Gisela Nyberg

A 4-year, cluster-randomized, controlled childhood obesity prevention study: STOPP.

Objective:To assess the efficacy of a school-based intervention programme to reduce the prevalence of overweight in 6 to 10-year-old children.Design:Cluster-randomized, controlled study.Subjects:A total of 3135 boys and girls in grades 1–4 were included in the study.Methods:Ten schools were selected in Stockholm county area and randomized to intervention (n=5) and control (n=5) schools. Low-fat dairy products and whole-grain bread were promoted and all sweets and sweetened drinks were eliminated in intervention schools. Physical activity (PA) was aimed to increase by 30 min day−1 during school time and sedentary behaviour restricted during after school care time. PA was measured by accelerometry. Eating habits at home were assessed by parental report. Eating disorders were evaluated by self-report.Results:The prevalence of overweight and obesity decreased by 3.2% (from 20.3 to 17.1) in intervention schools compared with an increase of 2.8% (from 16.1 to 18.9) in control schools (P<0.05). The results showed no difference between intervention and controls, after cluster adjustment, in the longitudinal analysis of BMIsds changes. However, a larger proportion of the children who were initially overweight reached normal weight in the intervention group (14%) compared with the control group (7.5%), P=0.017. PA did not differ between intervention and control schools after cluster adjustment. Eating habits at home were found to be healthier among families with children in intervention schools at the end of the intervention. There was no difference between children in intervention and control schools in self-reported eating disorders.Conclusions:A school-based intervention can reduce the prevalence of overweight and obesity in 6 to 10-year-old children and may affect eating habits at home. The effect of the intervention was possibly due to its effect on healthy eating habits at school and at home rather than on increased levels of PA.

Physical activity patterns measured by accelerometry in 6- to 10-yr-old children.

PURPOSE To examine differences in patterns of objectively measured physical activity (PA) among weekdays and weekend days and across different time blocks during the day in relation to age and gender. This knowledge is important when planning preventive initiatives aimed at increasing levels of PA in children. METHODS This is a cross-sectional analysis in 653 girls and 640 boys (6-10 yr) measured during 1 wk with accelerometry. Periods of the day were divided into school time (8:00 a.m. to 1:30 p.m.), after school care time (1:30-4:00 p.m.), and evening time (4:00-9:00 p.m.). Multivariate ANOVA was used to analyze mean PA. RESULTS Mean daily PA differed significantly across age groups (6-10 yr) in both boys and girls (P < 0.001). Mean (SE) daily PA was significantly lower during weekends compared with weekdays in all age groups (girls 782 (6.7) vs 681 (7.7) counts per min (CPM), P < 0.001; boys 853 (7.1) vs 729 (8.0) CPM, P < 0.001). This decline was similar across low, medium, and highly active children. Mean PA was highest during after school care time on weekdays (girls 879 (9.8) and boys 990 (10.0) CPM) compared with all other periods. The difference in mean PA between boys and girls was highest during school time (P < 0.001) and after school care time (P < 0.001). CONCLUSIONS The decline in PA in children may start already at the age of 6 yr. The school setting may be an important arena for targeting activity levels in girls because the difference in PA levels between girls and boys is most pronounced during school time. In both girls and boys, PA levels are disproportionally low during weekends and might be important targets for interventions aimed to increase PA.

Sleep, physical activity and BMI in six to ten-year-old children measured by accelerometry: a cross-sectional study

BackgroundThe aim of this study is to describe the relationship between objective measures of sleep, physical activity and BMI in Swedish pre-adolescents. The day-to-day association between physical activity and sleep quality as well as week-day and weekend pattern of sleep is also described.MethodWe conducted a cross sectional study consisted of a cohort of 1.231 children aged six to ten years within the Stockholm county area. Sleep and physical activity were measured by accelerometry during seven consecutive days. Outcome measures are total sleep time, sleep efficiency, sleep start and sleep end; physical activity intensity divided into: sedentary (<1.5 METS), light (1.5 to 3 METS) and moderate-to-vigorous (> 3 METS); and Body Mass Index standard deviations score, BMIsds.ResultsTotal sleep time decreased with increasing age, and was shorter in boys than girls on both weekdays and weekends. Late bedtime but consistent wake-up time during weekends made total sleep time shorter on weekends than on weekdays. Day-to-day within-subject analysis revealed that moderate-to-vigorous intense physical activity promoted an increased sleep efficiency the following night (CI < 0.001 to 0.047), while total sleep time was not affected (CI -0.003 to 0.043). Neither sleep duration (CI -0.024 to 0.022) nor sleep efficiency (CI -0.019 to 0.028) affected mean physical activity level the subsequent day. The between-subject analysis indicates that the sleep of children characterized by high moderate-to-vigorous physical activity during the day was frequently interrupted (SE = -.23, P < .01). A negative association between BMIsds and sleep duration was found (-.10, p < .01).ConclusionsShort sleep duration was associated with high BMI in six to ten year old children. This study underscores the importance of consistent bedtimes throughout the week for promoting sleep duration in preadolescents. Furthermore, this study suggests that a large proportion of intensive physical activity during the day might promote good sleep quality.

