Protocol paper for the Movimente school-based program: A cluster-randomized controlled trial targeting physical activity and sedentary behavior among Brazilian adolescents

A Systematic Review of School-Based Nutrition Interventions for Promoting Healthy Dietary Practices and Lifestyle Among School Children and Adolescents

Childhood malnutrition is one of the foremost community health problems in the world, particularly in developing countries like India. This current review was conducted to evaluate the effectiveness of various school-centered nutrition interventions/intervention programs developed in recent years, and their impact on the nutritional status, dietary habits, food preferences, lifestyle, and dietary behaviors in relation to diet, as well as physical activities for school children, especially adolescents. This review included studies found in the PubMed/Medline, SCOPUS, and Web of Science (WOS) databases, published from July 2017 to 2023. They were analyzed for eligibility criteria defined for this study, including school children and adolescents, school-based nutrition interventions/strategies/policies/initiatives, nutritional status, physical activity, dietary habits, and lifestyle. The Risk of Bias assessment was conducted using Review Manager version 5.4. Among 1776 potentially related studies, 108 met the eligibility criteria. Following this review, 62 studies were identified as eligible for this study, in which 38 intervention programs were discussed. A total of 13 studies were considered comprehensive and multi-component, 15 were nutrition education interventions, six were identified as physical activity interventions, and four focused on lifestyle and dietary behavior-related interventions. Another 24 of the 62 studies reviewed (approximately 39%) were either original articles, review articles, or articles pertaining to nutritional program guidelines, protocols, and/or reports. These studies uncovered a possible relationship between a decrease in BMI and school children's engagement in diet and/or physical activity. Results also suggest that these programs can be effective, although evidence for the long-term sustainability of changes in BMI was less evident and not fully substantiated/supported. Most of these findings are based on self-reported program data and may consist of biases linked to recall, selection of participants, and the desire to report favorable final measures (physical activity, lifestyle, and dietary habits). This study has the potential for use in public health programs devoted to healthy nutrition behavior and lifestyle practices. This research was primarily conducted by clinical researchers and did not receive any standardized institutional or organization-derived grant funding and support.

Independent and joint associations of cardiorespiratory fitness and weight status with health-related quality of life among Brazilian adolescents

PURPOSE

To investigate the independent and joint associations of cardiorespiratory fitness and body mass index (BMI) with five dimensions of Health-Related Quality of Life (HRQoL) in a cross-sectional sample of Brazilian adolescents.

METHODS

619 Brazilian schoolchildren answered a survey, BMI categories (healthy weight and overweight/obesity) were assessed by their weight and height, and they participated in a 20-m shuttle run test. HRQoL was measured using the KIDSCREEN-27 across five dimensions: Physical Well-Being, Psychological Well-Being, Autonomy and Parent Relation, Peers and Social Support, and School Environment. Sex, age, maternal education, physical activity level, and habitual sedentary behaviour were assessed and used as adjusting variables. Cardiorespiratory fitness was categorized in tertiles and independent and joint associations were tested using mixed-effects linear regressions.

RESULTS

Higher levels of cardiorespiratory fitness were favourably associated with the physical well-being, psychological well-being, and peer and social support dimensions of HRQoL. Adolescents with overweight/obesity presented higher scores on peer and social support dimensions when compared to healthy-weight adolescents. Independent of the adolescents' BMI categories, better cardiorespiratory fitness was positively associated with physical and psychological well-being when compared with the category of overweight/obesity and low cardiorespiratory fitness. In addition, adolescents with overweight/obesity combined with intermediate cardiorespiratory fitness or high cardiorespiratory fitness had higher scores on the peer and social support dimension.

CONCLUSION

Cardiorespiratory fitness is a strong correlate of HRQoL across most of the dimensions measured, while BMI was a correlate of one dimension of HRQoL. Future studies should evaluate these relationships prospectively and experimentally.

Clustering of Physical Activity, Sleep, Diet, and Screen-Based Device Use Associated with Self-Rated Health in Adolescents

BACKGROUND

Little is known about how the interplay among health-related behaviors impacts self-rated health (SRH). We examined the clustering of physical activity (PA), sleep, diet, and specific screen-based device use, and the associations between the emergent clusters and SRH among Brazilian adolescents.

