A system dynamics approach to understand Dutch adolescents' sleep health using a causal loop diagram.

BACKGROUND: Healthy sleep is crucial for the physical and mental wellbeing of adolescents. However, many adolescents suffer from poor sleep health. Little is known about how to effectively improve adolescent sleep health as it is shaped by a complex adaptive system of many interacting factors. This study aims to provide insights into the system dynamics underlying adolescent sleep health and to identify impactful leverage points for sleep health promotion interventions. METHODS: Three rounds of single-actor workshops, applying Group Model Building techniques, were held with adolescents (n = 23, 12-15 years), parents (n = 14) and relevant professionals (n = 26). The workshops resulted in a multi-actor Causal Loop Diagram (CLD) visualizing the system dynamics underlying adolescent sleep health. This CLD was supplemented with evidence from the literature. Subsystems, feedback loops and underlying causal mechanisms were identified to understand overarching system dynamics. Potential leverage points for action were identified applying the Action Scales Model (ASM). RESULTS: The resulting CLD comprised six subsystems around the following themes: (1) School environment; (2) Mental wellbeing; (3) Digital environment; (4) Family & Home environment; (5) Health behaviors & Leisure activities; (6) Personal system. Within and between these subsystems, 16 reinforcing and 7 balancing feedback loops were identified. Approximately 60 potential leverage points on different levels of the system were identified as well. CONCLUSIONS: The multi-actor CLD and identified system dynamics illustrate the complexity of adolescent sleep health and supports the need for developing a coherent package of activities targeting different leverage points at all system levels to induce system change.

Do financial constraint and perceived stress modify the effects of food tax schemes on food purchases: moderation analyses in a virtual supermarket experiment.

OBJECTIVE: To investigate whether financial constraint and perceived stress modify the effects of food-related taxes on the healthiness of food purchases. DESIGN: Moderation analyses were conducted with data from a trial where participants were randomly exposed to: a control condition with regular food prices, an sugar-sweetened beverage (SSB) tax condition with a two-tiered levy on the sugar content in SSB (5-8 g/100 ml: €0·21 per l and ≥8 g/100 ml: €0·28 per l) or a nutrient profiling tax condition where products with Nutri-Score D or E were taxed at a 20 percent level. Outcome measures were overall healthiness of food purchases (%), energy content (kcal) and SSB purchases (litres). Effect modification was analysed by adding interaction terms between conditions and self-reported financial constraint or perceived stress in regression models. Outcomes for each combination of condition and level of effect modifier were visualised. SETTING: Virtual supermarket. PARTICIPANTS: Dutch adults (n 386). RESULTS: Financial constraint or perceived stress did not significantly modify the effects of food-related taxes on the outcomes. Descriptive analyses suggest that in the control condition, the overall healthiness of food purchases was lowest, and SSB purchases were highest among those with moderate/high levels of financial constraint. Compared with the control condition, in a nutrient profiling tax condition, the overall healthiness of food purchases was higher and SSB purchases were lower, especially among those with moderate/high levels of financial constraint. Such patterns were not observed for perceived stress. CONCLUSION: Further studies with larger samples are recommended to assess whether food-related taxes differentially affect food purchases of subgroups.

Development of an action programme tackling obesity-related behaviours in adolescents: a participatory system dynamics approach.

System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10-14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system's structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice.

The effects of a sugar-sweetened beverage tax and a nutrient profiling tax based on Nutri-Score on consumer food purchases in a virtual supermarket: a randomised controlled trial.

