Effects of an intervention aimed at reducing the intake of sugar-sweetened beverages in primary school children: a controlled trial

Provisions Related to Health, Nutrition, and Healthy Beverage Promotion in University Pouring Rights Contracts: A Content Analysis

PURPOSE

Many universities maintain pouring rights contracts (PRCs) with beverage companies wherein one company exchanges sponsorship payments for exclusive beverage marketing rights. Separately, universities may have healthy beverage initiatives (HBIs) to encourage healthier choices on campus. This study aimed to assess how and how frequently PRCs included provisions related to health and nutrition to examine how PRCs may support or undermine HBIs.

DESIGN

Cross-sectional.

SETTING

U.S. public universities with >20,000 students.

SAMPLE

131 PRCs obtained from 124 of 143 universities in 2019-2020.

MEASURES

Primary outcomes were the presence of provisions that could encourage or discourage promotion of healthy beverages (water, diet soda, unsweetened coffee or tea, and 100% juice), and any other provisions explicitly or implicitly referencing health or nutrition.

ANALYSIS

Descriptive statistics.

RESULTS

Twelve contracts (9%) had explicit commitments from the company or university to promote healthy beverages or adhere to nutrition standards, including five committing to support HBIs, four committing to healthy vending policies, and three describing activities to promote healthy beverage brands. Ten (8%) had provisions explicitly inhibiting water promotion and 55 (42%) had provisions that could be interpreted that way. Eleven (8%) included other health and nutrition provisions, such as funding for unspecified wellness activities.

CONCLUSION

Most university beverage contracts did not expressly aim to support healthy choices, and more than half had provisions potentially limiting universities' ability to implement HBIs. When present, nutrition standards were weak.

A Scoping Review of Tailoring in Pediatric Obesity Interventions

Background: Families with children who have or are at risk for obesity have differing needs and a one-size-fits-all approach can negatively impact program retention, engagement, and outcomes. Individually tailored interventions could engage families and children through identifying and prioritizing desired areas of focus. Despite literature defining tailoring as individualized treatment informed by assessment of behaviors, intervention application varies. This review aims to exhibit the use of the term "tailor" in pediatric obesity interventions and propose a uniform definition. Methods: We conducted a scoping review following PRISMA-ScR guidelines among peer-reviewed pediatric obesity prevention and management interventions published between 1995 and 2021. We categorized 69 studies into 6 groups: (1) individually tailored interventions, (2) computer-tailored interventions/tailored health messaging, (3) a protocolized group intervention with a tailored component, (4) only using the term tailor in the title, abstract, introduction, or discussion, e) using the term tailor to describe another term, and (5) interventions described as culturally tailored. Results: The scoping review exhibited a range of uses and lack of explicit definitions of tailoring in pediatric obesity interventions including some that deviate from individualized designs. Effective tailored interventions incorporated validated assessments for behaviors and multilevel determinants, and recipient-informed choice of target behavior(s) and programming. Conclusions: We urge interventionists to use tailoring to describe individualized, assessment-driven interventions and to clearly define how an intervention is tailored. This can elucidate the role of tailoring and its potential for addressing the heterogeneity of behavioral and social determinants for the prevention and management of pediatric obesity.

Understanding the behavioral determinants of adolescents' water consumption: A cross-country comparative study

Substituting the consumption of sugar-sweetened beverages (SSB) with that of water can have a positive effect on adolescents' health. However, despite the attention on this topic in the Global North, it is relatively understudied in other regions of the world, such as the Caribbean. To guide the development of future interventions, understanding the factors determining water consumption among Caribbean adolescents is important. This study examined the behavioral determinants of water consumption among adolescents in Aruba (the Caribbean) and compared them to those in the Netherlands (Western Europe). We used a theoretical model that integrates the dominant theoretical perspectives in the field of public health, including theories of planned behavior, social norms, and intrinsic motivation. This cross-country study included 1,584 adolescents from Aruba and the Netherlands (52% girls; M = 12.34 years; SD = 2.14). The data were analyzed using regression analyses. This study found that in Aruba, adolescents with higher scores of intrinsic motivation, friends' descriptive norms, attitudes, and behavioral control regarding water consumption drank more water. Moreover, the associations between water consumption and both intrinsic motivation as well as friends' descriptive norms for adolescents in Aruba were stronger than those found in the Netherlands. These associations imply that it is even more important for Aruban adolescents than Dutch adolescents to be intrinsically motivated or to perceive their friends often consuming water to drink more water. The cross-country comparison implies that future interventions in Aruba aimed at increasing adolescents' water consumption as an alternative to SSB should focus on enhancing their intrinsic motivation while considering their friends' social norms.

Decreasing consumption of sugar-sweetened beverages and Raising tap water consumption through Interventions based on Nutrition and sustainability for Kids: study protocol of the "DRINK" cluster randomised controlled trial

BACKGROUND

Effectiveness of actions to reduce sugar-sweetened beverage (SB) consumption in children still needs to be improved. Furthermore, the growing concern about sustainable food systems encourages to develop sustainability-based interventions. The objective of this cluster randomised controlled trial is to evaluate the long-term effectiveness of nutrition- and environmental sustainability-based interventions on the reduction in SB intake and on the increase in tap water consumption in 3rd to 6th grade primary school children (8 to 11 years of age).

METHODS

Forty-eight French-speaking Belgian primary schools (equivalent to around 3500 pupils involved in the evaluation) are randomised using a factorial plan: (i) control, (ii) nutrition-based intervention, (iii) sustainability-based intervention, and (iv) both. The interventions (encouragement of water breaks; provision of posters, leaflets, reusable cups, and glass bottles; website; meetings at school) were undertaken from February 2022 to June 2023. Evaluation includes questionnaires for the children and their parents on various determinants of dietary behaviour, a 4-day diary to collect information on the child's beverage consumption, and audits at schools. The first evaluation was conducted in Spring 2021 before any intervention, with the two post-intervention evaluations being held in 2022 and 2023. The main quantitative judgement criterion will be the change over time in the mean SB consumption (in ml/day) in the intervention groups compared with the control group. Given the context of the research (school), the safety of the intervention, and the content of data collection, a consent was acknowledged as unnecessary by the Ethical Committee of the Faculty of Psychology (ULB; n°073/2021), but children and parents are explicitly informed of their right to refuse to fill in the questionnaires.

DISCUSSION

Multicomponent interventions based on nutrition and on environmental sustainability, alone or mixed, will provide an original and topical insight into health promotion at school around dietary behaviours. The dissemination plan will enable to widely inform stakeholders, school staff, and families, in addition to the scientific community through the usual medium (articles, conferences), about the research findings in 2024-2025.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN99843102. Retrospectively registered on 25 May 2021.

Effectiveness of a School Drinking Water Promotion and Access Program for Overweight Prevention

BACKGROUND AND OBJECTIVE

Drinking water promotion and access shows promise for preventing weight gain. This study evaluated the impact of Water First, a school-based water promotion and access intervention on changes in overweight.

METHODS

Low-income, ethnically diverse elementary schools in California's Bay Area were cluster-randomized to intervention and control groups. Water First includes classroom lessons, water stations, and schoolwide water promotion over 1 school year. The primary outcome was overweight prevalence (BMI-for-age-and-sex ≥85th percentile). Students (n = 1249) in 56 fourth-grade classes in 18 schools (9 intervention, 9 control) from 2016 to 2019 participated in evaluation at baseline, 7, and 15 months. Data collection was interrupted in 8 additional recruited schools because of coronavirus disease 2019.

RESULTS

Of 1262 students from 18 schools, 1249 (47.4% girls; mean [SD] age, 9.6 [0.4] years; 63.4% Hispanic) were recruited. From baseline to 7 months, there was no significant difference in changes in overweight prevalence in intervention schools (-0.2%) compared to control schools (-0.4%) (adjusted ratio of odds ratios [ORs]: 0.7 [confidence interval (CI): 0.2-2.9] P = 0.68). From baseline to 15-months, increases in overweight prevalence were significantly greater in control schools (3.7%) compared to intervention schools (0.5%). At 15 months, intervention students had a significantly lower change in overweight prevalence (adjusted ratio of ORs: 0.1 [CI: 0.03-0.7] P = .017) compared to control students. There were no intervention effects for obesity prevalence.

CONCLUSIONS

Water First prevented increases in the prevalence of overweight, but not obesity, in elementary school students.

