Effects of lifestyle-based interventions to improve Mediterranean diet adherence among the young population: a meta-analysis of randomized controlled trials

CONTEXT

Despite the large number of studies published to date, the effect of lifestyle-based interventions on improving adherence to the Mediterranean diet (MedDiet) in young people has not been meta-analyzed.

OBJECTIVE

The aim of the present systematic review and meta-analysis was two-fold: (1) to determine the pooled intervention effects of lifestyle-based interventions on improving adherence to the MedDiet in a young population aged 3 years-18 years and (2) to examine the potential factors related to those intervention effects.

DATA SOURCES

A systematic search of the MEDLINE (via PubMed), Scopus, Cochrane Library, and Web of Science databases was performed from their inception until June 15, 2023.

DATA EXTRACTION

Different meta-analyses were independently performed to observe the effect of lifestyle-based interventions on adherence to the MedDiet (according to the Mediterranean Diet Quality Index in children and adolescents [KIDMED]).

DATA ANALYSIS

Compared with the control group, the intervention group showed a small increase in KIDMED score (d = .27; 95% confidence interval [CI], .11 to .43; P < .001; I2 = 89.7%). Similarly, participants in the lifestyle-based intervention groups had a 14% higher probability of achieving optimal adherence to the MedDiet (risk difference = .14; 95% CI, .02 to .26; P = .023; I2 = 96.8%). Greater improvements in achieving optimal adherence to the MedDiet were found in interventions delivered out of school (risk difference = .24, 95% CI, .04 to .44; I2 = 88.4%), those aimed at parents or at both children and parents (risk difference = .20, 95% CI, .07 to .34; I2 = 98.2%), and those including only participants with overweight/obesity (risk difference = .34, 95% CI, .15 to .52; I2 = .0%).

CONCLUSION

Healthy lifestyle-based interventions seem to be effective in increasing adherence to the MedDiet and in achieving optimal adherence to this dietary pattern among children and adolescents.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD2022369409.

The "Planning Health in School" Programme (PHS-pro) to Improve Healthy Eating and Physical Activity: Design, Methodology, and Process Evaluation

Few interventions have successfully promoted healthy eating and active living among children with effective changes in anthropometric health outcomes. Well-designed interventions involving multiple strategies to convert the knowledge already available into action are needed for preventing childhood obesity. In this study, an educational programme called "Planning Health in School" (PHS-pro) was designed, implemented and evaluated to contribute to the prevention of obesity in childhood. The PHS-pro aimed at improving the eating behaviours and lifestyles of Portuguese grade-6 children towards healthier nutritional status. This paper describes and evaluates the PHS-pro concerning: (i) the research design within the theoretical framework grounded on "The Transtheoretical Model" and the stages of change; (ii) the educational components and the application of the participatory methodology to engage children to meet their needs, as active participants in their change process; and (iii) the process evaluation of the intervention. The implementation of the PHS-pro took into account the views and inputs of the participants for evaluating the educational components that should be considered in the designing of interventions aiming to be effective strategies. From the health promotion perspective, this study is important because it examines new approaches and pathways to effectively prevent overweight and obesity in children.

Barriers and enablers to the implementation of school-based obesity prevention strategies in Jeddah, KSA

Introduction

Despite schools' recognised role in mitigating childhood overweight, many schools fail to implement physical activity or nutrition strategies. The current study explored the enablers and barriers to implementing obesity prevention strategies in Jeddah, KSA.

Methods

This research is based on 14 semi-structured interviews with intermediate school principals and sports teachers to gain insight into their perception of barriers and enablers to implementing obesity prevention strategies. Themes were deductively generated from the data.

Results

Participants estimated the prevalence of overweight and obesity among their students to be between 3 and 15% with an increasing trend, particularly among female students. Participants identified five categories of barriers to implementation of obesity prevention intervention: curriculum; schools strategies promoting healthy weight; lack of resources; student’s lifstyle; and a lack of teachers in nutrition and sports. School regulations, staff and sufficient resources were the most frequently reported enablers. Participants also identified food services, awareness, and partnerships as barriers and enablers.

Conclusion

There is a need for better infrastructure and financial support for schools and professional development opportunities for teachers from the Saudi Ministry of Education. The Ministry also needs to support the development of multilevel health promotion strategies at school and home and reach out to the broader community.

Evaluation of Social Impact Within Primary School Health Promotion: A Systematic Review

BACKGROUND

Health promotion programs and interventions are designed to encourage behavioral changes in children, encouraging them to make safe and healthy life choices. This systematic review seeks to examine how social impact is measured in primary school health promotion interventions.

METHOD

A systematic search and review process was used to identify and examine primary school health promotion interventions. The PRISMA guidelines were followed to source articles from 6 electronic databases reporting school health promotion programs or interventions in Australia, Canada, New Zealand, or the United Kingdom.

RESULTS

A total of 77 studies were located, representing 55 health promotion interventions delivered in primary school settings. Of these interventions, only 8 (15%) measured or attempted to measure social impact, whereas another 8 (15%) alluded to social impact. The predominant theories reported were social based theories (theories which examine the social influences on people, environments, and behaviors) (n = 17, 59%), with almost a third not informed by an overt health promotion framework or model (n = 34, 59%). A systematic rating system identified some level of stakeholder engagement (n = 30, 53%).

CONCLUSIONS

This systematic review highlights the need for social impact measurement within health promotion to illuminate the role of school programs in delivering lasting change.

Development of Food Competence in Early Childhood Education

The increase in childhood obesity requires the incorporation of nutritional competence into school programs through appropriate activities, starting in the early years. In addition, it is important to promote scientific and cognitive skills during childhood education. The main objective of this study was the implementation of an instructional sequence focused on the learning of skills such as observation, measurement, or interpretation of data related to plants, their germination, and their growth, as well as its relation with the development of food competence. To do so, a set of differentiated activities, organized into several stages, was designed, starting from simple and concrete situations and progressively increasing in complexity and abstraction. The aims were to express ideas about known fruits, vegetables, and legumes in order to expand them by learning new information through student-centered activities, in which children were able to practice and talk about science. The activities were carried out in a class of 24 students aged 4–5 years and data were compared with a control group. The results revealed that the children were motivated in all the activities, which provided an excellent opportunity to initially develop an interest in science and to start to develop food competence in the early years.

Context, importance, and process for creating a body mass index surveillance system to monitor childhood obesity within the New York City public school setting

The Office of School Health, a joint program of the Departments of Health and Education, administers New York City’s (NYC) body mass index (BMI) surveillance system to monitor childhood obesity. We describe the context, importance, and process for creating a multi-agency, school-based BMI surveillance system using BMI collected from annual FITNESSGRAM® physical fitness assessments conducted as part of a larger physical activity and wellness curriculum in NYC public schools. We also summarize our current system and methodology, highlighting the types of data and data sources that comprise the system and partnership between the Departments of Health and Education that enable data sharing. Strategies for addressing threats to data quality, including missing data, biologically implausible values, and imprecise/subjective weight or height equipment are discussed. We also review current and future surveillance data products, and provide recommendations for collecting, analyzing, interpreting, and reporting BMI data for childhood obesity surveillance. Collaboration between Departments of Health and Education as well as attention to safeguards of BMI reporting and data quality threats have enabled NYC to collect high quality BMI data to accurately monitor childhood obesity trends. These findings have implications for youth BMI surveillance systems in the United States and globally.

Effectiveness of the "Planning Health in School" Programme on Children's Nutritional Status

Effective interventions for guiding children to change behaviours are needed to tackle obesity. We evaluated the effectiveness of the 'Planning Health in School' programme (PHS-pro) on children's nutritional status. A non-randomised control group pretest-posttest trial was conducted at elementary schools of a sub-urban municipality in Porto's metropolitan area (Portugal). A total of 504 children of grade-6, aged 10-14, were assigned in two groups: children of one school as the intervention group (IG), and three schools as the control group (CG). Anthropometric measures included height, weight, waist circumference (WC), BMI and waist-to-height ratio (WHtR), and lifestyle behaviours (self-reported questionnaire) were assessed at baseline and after PHS-pro. IG children grew significantly taller more than CG ones (p < 0.001). WC had reduced significantly in IG (-0.4 cm) whereas in the CG had increased (+0.3 cm; p = 0.015), and WHtR of IG showed a significant reduction (p = 0.002) compared with CG. After PHS-pro, IG children consumed significantly fewer soft drinks (p = 0.043) and ate more fruit and vegetables daily than CG. Physical activity time increased significantly in IG (p = 0.022), while CG maintained the same activity level. The PHS-pro did improve anthropometric outcomes effectively leading to better nutritional status and appears to be promising in reducing overweight and obesity.

