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

Promoting hEalthy Diet and Active Lifestyle (PEDAL): a protocol for the development and feasibility study of a multicomponent intervention among primary school children in Singapore

BACKGROUND

Setting healthy lifestyle habits during the formative years of childhood is critical as habits can track to adulthood and help prevent obesity and chronic disease risks in later life. While multicomponent interventions have been shown to be effective in changing the lifestyle behaviours of children, there is a limited understanding of the feasibility of such interventions in primary schools in Singapore. A multiphase mixed method study was conducted to develop and examine the feasibility of a theory-based multicomponent school-based intervention-Promoting hEatlthy Eating and Active Lifestyle (PEDAL).

METHODS

Underpinned by Kincaid's ideation model, the PEDAL intervention was developed to increase fruit and vegetable consumption and decrease sedentary behaviours among children. This study consists of three phases. Phase 1 details the development of PEDAL, which consists of four components: (A) a series of interactive health education lessons, (B) actionable home activities to support habit formation, (C) parental/guardian engagement, and (D) optimising the school environment. In Phase 2, components A and B of PEDAL were implemented in two public, co-educational primary schools among Primary 5 students (aged 10-12 years) in Singapore. Data was collected quantitatively using questionnaires and qualitatively using focus group discussions (FGDs) with students and teachers. The feasibility dimensions of components A and B, including recruitment capability, data collection, social validity, and practicality were examined, and ideation on healthy eating and physical activity was explored. In Phase 3, the full PEDAL intervention was pilot-tested in two other public, co-education primary schools with the same target population, using a concurrent mixed method quasi-experimental study design. Feasibility dimensions and potential effectiveness of the intervention will be assessed.

DISCUSSION

This study will provide insights into the feasibility of PEDAL and inform its refinement. Findings from the pilot test will guide the planning of a larger-scale definitive trial.

TRIAL REGISTRATION

Registered with ISRCTN registry (ISRCTN16114046) on 16 October 2022.

Effectiveness of School-Based Interventions in Europe for Promoting Healthy Lifestyle Behaviors in Children

The objective of this narrative review was to summarize existing literature on the effectiveness of school-based interventions, implemented in Europe, under the aim of promoting healthy lifestyle behaviors in children (6-10 years old). A search of PubMed, Scopus, EFSA and Google Scholar databases was performed for studies published from January 2016 to June 2022. Specific search terms and exclusion criteria were used. Based on the results, diet and physical activity interventions had favorable effects on a series of health outcomes, including anthropometric parameters, biomarkers, eating behavior and self-efficacy. Diet-only interventions had a positive impact specifically on eating habits, mostly on water consumption. Most successful interventions lasted for 1 school year, and they were characterized by parental involvement and teachers' training.

Effectiveness of School-Based Interventions in Europe for Promoting Healthy Lifestyle Behaviors in Children

The objective of this narrative review was to summarize existing literature on the effectiveness of school-based interventions, implemented in Europe, under the aim of promoting healthy lifestyle behaviors in children (6-10 years old). A search of PubMed, Scopus, EFSA and Google Scholar databases was performed for studies published from January 2016 to June 2022. Specific search terms and exclusion criteria were used. Based on the results, diet and physical activity interventions had favorable effects on a series of health outcomes, including anthropometric parameters, biomarkers, eating behavior and self-efficacy. Diet-only interventions had a positive impact specifically on eating habits, mostly on water consumption. Most successful interventions lasted for 1 school year, and they were characterized by parental involvement and teachers' training.

Health behavior of Austrian tertiary students focusing on diet type linked to sports and exercise-first glimpse of results from the "sustainably healthy-from science 2 high school and university" study

Background

There is a strong association between lifestyle behavior and health status. While young adulthood is a critical period for adopting and stabilizing lifelong healthy behavior, university life is independently associated with psychological stressors that may further affect health and well-being.

Objective

The present multidisciplinary study aimed to examine the health behavior of Austrian college and university students, differentiated based on diet types (vegan, vegetarian, and omnivorous) and physical activity (PA) habits.

Methods

Following a cross-sectional study design, a total number of 6,148 students (65.3% females; 66.1% bachelor students, 67.0% from urban areas; mean age: 24.8 years) from 52 Austrian college/universities participated in an online survey and provided data on sociodemographic characteristics, dietary patterns, PA habits, and other lifestyle behavior characteristics, including alcohol intake and smoking.

Results

Across the total sample, 74.0% had a normal weight (BMI = 18.5-25.0 kg/m2), while the prevalence of overweight/obesity (BMI ≥ 30.0 kg/m2) was lower in females than males and more in rural than urban students (p < 0.01). The general prevalence of vegetarian and vegan diets was 22.8 and 6.0%, respectively, with a predominance of females, graduates, and urban students compared to their peers (p < 0.01). The majority of students (79.3%) had a regular engagement in sport/exercise, with a predominance of vegetarian or vegan students compared to omnivores (p < 0.01). Vegans and vegetarians had a lower alcohol intake (p < 0.01) but no differences in smoking habits (p > 0.05) compared to omnivores. Students engaging in sport/exercise had a lower smoking rate and higher intake of fruits, vegetables, and fluids compared to inactive students (p < 0.01).

Conclusion

The present findings suggest that diet type and PA habits of college/university students have an impact on other health behaviors, highlighting the interconnected nature of lifestyle habits and health behavior.

Prediction Equation for Physical Activity Energy Expenditure in 11-13-Year-Old Sri Lankan Children

This study aimed to develop a regression equation to predict physical activity energy expenditure (PAEE) using accelerometry. Children aged 11-13 years were recruited and randomly assigned to validation (n = 54) and cross-validation (n = 25) groups. The doubly labelled water (DLW) technique was used to assess energy expenditure and accelerometers were worn by participants across the same period. A preliminary equation was developed using stepwise multiple regression analysis with sex, height, weight, body mass index, fat-free mass, fat mass and counts per minute (CPM) as independent variables. Goodness-of-fit statistics were used to select the best prediction variables. The PRESS (predicted residual error sum of squares) statistical method was used to validate the final prediction equation. The preliminary equation was cross-validated on an independent group and no significant (p > 0.05) difference was observed in the PAEE estimated from the two methods. Independent variables of the final prediction equation (PAEE = [0.001CPM] - 0.112) accounted for 70.6% of the variance. The new equation developed to predict PAEE from accelerometry was found to be valid for use in Sri Lankan children.

Development and evaluation of an intervention to improve food and nutrition literacy among Iranian Kurdish primary school children: An application of intervention mapping approach

Background

Food and nutrition literacy (FNLIT) is a relatively new term that is used to define the knowledge, skills, and behaviors necessary to achieve a healthy diet. Improving food and nutritional literacy in children is a necessary solution to eliminate nutritional disorders in this age group. The purpose of this study was to design, implement and evaluate an intervention to improve food and nutrition literacy in children aged 10-12 years old based on an intervention mapping (IM) approach.

Methods

This experimental study was performed in three phases. Through the first phase, an intervention was developed using the (IM) approach. In the second phase, the intervention was implemented for 6 months, and in the third phase, the intervention outcomes were evaluated and compared with the control group through a randomized controlled trial among 300 participants (each control and intervention group = 150).

Results

Before the intervention, there was no significant difference between the control and intervention groups in all subscales of FNLIT. After the intervention, there was a significant difference between the control and intervention groups in all subscales of FNLIT (P < 0/001). There were no differences between the two groups in terms of the FNLIT scores at baseline (P > 0.05). However, after 6 months of intervention, a significant difference was observed between the two groups (intra-group differences) (P < 0.001). Such a difference was not identified in the control group after 6 months also the results show the impact of socioeconomic factors and parental literacy on the average score of students' FNLIT and after the intervention, a significant difference was observed between the scores of control and intervention groups in all subscales of the FNLIT (P < 0.001).

Conclusions

The school-based intervention developed and evaluated in this study provides a basis for future programs targeting the improvement of FNLIT in children, especially in poor and deprived areas such as Kurdistan province.

Clinical trial registration

Iranian Clinical Trials Registry (IRCT) Code: 32094.

