Cost Effectiveness of an Elementary School Active Physical Education Policy

Sustainable effects of a motor skill programme on physical activity levels in 7-8 years old children, in the Eastern Cape Province of South Africa

BACKGROUND

Deteriorating global physical activity (PA) levels among children warrants new and sustainable approaches to increase PA levels. This study aimed to determine the immediate and sustainable influences of a 9-week movement program on the PA levels in 7 to 8-year-old school children in the Raymond Mhlaba Municipality in the Eastern Cape Province of South Africa.

METHODS

A randomized control trial including two groups (control group (CG) and intervention group (IG)), pre-post-retest (after six months of no intervention) design was used. Seventy school children, mean age 7.12 years (± 0.71) (n = 35 IG; n = 35 CG) participated in the study. A 9-week movement program was followed twice a week for 30 min during school hours. PA was measured for 7 consecutive days using a hip-mounted wGT3X-BT Actigraph accelerometer. The Test of Gross Motor Development-Third Edition (TGMD-3) was used to assess motor skills. Hierarchical Linear Modelling (HLM) was applied to analyze the data with time, sex, and group as predictors. Effect sizes were computed using Cohen's d-cut points to assess the practical significance of changes over time. Estimated regression coefficients were also computed to determine the strength of the relationship between moderate-to-vigorous physical activity (MVPA) and fundamental movement skills (FMS).

RESULTS

Before the intervention, 60% of the IG met the 60 min of daily MVPA guideline, while light physical activity (LPA) per day was also higher than sedentary behavior (SB) in both groups. No immediate (p < 0.01) or sustainable (p < 0.01) increases in MVPA levels were found and no positive associations emerged between FMS and MVPA levels.

CONCLUSIONS

This intervention had little to no effect on children's MVPA. More understanding of the activity behavior and interests of children is needed to improve their PA behavior through the content of movement programs. Strategies are also needed to communicate clear messages at a personalized but also parental level, focusing on enhancing health through regular PA, especially to promote PA in young children.

Health and Economic Value of Eliminating Socioeconomic Disparities in US Youth Physical Activity

Importance

There are considerable socioeconomic status (SES) disparities in youth physical activity (PA) levels. For example, studies show that lower-SES youth are less active, have lower participation in organized sports and physical education classes, and have more limited access to PA equipment.

Objective

To determine the potential public health and economic effects of eliminating disparities in PA levels among US youth SES groups.

Design and Setting

An agent-based model representing all 6- to 17-year-old children in the US was used to simulate the epidemiological, clinical, and economic effects of disparities in PA levels among different SES groups and the effect of reducing these disparities.

Main Outcomes and Measures

Anthropometric measures (eg, body mass index) and the presence and severity of risk factors associated with weight (stroke, coronary heart disease, type 2 diabetes, or cancer), as well as direct and indirect cost savings.

Results

This model, representing all 50 million US children and adolescents 6 to 17 years old, found that if the US eliminates the disparity in youth PA levels across SES groups, absolute overweight and obesity prevalence would decrease by 0.826% (95% CI, 0.821%-0.832%), resulting in approximately 383 000 (95% CI, 368 000-399 000) fewer cases of overweight and obesity and 101 000 (95% CI, 98 000-105 000) fewer cases of weight-related diseases (stroke and coronary heart disease events, type 2 diabetes, or cancer). This would result in more than $15.60 (95% CI, $15.01-$16.10) billion in cost savings over the youth cohort's lifetime. There are meaningful benefits even when reducing the disparity by just 25%, which would result in $1.85 (95% CI, $1.70-$2.00) billion in direct medical costs averted and $2.48 (95% CI, $2.04-$2.92) billion in productivity losses averted. For every 1% in disparity reduction, total productivity losses would decrease by about $83.8 million, and total direct medical costs would decrease by about $68.7 million.

Conclusions and Relevance

This study quantified the potential savings from eliminating or reducing PA disparities, which can help policymakers, health care systems, schools, funders, sports organizations, and other businesses better prioritize investments toward addressing these disparities.

A systematic review of economic evaluations of interventions targeting childhood overweight and obesity

This systematic review critically appraised and synthesized evidence from economic evaluations of interventions targeting childhood excess weight. We conducted systematic searches in 11 databases from inception to April 19, 2023. Studies were eligible if they evaluated interventions targeting children up to 18 years and the study intervention(s) targeted childhood excess weight or sought to improve diet or physical activity, regardless of the type of economic evaluation or the underpinning study design. We synthesized evidence using narrative synthesis methods. One-hundred fifty-one studies met the eligibility criteria and were classified into three groups based on the intervention approach: prevention-only (13 studies), prevention and treatment (100 studies), and treatment-only (38 studies). The predominant setting and study design differed considerably between the three groups of studies. However, compared with usual care, most interventions were deemed cost-effective. The study participants' ages, sex, and socioeconomic status were crucial to intervention cost-effectiveness. Interventions whose effects were projected beyond childhood, such as bariatric surgery, lower protein infant formula, and home-based general practitioner consultations, tended to be cost-effective. However, cost-effectiveness was sensitive to the assumptions underlying the persistence and intensity of such effects. Our findings can inform future recommendations on the conduct of economic evaluations of interventions targeting childhood overweight and obesity, as well as practice and policy recommendations.

Economic evaluation of a multi-strategy intervention that improves school-based physical activity policy implementation

BACKGROUND

Internationally, government policies mandating schools to provide students with opportunities to participate in physical activity are poorly implemented. The multi-component Physically Active Children in Education (PACE) intervention effectively assists schools to implement one such policy. We evaluated the value of investment by health service providers tasked with intervention delivery, and explored where adaptations might be targeted to reduce program costs for scale-up.

