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To examine the effect of the intervention implemented in the ToyBox-study on changes observed in age- and sex-specific BMI percentile and investigate the role of perinatal factors, parental perceptions and characteristics on this change.
A multicomponent, kindergarten-based, family-involved intervention with a cluster-randomised design. A standardised protocol was used to measure children’s body weight and height. Information was also collected from parents/caregivers via the use of validated questionnaires. Linear mixed effect models with random intercept for country, socio-economic status and school were used.
Selected preschools within the provinces of Oost-Flanders and West-Flanders (Belgium), Varna (Bulgaria), Bavaria (Germany), Attica (Greece), Mazowieckie (Poland) and Zaragoza (Spain).
A sample of 6268 preschoolers aged 3·5–5·5 years (51·9 % boys).
There was no intervention effect on the change in children’s BMI percentile. However, parents’ underestimation of their children’s actual weight status, parental overweight and mothers’ pre-pregnancy overweight/obesity were found to be significantly and independently associated with increases in children’s BMI percentile in multivariate modelling.
As part of a wide public health initiative or as part of a counseling intervention programme, it is important to assist parents/caregivers to correctly perceive their own and their children’s weight status. Recognition of excessive weight by parents/caregivers can increase their readiness to change and as such facilitate higher adherence to favourable behavioural changes within the family.
Introduction: Childhood obesity is rising in all countries. Dietary habits are modifiable factors which develop early in life. During growth, several factors, such as peer- influence and food availability, determine the development of food preferences and eating behaviour. Parents play also a key role model by influencing their own food intake.
Objetives: The purpose of this study was to assess the influence of parental role modelling, as predictor of fruits and vegetables intake in European pre-schoolers.
Methods: The present study included a sample of 6633 preschool children (51.9% boys) from six European centres (Belgium, Bulgaria, Germany, Greece, Poland and Spain), 3.5 to 5.5 years of age, participating in the ToyBox-study. Data on parental role modelling related with their own fruits and vegetables intake (portions/day) and children's fruits and vegetables intake (portions/day) were collected via standardized proxy-administered questionnaires. Linear regression model was used to assess this association. The adjusted model included socioeconomic status and weight status.
Results: In the unadjusted model, boys whose parents consumed fruits, showed a mean intake of 0.09 (95% CI: 0.08–0.11; p ≤ 0.001) portions of fruits more than the boys whose parents did not consume fruits. Also, girls whose parents consumed fruits, had intake of 0.10 (95% CI: 0.08–0.12; p ≤ 0.001) portions of fruits more than the girls whose parents did not consume fruits.
Moreover, boys whose parents consumed vegetables, showed a mean intake of 0.09 (95% CI: 0.07–0.11; p ≤ 0.001) portions of vegetables more than the boys whose parents did not consume vegetables. Also, girls whose parents consumed fruits, had intake of 0.11 (95% CI: 0.09–0.13; p ≤ 0.001) portions of vegetables more than the girls whose parents did not consume vegetables.
Finally, parental role related with fruits consumption explained 19.3% of fruits intake in European pre-schoolers and the 17.8% of vegetables intake in boys and 21.9% of vegetable intake in girls taking into consideration the potential effect of socioeconomic status of the family and the weight status of the children.
Conclusions: Parental role model of fruit intake has moderate effect on the pre-schooler's dietary intake. However, home environment characteristics such as family rules or availability and accessibility of foods should be considered as potential factors related to food intake in pre-schoolers.
Introduction: Dietary habits are established from a very young age. Parental role modeling is an important factor influencing the eating behavior of their children. Drinking behavior may have an impact in the development of childhood obesity. This study aimed to explore the correlations of core drinking beverages between parents and their children.
