Maartje M. van Stralen

Differences in Weight Status and Energy-Balance Related Behaviors among Schoolchildren across Europe: The ENERGY-Project

Background Current data on the prevalence of overweight and energy-balance behaviors among European children is necessary to inform overweight prevention interventions. Methodology/Principal Findings A school-based survey among 10–12 year old children was conducted in seven European countries using a standardized protocol. Weight, height, and waist circumference were measured; Engagement in physical activity, sedentary and dietary behaviors, and sleep duration were self-reported. Descriptive analyses were conducted, looking at differences according to country, gender, and parental education. 7234 children (52%girls; 11.6±0.7 years) participated. 25.8% and 5.4% of boys, and 21.8% and 4.1% of girls were overweight (including obese) and obese (according to International Obesity Task Force criteria), respectively. Higher prevalence of overweight/obesity was observed in Greece, Hungary, Slovenia and Spain than in Belgium, Netherlands and Norway. Large differences between countries were found in intakes of sugar-sweetened beverages, breakfast, active transport, TV and computer time. More favorable overweight status and behavior patterns were found in girls than boys and in children of higher educated parents than in children of lower educated parents. Conclusions/Significance High levels and striking differences in overweight status and potential risk behaviors were found among schoolchildren across Europe.

European energy balance research to prevent excessive weight gain among youth (ENERGY) project: Design and methodology of the ENERGY cross-sectional survey

BackgroundObesity treatment is by large ineffective long term, and more emphasis on the prevention of excessive weight gain in childhood and adolescence is warranted. To inform energy balance related behaviour (EBRB) change interventions, insight in the potential personal, family and school environmental correlates of these behaviours is needed. Studies on such multilevel correlates of EBRB among schoolchildren in Europe are lacking. The ENERGY survey aims to (1) provide up-to-date prevalence rates of measured overweight, obesity, self-reported engagement in EBRBs, and objective accelerometer-based assessment of physical activity and sedentary behaviour and blood-sample biomarkers of metabolic function in countries in different regions of Europe, (2) to identify personal, family and school environmental correlates of these EBRBs. This paper describes the design, methodology and protocol of the survey.Method/DesignA school-based cross-sectional survey was carried out in 2010 in seven different European countries; Belgium, Greece, Hungary, the Netherlands, Norway, Slovenia, and Spain. The survey included measurements of anthropometrics, child, parent and school-staff questionnaires, and school observations to measure and assess outcomes (i.e. height, weight, and waist circumference), EBRBs and potential personal, family and school environmental correlates of these behaviours including the social-cultural, physical, political, and economic environmental factors. In addition, a selection of countries conducted accelerometer measurements to objectively assess physical activity and sedentary behaviour, and collected blood samples to assess several biomarkers of metabolic function.DiscussionThe ENERGY survey is a comprehensive cross-sectional study measuring anthropometrics and biomarkers as well as assessing a range of EBRBs and their potential correlates at the personal, family and school level, among 10-12 year old children in seven European countries. This study will result in a unique dataset, enabling cross country comparisons in overweight, obesity, risk behaviours for these conditions as well as the correlates of engagement in these risk behaviours.

Behaviour, the key factor for sports injury prevention

Safety in sports and physical activity is an important prerequisite for continuing participation in sports, as well as for maintenance of a healthy physically active lifestyle. For this reason, prevention, reduction and control of sports injuries are important goals for society as a whole. Recent advances in sports medicine discuss the need for research on real-life injury prevention. Such views call for a more behavioural approach when it comes to actual sports injury prevention. Nevertheless, the role of behaviour in sports injury prevention remains under-researched. In order to push the field of sports injury prevention forward, this article provides an overview of the relationship between behaviour and sports injury risk.Different types of behaviour relate to injury risk factors and injury mechanisms. Behaviour that influences risk factors and injury mechanisms is not confined only to the athlete. Various types of behaviour by, for example, the coach, referee, physical therapist or sports associations, also influence risk factors and injury mechanisms. In addition, multiple behaviours often act together. Some types of behaviour may directly affect injury risk and are by definition a risk factor. Other behaviours may only affect risk factors and injury mechanisms, and influence injury risk indirectly.Recent ideas on injury prevention that call for studies on real-life injury prevention still rely heavily on preventive measures that are established through efficacy research.A serious limitation in such an approach is that one expects that proven preventive measures will be adopted if the determinants and influences of sports safety behaviours are understood. Therefore, if one truly wants to prevent sports injuries in a real-life situation, a broader research focus is needed. In trying to do so, we need to look at lessons learned from other fields of injury prevention research.