METHODS

A prospective trial-based economic evaluation of an implementation intervention in 61 primary schools in New South Wales (NSW), Australia. Schools were randomised to the PACE intervention or a wait-list control. PACE strategies included centralised technical assistance, ongoing consultation, principal's mandated change, identifying and preparing in-school champions, educational outreach visits, and provision of educational materials and equipment. Effectiveness was measured as the mean weekly minutes of physical activity implemented by classroom teachers, recorded in a daily log book at baseline and 12-month follow-up. Delivery costs (reported in $AUD, 2018) were evaluated from a public finance perspective. Cost data were used to calculate: total intervention cost, cost per strategy and incremental cost (overall across all schools and as an average per school). Incremental cost-effectiveness ratios (ICERs) were calculated as the incremental cost of delivering PACE divided by the estimated intervention effect.

RESULTS

PACE cost the health service provider a total of $35,692 (95% uncertainty interval [UI] $32,411, $38,331) to deliver; an average cost per school of $1151 (95%UI $1046, $1236). Training in-school champions was the largest contributor: $19,437 total; $627 ($0 to $648) average per school. Educational outreach was the second largest contributor: $4992 total; $161 ($0 to $528) average per school. The ICER was $29 (95%UI $17, $64) for every additional minute of weekly physical activity implemented per school.

CONCLUSION

PACE is a potentially cost-effective intervention for increasing schools implementation of a policy mandate. The investment required by the health service provider makes use of existing funding and infrastructure; the additional cost to assist schools to implement the policy is likely not that much. PACE strategies may be adapted to substantially improve delivery costs.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12617001265369; Prospectively registered 1st September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373520.

Moderate Effects of School-Based Time Increasing Physical Education Intervention on Physical Fitness and Activity of 7-Year Pupils—A Report from a Follow-Up of a HCSC Study

We evaluated the effectiveness of a 15-week intervention that increased from three to five lessons of physical education (PE) a week on 7-year-old boys’ and girls’ physical fitness (PF), physical activity (PA) and sedentary behaviour on week and weekend days. A total of 212 first grade pupils (mean age 6.95 ± 0.43) from two urban schools in Poznań were randomly assigned to the experimental or control groups. The PF was measured with a battery of field tests, while health-related behaviours were assessed with the Healthy Children in Sound Communities questionnaire. There were some interaction effects noticed in the PF scores in the case of a 20-min run for boys (F_2,196 = 5.29, p = 0.0058) and for girls (F_2,220 = 3.31, p = 0.0382) and the sit-ups test for boys (F_2,196 = 1.93, p = 0.1478) and for girls (F_2,220 = 3.98, p = 0.0201) and for the sit and reach test in the case of girls (F_2,220 = 3.98, p = 0.0201). In terms of outdoor PA levels, there were no major differences between any of the examined groups. Differences were found between girls from the experimental and control groups in the post-test (p = 0.0107) and follow-up (p = 0.0390) during the weekdays, with no differences between the groups of boys. Despite the moderate effects of the extended PE time programme right after the intervention, there were some indications of progress in the follow-up experiments.

Health Economic Aspects of Childhood Excess Weight: A Structured Review

An economic perspective is crucial to understand the broad consequences of childhood excess weight (CEW). These can manifest in the form of elevated health care and societal costs, impaired health status, or inefficiencies in the allocation of resources targeted at its prevention, management, or treatment. Although existing systematic reviews provide summaries of distinct economic research strands covering CEW, they have a restricted focus that overlooks relevant evidence. The overarching aim of this structured review was to update and enhance recent key reviews of four strands of economic evidence in this area, namely, (1) economic costs associated with CEW, (2) health utilities associated with CEW, (3) economic evaluations of interventions targeting CEW, and (4) economic determinants and broader consequences of CEW. Our de novo searches identified six additional studies for the first research strand, five studies for the second, thirty-one for the third, and two for the fourth. Most studies were conducted in a small number of high-income countries. Our review highlights knowledge gaps across all the research strands. Evidence from this structured review can act as data input into future economic evaluations in this area and highlights areas where future economic research should be targeted.

Effect of reducing ultraprocessed food consumption on obesity among US children and adolescents aged 7-18 years: evidence from a simulation model

BACKGROUND

Children and adolescents in the USA consume large amounts of daily calories from ultraprocessed foods (UPFs). Recent evidence links UPF consumption to increased body fat in youth. We aimed to estimate the potential impact of reducing UPF consumption on childhood obesity rate in the USA.

METHODS

We developed a microsimulation model to project the effect of reducing UPF consumption in children's diet on reducing the prevalence of overweight or obesity among US youth. The model incorporated nationally representative data on body mass index (BMI) percentile and dietary intake of 5804 children and adolescents aged 7-18 years from the National Health and Nutrition Examination Survey 2011-2016, and the effect of reducing UPF consumption on calorie intake from a recent randomised controlled trial. Uncertainties of model inputs were incorporated using probabilistic sensitivity analysis with 1000 simulations.

RESULTS

Reducing UPFs in children's diet was estimated to result in a median of -2.09 kg/m² (95% uncertainty interval -3.21 to -0.80) reduction in BMI among children and adolescents aged 7-18 years. The median prevalence of overweight (BMI percentile ≥85th) and obesity (BMI percentile ≥95th percentile) was reduced from 37.0% (35.9%, 38.1%) to 20.9% (15.1%, 29.9%) and from 20.1% (19.2%, 21.0%) to 11.0% (7.86%, 15.8%), respectively. Larger BMI and weight reductions were seen among boys than girls, adolescents than children, non-Hispanic black and Hispanic youth than non-Hispanic white youth, and those with lower levels of parental education and family income.