The Association between Maternal Sugar-Sweetened Beverage Consumption and Infant/Toddler Added Sugar Intakes

Intake of added sugars during early life is associated with poor health outcomes. Maternal dietary intake influences the intake of their children, but little research investigates the relationship between maternal sugar sweetened beverage (SSB) and infant/toddler added sugar intakes. Our objective was to explore the relationship between maternal total sugars and SSB intakes and infant/toddler added sugar intakes. This cross-sectional study (n = 101) of mother-infant dyads measured maternal dietary intake by food frequency questionnaire and infant intake by three 24-h dietary recalls. Pearson’s correlations explored the relations between maternal total sugars and SSB intakes and infant added sugar intakes. Hierarchical stepwise regressions determined if maternal total sugars and SSB intakes explained the variation in infant added sugar intakes after accounting for known risk factors for early introduction of added sugars. Maternal total sugars (r = 0.202, p = 0.043) and SSB (r = 0.352, p < 0.001) intakes were positively correlated with infant/toddler added sugar intakes. In the hierarchical models, maternal total sugar intakes did not account for more variance in infant added sugar intakes (β = 0.046, p = 0.060), but maternal SSB intake was a significant contributor of infant added sugar intakes (β = 0.010, p = 0.006) after accounting for confounders. Interventions to reduced maternal SSB consumption may help reduce infant/toddler added sugar intakes.

Padres Preparados, Jóvenes Saludables: intervention impact of a randomized controlled trial on Latino father and adolescent energy balance-related behaviors

BACKGROUND

Studies have shown associations among food and activity behaviors and body weight of Latino fathers and adolescents. However, few Latino father-focused interventions have been designed to improve energy balance-related behaviors (EBRBs) and weight status among early adolescents. Thus, this efficacy study aims to evaluate the Padres Preparados, Jóvenes Saludables (Padres) youth obesity prevention program for positive changes in EBRBs (fruit, vegetable, sugar-sweetened beverage (SSB), sweet/salty snack, and fast-food consumption, physical activity, and screen time) and weight status among low-income Latino fathers and adolescents (10-14 years).

METHODS

A two-arm (treatment versus delayed-treatment control group) randomized controlled trial was conducted to evaluate the efficacy of 8 weekly experiential learning sessions (2.5 hours each) based on social cognitive theory. The sessions included food preparation, parenting skills, nutrition, and physical activity. The program was delivered to father-adolescent dyads (mothers were encouraged to attend) in trusted community-based settings in a Midwest metropolitan area between 2017 and 2019. In March 2020, in-person implementation was discontinued due to COVID-19 pandemic restrictions, which limited the sample size. Father/adolescent dyads were randomized to treatment or control group within each site. Surveys and measurements were completed by fathers and adolescents to assess changes in food and activity behaviors from baseline to post-intervention. Adolescents also completed 24-hour dietary recall interviews at baseline and post-intervention. Intervention effects were assessed using linear regression mixed models adjusted for covariates and accounting for clustering of participants within sites.

RESULTS

Data from 147 father/adolescent dyads who completed at least the baseline data collection were used. No significant differences were observed for baseline to post-intervention changes in adolescents' and fathers' EBRBs or weight status between treatment and control groups. Fathers' SSB and fast food intakes were not statistically significant (p = 0.067 and p = 0.090, respectively).

CONCLUSIONS

The Padres program resulted in no significant improvements in adolescent and father EBRBs and weight status. Additional Latino father-focused interventions are needed to examine intervention effects on EBRBs among Latino adolescents.

TRIAL REGISTRATION

The Padres Preparados, Jóvenes Saludables study is registered with the U.S. National Library of Medicine, ClinicalTrials.gov Identifier: NCT03469752 (19/03/2018).

Perceptions of sugar-sweetened beverages among adolescents in North Carolina

Introduction

Sugar-sweetened beverage (SSB) consumption among adolescents contributes to diet-related chronic disease including obesity, type 2 diabetes, and poor oral health.

Objective

To better understand adolescents' perceptions, attitudes, and consumption behaviors around SSBs by conducting virtual workshop discussions with adolescents in NC.

Materials and methods

Adolescents ages 11-17 in communities with a high proportion of Supplemental Nutrition Assistance Program (SNAP) eligible households were selected to participate in a series of virtual group workshops during summer 2021. A semi-structured discussion guide was used by a workshop facilitator. Workshop discussions centered around general health perceptions, SSB perceptions, and consumption behaviors. A thematic analysis was used to summarize knowledge, beliefs, attitudes, and perceptions around SSBs.

Results

Approximately 36 adolescents participated across four group workshops. Parents and caregivers influenced adolescents most when it came to making beverage choices. Positive SSB perceptions included liking the taste and the association with special times and social events. Negative opinions focused on associated health risks (diet-related chronic disease and poor oral health). Some adolescents acknowledged SSBs were not healthy but suggested they could be consumed occasionally. Very few participants mentioned any benefits from SSBs; those that mentioned benefits stated they provided energy, replaced electrolytes, and tasted good.

Conclusion

Findings provide several key insights that can contribute to the development of messages aimed at curbing SSB consumption among adolescents. For example, messages that focus on catching adolescents' attention and sharing short- and long-term health consequences of high SSB consumption resonated with adolescents, but because occasional SSB intake was not seen as consequential, messages that suggest abstinence from SSBs may not be helpful in reducing consumption.

'I Knew I Should Stop, but I Couldn't Control Myself': a qualitative study to explore the factors influencing adolescents' consumption of sugar-sweetened beverages and sugary snacks from a socio-ecological perspective

OBJECTIVE

To explore the factors influencing Taiwanese adolescents' consumption of sugar-sweetened beverages (SSB) and sugary snacks from a socio-ecological perspective.

DESIGN

This study adopted a qualitative design by using face-to-face, in-depth interviews guided by a semistructured questionnaire.

SETTING

Eight junior high schools in New Taipei City and Changhua County, Taiwan, September to November 2018.

PARTICIPANTS

Fifty-nine participants aged 12-14 years participated in this study.

RESULTS

Reflexive thematic analysis was used to analyse the data. This study identified four themes to address the multifaceted factors that influence adolescents' consumption of SSB and sugary snacks. At the intrapersonal level, physiological factors, psychological factors, individual economic factors and taste preferences were mentioned in connection with people's consumption of SSB and sugary snacks. Positive or negative influences of parents, siblings, peers and teachers on SSB and sugary snack intake were identified at the interpersonal level. The availability of SSB and sugary snacks at home, their availability in vending machines or in school stores in the school environment and participants' access to convenience stores and hand-shaken drink shops in the broader community influenced SSB and sugary snack consumption. Additionally, food culture and food advertising were identified as influencing societal factors.

CONCLUSIONS

Overall, this qualitative study determined not only that the consumption of SSB and sugary snacks is influenced by intrapersonal factors but also that interpersonal, environmental and societal factors affect adolescents' increased sugar intake. The findings are helpful to broaden the options for designing and developing interventions to decrease SSB and sugary snack consumption by adolescents.

Intervention effects of a school-based health promotion programme on children’s nutrition behaviour

Aim

The programme “Join the Healthy Boat” promotes amongst other things a healthy diet in primary school children. In order to evaluate the programme’s effectiveness, this study longitudinally investigated children’s nutrition behaviour.

Subject and methods

A total of 1564 children (7.1 ± 0.6 years) participated in a cluster-randomised study. Teachers delivered lessons including behavioural contracting and budgeting. Nutritional behaviours of parents and child were assessed via parental report. Anthropometrics were measured on site.

Results

After one year, children in the intervention group (IG) showed a significant reduction in the consumption of pure juices (p ≤ 0.001). Soft drink consumption reduced in both groups, although with a trend towards a slightly greater reduction in the IG. Children with fathers of normal weight as well as first graders showed a significant reduction of soft drink consumption in the IG (p = 0.025 and p = 0.022 respectively). Fruit and vegetable intake increased significantly for first graders (p = 0.050), children from families with a high parental education level (p = 0.023), and for children with an overweight father (p = 0.034). Significant group differences were found for fruit and vegetable intake of children with migration background (p = 0.01) and children of parents with a high school degree could be observed (p = 0.019).

Conclusion

This shows that the programme appeals to a wider range of children, and is therefore more likely to compensate for differences due to origin or other social inequalities, which also shows that active parental involvement is vital for successful interventions.

Effectiveness of education intervention to reduce sugar-sweetened beverages and 100% fruit juice in children and adolescents: a scoping review

OBJECTIVE

To determine the impact of educational intervention in reducing the consumption of sugar-sweetened beverages (SSBs) and 100% fruit juice in children and adolescents.

