Effectiveness of universal parental support interventions addressing children's dietary habits, physical activity and bodyweight: A systematic review

Universal healthy school start intervention reduced the body mass index of young children with obesity

AIM

To evaluate the effect of a universal, school-based family support programme on body mass index (BMI) of children aged 5-7 years, using pooled data from three trials.

METHODS

The programme has three to four components and is delivered during the first school year. It aims to promote healthy dietary and physical activity behaviours, and secondarily prevent unhealthy weight gain. Three cluster-randomised controlled trials were conducted between 2010 and 2018 in low and mixed socioeconomic status areas in Sweden. Weight and height were measured. Multiple mixed linear regression analysis was performed on the pooled data.

RESULTS

In total, 961 children were included (50% girls, mean age 6.3 years). The post-intervention effect on BMI z-score in all children was small, but in those with obesity at baseline, we observed a significant, clinically relevant, decrease in BMI z-score (-0.21). This was most pronounced in children with a non-Nordic born parent (-0.24). Five to six months after the intervention, decreases were no longer statistically significant.

CONCLUSION

The intervention resulted in changes in BMI comparable to obesity treatment programmes focusing on behaviour change. However, the effect attenuated with time suggesting the programme should be sustained and evaluated for a longer time.

A blended face-to-face and eHealth lifestyle intervention on physical activity, diet, and health outcomes in Hong Kong community-dwelling older adults: a study protocol for a randomized controlled trial

Background

Aging individuals are vulnerable to various Noncommunicable Diseases (NCDs). Different behaviors are closely related to a decreased risk of suffering from NCDs: sufficient Physical Activity (PA) (e.g., at least 150 mins Moderate-to-vigorous Physical Activity (MVPA) per week) and a healthy daily diet (e.g., at least five portions of Fruit and Vegetable Intake (FVI), 5-6 taels (189.0-226.8 g) Meat, Fish, Egg and Alternatives (MFEA)). Traditional face-to-face interventions were effective in behavior change. However, it was revealed to be resource-intensive and limited transfer due to poor self-regulation skills outside of face-to-face sessions. Thus, eHealth could be a supplement for older adults outside traditional face-to-face settings. The blended approach combining these two interventions might optimize the intervention effects on lifestyle behavior initiation and maintenance, but little research can be found among Hong Kong older adults. Therefore, the study aims to test a blended intervention to promote PA, diet, and health outcomes among Hong Kong community-dwelling older adults.

Methods

This study will adopt a 10-week three-arm randomized controlled trial. The blended group will receive weekly (1) two 60-min face-to-face sessions with one for PA and one for diet, and (2) two web-based sessions with one for PA and one for diet. The face-to-face group will receive the same intervention content as the face-to-face sessions in the blended group. The control condition will receive a biweekly telephone call. The outcomes will include MVPA (minutes/week), FVI (portions/day), MFEA consumption (taels/day), social-cognitive factors (self-efficacy, planning, social support, action control), physical health outcomes (clinical indicators, senior physical fitness), mental health outcomes (depression, loneliness) and health-related quality of life. Data collection will be implemented at the pre-test, post-test, and 3-month follow-up test.

Discussion

This is the first study evaluating a blended intervention promoting multiple health behaviors among Hong Kong community-dwelling older adults. If the effect of the blended intervention is superior to the traditional face-to-face group and the control group, it will enrich lifestyle intervention approaches and can be applied to older adults, helping them obtain health benefits. Furthermore, a better understanding of mechanisms will also have implications for theory-building.

Clinical trial registration

https://www.isrctn.com/ISRCTN32329348, ISRCTN32329348.

Influencing factors for the implementation of school-based interventions promoting obesity prevention behaviors in children with low socioeconomic status: a systematic review

BACKGROUND

Health inequity (HI) remains a major challenge in public health. Improving the health of children with low socioeconomic status (SES) can help to reduce overall HI in children. Childhood obesity is a global problem, entailing several adverse health effects. It is crucial to assess the influencing factors for adoption, implementation, and sustainment of interventions. This review aims to identify articles reporting about influencing factors for the implementation of school-based interventions promoting obesity prevention behaviors in children with low SES. It aims to critically appraise the articles' quality, assess influencing factors, categorize and evaluate them, and to discuss possible implications.

METHODS

A systematic search was conducted in 7 databases with the following main inclusion criteria: (1) school-based interventions and (2) target group aged 5-14 years. The Consolidated Framework for Implementation Research, its five domains (intervention characteristics, inner setting, outer setting, characteristics of individuals, process) along with 39 categories within these domains were used as deductive category system for data analysis. We grouped the articles with regard to the characteristics of the interventions in simple and complex interventions. For each domain, and for the groups of simple and complex interventions, the most commonly reported influencing factors are identified.

RESULTS

In total, 8111 articles were screened, and 17 met all eligibility criteria. Included articles applied mixed methods (n=11), qualitative (n=5), and quantitative design (n=1). Of these, six were considered to report simple interventions and eleven were considered to report complex interventions. In total, 301 influencing factors were assessed. Aspects of the inner setting were reported in every study, aspects of the outer setting were the least reported domain. In the inner setting, most reported influencing factors were time (n=8), scheduling (n=6), and communication (n=6).

CONCLUSION

This review found a wide range of influencing factors for implementation and contributes to existing literature regarding health equity as well as implementation science. Including all stakeholders involved in the implementation process and assessing the most important influencing factors in the specific setting, could enhance implementation and intervention effectiveness. More empirical research and practical guidance are needed to promote obesity prevention behaviors among children with low SES.

REGISTRATION

CRD42021281209 (PROSPERO).

Prevalence and determinants of overweight and obesity among preschool-aged children from migrant and socioeconomically disadvantaged contexts in Montreal, Canada

Among migrant and socioeconomically disadvantaged preschool-aged children followed in social perinatal primary care services in Montreal, Canada, we estimated the prevalence of overweight/obesity and identified determinants of body mass index z-score (zBMI) at 4-5 years old. We conducted a retrospective cohort study using electronic medical records of 275 child-mother dyads followed from birth to 4-5 years. Anthropometric measures and established maternal, perinatal and child risk factors for childhood obesity were examined. Age- and sex-specific zBMI at 4-5-years were computed and categorized according to WHO standards. Linear regression with model averaging was used to identify early life factors associated with zBMI. At 4-5 years, children's weight status was classified as underweight (1.5%), normal weight (69.7%), at-risk-of-overweight (19.2%), overweight (6.9%), and obesity (2.7%). Primiparity (0.51, 95% CI 0.24; 0.78), higher birthweight (1.04, 95% CI 0.70; 1.37), accelerated weight gain in the first year of life (0.21, 95% CI 0.13; 0.31), and introduction to solid foods before 6 months (0.89, 95% CI 0.42; 1.36) were associated with a higher zBMI, while less than high school education (-0.50, 95% CI -0.95; -0.05) and higher gestational age (-0.14, 95% CI -0.21; -0.05) were associated with lower zBMI at 4-5 years. Overweight/obesity is prevalent among preschool-aged children from migrant and socioeconomically disadvantaged contexts and is associated with known risk factors. Future research is needed to better understand the role of social perinatal primary care services in promoting optimal weight gain among children living in contexts of vulnerability.

Policies are Needed to Increase the Reach and Impact of Evidence-Based Parenting Supports: A Call for a Population-Based Approach to Supporting Parents, Children, and Families

Parents can be essential change-agents in their children's lives. To support parents in their parenting role, a range of programs have been developed and evaluated. In this paper, we provide an overview of the evidence for the effectiveness of parenting interventions for parents and children across a range of outcomes, including child and adolescent mental and physical health, child and adolescent competencies and academic outcomes, parental skills and competencies, parental wellbeing and mental health, and prevention of child maltreatment and family violence. Although there is extensive research showing the effectiveness of evidence-based parenting programs, these are not yet widely available at a population level and many parents are unable to access support. We outline how to achieve increased reach of evidence-based parenting supports, highlighting the policy imperative to adequately support the use of these supports as a way to address high priority mental health, physical health, and social problems.

Parents' experiences of participating in the Healthy School Start Plus programme - a qualitative study

BACKGROUND

The rise in overweight and obesity among children is a global problem and effective prevention interventions are urgently required. Parents play an important role in children's lifestyle behaviours and body weight development and therefore there is a great need to investigate how to involve parents effectively in health promotion and prevention programmes. The aim of the study was to describe parents' experiences of barriers and facilitators of participating in the Healthy School Start Plus (HSSP) intervention study.

METHODS

HSSP is a parental support programme, conducted in Sweden, with the aim to promote a healthy diet, physical activity and preventing obesity in 5-7-year-old children starting school. In total 20 parents from 7 schools participated in semi-structured telephone-based interviews. The data was analysed using qualitative content analysis, with a deductive approach based on the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Parental experiences of barriers and facilitators informing the implementation of the HSSP intervention were identified within all five domains of the CFIR. Two additional constructs, not included in the CFIR were identified: Social factors and Cooperation. The findings of parental experiences of barriers and facilitators related to the importance of (1) adaptation of the intervention to fit the abilities of the parents with different social and cultural backgrounds; (2) the need for continuous delivery of information related to healthy behaviours; (3) the commitment and efforts of the deliverers of the intervention; (4) the need for repetition of information related to healthy behaviours given by the deliverers of the intervention; (5) encouragement and facilitation of the involvement of the family and key people around them through the intervention activities and by the deliverers of the intervention; (6) awareness of unexpected impacts and social and cultural conditions complicating the execution of the intervention and; (7) cooperation and a well-functioning interaction between parents and school staff.

