In 2022, the Harvard/Beth Israel Deaconess Disaster Medicine Fellowship conducted a full-scale exercise (FSX) with the dual mission of 1) training Disaster Medicine Fellows (DMFs) in exercise design, planning, and execution, and 2) expanding local first responder experience with pediatric casualties in a mixed-method terrorist attack.

Project PUNCH (Preparedness for Uncertain and Novel Chemical Hazards) was planned in two stages. A tabletop exercise in the form of a facilitated discussion was conducted in March 2022 with stakeholders from Fire, Emergency Medical Services (EMS), and the Massachusetts HazMat Team. A FSX simulating a combined blast and chemical attack on a family gathering was held in June 2022 at Anna Maria College in Paxton, MA.

Fire, EMS, HazMat, LifeFlight, local Police, MA State Police, a local Medical Reserve Corps, and over 40 volunteer victims including 16 pediatric volunteers participated in the FSX. The FSX was a two-hour exercise with a simulated explosion and a secondary drone-deployed dummy-opioid aerosol release. This was the first FSX for the Paxton Region since the coronavirus pandemic began. Planning was conducted by the DMFs between January and June 2022 with the aid of Fellowship faculty and local stakeholders following Homeland Security Exercise and Evaluation Program guidelines. Local and Fellowship leadership with Pediatric expertise were engaged to plan pediatric specific considerations, precautions and safety measures. COVID precaution guidelines were followed. These efforts are detailed in the forthcoming field report. Educational guides for toxidromes and triage and resuscitation of pediatric victims were distributed to first responders.

The end outcome was a FSX that trained DMFs in exercise design, planning, and execution, and increased experience of local first responders with the concepts of asymmetric terrorist attacks and comfort with pediatric disaster victims. Multi-agency disaster drills remain an important training tool for preparedness and response to mass casualty events.

Adolescents’ snacking habits are driven by both explicit reflective and implicit hedonic processes. Hedonic pathways and differences in sensitivity to food rewards in addition to reflective determinants should be considered. The present study evaluated the feasibility and impact of a mobile phone-delivered intervention, incorporating explicit reflective and implicit rewarding strategies, on adolescents’ snack intake.

Adolescents (n 988; mean age 14·9 (sd 0·70) years, 59·4 % boys) completed a non-randomized clustered controlled trial. Adolescents (n 416) in the intervention schools (n 3) were provided with the intervention application for four weeks, while adolescents (n 572) in the control schools (n 3) followed the regular curriculum. Outcomes were differences in healthy snacking ratio and key determinants (awareness, intention, attitude, self-efficacy, habits and knowledge). Process evaluation data were collected via questionnaires and through log data of the app.

No significant positive intervention effects on the healthy snack ratio (b=−3·52 (se 1·82), P>0·05) or targeted determinants were observed. Only 268 adolescents started using the app, of whom only fifty-five (20·5 %) still logged in after four weeks. Within the group of users, higher exposure to the app was not significantly associated with positive intervention effects. App satisfaction ratings were low in both high and low user groups. Moderation analyses revealed small positive intervention effects on the healthy snack ratio in high compared with low reward-sensitive boys (b=1·38 (se 0·59), P<0·05).

The intervention was not able to improve adolescents’ snack choices, due to low reach and exposure. Future interventions should consider multicomponent interventions, teacher engagement, exhaustive participatory app content development and tailoring.

To study the quantity and quality of water intake from beverages among pre-schoolers and investigate associations with gender and socio-economic status (SES).

Kindergarten-based cross-sectional survey within the large-scale European ToyBox-study. A standardized protocol was used and parents/caregivers filled in sociodemographic data and a semi-quantitative FFQ.

Kindergartens in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain).

European pre-schoolers (aged 3·5–5·5 years) and their parents/caregivers (n 7051).

Mean water intake was 1051 ml/d; plain water, 547 ml/d; plain milk, 241 ml/d; other fruit juice, 104 ml/d; pure fruit juice, 59 ml/d; soft drinks, 55 ml/d; tea, 45 ml/d; sugared and chocolate milk, 37 ml/d; smoothies, 15 ml/d; and light soft drinks, 6 ml/d. Boys had a higher water intake than girls due to a higher consumption of plain water, but more importantly to the consumption of beverages of less quality. Lower-SES pre-schoolers scored better on quantity than high-SES pre-schoolers, but as a consequence of consumption of sugared beverages. Nevertheless, the associations differed by country.

