A randomized controlled trial of students for nutrition and eXercise: a community-based participatory research study

Effectiveness of Participatory Research Interventions on Obesity and Obesity-Related Behaviors in Adolescents: A Systematic Review and Meta-analysis

CONTEXT

Adolescence is an optimal period to promote healthy lifestyles because behavior patterns are established in this stage. It has been suggested that engaging youth increases the effectiveness of interventions, but an overview is lacking.

OBJECTIVE

This study aims to evaluate the effectiveness of participatory research (PR) interventions, where adolescents (11-18 years old) from high-income countries had a significant role in the intervention development and/or delivery, compared with no (PR) intervention control groups on obesity-related outcomes and healthy lifestyle behaviors (HLBs).

DATA SOURCES

Eight databases (Embase, Medline ALL, Web of Science Core Collection, PsycINFO, ERIC, CINAHL, Scopus, and Cochrane Central Register of Controlled Trials) and Google Scholar were searched from 1990 to 2024 for randomized controlled trials (RCTs) and non-RCTs (in English).

DATA EXTRACTION

Two researchers independently performed the data extraction and risk-of-bias assessment.

DATA ANALYSIS

Sixteen studies were included and outcomes have been narratively described. Seven studies evaluated youth-led interventions, 3 studies evaluated co-created interventions, and 6 studies evaluated the combination of both. Six studies focused on physical activity (PA), 2 on nutrition, and 8 on a combination of PA, nutrition, and/or obesity-related outcomes. Ten studies presented at least 1 significant effect on PA, nutrition, or obesity-related outcomes in favor of the intervention group. Additionally, 12 studies were pooled in a meta-analysis. Whereas a small desired effect was found for fruit consumption, a small undesired effect was found for vegetable consumption. The pooled analysis found no significant effects on moderate-vigorous PA, total PA, and PA self-efficacy.

CONCLUSION

We found some evidence that youth empowerment in research may have positive effects on obesity-related HLBs, specifically an increased fruit consumption. However, the overall evidence was inconclusive due to limited studies and the heterogeneity of the studies included. This overview may guide future public health interventions that aim to engage and empower adolescents.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration Nº CRD42021254135.

Mechanisms of school-based peer education interventions to improve young people's health literacy or health behaviours: A realist-informed systematic review

INTRODUCTION

Peer education interventions are widely used in secondary schools with an aim to improve students' health literacy and/or health behaviours. Although peer education is a popular intervention technique with some evidence of effectiveness, we know relatively little about the key components that lead to health improvements among young people, or components that may be less helpful. This review aims to identify the main mechanisms involved in school-based peer education health interventions for 11-18-year-olds.

METHODS

Five electronic databases were searched for eligible studies during October 2020, an updated search was then conducted in January 2023 to incorporate any new studies published between November 2020 and January 2023. To be included in the review, studies must have evaluated a school-based peer education intervention designed to address aspects of the health of students aged 11-18 years old and contain data relevant to mechanisms of effect of these interventions. No restrictions were placed on publication date, or country but only manuscripts available in English language were included.

RESULTS

Forty papers were identified for inclusion with a total of 116 references to intervention mechanisms which were subsequently grouped thematically into 10 key mechanisms. The four most common mechanisms discussed were: 1) Peerness; similar, relatable and credible 2) A balance between autonomy and support, 3) School values and broader change in school culture; and 4) Informal, innovative and personalised delivery methods. Mechanisms were identified in quantitative, qualitative and mixed methods intervention evaluations.

DISCUSSION

This study highlights a number of key mechanisms that can be used to inform development of future school-based peer education health interventions to maximise effectiveness. Future studies should aim to create theories of change or logic models, and then test the key mechanisms, rather than relying on untested theoretical assumptions. Future work should also examine whether particular mechanisms may lead to harm, and also whether certain mechanisms are more or less important to address different health issues, or whether a set of generic mechanisms always need to be activated for success.

Interventions to prevent obesity in children aged 12 to 18 years old

BACKGROUND

Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI slightly at medium-term (MD -0.32, 95% CI -0.53 to -0.11; 3 studies, 2143 participants) and long-term (MD -0.28, 95% CI -0.51 to -0.05; 1 study, 985 participants) follow-up; both low-certainty evidence. Seven studies (5428 participants; low-certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short-term follow-up (MD 0.03, 95% CI -0.07 to 0.13; 11 studies, 3429 participants; high-certainty evidence), and probably do not reduce BMI at medium-term (MD 0.01, 95% CI -0.09 to 0.11; 8 studies, 5612 participants; moderate-certainty evidence) or long-term (MD 0.06, 95% CI -0.04 to 0.16; 6 studies, 8736 participants; moderate-certainty evidence) follow-up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD -0.09, 95% CI -0.2 to 0.02; 3 studies, 515 participants; very low-certainty evidence), and they may not reduce zBMI at medium-term (MD -0.05, 95% CI -0.1 to 0.01; 6 studies, 3511 participants; low-certainty evidence) or long-term (MD -0.02, 95% CI -0.05 to 0.01; 7 studies, 8430 participants; low-certainty evidence) follow-up. Four studies (2394 participants) reported data on serious adverse events (very low-certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect.

AUTHORS' CONCLUSIONS

The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low-certainty evidence that activity interventions may have a small beneficial effect on BMI at medium- and long-term follow-up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples.

Evaluating the effect of a 12-month youth advisory group on adolescent's leadership skills and perceptions related to chronic disease prevention research: a mixed-methods study

BACKGROUND

Youth Advisory Groups (YAGs) represent a promising method to engage adolescents in research of relevance to them and their peers. However, YAGs are rarely implemented or evaluated in chronic disease prevention research. The aims of this study were firstly, to evaluate the effect of participation in a 12-month YAG on adolescents' leadership skills and perceptions related to chronic disease prevention research and secondly, to evaluate the process of establishing and facilitating a 12-month YAG and identify barriers and enablers to establishment and facilitation.

METHODS

This study was a 12-month pre-post study. Eligible participants were adolescents (13-18-years) and current members of an established YAG. Data collection involved online surveys and semi-structured interviews at baseline, six-months and 12-months follow-up. Participatory outcomes such as self-efficacy, leadership skills, and collective participation were derived from Youth Participatory Action Research Principles (YPAR), and the Lansdown-UNICEF conceptual framework for measuring outcomes of adolescent participation. Process evaluation data were captured via meeting minutes, Slack metrics and researcher logs. Quantitative data was analysed using descriptive statistics and qualitative data was thematically analysed using a reflexive thematic analysis approach.

RESULTS

Thirteen (13/16) YAG youth advisors consented to participate in the evaluation study (mean age 16.0 years, SD 1.3; 62% (8/13) identified as female). Survey data assessing participatory outcomes found an increase in leadership and life skills scores over 12-months (+ 8.90 points). Semi-structured interview data collected over the 12-month term revealed three key themes namely: influence, empowerment, and contribution. Comparison of pre-post themes determined a positive trend at follow-ups, demonstrating improved participatory outcomes. Process indicators revealed that at 12-month follow-up the YAG was implemented as planned. Semi-structured interview data determined barriers to YAG facilitation included time and limited face-to-face components, while enablers to YAG facilitation included flexibility, accessible delivery methods, and a supportive adult facilitator.

CONCLUSION

This study found that a YAG fostered positive participatory outcomes and unique opportunities for youth participants. A successful YAG based on YPAR principles requires researchers to ensure YAG establishment and facilitation is an iterative process. Taking into consideration important barriers and enablers to YAG facilitation ensures adolescent engagement in a YAG is both meaningful and impactful.

School-based peer education interventions to improve health: a global systematic review of effectiveness

INTRODUCTION

Peer education, whereby peers ('peer educators') teach their other peers ('peer learners') about aspects of health is an approach growing in popularity across school contexts, possibly due to adolescents preferring to seek help for health-related concerns from their peers rather than adults or professionals. Peer education interventions cover a wide range of health areas but their overall effectiveness remains unclear. This review aims to summarise the effectiveness of existing peer-led health interventions implemented in schools worldwide.

METHODS

Five electronic databases were searched for eligible studies in October 2020. To be included, studies must have evaluated a school-based peer education intervention designed to address the health of students aged 11-18-years-old and include quantitative outcome data to examine effectiveness. The number of interventions were summarised and the impact on improved health knowledge and reductions in health problems or risk-taking behaviours were investigated for each health area separately, the Mixed Methods Appraisal Tool was used to assess quality.

