The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study: a cluster randomised controlled trial testing the clinical effectiveness and cost-effectiveness of a multifaceted obesity prevention intervention programme targeted at children aged 6-7 years

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

The cost-effectiveness of school-based interventions for chronic diseases: a systematic review

BACKGROUND

Chronic diseases, or non-communicable diseases (NCD), are conditions of long duration and often influenced and contributed by complex interactions of several variables, including genetic, physiological, environmental, and behavioral factors. These conditions contribute to death, disability, and subsequent health care costs. Primary and secondary school settings provide an opportunity to deliver relatively low cost and effective interventions to improve public health outcomes. However, there lacks systematic evidence on the cost-effectiveness of these interventions.

METHODS

We systematically searched four databases (PubMed/Medline, Cochrane, Embase, and Web of Science) for published studies on the cost-effectiveness of chronic-disease interventions in school settings. Studies were eligible for inclusion if they assessed interventions of any chronic or non-communicable disease, were conducted in a school setting, undertook a full cost-effectiveness analysis and were available in English, Spanish, or French.

RESULTS

Our review identified 1029 articles during our initial search of the databases, and after screening, 33 studies were included in our final analysis. The most used effectiveness outcome measures were summary effectiveness units such as quality-adjusted life years (QALYs) (22 articles; 67%) or disability-adjusted life years (DALYs) (4 articles; 12%). The most common health condition for which an intervention targets is overweight and obesity. Almost all school-based interventions were found to be cost-effective (30 articles; 81%).

CONCLUSION

Our review found evidence to support a number of cost-effective school-based interventions targeting NCDs focused on vaccination, routine physical activity, and supplement delivery interventions. Conversely, many classroom-based cognitive behavioral therapy for mental health and certain multi-component interventions for obesity were not found to be cost-effective.

Are Physical Activity Interventions Effective in Improving Health-Related Quality of Life in Children and Adolescents? A Systematic Review and Meta-Analysis

CONTEXT

Physical activity (PA) interventions improve well-being and positive mental health in children and adolescents, but the results of previous systematic reviews included participants with chronic medical conditions and did not accurately assess the multidimensional nature of health-related quality of life (HRQoL).

OBJECTIVE

The aims of this meta-analysis were to (1) evaluate the effects of PA interventions on several domains of HRQoL in healthy <18-year-olds and (2) examine the effectiveness of interventions on HRQoL according to whether they were successful in increasing PA, the type of intervention delivered, and the duration of the intervention.

DATA SOURCES

PubMed (Medline), EMBASE, the Cochrane Library, SCIELO, SPORTDiscus, and PEDro databases were systematically searched from inception to September 30, 2022.

STUDY SELECTION

Experimental studies that examined the effectiveness of PA interventions on HRQoL participants aged <18 years.

STUDY DESIGN

Systematic review with meta-analysis and meta-regression.

LEVEL OF EVIDENCE

Level 1.

METHODS

Random-effects models were used to calculate pooled effect size (ES) for total HRQoL score and its dimensions. Subgroup analyses were conducted to examine the effect of PA program characteristics.

RESULTS

A total of 17 studies were included. Pooled ES (95% CI) estimations were as follows: 0.179 (0.045, 0.002) for total HRQoL score, 0.192 (0.077, 0.306) for physical well-being, 0.158 (0.080, 0.237) for psychological well-being, 0.118 (0.044, 0.192) for autonomy and parent relation, 0.135 (0.043, 0.227) for social support and peers, and 0.129 (-0.013, 0.270) for school environment. Subgroup analyses suggested there were no differences in the effectiveness of the interventions by category of PA increase or by type and duration of intervention.

CONCLUSION

Exercise interventions are an effective strategy for improving overall HRQoL and its most significant domains in children and adolescents.

Reporting involvement activities with children and young people in paediatric research: a framework analysis

BACKGROUND

The active involvement of patients and the public in the design and delivery of health research has been increasingly encouraged, if not enforced. Knowledge of how this is realised in practice, especially where children and young people (CYP) are concerned, is limited, partly due to the low level of reporting of patient and public involvement (PPI) in general. The aim of this work was to assess how researchers funded by the National Institute for Health and Care Research (NIHR) report the involvement of CYP in the design and conduct of child health research to better understand the opportunities offered to CYP, and the realities of involvement in practice.

