Cardiovascular risk factor prevention in black schoolchildren: two-year results of the "Know Your Body" program

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

BACKGROUND

Physical activity among children and adolescents is associated with lower adiposity, improved cardio-metabolic health, and improved fitness. Worldwide, fewer than 30% of children and adolescents meet global physical activity recommendations of at least 60 minutes of moderate to vigorous physical activity per day. Schools may be ideal sites for interventions given that children and adolescents in most parts of the world spend a substantial amount of time in transit to and from school or attending school.

OBJECTIVES

The purpose of this review update is to summarise the evidence on effectiveness of school-based interventions in increasing moderate to vigorous physical activity and improving fitness among children and adolescents 6 to 18 years of age. Specific objectives are: • to evaluate the effects of school-based interventions on increasing physical activity and improving fitness among children and adolescents; • to evaluate the effects of school-based interventions on improving body composition; and • to determine whether certain combinations or components (or both) of school-based interventions are more effective than others in promoting physical activity and fitness in this target population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, BIOSIS, SPORTDiscus, and Sociological Abstracts to 1 June 2020, without language restrictions. We screened reference lists of included articles and relevant systematic reviews. We contacted primary authors of studies to ask for additional information.

SELECTION CRITERIA

Eligible interventions were relevant to public health practice (i.e. were not delivered by a clinician), were implemented in the school setting, and aimed to increase physical activity among all school-attending children and adolescents (aged 6 to 18) for at least 12 weeks. The review was limited to randomised controlled trials. For this update, we have added two new criteria: the primary aim of the study was to increase physical activity or fitness, and the study used an objective measure of physical activity or fitness. Primary outcomes included proportion of participants meeting physical activity guidelines and duration of moderate to vigorous physical activity and sedentary time (new to this update). Secondary outcomes included measured body mass index (BMI), physical fitness, health-related quality of life (new to this update), and adverse events (new to this update). Television viewing time, blood cholesterol, and blood pressure have been removed from this update.  DATA COLLECTION AND ANALYSIS: Two independent review authors used standardised forms to assess each study for relevance, to extract data, and to assess risk of bias. When discrepancies existed, discussion occurred until consensus was reached. Certainty of evidence was assessed according to GRADE. A random-effects meta-analysis based on the inverse variance method was conducted with participants stratified by age (children versus adolescents) when sufficient data were reported. Subgroup analyses explored effects by intervention type.

MAIN RESULTS

Based on the three new inclusion criteria, we excluded 16 of the 44 studies included in the previous version of this review. We screened an additional 9968 titles (search October 2011 to June 2020), of which 978 unique studies were potentially relevant and 61 met all criteria for this update. We included a total of 89 studies representing complete data for 66,752 study participants. Most studies included children only (n = 56), followed by adolescents only (n = 22), and both (n = 10); one study did not report student age. Multi-component interventions were most common (n = 40), followed by schooltime physical activity (n = 19), enhanced physical education (n = 15), and before and after school programmes (n = 14); one study explored both enhanced physical education and an after school programme. Lack of blinding of participants, personnel, and outcome assessors and loss to follow-up were the most common sources of bias.  Results show that school-based physical activity interventions probably result in little to no increase in time engaged in moderate to vigorous physical activity (mean difference (MD) 0.73 minutes/d, 95% confidence interval (CI) 0.16 to 1.30; 33 studies; moderate-certainty evidence) and may lead to little to no decrease in sedentary time (MD -3.78 minutes/d, 95% CI -7.80 to 0.24; 16 studies; low-certainty evidence). School-based physical activity interventions may improve physical fitness reported as maximal oxygen uptake (VO₂max) (MD 1.19 mL/kg/min, 95% CI 0.57 to 1.82; 13 studies; low-certainty evidence). School-based physical activity interventions may result in a very small decrease in BMI z-scores (MD -0.06, 95% CI -0.09 to -0.02; 21 studies; low-certainty evidence) and may not impact BMI expressed as kg/m² (MD -0.07, 95% CI -0.15 to 0.01; 50 studies; low-certainty evidence). We are very uncertain whether school-based physical activity interventions impact health-related quality of life or adverse events.

AUTHORS' CONCLUSIONS

Given the variability of results and the overall small effects, school staff and public health professionals must give the matter considerable thought before implementing school-based physical activity interventions. Given the heterogeneity of effects, the risk of bias, and findings that the magnitude of effect is generally small, results should be interpreted cautiously.

Individual-, family-, and school-level interventions targeting multiple risk behaviours in young people

BACKGROUND

Engagement in multiple risk behaviours can have adverse consequences for health during childhood, during adolescence, and later in life, yet little is known about the impact of different types of interventions that target multiple risk behaviours in children and young people, or the differential impact of universal versus targeted approaches. Findings from systematic reviews have been mixed, and effects of these interventions have not been quantitatively estimated.

OBJECTIVES

To examine the effects of interventions implemented up to 18 years of age for the primary or secondary prevention of multiple risk behaviours among young people.

SEARCH METHODS

We searched 11 databases (Australian Education Index; British Education Index; Campbell Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Embase; Education Resource Information Center (ERIC); International Bibliography of the Social Sciences; MEDLINE; PsycINFO; and Sociological Abstracts) on three occasions (2012, 2015, and 14 November 2016)). We conducted handsearches of reference lists, contacted experts in the field, conducted citation searches, and searched websites of relevant organisations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster RCTs, which aimed to address at least two risk behaviours. Participants were children and young people up to 18 years of age and/or parents, guardians, or carers, as long as the intervention aimed to address involvement in multiple risk behaviours among children and young people up to 18 years of age. However, studies could include outcome data on children > 18 years of age at the time of follow-up. Specifically,we included studies with outcomes collected from those eight to 25 years of age. Further, we included only studies with a combined intervention and follow-up period of six months or longer. We excluded interventions aimed at individuals with clinically diagnosed disorders along with clinical interventions. We categorised interventions according to whether they were conducted at the individual level; the family level; or the school level.

