Identifying effective behavioural models and behaviour change strategies underpinning preschool- and school-based obesity prevention interventions aimed at 4-6-year-olds: a systematic review

Interactive Malaysian Childhood Healthy Lifestyle (i-MaCHeL) programme: a single-arm pilot study

BACKGROUND

The growing obesity epidemic in Malaysia presents a public health challenge that requires innovative intervention strategies. In an effort to address this problem, an Interactive Malaysian Childhood Healthy Lifestyle (i-MaCHeL) programme, which is a web-based initiative designed for preschool child-parent dyads offers a novel approach. Nevertheless, the success of such a web-based intervention depends on several interrelated factors. This research aims to examine the feasibility of i-MaCHeL in the Malaysian context, its usability for preschool child-parent dyads, and the acceptability of the programme among these user groups.

METHODS

This was a single-arm pilot study involving 46 child-parent dyads recruited from six government preschools in Terengganu, Malaysia. The preschools were selected using a cluster random sampling technique at the preschool level. The intervention feasibility was determined based on the retention rate of participants in the pilot study. The System Usability Scale (SUS) and intervention process evaluation were used to assess the usability and acceptability of the web-based i-MaCHeL programme.

RESULTS

The retention data demonstrated that 42 out of 46 participants completed the 13-week intervention programme, which showed that the overall retention rate was 91.3%. A mean (SD) SUS score of 84.70 (13.82) was obtained from parents, indicating that the web-based i-MaCHeL had an acceptable usability level. The mean scores of the process evaluation items ranged from 4.52 (0.63) to 4.83 (0.38), demonstrating that the web-based i-MaCHeL was highly accepted by the parents. The acceptability data also indicated that at least 92.9% (39/42) of the parents agreed/strongly agreed that the web content, programme duration, intervention dose, WhatsApp group, and delivery mode were appropriate.

CONCLUSIONS

According to these findings, the i-MaCHeL intervention using a web-based approach was feasible, usable, and acceptable as part of a weight-related behaviour change intervention for preschool child-parent dyads. This pilot study demonstrated that the web-based i-MaCHeL was feasible and promising for delivering weight-related behavioural intervention to child-parent dyads.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04711525 . Registered on January 15, 2021.

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being "in tune with" the child's needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

Optimal timing of introduction of complementary feeding: a systematic review and meta-analysis

CONTEXT

The timing of introducing complementary feeding (CF) is crucial because premature or delayed CF can be associated with adverse health outcomes in childhood and adulthood.

OBJECTIVE

This systematic review aims to evaluate the impact of the timing of CF introduction on health, nutrition, and developmental outcomes among normal-term infants.

DATA SOURCES

Electronic databases and trial registries were searched, along with the reference lists of the included studies and relevant systematic reviews.

DATA EXTRACTION

Two investigators independently extracted data from the included studies on a standardized data-extraction form.

DATA ANALYSIS

Data were meta-analyzed separately for randomized controlled trials (RCTs) and observational studies on the basis of early introduction of CF (< 3 months, < 4 months, < 6 months of age) or late introduction of CF (> 6 months, > 8 months of age). Evidence was summarized according to GRADE criteria. In total, 268 documents were included in the review, of which 7 were RCTs (from 24 articles) and 217 were observational studies (from 244 articles). Evidence from RCTs did not suggest an impact of early introduction, while low-certainty evidence from observational studies suggested that early introduction of CF (< 6 months) might increase body mass index (BMI) z score and overweight/obesity. Early introduction at < 3 months might increase BMI and odds of lower respiratory tract infection (LRTI), and early introduction at < 4 months might increase height, LRTI, and systolic and diastolic blood pressure (BP). For late introduction of CF, there was a lack of evidence from RCTs, but low-certainty evidence from observational studies suggests that late introduction of CF (> 6 months) might decrease height, BMI, and systolic and diastolic BP and might increase odds of intestinal helminth infection, while late introduction of CF (> 8 months) might increase height-for-age z score.

CONCLUSION

Insufficient evidence does suggest increased adiposity with early introduction of CF. Hence, the current recommendation of introduction of CF should stand, though more robust studies, especially from low- and middle-income settings, are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020218517.

Which behaviour change techniques are associated with interventions that increase physical activity in pre-school children? A systematic review

BACKGROUND

Insufficient physical activity (PA) is a significant risk factor that contributes to several health problems and there is a need to improve our understanding of how to increase PA, particularly among young children. This review (PROSPERO registration: CRD42022328841) investigated the relationship between behaviour change techniques (BCTs) and interventions that increased PA among pre-school children aged < 6 years old.

METHODS

Systematic searches of six databases were undertaken from inception to July 2022, updated in December 2022, to locate studies that evaluated interventions and reported a positive change in PA levels in children aged < 6 years old.

RESULTS

A total of 5,304 studies were screened, and 28 studies involving 10,605 subjects aged 2.5 to 5.9 years met the eligibility criteria. Each eligible study (n = 28) was independently appraised by two researchers using the Cochrane risk of bias tool. The BCT Taxonomy v1 and the Template for Intervention Description and Replication (TIDieR) guided the extraction and analysis of data, and this process led to the identification of 27 BCTs.

CONCLUSIONS

Potentially promising BCTs for increasing PA among young children included 'shaping knowledge,' 'antecedents,' 'goals and planning,' and 'comparison of behaviour.' Future PA interventions that target young children should consider integrating these promising BCTs into their programmes. However, such consideration needs to be tempered by the fact that most of the reviewed studies were deemed to have a high or unclear risk of bias and/or were limited with respect to the populations that they targeted. Further research using rigorous methodologies is required to establish a higher standard that addresses the needs of young children who are expected to have insufficient levels of physical activity.

Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years

BACKGROUND

Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health.

OBJECTIVES

To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions.

SEARCH METHODS

We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes.

MAIN RESULTS

We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).

AUTHORS' CONCLUSIONS

ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.

Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years

BACKGROUND

Dietary intake during early childhood can have implications on child health and developmental trajectories. Early childhood education and care (ECEC) services are recommended settings to deliver healthy eating interventions as they provide access to many children during this important period. Healthy eating interventions delivered in ECEC settings can include strategies targeting the curriculum (e.g. nutrition education), ethos and environment (e.g. menu modification) and partnerships (e.g. workshops for families). Despite guidelines supporting the delivery of healthy eating interventions in this setting, little is known about their impact on child health.

OBJECTIVES

To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non-dietary intervention. Secondary objectives were to assess the impact of ECEC-based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality-of-life outcomes. We also report on cost and adverse consequences of ECEC-based healthy eating interventions.

SEARCH METHODS

We searched eight electronic databases including CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, Scopus and SportDiscus on 24 February 2022. We searched reference lists of included studies, reference lists of relevant systematic reviews, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov and Google Scholar, and contacted authors of relevant papers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, stepped-wedge RCTs, factorial RCTs, multiple baseline RCTs and randomised cross-over trials, of healthy eating interventions targeting children aged six months to six years that were conducted within the ECEC setting. ECEC settings included preschools, nurseries, kindergartens, long day care and family day care. To be included, studies had to include at least one intervention component targeting child diet within the ECEC setting and measure child dietary or physical outcomes, or both.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened titles and abstracts and extracted study data. We assessed risk of bias for all studies against 12 criteria within RoB 1, which allows for consideration of how selection, performance, attrition, publication and reporting biases impact outcomes. We resolved discrepancies via consensus or by consulting a third review author. Where we identified studies with suitable data and homogeneity, we performed meta-analyses using a random-effects model; otherwise, we described findings using vote-counting approaches and via harvest plots. For measures with similar metrics, we calculated mean differences (MDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes. We calculated standardised mean differences (SMDs) for primary and secondary outcomes where studies used different measures. We applied GRADE to assess certainty of evidence for dietary, cost and adverse outcomes.  MAIN RESULTS: We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster-RCTs. Twenty-nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty-eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias. ECEC-based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate-certainty evidence that ECEC-based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC-based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI -0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate-certainty evidence that ECEC-based healthy eating interventions likely result in little to no difference in children's consumption of non-core (i.e. less healthy/discretionary) foods (SMD -0.05, 95% CI -0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar-sweetened beverages (SMD -0.10, 95% CI -0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children). Thirty-six studies measured BMI, BMI z-score, weight, overweight and obesity, or waist circumference, or a combination of some or all of these. ECEC-based healthy eating interventions may result in little to no difference in child BMI (MD -0.08, 95% CI -0.23 to 0.07; P = 0.30, I2 = 65%; 15 studies, 3932 children) or in child BMI z-score (MD -0.03, 95% CI -0.09 to 0.03; P = 0.36, I2 = 0%; 17 studies; 4766 children). ECEC-based healthy eating interventions may decrease child weight (MD -0.23, 95% CI -0.49 to 0.03; P = 0.09, I2 = 0%; 9 studies, 2071 children) and risk of overweight and obesity (RR 0.81, 95% CI 0.65 to 1.01; P = 0.07, I2 = 0%; 5 studies, 1070 children). ECEC-based healthy eating interventions may be cost-effective but the evidence is very uncertain (6 studies). ECEC-based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies). Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).

AUTHORS' CONCLUSIONS

ECEC-based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC-based healthy eating interventions on vegetable consumption. ECEC-based healthy eating interventions may result in little to no difference in child consumption of non-core foods and sugar-sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z-scores. Future studies exploring the impact of specific intervention components, and describing cost-effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC-based healthy eating interventions.