METHOD

The data used in this cross-sectional study were from the baseline of the Movimente Program. Self-reported data were analyzed. SRH was recorded as a 5-point scale (from poor to excellent). Daily duration of exposure to the computer, the television, the cell phone, and games; PA; sleep; and weekly consumption of fruits and vegetables and ultra-processed foods were included in a Two-Step cluster analysis. Multilevel ordered logistic regressions assessed the associations between the clusters and SRH.

RESULTS

The data of 750 students (girls: 52.8%, 13.1 ± 1.0 years) were analyzed. Good SRH was more prevalent (52.8%). Three clusters were identified: the Phubbers (50.53%; characterized by the longest cell phone use duration, shortest gaming and computer use, lowest PA levels, and low consumption of fruits and vegetables), the Gamers (22.80%; longest gaming and computer use duration, PA < sample average, highest intake of ultra-processed foods), and a Healthier cluster (26.67%; physically active, use of all screen-based devices < sample average, and healthier dietary patterns). For both Gamers (-0.85; 95% CI -1.24, -0.46) and Phubbers (-0.71; 95% CI -1.04, -0.38), it was found a decrease in the log-odds of being in a higher SRH category compared with the Healthier cluster.

CONCLUSION

Specific clusters represent increased health-related risk. Assuming the interdependence of health-related behaviors is indispensable for accurately managing health promotion actions for distinguishable groups.

Effectiveness and moderators of a multicomponent school-based intervention on screen time devices: the Movimente cluster-randomized controlled trial

Background

Interventions targeting reduce screen time in adolescents are urgently needed, mainly in low and middle-income countries because of the lack of evidence. Thus, the aims of the study were to examine the effect of a cluster-randomized controlled trial on screen time (ST) devices among Brazilian adolescents and to identify possible moderators.

Methods

Movimente was a multicomponent school-based intervention that was performed in 2017 and consisted of teacher training, education curriculum, and environmental improvements. Baseline and post-intervention assessments (over one academic year) were conducted with students aged 10–16 years at baseline (baseline n = 921, [n = 538 intervention group; n = 383 control group]). A self-report questionnaire was used to measure daily minutes of device specific screen time (TV, computer, video games and smartphone) and demographic variables. Linear mixed models were used to examine intervention effects and an exploratory moderation analysis (sex, grade and socioeconomic status) was performed.

Results

The intervention had no significant effects on TV time (β = − 6.4, 95% CI: − 6.1;13.4), game time (β = − 8.2, 95% CI: − 7.2;10.8), computer time (β = 1.1, 95% CI: − 6.3;18.5), smartphone time (β = − 10.2, 95% CI: − 32.5;12.1), screen time (β = − 12.8, 95% CI: − 50.5;24.8), meeting screen time guidelines (OR: 1.29, 95% CI: 0.65,2.57) and meeting screen time guidelines with smartphone (OR: 1.66, 95% CI: 0.37,7.40). There was a significant intervention effect on reducing TV time (β = − 37.1, 95% CI: − 73.0, − 1.3) among 8th grade students only.

Conclusions

The Movimente intervention was effective only for TV time among 8th grade students. Understanding how school-based interventions can improve adolescents’ device specific screen time across age groups is needed. Future strategies should cover all screen-based devices. Further, there is a need for more studies in low- and-middle income countries to assist in the development of effective strategies.

Trial registration

Clinicaltrials.gov identifier NCT02944318 (25/10/2016).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11895-2.

