Evaluation of a health and nutrition education program in primary school children of Crete over a three-year period

The level of food literacy and its association with food intake and obesity status among Seoul citizens: results from Seoul Food Survey 2021

BACKGROUND/OBJECTIVES

Food literacy (FL) is a crucial skill for selecting sustainable and healthy food options, necessitating the identification of vulnerable groups in the community using valid measurement tools. Identifying weak domains in FL is essential for enhancing the overall FL. This study examined the FL levels of Seoul citizens based on their sociodemographic characteristics and assessed the relationship between FL, food intake, and weight status.

SUBJECTS/METHODS

This study utilized the data from the Seoul Food Survey, a cross-sectional study employing representative samples of Seoul citizens. Data collection occurred from September to October 2021, with 4,039 citizens aged 18 yrs and above participating in face-to-face surveys. Thirty-three FL items were assessed, comprising 14 items in the nutrition and safety (NS) domain, eight items in the cultural and relational (CR) domain, and 11 items in the socio-ecological (SE) domain. In addition, data on food intake sufficiency and obesity status were collected. The descriptive statistics, t-tests, analysis of variance, and logistic regression analysis were used for analysis.

RESULTS

Men, students, young adults, older citizens, and people experiencing food insecurity had the lowest scores for all the FL domains. The highest quartile group of NS scores had a higher probability of consuming adequate servings of vegetables and fruits, with significant linear trends observed (P for trend < 0.05). In all three FL domains, the odds ratio for obesity was significantly lower in the groups with high FL scores (P < 0.05).

CONCLUSIONS

A close relationship was observed between low FL, obesity, and food intake, even after controlling for other covariates. Vulnerable groups with low FL were also identified. Therefore, it is essential to develop programs to improve FL and the health and well-being of these groups.

Assessments Related to the Physical, Affective and Cognitive Domains of Physical Literacy Amongst Children Aged 7-11.9 Years: A Systematic Review

Background

Over the past decade, there has been increased interest amongst researchers, practitioners and policymakers in physical literacy for children and young people and the assessment of the concept within physical education (PE). This systematic review aimed to identify tools to assess physical literacy and its physical, cognitive and affective domains within children aged 7–11.9 years, and to examine the measurement properties, feasibility and elements of physical literacy assessed within each tool.

Methods

Six databases (EBSCO host platform, MEDLINE, PsycINFO, Scopus, Education Research Complete, SPORTDiscus) were searched up to 10th September 2020. Studies were included if they sampled children aged between 7 and 11.9 years, employed field-based assessments of physical literacy and/or related affective, physical or cognitive domains, reported measurement properties (quantitative) or theoretical development (qualitative), and were published in English in peer-reviewed journals. The methodological quality and measurement properties of studies and assessment tools were appraised using the COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist. The feasibility of each assessment was considered using a utility matrix and elements of physical literacy element were recorded using a descriptive checklist.

Results

The search strategy resulted in a total of 11467 initial results. After full text screening, 11 studies (3 assessments) related to explicit physical literacy assessments. Forty-four studies (32 assessments) were relevant to the affective domain, 31 studies (15 assessments) were relevant to the physical domain and 2 studies (2 assessments) were included within the cognitive domain. Methodological quality and reporting of measurement properties within the included studies were mixed. The Canadian Assessment of Physical Literacy-2 and the Passport For Life had evidence of acceptable measurement properties from studies of very good methodological quality and assessed a wide range of physical literacy elements. Feasibility results indicated that many tools would be suitable for a primary PE setting, though some require a level of expertise to administer and score that would require training.

Conclusions

This review has identified a number of existing assessments that could be useful in a physical literacy assessment approach within PE and provides further information to empower researchers and practitioners to make informed decisions when selecting the most appropriate assessment for their needs, purpose and context. The review indicates that researchers and tool developers should aim to improve the methodological quality and reporting of measurement properties of assessments to better inform the field.

Trial registration

PROSPERO: CRD42017062217

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-021-00324-8.

An 11-week school-based 'health education through football programme' improves health knowledge related to hygiene, nutrition, physical activity and well-being-and it's fun! A scaled-up, cluster-RCT with over 3000 Danish school children aged 10-12 years old

ObjectivesOur large-scale cluster randomised controlled trial aimed to investigate the effects on health knowledge and enjoyment of an 11 week 'health education through football' programme for children aged 10-12 years old. Methods 3127 Danish school children (49% girls) aged 10-12 years from a total of 154 schools located in 63% of the Danish municipalities (69 of 98) took part in the analysis. A 5:1 cluster randomisation was performed at school level for the intervention group (IG) or the control group (CG). The twice-weekly 45 min intervention was the '11 for Health in Denmark' programme, which includes health education, football drills and small-sided games. The health education element focused on hygiene, nutrition, physical activity and well-being. Outcomes: The participants completed a 34-item multiple-choice computer-based health knowledge questionnaire preintervention and postintervention. IG also evaluated whether the programme was enjoyable. Results Between-group differences (p<0.05) were observed in overall health knowledge in favour of IG (+7.2% points, 95% CI 6.1% to 8.4%, effect size, ES:0.59), with similar effects for girls (+7.4% points, 95% CI 5.9% to 9.0%, ES:0.57) and for boys (+7.0% points, 95% CI 5.3% to 8.7%, p<0.05, ES:0.51). Marked between-group differences were observed in favour of IG, for health knowledge related to hygiene (IG vs CG:+13.9% points, 95% CI 11.1% to 16.7%, ES:0.53), nutrition (+10.3% points, 95% CI 8.5% to 12.1%, ES:0.53), physical activity (+5.9% points, 95% CI 4.1% to 7.7%, ES:0.36) and well-being (+4.4% points, 95% CI 2.7% to 6.1%, ES:0.28). Both girls and boys gave the programme moderate to high scores for enjoyment (3.6±1.0 and 3.7±1.1, respectively). Conclusion Health education through sport, using the '11 for Health' model, was enjoyable for girls and boys aged 10-12 years old, and improved health knowledge related to hygiene, nutrition, physical activity and well-being.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

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.

Impact of a one-year school-based teacher-implemented nutrition and physical activity intervention: main findings and future recommendations

BACKGROUND

The aim of the current study is to describe the effectiveness of a school-based intervention when delivered by a non-nutrition specialist (trained schoolteachers) as compared to an expert in nutrition.

METHODS

Two trials of the same school-based intervention using the same intervention package were delivered, one by nutritionists and another by trained schoolteachers. The intervention focused mainly on dietary behaviours, as well as physical activity. In both trials, purposively selected schools were randomized to intervention or control groups; students (aged 9-11 years) in both groups were compared at post-test on knowledge and self-efficacy scores, as well as dietary and physical activity behaviours, controlling for their baseline status on the various measures. All analyses accounted for clustering at the school level.

RESULTS

In both trials, a statistically significantly greater improvement was observed for both the knowledge and self-efficacy scores in intervention vs. school students. When the programme was delivered by trained schoolteachers, frequency of breakfast intake was increased, crisps consumption was reduced, but no change in fruit and vegetable consumption was observed (latter increased when delivered by nutrition professionals only). Physical activity did not improve in both trials.