OBJECTIVE: To investigate the effects of a sugar-sweetened beverage (SSB) tax and a nutrient profiling tax on consumer food purchases in a virtual supermarket. DESIGN: A randomised controlled trial was conducted with a control condition with regular food prices (n 152), an SSB tax condition (n 130) and a nutrient profiling tax condition based on Nutri-Score (n 112). Participants completed a weekly grocery shop for their household. Primary outcome measures were SSB purchases (ordinal variable) and the overall healthiness of the total shopping basket (proportion of total unit food items classified as healthy). The secondary outcome measure was the energy (kcal) content of the total shopping basket. Data were analysed using regression analyses. SETTING: Three-dimensional virtual supermarket. PARTICIPANTS: Dutch adults aged ≥18 years are being responsible for grocery shopping in their household (n 394). RESULTS: The SSB tax (OR = 1·62, (95 % CI 1·03, 2·54)) and the nutrient profiling tax (OR = 1·88, (95 %CI 1·17, 3·02)) increased the likelihood of being in a lower-level category of SSB purchases. The overall healthiness of the total shopping basket was higher (+2·7 percent point, (95 % CI 0·1, 5·3)), and the energy content was lower (-3301 kcal, (95 % CI -6425, -177)) for participants in the nutrient profiling tax condition than for those in the control condition. The SSB tax did not affect the overall healthiness and energy content of the total shopping basket (P > 0·05). CONCLUSIONS: A nutrient profiling tax targeting a wide range of foods and beverages with a low nutritional quality seems to have larger beneficial effects on consumer food purchases than taxation of SSB alone.

Perceptions of employees with a low and medium level of education towards workplace health promotion programmes: a mixed-methods study.

BACKGROUND: Understanding the perceptions of lower socioeconomic groups towards workplace health promotion is important because they are underrepresented in workplace health promotion activities and generally engage in unhealthier lifestyle behaviour than high SEP groups. This study aims to explore interest in workplace health promotion programmes (WHPPs) among employees with a low and medium level of education regarding participation and desired programme characteristics (i.e. the employer's role, the source, the channel, the involvement of the social environment and conditions of participation). METHODS: A mixed-methods design was used, consisting of a questionnaire study (n = 475) and a sequential focus group study (n = 27) to enrich the questionnaire's results. Multiple logistic regression analysis was performed to analyse the associations between subgroups (i.e. demographics, weight status) and interest in a WHPP. The focus group data were analysed deductively through thematic analysis, using MAXQDA 2018 for qualitative data analysis. RESULTS: The questionnaire study showed that 36.8% of respondents were interested in an employer-provided WHPP, while 45.1% expressed no interest. Regarding subgroup differences, respondents with a low level of education were less likely to express interest in a WHPP than those with a medium level of education (OR = .54, 95%, CI = .35-.85). No significant differences were found concerning gender, age and weight status. The overall themes discussed in the focus groups were similar to the questionnaires (i.e. the employer's role, the source, the channel, the involvement of the social environment and conditions of participation). The qualitative data showed that participants' perceptions were often related to their jobs and working conditions. CONCLUSIONS: Employees with a medium level of education were more inclined to be interested in a WHPP than those with a low level of education. Focus groups suggested preferences varied depending on job type and related tasks. Recommendations are to allow WHPP design to adapt to this variation and facilitate flexible participation. Future research investigating employers' perceptions of WHPPs is needed to enable a mutual understanding of an effective programme design, possibly contributing to sustainable WHPP implementation.

Stakeholder views on taxation of sugar-sweetened beverages and its adoption in the Netherlands.

An increasing number of governments worldwide have introduced a tax on sugar-sweetened beverages (SSB) for public health. However, the adoption of such a policy is still debated in many other countries, such as in the Netherlands. We investigated Dutch stakeholder views on taxation of SSB and perceived barriers and facilitators to its adoption in the Netherlands. Semi-structured interviews were conducted in 2019 with 27 stakeholders from health and consumer organizations, health professional associations, trade associations, academia, advisory bodies, ministries and parliamentary parties. Data were analysed using a thematic content approach. The findings reveal that, between and within sectors, stakeholders expressed contradictory views on the effectiveness, appropriateness and (socio)economic effects of an SSB tax. Perceived barriers to the adoption of an SSB tax in the Netherlands included an unfavourable political context, limited advocacy for an SSB tax, a strong lobby against an SSB tax, perceived public opposition, administrative load and difficulties in defining SSB. Perceived facilitators to its adoption included an increasing prevalence of overweight, disappointing results from voluntary industry actions, a change of government, state budget deficits, a shift in public opinion, international recommendations and a solid legal basis. In conclusion, this study shows that several challenges remain to be overcome for the adoption of an SSB tax in the Netherlands. Similar research on stakeholder views in other countries may further inform SSB tax policy processes.

Public acceptability of a sugar-sweetened beverage tax and its associated factors in the Netherlands.

