Effectiveness of the mHealth intervention 'MyDayPlan' to increase physical activity: an aggregated single case approach.

BACKGROUND: e- and mHealth interventions using self-regulation techniques like action and coping planning have the potential to tackle the worldwide problem of physical inactivity. However, they often use one-week self-regulation cycles, providing support toward an active lifestyle on a weekly basis. This may be too long to anticipate on certain contextual factors that may fluctuate from day to day and may influence physical activity. Consequently, the formulated action and coping plans often lack specificity and instrumentality, which may decrease effectiveness of the intervention. The aim of this study was to evaluate effectiveness of a self-regulation, app-based intervention called 'MyDayPlan'. "MyDayPlan' provides an innovative daily cycle in which users are guided towards more physical activity via self-regulation techniques such as goal setting, action planning, coping planning and self-monitoring of behaviour. METHODS: An ABAB single-case design was conducted in 35 inactive adults between 18 and 58 years (M = 40 years). The A phases (A1 and A2) were the control phases in which the 'MyDayPlan' intervention was not provided. The B phases (B1 and B2) were the intervention phases in which 'MyDayPlan' was used on a daily basis. The length of the four phases varied within and between the participants. Each phase lasted a minimum of 5 days and the total study lasted 32 days for each participant. Participants wore a Fitbit activity tracker during waking hours to assess number of daily steps as an outcome. Single cases were aggregated and data were analysed using multilevel models to test intervention effects and possible carry-over effects. RESULTS: Results showed an average intervention effect with a significant increase in number of daily steps from the control to intervention phases for each AB combination. From A1 to B1, an increase of 1424 steps (95% CI [775.42, 2072.32], t (1082) = 4.31,p < .001), and from A2 to B2, an increase of 1181 steps (95% CI [392.98, 1968.16], t (1082) = 2.94, p = .003) were found. Furthermore, the number of daily steps decreased significantly (1134 steps) when going from the first intervention phase (B1) to the second control phase (A2) (95% CI [- 1755.60, - 512.38], t (1082) = - 3.58, p < .001). We found no evidence for a difference in trend between the two control (95% CI [- 114.59, 197.99], t (1078) = .52, p = .60) and intervention phases (95% CI [- 128.79,284.22], t (1078) = .74, p = .46). This reveals, in contrast to what was hypothesized, no evidence for a carry-over effect after removing the 'MyDayPlan' app after the first intervention phase (B1). CONCLUSION: This study adds evidence that the self-regulation mHealth intervention, 'MyDayPlan' has the capacity to positively influence physical activity levels in an inactive adult population. Furthermore, this study provides evidence for the potential of interventions adopting a daily self-regulation cycle in general.

Content validity and methodological considerations in ecological momentary assessment studies on physical activity and sedentary behaviour: a systematic review.

BACKGROUND: Ecological momentary assessment (EMA) is a method of collecting real-time data based on repeated measures and observations that take place in participant's daily environment. EMA has many advantages over more traditional, retrospective questionnaires. However, EMA faces some challenges to reach its full potential. The aims of this systematic review are to (1) investigate whether and how content validity of the items (i.e. the specific questions that are part of a larger EMA questionnaire) used in EMA studies on physical activity and sedentary behaviour was assessed, and (2) provide an overview of important methodological considerations of EMA in measuring physical activity and sedentary behaviour. METHODS: Thirty papers (twenty unique studies) were systematically reviewed and variables were coded and analysed within the following 4 domains: (1) Content validity, (2) Sampling approach, (3) Data input modalities and (4) Degree of EMA completion. RESULTS: Only about half of the studies reported the specific items (n = 12) and the source of the items (n = 11). None of the studies specifically assessed the content validity of the items used. Only a minority (n = 5) of the studies reported any training, and one tested the comprehensibility of the EMA items. A wide variability was found in the design and methodology of the EMA. A minority of the studies (n = 7) reported a rationale for the used prompt frequency, time selection, and monitoring period. Retrospective assessment periods varied from 'now' to 'in the last 3.5 hours'. In some studies there was a possibility to delay (n = 6) or deactivate (n = 10) the prompt, and some provided reminders after the first prompt (n = 9). CONCLUSIONS: Almost no EMA studies reported the content validation of the items used. We recommend using the COSMIN checklist (COnsensus-based Standards for the selection of health Measurement INstruments) to report on the content validity of EMA items. Furthermore, as often no rationale was provided for several methodological decisions, the following three recommendations are made. First, provide a rationale for choosing the sampling modalities. Second, to ensure assessment 'in the moment', think carefully about the retrospective assessment period, reminders, and deactivation of the prompt. Third, as high completion rates are important for representativeness of the data and generalizability of the findings, report completion rates. TRIAL REGISTRATION: This review is registered in PROSPERO, the International prospective register of systematic reviews (registration number: CRD42017077996).

