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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.
Lambrinou, CP, Androutsos, O, Karaglani, E, Cardon, G, Huys, N, Wikström, K, Kivelä, J, Ko, W, Karuranga, E, Tsochev, K, et al
BMC endocrine disorders. 2020;(Suppl 2):52
Abstract
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.
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A National e-Health Program for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence in Greece.
Tragomalou, A, Moschonis, G, Kassari, P, Papageorgiou, I, Genitsaridi, SM, Karampatsou, S, Manios, Y, Charmandari, E
Nutrients. 2020;(9)
Abstract
Obesity in childhood and adolescence represents one of the most challenging public health problems of the 21st century owing to its epidemic proportions worldwide and the associated significant morbidity, mortality and public health costs. In Greece, the prevalence of overweight and obesity in childhood and adolescence exceeds 30-35%. To address the increasing prevalence of overweight and obesity in children and adolescents in our country, we developed the 'National e-Health Program for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence', which provides specific and detailed guidance to all primary health care physicians about the personalized management of children and adolescents with overweight or obesity. In the present study we evaluated 2400 children and adolescents [mean age ± SEM: 10.10 ± 0.09 years.; Males: 1088, Females: 1312; Obesity (n = 1370, 57.1%), Overweight (n = 674, 28.1%), normal BMI (n = 356, 14.8%)], who followed the personalized multi-disciplinary management plan specified by the 'National e-Health Program for the Prevention and Management of Overweight and Obesity in Childhood and Adolescence', and were studied prospectively for 1 year. We demonstrated that at the end of the first year, the prevalence of obesity decreased by 32.1%, the prevalence of overweight decreased by 26.7%, and the cardiometabolic risk factors improved significantly. These findings indicate that our National e-Health Program is effective at reducing the prevalence of overweight and obesity in childhood and adolescence after one year of intervention in the largest sample size reported to date.
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Assessing the acceptability of an adapted preschool obesity prevention programme: ToyBox-Scotland.
Malden, S, Reilly, JJ, Hughes, A, Bardid, F, Summerbell, C, De Craemer, M, Cardon, G, Androutsos, O, Manios, Y, Gibson, AM
Child: care, health and development. 2020;(2):213-222
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BACKGROUND Childhood obesity is a global public health issue. Interventions to prevent the onset of obesity in the early years are often implemented in preschool settings. The ToyBox intervention was delivered across Europe and targeted energy balance-related behaviours in preschools and children's homes through teacher-led activities and parental education materials and was adapted for use in Scotland. This study assessed the acceptability of the 18-week adapted intervention to both parents and teachers. METHODS Mixed methods were employed to collect both qualitative and quantitative data. Preschool staff and children's parents/caregivers completed post-intervention feedback surveys, from which acceptability scores were calculated and presented as proportions. Focus groups were conducted with preschool staff, whereas parents/caregivers participated in semi-structured interviews. A thematic analysis was applied to qualitative data following the development of a coding framework. Quantitative and qualitative data were analysed using SPSS and NVivo 10, respectively. RESULTS Preschool staff rated the intervention as highly acceptable based on post-intervention feedback surveys (80%; mean score 8.8/11). Lower acceptability scores were observed for parents/caregivers (49%; 3.9/8). Nine preschool practitioners participated in focus groups (n = 3). User-friendliness of the intervention materials, integration of the intervention with the curriculum, and flexibility of the intervention were identified as facilitators to delivery. Barriers to delivery were time, insufficient space, and conflicting policies within preschools with regard to changing classroom layouts. Parental interviews (n = 4) revealed a lack of time to be a major barrier, which prevented parents from participating in home-based activities. Parents perceived the materials to be simple to understand and visually appealing. CONCLUSIONS This study identified a number of barriers and facilitators to the delivery and evaluation of the ToyBox Scotland preschool obesity prevention programme, which should be considered before any further scale-up of the intervention.
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Combining Effect and Process Evaluation on European Preschool Children's Snacking Behavior in a Kindergarten-Based, Family-Involved Cluster Randomized Controlled Trial: The ToyBox Study.
