Theory-informed nutrition education curriculum Tools For Feeling Good promotes healthy eating patterns among fifth grade pupils: cross-sectional study

BACKGROUND

The eating patterns of school-aged children rarely meet recommendations: meal frequency is irregular and the consumption of vegetables is lower and sugar-sweetened products higher than recommended. Although school is an excellent arena for nutrition education to support pupils eating patterns, teachers usually lack efficient tools. The present study aimed to develop a curriculum for nutrition education to be used by teachers and to examine its efficacy in the school environment with respect to the eating patterns of pupils.

METHODS

The curriculum was developed in collaboration with school teachers using self-determination theory as a theoretical standpoint. The Health at Every Size concept and sensory-based food education were utilised in the curriculum. Self-reported questionnaires were used to assess the feasibility and impact of the curriculum. Fourteen teachers implemented the curriculum during 2012-2013 with 194 pupils aged 10-13 years (fifth and sixth grades). The control schools included 140 pupils of the same age not following the curriculum.

RESULTS

The teachers reported that the curriculum was easy to integrate in the school environment. The fifth graders improved their breakfast frequency, increased their consumption of vegetables and reduced their consumption of ice cream, sweets and sugar-sweetened drinks. No improvement was found in the fifth graders at the control schools. In the sixth graders, no dietary changes were detected in the intervention or control schools.

CONCLUSIONS

The pupils in the fifth grade appeared to comprise a responsive target group for nutrition education at schools. The curriculum offers a promising approach for developing healthy eating patterns among fifth graders. Collaboration with teachers in developing the curriculum likely enhanced its feasibility and teacher commitment for implementation.

Parent-child relationship of physical activity patterns and obesity

OBJECTIVE

To study differences in physical activity between normal-weight and obese children, as well as parent-child associations of obesity and physical activity.

DESIGN

Cross-sectional study.

SUBJECTS

129 obese children (67 girls and 62 boys), 142 normal-weight controls (81 boys and 61 girls), and mothers (n = 245) and fathers (n = 222) of the children.

METHODS

Physical activity was assessed by a 3-day physical activity record (children and parents), by a questionnaire (children), and by one question on habitual physical activity (parents). The data were analysed by stepwise linear and logistic regressions. Obesity was assessed from relative weight (children) and BMI (parents).

RESULTS

Parent inactivity was a strong and positive predictor of child inactivity (beta-coefficients 0.25 and 0.16, P<0.001, for mother and father inactivity, respectively). Scores of parent activity were somewhat weaker predictors of child vigorous activity hours and total physical activity level (beta-coefficients 0.13-0.25, P = 0.003-0.08). Child obesity was negatively associated with child habitual physical activity (odds ratio 0.88, P<0.001). In addition, parent obesity (body mass index > or =30 kg/m2) was another strong predictor of child obesity (odds ratio 2.38-3.50, P<0.002).

CONCLUSIONS

The present study underscores the parents' role in childhood activity patterns and obesity. A novel finding was that the parent-child relationship of inactivity appeared to be stronger than that of vigorous activity. Hence, parents who want to reduce their children's inactivity may have to pay attention to their own lifestyle.

Validation of a short dietary questionnaire and a qualitative fat index for the assessment of fat intake

In connection with a population-based study on familial and non-familial determinants of serum total cholesterol an interviewer-administered short questionnaire, including 21 food items, and a qualitative fat index based on four questions were developed. Subjects for the validation study, 51 women and 31 men, aged 16-71 years, were selected from the population-based study (n = 892). The short questionnaire and the qualitative fat index were validated with a 3 day food record as the reference method. The short questionnaire captured 90-97% of the mean intakes of total fat, saturated, monounsaturated and polyunsaturated fatty acids and cholesterol. The Pearson correlation coefficients between the fat intakes based on the questionnaire and the diet records were strongest for the intake of total fat (r = 0.80). The qualitative fat index was based on four questions concerning type of fat: the higher the scores the higher the intakes of polyunsaturated fatty acids. The Spearman correlation coefficients between the qualitative fat index and the intakes based on the diet records were -0.55 for saturated, 0.34 for monounsaturated and 0.52 for polyunsaturated fatty acids. The respective correlation for the P/S ratio (total amounts of polyunsaturated fatty acids/saturated fatty acids) and the PM/S ratio (total amounts of polyunsaturated and monounsaturated fatty acids/saturated fatty acids) were 0.50 and 0.53. An inverse association between serum total cholesterol and the qualitative fat index was found in the whole study population, suggesting the impact of dietary fat on serum cholesterol in this study population. In conclusion, the short questionnaire proved to be accurate in measuring the intake of different fatty acids at the group level, whereas the simpler fat index measured the quality of fat quite well.

Long-term effects of weight reduction on serum lipids and plasma insulin in obese children

The long-term metabolic effects of weight reduction on serum lipids and plasma insulin were evaluated in 32 obese children with a mean (+/- SD) relative weight of 160.9 +/- 20.1% before and after active treatment for 1 y and after observation for another 4 y. The obese subjects had higher serum triglyceride and plasma insulin concentrations initially but lower high-density-lipoprotein (HDL)-cholesterol concentrations and a lower ratio of HDL cholesterol to total cholesterol (TC) than 29 normal-weight children. There was a decrease of 15.8% in relative weight over the first year with a parallel decrease in serum triglyceride and plasma insulin, whereas HDL cholesterol and the ratio of HDL cholesterol to TC increased (P < 0.001). These changes remained stable over the second year. At 5 y the obese subjects still had a reduced weight (12.8% lower than initially) and higher HDL cholesterol. These results indicate that weight reduction in obese children is associated with a change in serum lipids toward normal and reduced peripheral hyperinsulinemia.