Acceptability and feasibility of the mHealth intervention 'MyDayPlan' to increase physical activity in a general adult population.

BACKGROUND: Electronic health (eHealth) and mobile health (mHealth) interventions have the potential to tackle the worldwide problem of physical inactivity. However, they often suffer from large attrition rates. Consequently, feasibility and acceptability of interventions have become important matters in the creation of e- and mHealth interventions. The aim of this study was to evaluate participants' opinions regarding acceptability and feasibility of a self-regulation, app-based intervention called 'MyDayPlan'. 'MyDayPlan' provides an innovative daily cycle providing several self-regulation techniques throughout the day that guide users towards an active lifestyle via various self-regulation techniques. METHODS: Semi-structured interviews were conducted with 20 adults after using the app for 2 weeks. A directed content analysis was performed using NVivo Software. RESULTS: 'MyDayPlan' was well-received and seems to be feasible and acceptable with inactive adults. The straightforward lay out and ease of use of the app were appreciated. Furthermore, the incorporation of the techniques 'action planning', and 'prompting review of behavioral goals' was positively evaluated. However, the users gave some recommendations: implementation of activity trackers to self-monitor physical activity could be of added value. Furthermore, increasing intuitiveness by minimizing text input and providing more preprogrammed options could further increase the ease of use. Finally, users indicated that they would benefit from more guidance during the "coping planning" component (barrier identification/problem solving), for example by receiving more tailored examples. CONCLUSIONS: Based on these findings, adaptations will be made to the 'MyDayPlan' app before evaluating its effectiveness. Furthermore, involving potential end users and evaluating acceptability and feasibility during the development of an e- and mHealth intervention is key. Also, creating interventions with a large ease of use and straightforward layout that provides tailored support during action and coping planning is key.

Which healthy lifestyle factors are associated with a lower risk of suicidal ideation among adolescents faced with cyberbullying?

Cyberbullying is associated with negative mental health outcomes including adolescent suicidal ideation. This requires effective and accessible preventive efforts. Healthy lifestyles are factors adolescents themselves can modify that may lower their risk of suicidal ideation. The aim of this study was to examine associations between physical activity, (outdoor) sport participation, a healthy diet, higher sleep duration and low levels of smoking and alcohol use, and suicidal ideation when faced with cyberbullying. A cross-sectional survey was administered in 2014-2015 to 1037 adolescents (12-18 years, M age = 15; 50% girls) in Flanders, Belgium. Logistic regression analyses were conducted to assess direct effects of cyberbullying involvement (victim, perpetrator, bystander) on suicidal ideation, and interaction effects between cyberbullying involvement, healthy lifestyles and suicidal ideation. Results showed that cyberbullying victimization, perpetration and bystanding were associated with higher suicidal ideation, but that the association with cyberbullying perpetration disappeared when corrected for other cyberbullying involvement forms. More physical activity, sleeping longer, more often taking a healthy diet and lower levels of smoking were associated with lower suicidal ideation. Some associations of healthy lifestyles with suicidal ideation disappeared at higher levels of cyberbullying involvement. Low alcohol consumption and (outdoor) sport participation were not associated with suicidal ideation, and sport participation was even associated with higher suicidal ideation at low levels of cyberbullying involvement. These findings suggest a novel approach to suicide prevention may be warranted, by strengthening healthy lifestyles as factors that adolescents themselves can modify to increase their resilience and reduce suicidal ideation.