DESIGN

We conducted a comprehensive Ovid Medline and Scopus search. Articles had to be peer-reviewed, full-text and published in English. Studies had to be controlled intervention, published between 1 January 2010 to 7 February 2021, and in children and adolescents. Study quality was measured using the Quality Assessment Tool for Controlled Intervention Studies.

RESULTS

Forty intervention articles were included in this review involving 25,069 children and adolescents. All studies employed a quantitative research method using the Randomized Controlled Trial designs. Twenty-eight out of forty interventions used psychosocial theories. Study quality ranged from 'fair' to 'good.' Results showed that education intervention effectively reduced SSBs, and reduced 100% fruit juice in children.

EXPERT OPINION

Reducing the SSBs consumption in children should be initiated by conducting school-based programs consisting of interactive learning process, psychosocial theories and the involvement of parents or caregivers. Theories that focus on personal, behavior and environment factors improve the effectiveness of the intervention. More research is warranted to investigate the impacts of 100% fruit juice on obesity, dental caries and risk of co-morbidities in children.

Evaluation of the 'H2NOE Water Schools' programme to promote water consumption in elementary school children - a non-randomised controlled cluster trial

Objective:

This study evaluated a simple environmental intervention called ‘Water Schools’ in Lower Austria providing free refillable water bottles and educational material.

Design:

Non-randomised controlled cluster trial with three measurements: at baseline (T0), after the intervention at 9 months (T1) and after 1-year follow-up (T2).

Setting:

Half-day elementary schools in Lower Austria (Austria).

Participants:

Third-grade pupils from twenty-two schools in the intervention group (IG) and thirty-two schools in the control group (CG) participated in the study. Data were analysed for 569 to 598 pupils in the IG and for 545 to 613 in the CG, depending on the time of measurement.

Results:

The consumption of tap water increased in the IG from baseline to T1 and then decreased again at T2, but this was similar in the CG (no statistically significant difference in the time trend between the IG and CG). Similar results were seen for tap water consumption in the mornings. The proportion of children who only drank tap water on school mornings increased significantly from baseline to T1 in the IG compared to the CG (P = 0·020). No difference in the changes over time occurred between the groups for the proportion of pupils drinking approximately one bottle of tap water during school mornings.

Conclusions:

Not only the children in the IG but also those in the CG drank more tap water after 1 school year than at the beginning. The measurement of drinking habits in the CG may have been intervention enough to bring about changes or to initiate projects.

Study protocol for the evaluation of long-term effects of the school-based obesity prevention program Lekker Fit! ('enjoy being fit'): a retrospective, controlled design

INTRODUCTION

Preventive interventions to reduce overweight and obesity in childhood and adolescence are studied on their effectiveness worldwide. A number with positive results. However, long-term effects of these interventions and their potentially wider influence on well-being and health have been less studied. This study aims to evaluate the long-term effects of a multicomponent intervention in elementary school children targeting individual behaviour as well as environment (Lekker Fit!). The primary outcomeis body mass index and the secondary outcomes are waist circumference, weight status, physical fitness, lifestyle, psychosocial health and academic performance.

METHODS AND ANALYSIS

In a naturalistic effect evaluation with a retrospective, controlled design adolescents in secondary schools, from intervention and non-intervention elementary schools, will be compared on a wide set of outcome variables. Data will be collected by questionnaires and through anthropometric and fitness measurements by trained physical education teachers and research assistants. Baseline data consist of measurements from the adolescents at the age of 5 years old and are gathered from preventive youth healthcare records, from before the intervention took place. Multilevel regression models will be used and adjusted for baseline measurements and potential confounding variables on the individual and environmental level. Furthermore, propensity scores will be applied.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Research Ethics Committee of the Erasmus Medical Centre, Rotterdam, The Netherlands (permission ID: MEC-2020-0644). Study findings will be disseminated in peer-reviewed journals and by conference presentations.

TRIAL REGISTRATION NUMBER

NL8799. Pre-results.

Promoting water consumption among Dutch children: an evaluation of the social network intervention Share H2O

Background

There is a need to develop and improve interventions promoting healthy drinking behaviors among children. A promising method could be to stimulate peer influence within children’s social networks. In the Share H₂O social network intervention (SNI), peer influence was utilized by selecting a subset of influential children and training them as ‘influence agents’ to promote water consumption—as an alternative to SSBs. Previous research has mainly focused on the process of selecting influence agents. However, the process of motivating influence agents to promote the behavior has hardly received any research attention. Therefore, in the SNI Share H₂O SNI, this motivation process was emphasized and grounded in the self-determination theory (SDT). This study evaluated the implementation of the Share H₂O SNI, focusing on whether and how applying SDT-based techniques can motivate the influence agents and, indirectly, their peers.

Methods

This study included data collected in the Netherlands from both the influence agents (n = 37) and the peers (n = 112) in the classroom networks of the influence agents.

Self-reported measurements assessed the influence agents’ enjoyment of the training, duration and perceived autonomy support during the training, and changes in their intrinsic motivation and water consumption before and after the start of the intervention. Changes in the peers’ intrinsic motivation, perceived social support, and social norms were measured before and after the start of the intervention.

Results

The influence agents enjoyed the training, the duration was adequate, and perceived it as autonomy supportive. There was an increase in the influence agents’ intrinsic motivation to drink water and their actual water consumption. Providing personal meaningful rationales seemed to have motivated the influence agents. The intrinsic motivation and perceived descriptive norm of the peers remained stable. The peers reported an increase in their perceived social support and injunctive norm concerning water drinking after the intervention. Influence agents appeared to mainly use face-to-face strategies, such as modeling, talking to peers, and providing social support to promote the behavior.

Conclusions

The current findings provided preliminary evidence of the promising effects of using SDT-based techniques in an SNI to motivate the influence agents and, indirectly, their peers.

Trial registration

NTR, NL6905, Registered 9 January 2018, https://www.trialregister.nl/trial/6905

Characterizing Sugar-Sweetened Beverage Consumption for US Children and Adolescents by Race/Ethnicity

OBJECTIVES

To examine racial/ethnic differences in type of SSB most frequently consumed and in correlates of youth sugar-sweetened beverage (SSB) intake.

METHODS

Data were obtained from the National Health and Nutrition Examination Survey (NHANES), 2011-2016, for children and adolescents aged 5-17 years (n = 6507). The main outcome was SSB consumption (i.e., sodas, sweetened fruit drinks, nectars, sports and energy drinks, sweetened coffees and teas, enhanced waters). Mean and proportions of SSB intake were estimated accounting for complex sampling strategy and weighting. Multivariable regression models were developed for each race/ethnicity and age group.

RESULTS

Two-thirds of children and adolescents reported consuming SSB on a given day. Among consumers, mean SSB consumption was greatest for Black children and White adolescents and lowest for Asian American children and adolescents. The most popular type of SSB consumed was sweetened fruit drinks among children and soda among adolescents, except among White and Mexican American children for whom soda and Black adolescents for whom sweetened fruit drinks were most popular. Female sex and water intake were negatively associated with SSB consumption across most races/ethnicities. Screen time, dentist visits, nativity, and guardian education were associated with SSB intake among a subset of races/ethnicities.

CONCLUSIONS

Associations between covariates and SSB intake as well as types of beverages preferred vary by race/ethnicity, as such chronic disease policies should not be 'one size fits all'. Targeted interventions for specific groups of vulnerable youths hold promise for further reducing SSB consumption, including directing efforts towards reducing sweetened fruit drinks for Black children.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review

Poor diets, including excess added sugar consumption, contribute to the global burden of disease. Subsequently, many nutrition policies have been implemented to reduce added sugar intake and improve population health, including taxes, education, labelling and environmental interventions. A potential consequence of these policy actions is the substitution of added sugars with non-nutritive sweeteners (NNS) in a variety of foods and beverages. NNS are used to reduce the energy and sugar content of foods and beverages while maintaining their palatability. Evidence of the toxicological risks of NNS is inconsistent, though concerns have been raised over the potential substitution effects of ultra-processed foods containing NNS for whole foods. This review aimed to provide an overview of current NNS food supply and consumption patterns, assess added sugar-reduction policies and their impact on NNS, and determine the impact of NNS on food choice, energy intake and diet quality. NNS are widely available in a variety of products, though most commonly in carbonated beverages, dairy products, confectionery, table-top sweeteners and fruit drinks. However, the longitudinal trends of different product categories, and differences between geographies and economy-income levels, require further study. Few studies have examined NNS consumption trends globally, though an increase in NNS consumption in beverages has been observed in some regions. Research examining how the increased availability of low-sugar, NNS-containing products affects global dietary patterns is limited, particularly in terms of their potential substitution effects.

