A healthy school start - Parental support to promote healthy dietary habits and physical activity in children: Design and evaluation of a cluster-randomised intervention

<p>Abstract</p> <p>Background</p> <p>Childhood obesity is multi-factorial and determined to a large extent by dietary habits, physical activity and sedentary behaviours. Previous research has shown that school-based programmes are effective but that their effectiveness can be improved by including a parental component. At present, there is a lack of effective parental support programmes for improvement of diet and physical activity and prevention of obesity in children.</p> <p>Methods/Design</p> <p>This paper describes the rationale and design of a parental support programme to promote healthy dietary habits and physical activity in six-year-old children starting school. The study is performed in close collaboration with the school health care and is designed as a cluster-randomised controlled trial with a mixed methods approach. In total, 14 pre-school classes are included from a municipality in Stockholm county where there is large variation in socio-economic status between the families. The school classes are randomised to intervention (n = 7) and control (n = 7) groups including a total of 242 children. The intervention is based on social cognitive theory and consists of three main components: 1) a health information brochure; 2) two motivational interviewing sessions with the parents; and 3) teacher-led classroom activities with the children. The primary outcomes are physical activity in the children measured objectively by accelerometry, children's dietary and physical activity habits measured with a parent-proxy questionnaire and parents' self-efficacy measured by a questionnaire. Secondary outcomes are height, weight and waist circumference in the children. The duration of the intervention is six months and includes baseline, post intervention and six months follow-up measurements. Linear and logistic regression models will be used to analyse differences between intervention and control groups in the outcome variables. Mediator and moderator analysis will be performed. Participants will be interviewed.</p> <p>Discussion</p> <p>The results from this study will show if it is possible to promote a healthy lifestyle and a normal weight development among children from low-income districts with relatively limited efforts involving parents. Hopefully the study will provide new insights to the further development of effective programmes to prevent overweight and obesity in children.</p> <p>Trial registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN32750699">ISRCTN32750699</a></p

Overweight among ten year old children in Stockholm county over a four year period : gender and socioeconomic differences

Syftet med studien var att beskriva prevalens av övervikt, fetma och undervikt hos 10-11-åriga barn under en fyraårsperiod. Detta gjordes genom att jämföra två födelsekohorter, 1989 och 1993 med fokus på könsskillnader och skillnader i socioekonomi (SES) definierat utifrån inkomst i fyra olika typområden. Studien utfördes i Stockholms län 2005 där SES-områden och skolor inom dessa områden valdes slumpmässigt. Antropometriska data från skolhälsovårdsjournaler insamlades från barn i skolår fyra. Vikt, längd och födelsedata erhölls från 2416 10-11-åringar födda 1989 och från 2183 barn födda 1993. Övervikt och fetma definierades enligt Cole ́s ålders- och könsspecifika BMI-gränser. Undervikt definierades som – 2 SD enligt referenskurvor från Karlberg 2001. En tydlig könsskillnad kan ses vad gäller prevalens av övervikt och fetma. Hos pojkarna var 21,3 % överviktiga både i kohort 1989 och 1993 medan fetma ökade ickesignifikant från 3,1 % till 4,0 %. Hos flickorna minskade övervikten från 22,9 % till 19,7 % (ns) och fetma minskade från 4,6 % till 2,9 % (RR= 0,62 95 % CI:0,41-0,98). Undervikten tenderade att minska både hos flickor och hos pojkar. Vid jämförelse av de olika SES-områdena var den sociala gradienten mer tydlig i födelsekohort 1993 jämfört med 1989. I födelsekohort 1993 var 17,1 % av pojkarna överviktiga i det mest resursstarka området jämfört med 29,0 % i det mest resurssvaga området. För fetma var motsvarande siffror 1,9 % och 6,0 %. Flickorna uppvisade ett helt annat mönster; hos flickor i det mest resurssvaga området var överviktsprevalensen nästan identisk vid de två studerade tidpunkterna; 28,4 % och 28,3 %. I de övriga SES-områdena var övervikten lägre hos flickor i födelsekohort 1993 jämfört med födelsekohort 1989. Studien visar att trenden av övervikt och fetma delvis ändrat riktning med en minskning av fetma hos flickorna medan pojkarna fortsätter att öka särskilt i resursfattiga områden. Det finns en tendens till att den sociala gradienten har ökat under den studerade fyraårsperioden vilket understryker vikten av förebyggande åtgärder för barn och deras familjer i särskilt resursfattiga områdenThe objective of the study was to describe prevalence of overweight, obesity, and underweight among 10-11 year old children during a four year period. This was done by comparing 1989 and 1993 birth cohorts, with focus on gender and socioeconomic (SES) using data from small geographical areas. The study was performed 2005 in Stockholm county where SES areas and schools within SES areas were randomly sampled. In selected schools, anthropometric data from routine assessments of 4thgraders were abstracted from school records. Weights, heights and birthdates were retrieved from 2416 10-11 year olds born in 1989 and 2183 born in 1993. Overweight and obesity were defined according to Cole’s age- and sex-specific BMI cut-off points. Underweight was defined as -2 SD according to the national growth reference curves established by Karlberg and coworkers 2001. Secular trends in prevalence between 1989 and 1993 seemed to vary by sex. In boys, the prevalence of overweight was 21.3 % in both birth cohorts, while obesity increased non-significantly from 3.1 to 4.0 %. In girls overweight decreased non-significantly from 22.9 to 19.7 and obesity decreased from 4.6 to 2.9 % (RR= 0.62 95 % CI: 0.41-0.98). The prevalence of underweight decreased non-significantly both in boys and in girls. When comparing the different SES-areas the social gradient was more obvious in birth cohort 1993 than cohort 1989. In birth cohort 1993 17.1 % of the boys were overweight in the most affluent area compared to 29.0 % in the low SES area. For obesity the prevalences were 1.9 % and 6.0 % respectively. In girls there is a slightly different pattern; among girls in the low SES areas the prevalence of overweight are almost identical 28.4 and 28.3. In the other areas the 1993 cohort shows a lower overweight prevalence compared to girls born 1989. In summary decreases in obesity occurred in girls from the two respective birth cohorts; at the same time both overweight and underweight tended to decrease. In contrast, among boys, there were no significant differences over time, although increases in obesity were detected among boys in less advantaged socioeconomic areas.This underlines the need for computer based monitoring of routine height and weight measurements in schools and preventive efforts which target children and their families in areas of low-socioeconomic status in early childhood.ISBN 91-7997-158-x</p

