Concepts and strategies on how to train and motivate teachers to implement a kindergarten-based, family-involved intervention to prevent obesity in early childhood. The ToyBox-study

Optimal timing of introduction of complementary feeding: a systematic review and meta-analysis

CONTEXT

The timing of introducing complementary feeding (CF) is crucial because premature or delayed CF can be associated with adverse health outcomes in childhood and adulthood.

OBJECTIVE

This systematic review aims to evaluate the impact of the timing of CF introduction on health, nutrition, and developmental outcomes among normal-term infants.

DATA SOURCES

Electronic databases and trial registries were searched, along with the reference lists of the included studies and relevant systematic reviews.

DATA EXTRACTION

Two investigators independently extracted data from the included studies on a standardized data-extraction form.

DATA ANALYSIS

Data were meta-analyzed separately for randomized controlled trials (RCTs) and observational studies on the basis of early introduction of CF (< 3 months, < 4 months, < 6 months of age) or late introduction of CF (> 6 months, > 8 months of age). Evidence was summarized according to GRADE criteria. In total, 268 documents were included in the review, of which 7 were RCTs (from 24 articles) and 217 were observational studies (from 244 articles). Evidence from RCTs did not suggest an impact of early introduction, while low-certainty evidence from observational studies suggested that early introduction of CF (< 6 months) might increase body mass index (BMI) z score and overweight/obesity. Early introduction at < 3 months might increase BMI and odds of lower respiratory tract infection (LRTI), and early introduction at < 4 months might increase height, LRTI, and systolic and diastolic blood pressure (BP). For late introduction of CF, there was a lack of evidence from RCTs, but low-certainty evidence from observational studies suggests that late introduction of CF (> 6 months) might decrease height, BMI, and systolic and diastolic BP and might increase odds of intestinal helminth infection, while late introduction of CF (> 8 months) might increase height-for-age z score.

CONCLUSION

Insufficient evidence does suggest increased adiposity with early introduction of CF. Hence, the current recommendation of introduction of CF should stand, though more robust studies, especially from low- and middle-income settings, are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020218517.

Implementation of Healthy Eating Interventions in Center-Based Childcare: The Selection, Application, and Reporting of Theories, Models, and Frameworks

PURPOSE

To explore the selection, use, and reporting of theories, models, and frameworks (TMFs) in implementation studies that promoted healthy eating in center-based childcare.

DATA SOURCE

We searched 11 databases for articles published between January 1990 and October 2018. We also conducted a hand search of studies and consulted subject matter experts.

STUDY INCLUSION AND EXCLUSION CRITERIA

We included studies in center-based settings for preschoolers that addressed the development, delivery, or evaluation of interventions or implementation strategies related to healthy eating and related subjects and that explicitly used TMF. Exclusion criteria include not peer reviewed or abstracts and not in English, French, German, and Korean.

DATA EXTRACTION

The first author extracted the data using extraction forms. A second reviewer verified data extraction.

DATA SYNTHESIS

Direct content analysis and narrative synthesis.

RESULTS

We identified 8222 references. We retained 38 studies. Study designs included quasi-experimental, randomized controlled trials, surveys, case studies, and others. The criteria used most often for selecting TMFs were description of a change process (n = 12; 23%) or process guidance (n = 8; 15%). Theories, models, and frameworks used targeted different socioecological levels and purposes. The application of TMF constructs (e.g., factors, steps, outcomes) was reported 69% (n = 34) of times.

CONCLUSION

Reliance on TMFs focused on individual-level, poor TMF selection, and application and reporting for the development of implementation strategies could limit TMF utility.

Development of the DAGIS intervention study: a preschool-based family-involving study promoting preschoolers' energy balance-related behaviours and self-regulation skills

Background

Preschoolers’ energy balance-related behaviours (EBRBs) and self-regulation skills are important for their later health. Few preschool-based interventions aiming to promote preschoolers’ EBRBs and self-regulation skills, simultaneously reducing differences in EBRBs, due to children’s socio-economic status (SES) background, have been conducted. This study will present the Increased Health and Wellbeing in Preschools (DAGIS) intervention development process applying the Intervention Mapping (IM) framework.

