Health and nutrition education program in primary schools of Crete: changes in blood pressure over 10 years

Long-term follow-up on biological risk factors, adiposity, and cardiorespiratory fitness development in a physical education intervention: a natural experiment (CHAMPS-study DK)

Background

Schools are a key setting for large-scale primordial non-communicable disease prevention in young people, but little data on sustainability of impacts on cardiometabolic risk markers is available.

Methods

Six and a half year follow-up of a natural experiment. In 2008, six public schools in the municipality of Svendborg (Denmark) augmented their curricular physical education (intervention) and four matched schools served as controls. At long term follow up in 2015 n = 312 participants aged 5–11 years had complete data (33% of children providing necessary baseline data). The intervention, that consisted of a trebling of weekly physical education lessons and courses provided to physical education teachers, was provided at intervention schools up until 6th grade. Participants attended 6th to 10th grade at follow-up. Differences in the homeostasis model assessment of insulin resistance, blood pressure, triglycerides, cholesterol ratios, cardiorespiratory fitness, waist-circumference, and a composite score of these, between participants attending intervention and control schools were analysed by mixed linear regression models. Differences in physical activity at follow-up was analysed cross-sectionally (no baseline available) in n = 495.

Results

Compared to controls, children at intervention schools had a non-significant − 0.07 (− 0.32 to 0.18) standard deviations lower composite risk score 6.5 years after project initiation. Likewise, no statistically significant differences between intervention and control schools were found for any of the other outcomes (p-values ≥ 0.41). However, six of seven outcomes were in a direction favouring intervention schools. No statistically significant differences between intervention and control schools were observed for physical activity outcomes (p-values ≥ 0.13).

Conclusions

An augmented physical activity program including 270 min of weekly physical education provided for three to seven years did not materialize in statistically significant differences in established risk markers in children from intervention compared to control schools. As the intervention was discontinued after 6th grade, the post-intervention effect of augmented physical education throughout adolescence is unknown. School-based physical activity programs may benefit from incorporating instruments for behaviour translation to leisure time in their intervention models to increase the probability of achieving public health relevance.

Trial registration

ClinicalTrials.gov Identifier: NCT03510494.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5524-4) contains supplementary material, which is available to authorized users.

Evaluation of physical activity interventions in children via the reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) framework: A systematic review of randomized and non-randomized trials

CONTEXT

Existing reviews of physical activity (PA) interventions designed to increase PA behavior exclusively in children (ages 5 to 11years) focus primarily on the efficacy (e.g., internal validity) of the interventions without addressing the applicability of the results in terms of generalizability and translatability (e.g., external validity).

OBJECTIVE

This review used the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance) framework to measure the degree to which randomized and non-randomized PA interventions in children report on internal and external validity factors.

METHODS AND RESULTS

A systematic search for controlled interventions conducted within the past 12years identified 78 studies that met the inclusion criteria. Based on the RE-AIM criteria, most of the studies focused on elements of internal validity (e.g., sample size, intervention location and efficacy/effectiveness) with minimal reporting of external validity indicators (e.g., representativeness of participants, start-up costs, protocol fidelity and sustainability).

CONCLUSIONS

Results of this RE-AIM review emphasize the need for future PA interventions in children to report on real-world challenges and limitations, and to highlight considerations for translating evidence-based results into health promotion practice.

Long-term predictors of blood pressure among adolescents during an 18-month school-based obesity prevention intervention

PURPOSE

To evaluate the effectiveness of the HEROES (Healthy, Energetic, Ready, Outstanding, Enthusiastic Schools) initiative, a multicomponent school-based obesity prevention intervention based on the Centers for Disease Control and Prevention's coordinated school health approach, on the improvement of blood pressure (BP) and to determine long-term predictors of systolic and diastolic BP changes among high school students who were exposed to the intervention.

METHODS

Biometric and behavioral data from high school students were analyzed at baseline, 6, 12, and 18 months (N = 847, three schools). The attrition rate at 18 months was 26.1%. Sequential generalized estimating equation models were fit to the data using SAS 9.3, taking into account clustering effects within the same school and correlations within repeated measures.

RESULTS

A significant downward trend was observed in systolic BP (p = .0006) and diastolic BP (p < .0001) among the students who were exposed to the HEROES initiative. The prevalence of hypertension decreased from 17.1% at baseline to 12.8% at 6 months (p < .0001), 12.0% at 12 months (p < .0001), and 15.0% (p = .0024) at 18 months. Baseline body mass index, increases in body mass index percentiles, and increases of television-viewing hours were associated with BP increases. Increases in frequencies of eating french fries or chips, skipping breakfast, and consuming supersize meals when eating fast food were predictive of systolic BP changes, not of diastolic BP changes.