Managing Implementation of a Parental Support Programme for Obesity Prevention in the School Context : The Importance of Creating Commitment in an Overburdened Work Situation, a Qualitative Study.

Health-related behaviours in children can be influenced by parental support programmes. The aim of this study was to explore barriers to and facilitators for the implementation of a parental support programme to promote physical activity and healthy dietary habits in a school context. We explored the views and experiences of 17 coordinating school nurses, non-coordinating school nurses, and school principals. We based the interview guide on the Consolidated Framework for Implementation Research. We held four focus group discussions with coordinating and non-coordinating school nurses, and conducted three individual interviews with school principals. We analysed data inductively using qualitative content analysis. We identified "Creating commitment in an overburdened work situation" as an overarching theme, emphasising the high workload in schools and the importance of creating commitment, by giving support to and including staff in the implementation process. We also identified barriers to and facilitators of implementation within four categories: (1) community and organisational factors, (2) a matter of priority, (3) implementation support, and (4) implementation process. When implementing a parental support programme to promote physical activity and healthy dietary habits for 5- to 7-year-old children in the school context, it is important to create commitment among school staff and school nurses. The implementation can be facilitated by political support and additional funding, external guidance, use of pre-existing resources, integration of the programme into school routines, a clearly structured manual, and appointment of a multidisciplinary team. The results of this study should provide useful guidance for the implementation of similar health promotion interventions in the school context

Effects of the intervention on health related behaviours at time 2 and time 3.

<p>b = Standardised regression coefficient (beta), CI = 95% confidence interval.</p><p>p = between intervention and control groups.</p><p>¹Results of Generalised linear models regression analysis (Poisson distribution) adjusted for sex and baseline values.</p><p>²Results of ANCOVA adjusted for sex and baseline values.</p><p>^<u>a</u><u>serving sizes (examples below):</u></p><p>drinks = 1,5 dl</p><p>vegetables = 2 dl grated carrots/cabbage or a big tomato or 2–3 broccoli stalks</p><p>Fruit = a small apple or a bunch of grapes (about 10)</p><p>Snacks = 1,5 dl</p><p>Sweets = about 1,5 dl of sweets or 4 pieces from a of chocolate bar</p><p>Cakes = a small bun, or 5 small biscuits</p><p>Ice-cream = a small popsicle stick or 1 dl ice cream</p><p>^b stratified analysis due to interaction effect (group × sex) at time 3.</p><p>Effects of the intervention on health related behaviours at time 2 and time 3.</p

