs (PR=1.8, 95%CI 1.0-3.0) and policy implications (PR=2.5, 95%CI 1.5-4.0).

CONCLUSION

SRs should discuss the policy and practice implications of their findings to maximise the influence of SRs on policy making. It is recommended that SR guidelines are updated to include generalisability and discussion of policy and practice implications as a requirement.

School-Based Interventions to Reduce Obesity Risk in Children in High- and Middle-Income Countries

School-based interventions are relatively new and were first introduced in the United States in the 1990s. Early programs were mainly education based with many of the findings now embedded in school policy in the form of a healthy eating curriculum. More recent school programs have taken education outside the classroom and attempted to engage parents as well as teachers. Environmental changes such as improving the quality of foods available at lunchtime and at other times during the school day are now common. Reviews of evaluations of school-based programs have demonstrated that they are effective and successfully improve dietary quality such as increasing fruit and vegetable intake and decreasing sweet and savory snacks and sweetened drinks; not just in school but over the whole day and particularly in younger school children. School-based interventions are also effective at reducing obesity if components to increase physical activity and reduce sedentary behaviors are also targeted but not if only dietary behaviors are tackled. Most of the high-quality evaluation studies using randomized controlled trials have been carried out in high-income countries as they are costly to run. However, middle-income countries have benefitted from the information available from these evaluation studies and many are now starting to fund and evaluate school-based programs themselves, resulting in unique problems such as concomitant under- and overnutrition being addressed. Action for the future demands more focus on populations most at risk of poor dietary quality and obesity in order to reduce inequalities in health and on adolescents who have not benefited as much as younger children from school-based interventions. This will involve innovative solutions within schools as well as targeting the food environment outside schools such as reducing the density of fast-food outlets and marketing of sweet and savory snacks and drinks.

RE-AIM analysis of a randomized school-based nutrition intervention among fourth-grade classrooms in California

Childhood overweight and obesity are major health problems. School-based programs enable intervening with large groups of children, but program overall health impact is rarely completely assessed. A RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) analysis tested the overall public health impact of the fourth-grade "Nutrition Pathfinders" school-based nutrition-education program. A randomized controlled trial in 47 fourth-grade California classrooms (1713 students) tested program efficacy, and a secondary analysis of archival data tested program dissemination. Desired effects were seen in child nutrition knowledge, attitudes, consumption of low-nutrient high-density foods, sugar-sweetened beverages, proteins, grains, and parent willingness to serve new foods. The program was disseminated to ∼25 % of public school fourth-grade classrooms in California and cost about $1.00 per student to implement. The Nutrition Pathfinders program demonstrates potential for moderate to high public health impact due to its wide dissemination, effectiveness in altering attitudes and behaviors, and its relatively inexpensive cost of implementation.

Games for Health for Children-Current Status and Needed Research

Videogames for health (G4H) offer exciting, innovative, potentially highly effective methods for increasing knowledge, delivering persuasive messages, changing behaviors, and influencing health outcomes. Although early outcome results are promising, additional research is needed to determine the game design and behavior change procedures that best promote G4H effectiveness and to identify and minimize possible adverse effects. Guidelines for ideal use of different types of G4H by children and adolescents should be elucidated to enhance effectiveness and minimize adverse effects. G4H stakeholders include organizational implementers, policy makers, players and their families, researchers, designers, retailers, and publishers. All stakeholders should be involved in G4H development and have a voice in setting goals to capitalize on their insights to enhance effectiveness and use of the game. In the future, multiple targeted G4H should be available to meet a population's diverse health needs in developmentally appropriate ways. Substantial, consistent, and sophisticated research with appropriate levels of funding is needed to realize the benefits of G4H.

Effect of School-based Interventions to Control Childhood Obesity: A Review of Reviews

Effectiveness of school-based interventions to prevent or control overweight and obesity among school children was reviewed for a 11-year period (January 2001 to December 2011). All English systematic reviews, meta-analyses, reviews of reviews, policy briefs and reports targeting children and adolescents which included interventional studies with a control group and aimed to prevent or control overweight and/or obesity in a school setting were searched. Four systematic reviews and four meta-analyses met the eligibility criteria and were included in the review. Results of the review indicated that implementation of multi-component interventions did not necessarily improve the anthropometric outcomes. Although intervention duration is a crucial determinant of effectiveness, studies to assess the length of time required are lacking. Due to existing differences between girls and boys in responding to the elements of the programs in tailoring of school-based interventions, the differences should be taken into consideration. While nontargeted interventions may have an impact on a large population, intervention specifically aiming at children will be more effective for at-risk ones. Intervention programs for children were required to report any unwanted psychological or physical adverse effects originating from the intervention. Body mass index was the most popular indicator used for evaluating the childhood obesity prevention or treatment trials; nonetheless, relying on it as the only indicator for adiposity outcomes could be misleading. Few studies mentioned the psychological theories of behavior change they applied. Recommendations for further studies on school-based interventions to prevent or control overweight/obesity are made at the end of this review.