Physical activity in children measured by accelerometry: stability over time

The aim of this study was to examine the stability of objectively measured physical activity in Swedish children and to study variables that predicted physical activity and body mass index standard deviation score (BMI SDS) at follow‐up. A total of 97 children provided valid repeated measurements of physical activity between 2002 and 2005. The children were on average 7.5 years at baseline (SD±0.92) and 9 years at follow‐up (SD±0.92). The mean follow‐up time was approximately 1.5 years (mean 558 days, SD±224). An accelerometer (Actiwatch®, Cambridge Neurotechnology Ltd., Cambridge, UK) was used to measure physical activity during 7 consecutive days. Yearly weight and height were examined and BMI SDS was calculated. Baseline physical activity was significantly correlated with physical activity at follow‐up (r=0.59) with a stronger correlation for boys (r=0.72) than for girls (r=0.51). High physical activity levels were more stable (r=0.74) than low physical activity levels (r=0.55). Physical activity at follow‐up was explained by physical activity at baseline and season (R2=0.46) whereas BMI SDS at follow‐up was explained by BMI SDS at baseline and age (R2=0.90). The results of this study suggest that physical activity levels are fairly stable in 6–10‐year‐old children.

Importance of Age for 3-Year Continuous Behavioral Obesity Treatment Success and Dropout Rate

Objective: To assess whether first year weight loss, age, and socioeconomic background correlate with the success rate of continuous long-term behavioral obesity treatment. Methods: In a 3-year longitudinal study, obese children (n = 684) were divided into three groups based on age at the start of treatment, age 6–9 years, 10–13 years, and 14–16 years. Results: The mean BMI standard deviation score (BMI-SDS) decline was age-dependent (p = 0.001), independently of adjustment for missing data: –1.8 BMI-SDS units in the youngest, –1.3 in the middle age group, and –0.5 in the oldest age group. SES and parental BMI status did not affect the results. 30% of the adolescents remained in treatment at year 3. There was only a weak correlation between BMI-SDS change after 1 and 3 years: r = 0.51 (p < 0.001). Among children with no BMI-SDS reduction during year 1 (n = 46), 40% had a clinically significantly reduced BMI-SDS after year 3. Conclusion: Behavioral treatment should be initiated at an early age to increase the chance for good results. Childhood obesity treatment should be continued for at least 3 years, regardless of the initial change in BMI-SDS.

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

Objective 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. Methods 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. Results 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. Conclusions 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. Trial Registration Controlled-trials.com ISRCTN32750699

Differences in metabolic risk factors between normal weight and overweight children

BACKGROUND The effect of overweight on metabolic risk factors and the role of physical activity (PA) in pre-pubertal children is unclear. OBJECTIVE To study differences in metabolic risk factors between groups of normal weight and overweight children and how these risk factors are associated with objectively measured PA and cardio-respiratory fitness (CRF). DESIGN A cross-sectional study was conducted with 68 children aged 8?11 years. Children were categorized into normal weight (n = 39) and overweight/obese (n = 24/5). PA and CRF were measured objectively. An oral glucose tolerance test (OGTT) was performed and triglycerides (TG) and HDL-cholesterol (HDL-C) were measured. A metabolic risk score (MRS) was calculated from the standardized values of insulin, glucose, TG, inverted HDL-C and blood pressure. RESULTS There was a significant (P < 0.05) difference between normal weight and overweight children in clustered metabolic risk, insulin (AUC), fasting insulin and systolic blood pressure. PA and CRF did not differ significantly between groups. In linear regression analysis combining the two groups, PA was negatively associated with insulin (AUC) (? = ?0.25, 95% CI = ?0.50, ?0.002) and CRF was negatively associated with fasting insulin (? = ?0.41, 95% CI = ?0.67, ?0.15). CONCLUSIONS Metabolic risk factors are elevated in overweight pre-pubertal children compared with normal weight controls. This is not explained by lower PA or CRF in the overweight group although PA and CRF were associated with lower insulin levels in pooled analyses. This highlights the importance of preventing overweight in children from an early age in order to prevent the metabolic syndrome and its associated diseases.