Developing Healthy Lifestyle Behaviors in Early Age-An Intervention Study in Kindergartens

Childhood obesity prevention is a leading public health challenge requiring the adoption of healthy lifestyles at an early age. We examined how the kindergarten environment can promote eating sensibly, drinking water and becoming physically active. The effects of an intervention program among 42 Israeli kindergartens (1048 children, aged 4-6) whose teachers participated in a health education training program were compared to 32 kindergartens (842 children) whose teachers did not undergo this training program. An eight-month intervention program focused on knowledge/mathematical/logical/critical thinking, self-regulation/control acquisition, and sensible decision-making abilities. We hypothesized that nutrition and physical-exercise-oriented intervention programs, combining knowledge/mathematical logical thinking, would positively impact the quality of children's mid-morning snack and water consumption, their ability to express feelings following physical exercise, and the adoption of healthy lifestyles at home. The quality of mid-morning snacks and water consumption were observed in both groups pre- and post-intervention. Qualitative interviews documented children's subjective feelings following physical exercise. A significant improvement (p < 0.001) was observed in the mid-morning snacks composition and in water drinking habits in the intervention group; 80% of children offered a physiological explanation regarding energy expenditure processes following intense physical exercise. In conclusion, kindergarten interventions implemented by trained teachers can promote adoption of health behaviors necessary for obesity prevention.

Lifestyle Risk Factors for Overweight/Obesity in Spanish Children

Childhood obesity is one of the main public health concerns in Europe. The aim was to identify possible risk factors associated with overweight/obesity in Spanish preschool and school-age children. The sample (1075 (50.7% girls) children aged 3 to 12) is part of the project 'Alimentando el Cambio' whose objective is to promote healthy lifestyles in schools. Child height and weight were measured, and parents filled out questionnaires related to the children's lifestyle. There was a positive and significant association between sweetened beverage consumption and body mass index (BMI) z-score in both sexes and age groups. There was a negative and significant association between BMI z-score and dairy products in girls of both age groups. There was also a protective effect of regular nut consumption on overweight/obesity in girls 6-12 y. Night-time sleep during weekdays showed a negative association with BMI z-score for older boys and girls. A positive and significant association was found between total screen time and BMI z-score during weekdays. Regarding emotional well-being and self-esteem, having girls 6-12 y laughing and feeling happy and good about themselves in the last week was a protective factor against overweight/obesity. Childhood obesity prevention efforts may benefit from targeting these key risk factors.

An internet-based educational intervention for mothers targeting preschoolers' weight management promotion (PWMP): a pilot study

BACKGROUND

The prevalence of overweight and obesity among children has raised public health concerns. This study aimed to design and evaluate a behaviour change intervention program to promote weight management among Tehranian preschoolers.

METHODS

The PRECEDE-PROCEED model is one of the most popular models in health education used to develop and evaluate most educational interventions. In this one-group pre and post-pilot study, 13 mothers of preschoolers were recruited from preschools in Tehran (the capital of Iran), in August 2020. Mothers received a six-week educational intervention, including text messages and educational videos via WhatsApp, to increase their self-efficacy to overcome barriers changing their children's lifestyle. Mothers reported preschoolers' height and weight to assess Body Mass Index and filled out the Food Frequency Questionnaire, the Persian version of the children's health-related quality of life questionnaire, and demographic features. The "Children's physical activity and sedentary behaviors checklist," newly designed by the researchers, was also filled out by mothers. These behaviors were measured according to the minutes that children were involved in these activities in a day, and the days they spent in a week for them. All variables were measured at baseline, immediately after the intervention and three months later. Data analysis was performed using SPSS IBM statistics version 22. Friedman test was used to evaluate changes over time.

RESULTS

The findings demonstrated that the mean BMI z-score stayed steady between baseline, immediately after the intervention and after three months (P = 0.60). Besides, after three months, the intervention programme led to a decrease in soft drink consumption (P = 0.001), and an increase in parental perception of their child's general health (P = 0.05), the parental concern regarding their child's emotional and physical health (P = 0.002) and minutes of physical activity per day (P = 0.02). However, fruit intake decreased (P = 0.01), and simple sugar, such as cube, increased (P = 0.03).

CONCLUSION

Results from this study are promising but should be interpreted with caution and should be replicated on a larger scale and compared with a control group to evaluate whether effects are maintained in a larger sample.

A Systematic Review of the Education and Awareness Interventions to Prevent Online Child Sexual Abuse

Online child sexual abuse is highly prevalent in current society, in part, due to how technologically advanced children and adults have become. While much of the focus has been on perpetrator intervention, it is prudent to consider responses safeguarding children from potential perpetrators. Therefore, this review aimed to identify all the available empirical research on the prevention methods linked to education and awareness to determine the approaches' effectiveness, successes, and failures to aid future interventions. Databases were systematically searched for studies published between 2000 to 2020. Nine studies providing different prevention methods for online child sexual abuse were selected. A total sample of n = 672 and a descriptive approach was used for this study. While the interventions seemed to improve knowledge retainment of online safety, there was no significant change for risky online behavior. These findings provide specific suggestions for future interventions, particularly those focusing on risky online behaviors.

Development of a core outcome set for school-based intervention studies on preventing childhood overweight and obesity: study protocol

INTRODUCTION

Prevention of childhood overweight is an important health priority. Evidence synthesis from studies evaluating school-based overweight preventive interventions is hampered by the wealth of different outcomes across studies. Therefore, consensus on a core set of outcomes for school-based overweight prevention studies is needed. This paper presents the protocol for the development of a core outcome set (COS) for school-based intervention studies aimed at childhood overweight prevention.

METHODS AND ANALYSIS

First, a scoping review will be performed to identify outcomes included in studies evaluating school-based overweight prevention interventions in 6-12 year-old children. Additionally, child focus groups will be organised in three countries to list the outcomes children consider important in school-based interventions. Next, an expert panel will identify all unique outcomes (eg, body composition) from the results of the scoping review and focus groups, ruling out how outcomes were defined and measured (eg, body mass index, body fat). In the next phase, a group of international stakeholders will participate in a Delphi study in which they will rate all unique outcomes on a 9-point Likert scale over three rounds to reach consensus on a COS. Participants will include healthcare professionals, policymakers, teachers, school leaders and parents of 6-12 year-olds. All rated outcomes will be presented to stakeholders in two online consensus meetings.

ETHICS AND DISSEMINATION

The Medical Ethics Committee of the VU Medical Center approved the child focus group study in the Netherlands (nr. 2020.071) and the Delphi study-including the consensus meeting (nr. 2022.0295). Other sites will obtain ethics approval for focus groups in their country. The University of Strathclyde School of Psychological Sciences ethics committee approved the Delphi study-including consensus meeting (nr. 72.27.04.2022 .A). The final COS will be disseminated through the diverse networks of all authors and participants.

TRIAL REGISTRATION NUMBER

This COS initiative is registered with the Core Outcome Measures in Effectiveness initiative (registration nr. 971).

Can food parenting practices explain the association between parental education and children's food intake? The Feel4Diabetes-study

OBJECTIVE

This study aimed to investigate the mediating role of food parenting practices (FPP), including home availability of different types of foods and drinks, parental modelling of fruit intake, permissiveness and the use of food as a reward in the relationship between parental education and dietary intake in European children.

DESIGN

Single mediation analyses were conducted to explore whether FPP explain associations between parents' educational level and children's dietary intake measured by a parent-reported FFQ.

SETTING

Six European countries.

PARTICIPANTS

Parent-child dyads (n 6705, 50·7 % girls, 88·8 % mothers) from the Feel4Diabetes-study.

RESULTS

Children aged 8·15 ± 0·96 years were included. Parental education was associated with children's higher intake of water, fruits and vegetables and lower intake of sugar-rich foods and savoury snacks. All FPP explained the associations between parental education and dietary intake to a greater or lesser extent. Specifically, home availability of soft drinks explained 59·3 % of the association between parental education and sugar-rich food intake. Home availability of fruits and vegetables was the strongest mediators in the association between parental education and fruit and vegetable consumption (77·3 % and 51·5 %, respectively). Regarding savoury snacks, home availability of salty snacks and soft drinks was the strongest mediators (27·6 % and 20·8 %, respectively).

CONCLUSIONS

FPP mediate the associations between parental education and children's dietary intake. This study highlights the importance of addressing FPP in future interventions targeting low-educated populations.

Neophobia—A Natural Developmental Stage or Feeding Difficulties for Children?

Food neophobia is the tendency to reject or be reluctant to try new and unfamiliar foods. Due to the period of its occurrence, which falls in the years of early childhood, it can significantly affect the child’s food choices, shape taste preferences, and significantly influence the quality of the child’s diet. The neophobic attitude has an important evolutionary significance because it protects the individual from ingesting potentially dangerous substances. On the other hand, it fosters avoidance behaviors that can also relate to the beneficial aspects of obtaining and consuming food. Currently, the strong emphasis placed on food safety means that neophobia may be less adaptive; nevertheless, a conservative attitude toward new foods still prevails. There is a strong association between food neophobia and the diversity of a person’s diet and previous exposure to different foods. This review describes behaviors associated with food neophobia and analyzes other feeding and eating difficulties in children that should be differentiated from food neophobia. Management approaches affecting the reduction in food neophobia in children through various dietary and psychological interventions are also proposed.