CONCLUSIONS

An 18-month multicomponent school-based obesity intervention program may be effectively used to decrease rates of high BP among adolescents.

Childhood obesity prevention: a review of school nurse perceptions and practices

PURPOSE

The purpose of this review is to examine key school nurse perceptions that may promote or deter school nurse involvement in childhood obesity prevention (COP) practices.

CONCLUSIONS

Ten research articles were identified through a systematic review of the literature. School nurse participation in COP is inconsistent, and this variation is not well understood. Some variations in COP practices may be explained by differences in self-efficacy, perceived benefits, and perceived barriers.

PRACTICE IMPLICATIONS

Efforts are needed to develop and implement interventions and policies to modify those perceptions that may promote school nurse active engagement in COP practices.

Long-term effect of a school-based physical activity program (KISS) on fitness and adiposity in children: a cluster-randomized controlled trial

Background

School-based intervention studies promoting a healthy lifestyle have shown favorable immediate health effects. However, there is a striking paucity on long-term follow-ups. The aim of this study was therefore to assess the 3 yr-follow-up of a cluster-randomized controlled school-based physical activity program over nine month with beneficial immediate effects on body fat, aerobic fitness and physical activity.

Methods and Findings

Initially, 28 classes from 15 elementary schools in Switzerland were grouped into an intervention (16 classes from 9 schools, n = 297 children) and a control arm (12 classes from 6 schools, n = 205 children) after stratification for grade (1st and 5th graders). Three years after the end of the multi-component physical activity program of nine months including daily physical education (i.e. two additional lessons per week on top of three regular lessons), short physical activity breaks during academic lessons, and daily physical activity homework, 289 (58%) participated in the follow-up. Primary outcome measures included body fat (sum of four skinfolds), aerobic fitness (shuttle run test), physical activity (accelerometry), and quality of life (questionnaires). After adjustment for grade, gender, baseline value and clustering within classes, children in the intervention arm compared with controls had a significantly higher average level of aerobic fitness at follow-up (0.373 z-score units [95%-CI: 0.157 to 0.59, p = 0.001] corresponding to a shift from the 50th to the 65th percentile between baseline and follow-up), while the immediate beneficial effects on the other primary outcomes were not sustained.

Conclusions

Apart from aerobic fitness, beneficial effects seen after one year were not maintained when the intervention was stopped. A continuous intervention seems necessary to maintain overall beneficial health effects as reached at the end of the intervention.

Trial Registration

ControlledTrials.com ISRCTN15360785

High cardiorespiratory fitness is inversely associated with incidence of overweight in adolescence: a longitudinal study

To assess the association of baseline cardiorespiratory fitness (CRF) with incidence of overweight over a 4.6-year period in adolescence. In a cohort of 4878 adolescents, we assessed body mass index in years 2001-2003 and 2007. CRF was assessed at baseline as maximal oxygen consumption (VO2max , mL/kg/min) using the 20-m shuttle run test and was examined against incidence of overweight at follow-up. Estimated VO2max at baseline was higher in males than in females, P < 0.001, and was lower in overweight and obese than in non-overweight subjects. The incidence of overweight at follow-up among non-overweight participants at baseline was 15.5% [95% confidence interval (CI) 13.7% to 17.3%] in males and 5.6% (95% CI 4.9% to 7.0%) in females, P < 0.001. Adjusted odds ratio for incidence of overweight in participants in the fourth quartile of VO2max was 0.40 (95%CI 0.26 to 0.61) in males and 0.57 (95% CI 0.33 to 0.99) in females in comparison with participants in the first quartiles of VO2max . Incidence of overweight was three times more frequent in males than in females. Among non-overweight at baseline, high fitness levels were inversely associated with incidence of overweight at follow-up, suggesting that interventions aiming to increase CRF in early childhood might help reverse increasing trends in obesity.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

The World Health Organization (WHO) estimates that 1.9 million deaths worldwide are attributable to physical inactivity and at least 2.6 million deaths are a result of being overweight or obese. In addition, WHO estimates that physical inactivity causes 10% to 16% of cases each of breast cancer, colon, and rectal cancers as well as type 2 diabetes, and 22% of coronary heart disease and the burden of these and other chronic diseases has rapidly increased in recent decades.

