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Hodder RK, O'Brien KM, Wyse RJ, Tzelepis F, Yoong S, Stacey FG, Wolfenden L. Interventions for increasing fruit and vegetable consumption in children aged five years and under. Cochrane Database Syst Rev 2024; 9:CD008552. [PMID: 39312396 PMCID: PMC11418976 DOI: 10.1002/14651858.cd008552.pub8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Abstract
BACKGROUND Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions designed to increase children's consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment, is required to assess the potential to reduce this disease burden. OBJECTIVES To assess the benefits and harms of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 March 2023. We searched Proquest Dissertations and Theses in December 2022. We reviewed reference lists of included trials and contacted authors of the included trials to identify further potentially relevant trials. SELECTION CRITERIA We included randomised controlled trials (RCTs), including cluster-randomised controlled trials (C-RCTs) and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both amongst children aged five years and under compared to no-intervention control, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. We used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures. MAIN RESULTS We included 53 trials with 120 trial arms and 12,350 participants. Sixteen trials examined the impact of child-feeding practice interventions only (e.g. repeated food exposure) in increasing child vegetable intake. Twenty trials examined the impact of multicomponent interventions primarily conducted in the childcare setting (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Seventeen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children only in increasing child fruit and vegetable intake and one each examined a child-focused mindfulness intervention or providing families with fruit and vegetable interventions. We judged nine of the 53 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is moderate-certainty evidence that child-feeding practice interventions versus no-intervention control probably have a small positive effect on child vegetable consumption, equivalent to an increase of 15.5 grams as-desired consumption of vegetables (SMD 0.44, 95% confidence interval (CI) 0.24 to 0.65; 15 trials, 1976 participants; mean post-intervention follow-up = 12.3 weeks). No trials in this comparison reported information about intervention costs. One trial reported no harms or serious unintended adverse consequences (low-certainty evidence). Multicomponent interventions versus no-intervention control probably have a small effect on child consumption of fruit and vegetables (SMD 0.27, 95% CI 0.11 to 0.43; 14 trials, 4318 participants; moderate-certainty evidence; mean post-intervention follow-up = 4.0 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. One trial, which tested a multicomponent garden-based intervention, reported the installation of the garden as part of the intervention to be USD 1500 per childcare centre (low-certainty evidence). No trials in this comparison reported information about unintended adverse consequences of interventions. Parent nutrition education interventions may have little to no short-term impact on child consumption of fruit and vegetables versus no-intervention control (SMD 0.10, 95% CI -0.02 to 0.22; 14 trials, 4122 participants; low-certainty evidence; mean post-intervention follow-up = 6.4 weeks). One trial reported the total estimated cost of delivering a parent nutrition education intervention for infant feeding, physical activity and sedentary behaviours delivered by a dietitian as approximately AUD 500 per family (low-certainty evidence). One trial reported no unintended adverse consequences on family food expenditure following implementation of an intervention delivered over the telephone to improve parental knowledge and skills about the home food environment (low-certainty evidence). Trials reported receiving governmental or charitable funds, except for one trial reporting industry funding. AUTHORS' CONCLUSIONS There was moderate-certainty evidence that child-feeding practice interventions and multicomponent interventions probably lead to only small increases in fruit and vegetable consumption in children aged five years and under. Parent nutrition education interventions may have little or no effect on increasing fruit and vegetable consumption in children aged five years and under. Future research should be prioritised on assessment and reporting of both intervention cost and adverse effects, and development and evaluation of interventions in research gaps, including in a broader range of settings and in low- and middle-income countries. This review continues to be maintained as a living systematic review with monthly searches for new evidence and incorporation of relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Rebecca K Hodder
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton, Australia
- National Centre of Implementation Science, The University of Newcastle, Callaghan, Australia
| | - Kate M O'Brien
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton, Australia
- National Centre of Implementation Science, The University of Newcastle, Callaghan, Australia
| | - Rebecca J Wyse
- School of Medicine and Public Health, The University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
| | - Flora Tzelepis
- School of Medicine and Public Health, The University of Newcastle, Callaghan, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton, Australia
| | - Serene Yoong
- National Centre of Implementation Science, The University of Newcastle, Callaghan, Australia
- Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, Deakin University, Melbourne, Australia
| | - Fiona G Stacey
- School of Medicine and Public Health, The University of Newcastle, Callaghan, Australia
| | - Luke Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton, Australia
- National Centre of Implementation Science, The University of Newcastle, Callaghan, Australia
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Pillay D, Ali A, Wham CA. Examining the New Zealand school food environment: what needs to change? Nutr Res Rev 2023; 36:406-419. [PMID: 35968693 DOI: 10.1017/s0954422422000154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Habitual dietary intakes and nutrition behaviours developed during childhood and adolescence pave the way for similar behaviours to manifest in adulthood. Childhood obesity rates have now reached a point where one in six children globally are classified as overweight or obese. Schools have the unique ability to reach almost all children during key developmental stages, making them an ideal setting for influencing children's nutrition behaviours. Evidence suggests the school food environment is not always conducive to healthy food choices and may be obesogenic. The aim of this narrative review is to explore factors that influence the healthy food and drink environment in and around schools in New Zealand. The review focused on evidence from New Zealand and Australia given the close resemblance in education systems and school food guidance. Using the Analysis Grid for Environments Linked to Obesity (ANGELO) framework, the school food environment was categorised into the following domains: economic, political, physical and socio-cultural factors. Findings suggest that food policies are not utilised within schools, and guidelines to improve the school food environment are not well implemented. Canteen profit models, lack of staff support and resources, and higher availability of low-cost unhealthy foods are among barriers that hinder implementation. This review highlights recommendations from existing evidence, including canteen pricing strategies, restriction of unhealthy foods and using peer modelling in a time-scarce curriculum to improve the school food environment. Key areas for improvement, opportunities to enhance policy implementation and untapped avenues to improve the food and nutrition behaviours of children are highlighted.