Materials and Methods: The present study included children of 3.5–5.5 years and their parents from the (Multifactorial evidence-based approach using behavioral models in understanding and promoting fun, healthy food, play and policy for the prevention of obesity in early childhood) ToyBox study. The study was a kindergarten-based family-involved intervention, in preschool children from six European countries: Belgium, Bulgaria, Germany, Greece, Poland, and Spain. For this study, we analyzed data from the baseline cross-sectional survey.
Data on consumption frequency of water, homemade or fresh fruit juice, prepacked fruit juice, light beverages and sugared sweetened beverages consumption from parents and their children was obtained via a validated food frequency questionnaire. Parents were given examples of serving sizes and asked about how to self-report their usual consumption per day or week. Beverage consumption of children was reported by their parents and information about frequency and portion sizes was collected. Body weight and height of children was measured and classified according to the International Obesity Task Force (IOTF). Bivariate correlations were performed to analyze beverage consumption (servings per day) in children and their parents.
Results: The studied sample included 5266 pairs of children (49.2% girls) and parents (91.7% women) that were included in the analysis.
Girls presented higher correlations in water (r2 = 0,317) and sugar sweetened beverages (r2 = 0,302), whereas boys, presented slightly higher correlations of light soft drinks (r2 = 0,273), pure fruit juices (r2 = 0,308) and prepacked fruit juices (r2 = 0,324), all of them at < 0.01 level of significance. Considering boys and girls together, a slightly higher significant correlation coefficients were found between children-parents’ dyads with overweight/obesity compared to normal weight children-parentś for sugar sweetened beverages (r2 = 0,303) and light soft drinks (r2 = 0,396).
Discussion: Beverage consumption of children and their parents were found to be moderately correlated. Overweight children seem to have better correlations with their parents in relation of sugar sweetened beverages and light soft drinks. Parents should encourage a healthy beverage consumption for their own health and most important, because there are key role models to their children.
To develop a scale to assess health motivation influencing food choices and to explore its performance in the associations with food intakes and nutritional biomarkers.
Psychometric study using cross-sectional self-report questionnaires and nutritional biomarkers.
Multi-centre investigation conducted in ten European cities.
2954 adolescents who were included in the HELENA study and completed the Food Choices and Preferences (FCP) questionnaire.
Nineteen out of 124 items of the FCP questionnaire were in the same dimension. Sixteen presented adequate parameters for the Scale of evaluatiOn of Food choIcEs (SOFIE). The scores were positively associated with the intakes of cereals, dairy products, meats and eggs, and fish, as well as with blood concentrations of vitamin C, β-carotene, n-3 fatty acids, cobalamin, holo-transcobalamin and folate; scores were negatively associated with the intake of alcohol.
SOFIE can improve the assessment of motivation influencing food choices based on items with the best performance and is proposed as a new measure to health-related studies.
To analyse the Nutritional Knowledge Test (NKT) using Item Response Theory (ITR) analysis and to assess the construct validity of the Nutritional Knowledge Scale (NKTS) and its associations with adolescent food group consumption and nutritional biomarkers.
Multicentre investigation conducted in ten European cities.
Adolescents aged 12·5–17·5 years (n 3215) who completed over 75 % of the NKT.
Factor analysis indicated that the NKT can be analysed with a one-dimensional model. Eleven out of twenty-three items from the NKT presented adequate parameters and were selected to be included in the NKTS. Nutrition knowledge was positively associated with consumption of fruits, cereals, dairy products, pulses, meat and eggs, and fish, as well as with blood concentrations of vitamin C, β-carotene, n-3 fatty acids, holo-transcobalamin, cobalamin and folate; nutrition knowledge was negatively associated with intake of olives and avocado, alcohol and savoury snacks.
The NKTS assessed nutritional knowledge adequately and it is proposed as a new tool to investigate this subject in future studies.
The present study aimed to explore the mediating role of family-related determinants on the effects of the ToyBox-intervention on pre-school children’s consumption of healthy and unhealthy snacks.
The ToyBox-intervention was a kindergarten-based, family-involved intervention with a cluster-randomized design, aiming to promote healthy lifestyle behaviours to prevent obesity at pre-school age.