Exploring the relationship between perceived barriers to healthy eating and dietary behaviours in European adults.

PURPOSE: Dietary behaviours may be influenced by perceptions of barriers to healthy eating. Using data from a large cross-European study (N = 5900), we explored associations between various perceived barriers to healthy eating and dietary behaviours among adults from urban regions in five European countries and examined whether associations differed across regions and socio-demographic backgrounds. METHODS: Frequency of consumption of fruit, vegetables, fish, fast food, sugar-sweetened beverages, sweets, breakfast and home-cooked meals were split by the median into higher and lower consumption. We tested associations between barriers (irregular working hours; giving up preferred foods; busy lifestyle; lack of willpower; price of healthy food; taste preferences of family and friends; lack of healthy options and unappealing foods) and dietary variables using multilevel logistic regression models. We explored whether associations differed by age, sex, education, urban region, weight status, household composition or employment. RESULTS: Respondents who perceived any barrier were less likely to report higher consumption of healthier foods and more likely to report higher consumption of fast food. 'Lack of willpower', 'time constraints' and 'taste preferences' were most consistently associated with consumption. For example, those perceiving lack of willpower ate less fruit [odds ratio (OR) 0.57; 95% confidence interval (CI) 0.50-0.64], and those with a busy lifestyle ate less vegetables (OR 0.54; 95% CI 0.47-0.62). Many associations differed in size, but not in direction, by region, sex, age and household composition. CONCLUSION: Perceived 'lack of willpower', 'time constraints' and 'taste preferences' were barriers most strongly related to dietary behaviours, but the association between various barriers and lower intake of fruit and vegetables was somewhat more pronounced among younger participants and women.

International study of objectively measured physical activity and sedentary time with body mass index and obesity: IPEN adult study.

BACKGROUND: Physical activity (PA) has been consistently implicated in the etiology of obesity, whereas recent evidence on the importance of sedentary time remains inconsistent. Understanding of dose-response associations of PA and sedentary time with overweight and obesity in adults can be improved with large-scale studies using objective measures of PA and sedentary time. The purpose of this study was to examine the strength, direction and shape of dose-response associations of accelerometer-based PA and sedentary time with body mass index (BMI) and weight status in 10 countries, and the moderating effects of study site and gender. METHODS: Data from the International Physical activity and the Environment Network (IPEN) Adult study were used. IPEN Adult is an observational multi-country cross-sectional study, and 12 sites in 10 countries are included. Participants wore an accelerometer for seven consecutive days, completed a socio-demographic questionnaire and reported height and weight. In total, 5712 adults (18-65 years) were included in the analyses. Generalized additive mixed models, conducted in R, were used to estimate the strength and shape of the associations. RESULTS: A curvilinear relationship of accelerometer-based moderate-to-vigorous PA and total counts per minute with BMI and the probability of being overweight/obese was identified. The associations were negative, but weakened at higher levels of moderate-to-vigorous PA (>50 min per day) and higher counts per minute. No associations between sedentary time and weight outcomes were found. Complex site- and gender-specific findings were revealed for BMI, but not for weight status. CONCLUSIONS: On the basis of these results, the current Institute of Medicine recommendation of 60 min per day of moderate-to-vigorous PA to prevent weight gain in normal-weight adults was supported. No relationship between sedentary time and the weight outcomes was present, calling for further examination. If moderator findings are confirmed, the relationship between PA and BMI may be country- and gender-dependent, which could have important implications for country-specific health guidelines.

Occurrence and duration of various operational definitions of sedentary bouts and cross-sectional associations with cardiometabolic health indicators: the ENERGY-project.