Implementation and Evaluation of a School-Based Educational Program Targeting Healthy Diet and Exercise (DIEX) for Greek High School Students

The present study examined the effectiveness of a school-based health education program promoting healthy diet and exercise, named DIEX, implemented on adolescents. The program is based on the Theory of Planned Behavior (TPB) and is supported by life skills training. The recipients of the program were high school students (n = 367; 168 boys and 199 girls) from 14 schools in Greece who attended 10 1 h sessions implemented by their schoolteachers. Data were collected before and after the program implementation through online questionnaires for: a. attitude, intention, subjective norms, and PBC toward healthy eating; b. knowledge about healthy eating; c. exercise behavior and attitude toward the DIEX program; and d. satisfaction with the DIEX program (only post-program). The results showed that there were significant differences among the pre- and post-measures of students' knowledge and behavior about healthy diet, as well as attitudes and satisfaction toward the program's application. The results show that the DIEX program may have improved nutrition behavior variables. Conclusively, a theory-based behavioral intervention with skills training may result in positive behavioral changes for young students during health education in school settings with the assistance of new technologies.

Study Protocol of "Sustainably Healthy-From Science 2 Highschool & University"-Prevalence of Mixed, Vegetarian, and Vegan Diets Linked to Sports & Exercise among Austrian Tertiary Students and Lecturers/Academic Staff

Healthy lifestyle is the major indicator of individual and public health especially in target populations (e.g., during emerging adulthood). Evidence indicates that unhealthy lifestyle behaviors are strongly associated with the increasing prevalence of chronic diseases. The dual approach of sustainable health (i.e., physical exercise tied to a healthy diet) is an effective lifestyle strategy to control and manage health-related disorders, including overweight/obesity. Based on the evidence on plant-based diets regarding health and considering the growing prevalence of vegans and vegetarians worldwide, limited data exist on the health-related behaviors of those who follow plant-based vs. mixed diets in young adulthood. This multidisciplinary study is the first to examine the association between diet type (mixed, vegetarian, and vegan diets) and various health-related behaviors (primarily physical activity, sport, & exercise) among college/university students and lecturers/academic staff in Austria nationwide. Following a cross-sectional study design and using online questionnaires, 4510 tertiary students and 1043 lecturers/academic staff provided data on sociodemographic characteristics, dietary patterns, physical exercise habits, and other lifestyle behaviors (sleep, alcohol intake, smoking, etc.) along with information on health status and quality of life. While the data will be analyzed based on differentiated sociodemographic and health-related categories, the influence of the COVID-19 pandemic on lifestyle behaviors will also be evaluated. As a study protocol, this article represents comprehensive details of the design, purposes, and associated analytical measures of the present study within the tertiary educational context.

School health programs of physical education and/or diet among pupils of primary and secondary school levels I and II linked to body mass index: A systematic review protocol within the project From Science 2 School

The most common causes of death in Western countries today are preventable diseases mainly attributed to daily behavior. It has been well documented that genetics are influential but not the deciding factor for developing non-communicable diseases. Ideally, the public should be educated to perform methods of optimal health and wellbeing independently, meaning that individuals should be in control of their health without relying on others. As behavior is known to be consistent over time, good or poor health behavior will track from childhood into adulthood. Physical activity and diet are permanently linked to the individual's state of health, and when properly balanced, the effects on personal health summate, resulting in greater benefits from this dual-approach for public health. The objective is to highlight the different approaches (physical intervention, nutritional intervention, and dual-approach of diet and exercise) and identify effective interventions for sustainable body weight and healthy body mass index in school children. A systematic review will be conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The review will assess school-based diet and exercise interventions on children in primary and secondary school levels I and II. Overweight and obesity develop as a result of a prolonged imbalance in the energy balance model, with both physical activity and diet being influential in the fluctuation of body weight. A dual-approach including physical activity and diet could therefore be a very promising method to promote sustainable healthy body weight in school children.

Study protocol of "From Science 2 School"-prevalence of sports and physical exercise linked to omnivorous, vegetarian and vegan, diets among Austrian secondary schools

The increasing prevalence of unhealthy lifestyle choices contribute to almost all chronic conditions negatively affecting individual and public health. As the most beneficial preventative solution, a healthy lifestyle focusing on the dual approach of physical activity (PA) and a healthful diet is highly recommended. Considering the growing number of people interested in sustainable, plant-based diets, it seems crucial to analyze lifestyle behaviors with a special focus on diet type to delve deeper into the unenthusiastic health status among young populations. Therefore, this multidisciplinary study aims to survey and scale health behaviors with a special focus on the prevalence of traditional and vegetarian diets in connection with PA levels among Austrian pupils (10-19 years), teachers and principals in secondary education levels I and II. Following a cross-sectional design, sociodemographic and school-related data along with a complete profile of lifestyle behaviors, including detailed information regarding diet, PA, sports & exercise, and other health-related behaviors, were collected using online-based questionnaires. A total number of 8,845 children/adolescents (~1.2% of the eligible 771,525 Austrian secondary school pupils) and 1,350 adults (~1.5% of total eligible 89,243 Austrian teachers/principals) participated in the study. As this is the first investigation to explore the prevalence of veganism/vegetarianism amongst a large group of pupils, the present study will add an important contribution to overcome the lack of knowledge on PA, sports & exercise linked to healthy alternative diets. With a sustainable healthy lifestyle, a healthy transition from childhood to adulthood occurs, which can result in growing healthier functioning generations at all social levels. As a study protocol, the present article is intended to present comprehensive details of the study design, objectives, and the associated analytical procedures of the "From Science 2 School" study.

FAST Heroes: Results of Cross-Country Implementation of a Global School-Based Stroke Education Campaign

Background

Educating the at-risk population about stroke symptoms and requirement of calling an ambulance when stroke strikes is challenging. This exploratory cross-country study provides insights to the FAST Heroes educational campaign and outcomes hitherto achieved.

Aims

The primary aim of the study was to measure the transfer of stroke-related knowledge to parents after a global school-based FAST Heroes educational campaign for 5- to 9-year-old children in 14 different countries. The secondary aim was to evaluate parents and teachers' acceptability toward the program.

Methods

The duration of the program was 5 h; 1 h per week, joining face-to-face educational sessions with workbooks, cartoons, web-based learning, and other fun activities. Outcomes were measured before implementation (t1), after implementation (t2), and at 6-month follow-up (t3). Program acceptability and stroke knowledge were evaluated by feedback surveys for teachers and parents.

Results

Worldwide, 4,202 parents completed the program with their children and answered surveys at t1 and t2. They increased their knowledge of three stroke symptoms from 48 to 83% (p &lt; 0.001). All three surveys were completed by 86 parents, who improved their knowledge of stroke symptoms, 55% (t1), 79% (t2), and 94% (t3) (p &lt; 0.001). Overall, the educational messages were successfully passed onward.

Conclusions

Findings confirm the primary aim of the study that is knowledge about stroke transfer well from children to their families through the FAST Heroes program. Second, parents and teachers globally consider the program feasible and worthwhile. The results will inform further rollout of the campaign.

Facilitators, Barriers, and Structural Determinants of Physical Activity in Nulliparous Pregnant Women: A Qualitative Study

Aims & Backgrounds. Reduced physical activity in pregnant women is highly stemmed from their misconceptions and attitudes during pregnancy. This study is aimed at recognizing the facilitators, barriers, and structural factors that influence activity among pregnant women. Participants & Methods. This qualitative study was conducted from January to June 2020 in nulliparous pregnant women. Forty participants selected randomly from the Pounak Health Center of Tehran City, Iran, answered open-ended questions about the obstacles that deprived them of physical activity during pregnancy. Data were analyzed by MAXQDA 12 software. Findings. 620 primary codes, 42 secondary codes, 11 subthemes, and 6 themes were extracted. These themes were divided into the PEN-3 categories: facilitators, barriers, and structural factors. The nurture factors as facilitators had communication and support from others as subthemes. Barriers consisted of sociocultural (participate in pregnancy class with a companion, social beliefs, and culture of poverty), socioeconomic (financial problems), and individual factors (physical, psychoemotional, and spiritual dimensions), and structural factors consisted of environmental (equipment) and organizational (possibilities in health centers) factors. Conclusion. Lack of awareness and misinformation, accessibility obstacles, and economic problems are the worst physical activity barriers during pregnancy. Being among other pregnant women and the physicians’ recommendations are the best facilitators of physical activity during pregnancy.

Effects of 'SPRAT' programme for dietary and lifestyle education to improve psychosomatic symptoms and dietary habits among adolescents: a cluster randomised controlled trial

BACKGROUND

Dietary and lifestyle modifications to reduce subjective psychosomatic symptoms (SPS) have become an important topic worldwide. We developed a school-based dietary and lifestyle education programme that involved parents/guardians in reducing SPS in adolescents (SPRAT). The programme encouraged parents/guardians to participate in adolescents' healthy dietary and lifestyle modifications to reduce SPS, increase enjoyment of school life, and foster appropriate dietary intake. This study evaluated the effectiveness of SPRAT in reducing SPS and in altering dietary behaviour among adolescents.

