Changes in adolescents' and parents' intakes of sugar-sweetened beverages, fruit and vegetables after 20 months: results from the HEIA study - a comprehensive, multi-component school-based randomized trial

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.

Mediators and moderators of the effects of a school-based intervention on adolescents' fruit and vegetable consumption: the HEIA study

OBJECTIVE

To examine whether targeted determinants mediated the effects of the HEalth In Adolescents (HEIA) intervention on fruit and vegetable (FV) consumption and explore if these mediating effects were moderated by sex, parental education or weight status.

DESIGN

Cluster-randomised controlled trial.

SETTING

The HEIA study (2007-2009) was a Norwegian 20-month multi-component school-based intervention to promote healthy weight development. FV consumption and targeted determinants were self-reported at baseline, mid-way (8 months) and post-intervention (20 months).

PARTICIPANTS

Adolescents (11-13-year-old) in twenty-five control schools (n 746) and twelve intervention schools (n 375).

RESULTS

At post-intervention, more adolescents in the intervention group compared with the control group had knowledge of the FV recommendations (OR: 1·4, 95 % CI 1·1, 1·9) and reported a decreased availability of vegetables at home (β: -0·1, 95 % CI -0·2, 0·0). Availability/accessibility of FV at home, availability of vegetables at dinner, taste preferences for different types of FV and knowledge of the FV recommendations were positively associated with the consumption of FV. However, none of the post-intervention determinants significantly mediated the intervention effects on FV consumption. Although no moderating influences by sex, parental education or weights status were observed on the mediating effects, exploratory analyses revealed significant moderations in the b-paths.

CONCLUSIONS

Since none of the targeted determinants could explain the increase in FV consumption, it remains unclear why the intervention was effective. Reporting on a wide range of mediators and moderators in school-based interventions is needed to reveal the pathways through which intervention effects are achieved.

A Community Guide Systematic Review: School Dietary and Physical Activity Interventions

CONTEXT

Schools can play an important role in supporting a healthy lifestyle by offering nutritious foods and beverages and providing opportunities for physical activity. A healthy diet and regular physical activity may reduce the risk of obesity. This manuscript reports on a Community Guide systematic review examining the effectiveness of interventions in schools combining school meal or fruit and vegetable snack programs and physical activity.

EVIDENCE ACQUISITION

Studies meeting the intervention definition were identified from a literature search (search period: January 1990-November 2019). Community Guide systematic review methods were used to assess effectiveness as measured by dietary behavior, physical activity, and weight changes; analyses were conducted in 2020.

EVIDENCE SYNTHESIS

Interventions (n=24 studies) were considered effective for increasing physical activity (median increase=21.8 minutes/day; interquartile interval= -0.8 to 27.4 minutes/day), modestly increasing fruit and vegetable intake (median relative increase=12.1%; interquartile interval= -4.6%, 73.4%), and decreasing the prevalence of overweight and obesity (median decrease=2.5 percentage points; interquartile interval= -8.1, -1.6 percentage points) among elementary school students through sixth grade. There were not enough studies to determine the effectiveness of interventions for middle- and high-school students.

CONCLUSIONS

School meal or fruit and vegetable snack interventions combined with physical activity were effective in increasing physical activity, with modest effects for improving fruit and vegetable consumption and reducing the prevalence of overweight and obesity among elementary students. These results may inform researchers and school administrators about healthy eating and physical activity interventions.

Effect of School-Based Food and Nutrition Education Interventions on the Food Consumption of Adolescents: A Systematic Review and Meta-Analysis

The school is a favorable environment for the development of interventions to prevent obesity. The objective of this systematic review is to evaluate the effects of school-based food and nutrition education interventions on adolescent food consumption. The literature search was conducted on databases: MEDLINE/PubMed, Embase, Scopus, ERIC, Science Direct, Web of Science, Cochrane, LILACS, and ADOLEC. The following research strategies were focused on: population (adolescents), intervention (food and nutrition education), outcome (food consumption), and study design (clinical trial). The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement guidelines were followed and all stages of this review were performed by two researchers and, when necessary, a third researcher resolved discrepancies. Included studies are randomized clinical trials (RCT). A total of 24 articles were included for review and 11 articles in meta-analysis. In the evaluation of the general effects, there was a significant effect (mean difference (MD) for fruit consumption (MD = 0.09, CI 0.05, 0.14) in serving/day; and for vegetables (MD = 0.59, IC 0.15, 1.03) at times/week. In the consumption of FV (fruits and vegetables), there was no significant effect (standardized mean difference (SMD) of interventions in their consumption (SMD = 0.00, 95% C1 -0.11, 0.11). The evidence available in this review and meta-analysis concludes that food and nutrition education interventions in schools presented favorable results in the food consumption of adolescents. Registered on the PROSPERO database (CRD42019116520).