Effectiveness of a Universal Parental Support Programme to Promote Healthy Dietary Habits and Physical Activity and to Prevent Overweight and Obesity in 6-Year-Old Children: The Healthy School Start Study, a Cluster-Randomised Controlled Trial

<div><p>Objective</p><p>To develop and evaluate the effectiveness of a parental support programme to promote healthy dietary and physical activity habits and to prevent overweight and obesity in Swedish children.</p><p>Methods</p><p>A cluster-randomised controlled trial was carried out in areas with low to medium socio-economic status. Participants were six-year-old children (n = 243) and their parents. Fourteen pre-school classes were randomly assigned to intervention (n = 7) and control groups (n = 7). The intervention lasted for 6 months and included: 1) Health information for parents, 2) Motivational Interviewing with parents and 3) Teacher-led classroom activities with children. Physical activity was measured by accelerometry, dietary and physical activity habits and parental self-efficacy through a questionnaire. Body weight and height were measured and BMI standard deviation score was calculated. Measurements were conducted at baseline, post-intervention and at 6-months follow-up. Group differences were examined using analysis of covariance and Poisson regression, adjusted for gender and baseline values.</p><p>Results</p><p>There was no significant intervention effect in the primary outcome physical activity. Sub-group analyses showed a significant gender-group interaction in total physical activity (TPA), with girls in the intervention group demonstrating higher TPA during weekends (p = 0.04), as well as in sedentary time, with boys showing more sedentary time in the intervention group (p = 0.03). There was a significantly higher vegetable intake (0.26 servings) in the intervention group compared to the control group (p = 0.003). At follow-up, sub-group analyses showed a sustained effect for boys. The intervention did not affect the prevalence of overweight or obesity.</p><p>Conclusions</p><p>It is possible to influence vegetable intake in children and girls’ physical activity through a parental support programme. The programme needs to be intensified in order to increase effectiveness and sustain the effects long-term. These findings are an important contribution to the further development of evidence-based parental support programmes to prevent overweight and obesity in children.</p><p>Trial Registration</p><p>Controlled-trials.com <a href="http://www.isrctn.com/ISRCTN32750699" target="_blank">ISRCTN32750699</a></p></div

Descriptive characteristics of children at baseline categorised by intervention and control group.

<p>Data are means and standard deviations (SD).</p><p>p = between intervention and control groups, TPA: total physical activity, cpm = counts per minute, MVPA: moderate to vigorous physical activity.</p><p>Results of independent t-test and chi-square test.</p><p>^aPSE for controlling unhealthy dietary and PA behaviours in children.</p><p>^bPSE for engaging children in healthy PA behaviours.</p><p>^cPSE for arranging positive meal patterns for children.</p><p>Descriptive characteristics of children at baseline categorised by intervention and control group.</p

Effects of the intervention on physical activity levels at time 2 and time 3.

<p>b = Standardised regression coefficient (beta), CI = 95% confidence interval.</p><p>p = between intervention and control groups.</p><p>TPA: total physical activity, cpm: counts per minute, MVPA: moderate to vigorous physical activity.</p><p>Results of ANCOVA adjusted for sex, monitor wear time and baseline values.</p><p>^a stratified analysis due to interaction effect (group × sex) at time 2.</p><p>Effects of the intervention on physical activity levels at time 2 and time 3.</p

Effects of the intervention on health related behaviours at time 2 and time 3.

<p>b = Standardised regression coefficient (beta), CI = 95% confidence interval.</p><p>p = between intervention and control groups.</p><p>¹Results of Generalised linear models regression analysis (Poisson distribution) adjusted for sex and baseline values.</p><p>²Results of ANCOVA adjusted for sex and baseline values.</p><p>^<u>a</u><u>serving sizes (examples below):</u></p><p>drinks = 1,5 dl</p><p>vegetables = 2 dl grated carrots/cabbage or a big tomato or 2–3 broccoli stalks</p><p>Fruit = a small apple or a bunch of grapes (about 10)</p><p>Snacks = 1,5 dl</p><p>Sweets = about 1,5 dl of sweets or 4 pieces from a of chocolate bar</p><p>Cakes = a small bun, or 5 small biscuits</p><p>Ice-cream = a small popsicle stick or 1 dl ice cream</p><p>^b stratified analysis due to interaction effect (group × sex) at time 3.</p><p>Effects of the intervention on health related behaviours at time 2 and time 3.</p