Effects of a school-based intervention to reduce cardiovascular disease risk factors in elementary-school children: the Cardiovascular Health in Children (CHIC) study

Effectiveness of a 5-year health empowerment programme on promoting cardiovascular health for adults from low-income families in Hong Kong

OBJECTIVE

This study aimed to evaluate the effectiveness of a health empowerment programme (HEP) to enhance cardiovascular health for adults from low-income families.

METHODS

A prospective cohort study (N = 219, Intervention group: n = 103, comparison group: n = 116) was conducted with participants recruited from January 2013 to November 2015 and followed up until January 2022. Throughout the study duration, intervention group were invited to participate in the HEP. The cardiovascular health status of both groups at baseline and follow-up were assessed using the adapted Ideal Cardiovascular Health Index (ICHI) defined by the American Heart Association. After inverse propensity score weighting, multiple linear regression and Poisson regression were employed to examine the effects of the HEP.

RESULTS

The HEP was associated with a greater increase in ICHI total score (B = 0.33, p < 0.001), and the increase of proportion of people achieving a normal blood pressure (Incidence rate ratio: 3.39, p < 0.05).

CONCLUSION

HEP can be an effective and sustainable strategy to reduce social disparities in cardiovascular health of adults from low-income families, as indicated by improvement in the ICHI total score and blood pressure status.

PRACTICAL IMPLICATIONS

The sustainable HEP in the community setting has potential for generalizability and scalability to other financially challenged families.

The effectiveness of physical activity interventions on blood pressure in children and adolescents: A systematic review and network meta-analysis

BACKGROUND

High blood pressure (BP) is a major contributor to mortality and cardiovascular diseases. Despite the known benefits of exercise for reducing BP, it is crucial to identify the most effective physical activity (PA) intervention. This systematic review and network meta-analysis (NMA) aimed to evaluate the available evidence on the effectiveness of various PA interventions for reducing BP and to determine their hierarchy based on their impact on BP.

METHODS

A search of PubMed, SPORTDiscus, PsycINFO, Web of Science, CINAHL, Cochrane, and Eric databases was conducted up to December 2022 for this systematic review and NMA. Randomized controlled trials and quasi-experimental studies targeting healthy children and adolescents aged 6-12 years old were included in this study. Only studies that compared controlled and intervention groups using PA or exercise as the major influence were included. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent investigators performed the literature screening, data extraction, and risk of bias assessment. We used Bayesian arm-based NMA to synthesize the data. The primary outcomes were systolic BP and diastolic BP. We calculated the mean differences (MDs) in systolic BP and diastolic BP before and after treatment. Mean treatment differences were estimated using NMA and random-effect models.

RESULTS

We synthesized 27 studies involving 15,220 children and adolescents. PA combined with nutrition and behavior change was the most effective intervention for reducing both systolic BP and diastolic BP ((MD = -8.64, 95% credible interval (95%CI):-11.44 to -5.84); (MD = -6.75, 95%CI: -10.44 to -3.11)), followed by interventions with multiple components ((MD = -1.39, 95%CI: -1.94 to -0.84); (MD = -2.54, 95%CI: -4.89 to -0.29)).

CONCLUSION

Our findings suggest that PA interventions incorporating nutrition and behavior change, followed by interventions with multiple components, are most effective for reducing both systolic BP and diastolic BP in children and adolescents.

Impact of a simple educational intervention on awareness regarding cardiovascular disease among school-going adolescents in a rural area of Bengaluru district, India

BACKGROUND

Cardiovascular disease (CVD) is the number one cause of death in India. Atherosclerosis begins in the second decade of life; thus, preventive efforts beginning in adolescence are crucial. Yet, there are no national or regional school-based educational programs in India for the prevention of CVD. We aimed to assess the impact of a simple educational intervention on the awareness regarding CVD among school-going adolescents in a rural area of Bengaluru.

MATERIALS AND METHODS

This study was conducted using a convenience sample of school-going adolescents of classes 8, 9, and 10 in three schools in a rural area of Anekal subdistrict, Bengaluru, with a sample size of 170. A standardized, validated questionnaire testing CVD awareness was administered, followed by a simple lecture with audio-visual aids on key aspects of CVD. Three weeks later, the same questionnaire was administered to the same students. The results were then analyzed using appropriate descriptive (mean, percentage) and inferential analyses (Chi-square, paired t-test).

RESULTS

The mean (SD) age was 14.5 (1.0) years, and 54% (n = 100) were boys. 75% (139) belonged to privately funded schools. 23% (43) belonged to class 8, 37% (69) to class 9, and 40% (74) to class 10. The mean (SD) total score on baseline assessment was 27.4 (9.3) out of 100, with girls and students of private schools scoring higher. The mean (SD) post-test total score was 48.5 (15.7), with significant increases in all domains of awareness, and in all categories of students.

DISCUSSION

Awareness regarding CVD among adolescents from rural Bengaluru was poor, highlighting the need for educational interventions to aid preventive efforts. A simple educational intervention resulted in significant improvements in CVD awareness, even after 3 weeks.

Perception of School Committee Members (SCMs) on Factors Contributing to Overweight and Obesity Among High School Students in Kiribati: A Qualitative Study

Background

Schools are vital settings for overweight and obesity prevention among children and adolescents. School Committee Members (SCMs) are crucial assets to engaging students with overweight and obesity prevention programs. This study aimed to determine factors contributing to overweight and obesity among high school students in Kiribati through the perception of SCMs.

Methods

This prospective qualitative study was conducted in four randomly selected senior high schools in South Tarawa, Kiribati, from August to November 2020. With a purposive selection of 20 SCMs employed at the four high schools, both male and female participants consented to participate in the study. A semi-structured open-ended questionnaire was used for data collection using focus group discussions (FGDs). Data were transcribed and analyzed using the thematic analysis method.

Results

Twenty participants were involved in FGDs with equal number of SCMs (n = 5) who attended FGDs for each school and 45% of them were female participants. Six themes were identified, namely, knowledge, behaviors, perceived status toward overweight and obesity, perceived action benefits, perceived barriers to practices, and proposed strategies to overweight and obesity prevention. These themes reveal that SCMs have a broad understanding and skill set for overweight and obesity causes and effects. However, the aptitude alone is not enough to prevent the occurrence, and thus, proposed feasible plans were voiced for responsible stakeholders to include in policy developments for overweight and obesity prevention.

Conclusion

This study recognized that the knowledge-behavior gap is the main reason behind the failure in preventative strategic approaches among adolescents. As role models to students, SCMs and their schools should team up in implementing the public health policies and building mutual awareness and understanding with students and other specialist stakeholders for a more momentous and viable impact.