Knowledge, attitudes, and preventive practices regarding ischemic heart disease among HIV-positive individuals in northern Tanzania

OBJECTIVES

To describe knowledge, attitudes, and practices (KAP) regarding ischemic heart disease (IHD) among adults with HIV in Tanzania.

METHODS

Adults presenting for routine HIV care at a clinic in northern Tanzania were consecutively enrolled and were administered a standardised KAP survey. For each participant, an IHD knowledge score was calculated by tallying correct answers to the IHD knowledge questions, with maximum score 10. Individual 5-year risk of cardiovascular event was calculated using the Harvard NHANES model. Associations between participant characteristics and IHD knowledge scores were assessed via Welch's t-test.

RESULTS

Among the 500 participants, the mean (SD) age was 45.3 (11.4) years and 139 (27.8%) were males. Most participants recognised high blood pressure (n = 313, 62.6%) as a risk factor for IHD, but fewer identified diabetes as a risk factor (n = 241, 48.2%), or knew that aspirin reduces the risk of a secondary cardiovascular event (n = 73, 14.6%). Higher IHD knowledge score was associated with post-primary education (mean 6.27 vs. 5.35, p = 0.001) and with >10% 5-year risk of cardiovascular event (mean 5.97 vs. 5.41, p = 0.045). Most participants believed there were things they could do to reduce their chances of having a heart attack (n = 361, 72.2%). While participants indicated that they adhered to their prescribed medications (n = 488, 97.6%), only 106 (21.2%) attended regular health check-ups.

CONCLUSION

Efforts are needed to improve gaps in IHD knowledge, and increase uptake of cardiovascular preventative practices among Tanzanian adults with HIV.

Children Learn, Children Do! Results of the "Planning Health in School", a Behavioural Change Programme

The ‘Planning Health in School’ programme (PHS-pro) is a behavioural change intervention to assess and improve the eating habits of children, particularly the intake of fruit and vegetables, and to guide them towards healthy choices. The programme and its educational components are based on the Transtheoretical Model of stages of change to integrate nutritional literacy and build up problem-solving and decision-making skills. Children (n = 240, ages 10–12) of one large suburban school in Porto’s metropolitan area (Portugal) were evaluated throughout PHS-pro implementation during one school year in a repeated time–series design. Children’s outcome evaluations were conducted through seven 3-day food records for nine eating behaviour, documented after each learning module and through participatory activities which analysed attitudes, preferences and expectations. Changes were observed in children’s eating behaviour, supported by changes in motivation as perceived in their attitudes and expectations. Significant changes were found in a higher consumption of vegetable soup (p = 0.003), milk products (p = 0.024), and fruit (p = 0.008), while the consumption of high-energy dense food (p = 0.048) and soft drinks (p = 0.042) significantly decreased. No positive effects on fried food, water, vegetables and bread consumption were found. The PHS-pro intervention proved to be effective in developing healthy eating behaviour in young people.

Is School Gardening Combined with Physical Activity Intervention Effective for Improving Childhood Obesity? A Systematic Review and Meta-Analysis

School gardening activities (SGA) combined with physical activities (PA) may improve childhood dietary intake and prevent overweight and obesity. This study aims to evaluate the effect of SGA combined with PA on children’s dietary intake and anthropometric outcomes. We searched studies containing randomized controlled trials up to January 2021 in Web of Science, PubMed, Cochrane Library, and the EBSCO database on this topic for children aged 7 to 12 years. Fourteen studies met the requirements for meta-analysis (n = 9187). We found that SGA has no obvious effect on improving children’s BMI (WMD = −0.49; p = 0.085; I² = 86.3%), BMI z-score (WMD = −0.12; p = 0.235; I² = 63.0%), and WC (WMD = −0.98; p = 0.05; I² = 72.9%). SGA can effectively improve children’s FVs (WMD = 0.59, p = 0.003, I² = 95.3%). SGA combined with PA can significantly increase children’s FVs but cannot greatly improve weight status. Although more studies on this topic are needed to prove the effectiveness of this method, the results of our review show that both SGA and SGA combined with PA has a modest but positive impact of reducing BMI and WC outcomes but can significantly increase children’s FVs.

Evaluating Digital Program Support for the Physical Activity 4 Everyone (PA4E1) School Program: Mixed Methods Study

BACKGROUND

Effectively scaled-up physical activity interventions are urgently needed to address the high prevalence of physical inactivity. To facilitate scale-up of an efficacious school-based physical activity program (Physical Activity 4 Everyone [PA4E1]), provision of implementation support to physical education (PE) teachers was adapted from face-to-face and paper-based delivery modes to partial delivery via a website. A lack of engagement (usage and subjective experience) with digital delivery modes, including websites, may in part explain the typical reduction in effectiveness of scaled-up interventions that use digital delivery modes. A process evaluation focused on the PA4E1 website was undertaken.

OBJECTIVE

The 2 objectives were to (1) describe the usage of the PA4E1 program website by in-school champions (PE teachers leading the program within their schools) and PE teachers using quantitative methods; (2) examine the usage, subjective experience, and usability of the PA4E1 program website from the perspective of in-school champions using mixed methods.

METHODS

The first objective used website usage data collected across all users (n=273) throughout the 9 school terms of the PA4E1 implementation support. The 4 usage measures were sessions, page views, average session duration, and downloads. Descriptive statistics were calculated and explored across the duration of the 26-month program. The second objective used mixed methods, triangulating data from the first objective with data from a think-aloud survey and usability test completed by in-school champions (n=13) at 12 months. Qualitative data were analyzed thematically alongside descriptive statistics from the quantitative data in a triangulation matrix, generating cross-cutting themes using the "following a thread" approach.

RESULTS

For the first objective, in-school champions averaged 48.0 sessions per user, PE teachers 5.8 sessions. PE teacher sessions were of longer duration (10.5 vs 7.6 minutes) and included more page views (5.4 vs 3.4). The results from the mixed methods analysis for the second objective found 9 themes and 2 meta-themes. The first meta-theme indicated that the website was an acceptable and appropriate delivery mode, and usability of the website was high. The second meta-theme found that the website content was acceptable and appropriate, and identified specific suggestions for improvement.

CONCLUSIONS

Digital health interventions targeting physical activity often experience issues of lack of user engagement. By contrast, the findings from both the quantitative and mixed methods analyses indicate high usage and overall acceptability and appropriateness of the PA4E1 website to school teachers. The findings support the value of the website within a multidelivery mode implementation intervention to support schools to implement physical activity promoting practices. The analysis identified suggested intervention refinements, which may be adopted for future iterations and further scale-up of the PA4E1 program.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12617000681358; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372870.

Use of Community Based Participatory Research to Design Interventions for Healthy Lifestyle in an Alternative Learning Environment

Introduction/Objectives

Childhood obesity develops as the result of the interplay between individual and environmental factors. Community based participatory research (CBPR) is an effective tool for improving health of communities. There is limited research on CBPR for facilitating healthy lifestyle in community schools with an alternative learning environment. The objective of the study was to explore student and staff perspectives via focus groups on barriers and facilitators for healthy eating and physical activity in a community school with alternative learning environment and to prioritize, design, and implement suggested interventions to improve healthy lifestyle.

Methods

We conducted qualitative research through 8 focus groups of middle and high school students (n = 40) and 2 focus groups of school staff (n = 8). The school community and research team subsequently identified and implemented interventions for facilitating healthy lifestyle in students within the school environment.