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Affiliation(s)
- Danika Pillay
- School of Sport, Exercise and Nutrition, Massey University, Auckland, New Zealand
| | - Ajmol Ali
- School of Sport, Exercise and Nutrition, Massey University, Auckland, New Zealand
| | - Carol A Wham
- School of Sport, Exercise and Nutrition, Massey University, Auckland, New Zealand
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Lovell AL, Roy R, Klein A, Cavadino A, Foster M, Krebs JD, Braakhuis A, Merry TL. Habitual Dietary Patterns, Nutrient Intakes, and Adherence to the Mediterranean Diet among New Zealand Adults: The NZ MED Cross-Sectional Study. Nutrients 2023; 15:2663. [PMID: 37375568 DOI: 10.3390/nu15122663] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/27/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
There is increasing evidence that adherence to a Mediterranean dietary pattern reduces the incidence of diet-related diseases. To date, the habitual dietary intake of New Zealand (NZ) adults has not been examined in relation to its alignment with a Mediterranean-style dietary pattern. This study aimed to define the habitual dietary patterns, nutrient intakes, and adherence to the Mediterranean Diet in a sample of 1012 NZ adults (86% female, mean age 48 ± 16 years) who had their diabetes risk defined by the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK). Dietary intakes were collected using a validated semi-quantitative NZ food frequency questionnaire, and dietary patterns were identified using principal component analysis. Reported intakes from the FFQ were used in conjunction with the Mediterranean-Style Dietary Pattern Score (MSDPS) to determine adherence to a Mediterranean dietary pattern. Mixed linear models were used to analyze the association between dietary patterns and MSDPS with demographics, health factors, and nutrient intakes. Two distinct dietary patterns were identified: Discretionary (positive loadings on processed meat, meat/poultry, fast food, sweet drinks, and sugar, sweets, and baked good) and Guideline (positive loadings on vegetables, eggs/beans, and fruits). Adherence to dietary patterns and diet quality was associated with age and ethnicity. Dietary patterns were also associated with sex. Adherence to a Mediterranean dietary pattern defined by the MSDPS was low, indicating that a significant shift in food choices will be required if the Mediterranean Diet is to be adopted in the NZ population.
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Affiliation(s)
- Amy L Lovell
- Department of Nutrition and Dietetics, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand
- High-Value Nutrition Ko Ngā Kai Whai Painga National Science Challenge, The Liggins Institute, Auckland 1023, New Zealand
| | - Rajshri Roy
- Department of Nutrition and Dietetics, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand
- High-Value Nutrition Ko Ngā Kai Whai Painga National Science Challenge, The Liggins Institute, Auckland 1023, New Zealand
| | - Alana Klein
- Department of Nutrition and Dietetics, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand
| | - Alana Cavadino
- Department of Nutrition and Dietetics, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand
| | - Meika Foster
- High-Value Nutrition Ko Ngā Kai Whai Painga National Science Challenge, The Liggins Institute, Auckland 1023, New Zealand
- Edible Research Ltd., Canterbury 7692, New Zealand
| | - Jeremy D Krebs
- High-Value Nutrition Ko Ngā Kai Whai Painga National Science Challenge, The Liggins Institute, Auckland 1023, New Zealand
- Department of Medicine, University of Otago, Wellington 6242, New Zealand
| | - Andrea Braakhuis
- Department of Nutrition and Dietetics, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand
- High-Value Nutrition Ko Ngā Kai Whai Painga National Science Challenge, The Liggins Institute, Auckland 1023, New Zealand
| | - Troy L Merry
- Department of Nutrition and Dietetics, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand
- High-Value Nutrition Ko Ngā Kai Whai Painga National Science Challenge, The Liggins Institute, Auckland 1023, New Zealand
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Astbury CC, Lee KM, McGill E, Clarke J, Egan M, Halloran A, Malykh R, Rippin H, Wickramasinghe K, Penney TL. Systems Thinking and Complexity Science Methods and the Policy Process in Non-communicable Disease Prevention: A Systematic Scoping Review. Int J Health Policy Manag 2023; 12:6772. [PMID: 37579437 PMCID: PMC10125079 DOI: 10.34172/ijhpm.2023.6772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/14/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Given the complex determinants of non-communicable diseases (NCDs), and the dynamic policy landscape, researchers and policymakers are exploring the use of systems thinking and complexity science (STCS) in developing effective policies. The aim of this review is to systematically identify and analyse existing applications of STCS-informed methods in NCD prevention policy. METHODS Systematic scoping review: We searched academic databases (Medline, Scopus, Web of Science, EMBASE) for all publications indexed by 13 October 2020, screening titles, abstracts and full texts and extracting data according to published guidelines. We summarised key data from each study, mapping applications of methods informed by STCS to policy process domains. We conducted a thematic analysis to identify advantages, limitations, barriers and facilitators to using STCS. RESULTS 4681 papers were screened and 112 papers were included in this review. The most common policy areas were tobacco control, obesity prevention and physical activity promotion. Methods applied included system dynamics modelling, agent-based modelling and concept mapping. Advantages included supporting evidence-informed decision-making; modelling complex systems and addressing multi-sectoral problems. Limitations included the abstraction of reality by STCS methods, despite aims of encompassing greater complexity. Challenges included resource-intensiveness; lack of stakeholder trust in models; and results that were too complex to be comprehensible to stakeholders. Ensuring stakeholder ownership and presenting findings in a user-friendly way facilitated STCS use. CONCLUSION This review maps the proliferating applications of STCS methods in NCD prevention policy. STCS methods have the potential to generate tailored and dynamic evidence, adding robustness to evidence-informed policymaking, but must be accessible to policy stakeholders and have strong stakeholder ownership to build consensus and change stakeholder perspectives. Evaluations of whether, and under what circumstances, STCS methods lead to more effective policies compared to conventional methods are lacking, and would enable more targeted and constructive use of these methods.