CONCLUSION

Trained schoolteachers can have a positive impact on students' dietary behaviours with the appropriate training to ensure they are equipped with the right information, skills, and resources to deliver the programme with the highest fidelity.

TRIAL REGISTRATION

ClinicalTrial.gov Identifier: NCT03040271. Retrospectively registered on 2 February 2017.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

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.

Interventions for preventing obesity in children

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.

Effectiveness of school-based physical activity and nutrition interventions with direct parental involvement on children's BMI and energy balance-related behaviors - A systematic review

BACKGROUND

The aims of this systematic review were to study the effectiveness of primary school-based physical activity, sedentary behavior and nutrition interventions with direct parental involvement on children's BMI or BMI z-score, physical activity, sedentary behavior and nutrition behavior and categorize intervention components into targeted socio-cognitive determinants and environmental types using the Environmental Research framework for weight Gain prevention.

METHODS

In March 2018, a systematic search was conducted in four electronic literature databases. Articles written in English about effectiveness studies on school-based interventions with direct parental involvement targeting 4-12 year olds were included. Interventions with indirect parental involvement, interventions not targeting the school environment, and pilot studies were excluded. Study and intervention characteristics were extracted. Study quality and study effectiveness were assessed and effect sizes (Cohen's d) were calculated for the outcome measures. Types of socio-cognitive factors and environmental types targeted were distinguished.

RESULTS

In total, 25 studies were included. Most studies on BMI or BMI z-score, physical activity and sedentary behavior found favorable results: 61.1%, 81.1% and 75%, respectively. Results regarding nutrition behavior were inconclusive. Methodological study quality varied. All interventions targeted multiple environmental types in the school and family environment. Five targeted socio-cognitive determinants (knowledge, awareness, attitude, self-efficacy and intrinsic motivation) of the children were identified. No consistent pattern was found between either type of environment targeted, number of type of environment targeted, or the child's targeted socio-cognitive determinants and intervention effectiveness.

DISCUSSION

School-based interventions with direct parental involvement have the potential to improve children's weight status, physical activity and sedentary behavior. Based on the results, it is recommended that school-based interventions with direct parental involvement target more than one EBRB, last at least one year, and focus particularly on the physical and social environment within both the school and the family environment.

Study protocol of the quasi-experimental evaluation of "KEIGAAF": a context-based physical activity and nutrition intervention for primary school children

Background

The environment affects children’s energy balance-related behaviors to a considerable extent. A context-based physical activity and nutrition school- and family-based intervention, named KEIGAAF, is being implemented in low socio-economic neighborhoods in Eindhoven, The Netherlands. The aim of this study was to investigate: 1) the effectiveness of the KEIGAAF intervention on BMI z-score, waist circumference, physical activity, sedentary behavior, nutrition behavior, and physical fitness of primary school children, and 2) the process related to the implementation of the intervention.

Methods

A quasi-experimental, controlled study with eight intervention schools and three control schools was conducted. The KEIGAAF intervention consists of a combined top-down and bottom-up school intervention: a steering committee developed the general KEIGAAF principles (top-down), and in accordance with these principles, KEIGAAF working groups subsequently develop and implement the intervention in their local context (bottom-up). Parents are also invited to participate in a family-based parenting program, i.e., Triple P Lifestyle. Children aged 7 to 10 years old (grades 4 to 6 in the Netherlands) are included in the study. Effect evaluation data is collected at baseline, after one year, and after two years by using a child questionnaire, accelerometers, anthropometry, a physical fitness test, and a parent questionnaire. A mixed methods approach is applied for the process evaluation: quantitative (checklists, questionnaires) and qualitative methods (observations, interviews) are used. To analyze intervention effectiveness, multilevel regression analyses will be conducted. Content analyses will be conducted on the qualitative process data.

Discussion

Two important environmental settings, the school environment and the family environment, are simultaneously targeted in the KEIGAAF intervention. The combined top-down and bottom-up approach is expected to make the intervention an effective and sustainable version of the Health Promoting Schools framework. An elaborate process evaluation will be conducted alongside an effect evaluation in which multiple data collection sources (both qualitative and quantitative) are used.

Trial registration

Dutch Trial Register NTR6716 (registration date 27/06/2017, retrospectively registered), METC163027, NL58554.068.16, Fonds NutsOhra project number 101.253.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5764-3) contains supplementary material, which is available to authorized users.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

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 January 2018. We searched Proquest Dissertations and Theses in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies 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 studies; 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 63 trials with 178 trial arms and 11,698 participants. Thirty-nine trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fourteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Nine studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 63 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 studies.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 3.50 g as-desired consumption of vegetables (SMD 0.33, 95% CI 0.13 to 0.54; participants = 1741; studies = 13). Multicomponent interventions versus no intervention may have a very small effect on child consumption of fruit and vegetables (SMD 0.35, 95% CI 0.04 to 0.66; participants = 2009; studies = 5; low-quality evidence), equivalent to an increase of 0.37 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; participants = 3078; studies = 11; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for four studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 63 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low- and low-quality evidence respectively that child-feeding practice and multicomponent interventions may lead to very 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 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.

Relationships between parents' academic backgrounds and incomes and building students' healthy eating habits

BACKGROUND

Building healthy eating habit is essential for all people. School and family are the prime institutions to instill this habit during early age. This study is aimed at understanding the impact of family such as parents' educations and incomes on building students' healthy eating habits.

METHODS

A survey on building students' eating habits was conducted among primary school students of grade 4 (11 years) and 5 (12 years) from Kulim district, Malaysia. Data from 318 respondents were analysed. Descriptive statistics were used to find the present scenario of their knowledge, attitude and practices towards their eating habits while one-way ANOVA and independent sample t-test were used to find the differences between their practices based on students' gender, parents' educations and incomes.

RESULTS

The study finds that the students have a good knowledge of types of healthy food but yet their preferences are towards the unhealthy food. Though the students' gender and parents' educations are not found significantly related to students' knowledge, attitude and practices towards healthy eating habits, parents' incomes have significant influence on promoting the healthy eating habit.

DISCUSSION

Findings of this study can be useful to guide parents in healthy food choices and suggest them to be models to their children in building healthy eating habits.

The Effects of a Community-Based Lifestyle Intervention on Metabolic Syndrome and Its Components in Adolescents: Findings of a Decade Follow-Up

BACKGROUND

The increasing prevalence of metabolic syndrome (MetS) in childhood makes lifestyle interventions imperative during adolescence. This study aimed to assess the effects of a community-based lifestyle intervention on MetS and its components in adolescents.

METHODS

Adolescents, based on their residential area were categorized into three groups: complete intervention (residing in the intervention area at baseline and during all follow-ups), incomplete intervention (residing in either the intervention or control areas and were in transition between these two areas), and control group (residing in the control area at baseline and throughout all follow-ups). All measurements were repeated every 3 years for up to 9 years. Lifestyle intervention aimed at achieving healthy dietary patterns and increasing physical activity. Generalized estimating equation models were used to analyze data.

