Literature Review - Health behaviour change models and approaches for families and young people to support HEAT 3: Child Healthy Weight Programmes

The literature review has been commissioned by NHS Health Scotland to review the health behaviour change models and approaches for families, children and young people to support the development and delivery of effective child healthy weight programmes. Despite the consistent recommendations from NICE and SIGN for the inclusion of behavioural components in child healthy weight programmes, there is little information on effectiveness of specific techniques and which to incorporate. The aim was therefore to provide information on which specific behavioural treatment components, behaviour change models and approaches should underpin clinical guidelines and childhood obesity treatment programmes. Secondly, in light of recommendations for programmes to be delivered by appropriately trained professionals, the review aimed to identify the skills and competencies required and resources and training available for effective delivery of the behavioural components. The outcomes of the literature review will be applied in enhancing the guidance for practitioners involved in the development and delivery of effective child healthy weight programmes; and thereby support achievement of the Scottish Government’s HEAT 3 target aimed at monitoring the attendance and completion of approved ’child healthy weight intervention programmes’. The report includes the background, aims, and objectives, sets out the scope of the review, presents a brief description of the methods and main findings. The methods and stakeholder views are then presented followed by a discussion of the implications for applying the evidence in practice and further research recommendations

Leeds Free School Meals Research Project (Phase 2 Report: Findings from the pilot phase Leeds Metropolitan University)

Free school meals aim to provide a “nutritional safety net” for the poorest UK children. Yet it is estimated that up to 30% of those entitled do not take up this entitlement. In Leeds approximately 6,000 children do not take the free school meals that they are entitled to. National and local targets are for 100% take up. Phase 2 of the Leeds Free School Meal Research Project aimed to develop, implement and evaluate a series of interventions to increase the uptake of free school meals. The interventions were tested in ten Leeds schools between December 2007 and October 2008. The research was undertaken by the Department of Nutrition & Dietetics within The Centre of Food Nutrition and Health at Leeds Metropolitan University on behalf of Education Leeds

Factors influencing take-up of free school meals in primary- and secondary-school children in England.

OBJECTIVE: The present study sought to explore the factors that influence registration for free school meals and the subsequent take-up following registration in England. DESIGN: The research design consisted of two phases, a qualitative research phase followed by an intervention phase. Findings are presented from the qualitative research phase, which comprised interviews with head teachers, school administrators, parents and focus groups with pupils. SETTING: The study took place in four primary schools and four secondary schools in Leeds, UK. SUBJECTS: Participants included head teachers, school administrators, parents and pupils. RESULTS: Findings suggested that parents felt the registration process to be relatively straightforward although many secondary schools were not proactive in promoting free school meals. Quality and choice of food were regarded by both pupils and parents as significant in determining school meal choices, with stigma being less of an issue than originally anticipated. CONCLUSIONS: Schools should develop proactive approaches to promoting free school meals and attention should be given not only to the quality and availability of food, but also to the social, cultural and environmental aspects of dining. Processes to maintain pupils' anonymity should be considered to allay parents' fear of stigma

Interventions to increase free school meal take-up

Purpose: The purpose of this paper is to design and implement interventions to increase free school meal (FSM) uptake in pilot schools. This paper describes the interventions, reports on acceptability (as perceived by school working parties) and explores the process of implementing change. Design/methodology/approach: The research consisted of two phases, an exploratory phase followed by an intervention phase. Findings from the latter are presented. Ten pilot schools (five primary and five secondary) in Leeds, England were recruited. Each established a working party, examined current claiming processes and implemented individualised action plans. This paper draws on the final action plans and interviews/focus groups with working parties. Findings: Interventions to improve FSM claiming process, minimise discrimination and maximise awareness were designed. The majority were implemented successfully, the exception being amending anti-bullying policies. Creative ways of delivering interventions were demonstrated. The process of change was effective, critical factors being having individualised action plans that allowed flexibility in implementation, reflecting on current claiming processes, and setting up working parties. Practical implications: Ways of working with schools to increase FSM uptake and more generally improve nutritional policies are suggested. Amending claiming systems in schools is recommended as is greater pupil and parent involvement in nutrition policies. Originality/value: An estimated 300,000 UK children do not take FSMs they are entitled to – with many schools unaware of the issue. This study worked with schools to discover how to address this issue and evaluated the perceived acceptability and feasibility of the approach