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Affiliation(s)
- Chloe Clifford Astbury
- Global Food System & Policy Research, School of Global Health, York University, Toronto, ON, Canada
| | - Kirsten M. Lee
- Global Food System & Policy Research, School of Global Health, York University, Toronto, ON, Canada
| | - Elizabeth McGill
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Janielle Clarke
- Global Food System & Policy Research, School of Global Health, York University, Toronto, ON, Canada
| | - Matt Egan
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Afton Halloran
- World Health Organization European Office for the Prevention and Control of Noncommunicable Diseases, Moscow, Russian Federation
- Department of Nutrition, ExercDepartment of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.ise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Regina Malykh
- World Health Organization European Office for the Prevention and Control of Noncommunicable Diseases, Moscow, Russian Federation
| | - Holly Rippin
- World Health Organization European Office for the Prevention and Control of Noncommunicable Diseases, Moscow, Russian Federation
| | - Kremlin Wickramasinghe
- World Health Organization European Office for the Prevention and Control of Noncommunicable Diseases, Moscow, Russian Federation
| | - Tarra L. Penney
- Global Food System & Policy Research, School of Global Health, York University, Toronto, ON, Canada
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Zolfaghari M, Meshkovska B, Banik A, Kamphuis CBM, Kopainsky B, Luszczynska A, Murrin C, Lien N. Applying a systems perspective to understand the mechanisms of the European School Fruit and Vegetable Scheme. Eur J Public Health 2022; 32:iv107-iv113. [PMID: 36444113 PMCID: PMC9706111 DOI: 10.1093/eurpub/ckac054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND For the past two decades, the percentage of European children who consume fruit daily has remained at around 40%, despite numerous school-based policy efforts and interventions. This study aimed to apply a systems approach to provide an integrated perspective of the mechanisms of the European School Fruit and Vegetable Scheme (the Scheme) to understand better how to increase its long-term impact on children's fruit and vegetable consumption. METHODS We developed a causal loop diagram by synthesizing peer-reviewed articles and national government documents related to the Scheme, following the conceptualization steps of system dynamics. The initial causal loop diagrams were then validated in three stages by consulting with experts (two individuals and a group) in school-based fruit and vegetable programmes, children's fruit and vegetable consumption and the Scheme, using disconfirmatory interview guidelines. RESULTS The findings suggest that a central self-reinforcing mechanism through which children socialize during fruit and vegetable consumption is critical in the habituation process. Additionally, the initial increase in children's fruit and vegetable consumption following the Scheme implementation is due to growth in three self-reinforcing loops related to motivation and capability mechanisms; however, this trend gradually slows and stops due to four balancing feedback loops with alternative goals related to opportunity mechanisms that reach their limits. CONCLUSIONS The scheme's design should incorporate activities that align the objectives of the implementers and recipients of the Scheme at all levels. This alignment should provide children with ongoing opportunities to consume fruits and vegetables and strengthen the motivation and capability mechanisms.
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Affiliation(s)
- Mahshid Zolfaghari
- Correspondence: Mahshid Zolfaghari, Department of Nutrition, University of Oslo, P.O. Box 1046 Blindern, 0317 Oslo, Norway, Tel: +47 45 91 70 38, e-mail:
| | | | - Anna Banik
- Wroclaw Faculty of Psychology, SWPS University of Social Sciences and Humanities, Wroclaw, Poland
| | - Carlijn B M Kamphuis
- Department of Interdisciplinary Social Science, Utrecht University, Utrecht, The Netherlands
| | - Birgit Kopainsky
- Department of Geography, System Dynamics Group, University of Bergen, Bergen, Norway
| | - Aleksandra Luszczynska
- Wroclaw Faculty of Psychology, SWPS University of Social Sciences and Humanities, Wroclaw, Poland
| | - Celine Murrin
- School of Public Health, Physiotherapy and Sport Science, University College Dublin, Dublin, Ireland
| | - Nanna Lien
- Department of Nutrition, University of Oslo, Oslo, Norway
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Savila F, Harding T, Swinburn B, Bagg W, Letele D, Laban F, Goodyear-Smith F. Building culturally-centred, system dynamics logic models for the Brown Buttabean Motivation organization: a study protocol (Preprint). JMIR Res Protoc 2022. [DOI: 10.2196/44229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
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7
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McKelvie-Sebileau P, Rees D, Tipene-Leach D, D’Souza E, Swinburn B, Gerritsen S. Community Co-Design of Regional Actions for Children's Nutritional Health Combining Indigenous Knowledge and Systems Thinking. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:4936. [PMID: 35564331 PMCID: PMC9106006 DOI: 10.3390/ijerph19094936] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/01/2022] [Accepted: 04/15/2022] [Indexed: 02/01/2023]
Abstract
Children's nutrition is highly influenced by community-level deprivation and socioeconomic inequalities and the health outcomes associated, such as childhood obesity, continue to widen. Systems Thinking using community-based system dynamics (CBSD) approaches can build community capacity, develop new knowledge and increase commitments to health improvement at the community level. We applied the formal structure and resources of a Group Model Building (GMB) approach, embedded within an Indigenous worldview to engage a high deprivation, high Indigenous population regional community in New Zealand to improve children's nutrition. Three GMB workshops were held and the youth and adult participants created two systems map of the drivers and feedback loops of poor nutrition in the community. Māori Indigenous knowledge (mātauranga) and approaches (tikanga) were prioritized to ensure cultural safety of participants and to encourage identification of interventions that take into account social and cultural environmental factors. While the adult-constructed map focused more on the influence of societal factors such as cost of housing, financial literacy in communities, and social security, the youth-constructed map placed more emphasis on individual-environment factors such as the influence of marketing by the fast-food industry and mental wellbeing. Ten prioritized community-proposed interventions such as increasing cultural connections in schools, are presented with the feasibility and likely impact for change of each intervention rated by community leaders. The combination of community-based system dynamics methods of group model building and a mātauranga Māori worldview is a novel Indigenous systems approach that engages participants and highlights cultural and family issues in the systems maps, acknowledging the ongoing impact of historical colonization in our communities.