CONCLUSIONS

Reducing UPF consumption in children's diet has the potential to substantially reduce childhood obesity rate among children and adolescents in the USA.

Cost-effectiveness of physical activity intervention in children - results based on the Physical Activity and Nutrition in Children (PANIC) study

Background

We assessed the cost-effectiveness of a 2-year physical activity (PA) intervention combining family-based PA counselling and after-school exercise clubs in primary-school children compared to no intervention from an extended service payer’s perspective.

Methods

The participants included 506 children (245 girls, 261 boys) allocated to an intervention group (306 children, 60 %) and a control group (200 children, 40 %). The children and their parents in the intervention group had six PA counselling visits, and the children also had the opportunity to participate in after-school exercise clubs. The control group received verbal and written advice on health-improving PA at baseline. A change in total PA over two years was used as the outcome measure. Intervention costs included those related to the family-based PA counselling, the after-school exercise clubs, and the parents’ taking time off to travel to and participate in the counselling. The cost-effectiveness analyses were performed using the intention-to-treat principle. The costs per increased PA hour (incremental cost-effectiveness ratio, ICER) were based on net monetary benefit (NMB) regression adjusted for baseline PA and background variables. The results are presented with NMB and cost-effectiveness acceptability curves.

Results

Over two years, total PA increased on average by 108 h in the intervention group (95 % confidence interval [CI] from 95 to 121, p < 0.001) and decreased by 65.5 h (95 % CI from 81.7 to 48.3, p < 0.001) in the control group, the difference being 173.7 h. the incremental effectiveness was 87 (173/2) hours. For two years, the intervention costs were €619 without parents’ time use costs and €860 with these costs. The costs per increased PA hour were €6.21 without and €8.62 with these costs. The willingness to pay required for 95 % probability of cost-effectiveness was €14 and €19 with these costs. The sensitivity analyses revealed that the ICER without assuming this linear change in PA were €3.10 and €4.31.

Conclusions

The PA intervention would be cost-effective compared to no intervention among children if the service payer’s willingness-to-pay for a 1-hour increase in PA is €8.62 with parents’ time costs.

Trial registration

ClinicalTrials.gov: NCT01803776. Registered 4 March 2013 - Retrospectively registered, https://clinicaltrials.gov/ct2/results?cond=&term=01803776&cntry=&state=&city=&dist=.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01181-0.

State laws governing school physical education in relation to attendance and physical activity among students in the USA: A systematic review and meta-analysis

BACKGROUND

This study systematically synthesized and quantified the relationship linking state laws governing school physical education (PE) to PE attendance and physical activity (PA) in class and throughout the day and week among students in the USA.

METHODS

A keyword search was performed in PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Complete, and EconLit. Meta-analyses were performed to estimate the effects of state PE laws.

RESULTS

A total of 17 studies were included in the review, and five contributed to the meta-analyses. A total of 8 studies used nationally representative school- or student-level data, three focused on multiple states, and the remaining six examined the PE laws of a single state. The presence and strength of state PE laws were positively associated with PE attendance and the frequency and duration of PA during PE classes and throughout the school day. Compared to those residing in states with weak or no PE laws, students in states with strong PE laws had an additional 0.2 days (95% confidence interval (95%CI): 0.1-0.4) of PE attendance per week and spent an additional 33.9 min (95%CI: 22.7-45.0) participating PE classes per week. State PE laws affected girls' PA more than boys'. Different aspects of state PE laws tended to affect students' PE attendance differently. Disparities in the implementation of state PE laws existed across schools.

CONCLUSION

Future studies should adopt objective measures on PE and PA participation and examine the roles schools and districts play in mediating the effect of state PE laws on students' PE attendance and PA.

A Cost Analysis of School-Based Lifestyle Interventions

A uniform approach for costing school-based lifestyle interventions is currently lacking. The objective of this study was to develop a template for costing primary school-based lifestyle interventions and apply this to the costing of the "Healthy Primary School of the Future" (HPSF) and the "Physical Activity School" (PAS), which aim to improve physical activity and dietary behaviors. Cost-effectiveness studies were reviewed to identify the cost items. Societal costs were reflected by summing up the education, household and leisure, labor and social security, and health perspectives. Cost inputs for HPSF and PAS were obtained for the first year after implementation. In a scenario analysis, the costs were explored for a hypothetical steady state. From a societal perspective, the per child costs were €2.7/$3.3 (HPSF) and €- 0.3/$- 0.4 (PAS) per day during the first year after implementation, and €1.0/$1.2 and €- 1.3/$- 1.6 in a steady state, respectively (2016 prices). The highest costs were incurred by the education perspective (first year: €8.7/$10.6 (HPSF) and €4.0/$4.9 (PAS); steady state: €6.1/$7.4 (HPSF) and €2.1/$2.6 (PAS)), whereas most of the cost offsets were received by the household and leisure perspective (first year: €- 6.0/$- 7.3 (HPSF) and €- 4.4/$- 5.4 (PAS); steady state: €- 5.0/$- 6.1 (HPSF) and €- 3.4/$- 4.1 (PAS)). The template proved helpful for costing HPSF and PAS from various stakeholder perspectives. The costs for the education sector were fully (PAS) and almost fully (HPSF) compensated by the savings within the household sector. Whether the additional costs of HPSF over PAS represent value for money will depend on their relative effectiveness.