RESULTS

A total of 2125 studies were identified after the initial search and 73 articles were included in the review. The majority of papers evaluated interventions focused on sex education/HIV prevention (n = 23), promoting healthy lifestyles (n = 17) and alcohol, smoking and substance use (n = 16). Papers mainly reported peer learner outcomes (67/73, 91.8%), with only six papers (8.2%) focussing solely on peer educator outcomes and five papers (6.8%) examining both peer learner and peer educator outcomes. Of the 67 papers reporting peer learner outcomes, 35/67 (52.2%) showed evidence of effectiveness, 8/67 (11.9%) showed mixed findings and 24/67 (35.8%) found limited or no evidence of effectiveness. Of the 11 papers reporting peer educator outcomes, 4/11 (36.4%) showed evidence of effectiveness, 2/11 (18.2%) showed mixed findings and 5/11 (45.5%) showed limited or no evidence of effectiveness. Study quality varied greatly with many studies rated as poor quality, mainly due to unrepresentative samples and incomplete data.

DISCUSSION

School-based peer education interventions are implemented worldwide and span a wide range of health areas. A number of interventions appear to demonstrate evidence for effectiveness, suggesting peer education may be a promising strategy for health improvement in schools. Improvement in health-related knowledge was most common with less evidence for positive health behaviour change. In order to quantitatively synthesise the evidence and make more confident conclusions, there is a need for more robust, high-quality evaluations of peer-led interventions using standardised health knowledge and behaviour measures.

Improving Obesogenic Dietary Behaviors among Adolescents: A Systematic Review of Randomized Controlled Trials

The overweight and obesity epidemic persists, and over 340 million children and adolescents aged 5–19 were classified as overweight or obese worldwide in 2020. Obesity intervention becomes crucial during the adolescent years due to the increased autonomy and adolescent motivation to oversee one’s own behaviors and lifestyle-related decisions. The objective of the current study was to conduct a systematic review of randomized controlled trials aimed at improving dietary intake and behaviors among adolescents. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized. The key terms used in the searches referred to the study population and the topic of interest and included words and phrases such as “obesity or overweight and adolescents”, “dietary behaviors and adolescents”, “dietary intake and adolescents”, and “dietary habits and adolescents.” A tertiary screening process was employed, and the National Heart, Lung, and Blood Institute Quality Assessment of Controlled Intervention Studies quality scoring tool was utilized to assess the quality of research articles independently by n = 2 researchers. A total of 7441 articles were identified through the database search, and 36 were included in the current systematic review. The most common outcomes explored included dietary behaviors, anthropometric or biometric outcomes, and physical activity. Approximately half of the studies demonstrated significant improvements in the primary outcomes investigated. The majority of the high-impact studies where significant improvements in primary outcomes were demonstrated were conducted in school settings or were multicomponent or multilevel in nature. Thus, interventions targeting dietary behaviors in adolescents that are delivered in the school setting and are multicomponent or multilevel in nature are the most effective in terms of impact on dietary intake, anthropometric or biometric outcomes, and physical activity.

The Impact of Modifying Food Service Practices in Secondary Schools Providing a Routine Meal Service on Student's Food Behaviours, Health and Dining Experience: A Systematic Review and Meta-Analysis

The education sector is recognised as an ideal platform to promote good nutrition and decision making around food and eating. Examining adolescents in this setting is important because of the unique features of adolescence compared to younger childhood. This systematic review and meta-analysis examine interventions in secondary schools that provide a routine meal service and the impact on adolescents’ food behaviours, health and dining experience in this setting. The review was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist and Cochrane Handbook recommendations. Studies published in English searched in four databases and a hand search yielded 42 interventions in 35 studies. Risk of bias was assessed independently by two reviewers. Interventions were classified using the NOURISHING framework, and their impact analysed using meta-analysis, vote-counting synthesis or narrative summary. The meta-analysis showed an improvement in students selecting vegetables (odds ratio (OR): 1.39; 1.12 to 1.23; p = 0.002), fruit serves selected (mean difference (MD): 0.09; 0.09 to 0.09; p < 0.001) and consumed (MD: 0.10; 0.04 to 0.15; p < 0.001), and vegetable serves consumed (MD: 0.06; 0.01 to 0.10; p = 0.024). Vote-counting showed a positive impact for most interventions that measured selection (15 of 25; 41% to 77%; p = 0.002) and consumption (14 of 24; 39% to 76%; p = 0.013) of a meal component. Interventions that integrate improving menu quality, assess palatability, accessibility of healthier options, and student engagement can enhance success. These results should be interpreted with caution as most studies were not methodologically strong and at higher risk of bias. There is a need for higher quality pragmatic trials, strategies to build and measure sustained change, and evaluation of end-user attitudes and perceptions towards intervention components and implementation for greater insight into intervention success and future directions (PROSPERO registration: CRD42020167133).

Theoretical and practical approaches for dietary behavior change in urban socioeconomically disadvantaged adolescents: a systematic review

CONTEXT

There is limited evidence on strategies used to promote dietary behavior changes in socioeconomically disadvantaged urban adolescents and on their effectiveness.

OBJECTIVE

A synthesis of nutrition interventions used in this group of adolescents is provided in this systematic review.

DATA SOURCES

Five electronic databases (PubMed, Web of Science, CINAHL, PsycINFO, and ERIC) were searched until November 2020 to identify relevant studies.

DATA EXTRACTION

Forty-six manuscripts (n = 38 intervention studies) met the inclusion criteria. Quality was assessed with the Effective Public Health Practice Project Quality Assessment Tool. A qualitative synthesis summarizing data on study characteristics was conducted.

DATA ANALYSIS

Studies were classified by intervention type as those focusing on hedonic determinants of dietary intake (n = 1), environmental changes to promote a specific dietary intake (n = 3), cognitive determinants (n = 29), and multicomponent strategies (n = 13). The social cognitive theory was the most applied theoretical framework, either alone or combined with other frameworks. Most of the intervention studies targeted multiple dietary outcomes, and success was not always reported for each.

CONCLUSIONS

Despite the heterogeneity of the studies and lack of combination of dietary outcomes into dietary scores or patterns to evaluate changes on the individuals' whole diets, long-term, theory-driven interventions targeting a single dietary factor seem promising in obtaining sustainable dietary behavior changes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020188219.

Shifting From Tokenism to Meaningful Adolescent Participation in Research for Obesity Prevention: A Systematic Scoping Review

Background: Traditionally, adolescent participation in research has been tokenistic. Adolescents are rarely afforded the opportunity to influence decision-making in research designed to prevent obesity. Engaging adolescents in meaningful decision-making may enhance research translation. This review aimed to analyze the current modes and nature of adolescent participation in obesity prevention research decision-making. Methods: A systematic scoping review was conducted using Arksey and O'Malley's six-stage framework. Six major databases were searched for peer-reviewed primary research studies with adolescent participation related to obesity, physical activity, and diet. Modes of adolescent participation were categorized based on the Lansdown-UNICEF conceptual framework for measuring outcomes of adolescent participation. The framework outlines three modes of meaningful participation: (i) consultative, which involves taking opinions and needs into consideration; (ii) collaborative, where adolescents are partners in the decision-making process; and (iii) adolescent-led participation where adolescents have the capacity to influence the process and outcomes. The degree of involvement in research cycles was classified based on the National Health and Medical Research Council consumer engagement framework. Five stages of the research cycle were determined: identify, design and develop, conduct, analyze and disseminate. Results: In total, 126 papers describing 71 unique studies were identified. Of these, 69% (49/71) took place in the USA, and 85% (52/61) were conducted in minority or underserved communities, while males were more likely to be under-represented. In 49% (35/71) of studies, participation was consultative and 9% (6/71) of studies involved an adolescent-led approach. Furthermore, 87% (62/71) of studies incorporated adolescent participation in one or more of the research cycle's formative phases, which involve eliciting views, opinions and idea generation. Only 11% of studies engaged adolescents in all five stages of the research cycle where adolescents could have more influence over the research process. Conclusion: Meaningful adolescent participation in the obesity prevention research cycle is limited. Empowering and mobilizing equal partnership with adolescents should be at the forefront of all adolescent-related obesity prevention research.