Health promotion intervention to prevent risk factors of chronic diseases: Protocol for a cluster randomized controlled trial among adolescents in school settings of Chandigarh (India)

Background

Chronic diseases like diabetes, cardiovascular diseases and cancers are on the rise. Most of the risk factors of these diseases commence in Adolescence. Therefore, a cluster randomised controlled trial is designed to evaluate the effect of school-based health promotion intervention on the risk factors of chronic diseases.

Methodology

Considering school as a cluster, twelve schools will be randomly selected from the public schools of Chandigarh, a city in India. After baseline assessment, six schools will be randomly allocated to intervention and six to the control arm. Study participants will be students of 8th grade (age 10–16 years), their parents and teachers. A sample of 360 students (12 clusters x 30 students) has been estimated to provide statistically valid inference. The PRECEDE PROCEED Model will be used to develop health promotion interventions to prevent the use of an unbalanced diet, physical inactivity, alcohol, and tobacco. Interventions will be implemented for six-months in the school setting. For students, the intervention will comprise interactive learning sessions of 30 minutes duration per week and physical activity sessions of 30 minutes duration four times every week. Educational sessions will be conducted for parents and teachers for 30 minutes, four times during the intervention period. Primary outcomes will be changes in the prevalence of behavioural risk factors from pre- to post-intervention. Changes in anthropometric, physiological, and biochemical measures will be the secondary outcomes. The difference-in-difference (DID) method will be used to measure the net change in the outcomes.

Discussion

It is essential to understand whether health promotion interventions implemented in the school setting simultaneously targeting adolescents, teachers, and parents are effective. Using the PRECEDE-PROCEED model for planning, implementing, and evaluating the intervention as part of a cluster Randomized Controlled Trial design with DID analysis, could objectively assess the impact.

A Controlled Evaluation of a CBPR Intervention's Effects on Physical Activity and the Related Psychosocial Constructs Among Minority Children in an Underserved Community

BACKGROUND

Effective physical activity interventions are needed for children because health behaviors track into adulthood, and risk factors for diseases begin early in life. No study has determined whether an intervention designed using a Community-Based Participatory Research approach can improve moderate to vigorous physical activity (MVPA) and the related psychosocial constructs in underserved children. This study determined whether improvements in MVPA and related psychosocial constructs (self-efficacy, knowledge, beliefs, attitudes, and skills) occurred following a Community-Based Participatory Research intervention in underserved, rural children. It was then determined if these constructs were mediators of MVPA.

METHODS

Two fifth-grade classes at a school (n = 19 and n = 20) were randomly assigned to an intervention or comparison group. The intervention group participated in a 4-week intervention designed to improve MVPA (wGT3X-BT accelerometer; ActiGraph, Pensacola, FL) and the related psychosocial constructs (written survey). Groups were assessed prior to and immediately following the intervention.

RESULTS

There were no differences at baseline between groups. MVPA (30.0 [4.4] min), knowledge, and skill scores were significantly higher in the intervention group compared with the comparison group at follow-up (P < .05). Knowledge and skills were mediating variables of MVPA.

CONCLUSIONS

Priority should be placed on research that determines the sustained impact of similar Community-Based Participatory Research interventions.

Katalyst Pilot Study: Using Interactive Activities in Anatomy and Physiology to Teach Children the Scientific Foundation of Healthy Lifestyles

This pilot study evaluated the impact of the Katalyst curriculum, a fifth-grade experiential learning program, on students' knowledge of a healthy lifestyle's impact on body functions. Katalyst's interactive curriculum spans two days and includes four, 60-min stations on body systems: cardiovascular/endocrine, gastrointestinal, neurological, and respiratory/musculoskeletal. Three schools were recruited, and two schools completed the intervention sessions. Prior to beginning the stations, fifth-grade students completed a 37-item questionnaire to assess knowledge and perceptions. Students completed the same survey at the end of the Katalyst intervention. Teachers at the school also completed a survey post intervention to provide feedback on the program. Frequency and paired analyses were conducted on student responses and summative content analysis on teacher and volunteer feedback. The School 1 completer (n = 63) baseline mean knowledge score was 66.2%. The School 2 completer (n = 47) baseline mean knowledge score was 67.3%. Following the Katalyst intervention, both schools showed a statistically significant increase in the mean post score to 70.3% (p = 0.0017) and 78.4%(p < 0.0001) at School 1 (n = 63) and School 2 (n = 47), respectively. Teacher feedback (n = 7) revealed that Katalyst was effective in meeting state educational health standards and teachers perceived that the students benefitted from the program more than "reading about the body systems in a textbook or health magazine". The Katalyst pilot study appeared to improve fifth-grade students' knowledge of body systems and health. Katalyst aligned with state educational standards and is supported by teachers for an experiential learning opportunity. The Katalyst curriculum could be a potential avenue for health educators in Appalachia.

School-Based Exercise Programs and Cardiometabolic Risk Factors: A Meta-analysis

CONTEXT

The effects of school-based physical activity (PA) programs on different cardiometabolic risk factors and the most appropriate features of PA programs to achieve maximum effectiveness are unclear.

OBJECTIVE

To provide a comprehensive synthesis of the effectiveness of school-based PA interventions on cardiometabolic risk factors in children.

DATA SOURCES

We identified studies from database inception to February 22, 2018.

STUDY SELECTION

We selected studies that were focused on examining the effect of school-based PA interventions on cardiometabolic risk factors in children.

DATA EXTRACTION

Random-effects models were used to calculate the pooled effect size (ES) for the included cardiometabolic risk factors (waist circumference [WC], triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, systolic blood pressure and diastolic blood pressure (DBP), and fasting insulin and glucose).

RESULTS

Nineteen randomized controlled trials (which included 11 988 children aged 3-12 years) were included in the meta-analysis. School-based PA programs were associated with a significant small improvement in WC (ES = -0.14; 95% confidence interval [CI]: -0.22 to -0.07; P < .001), DBP (ES = -0.21; 95% CI: -0.42 to -0.01; P = .040), and fasting insulin (ES = -0.12; 95% CI: -0.20 to -0.04; P = .003).

LIMITATIONS

Authors of few studies described the implementation conditions of their interventions in detail, and compliance rates were lacking in most studies. In addition, results by sex were provided in a small number of studies.

CONCLUSIONS

School-based PA interventions improve some cardiometabolic risk factors in children, such as WC, DBP, and fasting insulin.