A Review of Experiential School-Based Culinary Interventions for 5–12-Year-Old Children

Cooking is an essential skill and the acquisition of cooking skills at an early age is associated with higher diet quality. This review aimed to describe the characteristics of school-based experiential culinary interventions and to determine the value of these to child (5–12 years) health outcomes. Interventions were eligible for inclusion if they took place in school during school hours, included ≥3 classes, and had a control group. Interventions published up to May 2021 were included. The databases searched were PubMed, CINAHL, and EMBASE, and the grey literature was searched for published reports. The search strategy yielded 7222 articles. After screening, five published studies remained for analysis. Four studies targeted children aged 7–11 years, and one targeted children aged 5–12 years. The interventions included food tasting, food gardening, and/or nutrition education alongside experiential cooking opportunities. Improvements were evident in self-reported attitudes toward vegetables, fruits, and cooking, and two studies reported small objective increases in vegetable intake. School-based experiential cookery interventions have the potential to positively impact health-related aspects of the relationship children develop with food. However, a greater number of long-term methodologically rigorous interventions are needed to definitively quantify the benefits of such interventions.

Parent Involvement in Diet or Physical Activity Interventions to Treat or Prevent Childhood Obesity: An Umbrella Review

Parents substantially influence children’s diet and physical activity behaviors, which consequently impact childhood obesity risk. Given this influence of parents, the objective of this umbrella review was to synthesize evidence on effects of parent involvement in diet and physical activity treatment and prevention interventions on obesity risk among children aged 3–12 years old. Ovid/MEDLINE, Elsevier/Embase, Wiley/Cochrane Library, Clarivate/Web of Science, EBSCO/CINAHL, EBSCO/PsycInfo, and Epistemonikos.org were searched from their inception through January 2020. Abstract screening, full-text review, quality assessment, and data extraction were conducted independently by at least two authors. Systematic reviews and meta-analyses of diet and physical activity interventions that described parent involvement, included a comparator/control, and measured child weight/weight status as a primary outcome among children aged 3–12 years old were included. Data were extracted at the level of the systematic review/meta-analysis, and findings were narratively synthesized. Of 4158 references identified, 14 systematic reviews and/or meta-analyses (eight treatment focused and six prevention focused) were included and ranged in quality from very low to very high. Our findings support the inclusion of a parent component in both treatment and prevention interventions to improve child weight/weight status outcomes. Of note, all prevention-focused reviews included a school-based component. Evidence to define optimal parent involvement type and duration and to define the best methods of involving parents across multiple environments (e.g., home, preschool, school) was inadequate and warrants further research. PROSPERO registration: CRD42018095360.

"Sleep is healthy for your body and brain." Use of student-centered photovoice to explore the translation of sleep promotion at school to sleep behavior at home

STUDY OBJECTIVES

Schools are an important setting to teach and reinforce positive health behaviors such as sleep, however, research that incorporates the student perspective of school-based sleep promotion initiatives is limited. This study explored student's perceptions of sleep behavior (how they understood and valued positive and negative sleep behaviors) and determined if and how students translate school-based sleep promotion to the home.

METHODS

Forty-five grade 4 and 5 children (aged 9-11 years) were purposefully sampled from 3 schools participating in the Alberta Project Promoting healthy Living for Everyone in schools (APPLE) in Edmonton, Canada. Using focused ethnography as the method and photovoice as a data generating strategy, qualitative in-depth information was generated through photo-taking and one-on-one interviews. Data were analyzed in an iterative, cyclical process using latent content analysis techniques.

RESULTS

Four themes related to students' perception of sleep behavior within the context of a school-based sleep promotion initiative were identified: sleep is "healthy for your body and brain," sleep habits are rooted in the home environment, school experiences shape positive sleep habits at home, and students translate sleep promotion home if they think it is useful or would be acceptable to the family.

CONCLUSION AND IMPLICATIONS

School-based sleep promotion interventions that are grounded in the comprehensive school health (CSH) approach hold promise for successfully shaping student sleep behavior. To promote health and academic success in children, future interventions should include home-school partnerships that address child sleep across multiple critical learning environments.

Health professionals' views and experiences of discussing weight with children and their families: A systematic review of qualitative research

BACKGROUND

Healthcare professionals are ideally placed to discuss weight management with children and families to treat and prevent childhood obesity. The aim of this review was to collect and synthesize primary research evidence relating to health professional's views and experiences of discussing weight with children and their families.

METHODS

Systematic searches were conducted using the following databases: MEDLINE (OVID), Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE (OVID), PsycINFO (OVID) and Healthcare Management Information Consortium (HMIC). Twenty-six full text qualitative studies published in English Language journals since inception to October 2019 were included. Papers were quality assessed and synthesized using an inductive thematic analysis approach.

RESULTS

Data analysis generated five themes: sensitivity of the issue, family-professional relationships, whole systems approach, professional competency and sociocultural context.

CONCLUSION

Supporting behaviour change through discussion of healthy weight with children and families is an important part of the health professional's role. Tailored information for professionals, including resources and training, facilitates them to confidently talk to children and families about weight prioritized within interventions. The success of such interventions requires commitment from a range of professionals to ensure healthy weight is tackled through a whole system approach.

Parental perceptions, attitudes and knowledge on European preschool children's total screen time: the ToyBox-study

BACKGROUND

Preschool children spend a significant proportion of their waking hours being sedentary. Parents play a critical role in developing and shaping their children's lifestyle behaviours, particularly in the early years of life. This study aims to assess parental perceptions, attitudes and knowledge of their preschool children's sedentary behaviours and the association with children's television (TV)/video/DVDs viewing and total screen time.

METHODS

Data were obtained from a sample of 4836 children (3.5-5.5 years), participating in the multi-centre ToyBox-study at baseline (T0) and at 1-year follow-up (T1) periods. Data on children's sedentary behaviours were collected via a standardized proxy-administered primary caregiver's questionnaire.

RESULTS

Regarding total screen time, 66.6% of the children at T0 and 71.8% at T1 in the control group exceeded the recommendations, whereas the proportion in the intervention group varied from 69.7% at T0 to 72.5% at T1. The odds of exceeding total screen time recommendations were significantly higher when parental perceptions towards limiting the total screen time were negative [(both T0 and T1 and in the intervention and control groups (P < 0.05)]. Similarly, the odds of exceeding TV/video/DVDs viewing recommendations were significantly higher (both T0 and T1 is observed in both groups) when parental knowledge of recommendation were absent.

CONCLUSIONS

Preschool children whose caregivers stated rules limiting their sedentary screen time were less likely to spend a high amount of time watching TV/video/DVDs. Interventions to increase parental practices may be a promising approach to decrease total screen time of preschool children but studies are needed to confirm this.

What behavior change techniques are associated with effective interventions to reduce screen time in 0-5 year olds? A narrative systematic review

•

Daily screen time reduced by 25–39 min in interventions targeting 0–5 year olds.

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Eleven behavior change techniques (BCTs) were considered promising.

•

Promising BCTs included “behavior substitution” and “demonstration of the behavior”.

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Promising BCTs related to self-efficacy, role modelling, and developmental outcomes.

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BCTs are identified which can be included in future public health interventions.

Screen time has been linked to obesity in young children. Therefore, this systematic review aims to investigate which Behavior Change Techniques (BCTs) are associated with the effectiveness of interventions to reduce screen time in 0–5 year olds.

Seven databases were searched, including PsycInfo, PubMed, and Medline. Grey literature searches were conducted. Inclusion criteria were interventions reporting pre- and post- outcomes with the primary objective of reducing screen time in 0-5 year olds. Studies were quality assessed using the Effective Public Health Practice Project criteria. Data extracted included participant characteristics, intervention characteristics and screen time outcomes. The BCT Taxonomy was used to extract BCTs. Interventions were categorised as “very”, “quite” or “non” promising based on effect sizes. BCTs were deemed promising if they were in twice as many very/quite promising interventions as non-promising interventions.

Seven randomised controlled trials were included, involving 642 participants between 2.5 and 5.0 years old. One very promising, four quite promising, and two non-promising interventions were identified. Screen time decreased by 25-39 min per day in very/quite promising interventions. Eleven BCTs were deemed promising, including “behavior substitution” and “information about social and environmental consequences”.

This review identified eleven promising BCTs, which should be incorporated into future screen time interventions with young children. However, most included studies were of weak quality and limited by the populations targeted. Therefore, future methodologically rigorous interventions targeting at-risk populations with higher screen time, such as those of a low socioeconomic status and children with a high BMI, should be prioritized.

Child Involvement in Choosing a Recipe, Purchasing Ingredients, and Cooking at School Increases Willingness to Try New Foods and Reduces Food Neophobia

OBJECTIVE

To investigate the effect of involving children in their feeding process (choosing a recipe, purchasing the ingredients, and cooking) on their lunch food choice in a school environment.

DESIGN

Quasi-experimental.

SETTING

Two schools in Bilbao, Spain.

PARTICIPANTS

A total of 202 children (aged 8-9 years) participated in the study (43% girls), with 99 in the nutrition education (NE) group and 103 in the hands-on (HO) group.