Effectiveness of Triple Benefit Health Education Intervention on Knowledge, Attitude and Food Security towards Malnutrition among Adolescent Girls in Borno State, Nigeria

Knowledge and attitude are essential components of food security as malnutrition remains a critical public health concern among adolescents. The study evaluates the effectiveness of a Triple Benefit Health Education Intervention on knowledge, attitude and food security towards malnutrition among adolescent girls. This was a cluster randomized controlled trial among 417 randomly selected adolescent girls aged 10 to 19 years old in Maiduguri, Borno state, Nigeria from October 2019 to March 2020. About 208 respondents were assigned to experimental while 209 to control group, respectively, using an opaque sealed envelope. A structured questionnaire using KoBo Collect Toolbox was used for the collection of data at baseline, three and six-months post intervention while the data collected were analyzed using generalized estimating equation (GEE). The outcome of the baseline shows no statistically significant difference in sociodemographic characteristics, knowledge, attitude and food security between experimental and control groups. The study reveals a statistically significant difference between experimental and control groups for knowledge (p < 0.001; p < 0.001), attitude (p < 0.001; p < 0.001) and food security (p = 0.026; p = 0.001) at three and six-months post intervention, respectively. The triple benefit health education intervention package employed in this study can serve as an intervention tool to combat malnutrition among adolescent girls in Nigeria at large.

Perceptions and Impact of a Youth-led Childhood Obesity Prevention Intervention among Youth-leaders

Objective

To evaluate the impact of a youth-led nutrition intervention on youth-leaders themselves.

Design

Mixed methods, including: in-depth interviews and a quasi-experimental quantitative study comparing youth-leaders and nonparticipant comparison youth.

Analysis

Qualitative analysis using direct content analysis. Difference-in-differences analyses assessing quantitative program impact.

Results

Youth-leaders perceived that the intervention impacted themselves, the youth-participants, and their respective social networks. Youth-leaders experienced greater increases in intentions to eat healthfully (p=0.04), and greater decreases in support for healthy eating from their friends (p=0.01), than the comparison group.

Conclusions/Implications

Youth-leaders reported multiple levels of intervention impact, and increased intentions for healthy eating; however, additional research is needed to enhance impact on behavioral outcomes.

Community readiness for childhood obesity prevention programs: findings from an urban population in Iran

This study aimed to examine the Iranian local communities' readiness stage to engage with childhood obesity prevention programs for late primary school children in districts 2 and 16 of Tehran as the representatives of high and low socio-economic districts, respectively. First, a Delphi approach was conducted to assess the socio-cultural necessity/appropriateness and adequacy of the community readiness model and its dimensions as a planning basis for childhood obesity prevention program(s) in Iran. Then, the community readiness interview guide's translation, modification, content and face validity were performed. Finally, 66 interviews with key informants were conducted and scored to assess community readiness. The socio-cultural necessity/appropriateness and adequacy of community readiness model and its dimensions were confirmed by Delphi participants and two questions were added to the interview guide. Content and face validity of the interview guide were at acceptable levels. Assessment of the community readiness based on the key informants' perspective showed that the overall mean readiness score of targeted local communities was 4.61 ± 0.54 and 4.22 ± 0.26 in high and low socio-economic districts, respectively, corresponded to 'preplanning stage'. The highest score was 5.00 ± 0.48 correspond to the 'preparation stage', which belonged to girls' schools in district 2. Small differences were found in the readiness stage of local communities by sex and socio-economic status of schools. The results highlight the need to increase community awareness, gain their support to recognize childhood obesity as a priority, address cultural misconceptions and improve the obesity prevention programs to achieve a higher level of readiness.

Themes in Train-the-Trainer Nutrition Education Interventions Targeting Middle School Students: A Systematic Review

Context-appropriate nutrition education interventions targeting middle school students have the potential to promote healthy dietary patters that may help prevent unnecessary weight gain at a point in childhood development when youth experience increasing agency over their food choices. The aim of this review was to identify and synthesize themes in train-the-trainer approaches, intervention content and delivery, and youth receptivity across teacher, mentor, and peer-led nutrition education interventions that targeted middle school-age youth in urban, primarily low-income settings. A systematic, electronic literature search was conducted in seven electronic databases, PubMed/Medline, CINAHL, ERIC, PsycINFO, Scopus, SPORTDiscus, and Cochrane CENTRAL, using fixed inclusion and exclusion criteria. A total of 53 papers representing 39 unique interventions were selected for data extraction and quality assessment. A framework synthesis approach was used to organize the interventions into six categories and identify themes according to whether the intervention was classroom-based or out-of-school-based and whether adults, cross-age peers or same-age peers delivered the intervention. Ten of the interventions contained multiple components such that they were included in two of the categories. The review findings indicated that trainings should be interactive, include opportunities to role-play intervention scenarios and provide follow-up support throughout intervention delivery. Interventions targeting middle school youth should include positive messaging and empower youth to make healthy choices within their specific food environment context.

Impact of a nutrition education programme on free sugar intake & nutrition-related knowledge in fifth-grade schoolchildren

BACKGROUND

The objective was to evaluate a 5-week nutrition education programme (ACTION) in fifth-grade schoolchildren in Austria on free sugar intake, nutrition-related knowledge (NRK) and with the RE-AIM framework on the overall public health impact.

METHODS

A prospective case-controlled cohort (pre-post design) from seven secondary schools in Vienna tested programme efficacy. NRK was assessed with a 20-item questionnaire and dietary behaviour and free sugar intake with a semi-quantitative Food Frequency Questionnaire. A total of 12 intervention classes (IG) received the programme, conducted by teachers and integrated in the curriculum, and 6 control classes followed their usual curriculum.

RESULTS

In 344 children, aged 10.4 (0.8) years, free sugar intake decreased significantly over time in IG by 13% (P=0.001) with a group difference of -10.1 (95% CI -18.8, -1.5; P=0.021) g/day. The food groups 'sweets & pastries', 'soft drinks', 'fast food' and 'salty snacks' mainly contributed to this reduction. Moreover, NRK increased significantly over time in IG with a group difference of 9.0% of correct answers (95% CI 5.8, 12.2; P<0.001; Cohen's d 0.57). The programme was disseminated to 10% of fifth-grade classrooms in Austrian secondary schools and to 12% in Vienna.

CONCLUSIONS

The ACTION programme shows potential for public health impact with improving dietary behaviour as free sugar intake, NRK, and its dissemination. It required a minimum of money per schoolchild as the programme was conducted by teachers and was integrated in the curriculum.

Interventions to Promote Healthy Meals in Full-Service Restaurants and Canteens: A Systematic Review and Meta-Analysis

Out-of-home eating is increasing, but evidence about its healthiness is limited. The present systematic review and meta-analysis aimed to elucidate the effectiveness of full-service restaurant and canteen-based interventions in increasing the dietary intake, food availability, and food purchase of healthy meals. Studies from 2000-2020 were searched in Medline, Scopus, and Cochrane Library using the PRISMA checklist. A total of 35 randomized controlled trials (RCTs) and 6 non-RCTs were included in the systematic review and analyzed by outcome, intervention strategies, and settings (school, community, workplace). The meta-analysis included 16 RCTs (excluding non-RCTs for higher quality). For dietary intake, the included RCTs increased healthy foods (+0.20 servings/day; 0.12 to 0.29; p < 0.001) and decreased fat intake (-9.90 g/day; -12.61 to -7.19; p < 0.001), favoring the intervention group. For food availability, intervention schools reduced the risk of offering unhealthy menu items by 47% (RR 0.53; 0.34 to 0.85; p = 0.008). For food purchases, a systematic review showed that interventions could be partially effective in improving healthy foods. Lastly, restaurant- and canteen-based interventions improved the dietary intake of healthy foods, reduced fat intake, and increased the availability of healthy menus, mainly in schools. Higher-quality RCTs are needed to strengthen the results. Moreover, from our results, intervention strategy recommendations are provided.

A systematic review and meta-analysis of school-based interventions with health education to reduce body mass index in adolescents aged 10 to 19 years

BACKGROUND

Adolescents are increasingly susceptible to obesity, and thus at risk of later non-communicable diseases, due to changes in food choices, physical activity levels and exposure to an obesogenic environment. This review aimed to synthesize the literature investigating the effectiveness of health education interventions delivered in school settings to prevent overweight and obesity and/ or reduce BMI in adolescents, and to explore the key features of effectiveness.