RESULTS

In boys with incomplete intervention versus controls, the prevalence of MetS was significantly lower in the short term (14.0 vs. 22.9), but not in long term. In boys with complete intervention, the prevalence was significantly lower versus controls (9.0 vs. 23.4) in the long term. In girls, the short-term prevalence of MetS was significantly lower in the complete intervention group compared with controls (2.5 vs. 9.1) and then remained constantly low in all study groups after that. Among MetS components, in boys, triglycerides and fasting plasma glucose in the short term and high-density lipoprotein mid term, and in girls HDL in mid and long term were both significantly improved. The odds of MetS decreased significantly in the complete [odds ratio (OR): 0.516, confidence interval (95% CI): 0.273-0.973] and incomplete (OR: 0.591, 95% CI: 0.358-0.976) intervention groups only in boys. The short- and long-term interventions resulted improvement in some of the MetS components in both genders.

CONCLUSIONS

The healthy lifestyle intervention reduced the risk of MetS in both genders in short and long term, but with different patterns and improved some of the MetS components.

Impact of school policies on non-communicable disease risk factors - a systematic review

BACKGROUND

Globally, non-communicable diseases (NCDs) are identified as one of the leading causes of mortality. NCDs have several modifiable risk factors including unhealthy diet, physical inactivity, tobacco use and alcohol abuse. Schools provide ideal settings for health promotion, but the effectiveness of school policies in the reduction of risk factors for NCD is not clear. This study reviewed the literature on the impact of school policies on major NCD risk factors.

METHODS

A systematic review was conducted to identify, collate and synthesize evidence on the effectiveness of school policies on reduction of NCD risk factors. A search strategy was developed to identify the relevant studies on effectiveness of NCD policies in schools for children between the age of 6 to 18 years in Ovid Medline, EMBASE, and Web of Science. Data extraction was conducted using pre-piloted forms. Studies included in the review were assessed for methodological quality using the Effective Public Health Practice Project (EPHPP) quality assessment tool. A narrative synthesis according to the types of outcomes was conducted to present the evidence on the effectiveness of school policies.

RESULTS

Overall, 27 out of 2633 identified studies were included in the review. School policies were comparatively more effective in reducing unhealthy diet, tobacco use, physical inactivity and inflammatory biomarkers as opposed to anthropometric measures, overweight/obesity, and alcohol use. In total, for 103 outcomes independently evaluated within these studies, 48 outcomes (46%) had significant desirable changes when exposed to the school policies. Based on the quality assessment, 18 studies were categorized as weak, six as moderate and three as having strong methodological quality.

CONCLUSION

Mixed findings were observed concerning effectiveness of school policies in reducing NCD risk factors. The findings demonstrate that schools can be a good setting for initiating positive changes in reducing NCD risk factors, but more research is required with long-term follow up to study the sustainability of such changes.

Evaluating the Efficacy of the Feeding Exercise Randomized Trial in Overweight and Obese Adolescents

BACKGROUND

The Feeding Exercise Trial in Adolescents (FETA) aimed to evaluate whether a community-based, parents-involving, combined physical activity and nutritional education program was effective in improving adiposity profiles in overweight and obese adolescents.

METHODS

A total of 181 overweight and obese adolescents aged 13-15 years old were randomized in the three study groups ("Diet & Activity," "Activity," and Control). The Activity intervention included a 45-minute, 3-day per week supervised training program, while the Diet & Activity intervention included a supplementary 15 minutes of group-based sessions attended by the parents. The intervention lasted 3 months and the participants were followed for another 3 months after the intervention. The participants were assessed for anthropometric measures and activity and fulfilled the modified version of the questionnaire "Family Eating and Activity Habits Questionnaire" (FEAHQ).

RESULTS

Both "Activity" only and "Diet & Activity" groups reduced significantly (p < 0.001) their mean body mass index (BMI) (-1.1, 95% CI -1.3, -0.8, and -1.4, 95% CI -1.7, -1.2, respectively), waist circumference, systolic and diastolic blood pressure, pulses per minute, and 50 m sprint run test at 3 months, while greater reductions in BMI were observed at 6 months (-2.3, 95% CI -2.6, -2.0, and -3.1, 95% CI -3.3, -2.8). Significant changes in the total FEAHQ score were achieved only in the "Diet & Activity" group both at 3 months and at 6 months.

CONCLUSIONS

FETA resulted in significant effects on improving adiposity profiles in overweight and obese adolescents, as well as family activity and feeding habits, maintained at 3 months follow-up.

The effects of school-based lifestyle interventions on body mass index and blood pressure: a multivariate multilevel meta-analysis of randomized controlled trials

Primary prevention of childhood obesity and related hypertension is warrant given that both risk factors are intertwined and track into adulthood. This systematic review and meta-analysis assess the impact of school-based lifestyle interventions on children's body mass index (BMI) and blood pressure. We searched databases and prior reviews. Eligibility criteria were the following: randomized controlled trial design, evaluation of a school-based intervention, targeting children aged 4-12 years, reporting on BMI and/or related cardiovascular risk factors, reporting data on at least one follow-up moment. The effects on BMI, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were evaluated by means of univariate and multivariate three-level random effects models. A total of 85 RCTs (91 papers) were included in the meta-analyses. In univariate models, the pooled effects were -0.072 (95%CI: -0.106; -0.038) for BMI, -0.183 (95%CI: -0.288; -0.078) for SBP and -0.071 (95%CI: -0.185; 0.044) for DBP. In multivariate analyses, the pooled effects of interventions were -0.054 (95%CI: -0.131; 0.022) for BMI, -0.182 (95%CI: -0.266; -0.098) for SBP and -0.144 (95%CI: -0.230; -0.057) for DBP. Parental involvement accentuated the beneficial effects of interventions. School-based lifestyle prevention interventions result in beneficial changes in children's BMI and blood pressure, and the effects on the latter may be stronger than and accrue independently from those in the former.

What childhood obesity prevention programmes work? A systematic review and meta-analysis

Previous reviews of childhood obesity prevention have focused largely on schools and findings have been inconsistent. Funded by the US Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health, we systematically evaluated the effectiveness of childhood obesity prevention programmes conducted in high-income countries and implemented in various settings. We searched MEDLINE®, Embase, PsycINFO, CINAHL®, ClinicalTrials.gov and the Cochrane Library from inception through 22 April 2013 for relevant studies, including randomized controlled trials, quasi-experimental studies and natural experiments, targeting diet, physical activity or both, and conducted in children aged 2-18 in high-income countries. Two reviewers independently abstracted the data. The strength of evidence (SOE) supporting interventions was graded for each study setting (e.g. home, school). Meta-analyses were performed on studies judged sufficiently similar and appropriate to pool using random effect models. This paper reported our findings on various adiposity-related outcomes. We identified 147 articles (139 intervention studies) of which 115 studies were primarily school based, although other settings could have been involved. Most were conducted in the United States and within the past decade. SOE was high for physical activity-only interventions delivered in schools with home involvement or combined diet-physical activity interventions delivered in schools with both home and community components. SOE was moderate for school-based interventions targeting either diet or physical activity, combined interventions delivered in schools with home or community components or combined interventions delivered in the community with a school component. SOE was low for combined interventions in childcare or home settings. Evidence was insufficient for other interventions. In conclusion, at least moderately strong evidence supports the effectiveness of school-based interventions for preventing childhood obesity. More research is needed to evaluate programmes in other settings or of other design types, especially environmental, policy and consumer health informatics-oriented interventions.

