Design and methods for a community-based intervention to reduce sugar-sweetened beverage consumption among youth: H2GO! study

A cluster randomized controlled trial of a brief positive healthy eating intervention

Excessive sugar intake poses a significant risk factor for non-communicable diseases. A positive healthy eating (PHE) intervention was developed to promote low-sugar dietary practices in families. The PHE intervention capitalized on positive psychological constructs to overcome barriers to health behavior change by helping families associate feelings of joy, gratitude, and savoring with healthy eating. In a cluster randomized controlled trial, 1983 participants from 1467 families were recruited in Hong Kong. PHE included a core and booster session. Data were collected at pre-intervention, post-intervention, and at 1-month and 3-month follow-up. Compared to the control, PHE showed greater increase in intention to change at post-intervention, engagement in low-sugar dietary practices individually and with family members at 3-month follow-up, and greater reduction in sugar-sweetened beverage intake at 1-month and 3-month follow-up. Intentions to change mediated PHE's effects on low-sugar dietary practices. Focus group interviews revealed the behavior-change process and family quality of life.

Non-pharmaceutical interventions to optimize cancer immunotherapy

The traditional picture of cancer patients as weak individuals requiring maximum rest and protection is beginning to dissolve. Too much focus on the medical side and one's own vulnerability and mortality might be counterproductive and not doing justice to the complexity of human nature. Unlike cytotoxic and lympho-depleting treatments, immune-engaging therapies strengthen the immune system and are typically less harmful for patients. Thus, cancer patients receiving checkpoint inhibitors are not viewed as being vulnerable per se, at least not in immunological and physical terms. This perspective article advocates a holistic approach to cancer immunotherapy, with an empowered patient in the center, focusing on personal resources and receiving domain-specific support from healthcare professionals. It summarizes recent evidence on non-pharmaceutical interventions to enhance the efficacy of immune checkpoint blockade and improve quality of life. These interventions target behavioral factors such as diet, physical activity, stress management, circadian timing of checkpoint inhibitor infusion, and waiving unnecessary co-medication curtailing immunotherapy efficacy. Non-pharmaceutical interventions are universally accessible, broadly applicable, instantly actionable, scalable, and economically sustainable, creating value for all stakeholders involved. Most importantly, this holistic framework re-emphasizes the patient as a whole and harnesses the full potential of anticancer immunity and checkpoint blockade, potentially leading to survival benefits. Digital therapeutics are proposed to accompany the patients on their mission toward change in lifestyle-related behaviors for creating optimal conditions for treatment efficacy and personal growth.

Pilot Intervention Targeting Sugary Drink Intake Associated With Improvements in Adolescent Sleep Duration

OBJECTIVE

To examine temporal associations between participation in a community-based intervention targeting sugary drink intake and sleep outcomes among children.

METHODS

Data are from an ethnically diverse sample of 100 children aged 9-12 years from 2 Massachusetts Boys and Girls Club (BGC) sites who participated in a pilot-site randomized trial (usual BGC programming plus H₂GO! intervention vs usual BGC programming). Secondary outcomes of the trial (sleep duration and adequate sleep duration [≥ 9 h/night] were assessed via a self-report survey at baseline, 2 months, and 6 months. Generalized linear and logistic regression models estimated intervention effects associated with outcomes.

RESULTS

The intervention was associated with increased sleep duration (β = 0.74; 95% confidence interval, 0.03-1.45) and higher odds of adequate sleep (odds ratio, 2.47; 95% confidence interval, 1.06-5.74) at 2 months. Sleep did not differ by treatment condition at 6 months.

CONCLUSIONS AND IMPLICATIONS

This community-based sugary drink intake intervention may be a potential avenue to improve child sleep outcomes in the short term.

The Combination of School-Based and Family-Based Interventions Appears Effective in Reducing the Consumption of Sugar-Sweetened Beverages, a Randomized Controlled Trial among Chinese Schoolchildren

To examine whether environmental interventions, student awareness and parents’ model roles are associated with the consumption of sugar-sweetened beverages (SSBs), a randomized controlled trial was conducted among Chinese schoolchildren. A multi-stage cluster random sampling method was applied to select four primary schools, two in urban areas and two in rural areas, in Nanjing, eastern China. Classes of the third grade in the selected four schools were randomly assigned to the intervention group and control group. Among selected students in those classes, aged 9–10 years, those in the intervention group received intervention measures comprising school-based and family-based measures and accepted monthly monitoring along with interventions, for two consecutive semesters, while those in the control group did not receive any specific interventions. After intervention, there was a significant increase in SSB knowledge and an improvement in the family environment with parents in the intervention group. The proportion of frequent consumption (≥4 times/week) of any SSBs in the intervention group was lower than that in the control group (31.5% vs. 56.2%, p < 0.01). Multivariate analysis indicated that parental education level is positively associated with reduced SSB consumption. Interventions showed an average decrease in SSBs consumption by 1.77 units, those living in urban areas decreased by 2.05 units. The combination of school-based and family-based interventions appears effective in reducing SSB consumption among Chinese schoolchildren, especially in urban areas and for those with parents with lower educational levels.