CONCLUSIONS

Barriers and facilitators indicated by the parents highlighted that interventions like the HSSP need to be adapted to fit the parents' abilities, with reminders, follow-ups and delivery of relevant information. Variations in social and cultural conditions need to be taken into consideration. The commitment of the school and the interaction between the school staff and the family as well as key people around them appears to be important.

TRIAL REGISTRATION

The Healthy School Start Plus trial was retrospectively registered in the International Standard Randomised Controlled Trial Number Registry on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725.

Hispanic caregivers' preferences for content, delivery methods, and sources of nutrition education from their child's preschool: Qualitative research findings

Background: With the obesity epidemic disproportionately affecting Hispanic children and preschool being a critical period when interventions may be effective to prevent it, nutrition education interventions in the preschool setting have the potential to stem obesity's spread. However, the nutrition education needs of low-income Hispanic populations and methods of delivery of that information require further exploration as culturally tailored approaches have seen limited reach to the target audience. Aim: To explore content, delivery methods, and sources of nutrition education that Hispanic caregivers prefer to receive from their child's preschool. Methods: Qualitative interviews with 25 self-identified Hispanic caregivers (≥18 years of age) of 3- to 5-year-old children at Head Start centers in the Washington, D.C., area. Caregivers were interviewed about preferred nutrition education topics, how nutrition education should be delivered, and by whom. Audio-recorded interviews were transcribed verbatim. Transcripts were analyzed using thematic analysis in NVivo v12. Results: Caregivers wanted to know about healthy foods and appropriate portion sizes to feed their children, fruit and vegetable feeding strategies, and how to incorporate Hispanic foods in healthy meals. Preferred delivery methods included receiving nutrition education and recipes in print and digital formats and in-person nutrition classes. Special Supplemental Nutrition Program for Women, Infants, and Children educators were regarded as trusted nutrition education sources. Conclusion: Tailored nutrition education messages combined with multiple delivery methods could be an effective way to reach Hispanic caregivers of preschoolers to increase their nutrition knowledge.

Family-Based Telehealth Initiative to Improve Nutrition and Physical Activity for Children With Obesity and Its Utility During COVID-19: A Mixed Methods Evaluation

Guidelines recommend primary care providers refer children with obesity to behavioral interventions, but given limited program availability, access, and parental engagement, referrals remain rare. We developed telehealth coaching interventions for families whose children received care at a health system in Pennsylvania, United States in 2019-2020. Intervention referrals were facilitated by the pediatrician and/or project team for 6–12-year-old children with obesity following well-child visits. Participants chose one of three 26-week interventions focused on healthy eating, physical activity, or a hybrid clinical/nutrition intervention. Interventions engaged parents as change agents, enhancing self-efficacy to model and reinforce behavior and providing resources to help create a healthy home environment. We enrolled 77 of 183 eligible parent/child dyads. We used mixed methods to evaluate the interventions. Repeated measures models among participants showed significant reductions in obesogenic nutrition behaviors post-intervention and at 1-year follow-up, including a reduction in sugar-sweetened beverage intake of 2.14 servings/week (95% confidence interval: −3.45, −0.82). There were also improvements in obesoprotective nutrition behaviors (e.g., frequency of family meals, parental self-efficacy related to meal management). One year post-baseline, we observed no significant differences in changes in body mass index (BMI) z-scores comparing child participants with matched controls. Given potential impacts of COVID-19 community restrictions on study outcomes, we conducted qualitative interviews with 13 participants during restrictions, which exemplified how disrupted routines constrained children’s healthy behaviors but that intervention participation prepared parents by providing cooking and physical activities at home. Findings support the potential of a telehealth-delivered nutrition intervention to support adoption of healthy weight behaviors.

Children’s Changes in Perceptions and Body Composition Following a Family-Based Fitness Intervention

Physical fitness is associated with decreased weight in children, which helps improve youth obesity rates. Family programs can provide practical approaches to improving physical fitness for children. The purpose of this study was to assess the influence of a family-based fitness intervention on changes in body composition, fitness status, and perceptions of obese children. Families attended exercise and education sessions for 60–90 min once per week for 10 weeks. Participants consisted of 10 children who participated in semi-structured interviews, body composition, and fitness assessments at pre- and posttest. Following the intervention, results showed that children had a significant increase in sit-ups (p = .03, effect size = 0.79), lean mass (p < .001, Cohen’s d = 1.95), and bone mineral content (p < .001, Cohen’s d = 0.46). Using thematic analysis, four main themes emerged from the pre- and postintervention interviews: an increase in after-school and weekend intentional physical fitness, rules regarding sedentary behavior and screen time, more prevalent physical fitness reinforcements, and a shift in perception of exercise. Results from this study indicate a family-based intervention had an influence on children’s appreciation for and engagement in physical fitness, as well as healthy body composition and fitness outcomes.

Improving phenylalanine and micronutrients status of children with phenylketonuria: a pilot randomized study

Background

Children with Phenylketonuria (PKU) need a special diet to avoid a variety of physical and psychological complications. The aim of this study was to compare and assess the effects of two interventions on and levels of phenylalanine and micronutrients in children with PKU.

Methods

Forty-six children with PKU (ages 1–12 years) and their caregivers were randomly assigned to one of two 10-week interventions: a caregiver educational intervention based on the Integrative Model of Behvioral Prediction (IMBP) and supplementary low-protein-modified foods. Outcomes consisted of Children's plasma phenylalanine and micronutrients (i.e., vitamin B12, vitamin D3, and zinc) and hemoglobin levels. To assess the sustainability of outcomes, we also compared the children’s phenylalanine level at five-time points including baseline and 10-week, 6 months, 12 months, and 24 months follow-ups. In addition, caregivers of both groups were asked to complete a questionnaire to assess how well the interventions were implemented as well as satisfaction with interventions.

Results

While a large percentage of children had phenylalanine levels out of range indicating non-adherence (69.6% and 81% in the educational and food items group, respectively), micronutrient deficiencies were not prevalent in the patient cohort. The levels of phenylalanine in both groups decreased significantly over time. However, conducting a repeated-measures ANOVA to evaluating the change in groups across five-time points, revealed a significant difference between groups (F = 4.68, p = 0.03). That is, the educational intervention was more effective in lowering the children's phenylalanine level. At 24-month follow-up, the percentage of children with a normal range of phenylalanine level in the educational and food items groups increased to 73.9 and 57.1 percent, respectively, from 26 and 38 percent at baseline. There were no significant changes in children's micronutrients level following the interventions, except in the hemoglobin. In this way, at 10-week follow-up, the mean hemoglobin of children in the educational group reduced significantly (P = 0.041). However, there was no significant difference between the two groups. In general, all caregivers completed the process evaluation checklist, the feedback was largely positive.

Conclusions

The results of this study demonstrated that both educational and providing food item interventions resulted in a significant reduction in phenylalanine levels. Empowering caregivers of patients, creating and fortifying social networks, providing favorable social supports, and providing access to special food items may be effective in controlling PKU.

Clinical trial registration: Iranian Registry of Clinical Trials (IRCT20180506039548N1). Registered 6th Jun 2018, https://www.irct.ir/trial/30977.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-02094-8.

Reflections on a complex intervention targeting healthy eating in young children

In this article, the author offers her experiences of conducting a public health nursing intervention based on the use of the Medical Research Council framework for complex interventions. This article provides examples aimed at helping and inspiring others who might be interested in conducting a complex intervention study. The intervention focused on counseling about food and feeding practices provided by public health nurses in a sample of child health centers in Norway 2015-2018. Aspects of food and nutrition are central to public health nurses' counseling at the child health center, and they experience challenges when counseling on these themes. This article offers an approach to handling the complexity of public health nursing interventions on counseling among families. The topics presented on planning and performing an intervention and the related challenges might have relevance for public health nursing in several countries.

Perceived Parental Attitudes Are Indirectly Associated with Consumption of Junk Foods and Sugar-Sweetened Beverages among Chinese Adolescents through Home Food Environment and Autonomous Motivation: A Path Analysis

This study aimed to use path analysis to determine the association between perceived parental attitudes toward restricting junk food (JF)/sugar-sweetened beverage (SSB) intake and JF/SSB consumption among Chinese adolescents, and whether JF/SSB availability in the home environment and autonomous motivation of adolescents mediated the association. A cross-sectional survey was conducted using questionnaires adapted from the Family Life, Activity, Sun, Health, and Eating (FLASHE) Study to collect data on 3819 participants with an average age of 14.7 years (SD = 1.7). Spearman correlations and path analysis were performed. It was found that perceived parental attitudes were not directly associated with adolescents’ JF/SSB consumption frequency, but indirectly related to them through JF/SSB availability in the home environment and autonomous motivation of adolescents. When parents held a less positive attitude toward JF/SSB consumption and kept less JFs/SSBs at home, youth displayed more autonomous motivation for restricting JF/SSB intake and consumed fewer JFs/SSBs.