METHODS

A participation matrix, analysis framework and accompanying tools were adapted from existing frameworks, including a child-rights informed framework, the Guidance for Reporting Involvement of Patients and the Public Checklist Short Form (GRIPP2SF), and NIHR reporting expectations. Child-focused research reports were identified from the NIHR Journals Library, including any interventional or observational study involving CYP aged 0-< 24 years. In two co-design workshops with healthcare professionals and CYP, we tested and refined the participation matrix, analysis framework and accompanying tools.

RESULTS

Only thirty-two NIHR reports out of 169 (19%) were identified as relevant and included reporting of PPI with CYP. We identified significant variability in the way PPI with CYP was reported. Only 4/32 (12%) reports fully met NIHR (and GRIPP2SF) reporting criteria. Only 3/32 (9%) reports formally evaluated or self-reflected on PPI activities with CYP, whilst 15/32 (47%) provided minimal information about CYP involvement. The most common approach to involving CYP (23/32, 72%) was through the medium of existing groups or networks.

CONCLUSION

Despite the NIHR's commitment to increase the quality, transparency, and consistency of reporting PPI, the reporting of involvement with CYP remains sub-optimal. Neglecting to report key details of involvement methods and impacts deprives the research community of knowledge to advance the field of delivering 'meaningful' PPI with CYP. Practical guidance on how researchers can report the processes and outputs of CYP involvement more rigorously may help child health researchers to involve them more meaningfully. This research offers practical tools informed by CYP to aid the reporting process.

Physical activity interventions for the mental health of children: A systematic review

OBJECTIVE

This systematic review explored the effectiveness of using physical activity (PA) interventions to enhance psychological well-being and reduce psychological ill-being (e.g., anxiety and depression) in children aged six to 11 years old from the general population.

METHODS

Electronic databases were searched for studies published between January 2005 and June 2020: Web of Science, ProQuest Psychology Journals, PsycINFO, Pub Med, ASSIA, CINHAL PLUS, SPORTDiscus, EMBASE and Wiley Online Library. Search terms included 'physical activity intervention', 'psychological well-being' and 'child*'. After removing duplicates, 11 390 studies were independently screened by two authors based on inclusion/exclusion criteria and assessed for risk of bias.

RESULTS

A total of 23 studies were narratively synthesized and categorized into four domains: Quality of Life (QOL), body image, self-esteem and psychological ill-being. Evidence was provided for the impact of PA interventions in improving QOL, body image and self-esteem. Despite the positive effect on psychological well-being, evidence for a reduction in the frequency and severity of symptoms associated with psychological ill-being in children is less clear.

CONCLUSIONS

Reviewed studies support the use of PA interventions in enhancing the psychological well-being of children in school and community settings. More research is warranted to understand the impact of PA interventions on reducing psychological ill-being in children from the general population.

A hybrid approach to comparing parallel-group and stepped-wedge cluster-randomized trials with a continuous primary outcome when there is uncertainty in the intra-cluster correlation

BACKGROUND/AIMS

To evaluate how uncertainty in the intra-cluster correlation impacts whether a parallel-group or stepped-wedge cluster-randomized trial design is more efficient in terms of the required sample size, in the case of cross-sectional stepped-wedge cluster-randomized trials and continuous outcome data.

METHODS

We motivate our work by reviewing how the intra-cluster correlation and standard deviation were justified in 54 health technology assessment reports on cluster-randomized trials. To enable uncertainty at the design stage to be incorporated into the design specification, we then describe how sample size calculation can be performed for cluster- randomized trials in the 'hybrid' framework, which places priors on design parameters and controls the expected power in place of the conventional frequentist power. Comparison of the parallel-group and stepped-wedge cluster-randomized trial designs is conducted by placing Beta and truncated Normal priors on the intra-cluster correlation, and a Gamma prior on the standard deviation.