Obesogenic Clusters Associated with Weight Status in Brazilian Adolescents of the Movimente School-Base Intervention

Background: the relationship between behavior clusters and weight status, mainly in low- and middle-income countries, remains unclear. This study aimed to examine the association between profiles of physical activity (PA), diet and sedentary behavior (SB) with weight status in adolescents from a southern Brazilian city, according to sex. Methods: data from the Movimente Intervention study were analyzed (n = 812 / mean age 13.0 years (sd 1.04). Data on SB hours per day, PA minutes per week and weekly consumption frequencies of fruits, vegetables, salty snacks, candies and soda were self-reported on the validated Movimente questionnaire. Classes of healthy and unhealthy behaviors were derived by latent class analysis. Logistic regression analysis was used to estimate the associations between adolescents’ weight status and classes. Results: two classes were identified for the whole sample and for boys and girls. All classes had high probabilities of engaging high time in SB. Male adolescents in the unhealthy class had low probabilities of being active and high probability of consuming a low-quality diet. In contrast, girls’ healthiest profile presented lower probabilities of being active compared to boys’ healthiest profiles. No association was found between weight status and classes. Conclusion: All classes had at least one unhealthy behavior, for both the whole sample, and for girls and boys. Girls’ profiles were unhealthier compared to boys’ profiles. Hence, it is recommended that intervention strategies to change behaviors need to be distinct according to sex, targeting more than one obesogenic behavior at the same time.

Psychometric analysis of the Brazilian-version Kidscreen-27 questionnaire

Background

The objective of this study was to verify the reliability, discriminatory power and construct validity of the Kidscreen-27 questionnaire in Brazilian adolescents.

Methods

Adolescents that participated of the pilot study (210 adolescents; 52.9% boys; 13.7 years old) and of the baseline (816 participants; 52.7% girls; 13.1 years old) of the Movimente Project in 2016/2017 composed the sample of the present study. This project was carried out in six public schools in the city of Florianópolis, Santa Catarina, Brazil. Test–retest reproducibility was assessed by the intraclass correlation coefficient and Gwet coefficient; internal consistency through McDonald's Omega; Hankins' Delta G coefficient verified the scale's discriminatory power and; confirmatory factor analysis to assess construct validity.

Results

Reproducibility values ranged from 0.71 to 0.78 for the dimensions (ICC), and ranged from 0.60 to 0.83 for the items (Gwet). McDonald's Ômega (0.82–0.91) for internal consistency measures. Discriminatory power ranging from 0.94 for the dimension Social Support and Friends to 0.98 for Psychological Well-Being. The factorial loads were > 0.40, except for item 19 (0.36). The fit quality indicators of the model were adequate (X²[df] = 1022.89 [311], p < 0.001; RMSEA = 0.053 (0.049–0.087); CFI = 0.988; TLI = 0.987), confirming the five-factor structure originally proposed.

Conclusions

The Brazilian-version Kidscreen-27 achieved good levels of reproducibility, internal consistency, discriminatory power and construct validity. Its use is adequate to measure the health-related quality of life of adolescents in the Brazilian context.

Implementation of a school-based physical activity intervention for Brazilian adolescents: a mixed-methods evaluation

The effectiveness of physical activity interventions can be improved through examining the aspects related to their implementation. However, little such evidence has been collected, particularly in low- and middle-income countries. This study aimed to evaluate the implementation of a school-based physical activity intervention with qualitative and quantitative data from different actors (students, teachers and parents) involved in developing the program. The program was conducted in 2017 with three main components: (i) teacher training, (ii) environmental changes and (iii) educational actions. Mixed-method evaluation was performed by an independent evaluation team using a validated indicator matrix for the implementation process, including the self-reported information of students, teachers and parents, as well as interviews with teachers. In the 3 eligible schools, 350 adolescents (51% girls) answered the implementation questionnaire, as did 45 parents (84% mothers), and 47 teachers (70% female). In the qualitative analysis, 18 teachers participated. Categorical analysis found that the intervention was considered feasible by teachers. In general, teachers had a more positive perception of the implementation than did students. The lack of engagement from the school community and parents and the busy schedule of teachers were indicated to be the main difficulties. In conclusion, despite the teachers' motivation, some barriers prevented the successful implementation of the program.