METHODS

A 6-month cluster randomised controlled trial using SPRAT and the usual school programme (control) was performed. Participants were middle school students in Japan who provided informed consent. Outcomes were SPS scores assessed at baseline and 2, 4, and 6 months after baseline and the proportions of dietary and lifestyle factors achieved such as enjoyment of school life and dietary intakes assessed by FFQW82. Change from baseline (CFB) at 6 months was the primary endpoint. A linear mixed-effects model was applied. As for dietary intake, the treatment effect was estimated as an interaction term between baseline and treatment "baseline*treatment".

RESULTS

The intention-to treat analysis included 951 (94.7%) and 1035 (89.8%) individuals in the SPRAT and control groups, respectively. The CFB in the 6-month SPS score adjusted for baseline was lower in the SPRAT group (-0.29) than in the control group (0.62), but the difference was not statistically significant -0.91 (p = 0.093).

CONCLUSIONS

Although the primary endpoint tended to denote improvement in the SPRAT group compared to the control group, the improvement was not significant. Favourable effects were observed in some secondary outcomes and statistically significant treatment*baseline interactions were observed for several dietary intakes. These results imply that CFBs of dietary intake were increased or decreased in a favourable direction depending on the baseline intake, especially in the SPRAT group.

TRIAL REGISTRATION

UMIN000026715. (27/03/2017).

Teacher Training and Engagement in Health Promotion Mediates Health Behavior Outcomes

School-based health promotion interventions have been shown to lead to measurable changes in the nutrition and physical activity behaviors. This study examines whether the impact of an intervention program on students’ healthy eating and physical activity was mediated by teacher training and engagement in health promotion. The trial was conducted in three phases: needs assessment of the baseline survey of teachers, mothers’ and children; intervention among seven randomly selected schools that included teacher training in healthy eating and physical activity; and a post-intervention evaluation survey. The SPSS PROCESS for Hayes (Model8) was used to determine moderation and mediation effects. The difference in difference (DID) was calculated for the three main outcomes of the study: eating breakfast daily (DID = 17.5%, p < 0.001); consuming the recommended servings of F&V (DID = 29.4%, p < 0.001); and being physically active for at least 5 days/week (DID = 45.2%, p < 0.001). Schoolchildren’s eating breakfast daily was mediated by their teachers’ training in nutrition (β = 0.424, p = 0.002), teachers’ engagement (β = 0.167, p = 0.036), and mothers preparing breakfast (β = 1.309, p < 0.001). Schoolchildren’s consumption of F&V was mediated by teachers’ engagement (β = 0.427, p = 0.001) and knowing the recommended F&V servings (β = 0.485, p < 0.001). Schoolchildren’s physical activity was mediated by their teachers’ training in physical activity (β = 0.420, p = 0.020) and teachers’ engagement (β = 0.655, p < 0.001). Health behavior changes in the school setting including improvements in eating breakfast, consuming the recommended F&V and physical activity was mediated by teacher training and engagement. Effective teacher training leading to teacher engagement is warranted in the design of health-promotion interventions in the school setting.

Effect of the multicomponent healthy high school intervention on meal frequency and eating habits among high school students in Denmark: a cluster randomized controlled trial

BACKGROUND

Previous studies have shown that multicomponent interventions may improve meal frequency and eating habits in children, but evidence among young people is limited. This study evaluated the effect of the Healthy High School (HHS) intervention on daily intake of breakfast, lunch, water, fruit, and vegetables at 9-month follow-up.

METHODS

The study included first-year students (≈16 years) attending high school in Denmark. Participating schools were randomized into the HHS intervention (N = 15) or control group (operating as usual) (N = 15). The intervention was designed to promote well-being (primary outcome) by focusing on healthy habits including meals, stress prevention, and strong peer relations. It included a curriculum, structural and organisational initiatives, a workshop, and a smartphone application. Students completed self-administered online questionnaires at the beginning of the school year and nine months later. To account for clustering of data, we used multilevel logistic regression analyses to estimate odds ratios (OR). We applied an intention-to-treat approach with multiple imputations of missing data.

RESULTS

At baseline 4577 of 5201 students answered the questionnaire and 4512 at follow-up. In both groups the proportion of students eating breakfast decreased from approximately 50% to 40% from baseline to follow-up, and lunch frequency decreased from approximately 50% to 47%. Daily water intake, intake of fresh fruit and intake of vegetables remained unchanged from baseline to follow-up. There were no significant between group differences on any of the outcomes at first follow-up: breakfast: OR = 0.85 (95% CI: 0.65;1.10), lunch: OR = 0.96 (95% CI: 0.75;1.22), water intake: OR = 1.14 (95% CI: 0.92;1.40), intake of fresh fruit: (OR = 1.07, 95% CI: 0.84;1.37), vegetables: (OR = 1.01, 95% CI: 0.77;1.33).

CONCLUSION

No evidence of an effect of the HHS intervention was found for any of the outcomes. Future studies are warranted to explore how health promoting interventions can be integrated in further education to support educational goals. Moreover, how to fit interventions to the lives and wishes of young people, by also including systems outside of the school setting.

TRIAL REGISTRATION

ISRCTN, ISRCTN43284296 . Registered 28 April 2017 - retrospectively registered.

Second Graders' Grapho-Motor Skill Learning and Verbal Learning: The Effects of Socio-Educational Factors

Introduction: Children from low socioeconomic status (SES) families, and in particular, those with a lower level of maternal education, show lower fine-motor skills and lower vocabulary scores than their SES peers whose mothers have a higher level of education. Furthermore, low SES children frequently have difficulties in reading and spelling. These difficulties are attributed to deficits in the acquisition of skills through practice, such as those required for developing visual-motor routines, alongside deficits in the intentional acquisition of knowledge, such as those required in verbal learning. The aim of the current study was to test the effect of two background factors: low maternal education (ME) and risk of reading and spelling difficulties on practice-dependent learning of a motor task and intentional learning of a verbal task in second graders from low SES families. Methods: In 2016/17, 134 low-SES second graders with higher and lower ME (95 typical learners and 39 with reading and spelling difficulties) were assessed with (a) the Invented Letter Task (ILT; a grapho-motor skill learning task) across five time-points (initial- and end-training Day 1; initial- and end-training Day 2; and 2-weeks post-training), as well as an ILT transfer task; and (b) The Rey Auditory Verbal Learning Test (RAVLT; an intentional word-learning task in which a word list is read to children for five learning trials and is recalled 20 min later). Findings: Lower ME was associated with surplus segments in the performance of the motor task and its transfer to a novel condition as well as with lower recall on the verbal task, but not with the learning of both the motor and the verbal task. Having reading and spelling difficulties affected motor-task accuracy and also the way children learned the task, as evidenced by surplus segments at the beginning of Day 2, which were reduced with further practice. Conclusion: Low ME affected overall performance level. Reading and spelling difficulties resulted in atypical learning of the motor task. Future research on practice-dependent learning in the context of children coming from low SES families should focus on subgroups within this heterogeneous population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

School-based interventions for the treatment of childhood obesity: a systematic review, meta-analysis and meta-regression of cluster randomised controlled trials

OBJECTIVE

Schools offer an ideal setting for childhood obesity interventions due to their access to children and adolescents. This review aimed to systematically review the impact of school-based intervention for the treatment of childhood obesity.

DESIGN

Eight databases were searched from inception till 30 May 2020. A revised Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development and Evaluations criteria were used to evaluate the risk of bias and overall evidence. Meta-analysis and meta-regression were performed on Stata software using the random effects model. Overall effect was evaluated using Hedges' g, and heterogeneity was assessed using Cochran's Q and I2.

SETTING

Cluster randomised controlled trials (cluster-RCT) delivered in school.

PARTICIPANTS

Children and adolescents (6-18 years of age) with overweight and obesity.

RESULTS

Twelve cluster-RCT from seven countries with 1755 participants were included in the meta-analysis. School-based interventions for the treatment of childhood obesity reduced BMI and BMI z-scores with a medium effect (g = 0·52). Subgroup analyses showed greater effectiveness of brief school-based interventions and the interventions conducted in lower-middle to upper-middle economies. Meta-regression assessed the heterogeneity and the final model, with covariates of the type of economies and trial duration, accounted for 41·2 % of the variability. The overall quality of evidence was rated low because of the high risk of bias and inconsistency.