Assessing the Lifetime Cost-Effectiveness of Low-Protein Infant Formula as Early Obesity Prevention Strategy: The CHOP Randomized Trial

Background: Although there is a growing number of early childhood obesity prevention programs, only a few of them are effective in the long run. Even fewer reports exist on lifetime cost-effectiveness of early prevention strategies. This paper aimed to assess the lifetime cost-effectiveness of infant feeding modification aiming at reducing risk of later obesity. Methods: The simulation model consists of two parts: (a) Model I used data from the European Childhood Obesity Project (CHOP) trial (up to 6 years) and the German Interview and Examination Survey for Children (KiGGS) (6–17 years) to evaluate BMI trajectories of infants receiving either lower protein (LP) or higher protein (HP) content formula; and (b) Model II estimated lifetime cost-effectiveness based on Model I BMI trajectories. Compared to HP formula, LP formula feeding would incur lower costs that are attributable to childhood obesity across all decades of life. Results: Our analysis showed that LP formula would be cost-effective in terms of a positive net monetary benefit (discounted 3%) as an obesity prevention strategy. For the 19% of infants fed with formula in Germany, the LP strategy would result in cost savings of € 2.5 billion. Conclusions: Our study is one of the first efforts to provide much-needed cost-effectiveness evidence of infant feeding modification, thereby potentially motivating interventionists to reassess their resource allocation.

The Effect of Nurse-Led Diet and Physical Activity Program for Health on Diet and Physical Activity Behavior of Children

BACKGROUND

Many health problems encountered in childhood, adolescence, and adulthood periods arise from problematic eating behavior, an unhealthy dietary approach, and inactive lifestyles. The aim of this study was to determine the effect of the Diet and Physical Activity Program for Health, under the leadership of a nurse, on the dietary and physical activity behaviors of children.

METHODS

This study was planned in a quasi-experimental design with pretesting, posttesting, follow-up testing, and a control group. The study was conducted with 114 students in 2 schools. A total of 12 hours of training was given to the experimental group for 6 weeks. Institutional permission required for performing the study and an ethical consent from the commission for clinical trials of Marmara University institute of health sciences were received.

RESULTS

The results of the study reveal that Diet and Physical Activity Program for Health in posttest and follow-up periods was effective in improving dietary and physical activity behaviors of children within the program. However, the program's effect on dietary and physical activity self-efficacy was limited.

CONCLUSION

The results of the study indicate that this program was effective in development of children's behavior regarding diet and physical activity.

Co-producing active lifestyles as whole-system-approach: theory, intervention and knowledge-to-action implications

Population health interventions tend to lack links to the emerging discourse on interactive knowledge production and exchange. This situation may limit both a better understanding of mechanisms that impact health lifestyles and the development of strategies for population level change. This paper introduces an integrated approach based on structure-agency theory in the context of 'social practice'. It investigates the mechanisms of co-production of active lifestyles by population groups, professionals, policymakers and researchers. It combines a whole system approach with an interactive knowledge-to-action strategy for developing and implementing active lifestyle interventions. A system model is outlined to describe and explain how social practices of selected groups co-produce active lifestyles. Four intervention models for promoting the co-production of active lifestyles through an interactive-knowledge-to-action approach are discussed. Examples from case studies of the German research network Capital4Health are used to illustrate, how intervention models might be operationalized in a real-world intervention. Five subprojects develop, implement and evaluate interventions across the life-course. Although subprojects differ with regard to settings and population groups involved, they all focus on the four key components of the system model. The paper contributes new strategies to address the intervention research challenge of sustainable change of inactive lifestyles. The interactive approach presented allows consideration of the specificities of settings and scientific contexts for manifold purposes. Further research remains needed on what a co-produced knowledge-to-action agenda would look like and what impact it might have for whole system change.

Cost-Effectiveness of Improvements to the Built Environment Intended to Increase Physical Activity

Background: Improving sidewalks may encourage physical activity by providing safe, defined, and connected walking spaces. However, it is unknown if reduced health care expenditures assumed by increased physical activity offset the investment for sidewalk improvements. Methods: This cost-effectiveness analysis of sidewalk improvements in Houston, TX, was among adults enrolled in the Houston Travel-Related Activity in Neighborhoods Study, 2013-2017 . The 1-year change in physical activity was measured using self-report (n = 430) and accelerometry (n = 228) and expressed in metabolic equivalent (MET) hours per year (MET·h·y^-1). Cost-effectiveness ratios were calculated by comparing annualized sidewalk improvement costs (per person) with 1-year changes in physical activity. Results: The estimated cost-effectiveness ratio were $0.01 and -$0.46 per MET·h·y^-1 for self-reported and accelerometer-derived physical activity, respectively. The cost-effectiveness benchmark was $0.18 (95% confidence interval, $0.06-$0.43) per MET·h·y^-1 gained based on the volume of physical activity necessary to avoid health care costs. Conclusions: Improving sidewalks was cost-effective based on self-reported physical activity, but not cost-effective based on accelerometry. Study findings suggest that improving sidewalks may not be a sufficient catalyst for changing total physical activity; however, other benefits of making sidewalks more walkable should be considered when deciding to invest in sidewalk improvements.