DATA COLLECTION AND ANALYSIS

We identified a total of 34,680 titles, screened 27,691 articles and assessed 424 full-text articles for eligibility. Two or more review authors independently assessed studies for inclusion in the review, extracted data, and assessed risk of bias.We pooled data in meta-analyses using a random-effects (DerSimonian and Laird) model in RevMan 5.3. For each outcome, we included subgroups related to study type (individual, family, or school level, and universal or targeted approach) and examined effectiveness at up to 12 months' follow-up and over the longer term (> 12 months). We assessed the quality and certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included in the review a total of 70 eligible studies, of which a substantial proportion were universal school-based studies (n = 28; 40%). Most studies were conducted in the USA (n = 55; 79%). On average, studies aimed to prevent four of the primary behaviours. Behaviours that were most frequently addressed included alcohol use (n = 55), drug use (n = 53), and/or antisocial behaviour (n = 53), followed by tobacco use (n = 42). No studies aimed to prevent self-harm or gambling alongside other behaviours.Evidence suggests that for multiple risk behaviours, universal school-based interventions were beneficial in relation to tobacco use (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.60 to 0.97; n = 9 studies; 15,354 participants) and alcohol use (OR 0.72, 95% CI 0.56 to 0.92; n = 8 studies; 8751 participants; both moderate-quality evidence) compared to a comparator, and that such interventions may be effective in preventing illicit drug use (OR 0.74, 95% CI 0.55 to 1.00; n = 5 studies; 11,058 participants; low-quality evidence) and engagement in any antisocial behaviour (OR 0.81, 95% CI 0.66 to 0.98; n = 13 studies; 20,756 participants; very low-quality evidence) at up to 12 months' follow-up, although there was evidence of moderate to substantial heterogeneity (I² = 49% to 69%). Moderate-quality evidence also showed that multiple risk behaviour universal school-based interventions improved the odds of physical activity (OR 1.32, 95% CI 1.16 to 1.50; I² = 0%; n = 4 studies; 6441 participants). We considered observed effects to be of public health importance when applied at the population level. Evidence was less certain for the effects of such multiple risk behaviour interventions for cannabis use (OR 0.79, 95% CI 0.62 to 1.01; P = 0.06; n = 5 studies; 4140 participants; I² = 0%; moderate-quality evidence), sexual risk behaviours (OR 0.83, 95% CI 0.61 to 1.12; P = 0.22; n = 6 studies; 12,633 participants; I² = 77%; low-quality evidence), and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06; P = 0.13; n = 3 studies; 6441 participants; I² = 49%; moderate-quality evidence). It is important to note that some evidence supported the positive effects of universal school-level interventions on three or more risk behaviours.For most outcomes of individual- and family-level targeted and universal interventions, moderate- or low-quality evidence suggests little or no effect, although caution is warranted in interpretation because few of these studies were available for comparison (n ≤ 4 studies for each outcome).Seven studies reported adverse effects, which involved evidence suggestive of increased involvement in a risk behaviour among participants receiving the intervention compared to participants given control interventions.We judged the quality of evidence to be moderate or low for most outcomes, primarily owing to concerns around selection, performance, and detection bias and heterogeneity between studies.

AUTHORS' CONCLUSIONS

Available evidence is strongest for universal school-based interventions that target multiple- risk behaviours, demonstrating that they may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behaviour, and in improving physical activity among young people, but not in preventing other risk behaviours. Results of this review do not provide strong evidence of benefit for family- or individual-level interventions across the risk behaviours studied. However, poor reporting and concerns around the quality of evidence highlight the need for high-quality multiple- risk behaviour intervention studies to further strengthen the evidence base in this field.

A systematic review of children's dietary interventions with parents as change agents: Application of the RE-AIM framework

INTRODUCTION

Interventions targeting children's dietary behavior often include strategies that target parents as implementation agents of change, though parent involvement on intervention effectiveness is unclear. The present study systematically assessed (1) reporting of reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of child dietary intervention studies with parents as change agents and (2) evaluated within these studies the comparative effectiveness of interventions with and without a parent component.

METHODS

The search was conducted in PubMed, PsycINFO, and Cochrane Library. Eligible studies were required to include a condition with a parental component, a comparison/control group, and target a child dietary behavior outcome. Forty-nine articles met criteria. Raters extracted RE-AIM and parent implementation information for each study.

RESULTS

Effectiveness (72.5%) was the highest reported RE-AIM element, followed by reach (27.5%), adoption (12.5%), implementation (10%), and maintenance (2.5%). Median reporting of parent implementation was highest for adoption and enactment (20%), followed by receipt (7.5%), and maintenance (2.5%). Six studies tested comparative effectiveness of parental involvement on child dietary outcomes.

CONCLUSION

Current RE-AIM reporting among children's dietary interventions is inchoate. The contribution of parental involvement on intervention effectiveness remains unclear. Increased focus should be placed on reporting of external validity information, to enable better translation of research to practical applications.

Implications for public health research of models and theories of disability: a scoping study and evidence synthesis

Background

Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments.

Objectives

(1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice.

Review methods

The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people.

Results

The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability.

Limitations

The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action.

Conclusions

Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability.

Future work

Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

Funding

The National Institute for Health Research Public Health Research programme.

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

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

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.

Effect of childhood obesity prevention programmes on blood lipids: a systematic review and meta-analysis

We aimed to assess the effects of childhood obesity prevention programmes on blood lipids in high-income countries. We searched MEDLINE®, Embase, PsychInfo, CINAHL®, clinicaltrials.gov, and the Cochrane Library up to 22 April 2013 for relevant randomized controlled trials, quasi-experimental studies and natural experiments published in English. Studies were included if they implemented diet and/or physical activity intervention(s) with ≥1 year follow-up (or ≥6 months for school-based intervention studies) in 2-18-year-olds, and were excluded if they targeted only overweight/obese children, or those with a pre-existing medical condition. Seventeen studies were finally included. For total cholesterol, the pooled intervention effect was -0.97 mg dL(-1) [95% confidence interval (CI): -3.26, 1.32; P = 0.408]; for low-density lipoprotein cholesterol (LDL-C), -6.06 mg dL(-1) (95% CI: -11.09, -1.02; P = 0.018); for high-density lipoprotein cholesterol (HDL-C), 1.87 mg dL(-1) (95% CI: 0.39, 3.34; P = 0.013); and for triglycerides, -1.95 mg dL(-1) (95% CI: -4.94, 1.04; P = 0.202). Most interventions (70%) showed similar significant or no effects on adiposity- and lipids outcomes: 15% interventions improved both adiposity- and lipids outcomes; 55% had no significant effects on either. Childhood obesity prevention programmes had a significant desirable effect on LDL-C and HDL-C. Two-thirds of interventions showed similar significant or no effects in adiposity- and lipids outcomes. Assessing lipids outcomes provide additional useful information on obesity prevention programme benefits.

Action Schools! BC implementation: from efficacy to effectiveness to scale-up

OBJECTIVES

To describe Action Schools! BC (AS! BC) from efficacy to scale-up.

PARTICIPANTS/SETTING

Education and health system stakeholders and children in grades 4-6 from elementary schools in British Columbia, Canada.

INTERVENTION

At the provincial level, the AS! BC model reflected socioecological theory and a partnership approach to social change. Knowledge translation and exchange were embedded as a foundational element. At the school level, AS! BC is a comprehensive school health-based model providing teachers and schools with training and resources to integrate physical activity (PA) and healthy eating (HE) into the school environment. Our research team partnered with key community and government stakeholders to deliver and evaluate AS! BC over efficacy, effectiveness and implementation trials.