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Affiliation(s)
- Pippa McKelvie-Sebileau
- School of Population Health, University of Auckland, Auckland 1023, New Zealand; (B.S.); (S.G.)
- Research and Innovation Centre, Eastern Institute of Technology, Napier 4112, New Zealand;
| | - David Rees
- Synergia Consulting Ltd., Auckland 1011, New Zealand;
| | - David Tipene-Leach
- Research and Innovation Centre, Eastern Institute of Technology, Napier 4112, New Zealand;
| | - Erica D’Souza
- School of Future Environments, AUT University, Auckland 1141, New Zealand;
| | - Boyd Swinburn
- School of Population Health, University of Auckland, Auckland 1023, New Zealand; (B.S.); (S.G.)
| | - Sarah Gerritsen
- School of Population Health, University of Auckland, Auckland 1023, New Zealand; (B.S.); (S.G.)
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8
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McKelvie-Sebileau P, Rees D, Swinburn B, Gerritsen S, D'Souza E, Tipene-Leach D. Combining Cognitive Mapping and indigenous knowledge to improve food environments in regional New Zealand. Health Promot J Austr 2021; 33:631-641. [PMID: 34674331 PMCID: PMC9542597 DOI: 10.1002/hpja.549] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 09/27/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
Issue addressed Hawke's Bay has one of the highest rates of childhood obesity in New Zealand. While several initiatives exist aiming to decrease obesity through physical activity, there are few nutritional interventions. This study adopted a systems science and mātauranga Māori approach to identify and target underlying drivers of rising childhood obesity and engage the community to improve the food environment. Methods Cognitive mapping interviews (CM) with local stakeholders (school principals, Iwi and district health board representatives, education managers and local councillors) were conducted. The aim was to map participants’ mental models of the causes of rising childhood obesity and to identify key principles for engaging with the local community in a meaningful, impactful and culturally appropriate way for future action. Results Eleven interviews were conducted face‐to‐face and cognitive maps were constructed. Follow‐up interviews were carried out online, due to COVID restrictions, to present the maps and for interviewees to make any adjustments. Four composite themes emerged through centrality and cluster analysis of the resulting cognitive maps: the importance of building in mātauranga Māori (Māori knowledge and ways of being), the “hauora” of children, working with the community and integrating existing initiatives. Two contextual factors are also considered: the growing need for food security in our communities and the opportunity to start interventions in the school setting. Conclusion Cognitive mapping can produce useful insights in the early stages of community engagement. The six “pou” (pillars) underscore the importance of incorporating indigenous knowledge when embarking on public health interventions, particularly around obesity and in regional communities. So what? When designing a public health initiative with a community with a high indigenous population, indigenous knowledge should be promoted to focus on holistic health, working with the community and creating opportunities for cohesion. These founding principles will be used to structure future community actions to improve children's food environments in regional New Zealand.
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Affiliation(s)
- Pippa McKelvie-Sebileau
- Research and Innovation Centre, Eastern Institute of Technology, Napier, New Zealand.,School of Population Health, University of Auckland, Auckland, New Zealand
| | | | - Boyd Swinburn
- Research and Innovation Centre, Eastern Institute of Technology, Napier, New Zealand
| | - Sarah Gerritsen
- Research and Innovation Centre, Eastern Institute of Technology, Napier, New Zealand
| | - Erica D'Souza
- Research and Innovation Centre, Eastern Institute of Technology, Napier, New Zealand.,School of Population Health, University of Auckland, Auckland, New Zealand
| | - David Tipene-Leach
- School of Population Health, University of Auckland, Auckland, New Zealand
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Sawyer A, den Hertog K, Verhoeff AP, Busch V, Stronks K. Developing the logic framework underpinning a whole-systems approach to childhood overweight and obesity prevention: Amsterdam Healthy Weight Approach. Obes Sci Pract 2021; 7:591-605. [PMID: 34631137 PMCID: PMC8488454 DOI: 10.1002/osp4.505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/16/2021] [Accepted: 02/27/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Whole-systems approaches (WSAs) are well placed to tackle the complex local environmental influences on overweight and obesity, yet there are few examples of WSAs in practice. Amsterdam Healthy Weight Approach (AHWA) is a long-term, municipality-led program to improve children's physical activity, diet, and sleep through action in the home, neighborhood, school, and city. Adopting a WSA, local political, physical, social, educational, and healthcare drivers of childhood obesity are viewed as a complex adaptive system. Since 2013, AHWA has reached >15,000 children. During this time, the estimated prevalence of 2-18-year-olds with overweight or obesity in Amsterdam has declined from 21% in 2012 to 18.7% in 2017. Declining trends are rarely observed in cities. There is a need to formally articulate AHWA program theory in order to: (i) inform future program evaluation which can interpret this decline within the context of AHWA and (ii) contribute a real-life example of a WSA to the literature. METHODS This study aimed to formally document the program theory of AHWA to permit future evaluation. A logic framework was developed through extensive document review and discussion, during program implementation. RESULTS The working principles of the WSA underpinning AHWA were made explicit in an overarching theory of change, articulated in a logic framework. The framework was operationalized using an illustrative example of sugar intake. CONCLUSIONS The logic framework will inform AHWA development, monitoring, and evaluation and responds to a wider need to outline the working principles of WSAs in public health.