OBJECTIVE: To investigate the level of public acceptability of a sugar-sweetened beverage (SSB) tax and its associated factors. DESIGN: Participants completed an online self-administered questionnaire. Acceptability of an SSB tax was measured on a seven-point Likert scale (strongly disagree to strongly agree). Associations between acceptability and sociodemographic factors, weight status, SSB consumption and beliefs about effectiveness (e.g., 'An SSB tax would reduce people's SSB consumption'), appropriateness, socioeconomic and economic benefit, implementation and trust were assessed using multivariable linear regression analyses. SETTING: The Netherlands. PARTICIPANTS: Dutch adults aged ≥18 years representative of the Dutch population for age, sex, education level and location (n 500). RESULTS: Of the participants, 40 % supported and 43 % opposed an SSB tax in general. Moreover, 42 % supported (43 % opposed) an SSB tax as a strategy to reduce overweight, and 55 % supported (32 % opposed) an SSB tax if revenue is used for health initiatives. Participants with a low education level (B = -0·82, 95 % CI -1·31, -0·32), overweight (B = -0·49, 95 % CI -0·89, -0·09), moderate or high SSB consumption (B = -0·86, 95 % CI -1·30, -0·43 and B = -1·01, 95 % CI -1·47, -0·56, respectively) and households with adolescents (B = -0·57, 95 % CI -1·09, -0·05) reported a lower acceptability of an SSB tax than their counterparts. Beliefs about effectiveness, appropriateness, socioeconomic and economic benefit, implementation and trust were associated with acceptability (P < 0·001). CONCLUSIONS: Public acceptability of an SSB tax tends to be higher if revenue is used for health initiatives. The factors associated with acceptability should be taken into consideration.

Food and health promotion literacy among employees with a low and medium level of education in the Netherlands.

BACKGROUND: Prior research indicates a positive association between socioeconomic position and health literacy levels. We hypothesize comparable socioeconomic gradients for food literacy. This study aims to determine the level of self-perceived food literacy and health promotion literacy among adults with a low and medium level of education and from various subgroups, as well as the association between these food and health literacy levels. Furthermore, this study aims to explore the associations of self-perceived food literacy (SPFL) and health promotion literacy (HPL) in BMI. METHODS: A cross-sectional study was conducted among employees with a low and medium level of education. Descriptive analyses were performed to compute SPFL and HPL levels. Analyses of variance were performed to test differences between subgroups. The correlation between SPFL and HPL was computed by Pearson's r. Multivariate linear regression analyses were used to explore 1) the association between SPFL and HPL adjusted for demographic characteristics 2) the associations between SPFL and HPL in BMI. RESULTS: The majority (63.1%) of all participants (n = 222) scored low on SPFL and 34.5% scored inadequate or problematic on HPL. No significant educational or weight-status differences were found in SPFL or HPL levels. On most levels, women compared to men and older compared to younger employees scored significantly higher. A small positive correlation between the two mean levels was found, r = .25, P < .001 (n = 203). Multivariate linear regression analyses showed a significant association between SPFL and HPL (B = .31, 95% CI = .15-.48). No significant associations between SPFL and HPL in BMI were found. CONCLUSIONS: This study suggests there is room for improvement in SPFL and HPL among adults with a low and medium level of education. Future research should consider comparing low and middle socioeconomic with high socioeconomic groups when exploring food and health literacy. Regarding health promotion activities for adults with a low and medium level of education, it is recommended to focus on improving both food and health literacy. Furthermore, more research is needed to explore direct proxies of weight-status to better understand the role of food and health literacy in overweight patterns.

Predictors of Changes in Sleep Duration in Dutch Primary Schoolchildren: the ChecKid Study.