OBJECTIVES

The purpose of this systematic review was to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents.

SEARCH METHODS

The search strategy included searching several databases to October 2011. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information.

SELECTION CRITERIA

To be included, the intervention had to be relevant to public health practice (focused on health promotion activities), not conducted by physicians, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, included all school-attending children, and be implemented for a minimum of 12 weeks. In addition, the review was limited to randomized controlled trials and those that reported on outcomes for children and adolescents (aged 6 to 18 years). Primary outcomes included: rates of moderate to vigorous physical activity during the school day, time engaged in moderate to vigorous physical activity during the school day, and time spent watching television. Secondary outcomes related to physical health status measures including: systolic and diastolic blood pressure, blood cholesterol, body mass index (BMI), maximal oxygen uptake (VO2max), and pulse rate.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to assess each study for relevance and for data extraction. In addition, each study was assessed for risk of bias as specified in the Cochrane Handbook for Systematic Reviews of Interventions. Where discrepancies existed, discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated, and outcomes measured.

MAIN RESULTS

In the original review, 13,841 records were identified and screened, 302 studies were assessed for eligibility, and 26 studies were included in the review. There was some evidence that school-based physical activity interventions had a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally, school-based interventions had little effect on physical activity rates, systolic and diastolic blood pressure, BMI, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity resulted in positive effects.In this update, given the addition of three new inclusion criteria (randomized design, all school-attending children invited to participate, minimum 12-week intervention) 12 of the original 26 studies were excluded. In addition, studies published between July 2007 and October 2011 evaluating the effectiveness of school-based physical interventions were identified and if relevant included. In total an additional 2378 titles were screened of which 285 unique studies were deemed potentially relevant. Of those 30 met all relevance criteria and have been included in this update. This update includes 44 studies and represents complete data for 36,593 study participants. Duration of interventions ranged from 12 weeks to six years.Generally, the majority of studies included in this update, despite being randomized controlled trials, are, at a minimum, at moderate risk of bias. The results therefore must be interpreted with caution. Few changes in outcomes were observed in this update with the exception of blood cholesterol and physical activity rates. For example blood cholesterol was no longer positively impacted upon by school-based physical activity interventions. However, there was some evidence to suggest that school-based physical activity interventions led to an improvement in the proportion of children who engaged in moderate to vigorous physical activity during school hours (odds ratio (OR) 2.74, 95% confidence interval (CI), 2.01 to 3.75). Improvements in physical activity rates were not observed in the original review. Children and adolescents exposed to the intervention also spent more time engaged in moderate to vigorous physical activity (with results across studies ranging from five to 45 min more), spent less time watching television (results range from five to 60 min less per day), and had improved VO2max (results across studies ranged from 1.6 to 3.7 mL/kg per min). However, the overall conclusions of this update do not differ significantly from those reported in the original review.

AUTHORS' CONCLUSIONS

The evidence suggests the ongoing implementation of school-based physical activity interventions at this time, given the positive effects on behavior and one physical health status measure. However, given these studies are at a minimum of moderate risk of bias, and the magnitude of effect is generally small, these results should be interpreted cautiously. Additional research on the long-term impact of these interventions is needed.

Effect of school-based interventions on physical activity and fitness in children and adolescents: a review of reviews and systematic update

BACKGROUND

School-based interventions are thought to be the most universally applicable and effective way to counteract low physical activity (PA) and fitness although there is controversy about the optimal strategy to intervene.

OBJECTIVES

The objective of this review was to summarise recent reviews that aimed to increase PA or fitness in youth and carry out a systematic review of new intervention studies.

METHODS

Relevant systematic reviews and original controlled and randomised controlled school-based trials with a PA or fitness outcome measure, a duration of ≥12 weeks, a sufficient quality and involvement of a healthy population aged 6-18 years that were published from 2007 to 2010 were included. Results In these reviews, 47-65% of trials were found to be effective. The effect was mostly seen in school-related PA while effects outside school were often not observed or assessed.

CONCLUSIONS

The school-based application of multicomponent intervention strategies was the most consistent, promising strategy, while controversy existed regarding the effectiveness of family involvement, focus on healthy populations at increased risk or duration and intensity of the intervention. All 20 trials in the review update showed a positive effect on in-school, out-of-school or overall PA, and 6 of 11 studies showed an increase in fitness. Taking into consideration both assessment quality and public health relevance, multicomponent approaches in children including family components showed the highest level of evidence for increasing overall PA. This review confirms the public health potential of high quality, school-based PA interventions for increasing PA and possibly fitness in healthy youth.