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Affiliation(s)
- Alexia Sawyer
- Department of Public and Occupational HealthAcademic Medical CentreAmsterdam University Medical CentresAmsterdamThe Netherlands
| | - Karen den Hertog
- Amsterdam Healthy Weight ApproachPublic Health Service (GGD)AmsterdamThe Netherlands
| | - Arnoud P Verhoeff
- Sarphati AmsterdamPublic Health Service (GGD)AmsterdamThe Netherlands
- Department of SociologyUniversity of AmsterdamAmsterdamThe Netherlands
| | - Vincent Busch
- Sarphati AmsterdamPublic Health Service (GGD)AmsterdamThe Netherlands
| | - Karien Stronks
- Department of Public and Occupational HealthAcademic Medical CentreAmsterdam University Medical CentresAmsterdamThe Netherlands
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10
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Waterlander WE, Singh A, Altenburg T, Dijkstra C, Luna Pinzon A, Anselma M, Busch V, van Houtum L, Emke H, Overman ML, Chinapaw MJM, Stronks K. Understanding obesity-related behaviors in youth from a systems dynamics perspective: The use of causal loop diagrams. Obes Rev 2021; 22:e13185. [PMID: 33369045 PMCID: PMC8243923 DOI: 10.1111/obr.13185] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022]
Abstract
This paper reports how we applied systems dynamics methods to gain insight into the complexity of obesity-related behaviors in youth, including diet, physical activity, sedentary behavior, and sleep, by integrating a literature review into causal loop diagrams (CLDs). Results showed that the CLDs consisted of multiple subsystems and three types of dynamics appeared, including (1) feedback loops, (2) connections between feedback loops and subsystems, and (3) mechanisms. We observed clear similarities in the dynamics for the four behaviors in that they relate to "traditional" subsystems, such as home and school environments, as well as to newly added subsystems, including macroeconomics, social welfare, and urban systems. The CLDs provided insights that can support the development of intervention strategies, including (1) the confirmation that a range of mechanisms cover and connect multiple levels and settings, meaning that there is no silver bullet to address obesity; (2) understanding of how interventions in one particular setting, such as school, might be influenced by the interactions with other settings, such as urban systems; and (3) a comprehensive view of (un)intended consequences. This way of framing the problem will assist moving towards public health interventions that respond to and operate in the complexity of the real world.
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Affiliation(s)
- Wilma E Waterlander
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Amika Singh
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Mulier Institute, Utrecht, The Netherlands
| | - Teatske Altenburg
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Coosje Dijkstra
- Department of Health Sciences, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Angie Luna Pinzon
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Manou Anselma
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Vincent Busch
- Public Health Service Amsterdam, Sarphati Amsterdam, Amsterdam, The Netherlands
| | - Lieke van Houtum
- Public Health Service Amsterdam, Sarphati Amsterdam, Amsterdam, The Netherlands
| | - Helga Emke
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Meredith L Overman
- Department of Health Promotion, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Mai J M Chinapaw
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Karien Stronks
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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11
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Justamente I, Raudeniece J, Ozolina-Moll L, Guadalupe-Grau A, Reihmane D. Comparative Analysis of the Effects of Daily Eating Habits and Physical Activity on Anthropometric Parameters in Elementary School Children in Latvia: Pach Study. Nutrients 2020; 12:E3818. [PMID: 33327418 PMCID: PMC7764828 DOI: 10.3390/nu12123818] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/05/2020] [Accepted: 12/10/2020] [Indexed: 11/17/2022] Open
Abstract
Growing incidence of obesity and related diseases in children poses new challenges and calls for a review of lifestyle habits. This study aimed to assess daily eating habits (EH) and physical activity (PA) levels and identify their association with obesity in 8-10-year-old children. Children's EH and time spent in moderate-to-vigorous physical intensity (MVPA) was estimated from questionnaires (N = 1788). Weight, height, and waist circumference (WC) were collected, and body mass index (BMI) calculated. Girls consumed more fruits and vegetables, drank more water, and ate smaller portions of carbohydrate and protein rich foods but spent less time in MVPA compared to boys (p < 0.05). Obese children skipped breakfast more often and consumed less fruits and vegetables. Children who chose to eat in front of the screen had higher WC (62.88 ± 8.70 vs 60.59 ± 7.40 cm, p < 0.001) and higher BMI, and chose smaller vegetable portions and more calorie dense snacks (p < 0.001). 15.4% of pupils covered weekly MVPA recommendations with structured PA on weekdays. Increasing MVPA was related to a smaller number of unhealthy EH (p < 0.001). In conclusion, EH and PA levels differ between sexes and obese children have unhealthier EH. Higher levels of MVPA are related to healthier food choices, while pupils having meals in front of the screen have unhealthier EH and anthropometric measures. The majority of pupils did not reach the WHO recommendations of MVPA through structured PA on weekdays. Association between factors (EH and time spent in PA) and BMI was not found in this study.