Evaluation of Parental Acceptability and Use of Intervention Components to Reduce Pre-School Children's Intake of Sugar-Rich Food and Drinks

Knowledge is needed about effective tools that reach public health objectives focused on reducing the intake of sugar-rich foods and drinks. The purpose of this study was to assess the parental acceptability, use and motivational potential of intervention components developed in the randomized family-based trial ‘Are you too sweet?’ aimed at reducing the intake of sugar-rich foods and drinks among children (5–7 y). Intervention components included guidance on sugar-rich foods and drinks at a school health nurse consultation, a box with home-use materials and a digital platform. The methods used were a questionnaire among intervention families (n = 83) and semi-structured interviews with parents in selected intervention families (n = 24). Results showed the good acceptability and usefulness of the components, with reported frequencies of use of materials ranging from 48% to 94% and a high satisfaction rate with the school health nurse consultation. Personalized feedback and guidance from the school health nurse seemed to be a motivational trigger, and components that were compatible with existing practices were most frequently used. However, the components were not considered engaging by all families. Overall, intervention components were well received and hold the potential for enhancing parental knowledge and parenting practices regarding limiting the intake of sugar-rich foods and drinks.

The Impact of School-Based Nutrition Interventions on Parents and Other Family Members: A Systematic Literature Review

Little is known about the impact of school-based nutrition interventions on parents and other family members. This systematic review aims to explore the impact of school-based nutrition interventions on different parental/family outcomes, mainly dietary intake, nutrition knowledge, and health outcomes. PubMed, Web of Science, PsycINFO, EconLit, Cochrane Reviews, and Google Scholar were systematically searched for controlled trials or natural experiments measuring the impact of school-based nutrition interventions, with or without parental involvement, on parents/families of school children. Twenty-two studies met the inclusion criteria. Of which, 15 studies assessed the impact of school-based nutrition interventions on parental/family dietary intake, 10 on parental/family nutrition knowledge, and 2 on parental/family health outcomes. Inconsistent results were found for parental dietary intake with six studies reporting favorable effects. Most studies found improved parental nutrition knowledge. Positive impacts were seen by both studies that assessed the impact on a parental health outcome. Overall, we found that there is potential for school-based nutrition interventions to result in positive effects for parents, in particular for nutrition knowledge. More research is needed to assess the impacts of school-based nutrition interventions on parents and other family members and to assess important intervention characteristics in creating a positive impact.

Cost-effectiveness and return on investment of school-based health promotion programmes for chronic disease prevention

BACKGROUND

While school-based health prevention programmes are effective in addressing unhealthy diet and physical inactivity, little is known about their economic implications. We conducted an economic evaluation of the programmes that were previously identified as feasible, acceptable, and sustainable in the Canadian context.

METHODS

This study builds on a meta-analysis of the effectiveness of feasible, acceptable, and sustainable school-based health promotion programmes. A micro-simulation model incorporated intervention effects on multiple risk factors to estimate incremental cost-effectiveness and return on investment (ROI) of comprehensive school health (CSH), multicomponent, and physical education (PE) curriculum modification programmes. Cost-effectiveness was expressed as the programme costs below which the programme would be cost-effective at a CA$50 000 threshold level.

RESULTS

The estimated costs below which interventions were cost-effective per quality-adjusted life year gained were CA$682, CA$444, and CA$416 per student for CSH, multicomponent, and PE curriculum modification programmes, respectively. CSH programmes remained cost-effective per year of chronic disease prevented for costs of up to CA$3384 per student, compared to CA$1911 and CA$1987 for multicomponent and PE curriculum modification interventions, respectively. If the interventions were implemented at total discounted intervention costs of CA$100 per student, ROI through the avoidance of direct healthcare costs related to the treatment and management of chronic diseases would be 824% for CSH, 465% for multicomponent interventions, and 484% for PE curriculum modification interventions.