Association of leisure time physical activity and sports competition activities with high blood pressure levels: study carried out in a sample of Portuguese children and adolescents

BACKGROUND

A better understanding of the different domains and characteristics of children's and adolescent's physical activity (PA) could be a strategy to clarify the association of this behaviour with the early development of cardiovascular risk factors.

OBJECTIVES

To examine the relationship between leisure time physical activity (LTPA) and sports competition activities (SCA) with high blood pressure (HBP) levels in a sample of children and adolescents from Porto, Portugal.

STUDY DESIGN

This is a cross-sectional study, which comprised 503 boys and 572 girls, aged 8-17 years old. LTPA and SCA were assed by self-reported. Students were assigned as active and non-active in SCA or LTPA according to their self-reported participation. Participants were classified as HBP when they are above of the last quartile for systolic and/or diastolic BP adjusted for gender and age.

RESULTS

Do not be engaged in LTPA (OR: 1.47; 95% CI: 1.12; 1.93) and SCA (OR: 1.36; 95% CI: 1.02; 1.81) was significantly associated with the likelihood of being HBP. However, when cardiorespiratory fitness (CRF) (OR: 1.23; 95% CI: 0.91; 1.67) and body mass index (BMI) (OR: 1.31; 95% CI: 0.98; 1.75) were included on SCA model, the association between SCA with HBP did not showed significant results.

CONCLUSION

Children and adolescents who are not engaged in SCA or LTPA are more likely to be classified as having HBP; however, the relationship between SCA and HBP was dependent of CRF and BMI. Further, PA strategies should take these differences on the relationship between HBP, SCA and LTPA.

Dietary education in school-based childhood obesity prevention programs

The purpose of this article was to review school based interventions designed to prevent childhood and adolescent obesity that focused on modifying dietary behavior and were published between 2000 and May 2009. A total of 25 interventions met the criteria. The grade range of these interventions was from K to 12; 13 studies exclusively targeted elementary school, 2 targeted both elementary and middle school, 9 exclusively targeted middle school, and 1 targeted high school. The majority of the interventions focused on both dietary and physical activity behaviors, whereas 8 interventions focused exclusively on dietary behaviors. Approximately one-half of the interventions were based on a behavioral theory. In terms of duration, 13 were longer than 6 mo, 4 were less than 1 mo, and 8 had a duration between 1 and 6 mo. The majority of the interventions were implemented by teachers. In terms of activities, almost all interventions had a curricular component except 2 that distributed free fruit or vegetables. Besides curricular instructions, parental and family involvement was also utilized by several interventions. Environmental and policy changes were used in 7 interventions. For evaluation, the 2 most popular designs were experimental design with random assignment at group level and quasi experimental design, both of which were used by 9 interventions each. In terms of impact on adiposity indices, only 14 interventions measured it and only 6 of those were able to demonstrate significant changes. Recommendations for enhancing the effectiveness of school based dietary education interventions for childhood obesity prevention are presented.

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

It is the purpose of this study to systematically review the evidence of school-based interventions targeting dietary and physical activity behaviour in primary (6-12 years old) and secondary school (12-18 years old) children in Europe. Eleven studies (reported in 27 articles) met the inclusion criteria, six in primary school and five in secondary school children. Interventions were evaluated in terms of behavioural determinants, behaviour (diet and physical activity) and weight-related outcomes (body mass index [BMI] or other indicators of obesity). The results suggest that combining educational and environmental components that focus on both sides of the energy balance give better and more relevant effects. Furthermore, computer-tailored personalized education in the classroom showed better results than a generic classroom curriculum. Environmental interventions might include organized physical activities during breaks, or before and after school; improved availability of physical activity opportunities in and around the school environment; increased physical education lesson time; improved availability or accessibility of healthy food options; and restricted availability and accessibility of unhealthy food options. More high-quality studies are needed to assess obesity-related interventions in Europe.

Eight-year follow-up of school-based intervention on childhood overweight--the Kiel Obesity Prevention Study

OBJECTIVE

The aim of this study was to evaluate the 8-year outcome of school-based intervention on weight status, lifestyle and blood pressure (BP) as part of the Kiel Obesity Prevention Study (KOPS).

METHODS

Within a quasi-randomized controlled trial, 240 intervention (I) and 952 non-intervention (NI) students at age 6 and 14 years were assessed in schools. Six nutrition units followed by 20-min running games were performed within the first year at school. Primary outcome was the 8-year change in body mass index standard deviation score (BMI-SDS) according to German references. Effective intervention was tested using multilevel linear regression analysis.