Results

Barriers identified for healthy lifestyle included lack of motivation, lack of healthy food options at school, inadequate knowledge about healthy lifestyle and insufficient opportunities for physical activity. Facilitators for healthy lifestyle were support and motivation from mentors and knowledge about healthy nutrition. Key strategies implemented were addition of healthier food options, educational materials for healthy eating, creation of a walk path, standing desks in classrooms and additional equipment in the school gymnasium.

Conclusions

Formative feedback from students and staff was helpful in the implementation of strategies for facilitating healthy lifestyle among students within a community school with an alternative learning environment.

Unpalatable food for thought: Let marketing research guide effective public obesity interventions

The prevalence of obesity is growing unabatedly despite the considerable efforts directed at the problem. Although abundant research has contributed to our understanding of the multifactorial causes of obesity, there is less attention to research that is relevant for guiding social marketers, public health professionals and policymakers in delivering public health interventions for countering and/or preventing the problem of obesity. This review offers six points for identifying and developing research relevant for guiding community-wide obesity interventions based on the idea that an applied marketing research perspective offers a better model for identifying effective interventions than more theoretical academic research. Specifically, the research guiding public health and social marketing interventions needs to (1) provide information on ultimate outcomes (weight, health and unintended consequences) more than intermediate outcomes (beliefs, attitudes and behaviour), (2) report on observations collected over the longer term, (3) use natural settings (even at a cost of internal validity), (4) endeavour to overcome observer-effects, (5) report effect sizes (rather than statistical significance) and (6) use moderator analyses to capture variation in how a population responds to interventions.

Effectiveness of lifestyle interventions in preventing harmful weight gain among adolescents: A systematic review of systematic reviews

Obesity in adolescence is associated with stigma during school years, early emergence of co-morbidities in adulthood and premature mortality. Adolescence presents a key window of opportunity to intervene for building healthy eating and physical activity routines and prevent weight gain. This review of reviews assesses the evidence on the effectiveness of prevention interventions conducted with adolescents. Nine reviews assessing the effects of lifestyle interventions in adolescents (defined as age 10 to 19 years old) on weight gain were identified from the 10 health databases searched. Only four reviews conducted meta-analyses, of which, three (two exercise-focused) demonstrated positive changes in primary outcomes of body mass index (BMI) and/or BMI z-score (range of decrease in BMI from 0.06 to 0.47 kg/m²⁾ ). Most were conducted in school settings, and all but two reviews were of low quality. Few reviews reported external validity components that would enable clearer directions for policy makers to implement in real-world settings. More than 140 distinct interventions were included in the reviews, but there remains a serious gap in evidence for effective interventions in adolescents.

Associations between in-school-hours physical activity and child health-related quality of life: A cross-sectional study in a sample of Australian primary school children

The aim of the current study was to examine the association between Australian primary school children's objectively measured in-school-hours weekly physical activity (PA) and their health-related quality of life (HRQoL). A cross-sectional study of 1128 Grade 2 and 3 children, aged 7-9 years, from 62 primary schools was conducted in New South Wales, Australia between October 2017 and April 2018. Children's PA was assessed via an accelerometer worn for five days during school hours. Their parents completed a telephone interview, answering demographic, child HRQoL and out-of-school-hours PA questions. Children's in-school-hours PA was classified as total PA and moderate-to-vigorous PA (MVPA). HRQoL scores were aggregated and reported at the high construct level domains (Total Quality of Life (Total HRQoL), Physical and Psychosocial Health Summary Scores). Multiple linear mixed regression analyses accounting for clustering were conducted to evaluate the association between children's in-school-hours weekly PA and their HRQoL. After adjusting for potential confounders, significant positive associations were found between children's in-school-hours weekly total PA and Total HRQoL (0.62 units, 95% CI: 0.29; 0.94, p < 0.001), Physical (0.71 units, 95% CI: 0.38; 1.04, p ≤ 0.001) and Psychosocial (0.58 units, 95% CI: 0.19; 0.97, p = 0.004) scores, with a stronger association observed between average weekly MVPA than average weekly total PA. There were also positive associations between PA and HRQoL for each sex when analysed separately. Our findings demonstrate a positive association between children's objectively-measured in-school-hours PA and parent-reported child HRQoL, strengthening evidence supporting the continued implementation of school-based PA programs for broader health outcomes.

The effect of school intervention programs on the body mass index of adolescents: a systematic review with meta-analysis

Effective obesity interventions in adolescent populations have been identified as an immediate priority action to stem the increasing prevalence of adult obesity. The purpose of this meta-analysis was to make a quantitative analysis of the impact of school-based interventions on body mass index during adolescence. Studies were retrieved from PubMed, Scopus, Science Direct and Web of Science databases. Results were pooled using a random-effects model with 95% confidence interval considered statistically significant. Of the 18 798 possible relevant articles identified, 12 articles were included in this meta-analysis. The global result showed a low magnitude effect, though it was statistically significant (N = 14 428), global e.s. = -0.055, P = 0.004 (95% CI = -0.092, -0.017). Heterogeneity was low among the studies (I2 = 9.017%). The funnel plot showed no evidence of publication bias. The rank-correlation test of Begg (P = 0.45641) and Egger's regression (P = 0.19459) confirmed the absence of bias. This meta-analysis reported a significant effect favoring the interventions; however, future research are needed since the reported the evidence was of low magnitude, with the studies following a substantial range of approaches and mostly had a modest methodological quality.

Scale-up of the Physical Activity 4 Everyone (PA4E1) intervention in secondary schools: 12-month implementation outcomes from a cluster randomized controlled trial

BACKGROUND

'Physical Activity 4 Everyone' (PA4E1) was an efficacious multi-component school-based physical activity (PA) program targeting adolescents. PA4E1 has seven PA practices. It is essential to scale-up, evaluate effectiveness and assess implementation of such programs. Therefore, the aim is to assess the impact of implementation support on school practice uptake of the PA4E1 program at 12 and 24 months.

METHODS

A cluster randomised controlled trial, utilising a type III hybrid implementation-effectiveness design, was conducted in 49 randomly selected disadvantaged Australian Government and Catholic secondary schools. A blinded statistician randomly allocated schools to a usual practice control (n = 25) or the PA4E1 program group (n = 24), with the latter receiving seven implementation support strategies to support school PA practice uptake of the seven practices retained from the efficacy trial. The primary outcome was the proportion of schools adopting at least four of the seven practices, assessed via telephone surveys with Head Physical Education Teachers and analysed using exact logistic regression modelling. This paper reports the 12-month outcomes.

RESULTS

Schools were recruited from May to November 2017. At baseline, no schools implemented four of the seven practices. At 12 months significantly more schools in the program group had implemented four of the seven practices (16/24, 66.7%) than the control group (1/25, 4%) (OR = 33.0[4.15-1556.4], p < 0.001). The program group implemented on average 3.2 (2.5-3.9) more practices than the control group (p < 0.001, mean 3.9 (SD 1.5) vs 0.7 (1.0)). Fidelity and reach of the implementation support intervention were high (both > 80%).

CONCLUSIONS

Through the application of multiple implementation support strategies, secondary schools were able to overcome commonly known barriers to implement evidence based school PA practices. As such practices have been shown to result in an increase in adolescent PA and improvements in weight status, policy makers and practitioners responsible for advocating PA in schools should consider this implementation approach more broadly when working with schools. Follow-up is required to determine whether practice implementation is sustained.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12617000681358 registered 12th May 2017.