Validity and Reliability of a Parental Self-Efficacy Instrument in the Healthy School Start Prevention Trial of Childhood Obesity

Introduction. Measures of parental self-efficacy (PSE) for healthy dietary or physical activity (PA) behaviors in children have been used in several studies; however, further psychometric validation of PSE for these behaviors is needed. The purpose of the present study was to evaluate the psychometric properties of a new PSE instrument. Methods. Mothers (n = 162) of 6-year-old children in the Healthy School Start prevention trial of childhood obesity responded to the instrument and a parent-report questionnaire on diet and PA in children. In addition, PA was objectively assessed by accelerometry. Results. Exploratory factor analysis yielded a structure composed of three factors of PSE for dietary and PA behaviors in children, and PSE was associated with parent-report of these behaviors. Internal consistency was good. Discussion. Preliminary support of the validity and reliability of the PSE instrument was provided. The measure may be useful in prevention and treatment trials of childhood obesity.

Factors influencing the implementation of a school-based parental support programme to promote health-related behaviours-interviews with teachers and parents

BackgroundThe ‘Healthy School Start’ programme was developed to promote healthy dietary habits and physical activity, targeting parents of 6-year-old children in pre-school class. Knowledge of barriers and facilitators of implementation is crucial before introducing this kind of programme on a larger scale. The aim of this study was to explore the views of teachers and parents regarding factors influencing the implementation of a school-based parental support programme to promote physical activity and healthy diet.MethodsAn inductive qualitative method was used to explore the experiences and views of teachers and parents involved in the programme. A group discussion was held with three teachers, and semi-structured interviews were conducted with 14 parents. Data were analysed using qualitative content analysis.ResultsClear communication on roles and responsibilities was identified as an overarching theme, emphasising the importance of clear information and well-functioning cooperation between project management, schools and parents when implementing the programme in a school setting. Five categories at a manifest level described aspects influencing the implementation: 1) ‘The programme’ underlining the importance of flexibility and feed-back; 2) ‘the school’ referring to management and work routines; 3) ‘family conditions’, implying various life situations; 4) ‘group dynamics’ dealing with attitudes among children and parents; and 5) ‘the surrounding community’ including accessibility and attitudes within society.ConclusionsWhen implementing a parental support programme in a school setting it is important to facilitate communication and clearly define the division of responsibilities between project management, schools and parents. This emphasises the need for managerial support, and a professional prevention support system.

One size does not fit all–qualitative process evaluation of the Healthy School Start parental support programme to prevent overweight and obesity among children in disadvantaged areas in Sweden

BackgroundParental support interventions have shown some effectiveness in improving children’s dietary and physical activity habits and preventing overweight and obesity. To date, there is limited research on barriers and facilitators of school-based parental support interventions targeting overweight and obesity. This study aimed to describe barriers and facilitators influencing implementation of the Healthy School Start (HSS) intervention in disadvantaged areas in Stockholm, Sweden, from the perspective of parents and teachers.MethodsFocus groups and individual interviews with teachers (n = 10) and focus groups with parents (n = 14) in the intervention group of the HSS were undertaken, guided by the Consolidated Framework for Implementation Research (CFIR). Transcriptions were analysed using qualitative content analysis in two steps: deductive sorting in two domains of the CFIR (intervention characteristics and process), and subsequent inductive analysis.ResultsThe overarching theme “tailoring the intervention to increase participant engagement” was found. Among teachers, barriers and facilitators were related to how the intervention was introduced, perceptions of the usefulness of the classroom material, preparation ahead of the start of the intervention, cooperation between home and school and children’s and parents’ active engagement in the intervention activities.For parents, barriers and facilitators were related to the perceived relevance of the intervention, usefulness of the material, experiences of the Motivational Interviewing (MI) sessions, the family member targeted by the intervention, cooperation between home and school and parents’ ability to act as good role models.ConclusionIt seems important to tailor the intervention to the abilities of the target group in order to increase participant engagement. Including activities that focus on parents as role models and cooperation between parents seems important to bring about changes in the home environment. It also appears important to include activities that target cooperation between home and school.