BACKGROUND: Healthy sleep duration is essential to health and well-being in childhood and later life. Unfortunately, recent evidence shows a decline in sleep duration among children. Although effective interventions promoting healthy sleep duration require insight into its predictors, data on these factors are scarce. This study therefore investigated (i) which individual (lifestyle), social and cultural factors, and living conditions and (ii) which changes in these factors might be associated with the changes in sleep duration of Dutch primary schoolchildren observed over time. METHOD: Data from the ChecKid study was used, a dynamic cohort study among 4-13-year-old children living in the city of Zwolle, the Netherlands. Associations between changes in sleep duration and individual (lifestyle) factors (i.e., age, sex, physical activity behavior, sugar-sweetened beverage consumption, screen behavior), social and cultural factors (i.e., parental rules, ethnicity), and living conditions (i.e., parental education, presence of screens in the bedroom, household size) were analyzed using multivariable linear regression. RESULTS: A total of 1180 children participated, aged 6.6 ± 1.4 years in 2009. Mean sleep duration decreased from 11.4 ± 0.5 h/night in 2009 to 11.0 ± 0.5 h/night in 2012. Older children, boys, children who used screens after dinner, children with greater computer/game console use, and children whose parents had low levels of education had a greater decrease in sleep duration. CONCLUSIONS: This article reports on one of the first large, longitudinal cohort studies on predictors of child sleep duration. The results of the study can inform future interventions aimed at promoting healthy sleep in primary schoolchildren.

Children's Attention-Deficit/Hyperactivity Disorder Symptoms Predict Lower Diet Quality but Not Vice Versa: Results from Bidirectional Analyses in a Population-Based Cohort.

BACKGROUND: As an adjuvant for medication, dietary changes focused on specific nutrients have been proposed to prevent or reduce attention-deficit/hyperactivity disorder (ADHD) symptoms. However, whether an overall healthy dietary pattern is associated with ADHD symptom severity during childhood remains unclear. Furthermore, it is not clear what the direction of this association is. OBJECTIVES: We aimed to examine the association between dietary patterns and ADHD symptoms in school-aged children. In addition, we aimed to identify the temporal direction of this association-that is, whether dietary patterns predict ADHD symptoms or vice versa. METHODS: We analyzed data from 3680 children participating in the Generation R Study, a prospective cohort in Rotterdam, Netherlands. ADHD symptoms were assessed with parent-report questionnaires at ages 6 and 10 y using the Child Behavior Checklist. Dietary intake was assessed at the age of 8 y with a validated food-frequency questionnaire. We computed a diet quality score reflecting adherence to dietary guidelines. We examined bidirectional associations of diet quality with ADHD symptom scores using multivariable linear regression analysis and cross-lagged modeling. RESULTS: Linear regressions showed that more ADHD symptoms at age 6 y were associated with a lower diet quality score at age 8 y (SD score = -0.08; 95% CI: -0.11, -0.05) but that diet quality at age 8 y was not associated with ADHD symptoms at age 10 y. Cross-lagged models confirmed a unidirectional relation from ADHD symptoms to diet quality but not vice versa. Associations did not differ by overweight status or between boys and girls. CONCLUSION: Our study suggests that children with more ADHD symptoms may be at higher risk of an unhealthy diet but that overall diet quality does not affect ADHD risk.

Political and public acceptability of a sugar-sweetened beverages tax: a mixed-method systematic review and meta-analysis.

BACKGROUND: Taxation of sugar-sweetened beverages (SSBs), as a component of a comprehensive strategy, has emerged as an apparent effective intervention to counteract the rising prevalence of overweight and obesity. Insight into the political and public acceptability may help adoption and implementation in countries with governments that are considering an SSBs tax. Hence, we aimed to conduct a systematic review and meta-analysis to synthesize the existing qualitative and quantitative literature on political and public acceptability of an SSBs tax. METHODS: Four electronic databases (PubMed, Embase, Scopus, Web of Science) were searched until November 2018. The methodological quality of the included studies was assessed using the Mixed Methods Appraisal Tool. Qualitative studies were analyzed using a thematic synthesis. Quantitative studies were analyzed using a random-effects meta-analysis for the pooling of proportions. RESULTS: Thirty-seven articles reporting on forty studies were eligible for inclusion. Five themes derived from the thematic synthesis: (i) beliefs about effectiveness and cost-effectiveness, (ii) appropriateness, (iii) economic and socioeconomic benefit, (iv) policy adoption and implementation, and (v) public mistrust of the industry, government and public health experts. Results of the meta-analysis indicated that of the public 42% (95% CI = 0.38-0.47) supports an SSBs tax, 39% (0.29-0.50) supports an SSBs tax as a strategy to reduce obesity, and 66% (0.60-0.72) supports an SSBs tax if revenue is used for health initiatives. CONCLUSIONS: Beliefs about effectiveness and cost-effectiveness, appropriateness, economic and socioeconomic benefit, policy adoption and implementation, and public mistrust of the industry, government and public health experts have important implications for the political and public acceptability of an SSBs tax. We provide recommendations to increase acceptability and enhance successful adoption and implementation of an SSBs tax: (i) address inconsistencies between identified beliefs and scientific literature, (ii) use raised revenue for health initiatives, (iii) communicate transparently about the true purpose of the tax, and (iv) generate political priority for solutions to the challenges to implementation.