RESULTS

On the basis of significant increases in PA, cardiovascular fitness, bone and HE in AS! BC schools during efficacy trials, the BC government supported a provincial scale-up. Since its inception, the AS! BC Support Team and >225 trained regional trainers have delivered 4677 teacher-focused workshops (training approximately 81,000 teachers), reaching approximately 500,000 students. After scale-up, PA delivery was replicated but the magnitude of change appeared less. One (HE) and 4 (PA) years after scale-up, trained AS! BC teachers provided more PA and HE opportunities for students even in the context of supportive provincial policies.

CONCLUSIONS

Whole school models like AS! BC can enhance children's PA and health when implemented in partnership with key stakeholders. At the school level, adequately trained and resourced teachers and supportive school policies promoted successful scale-up and sustained implementation. At the provincial level, multisectoral partnerships and embedded knowledge exchange mechanisms influenced the context for action at the provincial and school level, and were core elements of successful implementation.

TRIAL REGISTRATION NUMBER

Clinical Trials Registry NCT01412203.

Effect of childhood obesity prevention programs on blood pressure: a systematic review and meta-analysis

BACKGROUND

Childhood overweight and obesity are associated with elevated blood pressure (BP). However, little is known about how childhood obesity lifestyle prevention programs affect BP. We assessed the effects of childhood obesity prevention programs on BP in children in developed countries.

METHODS AND RESULTS

We searched databases up to April 22, 2013, for relevant randomized, controlled trials, quasi-experimental studies, and natural experiments. Studies were included if they applied a diet or physical activity intervention(s) and were followed for ≥ 1 year (or ≥ 6 months for school-based intervention studies); they were excluded if they targeted only overweight/obese subjects or those with a medical condition. In our meta-analysis, intervention effects were calculated for systolic BP and diastolic BP with the use of weighted random-effects models. Of the 23 included intervention studies (involving 18 925 participants), 21 involved a school setting. Our meta-analysis included 19 studies reporting on systolic BP and 18 on diastolic BP. The pooled intervention effect was -1.64 mm Hg (95% confidence interval, -2.56 to -0.71; P=0.001) for systolic BP and -1.44 mm Hg (95% confidence interval, -2.28 to -0.60; P=0.001) for diastolic BP. The combined diet and physical activity interventions led to a significantly greater reduction in both systolic BP and diastolic BP than the diet-only or physical activity-only intervention. Thirteen interventions (46%) had a similar effect on both adiposity-related outcomes and BP, whereas 11 interventions (39%) showed a significant desirable effect on BP but not on adiposity-related outcomes.

CONCLUSIONS

Obesity prevention programs have a moderate effect on reducing BP, and those targeting both diet and physical activity seem to be more effective.

Implementation of a school-based internet obesity prevention program for adolescents

OBJECTIVE

To evaluate the reach, adoption, and implementation of HEALTH[e]TEEN, a school-based Internet obesity prevention program, and examine differences in student participation and satisfaction by school, gender, age, and race/ethnicity.

DESIGN

Concurrent mixed method evaluation.

SETTING

Three public high schools in Connecticut.

PARTICIPANTS

Three hundred eighty-four adolescents, 8 teachers.

INTERVENTION(S)

HEALTH[e]TEEN vs HEALTH[e]TEEN plus coping skills training.

MAIN OUTCOME MEASURE(S)

Demographic and state-available data, measurements of student satisfaction and participation, interviews with school administrators and teachers.

ANALYSIS

Mixed and logistic models, content analysis.

RESULTS

The sample (n = 384) was diverse (35% white), with a mean age of 15.3 years and mean body mass index of 24.7 kg/m(2). Student participation (83% of lessons completed) and satisfaction (mean 3.6 out of 5) was high. Schools implementing the program in class had higher satisfaction and participation compared with schools that implemented the program as homework (P ≤ .001 and < .001, respectively). Girls had higher satisfaction and participation compared with boys (P = .02 and .03, respectively). Younger students had higher participation compared with older students, but no difference in satisfaction was noted (P = .03).

CONCLUSIONS AND IMPLICATIONS

Two school-based Internet programs to decrease obesity reached diverse adolescents, and were adopted and implemented with high student satisfaction and participation. Implementation of the intervention was influenced by setting (classroom vs homework), teacher characteristics, student age, and gender.

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.

Cut-off values of body mass index, waist circumference, and waist-to-height ratio to identify excess abdominal fat: population-based screening of Japanese school children

Background

School-based screening and prevention programs for adiposity generally target school children in grades 4 and 6 (age 9–11 years). The aims of this study were to evaluate the validity of body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR) in identifying abdominal adiposity in fifth-grade Japanese school children and to determine optimal cut-off values for anthropometric measures.

Methods

The target population was fifth-grade school children enrolled in 2 schools in Shizuoka, Japan between 2008 and 2010; 422 of the 466 children participated in the present study. Abdominal adiposity was defined as percent trunk fat in the 95th percentile or higher, as determined by dual-energy x-ray absorptiometry (DXA). We analyzed the validity of BMI, WC, and WHtR using receiver operating characteristic (ROC) curve analysis. The Youden index was used to determine cut-off values of BMI, WC, and WHtR that identify excess abdominal fat.

Results

Optimal cut-off values to identify abdominal adiposity were 20.8 kg/m² (BMI), 76.5 cm (WC), and 0.519 (WHtR) for boys, and 19.6 kg/m² (BMI), 73.0 cm (WC), and 0.499 (WHtR) for girls. Areas under the ROC curve were 0.983 (BMI), 0.987 (WC), and 0.981 (WHtR) for boys, and 0.981 (BMI), 0986 (WC), and 0.992 (WHtR) for girls.

Conclusions

BMI, WC, and WHtR successfully identified a high proportion of children with excess abdominal fat as measured by DXA, demonstrating that these measures are useful indices for school screening.

Policy options to support physical activity in schools

Rates of child and youth obesity and associated chronic diseases are rising worldwide, in part as a result of inadequate physical activity (PA) levels. Environmental change is needed in multiple settings to encourage the adoption of healthy lifestyle behaviours at an early age. Schools are an ideal setting in which to incorporate a variety of interventions in order to improve student PA levels and healthy eating environments. This paper reviews effective and promising policies for increasing PA levels in the school setting and introduces other untested interventions that could become the basis of future well-designed studies. Policies outlined in this review should be considered by a range of stakeholders and be carefully monitored and evaluated. These policies should include daily, quality, safe physical education and physical activity; extracurricular physical activity; training of physical activity leaders; active transportation to and from school; adequate facilities; and community outreach. Successful school initiatives and stakeholders should also be recognized formally for their contribution.

Height-specific serum cholesterol levels in pubertal children: data from population-based Japanese school screening

Background

Inverse associations between height and serum lipid levels in pubertal children have been reported. To develop criteria for normal serum lipid levels stratified by height in pubertal children, we examined height-specific cholesterol levels, using data from a population-based school screening.