Moderators of School-Based Physical Activity Interventions on Cardiorespiratory Endurance in Primary School-Aged Children: A Meta-Regression

The purpose of this study was to examine potential moderators of school-based physical activity interventions on cardiorespiratory endurance in primary school-aged children using meta-regression. An Internet search with several databases was employed, extracting school-based pediatric physical activity intervention studies published within the past 30 years. Studies were included if there was a control or comparison group, if the study sample included primary school-aged children, if the targeted outcome of cardiorespiratory endurance was objectively assessed, if the intervention was at least partially school-based, and if the effect estimate's variability was reported. An inverse-variance random effects meta-regression was employed using the primary predictors of component number (single component or multi-component) and intervention length using 20 extracted studies with 23 total effects. The overall pooled effect on cardiorespiratory endurance was statistically significant (Hedges' g = 0.30, 95% C.I.: 0.19⁻0.40; p < 0.001). Using random effects meta-regression, neither component number (b = ⁻0.09, 95% C.I.: ⁻0.40⁻0.23; p = 0.560) or intervention length (b = 0.001, 95% C.I.: ⁻0.002⁻0.004; p = 0.427) yielded a significant modifying effect on cardiorespiratory endurance. School-based physical activity interventions have a significant pooled effect on cardiorespiratory endurance in primary school-aged children. Component number and intervention length does not modify this effect, suggesting other sources for between-study heterogeneity.

Effects of Before-School Physical Activity on Obesity Prevention and Wellness

INTRODUCTION

The effects of Build Our Kids Success-a 12-week, 1-hour before-school physical activity program-on BMI and social-emotional wellness among kindergarten to eighth grade students was examined.

STUDY DESIGN

This was a nonrandomized trial.

SETTING/PARTICIPANTS

Participants were from 24 schools in Massachusetts; there were 707 children from kindergarten to eighth grade.

INTERVENTION

Children registered for Build Our Kids Success in 2015-2016 participated in a 2 days/week or 3 days/week program. Nonparticipating children served as controls.

MAIN OUTCOME MEASURES

At baseline and 12 weeks, study staff measured children's heights/weights; children aged ≥8 years completed surveys. Main outcomes were 12-week change in BMI z-score, odds of a lower BMI category at follow-up, and child report of social-emotional wellness. Analyses were completed in March-June 2017.

RESULTS

Follow-up BMI was obtained from 67% of children and self-reported surveys from 72% of age-eligible children. Children in the 3 days/week group had improvements in BMI z-score (-0.22, 95% CI= -0.31, -0.14) and this mean change was significantly different than the comparison group (-0.17 difference, 95% CI= -0.27, -0.07). Children in the 3 days/week group also had higher odds of being in a lower BMI category at follow-up (OR=1.35, 95% CI=1.12, 1.62); significantly different than the comparison group (p<0.01). Children in the 2 days/week program had no significant changes in BMI outcomes. Children in the 3 days/week group demonstrated improvement in their student engagement scores (0.79 units, p=0.05) and had nonsignificant improvements in reported peer relationships, affect, and life satisfaction versus comparison. The 2 days/week group had significant improvements in positive affect and vitality/energy versus comparison.

CONCLUSIONS

A 3 days/week before-school physical activity program resulted in improved BMI and prevented increases in child obesity. Both Build Our Kids Success groups had improved social-emotional wellness versus controls.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03190135.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

Exercise and eating habits among urban adolescents: a cross-sectional study in Kolkata, India

BACKGROUND

Unhealthy eating and lack of exercise during adolescence culminated into earlier onset and increasing burden of atherosclerotic cardiovascular diseases (CVDs) worldwide. Among urban Indian adolescents, prevalence of these risk factors of CVD seemed to be high, but data regarding their pattern and predictors was limited. To address this dearth of information, a survey was conducted among urban adolescent school-students in Kolkata, a highly populated metro city in eastern India.

METHODS

During January-June, 2014, 1755 students of 9th-grade were recruited through cluster (schools) random sampling. Informed consents from parents and assents from adolescents were collected. Information on socio-demographics, CVD-related knowledge and perception along with eating and exercise patterns were collected with an internally validated structured questionnaire. Descriptive and regression analyses were performed in SAS-9.3.2.

RESULTS

Among 1652 participants (response rate = 94.1%), about 44% had poor overall knowledge about CVD, 24% perceived themselves as overweight and 60% considered their general health as good. Only 18% perceived their future CVD-risk and 29% were engaged in regular moderate-to-vigorous exercise. While 55% skipped meals regularly, 90% frequently consumed street-foods and 54% demonstrated overall poor eating habits. Males were more likely to engage in moderate-to-vigorous exercise [adjusted odds ratio (AOR) = 3.40(95% confidence interval = 2.55-4.54)] while students of higher SES were less likely [AOR = 0.59(0.37-0.94)]. Males and those having good CVD-related knowledge were more likely to exercise at least 1 h/day [AOR = 7.77(4.61-13.07) and 2.90(1.46-5.78) respectively]. Those who perceived their future CVD-risk, skipped meals more [2.04(1.28-3.25)] while Males skipped them less [AOR = 0.62(0.42-0.93)]. Subjects from middle class ate street-foods less frequently [AOR = 0.45(0.24-0.85)]. Relatively older students and those belonging to higher SES were less likely to demonstrate good eating habits [AOR = 0.70(0.56-0.89) and 0.23(0.11-0.47) respectively]. A large knowledge-practice gap was evident as students with good CVD-related knowledge were less likely to have good eating habits [AOR = 0.55(0.32-0.94)].

CONCLUSIONS

CVD-related knowledge as well as eating and exercise habits were quite poor among adolescent school-students of Kolkata. Additionally, there was a large knowledge-practice gap. Multi-component educational interventions targeting behavioral betterment seemed necessary for these adolescents to improve their CVD-related knowledge, along with appropriate translation of knowledge into exercise and eating practices to minimize future risk of CVDs.

Conducting Nursing Research to Advance and Inform Health Policy

The primary roles of nurse scientists in conducting health policy research are to increase knowledge in the discipline and provide evidence for informing and advancing health policies with the goal of improving the health outcomes of society. Health policy research informs, characterizes, explains, or tests hypotheses by employing a variety of research designs. Health policy research focuses on improving the access to care, the quality and cost of care, and the efficiency with which care is delivered. In this article, we explain how nurses might envision their research in a policy process framework, describe research designs that nurse researchers might use to inform and advance health policies, and provide examples of research conducted by nurse researchers to explicate key concepts in the policy process framework. Health policies are well informed and advanced when nurse researchers have a good understanding of the political process. The policy process framework provides a context for improving the focus and design of research and better explicating the connection between research evidence and policy. Nurses should focus their research on addressing problems of importance that are on the healthcare agenda, work with interdisciplinary teams of researchers, synthesize, and widely disseminate results.

