Olivia Wartha

Overweight Prevention Implemented by Primary School Teachers: A Randomised Controlled Trial

Objective: To describe the effects of URMEL-ICE, a German school-based intervention for overweight prevention, on children’s BMI and other measures of fat mass. Methods: A cluster-randomised controlled design was used. The intervention which focused on physical activity, TV time and soft drink consumption was integrated into a second-grade curriculum and was implemented by classroom teachers themselves. It comprised 29 teaching lessons, 2 short exercise blocks per day and 6 family homework lessons. BMI was assessed as primary outcome measure, waist circumference and skinfold thickness as secondary outcomes. Data of 945 children were analysed. Results: Multivariate analyses adjusted for baseline values showed no statistically significant effect of the intervention on BMI, but on waist circumference (–0.85; 95% confidence interval (95% CI) –1.59 to –0.12) and subscapular skinfold thickness (–0.64; 95% CI –1.25 to –0.02). After additional adjustment for individual time lag between baseline and follow-up, these effects were reduced to –0.60 (95% CI –1.25 to 0.05) and –0.61 (95% CI –1.26 to 0.04) and lost their statistical significance. Conclusion: This study contributes to the field of randomised school-based studies on overweight prevention and shows that within a 1-year, integrated intervention no effect on BMI, but a tendency towards effects on fat mass can be achieved.

Intervention effects of a school-based health promotion programme on obesity related behavioural outcomes.

Studies have shown preventive effects of an active lifestyle during childhood on later life; therefore, health promotion has to start early. The programme “Join the Healthy Boat” promotes a healthy lifestyle in primary school children. In order to evaluate it, childrens behaviours in respect of increased physical activity (PA), a decrease in screen media use (SMU), more regular breakfast, and a reduction of the consumption of soft drinks (SDC) were investigated. 1943 children (7.1 ± 0.6 years) participated in the cluster-randomised study and were assessed at baseline and 1736 of them at follow-up. Teachers delivered lessons, which included behavioural contracting and budgeting of SMU and SDC. Daily SMU, PA behaviours, SDC, and breakfast patterns were assessed via parental questionnaire. After one-year intervention, significant effects were found in the intervention group for SMU of girls, children without migration background, and children with parents having a low education level. In the control group, second grade children skipped breakfast significantly more often. Tendencies but no significant differences were found for PA and SDC. This intervention seems to affect groups, which are usually hard to reach, such as children of parents with low education levels, which shows that active parental involvement is vital for successful interventions.

Reference Values and Early Determinants of Intra-Abdominal Fat Mass in Primary School Children

Background: Intra-abdominal fat (IAF) is a valuable predictor of cardiovascular morbidity. However, neither reference values nor determinants are known in children. Methods: IAF was assessed as sonographically measured intra-abdominal depth in 1,046 children [median age 7.6 years, interquartile range (IQR) 7.2–7.9; 54% boys] of the URMEL-ICE study. Results: The intraclass correlation coefficient for intraobserver agreement was 0.93. The median IAF showed a significant gender difference (boys: 54.6 mm, IQR 50.1–59.3, vs. girls: 51.7 mm, IQR 46.3–56.4; p < 0.001). Age- and gender-specific centiles were generated. IAF showed a positive correlation to systolic blood pressure [regression coefficient (β) = 0.24 mm Hg/mm; p < 0.001] and a negative correlation to HDL cholesterol (β = –0.01 mmol/l/mm; p < 0.001). IAF showed a positive association with increased paternal and maternal BMI (β = 0.28 mm/kg/m2 and 0.27 mm/kg/m2; p < 0.001), increased weight gain in the first 2 years of life (β = 3.04 mm; p < 0.001), and maternal smoking during pregnancy (β = 2.4 mm; p = 0.001). Increased parental education was negatively associated with IAF (maternal: β = –0.65 mm/degree; p = 0.004, and paternal: β = –0.61 mm/degree; p = 0.002). Conclusion: Sonography was a reliable tool to estimate IAF. Factors influencing IAF included rapid infant weight gain, smoking during pregnancy, and parental BMI and education. Since IAF showed an association with cardiovascular risk factors even in prepubertal children, it might become a valuable predictor of cardiovascular vulnerability.

