School health education programs in Crete: evaluation of behavioural and health indices a decade after initiation

Risk of hypertension in school-aged children undergoing a long-term community-based lifestyle intervention: Tehran Lipid and Glucose Study

Childhood hypertension which increases the risk of cardiovascular diseases in adulthood is becoming more prevalent. For the first time in the Middle-East region, this study aimed to assess the long-term effectiveness of a community-based lifestyle intervention on the incidence of hypertension in school-aged children during 16 years of follow-up. This study was conducted within the framework of the Tehran Lipid and Glucose Study (TLGS). Participants were 2080 children aged 8-18 years with normal blood pressure who were under the coverage of three health care centers selected using multistage cluster random sampling method. One of the health care centers far from the other two was selected for implementing lifestyle intervention (1053 children, 48.2% boys). Triennial examinations were conducted, and survival Cox models were used to assess intervention effects on the incidence of hypertension in boys and girls. Crude incidence rates (per 1000 person-years) of hypertension were 8.11, 3.7, and 5.8 among boys, girls, and the total sample, respectively. Our results showed that HTN has occurred significantly less (P = 0.025) in the intervention group than in the control group, only in female participants. These results remained significant even after adjusting for individuals' and parental characteristics (P = 0.033). Although the risk of hypertension in boys was more than twice that observed in girls, the effectiveness of the recent community-based healthy lifestyle intervention was observed only in girls and not in boys. Further studies are needed to understand gender differences in promoting the effectiveness of similar future programs. The TLGS is registered at Iran Registry for Clinical Trials, a WHO primary registry (http://irct.ir; IRCTID: IRCT138705301058N1).

Shape Up Somerville's return on investment: Multi-group exposure generates net-benefits in a child obesity intervention

Community-based interventions may reduce and prevent childhood obesity by transforming the environments in which children live, learn, and play through a series of interventions implemented throughout the community that encourage healthy behaviors. While empirical support is building for the effectiveness of such interventions, little is known about the economic costs and benefits of community-wide childhood obesity interventions. This study examined whether the benefits of a community-wide, child-focused, obesity prevention intervention, Shape Up Somerville: Eat Smart Play Hard (SUS), exceeded its costs by estimating its return on investment. The SUS intervention study occurred in Somerville, Massachusetts (and in two additional geographic areas, which were the study's control group) during the 2003/04 and 2004/05 school years. We estimated SUS's costs using SUS data over the two-year intervention. We estimated benefits (i.e., healthcare costs and productivity losses averted for children and their parents) over a ten-year time horizon using SUS effectiveness results and other sources. SUS generated an estimated $1.51 in savings for every $1.00 invested in the program (return on investment of $0.51). Over ten years, the estimated costs averted were over $500,000 with net benefits of $197,120 (2014 dollars). SUS was estimated to be a cost-saving intervention when examined over a ten-year time horizon. The excess benefits generated by SUS likely arose from the community-wide nature of the intervention which extended exposure (and estimated benefits) beyond children to parents as well. These results illustrate that allocating resources to community-wide, child-focused obesity prevention interventions may be a beneficial investment.

Interventions for preventing obesity in children

EDITORIAL NOTE

This Cochrane review is now out of date and should not be used for reference. It has been split into four age groups and updated. Please refer to the 5‐11 and 12‐18 age group Cochrane reviews which were published in May 2024: https://doi.org/10.1002/14651858.CD015328.pub2 https://doi.org/10.1002/14651858.CD015330.pub2 The 2‐4 age group Cochrane review is planned for publication in September 2024.

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

Consumption of licit and illicit substances in Portuguese young people: a population-based cross-sectional study

Background

The consumption of addictive substances is common in adolescence and raises concerns about future addiction. We investigated addictive substance consumption among young people to inform the design of drug intervention programmes.

Methods

Participants were a population-based sample of 14- to 24-year-olds from Paredes, northern Portugal. A self-report questionnaire measured social and health variables, including tobacco, alcohol and illicit drug consumption.