De Craemer, M, Verbestel, V, Verloigne, M, Androutsos, O, Moreno, L, Iotova, V, Koletzko, B, Socha, P, Manios, Y, Cardon, G
International journal of environmental research and public health. 2020;(19)
Abstract
This study aimed at (1) studying the effect of the standardized ToyBox intervention on European preschoolers' snacking behavior, and (2) studying whether a higher process evaluation score from teachers and parents/caregivers was associated with a more positive result for preschoolers' snack intake. A sample of 4970 preschoolers (51.4% boys, 4.74 ± 0.44 years) from six European countries provided information on snack intake with the use of a Food Frequency Questionnaire. To investigate the effect of the intervention, multilevel repeated measures analyses were executed for the total sample and the six country-specific samples. Furthermore, questionnaires to measure process evaluation were used to compute a total process evaluation score for teachers and parents/caregivers. No significant intervention effects on preschoolers' snack intake were found (all p > 0.003). In general, no different effects of the intervention on snack intake were found according to kindergarten teachers' and parents'/caregivers' process evaluation scores. The lack of effects could be due to limited intervention duration and dose. To induce larger effects on preschoolers' snack intake, a less standardized intervention which is more tailored to the local needs might be needed.
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Childhood obesity and leucocyte telomere length.
Lamprokostopoulou, A, Moschonis, G, Manios, Y, Critselis, E, Nicolaides, NC, Stefa, A, Koniari, E, Gagos, S, Charmandari, E
European journal of clinical investigation. 2019;(12):e13178
Abstract
BACKGROUND Obesity in adulthood is associated with decreased leucocyte telomere length (LTL), which is associated with cardiovascular disease and diabetes mellitus type 2. The aim of our study was to investigate whether increased body mass index (BMI) is associated with decreased LTL in children and adolescents, and to identify other risk factors of shorter LTL in this population. MATERIALS AND METHODS A cross-sectional study was conducted among 919 Greek children aged 9-13 years (The Healthy Growth Study). Participants were classified as obese (n = 124), overweight (n = 276) or of normal BMI (n = 519). LTL was determined by monochrome multiplex quantitative real-time polymerase chain reaction. Univariate and multivariable linear regression analyses were applied to determine the predictive factors of LTL. RESULTS Both overweight and obese children had significantly shorter LTL than their normal-BMI counterparts. Following adjustment for age, sex, total daily energy intake and average weekly physical activity (average total steps per day), increasing weight category was inversely associated with LTL in children and adolescents (β: -0.110 ± 0.035; P = .002). CONCLUSION Overweight and obesity in childhood and adolescence are associated with shorter LTL, even following adjustment for potential confounding effects. Therefore, the increased BMI in childhood and adolescence may be associated with accelerated biological ageing and may have an adverse impact on future health in adulthood.
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A school- and community-based intervention to promote healthy lifestyle and prevent type 2 diabetes in vulnerable families across Europe: design and implementation of the Feel4Diabetes-study.
Manios, Y, Androutsos, O, Lambrinou, CP, Cardon, G, Lindstrom, J, Annemans, L, Mateo-Gallego, R, de Sabata, MS, Iotova, V, Kivela, J, et al
Public health nutrition. 2018;(17):3281-3290
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OBJECTIVE To describe the design of the Feel4Diabetes-intervention and the baseline characteristics of the study sample. DESIGN School- and community-based intervention with cluster-randomized design, aiming to promote healthy lifestyle and tackle obesity and obesity-related metabolic risk factors for the prevention of type 2 diabetes among families from vulnerable population groups. The intervention was implemented in 2016-2018 and included: (i) the 'all-families' component, provided to all children and their families via a school- and community-based intervention; and (ii) an additional component, the 'high-risk families' component, provided to high-risk families for diabetes as identified with a discrete manner by the FINDRISC questionnaire, which comprised seven counselling sessions (2016-2017) and a text-messaging intervention (2017-2018) delivered by trained health professionals in out-of-school settings. Although the intervention was adjusted to local needs and contextual circumstances, standardized protocols and procedures were used across all countries for the process, impact, outcome and cost-effectiveness evaluation of the intervention. SETTING Primary schools and municipalities in six European countries. SUBJECTS Families (primary-school children, their parents and grandparents) were recruited from the overall population in low/middle-income countries (Bulgaria, Hungary), from low socio-economic areas in high-income countries (Belgium, Finland) and from countries under austerity measures (Greece, Spain). RESULTS The Feel4Diabetes-intervention reached 30 309 families from 236 primary schools. In total, 20 442 families were screened and 12 193 'all families' and 2230 'high-risk families' were measured at baseline. CONCLUSIONS The Feel4Diabetes-intervention is expected to provide evidence-based results and key learnings that could guide the design and scaling-up of affordable and potentially cost-effective population-based interventions for the prevention of type 2 diabetes.