The water intake from beverages did not meet the European Food Safety Authority standard of 1280 ml/d; especially in Western European countries water intake from beverages was low. The most important water sources were plain water, milk and fruit juices. Interventions aiming at a proper and sufficient water intake should focus on both quantity and quality. Messages about water and water sources should be clear for everyone and interventions should be sufficiently tailored.

The aim of the present study was to investigate if context-specific measures of parental-reported physical activity and sedentary behaviour are associated with objectively measured physical activity and sedentary time in children.

Cross-sectional study.

Seven European countries taking part in the IDEFICS (Identification and Prevention of Dietary- and Lifestyle-induced Health Effects in Children and Infants) study.

Data were analysed from 2–9-year-old children (n 5982) who provided both parental-reported and accelerometer-derived physical activity/sedentary behaviour measures. Parents reported their children’s daily screen-time, weekly sports participation and daily outdoor playtime by means of the Outdoor Playtime Checklist (OPC) and Outdoor Playtime Recall Questions (OPRQ).

Sports participation, OPC- and OPRQ-derived outdoor play were positively associated with accelerometer-derived physical activity. Television viewing and computer use were positively associated with accelerometer-derived sedentary time. All parental-reported measures that were significantly associated with accelerometer outcomes explained only a minor part of the variance in accelerometer-derived physical activity or sedentary time.

Parental-reported measures of physical activity and sedentary behaviour are not useful as a proxy for 2–9-year-old children’s physical activity and sedentary time. Findings do not preclude the use of context-specific measures but imply that conclusions should be limited to the context-specific behaviours that are actually measured. Depending on the aim of the study, future research should carefully consider the choice of measurements, including the use of subjective or objective measures of the behaviour of interest or a combination of both.

The increasing prevalence of childhood overweight is an important health issue. There is a need for longitudinal research among children in order to identify risk factors for childhood overweight. The objective of the present research was to identify potential sociodemographic and behavioural risk factors for development of childhood overweight among 3- to 6-year-old children.

Longitudinal study.

Sixteen pre-primary and primary schools.

BMI Z-scores at baseline and two follow-up measurements were calculated for 568 children. Sociodemographic, parental adiposity, familial composition, child's diet, physical activity and sedentary behavioural data were collected through questionnaires.

Several risk factors for the development of childhood overweight were found. Being an only child, lower maternal educational level, maternal and paternal overweight, more than 1 h screen time on weekdays and high soft drinks consumption were shown to be positively associated with the development of childhood overweight.

Although behavioural factors are important, our findings support the thesis that interventions on the prevention of childhood overweight should focus on high-risk groups, i.e. children from low socio-economic background or with high parental BMI. Interventions should address the whole family and take into account their lifestyle and structure.

The aim of the present study was to evaluate the effects of a 1-year family-based healthy lifestyle intervention implemented through day-care centres on toddlers’ BMI Z-scores and reported activity- and dietary-related behaviours.

Pilot cluster-randomized controlled trial.

Seventy child-care centres in three different intervention communities and three paired-matched control communities in Flanders, Belgium.

A sample of 203 Belgian toddlers aged 9–24 months was included in the study. Objectively assessed weight and height were used to calculate BMI Z-scores. A parental-report questionnaire was used to assess children's lifestyle behaviours.

Positive intervention effects were found on BMI Z-score. No intervention effects were found for activity- and dietary-related behaviours targeted by the intervention. In both intervention and control groups, daily consumption of water, soft drinks, sweets and savoury snacks increased while daily consumption of fruit and vegetables decreased over 1 year. Daily physical activity remained stable but screen-time behaviour increased in both groups over time.

The study showed that a family-based healthy lifestyle intervention implemented through day-care centres can lead to healthier weight outcomes in toddlers. In both groups, an unhealthier lifestyle pattern was observed over 1 year which underlines the importance of the early childhood period as the focus of future behavioural interventions.

The main objective was to assess the relationship of breakfast skipping, television (TV) viewing at breakfast and breakfast without TV with weight status among parents of 10–12-year-olds in eight European countries.

A cross-sectional survey assessed breakfast eating and TV viewing at breakfast by three frequency questions and parents were categorized into: (i) breakfast skippers; (ii) breakfast with TV (TV watchers at breakfast); and (iii) breakfast without TV (breakfast eaters who do not watch TV during breakfast). Self-reported weight and height were used to categorize weight status as underweight, normal weight, overweight and obese. Multinomial logistic regression analyses were conducted with weight status as the dependent variable and breakfast habits as predictors, adjusting for sex, ethnicity and level of education.

The survey was conducted in 2010 in 199 primary schools across eight European countries participating in the ENERGY (EuropeaN Energy balance Research to prevent excessive weight Gain among Youth) cross-sectional study.