Weight loss, body composition and risk factors for cardiovascular disease in obese children: long-term effects of two treatment strategies

Two treatment strategies were compared to determine their effects on weight loss, body composition and risk factors for cardiovascular disease (CVD) in 32 obese children (relative weight > 120%) aged 6-15 years. Modes of therapy included individual (Group I) or group treatment (Group II). The children were treated for 1 year and observed during the second year. Relative body weight decreased by 16.6% in Group I (p < 0.001) and by 15.8% (p < 0.01) in Group II during the first year; in both groups the lower relative body weight was maintained during the year of observation. No changes were observed in linear growth or lean body mass. Weight reduction was accompanied by increased high-density lipoprotein cholesterol (HDL-C) levels, increased ratio of HDL-C to total cholesterol, and reduced triglyceride concentrations in both groups. Fasting plasma insulin concentrations decreased significantly in Group I. In conclusion, intensive treatment produced significant weight loss, improved serum lipid profile and reduced hyperinsulinemia. These changes, if sustained, may reduce the risk of CVD later in life.

Predictors of weight reduction in obese children

The characteristics of successful and unsuccessful weight losers were studied in 48 obese children (relative weight > 120%) aged 6-15 years who were treated for 1 year and observed for another. Successful weight loss was defined as a decrease in relative weight of > or = 0.8 in the standard deviation score (SDS) at the end of the study. Thirty-two children were treated intensively, 16 with individual counselling and 16 in group therapy, while the remaining 16 children were treated conventionally in a school health care setting. Three children dropped out of the study. In 2 years, the relative body weight decreased by 1.7 SDS in those who were successful weight losers (n = 21, 47%), but remained unchanged in those who had been unsuccessful (n = 24). At baseline there were no differences between the two groups. At 1 year, the successful weight losers had lower body weight (P < 0.05), less lean body mass (0.05) and lower fasting concentrations of circulating insulin (P < 0.01) than the unsuccessful children did. A decrease in mothers' body mass index (BMI) and in documented energy intake over the first year as well as energy intake at 1 year were significant predictors of success at 2 years. The combination of these three predictors resulted in correct classification of about 3/4 of the cases as successful or unsuccessful weight losers. It appears, however, difficult to develop a clinically useful model for predicting the treatment outcome in obese children.

Long-term weight control in obese children: persistence of treatment outcome and metabolic changes

Maintenance of achieved weight loss and clinical and biochemical changes were studied in 48 obese children (relative weight greater than 120%) over a three-year period after active treatment for one year and initial observation for another year. The control group comprised 29 normal weight children (relative weight less than 120%). The children were 6-16 years old at the beginning of the study. The successful weight loser was defined as a child with a decrease of at least 10% in relative weight at the end of the initial two year study period. Twenty-two subjects (49%) were treated successfully while 23 children were unsuccessful. Three obese children dropped out of the study. In successful children the relative body weight decreased by 24.7% (P less than 0.001) during the initial two-year period, and the lower body weight was maintained during the subsequent observation. The relative height also decreased significantly in the successful subjects but was still normal at the end of the study. Success in weight reduction was associated with increased HDL-cholesterol (HDL-C) levels, increased ratio of HDL-C to total cholesterol and reduced concentrations of triglyceride and plasma insulin. All of these changes were maintained throughout the five year study period. In normal weight children concentrations of serum lipids and plasma insulin remained unchanged during the five years. In conclusion, initial success in weight loss was associated with long-term favourable changes in the serum lipid profile and reduced hyperinsulinemia. A majority of the initially successful weight losers (14 of 22) managed to maintain their reduced weight up to five years.

Long-term effects of dietary counselling on nutrient intake and weight loss in obese children

The effects of dietary counselling on food and nutrient intake and weight loss were studied over a two-year period in 32 obese children (relative weight greater than 120%) with intensive treatment (Group I) and in 16 obese children treated in a school health-care setting (Group II). The control group (Group III) comprised 29 normal-weight children (relative weight less than 120%). The children were 6-16 years old. The obese children were treated for one year and observed for another year. Food consumption data were collected by a four-day food record method. At baseline there were no differences in food consumption or nutrient intake between obese and normal-weight children. During treatment the children in Group I reduced their mean daily fat intake (P less than 0.001) and this reduction was maintained throughout the observation period. In Groups II and III no change was observed in mean daily fat intake. The relative body weight decreased by 16.2% in Group I (P less than 0.001) during the first year and the lower body weight was maintained during the observation year. No significant weight reduction was observed in Group II. The decrease in energy intake was significantly correlated with the reduction in body fat mass over the first year (rs = 0.50; P = 0.05, n = 16) in obese children passing through their pubertal growth spurt and to the reduction in relative weight over the first year (rs = 0.90; P less than 0.05, n = 5), as well as to the decrease in fat mass over the second year (rs = 0.70; P less than 0.05, n = 11) in adolescents beyond their growth spurt. In conclusion, intensive treatment resulted in decreased fat intake and also led to a reduction in relative weight, whereas a conventional approach appeared to be ineffective with regard to nutrient intake and weight loss.