CONCLUSIONS

School-based interventions are a possible approach to provide universal healthcare for the treatment of childhood obesity, and further well-designed cluster-RCT with longer follow-up are needed. This study is registered with PROSPERO (CRD42020160735).

Physiotherapy and related management for childhood obesity: A systematic scoping review

INTRODUCTION

Despite targeted efforts globally to address childhood overweight/obesity, it remains poorly understood and challenging to manage. Physiotherapists have the potential to manage children with obesity as they are experts in movement and physical activity. However, their role remains unclear due to a lack of physiotherapy-specific guidelines. This scoping review aims to explore existing literature, critically appraising and synthesising findings to guide physiotherapists in the evidence-based management of childhood overweight/obesity.

METHOD

A scoping review was conducted, including literature up to May 2020. A review protocol exists on Open Science Framework at https://osf.io/fap8g/. Four databases were accessed including PubMed, Embase, CINAHL, Medline via OVID, with grey literature searched through google via "file:pdf". A descriptive synthesis was undertaken to explore the impact of existing interventions and their efficacy.

RESULTS

From the initial capture of 1871 articles, 263 intervention-based articles were included. Interventions included qualitative focused physical activity, quantitative focused physical activity and multicomponent interventions. Various outcome measures were utilised including health-, performance- and behaviour-related outcomes. The general trend for physiotherapy involvement with children who are obese appears to favour: 1) multicomponent interventions, implementing more than one component with environmental modification and parental involvement and 2) quantitative physical activity interventions, focusing on the quantity of bodily movement. These approaches most consistently demonstrated desirable changes across behavioural and health-related outcome measures for multicomponent and quantitative physical activity interventions respectively.

CONCLUSION

When managing children with obesity, physiotherapists should consider multicomponent approaches and increasing the quantity of physical activity, given consistent improvements in various obesity-related outcomes. Such approaches are well suited to the scope of physiotherapists and their expertise in physical activity prescription for the management of childhood obesity. Future research should examine the effect of motor skill interventions and consider the role of environmental modification/parental involvement as factors contributing to intervention success.

Teacher Evaluation of an Experiential Vegetable Education Program for Australian Primary Schools: Does Face-to-Face Training Add Value above Digital Training?

The teacher-led implementation of healthy eating programs in schools is cost-effective and potentially impactful. Teacher acceptability is important for uptake; however, process evaluations are scarce. This study evaluated the effect of two intensities of teacher training on the evaluation of a vegetable education program for Australian primary schools by teachers. The teachers (n = 65) who implemented the program as part of a cluster RCT (25 schools in two states, New South Wales and South Australia) received either low- (provision with materials and online training) or high (additional face-to-face (F2F) training)-intensity training prior to implementing a 5-week vegetable education program. They evaluated the acceptability of a digital training module and program by indicating the level of agreement with 15 and 18 statements, respectively, using 5-point Likert scales. The average item scores ranged from 3.0 to 4.2. All but one item, including student engagement, alignment to the curriculum and intent for reuse of the program, had a rounded average or median score of 4. The level of training intensity did not impact the teacher acceptability ratings. In conclusion, the teacher acceptability was good, and additional F2F training does not add value above the solely digital training of the teachers.

A Systematic Review of Multi-Component Comprehensive School Physical Activity Program (CSPAP) Interventions

OBJECTIVE

To identify, review, and describe multicomponent physical activity (PA) interventions in terms of: (a) number and combination of Comprehensive School Physical Activity Program (CSPAP) components, (b) study characteristics, and (c) primary outcomes.

DATA SOURCE

Five electronic databases (i.e., PubMed, PsychInfo, Physical Education Index, Sport Discus, and ERIC).

STUDY INCLUSION AND EXCLUSION CRITERIA

Included articles were peer-reviewed, written in English language, published since 1987, and included multicomponent school-based interventions.

DATA EXTRACTION

Data items extracted were: school level, setting, CSPAP component description, health outcomes, academic outcomes, main conclusion, and reference.

DATA SYNTHESIS

Included articles were synthesized by: (1) CSPAP components utilized, and (2) research outcome measured (i.e., health or academic).

RESULTS

Across 32 studies, 11 included physical education plus 1 additional CSPAP component (PE + 1); 10 included PE + 2 additional CSPAP components; 8 included PE + 3 additional CSPAP components; and 1 included all 5 CSPAP components. Two other studies included 2 or 3 CSPAP components without PE. Most interventions targeted health outcomes (94%) rather than academic outcomes (6%).

CONCLUSIONS

Multicomponent approaches aligned with CSPAPs are effective in promoting PA and other positive outcomes for youth in schools. Future research should seek to understand effects of CSPAP components on a variety of outcomes and settings.

A cluster-randomised controlled trial of the LifeLab education intervention to improve health literacy in adolescents

Adolescence offers a window of opportunity during which improvements in health behaviours could benefit long-term health, and enable preparation for parenthood-albeit a long way off, passing on good health prospects to future children. This study was carried out to evaluate whether an educational intervention, which engages adolescents in science, can improve their health literacy and behaviours. A cluster-randomised controlled trial of 38 secondary schools in England, UK was conducted. The intervention (LifeLab) drew on principles of education, psychology and public health to engage students with science for health literacy, focused on the message "Me, my health and my children's health". The programme comprised: • Professional development for teachers. • A 2-3 week module of work for 13-14-year-olds. • A "hands-on" practical health science day visit to a dedicated facility in a university teaching hospital. Data were collected from 2929 adolescents (aged 13-14 years) at baseline and 2487 (84.9%) at 12-month follow-up. The primary outcome was change in theoretical health literacy from pre- to 12 months post- intervention. This study is registered (ISRCTN71951436) and the trial status is complete. Participation in the LifeLab educational intervention was associated with an increase in the students' standardised total theoretical health literacy score (adjusted difference between groups = 0.27 SDs (95%CI = 0.12, 0.42)) at 12-month follow-up. There was an indication that intervention participants subsequently judged their own lifestyles more critically than controls, with fewer reporting their behaviours as healthy (53.4% vs. 59.5%; adjusted PRR = 0.94 [0.87, 1.01]). We conclude that experiencing LifeLab led to improved health literacy in adolescents and that they demonstrated a move towards a more critical judgement of health behaviour 12 months after the intervention. Further work is needed to examine whether this leads to sustained behaviour change, and whether other activities are needed to support this change.

Teachers' self-efficacy beliefs in teaching food and nutrition subjects in Australian secondary schools

Purpose

Teachers play important roles in school food and nutrition education. This study aims to explore Australian teachers' self-efficacy beliefs (i.e. belief in their own capabilities to perform specific teaching tasks) in teaching secondary school food and nutrition-related subjects.

Design/methodology/approach

Teachers' overall self-efficacy beliefs in teaching these subjects (overall-SEB) and self-efficacy beliefs in teaching different food and nutrition-related topics (topics-SEB) were explored using a survey among 183 teachers in 2017. Principal components analysis derived three overall-SEB components: “Motivation and accommodation of individual differences”, “Classroom management” and “Communication and clarification” and three topics-SEB components: “Food system”, “Food and nutrition information” and “Food preparation”.

Findings

Overall, higher percentages of teachers were confident or very confident in the majority of items that loaded on “Classroom management” and “Communication and clarification” compared to “Motivation and accommodation of individual differences”. Moreover, higher percentages of teachers were confident or very confident about items that loaded on “Food and nutrition information” and “Food preparation” compared” to “Food system”. The overall-SEB and topics-SEB were higher among more experienced teachers. There were moderate positive correlations between overall-SEB and topics-SEB components.

Originality/value

The exploration of broader aspects of self-efficacy beliefs related to teaching secondary school food and nutrition-related subjects makes this study unique. The findings highlight that these teachers had high self-efficacy beliefs in teaching food and nutrition education, but there are gaps in tailoring the teaching process to meet the diverse needs of students and teaching broader food-related topics.

A cluster randomised controlled trial of a secondary school intervention to reduce intake of sugar-sweetened beverages: Mid-intervention impact of switchURsip environmental strategies

ISSUE ADDRESSED

Secondary schools provide an opportune setting for interventions addressing excessive sugar-sweetened beverage (SSB) intake in adolescence. This trial aimed to assess the impact of school environmental strategies, delivered as part of a broader intervention, among Year 7-9 students' SSB consumption.