Results

Data were analysed for 731 valid responses. Participants who had drunk alcohol did so first at 14.7 years (mean); 15.3% (95% confidence intervals [CI]: 12.9–18.1) drank alcohol regularly (more than 1/week, adjusted for age and sex) (95% CI: 12.9–18.1). Participants who had smoked tobacco did so first at 14.8 years (mean); 16.6% (95% CI: 14.0–19.5) were regular smokers. Illicit drug consumption was reported by 16.7% of participants (95% CI: 14.2–19.6) and 10.4% consumed drugs regularly.

Conclusion

We found a high prevalence of addictive substance consumption, particularly alcohol. As cultural attitudes likely influence alcohol consumption, a multigenerational approach is needed to address adolescent consumption. Participants’ main sources of drug information were family members. Strategies are needed to promote drug literacy in parents and other relatives to change adolescents’ culturally acquired habits of addictive substance consumption.

The Effects of a Community-Based Lifestyle Intervention on Metabolic Syndrome and Its Components in Adolescents: Findings of a Decade Follow-Up

BACKGROUND

The increasing prevalence of metabolic syndrome (MetS) in childhood makes lifestyle interventions imperative during adolescence. This study aimed to assess the effects of a community-based lifestyle intervention on MetS and its components in adolescents.

METHODS

Adolescents, based on their residential area were categorized into three groups: complete intervention (residing in the intervention area at baseline and during all follow-ups), incomplete intervention (residing in either the intervention or control areas and were in transition between these two areas), and control group (residing in the control area at baseline and throughout all follow-ups). All measurements were repeated every 3 years for up to 9 years. Lifestyle intervention aimed at achieving healthy dietary patterns and increasing physical activity. Generalized estimating equation models were used to analyze data.

RESULTS

In boys with incomplete intervention versus controls, the prevalence of MetS was significantly lower in the short term (14.0 vs. 22.9), but not in long term. In boys with complete intervention, the prevalence was significantly lower versus controls (9.0 vs. 23.4) in the long term. In girls, the short-term prevalence of MetS was significantly lower in the complete intervention group compared with controls (2.5 vs. 9.1) and then remained constantly low in all study groups after that. Among MetS components, in boys, triglycerides and fasting plasma glucose in the short term and high-density lipoprotein mid term, and in girls HDL in mid and long term were both significantly improved. The odds of MetS decreased significantly in the complete [odds ratio (OR): 0.516, confidence interval (95% CI): 0.273-0.973] and incomplete (OR: 0.591, 95% CI: 0.358-0.976) intervention groups only in boys. The short- and long-term interventions resulted improvement in some of the MetS components in both genders.

CONCLUSIONS

The healthy lifestyle intervention reduced the risk of MetS in both genders in short and long term, but with different patterns and improved some of the MetS components.

Systematic review of universal school-based 'resilience' interventions targeting adolescent tobacco, alcohol or illicit substance use: A meta-analysis

Universal school-based interventions that address adolescent 'resilience' may represent a means of reducing adolescent substance use, however previous systematic reviews have not examined the effectiveness of such an intervention approach. A systematic review was undertaken to 1) assess whether universal school-based 'resilience' interventions are effective in reducing the prevalence of tobacco, alcohol or illicit substance use by adolescents, and 2) describe such effectiveness per intervention characteristic subgroups. Eligible studies were peer-reviewed reports (1994-2015) of randomised controlled trials including participants aged 5-18years that reported adolescent tobacco, alcohol or illicit substance use, and implemented a universal school-based 'resilience' intervention (i.e. those addressing both individual (e.g. self-esteem) and environmental (e.g. school connectedness) protective factors of resilience). Trial effects for binary outcomes were synthesised via meta-analyses and effect sizes reported as odds ratios. Subgroup (by intervention type, prevention approach, setting, intervention duration, follow-up length) and sensitivity analyses (excluding studies at high risk of bias) were conducted. Nineteen eligible studies were identified from 16,619 records (tobacco: n=15, alcohol: n=17, illicit: n=11). An overall intervention effect was found for binary measures of illicit substance use (n=10; OR: 0.78, 95%CI: 0.6-0.93, p=0.007,Tau²=0.0, I²=0%), but not tobacco or alcohol use. A similar result was found when studies assessed as high risk of bias were excluded. Overall intervention effects were evident for illicit substance use within multiple intervention characteristic subgroups, but not tobacco and alcohol. Such results support the implementation of universal school-based interventions that address 'resilience' protective factors to reduce adolescent illicit substance use, however suggest alternate approaches are required for tobacco and alcohol use. PROSPERO registration: CRD42014004906.