CONCLUSIONS

Whereas each examined intervention types showed favourable economic benefits, CSH programmes appeared to be the most cost-effective and to have the highest ROI.

Effects of School-Based Interventions on Reducing Sugar-Sweetened Beverage Consumption among Chinese Children and Adolescents

We set up a series of school-based interventions on the basis of an ecological model targeting sugar-sweetened beverage (SSB) reduction in Chinese elementary and middle schools and evaluated the effects. A total of 1046 students from Chinese elementary and middle schools were randomly recruited in an intervention group, as were 1156 counterparts in a control group. The interventions were conducted in the intervention schools for one year. The participants were orally instructed to answer all the questionnaires by themselves at baseline and after intervention. The difference in difference statistical approach was used to identify the effects exclusively attributable to the interventions. There were differences in grade composition and no difference in sex distribution between the intervention and control groups. After adjusting for age, sex, and group differences at baseline, a significant reduction in SSB intake was found in the intervention group post intervention, with a decrease of 35.0 mL/day (p = 0.034). Additionally, the frequency of SSB consumption decreased by 0.2 times/day (p = 0.071). The students in the elementary schools with interventions significantly reduced their SSB intake by 61.6 mL/day (p = 0.002) and their frequency of SSB consumption by 0.3 times/day (p = 0.017) after the intervention. The boys in the intervention group had an intervention effect of a 50.2 mL/day reduction in their SSB intake (p = 0.036). School-based interventions were effective in reducing SSB consumption, especially among younger ones. The boys were more responsive to the interventions than the girls. (ChiCTR, ChiCTR1900020781.)

Knowledge, Attitude, and Practice of Adolescent Parents on Free Sugar and Influencing Factors about Recognition

Physiological problems caused by excessive intake of free sugar have been concerning important public health issues, especially the impact on adolescents. The World Health Organization (WHO) strongly recommends controlling daily sugar intake in order to reduce the stress caused by high sugar uptake. Finding out the factors that affect adolescents’ sugar intake will help further interventions to control the intake of sugar. Therefore, we conducted a cross-sectional study among 10 middle schools in Changsha, the capital of Hunan province. Two classes of the first and second grades were randomly selected from each school, and their parents in these classes participated in the survey. Questionnaires were used to access the status of adolescent parents’ knowledge, attitude and practice (KAP) towards free sugar. Out of 1136 valid participants, 70.4% of respondents were female with the mean (Standard Deviation) age of 41.76 (±5.27) years. They had a good attitude but relatively poor knowledge and behavior towards free sugar. Binary logistic regression analysis found that parents whose gender is female, with a high education level and a girl as their child, hold a high level of free sugar recognition. These findings could help free sugar control interventions for adolescents in the future.

Effectiveness of school-based health promotion interventions prioritized by stakeholders from health and education sectors: A systematic review and meta-analysis

Childhood obesity and associated modifiable risk factors exert significant burden on the health care system. The goal of this systematic review and meta-analysis was to examine the effectiveness of school-based intervention types perceived by Canadian stakeholders in health and education as feasible, acceptable and sustainable in terms of improving physical activity (PA), fruit and vegetable intake, and body weight. We searched multiple databases for studies that evaluated school-based interventions to prevent obesity and associated risk factors (i.e., unhealthy diet, physical inactivity, sedentary behaviour) in children aged 4–18 years from January 1, 2012 to January 28, 2020. From 10,871 identified records, we included 83 and 80 studies in our systematic review and meta-analysis, respectively. Comprehensive School Health (CSH) and interventions which focused on modifications to school nutrition policies showed statistically significant positive effects on fruit intake of 0.13 (95% CI: 0.04, 0.23) and 0.30 (95% CI: 0.1, 0.51) servings per day, respectively. No intervention types showed statistically significant effect on vegetable intake. CSH, modifications to physical education (PE) curriculum, and multicomponent interventions showed statistically significant difference in BMI of −0.26 (95% CI: −0.40, −0.12), −0.16 (95% CI: −0.3, −0.02), and −0.18 (95% CI: −0.29, −0.07), respectively. CSH interventions showed positive effect on step-count per day, but no other types of interventions showed significant effect on any of PA outcome measures. Thus, the results of this systematic review and meta-analysis suggest that decision-makers should carefully consider CSH, multicomponent interventions, modifications to PE curricula and school nutrition policies to prevent childhood obesity.

Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: a systematic review and meta-analysis

Context

Consumption of sugar-sweetened beverages (SSBs) among children has been associated with adverse health outcomes. Numerous behavioral interventions aimed at reducing the intake of SSBs among children have been reported, yet evidence of their effectiveness is lacking.

Objective

This systematic review explored the effectiveness of educational and behavioral interventions to reduce SSB intake and to influence health outcomes among children aged 4 to 16 years.

Data Sources

Seven databases were searched for randomized controlled trials published prior to September 2016. Studies identified were screened for eligibility.

Study Selection

Trials were included in the review if they met the PICOS (Population, Intervention, Comparison, Outcome, and Study design) criteria for inclusion of studies.

Data Extraction

Data were extracted by 2 reviewers following Cochrane guidelines and using Review Manager software.

Results

Of the 16 trials included, 12 were school based and 4 were community or home based. Only 3 trials provided data that could be pooled into a meta-analysis for evaluating change in SSB intake. Subgroup analyses showed a trend toward a significant reduction in SSB intake in participants in school-based interventions compared with control groups. Change in body mass index z scores was not statistically significant between groups.

Conclusions

The quality of evidence from included trials was considered moderate, and the effectiveness of educational and behavioral interventions in reducing SSB intake was modest.

Systematic Review Registration

PROSPERO registration number CRD42014004432.

Interventions for preventing obesity in children

EDITORIAL NOTE

This Cochrane review is now out of date and should not be used for reference. It has been split into four age groups and updated. Please refer to the 5‐11 and 12‐18 age group Cochrane reviews which were published in May 2024: https://doi.org/10.1002/14651858.CD015328.pub2 https://doi.org/10.1002/14651858.CD015330.pub2 The 2‐4 age group Cochrane review is planned for publication in September 2024.

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

Tackling the Consumption of High Sugar Products among Children and Adolescents in the Pacific Islands: Implications for Future Research

The Pacific Islands are experiencing an obesity epidemic with a rate of overweight and obesity as high as 80% among adults in some Pacific Island nations. Children and adolescents in the region are also affected by overweight and obesity, which is alarming due to the increased likelihood of remaining overweight as an adult. Research supports an association between poor diet and an increased risk of obesity and development of non-communicable diseases (NCDs). Excess consumption of free sugars is associated with poorer overall diet quality and increased risk of weight gain, chronic inflammation and dental caries. Traditional diets in the Pacific Islands are being supplemented with processed, high-sugar foods and beverages; thus, there is a clear need for effective interventions promoting positive dietary behaviors in the region. School and community based interventions offer an opportunity to promote positive behavior change among children and adolescents. This review aims to evaluate interventions targeting the consumption of high-sugar products in this population in the Pacific Islands.

Dietary sources of sugars in adolescents' diet: the HELENA study

OBJECTIVE

To report dietary sugars consumption and their different types and food sources, in European adolescents.

METHODS

Food consumption data of selected groups were obtained from 1630 adolescents (45.6% males, 12.5-17.5 years) from the HELENA study using two nonconsecutive 24-h recalls. Energy intake, total sugars and free sugars were assessed using the HELENA-DIAT software. Multiple regression analyses were performed adjusting for relevant confounders.

RESULTS

Total sugars intake (137.5 g/day) represented 23.6% and free sugars (110.1 g/day), 19% of energy intake. Girls had significantly lower intakes of energy, carbohydrates, total sugars and free sugars. 94% of adolescents had a consumption of free sugars above 10% of total energy intake. The main food contributor to free sugars was 'carbonated, soft and isotonic drinks,' followed by 'non-chocolate confectionary' and 'sugar, honey, jam and syrup.' Older boys and girls had significantly higher intakes of free sugars from 'cakes, pies and biscuits.' Free sugars intake was negatively associated with low socioeconomic status for 'non-chocolate confectionary' and 'sugar, honey and jam' groups; with low maternal educational level for carbonated and 'soft drinks,' 'sugar, honey and jam,' 'cakes and pies' and 'breakfast cereals' groups; and with high paternal educational level for 'carbonated and soft drinks' and 'chocolates' group.