The explanatory role of maternal feeding practices: do they explain ethnic differences in body weight of preadolescents?

INTRODUCTION: This study aimed to explore the role of ethnicity and maternal perceived weight status in the association between maternal child feeding practices and childhood Body Mass Index (BMI) at the age of 11-12 years in a multi-ethnic population. METHODS: We collected data on child feeding practices by the validated Child Feeding Questionnaire (CFQ) among 2398 mothers of adolescents (Mage = 11.2, SDage = 0.6). Multivariate linear analyses were used to determine the cross-sectional association between child feeding practices ('Restriction', 'Pressure to eat', and 'Monitoring'), maternal perception of child's weight status, SDS-BMI, and ethnicity. RESULTS: 'Restriction' (ß = 0.16; 95% CI [0.11; 0.20]) and 'Pressure to eat' (ß = -0.32 [-0.36;-0.28]) were significantly associated with child SDS-BMI. Both associations were strongly influenced by the mother's perception of child's weight status. Besides, non-native Dutch mothers performed significantly higher levels of 'Restriction' (M±SD = 12.17 ±â€¯4.41) and 'Pressure to eat' (10.75 ±â€¯4.03) compared to native Dutch mothers (11.25 ±â€¯4.15 and 9.99 ±â€¯3.83, respectively). Native Dutch mothers performed higher levels of 'Monitoring' (17.15 ±â€¯2.54) compared to non-native Dutch mothers (16.73 ±â€¯3.01). Furthermore, children of non-native Dutch mothers had a 0.15 (0.27; 0.46) higher SDS-BMI. Finally, results showed that the association between 'Pressure to eat' and SDS-BMI was stronger in native Dutch mothers (ß = -0.20; 95% CI [-0.24; -0.15]) compared to non-native Dutch mothers (ß = -0.11; 95% CI [-0.18; -0.04]). DISCUSSION AND CONCLUSION: Ethnic differences in childhood BMI seemed to be partially attributable to the maternal perception of her child's weight status. Besides, maternal perception of child's weight appeared to play an important role in the association between maternal child feeding practices and childhood SDS-BMI. Hence, our findings contribute to the growing evidence concerning the bi-directional association between child feeding practices and childhood BMI.

Parental physical activity is associated with objectively measured physical activity in young children in a sex-specific manner: the GECKO Drenthe cohort.

BACKGROUND: Physical activity (PA) is important in combating childhood obesity. Parents, and thus parental PA, could influence PA in young children. We examined whether the time spent at different intensities of PA and the type of parental PA are associated with the PA of children aged 4-7 years, and whether the associations between child-parent pairs were sex-specific. METHODS: All the participants were recruited from the Groningen Expert Center for Kids with Obesity (GECKO) birth cohort (babies born between 1 April 2006 and 1 April 2007 in Drenthe province, the Netherlands) and were aged 4-7 years during measurement. PA in children was measured using the ActiGraph GT3X (worn at least 3 days, ≥10 h per day). PA in parents was assessed using the validated SQUASH questionnaire. RESULTS: Of the N = 1146 children with valid ActiGraph data and 838 mothers and 814 fathers with valid questionnaire data, 623 child-parent pairs with complete data were analysed. More leisure time PA in mothers was associated with more time spent in moderate-to-vigorous PA (MVPA) in children (Spearman r = 0.079, P < .05). Maternal PA was significantly related to PA in girls, but not boys. More time spent in maternal vigorous PA, in sports activity, and leisure time PA, were all related to higher MVPA in girls (Spearman r = 0.159, r = 0.133 and r = 0.127 respectively, Pall < .05). In fathers, PA levels were predominantly related to PA in sons. High MVPA in fathers was also related to high MVPA in sons (r = 0.132, P < 0.5). Spending more time in light PA was related to more sedentary time and less time in MVPA in sons. CONCLUSIONS: Higher PA in mothers, for instance in leisure activities, is related to higher PA in daughters, and more active fathers are related to more active sons. To support PA in young children, interventions could focus on the PA of the parent of the same sex as the child. Special attention may be needed for families where the parents have sedentary jobs, as children from these families seem to adopt more sedentary behaviour.