OBJECTIVE: This study examined the occurrence and duration of sedentary bouts and explored the cross-sectional association with health indicators in children applying various operational definitions of sedentary bouts. METHODS: Accelerometer data of 647 children (10-13 years old) were collected in five European countries. We analyzed sedentary time (<100 cpm) accumulated in bouts of at least 5, 10, 20 or 30 min based on four operational definitions, allowing 0, 30 or 60s ≥100 cpm within bouts. Health indicators included anthropometrics (i.e. waist circumference and body mass index (BMI)) and in a subsample from two European countries (n=112) fasting capillary blood levels of glucose, C-peptide, high-density- and low-density cholesterol, and triglycerides. Data collection took place from March to July 2010. Associations were adjusted for age, gender, moderate-to-vigorous physical activity, total wear time and country. RESULTS: Occurrence of sedentary bouts varied largely between the various definitions. Children spent most of their sedentary time in bouts of ≥5 min while bouts of ≥20 min were rare. Linear regression analysis revealed few significant associations of sedentary time accumulated in bouts of ≥5-30 min with health indicators. Moreover, we found that more associations became significant when allowing no tolerance time within sedentary bouts. CONCLUSION: Despite a few significant associations, we found no convincing evidence for an association between sedentary time accumulated in bouts and health indicators in 10-13 year old children.

Development and usability of a computer-tailored pedometer-based physical activity advice for breast cancer survivors.

This observational study aimed to adapt a computer-tailored step advice for the general population into a feasible advice for breast cancer survivors and to test its usability. First, several adaptations were made to the original design (adding cancer-related physical activity (PA) barriers and beliefs, and self-management strategies to improve survivors' personal control). Second, the adapted advice was evaluated in two phases: (1) a usability testing in healthy women (n = 3) and survivors (n = 6); and (2) a process evaluation during 3 weeks in breast cancer survivors (n = 8). Preliminary usability testing revealed no problems during logging-in; however, three survivors misinterpreted some questions. After refining the questionnaire and advice, survivors evaluated the advice as interesting, attractive to read, comprehensible and credible. Inactive survivors found the advice novel, but too long. The process evaluation indicated that the majority of the women (n = 5/8) reported increased steps. Monitoring step counts by using a pedometer was perceived as an important motivator to be more active. To conclude, this study provides initial support for the usability and acceptability of a computer-tailored pedometer-based PA advice for breast cancer survivors. After testing efficacy and effectiveness of this intervention, this tool can broaden the reach of PA promotion in breast cancer survivors.

Adherence to the obesity-related lifestyle intervention targets in the IDEFICS study.

BACKGROUND/OBJECTIVES: To address behaviours associated with childhood obesity, certain target values are recommended that should be met to improve children's health. In the IDEFICS (Identification and prevention of Dietary- and lifestyle-induced health Effects in Children and infantS) study such lifestyle recommendations were conveyed as six key messages. Here, we investigate the adherence of European children to these messages. METHODS: The IDEFICS intervention was based on the intervention mapping approach with the following six targets: increase water consumption (to replace sugar-containing beverages), increase fruit/vegetable consumption, reduce daily screen time, increase daily physical activity, improve the quality of family life and ensure adequate sleep duration. Internationally recommended target values were applied to determine the prevalence of children meeting these targets. RESULTS: In a cohort of 18,745 children participating in the IDEFICS baseline survey or newly recruited during follow-up, data on the above lifestyle behaviours were collected for a varying number of 8302 to 17,212 children. Information on all six behaviours was available for 5140 children. Although 52.5% of the cohort was classified in the highest category of water consumption, only 8.8% met the target of an intake of fruits/vegetables five times a day. The prevalence of children adhering to the recommendation regarding total screen time-below 1 h for pre-school children and 2 h for school children-was 51.1%. The recommended amount of at least 60 min of moderate-to-vigorous physical activity per day was fulfilled by 15.2%. Family life of the child measured by various indicators was considered as satisfactory in 22.8%. Nocturnal sleep duration of 11 (10) hours or more in pre-school (school) children was achieved by 37.9%. In general, children in northern countries and younger children showed better adherence to the recommendations. Only 1.1% of the children adhered to at least five of these recommendations. CONCLUSIONS: Current adherence of children to lifestyle recommendations to prevent childhood obesity is low where observed differences with respect to country, age and gender call for targeted intervention.

A longitudinal analysis of gross motor coordination in overweight and obese children versus normal-weight peers.