Early childhood oral health promotion for First Nations and Métis communities and caregivers in Manitoba

INTRODUCTION

Early childhood caries is a public health concern, and the considerable burden exhibited by Indigenous children highlights the oral health inequities across populations in Canada. Barriers include lack of access to oral health care and lack of culturally appropriate oral health promotion. The purpose of this study was to determine where and how First Nations and Métis parents, caregivers and community members learn about caring for young children's oral health, and what ideas and suggestions they have on how to disseminate information and promote early childhood oral health (ECOH) in Indigenous communities.

METHODS

Sharing circles and focus groups engaged eight groups of purposively sampled participants (n = 59) in four communities in Manitoba. A grounded theory approach guided thematic analysis of audiorecorded and transcribed data.

RESULTS

Participants said that they learned about oral health from parents, caregivers and friends, primary care providers, prenatal programs, schools and online. Some used traditional medicines. Participants recommended sharing culturally appropriate information through community and prenatal programs and workshops; schools and day care centres; posters, mailed pamphlets and phone communication (calls and text messages) to parents and caregivers, and via social media. Distributing enticing and interactive oral hygiene products that appeal to children was recommended as a way to encourage good oral hygiene.

CONCLUSION

Evidence-based oral health information and resources tailored to First Nations and Métis communities could, if strategically provided, reach more families and shift the current trajectory for ECOH.

A youth empowerment intervention to prevent childhood obesity: design and methods for a cluster randomized trial of the H2GO! program

BACKGROUND

Reducing sugar-sweetened beverage (SSB) consumption is a promising dietary target for childhood obesity prevention. This paper describes the design and methods of a cluster randomized trial of H2GO!, a youth empowerment intervention to prevent childhood obesity through reducing SSB consumption among a low-income, ethnically diverse sample of youth.

METHODS

This cluster randomized controlled trial is an academic-community partnership with the Massachusetts Alliance of Boys and Girls Clubs (BGC). Ten BGC sites will be randomly assigned to the H2GO! intervention or a wait-list, usual care control. Eligible study participants will be N = 450 parent-child pairs (youth ages 9-12 years and their parents/caregivers) recruited from participating BGCs. The 6-week in-person H2GO! intervention consists of 12 group-based sessions delivered by BGC staff and youth-led activities. An innovative feature of the intervention is the development of youth-produced narratives as a strategy to facilitate youth empowerment and parental engagement. Child outcomes include measured body mass index z scores (zBMI), beverage intake, and youth empowerment. Parent outcomes include beverage intake and availability of SSBs at home. Outcomes will be measured at baseline and at 2, 6, and 12 months. With a 75% retention rate, the study is powered to detect a minimum group difference of 0.1 zBMI units over 12 months.

DISCUSSION

Empowering youth may be a promising intervention approach to prevent childhood obesity through reducing SSB consumption. This intervention was designed to be delivered through BGCs and is hypothesized to be efficacious, relevant, and acceptable for the target population of low-income and ethnically diverse youth.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04265794 . Registered 11 February 2020.

Understanding disadvantaged adolescents' perception of health literacy through a systematic development of peer vignettes

Background

Adolescence represents a crucial phase of life where health behaviours, attitudes and social determinants can have lasting impacts on health quality across the life course. Unhealthy behaviour in young people is generally more common in low socioeconomic groups. Nevertheless, all adolescents should have a fair opportunity to attain their full health potential. Health literacy is positioned as a potential mediating factor to improve health, but research regarding health literacy in adolescents and socially disadvantaged populations is limited. As part of Phase one of the Ophelia (OPtimising HEalth LIterAcy) framework, The purpose of this study was to explore the perceptions of socially disadvantaged Irish adolescents in relation to health literacy and related behaviours, and utilise this data to develop relevant vignettes.