IMplementation and evaluation of the school-based family support PRogram a Healthy School Start to promote child health and prevent OVErweight and obesity (IMPROVE) - study protocol for a cluster-randomized trial

Background

IMPROVE aims to conduct a hybrid type 3 evaluation design to test the effectiveness of bundled implementation strategies on intervention fidelity of the Healthy School Start (HSS) program, while simultaneously monitoring effects on health outcomes of children and parents. The HSS is a 4-component family support program for children starting school (5–7 years of age) promoting healthy dietary habits and physical activity in the home environment to prevent childhood obesity and parents’ risk of developing type 2 diabetes.

Methods

IMPROVE is a cluster-randomized controlled trial with two arms to evaluate and compare the effects of two different bundles of implementation strategies on intervention fidelity expressed as adherence and responsiveness at 12 and 24 months (primary outcomes). Thirty schools in two municipalities will participate in the study reaching about 1400 families per school year. In stakeholder workshops, key implementation determinants were identified according to the domains of the Consolidated Framework for Implementation Research. Through a consensus process with stakeholders, two bundles of implementation strategies were tailored to address context-specific determinants. Schools randomly assigned to group 1 will receive bundle 1 (Basic) and group 2 will receive bundle 1 + 2 (Enhanced). Bundle 2 consists of external facilitation, fidelity monitoring and feedback strategies. Secondary outcomes will include change in acceptability, appropriateness, feasibility, and organisational readiness as perceived by school staff. In addition, child weight status and diet, and parents’ feeding practices and risk of type 2 diabetes will be monitored. Linear and ordinal regression analysis will be used to test the effect on the primary and secondary outcomes, taking clustering and covariates into consideration where needed. Process evaluation will be conducted through key stakeholder interviews to investigate experiences of the program and perceptions on sustainability.

Discussion

This systematic approach to investigating the effectiveness of two different bundles of implementation strategies tailored to context-specific determinants on the fidelity of the HSS intervention will provide new insight into feasible implementation strategies and external support needed for the HSS to be effective and sustainable. Results will help inform how to bridge the gap between the research on school-based health programs and routine practice in schools.

Trial registration

Registered prospectively at ClinicalTrials.gov ID: NCT04984421, registered July 30, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11663-2.

The Families and Schools for Health Project: A Longitudinal Cluster Randomized Controlled Trial Targeting Children with Overweight and Obesity

This cluster randomized controlled trial aimed at overweight and obese children compared three treatments. Two psychoeducation interventions for parents and children were conducted: Family Lifestyle (FL) focused on food and physical activity; Family Dynamics (FD) added parenting and healthy emotion management. A third Peer Group (PG) intervention taught social acceptance to children. Crossing interventions yielded four conditions: FL, FL + PG, FL + FD, and FL + FD + PG-compared with the control. Longitudinal BMI data were collected to determine if family- and peer-based psychosocial components enhanced the Family Lifestyle approach. Participants were 1st graders with BMI%ile >75 (n = 538: 278 boys, 260 girls). Schools were randomly assigned to condition after stratifying for community size and percent American Indian. Anthropometric data were collected pre- and post-intervention in 1st grade and annually through 4th grade. Using a two-level random intercept growth model, intervention status predicted differences in growth in BMI or BMI-M% over three years. Children with obesity who received the FL + FD + PG intervention had lower BMI gains compared to controls for both raw BMI (B = -0.05) and BMI-M% (B = -2.36). Interventions to simultaneously improve parent, child, and peer-group behaviors related to physical and socioemotional health offer promise for long-term positive impact on child obesity.

Managing Implementation of a Parental Support Programme for Obesity Prevention in the School Context: The Importance of Creating Commitment in an Overburdened Work Situation, a Qualitative Study

Health-related behaviours in children can be influenced by parental support programmes. The aim of this study was to explore barriers to and facilitators for the implementation of a parental support programme to promote physical activity and healthy dietary habits in a school context. We explored the views and experiences of 17 coordinating school nurses, non-coordinating school nurses, and school principals. We based the interview guide on the Consolidated Framework for Implementation Research. We held four focus group discussions with coordinating and non-coordinating school nurses, and conducted three individual interviews with school principals. We analysed data inductively using qualitative content analysis. We identified "Creating commitment in an overburdened work situation" as an overarching theme, emphasising the high workload in schools and the importance of creating commitment, by giving support to and including staff in the implementation process. We also identified barriers to and facilitators of implementation within four categories: (1) community and organisational factors, (2) a matter of priority, (3) implementation support, and (4) implementation process. When implementing a parental support programme to promote physical activity and healthy dietary habits for 5- to 7-year-old children in the school context, it is important to create commitment among school staff and school nurses. The implementation can be facilitated by political support and additional funding, external guidance, use of pre-existing resources, integration of the programme into school routines, a clearly structured manual, and appointment of a multidisciplinary team. The results of this study should provide useful guidance for the implementation of similar health promotion interventions in the school context.

Lessons From the Feasibility Testing of a Parent-Focused, Life Skills-Based Intervention to Prevent Obesity in Preschoolers From Underserved Families

This article describes lessons from the feasibility testing of a parent-focused, life skills-based intervention to promote healthy weight in 58 low-income children aged 2 to 5 years. This intervention was feasible and acceptable, with a potential to impact child weight and diet (calories) and parental quality of life (QOL). The group delivery approach through a partnering organization (Head Start) was a more efficient way to reach/engage parents. Compared with one-on-one sessions, the group could provide an avenue to enhance parental psychosocial well-being, given QOL improvements among parents in group sessions. Lessons will inform future research to test the effectiveness of life skills interventions.

Involving Parents in Promoting Healthy Energy Balance-Related Behaviors in Preschoolers: A Mixed Methods Impact and Process Evaluation of SuperFIT

Parental involvement is an essential component of obesity prevention interventions for children. The present study provides a process and impact evaluation of the family component of SuperFIT. SuperFIT is a comprehensive, integrated intervention approach aiming to improve energy balance-related behaviors (EBRBs) of young children (2-4 years). A mixed methods design combined in-depth interviews with parents (n = 15) and implementers (n = 3) with questionnaire data on nutritional and physical activity-related parenting practices (CFPQ and PPAPP), the physical home environment (EPAO_SR) (n = 41), and intervention appreciation (n = 19). Results were structured using the concepts of reach, adoption, implementation, and perceived impact. Findings indicated that the families reached were mostly those that were already interested in the topic. Participants of the intervention appreciated the information received and the on-the-spot guidance on their child's behavior. Having fun was considered a success factor within the intervention. Parents expressed the additional need for peer-to-peer discussion. SuperFIT increased awareness and understanding of parents' own behavior. Parents made no changes in daily life routines or the physical home environment. Translating knowledge and learned strategies into behavior at home has yet to be achieved. To optimize impact, intervention developers should find the right balance between accessibility, content, and intensity of interventions for parents.

Child Health Behaviour and Parent Priorities for a School-Based Healthy Lifestyle Programme

OBJECTIVE

The purpose of this study was to characterise parents' concerns for their children's health behaviours and perceptions of motivators and barriers to positive child health behaviour change, and to determine associations between motivators and barriers and parents' priorities for a school-based healthy lifestyle programme.

DESIGN

Cross-sectional study of 46 parents who had completed an un-validated survey distributed during school-wide events.

SETTING

School for children aged 5-14 years in The Bronx, New York City, USA.

METHODS

Wilcoxon Rank Sum tests compared motivators and barriers to positive child health behaviour change by heath behaviour concern; Spearman's correlation measured associations between motivators and barriers and programme priorities.

RESULTS

Parents concerned about child weight significantly ranked keeping up with others and decreasing clothing size as motivators, while parents concerned about child food choices significantly ranked improving food choices and decreasing BMI and clothing size as motivators. Food-, play-, and self-esteem-related motivators were associated with nutrition education (r_s ≥ .41, p ≤ .01), physical activity classes (r_s ≥ .29, p ≤ .04) and child involvement in programme decision-making (r_s ≥ .43, p ≤ .01) priorities. Consistency-, child resistance-, and home rules-related barriers were associated with nutrition education (r_s ≥ .37, p=.02), physical activity classes (r_s ≥ .32, p = .02), and child involvement (r_s ≥ .40, p ≤ .02) priorities.

CONCLUSIONS

Despite the study sample size, selection bias, and generalisability limitations, prioritising nutrition, physical activity and child involvement in programme decision-making may enhance parent support for school-based healthy lifestyle programmes.