BACKGROUND: The relationship of childhood overweight (OW) and obesity (OB) with motor skill and coordination is gaining due attention; however, longitudinal evidence is currently lacking. OBJECTIVE: The dual purpose of this study was (1) to investigate the short-term evolution in the level of gross motor coordination according to children's weight status, and (2) to identify those factors predicting their gross motor coordination performance over a 2-year interval. SUBJECTS: Participants were 50 children with OW, including 8 with OB (aged 6-10 years at baseline, with 52% boys), and 50 with normal-weight (NW) matched for gender and age. MEASUREMENTS: Anthropometrics (body height, body weight, body mass index (BMI), %body fat) and level of gross motor coordination (Körperkoordinationstest für Kinder, KTK) were assessed in 2007 (baseline) and 2 years later in 2009 (follow-up). At baseline, participants completed a survey based on the Flemish Physical Activity Questionnaire (FPAQ) to obtain socio-demographic information and to determine physical activity levels in diverse domains. RESULTS: The evolution in the level of gross motor coordination over time was strongly related to children's weight status. Participants in the NW group showed more progress than their OW/OB peers, who demonstrated significantly poorer performances. Accordingly, between-group differences in KTK outcomes (that is, raw item scores and total motor quotient) became more evident over time. Multiple linear regression analysis further indicated that, in addition to BMI per se (negative predictor), participation in organized sports within a sports club (positive predictor) determines gross motor coordination performance(s) 2 years later. CONCLUSION: Our results provide conclusive evidence for an increasingly widening gap of OW/OB children's gross motor coordination relative to NW peers across developmental time in the absence of targeted initiatives. Special attention is thus needed for OW/OB children, especially for those not practicing sports in a club environment, in terms of motor skill improvement to promote regular participation in physical activity.

Physical activity levels and supportive care needs for physical activity among breast cancer survivors with different psychosocial profiles: a cluster-analytical approach.

The transition from breast cancer patient to survivor is associated with many treatment-related and psychosocial factors, which can influence health behaviour and associated needs. First, this study aimed to identify clusters of treatment-related and psychosocial factors among breast cancer survivors. Second, clusters' physical activity levels and care needs for physical activity were evaluated. Breast cancer survivors (n= 440; 52 ± 8 years) (3 weeks to 6 months post treatment) completed self-reports on physical and psychological symptoms; illness representations; social support and coping; physical activity and care needs for physical activity. Analyses identified four clusters: (1) a low distress-active approach group; (2) a low distress-resigned approach group; (3) a high distress-active approach group; and (4) a high distress-emotional approach group. Physical activity levels were higher in the low distress groups than in the high distress-emotional approach group. However, women with low distress and an active approach reported equal care needs for physical activity than women with high distress and an emotional approach. These findings suggest that care needs for physical activity are unrelated to distress and actual physical activity levels. The results emphasise the importance of screening for needs and provide a framework supporting the referral of breast cancer survivors to tailored interventions.

The effectiveness of school-based smoking prevention interventions among low- and high-SES European teenagers.

Preventing smoking initiation among adolescents of lower socio-economic groups is crucial for the reduction of socio-economic inequalities in health. The aim of the present study was to examine whether effective smoking prevention interventions in Europe are equally effective among adolescents of low- and high-socio-economic status (SES). As part of the European Union-funded TEENAGE project, three school-based smoking prevention intervention studies in Europe were selected for secondary analyses: (i) a Dutch class competition intervention, (ii) the European Smoking Prevention Framework (ESFA) study and (iii) the A Stop Smoking in Schools Trial (ASSIST) intervention. All three studies differed in effectiveness by SES. The Dutch class competition study only had a significant effect among higher SES adolescents. The results for the ESFA study and ASSIST study were mixed and depended on which SES indicator was used. The conclusion of the study is that stratified analyses provide important insights in differential intervention effects for higher and lower socio-economic groups. Although findings from the different studies were mixed, interventions that use a social network approach in which youngsters are allowed to deliver the intervention themselves may be a successful strategy in targeting adolescents from lower socio-economic groups.

Bicycling to school during the transition from childhood into adolescence: a six-year longitudinal study.