The Effects of Physical Activity and Diet Interventions on Body Mass Index in Latin American Children and Adolescents: A Systematic Review and Meta-Analysis

The objective of this systematic review and meta-analysis is to compare the effect of physical activity only with that of physical activity plus diet interventions on body mass index (BMI) in Latin American children and adolescents. We searched the Medline, Embase, Scopus, Web of Science, and Scielo databases from their inception until March 2020, including studies examining the effect of physical activity or physical activity plus diet interventions on BMI in children and adolescents and based on data from intervention studies. The DerSimonian and Laird method was used to compute a pooled standardized mean difference for BMI in terms of effect size (ES) and respective 95% confidence intervals (CIs). Eighteen studies were included. Analyses were performed based on intervention (four studies were included for physical activity only and four studies were included for physical activity plus diet). In the analysis of physical activity only versus control, there was no effect on BMI (ES = 0.00; 95% CI −0.17–0.17, I² = 0.0%; p = 0.443). In the analysis of physical activity plus diet versus control, there was a decrease in BMI in favour of the intervention group (ES = −0.28; 95% CI −0.42–−0.14, I² = 74.5%; p = 0.001). When ES was estimated considering only the effect in intervention groups, there was no evidence of a decrease in BMI (ES = −0.17; 95% CI −0.44–0.11, I² = 84.5%; p < 0.001) for physical activity only (eight studies). However, there was a statistically significant decrease in BMI (ES = −0.30; 95% CI −0.50–0.11, I² = 95.8%; p < 0.001) for physical activity plus diet (ten studies). Some limitations of this review could compromise our results, but the main limitation that should be stated is the quality of the studies (mainly medium/moderate), especially as physical activity and diet interventions cannot be blinded, compromising the quality of these studies. In summary, this meta-analysis offers evidence that physical activity plus diet interventions produced a reduction in BMI in Latin American children and adolescents, but physical activity only interventions did not.

School Gardening Activities Aimed at Obesity Prevention Improve Body Mass Index and Waist Circumference Parameters in School-Aged Children: A Systematic Review and Meta-Analysis

Background: Childhood obesity, due to its increasing prevalence, is one of the most challenging problems in public health and prevention. Recent strategies have been implemented to tackle this trend, including school gardening projects. This systematic review analyzes the main elements of school gardening with a specific meta-analysis about its impact on anthropometric parameters. Materials and Methods: We searched studies in PubMed, EMBASE, and Cochrane Library on school gardening projects carried out until February 2019 and addressed to children aged 6 to 13 years. Results: Thirty-three studies passed the screening selection. Outcomes analyzed were fruits and vegetables consumption/knowledge, nutritional attitudes and behavior, anthropometric outcomes (i.e., BMI, waist circumference-WC) and other outcomes (i.e., blood pressure, science achievement, and physical activity). We performed descriptive analyses of these outcomes and found a general benefit from school gardening projects. We subsequently performed a meta-analysis on anthropometric outcomes, highlighting a significant reduction of both BMI percentile (%) (-1.37%) and WC (-1.30 cm). Conclusions: Although more high-quality studies are needed on this topic, along with a greater homogeneity of anthropometric measurements, the results of our article show a modest but positive impact of school gardening projects on anthropometric measures and more generally on children's health.

Effects of physical activity interventions on the body mass index of children and adolescents in Latin America: a protocol for a systematic review and meta-analysis

INTRODUCTION

In Latin America, the number of children and adolescents who are overweight or obese has significantly increased in recent decades, and this situation has become a major public health concern. To address this problem, several intervention programmes, based on factors such as physical activity and nutrition, have been implemented, and body mass index (BMI) has been widely used as a means of measuring the impact of such interventions. Although some Latin America-based systematic reviews have been performed, there have been no previous meta-analyses of findings regarding the effect of physical activity interventions on BMI. Thus, the objective of the systematic review and meta-analysis will be to provide an up-to-date synthesis of the effects of physical activity interventions on BMI of Latin American children and adolescents aged 4-18 years.

METHODS AND ANALYSIS

This systematic review and meta-analysis protocol is based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. The literature search will involve MEDLINE, EMBASE, Cochrane Library, Web of Science and Scielo for articles published up to July 2019. This search will include randomised controlled trials (RCTs), non-randomised experimental studies and single-arm pre-post studies. Further, the Cochrane Collaboration's tool for RCT studies and the Quality Assessment Tool for Quantitative Studies for non-randomised experimental and single-arm pre-post studies will be used to assess the risk of bias among the studies included in the systematic review. For the meta-analysis, the statistical program STATA V.14 will be used, and standardised mean differences are calculated as the primary outcomes. Subgroup analyses will then be performed based on the characteristics of the interventions and populations included in the studies examined.

ETHICS AND DISSEMINATION

This systematic review protocol is designed to provide updated evidence regarding the effects of physical activity interventions on the Latin American population; such evidence may be useful for institutions responsible for the development of public health policies and for those tasked with implementing such interventions among children and adolescents in Latin America. The results should be disseminated through publication in a peer-reviewed journal. Since the data used in systematic reviews of this type will be extracted exclusively from published studies, approval from an ethics committee will not be required.

PROSPERO REGISTRATION NUMBER

CRD42019077702.

Rationale and design of the school-based SI! Program to face obesity and promote health among Spanish adolescents: A cluster-randomized controlled trial

Unhealthy habits in adolescents are increasing at an alarming rate. The school offers a promising environment in which to implement effective preventive strategies to improve adolescents' lifestyle behaviors. The SI! Program is a multilevel multicomponent school-based health-promotion intervention aimed at all stages of compulsory education in Spain. We present the study design of the SI! Program for Secondary Schools, targeting adolescents aged 12 to 16 years.

AIM

The main goal of this study is to evaluate the impact of the SI! Program educational intervention on adolescent lifestyle behaviors and health parameters.

METHODS

The study was designed as a cluster-randomized controlled intervention trial and enrolled 1326 adolescents from 24 public secondary schools in Spain, together with their parents/caregivers. Schools and their students were randomly assigned to the intervention group (the SI! curriculum-based educational program over 2 or 4 academic years) or to the control group (usual curriculum). The primary endpoint will be the change from baseline at 2-year and 4-year follow-up in the composite Ideal Cardiovascular Health (ICH) score, consisting of four health behaviors (body mass index, dietary habits, physical activity, and smoking) and three health factors (blood pressure, total cholesterol, and glucose). Secondary endpoints will include 2-year and 4-year changes from baseline in ICH score subcomponents, the Fuster-BEWAT health scale, adiposity markers (waist circumference and body composition), polyphenol and carotenoid intake, and emotion management.

DISCUSSION

The overarching goal of the SI! Program is to instill healthy behaviors in children and adolescents that can be sustained into adulthood. The SI! Program for Secondary School is a comprehensive health-promotion intervention targeting 12-16-year-old adolescents and their immediate environment. The present study addresses the optimal timing and impact of the educational intervention on health in adolescence.

Peer Status Position within School-Based Hierarchies and Excessive Fat Accumulation in Adulthood-A 30 Year Follow up of a Stockholm Cohort

Disadvantaged socioeconomic status is arguably the one exposure that has most consistently been linked to obesity, even more strongly so than diet and physical inactivity, which are the two main perceived root causes of weight gain. However, we still know very little about the relationship between having a disadvantaged social position and excessive fat accumulation, particularly when it comes to whether the relationship in question can also be seen as a long-term one, i.e., spanning from childhood to adulthood. By making use of the unique Stockholm Birth Cohort Multigenerational Study, the present study uses generalized ordered logistic regressions to examine the association between sociometrically assessed peer status position in school at age 13 and excessive fat accumulation at age 32. The results suggest that the odds of having excessive fat accumulation are about 0.5 times lower among popular and accepted children (ORs = 0.52 and 0.56, respectively), compared to those with a marginalized peer status position, independent of other obesogenic risk factors measured both prior and subsequent to peer status position. Our results give support to the notion that improved weight status may be another positive consequence of policies aiming to increase social inclusion within schools.

A cluster randomised trial of an intervention to increase the implementation of physical activity practices in secondary schools: study protocol for scaling up the Physical Activity 4 Everyone (PA4E1) program

Background

The implementation of interventions at-scale is required to maximise population health benefits. ‘Physical Activity 4 Everyone (PA4E1)’ was a multi-component school-based program targeting adolescents attending secondary schools in low socio-economic areas. An efficacy trial of the intervention demonstrated an increase in students’ mean minutes of moderate-to-vigorous physical activity (MVPA) per day and lower weight gain at low incremental cost. This study aims to assess the effectiveness and cost effectiveness of a multi-component implementation support intervention to improve implementation, at-scale, of the evidence based school physical activity (PA) practices of the PA4E1 program. Impact on student PA levels and adiposity will also be assessed, in addition to the cost of implementation.