Efficacy of Two Tailored Interventions Promoting Physical Activity in Older Adults

BACKGROUND Important health benefits can be obtained if effective low-cost interventions promoting physical activity, especially among older adults, are developed. DESIGN This RCT investigated the efficacy of two tailored physical activity interventions in promoting awareness, initiation, and maintenance of physical activity among older adults compared to a wait-list control group. Data were collected in 2007. Analyses were conducted in 2008. SETTING/PARTICIPANTS In total, 1971 Dutch older adults (mean age=64 years, 57% women) participated. INTERVENTION Two tailored physical activity interventions, consisting of three tailored letters delivered during 4 months, were systematically developed. The basic tailored intervention targeted psychosocial determinants alone, while the environmentally tailored intervention (intervention-plus) additionally targeted environmental determinants. MAIN OUTCOME MEASURES Awareness of personal physical activity behavior, self-reported level of physical activity, and compliance with the physical activity guideline were assessed at baseline, 3 months, and 6 months. RESULTS Intervention participants became more aware of their personal physical activity level at 6 months (OR(Ibasic)=1.7, OR(Iplus)=1.6) and were significantly more physically active at 3 (EffectSize[ES](Ibasic)=0.20, ES(Iplus)=0.20) and 6 months (ES(Ibasic)=0.30, ES(Iplus)=0.35) when compared to control participants. Moderation analyses showed that the interventions enhanced physical activity initiation at 3 (ES(Ibasic)=0.26, ES(Iplus)=0.21) and 6 months (ES(Ibasic)=0.32, ES(Iplus)=0.27) among participants insufficiently active at baseline, and induced maintenance at 6 months among participants sufficiently active at baseline (ES(Ibasic)=0.33, ES(Iplus)=0.34) when compared to the control condition. No differences between the intervention arms were found. CONCLUSIONS The results indicate that tailoring can be an effective tool in attaining and enhancing awareness, initiation, and maintenance of physical activity among older adults. Targeting environmental determinants in addition to psychosocial determinants, however, did not result in an additional increase in physical activity behavior. TRIAL REGISTRATION This study was registered with the Dutch Trial Register NTR 920.

The long-term efficacy of two computer-tailored physical activity interventions for older adults: main effects and mediators

OBJECTIVE Low-cost (e.g., computer-tailored) interventions with sustained effects are needed to increase and maintain physical activity in older adults. This study examined the long-term efficacy of 2 computer-tailored physical activity interventions for older adults and its psychosocial and environmental mediators. METHODS A clustered randomized controlled trial (N = 1,971) was conducted that included 3 research arms: (a) basic computer-tailored print intervention, targeting psychosocial mediators; (b) environmentally computer-tailored print intervention, targeting psychosocial and environmental mediators; and (c) no-intervention control group. Interventions were developed using the intervention mapping approach and consisted of 3 computer-tailored letters delivered over 4 months. Questionnaires assessed the study outcomes (i.e., total weekly days and total weekly minutes of physical activity) at baseline and 12 months. Potential mediators (i.e., awareness, attitude, self-efficacy, intention, social influence, intrinsic motivation, self-regulation, and perceived environment) were assessed at baseline and at 3 or 6 months. RESULTS Multilevel regression analyses revealed that both interventions significantly changed total weekly days of physical activity compared with the control group, but only the environmentally computer-tailored print intervention significantly changed weekly minutes of physical activity. Multiple mediation models showed that the effects of both interventions on weekly days of physical activity were mediated by changes in awareness and intention. CONCLUSIONS Computer-tailored interventions were effective in inducing long-term behavioral changes in physical activity behavior of older adults. Awareness and intention were found to be important mediators of changing daily physical activity and should be included in future computer-tailored intervention studies.