Parental feeding styles, young children's fruit, vegetable, water and sugar-sweetened beverage consumption, and the moderating role of maternal education and ethnic background.

OBJECTIVE: To examine the associations between parental feeding styles and children's dietary intakes and the modifying effect of maternal education and children's ethnicity on these associations. DESIGN: Cross-sectional study of parental feeding styles, assessed by the Parental Feeding Style Questionnaire, and children's dietary intakes. Multiple regression analyses were carried out to assess the associations between the parental feeding styles studied ('control', 'emotional feeding', 'encouragement to eat' and 'instrumental feeding') and children's dietary intakes (consumption of fruit, vegetables, water and sugar-sweetened beverages (SSB)). The modifying effect of maternal education and children's ethnicity on these associations was explored. SETTING: North-western part of the Netherlands. SUBJECTS: Children aged 3-7 years (n 5926). RESULTS: Both 'encouragement' and 'control' were associated with higher consumption of vegetables and lower consumption of SSB, but only 'encouragement' was positively associated with fruit and water intakes. 'Instrumental feeding' showed a positive association with SSB and negative associations with fruit, vegetable and water consumption. No significant associations were found for 'emotional feeding'. Maternal educational level and children's ethnicity moderated some associations; for example, 'control' was beneficial for vegetable intake in all subgroups, whereas the association with SSB was beneficial only in highly educated mothers. CONCLUSIONS: The study shows that both encouraging and controlling feeding styles may improve children's dietary behaviour, while 'instrumental feeding' may have a detrimental effect. Furthermore, maternal educational level and children's ethnicity influence these associations. The study's findings could provide a basis for development of interventions to improve parental feeding styles.

Inequalities in energy-balance related behaviours and family environmental determinants in European children: changes and sustainability within the EPHE evaluation study.

BACKGROUND: Increasing social inequalities in health across Europe are widening the gap between low and high socio-economic groups, notably in the prevalence of obesity. Public health interventions may result in differential effects across population groups. Therefore, the EPHE (EPODE for the Promotion of Health Equity) project analysed the added value of community-based programmes, based on the EPODE (Ensemble Prévenons l'Obésité Des Enfants-Together Let's Prevent Obesity) model, to reduce socio-economic inequalities in energy balance-related behaviours of children and their family-environmental related determinants in seven European communities. This study presents the changes between baseline and follow-up after the one-year interventions and their sustainability one year after. METHODS: This is a prospective study with a one school-year intervention, followed by one year of follow-up. In all, 1266 children (age 6-8 years) and their families from different socio-economic backgrounds were recruited at baseline. For 1062 children, information was available after one year (T1) and for 921 children after two years (T2). A self-reported questionnaire was completed by the parents to examine the children's energy balance-related behaviours and family- environmental determinants. Socio-economic status was defined by the educational level of the mother. The Wilcoxon signed-rank test for paired data was used to test the differences between baseline and intermediate, and between intermediate and final, measurements for each of the socio-economic status groups. RESULTS: Post-intervention effects in energy-balance related behaviours showed the following improvements among the low socio-economic status groups: increased fruit consumption (Netherlands), decreased fruit juices amount consumed (Romania) and decreased TV time on weekdays (Belgium). Whereas in only the latter case the behavioural change was accompanied with an improvement in a family-environmental determinant (monitoring the time the child watches TV), other improvements in parental rules and practices related to soft drinks/fruit juices and TV exposure were observed. A few of those effects were sustainable, notably in the case of Belgium. CONCLUSIONS: Inequalities in obesity-related behaviours could be potentially reduced when implementing community-based interventions, tailored to inequality gaps and using the EPODE methodology. Within-group changes varied widely, whereas monitoring of interventions and process evaluation are crucial to understand the observed results.