Weighing the Evidence of Common Beliefs in Obesity Research

Obesity is a topic on which many views are strongly held in the absence of scientific evidence to support those views, and some views are strongly held despite evidence to contradict those views. We refer to the former as "presumptions" and the latter as "myths." Here, we present nine myths and 10 presumptions surrounding the effects of rapid weight loss; setting realistic goals in weight loss therapy; stage of change or readiness to lose weight; physical education classes; breastfeeding; daily self-weighing; genetic contribution to obesity; the "Freshman 15"; food deserts; regularly eating (versus skipping) breakfast; eating close to bedtime; eating more fruits and vegetables; weight cycling (i.e., yo-yo dieting); snacking; built environment; reducing screen time in childhood obesity; portion size; participation in family mealtime; and drinking water as a means of weight loss. For each of these, we describe the belief and present evidence that the belief is widely held or stated, reasons to support the conjecture that the belief might be true, evidence to directly support or refute the belief, and findings from randomized controlled trials, if available. We conclude with a discussion of the implications of these determinations, conjecture on why so many myths and presumptions exist, and suggestions for limiting the spread of these and other unsubstantiated beliefs about the obesity domain.

The value of using schools as community assets for health

In planning, designing, procuring and ensuring delivery of improved services ('commissioning') for the school age population, the outcomes should be students who are healthy to learn and who learn to be healthy. Intuitively, linking education and health development together within the wider learning environment seems a good start to planning school health. However there has been a shortage of either theoretical models that can span different settings or experimental research that demonstrates improved community health. Is there evidence that the wider learning environment provided in a school is valuable in improving health? An initial scoping exercise identified domains of health where there was a promise of health gain. International literature on school health outcomes using the framework of Asset-Based Community Development (ABCD) has been reviewed. It was found that research on a variety of interventions was relevant to schools as an asset for public health. Effective areas for health gain were identified for local planning and evaluation using this community model. However, none of the studies reviewed was originally designed to test schools as assets and most of the research lacked methodological rigour, especially regarding children in low income countries. The ABCD model could help national governments develop resources for both education and health, but there is a global need to generate better quality evidence. Then people who commission for their local communities can make more effective use of these multifaceted assets to improve health and education outcomes for children.

Long-term student outcomes of the Integrated Nutrition and Physical Activity Program

OBJECTIVE

To examine the long-term effects of the Integrated Nutrition and Physical Activity Program (INPAP), a school-based nutrition education program.

DESIGN

Quasi-experimental design comparing intervention and comparison cohorts at 3-6 years after delivery of the INPAP intervention on nutrition- and physical activity-related outcomes.

SETTING

This study was conducted in 1 school district in a low-income rural county of ∼15,000 residents in south-central Colorado.

PARTICIPANTS

In second grade, intervention and comparison cohorts included 173 (fall 2000) and 190 (fall 1999) students, respectively. Approximately 60% of these students completed assessments in eighth grade.

INTERVENTIONS

INPAP is an experiential school-based nutrition education program, grounded in social cognitive theory and Piaget's cognitive development theory and adapted for use in a rural setting.

OUTCOMES

Nutrition and physical activity knowledge, self-efficacy, attitudes and behaviors, body mass index.

ANALYSIS

Wilcoxon signed rank test, chi-square test for proportions, and t test for means.

RESULTS

Long-term effects were observed in nutrition-related knowledge and attitudes but not self-efficacy or behavior change. The effects that did occur were attenuated over time.

CONCLUSION AND IMPLICATIONS

This study found that INPAP implemented in elementary school had limited lasting effects by the end of middle school, a time when students have increased autonomy to make food choices.

The costs and cost-effectiveness of a school-based comprehensive intervention study on childhood obesity in China

Background

The dramatic rise of overweight and obesity among Chinese children has greatly affected the social economic development. However, no information on the cost-effectiveness of interventions in China is available. The objective of this study is to evaluate the cost and the cost-effectiveness of a comprehensive intervention program for childhood obesity. We hypothesized the integrated intervention which combined nutrition education and physical activity (PA) is more cost-effective than the same intensity of single intervention.

Methods

And Findings: A multi-center randomized controlled trial conducted in six large cities during 2009-2010. A total of 8301 primary school students were categorized into five groups and followed one academic year. Nutrition intervention, PA intervention and their shared common control group were located in Beijing. The combined intervention and its’ control group were located in other 5 cities. In nutrition education group, ‘nutrition and health classes’ were given 6 times for the students, 2 times for the parents and 4 times for the teachers and health workers. "Happy 10" was carried out twice per day in PA group. The comprehensive intervention was a combination of nutrition and PA interventions. BMI and BAZ increment was 0.65 kg/m² (SE 0.09) and 0.01 (SE 0.11) in the combined intervention, respectively, significantly lower than that in its’ control group (0.82±0.09 for BMI, 0.10±0.11 for BAZ). No significant difference were found neither in BMI nor in BAZ change between the PA intervention and its’ control, which is the same case in the nutrition intervention. The single intervention has a relative lower intervention costs compared with the combined intervention. Labor costs in Guangzhou, Shanghai and Jinan was higher compared to other cities. The cost-effectiveness ratio was $120.3 for BMI and $249.3 for BAZ in combined intervention, respectively.

Conclusions

The school-based integrated obesity intervention program was cost-effectiveness for children in urban China.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-PRC-09000402 URL:http://www.chictr.org/cn/

Obesity: a systematic review on parental involvement in long-term European childhood weight control interventions with a nutritional focus

In Europe, about 20% of children are overweight. Focus on parental responsibility is an effective method in weight control interventions in children. In this systematic review we describe the intensity of parental involvement and behaviour change aimed at parents in long-term European childhood weight control interventions. We include European Union studies targeting parents in order to improve children's weight status in multi-component (parental, behaviour change and nutrition) health promotion or lifestyle interventions. The included studies have at least one objectively measured anthropometric outcome in the weight status of the child. Parental involvement was described and categorized based on the intensity of parental involvement and coded using a validated behaviour change taxonomy specific to childhood obesity. Twenty-four studies were analysed. In effective long-term treatment studies, medium and high intensity parental involvement were identified most frequently; whereas in prevention studies low intensity parental involvement was identified most frequently. Parenting skills, generic and specific to lifestyle behaviour, scored frequently in effective weight control interventions. To list parental skills in generic and specific to lifestyle, descriptions of the included studies were summarized. We conclude that intensity of parental involvement and behaviour change techniques are important issues in the effectiveness of long-term childhood weight control interventions.

A pilot comprehensive school nutrition program improves knowledge and intentions for intake of milk and milk alternatives among youth in a remote first nation

OBJECTIVE

To evaluate the impact of a pilot comprehensive school nutrition program modeled on Social Cognitive Theory on knowledge, intentions, self-efficacy, and intake of milk and milk alternatives (MMA) in First Nations youth.