A Systematic Review of Methods, Study Quality, and Results of Economic Evaluation for Childhood and Adolescent Obesity Intervention

Many suggested policy interventions for childhood and adolescent obesity have costs and effects that fall outside the health care sector. These cross-sectorial costs and consequences have implications for how economic evaluation is applied and although previous systematic reviews have provided a summary of cost-effectiveness, very few have conducted a review of methods applied. We undertook this comprehensive review of economic evaluations, appraising the methods used, assessing the quality of the economic evaluations, and summarising cost-effectiveness. Nine electronic databases were searched for full-economic evaluation studies published between January 2001 and April 2017 with no language or country restrictions. 39 economic evaluation studies were reviewed and quality assessed. Almost all the studies were from Western countries and methods were found to vary by country, setting and type of intervention. The majority, particularly "behavioural and policy" preventive interventions, were cost-effective, even cost-saving. Only four interventions were not cost effective. This systematic review suggests that economic evaluation of obesity interventions is an expanding area of research. However, methodological heterogeneity makes evidence synthesis challenging. Whilst upstream interventions show promise, an expanded and consistent approach to evaluate cost-effectiveness is needed to capture health and non-health costs and consequences.

Children Present a Window of Opportunity for Promoting Health: JACC Review Topic of the Week

Cardiovascular disease is the leading cause of death and disability in the world, largely because of risk factors modifiable by changes in behavior. There is evolving evidence that our behavior as adults has its roots in the environment that we live in from early childhood. Early sustained multicomponent educational programs focused on health promotion in children may represent a window of opportunity to potentially prevent disease in adulthood. The integration of school-based, family-based, and community-based strategies, along with the support of public policies, are likely necessary for the success of these programs. In this review, the authors describe the future of promoting health. Specifically: 1) reasons why children should be a focus for health promotion (alarming trends of risk factors, association between unhealthy factors and subclinical disease, and cost-effectiveness); 2) strategies for health promotion in children (school-based, family-based, and community-based approaches) along with legislative efforts; and 3) research gaps are discussed.

A systematic review on economic evaluations of school-based lifestyle interventions targeting weight-related behaviours among 4-12 year olds: Issues and ways forward

Current guidelines for economic evaluations do not provide specific recommendations for the evaluation of school-based lifestyle interventions. This study examined and discussed the key aspects in the design of economic evaluations on school-based interventions targeting weight-related behaviours among 4-12 year olds. The PubMed and CRD databases (NHS EED) were searched. Grey literature was identified from reference lists and websites of relevant organizations. Full economic evaluations on school-based interventions targeting physical activity, sedentariness, or diet were selected. Key aspects included the objective, audience, intervention, comparator, population, type of analysis, perspective, costs, outcomes, and time horizon. Information was also extracted on measuring and valuing costs and outcomes, linking and extrapolating outcomes, and the maintenance of intervention effects. The 23 included studies reported on cost-effectiveness (CEAs) (N = 12), cost-utility (CUAs) (N = 9), social cost benefit (SCBA) (N = 2), and social return on investment (SROI) (N = 1) analysis. The usual practice comparator was generally not clearly defined. The SROI analysis was the single study that included outcomes in other persons than the child. Healthcare costs (N = 14), productivity costs (N = 4), and costs to the household (N = 3), or education (N = 2) sector were examined. The outcome in trial-based CEAs consisted of a variety of weight-related measures. Seven distinctive models were used to extrapolate health and/or productivity costs. To enhance the usefulness of economic evaluations on school-based lifestyle interventions in allocating public health budgets, transparent reporting on key aspects, broadening the scope of economic evaluations, and standardizing the measurement, valuation, and extrapolation of costs and outcomes should be improved. This study was conducted in Maastricht, the Netherlands.

State Agency Support of Weight-Related School Policy Implementation

BACKGROUND

In this study, we describe state agency strategies to support weight-related policy implementation in schools, and examine the association among state support, obesity prevalence, and strength of state policies governing school nutrition and physical education.

METHODS

The 2012 School Health Policies and Practices Study describes prevalence of implementation support state agencies provided to schools/districts. Implementation support items were analyzed by weight-related policy area (eg, advertising, wellness policy) and by type of support (eg, technical assistance). Results were summed to create a total weight-related policy support score. Linear regression was used to examine associations between policy support and state youth obesity prevalence (2011-2012 National Survey for Children's Health), overall and stratified by state policy strength (2012 Classification of Laws Associated with School Students).

RESULTS

States provided support most commonly for school meals and wellness policies (89% and 81%, respectively) and least often for after-school PE (26%). Most states (80%) provided technical assistance. The total weight-related policy support score had a significant positive association with state-level youth overweight/obesity prevalence (p = .03).

CONCLUSION

State agencies appear to be responding to their youth obesity prevalence with technical support. Schools and state agencies should work in collaboration to provide a healthy school environment for all students.

Fitness Measures Among Boy Scouts Completing the Personal Fitness Merit Badge

Introduction

A formative framework for positive lifestyle and health behaviors is established during adolescence. The Boy Scouts of America (BSA) is one organization that promotes healthy lifestyles among adolescent males and includes earning the Personal Fitness Merit Badge (PFMB). Despite the BSA Oath “to keep myself physically strong”, there is a paucity of evidence describing fitness test (FT) outcomes or correlations between FT and variables including age or body mass index (BMI) among Boy Scouts. Therefore, the purpose of this study is to describe and correlate FT to age and BMI among adolescent Boy Scouts.

Methods

A prospective study design recruited Boy Scouts aged 11-17 years from Southeast Michigan using a sample of convenience. After securing physician clearance to participate, FT measures were performed utilizing previously established methodology. Third year doctor of physical therapy students trained in the measurement protocol performed the FT measures. Measures encompassed those required for the PFMB: BMI, pull-ups, push-ups, sit and reach flexibility test (SRF), sit-ups, and the one mile run (1MR). Data was analyzed using descriptive statistics, a Kruskal-Wallis test examined relationships between BMI and FT, and a nonparametric Spearman correlation examined correlations between FT performance and both age and BMI with statistical significance set at less than 0.05.