Randomised controlled trial of primary school based intervention to reduce risk factors for obesity

OBJECTIVE: To assess if a school based intervention was effective in reducing risk factors for obesity. DESIGN: Group randomised controlled trial. SETTING: 10 primary schools in Leeds. PARTICIPANTS: 634 children aged 7­-11 years. INTERVENTION: Teacher training, modification of school meals, and the development of school action plans targeting the curriculum, physical education, tuck shops, and playground activities. MAIN OUTCOME MEASURES: Body mass index, diet, physical activity, and psychological state. RESULTS: Vegetable consumption by 24 hour recall was higher in children in the intervention group than the control group (weighted mean difference 0.3 portions/day, 95% confidence interval 0.2 to 0.4), representing a difference equivalent to 50% of baseline consumption. Fruit consumption was lower in obese children in the intervention group ( - 1.0, - 1.8 to - 0.2) than those in the control group. The three day diary showed higher consumption of high sugar foods (0.8, 0.1 to 1.6)) among overweight children in the intervention group than the control group. Sedentary behaviour was higher in overweight children in the intervention group (0.3, 0.0 to 0.7). Global self worth was higher in obese children in the intervention group (0.3, 0.3 to 0.6). There was no difference in body mass index, other psychological measures, or dieting behaviour between the groups. Focus groups indicated higher levels of self reported behaviour change, understanding, and knowledge among children who had received the intervention. CONCLUSION: Although it was successful in producing changes at school level, the programme had little effect on children's behaviour other than a modest increase in consumption of vegetables

Evaluation of implementation and effect of primary school based intervention to reduce risk factors for obesity

OBJECTIVES: To implement a school based health promotion programme aimed at reducing risk factors for obesity and to evaluate the implementation process and its effect on the school. DESIGN: Data from 10 schools participating in a group randomised controlled crossover trial were pooled and analysed. SETTING: 10 primary schools in Leeds. Participants 634 children (350 boys and 284 girls) aged 7­11 years. MAIN OUTCOME MEASURES: Response rates to questionnaires, teachers' evaluation of training and input, success of school action plans, content of school meals, and children's knowledge of healthy living and self reported behaviour. RESULTS: All 10 schools participated throughout the study. 76 (89%) of the action points determined by schools in their school action plans were achieved, along with positive changes in school meals. A high level of support for nutrition education and promotion of physical activity was expressed by both teachers and parents. 410 (64%) parents responded to the questionnaire concerning changes they would like to see implemented in school. 19 out of 20 teachers attended the training, and all reported satisfaction with the training, resources, and support. Intervention children showed a higher score for knowledge, attitudes, and self reported behaviour for healthy eating and physical activity. CONCLUSION: This programme was successfully implemented and produced changes at school level that tackled risk factors for obesity

Parents understanding of vitamin D requirements, and the use of fortified foods

One in four toddlers are not achieving the recommended vitamin D intake crucial for their healthy development(1, 2). This study explored parents’ acceptability of factors affecting purchasing of foods and drinks fortified with Vitamin D in children aged 0-2 years old. A total of 194 parents completed an online parent questionnaire. Focus groups and interviews were used to explore in depth perceptions of vitamin D fortification. Thirteen participants participated in the 5 focus groups, 5 completed interviews. The majority of participants were female (mothers) and of White-British ethnic background, aged between 25-40 years, with 89% of the sample with a level 3 qualification (e.g. 2 or more A levels, NVQ level 3). Basic descriptive statistics were calculated from the questionnaire data and a thematic analysis methodology was applied to the qualitative data. The findings indicated low purchasing of vitamin D fortified foods/drinks by parents (21% of the sample). The foods/drinks most purchased were cereal, yogurts and alternative milks. Willingness to purchase certain products fortified with vitamin D to increase their child’s vitamin D was however high. After excluding formula milk, parents would be willing to buy yogurt, yogurt drinks, cereals, milk-based drinks, fruit juice and margarine. The table outlines parents’ views on the facilitators and barriers to purchasing vitamin D fortified foods and drinks. There is a potential for fortified foods to play a role in increasing the intake of vitamin D intake. Parents need quality education explaining the need to prevent vitamin D deficiency, though fortified products. Products also need to be suitable for babies and toddlers; better labelled, lower cost; with healthy options available with lower sugar and salt content, tasty, longer shelf life and better availability in local shops and supermarkets. Future research should determine if consumption of fortified foods/drinks alone rather than supplementation is sufficient to meet children’s daily intake of vitamin D(3)