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Affiliation(s)
- Ilze Justamente
- Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, Jelgavas Street 1, LV-1004 Riga, Latvia; (I.J.); (J.R.); (L.O.-M.)
- Department of Human Physiology and Biochemistry, Riga Stradiņš University, Dzirciema Street 16, LV-1007 Riga, Latvia
| | - Jelena Raudeniece
- Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, Jelgavas Street 1, LV-1004 Riga, Latvia; (I.J.); (J.R.); (L.O.-M.)
- Department of Human Physiology and Biochemistry, Riga Stradiņš University, Dzirciema Street 16, LV-1007 Riga, Latvia
| | - Liga Ozolina-Moll
- Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, Jelgavas Street 1, LV-1004 Riga, Latvia; (I.J.); (J.R.); (L.O.-M.)
| | - Amelia Guadalupe-Grau
- ImFINE Research Group, Department of Health and Human Performance, Universidad Politécnica de Madrid, 28040 Madrid, Spain;
| | - Dace Reihmane
- Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, Jelgavas Street 1, LV-1004 Riga, Latvia; (I.J.); (J.R.); (L.O.-M.)
- Department of Human Physiology and Biochemistry, Riga Stradiņš University, Dzirciema Street 16, LV-1007 Riga, Latvia
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12
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'I should be disease free, healthy and be happy in whatever I do': a cross-country analysis of drivers of adolescent diet and physical activity in different low- and middle-income contexts. Public Health Nutr 2020; 24:5238-5248. [PMID: 33032672 DOI: 10.1017/s1368980020001810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To explore perceptions of how context shapes adolescent diet and physical activity in eight low- and middle-income (LMIC) sites at different stages of societal and economic transition. DESIGN Novel qualitative secondary analysis of eight data sets generated as part of the international Transforming Adolescent Lives through Nutrition (TALENT) collaboration. SETTING Diverse sites in India and Sub-Saharan Africa. PARTICIPANTS Fifty-two focus group discussions with 491 participants (303 adolescents aged 10-17 years; 188 caregivers). RESULTS Analysis of pooled qualitative data identified three themes: (1) transitions in generational nutrition education and knowledge; (2) transition in caregiver-adolescent power balance and (3) the implications of societal and economic transition for diet and physical activity. Adolescents in urban and peri-urban areas could readily access 'junk' food. Diets in rural settings were determined by tradition, seasonality and affordability. Physical activity was inhibited by site-specific factors including lack of space and crime in urban settings, and the prioritisation of academic performance. Gender influenced physical activity across all sites, with girls afforded fewer opportunities. CONCLUSIONS Interventions to improve adolescent diet and physical activity in LMIC need to be complex, context-specific and responsive to transitions at the individual, economic and societal levels. Moreover, solutions need to acknowledge gender inequalities in different contexts, as well as structural and cultural influences on diet and physical activity in resource-limited settings. Programmes need to be effective in engaging and reconciling adolescents' and caregivers' perspectives. Consequently, there is a need for action at both the community-household level and also through policy.
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13
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Waterlander WE, Luna Pinzon A, Verhoeff A, den Hertog K, Altenburg T, Dijkstra C, Halberstadt J, Hermans R, Renders C, Seidell J, Singh A, Anselma M, Busch V, Emke H, van den Eynde E, van Houtum L, Nusselder WJ, Overman M, van de Vlasakker S, Vrijkotte T, van den Akker E, Kremers SPJ, Chinapaw M, Stronks K. A System Dynamics and Participatory Action Research Approach to Promote Healthy Living and a Healthy Weight among 10-14-Year-Old Adolescents in Amsterdam: The LIKE Programme. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17144928. [PMID: 32650571 PMCID: PMC7400640 DOI: 10.3390/ijerph17144928] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/02/2020] [Accepted: 07/04/2020] [Indexed: 11/25/2022]
Abstract
This paper describes the design of the LIKE programme, which aims to tackle the complex problem of childhood overweight and obesity in 10–14-year-old adolescents using a systems dynamics and participatory approach. The LIKE programme focuses on the transition period from 10-years-old to teenager and was implemented in collaboration with the Amsterdam Healthy Weight Programme (AHWP) in Amsterdam-East, the Netherlands. The aim is to develop, implement and evaluate an integrated action programme at the levels of family, school, neighbourhood, health care and city. Following the principles of Participatory Action Research (PAR), we worked with our population and societal stakeholders as co-creators. Applying a system lens, we first obtained a dynamic picture of the pre-existing systems that shape adolescents’ behaviour relating to diet, physical activity, sleep and screen use. The subsequent action programme development was dynamic and adaptive, including quick actions focusing on system elements (quick evaluating, adapting and possibly catalysing further action) and more long-term actions focusing on system goals and/or paradigm change. The programme is supported by a developmental systems evaluation and the Intervention Level Framework, supplemented with routinely collected data on weight status and health behaviour change over a period of five years. In the coming years, we will report how this approach has worked to provide a robust understanding of the programme’s effectiveness within a complex dynamic system. In the meantime, we hope our study design serves as a source of inspiration for other public health intervention studies in complex systems.
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Affiliation(s)
- Wilma E. Waterlander
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.L.P.); (T.V.); (K.S.)