METHODS

Between March and July 2018, we conducted a cluster randomised controlled trial with 862 students attending six secondary schools (3 intervention and 3 control) in New South Wales. The intervention targeted SSB availability, placement, promotion and pricing, and increased availability and promotion of water. Control schools followed their usual programmes. Primary outcomes included mean daily SSB consumption (millilitres) and mean daily percentage energy from SSB (kilojoules). Sub-group analysis explored primary outcomes for gender, school year level and frequency of canteen use.

RESULTS

Of the 2265 eligible students, 1092 (50.2%) provided active parental consent and 940 (86.0%) participated in baseline data collection. No significant differences were observed between groups at follow-up for mean daily SSBs consumed (-10.17 mL, CI: -24.78; 45.12, P = 0.57) or mean daily percentage energy from SSBs (-0.20%, CI: -0.87; 0.47, P = .56). Significant effects were observed among girls in intervention compared to girls in control schools for mean daily SSB consumption (-52.02 mL, CI 99.8; 94.14, P = .03) and mean daily percentage of energy from SSBs (-0.90%, CI: -1.82; 0.02, P = .05).

CONCLUSIONS

At 3-month mid-intervention evaluation, the intervention failed to impact on mean daily consumption and mean percentage energy from SSBs, overall. However, an intervention effect was observed in girls. The limited overall effect is likely due to inadequate intervention dose related to the short duration, limiting opportunities for schools to fully implement the environmental strategies. SO WHAT?: A longer intervention duration with additional implementation support to allow adequate time to embed the strategies within the school is recommended. Implementation support strategies would ensure staff are supported throughout the process.

The effect of physical activity intervention and nutritional habits on anthropometric measures in elementary school children: the health oriented pedagogical project (HOPP)

BACKGROUND

Overweight and obesity are a burden of the modern world that requires urgent action. Prevention has proven to be efficient in the fight against overweight and obesity. As many children gain excessive weight at an early age, intervention during school years are important. While daily physical activity (PA) is known to have an influence on overweight and obesity prevention, the importance of a healthy lifestyle, including dietary habits, should not be underestimated. The aim of this study was to assess how a combination of daily PA and healthy/unhealthy diet affect the anthropometric measures of 4th graders in Norway.

METHODS

The Health Oriented Pedagogical Project (HOPP) is a longitudinal intervention in primary school children, which includes increased amount of daily physical activity during teaching- active learning. Assessed were weight, muscle and bone mass, as well as fat mass, using a bio-impedance Tanita scale. A dietary survey, Ungkost 2000, with 18 multiple-choice questions was used to evaluate the overall nutrition characteristics of the children.

RESULTS

Between 2015 and 2018, a total of 917 (intervention group n = 614, control group n = 303) 4th graders from nine different schools from the south-east part of Norway participated. We observed that daily PA and a regular healthy diet increases-while an unhealthy diet decreases-muscle and bone mass despite daily PA. Daily PA appears to counteract some of the effects of an unhealthy diet on weight and fat mass. In addition, daily PA and a regular intake of fruits and berries lowers weight and fat mass in children with overweight.

CONCLUSION

Combination of daily 45-minute of PA and a healthy diet leads to reductions in body weight and incease in muscle and bone mass in elementary school children.

Magnitude of Overweight, Obesity and Insufficient Physical Sports Activities Among Secondary School Students in Kinondoni Municipal, Dar es Salaam

INTRODUCTION

There is an overwhelming increase of Non-Communicable Disease worldwide such as diabetes and cardiovascular diseases. Overweight and obesity are highly associated with development of these diseases. Unhealthy lifestyle such as excessive sugar, alcohol intake and lack of adequate physical activities has been associated with development of obesity. However, these risk factors are not well elucidated among adolescents in Tanzania. We conducted this survey to determine obesity, overweight, self-reported physical activities, and preferred foods among secondary school students in Kinondoni Municipal in Dar es salaam, Tanzania.

METHODS

A cross sectional descriptive survey was conducted among secondary school students at Kambangwa and Makumbusho secondary schools in Kinondoni municipal in Dar es Salaam city. A simple random sampling technique was used to select participating schools with systemic random selection procedure was used to select participants. A pre structured, self-administered questionnaire was used to collect demographic information from the participants. Anthropometric measurement for Body Mass Index (BMI) was done using standard tools. Interpretation of the findings was done using World Health Organization (WHO) standard charts for age and sex. Data were analysed using Statistical Package for Social Sciences (SPSS version 20; SPSS Inc., Chicago, US).

RESULTS

A total of 234 participants were enrolled in the study. A total of 204 (87.2%) of study participants reported to regularly participate in physical sports activities. Furthermore, Males reported to participate more in physical sports activities compared to females (χ2 (1) =8.13., p = 0.004). During sex-wise comparison, 30 (46.2%) of males reported to participate in sports once per week compared to 71 (51.5%) of females. Reported frequency was influenced by participants' sex (χ2 (3) =16.4., p= 0.001). A total of 28 (12%) participants reported fruits as their favourite food. Food preference was influenced by the participants' sex (X 2 (5) =13.1., p < 0.02). 32(47.7%) of males reported fresh fruits juice as their favourite drink compared to 106(63.5%) of females) while 6(9%) of males reported to prefer commercial industrial juice compared to 4 (2.4%) of females.

CONCLUSION

Obesity and overweight are prevalent among secondary school adolescents in Kinondoni Municipal, Dar es salaam. In addition, the magnitude of physical activities was below the recommended amount. Therefore, awareness campaigns and advocacy programs aiming at preventive measures against NCDs such as healthy eating behaviour and promotion of physical activities among adolescents should be given high priority.

School-based obesity prevention interventions in Latin America: A systematic review

OBJECTIVE

To evaluate the implementation and effectiveness of school-based interventions to prevent obesity conducted in Latin America and provide suggestions for future prevention efforts in countries of the region.

METHODS

Articles published in English, Spanish, and Portuguese between 2000 and 2017 were searched in four online databases (Google Scholar, PubMed, LILACS, and REDALYC). Inclusion criteria were: studies targeting school-aged children and adolescents (6-18 years old), focusing on preventing obesity in a Latin American country using at least one school-based component, reporting at least one obesity-related outcome, comprising controlled or before-and-after design, and including information on intervention components and/or process.

RESULTS

Sixteen studies met the inclusion criteria. Most effective interventions (n = 3) had moderate quality and included multi-component school-based programs to promote health education and parental involvement focused on healthy eating and physical activity behaviors. These studies also presented a better study designs, few limitations for execution, and a minimum duration of six months.

CONCLUSIONS

Evidence-based prevention experiences are important guides for future strategies implemented in the region. Alongside gender differences, an adequate duration, and the combined use of quantitative and qualitative evaluation methods, evidence-based prevention should be considered to provide a clearer and deeper understanding of the true effects of school-based interventions.

A systematic review of the determinants of seafood consumption

Although seafood is considered to be an important part of a balanced diet, many national food consumption surveys suggest that seafood is not consumed in sufficient amounts. As consumers are moving to diversify their diet from animal-based protein, it is important to understand the factors influencing consumption of marine foods. This review aims to assess the characteristics of seafood consumers as well as the influences on seafood consumption in Europe, USA, Canada, Australia and New Zealand. Systematic search strategies were used to identify relevant journal articles from three electronic databases (PubMed, Web of Science and Embase). Three searches were carried out and identified 4405 unique publications from which 121 met the criteria for the review process. The reviewed studies revealed that seafood consumers were more likely to be older, more affluent and more physically active and were less likely to smoke compared with non-seafood consumers. Sex and BMI did not appear to have a directional association with seafood consumption. The most commonly reported barriers to seafood consumption were cost, followed by sensory or physical barriers, health and nutritional beliefs, habits, availability and cooking skills. The most commonly reported influences were beliefs about the contribution of seafood to health, environmental influences and personal preferences. Based on the findings of this review, future intervention strategies to increase seafood consumption may need to consider affordability and education in terms of health, nutrition and cooking skills. More research is needed to explore the effectiveness of specific interventions at increasing the consumption of seafood.