Kindergartens (n 309) in six European countries.
A total of 6290 pre-schoolers and their families participated in the ToyBox-intervention in 2012–2013 and data from 5212 pre-schoolers/families were included in the current analyses.
Even though the total effect of the ToyBox-intervention on healthy and unhealthy snacking was not significant, the ToyBox-intervention significantly improved parental rule setting on children’s unhealthy snack consumption (i.e. restriction of snacking while watching television and permission only at certain occasions) and parental consumption of unhealthy snacks, while it increased parental knowledge on snacking recommendations. Regarding healthy snacking, the ToyBox-intervention improved children’s attitude towards fruit and vegetables (F&V). All previously mentioned family-related determinants mediated the intervention effects on pre-schoolers’ consumption of healthy and unhealthy snacks. Almost all family-related determinants examined in the study were independently associated with pre-schoolers’ consumption of healthy and unhealthy snacks.
The intervention was effective in improving relevant family-related determinants. Interventions aiming to promote F&V consumption and limit the consumption of unhealthy snacks in pre-schoolers should target on these mediators, but also identify new family-, school- or peer-related determinants, to enhance their effectiveness.
To describe the design of the Feel4Diabetes-intervention and the baseline characteristics of the study sample.
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.
Primary schools and municipalities in six European countries.
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).
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.
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.
Energy balance-related behaviours (EBRB) are established in childhood and seem to persist through to adulthood. A lower parental educational level was associated with unhealthy behavioural patterns. The aim of the study is to identify clusters of EBRB and examine their association with preschool children’s BMI and maternal, paternal and parental education. A subsample of the ToyBox study (n 5387) conducted in six European countries was used. Six behavioural clusters (‘healthy diet and low activity’, ‘active’, ‘healthy lifestyle’, ‘high water and screen time; low fruits and vegetables (F&V) and physical activity (PA)’, ‘unhealthy lifestyle’ and ‘high F&V consumers’) emerged. The healthiest group characterised by high water and F&V consumption and high PA z scores (‘healthy lifestyle’) was more prevalent among preschool children with at least one medium- or higher-educated parent and showed markedly healthier trends for all the included EBRB. In the opposite, the ‘unhealthy lifestyle’ cluster (characterised by high soft drinks and screen time z scores, and low water, F&V and PA z scores) was more prevalent among children with lower parental, paternal and maternal education levels. OR identified that children with lower maternal, paternal and parental education levels were less likely to be allocated in the ‘healthy lifestyle’ cluster and more likely to be allocated in the ‘unhealthy lifestyle’ cluster. The ‘unhealthy lifestyle’ cluster was more prevalent among children with parents in lower parental educational levels and children who were obese. Therefore, parental educational level is one of the key factors that should be considered when developing childhood obesity prevention interventions.
To study diet quality among pre-schoolers using the Diet Quality Index (DQI) and to investigate differences according to gender, socio-economic status (SES) and overweight/obesity status.
Kindergarten-based cross-sectional survey within the ToyBox-study. A standardized protocol was used and parents/caregivers self-reported sociodemographic data and a semi-quantitative FFQ. A total DQI and its four subcomponents (diversity, quality, equilibrium and meal index) were calculated based on this FFQ. High total DQI scores indicate better diet quality than low scores. Results of the total DQI and the subcomponents were reported as percentages of maximum scores (100 %).
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 7063).
The mean total DQI score was 68·3 %. Mean scores of the subcomponents were 61·7 % for diversity, 56·5 % for quality, 65·4 % for equilibrium and 89·7 % for the meal index. Pre-schoolers of lower-SES backgrounds had lower scores on the total DQI and all its subcomponents. No clear differences were found by gender and overweight status. Results differed slightly according to country.