- Correspondence:
| | - Angie Luna Pinzon
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.L.P.); (T.V.); (K.S.)
| | - Arnoud Verhoeff
- Public Health Service Amsterdam, Sarphati Amsterdam, 1018 WT Amsterdam, The Netherlands; (A.V.); (V.B.); (L.v.H.); (S.v.d.V.)
- Department of Sociology, University of Amsterdam, 1018 WV Amsterdam, The Netherlands
| | - Karen den Hertog
- Amsterdam Healthy Weight Programme, Public Health Service Amsterdam, 1018 WT Amsterdam, The Netherlands;
| | - Teatske Altenburg
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT Amsterdam, The Netherlands; (T.A.); (A.S.); (M.A.); (H.E.); (M.C.)
| | - Coosje Dijkstra
- Department of Health Sciences, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (C.D.); (J.H.); (C.R.); (J.S.)
| | - Jutka Halberstadt
- Department of Health Sciences, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (C.D.); (J.H.); (C.R.); (J.S.)
| | - Roel Hermans
- Department of Health Promotion, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, 6229 ER Maastricht, The Netherlands; (R.H.); (M.O.); (S.P.J.K.)
| | - Carry Renders
- Department of Health Sciences, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (C.D.); (J.H.); (C.R.); (J.S.)
| | - Jacob Seidell
- Department of Health Sciences, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (C.D.); (J.H.); (C.R.); (J.S.)
| | - Amika Singh
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT Amsterdam, The Netherlands; (T.A.); (A.S.); (M.A.); (H.E.); (M.C.)
| | - Manou Anselma
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT Amsterdam, The Netherlands; (T.A.); (A.S.); (M.A.); (H.E.); (M.C.)
| | - Vincent Busch
- Public Health Service Amsterdam, Sarphati Amsterdam, 1018 WT Amsterdam, The Netherlands; (A.V.); (V.B.); (L.v.H.); (S.v.d.V.)
| | - Helga Emke
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT Amsterdam, The Netherlands; (T.A.); (A.S.); (M.A.); (H.E.); (M.C.)
| | - Emma van den Eynde
- Department of Pediatric Endocrinology, Erasmus MC, University Medical Center, 3025 GD Rotterdam, The Netherlands; (E.v.d.E.); (E.v.d.A.)
| | - Lieke van Houtum
- Public Health Service Amsterdam, Sarphati Amsterdam, 1018 WT Amsterdam, The Netherlands; (A.V.); (V.B.); (L.v.H.); (S.v.d.V.)
| | - Wilma J. Nusselder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3015 CN Rotterdam, The Netherlands;
| | - Meredith Overman
- Department of Health Promotion, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, 6229 ER Maastricht, The Netherlands; (R.H.); (M.O.); (S.P.J.K.)
| | - Susan van de Vlasakker
- Public Health Service Amsterdam, Sarphati Amsterdam, 1018 WT Amsterdam, The Netherlands; (A.V.); (V.B.); (L.v.H.); (S.v.d.V.)
| | - Tanja Vrijkotte
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.L.P.); (T.V.); (K.S.)
| | - Erica van den Akker
- Department of Pediatric Endocrinology, Erasmus MC, University Medical Center, 3025 GD Rotterdam, The Netherlands; (E.v.d.E.); (E.v.d.A.)
| | - Stef P. J. Kremers
- Department of Health Promotion, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, 6229 ER Maastricht, The Netherlands; (R.H.); (M.O.); (S.P.J.K.)
| | - Mai Chinapaw
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, NL-1081 BT Amsterdam, The Netherlands; (T.A.); (A.S.); (M.A.); (H.E.); (M.C.)
| | - Karien Stronks
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.L.P.); (T.V.); (K.S.)
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14
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Hodder RK, O'Brien KM, Tzelepis F, Wyse RJ, Wolfenden L. Interventions for increasing fruit and vegetable consumption in children aged five years and under. Cochrane Database Syst Rev 2020; 5:CD008552. [PMID: 32449203 PMCID: PMC7273132 DOI: 10.1002/14651858.cd008552.pub7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden. OBJECTIVES To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials. SELECTION CRITERIA We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures. MAIN RESULTS We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding. AUTHORS' CONCLUSIONS Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Rebecca K Hodder
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
- Priority Research Centre in Health and Behaviour, University of Newcastle, Callaghan, Australia
| | - Kate M O'Brien
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
- Priority Research Centre in Health and Behaviour, University of Newcastle, Callaghan, Australia
| | - Flora Tzelepis
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
- Priority Research Centre in Health and Behaviour, University of Newcastle, Callaghan, Australia
| | - Rebecca J Wyse
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
- Priority Research Centre in Health and Behaviour, University of Newcastle, Callaghan, Australia
| | - Luke Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
- Hunter Medical Research Institute, New Lambton, Australia
- Priority Research Centre in Health and Behaviour, University of Newcastle, Callaghan, Australia
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15
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Hodder RK, O'Brien KM, Stacey FG, Tzelepis F, Wyse RJ, Bartlem KM, Sutherland R, James EL, Barnes C, Wolfenden L. Interventions for increasing fruit and vegetable consumption in children aged five years and under. Cochrane Database Syst Rev 2019; 2019:CD008552. [PMID: 31697869 PMCID: PMC6837849 DOI: 10.1002/14651858.cd008552.pub6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden. OBJECTIVES To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials. SELECTION CRITERIA We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures. MAIN RESULTS We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding. AUTHORS' CONCLUSIONS Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Rebecca K Hodder
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Kate M O'Brien
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Fiona G Stacey
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
- University of NewcastlePriority Research Centre in Physical Activity and NutritionCallaghanAustralia
| | - Flora Tzelepis
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Rebecca J Wyse
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Kate M Bartlem
- University of NewcastleSchool of PsychologyUniversity DriveCallaghanNew South WalesAustralia2308
| | - Rachel Sutherland
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Erica L James
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
| | - Courtney Barnes
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
| | - Luke Wolfenden
- Hunter New England Local Health DistrictHunter New England Population HealthLocked Bag 10WallsendAustralia2287
- University of NewcastleSchool of Medicine and Public HealthCallaghanAustralia
- Hunter Medical Research InstituteNew LambtonAustralia
- University of NewcastlePriority Research Centre in Health and BehaviourCallaghanAustralia