Parents (n 6512) of 10–12-year-olds responded to the questionnaire.

In the total study sample, with breakfast without TV as the reference group and adjusting for sex, ethnicity and level of education, the OR of being respectively overweight or obese (compared with normal weight) was 1·2 (95 % CI 1·0, 1·4) or 1·8 (95 % CI 1·5, 2·3) for breakfast skippers. The OR of being respectively underweight or obese was 0·5 (95 % CI 0·2, 0·9) or 1·4 (95 % CI 1·1, 1·8) for breakfast with TV.

Breakfast skippers were significantly more likely to be overweight and obese, and those eating breakfast while watching TV were significantly more likely to be obese and less likely to be underweight.

To examine family- and school-based predictors of breakfast consumption, soft drink consumption and physical activity (PA) and moderating effects of gender and socio-economic status (SES).

Longitudinal study (6-year follow-up), including a questionnaire about dietary and activity behaviour.

Fifty-nine Flemish elementary schools.

Seven hundred and twenty-seven children (51·9 % girls, 51·9 % high SES, mean age 9·9 (sd 0·4) years at baseline).

Having breakfast together with parents (P < 0·001) at age 10 years related to more days of eating breakfast at age 16 years. More parental soft drink consumption (P = 0·04), less soft drink availability at home (P < 0·001) and less parental permissiveness (children received soft drinks from their parents whenever they asked for it and children could take soft drinks whenever they wanted; P = 0·02 and P = 0·001, respectively) at age 10 years related to less soft drink consumption at age 16 years. A more positive parental attitude towards PA (P = 0·009), more parental encouragement (P = 0·002) and a higher rating of PA's benefit ‘relaxing’ (P < 0·001) at age 10 years related to more PA at age 16 years. Gender and SES did not significantly moderate any of the associations.

Only parental factors at age 10 years were associated with breakfast consumption, soft drink consumption and PA at age 16 years. An intervention programme at age 10 years with a strong focus on the modifiable parental factors might lead to healthy behaviour in the long term.

The aim of the paper is to describe the formative evaluation of the feedback component of an online nutrition tailoring instrument, the Children's and Adolescents’ Nutrition Assessment and Advice on the Web (CANAA-W), among parents of schoolchildren.

Parents of pre-primary and primary-school children recorded their child's food intake over 3 d with CANAA-W and completed the evaluation questionnaire online. A subsample participated in focus group discussions.

Parents completed CANAA-W at home.

Forty-six parents completed the evaluation questionnaire. Seventeen parents participated in three focus group discussions.

Parents were enthusiastic: the majority (81 % or more) found the advice comprehensible, interesting, logical, useful, believable, well formulated, correct, personal, relevant, complete, attractive, containing enough and not too much information; they indicated that it is helpful to improve their children's eating habits and that they intend to use it. The qualitative analyses revealed that the respondents appreciated the confrontation with their child's diet and the visualization (i.e. traffic light colours, pictograms, food models, diagrams). The length of the feedback was rather a drawback, but it was useful nevertheless.

CANAA-W was well received by the parents; the scores on the feasibility questionnaire were high and the qualitative analyses showed that the confrontation with their child's diet, and attractive visualization of the most relevant feedback linked to more elaborated optional feedback, were well appreciated. The major challenge will be to convince parents who are less interested in food habits and less computer-literate to participate in this type of study.

To evaluate a web-based nutritional knowledge questionnaire for primary-school children.

Children's nutritional knowledge was assessed in five domains: healthy choices (twenty-seven items), estimated recommended portions/servings (eight items), nutrient content (five items), main food function (five items) and categorization of food items (eight items).

The questionnaires were completed in school.

A convenience sample of 576 Belgian children (aged 7–12 years) from fourteen primary schools completed the questionnaire once, 386 completed the questionnaire twice.

Healthy choices could be answered correctly by 73 % of the children, nutrients by 59 %, food categorization by 49 %, main function by 38 % and portion estimation by 36 %. Children's test–retest intra-class correlations were 0·75 for healthy choices, 0·33 for nutrients, 0·61 for food categorization, 0·44 for main function, 0·47 for portion estimation and 0·76 for the total scale. The intra-class correlation was lower in the youngest age group (grade 2: 0·51, grade 4: 0·65, grade 6: 0·66). The total score was significantly lower in the retest. The instrument was in general positively evaluated by the children.

The instrument is a promising, practical, inexpensive tool with acceptable test–retest reliability in fourth and sixth graders.