RESULTS

Many Health Technology Assessment reports did not adhere to the Consolidated Standards of Reporting Trials guideline of indicating the uncertainty around the assumed intra-cluster correlation, while others did not justify the assumed intra-cluster correlation or standard deviation. Even for a prior intra-cluster correlation distribution with a small mode, moderate prior densities on high intra-cluster correlation values can lead to a stepped-wedge cluster-randomized trial being more efficient because of the degree to which a stepped-wedge cluster-randomized trial is more efficient for high intra-cluster correlations. With careful specification of the priors, the designs in the hybrid framework can become more robust to, for example, an unexpectedly large value of the outcome variance.

CONCLUSION

When there is difficulty obtaining a reliable value for the intra-cluster correlation to assume at the design stage, the proposed methodology offers an appealing approach to sample size calculation. Often, uncertainty in the intra-cluster correlation will mean a stepped-wedge cluster-randomized trial is more efficient than a parallel-group cluster-randomized trial design.

Response to school-based interventions for overweight and obesity: A systematic scoping review

Heterogeneity of response to paediatric obesity interventions is one of the greatest challenges to obesity care. While evaluating school-based interventions by mean changes compared to control is important, it does not provide an understanding of the individual variability in response to intervention. The objective of this study was to comprehensively review school-based interventions that reported study results in terms of response and identify definitions of response used. A scoping review was conducted using a systematic search of five scientific databases from 2009 to 2021. Inclusion criteria included randomized controlled trial design, school-based setting, weight-based outcomes (e.g., BMI, BMI z-score), weight-based outcomes analysed among youth with overweight/obesity, a study conducted in a developed country and publication in English. A total of 26 reports representing 25 unique studies were included. Overall, 19% (5/26) of articles reported response. Response was defined in three ways: maintenance/decrease in BMI z-score, decrease in BMI z-score ≥0.10, and decrease in BMI z-score ≥0.20. Few school-based interventions identified an a priori intervention goal or identified the proportion of participants who responded to the intervention. Without such evaluation participants who do not benefit are likely to be overlooked.

Efficacy of a county-wide schools weight management intervention

AIMS

This study aimed to evaluate the effectiveness of the Local Authority commissioned large-scale public health service that provided a 6-week school-based weight management intervention for children aged 4-19 years.

METHODS

A quantitative retrospective cohort study identified participants from 130 schools consisting of 8550 potential children aged 4-19 years across a mixture of Lower Super Output Area (LSOA) deprivation groups. Participants were invited to take part in a 5- to 12-week Healthy Lifestyles intervention with a focus on weight management delivered by OneLife Suffolk between 1 January 2017 and 1 January 2020. This resulted in a final sample of 5163 participants. The following information for each child was collected anonymously: (1) age, (2) gender, (3) preprogramme body mass index (BMI), (4) postprogramme BMI, (5) weight category and (6) LSOA category.

RESULTS

Following the 6-week school-based intervention, there was a significant decrease in mean ΔBMI SDS (standardised body mass index) of -0.07 (-14.89%) among participants. Wilcoxon signed-rank test showed a significant change in weight status post 6-week weight management programme (WMP): BMI (Z = -15.87, p < .001), BMI SDS (Z = -21.54, p < .001), centile (Z = -20.12, p < .01) and weight category (Z = -7.89, p < .001), whereas Mann-Whitney U test showed no statistically significant difference in mean BMI SDS change between gender groups (p = .24) and Kruskal-Wallis test revealed no statistically significant differences in mean BMI SDS change between child LSOA groups (c2(4) = 1.67, p = .796), school LSOA groups (c2(4) = 4.72, p = .317), ethnic groups (c2(4) = 2.53, p = .640) and weight category at the start of the intervention (c2(3) = 6.20, p = .102).

CONCLUSIONS

This study contributes to the growing body of evidence demonstrating the efficacy of multicomponent school-based weight management interventions and demonstrates that such interventions can be successfully implemented as part of a wider healthy lifestyles service, without widening health inequalities.

