Design and methodology of a cluster-randomized trial in early care and education centers to meet physical activity guidelines: Sustainability via Active Garden Education (SAGE)

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-randomised controlled trials (C-RCTs) and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no-intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child-feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child-focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate-certainty evidence that child-feeding practice interventions versus no-intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as-desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post-intervention follow-up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low-certainty evidence). Multicomponent interventions versus no-intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate-certainty evidence; mean post-intervention follow-up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden-based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low-certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short-term impact on child consumption of fruit and vegetables versus no-intervention control (SMD 0.10, 95% CI -0.02 to 0.22; 14 trials, 4122 participants; low-certainty evidence; mean post-intervention follow-up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low-certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low-certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding.

AUTHORS' CONCLUSIONS

There was moderate-certainty evidence that child-feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low- and middle-income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

How Societal Forces of Change Are Transforming Youth Physical Activity Promotion in North America

BACKGROUND

Climate change, increasing recognition of institutionalized discrimination, and the COVID-19 pandemic are large-scale, societal events (ie, forces of change) that affect the timing, settings, and modes of youth physical activity. Despite the impact that forces of change have on youth physical activity and physical activity environments, few studies consider how they affect physical activity promotion.

METHODS

The authors use 2 established frameworks, the ecological model of physical activity and the youth physical activity timing, how, and setting framework, to highlight changes in physical activity patterns of youth in North America that have resulted from contemporary forces of change.

RESULTS

North American countries-Canada, Mexico, and the United States-have faced similar but contextually different challenges for promoting physical activity in response to climate change, increasing recognition of institutionalized discrimination, and the COVID-19 pandemic. Innovative applications of implementation science, digital health technologies, and community-based participatory research methodologies may be practical for increasing and sustaining youth physical activity in response to these forces of change.

CONCLUSIONS

Thoughtful synthesis of existing physical activity frameworks can help to guide the design and evaluation of new and existing physical activity initiatives. Researchers, practitioners, and policymakers are encouraged to carefully consider the intended and unintended consequences of actions designed to respond to forces of change.

Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years

BACKGROUND

Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health.

OBJECTIVES

To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions.

SEARCH METHODS

We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes.

MAIN RESULTS

We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).

AUTHORS' CONCLUSIONS

ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.

Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years

BACKGROUND

Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health.

OBJECTIVES

To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions.

SEARCH METHODS

We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes.  MAIN RESULTS: We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).

AUTHORS' CONCLUSIONS

ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.

Preschoolers' parent and teacher/director perceptions of returning to early childcare education during the COVID-19 pandemic

BACKGROUND

Early Care and Education (ECE) sites are critical hubs for social, emotional, and physical learning development of preschool children (ages 3-5). The COVID-19 pandemic has impacted ECE enrollment and participation; until June 2022, preschool children in the US were ineligible for COVID-19 vaccines. It is critical to identify perceptions of teachers/directors and parents to enhance safe return-to-school efforts.

METHODS

Focus groups (n = 7; 22 participants) were conducted with ECE teachers/directors throughout Arizona to examine perceptions of COVID-19 testing for families and staff at ECE sites, and current and possible COVID-19 mitigation strategies during Summer 2021. Preschool parents from underserved families in Phoenix (n = 41) completed a brief survey on their perceptions of benefits of ECE for themselves and their children, thoughts on COVID-19 mitigation strategies, and timing for safe return to school during Spring 2021. Focus groups were transcribed and analyzed for themes using constant comparison.

RESULTS

There were 4 focus group themes: 1) perceptions of saliva-based COVID-19 testing, 2) logistical strategies for COVID-19 testing at ECE sites; 3) successes and challenges with current COVID-19 mitigation strategies; 4) ideas to support improved COVID-19 mitigation, including outdoor gardening. Parents rated peace of mind about the child's education as the most important benefit for themselves of in-person ECE (74.6%), and social development for children as the most important benefit for their children (54.4%). Over 40% of parents reported it would not be safe to send children back until 2022.

CONCLUSIONS

COVID-19 continues to impact attendance at ECE sites, despite parents reporting key benefits to attending ECE sites. Teachers/directors supported COVID-19 mitigation strategies including saliva-based testing and gardening education to improve safe return to schools.