The active plus protocol: systematic development of two theory-and evidence-based tailored physical activity interventions for the over-fifties

BackgroundLimited data are available on the development, implementation and evaluation processes of physical activity promotion programmes among older adults. More integrative insights into interventions describing the planned systematic development, implementation and evaluation are needed.Methods and designThe purpose of this study is to give an integrative insight into the development of the Active plus programme applying the six-step Intervention Mapping protocol. The Active plus programme consisted of two theory- and evidence-based tailored physical activity promotion interventions, both comprising three tailored letters delivered over four months and aimed at raising awareness of insufficient physical activity, and stimulating physical activity initiation and maintenance among the over-fifties.The first intervention, the basic tailored intervention, provided tailored letters that intervened on the psychosocial determinants of physical activity. The second intervention, the intervention plus, provided the same tailored information but additionally provided tailored information about physical activity opportunities in the specific environment in which the older adults lived. This environment-based component also provided access to a forum and e-buddy system on a website. A plan for implementation and evaluation is also described.DiscussionThe planned development of the Active plus programme resulted in two theory- and evidence-based tailored physical activity interventions targeted at the over-fifties.Trial RegistrationDutch Trial Register NTR 920

For whom and under what circumstances do school‐based energy balance behavior interventions work? Systematic review on moderators

The aim of this review was to systematically review the results and quality of studies investigating the moderators of school-based interventions aimed at energy balance-related behaviors. We systematically searched the electronic databases of Pubmed, EMBASE, Cochrane, PsycInfo, ERIC and Sportdiscus. In total 61 articles were included. Gender, ethnicity, age, baseline values of outcomes, initial weight status and socioeconomic status were the most frequently studied potential moderators. The moderator with the most convincing evidence was gender. School-based interventions appear to work better for girls than for boys. Due to the inconsistent results, many studies reporting non-significant moderating effects, and the moderate methodological quality of most studies, no further consistent results were found. Consequently, there is lack of insight into what interventions work for whom. Future studies should apply stronger methodology to test moderating effects of important potential target group segmentations.

The working mechanisms of an environmentally tailored physical activity intervention for older adults: a randomized controlled trial

BackgroundThe aim of this study was to explore the working mechanisms of a computer tailored physical activity intervention for older adults with environmental information compared to a basic tailored intervention without environmental information.MethodA clustered randomized controlled trial with two computer tailored interventions and a no-intervention control group was conducted among 1971 adults aged ≥ 50. The two tailored interventions were developed using Intervention Mapping and consisted of three tailored letters delivered over a four-month period. The basic tailored intervention targeted psychosocial determinants alone, while the environmentally tailored intervention additionally targeted environmental determinants, by providing tailored environmental information. Study outcomes were collected with questionnaires at baseline, three and six months and comprised total physical activity (days/week), walking (min/week), cycling (min/week), sports (min/week), environmental perceptions and use and appreciation of the interventions.ResultsMediation analyses showed that changes in cycling, sports and total physical activity behaviour induced by the environmentally tailored intervention were mediated by changes in environmental perceptions. Changes in environmental perceptions did not mediate the effect of the basic tailored intervention on behaviour. Compared with the basic tailored intervention, the environmentally tailored intervention significantly improved cycling behaviour (τ = 30.2). Additionally, the tailored letters of the environmentally tailored intervention were better appreciated and used, although these differences did not mediate the intervention effect.DiscussionThis study gave some first indications of the relevance of environmental perceptions as a determinant of changing physical activity behaviours and the potential effectiveness of providing environmental information as an intervention strategy aimed at enhancing physical activity behaviour among older adults.