INTERVENTION

Three 1-hour workshops (1 workshop/wk), different for each group: HO, cooking-related activities, and NE, healthy habits promotion through nutrition education activities.

MAIN OUTCOME MEASURES

Food neophobia, diet quality, cooking self-efficacy and attitudes toward cooking, and food intake and selection of the experimental lunches.

ANALYSIS

Chi-square test of independence, ANCOVA, and t tests were performed.

RESULTS

Students from the HO group selected and ate more spinach/broccoli (P < 0.001 and P = 0.02, respectively) for the first lunch; and selected more spinach/broccoli (P = 0.04) for the second lunch. After the intervention, improvements were observed for spinach liking and neophobia for the HO group and cooking self-efficacy and KidMed score for both groups.

CONCLUSIONS AND IMPLICATIONS

Both interventions succeeded in improving children's diet quality, but only the HO group reduced food neophobia levels. Therefore, involving children in choosing a recipe, purchasing ingredients, and cooking may promote changing eating behaviors toward healthy habits such as increasing vegetable consumption.

Brief parental self-efficacy scales for promoting healthy eating and physical activity in children: a validation study

Background

Brief scales to measure parental self-efficacy (PSE) in relation to children’s obesogenic behaviours have not been developed and validated using more rigorous methodology such as invariance testing, limiting their generalisability to sub-groups.

This study aimed to assess the construct validity and measurement invariance of brief PSE scales for children’s intake of vegetables, soft drinks, and sweets, and physical activity.

Methods

Parents (n = 242) of five-to-seven-year-old children in disadvantaged and culturally diverse settings in Sweden responded to a questionnaire in Swedish with 12 items assessing PSE in relation to healthy and unhealthy behaviours. Construct validity was assessed with confirmatory factor analysis, invariance testing compared the scales by groups of parental sex, education, and child weight status. Criterion validity was evaluated using objective measures of children’s physical activity and semi-objective measures of diet.

Results

Two-factor models showed moderate to excellent fit to the data. Invariance was supported across all groups for healthy behaviour scales. Unhealthy behaviour scales were invariant for all groups except parental education where partial metric invariance was supported. Scales were significantly correlated with physical activity and diet.

Conclusion

This study provides preliminary evidence for the validity of brief PSE scales and invariance across groups suggesting their utility for research and clinical management of weight-related behaviours.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10581-7.

Balance Nutrition Messages Are Still Implemented in Preschools One Year Postintervention: Case Studies in Subang District, West Java, Indonesia

Thirty-two teachers from 10 preschools in Cisalak subdistrict, Subang district, West Java province, Indonesia, received a two-day training on Balance Nutrition and My Plate in February 2018. The main messages underlined in the training were consume a variety of foods, drink enough water daily, wash your hands with soap, be physically active, and monitor your body weight. The training was followed by an eight-week implementation period to preschoolers aged 3 to 6 y. The knowledge of the teachers increased by up to 33 percentage points (average score: 69 to 82 pre- vs. posttest) after training, and the teachers answered correctly to the same questions 15 mo later. The mothers' knowledge increased by up to 37 percentage points after parenting sessions. All seven teaching aids provided were used by end-line, but their usage decreased after seven months (range: 2 to 7) and further decreased by 12 mo postintervention (range: 2 to 5). A teacher's handbook and a flipchart were the two aids persistently used. The practices of washing hands with soap, bringing healthy packed lunches, and monitoring weight and height continued after 12 mo postintervention. Dissemination of Balance Nutrition knowledge to fellow teachers of the same school, colleagues from different schools, or to representatives of preschool associations was evident. Training should be scaled up to the district level, using trained teachers as trainers and adopting a cascade training method. National roll-out by teachers' associations, in collaboration with the Ministry of Education and the Ministry of Health, could improve the knowledge of over 200,000 preschool teachers and potentially improve the nutrition of 19 million preschoolers.

Family Perceptions of a Cooking and Nutrition Program for Low-Income Children and Adolescents

Background. Flint Kids Cook, a nutrition and culinary program for children and adolescents, was created in October 2017 to address health concerns among youth and families in a low-income, urban community. In this study, researchers examined family experiences with the 6-week, chef-led program, which was taught in a farmers' market kitchen. Methods. At the conclusion of each session, researchers used an open-ended focus group format to assess program experiences, perceived impact on youth self-efficacy for cooking and healthy eating, and caregiver support. This qualitative study was guided by thematic analysis. Results. Between November 2017 and December 2018, 72 caregivers (n = 38) and students (n = 34) participated in separate focus groups. Caregivers were primarily female (74%) and African American (71%). Most students were African American (76%) and half were female. Recurrent themes included food acceptance, dietary modifications, confidence in the kitchen, and program design. Caregivers and students agreed that location and design of the program alongside facilitation by an experienced chef were important factors for program success. Conclusions. This study demonstrated that a chef-led healthy cooking program for youth was effective in improving perceived food acceptance, dietary habits, and confidence in the kitchen. The program could be modeled in similar communities to address diet and health of children and adolescents.

The process of culturally adapting the Healthy Beginnings early obesity prevention program for Arabic and Chinese mothers in Australia

Background

Behavioural interventions for the early prevention of childhood obesity mostly focus on English-speaking populations in high-income countries. Cultural adaptation is an emerging strategy for implementing evidence-based interventions among different populations and regions. This paper describes the initial process of culturally adapting Healthy Beginnings, an evidence-based early childhood obesity prevention program, for Arabic and Chinese speaking migrant mothers and infants in Sydney, Australia.

Methods

The cultural adaptation process followed the Stages of Cultural Adaptation theoretical model and is reported using the Framework for Reporting Adaptations and Modifications-Enhanced. We first established the adaptation rationale, then considered program underpinnings and the core components for effectiveness. To inform adaptations, we reviewed the scientific literature and engaged stakeholders. Consultations included focus groups with 24 Arabic and 22 Chinese speaking migrant mothers and interviews with 20 health professionals. With input from project partners, bi-cultural staff and community organisations, findings informed cultural adaptations to the content and delivery features of the Healthy Beginnings program.

Results

Program structure and delivery mode were retained to preserve fidelity (i.e. staged nurse calls with key program messages addressing modifiable obesity-related behaviours: infant feeding, active play, sedentary behaviours and sleep). Qualitative analysis of focus group and interview data resulted in descriptive themes concerning cultural practices and beliefs related to infant obesity-related behaviours and perceptions of child weight among Arabic and Chinese speaking mothers. Based on the literature and local study findings, cultural adaptations were made to recruitment approaches, staffing (bi-cultural nurses and project staff) and program content (modified call scripts and culturally adapted written health promotion materials).

Conclusions

This cultural adaptation of Healthy Beginnings followed an established process model and resulted in a program with enhanced relevance and accessibility among Arabic and Chinese speaking migrant mothers. This work will inform the future cultural adaptation stages: testing, refining, and trialling the culturally adapted Healthy Beginnings program to assess acceptability, feasibility and effectiveness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10270-5.

Development of the Impact of a Preschool Obesity Prevention Intervention Enhanced With Positive Behavioral Supports for Mississippi Head Start Centers

OBJECTIVE

To describe the methodology of the Impact of a Preschool Obesity Prevention intervention enhanced with positive behavioral supports.

DESIGN

The social ecological model serves as the conceptual framework for this study, which has a within- and between-subjects design with an intervention group and a delayed intervention control group. This 3-year project will use formative methods to pretest materials in Year 1, collect data pre- and postintervention with a follow-up at 4 months in Years 2 and 3, and conduct summative and process evaluation in Year 3.

SETTING

Head Start centers in Southern and East-Central Mississippi counties.

PARTICIPANTS

Three hundred parents with 3-year-old children enrolled in 9 Head Start centers (53 classrooms) and 75 Head Start teachers.

INTERVENTIONS

During Year 2, Hip Hop to Health Jr., Parent-Child Interaction Therapy, and Positive Behavior Interventions and Supports will be implemented.

MAIN OUTCOME MEASURES

Primary outcomes include changes in parenting and teacher practices. Secondary outcomes include parent feeding styles as well as weight status and dietary intake. Variables will be measured using anthropometrics and validated surveys.

ANALYSIS

The primary analysis will be a multilevel 2 × 3 mixed ANOVA.

A pilot randomised controlled trial of a web-based implementation intervention to increase child intake of fruit and vegetables within childcare centres

Background

As dietary behaviours developed during early childhood are known to track into adulthood, interventions that aim to improve child nutrition at a population level are recommended. Whilst early childhood education and care (ECEC) is a promising setting for interventions targeting children’s nutrition behaviours, previous interventions have largely used high intensity, face-to-face approaches, limiting their reach, implementation and potential impact at a population level. Web-based modalities represent a promising means of supporting the delivery of childcare-based interventions whilst overcoming challenges of previous approaches; however, the feasibility of using such modalities to support implementation is largely unknown. As such, this study sought to collect feasibility and pilot data to inform the design of a web-based intervention together with health promotion officer support within childcare centres. Child dietary intake will also be assessed to provide an estimate of the impact of the implementation intervention.