METHODS

A pilot school nutrition program was implemented at Peetabeck Academy in Fort Albany, Ontario in May, 2010. The Knowledge, Self-Efficacy, and Intentions Questionnaire (KSIQ) and Waterloo Web-based Eating Behavior Questionnaire (WEB-Q) were used to assess change in attitudes and behavior from pre- to postprogram.

RESULTS

The KSIQ preprogram (n = 26), postprogram (n = 19); WEB-Q preprogram (n = 30), postprogram (n = 10). Improved knowledge (6.0 ± 1.5 vs. 6.9 ± 1.5, P = .05) and intention scores (9.6 ± 4.4 vs. 11.3 ± 4.1, P = .01) were observed.

CONCLUSIONS AND IMPLICATIONS

A comprehensive school nutrition program can improve knowledge and intentions for intake of MMA in First Nations youth. Environmental constraints beyond the school environment need to be addressed.

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

BACKGROUND

The World Health Organization (WHO) estimates that 1.9 million deaths worldwide are attributable to physical inactivity and at least 2.6 million deaths are a result of being overweight or obese. In addition, WHO estimates that physical inactivity causes 10% to 16% of cases each of breast cancer, colon, and rectal cancers as well as type 2 diabetes, and 22% of coronary heart disease and the burden of these and other chronic diseases has rapidly increased in recent decades.

OBJECTIVES

The purpose of this systematic review was to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents.

SEARCH METHODS

The search strategy included searching several databases to October 2011. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information.

SELECTION CRITERIA

To be included, the intervention had to be relevant to public health practice (focused on health promotion activities), not conducted by physicians, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, included all school-attending children, and be implemented for a minimum of 12 weeks. In addition, the review was limited to randomized controlled trials and those that reported on outcomes for children and adolescents (aged 6 to 18 years). Primary outcomes included: rates of moderate to vigorous physical activity during the school day, time engaged in moderate to vigorous physical activity during the school day, and time spent watching television. Secondary outcomes related to physical health status measures including: systolic and diastolic blood pressure, blood cholesterol, body mass index (BMI), maximal oxygen uptake (VO2max), and pulse rate.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to assess each study for relevance and for data extraction. In addition, each study was assessed for risk of bias as specified in the Cochrane Handbook for Systematic Reviews of Interventions. Where discrepancies existed, discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated, and outcomes measured.

MAIN RESULTS

In the original review, 13,841 records were identified and screened, 302 studies were assessed for eligibility, and 26 studies were included in the review. There was some evidence that school-based physical activity interventions had a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally, school-based interventions had little effect on physical activity rates, systolic and diastolic blood pressure, BMI, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity resulted in positive effects.In this update, given the addition of three new inclusion criteria (randomized design, all school-attending children invited to participate, minimum 12-week intervention) 12 of the original 26 studies were excluded. In addition, studies published between July 2007 and October 2011 evaluating the effectiveness of school-based physical interventions were identified and if relevant included. In total an additional 2378 titles were screened of which 285 unique studies were deemed potentially relevant. Of those 30 met all relevance criteria and have been included in this update. This update includes 44 studies and represents complete data for 36,593 study participants. Duration of interventions ranged from 12 weeks to six years.Generally, the majority of studies included in this update, despite being randomized controlled trials, are, at a minimum, at moderate risk of bias. The results therefore must be interpreted with caution. Few changes in outcomes were observed in this update with the exception of blood cholesterol and physical activity rates. For example blood cholesterol was no longer positively impacted upon by school-based physical activity interventions. However, there was some evidence to suggest that school-based physical activity interventions led to an improvement in the proportion of children who engaged in moderate to vigorous physical activity during school hours (odds ratio (OR) 2.74, 95% confidence interval (CI), 2.01 to 3.75). Improvements in physical activity rates were not observed in the original review. Children and adolescents exposed to the intervention also spent more time engaged in moderate to vigorous physical activity (with results across studies ranging from five to 45 min more), spent less time watching television (results range from five to 60 min less per day), and had improved VO2max (results across studies ranged from 1.6 to 3.7 mL/kg per min). However, the overall conclusions of this update do not differ significantly from those reported in the original review.

AUTHORS' CONCLUSIONS

The evidence suggests the ongoing implementation of school-based physical activity interventions at this time, given the positive effects on behavior and one physical health status measure. However, given these studies are at a minimum of moderate risk of bias, and the magnitude of effect is generally small, these results should be interpreted cautiously. Additional research on the long-term impact of these interventions is needed.

A systematic review of intervention effects on potential mediators of children's physical activity

Background

Many interventions aiming to increase children’s physical activity have been developed and implemented in a variety of settings, and these interventions have previously been reviewed; however the focus of these reviews tends to be on the intervention effects on physical activity outcomes without consideration of the reasons and pathways leading to intervention success or otherwise.

To systematically review the efficacy of physical activity interventions targeting 5-12 year old children on potential mediators and, where possible, to calculate the size of the intervention effect on the potential mediator.

Methods

A systematic search identified intervention studies that reported outcomes on potential mediators of physical activity among 5-12 year old children. Original research articles published between 1985 and April 2012 were reviewed.

Results

Eighteen potential mediators were identified from 31 studies. Positive effects on cognitive/psychological potential mediators were reported in 15 out of 31 studies. Positive effects on social environmental potential mediators were reported in three out of seven studies, and no effects on the physical environment were reported. Although no studies were identified that performed a mediating analysis, 33 positive intervention effects were found on targeted potential mediators (with effect sizes ranging from small to large) and 73% of the time a positive effect on the physical activity outcome was reported.

Conclusions

Many studies have reported null intervention effects on potential mediators of children’s physical activity; however, it is important that intervention studies statistically examine the mediating effects of interventions so the most effective strategies can be implemented in future programs.

Effect of a family focused active play intervention on sedentary time and physical activity in preschool children

Background

Early childhood provides a window of opportunity for the promotion of physical activity. Given the limited effectiveness of interventions to date, new approaches are needed. Socio-ecological models suggest that involving parents as intervention targets may be effective in fostering healthier lifestyles in children. This study describes the effectiveness of a family-focused ‘Active Play’ intervention in decreasing sedentary time and increasing total physical activity in preschool children.

Method

Seventy-seven families were recruited from 8 randomly selected SureStart children’s centres in the North West of England. Centres were randomly assigned to either an intervention (n = 4) or a comparison group (n = 4). Parents and children in the intervention group received a 10-week active play programme delivered by trained active play professionals; this included an activity and educational component. Families in the comparison group were asked to maintain their usual routine. Each participating parent and child wore a uni-axial accelerometer for 7 days at baseline and post-test. Week and weekend day sedentary time and total physical activity adjusted for child- and home- level covariates were analysed using multilevel analyses.

Results

Significant intervention effects were observed for sedentary time and physical activity for both week and weekend days. Children in the intervention group engaged in 1.5% and 4.3% less sedentary time during week and weekend days, respectively and 4.5% and 13.1% more physical activity during week and weekend days, respectively than children in the comparison group. Parent’s participation in sport and their physical activity levels, child’s sex, availability of media in the home and attendance at organised activities were significant predictors of sedentary time and physical activity in this age group.