Results

Ninety-nine Boy Scouts, whose mean age was 12.6 years (SD 1.4), met the inclusion criteria. The mean BMI was 21.5 (kg/height (cm)) ² (SD 5.4) with eight scouts meeting criteria of underweight, 56 normal weight, 14 overweight, and 21 obese. Fitness test results were as follows: pull-ups 1.75 (SD 2.7), push-ups 18.0 (SD 10.6), SRF 21.2 cm (SD 10.5), sit-ups 28.9 (SD 8.7), and the 1MR run 616.5 seconds (SD 156.8). When comparing normal weight scouts to overweight and obese scouts, a significantly higher frequency of pull-ups (p=0.002, p=.001), push-ups (p=0.02, p=0.03), sit-ups (p=0.01, p=0.003,), and decreased time for completion on the 1MR (p=0.001, p=0.001) was identified, respectively. Furthermore, while no correlations were identified by age, a negative correlation was identified between increased sit-up frequency (r=-0.36, p=0.001) and decreased 1MR time performance (r=0.39, p=0.001) and a higher BMI.

Discussion

While prior evidence suggests improved FT scores in adolescent males with advancing age, this was not observed. Less favorable PFMB required FT performance with an increased BMI among Boy Scouts is in congruence with prior reports for adolescent males.

Conclusion

Variations in FT performance levels were observed among Boy Scouts completing the initial FT requirements of the PFMB. However, correlations between higher BMI and less favorable FT performance were detected.

Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost-effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children

Background

Approximately one-third of children in England leave primary school overweight or obese. There is little evidence of effective obesity prevention programmes for children in this age group.

Objective

To determine the effectiveness and cost-effectiveness of a school-based healthy lifestyles programme in preventing obesity in children aged 9–10 years.

Design

A cluster randomised controlled trial with an economic and process evaluation.

Setting

Thirty-two primary schools in south-west England.

Participants

Children in Year 5 (aged 9–10 years) at recruitment and in Year 7 (aged 11–12 years) at 24 months’ post-baseline follow-up.

Intervention

The Healthy Lifestyles Programme (HeLP) ran during the spring and summer terms of Year 5 into the autumn term of Year 6 and included four phases: (1) building a receptive environment, (2) a drama-based healthy lifestyles week, (3) one-to-one goal setting and (4) reinforcement activities.

Main outcome measures

The primary outcome measure was body mass index (BMI) standard deviation score (SDS) at 24 months post baseline measures (12 months post intervention). The secondary outcomes comprised waist circumference SDS, percentage body fat SDS, proportion of children overweight and obese at 18 and 24 months, accelerometer-assessed physical activity and food intake at 18 months, and cost-effectiveness.

Results

We recruited 32 schools and 1324 children. We had a rate of 94% follow-up for the primary outcome. No difference in BMI SDS was found at 24 months [mean difference –0.02, 95% confidence interval (CI) –0.09 to 0.05] or at 18 months (mean difference –0.02, 95% CI –0.08 to 0.05) between children in the intervention schools and children in the control schools. No difference was found between the intervention and control groups in waist circumference SDS, percentage body fat SDS or physical activity levels. Self-reported dietary behaviours showed that, at 18 months, children in the intervention schools consumed fewer energy-dense snacks and had fewer negative food markers than children in the control schools. The intervention effect on negative food markers was fully mediated by ‘knowledge’ and three composite variables: ‘confidence and motivation’, ‘family approval/behaviours and child attitudes’ and ‘behaviours and strategies’. The intervention effect on energy-dense snacks was partially mediated by ‘knowledge’ and the same composite variables apart from ‘behaviours and strategies’. The cost of implementing the intervention was approximately £210 per child. The intervention was not cost-effective compared with control. The programme was delivered with high fidelity, and it engaged children, schools and families across the socioeconomic spectrum.

Limitations

The rate of response to the parent questionnaire in the process evaluation was low. Although the schools in the HeLP study included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, the number of children for whom English was an additional language was considerably lower than the national average.

Conclusions

HeLP is not effective or cost-effective in preventing overweight or obesity in children aged 9–10 years.

Future work

Our very high levels of follow-up and fidelity of intervention delivery lead us to conclude that it is unlikely that school-based programmes targeting a single age group can ever be sufficiently intense to affect weight status. New approaches are needed that affect the school, the family and the wider environment to prevent childhood obesity.

Trial registration

Current Controlled Trials ISRCTN15811706.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

Initial Outcomes of a Participatory-Based, Competency-Building Approach to Increasing Physical Education Teachers' Physical Activity Promotion and Students' Physical Activity: A Pilot Study