Methods

A superiority cluster randomised controlled trial with repeat cross-sectional data collection employing an effectiveness-implementation type-II hybrid design will be conducted with childcare centres within the Hunter New England region of New South Wales, Australia. Type-II hybrid designs provide the opportunity to assess intervention efficacy whilst piloting the feasibility of the implementation strategies. Centres allocated to the intervention group will receive access to a web-based program together with health promotion officer support to implement targeted healthy eating practices to improve child diet in care. A number of outcomes will be assessed to inform the feasibility to conduct a larger trial, including childcare centre and parent recruitment and consent rates for each component of data collection, uptake of the implementation strategies, acceptability of the intervention and implementation strategies, appropriateness of the implementation strategies and the contextual factors influencing implementation.

Discussion

This study will provide high-quality evidence regarding the potential feasibility of a web-based intervention and the impact of healthy eating practices on child diet in care. Web-based modalities provide a promising approach for population-wide implementation support to childcare centres given their potential reach and consistency with existing infrastructure.

Trial registration

Prospectively registered with Australian New Zealand Clinical Trial Registry (ACTRN12619001158156).

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s40814-020-00707-w.

Characteristics of successful primary school-based experiential nutrition programmes: a systematic literature review

OBJECTIVE

Diet and nutrition in childhood has been associated with the risk of chronic disease later in life. The aim of this review was to identify key characteristics of successful experiential nutrition interventions aimed to change nutrition-related cognitive and behavioural outcomes in primary schoolchildren.

DESIGN

A systematic literature review was undertaken using search terms ('food security', 'school', 'nutrition' and 'program') applied to five scientific databases (CINAHL, Scopus, Web of Science, Medline and Academic Search complete), with outcomes defined as nutrition-related knowledge, attitudes and/or dietary behaviours.

PARTICIPANTS

Primary school-aged children exposed to interventions conducted, at least partially, on school grounds.

RESULTS

A total of 3800 articles were identified from the initial search and manual searching, of which sixty-seven articles were eligible for inclusion. Forty-two articles met the criteria of being successful, defined as achieving significant differences in outcomes of interest, accompanied by a demonstrated reach. Interventions included school gardens (n 9), food provision (n 5), taste testing (n 8), cooking classes (n 10) and multicomponent programmes (n 10). Nutrition education (when combined with taste testing), cooking-related activities and gardening interventions increased children's willingness to taste unfamiliar foods including new fruits and vegetables, improved their cooking and food preparation skills and increased nutritional knowledge.

CONCLUSIONS

This review provides evidence that nutrition education programmes in primary schoolchildren that are experiential in nature are most likely to be successful if they include multiple strategies, have parental involvement and focus specifically on vegetable intake.

Flint Kids Cook: positive influence of a farmers' market cooking and nutrition programme on health-related quality of life of US children in a low-income, urban community

OBJECTIVE

To examine changes in health-related quality of life (HRQoL) among youth who participated in Flint Kids Cook, a 6-week healthy cooking programme for children, and assess whether changes in HRQoL were associated with changes in cooking self-efficacy, attitude towards cooking (ATC) and diet.

DESIGN

Pre-post survey (Pediatric Quality of Life Inventory, Block Kids Food Screener, 8-item cooking self-efficacy, 6-item ATC) using child self-report at baseline and programme exit. Analysis involved paired sample t-tests and Pearson's correlations.

SETTING

Farmers' market in Flint, Michigan, USA.

PARTICIPANTS

Children (n 186; 55·9 % female, 72·6 % African American) participated in Flint Kids Cook from October 2017 to February 2020 (mean age 10·55 ± 1·83 years; range 8-15).

RESULTS

Mean HRQoL summary score improved (P < 0·001) from baseline (77·22 ± 14·27) to programme exit (81·62 ± 14·43), as did mean psychosocial health summary score (74·68 ± 15·68 v. 79·04 ± 16·46, P = 0·001). Similarly, physical (P = 0·016), emotional (P = 0·002), social (P = 0·037), and school functioning (P = 0·002) improved. There was a correlation between change in HRQoL summary score and change in ATC (r = -0·194, P = 0·025) as well as change in cooking self-efficacy (r = -0·234, P = 0·008). Changes in HRQoL and psychosocial health summary scores were not correlated with dietary changes, which included decreased added sugar (P = 0·019) and fruit juice (P = 0·004) intake.

CONCLUSIONS

This study is the first to report modest yet significant improvements in HRQoL among children and adolescents who participated in a healthy cooking programme. Results suggest that cooking programmes for youth may provide important psychosocial health benefits that are unrelated to dietary changes.

The interactive effects of parental self-efficacy and child eating styles in relation to naturalistically-assessed craving, overeating, and loss of control eating

OBJECTIVE

Parental factors have been linked to weight-related outcomes in children, though less is known regarding the role of parental self-efficacy (PSE) for promoting healthy dietary behaviors (HDBs). This study examined associations between PSE for promoting HDBs and child reports of craving, overeating, and loss of control eating in daily life. The interactive effects of PSE and child eating style (emotional eating, external eating, and restraint) were also explored.

METHOD

Thirty-eight youth (ages 8-14; 55.3% female) with overweight/obesity and their parents completed the Dutch Eating Behavior Questionnaire for Children (DEBQ-C) and Parental Self-Efficacy for Healthy Dietary and Physical Activity Behaviors Scale, respectively. Youth completed ecological momentary assessment (EMA) to report craving, overeating, and loss of control eating.

RESULTS

Generalized estimating equations indicated no consistent main effects of PSE on EMA outcomes, but PSE interacted with DEBQ-C child eating styles to predict each EMA outcome. Among children of parents with lower PSE, (a) higher emotional eating was associated with greater overeating and loss of control eating; (b) higher external eating was associated with greater craving; and (c) higher restraint was associated with greater loss of control eating and craving. Conversely, these associations were attenuated among children of parents with higher PSE.

DISCUSSION

Together findings suggest the interplay of child characteristics and PSE regarding children's eating behaviors warrants future investigation in the context of eating and weight disorders. In particular, further research is needed to examine the directionality of effects and mechanisms underlying these associations.

Importance of Self-Efficacy in Eating Behavior and Physical Activity Change of Overweight and Non-Overweight Adolescent Girls Participating in Healthy Me: A Lifestyle Intervention with Mobile Technology

Very little is known about how multicomponent interventions directed to entire populations work in selected groups of adolescents. The aim was to evaluate the effectiveness of the Healthy Me one-year program on changes in healthy eating and physical activity among overweight and non-overweight female students. Randomization involved the allocation of full, partial or null intervention. The randomized field trial was implemented in 48 secondary schools (clusters) all over Poland among 1198 15-year-old girls. In this study, a sample of N = 1111 girls who participated in each evaluation study was analyzed. Using multimedia technologies, efforts were made to improve health behaviors and increase self-efficacy. The main outcome was a health behavior index (HBI), built on the basis of six nutritional indicators and one related to physical activity. HBI was analyzed before and immediately after intervention and at three months' follow-up, and the HBI change was modeled. Statistical analysis included nonparametric tests and generalized linear models with two-way interactions. Comparing the first and third surveys, in the overweight girls, the HBI index improved by 0.348 (SD = 3.17), while in the non-overweight girls it had worsened. After adjusting for other factors, a significant interaction between body weight status and level of self-efficacy as predictors of HBI changes was confirmed. The program turned out to be more beneficial for overweight girls.

González-Gil E, Tamás H, JANCSÓ Z, Liatis S, Makrilakis K, Manios Y. Effective strategies for childhood obesity prevention via school based, family involved interventions: a critical review for the development of the Feel4Diabetes-study school based component

BACKGROUND

Although there are many interventions targeting childhood obesity prevention, only few have demonstrated positive results. The current review aimed to gather and evaluate available school-based intervention studies with family involvement targeting dietary, physical activity and sedentary behaviors among primary schoolchildren and their families, in order to identify the most effective strategies.

METHODS

Studies published between 2000 and January 2015 were retrieved from scientific electronic databases and grey literature. The databases used included MEDLINE/PubMed, Web-of-Science, CINAHL and Scopus. Included studies had to be experimental controlled studies and had duration over 1 school year, had family involvement, combined PA and dietary behaviors and were implemented in school setting. A complementary search was executed to update the review to cover the period from February 2015 to January 2019.

RESULTS

From the studies examined (n = 425), 27 intervention programs (33 publications) fulfilled the inclusion criteria. Among these, 15 presented significant effect on weight status and/ or overweight/ obesity or clinical indices, 3 presented significant effect on most energy balance-related behaviors (EBRBs) while 9 presented significant effect on some/few EBRBs or determinants. Strategies implemented in effective interventions were: teachers acting as role-models and being actively involved in the delivery of the intervention, school policies supporting the availability of healthy food and beverage choices and limiting unhealthy snacks, changes in the schoolyard, in the recess rules and in the physical education classes to increase physical activity, and involving parents in the intervention via assignments, meetings, informative material and encouraging them to improve the home environment. Use of incentives for children, social marketing techniques, collaboration with local stakeholders were found to increase effectiveness. Programs that focused only on educational sessions and material for parents, without promoting relevant environmental and policy changes, were found to be less effective. Cultural adaptations have been suggested to increase the intervention's acceptance in specific or vulnerable population groups.

CONCLUSIONS

Several effective strategies were identified in the reviewed programs. Outcomes of the current review were taken into account in developing the Feel4Diabetes-intervention and summed up as recommendations in the current work in order to facilitate other researchers designing similar childhood obesity prevention initiatives.