Health promotion in school environment in Brazil

OBJECTIVE

Evaluate the school environments to which ninth-year students are exposed in Brazil and in the five regions of the country according to health promotion guidelines.

METHODS

Cross-sectional study from 2012, with a representative sample of Brazil and its macroregions. We interviewed ninth-year schoolchildren and managers of public and private schools. We proposed a score of health promotion in the school environment (EPSAE) and estimated the distribution of school members according to this score. Crude and adjusted odds ratios (OR) were used, by ordinal regression, to determine the schoolchildren and schools with higher scores, according to the independent variables.

RESULTS

A student is more likely to attend a school with a higher EPSAE in the South (OR = 2.80; 95%CI 2.67–2.93) if the school is private (OR = 4.52; 95%CI 4.25–4.81) and located in a state capital, as well as if the student is 15 years of age or older, has a paid job, or has parents with higher education.

CONCLUSIONS

The inequalities among the country’s regions and schools are significant, demonstrating the need for resources and actions that promote greater equity.

Effect of animated movie in combating child sleep health problems

Objective

Sleep deprivation among teens is a major health issue. Only 15% of teens get 8.5 h of sleep on school nights. Sleep deprivation can lead to poor grades, sleepiness and moodiness. We undertook a study to assess the prevalence of sleep habit disturbance among elementary school students in South Texas with Hispanic ethnicity predominance. We also found how much a video based on sleep education had an impact on these children.

Method

Once the Corpus Christi Independent School District (CCISD) approved the collection of baseline sleep data, questionnaires were administered using the Children’s Sleep Habit Questionnaire (CSHQ.) These questionnaires were distributed prior to the viewing of the educational and animated movie KNIGHTS (Keep Nurturing and Inspiring Good Habits in Teen Sleep). Four months later, a random follow-up was performed and the children were requested to respond to the same CSHQ.

Results

264 children from two elementary schools participated in this educational program. At baseline, 55.56% of the children had trouble sleeping. When the questionnaire was administered four months later, only 23.26% (p < 0.05) had trouble sleeping. Additionally, at baseline, approximately 60–70% children had some baseline bedtime resistance, anxiety dealing with sleep, issues with sleep duration and/or awakenings in the middle of the night. In the follow up questionnaire, results showed significant improvements in overall sleep habits, bedtime resistance, sleep anxiety and night awakenings amongst students (p < 0.05). However, no significant differences were seen in sleep duration and daytime sleepiness.

Conclusion

Sleep deprivation and good sleep habits remain as a pervasive challenge among elementary school students. Administering an animated video about sleep education along with a provider-based education may be an effective tool for educating elementary school students and decreasing the prevalence of these sleep-related issues. Future prospective randomized studies are suggested.