Predicting Family and Child Physical Activity across Six-Months of a Family-Based Intervention: An Application of Theory of Planned Behaviour, Planning and Habit

Family-based physical activity (PA) interventions have proven effective in modifying PA; yet, the underlying mechanisms are currently unclear. In this study, we follow-up upon prior trial data that showed changes to child moderate-to-vigorous PA (MVPA) as a result of a family education+planning intervention compared to an education-only condition. We examined parents' perceived family PA frequency, family PA social cognitions, and family PA habit over 26 weeks between the two conditions. One hundred and two parents (of children aged 6 to 12 yrs), were recruited through advertisements and randomized to either the planning + education condition (n = 52) or an education-only condition (n = 50). Self-reported family PA, and measures of theory of planned behaviour, planning intention, and habit were completed by the contact parent at baseline, six-week, 13-week, and 26-week time-periods. The education+planning intervention increased planning intention (p <.01) and family PA (p =.06) compared to the© education-only group. The effect of condition on the putative mediators did not explain these changes (all 95% CIs crossed 0), and family PA was associated with child MVPA only at 13 weeks (p <.01). Intervention 20 assignment had a small indirect effect on family PA (favouring©the education+planning group) via Habit. Perceived behavioural©control and habit were consistent predictors of family PA (p <.05), but not PA intention or planning intention (p >.05). The planning+education intervention showed improved family PA and planning intention, yet null mediation results suggest that other variables from the family system (e.g., child motivation, other parent's motivation and plans) are likely needed to fully understand the intervention effects. The promotion of perceived behavioural control and habit to assist in family PA is recommended for future research in this population.

Primary prevention of overweight and obesity in adolescents: An overview of systematic reviews

The aim of this overview of systematic reviews was to summarize evidence from up-to-date reviews of the effectiveness of interventions aimed at preventing overweight and obesity in adolescents aged 10 to 19 years. We searched nine databases for systematic reviews published between January 2008 and November 2019. We used A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 to assess the quality of reviews, excluding those of critically low quality, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to grade the certainty of included evidence. We included 13 reviews. Three reviews focused on dietary behaviour, six on physical activity, and four on both types of behaviours. Individual-oriented and school-based interventions dominated. Results across reviews showed little or no effect on body mass index, or physical activity levels of adolescents, whereas results from a couple of reviews suggest possibly beneficial effects of public health interventions on dietary behaviours (i.e., consumption of sugar-sweetened beverages). The certainty of evidence was low to very low for all outcomes. Overall, the evidence base for the effect of primary interventions to prevent overweight and obesity in adolescents is weak. In particular, there is a lack of reviews assessing the impact of environmental interventions targeting adolescents, and reviews addressing social inequality are virtually absent from this body of literature.

Parenting support to prevent overweight during regular well-child visits in 0-3 year old children (BBOFT+ program), a cluster randomized trial on the effectiveness on child BMI and health behaviors and parenting

Background

Prevention of overweight during early childhood seems promising.

Objective

To evaluate the effectiveness of the parenting-based BBOFT+ overweight prevention program on child BMI, child health behavior and parenting behavior among 0–36 month old children. BBOFT+ is an acronym for the key healthy lifestyle behaviors that are targeted in the BBOFT+ intervention: breastfeeding (B), daily breakfast (B), daily going outdoors (O), limiting sweet beverages (in Dutch, F) and minimal TV or computer time (T), complemented with healthy sleep behavior and improvement of parenting skills (+).

Methods

A cluster randomized controlled trial in newborn children visiting well-baby clinics, comparing the BBOFT+ intervention (N = 901) with care as usual (CAU) (N = 1094). In both groups, parents received regular well-child visits (±11 visits in the first 3 years). In the intervention group, care was supplemented with the BBOFT+ program, which focuses on improving parenting skills from birth onwards to increase healthy behavior. Questionnaires were filled in at child's age 2–4 weeks, 6, 14 and 36 months. In multivariate analyses we corrected for child’s birthweight, age, ethnic background, mother’s educational level and BMI.

Results

No differences were found in weight status at 36 months between intervention and control group children. At 6 months, BBOFT+ parents reported their child drinking less sweet beverages than control parents (48% vs 54%;p = .027), and going outdoors daily with their child less often (57% vs 62%;p = .03). At 14 months, more BBOFT+ parents than control parents reported to have breastfed for six months or longer (32% vs 29%;p = .022). At 36 months, more BBOFT+ parents than control parents reported their child going outside daily (78% vs 72%;p = .011) and having less TV/computer time on week- (38% vs 46%;p = .001) and weekend days (48% vs 56%;p = .002). Also, BBOFT+ parents reported having more parental control than control parents (3.92 vs 3.89;p = .02). No significant differences were found for daily breakfast, sleep duration and parenting practices in adjusted analyses.

Conclusion

The BBOFT+ overweight prevention program showed small improvements in parent-reported child health behaviors, compared to care as usual; no effect was observed on child BMI. The identified modifiable elements are potentially relevant for interventions that aim to prevent overweight.

A Media Literacy-Based Nutrition Program Fosters Parent-Child Food Marketing Discussions, Improves Home Food Environment, and Youth Consumption of Fruits and Vegetables

Background: Media use is a known contributor to childhood obesity, but encouraging reductions in screen use only partially eliminates media influence. We tested a family-centered, media literacy-oriented intervention to empower parents and children 9-14 years to skillfully use media to reduce marketing influences, enhance nutrition knowledge, improve the selection of foods in the home environment, and improve fruit and vegetable consumption. Methods: A community-based, 6-U program included separate parent and youth (ages 9-14 years) sessions, each of which was followed by a session together in which skills from the individual sessions were reinforced. A pretest to posttest field test with control groups (N = 189, parent-child dyads) tested the intervention's efficacy. Results: Standardized mean differences from the multiple analysis of covariance tests showed that the intervention group demonstrated improvements on parents' use of nutrition labels (0.29), the ratio of healthy to unhealthy food in the home environment (0.25), youth's fruit (0.30) and vegetable (0.25) consumption, parent and youth media literacy skills, and family communication dynamics about food. The largest effects found were for negative parental mediation (0.48) and parents' report of child-initiated discussion (0.47). Consistent but weaker results were revealed for Latinx families. Conclusions: This family-centered approach helped family members practice using media together to make better nutrition decisions without depending on the ability of parents to limit media use. It successfully addressed the often-negative impact of the media on behaviors that increase obesity risk while also cultivating the potential for media to provide useful information that can lead to behaviors that decrease obesity risk.

Effectiveness of Interventions to Promote Healthy Eating Habits in Children and Adolescents at Risk of Poverty: Systematic Review and Meta-Analysis

The objective of this review was to provide an up-to-date review of trials that include behavioral intervention on the eating habits of children and adolescents at risk of poverty, applying meta-analysis to estimate the size of the intervention effect. A systematic literature search was performed in the following databases: MEDLINE via Pubmed and via EBSCOhost, LILACS and IBECS via VHL. The MeSH terms were used: "social class", "poverty", "diet", "health promotion" (PROSPERO ID: 183900). A total of 14 articles were finally included in this systematic review. The primary results of the included studies were meta-analyzed with the RevMan 5.3 program, assuming a random effects model. Analysis of the overall effect showed combined standardized mean differences (SMD) of 0.16 (CI 95%: [0.03, 0.30], I² = 76%). The p-value for the Z statistic was 0.02, which reflects accuracy in the effect estimation. When establishing subgroups based on the intervention tracking time points, studies that provided longer-term follow-up data showed a combined SMD of 0.15 (CI 95%: [-0.02, 0.32], I² = 81%]). Small effects of behavioral interventions were found to promote healthy eating habits, but better effects were shown in cases where the invention was followed up in the long term.

Development of a consensus statement on the role of the family in the physical activity, sedentary, and sleep behaviours of children and youth

BACKGROUND

Children and youth who meet the physical activity, sedentary, and sleep behaviour recommendations in the Canadian 24-Hour Movement Guidelines are more likely to have desirable physical and psychosocial health outcomes. Yet, few children and youth actually meet the recommendations. The family is a key source of influence that can affect lifestyle behaviours. The purpose of this paper is to describe the process used to develop the Consensus Statement on the Role of the Family in the Physical Activity, Sedentary, and Sleep Behaviours of Children and Youth (0-17 years) and present, explain, substantiate, and discuss the final Consensus Statement.

METHODS

The development of the Consensus Statement included the establishment of a multidisciplinary Expert Panel, completion of six reviews (three literature, two scoping, one systematic review of reviews), custom data analyses of Statistics Canada's Canadian Health Measures Survey, integration of related research identified by Expert Panel members, a stakeholder consultation, establishment of consensus, and the development of a media, public relations, communications and launch plan.

RESULTS

Evidence from the literature reviews provided substantial support for the importance of family on children's movement behaviours and highlighted the importance of inclusion of the entire family system as a source of influence and promotion of healthy child and youth movement behaviours. The Expert Panel incorporated the collective evidence from all reviews, the custom analyses, other related research identified, and stakeholder survey feedback, to develop a conceptual model and arrive at the Consensus Statement: Families can support children and youth in achieving healthy physical activity, sedentary and sleep behaviours by encouraging, facilitating, modelling, setting expectations and engaging in healthy movement behaviours with them. Other sources of influence are important (e.g., child care, school, health care, community, governments) and can support families in this pursuit.

CONCLUSION

Family is important for the support and promotion of healthy movement behaviours of children and youth. This Consensus Statement serves as a comprehensive, credible, and current synopsis of related evidence, recommendations, and resources for multiple stakeholders.