Development of low alcoholic naturally carbonated fermented debittered beverage from grapefruit (Citrus paradisi)

A pure yeast Clavispora lusitaniae, isolated from whey beverage, phenotypically characterized and molecularly characterized by sequencing of D1/D2 domain of 26S rRNA and Internal Transcribed Spacer (ITS) region was used to produce low alcoholic naturally carbonated fermented debittered beverage from Grapefruit. C. lusitaniae produces enzyme naringinase. This enzyme is a mixture of ?-L-rhamnosidase and ?-D-glucosidase. The bitter component in citrus fruit, naringin can be hydrolyzed by ?-L-rhamnosidase to rhamnose and prunin then by ?-glucosidase to glucose and naringenin. The freshly prepared fermented Grapefruit beverage had TSS 14 °B, pH 4.7, acidity 0.26%, brix acid ratio 53.85, total sugars 11.6%, reducing sugars 3.34%, ascorbic acid 21.9 mg/100 ml, naringin 643.2 ppm, alcohol 0.00% (v/v), CO2 0.00 bar and total yeast count 5.83 (Log no.of cells/ml). Physico-chemical changes recorded after three months of storage at refrigerated temperature revealed TSS 12.0 °B, pH 4.2, acidity 0.54%, brix acid ratio 22.22, total sugars 8.97%, reducing sugars 1.94%, ascorbic acid 18.45 mg/100 ml, naringin 365.2 ppm, alcohol 0.76 % (v/v), CO2 1.35 bar and total yeast count 8.54 (Log no.of cells/ml). Naturally produced CO2 by C. lusitaniae during fermentation adds effervescence, sparkle, tangy taste to the beverage in addition to its antimicrobial properties. Thus bio-enzymatic debittering by C. lusitaniae may become the new direction of citrus juice processing in the future, due to its economical viability with strong ability to remove the bitter taste from citrus juice beverage

Using intervention mapping to develop a culturally appropriate intervention to prevent childhood obesity: the HAPPY (Healthy and Active Parenting Programme for Early Years) study.

INTRODUCTION: Interventions that make extensive use of theory tend to have larger effects on behaviour. The Intervention Mapping (IM) framework incorporates theory into intervention design, implementation and evaluation, and was applied to the development of a community-based childhood obesity prevention intervention for a multi-ethnic population. METHODS: IM was applied as follows: 1) Needs assessment of the community and culture; consideration of evidence-base, policy and practice; 2) Identification of desired outcomes and change objectives following identification of barriers to behaviour change mapped alongside psychological determinants (e.g. knowledge, self-efficacy, intention); 3) Selection of theory-based methods and practical applications to address barriers to behaviour change (e.g., strategies for responsive feeding); 4) Design of the intervention by developing evidence-based interactive activities and resources (e.g., visual aids to show babies stomach size). The activities were integrated into an existing parenting programme; 5) Adoption and implementation: parenting practitioners were trained by healthcare professionals to deliver the programme within Children Centres. RESULTS: HAPPY (Healthy and Active Parenting Programme for Early Years) is aimed at overweight and obese pregnant women (BMI > 25); consists of 12 × 2.5 hr. sessions (6 ante-natal from 24 weeks; 6 postnatal up to 9 months); it addresses mother's diet and physical activity, breast or bottle feeding, infant diet and parental feeding practices, and infant physical activity. CONCLUSION: We have demonstrated that IM is a feasible and helpful method for providing an evidence based and theoretical structure to a complex health behaviour change intervention. The next stage will be to assess the impact of the intervention on behaviour change and clinical factors associated with childhood obesity. The HAPPY programme is currently being tested as part of a randomised controlled feasibility trial