Sustainability via Active Garden Education: The Sustainability Action Plan Model and Process

Sustainability of intervention programming is challenging to achieve under real world conditions, since few models exist and many studies do not plan far beyond the funding period. Programming content in early care and education centers (ECECs) is often driven by guidelines. However, implementation is very sensitive to contextual factors, such as the setting and implementer (teacher) characteristics. This paper presents the model, definitions, and methodology used for the sustainability action plan capitalizing on a community-based participatory research (CBPR) approach, developed for a multi-site, multi-level garden-based childhood obesity prevention study, Sustainability via Active Garden Education (SAGE). The Ecologic Model of Obesity is applied to develop a sustainability action plan (SAP) and accompanying measures to link early care and education (ECE) environment, the community, policies, and classroom practices to an early childhood obesity prevention program. The SAGE SAP provides an example of how to iteratively evaluate and refine sustainability processes for an obesity prevention intervention utilizing CBPR approaches and will be applied to assess the sustainability of SAGE in a cluster randomized controlled trial. This SAP model can also help inform intervention delivery and scalability within ECECs.

Developing and Evaluating Newsletters for Parent Engagement in Sustainability via Active Garden Education (SAGE)

Physical activity and nutrition preschool programming must involve parents in positive long-term healthy habits. This paper describes parent outreach in the Sustainability via Active Garden Education (SAGE) study. Newsletters were sent home with children to promote family opportunities to increase physical activity and fruit and vegetable intake. The content was generated via a community advisory board participatory process. Messages linked SAGE curriculum topics with home and community activities. Parents rated frequency of receipt, helpfulness, satisfaction, and use of content. Most participants were Hispanic (>78%) and women (>95%). Most reported receiving newsletters; nearly all reported that they were helpful. Favorite newsletter components included recipes, pictures of their children and seasonal produce spotlights. Most reported doing physical activities from the newsletters (51.9%). Few reported doing featured physical activity (8.9%) and fruit and vegetable (12.7%) community activities. Newsletter outreach methods are a simple strategy to add value to preschool-based interventions promoting healthy families.

Early Care and Education Center Environmental Factors Associated with Product- and Process-Based Locomotor Outcomes in Preschool-Age Children

Environmental characteristics of early care and education centers (ECECs) are an important context for preschool-aged children’s development, but few studies have examined their relationship with children’s locomotor skills. We examined the association between characteristics of the ECEC environment with quantitatively (i.e., product-based) and qualitatively (i.e., process-based) measured locomotor skills, using the Progressive Aerobic Cardiovascular Endurance Run (PACER) and the locomotor portion of the Children’s Activity and Movement in Preschool Study (CHAMPS) motor skills protocol (CMSP), respectively. ECEC characteristics included outdoor and indoor play environment quality, outdoor and indoor play equipment, screen-time environment quality, and policy environment quality. Mean (SD) scores for the PACER (n = 142) and CSMP (n = 91) were 3.7 ± 2.3 laps and 19.0 ± 5.5 criteria, respectively, which were moderately correlated with each other (Pearson r = 0.5; p < 0.001). Linear regression models revelated that a better policy environment score was associated with fewer PACER laps. Better outdoor play and screen-time environment quality scores and more outdoor play equipment were positively associated with higher CMSP scores. ECEC environments that reflect best practice guidelines may be opportunities for locomotor skills development in preschool-aged children. ClinicalTrials.gov Identifier: NCT03261492 (8/25/17).

Community-Based Measurement of Body Composition in Hispanic Women: Concurrent Validity of Dual- and Single-Frequency Bioelectrical Impedance