Effectiveness of the Healthy Start-Départ Santé approach on physical activity, healthy eating and fundamental movement skills of preschoolers attending childcare centres: a randomized controlled trial

Background

Since young children spend approximately 30 h per week in early childcare centres (ECC), this setting is ideal to foster healthy behaviours. This study aimed to assess the effectiveness of the Healthy Start-Départ Santé (HSDS) randomized controlled trial in increasing physical activity (PA) levels and improving healthy eating and fundamental movement skills in preschoolers attending ECC.

Methods

Sixty-one ECC were randomly selected and allocated to either the usual practice (n = 30; n = 433 children) or intervention group (n = 31; n = 464 children). The HSDS intervention group was provided a 3-h on-site training for childcare educators which aimed to increase their knowledge and self-efficacy in promoting healthy eating, PA and development of fundamental movement skills in preschoolers. PA was measured during childcare hours for five consecutive days using the Actical accelerometer. Preschoolers’ fundamental movement skills were assessed using the standard TGMD-II protocol and POMP scores. Food intake was evaluated using digital photography-assisted weighted plate waste at lunch, over two consecutive days. All data were collected prior to the HSDS intervention and again 9 months later. Mixed-effect models were used to analyse the effectiveness of the HSDS intervention on all outcome measures.

Results

Total number of children who provided valid data at baseline and endpoint for PA, food intake and fundamental movement skills were 259, 670 and 492, respectively. Children in the HSDS intervention group had, on average, a 3.33 greater point increase in their locomotor motor skills scores than children in the control group (β = 3.33, p = 0.009). No significant differences in effects were observed for object control, PA and food intake. However, results demonstrated a marginal increase in portions of fruits and vegetables served in the intervention group compared to control group (β = 0.06, p = 0.05).

Conclusion

Of the 12 outcome variables investigated in this study, 10 were not different between the study groups and two of them (locomotor skills and vegetables and fruits servings) showed a significant improvement. This suggests that HSDS is an effective intervention for the promotion of some healthy behaviours among preschoolers attending ECC.

Trial registration

Clinical Trials NCT02375490. Registered on February 24, 2015; 77 retrospectively registered.

Development of the DAGIS intervention study: a preschool-based family-involving study promoting preschoolers' energy balance-related behaviours and self-regulation skills

Background

Preschoolers’ energy balance-related behaviours (EBRBs) and self-regulation skills are important for their later health. Few preschool-based interventions aiming to promote preschoolers’ EBRBs and self-regulation skills, simultaneously reducing differences in EBRBs, due to children’s socio-economic status (SES) background, have been conducted. This study will present the Increased Health and Wellbeing in Preschools (DAGIS) intervention development process applying the Intervention Mapping (IM) framework.

Methods

The development of the DAGIS intervention study, a preschool level clustered randomized controlled trial (RCT), was based on the IM framework. The protocol in IM guides the development process of an intervention through six steps: needs assessment and logic model of the problem, programme outcomes and objectives, design of the programme, production, implementation plan, and evaluation plan.

Results

The needs assessment, part of the step 1 in IM, yielded the base for the DAGIS logic model of change. The model includes objectives related to changes in children’s EBRBs, self-regulation skills, and in psychosocial and physical environment that is determined by parents and early educators. A 22-week programme was developed, and materials for preschools and families were produced. A feasibility study of the recruitment processes, acceptability of the materials and methods, and implementation was conducted. The DAGIS intervention study was conducted September 2017–May 2018 as a clustered RCT including a comprehensive effectiveness and process evaluation. The process evaluation was run throughout the intervention targeting preschools and families.

Conclusion

A preschool-based family-involving programme was developed in the DAGIS intervention study by applying the IM protocol. It was a time- and resource-consuming process. However, the systematic planning, development, and running of the programme have reinforced a comprehensive evaluation, which is a strength in the intervention. The results from the evaluation will enhance the knowledge of how to promote EBRBs and self-regulation skills among preschoolers, and diminish SES differences in them.

Trial registration

ISRCTN57165350 (Prospectively registered January the 8th, 2015).

GReat-Child Trial™ based on social cognitive theory improved knowledge, attitudes and practices toward whole grains among Malaysian overweight and obese children

Background

Studies have reported that improvement of dietary habits through increased whole grain foods consumption at an early age has the potential to lead to betterment in lifelong health and wellness. The GReat-Child Trial™ was a 12-week quasi-experimental study with 6 months follow-up investigating a multi-component whole grain intervention, which consisted of behavioral, personal and environmental factors based on Social Cognitive Theory (SCT). This study aimed to evaluate the feasibility and acceptability of the GReat-Child Trial™, as well as to determine the changes in knowledge, attitudes and practices (KAP) of whole grains consumption among overweight/obese children.

Methods

Two schools in Kuala Lumpur with similar socio-demographic characteristics were assigned as intervention (IG) and control (CG), respectively. Inclusion criteria were healthy Malaysian overweight/obese children aged 9 to 11 years who had no serious co-morbidity. Children who reported consuming whole grain foods in their 3-day diet-recall during recruitment were excluded. A total of 63 children (31 IG; 32 CG) completed the intervention. KAP questionnaire was self-administered at baseline [T0] and post intervention (at 3rd [T1] and 9th month [T2]). The baseline differences between the IG and CG across socio-demographics and scores of KAP toward whole grains were determined using chi-square and t-test, respectively. ANCOVA was performed to determine the effect of the GReat-Child Trial™ on KAP towards whole grains at post-intervention and follow-up. Baseline variables were considered as covariates.

Results

The IG attained significantly higher scores in knowledge (mean difference = 4.23; 95% CI: 3.82, 4.64; p < 0.001), attitudes (mean difference = 7.39; 95% CI: 6.36, 8.42; p < 0.001) and practice (mean difference = 6.13; 95% CI: 4.49, 7.77; p < 0.001) of whole grain consumption compared to the CG, after adjusting for confounders. The IG reported significantly higher scores in knowledge (mean difference = 6.84; 95% CI: 6.53, 7.15; p < 0.001), attitudes (mean difference = 9.16; 95% CI: 8.08, 10.24; p < 0.001) and practice (mean difference = 8.03; 95% CI: 5.34, 10.73; p < 0.001) towards whole grains at T2 compared to T0.

Conclusions

These findings indicate that this intervention made a positive impact on improving children’s KAP on whole grains. We anticipate the GReat-Child Trial™ to be a program that could be incorporated into school interventions to improve whole grain consumption among Malaysian children for obesity prevention.

An educational intervention to prevent overweight in pre-school years: a cluster randomised trial with a focus on disadvantaged families

BACKGROUND

Early prevention is a promising strategy for reducing obesity in childhood, and Early Years settings are ideal venues for interventions. This work evaluated an educational intervention with the primary aim of preventing overweight and obesity in pre-school children.

METHODS

A pragmatic, cluster randomised trial with a parallel, matched-pair design was undertaken. Interventions were targeted at both the cluster (Early Years' Centres, matched by geographical area) and individual participant level (families: mother and 2-year old child). At the cluster level, a staff training intervention used the educational resource Be Active, Eat Healthy. Policies and provision for healthy eating and physical activity were evaluated at baseline and 12-months. The intervention at participant level was the Healthy Heroes Activity Pack: delivered over 6 months by Centre staff to promote healthy eating and physical activity in a fun, interactive way. Child and parent height and weight were measured at four time-points over 2 years. The trial primary outcome was the change in BMI z-score of the child between ages 2 and 4 years. Secondary outcomes consisted of parent-reported measures administered at baseline and two-year follow-up.

RESULTS

Five pairs of Early Years' Centres were recruited. Four pairs were analysed as one Centre withdrew (47 intervention families; 34 control families). At the cluster level, improvement in Centre policies and practices was similar for both groups (p = 0.830). At the participant level, the intervention group reduced their mean BMI z-score between age 2 and 4 years (p = 0.002; change difference 0.49; 95% CI 0.17 to 0.80) whereas the control group showed increasing BMI z-score throughout. Changes in parent-reported outcomes and parent BMI (p = 0.582) were similar in both groups.

CONCLUSIONS

The Healthy Heroes educational resource deterred excess weight gain in pre-school children from poor socioeconomic areas. With training, Early Years' staff can implement the Healthy Heroes programme.

TRIAL REGISTRATION

ISRCTN22620137 Registered 21st December 2016.

Position of the Academy of Nutrition and Dietetics: Benchmarks for Nutrition in Child Care

It is the position of the Academy of Nutrition and Dietetics that early care and education (ECE) programs should achieve recommended benchmarks to meet children's nutrition needs and promote children's optimal growth in safe and healthy environments. Children's dietary intake is influenced by a number of factors within ECE, including the nutritional quality of the foods and beverages served, the mealtime environments, and the interactions that take place between children and their care providers. Other important and related health behaviors that may influence the development of obesity include children's physical activity, sleep, and stress within child care. Recent efforts to promote healthy eating and improve other health behaviors in ECE include national, state, and local policy changes. In addition, a number of interventions have been developed in recent years to encourage healthy eating and help prevent obesity in young children in ECE. Members of the dietetics profession, including registered dietitian nutritionists and nutrition and dietetics technicians, registered, can work in partnership with ECE providers and parents to help promote healthy eating, increase physical activity, and address other important health behaviors of children in care. Providers and parents can serve as role models to support these healthy behaviors. This Position Paper presents current evidence and recommendations for nutrition in ECE and provides guidance for registered dietitian nutritionists; nutrition and dietetics technicians, registered; and other food and nutrition practitioners working with parents and child-care providers. This Position Paper targets children ages 2 to 5 years attending ECE programs and highlights opportunities to improve and enhance children's healthy eating while in care.