Promoting Healthy Eating among Young People-A Review of the Evidence of the Impact of School-Based Interventions

Intro: Globally, the prevalence of overweight and obesity is increasing among children and younger adults and is associated with unhealthy dietary habits and lack of physical activity. School food is increasingly brought forward as a policy to address the unhealthy eating patterns among young people. Aim: This study investigated the evidence for the effectiveness of school-based food and nutrition interventions on health outcomes by reviewing scientific evidence-based intervention studies amongst children at the international level. Methods: This study was based on a systematic review using the PRISMA guidelines. Three electronic databases were systematically searched, reference lists were screened for studies evaluating school-based food and nutrition interventions that promoted children’s dietary behaviour and health aiming changes in the body composition among children. Articles dating from 2014 to 2019 were selected and reported effects on anthropometry, dietary behaviour, nutritional knowledge, and attitude. Results: The review showed that school-based interventions in general were able to affect attitudes, knowledge, behaviour and anthropometry, but that the design of the intervention affects the size of the effect. In general, food focused interventions taking an environmental approach seemed to be most effective. Conclusions: School-based interventions (including multicomponent interventions) can be an effective and promising means for promoting healthy eating, improving dietary behaviour, attitude and anthropometry among young children. Thus, schools as a system have the potential to make lasting improvements, ensuring healthy school environment around the globe for the betterment of children’s short- and long-term health.

Effectiveness and promising behavior change techniques of interventions targeting energy balance related behaviors in children from lower socioeconomic environments: A systematic review

This systematic review aims to summarize the evidence regarding the effectiveness of interventions targeting energy balance-related behaviors in children from lower socioeconomic environments and the applied behavior change techniques. The literature search was conducted in Cochrane, Embase, Psycinfo and Pubmed. Articles had to be published between January 2000 and September 2019. Studies were included that i) targeted dietary behavior, physical activity and/or sedentary behavior; ii) had a controlled trial design; iii) included children aged 9–12 years old; iv) focused on lower socioeconomic environments; and v) took place in upper-middle or high income countries. Two independent researchers extracted data, identified behavior change techniques using the Behavior Change Technique Taxonomy v1, and performed a methodological quality assessment using the quality assessment tool of the Effective Public Health Practice Project. We included 24 studies, of which one received a high and three a moderate quality rating. Demonstration, practice and providing instructions on how to perform a behavior were the most commonly applied behavior change techniques. Seven studies reported significant beneficial intervention effects: five on physical activity, one on physical activity and sedentary behavior and one on dietary behavior. When comparing effective versus non-effective interventions, and comparing our review to previous reviews focusing on children from the general population, similar behavior change techniques were applied. More high quality research is needed to evaluate the effectiveness of interventions and their behavior change techniques targeting children of low socioeconomic environments.

PROSPERO registration number: CRD42016052599

The effect of teacher-delivered nutrition education programs on elementary-aged students: An updated systematic review and meta-analysis

Research shows that schools can make a positive impact on children’s nutritional outcomes. However, it is also reported that schools and teaching staff note many barriers, which may restrict nutritional education programming and delivery. This is concerning, considering the view that teachers are the key agents for promoting health and nutrition within schools. The purpose of the updated systematic review and meta-analysis was to ascertain the impact that nutrition education programs have on elementary-aged students’ energy intake, fruit, vegetable, sugar consumption and nutritional knowledge. A systematic literature search was conducted using electronic databases (The Cochrane Central Register of Controlled Trials (CENTRAL); A + Education; ERIC; PsycINFO; MEDLINE; ProQuest Central, Journals@Ovid and SAGE Health Sciences Full-Text Collection) from 1990 to 31st October 2018. This process yielded 34 studies for inclusion in this systematic review and meta-analysis. Of these studies, seven studies had a focus on energy intake, five had a focus on sugar consumption, 21 of the studies looked at fruit and vegetable consumption and 13 studies focused on nutritional knowledge. The results suggest that the teaching of nutrition education in elementary schools by qualified teachers can make an important contribution to the knowledge and dietary habits of children. The small and medium effect sizes indicate that prudent, evidence-based decisions need to be made by policy makers and pedagogues as to the teaching strategies employed when delivering nutrition education programs to elementary-aged students.

The review is reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (van Sluijs et al., 2007).

Environmental Interventions to Reduce the Consumption of Sugar-Sweetened Beverages: Abridged Cochrane Systematic Review

BACKGROUND

Regular consumption of sugar-sweetened beverages (SSB) can increase the risk for obesity, type 2 diabetes, cardiovascular disease, and dental caries. Interventions that alter the physical or social environment in which individuals make beverage choices have been proposed to reduce the consumption of SSB.

METHODS

We included randomised controlled, non-randomised controlled, and interrupted time series studies on environmental interventions, with or without behavioural co-interventions, implemented in real-world settings, lasting at least 12 weeks, and including at least 40 individuals. Studies on the taxation of SSB were not included, as these are subject of a separate Cochrane review. We used standard Cochrane methods for data extraction, risk of bias assessment, and evidence grading and synthesis. Searches were updated to January 24, 2018.

RESULTS

We identified 14,488 unique records and assessed 1,030 full texts for eligibility. We included 58 studies comprising a total of 1,180,096 participants and a median length of follow-up of 10 months. We found moderate-certainty evidence for consistent associations with decreases in SSB consumption or sales for the following interventions: traffic light labelling, price increases on SSB, in-store promotion of healthier beverages in supermarkets, government food benefit programs with incentives for purchasing fruits and vegetables and restrictions on SSB purchases, multi-component community campaigns focused on SSB, and interventions improving the availability of low-calorie beverages in the home environment. For the remaining interventions we found low- to very-low-certainty evidence for associations showing varying degrees of consistency.

CONCLUSIONS

With observed benefits outweighing observed harms, we suggest that environmental interventions to reduce the consumption of SSB be considered as part of a wider set of measures to improve population-level nutrition. Implementation should be accompanied by evaluations using appropriate methods. Future studies should examine population-level effects of interventions suitable for large-scale implementation, and interventions and settings not yet studied thoroughly.

Using a social marketing approach to develop Healthy Me, Healthy We: a nutrition and physical activity intervention in early care and education

Although social marketing principles have been successfully employed in school-based interventions to prevent obesity, use in early care and education (ECE) settings has been limited. This paper describes the use of the social marketing approach to develop an ECE-based intervention that encourages an ECE provider-parent partnership to improve the quality of preschool children's diets and their level of physical activity. A six-step social marketing approach for public health interventions guided the development of this ECE-based intervention. These steps were as follows: (i) initial planning, (ii) formative research, (iii) strategy development, (iv) program development, (v) implementation, and (vi) monitoring and evaluation. During this process, we reviewed current literature, conducted focus groups with ECE providers and parents, developed a detailed conceptual model and content map, created and tested the campaign concept, and developed final campaign materials along with strategies for its implementation. The final intervention resulting from this process was an 8-month campaign known as Healthy Me, Healthy We. The campaign is delivered by the child care center and includes branded materials for use in the classroom and at home. The final campaign is being evaluated in a cluster-randomized trial. Healthy Me, Healthy We offers an innovative approach to promoting healthy eating and physical activity during early childhood, a key developmental period, that leverages partnership between ECE providers and parents to affect behavior change.

Associations between family and home-related factors and child's snack consumption in a multi-ethnic population

BACKGROUND

Energy-dense snacks are considered unhealthy due to their high concentrations of fat and sugar and low concentrations of micronutrients. The present study aimed to evaluate associations between family and home-related factors and children's snack consumption. We explored associations within subgroups based on ethnic background of the child.

METHODS

Cross-sectional data of 644 primary school children (mean age: 9.4 years, 53% girls) from the population-based 'Water Campaign' study conducted in the Netherlands were used. Logistic regression analyses were used to evaluate the associations between family and home-related factors and child's snack intake.

RESULTS

Of the children, 28.7% consumed more than one snack per day. Children of parents who expressed more restrictive parenting practices towards the child's snack consumption (odds ratio (OR) = 2.5, P < 0.001), and who modelled snack eating less often (OR = 2.2, P < 0.001) had lower snack intake. Restrictive parenting practices and parental modelling of healthy snacking were significant for children with a Dutch or Moroccan/Turkish ethnic background, but not for children with a Surinamese/Antillean ethnic background.