This study examined the initial effects of a participatory-based, competency-/skill-building professional development workshop for physical education (PE) teachers on the use of physical activity (PA) promotion practices (e.g., eliminating lines, small-sided games) and students' moderate-to-vigorous physical activity (MVPA). A total of 823 students (52.8% boys) wore accelerometers at baseline (fall 2015) and outcome (spring 2016) on PE and non-PE days. The System for Observing Fitness Instruction Time+ measured changes in PA promotion practices. Teachers ( n = 9) attended a 90-minute workshop prior to outcome data collection. Mixed-model linear regressions estimated changes in teacher practices and students' MVPA. Three of the nine targeted PA promotion practices changed in the desired direction (i.e., p < .05; increased motor content and lessons taught outdoors, reduced activities with lines), with three more teacher practices trending in the desired direction (i.e., reduced management time and activities with elimination, increased small-sided games). During PE, boys and girls increased MVPA by 2.0 (95% confidence interval [1.1, 3.0]), and 1.3 (95% confidence interval [0.5-2.0]) minutes, respectively. However, there were no statistically significant changes in boys' or girls' MVPA during the school day. Greater implementation of promotion practices by the PE teachers was associated with boys', but not girls', MVPA during PE. Girls in high- and low-implementing teachers' lessons experienced increases in MVPA, suggesting that even small changes in PA promotion practices can increase girls' MVPA during PE. Overall, the workshops were effective at increasing teachers' PA promotion and students' MVPA in PE. Other school-based strategies that complement and extend efforts targeting PE are recommended to increase children's total daily PA.

Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood

Participation in recommended levels of physical activity promotes a healthy body weight and reduced chronic disease risk. To inform investment in prevention initiatives, we simulate the national implementation, impact on physical activity and childhood obesity and associated cost-effectiveness (versus the status quo) of six recommended strategies that can be applied throughout childhood to increase physical activity in US school, afterschool and childcare settings. In 2016, the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) systematic review process identified six interventions for study. A microsimulation model estimated intervention outcomes 2015-2025 including changes in mean MET-hours/day, intervention reach and cost per person, cost per MET-hour change, ten-year net costs to society and cases of childhood obesity prevented. First year reach of the interventions ranged from 90,000 youth attending a Healthy Afterschool Program to 31.3 million youth reached by Active School Day policies. Mean MET-hour/day/person increases ranged from 0.05 MET-hour/day/person for Active PE and Healthy Afterschool to 1.29 MET-hour/day/person for the implementation of New Afterschool Programs. Cost per MET-hour change ranged from cost saving to $3.14. Approximately 2500 to 110,000 cases of children with obesity could be prevented depending on the intervention implemented. All of the six interventions are estimated to increase physical activity levels among children and adolescents in the US population and prevent cases of childhood obesity. Results do not include other impacts of increased physical activity, including cognitive and behavioral effects. Decision-makers can use these methods to inform prioritization of physical activity promotion and obesity prevention on policy agendas.

The theory of expanded, extended, and enhanced opportunities for youth physical activity promotion

BACKGROUND

Physical activity interventions targeting children and adolescents (≤18 years) often focus on complex intra- and inter-personal behavioral constructs, social-ecological frameworks, or some combination of both. Recently published meta-analytical reviews and large-scale randomized controlled trials have demonstrated that these intervention approaches have largely produced minimal or no improvements in young people's physical activity levels.

DISCUSSION

In this paper, we propose that the main reason for previous studies' limited effects is that fundamental mechanisms that lead to change in youth physical activity have often been overlooked or misunderstood. Evidence from observational and experimental studies is presented to support the development of a new theory positing that the primary mechanisms of change in many youth physical activity interventions are approaches that fall into one of the following three categories: (a) the expansion of opportunities for youth to be active by the inclusion of a new occasion to be active, (b) the extension of an existing physical activity opportunity by increasing the amount of time allocated for that opportunity, and/or (c) the enhancement of existing physical activity opportunities through strategies designed to increase physical activity above routine practice. Their application and considerations for intervention design and interpretation are presented. The utility of these mechanisms, referred to as the Theory of Expanded, Extended, and Enhanced Opportunities (TEO), is demonstrated in their parsimony, logical appeal, support with empirical evidence, and the direct and immediate application to numerous settings and contexts. The TEO offers a new way to understand youth physical activity behaviors and provides a common taxonomy by which interventionists can identify appropriate targets for interventions across different settings and contexts. We believe the formalization of the TEO concepts will propel them to the forefront in the design of future intervention studies and through their use, lead to a greater impact on youth activity behaviors than what has been demonstrated in previous studies.

New Strategies to Prioritize Nutrition, Physical Activity, and Obesity Interventions

Interventions for obesity have not often been based on considerations that could predict their effectiveness. However, advances in research provide several new approaches that can inform priorities for public health interventions directed at nutrition, physical activity, and obesity. These approaches include estimation of the effect size, comparison of the calorie gap with the caloric deficit induced by the intervention, population reach and impact, cost and cost effectiveness of the intervention, time required to evaluate the effect of the intervention on weight change, and feasibility of the intervention. Incorporation of these considerations by policymakers and public health practitioners will help identify those interventions most likely to achieve changes in the prevalence of obesity.

Cost effectiveness of a multi-component school-based physical activity intervention targeting adolescents: the 'Physical Activity 4 Everyone' cluster randomized trial

BACKGROUND

Few school-based interventions have been successful in reducing physical activity decline and preventing overweight and obesity in adolescent populations. As a result, few cost effectiveness analyses have been reported. The aim of this paper is to report the cost and cost effectiveness of the Physical Activity 4 Everyone (PA4E1) intervention which was a multi-component intervention implemented in secondary schools located in low-income communities. Cost effectiveness was assessed using both the physical activity and weight status trial outcomes.