Methods

A cluster randomised controlled trial, utilising an effectiveness-implementation hybrid design, will be conducted in up to 76 secondary schools located in lower socio-economic areas across four health districts in New South Wales (NSW), Australia. Schools will be randomly allocated to a usual practice control arm or a multi-component implementation support intervention to embed the seven school PA practices of the PA4E1 program. The implementation support intervention incorporates seven strategies including executive support, in-School Champion, teacher training, resources, prompts, audit and feedback and access to an external Support Officer. The primary trial outcome will be the proportion of schools meeting at least four of the seven physical activity practices of the program, assessed via surveys with Head Physical Education teachers at 12 and 24-months. Secondary outcomes will be assessed via a nested evaluation of student PA and adiposity at 12-months (Grade 8 students) and 24 months (Grade 9 students) undertaken in 30 schools (15 per group). Resource use associated with the implementation intervention will be measured prospectively. Linear mixed effects regression models will assess program effects on the primary outcome at each follow-up period.

Discussion

This study is one of few evidence-based multi-component PA programs scaled-up to a large number of secondary schools and evaluated via randomised controlled trial. The use of implementation science theoretical frameworks to implement the evidence-based program and the rigorous evaluation design are strengths of the study.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12617000681358 registered 12th May 2017. Protocol Version 1.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6965-0) contains supplementary material, which is available to authorized users.

Socioeconomic Inequalities in the Retail Food Environment around Schools in a Southern European Context

Across Europe, excess body weight rates are particularly high among children and adolescents living in Southern European contexts. In Spain, current food policies appeal to voluntary self-regulation of the food industry and parents’ responsibility. However, there is no research (within Spain) assessing the food environment surrounding schools. We examined the association between neighborhood-level socioeconomic status (NSES) and the spatial access to an unhealthy food environment around schools using both counts and distance measures, across the city of Madrid. We conducted a cross-sectional study citywide (n = 2443 census tracts). In 2017, we identified all schools (n = 1321) and all food retailers offering unhealthy food and beverages surrounding them (n = 6530) using publicly available data. We examined both the counts of retailers (within 400 m) and the distance (in meters) from the schools to the closest retailer. We used multilevel regressions to model the association of neighborhood-level socioeconomic status (NSES) with both measures, adjusting both models for population density. Almost all schools (95%) were surrounded by unhealthy retailers within 400 m (median = 17 retailers; interquartile range = 8–34). After adjusting for population density, NSES remained inversely associated with unhealthy food availability. Schools located in low-NSES areas (two lowest quintiles) showed, on average, 29% (IRR (Incidence Rate Ratio) = 1.29; 95% CI (Confidence Interval) = 1.12, 1.50) and 62% (IRR = 1.62; 95% CI = 1.35, 1.95) more counts of unhealthy retailers compared with schools in middle-NSES areas (ref.). Schools in high-NSES areas were farther from unhealthy food sources than those schools located in middle-NSES areas (β = 0.35; 95% CI = 0.14, 0.47). Regulating the school food environment (within and beyond school boundaries) may be a promising direction to prevent and reduce childhood obesity.

Implementing a School-Based Sleep Intervention in the First Year of Elementary School: Voices of the School Nurses as Intervention Deliverers

OBJECTIVE/BACKGROUND

Elementary school nurses are an important component of health care systems. However, translational research of their role in interventions is limited. This study aimed to determine the feasibility, acceptability and sustainability of training the school nursing workforce to deliver a brief behavioral sleep intervention and the associated delivery costs.

PARTICIPANTS

Twenty-four primary school nurses from the Victorian Department of Education and Training, Melbourne, Australia, involved in delivering the school-based sleep intervention as part of the Sleep Well - Be Well trial participated in three surveys and a focus group over 30 months.

METHODS

An embedded mixed methods design utilizing quantitative and qualitative data sources was used.

RESULTS

Qualitative and quantitative evidence demonstrated training school nurses to deliver a brief sleep intervention was feasible and acceptable. Competence and confidence levels were maintained 12 months after the completion of intervention delivery demonstrating sustainability for this low cost model. Benefits of school nurses' participation in translational research projects were also identified.

CONCLUSIONS

These findings highlight the potential for utilizing school nurses directly in interventions at the health and education interface. Further research is required to address the challenges of intervention implementation and to identify policy implications for other intervention opportunities which may exist.

Rationale and design of the SI! Program for health promotion in elementary students aged 6 to 11 years: A cluster randomized trial

Unhealthy habits in children are increasing at an alarming rate. The school provides a promising setting for effective preventive strategies to improve children's lifestyle behaviors. The SI! Program is a multilevel multicomponent school-based educational intervention aimed at all stages of compulsory education in Spain. Here, we present the design of the SI! Program for Elementary School cluster-randomized controlled trial, targeting children aged 6 to 11 years. This trial aims to study the impact of different timings and intensities of exposure to SI! Program activities on elementary school children and their immediate environment (parents/caregivers, teachers, and school). The trial includes 1770 children from 48 public elementary schools in Madrid (Spain), together with their parents and teachers. Schools and their children were randomly assigned to the intervention group (the SI! curriculum-based educational program over 3 or 6 academic years) or to the control group (standard curriculum). The primary outcomes are the change from baseline at 3-year and 6-year follow-up in children's scores for knowledge, attitudes, and habits (KAH) and health factors (blood pressure, height, weight, waist circumference, and skinfold thickness). Secondary outcomes include 3-year and 6-year changes from baseline in lifestyle questionnaire scores for parents/caregivers and teachers, and in the school environment questionnaire. The overarching goal of the SI! Program is to provide an effective and sustainable health promotion program for the adoption of healthy behaviors in children. The present trial will address the impact and the optimal timing and duration of this educational intervention in the elementary school setting.

Modeling the Diet Dynamics of Children: the Roles of Socialization and the School Environment

Childhood obesity is a health emergency in many parts of the world including the U.S. and, consequently, identifying local, regional or national intervention models capable, of altering the dynamics of obesity at scales that make a difference remains a challenge. The fact that consumption of healthful foods among most youth has yet to meet recommended nutritional standards highlights a lack of effective policies aimed at addressing the epidemic of obesity. Mathematical models are used to evaluate the roles of socialization and school environment on the diet dynamics of children. Data suggest that standard nutrition education programs may have, at best, minimal impact in altering diet dynamics at the population-level. Inclusion of peer influence (model as contagion) reinforced by the use of culturally-sensitive school menus (environmental disruption) may prove capable of modifying obesity enhancing diet dynamics; altering the diets of a significant (critical) proportion of youngsters. A framework is introduced to explore the value of behavior-based interventions and policies that account for the sociocultural environments of at risk communities. These models capture carefully choreographed scenarios to account for the fact that when dealing with diet-dynamics systems, thinking additively is not enough as it cannot account for the power of nonlinear effects.

Children Present a Window of Opportunity for Promoting Health: JACC Review Topic of the Week

Cardiovascular disease is the leading cause of death and disability in the world, largely because of risk factors modifiable by changes in behavior. There is evolving evidence that our behavior as adults has its roots in the environment that we live in from early childhood. Early sustained multicomponent educational programs focused on health promotion in children may represent a window of opportunity to potentially prevent disease in adulthood. The integration of school-based, family-based, and community-based strategies, along with the support of public policies, are likely necessary for the success of these programs. In this review, the authors describe the future of promoting health. Specifically: 1) reasons why children should be a focus for health promotion (alarming trends of risk factors, association between unhealthy factors and subclinical disease, and cost-effectiveness); 2) strategies for health promotion in children (school-based, family-based, and community-based approaches) along with legislative efforts; and 3) research gaps are discussed.

Evaluation of the Effectiveness of a 3-Year, Teacher-Led Healthy Lifestyle Program on Eating Behaviors Among Adolescents Living in Day School Hostels in Malaysia

BACKGROUND

Independence gained during adolescence may be associated with unhealthy eating behaviors. Although malnutrition among adolescents is evident, studies on eating behaviors among adolescents are scarce.