METHODS

A systematic search of electronic databases including MEDLINE, CINAHL, PsychINFO and ERIC for papers published from Jan 2006 was carried out in 2020, following PRISMA guidelines. Studies that evaluated health education interventions in 10-19-year-olds delivered in schools in high-income countries, with a control group and reported BMI/BMI z-score were selected. Three researchers screened titles and abstracts, conducted data extraction and assessed quality of the full text publications. A third of the papers from each set were cross-checked by another reviewer. A meta-analysis of a sub-set of studies was conducted for BMI z-score.

RESULTS

Thirty-three interventions based on 39 publications were included in the review. Most studies evaluated multi-component interventions using health education to improve behaviours related to diet, physical activity and body composition measures. Fourteen interventions were associated with reduced BMI/BMI z-score. Most interventions (n = 22) were delivered by teachers in classroom settings, 19 of which trained teachers before the intervention. The multi-component interventions (n = 26) included strategies such as environment modifications (n = 10), digital interventions (n = 15) and parent involvement (n = 16). Fourteen studies had a low risk of bias, followed by 10 with medium and nine with a high risk of bias. Fourteen studies were included in a random-effects meta-analysis for BMI z-score. The pooled estimate of this meta-analysis showed a small difference between intervention and control in change in BMI z-score (- 0.06 [95% CI -0.10, - 0.03]). A funnel plot indicated that some degree of publication bias was operating, and hence the effect size might be inflated.

CONCLUSIONS

Findings from our review suggest that school-based health education interventions have the public health potential to lower BMI towards a healthier range in adolescents. Multi-component interventions involving key stakeholders such as teachers and parents and digital components are a promising strategy.

Promoting Healthy Eating among Young People-A Review of the Evidence of the Impact of School-Based Interventions

Intro: Globally, the prevalence of overweight and obesity is increasing among children and younger adults and is associated with unhealthy dietary habits and lack of physical activity. School food is increasingly brought forward as a policy to address the unhealthy eating patterns among young people. Aim: This study investigated the evidence for the effectiveness of school-based food and nutrition interventions on health outcomes by reviewing scientific evidence-based intervention studies amongst children at the international level. Methods: This study was based on a systematic review using the PRISMA guidelines. Three electronic databases were systematically searched, reference lists were screened for studies evaluating school-based food and nutrition interventions that promoted children’s dietary behaviour and health aiming changes in the body composition among children. Articles dating from 2014 to 2019 were selected and reported effects on anthropometry, dietary behaviour, nutritional knowledge, and attitude. Results: The review showed that school-based interventions in general were able to affect attitudes, knowledge, behaviour and anthropometry, but that the design of the intervention affects the size of the effect. In general, food focused interventions taking an environmental approach seemed to be most effective. Conclusions: School-based interventions (including multicomponent interventions) can be an effective and promising means for promoting healthy eating, improving dietary behaviour, attitude and anthropometry among young children. Thus, schools as a system have the potential to make lasting improvements, ensuring healthy school environment around the globe for the betterment of children’s short- and long-term health.

Gender differences in the longitudinal association between multilevel latent classes of chronic disease risk behaviours and body mass index in adolescents

INTRODUCTION

Few studies have assessed the relationship between chronic disease risk behaviours and body mass index (BMI) in a longitudinal, sex/gender-specific context. This study used gender-specific analyses to assess the extent to which chronic disease risk behaviour latent classes are associated with BMI and weight status at follow-up.

METHODS

Longitudinal data from 4510 students in Grades 9 to 12, tracked from 2013- 2015, who participated in the COMPASS study were used to assess gender differences in the lagged association between previously determined latent classes (of physical activity and substance use) with BMI using multilevel mixed-effects models. Our multilevel regression models assessed the association between two latent classes, active experimenters and inactive non-using youth, with BMI when stratified by gender.

RESULTS

Male inactive non-substance-using youth were associated with a 0.29 higher continuous BMI (95% CI: 0.057, 0.53) and odds of overweight/obesity increased by 72% (OR = 1.72, 95% CI: 1.2, 2.4) for binary BMI at follow-up relative to active youth who experiment with substance use. No significant associations were detected in females.

CONCLUSION

Over time, physical activity has a protective role on BMI in male youth. Both substance use and physical inactivity should be addressed in obesity prevention efforts. Gender stratification in analyses is also important since females and males have different contributing factors to increases in BMI.

Systematic Review: Effect of Health Education Intervention on Improving Knowledge, Attitudes and Practices of Adolescents on Malnutrition

Adolescence is a phase in the life cycle of human beings. Adequate knowledge, attitudes and practices towards malnutrition are necessary for proper growth and development and for their future children. This systematic review aimed to determine the effect of health education intervention to improve the knowledge, attitudes and practices of adolescents on malnutrition. PubMed, Scopus, clinical trials, CINAHL, SAGE, Science Direct and Medline were searched according to Preferred Reporting Item for Systematic Reviews and Meat-analysis (PRISMA) guidelines to identified published studies from January 2013 to December 2019 based on the inclusion and exclusion criteria. A total of eight studies were included in this review. Data extraction was done based on randomized controlled trial only. Three out of the eight studies had low risk of bias, the overall evidence of the study was moderate. Findings from this study suggest that health education intervention among adolescents have significantly improved their knowledge, attitudes and practices. More specific interventions should be conducted in low and middle income countries since they bear more of the burden of malnutrition globally.

Kindergarten to 12th Grade School-Based Nutrition Interventions: Putting Past Recommendations Into Practice

School-based nutrition interventions are used to improve dietary habits of schoolchildren and reverse trends on obesity. This article reports on kindergarten through 12th grade nutrition interventions published between 2009 and 2018 compared with interventions published between 2000 and 2008 based on (1) behaviorally focused, (2) multicomponent, (3) healthful food/school environment (4) family involvement, (5) self-assessments, (6) quantitative evaluation, (7) community involvement, (8) ethnic/heterogeneous groups, (9) multimedia technology, and (10) sequential and sufficient duration. These 10 recommendations help guide educators, researchers, and nutritionists on more effective nutrition interventions. Future use of implementation science to determine potential drivers of adoption, nonadoption, and effectiveness of the recommendations is encouraged.

Farm to School Activities and Student Outcomes: A Systematic Review

Farm to school programs (F2SPs) operate in 42% of school districts and are supported in part through federal and state policies as well as philanthropic funding. Although research evaluating the effects of farm to school-related activities on student outcomes is growing, a systematic review of the results and thus a synthesis of implications for future programming have not occurred. The primary objective of this systematic literature review is to summarize and evaluate studies on student outcomes associated with farm to school-related activities up to 1 September, 2017. Four databases spanning 4 research disciplines were used to identify full-text, English-language studies. Twenty-one studies were reviewed: 7 explicitly investigated F2SPs, and 14 evaluated the impact of school-based interventions that were relevant to activities reported in the 2013 and/or 2015 Farm to School Census. All of the F2SP studies (n = 7) and 85.7% of farm to school-related activity studies (n = 12) were multicomponent, and there was a wide variety of implemented intervention components across the reviewed studies. Results from F2SP and farm to school-related activity studies consistently show positive impacts on food and nutrition-related knowledge; most studies also suggest a positive relation between farm to school-related activities and healthy food selection during school meals, nutrition self-efficacy, and willingness to try fruits and vegetables. The impact of farm to school activities on fruit and vegetable consumption and preferences is unclear. The most common F2SP study limitations were study designs that preclude causal inference, outcome measurement with no reported or limited psychometric testing, lack of long-term outcome evaluation, and challenges related to quantifying intervention implementation. These findings underscore the need for more conclusive evidence on the relation between farm to school-related activities and changes in fruit and vegetable consumption.