Conclusion

A 10-week family focused active play intervention produced positive changes in sedentary time and total physical activity levels in preschool children. Specific covariates were identified as having a significant effect on the outcome measures. Moreover, children whose parents were active engaged in less sedentary time and more physical activity suggesting that parent’s activity habits are mediators of physical activity engagement in this age group.

Atherogenic risk factors among preschool children in Crete, Greece

OBJECTIVE

To investigate the presence of atherogenic factors among preschool children of Crete, Greece.

MATERIALS AND METHODS

This was a cross-sectional study. The study population included 1189 children, aged four to seven years, examined from January to May 2005, in public kindergartens. Biochemical, anthropometric, and blood pressure measurements were performed.

RESULTS

Of the boys 27.4% were classified as overweight or obese (obese 10.8%). The respective percentage for girls was 28.5% (obese 9%); 7.4% percent of the boys and 7.9% of the girls had blood pressure above the ninety-fifth percentile. TC of > 200 mg / dl was found in 14.4% and LDL-C of > 130 mg / dl in 13.8% of the children. Children with serum TG of > 100 mg / dl had a significantly higher mean WC and BMI than those with triglyceride levels of ≤ 80 mg / dl (59.7 vs. 55.9 cm and 17.9 vs. 16.6 kg / m(2); P < 0.05). Similarly, children with HDL-C < 45 mg / dl had significantly higher WC and BMI than children with HDL-C ≥ 60 mg / dl (57.7 vs. 53.5 cm and 17.1 vs. 16.5 kg / m(2); P < 0.05). Obese children had an Odds Ratio of 2.87 (95% confidence interval, 1.05 - 7.85, P = 0.041) for hypertriglyceridemia, as compared to non-obese children.

CONCLUSION

Levels of obesity and especially central obesity were strongly related to other atherogenic risk factors in Cretan preschool children indicating the presence of this major public health problem in early ages.

One-year change in energy and macronutrient intakes of overweight and obese inner-city African American children: effect of community-based Taking Action Together type 2 diabetes prevention program

Taking Action Together (TAT) was a controlled community-based intervention protocol developed to reduce risk of T2DM among low-income, high BMI, 9-10 year old African American children. A secondary hypothesis of this study was that there would be greater improvements in the treatment group in dietary intakes and physical activity. To evaluate the primary study objectives, multiple linear regression models were employed, with 1 year change in dietary variables as dependent variables. Intervention group status was the independent variable of interest and BMIz was included as a covariate in all analyses to adjust for group differences in baseline obesity status of the children. The findings from this analysis suggest that 1 year change in dietary intakes in boys was associated with group intervention status, with boys in the treatment group reducing their intakes of energy and fat to a significantly greater extent than boys in the control group. Differences in energy intakes were not significant, however, for girls. Based on the differences in gender response to our comprehensive TAT intervention, we conclude that interventions designed for and delivered only to African American girls might be more successful than those delivered in mixed gender settings.

Less frequent eating predicts greater BMI and waist circumference in female adolescents

BACKGROUND

Little is known about the effect of eating frequency on adiposity.

OBJECTIVE

The study aim was to assess the prospective relation of an objective measure of eating frequency with adiposity in girls from ages 9-10 to 19-20 y.

DESIGN

By using data from 3-d diet records collected from 2372 girls in the National Heart, Lung, and Blood Institute Growth and Health Study, meal, snack, and total eating frequencies aggregated over the first 2 study years were examined in relation to 10-y change in BMI and waist circumference (WC).

RESULTS

Eating frequency was lower in black and older girls than in white and younger girls (P < 0.0001). In whites, lower initial snack and total eating frequencies were related to greater 10-y increases in BMI (P = 0.023 and 0.012, respectively) and WC (P = 0.030 and 0.015, respectively). In blacks, lower initial meal and snack frequencies were related to greater increases in BMI (P = 0.004 and 0.022, respectively) and WC (P = 0.052 and 0.005, respectively). Also, in blacks, lower initial total eating frequency was related to greater increases in WC (P = 0.010). After adjustment for baseline adiposity measure, race, parental education, physical activity, television and video viewing, total energy intake, and dieting for weight loss, lower initial total eating frequency remained related to greater 10-y increases in BMI (P = 0.013) and WC (P = 0.036).

CONCLUSIONS

A lower eating frequency predicts a greater gain in adiposity in adolescent females. Intervention trials are needed to test if changing the frequency of eating can affect obesity risk.

Interventions for preventing obesity in children

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 that governments, communities and families can implement to prevent obesity, and promote health, has been accumulating but remains unclear.

OBJECTIVES

This review primarily aims to update the previous Cochrane review of childhood obesity prevention research and determine the effectiveness of evaluated interventions intended to prevent obesity in children, assessed by change in Body Mass Index (BMI). Secondary aims were to examine the characteristics of the programs and strategies to answer the questions "What works for whom, why and for what cost?"

SEARCH METHODS

The searches were re-run in CENTRAL, MEDLINE, EMBASE, PsychINFO and CINAHL in March 2010 and searched relevant websites. Non-English language papers were included and experts were contacted.

SELECTION CRITERIA

The review includes data from childhood obesity prevention studies that used a controlled study design (with or without randomisation). Studies were included if they evaluated interventions, policies or programs in place for twelve weeks or more. If studies were randomised at a cluster level, 6 clusters were required.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies.  Data was extracted on intervention implementation, cost, equity and outcomes. Outcome measures were grouped according to whether they measured adiposity, physical activity (PA)-related behaviours or diet-related behaviours.  Adverse outcomes were recorded. A meta-analysis was conducted using available BMI or standardised BMI (zBMI) score data with subgroup analysis by age group (0-5, 6-12, 13-18 years, corresponding to stages of developmental and childhood settings).

MAIN RESULTS

This review includes 55 studies (an additional 36 studies found for this update). The majority of studies targeted children aged 6-12 years.  The meta-analysis included 37 studies of 27,946 children and demonstrated that programmes were effective at reducing adiposity, although not all individual interventions were effective, and there was a high level of observed heterogeneity (I(2)=82%).  Overall, children in the intervention group had a standardised mean difference in adiposity (measured as BMI or zBMI) of -0.15kg/m(2) (95% confidence interval (CI): -0.21 to -0.09).  Intervention effects by age subgroups were -0.26kg/m(2) (95% CI:-0.53 to 0.00) (0-5 years), -0.15kg/m(2) (95% CI -0.23 to -0.08) (6-12 years), and -0.09kg/m(2) (95% CI -0.20 to 0.03) (13-18 years). Heterogeneity was apparent in all three age groups and could not explained by randomisation status or the type, duration or setting of the intervention.  Only eight studies reported on adverse effects and no evidence of adverse outcomes such as unhealthy dieting practices, increased prevalence of underweight or body image sensitivities was found.  Interventions did not appear to increase health inequalities although this was examined in fewer studies.