Methods

Serum levels of total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) were investigated in 10 151 children (98.9% of the target population) aged 10 and 14 years who attended public schools in Iwata City from 2002 through 2007.

Results

The 95th percentiles of TC in the lowest and highest quintiles of height were 221 and 219 mg/dL, respectively, in 10-year-old boys, 215 and 203 mg/dL in 14-year-old boys, 220 and 204 mg/dL in 10-year-old girls, and 226 and 214 mg/dL in 14-year-old girls. The fifth percentiles of HDL-C in the lowest and highest quintiles of height were 45 and 43 mg/dL in 10-year-old boys, 43 and 40 mg/dL in 14-year-old boys, 46 and 42 mg/dL in 10-year-old girls, and 47 and 44 mg/dL in 14-year-old girls.

Conclusions

This study provided height-specific levels of serum lipids in 10-year-old and 14-year-old children. Height should be considered when evaluating cholesterol levels in pubertal children.

Relationship between height and blood pressure in Japanese schoolchildren

BACKGROUND

Blood pressure examinations for health education use have been conducted at several schools in Japan. It has been reported that blood pressure is closely associated with bodyweight and height in US children. The aim of the present paper was to evaluate the association between height and blood pressure in Japanese schoolchildren.

METHODS

In Iwata city in Japan, blood pressure screening was conducted by the school administration. A total of 98.9% (10,152/10,270 children) of all fifth (10-year-olds) and ninth graders (14-year-olds) residing in the Old Iwata area from 2002 to 2007 were analyzed.

RESULTS

In 10-year-old and 14-year-old boys, regression analysis indicated that a positive correlation between weight and blood pressure was the strongest among the three body size indices (height, weight, and body mass index), but the association between height and blood pressure was also significant. For girls from both the 10 and 14 year age groups, the correlation of weight and blood pressure was stronger than those for the other body size indices, but there were also significant associations between height and blood pressure, except for height and diastolic blood pressure in the 14-year-olds.

CONCLUSIONS

There is a significant positive relationship between height and blood pressure. Further study is necessary to provide a blood pressure reference based on height in the Japanese program to prevent children from developing lifestyle-related risk factors.

Parental involvement in interventions to improve child dietary intake: a systematic review

OBJECTIVE

Interventions that aim to improve child dietary quality and reduce disease risk often involve parents. The most effective methods to engage parents remain unclear. A systematic review of interventions designed to change child and adolescent dietary behavior was conducted to answer whether parent involvement enhanced intervention effectiveness, and what type of involvement was most effective in achieving desired outcomes.

METHOD

In 2008, Pub Med, Medline, Psych Info, and Cochrane Library databases were searched to identify programs designed to change child and adolescent dietary intake that also involved parents. Methods of parental involvement were categorized based on the type and intensity of parental involvement. These methods were compared against intervention design, dietary outcomes, and quality of reporting (evaluated using CONSORT checklist) for each study.

RESULTS

The literature search identified 1774 articles and 24 met review criteria. Four studies systematically evaluated parent involvement with inconsistent results. Indirect methods to engage parents were most commonly used, although direct approaches were more likely to result in positive outcomes. Four studies met >70% of CONSORT items.

CONCLUSION

Limited conclusions may be drawn regarding the best method to involve parents in changing child diet to promote health. However, direct methods show promise and warrant further research.

A culturally appropriate school wellness initiative: results of a 2-year pilot intervention in 2 Jewish schools

BACKGROUND

Despite the growing number of school-based interventions designed to reduce childhood obesity or otherwise promote health, no models or materials were found for Jewish schools. The current study describes an effort within a Jewish school system in Chicago to create, implement, and evaluate a school-based intervention tailored to the unique characteristics of Jewish religion, culture, and school structures.

METHODS

Two schools (with approximately 600 students) were selected for the 2-year pilot study. The schools were required to form a wellness council, write a wellness policy, and implement policy changes or activities in 5 target areas (health education, physical education, school environment, family involvement, and staff wellness). Objectives were measured using pre- and postintervention surveys for students, as well as the School Health Index and other tools.

RESULTS

Findings showed several significant increases in student knowledge, as well as an increase in the percentage of older students regularly meeting physical activity guidelines. Few changes in attitudes, other behaviors, or environmental factors were seen.

CONCLUSIONS

Due to a strong partnership between researchers, schools, and community organizations, meaningful changes were made within the pilot schools. These changes were reflected in a limited number of improvements in student knowledge and activity levels. Future work is needed to determine how to bring about behavioral changes, how to increase the sustainability of all of the changes, and how to disseminate the model and products of this intervention to other day schools.

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.

Systematic Review of Interventions to Increase Physical Activity and Physical Fitness in African-Americans

Objective.

To identify characteristics of effective interventions designed to increase physical activity (PA) or fitness among African-Americans.

Data Sources.

Articles published between 1985 and 2006.

Study Inclusion Criteria.

Studies reporting PA or fitness change data in African-American participants were included.

Data Extraction.

Information on study design, intervention, data collection methods, and outcomes was extracted using a standardized form.

Data Synthesis.

Studies were ranked on quality and were summarized separately for adults and children.

Results.

We identified 29 studies in adults and 14 studies in children. Most were randomized controlled trials. All but six specifically targeted African-Americans; comparisons of effectiveness in African-Americans vs. others were not possible. Methodological heterogeneity limited comparisons of findings across studies. In adults, most studies showed significant within-group pre-post improvements in PA, but only 10 studies found differences between intervention and comparison groups. Most studies in children were null.

Conclusions.

Effective programs in adults were from randomized controlled trials and involved structured exercise programs. Studies with explicit cultural adaptations did not necessarily result in better PA outcomes. Additional studies are needed with larger sample sizes, longer follow-up, attention controls, strategies informed by proven behavior change theories, and objective PA assessment.

Prevention of childhood obesity - what type of evidence should we consider relevant?

Two reviews, one by Summerbell et al. and the other by Doak et al. came to very different conclusions about the effectiveness of childhood obesity interventions. The aim of this commentary is to assess the extent to which inclusion and exclusion criteria, and the definition of effective outcomes, explain discrepant results. Differences in results were compared by inclusion criteria and outcome definitions. The most important summary recommendations for inclusion/exclusion criteria were to exclude all non-peer review articles, to maintain a 6-month lower limit for duration of study, to include interventions from before 1990, to include pre-school age groups, to include pilot studies and to intervene in high-risk communities. Authors did not reach consensus regarding inclusion of aims not specific to preventing weight gain and the manner of assessment of anthropometric measures. Combining both reviews and applying agreed exclusion criteria leaves 30 interventions; 50% are positive. Excluding studies without an aim specific to preventing weight gain leaves 10/24 (42%) positive interventions. The differences in the results of these two reviews relate to the inclusion criteria and outcome assessments. These findings underscore the importance of the evidence considered in assessing interventions.