Features of effective staff training programmes within school-based interventions targeting student activity behaviour: a systematic review and meta-analysis

BACKGROUND

Evaluations of school-based activity behaviour interventions suggest limited effectiveness on students' device-measured outcomes. Teacher-led implementation is common but the training provided is poorly understood and may affect implementation and student outcomes. We systematically reviewed staff training delivered within interventions and explored if specific features are associated with intervention fidelity and student activity behaviour outcomes.

METHODS

We searched seven databases (January 2015-May 2020) for randomised controlled trials of teacher-led school-based activity behaviour interventions reporting on teacher fidelity and/or students' device-measured activity behaviour. Pilot, feasibility and small-scale trials were excluded. Study authors were contacted if staff training was not described using all items from the Template for Intervention Description and Replication reporting guideline. Training programmes were coded using the Behaviour Change Technique (BCT) Taxonomy v1. The Effective Public Health Practice Project tool was used for quality assessment. Promise ratios were used to explore associations between BCTs and fidelity outcomes (e.g. % of intended sessions delivered). Differences between fidelity outcomes and other training features were explored using chi-square and Wilcoxon rank-sum tests. Random-effects meta-regressions were performed to explore associations between training features and changes in students' activity behaviour.

RESULTS

We identified 68 articles reporting on 53 eligible training programmes and found evidence that 37 unique teacher-targeted BCTs have been used (mean per programme = 5.1 BCTs; standard deviation = 3.2). The only frequently identified BCTs were 'Instruction on how to perform the behaviour' (identified in 98.1% of programmes) and 'Social support (unspecified)' (50.9%). We found moderate/high fidelity studies were significantly more likely to include shorter (≤6 months) and theory-informed programmes than low fidelity studies, and 19 BCTs were independently associated with moderate/high fidelity outcomes. Programmes that used more BCTs (estimated increase per additional BCT, d: 0.18; 95% CI: 0.05, 0.31) and BCTs 'Action planning' (1.40; 0.70, 2.10) and 'Feedback on the behaviour' (1.19; 0.36, 2.02) were independently associated with positive physical activity outcomes (N = 15). No training features associated with sedentary behaviour were identified (N = 11).

CONCLUSIONS

Few evidence-based BCTs have been used to promote sustained behaviour change amongst teachers in school-based activity behaviour interventions. Our findings provide insights into why interventions may be failing to effect student outcomes.

TRIAL REGISTRATION

PROSPERO registration number: CRD42020180624.

Methods for the economic evaluation of obesity prevention dietary interventions in children: A systematic review and critical appraisal of the evidence

OBJECTIVES

We aim to describe and provide a discussion of methods used to conduct economic evaluations of dietary interventions in children and adolescents, including long-term modelling, and to make recommendations to assist health economists in the design and reporting of such evaluations.

METHODS

A systematic review was conducted in 11 bibliographic databases and the grey literature with searches undertaken between January 2000 and December 2021. A study was included if it (1) was an economic evaluation or modelling study of an obesity-prevention dietary intervention and (2) targeted 2- to 18-year-olds.

RESULTS

Twenty-six studies met the inclusion criteria. Twelve studies conducted an economic evaluation alongside a clinical trial, and 14 studies modelled long-term health and cost outcomes. Four overarching methodological challenges were identified: modelling long-term impact of interventions, measuring and valuing health outcomes, cost inclusions and equity considerations.

CONCLUSIONS

Variability in methods used to predict, measure and value long-term benefits in adulthood from short-term clinical outcomes in childhood was evident across studies. Key recommendations to improve the design and analysis of future economic evaluations include the consideration of weight regain and diminishing intervention effects within future projections; exploration of wider intervention benefits not restricted to quality-of-life outcomes; and inclusion of parental or caregiver opportunity costs.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Prediction of Gestational Diabetes Mellitus under Cascade and Ensemble Learning Algorithm