Effects of the KEIGAAF intervention on the BMI z-score and energy balance-related behaviors of primary school-aged children

The aim of the current study was to evaluate the one- and two-year effectiveness of the KEIGAAF intervention, a school-based mutual adaptation intervention, on the BMI z-score (primary outcome), and energy balance-related behaviors (secondary outcomes) of children aged 7-10 years.A quasi-experimental study was conducted including eight intervention schools and three control schools located in low socioeconomic neighborhoods in the Netherlands. Baseline measurements were conducted in March and April 2017 and repeated after one and 2 years. Data were collected on children's BMI z-score, sedentary behavior (SB), physical activity (PA) behavior, and nutrition behavior through the use of anthropometric measurements, accelerometers, and questionnaires, respectively. All data were supplemented with demographics, and weather conditions data was added to the PA data. Based on the comprehensiveness of implemented physical activities, intervention schools were divided into schools having a comprehensive PA approach and schools having a less comprehensive approach. Intervention effects on continuous outcomes were analyzed using multiple linear mixed models and on binary outcome measures using generalized estimating equations. Intervention and control schools were compared, as well as comprehensive PA schools, less comprehensive PA schools, and control schools. Effect sizes (Cohen's d) were calculated.In total, 523 children participated. Children were on average 8.5 years old and 54% were girls. After 2 years, intervention children's BMI z-score decreased (B = -0.05, 95% CI -0.11;0.01) significantly compared to the control group (B = 0.20, 95% CI 0.09;0.31). Additionally, the intervention prevented an age-related decline in moderate-to-vigorous PA (MVPA) (%MVPA: B = 0.95, 95% CI 0.13;1.76). Negative intervention effects were seen on sugar-sweetened beverages and water consumption at school, due to larger favorable changes in the control group compared to the intervention group. After 2 years, the comprehensive PA schools showed more favorable effects on BMI z-score, SB, and MVPA compared to the other two conditions.This study shows that the KEIGAAF intervention is effective in improving children's MVPA during school days and BMI z-score, especially in vulnerable children. Additionally, we advocate the implementation of a comprehensive approach to promote a healthy weight status, to stimulate children's PA levels, and to prevent children from spending excessive time on sedentary behaviors.Trial registrationNetherlands Trial Register, NTR6716 ( NL6528 ), Registered 27 June 2017 - retrospectively registered.

A Web-Based Intervention to Prevent Multiple Chronic Disease Risk Factors Among Adolescents: Co-Design and User Testing of the Health4Life School-Based Program

BACKGROUND

Chronic diseases are the leading cause of death worldwide. Addressing key lifestyle risk factors during adolescence is critical for improving physical and mental health outcomes and reducing chronic disease risk. Schools are ideal intervention settings, and electronic health (eHealth) interventions afford several advantages, including increased student engagement, scalability, and sustainability. Although lifestyle risk behaviors tend to co-occur, few school-based eHealth interventions have targeted multiple behaviors concurrently.

OBJECTIVE

This study aims to summarize the co-design and user testing of the Health4Life school-based program, a web-based cartoon intervention developed to concurrently prevent 6 key lifestyle risk factors for chronic disease among secondary school students: alcohol use, smoking, poor diet, physical inactivity, sedentary recreational screen time, and poor sleep (the Big 6).

METHODS

The development of the Health4Life program was conducted over 18 months in collaboration with students, teachers, and researchers with expertise relevant to the Big 6. The iterative process involved (1) scoping of evidence and systematic literature review; (2) consultation with adolescents (N=815) via a cross-sectional web-based survey to identify knowledge gaps, attitudes, barriers, and facilitators in relation to the Big 6; (3) content and web development; and (4) user testing of the web-based program with students (n=41) and teachers (n=8) to evaluate its acceptability, relevance, and appeal to the target audience.

RESULTS

The co-design process resulted in a six-module, evidence-informed program that uses interactive cartoon storylines and web-based delivery to engage students. Student and teacher feedback collected during user testing was positive in terms of acceptability and relevance. Commonly identified areas for improvement concerned the length of modules, age appropriateness of language and alcohol storyline, the need for character backstories and links to syllabus information, and feasibility of implementation. Modifications were made to address these issues.

CONCLUSIONS

The Health4Life school-based program is the first universal, web-based program to concurrently address 6 important chronic disease risk factors among secondary school students. By adopting a multiple health behavior change approach, it has the potential to efficiently modify the Big 6 risk factors within one program and to equip young people with the skills and knowledge needed to achieve and maintain good physical and mental health throughout adolescence and into adulthood.

Effects of Lifestyle Modification Interventions to Prevent and Manage Child and Adolescent Obesity: A Systematic Review and Meta-Analysis

The objective of this review was to assess the impact of lifestyle interventions (including dietary interventions, physical activity, behavioral therapy, or any combination of these interventions) to prevent and manage childhood and adolescent obesity. We conducted a comprehensive literature search across various databases and grey literature without any restrictions on publication, language, or publication status until February 2020. We included randomized controlled trials and quasi-experimental studies from both high income countries (HIC) and low-middle-income countries (LMICs). Participants were children and adolescents from 0 to 19 years of age. Studies conducted among hospitalized children and children with any pre-existing health conditions were excluded from this review. A total of 654 studies (1160 papers) that met the inclusion criteria were included in this review. A total of 359 studies targeted obesity prevention, 280 studies targeted obesity management, while 15 studies targeted both prevention and management. The majority of the studies (81%) were conducted in HICs, 10% of studies were conducted in upper middle income countries, while only 2% of the studies were conducted in LMICs. The most common setting for these interventions were communities and school settings. Evidence for the prevention of obesity among children and adolescents suggests that a combination of diet and exercise might reduce the BMI z-score (MD: -0.12; 95% CI: -0.18 to -0.06; 32 studies; 33,039 participants; I2 93%; low quality evidence), body mass index (BMI) by 0.41 kg/m2 (MD: -0.41 kg/m2; 95% CI: -0.60 to -0.21; 35 studies; 47,499 participants; I2 98%; low quality evidence), and body weight (MD: -1.59; 95% CI: -2.95 to -0.23; 17 studies; 35,023 participants; I2 100%; low quality evidence). Behavioral therapy alone (MD: -0.07; 95% CI: -0.14 to -0.00; 19 studies; 8569 participants; I2 76%; low quality evidence) and a combination of exercise and behavioral therapy (MD: -0.08; 95% CI: -0.16 to -0.00; 9 studies; 7334 participants; I2 74%; low quality evidence) and diet in combination with exercise and behavioral therapy (MD: -0.13; 95% CI: -0.25 to -0.01; 5 studies; 1806 participants; I2 62%; low quality evidence) might reduce BMI z-score when compared to the control group. Evidence for obesity management suggests that exercise only interventions probably reduce BMI z-score (MD: -0.13; 95% CI: -0.20 to -0.06; 12 studies; 1084 participants; I2 0%; moderate quality evidence), and might reduce BMI (MD: -0.88; 95% CI: -1.265 to -0.50; 34 studies; 3846 participants; I2 72%) and body weight (MD: -3.01; 95% CI: -5.56 to -0.47; 16 studies; 1701 participants; I2 78%; low quality evidence) when compared to the control group. and the exercise along with behavioral therapy interventions (MD: -0.08; 95% CI: -0.16 to -0.00; 8 studies; 466 participants; I2 49%; moderate quality evidence), diet along with behavioral therapy interventions (MD: -0.16; 95% CI: -0.26 to -0.07; 4 studies; 329 participants; I2 0%; moderate quality evidence), and combination of diet, exercise and behavioral therapy (MD: -0.09; 95% CI: -0.14 to -0.05; 13 studies; 2995 participants; I2 12%; moderate quality evidence) also probably decreases BMI z-score when compared to the control group. The existing evidence is most favorable for a combination of interventions, such as diet along with exercise and exercise along with behavioral therapy for obesity prevention and exercise alone, diet along with exercise, diet along with behavioral therapy, and a combination of diet, exercise, and behavioral therapy for obesity management. Despite the growing obesity epidemic in LMICs, there is a significant dearth of obesity prevention and management studies from these regions.

Are primary/elementary school-based interventions effective in preventing/ameliorating excess weight gain? A systematic review of systematic reviews

This systematic review of systematic reviews addresses a current gap in evidence by synthesizing findings relating to weight management interventions set entirely in primary/elementary schools targeting, diet, and/or physical activity as key strategies. Eight databases were searched for systematic reviews of trials of school-based interventions targeting children aged 4 to 12 years that looked at biometric and behavioral outcomes. From the 10 selected systematic reviews, we found that interventions designed to promote physical activity or reduce sedentary behavior were most effective for weight loss. Interventions designed to improve diet and nutrition had a small effect on behavioral and cognitive outcomes, and these outcomes could be enhanced through the use of experiential learning. The most effective interventions involved a range of stakeholders in the development process and included parents and families in implementation. This systematic review of systematic reviews offers evidence-based guidance for the development and implementation of multistrategy weight-management interventions in primary/elementary schools.