Applying the information-motivation-behavioral skills model to explain adolescents' fruits and vegetables consumption

Inadequate fruits and vegetables consumption in adolescence increases adolescents' current and future chronic disease risk and is predictive of inadequate consumption in adulthood. Given that adolescents' engagement in dietary behaviors is complicated by intrapersonal, interpersonal, and environmental factors, a health behavior model of change incorporating all of these factors is most appropriate to inform research and intervention efforts. Yet, common preventive health behavior models used to explain adolescents' dietary behaviors do not adequately account for these factors. The current study explored the utility of a comprehensive, predictive model, that is the Information-Motivation-Behavioral Skills (IMB) model, for explaining adolescents' fruits and vegetables consumption in a cross-sectional national sample. Study hypotheses included (1) health information and motivation for fruits and vegetables would directly be related to fruits and vegetables consumption; and (2) the relationship between fruits and vegetables consumption and health information and motivation would be mediated by behavioral skills for consumption. Data from the adolescent diet-related surveys of the Family Life, Activity, Sun, Health, and Eating (FLASHE) study (N = 1646) were used. Structural equation modeling was used to test study hypotheses. Fruits and vegetables-related information and motivation were positively related to adolescents' fruits and vegetables consumption. For information and personal motivation (specifically fruits and vegetables preferences), the relationship with fruits and vegetables consumption was partially mediated through behavioral skills. These preliminary findings support the utility of the IMB model to explain adolescents' fruits and vegetables consumption.

Youth empowerment implementation project evaluation results: A program designed to improve the health and well-being of low-income African-American adolescents

Adolescent obesity is a major health issue facing today's youth. This may be the first generation to have a lower life expectancy than their parents. The Youth Empowerment Implementation Project's (YEIP) goal was to increase fruit and vegetable intake, lower junk food consumption, and increase physical activity among low-income African-American youth living in the Midwest. Thirty middle school aged youth participated in an evidenced-based program (i.e., Botvin's Life Skills Training) and were engaged in health education and physical activities. The results from baseline to follow-up demonstrated a reduction in junk food intake for participants and an increase in fruit and vegetable intake but not for physical activity. The health behaviors of participants improved for three out of four indicators following the intervention. Limitations, future research, and implications for future programs are also discussed.

Evaluation of the dissemination of SNaX, a middle school-based obesity prevention intervention, within a large US school district

Few evidence-based school obesity-prevention programs are disseminated. We used community-based participatory research principles to disseminate an evidence-based middle-school obesity-prevention program, Students for Nutrition and eXercise (SNaX), to a large, primarily Latino, school district. In the 2014-2015 school year, we trained a district "champion" to provide training and technical assistance to schools and supplied print- and web-based materials (www.snaxinschools.org). In one district region, 18 of 26 schools agreed to participate. We evaluated the dissemination process using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. All 18 schools implemented at least one SNaX component. Of 6,410 students who attended an informational session, 1,046 registered and 472 were selected to be Student Advocates, of whom 397 attended at least one meeting. Of 60 activities observed across schools, 77% were conducted with fidelity, but local resource constraints limited most activities to a relatively small number of Student Advocates (vs. the entire student body). Qualitative data from 46 school staff and 187 students indicated positive attitudes about the program. Teachers suggested that SNaX be implemented as part of the curriculum. In the 2015-2016 school year, 6 of the original schools continued to implement SNaX, and the champion trained 94 teachers from 57 schools districtwide. Cafeteria servings overall and fruit and vegetable servings, the primary outcomes, did not increase in SNaX schools versus matched-comparison schools. Our mixed-methods evaluation of SNaX showed acceptability and fidelity, but not effectiveness. Effectiveness may be improved by providing technical assistance to community stakeholders on how to tailor core intervention components while maintaining fidelity.

Healthier Choices in School Cafeterias: A Systematic Review of Cafeteria Interventions

OBJECTIVE

To describe school cafeteria interventions in terms of a behavioral economics scheme and to assess which system is more likely to be effective in improving food selection or consumption.

STUDY DESIGN

With this systematic review, we categorize cafeteria interventions using the behavioral economics theory of Kahneman into system 1 (fast and intuitive thinking) and system 2 (slow and cognitively demanding) or mixed (having elements of system 1 and system 2). Pertinent studies were identified from review of the literature of interventions performed in school and cafeteria settings in children grades K-12 within the past 5 years (2012-2017) at time of search.

RESULTS

In all, 48 of 978 studies met inclusion criteria. By defining success as a 30% improvement in a desired outcome or statistically significant reduction in body mass index, 89% of system 1, 67% of mixed (had both system 1 and 2 elements), and only 33% of system 2 interventions were successful.

CONCLUSIONS

This review found successful system 1 type school cafeteria interventions to be more common than system 2 type interventions and system 2 type interventions are less effective than system 1.

Systematic Review: Frameworks Used in School-Based Interventions, the Impact on Hispanic Children's Obesity-Related Outcomes

BACKGROUND

Childhood obesity among Hispanic children is a public health concern in the United States and Mexico. Although experiences from school-based intervention programs aimed at influencing obesity-related behaviors have been positive, the understanding of those framework elements that are associated with successful outcomes is limited. The purpose of this study was to examine the frameworks used within school-based intervention programs in the United States and Mexico that showed improvements in obesity-related outcomes among Hispanic children.

METHODS

A systematic review of the literature was conducted using 4 electronic databases. Inclusion criteria included: incorporating a framework or aspects of frameworks within an intervention, more than 50% of Hispanic children used in the study and obesity-related outcomes (eg, dietary behaviors and anthropometric measurements). Data extraction and evaluation were completed using the Academy of Nutrition and Dietetics Evidence Analysis Manual.

RESULTS

Ten articles (United States = 4; Mexico = 6) meeting inclusion criteria were evaluated. Eight studies that included a community-based framework, intensive nutrition education, and continuous communication among stakeholders resulted in improvements in dietary behaviors and anthropometric measurements among children compared to control groups.

CONCLUSIONS

Incorporating community-based frameworks may increase the efficacy of school-based intervention programs to reduce obesity-related outcomes among Hispanic children.

Promoting Self-Regulation in Health Among Vulnerable Brazilian Children: Protocol Study

The Health and Education Ministries of Brazil launched the Health in School Program (Programa Saúde na Escola - PSE) in 2007. The purpose of the PSE is two-fold: articulate the actions of the education and health systems to identify risk factors and prevent them; and promote health education in the public elementary school system. In the health field, the self-regulation (SR) construct can contribute to the understanding of life habits which can affect the improvement of individuals' health. This research aims to present a program that promotes SR in health (SRH). This program (PSRH) includes topics on healthy eating and oral health from the PSE; it is grounded on the social cognitive framework and uses story tools to train 5th grade Brazilian students in SRH. The study consists of two phases. In Phase 1, teachers and health professionals participated in a training program on SRH, and in Phase 2, they will be expected to conduct an intervention in class to promote SRH. The participants were randomly assigned into three groups: the Condition I group followed the PSE program, the Condition II group followed the PSRH (i.e., PSE plus the SRH program), and the control group (CG) did not enroll in either of the health promotion programs. For the baseline of the study, the following measures and instruments were applied: Body Mass Index (BMI), Simplified Oral Hygiene Index (OHI-S), Previous Day Food Questionnaire (PFDQ), and Declarative Knowledge for Health Instrument. Data indicated that the majority are eutrophic children, but preliminary outcomes showed high percentages of children that are overweight, obese and severely obese. Moreover, participants in all groups reported high consumption of ultraprocessed foods (e.g., soft drinks, artificial juices, and candies). Oral health data from the CI and CII groups showed a prevalence of regular oral hygiene, while the CG presented good oral hygiene. The implementation of both PSE and PSRH are expected to help reduce health problems in school, as well as the public expenditures with children's health (e.g., Obesity and oral diseases).

The prevalence of patient engagement in published trials: a systematic review

PLAIN ENGLISH SUMMARY

With the growing movement to engage patients in research, questions are being asked about who is engaging patients and how they are being engaged. Internationally, research groups are supporting and funding patient-oriented research studies that engage patients in the identification of research priorities and the design, conduct and uptake of research. As we move forward, we need to know what meaningful patient engagement looks like, how it benefits research and clinical practice, and what are the barriers to patient engagement?We conducted a review of the published literature looking for trials that report engaging patients in the research. We included both randomized controlled trials and non-randomized comparative trials. We looked at these trials for important study characteristics, including how patients were engaged, to better understand the practices used in trials. Importantly, we also discuss the number of trials reporting patient engagement practices relative to all published trials. We found that very few trials report any patient engagement activities even though it is widely supported by many major funding organizations. The findings of our work will advance patient-oriented research by showing how patients can be engaged and by stressing that patient engagement practices need to be better reported.