CONCLUSIONS

We observed that parenting practices and parental modelling were independently associated with the child's snack intake. Also, the relationships between these factors and the child's snack consumption differed for children with distinct ethnic backgrounds.

Interventions to increase the consumption of water among children: A systematic review and meta-analysis

The aim of this study was to conduct a systematic review and meta-analysis on the effectiveness of interventions to increase children's water consumption. A systematic literature search was conducted in seven electronic databases. Studies published in English before 18 February 2019 that evaluated any type of intervention that measured change in water consumption among children aged 2 to 12 years by applying any type of design were included. Of the 47 interventions included in the systematic review, 24 reported a statistically significant increase in water consumption. Twenty-four interventions (17 randomized controlled trials and seven studies with other controlled designs) were included in the meta-analysis. On average, children in intervention groups consumed 29 mL/d (confidence interval [CI] = 13-46 mL/d) more water than did children in control groups. This effect was larger in eight interventions focused specifically on diet (MD = 73 mL/d, CI = 20-126 mL/d) than in 16 interventions focused also on other lifestyle factors (MD = 15 mL/d, CI = 1-29 mL/d). Significant subgroup differences were also found by study setting and socioecological level targeted but not by children's age group, intervention strategy, or study design. In conclusion, there is evidence that, on average, lifestyle interventions can lead to small increases in children's daily water consumption. More research is needed to further understand the specific intervention elements that have the greatest effect.

A systematic review of the effectiveness of promoting water intake to reduce sugar-sweetened beverage consumption

OBJECTIVE

To examine whether the promotion of water intake could reduce sugar-sweetened beverage (SSB) consumption or purchases independent of interventions that target SSBs.

METHODS

Seven databases were systematically searched. Included studies used water promotion as the primary intervention; used a controlled trial, single group pre-post, or prospective cohort study design; included a measure of SSB consumption or purchase; enrolled human participants of any age who lived in high-income or middle-income countries; contained original data; and appeared in a peer-reviewed English-language article published from 1 January 2000 to January 4, 2019. The search yielded 7068 publications, from which 108 were chosen for full-text review. Seventeen were included in this review.

RESULTS

Nine of the 17 studies were randomized controlled trials, six were nonrandomized controlled trials, and 2 were single-group pre-post studies. Participants were primarily children and adolescents. Interventions included water provision, education or promotion activities. Ten of 17 studies were at low or some/moderate risk of bias. Seven studies showed a statistically significant decrease in SSB consumption of which only 2 were at low or some/moderate risk of bias.

CONCLUSIONS

This review found limited evidence that interventions aimed solely at increasing water consumption reduce SSB intake. Further research is needed to investigate whether interventions that combine water promotion and SSB reduction strategies could be synergistic for reducing SSB intake.

The Effect of a Family-Based Lifestyle Education Program on Dietary Habits, Hepatic Fat and Adiposity Markers in 8-12-Year-Old Children with Overweight/Obesity

Healthy lifestyle education programs are recommended for obesity prevention and treatment. However, there is no previous information on the effects of these programs on the reduction of hepatic fat percentage. The aims were (i) to examine the effectiveness of a 22-week family-based lifestyle education program on dietary habits, and (ii) to explore the associations of changes in dietary intake with percent hepatic fat reduction and adiposity in children with overweight/obesity. A total of 81 children with overweight/obesity (aged 10.6 ± 1.1 years, 53.1% girls) and their parents attended a 22-week family based healthy lifestyle and psychoeducational program accompanied with (intensive group) or without (control) an exercise program. Hepatic fat (magnetic resonance imaging), adiposity (dual energy X-ray absorptiometry) and dietary habits (two non-consecutive 24 h-recalls) were assessed before and after the intervention. Energy (p < 0.01) fat (p < 0.01) and added sugar (p < 0.03) intake were significantly reduced in both groups at the end of the program, while, in addition, carbohydrates intake (p < 0.04) was reduced exclusively in the control group, and simple sugar (p < 0.05) and cholesterol (p < 0.03) intake was reduced in the exercise group. Fruit (p < 0.03) and low-fat/skimmed dairy consumption (p < 0.02), the adherence to the Mediterranean Diet Quality Index for children and teenagers (KIDMED, p < 0.01) and breakfast quality index (p < 0.03) were significantly higher in both control and intervention groups after the intervention. Moreover, participants in the exercise group increased the adherence to the Dietary Approaches to Stop Hypertension (DASH) diet (p < 0.001), whereas the ratio of evening-morning energy intake was significantly lower exclusively in the control group after the program (p < 0.02). Changes in energy intake were significantly associated with changes in fat mass index (FMI) in the exercise group, whereas changes in sugar-sweetened beverages (SSB) consumption was associated with percent hepatic fat reduction (p < 0.05) in the control group. A 22-week family-based healthy lifestyle program seems to be effective on improving diet quality and health in children with overweight/obesity and these should focus on SSB avoidance and physical activity.

An early implementation assessment of Ontario's Healthy Kids Community Challenge: results from a survey of key stakeholders

BACKGROUND

In Ontario Canada, the Healthy Kids Community Challenge (HKCC) is a program intended to reduce the prevalence and prevent childhood overweight and obesity through community-based initiatives to improve health behaviours. Guided by the RE-AIM framework and Durlak and DuPre's Ecological Framework for Understanding Effective Implementation, the evaluation focused on two objectives: 1) to describe the organization of the program at the community level; and, 2) to identify opportunities for improvement through an early assessment of factors contributing to implementation.

METHODS

Participants (n = 320) - members of the HKCC local steering committee, including the local project manager - completed a cross-sectional survey using SurveyMonkey and descriptive statistics were calculated. A sample (20%) of qualitative open-ended responses was thematically analyzed.

RESULTS

Results indicated strong respondent agreement that the HKCC enhanced individual knowledge of access to health-promoting programs (88.3%) and messaging regarding healthy behaviours for healthy kids, with less for its effectiveness in reducing weight (53.1%). There was a high-level of adherence to HKCC social marketing messages and overall program structure, with few Local Project Manager reports of adaptations to theme one (9.2%) and theme two messages (15.4%). Fewer Local Project Managers (50%) reported the existence of private partnerships. While most respondents agreed they had the appropriate information to complete mandatory reporting, the usefulness of the HKCC online networking platform was in question (only 47% of Local Project Managers agreed that it was useful). Results reveal sufficient funding from the province to support program implementation, with a moderate level of local political commitment (63% of respondents).

CONCLUSIONS

Results indicate that the HKCC was considered beneficial for enhancing access to health promoting programs, could be feasibly implemented with adherence to centrally-developed social marketing messages, and was amendable to local adaptation. Despite this, few private partnerships were reported. Going forward, there is opportunity to further evaluate factors contributing to HKCC program implementation, particularly as it relates to buy-in from intervention providers, and strategies for forming private sector partnerships to support long-term program sustainability.

Trends in overweight and obesity by socioeconomic status in Year 6 school children, Australian Capital Territory, 2006-2018

Background

Due to the high prevalence and adverse consequences, overweight and obesity in children continues to be a major public health concern worldwide. Socioeconomic background and health-related behaviours (such as diet, physical activity and sedentary behaviors) are important factors associated with weight status in children. Using a series of height and weight assessments from the Australian Capital Territory Physical Activity and Nutrition Survey (ACTPANS), trends in prevalence of overweight and obesity by socioeconomic status were examined in ACT Year 6 school children between 2006 and 2018.

Methods

The ACTPANS has been conducted every 3 years since 2006. A total of 6729 children were surveyed. Complete data on height and weight were available for 6384 (94.9%) participants. Trends in the prevalence of overweight and obesity and associations between weight status and risk factors (such as socioeconomic status, physical activity, screen time and consumption of sugar-sweetened soft drinks (SSD)) were examined using logistic regression.

Results

The prevalence of overweight and obesity remained stable in girls (from 22.5% in 2006 to 21.6% in 2018) but declined in boys (from 27.8 to 17.9%). During the same period, levels of physical activity increased slightly, while screen time and the consumption of fast food and SSD decreased. Socioeconomic gradient, based on the school-level Index of Community Socio-Educational Advantage (ICSEA), was highly associated with prevalence of overweight and obesity. Since 2006, the estimated prevalence of overweight and obesity has remained high in the lowest SES groups, but a concurrent downward trend was observed in the highest SES group, leading to increasing disparity between SES groups. Children in the lowest ICSEA quintile were more likely to be overweight or obese compared to those in the moderate and highest ICSEA quintiles. Children in lower ICSEA quintiles also reported lower levels of physical activity, higher levels of screen time, and higher levels of fast food and SSD consumption compared to those in higher ICSEA quintiles.