Little is known about bicycling to school as children age. At baseline (2002) self-report data from 1070 children were gathered (51.9% boys; mean age: 10 years).The measurements were repeated in 2003 (n = 1039), 2004 (n = 907), 2005 (n = 549) and 2008 (n = 515). The rates of children bicycling to school significantly varied across time points from 46% at the age of ten, 69% at the age of 11, 83% at the age of 12, 70% at the age of 13 toward 78% at the age of 16. Starting from the age of 11, the average duration of time spent bicycling to school significantly increased over time. According to multilevel regression analyses 13.6% of the variance in rates of bicycling to school was situated at the school level, 39.6% at the pupil level and 46.7% at the measurement level. The differences in rates and durations across time points were independent from gender, BMI, SES and having siblings. Pupils engaging in bicycling to school at younger ages had a higher change of engaging in bicycling to school at 16 years old (ORs: 2.69-7.61; ICC bicycling rates: 0.46, ICC bicycling durations: 0.82). This finding emphasizes the need for promoting bicycling to school at young age.

Repeatability of maternal report on prenatal, perinatal and early postnatal factors: findings from the IDEFICS parental questionnaire.

OBJECTIVE: To investigate the repeatability of maternal self-reported prenatal, perinatal and early postnatal factors within the IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) study. DESIGN: Data are from the baseline survey of the longitudinal cohort study IDEFICS in eight European countries. SUBJECTS: A total of 420 parents from eight countries (43-61 per country) were asked to complete the parental questionnaire (PQ) twice at least 1 month apart. MEASUREMENTS: The PQ assesses prenatal (maternal weight gain), perinatal (child's birth weight and length, Caesarean (C)-section, week of delivery) and early postnatal factors (exclusive breastfeeding, breastfeeding, introduction of solid food). Intra-class correlation coefficients (ICCs) were calculated to compare maternal reports on prenatal, perinatal and early postnatal factors between the first and second PQ. RESULTS: In total, 249 data sets were considered for the analyses. Overall, maternal reports for prenatal and perinatal factors showed higher repeatability (ICC=0.81-1.00, P≤0.05 for all) than those for early infant nutrition (ICC=0.33-0.88, P≤0.05 for all). Perfect agreement was found for parental reports on C-section (ICC(all)=1.00, P≤0.05). There was stronger agreement for duration of breastfeeding (ICC=0.71, P≤0.05) compared with exclusive breastfeeding (ICC=0.33, P≤0.05). Maternal reports showed moderate correlation for the introduction of several types of food (cereals ICC=0.64, P≤0.05; fruits ICC=0.70, P≤0.05; meat ICC=0.83, P≤0.05; vegetables ICC=0.75, P≤0.05), and high correlation (ICC=0.88, P≤0.05) for cow's milk. CONCLUSION: Maternal reports on pregnancy and birth were highly reproducible, but parental recall of early infant nutrition was weaker and should be interpreted more cautiously.

The IDEFICS community-oriented intervention programme: a new model for childhood obesity prevention in Europe?

BACKGROUND AND OBJECTIVES: The European Union-as well as other parts of the world-faces a major challenge of increasing incidence of overweight/obesity. In particular, the increase in childhood obesity gives rise to a strong imperative for immediate action. Yet, little is known about the effectiveness of community interventions, and further research in this field is needed. There is, however, a growing consensus that such research should start from the paradigm that the current living environments tend to counteract healthy lifestyles. Questioning these environments thoroughly can help to develop new pathways for sustainable health-promoting communities. Against this background, the IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) study developed and implemented innovative community-oriented intervention programmes for obesity prevention and healthy lifestyle primarily in children aged 2-10 years in eight European countries: Sweden, Estonia, Germany, Belgium, Hungary, Italy, Spain and Cyprus. MATERIALS AND METHODS: The IDEFICS community-oriented intervention study mobilised an integrated set of interventional efforts at different levels of society, with the aim of facilitating the adoption of a healthy obesity-preventing lifestyle. The overall programme has been composed of 10 modules: three at community level, six at school level and one for parents. The main focus was on diet, physical activity and stress-coping capacity. The sphere of action encompassed both children and their (grand) parents, schools, local public authorities and influential stakeholders in the community. All materials for the interventions were centrally developed and culturally adapted. RESULTS: So far, the following has been achieved: focus group research, literature review and expert consultations were done in an early phase as a basis for the development of the intervention modules. The intervention mapping protocol was followed as guide for structuring the intervention research. The overall intervention programme's duration was 2 years, but a longer-term follow-up programme is under development. CONCLUSIONS: This large-scale European effort is expected to contribute significantly to the understanding of this major public health challenge.