Clustering of Risk Behaviors and their Social Determinants among Primary School Learners in Beijing, China: A Cross-sectional Study

Background:

Studies in developed countries reveal that poor lifestyle choices triggering diseases typically cluster among children. However, there is insufficient evidence on the clustering of risk behaviors among children in developing countries. This study aimed to determine the clustering of risk behaviors and their social determinants among 4^th-and 5^th -grade learners in Beijing, China.

Methods:

The sample comprised of 967 learners from six primary schools enrolled migrant and resident learners by two-stage stratified cluster sampling. Prevalence denoted the risk behaviors and their clustering. A log-linear model was used to explore the clustering patterns. Ordinal logistic regression determined the influence of demographic characteristics, school environment, and family context on behavioral clustering.

Results:

The prevalence of none, one, two, and three or more risk factors was 61.2%, 20.0%, 10.8%, and 8.1% for infectious diseases and 46.0%, 30.6%, 15.4%, and 8.0% for chronic diseases, respectively. Some behaviors appeared dependent and were more likely to be observed together. The three most influential factors for infectious diseases were school type (odds ratio [OR] =4.47, 95% confidence interval [CI] 3.00–6.66), school located in an inner suburb (OR = 0.27, 95% CI 0.18–0.38), and gender (OR = 0.56, 95% CI 0.42–0.74). Regarding risk behaviors for chronic diseases, clustering was not associated with household registration status and number of appliances, but was significantly associated with school type (OR = 5.36, 95% CI 3.72–7.73), school located in an inner suburb (OR = 0.59, 95% CI 0.43–0.81), and gender (OR = 0.61, 95% CI 0.47–0.78). School environment variables were the most significant contributor to the number of risk behaviors.

Conclusions:

The characteristics of schools enrolling migrants and residents influenced the number of risk behaviors. Therefore, improved school conditions and integrated behavioral interventions are particularly recommended for health promotion.

Cardiovascular health awareness and the effect of an educational intervention on school-aged children in a rural district of India

BACKGROUND AND OBJECTIVES

India is the second most populous country in the world and two-thirds of its population is less than 35 years old. This survey was conducted to assess the level of health awareness of cardiovascular disease in adolescent school-aged children 14-16 years old, with the goal of establishing school-based health education and development of heart-healthy lifestyle practices.

METHODS

A school-based survey was conducted in the rural district of West Midnapore, India between June and July of 2014. This involved a pre-evaluation of cardiovascular disease (CVD) health awareness, a short presentation on CVD, and a post-evaluation of CVD health awareness.

RESULTS

A total of 2995 students (48% response rate) from 20 schools participated in the survey. The mean age of the students in the study sample was 14.7 years, 46% were male, 53% were in the 9th grade, and the rest were in the 10th grade. After assessing students' awareness in six domains with 20 multiple-choice questions with a maximum score of 100, the mean pre-test score was 41.1 (SD±10.5) and the mean post-test score was 48.1 (SD±16.9) (p<0.001).

CONCLUSIONS

Awareness of CVD and its risk factors was far from optimal among the adolescent school-aged children in this study. A school-based educational program may help improve awareness of CVD and reduce the future disease burden in the community. The results of this study may be useful in formulating a nationwide school health program to deal with the emerging epidemic of CVD in countries such as India.

Heart Rate Variability in Adolescents - Normative Data Stratified by Sex and Physical Activity

BACKGROUND

Heart rate variability (HRV) refers to the beat-to-beat fluctuations in the cardiac rhythm occurring due to modulation of the pacemaker (sinoatrial node) activity of the heart by the sympathetic and parasympathetic branches of the autonomic nervous system. Nowadays, cardiovascular diseases and their risk factors are increasingly occurring at a younger age (children and adolescents) and recording of HRV in them will help us to identify cardiovascular autonomic derangement earlier. However, to be used clinically, normative data has to be established in this age group considering other major factors that can influence HRV such as sex, physical activity, and BMI.

MATERIALS AND METHODS

Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology has provided the standards for measurement of heart rate variability and we have followed the same. In the present study, we have described the normative data for HRV in the adolescent in the age group of 12-17 years, stratified based on sex and physical activity.

RESULTS

Data given below are expressed as median with interquartile range (Median (IQR)) in the following order: non-athlete girls, non athlete boys, athlete girls and athlete boys. Time domain indices - SDNN - 66.35 (40.78), 63.20 (36.20), 113.00 (31.40) and 94.20 (35.55); RMSSD - 69.00 (50.55), 58.70 (43.40), 94.90 (42.10) and 100.30 (47.50); NN50 - 137.50 (100.25), 116.00 (90.50), 137.00 (81.00) and 156.00 (81.50). The frequency domain indices - LF power 1015.00 (1098.75), 945.00 (831.00), 1465 (642.25), and 1211.00 (811.37); HF power - 1324.00 (1707.00), 988.00 (1426.50), 2409.00 (1387.50), and 2219.00 (1752.00); Total power - 3374.50 (3094.25), 2757.00 (2641.00), 5202.00 (2501.50) and 5273.00 (3507.50); LFnu - 45.44 (16.61), 47.63 (29.98), 38.59 (11.81) and 37.10 (11.21); HFnu - 54.56 (16.61), 52.37 (29.98), 61.41 (11.81) and 62.90 (11.21).

CONCLUSION

We have given sex and physical activity stratified HRV normative data for adolescents in the age between 12-17 years.

A national school-based health lifestyles interventions among Chinese children and adolescents against obesity: rationale, design and methodology of a randomized controlled trial in China

BACKGROUND

The prevalence of obesity among children and adolescents has been rapidly rising in Mainland China in recent decades, both in urban and rural areas. There is an urgent need to develop effective interventions to prevent childhood obesity. Limited rigid data regarding children and adolescent overweight prevention in China are available. A national random controlled school-based obesity intervention program was developed in the mainland of China.