Methods

The development of the DAGIS intervention study, a preschool level clustered randomized controlled trial (RCT), was based on the IM framework. The protocol in IM guides the development process of an intervention through six steps: needs assessment and logic model of the problem, programme outcomes and objectives, design of the programme, production, implementation plan, and evaluation plan.

Results

The needs assessment, part of the step 1 in IM, yielded the base for the DAGIS logic model of change. The model includes objectives related to changes in children’s EBRBs, self-regulation skills, and in psychosocial and physical environment that is determined by parents and early educators. A 22-week programme was developed, and materials for preschools and families were produced. A feasibility study of the recruitment processes, acceptability of the materials and methods, and implementation was conducted. The DAGIS intervention study was conducted September 2017–May 2018 as a clustered RCT including a comprehensive effectiveness and process evaluation. The process evaluation was run throughout the intervention targeting preschools and families.

Conclusion

A preschool-based family-involving programme was developed in the DAGIS intervention study by applying the IM protocol. It was a time- and resource-consuming process. However, the systematic planning, development, and running of the programme have reinforced a comprehensive evaluation, which is a strength in the intervention. The results from the evaluation will enhance the knowledge of how to promote EBRBs and self-regulation skills among preschoolers, and diminish SES differences in them.

Trial registration

ISRCTN57165350 (Prospectively registered January the 8th, 2015).

School Teachers' Awareness about National Obesity Prevention Programs in Turkey

Nutritional programs are one of the most important public health policies in order to prevent obesity. School teachers are role models for students and their nutrition knowledge about these policies can affect children's dietary habits. The aim of this observational descriptive study was to evaluate the school teachers' awareness about nutrition programs for the prevention of obesity of the Ministry of Education in Turkey. It was conducted to 87,070 classroom teachers working at state schools from all the cities of Turkey. Data collection was obtained with a plain web-based survey, and national nutrition programs (Nutrition-Friendly School Program, White-Flag Protocol, and circular letter on foods can be sold in school canteens) were questioned. Mean age of teachers was 38.3 ± 9.30 years and 50.4% of them were male. It was determined that only 66.2% of the teachers know whether their school is nutrition-friendly. Frequency of knowing "White-Flag" Protocol was 80.1%. Present study showed that educational programs about nutrition policies are required in order to increase knowledge among school teachers and thus, prevent childhood obesity.

Adapting the ToyBox obesity prevention intervention for use in Scottish preschools: protocol for a feasibility cluster randomised controlled trial

INTRODUCTION

There is an increasing need for the adoption of effective preschool obesity prevention interventions to combat the high levels of early-childhood obesity in the UK. This study will examine the feasibility and acceptability of the adapted version of the ToyBox intervention-a preschool obesity prevention programme-for use in Scotland (ToyBox-Scotland). This will inform the design of a full-scale cluster randomised controlled trial (RCT).

METHODS AND ANALYSIS

The ToyBox-Scotland intervention will be evaluated using a feasibility cluster RCT, which involves children aged 3-5 years at six preschools in Glasgow, three randomly assigned to the intervention group and three to the usual-care control group. The original ToyBox intervention was adapted for the Scottish context using a coproduction approach. Within the 18-week intervention, physical activity and sedentary behaviour will be targeted in the preschool through environmental changes to the classroom, physical activity sessions and movement breaks. Parents will receive home activity packs every 3 weeks containing sticker incentives and interactive parent-child games that target sedentary behaviour, physical activity, eating/snacking and water consumption. As this is a feasibility study, parameters such as recruitment rates, attrition rates and SDs of outcome measures will be obtained which will inform a power calculation for a future RCT. Additional variables to be assessed include accelerometer-measured physical activity, sedentary behaviour and sleep, body mass index, home screen time, eating/snacking and water consumption. Outcomes will be assessed at baseline and 14-17 weeks later. Intervention fidelity will be assessed using questionnaires and interviews with parents and practitioners, observation and session delivery records.