Snack food consumption among Bangladeshi children, supplementary data from a large RCT

Childhood obesity has been associated with consumption of energy-dense foods such as caloric beverages and fast foods. Many low- and middle-income countries like Bangladesh are now experiencing a rising problem of noncommunicable diseases along with the long-standing problem of stunting and undernutrition. WASH Benefits Bangladesh was a large community-based cluster randomized controlled trial conducted in rural Bangladesh. Study clusters were randomized into seven arms: single nutrition (N); water (W); sanitation (S); hygiene (H); combined water, sanitation, and hygiene (WSH); WSH and nutrition (N + WSH); and a double sized control (C). Nutrition intervention messages included four promotional components: maternal nutrition, breastfeeding, complementary feeding, and lipid-based nutrient supplements. The World Health Organization infant food frequency questionnaire (24-hr recall and 7-day recall) was administered at Year 1 and Year 2 of intervention. The likelihood of any snack food consumption was significantly lower (odds ratio 0.37: 95% confidence interval [0.28, 0.49]) in the nutrition intervention arms compared to the control arm in Year 2 follow-up. In addition, in the water intervention arm, fewer children (about 50% less) consumed soft drinks, but not the other sugar-sweetened beverages, compared with control in Year 2. There were no other differences between groups. Simple messages about balanced diet and feeding family foods were effective in lowering commercially produced snack food consumption of the young children in low-income rural communities of Bangladesh. Provision of safe water apparently encouraged mothers to reduce offering unhealthy beverages to the young children.

Socioeconomic inequalities and the equity impact of population-level interventions for adolescent health: an overview of systematic reviews

OBJECTIVES

Despite robust evidence on health inequalities in adulthood, less attention has been paid to inequalities in adolescence. The aim of this overview was to examine systematic review (SR) evidence on the equity impact of population-level interventions intended to improve health, happiness and wellbeing for adolescents.

STUDY DESIGN

An overview (review of systematic reviews).

METHODS

Eleven electronic databases were systematically searched to identify SRs of population-level interventions for adolescent health. A secondary data analysis of socioeconomic inequality was conducted to identify whether SRs reported on primary studies in terms of disadvantage, by measures of socioeconomic status (SES) and by differential effects.

RESULTS

35,310 review titles were screened; 566 full texts were retrieved and 140 SRs met the predefined selection criteria. Differential intervention effects were considered in 42/140 (30%) SRs, 18/140 (13%) reported primary studies using an SES measure and 16/140 (11%) explicitly reported differential effects. 15/140 SRs (11%) explicitly focused on socioeconomic inequalities; of these 4/15 reported differential intervention effects in more detail, 7/15 concluded there was insufficient primary evidence to identify the impact of interventions on socioeconomic inequalities and 4/15 planned to examine differential effects by SES, but this was not reported further.

CONCLUSIONS

Our overview identifies that there is limited SR evidence on the equity impact of population-level interventions for adolescent health. Strengthening the evidence on whether interventions narrow or widen inequalities for adolescents must be a priority for public health research.

Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors

BACKGROUND

Poor diet and insufficient physical activity are major risk factors for non-communicable diseases. Developing healthy diet and physical activity behaviors early in life is important as these behaviors track between childhood and adulthood. Parents and other adult caregivers have important influences on children's health behaviors, but whether their involvement in children's nutrition and physical activity interventions contributes to intervention effectiveness is not known.

OBJECTIVES

• To assess effects of caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors, including those intended to prevent overweight and obesity • To describe intervention content and behavior change techniques employed, drawing from a behavior change technique taxonomy developed and advanced by Abraham, Michie, and colleagues (Abraham 2008; Michie 2011; Michie 2013; Michie 2015) • To identify content and techniques related to reported outcomes when such information was reported in included studies SEARCH METHODS: In January 2019, we searched CENTRAL, MEDLINE, Embase, 11 other databases, and three trials registers. We also searched the references lists of relevant reports and systematic reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs evaluating the effects of interventions to improve children's dietary intake or physical activity behavior, or both, with children aged 2 to 18 years as active participants and at least one component involving caregivers versus the same interventions but without the caregiver component(s). We excluded interventions meant as treatment or targeting children with pre-existing conditions, as well as caregiver-child units residing in orphanages and school hostel environments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures outlined by Cochrane.

MAIN RESULTS

We included 23 trials with approximately 12,192 children in eligible intervention arms. With the exception of two studies, all were conducted in high-income countries, with more than half performed in North America. Most studies were school-based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The specific intervention strategies used were not always reported completely. However, based on available reports, the behavior change techniques used most commonly in the child-only arm were "shaping knowledge," "comparison of behavior," "feedback and monitoring," and "repetition and substitution." In the child + caregiver arm, the strategies used most commonly included additional "shaping knowledge" or "feedback and monitoring" techniques, as well as "social support" and "natural consequences." We considered all trials to be at high risk of bias for at least one design factor. Seven trials did not contribute any data to analyses. The quality of reporting of intervention content varied between studies, and there was limited scope for meta-analysis. Both validated and non-validated instruments were used to measure outcomes of interest. Outcomes measured and reported differed between studies, with 16 studies contributing data to the meta-analyses. About three-quarters of studies reported their funding sources; no studies reported industry funding. We assessed the quality of evidence to be low or very low. Dietary behavior change interventions with a caregiver component versus interventions without a caregiver component Seven studies compared dietary behavior change interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (mean difference [MD] -0.42%, 95% confidence interval [CI] -1.25 to 0.41, 1 study, n = 207; low-quality evidence) or from sodium intake (MD -0.12 g/d, 95% CI -0.36 to 0.12, 1 study, n = 207; low-quality evidence). No trial in this comparison reported data for children's combined fruit and vegetable intake, sugar-sweetened beverage (SSB) intake, or physical activity levels, nor for adverse effects of interventions. Physical activity interventions with a caregiver component versus interventions without a caregiver component Six studies compared physical activity interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's total physical activity (MD 0.20 min/h, 95% CI -1.19 to 1.59, 1 study, n = 54; low-quality evidence) or moderate to vigorous physical activity (MVPA) (standard mean difference [SMD] 0.04, 95% CI -0.41 to 0.49, 2 studies, n = 80; moderate-quality evidence). No trial in this comparison reported data for percentage of children's total energy intake from saturated fat, sodium intake, fruit and vegetable intake, or SSB intake, nor for adverse effects of interventions. Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component Ten studies compared dietary and physical activity interventions with and without a caregiver component. At the end of the intervention, we detected a small positive impact of a caregiver component on children's SSB intake (SMD -0.28, 95% CI -0.44 to -0.12, 3 studies, n = 651; moderate-quality evidence). We did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (MD 0.06%, 95% CI -0.67 to 0.80, 2 studies, n = 216; very low-quality evidence), sodium intake (MD 35.94 mg/d, 95% CI -322.60 to 394.47, 2 studies, n = 315; very low-quality evidence), fruit and vegetable intake (MD 0.38 servings/d, 95% CI -0.51 to 1.27, 1 study, n = 134; very low-quality evidence), total physical activity (MD 1.81 min/d, 95% CI -15.18 to 18.80, 2 studies, n = 573; low-quality evidence), or MVPA (MD -0.05 min/d, 95% CI -18.57 to 18.47, 1 study, n = 622; very low-quality evidence). One trial indicated that no adverse events were reported by study participants but did not provide data.

AUTHORS' CONCLUSIONS

Current evidence is insufficient to support the inclusion of caregiver involvement in interventions to improve children's dietary intake or physical activity behavior, or both. For most outcomes, the quality of the evidence is adversely impacted by the small number of studies with available data, limited effective sample sizes, risk of bias, and imprecision. To establish the value of caregiver involvement, additional studies measuring clinically important outcomes using valid and reliable measures, employing appropriate design and power, and following established reporting guidelines are needed, as is evidence on how such interventions might contribute to health equity.

Impact of Parent Engagement in Childhood Obesity Prevention Interventions on Anthropometric Indices among Preschool Children: A Systematic Review

Background: Home environment, modeling of weight-related behaviors, and general parenting style are very important predictors of obesity in children. The effect of parent engagement in prevention of obesity in children is not clear. The main objective of this systematic review was to address the effects of parent engagement in obesity prevention interventions on anthropometric changes among preschool children. Methods: PubMed/Medline, Cochrane Library, ISI Web of Knowledge, Scopus, Science Direct, and Google Scholar were searched. Eligible studies were randomized controlled trials in last 10 years (from 2008 until February 14, 2018), which had a parent engagement in obesity prevention interventions (as an intervention) and children's anthropometric indices (as an outcome). Results: Twenty-six studies were included. Half of studies targeted both parents and children, and the rest targeted only parents. Types of interventions ranged from a simple motivational interviewing to professional skill training approaches. Studies that targeted overweight or obese children in their intervention containing training sessions followed by maintenance for parents and those that focused on individual support for overweight children and their parents, resulted in higher improvement in BMI and other outcomes. Conclusions: Anthropometric indices and BMI are not appropriate for reflecting the effectiveness of parent engagement in obesity prevention interventions. Having an individual component in the intervention and focusing more on parents vs. children in the intervention may result in improvement in anthropometric outcomes. Focusing on weight-related behaviors as the main outcome in both, children and parents, rather than anthropometric indices, is highly recommended for future reviews.