To investigate test–retest reliability of primary-school children's reports of food preferences and to investigate agreement with parental reports.

Children completed an online test and retest, one to two weeks later, during school hours; parents completed a paper-and-pencil or an online questionnaire at home. The children's preferences questionnaire contained 148 food items, reduced to twelve scales; the parental questionnaire contained seventy-eight items reduced to nine scales.

Children of fourteen primary schools in Belgium-Flanders.

In total 572 children participated; test–retest data were available for 354 children, children's tests could be matched to 362 parental reports.

Test–retest intraclass correlations were on average 0·73, ranging between 0·62 and 0·86; correlations between children's and parents’ reports were on average 0·50, ranging between 0·32 and 0·62. Retest preferences were significantly higher for more than half of the scales. Children reported higher preferences than their parents for milk & milk products, fruit and soft drinks, while parents reported higher preferences for bread & breakfast cereals, meat, snacks and sauces.

The results indicate that the test–retest stability was good; however, agreement between parents and children was rather low to moderate.

Socio-economic status (SES) has been positively associated with physical activity (PA) levels in adolescents. In order to tackle these social inequalities, information is needed about the underlying mechanisms of this association. The present study aimed to investigate the potential mediating role of psychosocial correlates of PA on the relationship between SES and PA in European adolescents.

Cross-sectional study testing the mediating role of psychosocial correlates in the SES–PA association using the product-of-coefficients test of MacKinnon.

Ten European cities in nine different countries, the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) Study.

Adolescents (n 2780) aged 12·5–17·49 years self-reported on PA (moderate-to-vigorous intensity PA and total PA), SES indicators (education of the mother and Family Affluence Scale) and psychosocial correlates of PA (stage of change, attitudes, awareness, modelling, social support, self-efficacy, benefits, barriers and environmental correlates).

SES (Family Affluence Scale) was significantly associated with moderate-to-vigorous intensity PA. According to single-mediator models, this association was significantly mediated by stage of change (t = 3·6, P ≤ 0·001), awareness (t = 2·7, 0·001 < P ≤ 0·01), modelling (t = 4·8, P ≤ 0·001), self-efficacy (t = 2·5, 0·01<P ≤ 0·05), barriers (t = 2·7, 0·001 < P ≤ 0·01) and environmental (t = 3·0, 0·001 < P ≤ 0·01) correlates of PA. The multiple-mediators model showed that the mediating role of the combination of these psychosocial correlates was also significant (t = 6·2, P ≤ 0·001).

Adolescents with low family wealth scored lower on stage of change, awareness, modelling, self-efficacy and environmental correlates of PA, and higher on PA barriers, which in turn resulted in lower levels of moderate-to-vigorous PA. Future interventions should target these individual and environmental constructs in order to tackle and intervene on social inequalities in PA among adolescents.

The purpose of the present study was to evaluate the effects of a school-based, 2-year, multi-component intervention on BMI, eating and physical activity behaviour in Flanders, Belgium, targeting children aged 3–6 years in communities of high and low socio-economic status (SES).

Cluster-randomized controlled trial.

Thirty-one pre-primary and primary schools in three different intervention communities and three paired-matched (on SES profile) control communities in Flanders, Belgium.

BMI Z-scores at baseline and follow-up were calculated for 1102 children. Questionnaires with sociodemographic data and FFQ were available from 694 of these 1102 children.

No significant effects were found on BMI Z-scores for the total sample. However, there was a significant decrease in BMI Z-score of 0·11 in the low-SES intervention community compared with the low-SES control community, where the BMI Z-score increased by 0·04 (F = 6·26, P = 0·01). No significant intervention effects could be found for eating behaviour, physical activity or screen-time. There were no significant interaction effects of age and gender of the children on the outcome variables.

Although no significant effects were found for BMI Z-scores in the total sample, this intervention had a promising effect in the low-SES community of reducing excess weight gain among young children.

To identify family- and school-based correlates of specific energy balance-related behaviours (physical activity, sedentary behaviour, breakfast consumption, soft drink consumption) among 10–12-year-olds, using the EnRG framework (Environmental Research framework for weight Gain prevention).

A literature review to identify observational studies exploring at least one family- or school-based correlate of the specific behaviours, resulting in seventy-six articles.

Eighteen studies were conducted in Europe, forty-one studies in North America and seventeen studies in Australasia.

Healthy children aged 10–12 years.