Conclusions

While recent trends in overweight and obesity in ACT children are encouraging, the prevalence remains unacceptably high, especially in those from low socioeconomic backgrounds. Additional prevention efforts are required to address the socioeconomic disparity.

Assessing the relationship between water and nutrition knowledge and beverage consumption habits in children

OBJECTIVE

To examine the relationship between knowledge and beverage consumption habits among children.

DESIGN

Cross-sectional analysis. Linear regression was used to identify sociodemographic, dietary and behavioural determinants of beverage consumption and knowledge, and to describe the relationships between children's knowledge and water and sugar-sweetened beverage (SSB) consumption.

SETTINGS

Seventeen elementary schools in London, Ontario, Canada.

PARTICIPANTS

A total of 1049 children aged 8-14 years.

RESULTS

Knowledge scores were low overall. Children with higher knowledge scores consumed significantly fewer SSB (β = -0·33; 95 % CI -0·49, -0·18; P < 0·0001) and significantly more water (β = 0·34; 95 % CI 0·16, 0·52; P = 0·0002). More frequent refillable water bottle use, lower junk food consumption, lower fruit and vegetable consumption, female sex, higher parental education, two-parent households and not participating in a milk programme were associated with a higher water consumption. Male sex, higher junk food consumption, single-parent households, lower parental education, participating in a milk programme, less frequent refillable water bottle use and permission to leave school grounds at lunchtime were associated with a higher SSB consumption. Water was the most frequently consumed beverage; however, 79 % of respondents reported consuming an SSB at least once daily and 50 % reported consuming an SSB three or more times daily.

CONCLUSIONS

Elementary-school children have relatively low nutrition and water knowledge and consume high proportions of SSB. Higher knowledge is associated with increased water consumption and reduced SSB consumption. Interventions to increase knowledge may be effective at improving children's beverage consumption habits.

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.

Added Sugar and Dental Caries in Children: A Scientific Update and Future Steps

Excess added sugars, particularly in the form of sugar-sweetened beverages, is a leading cause of tooth decay in US children. Although added sugar intake is rooted in behavioral and social factors, few evidence-based, theory-driven socio-behavioral strategies are currently available to address added sugar intake. Dental health professionals are in a position to help identify and address problematic sugar-related behaviors in pediatric patients and advocate for broader upstream approaches, including taxes, warning labels, and policy changes, that can help reduce added sugar intake, prevent tooth decay, and improve health outcomes in vulnerable child populations.

Novel public-private partnerships to address the double burden of malnutrition

Public–private partnerships are an effective way to address the global double burden of malnutrition. While public–private partnerships operate in multiple forms, their leadership usually falls to governments, public health agencies, or nongovernmental organizations, with the private sector taking a subordinate role. The rapid ascent of social media and mass communications worldwide has provided a disruptive technology for new nutrition intervention programs. A new model, provisionally called private–public engagement, takes advantage of social media, mass media, and integrated social marketing to reach parents, families, and communities directly. These new private–public engagement initiatives need to be managed in ways suggested for public–private partnerships by the World Health Organization, especially if the private sector is in the lead. Once the rationale for engagement is defined, there is a need to mobilize resources, establish in-country partnerships and codes of conduct, and provide a plan for monitoring, evaluation, and accountability. Provided here is an example consistent with the private–public engagement approach, ie, the United for Healthier Kids program, which has been aimed at families with children aged less than 12 years. Materials to inspire behavioral change and promote healthier diets and lifestyle were disseminated in a number of countries through both digital and physical channels, often in partnership with local or regional governments. A description of this program, along with strategies to promote transparency and communication among stakeholders, serves to provide guidance for the development of future effective private–public engagements.

Effectiveness of school food environment policies on children's dietary behaviors: A systematic review and meta-analysis

Background

School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear.

Objective

To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children.

Methods

We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children’s dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg’s and Egger’s test evaluated potential publication bias.

Results

From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified.

Conclusions

Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.

A novel educational intervention targeting melanoma risk and prevention knowledge among children with a familial risk for melanoma

OBJECTIVE

To examine the acceptability of and preliminary effects associated with a novel educational intervention for children at elevated risk for melanoma. The intervention incorporated information on mechanisms through which melanoma preventive behaviors mitigate risk for melanoma and was delivered to parents and children concurrently.

METHODS

Twenty-two parents (with a personal history of melanoma or spouse with a history of melanoma) and 33 children (mean age 11.8 years) were asked to complete questionnaires immediately prior to and after an educational session and at a one-month follow-up.

RESULTS

Both parents and children endorsed that the educational materials were acceptable. Knowledge about melanoma risk and preventive and screening behaviors increased significantly. Children's perceived risk for melanoma increased significantly, while parents' perceptions of children's risk started at a higher level and remained constant. There were significant increases in reported engagement in sun protective behaviors.

CONCLUSION

The educational intervention shows promise in terms of its acceptability and effects on participant knowledge, perceived risk, and engagement in melanoma preventive behaviors.

PRACTICE IMPLICATION

Children at elevated risk for melanoma and their parents may benefit from receiving educational information on their disease risk and strategies for prevention and screening.

Effectiveness of interventions to improve lifestyle behaviors among socially disadvantaged children in Europe

Background

Unhealthy lifestyle behaviors and childhood overweight are more common among children from families with a low socioeconomic position and ethnic minority children (referred to as social disadvantaged children). : This systematic review evaluates the effectiveness of interventions aimed to improve lifestyle behaviours and/or prevent overweight among socially disadvantaged children in Europe. : Six major databases were searched for studies reporting intervention effects on adiposity measures, sedentary behaviours, physical activity behaviours or dietary behaviours. Studies were included when the study sample consisted of at least 50% socially disadvantaged children or when results were presented for subgroups of socially disadvantaged children separately. Methodological quality assessment was based on Cochrane criteria. In total, 11 studies reporting on eight interventions (one among infants 0-2 years, one among preschoolers 2-6 years, six among school-aged children 6-12 years) were identified. Of these eight interventions, five interventions primarily aimed to improve at least one adiposity measure and three primarily aimed to improve a specific lifestyle behaviour. In general, modest positive effects were found but interventions were limited by a short follow-up duration. Despite an urgent need for effective interventions to improve lifestyle behaviours and prevent overweight among socially disadvantaged children, research on the effectiveness of interventions in Europe is still scarce. Those interventions that have been evaluated show modest effects on lifestyle behaviours and adiposity measures, but long-term follow-up is needed to establish whether these effects are sustained over a longer period of time.

Interventions to reduce consumption of sugar-sweetened beverages or increase water intake: evidence from a systematic review and meta-analysis

A systematic review and meta-analyses were conducted to evaluate the effects of interventions to reduce sugar-sweetened beverages (SSB) or increase water intakes and to examine the impact of behaviour change techniques (BCTs) in consumption patterns. Randomized and nonrandomized controlled trials published after January 1990 and until December 2016 reporting daily changes in intakes of SSB or water in volumetric measurements (mL d^-1 ) were included. References were retrieved through searches of electronic databases and quality appraisal followed Cochrane principles. We calculated mean differences (MD) and synthesized data with random-effects models. Forty studies with 16 505 participants were meta-analysed. Interventions significantly decreased consumption of SSB in children by 76 mL d^-1 (95% confidence interval [CI] -105 to -46; 23 studies, P < 0.01), and in adolescents (-66 mL d^-1 , 95% CI -130 to -2; 5 studies, P = 0.04) but not in adults (-13 mL d^-1 , 95% CI -44 to 18; 12 studies, P = 0.16). Pooled estimates of water intakes were only possible for interventions in children, and results were indicative of increases in water intake (MD +67 mL d^-1 , 95% CI 6 to 128; 7 studies, P = 0.04). For children, there was evidence to suggest that modelling/demonstrating the behaviour helped to reduce SSB intake and that interventions within the home environment had greater effects than school-based interventions. In conclusion, public health interventions - mainly via nutritional education/counselling - are moderately successful at reducing intakes of SSB and increasing water intakes in children. However, on average, only small reductions in SSBs have been achieved by interventions targeting adolescents and adults. Complementary measures may be needed to achieve greater improvements in both dietary behaviours across all age groups.