Systematic review of interventions in the childcare setting with direct parental involvement: effectiveness on child weight status and energy balance-related behaviours

BACKGROUND

The early years are a crucial period to promote healthy energy balance-related behaviours in children and prevent overweight and obesity. The childcare setting is important for health-promoting interventions. Increasingly, attention has been paid to parental involvement in childcare-based interventions. The aim of this systematic review is to evaluate the effectiveness of these interventions with direct parental involvement on the children's weight status and behavioural outcomes.

METHODS

A systematic search was conducted in four electronic databases to include studies up until January 2019. Studies written in English, describing results on relevant outcomes (weight status, physical activity, sedentary behaviour and/or nutrition-related behaviour) of childcare-based interventions with direct parental involvement were included. Studies not adopting a pre-post-test design or reporting on pilot studies were excluded. To improve comparability, effect sizes (Cohen's d) were calculated. Information on different types of environment targeted (e.g., social, physical, political and economic) was extracted in order to narratively examine potential working principles of effective interventions.

RESULTS

A total of 22 studies, describing 17 different interventions, were included. With regard to the intervention group, 61.1% found some favourable results on weight status, 73.3% on physical activity, 88.9% on sedentary behaviour, and all on nutrition-related behaviour. There were studies that also showed unfavourable results. Only a small number of studies was able to show significant differences between the intervention and control group (22.2% weight status, 60.0% physical activity, 66.6% sedentary behaviour, 76.9% nutrition behaviour). Effect sizes, if available, were predominantly small to moderate, with some exceptions with large effect sizes. The interventions predominantly targeted the socio-cultural and physical environments in both the childcare and home settings. Including changes in the political environment in the intervention and a higher level of intensity of parental involvement appeared to positively impact intervention effectiveness.

CONCLUSION

Childcare-based interventions with direct parental involvement show promising effects on the children's energy balance-related behaviours. However, evidence on effectiveness is limited, particularly for weight-related outcomes. Better understanding of how to reach and involve parents may be essential for strengthening intervention effectiveness.

School-based obesity prevention for busy low-income families-Organisational and personal barriers and facilitators to implementation

BACKGROUND

Little research has targeted multiple-level barriers and facilitators in school-based parental support programmes. This qualitative study aims to describe barriers and facilitators, at organisational and personal levels, that teachers and parents in disadvantaged settings in Sweden perceived as influencing the implementation of the Healthy School Start II (HSS II) intervention.

METHODS

Data collection, analysis and interpretation were guided by the Consolidated Framework for Implementation Research (CFIR). Focus groups and interviews were conducted with 14 parents and ten teachers within the HSS II trial. Data were analysed using qualitative content analysis in a deductive step using the three CFIR domains-inner and outer setting, and personal characteristics-followed by an inductive analysis.

RESULTS

The theme 'being on the same page-getting burdened teachers and parents to work on common ground' was found. Among teachers, barriers and facilitators were related to the structure of the schoolwork and curriculum, involvement from other staff and school management, the practical school workday, perception of high family needs but low parental interest, insufficient resources in the families, and teacher's personal knowledge, interests, and opinions about health and food. For parents, barriers and facilitators were related to the perceived family needs and resources, parents' health knowledge, consensus about healthy behaviours and ability to cooperate, and school involvement in health issues and the intervention.

CONCLUSION

Interventions should facilitate parents' and teachers' work on common ground, with activities suitable for a stressful and burdensome workday and everyday life. This could be achieved by integrating evidence-based practices within school routines, and including activities that are practicable despite parents' stressful lives, and that increase parental consensus about promoting health. Strategies to increase involvement of parents in families with high needs are necessary. Also, this study suggests an expansion of the CFIR to capture the interface between different micro-level organisations, and account for several delivering/receiving organisations.

Nurse-Led Telephone Follow-Up to Improve Parent Promotion of Healthy Behaviors in Young Children With Motivational Interviewing Techniques

INTRODUCTION

The American Academy of Pediatrics (AAP) recommends primary care-based health promotion for obesity prevention at all visits, focusing on nutrition and activity.

METHODS

In this quality improvement project, a primary care innovation was developed to support parents in promoting healthy habits in their children ages 2 to 5 years old. Nurse-led telephone support using motivational interviewing was implemented during two follow-up phone calls aimed at helping parent-child dyads reach self-created activity or nutrition goals.

RESULTS

Parent-rated confidence and motivation related to meeting these goals showed significant increases. During the second call, 80% self-reported goal completion and high satisfaction with the visits. Registered nurses reported a significant increase in their self-efficacy of communication with parents.

DISCUSSION

This project showed the feasibility of using nurse telephone visits in an urban low-income primary care setting to improve parental recognition and understanding of healthy habits that align with American Academy of Pediatrics recommendations for obesity prevention.

Parental Perceived Facilitators for and Barriers to Participating in a Lifestyle Intervention to Reduce Early Childhood Obesity: A Qualitative Evaluation

This study aimed to examine low-income mothers' perceived facilitators for and barriers to participating in a lifestyle intervention. A phenomenography approach was used to individually interview 14 mothers from Midwestern U.S. The data were analyzed using content analysis. Drawing on the socio-ecological model, mothers' perceived facilitators included (a) intrapersonal factors including providing helpful information, being accommodating, motivating, and novel; (b) interpersonal factors, including two-way communication between mothers and preschoolers, social connectedness among mothers, and a positive relationship between mothers and researchers; and (c) environmental factors, including kid-friendly, and pleasant and comfortable intervention sites. Mothers' reported barriers were intrapersonal factors including (a) use of technology due to unreliable Wi-Fi access and unfamiliarity of electronic device, (b) being "busy moms" due to busy schedules and stressful daily lives, and (c) lack of reliable transportation. Future interventions to reduce early childhood obesity among low-income families should consider these identified facilitators and barriers.

Parental support in promoting children's health behaviours and preventing overweight and obesity - a long-term follow-up of the cluster-randomised healthy school start study II trial

BACKGROUND

Effects of obesity prevention interventions in early childhood are only meaningful if they are sustained over time, but long-term follow-up studies are rare. The school-based cluster-randomised Healthy School Start (HSS) trial aimed at child health promotion and obesity prevention through parental support was carried out in 31 pre-school classes (378 families) in disadvantaged areas in Sweden during 2012-2013. Post-intervention results showed intervention effects on intake of unhealthy foods and drinks, and lower BMI-sds in children with obesity at baseline. This study aimed to evaluate the long-term effectiveness 4 years post-intervention.

METHODS

Data were collected from 215 children in March-June 2017. Child dietary intake, screen time, and physical activity were measured through parental-proxy questionnaires. Child height and weight were measured by the research group. Group effects were examined using Poisson, linear, logistic, and quantile regression for data on different levels. Analyses were done by intention to treat, per protocol, and sensitivity analyses using multiple imputation.

RESULTS

No between-group effects on dietary intake, screen time, physical activity, or BMI-sds were found for the entire group at the four-year follow-up. In girls, a significant subgroup-effect was found favouring intervention compared to controls with a lower intake of unhealthy foods, but this was not sustained in the sensitivity analysis. In boys, a significant sub-group effect was found where the boys in the intervention group beyond the 95th percentile had significantly higher BMI-sds compared to boys in the control group. This effect was sustained in the sensitivity analysis. Analyses per protocol showed significant intervention effects regarding a lower intake of unhealthy foods and drinks in the children with a high intervention dose compared to controls.

CONCLUSIONS

Four years after the intervention, only sub-group effects were found, and it is unlikely that the HSS intervention had clinically meaningful effects on the children. These results suggest that school-based prevention programmes need to be extended for greater long-term effectiveness by e.g. integration into school routine practice. In addition, results showed that children with a high intervention dose had better long-term outcomes compared to controls, which emphasises the need for further work to increase family engagement in interventions.

TRIAL REGISTRATION

ISRCTN, ISRCTN39690370, retrospectively registered March 1, 2013, http://www.isrctn.com/ISRCTN39690370 .

Conceptualizing Family Influences on Children's Energy Balance-Related Behaviors: Levels of Interacting Family Environmental Subsystems (The LIFES Framework)

Healthy or unhealthy behavioral patterns develop and are maintained in a family context. The importance of the family environment for children’s and adolescents’ energy balance-related behaviors (EBRBs) has been shown previously. However, the way different family environmental factors are interrelated and interact with personal factors (e.g., motivation) are not well understood. Furthermore, the majority of studies have focused on the parent-child subsystem. However, there are family-level socialization dynamics that affect the development of a healthy lifestyle beyond the impact of parenting behaviors. The current paper aims to synthesize theoretical and empirical literature on different types of family influences. The Levels of Interacting Family Environmental Subsystems (LIFES) framework incorporates family influences on three levels (immediate, proximal, distal) and of three subsystems (individual, parent-child, family), relates them to each other and postulates potential paths of influence on children’s EBRBs. Several studies examining specific sections of the framework provide empirical support for LIFES’ propositions. Future studies should place their research in the context of the interrelationship of different family environmental influences. A better understanding of the interrelated influences would enhance the understanding of the development and maintenance of overweight and obesity among children and is crucial for the development of effective interventions.