METHODS/DESIGN

The study was designed as a national multi-centered cluster randomized controlled trial involving more than 70,000 children and adolescents aged 7-18 years from 7 provinces in China. In each center, about 12-16 primary and secondary schools, with totally at least 10000 participants were randomly selected (Primary: Secondary = 1:1). All of the selected schools were randomly allocated to either intervention or control group (Intervention: Control = 1:1).The multi-components school-based and family-involved scheme was conducted within the intervention group for 9 month, while students in the control group followed their usual health practice. The intervention consisted of four components: a) Create supportive school and family environment, b) Health lifestyles education and related compulsory physical activities, c) Instruct and promote school physical education, d) Self-monitor obesity related behaviors. Four types of outcomes including anthropometric, behavioral, blood chemical and physical fitness were measured to assess the effectiveness of the intervention program.

DISCUSSION

This is the first and largest multi-centered school-based obesity intervention program with the consideration of geographical and social-demographic characteristics of the rapidly increased obesity prevalence of Chinese children and adolescent. The intervention is based on Social Cognitive Theory and Social-Ecological Model of Health, and follows a stepwise approach guided by PRECEDE-PROCEED (P-P) Model and Intervention Map. The results of and lesson learned from this study will help guide future school-based national childhood obesity prevention programs in Mainland China.

TRIAL REGISTRATION

January 22, 2015;

REGISTRATION NUMBER

NCT02343588.

A meta-analysis of school-based obesity prevention programs demonstrates limited efficacy of decreasing childhood obesity

Childhood obesity is a global concern. The objectives of this meta-analytical study were to evaluate the effectiveness of school-based childhood obesity prevention programs, and to examine program components (moderators). The methods included searching databases (PubMed, Google Scholar, and the university's EBSCOhost Web service) as well as handsearching reference lists of articles published in English. Selection criteria for studies to be included in the meta-analysis were limited to studies that reported body mass index (BMI) or skinfold thickness as outcome measures and were school-based obesity prevention interventions; cross-sectional design studies were excluded. We hypothesized the meta-analysis would yield a summary effect size of magnitude which would indicate that school-based interventions have been effective in improving children's BMI or skinfold thickness values. A total of 26 114 children from 27 school-based childhood obesity prevention programs provided 54 effect sizes. A random-effects model calculated a small summary effect size of 0.039 (95% confidence interval -0.013 to 0.092). Heterogeneity among studies was observed which disappeared after pooling studies that used a randomized controlled trial design with one program moderator (physical activity or nutrition). We failed to accept our hypothesis and concluded that overall, school-based interventions have not been effective for improving body mass index or skinfold thickness to curb childhood obesity; however, randomized controlled trials that focused on physical activity or nutrition appeared to produce promising results.

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.

Effectiveness of school-based intervention programs in reducing prevalence of overweight

Objectives:

To assess the effectiveness of school-based interventions program in reducing the prevalence of overweight or obesity among schoolchildren.

Data source:

Ovid Medline (1950-December 2012), Embase (1980-2012), CINAHL (1982-2012), secondary references, review articles, and expert in the field.

Study selection:

All published clinical trials were eligible for study if were randomized, methodologically strong-based on a validity assessment, aimed to evaluate a school-based intervention for childhood overweight or obesity, and measured outcome in term of prevalence/incidence difference in overweight and obesity among both groups. Studies involved in cost-effective analysis of school-based intervention have been excluded. Data from eligible studies abstracted and pooled for relative risk.

Results:

Five trials with 3,904 schoolchildren were included. Mean age of the students (boys and girls) ranges 8.6-12.6 years. Meta-analysis showed a statistical significance beneficial effect of school-based intervention programs on obesity status of schoolchildren (risk ratio (RR) 0.58, 95% confidence interval (CI) 0.43-0.78) and suggested 42% reduction in prevalence of obesity among schoolchildren through school-based intervention programs. Individual studies also showed effectiveness of these school-based interventions.

Conclusion:

School-based intervention programs are effective in prevention of childhood overweight and obesity problem and our results quantitatively supported this argument.

School-based physical activity and nutritional education interventions on body mass index: a meta-analysis of randomised community trials - project PANE

OBJECTIVE

To evaluate the effect of school-based physical activity (PA) and nutritional education (NE) interventions on children's and adolescents' body mass index.

METHODS

We conducted a systematic search in fourteen databases until September 2012 for randomised controlled trials on PA and NE, conducted in the school setting, and delivered to children and adolescents. Additionally, we performed a cross-reference check in related papers. The title and abstract review and the quality assessment were performed by two independent researchers. The software EPPI-Reviewer3 was used to store, manage and analyse all data. The meta-analysis was conducted using the random-effects model, and the outcomes were reported as standardised mean difference (SMD). As a secondary analysis, we pooled together the interventions that considered PA or NE alone.

RESULTS

Thirty-eight studies met the eligibility criteria. The main analysis showed a SMD between intervention and control groups of -0.03 (95% CI: -0.09, 0.04; n=28,870; I(2)=83%). When we considered all 57 trials, there was no difference between the results of the primary analysis.

CONCLUSION

The synthesis of school-based PA and NE interventions showed no statistically significant mean reduction on children's and adolescents' body mass index. The high heterogeneity among studies requires caution in the generalisation of the results.

Promoting healthy lifestyles in high school adolescents: a randomized controlled trial

BACKGROUND

Although obesity and mental health disorders are two major public health problems in adolescents that affect academic performance, few rigorously designed experimental studies have been conducted in high schools.

PURPOSE

The goal of the study was to test the efficacy of the COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, Nutrition) Program, versus an attention control program (Healthy Teens) on: healthy lifestyle behaviors, BMI, mental health, social skills, and academic performance of high school adolescents immediately after and at 6 months post-intervention.

DESIGN

A cluster RCT was conducted. Data were collected from January 2010 to May of 2012 and analyzed in 2012-2013.

SETTING/PARTICIPANTS

A total of 779 culturally diverse adolescents in the U.S. Southwest participated in the trial.

INTERVENTION

COPE was a cognitive-behavioral skills-building intervention with 20 minutes of physical activity integrated into a health course, taught by teachers once a week for 15 weeks. The attention control program was a 15-session, 15-week program that covered common health topics.

MAIN OUTCOME MEASURES

Primary outcomes assessed immediately after and 6 months post-intervention were healthy lifestyle behaviors and BMI. Secondary outcomes included mental health, alcohol and drug use, social skills, and academic performance.