Pre-schoolers scored low on the total DQI and especially on dietary quality, as energy-dense, low-nutritious food items were more often consumed than highly nutritious food items. Furthermore, already in pre-schoolers lower-SES mothers were less likely to provide a good diet quality and this was consistent for all four subcomponents of the total DQI. Food intake in pre-schoolers should be enhanced, especially in pre-schoolers of lower-SES backgrounds.
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.
To investigate the magnitude and country-specific differences in underestimation of children’s weight status by children and their parents in Europe and to further explore its associations with family characteristics and sociodemographic factors.
Children’s weight and height were objectively measured. Parental anthropometric and sociodemographic data were self-reported. Children and their parents were asked to comment on children’s weight status based on five-point Likert-type scales, ranging from ‘I am much too thin’ to ‘I am much too fat’ (children) and ‘My child’s weight is way too little’ to ‘My child’s weight is way too much’ (parents). These data were combined with children’s actual weight status, in order to assess underestimation of children’s weight status by children themselves and by their parents, respectively. Chi-square tests and multilevel logistic regression analyses were conducted to examine the aims of the current study.
Eight European countries participating in the ENERGY (EuropeaN Energy balance Research to prevent excessive weight Gain among Youth) project.
A school-based survey among 6113 children aged 10–12 years and their parents.
In the total sample, 42·9 % of overweight/obese children and 27·6 % of parents of overweight/obese children underestimated their and their children’s weight status, respectively. A higher likelihood for this underestimation of weight status by children and their parents was observed in Eastern and Southern compared with Central/Northern countries. Overweight or obese parents (OR=1·81; 95 % CI 1·39, 2·35 and OR=1·78, 95 % CI 1·22, 2·60), parents of boys (OR=1·32; 95 % CI 1·05, 1·67) and children from overweight/obese (OR=1·60; 95 % CI 1·29, 1·98 and OR=1·76; 95 % CI 1·29, 2·41) or unemployed parents (OR=1·53; 95 % CI 1·22, 1·92) were more likely to underestimate children’s weight status.
Children of overweight or obese parents, those from Eastern and Southern Europe, boys, younger children and children with unemployed parents were more likely to underestimate their actual weight status. Overweight or obese parents and parents of boys were more likely to underestimate the actual weight status of their children. In obesity prevention such underestimation may be a barrier for behavioural change.
The purpose of the present study was to investigate the associations of family sociodemographic characteristics with children’s weight status and whether these potential associations are mediated by children’s breakfast habits.
A school-based survey among 10–12-year-old children was conducted in eight European countries. Children’s weight and height were measured and breakfast habits and family sociodemographic characteristics were self-reported by 5444 children and their parents. International Obesity Task Force cut-off points were used to categorize children as overweight/obese or normal weight. Mediation analyses were used to test the potential mediating effect of children’s breakfast consumption on the associations between family sociodemographic characteristics and children’s overweight/obesity.
Schools in eight European countries participating in the ENERGY (EuropeaN Energy balance Research to prevent excessive weight Gain among Youth) project.
Children aged 10–12 years and their parents (n 5444).
Children’s reported daily breakfast consumption varied from 56 % in Slovenia to 92 % in Spain on weekdays and from 79 % in Greece to 93 % in Norway on weekends. Children of native parents, with both parents employed and with at least one parent having more than 14 years of education were more likely to consume breakfast daily and less likely to be overweight/obese. Finally, mediation analyses revealed that the association of parental nationality and parental educational status with children’s overweight/obesity was partially mediated by children’s daily breakfast consumption.
The study shows that the lower likelihood of being overweight/obese among 10–12-year-old children of native background and higher parental educational status was partially mediated by children’s daily breakfast consumption.