Feeding styles, parenting styles and snacking behaviour in children attending primary schools in multiethnic neighbourhoods: a cross-sectional study

OBJECTIVE

The aim of the present study was to investigate whether feeding styles and parenting styles are associated with children's unhealthy snacking behaviour and whether the associations differ according to children's ethnic background.

METHOD

Cross-sectional data from the population-based 'Water Campaign' study were used. Parents (n=644) of primary school children (6-13 years) completed a questionnaire covering sociodemographic characteristics, feeding style dimensions ('control over eating', 'emotional feeding', 'encouragement to eat' and 'instrumental feeding'), parenting style dimensions ('involvement' and 'strictness') and children's unhealthy snacking behaviour. Logistic regression analyses were performed to determine whether feeding styles and parenting styles were associated with children's unhealthy snacking behaviour.

RESULT

Overall, children whose parents had a higher extent of 'control over eating' had a lower odds of eating unhealthy snacks more than once per day (OR, 0.57; 95% CI 0.42 to 0.76). Further stratified analysis showed that 'control over eating' was associated with less unhealthy snacking behaviour only in children with a Dutch (OR, 0.37; 95% CI 0.20 to 0.68) or a Moroccan/Turkish (OR, 0.44; 95% CI 0.25 to 0.77) ethnic background. 'Encouragement to eat' was associated with a lower odds of eating unhealthy snacks every day in children with a Dutch ethnic background only (OR, 0.48; 95% CI 0.25 to 0.90). 'Instrumental feeding' was associated with a higher odds of eating unhealthy snacks more than once a day in children with a Moroccan/Turkish ethnic background only (OR, 1.43; 95% CI 1.01 to 2.04).

CONCLUSION

Our results suggest that 'control over eating' may be associated with less unhealthy snack consumption in children. The associations of feeding styles and parenting styles with children's unhealthy snacking behaviour differed between children with different ethnic backgrounds.

Water Consumption in European Children: Associations with Intake of Fruit Juices, Soft Drinks and Related Parenting Practices

Background: High intake of fruit juices and soft drinks contributes to excessive weight gain and obesity in children. Furthermore, parenting practices play an important role in the development of children's dietary habits. The way parents play this role in the development of their children's choices of beverages is still unclear. Objectives: To study the associations: (1) of both fruit juices and soft drinks consumption with water consumption of children and (2) The associations between parenting practices towards fruit juices and soft drinks and water consumption of children. Design: Cross-sectional data from 6 to 8 year old children from seven European communities (n = 1187) were collected. Associations among fruit juices, soft drinks, the respective parenting practices and the child's water consumption were assessed by parental questionnaires. Results: The consumption of water was inversely associated with that of soft drinks but not with the consumption of fruit juices. The child's water intake was favorably influenced when stricter parenting practices towards soft drinks were adopted (e.g., less parental allowance, low home availability and high parental self-efficacy in managing intake). There was less influence observed of parenting practices towards fruit juices. Fruit juices were consumed more often than soft drinks. Conclusions: Low consumption of soft drinks-and not of fruit juices-was associated with high water consumption in children in the current study. Moreover, parenting practices towards both fruit juices and soft drinks were associated with the water intake of the children, irrespective of their socio-economic status.

Children's sugar-sweetened beverages consumption: associations with family and home-related factors, differences within ethnic groups explored

Background

The consumption of sugar-sweetened beverages (SSB) may contribute to the development of overweight among children. The present study aimed to evaluate associations between family and home-related factors and children’s SSB consumption. We explored associations within ethnic background of the child.

Methods

Cross-sectional data from the population-based ‘Water Campaign’ study were used. Parents (n = 644) of primary school children (6-13 years) completed a questionnaire on socio-demographic characteristics, family and home-related factors and child’s SSB intake. The family and home-related factors under study were: cognitive variables (e.g. parental attitude, subjective norm), environmental variables (e.g. availability of SSB, parenting practices), and habitual variables (e.g. habit strength, taste preference). Regression analyses were used to evaluate the associations between family and home-related factors and child’s SSB intake (p < 0.05).

Results

Mean age of the children was 9.4 years (SD: 1.8) and 54.1% were girls. The child’s average SSB intake was 0.9 litres (SD: 0.6) per day. Child’s age, parents’ subjective norm, parenting practices, and parental modelling were positively associated with the child’s SSB intake. The availability of SSB at home and school and parental attitude were negatively associated with the child’s SSB intake. The associations under study differed according to the child’s ethnic background, with the explained variance of the full models ranging from 8.7% for children from Moroccan or Turkish ethnic background to 44.4% for children with Dutch ethnic background.

Conclusions

Our results provide support for interventions targeting children’s SSB intake focussing on the identified family and home-related factors, with active participation of parents. Also, the relationships between these factors and the child’s SSB intake differed for children with distinct ethnic backgrounds. Therefore, we would recommend to tailor interventions taking into account the ethnic background of the family.

Trial registration

Number NTR3400; date April 4th 2012; retrospectively registered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4095-0) contains supplementary material, which is available to authorized users.

Mediating Mechanisms of Theory-Based Psychosocial Determinants on Behavioral Changes in a Middle School Obesity Risk Reduction Curriculum Intervention, Choice, Control, and Change

BACKGROUND

A limited number of school-based intervention studies have explored mediating mechanisms of theory-based psychosocial variables on obesity risk behavior changes. The current study investigated how theory-based psychosocial determinants mediated changes in energy balance-related behaviors (EBRBs) among urban youth.

METHODS

A secondary analysis study was conducted using data from a cluster randomized controlled trial. Data from students at 10 middle schools in New York City (n = 1136) were used. The intervention, Choice, Control, and Change curriculum, was based on social cognitive and self-determination theories. Theory-based psychosocial determinants (goal intention, cognitive outcome expectations, affective outcome expectations, self-efficacy, perceived barriers, and autonomous motivation) and EBRBs were measured with self-report questionnaires. Mediation mechanisms were examined using structural equation modeling, Results: Mediating mechanisms for daily sugar-sweetened beverage (SSB) consumption and purposeful stair climbing were identified. Models with best fit indices (root mean square error of approximation = 0.039/0.045, normed fit index = 0.916/0.882; comparative fit index = 0.945/0.932; Tucker-Lewis index = 0.896/0.882, respectively) suggested that goal intention and reduced perceived barriers were significant proximal mediators for reducing SSB consumption among both boys and girls or increasing physical activity by stair climbing among boys. Cognitive outcome expectations, affective outcome expectations, self-efficacy, and autonomous motivation indirectly mediated behavioral changes through goal intention or perceived barriers (p < 0.05 to p < 0.001). The final models explained 25%-27% of behavioral outcome variances.

CONCLUSIONS

Theory-based psychosocial determinants targeted in Choice, Control, and Change in fact mediated behavior changes in middle school students. Strategies targeting these mediators might benefit future success of behavioral interventions. Further studies are needed to determine other potential mediators of EBRBs in youth.

A Systematic Review to Assess Sugar-Sweetened Beverage Interventions for Children and Adolescents across the Socioecological Model

Sugar-sweetened beverage (SSB) consumption among children and adolescents is a determinant of childhood obesity. Many programs to reduce consumption across the socioecological model report significant positive results; however, the generalizability of the results, including whether reporting differences exist among socioecological strategy levels, is unknown. This systematic review aimed to examine the extent to which studies reported internal and external validity indicators defined by the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) model and assess reporting differences by socioecological level: Intrapersonal/interpersonal (Level 1), environmental/policy (Level 2), and multilevel (Combined Level). A systematic literature review was conducted in six major databases (PubMed, Web of Science, Cinahl, CAB Abstracts, Education Research Information Center, and Arcola) to identify studies from 2004-2015 meeting inclusion criteria (children aged 3 to 12 years, adolescents aged 13 to 17 years, and young adults aged 18 years, experimental or quasiexperimental, and substantial SSB component). Interventions were categorized by socioecological level, and data were extracted using a validated RE-AIM protocol. One-way analysis of variance assessed differences between levels. There were 55 eligible studies accepted, including 21 Level 1, 18 Level 2, and 16 Combined Level studies. Thirty-six studies (65%) were conducted in the United States, 19 studies (35%) were conducted internationally, and 39 studies (71%) were implemented in schools. Across levels, reporting averages were low for all RE-AIM dimensions (reach=29%, efficacy or effectiveness=45%, adoption=26%, implementation=27%, and maintenance=14%). Level 2 studies had significantly lower reporting on reach and effectiveness (10% and 26%, respectively) compared with Level 1 (44% and 57%, respectively) or Combined Level studies (31% and 52%, respectively) (P<0.001). Adoption, implementation, and maintenance reporting did not vary among levels. Interventions to reduce SSB consumption in children and adolescents across the socioecological spectrum do not provide the necessary information for dissemination and implementation in community nutrition settings. Future interventions should address both internal and external validity to maximize population influence.