CONCLUSIONS

The majority (94%) of studied adolescents consumed free sugars above 10% of daily energy intake. Our data indicate a broad variety in foods providing free sugars. Continued efforts are required at different levels to reduce the intake of free sugars, especially in families with a low educational level.

Oral Co-administration of Soy-derived Extracts with Alcohol or with Sugar-sweetened Beverages Exerts Liver and Sugar Protective Effects

Background and Aims: Both alcoholic drinks and high sugar-containing soft drinks cause major health problems worldwide. Oral administration of OS and M1 soy-derived extracts has been shown to alleviate liver injury in animal models. The aim of the present study was to determine the liver- and sugar-protective effect of OS and M1 soy-derived extracts when added to alcohol and sugar-enriched drinks. Methods: Mice were treated with alcohol or high sugar-containing drinks, with and without administration of a combination of OS and M1 soy extracts. Mice were observed for the effects on liver injury, glucose metabolism, and the immune system. Results: Co-administration of the soy extracts OS and M1 significantly alleviated the liver injury induced by acute alcohol, as evidenced by decreased liver enzymes. These beneficial effects were associated with promotion of subsets of regulatory T lymphocytes and with a trend towards a pro-inflammatory to an anti-inflammatory cytokine shift. Co-administration of OS M1 soy extracts with sugar-sweetened beverages significantly alleviated the increases in serum sugar levels. Conclusions: OS and M1 extracts exert a synergistic hepato- and glucose-protective effect in models of alcohol-induced liver damage and soft drinks-associated increases in serum glucose. These extracts may provide a solution to the two pressing health problems.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trends in Food Habits and Their Relation to Socioeconomic Status among Nordic Adolescents 2001/2002-2009/2010

Background

In the Nordic countries, substantial policy and intervention efforts have been made to increase adolescents' consumption of fruit and vegetables and to reduce their intake of sweets and soft drinks. Some initiatives have been formulated in a Nordic collaboration and implemented at national level. In recent years, social inequalities in food habits have been attracted particular governmental interest and several initiatives addressing the socioeconomic gradient in food habits have been highlighted. However, few internationally published studies have evaluated how trends in adolescents' food habits develop in the context of Nordic nutrition policy, or have compared differences between the Nordic countries.

Methods

The study was based on Danish, Finnish, Norwegian and Swedish cross-sectional data from the international Health Behaviour in School-Aged Children (HBSC) study, collected via three nationally representative and comparable questionnaire surveys in 2001/2002, 2005/2006 and 2009/2010. Food habits were identified by students' consumption of fruit, vegetables, sweets and sugar sweetened soft drink. Socioeconomic status (SES) was measured with the Family Affluence Scale (FAS). Multilevel logistic regression was used to analyze the data.

Results

Trends in fruit consumption developed differently across countries, characterized by an increase in Denmark and Norway and more stable trends in Sweden and Finland. Vegetable consumption increased particularly in Denmark and to a lesser extent in Norway, whereas Sweden and Finland displayed stable trends. Decreased trends were observed for sweet and soft drink consumption and were similar in Norway, Sweden and Finland. Sweet consumption decreased across all survey years, whereas soft drink consumption decreased between 2001/2002–2005/2006 and was stable thereafter. Denmark displayed an increase between 2001/2002–2005/2006 followed by a similar decrease between 2005/2006–2009/2010 for both sweet and soft drink consumption. Socioeconomic inequalities in fruit and vegetable consumption were observed in all countries, with no cross-country differences, and no changes over time. Small but not significant cross-country variation was identified for SES inequalities in sweet consumption. Reduced SES inequalities were observed in Sweden between 2005/2006 and 2009/2010. SES was not associated with soft drink consumption in this study population, with the exception of Denmark for the survey year 2009/2010.

Conclusion

Different trends resulted in increased country differences in food habits during the time of observations. In survey year 2009/2010, Danish students reported a higher intake of fruit and vegetable consumption than their counterparts in the other Nordic countries. Finnish students reported the lowest frequency of sweets and soft drink consumption. Despite the positive dietary trends documented in the present study, the majority of Nordic adolescents are far from meeting national dietary recommendations. Our findings underline the need for more comprehensive initiatives targeting young people's food habits as well as a more deliberate and focused action to close gaps in social inequalities that affect food choices.