Emerging data indicate that higher levels of insulin resistance (IR) are common among children and adolescents and are related to cardiometabolic risk; therefore, IR requires consideration early in life. In addition, there is a lack of conclusive evidence regarding the role of dietary nutrients on IR. The Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study (HELENA-CSS) was conducted in European adolescents aged 12·5–17·5 years. A total of 637 participants with valid homeostasis model assessment (HOMA) index data and who completed at least a 2 d 24 h dietary recall were included in the study (60 % of the total HELENA-CSS sample). There were two dietary indices calculated, with the only difference between them being the inclusion or not of physical activity (PA). Markers of IR such as HOMA and the quantitative insulin sensitivity check index (QUICKI) were calculated. Pubertal status, BMI and cardiorespiratory fitness (CRF) were measured as potential confounders. The dietary index including PA was inversely associated with HOMA and directly with the QUICKI in females, but not in males, after adjusting for pubertal status, centre, BMI and CRF. In conclusion, the present study indicates that considering PA as part of the dietary index is of relevance as the resulted index is inversely related to IR independently of potential confounders including CRF. Overall, these findings suggest that intervention studies aimed at preventing IR in young people should focus on increasing the quality of the diet and also on including an optimal PA level in healthy adolescents.
To record the prevalence of overweight and obesity in urban primary-school children in relation to several socio-economic and demographic factors.
A representative sample of 729 schoolchildren (379 male and 350 female), aged 9–13 years, stratified by parental educational level, was examined in the urban region of Athens. Weight and height were measured using standard procedures. The International Obesity Task Force thresholds were used for the definition of overweight and obesity. Several socio-economic and demographic data and the child’s ‘popularity’ score were also recorded with specifically designed standardized questionnaires.
The prevalence of overweight and obesity was 29·6 % and 11·1 %, respectively. Annual family income of €12 000–20 000 (OR = 1·58), residence ownership (OR = 1·63) and the grandmother as the child’s primary caregiver (OR = 1·38) were significantly associated with higher odds of childhood overweight and obesity. Non-Greek parental nationality (OR = 0·72) and higher ‘popularity’ scores of children (OR = 0·42) were significantly associated with lower odds of overweight and obesity. The grandmother as the child’s primary caregiver and an annual family income of €12 000–20 000 remained significantly associated with childhood overweight and obesity after adding all significant correlates of childhood overweight and obesity observed at the bivariate level in a multivariate regression model (OR = 1·51 and 1·61, respectively).
Among family income, residence ownership, child’s primary caregiver, parental nationality and popularity scores that were identified as significant correlates of childhood overweight and obesity at the bivariate level, lower family income and grandmother as the child’s primary caregiver were the only factors that remained significantly associated with childhood overweight and obesity at a multivariate level.
To develop an index that assesses the degree of adherence to existing diet–lifestyle recommendations for preschoolers (Preschoolers Diet–Lifestyle Index (PDL-Index)) and to investigate its association with obesity.
The PDL-Index was constructed using eleven components (i.e. questions regarding the frequency of consumption of selected foods/food groups, time spent on television watching and on moderate-to-vigorous physical activities).
Scores from 0 to 4 were assigned to all components of the index. The PDL-Index total score ranged from 0 to 44. Higher values of the PDL-Index indicate greater adherence to dietary and lifestyle recommendations for preschoolers or otherwise greater adherence to healthier dietary–lifestyle patterns.
As a validation procedure, a sample of 2287 preschoolers from Greece (GENESIS study) was used.
The participants following healthier diet–lifestyle patterns (third tertile of PDL-Index) were less likely to be obese or overweight/obese compared to those following unhealthy diet–lifestyle patterns (first tertile of PDL-Index). It was observed that a 1/44 unit increase in the score of the PDL-Index was associated with approximately 5 % and 3 % lower odds of being obese and overweight/obese, respectively. Statistically significant results were observed after adjusting for potential confounders.
The suggested PDL-Index could help public health policy makers in identifying vulnerable population subgroups and developing cost-effective, targeted intervention actions both in family and preschool settings. In addition, health-care professionals can use the PDL-Index to evaluate diet quality, lifestyle and risk for overweight/obesity at an individual level and counsel parents accordingly.
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