Gestational diabetes mellitus (GDM) is one of the risk factors for fetal dysplasia and maternal pregnancy difficulties. Therefore, the prediction of the risk of GDM in advance has become a big demand for millions of families. Therefore, machine learning technology is adopted to study GDM prediction. Firstly, the data is preprocessed, and the mean value is used for outlier processing. After preprocessing of the data, the IV value method is used to screen the features. Of the 83 features in the original sample data, 40 important features are screened out through feature engineering. On this basis, Logistics regression model, Lasso-Logistics, Gradient Boosting Decision Tree (GBDT), Extreme Gradient Boosting (Xgboost), Light Gradient Boosting Machine (Lightgbm), and Gradient Boosting Categorical Features (Catboost) are established, and multiple learners are integrated. Finally, the constructed model is tested on data sets. The accuracy of the proposed model is 80.3%, the accuracy is 74.6%, the recall rate is 79.3%, and the running time is only 2.53 seconds. This means that the proposed model is superior to the previous models in terms of accuracy, precision, recall rate, and F1 value, and the time consumption is also in line with the actual engineering requirements. The proposed scheme provides some ideas for the research of machine learning technology in disease prediction.

How Primary School Curriculums in 11 Countries around the World Deliver Food Education and Address Food Literacy: A Policy Analysis

(1) Background: As one of the biggest drivers of health and climate change, the food system has unrealised potential to influence consumption toward affordable, healthy, sustainable diets. A range of policy levers, including mandating food education, are needed. Schools are considered the best place for food education and childhood is a crucial period when eating habits that persist into adulthood are formed. Food education as part of the curriculum is crucial in generating population shifts in food systems improvements. The purpose of this policy analysis was to analyse mandatory curriculums in different countries to explore the ways in which primary school food education addresses food literacy. (2) Methods: This study analyses how food education within primary school education policy, in 11 countries, addresses Food Literacy (FL). It is the first study of this kind. A case study methodology was employed, and curriculum policy content analysis was conducted using a Food Literacy framework. (3) Results: Each country has a curriculum dedicated to food education, supported by food education in non-food curriculums. There is no standardized approach to primary school food education policy, no consensus in primary food education nomenclature or what curriculums constitute. Curriculums focus on cooking and health topics, but significantly less on social-cultural, equity, and sustainability issues. (4) Conclusion: How primary curriculums around the world deliver food education policy to address FL varies enormously. All 11 countries have dedicated food curriculums, supported by non-food curriculums, but there is no consensus as to what food education is called or constitutes. Countries rarely deal with FL comprehensively. The most comprehensive are single, detailed food curriculums, complemented by non-food curriculums where food knowledge and skills progress clearly and are the intended learning outcome.

School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18

BACKGROUND

Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school.

OBJECTIVES

The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are: • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents; • to evaluate the effects of school-based interventions on improving body composition; and • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information.

SELECTION CRITERIA

Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update.  DATA COLLECTION AND ANALYSIS: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type.

MAIN RESULTS

Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias.  Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events.

AUTHORS' CONCLUSIONS

Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.

Relationship between primary school healthy eating and physical activity promoting environments and children's dietary intake, physical activity and weight status: a longitudinal study in the West Midlands, UK

OBJECTIVE

We aimed to examine the association between food and physical activity environments in primary schools and child anthropometric, healthy eating and physical activity measures.

DESIGN

Observational longitudinal study using data from a childhood obesity prevention trial.

SETTING

State primary schools in the West Midlands region, UK.

PARTICIPANTS

1392 pupils who participated in the WAVES (West Midlands ActiVe lifestyle and healthy Eating in School children) childhood obesity prevention trial (2011-2015).

PRIMARY AND SECONDARY OUTCOME MEASURES

School environment (exposure) was categorised according to questionnaire responses indicating their support for healthy eating and/or physical activity. Child outcome measures, undertaken at three time points (ages 5-6, 7-8 and 8-9 years), included body mass index z-scores, dietary intake (using a 24-hour food ticklist) and physical activity (using an Actiheart monitor over 5 days). Associations between school food and physical activity environment categories and outcomes were explored through multilevel models.