Parental Perceived Facilitators for and Barriers to Participating in a Lifestyle Intervention to Reduce Early Childhood Obesity: A Qualitative Evaluation

This study aimed to examine low-income mothers' perceived facilitators for and barriers to participating in a lifestyle intervention. A phenomenography approach was used to individually interview 14 mothers from Midwestern U.S. The data were analyzed using content analysis. Drawing on the socio-ecological model, mothers' perceived facilitators included (a) intrapersonal factors including providing helpful information, being accommodating, motivating, and novel; (b) interpersonal factors, including two-way communication between mothers and preschoolers, social connectedness among mothers, and a positive relationship between mothers and researchers; and (c) environmental factors, including kid-friendly, and pleasant and comfortable intervention sites. Mothers' reported barriers were intrapersonal factors including (a) use of technology due to unreliable Wi-Fi access and unfamiliarity of electronic device, (b) being "busy moms" due to busy schedules and stressful daily lives, and (c) lack of reliable transportation. Future interventions to reduce early childhood obesity among low-income families should consider these identified facilitators and barriers.

Physical activity interventions in early life aimed at reducing later risk of obesity and related non-communicable diseases: A rapid review of systematic reviews

To identify useful components of interventions aimed at prevention of childhood obesity and related non-communicable diseases (NCDs), which included physical activity and which targeted any or all of four life-course stages: peri-conception; pregnancy; infancy and toddlerhood (0 to 23 months); and early childhood (24 to 59 months). In May 2016, WHO Geneva searched the Cochrane Library and PubMed for systematic reviews of interventions including physical activity to prevent childhood obesity or risk factors for obesity-related NCDs. Using a narrative synthesis, the efficacy of randomized controlled trials (RCTs) to alter energy balance outcomes (measures of weight status or body fatness) was characterized by life-course stage, study characteristics, intervention functions (as defined in the behaviour change wheel), and level of the socio-ecological model (SEM) targeted. The quality of included systematic reviews was assessed. We retrieved 82 reviews from the World Health Organization (WHO) search, of which 23 were eligible for the present synthesis. The number of eligible studies by life-course stage was: 0 (peri-conception); 0 (pregnancy); 8 (infancy and toddlerhood, age 0 to 23 months; seven RCTs; age); and 37 (early childhood, age 24 to 59 months; 30 RCTs;). Thus, there was a lack of evidence for physical activity interventions during peri-conception and pregnancy. Almost all relevant studies in the 0- to 23- and 24- to 59-month life-course stages were multicomponent interventions (ie, targeted physical activity, dietary, and/or sedentary behaviours). Interventions with evidence of efficacy tended to target multiple levels of the SEM, with emphasis on parents, and extend over long periods. Effective intervention elements for early life obesity prevention included classes on parenting skills, alteration of the kindergarten playground, and financial incentives. Evidence from low- and middle-income countries was scarce, and evidence for intervention effect on obesity-related NCDs was missing. Future physical activity interventions in toddlerhood and early childhood aimed at prevention of obesity should adopt the characteristics typical of effective interventions identified by the present synthesis. There is an urgent need for more evidence on physical activity interventions set in low- and middle-income countries and which target the peri-conception and pregnancy periods.

Effectiveness of Teacher-Led Nutritional Lessons in Altering Dietary Habits and Nutritional Status in Preschool Children: Adoption of a NASA Mission X-Based Program

The preschool years are a sensitive period for the development of food preferences that will affect physical growth and life-long health. The promotion of healthy eating and nutritional status was achieved by adapting the US National Aeronautics and Space Administration (NASA) Mission X (MX) Program among young children in South Korea. The intervention program was delivered by nutritional experts and class teachers over 10 weeks. Children from 37 school classes (n = 534) from 7 daycares and kindergartens were randomized into a control group (CG, n = 280) and an intervention group (IG, n = 254). Parents were surveyed for their children’s characteristics and nutrition quotient (NQ) at baseline and at the 10-week follow-up. At baseline, 18.8% (boys: 18.9%; girls: 18.8%) of the subjects were overweight or obese (body mass index ≥ 85th percentile). After the intervention, the mean differences in various anthropometric measures did not differ significantly between the groups in a linear regression model adjusted for age, sex, and type of school. The NQ grades were significantly higher in the IG than the CG after the intervention (p = 0.000). In summary, the 10-week South Korean MX program improved the eating behaviors and nutrition status of young children. A further multisector prevention program is needed to prevent childhood obesity in young children.

Obesity and the Mediterranean Diet: A Review of Evidence of the Role and Sustainability of the Mediterranean Diet

Several different socio-economic factors have caused a large portion of the population to adopt unhealthy eating habits that can undermine healthcare systems, unless current trends are inverted towards more sustainable lifestyle models. Even though a dietary plan inspired by the principles of the Mediterranean Diet is associated with numerous health benefits and has been demonstrated to exert a preventive effect towards numerous pathologies, including obesity, its use is decreasing and it is now being supplanted by different nutritional models that are often generated by cultural and social changes. Directing governments' political actions towards spreading adherence to the Mediterranean Diet's principles as much as possible among the population could help to tackle the obesity epidemic, especially in childhood. This document intends to reiterate the importance of acting in certain age groups to stop the spread of obesity and proceeds with a critical review of the regulatory instruments used so far, bearing in mind the importance of the scientific evidence that led to the consideration of the Mediterranean Diet as not just a food model, but also as the most appropriate regime for disease prevention, a sort of complete lifestyle plan for the pursuit of healthcare sustainability.

Proof of concept trial for a new theory-based intervention to promote child and adult behavior change

Interventions to change children's behavior typically target adults or children, but rarely both. The aims were to: (a) evaluate acceptability and feasibility of an innovative theory-based intervention designed to change both child and adult behavior, and (b) generate effect sizes for a definitive randomized controlled trial. The oral health of sixty children aged 5-9 years with a repaired cleft lip and/or palate was assessed before randomization to one of three conditions: (a) control group, (b) intervention group in which children and adults were asked to form implementation intentions, or (c) intervention plus booster group in which adults were additionally sent a reminder about the implementation intentions they and their children formed. Oral health assessments were repeated at 6-month follow-up alongside exit interviews. The procedures proved popular and participants exposed to the intervention additionally reported believing that forming implementation intentions was effective. Descriptive statistics generally showed oral health improvements across all conditions, although the effects were more marked in the intervention plus booster condition, where plaque improved by 44.53%, gingivitis improved by 20.00% and free sugar consumption improved by 8.92% (vs. 6.43% improvement, 15.00% deterioration and 15.58% improvement in the control group, respectively). Data collection procedures were acceptable and the intervention feasible. The effect sizes suggest that the intervention plus booster condition has sufficient promise to proceed to a fully-powered randomized controlled trial. The intervention has the potential to be adapted to tackle other child health behaviors and to be deployed at scale.

Combined Longitudinal Effect of Physical Activity and Screen Time on Food and Beverage Consumption in European Preschool Children: The ToyBox-Study

Lifestyle behavioral habits such as excess screen time (ST), a lack of physical activity (PA), and high energy-dense food consumption are associated with an increased risk of children being overweight or obese. This study aimed to (1) track longitudinal adherence to PA and ST recommendations at baseline (T0) and follow-up (T1) and (2) assess the association between changes in adherence to PA and ST recommendations and food and beverage consumption at follow-up. The present study included 2321 preschool children (3.5 to 6) participating in the multicenter ToyBox-study. A lineal mixed effects model was used to examine the association between different types of food and beverages and their relationship with changes in adherence to PA and ST recommendations. Approximately half of the children (50.4%) did not meet the PA and ST recommendations at both baseline and follow-up. However, only 0.6% of the sample met both PA and ST recommendations. Preschool children who met both recommendations consumed fewer fizzy drinks, juices, sweets, desserts, and salty snacks and consumed more water, fruits and vegetables, and dairy products than did those not meeting both recommendations. In conclusion, the proportion of European preschool children adhering to both PA and ST recommendations was very low and was associated with a low consumption of energy-dense foods.

A comprehensive multicomponent school-based educational intervention did not affect fruit and vegetable intake at the 14-year follow-up

The intake of fruit and vegetables is associated with beneficial health outcomes, and studies aimed at increasing fruit and vegetable intake lack long-term follow-up. The primary objective of this study was to evaluate the long-term (14-year) effects of a multicomponent school-based educational intervention targeted to increase fruit and vegetable intake in children. The secondary objective was to evaluate the potential synergistic effect between free school fruit and the educational program. A cluster randomized school-based intervention was initiated in 2001 in Norway, known as the Fruit and Vegetable Make the Marks study. In total, 38 schools were randomized; for the intervention (n = 18) and as control schools (n = 20). A subsample of the intervention schools (n = 9) were additionally given free school fruit, resulting in two intervention groups - one with and one without free fruit. Participants completed questionnaires in September 2001 (baseline, mean age 11.8), May 2002 (at the end of the intervention), May 2003, May 2005, September 2009 and throughout 2016 (mean age 26.5). Of 1950 participants, 982 (50.4%) completed the 14-year follow-up and were considered as the current study sample. Analysis yielded no 14-year effects of the educational program on fruit and vegetable intake. A synergistic effect between the educational program and free fruit was not observed either. Future studies might benefit from increased focus on more extensive parental involvement, increased home availability, and a longer intervention period. However, more long-term studies are needed to evaluate the effects of school-based interventions into adulthood. Trial registration number: Ethical approval and research clearance was obtained from The National Committees for Research Ethics in Norway (file number S-01076) and The Norwegian Centre for Research Data (file number 12395).