Secular changes of anthropometric measures for the past 30 years in South-West Germany

We investigated long-term changes in weight and skinfold thicknesses in German schoolchildren. In 2006, anthropometric measures were collected after a standardized protocol among 1079 children within the Ulm Research on Metabolism, Exercise and Lifestyle in children (URMEL-ICE) study. Data were compared with historical data (1975–1976). In URMEL-ICE, prevalence of overweight (IOTF criteria) was 16.5% (boys) and 17.3% (girls) and of obesity 3.5 and 3.6%, respectively. Compared with historical data the number of children above the 90th percentile1975/76 increased statistically significantly for weight (approximately 150% both sexes), for subscapular (boys 288%, girls 206%) and triceps skinfold thickness (boys 460%, girls 413%). Statistically significant increases above the 50th percentile1975/76 were found: weight 36 and 26%, subscapular 43 and 60% and triceps skinfold thickness 63 and 69% for boys and girls, respectively. Body fat among 6- to 9-year-old children increased dramatically within 30 years. Moreover, our data suggest substantial changes in body composition among normal-weight children towards an increased body fat mass.

Design, Implementation, and Study Protocol of a Kindergarten-Based Health Promotion Intervention

Inactivity and an unhealthy diet amongst others have led to an increased prevalence of overweight and obesity even in young children. Since most health behaviours develop during childhood health promotion has to start early. The setting kindergarten has been shown as ideal for such interventions. “Join the Healthy Boat” is a kindergarten-based health promotion programme with a cluster-randomised study focussing on increased physical activity, reduced screen media use, and sugar-sweetened beverages, as well as a higher fruit and vegetable intake. Intervention and materials were developed using Bartholomews Intervention Mapping approach considering Banduras social-cognitive theory and Bronfenbrenners ecological framework for human development. The programme is distributed using a train-the-trainer approach and currently implemented in 618 kindergartens. The effectiveness of this one-year intervention with an intervention and a control group will be examined in 62 kindergartens using standardised protocols, materials, and tools for outcome and process evaluation. A sample of 1021 children and their parents provided consent and participated in the intervention. Results of this study are awaited to give a better understanding of health behaviours in early childhood and to identify strategies for effective health promotion. The current paper describes development and design of the intervention and its implementation and planned evaluation. Trial Registration. The study is registered at the German Clinical Trials Register (DRKS), Freiburg University, Germany, ID: DRKS00010089.

Illness and determinants of health-related quality of life in a cross-sectional sample of schoolchildren in different weight categories.

Aim: To study associations between health-related quality of life (HRQoL), frequency of illness, and weight in primary school children in southern Germany. Methods: Data from baseline measurements of the outcome evaluation of a teacher based health promotion programme (“Join the Healthy Boat”) were analysed. Parents provided information about their children’s HRQoL (KINDLR, EQ5D-Y Visual Analogue Scale). The number of visits to a physician, children’s days of absence because of sickness, and parental days of absence from work due to their children’s illness during the last year of school/kindergarten were queried. Children’s weight status was determined by body mass index (BMI), central obesity by waist to height ratio (WHtR ≥0.5). Results: From 1,888 children (7.1±0.6 years), 7.8% were underweight, 82% had normal weight, 5.7% were overweight and 4.4% obese. 8.4% of all children were centrally obese. Bivariate analysis showed no significant differences for parental absence and visits to a physician in weight groups classified by BMI, but obese children had more sick days than non-obese. Centrally obese children differed significantly from the rest in the number of sick days and visits to a physician, but not in the frequency of parental absence. In regression analyses, central obesity correlated significantly with EQ5D-Y VAS, KINDLR total score and the subscales of “psyche”, “family” and “friends”. BMI weight groups showed no significant associations. Conclusions: Central obesity but not BMI derived overweight and obesity is associated with HRQoL and visits to a physician in primary school children. Future studies should include WHtR. Preventive measures for children should focus on a reduction of or slowed increase in waist circumference.

Effects of a Teacher-Centred, School-Based Intervention Program on Health Behavior and Cardiovascular Disease Risk in Elementary School Children

The increasing prevalence of overweight and obese children along with accompanying comorbidities has prompted an early acknowledgement of a healthy lifestyle. The purpose of this study was to examine the effect of a teacher-centered, school-based intervention on cardiovascular disease (CVD) risk and health behavior in elementary school children. 935 first- and second-grade children in southwest Germany provided valid data at baseline and follow-up. Trained technicians measured height and weight along with blood pressure, cholesterol, and intra-abdominal fat to determine CVD risk. Parent questionnaires were used to assess children’s health behavior. Within one year CVD risk declined in the intervention group, particularly due to an attenuation of the age-related increase in mean arterial pressure. The age-related decline in habitual sports participation was attenuated, and children in the intervention groups displayed higher odds of playing outside. Further, the consumption of sugar-sweetened beverages declined in the intervention group, and TV time remained stable, while it increased in the control group. These results indicate that a teacher-centered intervention positively affects health behavior and CVD risk. The incorporation of the intervention by the classroom-teacher should allow for a sustainable participation, which may result in more pronounced effects over time.