Equity-specific effects of 26 Dutch obesity-related lifestyle interventions

CONTEXT Reducing health inequalities is a policy priority in many developed countries. Little is known about effective strategies to reduce inequalities in obesity and its underlying behaviors. The goal of the study was to investigate differential effectiveness of interventions aimed at obesity prevention, the promotion of physical activity or a healthy diet by SES. EVIDENCE ACQUISITION Subgroup analyses in 2010 and 2011 of 26 Dutch studies funded by The Netherlands Organization for Health Research and Development after 1990 (n=17) or identified by expert contact (n=9). Methodologic quality and differential effects were synthesized in harvest plots, subdivided by setting, age group, intensity, and time to follow-up. EVIDENCE SYNTHESIS Seven lifestyle interventions were rated more effective and four less effective in groups with high SES; for 15 studies no differential effects could be demonstrated. One study in the healthcare setting showed comparable effects in both socioeconomic groups. The only mass media campaign provided modest evidence for higher effectiveness among those with high SES. Individually tailored and workplace interventions were either more effective in higher-SES groups (n=4) or no differential effects were demonstrated (n=9). School-based studies (n=7) showed mixed results. Two of six community studies provided evidence for better effectiveness in lower-SES groups; none were more effective in higher-SES groups. One high-intensity community-based study provided best evidence for higher effectiveness in low-SES groups. CONCLUSIONS Although for the majority of interventions aimed at obesity prevention, the promotion of physical activity, or a healthy diet, no differential effectiveness could be demonstrated, interventions may widen as well as reduce socioeconomic inequalities in these outcomes. Equity-specific subgroup analyses contribute to needed knowledge about what may work to reduce socioeconomic inequalities in obesity and underlying health behaviors.

Long-term efficacy of a printed or a Web-based tailored physical activity intervention among older adults

BackgroundThis study provides insight into the long-term efficacy (i.e. 12 month results) of the Web-based or print-delivered tailored Active Plus intervention (with and without environmental approach) to promote physical activity (PA) among the over-fifties. Differences in effect among subgroups are studied as well.MethodsIntervention groups (i.e. print-delivered basic (PB; N = 439), print-delivered environmental (PE; N = 435), Web-based basic (WB; N = 423), Web-based environmental (WE; N = 432)) and a waiting list control group (N = 411) were studied in a clustered randomized controlled trial. Intervention participants received tailored advice three times within 4 months. Long-term effects (12 months after the intervention has started, i.e. 8 months after the intervention was completed) on PA (i.e. self-reported weekly minutes and days of sufficient PA) were tested using multilevel linear regression analyses. Participants’ age, gender, BMI, educational level, PA intention and the presence of a chronic physical limitation were considered to be potential moderators of the effect.ResultsOverall, the Active Plus intervention was effective in increasing weekly days of sufficient PA (B=0.49; p=.005), but ineffective in increasing weekly minutes of PA (B=84.59; p=.071). Per intervention condition analysis showed that the PB-intervention (Bdays=0.64; p=.002; Bmin=111.36; p=.017) and the PE-intervention (Bdays=0.70; p=.001; Bmin=157.41; p=.001) were effective in increasing days and minutes of PA. Neither Web-based conditions significantly increased PA, while the control group decreased their PA. In contrast to the intervention effect on minutes of PA, the effect on weekly days of PA was significantly moderated by the participants’ baseline intention to be sufficiently physically active.ConclusionsIn general, after 12 months the print-delivered interventions resulted in stronger effects than the Web-based interventions. The participants’ baseline intention was the only significant moderator of the intervention effect. All other assessed user characteristics did not significantly moderate the effect of the intervention, which might indicate that the intervention is sufficiently tailored to the different participant characteristics. Additional efforts should be taken to increase the sustainability of Web-based interventions.Trial registrationDutch Trial Register: NTR2297.