METHODS

Intervention and Study Design: The PA4E1 cluster randomised controlled trial was implemented in 10 Australian secondary schools (5 intervention: 5 control) and consisted of intervention schools receiving seven physical activity promotion strategies and six additional strategies that supported school implementation of the intervention components. Costs associated with physical activity strategies, and intervention implementation strategies within the five intervention schools were estimated and compared to the costs of usual physical activity practices of schools in the control group. The total cost of implementing the intervention was estimated from a societal perspective, based on the number of enrolled students in the target grade at the start of the intervention (Grade 7, n = 837). Economic Outcomes: The economic analysis outcomes were cost and incremental cost effectiveness ratios for the following: minutes of moderate-to-vigorous physical activity (MVPA) per day gained, MET hours gained per person/day; Body Mass Index (BMI) unit avoided; and 10% reduction in BMI z-score.

RESULTS

The intervention cost AUD $329,952 over 24 months, or AUD$394 per student in the intervention group. This resulted in a cost effectiveness ratio of AUD$56 ($35-$147) per additional minute of MVPA, AUD$1 ($0.6-$2.7) per MET hour gained per person per day, AUD$1408 ($788-$6,570) per BMI unit avoided, and AUD$563 ($282-$3,942) per 10% reduction in BMI z-score.

CONCLUSION

PA4E1 is a cost effective intervention for increasing the physical activity levels and reducing unhealthy weight gain in adolescence, a period in which physical activity typically declines. Additional modelling could explore the potential economic impact of the intervention on morbidity and mortality.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000382875.

Exploring Categorical Body Mass Index Trajectories in Elementary School Children

BACKGROUND

Studies of body mass index (BMI) change have focused on understanding growth trajectories from childhood to adolescence and adolescence to adulthood, but few have explored BMI trajectories solely in elementary (grades K-5) school children. This report complements these studies by exploring changes in obesity status using analytic methods developed to investigate categorical changes in life-course events.

METHODS

Sequences of a 4-state BMI variable (underweight, normal, overweight, and obese) were calculated using height and weight data collected annually (2008-2013) from 414 kindergarten and first-grade students participating in the Community and Schools Together (CAST) project. These sequences were explored using the TraMineR software package to investigate the distribution of sequences and states, calculate transition rates among states, and examine clustering of sequences.

RESULTS

Aggregated cluster solutions were identified consisting of either 4 clusters (normal, stepped, mixed, and obese) or 3 clusters (aggregation of obese cluster cases into stepped cluster) with membership in the former predicted by ethnicity and socioeconomic status (SES) and the latter by SES alone. Transition rate patterns among states varied markedly by cluster and state.

CONCLUSION

The finding of early emergence of stable obesity states, especially in Hispanic children confirms the need for early childhood interventions to influence BMI.

Modeling the Cost Effectiveness of Child Care Policy Changes in the U.S

INTRODUCTION

Child care facilities influence diet and physical activity, making them ideal obesity prevention settings. The purpose of this study is to quantify the health and economic impacts of a multi-component regulatory obesity policy intervention in licensed U.S. child care facilities.

METHODS

Two-year costs and BMI changes resulting from changes in beverage, physical activity, and screen time regulations affecting a cohort of up to 6.5 million preschool-aged children attending child care facilities were estimated in 2014 using published data. A Markov cohort model simulated the intervention's impact on changes in the U.S. population from 2015 to 2025, including short-term BMI effects and 10-year healthcare expenditures. Future outcomes were discounted at 3% annually. Probabilistic sensitivity analyses simulated 95% uncertainty intervals (UIs) around outcomes.

RESULTS

Regulatory changes would lead children to watch less TV, get more minutes of moderate and vigorous physical activity, and consume fewer sugar-sweetened beverages. Within the 6.5 million eligible population, national implementation could reach 3.69 million children, cost $4.82 million in the first year, and result in 0.0186 fewer BMI units (95% UI=0.00592 kg/m(2), 0.0434 kg/m(2)) per eligible child at a cost of $57.80 per BMI unit avoided. Over 10 years, these effects would result in net healthcare cost savings of $51.6 (95% UI=$14.2, $134) million. The intervention is 94.7% likely to be cost saving by 2025.

CONCLUSIONS

Changing child care regulations could have a small but meaningful impact on short-term BMI at low cost. If effects are maintained for 10 years, obesity-related healthcare cost savings are likely.

Cost Effectiveness of Childhood Obesity Interventions: Evidence and Methods for CHOICES

INTRODUCTION

The childhood obesity epidemic continues in the U.S., and fiscal crises are leading policymakers to ask not only whether an intervention works but also whether it offers value for money. However, cost-effectiveness analyses have been limited. This paper discusses methods and outcomes of four childhood obesity interventions: (1) sugar-sweetened beverage excise tax (SSB); (2) eliminating tax subsidy of TV advertising to children (TV AD); (3) early care and education policy change (ECE); and (4) active physical education (Active PE).

METHODS

Cost-effectiveness models of nationwide implementation of interventions were estimated for a simulated cohort representative of the 2015 U.S. population over 10 years (2015-2025). A societal perspective was used; future outcomes were discounted at 3%. Data were analyzed in 2014. Effectiveness, implementation, and equity issues were reviewed.

RESULTS

Population reach varied widely, and cost per BMI change ranged from $1.16 (TV AD) to $401 (Active PE). At 10 years, assuming maintenance of the intervention effect, three interventions would save net costs, with SSB and TV AD saving $55 and $38 for every dollar spent. The SSB intervention would avert disability-adjusted life years, and both SSB and TV AD would increase quality-adjusted life years. Both SSB ($12.5 billion) and TV AD ($80 million) would produce yearly tax revenue.

CONCLUSIONS

The cost effectiveness of these preventive interventions is greater than that seen for published clinical interventions to treat obesity. Cost-effectiveness evaluations of childhood obesity interventions can provide decision makers with information demonstrating best value for the money.