Methods

A convergent mixed method design was used to co-create the vignettes. Questionnaires were completed by 962 adolescents (males n = 553, females n = 409, Mean age = 13.97 ± 0.96 years) from five participating disadvantaged schools in Leinster, Ireland. Focus groups were also conducted in each school (n = 31). Results were synthesised using cluster and thematic analysis, to develop nine vignettes that represented typical male and female subgroups across the schools with varying health literacy profiles. These vignettes were then validated through triangular consensus with students, teachers, and researchers.

Discussion

The co-creation process was a participatory methodology which promoted the engagement and autonomy of the young people involved in the project. The vignettes themselves provide an authentic and tangible description of the health issues and health literacy profiles of adolescents in this context. Application of these vignettes in workshops involving students and teachers, will enable meaningful engagement in the discussion of health literacy and health-related behaviours in Irish young people, and the potential co-designing of strategies to address health literacy in youth.

Conclusion

As guided by the Ophelia framework, the use of authentic, interactive and participatory research methods, such as the co-creation of vignettes, is particularly important in groups that are underserved by traditional research methods. The approach used in this study could be adapted to other contexts to represent and understand stakeholders’ perceptions of health, with a view to explore, and ultimately improve, health literacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10634-x.

Family-based lifestyle interventions: What makes them successful? A systematic literature review

Nearly one in five young people in the United States has obesity, putting one-fifth of America’s children at higher risk of having chronic health conditions and of having obesity into adulthood. Family-based lifestyle interventions (FBLI) have been proposed as effective mechanisms to improve the health through health education and the adoption of healthier behaviors. The aim of this review is to identify and summarize effective intervention activities and lessons learned that organizations can adopt when planning health promotion interventions for families, and to assess the effect of family-based lifestyle interventions on BMI z-score. A systematic review on lifestyle health-promotion interventions for families was conducted following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) statements. Inclusion criteria were: duration ≥12 weeks and inclusion of family members. Summary data about the assessment tools, intervention strategies, and outcomes in parents and children were extracted and compared for all studies. A meta-analysis of BMI z-score change was conducted. Thirty-four articles were included in this review. Frequent strategies used were delivering education and training on healthy habits and well-being (94%), engaging community in the planning and implementation phases (80.6%) and providing reminders and feedback (47.2%). BMI z-score mean differences were reported in 40 cohorts and included in a meta-analysis, with no statistically significant differences between groups. The findings of this systematic review and meta-analysis indicate that components of a successful family lifestyle intervention program include duration between six to twelve months and delivery in a community setting. Other key factors include constructing a multidisciplinary team, using a mentor/role model approach, and reinforcing messaging with technology.

A measure development study of sugar-sweetened beverage-related knowledge, self-efficacy, and intention among urban, low-income adults

BACKGROUND

Sugar-sweetened beverage (SSB) consumption is an important behavior that can influence individuals' risk for diabetes, obesity, and other chronic diseases. Nonetheless, there is a lack of valid measures to assess SSB-related constructs. Reliable and valid measures can help evaluate the efficacy of interventions designed to curb SSB consumption. Our aim was to develop a valid and reliable instrument to measure constructs related to SSB consumption in English and Spanish.

METHODS

A cross-sectional survey was conducted among a convenience sample of 150 adult residents of public housing developments in Boston, Massachusetts between July of 2016 and January of 2017. All households from two public housing developments were approached by study staff to solicit participation via door-to-door knocking and posted flyers. We developed questions to measure three SSB-related constructs informed by the Social Cognitive Theory: SSB knowledge, and self-efficacy and intention to act on SSB consumption. The questions were pilot tested in the population, and then administered in-person by bilingual study staff in either English or Spanish. Interviews were conducted most often in the participant's home and less frequently within a community space. Item normality was assessed with descriptive statistics. Difficulty of knowledge items was assessed with percent correct. Construct validity of self-efficacy items was assessed using confirmatory factor analysis (CFA). A model was considered a good fit if confirmatory factor index (CFI) > 0.95, root mean square error of approximation (RMSEA) < 0.05, and standardized root mean square residual (RMSR) < 0.05. Pearson correlations with consumption scores assessed criterion validity, and intraclass correlation coefficients (ICC) assessed test-retest reliability.

RESULTS

Of the eight knowledge items tested, only four items resulted in correct answers less than half of the time. CFA resulted in a 5-item scale with excellent fit indices (CFI = .99; RMSEA = .025: SRMR = .02) and Cronbach's (0.79), test-retest (ICC = 0.68), and significant correlation with intention and SSB consumption. Of the four intention items, one was significantly correlated with SSB consumption.

CONCLUSIONS

This study provides evidence for the validity of key constructs related to SSB consumption for use in adults, which could provide important theory-based markers for program evaluations of SSB-related interventions.