Guelph Family Health Study’s Home-Based Obesity Prevention Intervention Increases Fibre and Fruit Intake in Preschool-Aged Children

Purpose: The Guelph Family Health Study (GFHS) pilot was designed to examine the feasibility and effectiveness of a home-based obesity prevention intervention on health behaviours and obesity risk. The objective of this analysis was to determine the effect of the 6-month intervention on preschool-aged children’s dietary intakes.

Methods: Families with children aged 1.5–5 years old were randomized to receive one of the following: 4 home visits with a health educator as well as tailored emails and mailed incentives (4HV; n = 19 children); 2 home visits with a health educator as well as tailored emails and mailed incentives (2HV; n = 14 children); or general health advice through emails (control; n = 12 children). Three-day food records were completed by parents for their children before and after the 6-month intervention and analyzed for 3-day average intakes of energy, nutrients, and MyPlate food groups.

Results: After the 6-month intervention, the 4HV group had significantly higher fibre intake and the 4HV and 2HV groups had significantly higher fruit intake, both compared with the control group.

Conclusions: This study provides support for a home-based intervention approach to improve the diet quality of preschool-aged children.

Interventions to improve physical activity among socioeconomically disadvantaged groups: an umbrella review

Background

People from socioeconomically disadvantaged population groups are less likely to be physically active and more likely to experience adverse health outcomes than those who are less disadvantaged. In this umbrella review we examined across all age groups, (1) the effectiveness of interventions to improve physical activity among socioeconomically disadvantaged groups, (2) the characteristics of effective interventions, and (3) directions for future research.

Methods

PubMed/MEDLINE and Scopus were searched up to May 2017 to identify systematic reviews reporting physical activity interventions in socioeconomically disadvantaged populations or sub-groups. Two authors independently conducted study screening and selection, data extraction (one author, with data checked by two others) and assessment of methodological quality using the ‘Assessment of Multiple Systematic Reviews’ scale. Results were synthesized narratively.

Results

Seventeen reviews met our inclusion criteria, with only 5 (30%) reviews being assessed as high quality. Seven (41%) reviews focused on obesity prevention and an additional four focused on multiple behavioural outcomes. For pre school children, parent-focused, group-based interventions were effective in improving physical activity. For children, school-based interventions and policies were effective; few studies focused on adolescents and those that did were generally not effective; for adults, there was mixed evidence of effectiveness but characteristics such as group-based interventions and those that focused on physical activity only were associated with effectiveness. Few studies focused on older adults. Across all ages, interventions that were more intensive tended to be more effective. Most studies reported short-term, rather than longer-term, outcomes and common methodological limitations included high probability of selection bias, low response rates, and high attrition.

Conclusions

Interventions can be successful at improving physical activity among children from socioeconomically disadvantaged groups, with evidence for other age groups weak or inconclusive. More high-quality studies in this population group are needed, which adopt strategies to increase recruitment rates and reduce attrition, report longer term outcomes, and provide adequate intervention details, to allow determination of the characteristics of effective interventions. We recommend that the benefits of physical activity be recognised more broadly than obesity prevention in future studies, as this may have implications for the design and appeal of interventions.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0676-2) contains supplementary material, which is available to authorized users.

A formative study to understand perspectives of families eligible for a pediatric obesity program: a qualitative study

Background

Raising Well^® (RW) was initiated in 2015 by Envolve PeopleCare™ at the request of health plans seeking a solution to work with families on Medicaid that have a child with overweight or obesity. RW uses expert clinical coaches via phone contact to deliver an educational intervention promoting lifestyle change to families with at least one overweight or obese child in an eligible Medicaid health plan. This gives RW significant potential for reach and population impact. This project aimed to understand how to maximize this impact by exploring perspectives of RW, using a conceptual framework informed by the Conceptual Model of Implementation Research, including assessment of the feasibility, acceptability, and appropriateness of RW; determining satisfaction among those experiencing coaching; identifying reasons individuals do not participate; and developing recommendations to enhance interest and participation.

Methods

Semi-structured interviews were conducted with 70 RW-eligible families across four states, who were described as: active participants, respondents who dropped or stopped RW, and RW non-participants. Following the interviews, the transcripts were coded inductively and deductively using a grounded theory approach, considering themes from the conceptual framework; themes also emerged from the data.

Results

From this sample, 19 families reported to be active coaching participants, 24 had dropped coaching, and 27 were RW non-participants. A number of themes were identified. Feasibility themes included coaches’ flexibility and willingness to work with the family’s schedule. Acceptability themes suggest providing actionable strategies tailored to the family’s context and needs, beyond just nutrition information and tips, early in the coaching relationship so the family perceives a benefit for continued participation. With regard to appropriateness, families were also interested in other methods of communication including email, texting, and in person visits. Access to resources for activity and healthy eating in their local community was also recommended.

Conclusions

RW has the potential to improve health and promote wellness. To enhance the impact of this program, RW could incorporate these findings to promote feasibility, acceptability, and appropriateness and improve program implementation. Strategies may include modifying the information provided or the mode of delivering the information.

Lifestyle weight management programmes for children: A systematic review using Qualitative Comparative Analysis to identify critical pathways to effectiveness

This study aimed to identify critical features of successful lifestyle weight management interventions for overweight children (0-11years). Eleven qualitative UK-based studies examining children's, parents' and providers' perspectives and experiences of programmes were synthesised to identify components felt to be critical. Studies for this views synthesis were identified from existing reviews and an update of one review's search, which was run in December 2015. The identified components were then explored in a synthesis of intervention evaluations (five 'most effective' and 15 'least effective') conducted in western Europe, North America, Australia or New Zealand. The intervention evaluations were identified from existing reviews and an update of one review's search, which was run in March 2016. This evaluation synthesis was carried out using Qualitative Comparative Analysis. Three important mechanisms were present in all the most effective interventions but absent in all the least effective: 1/ showing families how to change: a) providing child physical activity sessions, b) delivering practical behaviour change strategy sessions, c) providing calorie intake advice; 2/ ensuring all the family are on board: a) delivering discussion/education sessions for both children and parents, b) delivering child-friendly sessions, c) aiming to change behaviours across the whole family; 3/ enabling social support for both parents and children by delivering both child group sessions and parent group sessions. To conclude, programmes should ensure the whole family is on board the programme, that parents and children can receive social support and are not just told what to change, but shown how.

Use of programme theory to understand the differential effects of interventions across socio-economic groups in systematic reviews-a systematic methodology review

BACKGROUND

Systematic review guidance recommends the use of programme theory to inform considerations of if and how healthcare interventions may work differently across socio-economic status (SES) groups. This study aimed to address the lack of detail on how reviewers operationalise this in practice.

METHODS

A methodological systematic review was undertaken to assess if, how and the extent to which systematic reviewers operationalise the guidance on the use of programme theory in considerations of socio-economic inequalities in health. Multiple databases were searched from January 2013 to May 2016. Studies were included if they were systematic reviews assessing the effectiveness of an intervention and included data on SES. Two reviewers independently screened all studies, undertook quality assessment and extracted data. A narrative approach to synthesis was adopted.

RESULTS

A total of 37 systematic reviews were included, 10 of which were explicit in the use of terminology for 'programme theory'. Twenty-nine studies used programme theory to inform both their a priori assumptions and explain their review findings. Of these, 22 incorporated considerations of both what and how interventions do/do not work in SES groups to both predict and explain their review findings. Thirteen studies acknowledged 24 unique theoretical references to support their assumptions of what or how interventions may have different effects in SES groups. Most reviewers used supplementary evidence to support their considerations of differential effectiveness. The majority of authors outlined a programme theory in the "Introduction" and "Discussion" sections of the review to inform their assumptions or provide explanations of what or how interventions may result in differential effects within or across SES groups. About a third of reviews used programme theory to inform the review analysis and/or synthesis. Few authors used programme theory to inform their inclusion criteria, data extraction or quality assessment. Twenty-one studies tested their a priori programme theory.

CONCLUSIONS

The use of programme theory to inform considerations of if, what and how interventions lead to differential effects on health in different SES groups in the systematic review process is not yet widely adopted, is used implicitly, is often fragmented and is not implemented in a systematic way.

The Development and Public Health Implications of Food Preferences in Children

Food preferences are a primary determinant of dietary intake and behaviors, and they persist from early childhood into later life. As such, establishing preferences for healthy foods from a young age is a promising approach to improving diet quality, a leading contributor to cardiometabolic health. This narrative review first describes the critical period for food preference development starting in utero and continuing through early childhood. Infants’ innate aversion to sour and bitter tastes can lead them to initially reject some healthy foods such as vegetables. Infants can learn to like these foods through exposures to their flavors in utero and through breastmilk. As solid foods are introduced through toddlerhood, children’s food preferences are shaped by parent feeding practices and environmental factors such as food advertising. Next, we discuss two key focus areas to improve diet quality highlighted by the current understanding of food preferences: (1) promoting healthy food preferences through breastfeeding and early exposures to healthy foods and (2) limiting the extent to which innate preferences for sweet and salty tastes lead to poor diet quality. We use an ecological framework to summarize potential points of intervention and provide recommendations for these focus areas, such as worksite benefits that promote breastfeeding, and changes in food retail and service environments. Individuals’ choices around breastfeeding and diet may ultimately be influenced by policy and community-level factors. It is thus crucial to take a multilevel approach to establish healthy food preferences from a young age, which have the potential to translate into lifelong healthy diet.