RESULTS

Eight-year changes in BMISDS were +0.18 and +0.22 with increases in prevalence of overweight from 8.3 to 10.4% and 7.0 to 11.2% in I and NI students, respectively. Cumulative 8-year incidence of overweight was 5.9% and 7.1% in I and NI students, respectively. There was no overall effect of intervention, but a significant interaction was shown between the intervention and the socio-economic status (SES), which demonstrated that in high SES, the 8-year change in BMI-SDS was in favour of I (-0.17 in I and +0.17 in NI; p < 0.01). Intervention had no measurable effects on lifestyle and BP.

CONCLUSIONS

School-based health promotion has some favourable and sustained effects on 8-year changes in BMI-SDS, which are most pronounced in students of high SES families. The data argue in favour of further preventive measures.

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

OBJECTIVE

To assess the long-term effectiveness of a school-based health education intervention program 10 years after its initiation.

METHOD

In 1992 the total population of first grade students from three counties of Crete participated in the study. Over 1000 students were randomly selected for initial and periodic evaluation. Biochemical and behavioural parameters (anthropometric, lipoproteins, blood pressure, physical activity, dietary record and health habits) were measured. Re-evaluation of the program was performed at 3, 6 and 10 years after its initiation.

RESULTS

Ten years after the initiation of the program, the results showed that BMI had increased significantly less (p<0.001) and performance in the shuttle run test was significantly better (p<0.001) in the intervention group as compared to the control group. The reduction in total cholesterol noted in both groups was significantly greater in the intervention group than in the control group (p<0.001). The incidence of smoking was also significantly lower in the intervention group (intervention group 7%, control group 13%, p<0.005).

CONCLUSION

This program appears to improve children's health and decrease risk factors for chronic diseases. If these positive effects are maintained in the forthcoming decades, the risk of chronic diseases may well be reduced.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18

BACKGROUND

The World Health Organization estimates that 1.9 million deaths worldwide are attributable to physical inactivity. Chronic diseases associated with physical inactivity include cancer, diabetes and coronary heart disease.

OBJECTIVES

The purpose of this systematic review is to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents.

SEARCH STRATEGY

The search strategy included searching several databases. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information.

SELECTION CRITERIA

To be included, the intervention had to be relevant to public health practice, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, report on outcomes for children and adolescents (aged 6 to 18 years), and use a prospective design with a control group.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to rate each study's methodological quality and for data extraction. Where discrepancies existed discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated and outcomes measured.

MAIN RESULTS

13,841 titles were identified and screened and 482 articles were retrieved. Multiple publications on the same project were combined and counted as one project, resulting in 395 distinct project accounts (studies). Of the 395 studies 104 were deemed relevant and of those, four were assessed as having strong methodological quality, 22 were of moderate quality and 78 were considered weak. In total 26 studies were included in the review. There is good evidence that school-based physical activity interventions have a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally school-based interventions had no effect on leisure time physical activity rates, systolic and diastolic blood pressure, body mass index, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity result in positive effects.

AUTHORS' CONCLUSIONS

Given that there are no harmful effects and that there is some evidence of positive effects on lifestyle behaviours and physical health status measures, ongoing physical activity promotion in schools is recommended at this time.

Systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity: an update to the obesity guidance produced by the National Institute for Health and Clinical Excellence

To determine the effectiveness of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity. MEDLINE and EMBASE were searched (January 2006 to September 2007) for controlled trials of school-based lifestyle interventions, minimum duration of 12 weeks, reporting weight outcome. Thirty-eight studies were included; 15 new studies and 23 studies included within the National Institute for Health and Clinical Excellence obesity guidance. One of three diet studies, five of 15 physical activity studies and nine of 20 combined diet and physical activity studies demonstrated significant and positive differences between intervention and control for body mass index. There is insufficient evidence to assess the effectiveness of dietary interventions or diet vs. physical activity interventions. School-based physical activity interventions may help children maintain a healthy weight but the results are inconsistent and short-term. Physical activity interventions may be more successful in younger children and in girls. Studies were heterogeneous, making it difficult to generalize about what interventions are effective. The findings are inconsistent, but overall suggest that combined diet and physical activity school-based interventions may help prevent children becoming overweight in the long term. Physical activity interventions, particularly in girls in primary schools, may help to prevent these children from becoming overweight in the short term.