Children Food and Nutrition Literacy - a New Challenge in Daily Health and Life, the New Solution: Using Intervention Mapping Model Through a Mixed Methods Protocol

Food and nutrition literacy is a fundamental and new idiom among health policymakers. Improving children's food and nutrition literacy is a fundamental task, and it requires detailed planning. The aim of this study is to design, implement, and evaluate a food and nutrition literacy promotion intervention in elementary school children based on the Intervention Mapping model. This is a sequential study to design, implement, and evaluate a food and nutrition literacy promotion intervention in elementary school children aged 10-12 years old in Baneh city (Kurdistan, Iran). The study has three sequential phases, six steps based on the Intervention Mapping model, and four sub-studies. The questionnaire was transformed and culturally adapted since it was previously built for the city of Tehran; the results of a population-based cross-sectional survey indicated that the score for understanding food and nutrition information of a sample of 390 students aged 10-12 was mostly moderate and low (90.3% of participants). Therefore, a qualitative study on how to fix existing barriers, and extract facilitators and the best methods of interventions for promoting food and nutrition literacy of participants was conducted. Finally, an interventional study within six months for two intervention and control groups of elementary children 10-12 years old was carried out. The findings of this research will be used to design interventions and strategies based on needs assessment for improving students' skills in food and nutrition literacy in all dimensions of food and nutrition literacy.

Impacts of school feeding on educational and health outcomes of school-age children and adolescents in low- and middle-income countries: protocol for a systematic review and meta-analysis

BACKGROUND

School feeding programs are beneficial for the physical, mental, and psychosocial development of school-age children and adolescents, particularly those in low- and middle-income countries (LMICs). While school feeding programs are ubiquitous in LMICs, the specific benefits of school feeding programs are unclear. The aim of this systematic review and meta-analysis is to evaluate the impacts of school feeding programs on the educational and health outcomes of children and adolescents in LMICs.

METHODS

Rigorously designed interventional studies on the impacts of school feeding on nutritional and health outcomes of children and adolescents receiving primary or secondary education in LMICs will be included. The following information sources were used to identify relevant published or unpublished studies: MEDLINE, EMBASE, CINAHL, the Cochrane Library, and governmental or organizational websites. The risk of bias of randomized and non-randomized studies will be assessed using the Cochrane Risk of Bias tool and the ROBINS-I tool, respectively. Two reviewers will independently conduct the selection of studies, data extraction, and assessment of the risk of bias. A narrative synthesis of all the included studies will be provided. Meta-analyses will be performed whenever appropriate. Heterogeneity of effects will be assessed by I², subgroup analyses, and meta-regression. The certainty of evidence for each outcome will be assessed using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach.

DISCUSSION

The design and implementation of school feeding programs in LMICs should be based on the understanding of the benefits of such programs. This work will provide a crucial evidence base for the educational and health benefits of school feeding on children and adolescents in LMICs.

SYSTEMATIC REVIEW REGISTRATION

This protocol was submitted for registration with the International Prospective Register of Systematic Reviews (PROSPERO) on November 18, 2019 (registration number: pending).

Clustering of lifestyle risk factors for non-communicable diseases in 304,779 adolescents from 89 countries: A global perspective

The precursors of non-communicable diseases (NCDs) are often manifested during childhood and adolescence with little knowledge about co-occurrence of their related lifestyle risk factors. To address this deficit, we estimated the prevalence and clustering of six major NCD-risk factors in adolescents around the world. Data from the Global School-based Student Health Survey, collected between 2007 and 2016, were analysed in 304,779 adolescents aged 11-17 years (52.2% females) from 89 countries. We compared the observed (O) to expected (E) prevalence ratios of 64 possible combinations of six risk factors to determine their clustering patterns. Overall, 82.4% (95% CI 82.1-82.7) of adolescents had ≥2 risk factors, while 34.9% (34.6-35.3) had ≥3. Adolescents aged 16-17 years, compared to those aged 11-13 years, had higher odds (OR 1.33; 95% CI 1.31-1.36) of reporting ≥3 risk factors. Risk factors clustered in multiple combinations and differed by sex. The clustering of physical inactivity and low fruit and vegetable intake was evident in both males (O/E 1.10; 95% CI 1.07-1.12) and females (1.08; 1.06-1.10). The co-occurrence of cigarette smoking, alcohol drinking, physical inactivity, and low fruit and vegetable intake was 165% greater in females (2.65; 2.28-3.07) and 110% greater in males (2.10; 1.90-2.32) than expected. Globally, adolescents exhibit multiple modifiable risk factors for future development of NCDs. Early gender-specific prevention strategies targeting clusters of lifestyle risk factors should be prioritised to help mitigate future burden of NCDs globally. Periodical collection of behavioural risk factor data should be encouraged to facilitate a sustainable global surveillance.

Implementation of KEIGAAF in Primary Schools: A Mutual Adaptation Physical Activity and Nutrition Intervention

School health promotion is advocated. Implementation studies on school health promotion are less often conducted as effectiveness studies and are mainly conducted conventionally by assessing fidelity of "one size fits all" interventions. However, interventions that allow for local adaptation are more appropriate and require a different evaluation approach. We evaluated a mutual adaptation physical activity and nutrition intervention implemented in eight primary schools located in low socioeconomic neighborhoods in the Netherlands, namely the KEIGAAF intervention. A qualitative, multiple-case study design was used to evaluate implementation and contextual factors affecting implementation. We used several qualitative data collection tools and applied inductive content analysis for coding the transcribed data. Codes were linked to the domains of the Consolidated Framework for Implementation Research. NVivo was used to support data analysis. The implementation process varied greatly across schools. This was due to the high level of bottom-up design of the intervention and differing contextual factors influencing implementation, such as differing starting situations. The mutual adaptation between top-down and bottom-up influences was a key element of the intervention. Feedback loops and the health promotion advisors played a crucial role by navigating between top-down and bottom-up. Implementing a mutual adaptation intervention is time-consuming but feasible.

School-Based Intervention Programs for Preventing Obesity and Promoting Physical Activity and Fitness: A Systematic Review

With the significant decrease in physical activity rates, the importance of intervention programs in the schools, where children spend a significant part of the day, has become indisputable. The purpose of this review is to systematically examine the possibility of school-based interventions on promoting physical activity and physical fitness as well as preventing obesity. A systematic approach adopting PRISMA statement was implemented in this study. Three different databases (2010-2019) were screened and primary and secondary school-based intervention programs measuring at least one variable of obesity, physical activity, or physical fitness were included. The risk of bias was assessed using the validated quality assessment tool for quantitative studies. Among 395 potentially related studies, 19 studies were found to meet the eligibility criteria. A general look at the studies examined reveals that among the outcomes, of which most (18/19) were examined, a significant improvement was provided in at least one of them. When the program details are examined, it can be said that the success rate of the physical activity-oriented programs is higher in all variables. School-based interventions can have important potential for obesity prevention and promotion of physical activity and fitness if they focus more on the content, quality, duration and priority of the physical activity.

The Impact of Mother-Child Dyad Dietary Intervention Using the Transtheoretical Model on Bone Mineral Density in Japanese Female Adolescents

PURPOSE

Peak bone mass, an important determinant of osteoporosis risk, is reached during adolescence. We evaluated the impact of mother-child dyad dietary intervention using the transtheoretical model (TTM) on bone mineral density in Japanese female adolescents.

DESIGN AND METHODS

The participants were dyads of female adolescents aged 15-16 years and their mothers (who are generally responsible for cooking). We enrolled 92 dyads, with 56 assigned to the intervention group and 36 to the control group. Bone mineral density was measured using quantitative ultrasound parameters (QUS). Nutrient intake and stage of behavioral change were collected via questionnaires. Evaluations were conducted at baseline and seven months later. The intervention group underwent the TTM-based dietary education program for six months.

RESULTS

After the intervention program, the ratio of change of the quantitative ultrasound parameter-speed of sound (SOS)-was significantly higher in the intervention than the control group (p < 0.001). Finally, we demonstrated that the intervention was found to significantly affect post-test outcomes in terms of SOS according to the result of analysis of covariance (p < 0.05).

CONCLUSIONS

Dietary intervention for female adolescents and their mothers using the TTM may enhance the bone mineral density in female adolescents.

PRACTICE IMPLICATIONS

We suggest that dietary intervention for female adolescents and their mothers using the transtheoretical model may enhance the bone mineral density in female adolescents.