The Influence of Home and School Environments on Children's Diet and Physical Activity, and Body Mass Index: A Structural Equation Modelling Approach

Introduction The home and school environments play important roles in influencing children's health behaviours. However, their simultaneous influence on childhood obesity has not yet been examined. We explore the relationship of the home and school environments with childhood obesity, to determine whether this relationship is mediated by children's fruit and vegetable intake and physical behaviours. Methods This study uses baseline data from 9 to 11 year old children, their parents and school principals (matched data n = 2466) from the Obesity Prevention and Lifestyle Project. Child-reported behaviours, parent-reported home environment and principal-reported school environment data were collected via questionnaires. Trained researchers measured children's height and weight, and Body Mass Index (BMI, kg/m²) was calculated. Structural equation modelling was used to assess the relationship of the home and school environments with children's fruit and vegetable intake, physical activity behaviours, and children's BMI. Result The home diet environment was positively associated with child diet (β = 0.18, p < 0.001). The home physical activity environment had the largest inverse association with BMI (β = - 0.11, p < 0.001), indirectly through child physical activity (β = 0.28 ,p < 0.001). Schools' healthy eating policy implementation was significantly associated with child diet (β = 0.52, p < 0.05), but physical activity policy was not associated with child activity (β = - 0.007, p > 0.05). The school environment was not associated with child BMI. Discussion The home environment had a stronger association with healthier child behaviours, compared to the school environment. These findings suggest that future childhood obesity interventions targeting healthier home environments and supporting parents can promote healthier child eating and physical activity behaviours.

Early Childhood Obesity Among Underserved Families: A Multilevel Community-Academic Partnership

A community-academic partnership, based on a social-ecological framework, addressed pediatric obesity by implementing a multilevel intervention for underserved families in Los Angeles, California. Individual- and interpersonal-level outcomes included significant positive changes in preschoolers' identification of unhealthy foods and in parents' shopping, cooking, and parenting behaviors. Organizational-, community-, and policy-level outcomes included healthy options at restaurants and a coalition supporting a parental initiative to create healthy checkout aisles in supermarkets. The multilevel intervention demonstrated favorable results using descriptive statistics and the paired-samples t-test.

Adapting the ToyBox obesity prevention intervention for use in Scottish preschools: protocol for a feasibility cluster randomised controlled trial

INTRODUCTION

There is an increasing need for the adoption of effective preschool obesity prevention interventions to combat the high levels of early-childhood obesity in the UK. This study will examine the feasibility and acceptability of the adapted version of the ToyBox intervention-a preschool obesity prevention programme-for use in Scotland (ToyBox-Scotland). This will inform the design of a full-scale cluster randomised controlled trial (RCT).

METHODS AND ANALYSIS

The ToyBox-Scotland intervention will be evaluated using a feasibility cluster RCT, which involves children aged 3-5 years at six preschools in Glasgow, three randomly assigned to the intervention group and three to the usual-care control group. The original ToyBox intervention was adapted for the Scottish context using a coproduction approach. Within the 18-week intervention, physical activity and sedentary behaviour will be targeted in the preschool through environmental changes to the classroom, physical activity sessions and movement breaks. Parents will receive home activity packs every 3 weeks containing sticker incentives and interactive parent-child games that target sedentary behaviour, physical activity, eating/snacking and water consumption. As this is a feasibility study, parameters such as recruitment rates, attrition rates and SDs of outcome measures will be obtained which will inform a power calculation for a future RCT. Additional variables to be assessed include accelerometer-measured physical activity, sedentary behaviour and sleep, body mass index, home screen time, eating/snacking and water consumption. Outcomes will be assessed at baseline and 14-17 weeks later. Intervention fidelity will be assessed using questionnaires and interviews with parents and practitioners, observation and session delivery records.

ETHICS AND DISSEMINATION

This study was granted ethical approval by the University of Strathclyde's School of Psychological Sciences and Health Ethics Committee. Results will be disseminated through publication in peer-reviewed journals, presentation at conferences and in lay summaries provided to participants.

TRIAL REGISTRATION NUMBER

ISRCTN12831555.

Caregiver perceptions of a fruit and vegetable prescription programme for low-income paediatric patients

OBJECTIVE

The physical and social environments that surround children should support good health. However, challenges with food security and access prevent many children from consuming a healthy diet, which is critical to proper growth and development. The present study sought to gain a better understanding of primary care initiatives to address these issues in a low-income setting.

DESIGN

Following the relocation of a paediatric clinic to a farmers' market building and the implementation of a fruit and vegetable prescription programme, researchers conducted thirty-two semi-structured interviews with caregivers. Researchers elicited caregivers' perceptions of clinic co-location with the farmers' market; experiences with the prescription programme; opinions of the farmers' market; and perceived impact on child consumption of fresh produce. Interview recordings were transcribed for textual analysis. Using thematic analysis, researchers examined qualitative data to identify patterns across transcripts and formulate emerging themes. Researchers concluded when data saturation was reached.

SETTING

Flint, Michigan, USA.

SUBJECTS

The majority of participants were female (91 %) and African American (53 %).

RESULTS

Four recurrent themes emerged during interviews: (i) convenience of relocation; (ii) attitude towards prescription programme; (iii) challenges with implementation; and (iv) perceived impact of combined interventions. Caregivers indicated that the co-location and prescription programme increased family shopping at the farmers' market, improved access to high-quality produce and improved food security.

CONCLUSIONS

A fruit and vegetable prescription programme involving a partnership between a farmers' market and paediatric clinic was perceived as effective in improving food security, food access and child consumption of fresh fruits and vegetables.

Impact of a Pilot School-Based Nutrition Intervention on Dietary Knowledge, Attitudes, Behavior and Nutritional Status of Syrian Refugee Children in the Bekaa, Lebanon

This study evaluated the impact of a 6-month school nutrition intervention on changes in dietary knowledge, attitude, behavior (KAB) and nutritional status of Syrian refugee children. A quasi-experimental design was followed; Syrian refuge children in grades 4 to 6 were recruited from three informal primary schools (two intervention and one control) located in the rural Bekaa region of Lebanon. The intervention consisted of two main components: classroom-based education sessions and provision of locally-prepared healthy snacks. Data on household socio-demographic characteristics, KAB, anthropometric measures and dietary intake of children were collected by trained field workers at baseline and post-intervention. Of the 296 school children enrolled, 203 (68.6%) completed post-intervention measures. Significant increases in dietary knowledge (β = 1.22, 95% CI: 0.54, 1.89), attitude (β = 0.69, 95% CI: 0.08, 1.30), and body mass index-for-age-z-scores (β = 0.25, 95% CI = 0.10, 0.41) were observed among intervention vs. control groups, adjusting for covariates (p < 0.05). Compared to the control, the intervention group had, on average, significantly larger increases in daily intakes of total energy, dietary fiber, protein, saturated fat, and several key micronutrients, p < 0.05. Findings suggest a positive impact of this school-based nutrition intervention on dietary knowledge, attitude, and nutritional status of Syrian refugee children. Further studies are needed to test the feasibility and long-term impact of scaling-up such interventions.

Effectiveness of a parental school-based intervention to improve young children’s eating patterns: a pilot study

Objective

To evaluate the effectiveness of a pilot study of a parental school-based intervention to promote healthy eating behaviours in young children.

Design

A quasi-experimental longitudinal design with three conditions (complete intervention (CIG), minimal intervention (MIG), control (CG)), with repeated measures at baseline, immediately after the intervention, 6 months and 1 year after intervention.

Setting

Fourteen public and state-funded kindergartens near Lisbon, Portugal.

Subjects

Parents (n349) of 3- to 6-year-old children assigned to the three conditions completed the baseline protocol. The ‘Red Apple’ intervention included four parental group sessions about young children’s growth, nutritional guidelines and positive parental feeding strategies, which was combined with adult–child activities at home and in the classroom, and newsletters (CIG). MIG included only a single nutritional counselling session, whereas the CG had no intervention. At the end, thirty-eight, twenty-six and fifty-four parents in the CIG, MIG and CG, respectively, had completed all evaluation components. Data regarding parental perception of children’s weight, self-efficacy, nutritional knowledge, feeding strategies, eating behaviours and BMI were collected at the four assessment moments.

Results

The CIG showed improvements in children’s healthy food intake, compared with the MIG and CG. Parental self-efficacy regarding the regulation of children’s eating behaviours decreased in the CG but not in both intervention groups.

Conclusions

Considering the low dosage of the intervention, the results obtained were positive. Future studies should offer additional solutions to overcome barriers to parents’ participation.

Effectiveness of school food environment policies on children's dietary behaviors: A systematic review and meta-analysis

Background

School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear.

Objective

To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children.

Methods

We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children’s dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg’s and Egger’s test evaluated potential publication bias.

Results

From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified.

Conclusions

Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.