BACKGROUND

Patient-Oriented Research (POR) is research informed by patients and is centred on what is of importance to them. A fundamental component of POR is that patients are included as an integral part of the research process from conception to dissemination and implementation, and by extension, across the research continuum from basic research to pragmatic trials [J Comp Eff Res 2012, 1:181-94, JAMA 2012, 307:1587-8]. Since POR's inception, questions have been raised as to how best to achieve this goal.We conducted a systematic review of randomized controlled trials and non-randomized comparative trials that report engaging patients in their research. Our main goal was to describe the characteristics of published trials engaging patients in research, and to identify the extent of patient engagement activities reported in these trials.

METHODS

The MEDLINE®, EMBASE®, Cinahl, PsycINFO, Cochrane Methodology Registry, and Pubmed were searched from May 2011 to June 16th, 2016. Title, abstract and full text screening of all reports were conducted independently by two reviewers. Data were extracted from included trials by one reviewer and verified by a second. All trials that report patient engagement for the purposes of research were included.

RESULTS

Of the 9490 citations retrieved, 2777 were reviewed at full text, of which 23 trials were included. Out of the 23 trials, 17 were randomized control trials, and six were non-randomized comparative trials. The majority of these trials (83%, 19/23) originated in the United States and United Kingdom. The trials engaged a range of 2-24 patients/ community representatives per study. Engagement of children and minorities occurred in 13% (3/23) and 26% (6/23) of trials; respectively. Engagement was identified in the development of the research question, the selection of study outcomes, and the dissemination and implementation of results.

CONCLUSIONS

The prevalence of patient engagement in patient-oriented interventional research is very poor with 23 trials reporting activities engaging patients. Research dedicated to determining the best practice for meaningful engagement is still needed, but adequate reporting measures also need to be defined.

A Youth-Leader Program in Baltimore City Recreation Centers: Lessons Learned and Applications

Peer-led interventions may be an effective means of addressing the childhood obesity epidemic; however, few studies have looked at the long-term sustainability of such programs. As part of a multilevel obesity prevention intervention, B'More Healthy Communities for Kids, 16 Baltimore college students were trained as youth-leaders (YLs) to deliver a skill-based nutrition curriculum to low-income African American children (10-14 years old). In April 2015, formative research was used to inform sustainability of the YL program in recreation centers. In-depth interviews were conducted with recreation center directors ( n = 4) and the YLs ( n = 16). Two focus groups were conducted with YLs ( n = 7) and community youth-advocates ( n = 10). Barriers to this program included difficulties with transportation, time constraints, and recruiting youth. Lessons learned indicated that improving trainings and incentives to youth were identified as essential strategies to foster continuity of the youth-led program and capacity building. High school students living close to the centers were identified as potential candidates to lead the program. Based on our findings, the initial intervention will be expanded into a sustainable model for implementation, using a train-the-trainer approach to empower community youth to be change agents of the food environment and role models.

Development of a Systems Science Curriculum to Engage Rural African American Teens in Understanding and Addressing Childhood Obesity Prevention

Engaging youth from racial and ethnic minority communities as leaders for change is a potential strategy to mobilize support for addressing childhood obesity, but there are limited curricula designed to help youth understand the complex influences on obesity. Our aim was to develop and pilot test a systems science curriculum to elicit rural African American youth perspectives on childhood obesity and enhance their understanding of and support for obesity prevention solutions. The curriculum was designed so it could be integrated with existing positive youth development curricula that help youth advocate for and implement identified solutions. We conducted four workshop sessions with youth that engaged them in systems learning activities such as guided systems diagramming activities. The participants ( n = 21) completed validated surveys presession and postsession that assessed their causal attributions of obesity and support for obesity prevention policies. The youths' perception that environmental factors cause obesity increased ( p < .05), and perceptions that individual behavior and biology cause obesity did not change. Their support for policies that addressed food access and food pricing significantly increased ( p < .05). The youths' system diagrams elucidated links between multilevel factors such as personal attitudes, social influence, and the built environment, which provides important information for designing synergistic solutions. The changes we observed in youths' perceptions of obesity and support for policy changes have important implications for youths' interest and willingness to advocate for social and environmental changes in their community. The strategies have a promising role in supporting community mobilization to address childhood obesity.

A systematic review of peer-supported interventions for health promotion and disease prevention

Prior research has examined peer programs with respect to specific peer roles (e.g.; peer support) or specific health/wellness domains (e.g.; exercise/diet), or have aggregated effects across roles and domains. We sought to conduct a systematic review that categorizes and assesses the effects of peer interventions to promote health and wellness by peer role, intervention type, and outcomes. We use evidence mapping to visually catalog and synthesize the existing research. We searched PubMed and WorldCat databases (2005 to 2015) and New York Academy of Medicine Grey Literature Report (1999 to 2016) for English-language randomized control trials. We extracted study design, study participants, type of intervention(s), peer role(s), outcomes assessed and measures used, and effects from 116 randomized controlled trials. Maps were created to provide a visual display of the evidence by intervention type, peer role, outcome type, and significant vs null or negative effects. There are more null than positive effects across peer interventions, with notable exceptions: group-based interventions that use peers as educators or group facilitators commonly improve knowledge, attitudes, beliefs, and perceptions; peer educators also commonly improved social health/connectedness and engagement. Dyadic peer support influenced behavior change and peer counseling shows promising effects on physical health outcomes. Programs seeking to use peers in public health campaigns can use evidence maps to identify interventions that have previously demonstrated beneficial effects. Those seeking to produce health outcomes may benefit from identifying the mechanisms by which they expect their program to produce these effects and associated proximal outcomes for future evaluations.

PROSPERO REGISTRATION NUMBER

Although we attempted to register our protocol with PROSPERO, we did not meet eligibility criteria because we were past the data collection phase. The full PROSPERO-aligned protocol is available from the authors.

Systematic review of control groups in nutrition education intervention research

Background

Well-designed research trials are critical for determining the efficacy and effectiveness of nutrition education interventions. To determine whether behavioral and/or cognition changes can be attributed to an intervention, the experimental design must include a control or comparison condition against which outcomes from the experimental group can be compared. Despite the impact different types of control groups can have on study outcomes, the treatment provided to participants in the control condition has received limited attention in the literature.

Methods

A systematic review of control groups in nutrition education interventions was conducted to better understand how control conditions are described in peer-reviewed journal articles compared with experimental conditions. To be included in the systematic review, articles had to be indexed in CINAHL, PubMed, PsycINFO, WoS, and/or ERIC and report primary research findings of controlled nutrition education intervention trials conducted in the United States with free-living consumer populations and published in English between January 2005 and December 2015. Key elements extracted during data collection included treatment provided to the experimental and control groups (e.g., overall intervention content, tailoring methods, delivery mode, format, duration, setting, and session descriptions, and procedures for standardizing, fidelity of implementation, and blinding); rationale for control group type selected; sample size and attrition; and theoretical foundation.

Results

The search yielded 43 publications; about one-third of these had an inactive control condition, which is considered a weak study design. Nearly two-thirds of reviewed studies had an active control condition considered a stronger research design; however, many failed to report one or more key elements of the intervention, especially for the control condition. None of the experimental and control group treatments were sufficiently detailed to permit replication of the nutrition education interventions studied.

Conclusions

Findings advocate for improved intervention study design and more complete reporting of nutrition education interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0546-3) contains supplementary material, which is available to authorized users.

Home Sweet Home: Parent and Home Environmental Factors in Adolescent Consumption of Sugar-Sweetened Beverages

OBJECTIVE

Sugar-sweetened beverages (SSBs) are key contributors to obesity among youth. We investigated associations among parental and home-related factors (parental attitudes and consumption; home availability) regarding 3 types of SSBs-soda, sports drinks, and fruit-flavored drinks-with consumption of each type of SSB in a general school-based sample of adolescents.

METHODS

Data were collected across 3 school semesters, from 2009 to 2011. A total of 1313 seventh grade student-parent dyads participated. Students completed in-class surveys across 9 schools in a large Los Angeles school district; their parents completed telephone interviews. Youth were asked about their SSB consumption (soda, sports drinks, and fruit-flavored drinks), and parents were asked about their attitudes, consumption, and home availability of SSBs.