ETHICS AND DISSEMINATION

This study was granted ethical approval by the University of Strathclyde's School of Psychological Sciences and Health Ethics Committee. Results will be disseminated through publication in peer-reviewed journals, presentation at conferences and in lay summaries provided to participants.

TRIAL REGISTRATION NUMBER

ISRCTN12831555.

SALTO - Study Protocol and Rationale of a Community-Oriented Obesity Prevention Program in the Kindergarten

BACKGROUND

The prevalence of early childhood overweight and obesity in Austria has reached average European levels of 20% in boys and 18% in girls. The rationale and study protocol of SALTO, Salzburg Together against Obesity will be presented, which is aimed to assist adults in increasing the rate of 4- to 6-year-old children with a healthy body weight.

METHODS

A controlled longitudinal sequential study design consisting of 14 intervention (IK) and 8 control (CK) kindergarten was used to investigate the effect of actions tailored for teachers and parents on BMI among 4- to 6-year-old children. The study launched in November 2014 was approved by the ethics committee of the University of Salzburg.

RESULTS

681 children, 181 parents (119 mothers, 62 fathers) and 30 teachers were investigated until October 2016. Preliminary analyses revealed that more boys (19%) and fathers (60% IK, 43% CK) were overweight and obese than girls (16%) and mothers (19% IK, 20% CK).

CONCLUSION

The challenges faced by the SALTO staff in the implementation of health-promoting actions in the kindergarten are manifold. The Community-Oriented Core Setting (COCS) intervention approach will show whether the actions will reduce the percentage of obesity and be sustainable in the long term.

Multibehavioural Interventions with a Focus on Specific Energy Balance-Related Behaviours Can Affect Diet Quality in Preschoolers from Six European Countries: The ToyBox-Study

The present study aimed to examine whether a multibehavioural intervention with a focus on specific energy balance-related behaviours can affect total diet quality and its four subcomponents in European preschoolers and to investigate if these intervention effects differed by socioeconomic status (SES). Parents/caregivers of 3.5 to 5.5 year-olds (n = 4968) recruited through kindergartens in six European countries within the ToyBox-study completed questionnaires on socio-demographics and a food frequency questionnaire on their preschoolers' diet. To assess intervention effects and differences by SES, multilevel repeated measures analyses were conducted. In contrast to no significant difference in total diet quality, in both the intervention and control group, the dietary quality and dietary equilibrium increased, with a larger increase in the intervention group (mean difference quality: +3.4%; mean difference equilibrium: +0.9%) compared to the control group (quality: +1.5%; equilibrium: +0.2%). SES was not a significant moderator for intervention effects on total diet quality, nor for the four subcomponents. This study indicates that multibehavioural interventions with a focus on specific energy balance-related behaviours in preschoolers not only affect those targeted behaviours, but can also have more generalized effects. The ToyBox-intervention effects were similar for both lower and high SES preschoolers.

A systematic review of methods to assess intake of sugar-sweetened beverages among healthy European adults and children: a DEDIPAC (DEterminants of DIet and Physical Activity) study

OBJECTIVE

Research indicates that intake of sugar-sweetened beverages (SSB) may be associated with negative health consequences. However, differences between assessment methods can affect the comparability of intake data across studies. The current review aimed to identify methods used to assess SSB intake among children and adults in pan-European studies and to inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods suitable for use in future European studies.

DESIGN

A literature search was conducted using three electronic databases and by hand-searching reference lists. English-language studies of any design which assessed SSB consumption were included in the review.

SETTING

Studies involving two or more European countries were included in the review.

SUBJECTS

Healthy, free-living children and adults.

RESULTS

The review identified twenty-three pan-European studies which assessed intake of SSB. The FFQ was the most commonly used (n 24), followed by the 24 h recall (n 6) and diet records (n 1). There were several differences between the identified FFQ, including the definition of SSB used. In total, seven instruments that were tested for validity were selected as potentially suitable to assess SSB intake among adults (n 1), adolescents (n 3) and children (n 3).

CONCLUSIONS

The current review highlights the need for instruments to use an agreed definition of SSB. Methods that were tested for validity and used in pan-European populations encompassing a range of countries were identified. These methods should be considered for use by future studies focused on evaluating consumption of SSB.