RESULTS

Post-intervention, COPE teens had a greater number of steps per day (p=0.03) and a lower BMI (p=0.01) than did those in Healthy Teens, and higher average scores on all Social Skills Rating System subscales (p-values <0.05). Teens in the COPE group with extremely elevated depression scores at pre-intervention had significantly lower depression scores than the Healthy Teens group (p=0.02). Alcohol use was 12.96% in the COPE group and 19.94% in the Healthy Teens group (p=0.04). COPE teens had higher health course grades than did control teens. At 6 months post-intervention, COPE teens had a lower mean BMI than teens in Healthy Teens (COPE=24.72, Healthy Teens=25.05, adjusted M=-0.34, 95% CI=-0.56, -0.11). The proportion of those overweight was significantly different from pre-intervention to 6-month follow-up (chi-square=4.69, p=0.03), with COPE decreasing the proportion of overweight teens, versus an increase in overweight in control adolescents. There also was a trend for COPE Teens to report less alcohol use at 6 months (p=0.06).

CONCLUSIONS

COPE can improve short- and more long-term outcomes in high school teens.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01704768.

Effects of school-based interventions for direct delivery of physical activity on fitness and cardiometabolic markers in children and adolescents: a systematic review of randomized controlled trials

To evaluate the effectiveness of school-based physical activity interventions on fitness, adiposity and cardiometabolic outcomes among schoolchildren. Medline, Embase, EBSCOhost CINAHL and ERIC databases were searched up to October 2012.

INCLUSION CRITERIA

intervention delivered at school with controls having no intervention or usual physical education classes; participants aged 5-18 years; outcomes spanning some or all of the above. We assessed levels of evidence for identified trials based on methodological quality and sample size. Dose of the interventions (a total summary measure of intensity, frequency and duration) were considered. Eighteen randomized controlled trials (RCTs, total participants = 6,207) were included, of which six were large, higher quality trials with high dose of the intervention. The intervention was consistent in increasing fitness with large, higher quality studies and high dose of intervention providing strong evidence. Dose of school-based physical activity is an important determinant of trial efficiency. Some large, higher quality RCTs provided strong evidence for interventions to decrease skin-fold thickness, increase fitness and high-density lipoprotein cholesterol. Evidence for body mass index, body fat and waist circumference, blood pressure and triglycerides, low-density lipoprotein cholesterol and total cholesterol remain inconclusive and require additional higher quality studies with high dose of interventions to provide conclusive evidence.

The COPE healthy lifestyles TEEN randomized controlled trial with culturally diverse high school adolescents: baseline characteristics and methods

Obesity and mental health disorders remain significant public health problems in adolescents. Substantial health disparities exist with minority youth experiencing higher rates of these problems. Schools are an outstanding venue to provide teens with skills needed to improve their physical and mental health, and academic performance. In this paper, the authors describe the design, intervention, methods and baseline data for a randomized controlled trial with 779 culturally diverse high-school adolescents in the southwest United States. Aims for this prevention study include testing the efficacy of the COPE TEEN program versus an attention control program on the adolescents' healthy lifestyle behaviors, Body Mass Index (BMI) and BMI%, mental health, social skills and academic performance immediately following the intervention programs, and at six and 12 months post interventions. Baseline findings indicate that greater than 40% of the sample is either overweight (n = 148, 19.00%) or obese (n = 182, 23.36%). The predominant ethnicity represented is Hispanic (n = 526, 67.52%). At baseline, 15.79% (n = 123) of the students had above average scores on the Beck Youth Inventory Depression subscale indicating mildly (n = 52, 6.68%), moderately (n = 47, 6.03%), or extremely (n = 24, 3.08%) elevated scores (see Table 1). Anxiety scores were slightly higher with 21.56% (n = 168) reporting responses suggesting mildly (n = 81, 10.40%), moderately (n = 58, 7.45%) or extremely (n = 29, 3.72%) elevated scores. If the efficacy of the COPE TEEN program is supported, it will offer schools a curriculum that can be easily incorporated into high school health courses to improve adolescent healthy lifestyle behaviors, psychosocial outcomes and academic performance.

School-based programmes for preventing smoking

BACKGROUND

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

OBJECTIVES

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

MAIN RESULTS

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.We were unable to analyse data for 49 studies (N = 152,544).Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

AUTHORS' CONCLUSIONS

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.

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.

An Environmental Approach to Obesity Prevention in Children: Medical College of Georgia FitKid Project Year 1 Results

OBJECTIVE

To test the hypothesis that third grade children (mean age = 8.7, SD = 0.5) who attended an 8-month after-school program would exhibit favorable changes in body composition, cardiovascular fitness, blood pressure, total cholesterol, and high-density lipoprotein-cholesterol compared with children in control condition.

RESEARCH METHODS AND PROCEDURES

Subjects were 61% African-American, 31% white, and 8% other racial background from 18 public schools. Sixty-eight percent were eligible for free or reduced price lunch. Percentage body fat and bone mineral density were assessed by DXA, cardiovascular fitness by heart rate response to a step test, resting blood pressure with a Dinamap, and non-fasting total cholesterol and high-density lipoprotein-cholesterol by finger stick. Data pre- and post-intervention were available for 447 children. Children in the nine intervention schools who attended at least 40% of the after-school sessions were compared with control subjects.

RESULTS

Compared with the control subjects and after controlling for race, sex, free/reduced price lunch status, and school-level covariates, youths in the intervention group showed a relative reduction of percentage body fat [-0.76 (95% confidence interval (CI), -1.42, -0.09)], a greater relative gain in bone mineral density [0.008 (95% CI, 0.001, 0.005)], and a greater relative reduction in heart rate response to the step test [-4.4 (95% CI, -8.2, 0.6)]. The other outcome variables showed non-significant trends in favor of the intervention subjects.

DISCUSSION

These results are promising in light of the potential impact on the emerging childhood obesity epidemic. The Medical College of Georgia FitKid Project has the potential to be institutionalized because it is built on the existing infrastructure in most public schools in the U.S.

An Assessment of nutrition education in selected counties in New York State elementary schools (kindergarten through fifth grade)

OBJECTIVE

To assess the extent to which nutrition education is implemented in selected counties in New York State elementary schools (kindergarten through fifth grade) and explore how nutrition knowledge is presented in the classroom and what factors support it.

DESIGN

Cross-sectional, self-administered survey.

SETTING

New York State elementary schools in selected counties.

PARTICIPANTS

New York State elementary school teachers (n = 137).

MAIN OUTCOME MEASURES

Hours spent teaching nutrition; nutrition topics, methods of teaching, education resources, and aspects of the school environment that may influence nutrition education.

ANALYSIS

Crosstabs with a chi-square statistic and ANOVA.