OBJECTIVE

To determine the effectiveness of a teacher-led Healthy Lifestyle Program on eating behaviors among adolescents in Malaysia.

METHODS

This was a cluster randomized controlled trial (conducted in 2012 to 2014), with 100 schools randomly selected from 721 schools, then assigned to 50 intervention schools and 50 control schools. A Healthy Eating and Be Active among Teens (HEBAT) module was developed for pretrained teachers to deliver a Healthy Lifestyle Program on eating behaviors among adolescents. Eating behaviors of the respondents was determined using Eating Behaviors Questionnaire. Linear Mixed Model analysis and χ² test were used to determine within- and between-group effects of studied variables.

RESULTS

A total of 4277 respondents participated in this study, with 2635 samples involved in the final analysis, comprised of 921 intervention and 1714 control respondents. There were 32.4% (36.4%) males and 67.6% (63.6%) females in the intervention (control) group. Mean age was comparable between the groups (intervention = 12.98 years; control = 12.97 years). Majority of the respondents skipped meals at baseline (intervention = 74.7%; control = 79.5%). After the program, intervention respondents had higher consumption frequency of lunch, dinner, and mid-morning snack but a lower consumption frequency of late-evening snack and meal skipping behaviors than their control counterparts.

CONCLUSION

The teacher-led Healthy Lifestyle Program was effective in reducing meal-skipping behaviors among Malaysian adolescents.

The Application of Optimal Defaults to Improve Elementary School Lunch Selections: Proof of Concept

BACKGROUND

In this study, we applied behavioral economics to optimize elementary school lunch choices via parent-driven decisions. Specifically, this experiment tested an optimal defaults paradigm, examining whether strategically manipulating the health value of a default menu could be co-opted to improve school-based lunch selections.

METHODS

The design was a randomized comparison of optimal versus suboptimal (standard) default lunch menus for all first-graders in a school district for a period of 1 week. We hypothesized that making the default lunch option healthier, while providing parents the opportunity to access and choose from the standard school menu for their child, would yield more frequent selection of healthier items than when the default option was suboptimal.

RESULTS

Overall, 127 (93%) first-grade children's families participated. Among those families randomized to receive the nutritionally optimized default menu, all but one remained with these options; of those parents randomized to the standard menu (suboptimal default), all parents remained with these options (Χ² = 123.06, df = 1, p < .001).

CONCLUSIONS

The mere positioning of choices, without restricting options, significantly affected which menu items the children received during the test period. Results are proof of concept for a strategy to increase health-promoting school lunch content, procedures, and policies.

Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost-effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children

Background

Approximately one-third of children in England leave primary school overweight or obese. There is little evidence of effective obesity prevention programmes for children in this age group.

Objective

To determine the effectiveness and cost-effectiveness of a school-based healthy lifestyles programme in preventing obesity in children aged 9–10 years.

Design

A cluster randomised controlled trial with an economic and process evaluation.

Setting

Thirty-two primary schools in south-west England.

Participants

Children in Year 5 (aged 9–10 years) at recruitment and in Year 7 (aged 11–12 years) at 24 months’ post-baseline follow-up.

Intervention

The Healthy Lifestyles Programme (HeLP) ran during the spring and summer terms of Year 5 into the autumn term of Year 6 and included four phases: (1) building a receptive environment, (2) a drama-based healthy lifestyles week, (3) one-to-one goal setting and (4) reinforcement activities.

Main outcome measures

The primary outcome measure was body mass index (BMI) standard deviation score (SDS) at 24 months post baseline measures (12 months post intervention). The secondary outcomes comprised waist circumference SDS, percentage body fat SDS, proportion of children overweight and obese at 18 and 24 months, accelerometer-assessed physical activity and food intake at 18 months, and cost-effectiveness.

Results

We recruited 32 schools and 1324 children. We had a rate of 94% follow-up for the primary outcome. No difference in BMI SDS was found at 24 months [mean difference –0.02, 95% confidence interval (CI) –0.09 to 0.05] or at 18 months (mean difference –0.02, 95% CI –0.08 to 0.05) between children in the intervention schools and children in the control schools. No difference was found between the intervention and control groups in waist circumference SDS, percentage body fat SDS or physical activity levels. Self-reported dietary behaviours showed that, at 18 months, children in the intervention schools consumed fewer energy-dense snacks and had fewer negative food markers than children in the control schools. The intervention effect on negative food markers was fully mediated by ‘knowledge’ and three composite variables: ‘confidence and motivation’, ‘family approval/behaviours and child attitudes’ and ‘behaviours and strategies’. The intervention effect on energy-dense snacks was partially mediated by ‘knowledge’ and the same composite variables apart from ‘behaviours and strategies’. The cost of implementing the intervention was approximately £210 per child. The intervention was not cost-effective compared with control. The programme was delivered with high fidelity, and it engaged children, schools and families across the socioeconomic spectrum.

Limitations

The rate of response to the parent questionnaire in the process evaluation was low. Although the schools in the HeLP study included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, the number of children for whom English was an additional language was considerably lower than the national average.

Conclusions

HeLP is not effective or cost-effective in preventing overweight or obesity in children aged 9–10 years.

Future work

Our very high levels of follow-up and fidelity of intervention delivery lead us to conclude that it is unlikely that school-based programmes targeting a single age group can ever be sufficiently intense to affect weight status. New approaches are needed that affect the school, the family and the wider environment to prevent childhood obesity.

Trial registration

Current Controlled Trials ISRCTN15811706.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

Effectiveness of educational and lifestyle interventions to prevent paediatric obesity: systematic review and meta-analyses of randomized and non-randomized controlled trials

OBJECTIVE

This review and meta-analysis aim at updating a previous meta-analysis carried out by Waters et al. on the efficacy of interventions aimed at preventing childhood obesity and at identifying predictors of outcome.

METHODS

Using an ad-hoc search string, PubMed database was searched for studies assessing body mass index reduction associated with programmes lasting ≥12 weeks in overweight and obese children aged 2-18 years. Studies designed for children with eating disorders or relevant comorbidities were excluded. Studies meeting inclusion criteria were classified according to patient age (<6, 6-12 and 13-18 years), and intervention type (physical activity, diet or both), setting (educational, family or both) and duration (≤1 or >1 year). The search was also extended to other databases. Hand-searching techniques were also applied. The Cochrane 'risk of bias' was applied for quality assessment.

RESULTS

Seventy-two studies were meta-analysed. Overall, the best results were achieved by programmes combining diet and physical activity (n = 39). With regard to the setting, programmes involving both school and family and lasting ≤1 year were the most efficacious for 6- to 12-year-old children (n = 26); family-based-only interventions were also effective in children <6 years old (n = 2), although results have to be interpreted cautiously because of the small number of patients enrolled and the high study heterogeneity. In 13- to 18-year-old patients, interventions delivered at school (n = 8) were substantially unsuccessful.

CONCLUSIONS

Interventions for childhood obesity prevention should include both diet and physical activity, be preferentially targeted towards school age children and involve both the school and family setting. However, because of the important methodological limitations associated with currently available literature, additional studies are needed to draw definite conclusions.

Cost-Effectiveness of Ready for Recess to Promote Physical Activity in Children

BACKGROUND

Many school-based recess interventions have been shown to be effective in increasing physical activity but their relative efficiency compared to other school-based programs are unknown. This study examined the cost-effectiveness of Ready for Recess, a program designed to increase students' physical activity in 2 elementary schools.

METHODS

Standard cost-effectiveness analysis method was used from a program's perspective for this study. Program effectiveness was measured as total metabolic equivalent (MET) hours gained. Program costs included equipment, training, and personnel costs during the 1-year intervention. The cost-effectiveness was measured as the ratio of program costs to total MET-hours gained.

RESULTS

Ready for Recess cost $27,643.97 for the 2 schools in the first year of implementation. Physical activity increased by 1.8 MET-hours per day per student. Approximately 32 cents were spent on Ready for Recess to produce an additional MET-hour per student per school day in the 2008-2009 school year.