Psychosocial correlates of objectively measured in-school and out-of-school physical activity among Brazilian adolescents

Physical activity is influenced by an interplay of time and setting, thus, the role of psychosocial factors on behavior is expected to vary across the day. This cross-sectional study identified the psychosocial correlates of time spent in physical activity during in-school (i.e., 08:00-11:59) and out-of-school (i.e., 12:00-22:00) time segments. The sample consisted of adolescents (7th to 9th grade) of two public schools in Florianópolis, Brazil. Accelerometer measured light-intensity (LPA) and moderate-to-vigorous-intensity physical activity (MVPA) were estimated. Psychosocial correlates of physical activity (i.e., outcome expectations, attitude, self-efficacy, support from parents, and support from peers) were self-reported. Linear mixed models were applied and interaction effects of gender and age were also analyzed. From a total of 194 participants, 138 and 112 provided in-school and out-of-school valid data, respectively. Outcome expectations were associated with out-of-school MVPA (β = 0.18; p = .006). Age interaction effects were observed for the associations between outcome expectations and out-of-school LPA (β = 0.21; p = .009) and between self-efficacy and out-of-school MVPA (β = 0.19; p = .009). In conclusion, psychosocial correlates were positively associated with out-of-school physical activity and the effects varied according to age. No psychosocial correlates were identified for LPA and MVPA performed during schooltime.

Effects of School-Based Physical Activity Programs on Health-Related Physical Fitness of Korean Adolescents: A Preliminary Study

As adolescents spend the majority of their time focused on exams and assignments, they do not have sufficient time to engage in physical activity; this lack of physical activity is an important public health concern. This study aimed to investigate how school-based physical activity programs affect the health-related physical fitness of adolescents in the Republic of Korea. For this study, a total of 120 high school students participated in a school-based physical activity program that included badminton and table tennis for 15 weeks each (35 min/day, three times a week), with a total of 30 weeks for one academic year. The parameters for health-related physical fitness measured muscle strength (handgrip strength), power (standing long jump), cardiorespiratory fitness (shuttle run test), flexibility (sit and reach), body mass index (BMI), and the total score. The results revealed a statistically significant improvement in muscle strength (p < 0.001), power (p < 0.001), cardiorespiratory fitness (p < 0.001), flexibility (p = 0.005), and the overall health-related physical fitness score (p = 0.001). However, students’ BMI showed no significant difference before and after participation (p = 0.825). The results of this study indicated that school-based physical activity programs can have a positive effect on the health-related physical fitness of adolescents.

Efforts on Changing Lifestyle Behaviors May Not Be Enough to Improve Health-Related Quality of Life Among Adolescents: A Cluster-Randomized Controlled Trial

Schools have been the main context for physical activity (PA) and sedentary behavior (SB) interventions among adolescents, but there is inconsistent evidence on whether they also improve dimensions of the health−related quality of life (HRQoL). The aim of this study was to evaluate the effects of a school-based active lifestyle intervention on dimensions of HRQoL. A secondary aim was to verify whether sex, age, and HRQoL at baseline were moderators of the intervention effect. A cluster-randomized controlled trial was conducted at three control and three intervention schools in Florianopolis, Brazil. All students from 7th to 9th grade were invited to participate. A school year intervention, designed primarily to increase PA and reduce SB, included strategies focused on (i) teacher training on PA, SB, and nutrition, and availability of teaching materials related to these contents; (ii) environmental improvements (i.e., creation and revitalization of spaces for the practice of PA in school); and (iii) education strategies, with the availability of folders and posters regarding PA, SB, and nutrition. Participants and the research staffs were not blinded to group assignment, but a standardized evaluation protocol was applied at baseline and after the intervention (March and November 2017) using the KIDSCREEN−27 to assess HRQoL across five dimensions. Mixed linear models were performed to evaluate the effect of the Movimente intervention on the five HRQoL dimensions. Of the 921 students who answered the questionnaire at baseline, 300 and 434 completed the study in control and intervention groups, respectively (dropouts: 20%). The results revealed no significant effects of the intervention on any HRQoL dimensions. A reduction of the school environment dimension was observed in both the control (-2.44; 95% CI: -3.41 to -1.48) and intervention groups (-2.09; 95% CI: -2.89 to -1.30). Sensitivity analyses showed that students in the highest baseline tertiles of HRQoL in any dimension had a reduction in their respective scores from pre- to post-intervention in both school groups. In conclusion, our results demonstrated no intervention effect on HRQoL dimensions and those students with the highest levels of HRQoL at baseline on all dimensions reduced from pre to post-intervention.