RESULTS

Eighty-three percent of teachers taught some nutrition (9.0 ± 10.5 hours) during the academic year. Teachers taught lessons about finding and choosing healthy food (61%), relationship between diet and health (54%), and MyPyramid (52%) most often. Suburban teachers (12.4 ± 12.5 hours) taught significantly (P = .006) more hours of nutrition than rural teachers (4.2 ± 3.9 hours). Teachers at schools with fewer than 80% nonwhite students taught significantly (P = .02) more (10.4 ± 11.4 hours) compared to schools with greater than 80% nonwhite students (5.6 ± 6.4 hours).

CONCLUSIONS AND IMPLICATIONS

Teachers reported that nutrition education is important and that they are willing to teach nutrition. Efforts should be made that support integrated nutrition topics, methods of instruction, and availability of resources.

Fifteen Years of Promise in School-Based Physical Activity Interventions: A Meta-Analysis

Increasing physical activity among children and adolescents continues to be a public health priority (Glickman et al., 2012), with a focus on evidence-based physical activity in school settings. While individual studies report benefits from school-based physical activity interventions, no data-based analysis of these interventions has been published. This meta-analysis examined the outcomes of 12 school-based interventions that reported data from both treatment and intervention groups. The design of each study was unique; including one or more of 19 dependent variables representing physical activity, knowledge, body composition, and cardiovascular measures, and one or more component of the Coordinated School Health Model (CSHM). Generally the benefits from the intervention were small and not significant; health knowledge was the exception. Interventions including more components of the CSHM and interventions of greater duration (e.g., more minutes) were associated with enhanced outcomes and explained 89% of the variance. Weaknesses in the design and analysis of some interventions were inappropriate experimental unit (individual rather than school), multiple analyses on the same data without correction (e.g., Bonferroni), multiple publications of the same data, and the inclusion of all students regardless of whether the student needed to increase physical activity/ftness or reduce body mass/fat.

Psychological Undertones of Family Poverty in Rural Communities in Cameroon: Resilience and Coping Strategies

The objectives of this exploratory study were to investigate (a) the effects of poverty, and (b) family resilience strategies used in managing poverty among the Bakweri of Bonavada villages in Cameroon. Fifty heads of families comprising 250 persons constituted the participants of the study. Ten of the family heads who are opinion leaders were interviewed using a semi-structured interview guide and ten participated in a focus group discussion. In addition, an unstructured interview was used to collect data from 40 heads of families. Data were analysed using content analysis and descriptively using percentages. The study found that the effects of family poverty are multifaceted, and families depend largely on resilience and their socio-cultural context to cope with poverty.

Cardiovascular risk factors in multi-ethnic middle school students: the HEALTHY primary prevention trial

OBJECTIVE

The objective of this study was to examine the effects of an integrated, multi-component, school-based intervention programme on cardiovascular disease (CVD) risk factors among a multi-ethnic cohort of middle school students.

METHODS

HEALTHY was a cluster randomized, controlled, primary prevention trial. Middle school was the unit of randomization and intervention. Half of the schools were assigned to an intervention programme consisting of changes in the total school food environment and physical education classes, enhanced by educational outreach and behaviour change activities and promoted by a social marketing campaign consisting of reinforcing messages and images. Outcome data reported (anthropometrics, blood pressure and fasting lipid levels) were collected on a cohort of students enrolled at the start of 6th grade (∼11-12 years old) and followed to end of 8th grade (∼13-14 years old).

RESULTS

Forty-two middle schools were enrolled at seven field centres; 4363 students provided both informed consent and CVD data at baseline and end of study. The sample was 52.7% female, 54.5% Hispanic, 17.6% non-Hispanic Black, 19.4% non-Hispanic White and 8.5% other racial/ethnic combinations, and 49.6% were categorized as overweight or obese (body mass index ≥ 85th percentile) at baseline. A significant intervention effect was detected in the prevalence of hypertension in non-Hispanic Black and White males. The intervention produced no significant changes in lipid levels.

CONCLUSIONS

The prevalence of some CVD risk factors is high in minority middle school youth, particularly males. A multi-component, school-based programme achieved only modest reductions in these risk factors; however, promising findings occurred in non-Hispanic Black and White males with hypertension.

Reading, writing, and obesity: America's failing grade in school nutrition and physical education

The childhood obesity epidemic has left healthcare professionals and laymen alike questioning the best strategy to improve children's health in the future. To effectively combat childhood obesity, we must have a thorough understanding of the establishment and development of programs currently responsible for pediatric health. This article explores the history of two influential programs affecting children's diet and physical activity levels in schools: the National School Lunch Program and physical education classes. It is revealed that the National School Lunch Program contributes to the overall school nutrition environment, including the presence of fast food and vending machines on campuses. The history of physical education is traced back to ancient Greece, and it is shown that the familiar sports-based curriculum is an advent of the 19th century, with the roots of physical education originating from the founders of preventive medicine. Select childhood obesity and health intervention studies are reviewed with a focus on identifying notable features pertaining to the effectiveness of these programs. Future directions and recommendations, based on the history of these programs as well as evidence from current pediatric health studies, outlining the basis for a modernized health-based physical education curriculum designed to address today's public health concerns, are further discussed.

Effectiveness of interventions to promote healthy weight in general populations of children and adults: a meta-analysis

BACKGROUND

Responding to the obesity epidemic requires robust evidence to help prioritize the allocation of scarce resources to preventive interventions. The aim of this study was to evaluate interventions that promote healthy weight [defined as reduction in body mass index (BMI) or percentage body fat] in general populations (unselected by weight) using a comprehensive meta-analysis. Interventions with both single and multiple components were considered.

METHODS

Studies were first identified through well-conducted systematic reviews complemented by a search for single studies in five large medical databases up to 6 November 2008. Sixty-eight controlled studies were included. For each intervention type and age group, all relevant studies were pooled in a random effects meta-analysis.

RESULTS

In children, the highest reductions in mean BMI were achieved through promoting reduced television viewing [-0.27 kg/m(2) (95% CI -0.4 to -0.13 kg/m(2))]. Programmes combining physical activity, specifically themed or general health education and nutrition achieved a lower reduction [-0.1 kg/m(2) (95% CI -0.17 to -0.04 kg/m(2))]. Other interventions had high heterogeneity or showed no statistically significant reduction in outcomes. In adults, single component interventions were found to reduce both outcome measures. Their mean percentage body fat was reduced through education by -1.22% (95% CI -1.92 to -0.52).

CONCLUSION

The evidence for the effectiveness of promoting healthy weight in general populations is limited, though multi-component interventions in schools and encouraging reduced children's television viewing are promising strategies. Improving the reporting of outcomes is vital, as imputation of inadequately reported measures may have contributed to the observed heterogeneity. Longer follow-up is essential for understanding policy relevance.