School-based smoking prevention programs with the promise of long-term effects

I provide a systematic review of trials of school-based smoking prevention programs that had at least 15 sessions, preferably with some in high school, that reported significant short-term effects, and that included long-term follow-up. This is supplemented with a description of some other programs that produce short-term effects that portend large long-term effects. I conclude that school-based programs can have long-term effects of practical importance it they: include 15 or more sessions over multiple years, including some in high school; use the social influence model and interactive delivery methods; include components on norms, commitment not to use, intentions not to use, and training and practice in the use of refusal and other life skills; and use peer leaders in some role. School-based programs of this type can reduce smoking onset by 25-30%, and school plus community programs can reduce smoking onset by 35-40% by the end of high school. Some early childhood programs that do not have smoking prevention as their main aim, including home nursing, the Good Behavior Game, the Positive Action program and others, seem to change the developmental trajectories of children so that they are less likely to engage in multiple problem behaviors, including smoking, as adolescents. This review makes it clear that effective school-based smoking prevention programs exist and can be adopted, adapted and deployed with success - and should be.

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

BACKGROUND

The World Health Organization estimates that 1.9 million deaths worldwide are attributable to physical inactivity. Chronic diseases associated with physical inactivity include cancer, diabetes and coronary heart disease.

OBJECTIVES

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

SEARCH STRATEGY

The search strategy included searching several databases. 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, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, report on outcomes for children and adolescents (aged 6 to 18 years), and use a prospective design with a control group.

DATA COLLECTION AND ANALYSIS

Standardized tools were used by two independent reviewers to rate each study's methodological quality and for data extraction. 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

13,841 titles were identified and screened and 482 articles were retrieved. Multiple publications on the same project were combined and counted as one project, resulting in 395 distinct project accounts (studies). Of the 395 studies 104 were deemed relevant and of those, four were assessed as having strong methodological quality, 22 were of moderate quality and 78 were considered weak. In total 26 studies were included in the review. There is good evidence that school-based physical activity interventions have 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 no effect on leisure time physical activity rates, systolic and diastolic blood pressure, body mass index, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity result in positive effects.

AUTHORS' CONCLUSIONS

Given that there are no harmful effects and that there is some evidence of positive effects on lifestyle behaviours and physical health status measures, ongoing physical activity promotion in schools is recommended at this time.

School-based obesity interventions: a literature review

BACKGROUND

Childhood obesity is an impending epidemic. This article is an overview of different interventions conducted in school settings so as to guide efforts for an effective management of obesity in children, thus minimizing the risk of adult obesity and related cardiovascular risk.

METHODS

PubMed and OVID Medline databases were searched for school-based obesity interventions with anthropometric measures in children and adolescents between the ages of 7 and 19 years from June 1986 to June 2006. Studies were reviewed by duration, type of intervention, and defined qualitative and quantitative measures, resulting in a yield of 51 intervention studies.

RESULTS

The interventions ranged from 4 weeks in length to as long as 8 continuing years. In total, 15 of the intervention studies exclusively utilized physical activity programs, 16 studies exclusively utilized educational models and behavior modification strategies, and 20 studies utilized both. In addition, 31 studies utilized exclusively quantitative variables like body mass indices and waist-to-hip ratios to measure the efficacy of the intervention programs, and another 20 studies utilized a combination of quantitative and qualitative measures that included self-reported physical activity and attitude toward physical activity and the tested knowledge of nutrition, cardiovascular health, and physical fitness. A total of 40 studies achieved positive statistically significant results between the baseline and the follow-up quantitative measurements.

CONCLUSIONS

No persistence of positive results in reducing obesity in school-age children has been observed. Studies employing long-term follow-up of quantitative and qualitative measurements of short-term interventions in particular are warranted.

Community and family perspectives on addressing overweight in urban, African-American youth

OBJECTIVE

To assess weight-related beliefs and concerns of overweight urban, African-American children, their parents, and community leaders before developing a family-based intervention to reduce childhood overweight and diabetes risk.

DESIGN

We conducted 13 focus groups with overweight children and their parents and eight semistructured interviews with community leaders.

PARTICIPANTS AND SETTING

Focus group participants (N = 67) from Chicago's South Side were recruited through flyers in community sites. Interview participants (N = 9) were recruited to sample perspectives from health, fitness, education, civics, and faith leaders.

RESULTS

Community leaders felt awareness was higher for acute health conditions than for obesity. Parents were concerned about their children's health, but felt stressed by competing priorities and constrained by lack of knowledge, parenting skills, time, and financial resources. Parents defined overweight in functional terms, whereas children relied upon physical appearances. Children perceived negative social consequences of overweight. Parents and children expressed interest in family-based interventions to improve nutrition and physical activity and offered suggestions for making programs interesting.

CONCLUSIONS

This study provides insights into the perspectives of urban, African-American overweight children, their parents, and community leaders regarding nutrition and physical activity. The specific beliefs of these respondents can become potential leverage points in interventions.

Nutrition education and Mediterranean diet: exploring the teaching process of a school-based nutrition and media education project in Cretan primary schools

Background:

During the past few decades there has been a gradual abandoning of the traditional Mediterranean diet by the population of Crete and especially among the younger generations. Since this is related to the rapidly increasing morbidity and mortality rates from chronic diseases, the need for educating young people on the principles of good nutrition becomes increasingly important. It is also acknowledged that the epidemiological field needs to focus on studying the implementation process, since this will allow for a deeper understanding of the outcomes.

Objectives:

The aims of the present study were to explore the process of implementing an innovation in Cretan primary schools and to identify best teaching practices and principles.

Design:

In three state primary schools on the island of Crete, 107 children took part in a 30-h nutrition and media education programme. Classroom observations were used to define attitudes towards the programme and teaching methods. Besides baseline and post evaluation, the pupils were also interviewed about 11 months after the end of the programme.

Implementation:

During observation of the teaching process, emerging issues were the teacher's motivation and interest in the course, his/her preparation before each class, teaching ability and communication skills, the respect and discipline he/she kept and the innovative teaching methods used. In some cases researcher intervention in the classroom could not be avoided.

Findings and conclusions:

Overall, individual teacher willingness and teaching skills were mainly responsible for the quality of teaching, the variety of educational methods used in classrooms and pupils' interest in the course. Changes in pupils' knowledge and recall of the course were related to teacher enthusiasm but also to researcher intervention. Exploring the teaching and learning process allowed a deeper understanding of the data. It is concluded that attempts to introduce the principles of a Mediterranean diet to children through nutrition education require innovative, enthusiastic and highly motivated teachers.