What childhood obesity prevention programmes work? A systematic review and meta-analysis

Previous reviews of childhood obesity prevention have focused largely on schools and findings have been inconsistent. Funded by the US Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health, we systematically evaluated the effectiveness of childhood obesity prevention programmes conducted in high-income countries and implemented in various settings. We searched MEDLINE®, Embase, PsycINFO, CINAHL®, ClinicalTrials.gov and the Cochrane Library from inception through 22 April 2013 for relevant studies, including randomized controlled trials, quasi-experimental studies and natural experiments, targeting diet, physical activity or both, and conducted in children aged 2-18 in high-income countries. Two reviewers independently abstracted the data. The strength of evidence (SOE) supporting interventions was graded for each study setting (e.g. home, school). Meta-analyses were performed on studies judged sufficiently similar and appropriate to pool using random effect models. This paper reported our findings on various adiposity-related outcomes. We identified 147 articles (139 intervention studies) of which 115 studies were primarily school based, although other settings could have been involved. Most were conducted in the United States and within the past decade. SOE was high for physical activity-only interventions delivered in schools with home involvement or combined diet-physical activity interventions delivered in schools with both home and community components. SOE was moderate for school-based interventions targeting either diet or physical activity, combined interventions delivered in schools with home or community components or combined interventions delivered in the community with a school component. SOE was low for combined interventions in childcare or home settings. Evidence was insufficient for other interventions. In conclusion, at least moderately strong evidence supports the effectiveness of school-based interventions for preventing childhood obesity. More research is needed to evaluate programmes in other settings or of other design types, especially environmental, policy and consumer health informatics-oriented interventions.

The value of using schools as community assets for health

In planning, designing, procuring and ensuring delivery of improved services ('commissioning') for the school age population, the outcomes should be students who are healthy to learn and who learn to be healthy. Intuitively, linking education and health development together within the wider learning environment seems a good start to planning school health. However there has been a shortage of either theoretical models that can span different settings or experimental research that demonstrates improved community health. Is there evidence that the wider learning environment provided in a school is valuable in improving health? An initial scoping exercise identified domains of health where there was a promise of health gain. International literature on school health outcomes using the framework of Asset-Based Community Development (ABCD) has been reviewed. It was found that research on a variety of interventions was relevant to schools as an asset for public health. Effective areas for health gain were identified for local planning and evaluation using this community model. However, none of the studies reviewed was originally designed to test schools as assets and most of the research lacked methodological rigour, especially regarding children in low income countries. The ABCD model could help national governments develop resources for both education and health, but there is a global need to generate better quality evidence. Then people who commission for their local communities can make more effective use of these multifaceted assets to improve health and education outcomes for children.

Effect of childhood obesity prevention programs on blood pressure: a systematic review and meta-analysis

BACKGROUND

Childhood overweight and obesity are associated with elevated blood pressure (BP). However, little is known about how childhood obesity lifestyle prevention programs affect BP. We assessed the effects of childhood obesity prevention programs on BP in children in developed countries.

METHODS AND RESULTS

We searched databases up to April 22, 2013, for relevant randomized, controlled trials, quasi-experimental studies, and natural experiments. Studies were included if they applied a diet or physical activity intervention(s) and were followed for ≥ 1 year (or ≥ 6 months for school-based intervention studies); they were excluded if they targeted only overweight/obese subjects or those with a medical condition. In our meta-analysis, intervention effects were calculated for systolic BP and diastolic BP with the use of weighted random-effects models. Of the 23 included intervention studies (involving 18 925 participants), 21 involved a school setting. Our meta-analysis included 19 studies reporting on systolic BP and 18 on diastolic BP. The pooled intervention effect was -1.64 mm Hg (95% confidence interval, -2.56 to -0.71; P=0.001) for systolic BP and -1.44 mm Hg (95% confidence interval, -2.28 to -0.60; P=0.001) for diastolic BP. The combined diet and physical activity interventions led to a significantly greater reduction in both systolic BP and diastolic BP than the diet-only or physical activity-only intervention. Thirteen interventions (46%) had a similar effect on both adiposity-related outcomes and BP, whereas 11 interventions (39%) showed a significant desirable effect on BP but not on adiposity-related outcomes.

CONCLUSIONS

Obesity prevention programs have a moderate effect on reducing BP, and those targeting both diet and physical activity seem to be more effective.