RESULTS

Data were available for 1304 children (94% of the study sample). At age 8-9 years, children in 10 schools with healthy eating and physical activity-supportive environments had a higher physical activity energy expenditure than those in 22 schools with less supportive healthy eating/physical activity environments (mean difference=5.3 kJ/kg body weight/24 hours; p=0.05). Children in schools with supportive physical activity environments (n=8) had a lower body mass index z-score than those in schools with less supportive healthy eating/physical activity environments (n=22; mean difference=-0.17, p=0.02). School food and physical activity promoting environments were not significantly associated with dietary outcomes.

CONCLUSIONS

School environments that support healthy food and physical activity behaviours may positively influence physical activity and childhood obesity.

TRIAL REGISTRATION NUMBER

ISRCTN97000586.

A Sex/Gender Perspective on Interventions to Reduce Sedentary Behaviour in Girls and Boys: Results of the genEffects Systematic Review

This systematic review aims to evaluate the extent of sex/gender consideration and effectiveness of interventions designed to reduce sedentary behaviour (SB). We searched for randomised or non-randomised controlled trials with the outcome SB and a sex/gender analysis in eleven electronic databases. Sixty-seven studies were included. Sex/gender considerations were qualitatively rated. Sex/gender was reported separately in 44.8% of studies, 14.9% of studies conducted a sex/gender interaction analysis, and 19.4% enrolled either girls or boys. SB was significantly reduced for girls in 16.4%, for boys in 11.9% and for both in 13.4%. No sex/gender intervention effect was found in 38.8%. According to the qualitative rating, studies without significant sex/gender effects reached "detailed" rating twice as often as studies finding a significant intervention effect for either girls or boys, or both. Overall, no clear pattern according to the qualitative rating and in terms of intervention effectiveness can be drawn. The results reveal a lack of sufficient sex/gender information in intervention planning and delivery. Further research should consider analysing sex/gender intervention effects as well as consider sex/gender inclusive intervention planning and delivery.

School-related physical activity interventions and mental health among children: a systematic review and meta-analysis

BACKGROUND

Low levels of physical activity, sedentary behaviour and mental health problems are issues that have received considerable attention in the last decade. The aim of this systematic review and meta-analysis was to investigate effects of interventions targeting school-related physical activity or sedentary behaviour on mental health in children and adolescents and to identify the features of effective interventions.

METHODS

Scientific articles published between January 2009 and October 2019 fulfilling the following criteria were included: general populations of children and adolescents between age 4 and 19, all types of school-related efforts to promote physical activity or reduce sedentary behaviour. Study selection, data extraction and quality assessment were done by at least two authors independently of each other. Data were analysed with a random effects meta-analysis and by narrative moderator analyses.

RESULTS

The literature search resulted in 10265 unique articles. Thirty-one articles, describing 30 interventions, were finally included. Eleven relevant outcomes were identified: health-related quality of life, well-being, self-esteem and self-worth, resilience, positive effect, positive mental health, anxiety, depression, emotional problems, negative effect and internalising mental health problems. There was a significant beneficial effect of school-related physical activity interventions on resilience (Hedges' g = 0.748, 95% CI = 0.326; 1.170, p = 0.001), positive mental health (Hedges' g = 0.405, 95% CI = 0.208; 0.603, p = < 0.001), well-being (Hedges' g = 0.877, 95% CI = 0.356; 1.398, p = < 0.001) and anxiety (Hedges' g = 0.347, 95% CI = 0.072; 0.623, p = 0.013). Heterogeneity was moderate to high (I² = 59-98%) between studies for all outcomes except positive effect, where heterogeneity was low (I² = 2%). The narrative moderator analyses of outcomes based on 10 or more studies showed that age of the children moderated the effect of the intervention on internalising mental health problems. Interventions in younger children showed a significantly negative or no effect on internalising mental health problems while those in older children showed a significant positive or no effect. Moreover, studies with a high implementation reach showed a significant negative or no effect while those with a low level of implementation showed no or a positive effect. No signs of effect moderation were found for self-esteem, well-being or positive mental health. Risk of publication bias was evident for several outcomes, but adjustment did not change the results.