Body size preferences and sociocultural influences on attitudes towards obesity among Moroccan Sahraoui women

The purpose of this investigation was to study body size preferences and to examine the influence of sociocultural factors on obesity among 249 Moroccan Sahraoui women. Participants rated their ideal body size and the size they thought to be "healthy," using a figural scale consisting of nine images ranging from thin to obese. They also noted which particular sociocultural influences affected their body size ratings. The results indicated that women's rating of ideal body size (4.88) was significantly larger than their rating of healthy body size (4.33). The desire to lose weight was very low even among the majority of obese women, and educational level did not affect desire to lose weight. Women not satisfied with their body size were more likely to report trying to gain weight rather than to lose it. The major factors reported to influence body size ideal were mothers, men, and traditional clothing. It is an enormous challenge for the health institutions of Morocco to prevent obesity and its complications. Prevention programs should include teenagers and key family members.

A meta-analytic review of obesity prevention programs for children and adolescents: the skinny on interventions that work

This meta-analytic review summarizes obesity prevention programs and their effects and investigates participant, intervention, delivery, and design features associated with larger effects. A literature search identified 64 prevention programs seeking to produce weight gain prevention effects, of which 21% produced significant prevention effects that were typically pre- to post effects. Larger effects emerged for programs that targeted children and adolescents (vs. preadolescents) and females, programs that were relatively brief, programs that solely targeted weight control versus other health behaviors (e.g., smoking), programs evaluated in pilot trials, and programs wherein participants must have self-selected into the intervention. Other factors, including mandated improvements in diet and exercise, sedentary behavior reduction, delivery by trained interventionists, and parental involvement, were not associated with significantly larger effects.

Hip-Hop to Health Jr. for Latino preschool children

OBJECTIVE

Hip-Hop to Health Jr. was a diet/physical activity intervention designed to reduce gains in BMI (kilograms per meter squared) in preschool minority children.

RESEARCH METHODS AND PROCEDURES

Twelve predominantly Latino Head Start centers participated in a group-randomized trial conducted between Fall 2001 and Winter 2003. Six centers were randomized to a culturally proficient 14-week (three times weekly) diet/physical activity intervention. Parents participated by completing weekly homework assignments. The children in the other six centers received a general health intervention that did not address either diet or physical activity. The primary outcome was change in BMI, and secondary outcomes were changes in dietary intake and physical activity. Measures were collected at baseline, post-intervention, and at Years 1 and 2 follow-up.

RESULTS

There were no significant differences between intervention and control schools in either primary or secondary outcomes at post-intervention, Year 1, or Year 2 follow-ups.

DISCUSSION

When Hip-Hop to Health Jr. was conducted in predominantly black Head Start centers, it was effective in reducing subsequent increases in BMI in preschool children. In contrast, when the program was conducted in Latino centers, it was not effective. Although the intervention did not prevent excessive weight gain in Latino children, it was very well received. Future interventions with this population may require further cultural tailoring and a more robust parent intervention.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising in some countries. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomized controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomized controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomized to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomized controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we computed pooled estimates only for those trials that could be analyzed together and for which statistical data were available. We predominantly synthesized the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence; multi-modal programmes). Within each group, we placed them into three categories (low, medium and high risk of bias) according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 94 randomized controlled trials identified, we classified 23 as category one (most valid). There was one category one study of information-giving and two of teaching social comeptence. There were thirteen category one studies of social influences interventions. Of these, nine found some positive effect of intervention on smoking prevalence, and four failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive eight-year programme on smoking behaviour. There were three category one RCTs of combined social influences and social competence interventions: one provided significant results and one only for instruction by health educators compared to self-instruction. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was one category one study providing data on social influences compared with information giving. There were four category one studies of multi-modal approaches but they provided limited evidence about the effectiveness of multi-modal approaches including community initiatives.

AUTHORS' CONCLUSIONS

There is one rigorous test of the effects of information-giving about smoking. There are well-conducted randomized controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies failed to detect an effect of the intervention. There are only three high quality RCTs which test the effectiveness of combinations of social influences and social competence interventions, and four which test multi-modal interventions; half showed significant positive results.

Position of the American Dietetic Association: individual-, family-, school-, and community-based interventions for pediatric overweight

The American Dietetic Association (ADA), recognizing that overweight is a significant problem for children and adolescents in the United States, takes the position that pediatric overweight intervention requires a combination of family-based and school-based multi-component programs that include the promotion of physical activity, parent training/modeling, behavioral counseling, and nutrition education. Furthermore, although not yet evidence-based, community-based and environmental interventions are recommended as among the most feasible ways to support healthful lifestyles for the greatest numbers of children and their families. ADA supports the commitment of resources for programs, policy development, and research for the efficacious promotion of healthful eating habits and increased physical activity in all children and adolescents, regardless of weight status. This is the first position paper of ADA to be based on a rigorous systematic evidence-based analysis of the pediatric overweight literature on intervention programs. The research showed positive effects of two specific kinds of overweight interventions: a) multicomponent, family-based programs for children between the ages of 5 and 12 years, and b) multicomponent, school-based programs for adolescents. Multicomponent programs include behavioral counseling, promotion of physical activity, parent training/modeling, dietary counseling, and nutrition education. Analysis of the literature to date points to the need for further investigation of promising strategies not yet adequately evaluated. Furthermore, this review highlights the need for research to develop effective and innovative overweight prevention programs for various sectors of the population, including those of varying ethnicities, young children, and adolescents. To support and enhance the efficacy of family- and school-based weight interventions, community-wide interventions should be undertaken; few such interventions have been conducted and even fewer evaluated.

The prevention of overweight and obesity in children and adolescents: a review of interventions and programmes

Overweight and obesity are serious, large-scale, global, public health concerns requiring population-based childhood overweight and obesity prevention. The overall objective of this review is to identify aspects of successful childhood overweight prevention programmes. This objective will be met by assessing existing interventions quantitatively as well as qualitatively, identifying efficacy, effectiveness and implementation, and evaluating potential adverse effects of previous studies. This review was limited to school-based studies with a quantitative evaluation using anthropometric outcomes and that intervene on diet or activity-related behaviours. Quantitative and qualitative approaches are used to identify factors related to successful interventions as well as adverse consequences. Sixty-eight per cent of the interventions, or 17 of the 25, were 'effective' based on a statistically significant reduction in body mass index (BMI) or skin-folds for the intervention group. Four interventions were effective by BMI as well as skin-fold measures. Of these, two targeted reductions in television viewing. The remaining two studies targeted direct physical activity intervention through the physical education programme combined with nutrition education. Of the interventions reported here, one was effective in reducing childhood overweight but was also associated with an increase in underweight prevalence. Few other studies reported outcomes for underweight. The majority of overweight/obesity prevention programmes included in this review were effective. Physical education in schools and reducing television viewing are two examples of interventions that have been successful. Because few studies report on underweight prevalence, this review recommends giving more attention to preventing adverse outcomes by reporting the intervention impact on the frequency distribution for both BMI and adiposity measures.