RESULTS

We estimated expected rates of youth SSB consumption for hypothetical parents at very low (5th) and very high (95th) percentiles for home/parental risk factors (ie, they consumed little, had negative attitudes, and did not keep SSBs in the home; or they consumed a lot, had positive attitudes, and did keep SSBs in the home). Youth of lower-risk parents (at the 5th percentile) were estimated to drink substantially less of each type of beverage than did youth of higher-risk parents (at the 95th percentile). For example, youth with higher-risk parents averaged nearly double the SSB consumption of youth of lower-risk parents (2.77 vs 1.37 glasses on the previous day; overall model significance F_22,1312 = 3.91, P < .001).

CONCLUSIONS

Results suggest a need to focus on parental and home environmental factors when intervening to reduce youths' SSB consumption.

Role of Health Coaches in Pediatric Weight Management

This study aims to describe patients' and families' perspectives regarding the ideal role and responsibilities of a health coach to facilitate pediatric weight management in the primary care setting. Systematic thematic analysis of semistructured interviews with overweight children and their parents was performed. The majority of participants self-identified as racial/ethnic minorities and were Medicaid eligible. Desired health coaching elements included ( a) customized support and encouragement, including goal setting and maintenance, cultural sensitivity, and consideration of budget and lifestyle; ( b) nutritional guidance, including meal planning, assistance obtaining healthy food, and education and counseling; and ( c) linkage to resources, including social services, physical activity support, and programs for children with special health care needs. We conclude that families' specific needs should be holistically considered in the design of health coaching programs targeting pediatric obesity. Such support may help overcome social and financial barriers to changing health behaviors related to weight management.

Child and youth participatory interventions for addressing lifestyle-related childhood obesity: a systematic review

A growing number of childhood obesity interventions involve children and youth in participatory roles, but these types of interventions have not been systematically reviewed. We aimed to identify child and youth participatory interventions in the peer-reviewed literature in order to characterize the approaches and examine their impact on obesity and obesity-related lifestyle behaviours. We searched PubMed/Medline, psychINFO and ERIC for quasi-experimental and randomized trials conducted from date of database initiation through May 2015 that engaged children or youth in implementing healthy eating, physical activity or weight management strategies. Eighteen studies met our eligibility criteria. Most (n = 14) trained youth to implement pre-defined strategies targeting their peers. A few (n = 4) assisted youth to plan and implement interventions that addressed environmental changes. Thirteen studies reported at least one statistically significant weight, physical activity or dietary change outcome. Participatory approaches have potential, but variation in strategies and outcomes leave questions unanswered about the mechanisms through which child and youth engagement impact childhood obesity. Future research should compare child-delivered or youth-delivered to adult-delivered health promotion interventions and more rigorously evaluate natural experiments that engage youth to implement environmental changes. With careful attention to theoretical frameworks, process and outcome measures, these studies could strengthen the effectiveness of child and youth participatory approaches.

Systematic Review of School-Based Interventions to Modify Dietary Behavior: Does Intervention Intensity Impact Effectiveness?

BACKGROUND

Owing to the associations between diet and health, it is important that effective health promotion strategies establish healthful eating behaviors from an early age. We reviewed the intensity of school-based interventions aimed to modify dietary behavior in preadolescent and adolescents and related intervention characteristics to effectiveness.

METHODS

Our systematic literature search of 8 databases sought to identify interventions measuring dietary intake in school settings to students aged 9 to 18. We evaluated these studies for effectiveness, intensity, intervention category, and follow-up measures.

RESULTS

Of the 105 interventions 81 were found to be effective immediately postintervention, irrespective of intensity. Studies that were 6 weeks to 5 months in duration, targeted students' environment or group (alone or in combination), and reached students only in schools were more effective. Only one-fifth of interventions conducted a follow-up measure, and a majority showed a loss of effectiveness from postintervention to follow-up.

CONCLUSIONS

We identified characteristics of effective interventions. These findings may inform the development of future interventions targeting dietary behavior in preadolescents and adolescents in the school-based setting.

Two-Year BMI Outcomes From a School-Based Intervention for Nutrition and Exercise: A Randomized Trial

OBJECTIVES

This study examined the long-term effects on BMI of a randomized controlled trial of Students for Nutrition and Exercise, a 5-week, middle school-based obesity prevention intervention combining school-wide environmental changes, encouragement to eat healthy school cafeteria foods, and peer-led education and marketing.

METHODS

We randomly selected schools from the Los Angeles Unified School District and assigned 5 to the intervention group and 5 to a wait-list control group. Of the 4022 seventh-graders across schools, a total of 1368 students had their height and weight assessed at baseline and 2 years' postintervention.

RESULTS

A multivariable linear regression was used to predict BMI percentile at ninth grade by using BMI percentile at seventh grade, school indicators, and sociodemographic characteristics (child gender, age, Latino race/ethnicity, US-born status, and National School Lunch Program eligibility [as a proxy for low-income status]). Although the Students for Nutrition and Exercise intervention did not exhibit significant effects on BMI percentile overall, intervention students who were classified as obese at baseline (in seventh grade) showed significant reductions in BMI percentile in ninth grade (b = -2.33 percentiles; SE, 0.83; P = .005) compared with control students. This outcome translated into ∼9 pounds (∼4.1 kg) lower expected body weight after 2 years for an obese student in the intervention school at the mean height and age of the sample at baseline.

CONCLUSIONS

Multilevel school-based interventions can have long-term effects on BMI among students who are obese. Future research should examine the mechanisms by which school-based obesity interventions can affect BMI over time.

Community-based fortified dietary intervention improved health outcomes among low-income African-American women

Poor dietary exposure disproportionately affects African-Americans and contributes to the persistence of disparities in health outcomes. In this study, we hypothesized that fortified dietary intervention (FDI) will improve measured dietary and related health outcomes and will be acceptable among low-income African-American women living in Tampa, FL. These objectives were tested using a prospective experimental study using pretest and posttest design with a control group, using a community-based participatory research approach. The intervention (FDI) was designed by the community through structural modification of a preexisting, diet-based program by the addition of a physical and mental health component. Paired sample t tests were used to examine preintervention and postintervention changes in study outcomes. A total of 49 women participated in the study, 26 in the FDI group and 23 controls. Two weeks postintervention, there were significant improvements in waist circumference and health-related quality of life related to physical health (P< .0001), physical fitness subscores (P= .002), and nutritional subscores (P= .001) in the FDI group. Among overweight/obese women, improvement in health-related quality of life related to physical health, a significant decrease in depressive score, and a reduction in waist circumference were noted. In the control group, a decrease in waist circumference was observed. Implementation of the FDI through a community-based participatory research approach is feasible and effective among low-income African-American women in general and overweight/obese women in particular. Social reengineering of a nutritional intervention coupled with community-based approach will enhance health outcomes of low-income women.

Cost and Cost-Effectiveness of Students for Nutrition and eXercise (SNaX)

OBJECTIVE

To examine the cost and cost-effectiveness of implementing Students for Nutrition and eXercise (SNaX), a 5-week middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education.

METHODS

Five intervention and 5 control middle schools (mean enrollment, 1520 students) from the Los Angeles Unified School District participated in a randomized controlled trial of SNaX. Acquisition costs for materials and time and wage data for employees involved in implementing the program were used to estimate fixed and variable costs. Cost-effectiveness was determined using the ratio of variable costs to program efficacy outcomes.

RESULTS

The costs of implementing the program over 5 weeks were $5433.26 per school in fixed costs and $2.11 per student in variable costs, equaling a total cost of $8637.17 per school, or $0.23 per student per day. This investment yielded significant increases in the proportion of students served fruit and lunch and a significant decrease in the proportion of students buying snacks. The cost-effectiveness of the program, per student over 5 weeks, was $1.20 per additional fruit served during meals, $8.43 per additional full-priced lunch served, $2.11 per additional reduced-price/free lunch served, and $1.69 per reduction in snacks sold.

CONCLUSIONS

SNaX demonstrated the feasibility and cost-effectiveness of a middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education. Its cost is modest and unlikely to be a significant barrier to adoption for many schools considering its implementation.

Lunchtime School Water Availability and Water Consumption Among California Adolescents

PURPOSE

To examine the potential impact of California SB 1413, which required school districts to provide free, fresh drinking water during mealtimes in food service areas by July 1, 2011, on greater water consumption among California adolescents.

METHODS

Data were drawn from the 2012 and 2013 state-representative California Health Interview Survey. A total of 2,665 adolescents aged 12-17 years were interviewed regarding their water consumption and availability of free water during lunchtime at their school.