Effects of a School Based Intervention on Children's Physical Activity and Healthy Eating: A Mixed-Methods Study

Combined diet and physical activity school-based interventions (rather than only diet or physical activity interventions) are more likely to help prevent children from becoming overweight in the long term. However, such interventions are less prevalent, and therefore, this pilot study aimed to assess the feasibility of a gardening intervention coupled with awareness about plant-based meals among 9-10 year old children in a London primary school. We recruited 60 children from two Year 5 classes, one class participated as an intervention group, and results were compared against another class who acted as the control group. Children's physical activity (PA) was measured using GENEActiv wrist-worn accelerometers. Their fruit and vegetable intake and attitudes to and preferences in eating fruits and vegetables were measured using a self-report questionnaire. Furthermore, three focus groups were held with children in the intervention group to understand the reasons behind any change as a result of the intervention. Results are inconclusive; however, they indicate some impact on reduction of sedentary behaviour, increase of moderate to vigorous PA, knowledge of nutrition and some level of acceptance in trying new vegetables. School-based interventions involving gardening show some promise to increase children's PA and improve their attitudes to eating fruits and vegetables.

Development of the 'Sigue la Huella' physical activity intervention for adolescents in Huesca, Spain

Engaging in physical activity (PA) on a regular and adequate basis generates considerable benefits for health. In developed countries, the time spent doing PA is decreasing, whilst sedentary time (ST) is increasing. A multicomponent school-based intervention programme, called 'Sigue la Huella' (Follow the Footprint), was developed to reduce sedentary lifestyles and increase PA levels. This programme has proven to be effective in increasing the daily levels of moderate to vigorous PA, in decreasing ST and in improving motivational outcomes in secondary education students, in the city of Huesca (Spain). The study design was quasi-experimental, longitudinal and by cohorts, and it was carried out in four schools, two as an experimental group (n = 368) and two as a control group (n = 314). During the 25 months' intervention, this programme adopted a holistic approach aiming to create favourable environments to engage in PA, and the empowerment of students to get actively involved in the design and execution of the activities, assuming responsibility for managing and optimizing their own PA. The programme is theoretically based on the social-ecological model and self-determination theory, and it provided evidence for four actions or components that can be used in school-based PA promotion: tutorial action, Physical Education at school, dissemination of information and participation in institutional programmes and events. The aim of this article is to describe the main characteristics of the intervention programme that have proved to be effective with respect to the objectives proposed.

Effects of body weight on the clinical and radiological outcomes of children with flexible flatfeet managed with the 'calcaneo-stop' procedure

This study aimed to evaluate the clinical and radiological outcomes of normal, overweight, and obese children with symptomatic flexible flatfeet managed with the 'calcaneo-stop' procedure (CSP), and to determine whether any correlation exists between patient weight and outcome. One hundred and seventy-four symptomatic flexible flatfeet were managed with CSP during the study period. The patients were divided into three groups according to their BMI and weight Z-scores: normal, overweight, and obese. Their clinical and radiographic outcomes were assessed preoperatively, and at 1 and 5 years after the index procedure. Although the radiographic criteria were comparable between the three groups, the clinical outcome was worse in obese children than in normal and overweight patients (P<0.05). BMI and the Z-score affected the outcomes of obese patients treated with CSP for symptomatic flexible flatfeet. Although the radiographic outcome was similar irrespective of BMI and Z-scores, obese patients had significantly lower clinical scores than the other patients.

The effect of introducing a free breakfast club on eating habits among students at vocational schools

Background

Unhealthy eating habits are a major problem among adolescents. The objective of the study was to assess the effect of a free breakfast club intervention on dietary habits among students at vocational schools.

Methods

The study included students (n = 318) from four vocational schools in Denmark. Food frequency questionnaires were used to measure eating habits at baseline, first, and second follow-up, after 7 and 14 weeks respectively, in a clustered randomized controlled intervention of four months. The effect of the intervention was evaluated through self-reported frequencies of breakfast intake, intake of whole grain products for breakfast and intake of unhealthy snacking in the morning. The outcome measures were daily breakfast intake (yes/no), daily intake of whole grain for breakfast (yes/no), and unhealthy snacking on school day mornings (yes/no).

Results

The proportion of students who had breakfast every school day increased significantly in the intervention schools from baseline to the first follow-up compared to the control group (OR: 3.77; P = 0.0149). The effect was attenuated at the second follow-up. The intake of whole grain products for breakfast increased significantly more among students in intervention schools compared to students in control schools both at first (OR: 4.13; P = 0.0079) and second follow-up (OR: 3.27; P = 0.0317). No significant change in unhealthy snacking was found.

Conclusion

Provision of free breakfast at vocational schools can improve the dietary quality of breakfast and decrease breakfast skipping. However, the sustainability of the intervention is a critical issue that needs to be further studied and addressed.

Trial registration

ISRCTN11265280. Registered 20 November 2018 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6701-9) contains supplementary material, which is available to authorized users.

Delivering in-school interventions to improve dietary behaviours amongst 11- to 16-year-olds: A systematic review

Childhood obesity is a global health concern, which has both short- and long-term health consequences for the individual, and is a potential burden on health care services and the wider economy. The school environment is a setting where changes can be applied to dietary behaviours, as schools have direct and intensive contact with children. This systematic review evaluated school-based interventions designed to improve dietary behaviours among adolescents (11- to 16-year-olds). The aims were to review types of interventions delivered, dietary behaviours targeted, and interventions' effectiveness in improving dietary behaviour and associated intervention components. Twenty-nine school-based interventional studies with this population were identified for review. The data were synthesized by identifying and comparing individual studies' results, intervention components, and characteristics. Interventions appeared more effective when they involved peers, used educational media to deliver health messages, increased availability of healthy foods in school, and incorporated computer-based individualized feedback with normative information on eating behaviours. A limitation of the review was the lack of description in certain reviewed studies and the nonfeasibility of conducting a meta-analysis owing to study heterogeneity. Future interventions with this population could consider including the aforementioned components, gender-specific feedback, and both short- and long-term follow-ups as change may not be apparent immediately and to determine if changes are sustained.

Effect of implementing school meals compared with packed lunches on quality of dietary intake among children aged 7-13 years

Strategies are needed to improve the dietary habits of children. The aim of the present study was to evaluate the effect of implementing a school food programme on the dietary quality of lunches consumed by school children aged 7–13 years compared with packed lunches brought from home. A secondary objective was to investigate if a possible effect would differ between the younger children and the older. A quasi-experimental study design with four intervention schools and four matched control schools was conducted. In total, 984 school children participated. Data on packed lunches were collected at baseline. At the 1st follow-up the children in the intervention schools were offered free school meals and at the 2nd follow-up children paid for their school meals. The control group had packed lunches at all measurements. A digital photographic method combined with a Meal Index of dietary Quality (Meal IQ) was used for dietary assessment. Multilevel modelling was employed for data analyses. The quality of dietary intake was improved when free school meals were offered (P = 0·004); if the school meals were paid for the use was limited and no difference in change in dietary quality was found (P = 0·343). The school food programme had no difference in effect according to age (P = 0·083). In conclusion, offering a free school meal had a positive effect on dietary quality of the lunches consumed by school children aged 7–13 years. No effect was measured when the school meals were not provided for free. The dietary effect did not depend on age.

Health benefits of electrically-assisted cycling: a systematic review

BACKGROUND

Electrically assisted bicycles (e-bikes) have been highlighted as a method of active travel that could overcome some of the commonly reported barriers to cycle commuting. The objective of this systematic review was to assess the health benefits associated with e-cycling.

METHOD

A systematic literature review of studies examining physical activity, cardiorespiratory, metabolic and psychological outcomes associated with e-cycling. Where possible these outcomes were compared to those from conventional cycling and walking. Seven electronic databases, clinical trial registers, grey literature and reference lists were searched up to November 2017. Hand searching occurred until June 2018. Experimental or observational studies examining the impact of e-cycling on physical activity and/or health outcomes of interest were included. E-bikes used must have pedals and require pedalling for electric assistance to be provided.

RESULTS

Seventeen studies (11 acute experiments, 6 longitudinal interventions) were identified involving a total of 300 participants. There was moderate evidence that e-cycling provided physical activity of at least moderate intensity, which was lower than the intensity elicited during conventional cycling, but higher than that during walking. There was also moderate evidence that e-cycling can improve cardiorespiratory fitness in physically inactive individuals. Evidence of the impact of e-cycling on metabolic and psychological health outcomes was inconclusive. Longitudinal evidence was compromised by weak study design and quality.

CONCLUSION

E-cycling can contribute to meeting physical activity recommendations and increasing physical fitness. As such, e-bikes offer a potential alternative to conventional cycling. Future research should examine the long-term health impacts of e-cycling using rigorous research designs.