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Adapting the ToyBox obesity prevention intervention for use in Scottish preschools: protocol for a feasibility cluster randomised controlled trial.
Malden, S, Hughes, AR, Gibson, AM, Bardid, F, Androutsos, O, De Craemer, M, Manios, Y, Summerbell, C, Cardon, G, Reilly, JJ
BMJ open. 2018;(10):e023707
Abstract
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.
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Abdominal obesity and its association with socioeconomic factors among adolescents from different living environments.
Costa de Oliveira Forkert, E, de Moraes, AC, Carvalho, HB, Kafatos, A, Manios, Y, Sjöström, M, González-Gross, M, Gottrand, F, Beghin, L, Censi, L, et al
Pediatric obesity. 2017;(2):110-119
Abstract
BACKGROUND Socioeconomic status has been associated with obesity in children and adolescents. This association may be dependent according with where adolescents lives. OBJECTIVE The aim of this study was to evaluate the association between different socioeconomic indicators such as parental education and occupation and socioeconomic status with abdominal obesity in adolescents from two observational studies: the Healthy Lifestyle in Europe by Nutrition in Adolescence cross-sectional study (HELENA-CSS) and the Brazilian Cardiovascular Adolescent Health (BRACAH) study. METHODS European (n = 3192, aged 12.5-17.5 years, with 53.1% girls from HELENA-CSS) and Brazilian (n = 991, aged 14-18 years, with 54.5% girls from BRACAH study) adolescents from two cross-sectional studies were included in this analysis. Complete data on waist circumference (WC), height, socioeconomic status indicators and several confounders were collected. Socioeconomic indicators were measured using a self-reported questionnaire in order to assess the family social status of the adolescents. Multilevel linear regression models were used to examine associations, and results were adjusted for potential confounders. RESULTS Adjusted results showed inverse associations between mother's and father's education levels (p < 0.001) and father's occupation level (p < 0.001) with waist-to-height ratio (WHtR) and WC in HELENA-CSS girls. Similarly in European girls, socioeconomic indicators by socioeconomic status and maternal occupation level were associated with WHtR. In HELENA-CSS boys, the same significant association was found between WHtR and WC with maternal occupation level. Moreover, in European boys WHtR was also associated with parental education. In Brazilian adolescents, both indicators of abdominal obesity did not remain associated with the independents variables, after adjustment for potential confounders. CONCLUSIONS Abdominal obesity was associated with socioeconomic indicators in higher-income countries, but this association was not observed in a lower-middle-income country.
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The role of family-related factors in the effects of the UP4FUN school-based family-focused intervention targeting screen time in 10- to 12-year-old children: the ENERGY project.
Van Lippevelde, W, Bere, E, Verloigne, M, van Stralen, MM, De Bourdeaudhuij, I, Lien, N, Vik, FN, Manios, Y, Grillenberger, M, Kovács, E, et al
BMC public health. 2014;:857
Abstract
BACKGROUND Screen-related behaviours are highly prevalent in schoolchildren. Considering the adverse health effects and the relation of obesity and screen time in childhood, efforts to affect screen use in children are warranted. Parents have been identified as an important influence on children's screen time and therefore should be involved in prevention programmes. The aim was to examine the mediating role of family-related factors on the effects of the school-based family-focused UP4FUN intervention aimed at screen time in 10- to 12-year-old European children (n child-parent dyads = 1940). METHODS A randomised controlled trial was conducted to test the six-week UP4FUN intervention in 10- to 12-year-old children and one of their parents in five European countries in 2011 (n child-parent dyads = 1940). Self-reported data of children were used to assess their TV and computer/game console time per day, and parents reported their physical activity, screen time and family-related factors associated with screen behaviours (availability, permissiveness, monitoring, negotiation, rules, avoiding negative role modeling, and frequency of physically active family excursions). Mediation analyses were performed using multi-level regression analyses (child-school-country). RESULTS Almost all TV-specific and half of the computer-specific family-related factors were associated with children's screen time. However, the measured family-related factors did not mediate intervention effects on children's TV and computer/game console use, because the intervention was not successful in changing these family-related factors. CONCLUSION Future screen-related interventions should aim to effectively target the home environment and parents' practices related to children's use of TV and computers to decrease children's screen time. TRIAL REGISTRATION The study is registered in the International Standard Randomised Controlled Trial Number Register (registration number: ISRCTN34562078).