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16
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Gerritsen S, Renker-Darby A, Harré S, Rees D, Raroa DA, Eickstaedt M, Sushil Z, Allan K, Bartos AE, Waterlander WE, Swinburn B. Improving low fruit and vegetable intake in children: Findings from a system dynamics, community group model building study. PLoS One 2019; 14:e0221107. [PMID: 31415644 PMCID: PMC6695127 DOI: 10.1371/journal.pone.0221107] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/12/2019] [Indexed: 12/13/2022] Open
Abstract
Many children globally do not meet government guidelines for daily fruit and vegetable intake, and in New Zealand, adherence to the vegetable intake recommendation is declining. This study aimed to identify systemic barriers to children meeting fruit and vegetable (FV) guidelines and generate sustainable actions within a local community to improve children's FV intake. A qualitative system dynamics method of community group model building was used. The research team partnered with Healthy Families Waitākere, a Ministry of Health funded prevention initiative, to recruit 17 participants (including students, parents, teachers, community leaders, local retailers and health promoters) from a low-income, ethnically-diverse community in West Auckland, New Zealand. Three group model building workshops were held during which a systems map was created and used to identify actions by considering causal pathways and reinforcing loops in the system. Barriers to children's FV intake identified by participants were the saturation of fast-food outlets in the community and ubiquitous marketing of these products, the high cost of fresh produce compared to fast food, and parents having little time for food preparation plus declining cooking skills and knowledge. Several actions to improve children's FV intake by improving the local food environment were identified, which will be co-designed further and tested by a collaborative group involving community leaders. This project highlights the effectiveness of group model building for engaging a local community in systems change to improve child nutrition, and supplies a blueprint for future qualitative system dynamics research.
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Affiliation(s)
- Sarah Gerritsen
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Ana Renker-Darby
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Sophia Harré
- School of Population Health, University of Auckland, Auckland, New Zealand
| | | | | | | | | | - Kerry Allan
- Healthy Families Waitakere, Auckland, New Zealand
| | - Ann E. Bartos
- School of Environment, University of Auckland, Auckland, New Zealand
| | - Wilma E. Waterlander
- Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Boyd Swinburn
- School of Population Health, University of Auckland, Auckland, New Zealand
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17
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Paquet C. Environmental Influences on Food Behaviour. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16152763. [PMID: 31382447 PMCID: PMC6696422 DOI: 10.3390/ijerph16152763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 11/16/2022]
Abstract
The ubiquitous presence of food cues in our modern environment is believed to contribute to the rising trends in overconsumption and associated obesity observed over the last few decades [...].
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Affiliation(s)
- Catherine Paquet
- Australian Centre for Precision Health, University of South Australia Cancer Research Institute, Adelaide, SA 5001, Australia.
- School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia.
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18
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Mother-Related Determinants of Children At-Home Fruit and Vegetable Dietary Patterns in a Polish National Sample. SUSTAINABILITY 2019. [DOI: 10.3390/su11123398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Fruit and vegetable intake is indicated among the features of sustainable diets, while children’s intake is strongly associated with the intake of their parents, as well as the availability of food products and their accessibility at home. The aim of the study was to analyze the mother-related determinants of children at-home fruit and vegetable dietary patterns in a Polish national sample of children aged 3–10 years. The random quota sampling (with quotas for age, education, and place of residence) was conducted to recruit the national representative sample of Polish mothers of children aged 3–10 years (n = 1200) who were interviewed using a Computer-Assisted Telephone Interviewing (CATI) method. They were asked about their children’s at-home fruit and vegetable dietary patterns, which were later compared in sub-groups that were stratified for age, educational background, marital status, place of residence, occupational status, and total net income in households. The indicated features, but not marital status, were indicated as determinants of children at-home fruit and vegetable dietary patterns. Children of younger mothers more often than others consumed fruits, whereas those of older mothers consumed vegetables. Children of mothers who had a lower level of education more commonly than others consumed fruits alone as a dish, and they had a higher preference for them, while those of mothers who had a higher level of education had a higher consumption of vegetables than others, although they had a medium preference for them. Children of mothers from villages had a lower consumption of vegetables and fruits than others, although they had a higher preference for fruits. Children of mothers with no professional job had a lower consumption of vegetables than others and more often consumed them processed, although they had a higher preference for fruits and vegetables. Children of mothers with low income had a lower consumption of vegetables than others and more often consumed fruits in a dish with other products, although they had a higher preference for fruits and vegetables. To summarize, an indication of a high preference for fruits and vegetables by mothers is not accompanied by the higher consumption and recommended dietary patterns for fruit and vegetable intake by their children. In particular, the sub-samples of mothers who had a low level of education, were from villages, did not have a professional job, and had low income may either overestimate the fruit and vegetable preference of their children or do not offer them sufficient amount of fruits and vegetables, although they indicate a higher preference. In order to encourage more sustainable diet following, in terms of the fruit and vegetable intake, it is essential to introduce actions toward the properly planned nutritional education for the indicated target groups.
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