Intervention effects of a school-based health promotion program on children’s motor skills

PurposePhysical activity (PA) has positive effects on children’s development. Particularly in childhood, PA plays an important role for children’s motor skills. The objective of this study was to examine the influence of the intervention program “Join the Healthy Boat” on motor abilities of primary school children.MethodsThe baseline measurements of this longitudinal intervention study with an intervention (IG) and control group (CG) were taken at the beginning of the school year 2010/2011 (T1) and follow up measurements in 2011/2012 (T2). Efficacy of the intervention on children’s motor abilities was assessed using a standardized and validated test battery (Dordel-Koch-Test). An exploratory factor analysis was performed in order to reduce dimensions. Differences between CG and IG were examined using analysis of covariance adjusting for age, gender, BMI percentiles and baseline data.ResultsChildren in the IG showed an significant improvement in the conditional skills (F(1,1571) = 5.20, p ≤ 0.02) and less decline in flexibility (F(1,1715) = 6.68, p ≤ 0.01) than children in the CG. Additionally, positive differences in the flexibility tests were ascertained for girls, F(1,839) = 100.88, p ≤ 0.02).ConclusionThe study showed that an intervention that aims to increase PA affects certain parts of children’s motor skills significantly. This was achieved without any extra PA lessons at school but with a low-threshold intervention integrated into the daily school routine.

Health Promotion in Primary Schools- Evaluation of Side-Effects on Cognitive and Academic Performance in a Randomized Trial

Background: School-based lifestyle interventions are a cost-effective way to prevent pediatric overweight. The program “Join the Healthy Boat” focuses on physical activity, healthy diet and screen media use in German primary school children, implemented by regular classroom teachers including teaching units, physical activity exercises, and work with parents. Objective of the study was to measure potential side-effects on children’s cognitive and academic performance. Methods: The program was evaluated in a RCT design, measurements took place before and after one year of intervention. Stratification of randomization was carried out for number of classes and grade level. Participants were 1st and 2nd graders of primary schools. Intervention and assessment took place on site at school; questionnaires were issued. N=442 children performed a computer based test battery measuring inhibitory control, cognitive flexibility and sustained attention. Academic achievement was assessed via parental questionnaire. Results: Multiple regression analyses controlling for age, gender and parental education and Mann-Whitney-Utests revealed no significant differences between intervention and control group in cognitive changes or academic development from baseline to follow up. In Cognitive Flexibility, however, the number of children who improved was higher in the intervention group. Conclusion: Taking time from the regular school curriculum for health promotion had no negative impacts on children’s cognitive or academic development. To obtain more positive effects a longer period of time and a more intense intervention are presumably necessary. The findings are in line with a recent review indicating no negative effects of school health programs. Eventually there is a positive impact of physical activity interventions on specific cognitive functions but findings regarding academic outcomes are still inconclusive. Weak evidence is reported for nutrition services.

Response to: Comment on “Intervention Effects of a School-Based Health Promotion Programme on Obesity Related Behavioural Outcomes”

Evaluating multicomponent health programmes in public institutions is always a complex task and requires careful planning [1]. Reporting the outcomes in a precise and understandable manner is a further challenge for the researcher [2]. The points raised by Li et al. [3] are very valid and were also considered by us when writing the paper. Although outlined by Dreyhaupt et al. [4], not all planned analyses were incorporated in our paper [5]. Since the paper [5] (especially Methods) ended up being considerably substantial, we refrained from adding results of further statistical analyses to the paper. Further, in previous paper concerning cross-sectional results of this study, we referred to the respective consideration of clustering effects including adequate statistical methods [6, 7]. Since almost no clustering effects were observed, we refrained from introducing them in the present paper, even due to the associated complexity [2]. However, we have compared the results of the logistic regression models used and published in the paper with the results of generalised linear mixed models considering possible clustering effects in schools. Only a slight difference between odds ratios (ORs) was derived from the logistic regression models and the ORs from generalised linear mixed models for the variables “soft drink consumption” and “skipping breakfast.” Hence, we refrained from explaining and mentioning it in the paper. To reveal these above-mentioned slight differences between the results published in the paper and those derived from mixed models accounting for clustering, we included Table 1, which shows the results from both types of analysis. The ORs for our outcome variables physical activity, screen media use, soft drink consumption, and breakfast habits show no significant differences, and therefore we assume no clustering effects in our data. Table 1 Comparison of the results derived from logistic regression models and generalised linear mixed models.