Fatty acid composition in breastfeeding and school performance in children aged 12 years.

PURPOSE: Breastfeeding has been associated with improved cognition. It remains unclear whether long-chain polyunsaturated fatty acids (LC-PUFAs) play a role in this association. We assessed the association between LC-PUFA concentrations in infant feeding and school performance at age 12. METHODS: Within a population-based birth cohort, we compared school performance of 277 non-breastfed children and 157 children who had fatty acid composition of their mothers' breast milk measured. Two indicators of school performance were: (1) the score on a standardized achievement test and (2) the teacher's advice regarding a child's potential performance level in secondary education. Linear regression and multinomial logistic regression analyses were performed to assess the independent association between LC-PUFA content of breast milk and school performance. RESULTS: Girls, who received breast milk with a relative high content (above the median) of docosahexaenoic acid (DHA), had a higher Cito-test score (ß = 2.96 points, 95 % CI 0.24; 5.69) than non-breastfed girls. Among the breastfed girls, each percentage point of higher content of total n-3 LC-PUFA (ß = 4.55, 95 % CI 0.43; 8.66) and DHA (ß = 7.09, 95 % CI 0.9; 13.3) was associated with a higher Cito-test score. The association between LC-PUFA content and teacher school advice showed a similar pattern. There was no association between LC-PUFA content and school performance in boys. CONCLUSION: Although a large part of the association between infant milk feeding and cognition seems to be explained by sociodemographic and lifestyle-related factors, a relative high content of n-3 PUFAs, especially DHA, in breast milk is associated with better school performance in 12-year-old girls but not in boys.

Identifying developmental trajectories of body mass index in childhood using latent class growth (mixture) modelling: associations with dietary, sedentary and physical activity behaviors: a longitudinal study.

BACKGROUND: To date, many epidemiologic studies examining associations between obesity and dietary and sedentary/physical activity behaviors have focused on assessing Body Mass Index (BMI) at one point in time. Recent developments in statistical techniques make it possible to study the potential heterogeneity in the development of BMI during childhood by identifying distinct subpopulations characterized by distinct developmental trajectories. Using Latent Class Growth (Mixture) Modelling (LCGMM) techniques we aimed to identify BMI trajectories in childhood and to examine associations between these distinct trajectories and dietary, sedentary and physical activity behaviors. METHODS: This longitudinal study explored BMI standard deviation score (SDS) trajectories in a sample of 613 children from 4 to 12 years of age. In 2006, 2009 and 2012 information on children's health related behaviors was obtained by parental questionnaires, and children's height and weight were measured. Associations with behaviors were investigated with logistic regression models. RESULTS: We identified two BMI SDS trajectories; a decreasing BMI SDS trajectory (n = 416; 68 %) and an increasing BMI SDS trajectory (n = 197; 32 %). The increasing BMI SDS trajectory consisted of more participants of lower socio-economic status (SES) and of non-western ethnicity. Maternal overweight status was associated with being in the increasing BMI SDS trajectory at both baseline and follow-up six years later (2006: Odds Ratio (OR), 2.9; 95 % confidence interval (CI) 1.9 to 4.3; 2012 OR, 1.8; 95 % CI 1.2 to 2.6). The increasing BMI SDS trajectory was associated with the following behaviors; drinking sugared drinks > 3 glasses per day, participation in organized sports < 1 h per week, and TV viewing > 2 h per day, though participation in organized sports at follow-up was the only significant result. CONCLUSIONS: Our results indicate the importance of healthy lifestyle behaviors at a young age, and indicate that maternal BMI is a very important risk factor for the development of childhood overweight. Comprehension of heterogeneity in the development of BMI and associations with modifiable health related behaviors is interesting for prevention by targeting high risk behaviors in early childhood, especially in low SES children, children of non-western ethnicity and children whose mother is overweight.

One-year effects of two intensive inpatient treatments for severely obese children and adolescents.