AUTHORS' CONCLUSIONS

We found strong evidence to support beneficial effects of child obesity prevention programmes on BMI, particularly for programmes targeted to children aged six to 12 years. However, given the unexplained heterogeneity and the likelihood of small study bias, these findings must be interpreted cautiously. A broad range of programme components were used in these studies and whilst it is not possible to distinguish which of these components contributed most to the beneficial effects observed, our synthesis indicates the following to be promising policies and strategies:·         school curriculum that includes healthy eating, physical activity and body image·         increased sessions for physical activity and the development of fundamental movement skills throughout the school week·         improvements in nutritional quality of the food supply in schools·         environments and cultural practices that support children eating healthier foods and being active throughout each day·         support for teachers and other staff to implement health promotion strategies and activities (e.g. professional development, capacity building activities)·         parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in screen based activitiesHowever, study and evaluation designs need to be strengthened, and reporting extended to capture process and implementation factors, outcomes in relation to measures of equity, longer term outcomes, potential harms and costs.Childhood obesity prevention research must now move towards identifying how effective intervention components can be embedded within health, education and care systems and achieve long term sustainable impacts.  

Outcomes of nutrition knowledge and healthy food choices in 5- to 6-year-old children who received a nutrition intervention based on Piaget's theory

PURPOSE

To develop nutrition education for preschool children based on Piaget's theory and to examine the effects of this education on children's nutritional knowledge, nutritional behaviors, and anthropometric measurements.

DESIGN AND METHODS

Pre- and postexperimental design. In experimental schools nutrition education was given. Children's nutritional knowledge, food consumption frequencies, and anthropometric measurements were evaluated.

RESULTS

The experimental group's nutritional knowledge scores increased and the group's food preferences positively changed. No significant difference was observed between the experimental and control groups' anthropometric measurements.

PRACTICE IMPLICATIONS

The nutrition education program used in this study may guide nurses in preparing education for preschoolers. The participation of families is recommended in their children's nutrition program.

For whom and under what circumstances do school-based energy balance behavior interventions work? Systematic review on moderators

The aim of this review was to systematically review the results and quality of studies investigating the moderators of school-based interventions aimed at energy balance-related behaviors. We systematically searched the electronic databases of Pubmed, EMBASE, Cochrane, PsycInfo, ERIC and Sportdiscus. In total 61 articles were included. Gender, ethnicity, age, baseline values of outcomes, initial weight status and socioeconomic status were the most frequently studied potential moderators. The moderator with the most convincing evidence was gender. School-based interventions appear to work better for girls than for boys. Due to the inconsistent results, many studies reporting non-significant moderating effects, and the moderate methodological quality of most studies, no further consistent results were found. Consequently, there is lack of insight into what interventions work for whom. Future studies should apply stronger methodology to test moderating effects of important potential target group segmentations.

Compliance with Mediterranean Diet Quality Index (KIDMED) and nutrition knowledge levels in adolescents. A case study from Turkey

Adopting an eating pattern complying with the Mediterranean diet not only decreases body fat mass and obesity risk, but also reduces development of various health problems. This study investigated the nutritional awareness and diet quality Mediterranean Diet Quality Index (KIDMED) of Turkish adolescents. The study was conducted with 890 voluntary participants (464 boys and 426 girls) aged 10-14 years. A questionnaire form was used to learn demographic characteristics of the participants. Participants' nutritional awareness was determined through a 20-item knowledge form and their nutritional habits through a 16-item Mediterranean Diet Quality Index (KIDMED). The average nutritional knowledge score was X=82.22 ± 0.42. Results indicated that 17.9% of the participants had a low quality diet (≤ 3 points), 59.2% had a mid-quality/needs-improvement diet (4-7 points) and 22.9% had an optimal quality diet (≥ 8 points). The study results showed that the subjects' diet quality was low and that their nutrition knowledge levels were related to their nutritional habits.

Systematic review of the effectiveness of weight management schemes for the under fives

Overweight and obesity in pre-school children are an increasing problem, with poor diet and exercise habits laying the foundation for serious health risks in later life. Yet most research into childhood obesity has focused on school-age children. Two previous systematic reviews of pre-school children have included uncontrolled designs and self-report outcomes potentially biasing the results in favour of the interventions. We have conducted a systematic review of the effectiveness and cost-effectiveness of weight management schemes for the under fives restricting the inclusion criteria to controlled trials with objective measures. We found four effectiveness randomized controlled trials of prevention. No treatment or cost-effectiveness studies were found. Only one study in a Latino community showed a statistically significant advantage from the intervention in a slower rate of increase in body mass index. However, trends in decrease in body mass index and weight loss favoured the intervention groups in other studies. From the studies characteristics we hypothesize that important features to include in future interventions may be; cultural sensitivity, sustained moderate to vigorous exercise, active engagement of the parents in the programme and as role models of healthy living and active engagement of the children in nutrition education. Further randomized controlled trials are needed in this population.

School-based interventions promoting both physical activity and healthy eating in Europe: a systematic review within the HOPE project

It is the purpose of this study to systematically review the evidence of school-based interventions targeting dietary and physical activity behaviour in primary (6-12 years old) and secondary school (12-18 years old) children in Europe. Eleven studies (reported in 27 articles) met the inclusion criteria, six in primary school and five in secondary school children. Interventions were evaluated in terms of behavioural determinants, behaviour (diet and physical activity) and weight-related outcomes (body mass index [BMI] or other indicators of obesity). The results suggest that combining educational and environmental components that focus on both sides of the energy balance give better and more relevant effects. Furthermore, computer-tailored personalized education in the classroom showed better results than a generic classroom curriculum. Environmental interventions might include organized physical activities during breaks, or before and after school; improved availability of physical activity opportunities in and around the school environment; increased physical education lesson time; improved availability or accessibility of healthy food options; and restricted availability and accessibility of unhealthy food options. More high-quality studies are needed to assess obesity-related interventions in Europe.

The integration of a family systems approach for understanding youth obesity, physical activity, and dietary programs

Rates of overweight in youth have reached epidemic proportions and are associated with adverse health outcomes. Family-based programs have been widely used to treat overweight in youth. However, few programs incorporate a theoretical framework for studying a family systems approach in relation to youth health behavior change. Therefore, this review provides a family systems theory framework for evaluating family-level variables in weight loss, physical activity, and dietary approaches in youth. Studies were reviewed and effect sizes were calculated for interventions that manipulated the family system, including components that targeted parenting styles, parenting skills, or family functioning, or which had novel approaches for including the family. Twenty-one weight loss interventions were identified, and 25 interventions related to physical activity and/or diet were identified. Overall, family-based treatment programs that incorporated training for authoritative parenting styles, parenting skills, or child management, and family functioning had positive effects on youth weight loss. Programs to improve physical activity and dietary behaviors that targeted the family system also demonstrated improvements in youth health behaviors; however, direct effects of parent-targeted programming is not clear. Both treatment and prevention programs would benefit from evaluating family functioning and parenting styles as possible mediators of intervention outcomes. Recommendations are provided to guide the development of future family-based obesity prevention and treatment programs for youth.