CONCLUSIONS

Ready for Recess was cost-effective in its first year of implementation using 35 cents as a benchmark and it was cost-effective relative to other school-based physical activity interventions. The program may be more cost-effective if implemented for a longer time and on a larger scale.

5-2-1-0 Activity and Nutrition Challenge for Elementary Students: New, Evidence-Based, Promising

Obesity prevention in youth is a health priority, and teaching healthy habits toward this end is one of a school nurse's many responsibilities. A school nurse developed and implemented a school-wide, 2-week-long Activity and Nutrition Challenge (ANC) using the evidence-based 5-2-1-0 initiative to prevent and fight childhood obesity. Despite minimal promotion, nearly half of the students at two elementary schools participated and earned points by following the guidelines in the ANC. The amount of chocolate milk consumed by students dropped significantly during the ANC, showing that the healthy behavior of choosing beverages without added sugar had been positively impacted. Anecdotal evidence suggested positive changes in other healthy behaviors as well. This ANC was a new way for a school nurse to teach healthy habits to a large group of children in a short period of time, with limited extra work, and with promising results.

Slowing BMI Growth Trajectories in Elementary School-Aged Children: The Northeast Iowa Food and Fitness Initiative

This project examines the Northeast Iowa Food and Fitness Initiative, a policy-, community-, and school-based effort to slow children's body mass index (BMI) growth over 6 years. Kindergarteners (K) to fifth graders (5) from 10 different school districts participated (N = 4101). Students with 0 to 1 years of initiative exposure showed greater growth in BMI compared with children who had 2 to 6 years of exposure, resulting in K-5 BMI savings of 1.5 points (6 lb) for median-height boys and girls. Results suggest that changes to policies, communities, and schools may provide effective obesity reduction in children.

The effects of school-based lifestyle interventions on body mass index and blood pressure: a multivariate multilevel meta-analysis of randomized controlled trials

Primary prevention of childhood obesity and related hypertension is warrant given that both risk factors are intertwined and track into adulthood. This systematic review and meta-analysis assess the impact of school-based lifestyle interventions on children's body mass index (BMI) and blood pressure. We searched databases and prior reviews. Eligibility criteria were the following: randomized controlled trial design, evaluation of a school-based intervention, targeting children aged 4-12 years, reporting on BMI and/or related cardiovascular risk factors, reporting data on at least one follow-up moment. The effects on BMI, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were evaluated by means of univariate and multivariate three-level random effects models. A total of 85 RCTs (91 papers) were included in the meta-analyses. In univariate models, the pooled effects were -0.072 (95%CI: -0.106; -0.038) for BMI, -0.183 (95%CI: -0.288; -0.078) for SBP and -0.071 (95%CI: -0.185; 0.044) for DBP. In multivariate analyses, the pooled effects of interventions were -0.054 (95%CI: -0.131; 0.022) for BMI, -0.182 (95%CI: -0.266; -0.098) for SBP and -0.144 (95%CI: -0.230; -0.057) for DBP. Parental involvement accentuated the beneficial effects of interventions. School-based lifestyle prevention interventions result in beneficial changes in children's BMI and blood pressure, and the effects on the latter may be stronger than and accrue independently from those in the former.

A quasi-experimental cross-disciplinary evaluation of the impacts of education outside the classroom on pupils' physical activity, well-being and learning: the TEACHOUT study protocol

Background

Education Outside the Classroom (EOTC) is a teaching method that aims to promote schoolchildren’s learning, physical activity (PA), social relations, motivation, and well-being. EOTC activities are characterized by teachers using the local environment in their teaching, and involve innovative teaching methods, child-led approaches to problem-solving, experimentation, cooperation, PA, and play. EOTC has become common practice for many teachers in Scandinavia; however, only case studies have evaluated its impacts.

The TEACHOUT study aims to evaluate the impacts of EOTC on Danish schoolchildren’s PA, social relations, motivation, well-being, and learning.

Methods

TEACHOUT is a quasi-experimental, cross-disciplinary study. Sixteen schools participated, containing 19 EOTC school classes and 19 parallel non-EOTC classes, with a total of 834 children aged 9 to 13 years. Measures of the children’s social relations, motivation for school, well-being, and academic performance were collected at the beginning and end of the school year. Data on PA levels were collected over ten-day periods during the school year using accelerometers. The amount and characteristics of the actual EOTC provided in both EOTC and non-EOTC classes were monitored day-to-day throughout the school year, using an online teacher survey platform. The effects of EOTC are mainly analysed by comparing EOTC pupils to non-EOTC (i.e. control) pupils based on their scores on the outcome variables (i.e. school performance, well-being, motivation, and social relations) at the end of the school year, adjusting for the baseline values (from the beginning of the year). The impacts of EOTC on PA are evaluated by comparing the total as well as context-specific amounts of PA of children participating in EOTC to those of children in their parallel non-EOTC classes. Furthermore, the interdependencies between PA, social relations, well-being, motivation, and learning are explored using path analysis. To help describe and understand the processes that have led to the quantitative outcomes, qualitative case observations of children’s practices and interactions in EOTC as well as classroom teaching were carried out and combined with qualitative interviews about children’s perceptions of these practices.

Discussion

The TEACHOUT study represents a holistic multidisciplinary approach to educational and school health-promotion research through its study design and combination of scientific disciplines and methods, as well as its focus on the interdependent relations between learning, PA, social relations, well-being, and motivation. This will result in a comprehensive picture of school health promotion and children’s health and well-being, which will broaden the understanding of the potential benefits of EOTC in school health promotion and primary education. These results can be used to inform and guide future policy and practice.

Elementary School-Based Obesity Intervention Using an Educational Curriculum

BACKGROUND

Pediatric obesity is a significant public health problem with a prevalence of 16.9% among US children. School-based obesity interventions show promise for reducing adiposity in elementary age children. This pilot study evaluated the impact of the Let's Go! 5-2-1-0 pediatric obesity intervention program in an elementary school setting.

METHODS

This was a cluster randomized controlled field trial comprising 8 classrooms of second- and third-grade children. The impact of implementation of a standardized 5-2-1-0 curriculum was evaluated in the classrooms by looking at health behavior (self-reported fruit and vegetable and sugar-containing beverage intake, and screen time), physical activity (steps measured by pedometer), and body mass index (BMI). Half of the classrooms were given 5-2-1-0 teaching over a 4-month period.

RESULTS

There was no statistical difference in improvement of healthy habits, BMI, or physical activity in the intervention group compared with the control group.

CONCLUSIONS

The 5-2-1-0 intervention used in this study was feasible. There was no significant change in healthy habits, likely due to the small number of participants in the study. The intervention and control sites were in different classrooms and there could be factors such as teacher enthusiasm, socioeconomic factors, and individual traits affecting habits. Future studies could use pre- and post-intervention quizzes to assess healthy habits knowledge retention, involving the environments the child participates in outside of school, using research-grade pedometers or accelerometers for measuring activity data collection, and recruiting larger samples to ensure adequate statistical power.

Modeling eating behaviors: The role of environment and positive food association learning via a Ratatouille effect

Eating behaviors among a large population of children are studied as a dynamic process driven by nonlinear interactions in the sociocultural school environment. The impact of food association learning on diet dynamics, inspired by a pilot study conducted among Arizona children in Pre-Kindergarten to 8th grades, is used to build simple population-level learning models. Qualitatively, mathematical studies are used to highlight the possible ramifications of instruction, learning in nutrition, and health at the community level. Model results suggest that nutrition education programs at the population-level have minimal impact on improving eating behaviors, findings that agree with prior field studies. Hence, the incorporation of food association learning may be a better strategy for creating resilient communities of healthy and non-healthy eaters. A Ratatouille effect can be observed when food association learners become food preference learners, a potential sustainable behavioral change, which in turn, may impact the overall distribution of healthy eaters. In short, this work evaluates the effectiveness of population-level intervention strategies and the importance of institutionalizing nutrition programs that factor in economical, social, cultural, and environmental elements that mesh well with the norms and values in the community.