CONCLUSIONS

School-related physical activity interventions may reduce anxiety, increase resilience, improve well-being and increase positive mental health in children and adolescents. Considering the positive effects of physical activity on health in general, these findings may reinforce school-based initiatives to increase physical activity. However, the studies show considerable heterogeneity. The results should therefore be interpreted with caution. Future studies should report on implementation factors and more clearly describe the activities of the control group and whether the activity is added to or replacing ordinary physical education lessons in order to aid interpretation of results.

TRIAL REGISTRATION

PROSPERO, CRD42018086757.

Effectiveness of a family intervention on health-related quality of life-a healthy generation, a controlled pilot trial

BACKGROUND

Physical activity is associated with better health, but knowledge about health promoting interventions, including physical activity for families in disadvantaged areas and the impact on health-related quality of life (HRQOL) is sparse. The aim of this study was to assess HRQOL in children and their parents after participation in the programme "A Healthy Generation".

METHODS

The programme is delivered in socioeconomically disadvantaged areas in Sweden and offers physical activity and a healthy meal or fruit twice a week from August to May to families with children in grade 2. Children (n = 67), aged 8-9 years, and their parents (n = 90) participated in this controlled study conducted in four schools, two control and two intervention schools. HRQOL of children and adults was assessed at baseline and follow-up after the intervention with the Pediatric Quality of Life Inventory (PedsQL) 4.0 and the Gothenburg Quality of Life scale, respectively. Analyses of covariance (ANCOVAs), linear regression and Pearson's correlation were conducted.

RESULTS

There were no significant differences between intervention and control in HRQOL among children or adults after the intervention. However, in a subgroup of children (n = 20) and adults (n = 29) with initial low HRQOL scores at baseline, there was a significant difference between the intervention group and control group after the intervention (children (total score): p = 0.02; adults (social domain) p = 0.04). Furthermore, within the intervention group, there was a significant relationship between level of participation in "A Healthy Generation" and the physical domain of HRQOL among girls (r = 0.44, p = 0.01), but not boys (r = - 0.07, p = 0.58).

CONCLUSION

Participation in the programme "A Healthy Generation" did not show a significant intervention effect on HRQOL in general. However, the findings suggest that HRQOL may be increased for children and adults with low HRQOL in disadvantaged areas. This knowledge can contribute to the development of health promoting interventions in such areas, and to more equitable health.

TRIAL REGISTRATION

ISRCTN ISRCTN11660938. Retrospectively registered 23 September 2019.

Economic evaluation of a childhood obesity prevention programme for children: Results from the WAVES cluster randomised controlled trial conducted in schools

Background

Childhood obesity is a serious public health challenge and schools have been identified as an ideal place to implement prevention interventions. The aim of this study was to measure the cost-effectiveness of a multi-faceted school-based obesity prevention intervention targeting children aged 6–7 years when compared to ‘usual activities’.

Methods

A cluster randomised controlled trial in 54 schools across the West Midlands (UK) was conducted. The 12-month intervention aimed to increase physical activity by 30 minutes per day and encourage healthy eating. Costs were captured from a public sector perspective and utility-based health related outcomes measured using the CHU-9D. Multiple imputation using chained equations was used to address missing data. The cost effectiveness was measured at 30 months from baseline using a hierarchical net-benefit regression framework, that controlled for clustering and prespecified covariates. Any uncertainty in the results was characterised using cost-effectiveness acceptability curves.

Results

At 30 months, the total adjusted incremental mean cost of the intervention was £155 (95% confidence interval [CI]: £139, £171), and the incremental mean QALYs gained was 0.006 (95% CI: -0.024, 0.036), per child. The incremental cost-effectiveness at 30 months was £26,815 per QALY and using a standard willingness to pay threshold of £30,000 per QALY, there was a 52% chance that the intervention was cost-effective.

Conclusions

The cost-effectiveness of the school-based WAVES intervention was subject to substantial uncertainty. We therefore recommend more research to explore obesity prevention within schools as part of a wider systems approach to obesity prevention.

Trial registration

This paper uses data collected by the WAVES trial: Controlled trials ISRCTN97000586 (registered May 2010).