Food as a tool for learning in everyday activities at preschool - an exploratory study from Sweden

Background

There is a need for research both in relation to food education at preschools and in relation to how the individual teacher can handle and relate to the many different scientific facts and paradigms that are prevalent in relation to food, health, and a sustainable lifestyle.

Objective

The aim of this study was to explore the experiences and meanings that preschool teachers associate with involving food as a tool for learning in planned educational activities.

Design

An exploratory study was conducted in 14 preschools with 131 teachers. Twenty semi-structured individual or group interviews with 45 preschool staff were conducted, and 10 interviews were selected for analysis.

Results

According to participants, both children and teachers developed a sensory language; children became more positive towards tasting and teachers discovered new possibilities for interdisciplinary work. However, the results also show that an allowing system, with both an interested and confident teacher who recognises the competent child and a supportive organisation, is needed in order to make food a meaningful tool for learning in preschool.

Discussion

According to previous studies, food has the potential to play an important part in everyday activities at preschool, both in planned educational activities as well as at meal situations. Our results imply that a holistic understanding of food in preschool is required for long-term work with food as a natural part of the everyday activities.

Conclusion

The results imply that it is fun and meaningful for both children and teachers, and quite possible, to work with food as a tool for learning in everyday activities at preschool. In order to include food as a way to work with the preschool curriculum for a sustainable lifestyle, an allowing system is needed.

A systematic review of methods to assess intake of fruits and vegetables among healthy European adults and children: a DEDIPAC (DEterminants of DIet and Physical Activity) study

Objective

Evidence suggests that health benefits are associated with consuming recommended amounts of fruits and vegetables (F&V), yet standardised assessment methods to measure F&V intake are lacking. The current review aims to identify methods to assess F&V intake among children and adults in pan-European studies and inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods suitable for use in future European studies.

Design

A literature search was conducted using three electronic databases and by hand-searching reference lists. English-language studies of any design which assessed F&V intake were included in the review.

Setting

Studies involving two or more European countries were included in the review.

Subjects

Healthy, free-living children or adults.

Results

The review identified fifty-one pan-European studies which assessed F&V intake. The FFQ was the most commonly used (n42), followed by 24 h recall (n11) and diet records/diet history (n7). Differences existed between the identified methods; for example, the number of F&V items on the FFQ and whether potatoes/legumes were classified as vegetables. In total, eight validated instruments were identified which assessed F&V intake among adults, adolescents or children.

Conclusions

The current review indicates that an agreed classification of F&V is needed in order to standardise intake data more effectively between European countries. Validated methods used in pan-European populations encompassing a range of European regions were identified. These methods should be considered for use by future studies focused on evaluating intake of F&V.

Effect and Process Evaluation of a Cluster Randomized Control Trial on Water Intake and Beverage Consumption in Preschoolers from Six European Countries: The ToyBox-Study

Background

Within the ToyBox-study, a kindergarten-based, family-involved intervention was developed to prevent overweight and obesity in European preschoolers, targeting four key behaviours related to early childhood obesity, including water consumption. The present study aimed to examine the effect of the ToyBox-intervention (cluster randomized controlled trial) on water intake and beverage consumption in European preschoolers and to investigate if the intervention effects differed by implementation score of kindergartens and parents/caregivers.

Method

A sample of 4964 preschoolers (4.7±0.4 years; 51.5% boys) from six European countries (Belgium, Bulgaria, Germany, Greece, Poland, Spain) was included in the data analyses. A standardized protocol was used and parents/caregivers filled in socio-demographic data and a food-frequency questionnaire. To assess intervention effects, multilevel repeated measures analyses were conducted for the total sample and for the six country-specific samples. Based on the process evaluation questionnaire of teachers and parents/caregivers, an implementation score was constructed. To assess differences in water intake and beverage consumption by implementation score in the total sample, multilevel repeated measures analyses were performed.