Systematic Review of School-Based Interventions to Modify Dietary Behavior: Does Intervention Intensity Impact Effectiveness?

BACKGROUND

Owing to the associations between diet and health, it is important that effective health promotion strategies establish healthful eating behaviors from an early age. We reviewed the intensity of school-based interventions aimed to modify dietary behavior in preadolescent and adolescents and related intervention characteristics to effectiveness.

METHODS

Our systematic literature search of 8 databases sought to identify interventions measuring dietary intake in school settings to students aged 9 to 18. We evaluated these studies for effectiveness, intensity, intervention category, and follow-up measures.

RESULTS

Of the 105 interventions 81 were found to be effective immediately postintervention, irrespective of intensity. Studies that were 6 weeks to 5 months in duration, targeted students' environment or group (alone or in combination), and reached students only in schools were more effective. Only one-fifth of interventions conducted a follow-up measure, and a majority showed a loss of effectiveness from postintervention to follow-up.

CONCLUSIONS

We identified characteristics of effective interventions. These findings may inform the development of future interventions targeting dietary behavior in preadolescents and adolescents in the school-based setting.

Consumption of sugar-sweetened beverages and its association with overweight among young children from China

Objective

To fully understand the sugar-sweetened beverage (SSB) consumption status among Chinese young children and to explore its association with weight gain.

Design

In this cross-sectional study, data on sociodemographic characteristics, SSB intake and weight/height were collected by means of face-to-face interviews. The intake of SSB among young Chinese children in relation to their age, different characteristics and types of SSB consumed is described, and the association between SSB intake and BMI-for-age Z-score and overweight is explored.

Setting

Seven large cities and two villages in China.

Subjects

Nine hundred and forty-six healthy children, aged 3–7 years.

Results

The proportion of SSB intake among Chinese young children was 80·5 %; 3·4 % were daily consumers, 34·0 % (31·4 %) consumed at least once per week (month). The per capita and per consumer SSB intake was 63·1 9 (sd 100·8) and 78·4 (sd 106·9) ml/d. Children from rural areas consumed twice, or even triple, the amount of SSB as those from urban areas (P<0·001) and great disparities existed between the types of SSB consumed by urban and rural children. An association was found between increased SSB intake and higher BMI-for-age Z-score (P<0·05) after adjusting for potential confounders; there was also an association between SSB intake and increased risk of being overweight or obese.

Conclusions

The consumption status of SSB in Chinese young children is of concern. There was a positive association between SSB intake and weight gain. Measures should be taken to improve the present situation of SSB consumption among Chinese young children.

Do children report differently from their parents and from observed data? Cross-sectional data on fruit, water, sugar-sweetened beverages and break-time foods

Background

Reliable assessment of children’s dietary behaviour is needed for research purposes. The aim of this study was (1) to investigate the level of agreement between observed and child-reported break-time food items; and (2) to investigate the level of agreement between children’s reports and those of their parents regarding children’s overall consumption of fruit, water and sugar-sweetened beverages (SSB).

Methods

The children in this study were 9–13 years old, attending primary schools in Rotterdam, the Netherlands. Children were observed with respect to foods brought for break-time at school. At the same day, children completed a questionnaire in which they were asked to recall the food(s) they brought to school to consume during break-time. Only paired data (observed and child-reported) were included in the analyses (n = 407 pairs). To determine each child’s daily consumption and average amounts of fruit, water and SSB consumed, children and their parents completed parallel questionnaires. Only paired data (parent-reported and child-reported) were included in the analyses (n = 275 pairs). The main statistical measures were level of agreement between break-time foods, fruit, water and SSB; and Intra-class Correlation Coefficients (ICC).

Results

More children reported bringing sandwiches and snacks for break-time than was observed (73 % vs 51 % observed and 84 % vs 33 % observed). The overall agreement between observed and child-reported break-time foods was poor to fair, with ICC range 0.16–0.39 (p < 0.05). Children reported higher average amounts of SSB consumed than did their parents (1.3 vs 0.9 L SSB, p < 0.001). Child and parent estimations of the child’s water and fruit consumption were similar. ICC between parent and child reports was poor to good (range 0.22–0.62, p < 0.05).

Conclusion

Children report higher on amount of break-time foods as compared to observations and children’s reports of SSB consumption are higher than those of their parents. Since the level of agreement between the observed break-time foods and that reported by children and the agreement of child’s intake between parent and child reports are relatively weak, future studies should focus on improving methods of evaluating children’s consumption behaviour or on ways on how to best use and interpret multiple-source dietary intake data.

Trial registration

Current Controlled Trials NTR3400.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2963-7) contains supplementary material, which is available to authorized users.

Plain water consumption in relation to energy intake and diet quality among US adults, 2005-2012

OBJECTIVE

The present study examined plain water consumption in relation to energy intake and diet quality among US adults.

METHODS

A nationally representative sample of 18 311 adults aged ≥18 years, from the National Health and Nutrition Examination Survey 2005-2012, was analysed. The first-difference estimator approach addressed confounding bias from time-invariant unobservables (e.g. eating habits, taste preferences) by using within-individual variations in diet and plain water consumption between two nonconsecutive 24-h dietary recalls.

RESULTS

One percentage point increase in the proportion of daily plain water in total dietary water consumption was associated with a reduction in mean (95% confidence interval) daily total energy intake of 8.58 (7.87-9.29) kcal, energy intake from sugar-sweetened beverages of 1.43 (1.27-1.59) kcal, energy intake from discretionary foods of 0.88 (0.44-1.32) kcal, total fat intake of 0.21 (0.17-0.25) g, saturated fat intake of 0.07 (0.06-0.09) g, sugar intake of 0.74 (0.67-0.82) g, sodium intake of 9.80 (8.20-11.39) mg and cholesterol intake of 0.88 (0.64-1.13) g. The effects of plain water intake on diet were similar across race/ethnicity, education attainment, income level and body weight status, whereas they were larger among males and young/middle-aged adults than among females and older adults, respectively. Daily overall diet quality measured by the Healthy Eating Index-2010 was not found to be associated with the proportion of daily plain water in total dietary water consumption.

CONCLUSIONS

Promoting plain water intake could be a useful public health strategy for reducing energy and targeted nutrient consumption in US adults, which warrants confirmation in future controlled interventions.

The Effectiveness of the BITSEA as a Tool to Early Detect Psychosocial Problems in Toddlers, a Cluster Randomized Trial

Objective

Effective early detection tools are needed in child health care to detect psychosocial problems among young children. This study aimed to evaluate the effectiveness of the Brief Infant-Toddler Social and Emotional Assessment (BITSEA), in reducing psychosocial problems at one year follow-up, compared to care as usual.

Method

Well-child centers in Rotterdam, the Netherlands, were allocated in a cluster randomized controlled trial to the intervention condition (BITSEA—15 centers), or to the control condition (‘care-as-usual’- 16 centers). Parents of 2610 2-year-old children (1,207 intervention; 1,403 control) provided informed consent and completed the baseline and 1-year follow-up questionnaire. Multilevel regression analyses were used to evaluate the effect of condition on psychosocial problems and health related quality of life (i.e. respectively Child Behavior Checklist and Infant-Toddler Quality of Life). The number of (pursuits of) referrals and acceptability of the BITSEA were also evaluated.

Results

Children in the intervention condition scored more favourably on the CBCL at follow-up than children in the control condition: B = -2.43 (95% confidence interval [95%CI] = -3.53;-1.33 p<0.001). There were no differences between conditions regarding ITQOL. Child health professionals reported referring fewer children in the intervention condition (n = 56, 5.7%), compared to the control condition (n = 95, 7.9%; p<0.05). There was no intervention effect on parents’ reported number of referrals pursued. It took less time to complete (parents) or work with (child health professional) the BITSEA, compared to care as usual. In the control condition, 84.2% of the parents felt (very) well prepared for the well-child visit, compared to 77.9% in the intervention condition (p<0.001).

Conclusion

The results support the use of the BITSEA as a tool for child health professionals in the early detection of psychosocial problems in 2-year-olds. We recommend future studies in large and varied populations to replicate these findings.

Trial registration

Current Controlled Trials NTR2035