The effects of the HEALTHY study intervention on middle school student dietary intakes

BACKGROUND

The HEALTHY study was designed to respond to the alarming trends in increasing rates of overweight, obesity, and type 2 diabetes mellitus in youth. The objective of this analysis was to examine the effects of the HEALTHY study on student self-reported dietary intakes (energy, macronutrients and grams consumed of selected food groups).

METHODS

HEALTHY was a cluster-randomized study in 42 public middle schools. Students, n=3908, self-reported dietary intake using the Block Kids Questionnaire. General linear mixed models were used to analyze differences in dietary intake at the end of the study between intervention and control schools.

RESULTS

The reported average daily fruit consumption was 10% higher at the end of the study in the intervention schools than in the control schools (138 g or approximately 2 servings versus 122 g, respectively, p=0.0016). The reported water intake was approximately 2 fluid ounces higher in the intervention schools than in the control (483 g versus 429 g respectively; p=0.008). There were no significant differences between intervention and control for mean intakes of energy, macronutrients, fiber, grains, vegetables, legumes, sweets, sweetened beverages, and higher- or lower-fat milk consumption.

CONCLUSION

The HEALTHY study, a five-semester middle school-based intervention program that integrated multiple components in nutrition, physical education, behavior change, and social marketing-based communications, resulted in significant changes to student's reported fruit and water intake. Subsequent interventions need to go beyond the school environment to change diet behaviors that may affect weight status of children.

Effects of a 2-year school-based daily physical activity intervention on cardiovascular disease risk factors: the Sogndal school-intervention study

The aim of this study was to investigate the effect of a 2-year school-based physical activity (PA) intervention in 9-year-old children on cardiovascular disease (CVD) risk factors. One intervention school (I-school) (n=125) and one control school (C-school) (n=131) were included. The children at the I-school carried out 60 min of PA daily. The PA lessons were planned, organized and led by expert physical education (PE) teachers. In the C-school, children were offered the normal 45 min of PE twice weekly. The intervention resulted in a greater beneficial development in systolic (P=0.003) and diastolic (P=0.002) blood pressure, total cholesterol-to-high-density lipoprotein cholesterol ratio (P=0.011), triglyceride (P=0.030) and peak oxygen uptake (P<0.001) in I-school children than in C-school children. No significant differences were observed in waist circumference, body mass index and the homeostasis model assessment for insulin resistance between the two groups. Furthermore, the intervention, primarily carried out at moderate intensity, had the strongest impact in children with the least favorable starting point. In conclusion, a daily school-based PA intervention can beneficially modify children's CVD risk profile if the intervention has sufficient duration and includes a substantial amount of daily PA, and if the PA is implemented by expert PE teachers.

School health education programs in Crete: evaluation of behavioural and health indices a decade after initiation

OBJECTIVE

To assess the long-term effectiveness of a school-based health education intervention program 10 years after its initiation.

METHOD

In 1992 the total population of first grade students from three counties of Crete participated in the study. Over 1000 students were randomly selected for initial and periodic evaluation. Biochemical and behavioural parameters (anthropometric, lipoproteins, blood pressure, physical activity, dietary record and health habits) were measured. Re-evaluation of the program was performed at 3, 6 and 10 years after its initiation.

RESULTS

Ten years after the initiation of the program, the results showed that BMI had increased significantly less (p<0.001) and performance in the shuttle run test was significantly better (p<0.001) in the intervention group as compared to the control group. The reduction in total cholesterol noted in both groups was significantly greater in the intervention group than in the control group (p<0.001). The incidence of smoking was also significantly lower in the intervention group (intervention group 7%, control group 13%, p<0.005).

CONCLUSION

This program appears to improve children's health and decrease risk factors for chronic diseases. If these positive effects are maintained in the forthcoming decades, the risk of chronic diseases may well be reduced.

Nutrition knowledge, attitudes, behaviours and the influencing factors among non-parent caregivers of rural left-behind children under 7 years old in China

OBJECTIVE

To explore and compare nutrition knowledge, attitudes and behaviours (KAB) between non-parent and parent caregivers of children under 7 years old in Chinese rural areas, and to identify the factors influencing their nutrition KAB.

DESIGN

Face-to-face interviews were carried out with 1691 non-parent caregivers and 1670 parent caregivers in the selected study areas; multivariate logistic regression models were used to identify the factors influencing nutrition KAB in caregivers.

RESULTS

The awareness rate of nutrition knowledge, the rate of positive attitudes and the rate of optimal behaviours in non-parent caregivers (52.2 %, 56.9 % and 37.7 %, respectively) were significantly lower than in the parent group (63.8 %, 62.1 % and 42.8 %, respectively). Multivariate logistic regression modelling showed that caregivers' family income and care will, and children's age and gender, were associated with caregivers' nutrition KAB after controlling the possible confounding variables (caregivers' age, gender, education and occupation).

CONCLUSIONS

Non-parent caregivers had relatively poor nutrition KAB. Extra efforts and targeted education programmes aimed to improve rural non-parent caregivers' nutrition KAB are wanted and need to be emphasized.

A cross-curricular physical activity intervention to combat cardiovascular disease risk factors in 11-14 year olds: 'activity knowledge circuit'

BACKGROUND

Cardiovascular disease is the leading cause of mortality worldwide. Risk factors associated with cardiovascular disease have been shown to track from childhood through to adulthood. Previous school-based physical activity interventions have demonstrated modest improvements to cardiovascular disease risk factors by implementing extra-curricular activities or improving current physical education curriculum. Few have attempted to increase physical activity in class-room taught curriculum subjects. This study will outline a school-based cross-curricular physical activity intervention to combat cardiovascular disease risk factors in 11-14 year old children.

METHOD/DESIGN

A South Wales Valley school of low socio-economic status has been selected to take part. Participants from year eight (12-13 years) are to be assigned to an intervention group, with maturation-matched participants from years seven (11-12 years) and nine (13-14 years) assigned to a control group. A cross-curricular physical activity intervention will be implemented to increase activity by two hours a week for 18 weeks. Participants will briskly walk 3200 m twice weekly during curriculum lessons (60 minutes duration). With the exception of physical education, all curriculum subjects will participate, with each subject delivering four intervention lessons. The intervention will be performed outdoors and on school premises. An indoor course of equal distance will be used during adverse weather conditions. Cardiovascular disease risk factors will be measured pre- and post-intervention for intervention and control groups. These will take place during physical education lessons and will include measures of stature, mass, waist, hip, and neck circumferences, together with skinfold measure's taken at four sites. Blood pressure will be measured, and fitness status assessed via the 20 m multi-stage fitness test. Questionnaires will be used to determine activity behaviour (physical activity questionnaire for adolescence), diet (seven day food diary) and maturation status. Fasting blood variables will include total cholesterol, low-density lipoprotein cholesterol, high density lipoprotein cholesterol, triglycerides, insulin, glucose, high-sensitivity C-reactive protein, interleukin-6, adiponectin, and fibrinogen. Motivational variables and psychological well-being will be assessed by questionnaire.

DISCUSSION

Our study may prove to be a cost effective strategy to increase school time physical activity to combat cardiovascular disease risk factors in children.

TRIAL REGISTRATION

[NCT00998478].