Results

Limited intervention effects on water intake from beverages and overall beverage consumption were found. However, important results were found on prepacked fruit juice consumption, with a larger decrease in the intervention group compared to the control group. However, also a decline in plain milk consumption was found. Implementation scores were rather low in both kindergartens and parents/caregivers. Nevertheless, more favorable effects on beverage choices were found in preschoolers whose parents/caregivers and kindergarten teachers had higher implementation scores compared to those with lower implementation scores.

Conclusion

The ToyBox-intervention can provide the basis for the development of more tailor-made interventions. However, new strategies to improve implementation of interventions should be created.

Developing the intervention material to increase physical activity levels of European preschool children: the ToyBox-study

Early childhood is an important period for adopting positive health-related behaviours. More than 95% of European preschool children attend kindergartens, making these settings ideal for the implementation of health promotion interventions. The ToyBox-intervention addressed preschool children, their parents/caregivers and teachers. The aim of the intervention was to improve four energy balance-related behaviours (i.e. healthy snacking, water consumption, physical activity and sedentary behaviour) by implementing a kindergarten-based, family-involved intervention in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain). The intervention material was developed following the intervention mapping protocol, taking into account local and cultural differences among the intervention countries. The present paper focuses on the development of the physical activity component of the intervention. Parental involvement was addressed by providing parents/caregivers with two newsletters, two tip cards and a poster. Teachers received a handbook with guidance on environmental changes in the classroom, 26 physical education sessions and suggestions for fun, interactive classroom activities aiming at total class participation to increase preschoolers' physical activity levels. The ToyBox-intervention material was distributed according to a standard time frame. Teachers received their material prior to the start of the intervention and parents/caregivers received their material during the intervention when each energy balance-related behaviour was implemented.

Designing and implementing teachers' training sessions in a kindergarten-based, family-involved intervention to prevent obesity in early childhood. The ToyBox-study

Since school-based interventions are mainly delivered by the school staff, they need to be well-trained and familiarized with the programme's aims, procedures and tools. Therefore, the institute, research group, governmental or non-governmental body in charge of the coordination and implementation of the programme needs to devote time and resources to train the school staff before programme's implementation. This is particularly crucial in multi-centre studies where more than one research teams are involved. Both research teams and school staff need to be trained, using standard protocols and procedures, to ensure that the intervention will be delivered in a standardized manner throughout the intervention centres. The ToyBox-intervention, a multi-component, kindergarten-based, family-involved intervention, focusing on water consumption, snacking, physical activity and sedentary behaviours in preschool children, was implemented over the academic year 2012-2013 in six European countries. As part of this intervention, three teachers' training sessions were delivered to motivate and train teachers in implementing the intervention. The local researchers were trained centrally before delivering the training sessions for the teachers and followed a common protocol using standardized presentations and procedures. The aim of the current paper is to describe the protocol and methodological issues related to the teachers' training sessions conducted within the ToyBox-intervention.

Applying the Intervention Mapping protocol to develop a kindergarten-based, family-involved intervention to increase European preschool children's physical activity levels: the ToyBox-study

Although sufficient physical activity is beneficial for preschoolers' health, activity levels in most preschoolers are low. As preschoolers spend a considerable amount of time at home and at kindergarten, interventions should target both environments to increase their activity levels. The aim of the current paper was to describe the six different steps of the Intervention Mapping protocol towards the systematic development and implementation of the physical activity component of the ToyBox-intervention. This intervention is a kindergarten-based, family-involved intervention implemented across six European countries. Based on the results of literature reviews and focus groups with parents/caregivers and kindergarten teachers, matrices of change objectives were created. Then, theory-based methods and practical strategies were selected to develop intervention materials at three different levels: (i) individual level (preschoolers); (ii) interpersonal level (parents/caregivers) and (iii) organizational level (teachers). This resulted in a standardized intervention with room for local and cultural adaptations in each participating country. Although the Intervention Mapping protocol is a time-consuming process, using this systematic approach may lead to an increase in intervention effectiveness. The presented matrices of change objectives are useful for future programme planners to develop and implement an intervention based on the Intervention Mapping protocol to increase physical activity levels in preschoolers.