Atherogenic risk factors among preschool children in Crete, Greece

OBJECTIVE

To investigate the presence of atherogenic factors among preschool children of Crete, Greece.

MATERIALS AND METHODS

This was a cross-sectional study. The study population included 1189 children, aged four to seven years, examined from January to May 2005, in public kindergartens. Biochemical, anthropometric, and blood pressure measurements were performed.

RESULTS

Of the boys 27.4% were classified as overweight or obese (obese 10.8%). The respective percentage for girls was 28.5% (obese 9%); 7.4% percent of the boys and 7.9% of the girls had blood pressure above the ninety-fifth percentile. TC of > 200 mg / dl was found in 14.4% and LDL-C of > 130 mg / dl in 13.8% of the children. Children with serum TG of > 100 mg / dl had a significantly higher mean WC and BMI than those with triglyceride levels of ≤ 80 mg / dl (59.7 vs. 55.9 cm and 17.9 vs. 16.6 kg / m(2); P < 0.05). Similarly, children with HDL-C < 45 mg / dl had significantly higher WC and BMI than children with HDL-C ≥ 60 mg / dl (57.7 vs. 53.5 cm and 17.1 vs. 16.5 kg / m(2); P < 0.05). Obese children had an Odds Ratio of 2.87 (95% confidence interval, 1.05 - 7.85, P = 0.041) for hypertriglyceridemia, as compared to non-obese children.

CONCLUSION

Levels of obesity and especially central obesity were strongly related to other atherogenic risk factors in Cretan preschool children indicating the presence of this major public health problem in early ages.

Medium-term evaluation of an educational intervention on dietary and physical exercise habits in schoolchildren: the Avall 2 study

OBJECTIVE

To assess whether the benefits seen in nutrition, physical activity. and body mass index were maintained at 2 years of completion of the educational intervention.

MATERIAL AND METHODS

An experimental, longitudinal, 4-year, two-arm, parallel study with cluster randomization to assess an intervention program aimed at children in their first year of primary schooling attending schools in the city of Granollers. Intervention consisted of promoting healthy dietary habits and increasing physical activity through the educational pedagogy Investigation, Vision, Action and Change (IVAC), applied over 2 school years (2006-2008). Weight and height of each child wee measured in situ, and families self-completed a physical activity survey and the Krece Plus quick test in 2006, 2008, and 2010.

RESULTS

A greater increase in body mass index was seen in 2010 in children from the control group (2.84 ± 0.22 vs 1.96 ± 0.163 kg/m(2), <.001). Prevalence of overweight and obesity increased by 8% and 0.5% respectively in schoolchildren in the control group, while the intervention group showed a 5.3% increase in prevalence of overweight and a 3.6%decrease in prevalence of obesity. Prevalence of excess weight therefore increased by 8.5% in the control group and by 1.8% in the intervention group. Reduction in body mass indexincrease was maintained 2 years after completion of educational intervention regardless of sex, origin, maternal obesity, and educational level of parents.

CONCLUSIONS

These results confirm that school-based interventions may help contain the current increase in childhood obesity.

Are sleep education programs successful? The case for improved and consistent research efforts

Sleep duration and quality are associated with a range of neuropsychological and psychosocial outcomes in children and adolescents but community awareness of this is low. A small body of literature on sleep education programs in children and adolescents delivered through school-based programs is attempting to address this. A review of the literature found only 8 studies and 4 pilot studies in abstract form. This paper presents these sleep education programs and evaluates their effectiveness. In general, findings suggest that when sleep knowledge was measured it was increased in most programs. However this did not necessarily equate to sleep behaviour change such as increased sleep duration or improved sleep hygiene. Reasons for this are discussed and may include motivation and readiness to change, salience to the individual, delivery, content, time allocation, or methodological underpinnings. This paper attempts to understand this and assess how best to improve future sleep education programs from a theoretical perspective. Specifically, it considers the theory of planned behaviour which may assist in ensuring maximum efficacy for the current and future development of sleep education programs.