The Healthy Primary School of the Future: study protocol of a quasi-experimental study

BACKGROUND

Unhealthy lifestyles in early childhood are a major global health challenge. These lifestyles often persist from generation to generation and contribute to a vicious cycle of health-related and social problems. This design article presents a study evaluating the effects of two novel healthy school interventions. The main outcome measure will be changes in children's body mass index (BMI). In addition, lifestyle behaviours, academic achievement, child well-being, socio-economic differences, and societal costs will be examined.

METHODS

In close collaboration with various stakeholders, a quasi-experimental study was developed, for which children of four intervention schools (n = 1200) in the southern part of the Netherlands are compared with children of four control schools (n = 1200) in the same region. The interventions started in November 2015. In two of the four intervention schools, a whole-school approach named 'The Healthy Primary School of the Future', is implemented with the aim of improving physical activity and dietary behaviour. For this intervention, pupils are offered an extended curriculum, including a healthy lunch, more physical exercises, and social and educational activities, next to the regular school curriculum. In the two other intervention schools, a physical-activity school approach called 'The Physical Activity School', is implemented, which is essentially similar to the other intervention, except that no lunch is provided. The interventions proceed during a period of 4 years. Apart from the effectiveness of both interventions, the process, the cost-effectiveness, and the expected legal implications are studied. Data collection is conducted within the school system. The baseline measurements started in September 2015 and yearly follow-up measurements are taking place until 2019.

DISCUSSION

A whole-school approach is a new concept in the Netherlands. Due to its innovative, multifaceted nature and sound scientific foundation, these integrated programmes have the potential to form a template for primary schools worldwide. The effects of this approach may extend further than the outcomes associated with well-being and academic achievement, potentially impacting legal and cultural aspects in our society.

TRIAL REGISTRATION

The study protocol was registered in the database ClinicalTrials.gov on 14-06-2016 with the reference number NCT02800616 .

Obesogenic environment - intervention opportunities

OBJECTIVES

To evaluate environmental obesogenic-related factors, such as physical activity in neighborhoods and schools, nutritional behavior, and intervention programs.

SOURCES

Critical analysis of literature with personal point of view from infant obesity experts and political advisors for public intervention.

DATA SYNTHESIS

Although obesity is a public health problem affecting several age groups, it is among children and adolescents that it plays a more important role, due to treatment complexity, high likelihood of persistence into adulthood, and association with other non-transmissible diseases while still in early age. Environment is a main component of the genesis and outcomes in the near future or long term. Modification of intake with high-density food, meal skipping, and high intake of saturated fat, sugar, and salt, associated to high levels of sedentarism are main causes of obesity.

CONCLUSION

Intervention opportunities are related to modifications in political, environmental, and individual settings. School and physical activities in the educational environment are intertwined with nutrition intervention in continuous education. A critical review of some different scenarios in Latin American countries is presented.

Physical activity and nutrition education at the school environment aimed at preventing childhood obesity: evidence from systematic reviews

OBJECTIVE

To organize the main findings and list the most frequent recommendations from systematic reviews of interventions developed at the school environment aimed at reducing overweight in children and adolescents.

DATA SOURCE

Searches for systematic reviews available until December 31, 2014 were conducted in five electronic databases: Cochrane, PubMed, SciELO, SPORTDiscus, and Web of Science. Manual search for cross-references were also performed.

SUMMARY OF THE FINDINGS

Of the initial 2139 references, 33 systematic reviews adequately met the inclusion criteria and were included in the descriptive summary. In this set, interventions with periods of time greater than six months in duration (nine reviews), and parental involvement in the content and/or planned actions (six reviews) were identified as the most frequent and effective recommendations. Additionally, it was observed that boys respond more effectively to structural interventions, whereas girls respond to behavioral interventions. None of the included reviews was able to make inferences about the theoretical basis used in interventions as, apparently, those in charge of the interventions disregarded this component in their preparation.

CONCLUSIONS

Although the summary identified evidence with important applications in terms of public health, there are still gaps to be filled in this field of knowledge, such as the effectiveness of different theoretical models, the identification of the best strategies in relation to gender and age of participants and, finally, the identification of moderating variables to maximize the benefits provided by the interventions.

Implementing Child-focused Activity Meter Utilization into the Elementary School Classroom Setting Using a Collaborative Community-based Approach

INTRODUCTION

The prevalence of pediatric obesity has increased over the past 3 decades and is a pressing public health program. New technology advancements that can encourage more physical in children are needed. The Zamzee program is an activity meter linked to a motivational website designed for children 8-14 years of age. The objective of the study was to use a collaborative approach between a medical center, the private sector and local school staff to assess the feasibility of using the Zamzee Program in the school-based setting to improve physical activity levels in children.

METHODS

This was a pilot 8-week observational study offered to all children in one fifth grade classroom. Body mass index (BMI), the amount of physical activity by 3-day recall survey, and satisfaction with usability of the Zamzee Program were measured pre- and post-study.

RESULTS

Out of 11 children who enrolled in the study, 7 completed all study activities. In those who completed the study, the median (interquartile range) total activity time by survey increased by 17 (1042) minutes and the BMI percentile change was 0 (8). Both children and their caregivers found the Zamzee Activity Meter (6/7) and website (6/7) "very easy" or "easy" to use.

CONCLUSION

The Zamzee Program was found to be usable but did not significantly improve physical activity levels or BMI. Collaborative obesity intervention projects involving medical centers, the private sector and local schools are feasible but the effectiveness needs to be evaluated in larger-scale studies.

Does School-Based Health Promotion Affect Physical Activity on Weekends? And, Does It Reach Those Students Most in Need of Health Promotion?

Objective

To determine whether a school-based health promotion program affects children’s weekend physical activity and whether this effect varies according to socioeconomic-status.

Methods

This was a quasi-experimental trial of school-based programs on physical activity levels implemented in disadvantaged neighborhoods in Alberta, Canada. In 2009 and 2011, 7 full days of pedometer data were collected from cross-sectional samples of grade 5 students (age 10–11 years) from 10 intervention schools in low-socioeconomic neighbourhoods and 20 comparison schools in middle-socioeconomic neighbourhoods. Multilevel models assessed differences in step-counts between intervention and comparison groups over-time by weight (objectively measured) and socioeconomic status subgroups.

Results

In 2009, children from intervention schools were less active on weekends relative to comparison schools (9212 vs. 11186 steps/day p<0.01). Two years later, daily step-counts on weekend days among children in low socioeconomic intervention schools increased such that they approximated those of children from middle socioeconomic comparison schools (12148 vs. 12121 steps/day p = 0.96). The relative difference in steps between intervention and comparison schools on weekends reduced from -21.4% to 0.2% following the intervention. The normalization of weekend step counts was similar for normal weight (–21.4% to +2.0%) and overweight (-19.1 to +3.9%) children, and was balanced across socioeconomic subgroups.

Conclusions

These data suggest that school-based health promotion is effective for reducing inequities in physical activity levels outside school hours. Investments in school-based health promotion lead to behavior modification beyond the school environment.

Trial Registration

ClinicalTrials.gov NCT01914185

Development of an educational intervention to promote healthy eating and physical activity in Mexican school-age children

Mexico has the highest and most alarming rates of childhood obesity worldwide. A study conducted in the State of Mexico revealed that one of every three children presents overweight or obesity. The objective of this paper is to provide a step-by-step description of the design and implementation of an educational intervention to promote healthy eating and physical activity called "Healthy Recess". The educational intervention was designed using the six stages of the Health Communication Process. This methodological model allowed identifying the needs of school-age children on information and participation in activities. In order to improve the strategy, adjustments were made to the print and audiovisual materials as well as to assessment tools. Typography was modified as well as the color of the images in student's workbook and facilitator's; special effects of the videos were increased; the narration of the radio spots was improved and common words and phrases were included. The Health Communication Process is an effective tool for program planners to design interventions aimed at managing prevalent health problems such as overweight and obesity in school-age children.