Counselling parents on young children's healthy diet: A modified scoping review

AIMS AND OBJECTIVES

To map and describe key information in existing research about counselling of parents of children aged 0-2 years on the child's healthy diet in preventive healthcare settings, particularly in public health nursing.

BACKGROUND

Many parents are likely to be concerned with their infant's food-related happiness "here and now," disregarding the child's long-term health and development related to feeding practices. Hence, a focus on counselling parents in considering young children's healthy diet is important.

DESIGN

A modified scoping review with an inductive qualitative content analysis of selected empirical studies.

METHODS

Systematic searches in EMBASE (1996-2015 Week 46), Ovid Nursing Database (1946-2015 November Week 1), Ovid MEDLINE and Ovid OLDMEDLINE (2000-18 November 2015) and CINAHL (2000-22 December 2015), using search terms based on aims.

RESULTS

Eight included studies, with participants per sample ranging from 19->500. Research designs were focus group discussions and/or interview study (n = 2), cluster-randomised trials (n = 2), randomised controlled trials (n = 2), a follow-up interview study (n = 1) to a previous randomised controlled trial and a cross-sectional electronic questionnaire study (n = 1). The studies included a total sample of 2,025 participants, 42 of them in interview studies. Findings indicate parents' perceptions of inconsistency, misconceptions and uncertainty related to the recommendations on child feeding from the authorities. Thus, adapted advice could impact healthier child diet. Maternal knowledge on child feeding and reduced use of food as a reward are mediators for improved diet quality in children.

CONCLUSIONS

Counselling on young children's healthy diet should be anticipatory, consistent and adapted to the family.

RELEVANCE TO CLINICAL PRACTICE

Due to inconsistent recommendations and omitted focus on anticipatory counselling on child feeding, parents might perceive pressure and uncertainty related to the child's diet.

Effectiveness of a universal parental support programme to promote health behaviours and prevent overweight and obesity in 6-year-old children in disadvantaged areas, the Healthy School Start Study II, a cluster-randomised controlled trial

Background

There is increasing evidence for the effectiveness of parental support programmes to promote healthy behaviours and prevent obesity in children, but only few studies have been conducted among groups with low socio-economic status. The aim of this study was to develop and evaluate the effectiveness of a parental support programme to promote healthy dietary and physical activity habits and to prevent overweight and obesity in six-year-old children in disadvantaged areas.

Methods

A cluster-randomised controlled trial was carried out in disadvantaged areas in Stockholm. Participants were six-year-old children (n = 378) and their parents. Thirty-one school classes from 13 schools were randomly assigned to intervention (n = 16) and control groups (n = 15). The intervention lasted for 6 months and included: 1) Health information for parents, 2) Motivational Interviewing with parents and 3) Teacher-led classroom activities with children. Physical activity was measured by accelerometry, dietary intake and screen time with a questionnaire, body weight and height were measured and BMI standard deviation score was calculated. Measurements were conducted at baseline, post-intervention and at 5months follow-up. Group effects were examined using Mixed-effect Regression analyses adjusted for sex, parental education and baseline values.

Results

Fidelity to all three intervention components was satisfactory. Significant intervention effects were found regarding consumption of unhealthy foods (p = 0.01) and unhealthy drinks (p = 0.01). At follow-up, the effect on intake of unhealthy foods was sustained for boys (p = 0.03). There was no intervention effect on physical activity. Further, the intervention had no apparent effect on BMI sds for the whole sample, but a significant difference between groups was detected among children who were obese at baseline (p = 0.03) which was not sustained at follow-up.

Conclusions

The Healthy School Start study shows that it is possible to influence intake of unhealthy foods and drinks and weight development in obese children by providing individual parental support in a school context. However, the effects were short-lived. Therefore, the programme needs to be prolonged and/or intensified in order to obtain stronger and sustainable effects. This study is an important contribution to the further development of evidence-based parental support programmes to prevent overweight and obesity in children in disadvantaged areas.

One size does not fit all-qualitative process evaluation of the Healthy School Start parental support programme to prevent overweight and obesity among children in disadvantaged areas in Sweden

Background

Parental support interventions have shown some effectiveness in improving children’s dietary and physical activity habits and preventing overweight and obesity. To date, there is limited research on barriers and facilitators of school-based parental support interventions targeting overweight and obesity. This study aimed to describe barriers and facilitators influencing implementation of the Healthy School Start (HSS) intervention in disadvantaged areas in Stockholm, Sweden, from the perspective of parents and teachers.

Methods

Focus groups and individual interviews with teachers (n = 10) and focus groups with parents (n = 14) in the intervention group of the HSS were undertaken, guided by the Consolidated Framework for Implementation Research (CFIR). Transcriptions were analysed using qualitative content analysis in two steps: deductive sorting in two domains of the CFIR (intervention characteristics and process), and subsequent inductive analysis.

Results

The overarching theme “tailoring the intervention to increase participant engagement” was found. Among teachers, barriers and facilitators were related to how the intervention was introduced, perceptions of the usefulness of the classroom material, preparation ahead of the start of the intervention, cooperation between home and school and children’s and parents’ active engagement in the intervention activities.

For parents, barriers and facilitators were related to the perceived relevance of the intervention, usefulness of the material, experiences of the Motivational Interviewing (MI) sessions, the family member targeted by the intervention, cooperation between home and school and parents’ ability to act as good role models.

Conclusion

It seems important to tailor the intervention to the abilities of the target group in order to increase participant engagement. Including activities that focus on parents as role models and cooperation between parents seems important to bring about changes in the home environment. It also appears important to include activities that target cooperation between home and school.

Associations between toddlers' and parents' BMI, in relation to family socio-demography: a cross-sectional study

BACKGROUND

It is well established that the pregnancy and the first years of life are important for future childhood health and body weight. Even though current evidence suggests that both parents are important for childhood health, the influence that parents' BMI and socio-demography has on toddlers' BMI has so far received little attention. This study aimed to increase our knowledge on the association between toddlers' and parents' BMI, in relation to family socio-demography. Further, the aim was to investigate the interaction between the mothers' and fathers' BMI in relation to their child's BMI.

METHODS

A total of 697 children with a median age of 18 months (range 16-24 months) participated in the study along with their mothers (n = 697) and fathers (n = 674). As regards representability, our parental sample had a lower proportion of immigrants and the parents were more gainfully employed compared to parents in the rest of Sweden (when the child was 18 months old). The parents completed a questionnaire on parental and child health. Data on parental weight, height, and socio-demographics were recorded along with the child's weight and height measured at an ordinary child health care visit. We used the thresholds for children's BMI that were recommended for surveillance by the Royal College of Paediatrics and Child Health in 2012 based on the WHO reference population.

RESULTS

Among the toddlers, 33 % had a BMI above the WHO 85(th) percentile and 14 % had a BMI above the WHO 95(th) percentile. The probability of a toddler having a BMI above the WHO 95(th) percentile was significantly increased if either the mother or father was overweight (BMI ≥ 25 kg/m(2)). Furthermore, we found a positive synergistic effect between the mother and father being overweight and their child having a BMI above the WHO 85(th) percentile. No associations were found between the toddlers' BMI and the family's socio-demographics, but there were associations between the parents' BMI and the family's socio-demographics.

CONCLUSION

High BMI is common even in toddlers in this population. The risk increases if one parent is overweight, and it increases even more if both parents are overweight. The results in this study confirm the importance of considering familial risk factors when examining child health and BMI at ordinary child health care visits already at an early age.

Factors influencing the implementation of a school-based parental support programme to promote health-related behaviours--interviews with teachers and parents

BACKGROUND

The 'Healthy School Start' programme was developed to promote healthy dietary habits and physical activity, targeting parents of 6-year-old children in pre-school class. Knowledge of barriers and facilitators of implementation is crucial before introducing this kind of programme on a larger scale. The aim of this study was to explore the views of teachers and parents regarding factors influencing the implementation of a school-based parental support programme to promote physical activity and healthy diet.

METHODS

An inductive qualitative method was used to explore the experiences and views of teachers and parents involved in the programme. A group discussion was held with three teachers, and semi-structured interviews were conducted with 14 parents. Data were analysed using qualitative content analysis.

RESULTS

Clear communication on roles and responsibilities was identified as an overarching theme, emphasising the importance of clear information and well-functioning cooperation between project management, schools and parents when implementing the programme in a school setting. Five categories at a manifest level described aspects influencing the implementation: 1) 'The programme' underlining the importance of flexibility and feed-back; 2) 'the school' referring to management and work routines; 3) 'family conditions', implying various life situations; 4) 'group dynamics' dealing with attitudes among children and parents; and 5) 'the surrounding community' including accessibility and attitudes within society.

CONCLUSIONS

When implementing a parental support programme in a school setting it is important to facilitate communication and clearly define the division of responsibilities between project management, schools and parents. This emphasises the need for managerial support, and a professional prevention support system.