Parental and maternal physical activity, doing physical activities with parents and parental logistic support were identified as the most important, positive correlates of physical activity. Parental rules was the most important correlate of sedentary behaviour and was inversely related to it. School socio-economic status was positively related to physical activity and inversely related to sedentary behaviour. The available studies suggested a positive relationship between soft drink availability at home and consumption. Soft drink availability and consumption at school were the most important school-based correlates of soft drink consumption. A permissive parenting style was related to more soft drink consumption and less breakfast consumption.

An important role has been awarded to parents, suggesting parents should be involved in obesity prevention programmes. Despite the opportunities a school can offer, little research has been done to identify school-environmental correlates of energy balance-related behaviours in this age group. Obesity prevention programmes can focus on the most important correlates to maximize the effectiveness of the programme. Future research should aim at longitudinal studies.

To investigate the feasibility and impact of the Food-O-Meter, an Internet-based computer-tailored nutrition intervention in adolescents.

Participants in the intervention condition received the computer-tailored advice at baseline and at 1 month, those in the control condition received standardised advice. Effects were evaluated at 1 month (n 621) and at 3 months (n 558) using multi-level modelling.

Secondary schools in six European cities. Adolescents accessed the intervention in the school computer room under the supervision of teachers.

Classes with students aged 12–17 years in the schools participating in the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) cross-sectional study were randomised into intervention and control schools.

In most participating centres the intervention was feasible and generally well appreciated, especially by girls. Technical problems and lack of motivation of the teachers hindered implementation in some centres. Overweight adolescents had higher scores for reading and using the advice than normal weight adolescents. After 1 month adolescents receiving the standardised advice reported an increase in fat intake, while fat intake in the intervention condition was stable (F = 4·82, P < 0·05). After 3 months, there was a trend in the total group for an intervention effect of the tailored advice on fat intake (F = 2·80, P < 0·10). In the overweight group there was a clear positive effect (F = 5·76, P < 0·05).

The Food-O-Meter should be developed further. The results were modest but clear for percentage energy from fat, specifically in the overweight group. Adaptations based on new research are needed to enhance the reliability and effectiveness of the intervention.

To identify the correlates of the home food environment (parents’ intake, availability and food-related parenting practices) at the age of 10 years with dietary patterns during childhood and in adolescence.

Primary-school children of fifty-nine Flemish elementary schools completed a questionnaire at school in 2002. Four years later they completed a questionnaire by e-mail or mail at home. Their parents completed a questionnaire on food-related parenting practices at baseline.

Longitudinal study.

The analyses included 609 matched questionnaires.

Multi-level regression analyses were used to identify baseline parenting practices (pressure, reward, negotiation, catering on demand, permissiveness, verbal praise, avoiding negative modelling, availability of healthy/unhealthy food items and mothers’ fruit and vegetable (F&V) and excess scores) associated with children’s dietary patterns (F&V and excess scores).

Mother’s F&V score was a significant positive independent predictor for children’s F&V score at baseline and follow-up, whereas availability of unhealthy foods was significantly negatively associated with both scores. Negotiation was positively associated with children’s follow-up score of F&V, while permissiveness was positively associated with children’s follow-up excess score. Availability of unhealthy foods and mother’s excess score were positively related to children’s excess score at baseline and follow-up.

Parental intake and restricting the availability of unhealthy foods not only appeared to have a consistent impact on children’s and adolescents’ diets, but also negotiating and less permissive food-related parenting practices may improve adolescents’ diets.

To explore the relationship between several physical activity (PA) and dietary behaviours and BMI Z-score and to investigate the relationship between changes in these variables and in the BMI Z-score over a 4-year period from childhood to adolescence.

Longitudinal study in which children were included in the fifth grade and measured for four consecutive years. Dietary and PA behaviours as well as height and weight were measured by means of self-reported validated questionnaires.

Fifty-nine Flemish elementary schools.

The baseline sample consisted of 51·9 % boys and the mean age was 10 (sd 0·4) years. During the first measurement year (2002), data on 1670 fifth graders were gathered. These measurements were repeated after 1 (n 1557), 2 (n 1151) and 3 (n 807) years.

Significant inverse relationships with BMI Z-score were observed for frequency of breakfast consumption (β = −0·033, se = 0·012) and frequency of sports participation (β = −0·011, se = 0·004) across four time points. Significant inverse relationships between changes in BMI Z-score and changes in frequency of sports participation (β = −0·011, se = 0·006) and hours of physical education (PE; β = −0·052, se = 0·023) were observed, meaning that decreases in sports participation and hours spent in PE were associated with increases in BMI Z-score.

The present study provides an important insight into different dietary and PA behaviours related to (changes in) BMI Z-score during the transition from childhood to adolescence.