An approach to improving science knowledge about energy balance and nutrition among elementary- and middle-school students

Unhealthy diets, lack of fitness, and obesity are serious problems in the United States. The Centers for Disease Control, Surgeon General, and Department of Health and Human Services are calling for action to address these problems. Scientists and educators at Baylor College of Medicine and the National Space Biomedical Research Institute teamed to produce an instructional unit, "Food and Fitness," and evaluated it with students in grades 3-7 in Houston, Texas. A field-test group (447 students) completed all unit activities under the guidance of their teachers. This group and a comparison group (343 students) completed pre and postassessments measuring knowledge of concepts covered in the unit. Outcomes indicate that the unit significantly increased students' knowledge and awareness of science concepts related to energy in living systems, metabolism, nutrients, and diet. Pre-assessment results suggest that most students understand concepts related to calories in food, exercise and energy use, and matching food intake to energy use. Students' prior knowledge was found to be much lower on topics related to healthy portion sizes, foods that supply the most energy, essential nutrients, what "diet" actually means, and the relationship between body size and basal metabolic rate.

A practical model for preventing type 2 diabetes in minority youth

PURPOSE

This article proposes a model grounded in behavioral theory and empirical evidence for use when developing a program to prevent type 2 diabetes in high-risk minority youth.

METHODS

The model is based on key concepts of 4 behavioral theories: the Health Belief Model, Social Learning Theory, the Theory of Planned Behavior, and the Ecological Model. Determinants of behavior to target for change are selected based on their theoretical link to behavior change, their success in changing behavior in past programs, and through thorough formative research in the target community.

RESULTS

Diabetes prevention in children requires modifying a complex set of behavior patterns. Social norms and the environment are especially important in children in whom cognitive processes have not fully developed. Family and community involvement is essential for developing a health program and providing a supportive environment in which to change behavior and ongoing reinforcement to maintain behavior changes.

CONCLUSIONS

Behavioral theory informs the selection of factors to target in a behavioral intervention. Special considerations apply when working with children. A program to target risk must be based in behavioral theory, supported by practical data, and tailored to the needs and beliefs of the target community.

The St-Louis du Parc Heart Health Project: a critical analysis of the reverse effects on smoking

OBJECTIVES

Although some school based smoking prevention programmes have shown positive impacts, others have had only short term effects, no effects, and in some cases reverse effects. The St-Louis du Parc Heart Health Project was a five year heart health promotion programme targeting children in eight elementary schools aged 9-12 years in disadvantaged multiethnic neighbourhoods in Montreal. In a controlled, longitudinal evaluation, the programme produced reverse effects on smoking--children exposed to the programme were more likely to initiate and to continue smoking than control children. This article explores hypotheses to explain the reverse effects.

DESIGN

Following work by an in-house committee, a consensus workshop with international experts was conducted to develop hypotheses to explain the reverse effects. This was complemented by an analysis of the programme's concordance with the standard guidelines on the school based prevention of tobacco use, and discussions with experts at the Centers for Disease Control and Prevention.

RESULTS

The programme respected most standard guidelines for smoking prevention programmes with respect to content and mode of delivery. Hypotheses to explain the reverse effects include: an unfavourable environment characterised by strong pro-smoking models and resistance to environmental interventions; heightened sensitivity to smoking among children most exposed to the programme; defence mechanisms among children stimulated by cognitive dissonance or anxiety; unanticipated effects associated with the health educator who delivered the programme; inadequate attention in programme development to the diverse cultural origins of the population targeted; and intervention content inappropriately targeted to children's stages of cognitive development.

CONCLUSION

Elementary school based interventions should aim to develop a clear and coherent social norm about the non-use of tobacco, as a precursor to or in close conjunction with having children as their primary target. Programme design should take key student characteristics into consideration and ensure that the modes of communication are adapted to the targeted group's characteristics. Neighbourhood level interventions should be orchestrated to complement regional, provincial, and national programmes.

School-based programmes for preventing smoking

BACKGROUND

Smoking rates in adolescents are rising. Helping young people to avoid starting smoking is a widely endorsed goal of public health, but there is uncertainty about how to do this. Schools provide a route for communicating with a large proportion of young people, and school-based programmes for smoking prevention have been widely developed and evaluated.

OBJECTIVES

To review all randomised controlled trials of behavioural interventions in schools to prevent children (aged 5 to12) and adolescents (aged 13 to18) starting smoking.

SEARCH STRATEGY

We searched The Cochrane Controlled Trials and Tobacco Review group registers, MEDLINE, EMBASE, Psyclnfo, ERIC, CINAHL, Health Star, Dissertation Abstracts and studies identified in the bibliographies of articles. Individual MEDLINE searches were made for 133 authors who had undertaken randomised controlled trials in this area.

SELECTION CRITERIA

Types of studies: those in which individual students, classes, schools, or school districts were randomised to the intervention or control groups and followed for at least six months.

TYPES OF PARTICIPANTS

Children (aged 5 to12) or adolescents (aged 13 to18) in school settings. Types of interventions: Classroom programmes or curricula, including those with associated family and community interventions, intended to deter use of tobacco. We included programmes or curricula that provided information, those that used social influences approaches, those that taught generic social competence, and those that included interventions beyond the school into the community. We included programmes with a drug or alcohol focus if outcomes for tobacco use were reported. Types of outcome measures: Prevalence of non-smoking at follow-up among those not smoking at baseline. We did not require biochemical validation of self-reported tobacco use for study inclusion.

DATA COLLECTION AND ANALYSIS

We assessed whether identified citations were randomised controlled trials. We assessed the quality of design and execution, and abstracted outcome data. Because of the marked heterogeneity of design and outcomes, we did not perform a meta-analysis. We synthesised the data using narrative systematic review. We grouped studies by intervention method (information; social competence; social influences; combined social influences/social competence and multi-modal programmes). Within each category, we placed them into three groups according to validity using quality criteria for reported study design.

MAIN RESULTS

Of the 76 randomised controlled trials identified, we classified 16 as category one (most valid). There were no category one studies of information giving alone. There were fifteen category one studies of social influences interventions. Of these, eight showed some positive effect of intervention on smoking prevalence, and seven failed to detect an effect on smoking prevalence. The largest and most rigorous study, the Hutchinson Smoking Prevention Project, found no long-term effect of an intensive 8-year programme on smoking behaviour. There was a lack of high quality evidence about the effectiveness of combinations of social influences and social competence approaches. There was limited evidence about the effectiveness of multi-modal approaches including community initiatives.

REVIEWER'S CONCLUSIONS

There is no rigorous test of the effects of information giving about smoking. There are well-conducted randomised controlled trials to test the effects of social influences interventions: in half of the group of best quality studies those in the intervention group smoke less than those in the control, but many studies showed no effect of the intervention. There is a lack of high-quality evidence about the effectiveness of combinations of social influences and social competence interventions, and of multi-modal programmes that include community interventions.