RESULTS

Three-fourths reported that their school provided free water at lunchtime, mainly via fountains. In a multivariate model that controlled for age, gender, income, race/ethnicity, body mass index, and school type, adolescents in schools that provided free water consumed significantly more water than adolescents who reported that water was not available, bivariate (standard error) = .67 (.28), p = .02. School water access did not significantly vary across the 2 years.

CONCLUSIONS

Lunchtime school water availability was related to water consumption, but a quarter of adolescents reported that their school did not provide free water at lunch. Future research should explore what supports and inducements might facilitate provision of drinking water during school mealtimes.

Effect on Physical Activity of a Randomized Afterschool Intervention for Inner City Children in 3rd to 5th Grade

Background

Less than 45% of U.S. children meet the 60 min^.d^-1 physical activity (PA) guideline. Structured after-school PA programing is one approach to help increase activity levels. This study aimed to evaluate the feasibility and short-term impact of a supervised after-school PA and nutrition education program on activity levels.

Methods

Forty-two 3^rd-5^th graders from an inner-city school in Boston, MA were randomly assigned to a 10-wk after-school program of either: 1) weekly nutrition education, or 2) weekly nutrition education plus supervised PA 3 d^.wk^-1 at a community-based center. At baseline and follow-up, PA was measured using accelerometry and fitness (VO_2max) was estimated using the PACER 15-m shuttle run. Additional measures obtained were non-fasting finger stick total cholesterol (TC) and glucose levels, waist circumference (WC), body mass index (BMI), percent body fat (%BF), and blood pressure (BP). Values are presented as mean±SE, unless noted otherwise.

Results

Thirty-six participants completed the study (mean±SD; age 9.7±0.9 years). Participants attended >80% of the sessions. After adjusting for accelerometer wear time and other design factors, light and moderate-to-vigorous PA (MVPA) increased in the nutrition+PA group (+21.5±14.5 and +8.6±8.0 min^.d^-1, respectively) and decreased in the nutrition only group (-35.2±16.3 and -16.0±9.0 min^.d^-1, respectively); mean difference between groups of 56.8±21.7 min^.d^-1 (light PA, p = 0.01) and 24.5±12.0 min^.d^-1 (MVPA, p = 0.04). Time spent in sedentary behaviors declined in the nutrition+PA group (-14.8±20.7 min^.d^-1) and increased in the nutrition only group (+55.4±23.2 min^.d^-1); mean difference between groups of -70.2±30.9 min^.d^-1 (p = 0.02). Neither group showed changes in TC, BP, WC, %BF, BMI percentile, or fitness (p>0.05).

Conclusions

The supervised afterschool community-based nutrition and PA program was well accepted and had high attendance. The changes in light PA and MVPA has potential to promote weight maintenance in inner-city elementary school children, however longer term studies with larger samples are needed.

Trial Registration

ClinicalTrials.gov NCT01104038

The “Healthy Habits, Healthy Girls” randomized controlled trial for girls: study design, protocol, and baseline results

The purpose of this article is to describe the study design, protocol, and baseline results of the “Healthy Habits, Healthy Girls” program. The intervention is being evaluated through a randomized controlled trial in 10 public schools in the city of São Paulo, Brazil. Data on the following variables were collected and assessed at baseline and will be reevaluated at 7 and 12 months: body mass index, waist circumference, dietary intake, nutrition, physical activity, social cognitive mediators, physical activity level, sedentary behaviors, self-rated physical status, and overall self-esteem. According to the baseline results, 32.4% and 23.4% of girls were overweight in the intervention and control groups, respectively, and in both groups a higher percentage failed to meet daily recommendations for moderate and vigorous physical activity and maximum screen time (TV, computer, mobile devices). There were no significant differences between the groups for most of the variables, except age (p = 0.000) and waist circumference (p = 0.014). The study showed a gap in the Brazilian literature on protocols for randomized controlled trials to prevent obesity among youth. The current study may thus be an important initial contribution to the field.

Youth peers put the "invent" into NutriBee's online intervention

BACKGROUND

Early adolescents perceive peers as credible and relatable. Peers therefore have a unique conduit to engage early adolescents in positive health behaviors through nutrition learning such as that recommended by the U.S. Institute of Medicine (IOM).

PURPOSE

We developed an online, peer leader component to an existing in-person preventive nutrition intervention called NutriBee. We reasoned that youth ages 13-18 could create intervention materials that could remain engaging, credible and relatable to younger peers ages 10-12 online. Peer leaders could potentially derive health benefits from their service-learning experience.

METHODS

From 2013-2014 youth could apply online to relate a personal interest to nutrition, an opportunity promoted at NutriBee pilot sites and through social media. The peer leaders with diverse backgrounds honed original ideas into tangible projects with the support of adult subject-matter experts chosen by the youth. Nutrition expertise was provided by NutriBee staff who then also converted the youth-invented projects from various media into an online curriculum.

RESULTS

19 of 27 (70%) of selected youth from 12 states and diverse backgrounds, created an online curriculum comprising 10% of NutriBee's 20-hour intervention. All 19 online projects modeled 1 or more of NutriBee's 10 positive health behaviors; 8 evoked the chemosenses; 6 conveyed food texture; and 13 provided social context. Peer leaders perceived career advancement and service learning benefits. The dose, pedagogic approach, and project content align with the IOM recommendation.

CONCLUSIONS

Youth created intervention materials which communicate positive health behaviors online in ways peers can adopt. In a customarily sight-sound digital platform, youth leveraged the senses of smell, taste and touch and social context important for food selection. Peer leaders derived health benefit, as indirectly assessed by IOM criteria.

Nutrition promotion approaches preferred by Australian adolescents attending schools in disadvantaged neighbourhoods: a qualitative study

Background

Links between socioeconomic disadvantage and unhealthy eating behaviours among adolescents are well established. Little is known about strategies that might support healthy eating among this target group. This study aimed to identify potential strategies and preferred dissemination methods that could be employed in nutrition promotion initiatives focussed on improving eating behaviours among socioeconomically disadvantaged adolescents.

Methods

Semi-structured interviews were conducted in 2011 among 22 adolescents (12–15 years) recruited from secondary schools in disadvantaged neighbourhoods in Victoria, Australia.

Results

Strategies suggested by adolescents to support healthy eating included increasing awareness about healthy eating; greater cooking involvement; greater parental and peer support; frequent family meal participation; greater parental and peer role-modelling of healthy eating; increased availability of healthy foods and decreased availability of unhealthy foods in homes and schools. Adolescents preferred electronic media, adolescent-specific recipe books, and school-based methods for distributing nutrition promotion messages and strategies.

Conclusions

A number of suggested strategies and methods identified in the present investigation have been employed with success in previous nutrition promotion interventions targeting socioeconomically disadvantaged adolescents. The present study also contributes novel insights into potential strategies and methods that could be employed in initiatives aiming to improve eating behaviours in this vulnerable group, and particularly highlights the importance of incorporating strategies involving parents and modifying the home food environment.

Middle school student attitudes about school drinking fountains and water intake

OBJECTIVE

To describe middle school student attitudes about school drinking fountains, investigate whether such attitudes are associated with intentions to drink water at school, and determine how intentions relate to overall water intake.

METHODS

Students (n = 3211) in 9 California middle schools completed surveys between 2009 and 2011. We used multivariate linear regression, adjusting for school sociodemographic characteristics, to examine how attitudes about fountains (5-point scale; higher scores indicating more positive attitudes) were associated with intentions to drink water at school and how intentions to drink water at school were related to overall water intake.

RESULTS

Mean age of students was 12.3 (SD = 0.7) years; 75% were Latino, 89% low income, and 39% foreign born. Fifty-two percent reported lower than recommended overall water intake (<3 glasses/day), and 30% reported that they were unlikely or extremely unlikely to drink water at school. Fifty-nine percent reported that school fountains were unclean, 48% that fountain water does not taste good, 33% that fountains could make them sick, 31% that it was not okay to drink from fountains, and 24% that fountain water is contaminated. In adjusted analyses, attitudes about school drinking fountains were related to intentions to drink water at school (β = 0.41; P < .001); intentions to drink water at school were also associated with overall water intake (β = 0.20; P < .001).

CONCLUSIONS

Students have negative attitudes about school fountains. To increase overall water intake, it may be important to promote and improve drinking water sources not only at school but also at home and in other community environments.