ABSTRACT

Szeszulski, J, Lorenzo, E, Arriola, A, and Lee, RE. Community-based measurement of body composition in hispanic women: concurrent validity of dual- and single-frequency bioelectrical impedance. J Strength Cond Res 36(2): 577-584, 2022-We examined the concurrent validity of single-frequency (SF) and dual-frequency (DF) bioelectrical impedance (BIA) scales among Hispanic women participating in a community-based health promotion program in Arizona. Hispanic women (N = 14), age 31.9 ± 6.5 years old, with a mean body mass index (BMI) of 31.1 ± 8.1 kg·m-2, were measured using SF BIA, DF BIA, BMI, and skinfold calipers in 2017. Intrarater reliability and concurrent validity were calculated. Bland-Altman plots examined agreement of each BIA measure within measurement tools, between tools, and with skinfold calipers. Scatter plots were used to examine agreement between BIAs and BMI. Short-term intrarater reliability was perfect within measurements for SF and DF BIAs (α = 1.0). The coefficient of variation within a measurement tool (CV%) was slightly smaller for DF BIA (0.2%; n = 13) than for SF BIA (0.3%; n = 14). Concurrent validity measures revealed that DF (M = 39.3 ± 7.3% fat; within sample CV% = 18.6; n = 14) and SF (M = 39.4 ± 7.5% body fat; within sample CV% = 19.0; n = 14) BIAs were highly correlated (Pearson r = 0.885; p < 0.001; n = 14) and had an absolute mean difference of -0.2 ± 3.5% fat (range 0.7-6.0% fat; n = 14). The CV% between BIA measures was 5.4%. Dual-frequency and SF BIAs were both strongly correlated with BMI and skinfolds. There was evidence of bias between skinfolds and both BIA measures. Strength and conditioning practitioners should feel confident in using either SF or DF BIA measures with Hispanic women who participate in training interventions in community-based settings, because they offer similar measurement value.

Impact of cocreation training capsules for preschool teachers on children's healthy habits: a pilot study conducted in Barcelona, Spain

Background

Healthy habits are essential for preschoolers to have a healthy lifestyle. The promotion of these healthy habits from a holistic approach by preschool teachers guarantees a better quality of life and a healthier society. Using cocreation, we designed training for healthy habit promotion for preschool teachers (all@once). Then, we implemented the training and evaluated its impact on classroom teaching strategies.

Methods

This study presents the all@once training design and its implementation and evaluation during 2019. The cocreation process involved 8 parents, 9 preschool teachers and 9 health professionals (selected by a nonprobabilistic sampling system according to quotas) to design training from a holistic perspective. To evaluate the all@once impact in classroom practice, a pilot study was undertaken in four public schools in Barcelona (Spain). All@once was implemented with 16 volunteer teachers selected by convenience sampling and 328 children. A mixed methods approach was chosen to collect data based on direct nonparticipating naturalist systematic observations in June and October 2019. After qualitative data categorization, changes in health routines and actions at school were assessed by either contingency table analysis of frequency distributions or nonparametric comparisons of two related samples.

Results

The cocreation process provided training organized into online capsules with a holistic view of health in four main dimensions (nutrition, hygiene, physical activity and emotional health). Of these dimensions, the emotional health dimension comprised half of the training content. Pilot testing of the impact of all@once on classroom health-related activities evidenced an increase in the likelihood of observing fruit consumption by children, healthy habit promotion and hand washing. The most significant all@once-induced changes that we observed were related to teaching strategies concerning the emotional health dimension of the training.

Conclusions

This pilot study provides evidence of cocreation being a productive way to design training for preschool teachers regarding inclusive education in integral health. This approach collects the needs of the school community, provides training with a holistic concept of health and effectively impacts classroom routines and family health habits in the short term.

Mindfulness-based programs for the prevention of childhood obesity: A systematic review

INTRODUCTION

The prevalence of overweight and obesity has increased worldwide at an alarming rate in recent decades and has become a serious public health problem. The purpose of this study is to carry out a systematic review of scientific research on mindfulness-based programs for the prevention of childhood obesity carried out in the last 10 years.

METHOD

A search of studies that used mindfulness to promote good eating behavior in minors was conducted. After applying the inclusion and exclusion criteria, a total of 16 studies were found.

RESULTS

Statistically significant improvements were found in most of the cases where changes in eating habits, food portions, reduction of stress, or reduction of cravings in minors were evaluated.

CONCLUSIONS

Mindfulness programs applied to improve eating behaviors appear to be an effective alternative to prevent childhood obesity, but further studies are needed to draw conclusions.