Preventing obesity in children and adolescents

In this review, we address the natural history of obesity in children, the most promising family- and school-based approaches to the prevention of obesity, and the barriers and opportunities associated with secondary prevention. In childhood, the most important periods of risk appear to be the periods of adiposity rebound and adolescence. Caution regarding the period of adiposity rebound is still warranted, because it is not yet clear that early rebound is attributable to changes in body fat. Families and schools represent the most important foci for preventive efforts in children and adolescents. One productive approach is to proceed from an examination of factors that affect energy balance to the identification of more proximal influences on those factors. This approach may help to narrow the strategies necessary to prevent or treat childhood obesity. For example, television viewing affects both energy intake and energy expenditure, and therefore represents a logical target for interventions. Anticipatory guidance by pediatricians may offer an effective mechanism by which to change parental attitudes and practices regarding television viewing. A similar process is used to emphasize the potential influence of school-based interventions directed at changes in food choices and sedentary behavior.

Prevalence of coronary heart disease risk factors in Costa Rican adolescents

PURPOSE

To determine the prevalence of coronary heart disease (CHD) risk factors among Costa Rican adolescents.

METHODS

The prevalence of high blood pressure, obesity, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, sedentarism, family history of premature CHD, saturated fat intake, diabetes mellitus, and cigarette smoking was determined in 328 adolescents, ages 12-18 years (167 males, 161 females), randomly selected from San José's urban and rural high schools.

RESULTS

Over 70% of the adolescents studied presented one risk factor for CHD. While the prevalence of family history of premature CHD, sedentarism, and cigarette smoking was significantly higher in urban adolescents, low HDL cholesterol and high blood pressure were significantly higher in rural adolescents. Girls demonstrated a significantly higher prevalence of sedentarism and LDL cholesterol >2.9 mmol/L than boys. Elevated saturated fat intake (>10% total energy) was found in 37% of the adolescents.

CONCLUSIONS

The prevalence of CHD risk factors among Costa Rican adolescents is high; particularly of saturated fat intake, sedentarism and low HDL-C levels. Primary prevention programs are urgently needed, especially among female adolescents and in the urban areas, to reduce the increased prevalence of CHD mortality among Costa Rican adults.

Public health interventions for the prevention and treatment of obesity

Epidemic obesity is one of the few undesirable consequences of humanity's mastery of the environment. This article reviews public health approaches to preventing and treating obesity. The most encouraging efforts to date have been interventions targeting children in both medical and community surroundings. Treating and preventing obesity in adults has been less successful. It is suggested that taking an environmental health perspective on the obesity problem may facilitate the advancement of scientific understanding of this important health issue.

Intrafamilial relations of cardiovascular disease risk factors in African-Americans: longitudinal results from DC SCAN

BACKGROUND

Few studies have examined intrafamilial patterns of cardiovascular disease (CVD) risk factors in African-American families or identified potential influences on these patterns. This study examines the effects of age and sex of child on correlations between siblings during childhood as well as between mothers and their offspring in African-American families at two points in time.

METHODS

CVD risk factors were assessed in a sample of 267 pairs of African-American siblings and their mothers. One hundred nine of these families were selected for a second assessment of CVD risk factors approximately 28 months later.

RESULTS

Older siblings had significantly greater correlations than younger siblings with mothers' low-density lipoproteins (r = 0.61 versus r = 0.43 for older and younger siblings, respectively), apolipoprotein A-I (r = 0. 46 versus r = 0.16), and lipoprotein (a) (r = 0.71 versus r = 0.34). Correlations between female siblings were significantly higher than between male siblings for total cholesterol (r = 0.74 versus r = 0. 18 for female versus male siblings), triglycerides (r = 0.56 versus r = 0.05), and apolipoprotein B (r = 0.72 versus r = 0.31); they were also higher between female siblings than between mixed-sex siblings for measures of adiposity (r = 0.46 versus r = 0.19) and total cholesterol (r = 0.74 versus r = 0.27).

CONCLUSIONS

Significant intrafamilial correlations for African-American children were influenced by both age and sex of siblings, reflecting potential genetic and environmental influences. Assessing family patterns of CVD risk factors in high-risk populations may assist in the early identification of children who can benefit most from intervention.

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

BACKGROUND

No national policy for health education in schools exists to date in Greece. The first attempt to apply a school-based health education intervention program was launched in 1992 on all 4,171 pupils registered in the first grade in two counties of Crete. The 1,510 pupils registered in a third county served as controls.

METHODS

The school-based intervention and the seminars organized for parents were primarily aimed at improving children's diet, fitness, and physical activity. Pupils in the first grade in a representative sample of 40 schools were examined prior to the intervention program on a variety of health knowledge, dietary, physical activity, fitness, anthropometric, and biochemical indices. The same measurements were taken after 3 years of the program on 288 intervention group and 183 control group pupils.

RESULTS

Positive serum lipid level changes occurred to a greater extent in the intervention group than the control group. BMI increased less in the intervention group than for controls. The increase in health knowledge and physical activity and fitness levels occurred to a higher extent in the intervention group compared to controls.

CONCLUSIONS

The short-term changes observed in the present study are markedly encouraging and indicate great potential for progressive improvement. Continuation and expansion of such a program may prove to be beneficial in initiating long-term changes.

Effects of physical activity interventions in youth. Review and synthesis

INTRODUCTION

Physical inactivity has been identified as an important public health concern for youth. School and community settings can be important infrastructures for promoting physical activity (PA). This paper reviews studies of physical activity in school and community settings among preschool through college-aged persons to determine characteristics and effects of interventions. Studies in progress are included.

METHODS

Studies from 1980 to 1997 testing physical activity interventions in schools and community settings were identified by computerized search methods and reference lists of published reviews. Studies needed to have used a quantitative assessment of PA, used a comparison or control group, included participants who were preschool through college age, and be conducted in the United States or foreign school or community settings. Significance of effects was examined overall and for various types of interventions.

RESULTS

Twenty-two school-based studies were reviewed, 14 completed and 8 in progress. Three studies were in countries other than the United States. The 8 studies in progress were all in the United States. Only 7 community studies were reviewed, all in the United States. Four studies were in progress. Several community studies involved a high percentage of African-American or Hispanic youth and their families. Studies showing the best results used randomized designs, valid and reliable measurements, and more extensive interventions. Some follow-up results showed PA was sustained after interventions ended.

CONCLUSIONS

The collection of school and community studies is limited for several age groups with none below third grade and only three at college age. There are few community studies. The most is known about upper-elementary-age-students, including the first multicenter randomized trial to report significant results for increasing moderate to vigorous physical activity (MVPA) in physical education (PE) and increase vigorous PA outside of school. A number of older study designs were weak and assessments less than optimal, but studies in progress are stronger. Special attention is needed for girls, middle schools, and community settings for all youth. More objective assessments are needed for measuring PA outside of school and in younger children, since they cannot provide reliable self-report.