A multivariate analysis of federally mandated school wellness policies on adolescent obesity

PURPOSE

To evaluate the effects of school wellness policies mandated by the 2004 Child Nutrition and WIC Reauthorization Act on the prevalence of overweight and obesity among adolescents.

METHODS

Multivariate logistic regressions, adjusted for clustering within school districts, were used to estimate the effects of district-level wellness policies on the odds of overweight and obesity among adolescents. The analyses were performed on a population-based sample obtained from the Utah Population Database, a compilation of vital characteristic, administrative, and genealogical records on all residents in Utah. Models controlled for individual, maternal, and familial characteristics, as well as characteristics of school district of residence. Self-reported body mass index was taken from drivers license data.

RESULTS

Each additional component included in a district's wellness policy was associated with as much as: 3.2% lower odds in the prevalence of adolescent overweight (OR = .968; 95% CI = .941-.997), 2.5% lower odds of obesity (OR = .975; CI = .952-.997), and 3.4% lower odds of severe obesity (OR = .966; CI = .938-.995). Wellness policy components related to diet were significantly associated with lower body mass indexes across all three thresholds, whereas those related to physical activity had significant associations for lower odds of severe obesity only.

CONCLUSION

Results suggest that school wellness policies can significantly reduce the risk of adolescent obesity. Further research should address specific policy components that are most effective in various populations, as well as the level of commitment that is required at both the school- and district-levels for sustained effect.

Contribution of social marketing strategies to community-based obesity prevention programmes in children

OBJECTIVES

To review child and adolescent obesity prevention programmes to determine whether they have included the Social Marketing Benchmark Criteria (BC). In addition, we analysed whether there was a relationship between the presence of the criteria and the effectiveness of the programme.

METHODS

Interventions had to be aimed at preventing obesity through behaviour changes relating to diet, physical activity, lifestyle and social support, separately or in combination. A total of 41 interventions were identified in PubMed and Embase that fulfilled the inclusion criteria.

RESULTS

The more recent the studies, the greater the number of the BC that seem to have been used. However, regarding behaviour changes, we found the most effective period to be 1997-2002, with 100% of the interventions resulting in behaviour changes (9/9). In addition, almost all interventions resulted in improvements in body composition variables: 5 of 6 for body mass index or overweight/obesity prevalence and 6 of 6 for skin-folds.

CONCLUSIONS

The presence of a higher number of BC does not assure higher effectiveness. Further research is required in this field. At the moment, studies aimed at preventing obesity in children and adolescents have not included social marketing aspects in their interventions in a comprehensive manner.

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.

Effects of strategies to promote children's physical activity on potential mediators

The aim of this paper is to review evidence of the effectiveness of interventions that present physical activity outcomes and potential mediators of behavioural change among 4-12-year-old children. A systematic search of electronic databases for original research articles published in peer-review journals between January 1985 and the end of June 2006 was carried out. A total of 19 studies that reported intervention effects on physical activity and mediators of behavioural change were identified. The most common mediators reported included physical activity knowledge or beliefs (11 studies); self-efficacy (8 studies); and enjoyment or preference for physical activity (6 studies). Less frequently reported mediators included attitudes, behavioural capability, intentions, outcome expectancies, social norms, social support and self-concept. Seven of the 11 interventions that reported intervention effects on knowledge/beliefs stated positive changes in this mediator. Four of the eight studies that reported intervention effects on self-efficacy had significant improvements; however, only two out of six interventions reported significant improvements in physical activity enjoyment or preference. None of the studies reviewed reported whether changes in these constructs mediated changes in children's physical activity behaviours. Although more than half of the studies reviewed reported a positive intervention effect on children's physical activity, no study carried out a mediating analysis to attempt to identify the mechanisms of change. Future research should more clearly identify the mediators of behavioural change that are being targeted and whether this explains intervention effects.

Improving the mental health, healthy lifestyle choices, and physical health of Hispanic adolescents: a randomized controlled pilot study

BACKGROUND

Obesity and mental health disorders are 2 major public health problems in American adolescents, with prevalence even higher in Hispanic teens. Despite the rapidly increasing incidence and adverse health outcomes associated with overweight and mental health problems, very few intervention studies have been conducted with adolescents to improve both their healthy lifestyles and mental health outcomes. Even fewer studies have been conducted with Hispanic youth. The purpose of this study was to evaluate the preliminary efficacy of the COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, and Nutrition) program, a manualized educational and cognitive behavioral skills-building program, on Hispanic adolescents' healthy lifestyle choices as well as mental and physical health outcomes.

METHODS

A cluster randomized controlled pilot study was conducted with 19 Hispanic adolescents enrolled in 2 health classes in a southwestern high school. One class received COPE and the other received an attention control program.

RESULTS

Adolescents in the COPE program increased their healthy lifestyle choices and reported a decrease in depressive and anxiety symptoms from baseline to postintervention follow-up. A subset of 7 overweight adolescents in the COPE program had a decrease in triglycerides and an increase in high-density lipoproteins. In addition, these overweight adolescents reported increases in healthy lifestyle beliefs and nutrition knowledge along with a decrease in depressive symptoms.

CONCLUSION

The COPE TEEN program is a promising school-based strategy for improving both physical and mental health outcomes in adolescents.

School-based interventions on childhood obesity: a meta-analysis

BACKGROUND

Over the past decade, childhood obesity has been recognized as an increasing health problem worldwide. It is a predictor of obesity during adulthood, which is strongly linked to chronic lifestyle diseases.

PURPOSE

This paper aims to evaluate the effectiveness of school-based programs in the prevention and management of childhood obesity.

METHODS

A comprehensive literature search was undertaken for RCTs and clinical controlled trials on school-based interventions that addressed childhood obesity, published between 1995 and 2007. The papers included for the meta-analysis were those in which ORs or standardized mean differences and their 95% CIs were reported or could be calculated from available data.

RESULTS

Meta-analysis showed that the odds of participants' being overweight and obese in the school-based intervention programs compared with the control arm were significantly protective in the short term (OR=0.74, 95% CI=0.60, 0.92). Interventions that were conducted for more than 1 year had a higher OR of decreasing the prevalence of obesity. However, intervention programs were not effective in decreasing BMI compared with control treatments, with a weighted mean difference of -0.62 (95% CI=-1.39, 0.14).

CONCLUSIONS

This meta-analysis showed that there was convincing evidence that school-based interventions are effective, at least short-term, in reducing the prevalence of childhood obesity. Longer-running programs were more effective than shorter programs.