Community-based sugar-sweetened beverage intervention associated with short-term improvements in self-rated oral health

OBJECTIVES

To assess the efficacy of a community-based childhood obesity prevention intervention targeting Sugar-sweetened beverage (SSB) consumption on self-rated oral health among children and their parents/caregivers.

METHODS

This study is a secondary analysis of data from a pilot site-randomized intervention (H₂ GO!) targeting SSB consumption and obesity risk among children. The 6-week SSB behavioural intervention was implemented in two Massachusetts Boys and Girls Club sites that were matched for size and racial/ethnic composition. Children ages 9-12 years and their parents/caregivers were eligible to participate. Data on self-rated oral health and sociodemographics were obtained via self-report surveys at baseline, 2 and 6 months. Generalized linear mixed regression models were used to estimate 2- and 6-month change in oral health associated with the intervention.

RESULTS

Data are from 100 child participants (46% female; 38% Black, 20% Hispanic, 13% White, 12% Multiracial, 11% Asian) and 87 parent participants (78.2% female; 37.9% Hispanic, 29.9% Black, 14.9% Asian, 10.3% White). At baseline, 47% of child participants rated their oral health as good, followed by very good (32%), fair (11%) and excellent (10%). Among parents, 46.3% rated their oral health as good, followed by very good (29.3%), excellent (9.8%), fair (9.7%) and poor (4.9%). The intervention was associated with 2- and 6-month improvements in child participants' mean self-rated oral health scores (β = 0.78; 95% CI: 0.48, 1.087; P < .001; β = 0.98; 95% CI: 0.61, 1.34; P < .001, respectively) and with 2-month improvements in parent participants' mean self-rated oral health (β = 0.42; 95% CI: 0.016, 0.82; P = .042).

CONCLUSION

Short-term improvements in oral health among children and their parents/caregivers were observed among those participating in a SSB behavioural intervention. Community-based behavioural programmes targeting SSB consumption may be a promising approach to promote oral health as well as prevent childhood obesity.

Reducing sugary drink intake through youth empowerment: results from a pilot-site randomized study

BACKGROUND

Efficacious strategies to reduce sugar-sweetened beverage (SSB) consumption among youth are needed. This pilot study assessed the feasibility and preliminary efficacy of a community-based youth empowerment intervention to reduce SSB consumption and obesity risk among a low-income, ethnically diverse sample of youth.

METHODS

The H2GO! intervention was pilot-tested in an afterschool setting (Boys and Girls Clubs (BGC)) in Massachusetts, USA. One site was randomized to receive the intervention; the other site received standard programming. Youth ages 9-12 years and their parents/caregivers were eligible to participate. A total of N = 110 parent-child pairs (N = 55 parent-child pairs per site) were recruited. The 6-week intervention consisted of group-based weekly sessions delivered by trained BGC staff and youth-led activities that engaged parents. Child outcomes included self-reported SSB and water intake and measured body mass index z scores (zBMI). Parent outcomes included self-reported SSB and water intake, SSB purchasing, and availability of SSBs at home. Outcomes were measured at baseline, 2 months, and 6 months. Generalized linear and logistic regression models were used to estimate intervention effects over time.

RESULTS

The final analytic study sample consisted of 100 child participants (38% Black, 20% Hispanic, 13% White, 12% Multiracial, 11% Asian) and 87 parent participants (78.2% female; 78.2% reporting eligibility for the free-or-reduced price lunch program). 6-month retention rates were ≥ 82%. Intervention attendance rates among intervention child participants (N = 51) averaged 78.1% (SD = 10.3). Over half (56.0%) of child participants were overweight or obese at baseline. Relative to the comparison site, intervention site child participants had decreased SSB intake (β = - 1.64; 95% CI: 2.52, - 0.76), increased water intake (β = 1.31; 95% CI: 0.38, 2.23), and decreased zBMI (- 0.23 units; 95% CI: - 0.31, - 0.14) over 6 months (p < 0.001). Intervention parent participants also reported decreased SSB intake (β = - 1.76; 95% CI: - 2.56, - 0.96) and increased water intake (β = 1.75; 95% CI: 1.11, 2.40) than comparison parent participants at 6 months (p < 0.001).

CONCLUSIONS

Findings demonstrate the potential of a youth empowerment intervention on reducing SSB intake and zBMI among a diverse sample. Findings will guide a larger cluster-randomized controlled trial to test intervention efficacy on preventing childhood obesity, as well as inform future interventions that aim to target additional diet and physical activity behaviors through youth empowerment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02890056 . Registered 31 August 2016.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.