BACKGROUND: Intensive inpatient lifestyle treatment may be a suitable alternative for severely obese children and adolescents who do not benefit from ambulatory obesity treatment. The aim was to evaluate the effectiveness of two intensive one-year lifestyle treatments with varying inpatient periods for severely obese children and adolescents with regard to SDS-BMI and cardiometabolic risk factors. METHODS: The study was designed as a randomized controlled trial with two active treatment groups. Eighty participants (8-19 years) with severe obesity received treatment at a specialized childhood obesity center in the Netherlands. Severe obesity was defined as a SDS-BMI ≥ 3.0 or a SDS-BMI ≥ 2.3 in combination with obesity-related comorbidity. Participants received an intensive one-year lifestyle treatment with an inpatient period of either two months and biweekly return visits during the next four months (short-stay group) or six months (long-stay group), both followed by six monthly return visits. Outcomes were assessed at baseline, six and 12 months and included SDS-BMI as primary outcome and cardiometabolic risk factors such as SDS-waist circumference, systolic- and diastolic blood pressure, and blood measurements as secondary outcomes. To evaluate differences in the course of the primary- and secondary outcomes over time between the two treatment groups, Generalized Estimating Equations (GEE) were performed. RESULTS: No differences in the course of SDS-BMI or secondary outcomes over time were found between the two treatment groups after one year of treatment. SDS-BMI decreased statistically significantly after one year of treatment compared with baseline in both groups (0.33 (0.48) in the short-stay and 0.52 (0.49) in the long-stay group). Similar results were found for SDS-waist circumference, diastolic blood pressure and HDL-cholesterol. CONCLUSIONS: Since there were no significant differences in effects between the short- and long-stay treatment and considering the burden of the long-stay treatment for children and families, we recommend implementation of the short-stay treatment. TRIAL REGISTRATION: Netherlands Trial Register NTR1678 , registered 20-Feb-2009.

Weight fluctuation during childhood and cardiometabolic risk at young adulthood.

OBJECTIVES: To test the hypothesis that greater weight fluctuation between 2 and 6 years is associated with an increase in weight measures (such as body mass index [BMI]) and cardiometabolic risk in young adulthood. STUDY DESIGN: Weight fluctuation (determined by BMI SD scores) was measured at least 3 times between the ages of 2 and 6 years in 166 girls and 116 boys from the Terneuzen Birth Cohort. Cardiometabolic risk factors in young adulthood include components of the metabolic syndrome and weight. The extent of weight fluctuation was determined by assessing each individual's SE (or variation) around each individual's linear regression slope (or weight slope). The obtained variation scores were subsequently related to adult BMI, other weight measures, and cardiometabolic risk factors. RESULTS: In girls, greater weight fluctuation between 2 and 6 years was statistically significantly related to greater adult weight measures (1.08; 95% CI 1.01-1.15) and nonsignificantly with the metabolic syndrome. For boys weight fluctuation was not associated with adult weight (1.04; 95% CI 0.97-1.11), but weight slope was statistically significantly associated with adult overweight. CONCLUSIONS: The results suggest that weight fluctuations during early childhood are predictive for adult overweight in girls. For boys weight slope instead of weight fluctuation is predictive for adult overweight.

Providing personal informal care to older European adults: should we care about the caregivers' health?

OBJECTIVE: In Europe, the demand for informal care is high and will increase because of the ageing population. Although caregiving is intended to contribute to the care recipient's health, its effects on the health of older European caregivers are not yet clear. This study explores the association between providing informal personal care and the caregivers' health. METHOD: Data were used from the longitudinal cohort (2004/2005-2010/2011) of the Survey of Health, Ageing and Retirement in Europe (SHARE) (n=7858). Generalized estimating equations were used to explore the longitudinal association of informal care and the caregiver's health using poor self-rated health (less than good), poor mental health (EURO-D score for depression ≥4), and poor physical health (≥2 health complaints). RESULTS: Providing informal personal care was significantly associated with poor mental health (OR=1.23, 95% CI=1.04-1.47) and poor physical health (OR=1.18, 95% CI=1.01-1.38), after adjusting for various socio-demographic and health-related factors. No statistical significant association was found for self-rated health in the adjusted models. CONCLUSION: Providing informal personal care may negatively influence the caregiver's mental and physical health. More awareness of the beneficial and detrimental effects of caregiving among policy makers is needed to make well-informed decisions concerning the growth of care demands in the ageing population.