Exploring Correlates of Preschool-Aged Children's Locomotor Skills: Individual and Parent Demographics and Home Environment

We examined individual and parental demographics and home environment factors associated with locomotor skills in predominantly Hispanic preschool-aged children. We used questionnaires to survey parents, included inquiries regarding parenting practices, parents' physical activity levels, and home-based physical activity resources; and we administered the Progressive Aerobic Cardiovascular Endurance Run (PACER) and the CHAMPS Motor Skills Protocol (CMSP) to children to measure the quantity and quality of their locomotor skills. Participants were 144 parents and their children (78.9% Hispanic, 49.3% girls) recruited from urban, community-based childcare and education centers. We examined the relationship between survey measures and PACER and CMSP scores with forward-selection stepwise linear regression models. Overall, 142 children completed the PACER, and 91 completed the CMSP. At the individual level, a child's age was positively associated with both PACER and CMSP scores, and girls had lower PACER scores than boys. In the home environment, parental promotion of more screen time was associated with a higher children's PACER score. In addition, higher parent concern for children's safety was associated with a lower PACER score. We identified several physical activity promoting parent practices as new home environment factors related to the preschool-aged children's locomotor development. Additional studies are needed to test new hypotheses generated from these data. ClinicalTrials.gov Identifier: NCT03261492 (date of registration 8/25/17).

Garden-based interventions and early childhood health: an umbrella review

BACKGROUND

Garden-based interventions show promise for improving not only child nutrition, but other indicators of child health. Yet, existing systematic reviews of garden-based interventions often focus on one particular health outcome or setting, creating a need to holistically summarize review-level evidence on the role of garden-based interventions in early childhood. To fill this gap, we performed an umbrella review of garden-based interventions to examine their role in early childhood health promotion for children ages 6 years and younger, examining effective components of garden-based interventions and critically evaluating existing evidence.

METHODS

We searched the following databases: PubMed, PubMed, PsycINFO, ERIC, CINAHL, Embase, Scopus, OVID-Agricola, and CAB Direct, limiting to reviews published from 1990 to August 2019. Of the 9457 references identified, we included a total of 16 unique reviews for analysis.

RESULTS

Across reviews, garden based-interventions were most effective at improving nutrition-related outcomes for children, including nutritional status and fruit and vegetable consumption. Few reviews examined child health outcomes of garden-based interventions that were not nutrition related, such as physical activity, or academic performance. Across settings, there was the most evidence in support of garden-based interventions conducted in home gardens, compared to evidence from early care and education or community settings. We were unable to report on most effective components of garden-based interventions due to limitations of included reviews.

CONCLUSIONS

Existing evidence is difficult to interpret due to methodological limitations at both the review and primary study level. Therefore, the lack of evidence for certain child health outcomes should not necessarily be interpreted as an absence of an effect of garden-based interventions for specific outcomes, but as a product of these limitations. Given the breadth of evidence for garden-based interventions to improve a number of dimensions of health with older children and adult populations, we highlight areas of future research to address evidence gaps identified in this umbrella review. Further research on the role of garden-based interventions, including their impact on non-nutrition early childhood health outcomes and how effectiveness differs by setting type is necessary to fully understand their role in early childhood health promotion.

PROSPERO REGISTRATION

CRD42019106848 .

Farm to Early Care and Education Programming: A Descriptive Study of Challenges and Opportunities to Promote Healthful Foods to Young Children

Interest in farm to early care and education (ECE) programming, which consists of gardening, nutrition education, and local food procurement, has been growing in the United States, as it may be a promising technique for promoting healthful foods to young children. However, there is limited information about current farm to ECE efforts in specific states, including Colorado, to support funding and resource needs. An online survey was distributed to licensed Colorado ECE providers in two phases to understand current participation in the farm to ECE as well as provider perspectives on benefits and barriers to programming. A total of 250 surveys were completed. Approximately 60% of ECE facilities participated in gardening and nutrition education with providers almost unanimously agreeing on the child-centric benefits of programming. Fewer facilities (37%) participated in local food procurement likely due to significant time, cost, and knowledge barriers. To increase participation in farm to ECE as a technique for promoting healthful foods to young children, future efforts should focus on innovative solutions to reduce ECE-specific barriers.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.