Effect of a tailored behavior change program on a composite lifestyle change score: a randomized controlled trial.

To evaluate the effect of a tailored behavior change program on a composite lifestyle change score. A randomized controlled trial conducted in Belgium in 2007-08 with 314 participants allocated to a control and an intervention condition. The intervention was a tailored behavior change program (web-based and individual coaching). The dose of the coaching was chosen by the participants and registered. Outcome measures were weight, saturated fat intake, fruit and vegetable intake, physical activity, smoking status and a composite lifestyle change score. Mann-Whitney U-tests, Kruskal-Wallis tests, t-tests and one-way analyses of variance were used to compare the study conditions and three intervention dose groups (no/low, medium and high intervention dose). There were no significant differences between the study conditions or between the intervention dose groups for the individual lifestyle factors. The composite lifestyle change score was significantly higher in the high intervention dose group compared with the no/low intervention dose group (P = 0.009). The composite lifestyle change score was positively related to the intervention dose, while the individual lifestyle factors were not. Behavior change programs that target multiple lifestyle factors could be evaluated by using a composite lifestyle change score taking into account the intervention dose.

Are physical activity interventions equally effective in adolescents of low and high socio-economic status (SES): results from the European Teenage project.

The aim was to study whether physical activity (PA) interventions in European teenagers are equally effective in adolescents of low versus high socio-economic status (SES). Based on a systematic review (Project TEENAGE), three school-based studies for secondary analyses were selected. SES stratified analyses were run in: (i) a Belgian multi-component intervention, (ii) a French multi-component intervention and (iii) a Belgian computer-tailored education trial. Results of the secondary analyses showed that no overall significant differences between low and high SES groups were found, but some interesting specific effects were revealed. Results from the first study showed an increase in objective PA in the low SES group (P = 0.015) compared with no significant effects in the high SES group. In the second study, larger effects were found in adolescents of high SES (increase of 11 min day(-1) P < 0.001), compared with adolescents of lower SES (increase of 7 min day(-1), P = 0.02) at the longer term. The third study showed a positive effect on school-related PA in adolescents of high SES (P < 0.05) and on leisure time transportation in adolescents of low SES (P < 0.05). To conclude, we were not able to show a significant widening or narrowing of inequalities in European adolescents.

Perceived social and physical environmental correlates of physical activity in older adolescents and the moderating effect of self-efficacy.

OBJECTIVE: To determine if perceptions of the social and physical environment are associated with active transport and leisure-time sports among Belgian youth and to investigate if this relationship is moderated by self-efficacy. METHODS: In February-May 2008, 1445 adolescents (17.4+/-0.6 yrs) were recruited in 20 randomly selected Belgian schools. Physical activity, psychosocial, and environmental factors were assessed using validated questionnaires. Moderated multilevel regression analysis was used to examine the association between physical activity and possible correlates. RESULTS: Social environmental variables (modeling and social support) were positively associated with active transportation and leisure-time sports (p<0.05). Higher land use mix diversity, higher street connectivity, more attractive environments, better access to recreational facilities, and higher emotional satisfaction with the neighborhood were associated with more active transportation (p<0.05). Higher perceived safety from traffic, better access to recreational facilities, more physical activity equipment at home, and fewer electronic devices in the bedroom were associated with more leisure-time sports (p<0.05). Lower perceived safety and poorer access to (recreational) facilities were only associated with lower active transport among youth with lower self-efficacy (p<0.05). CONCLUSION: Creating more supportive environments could have the potential to affect the physical activity levels of Belgian adolescents with both high and low self-efficacy.

A cognitive-behavioural pedometer-based group intervention on physical activity and sedentary behaviour in individuals with type 2 diabetes.

The purpose of this study was to investigate the benefits of a pedometer and a cognitive-behavioural group intervention for promoting physical activity (PA) in type 2 diabetes patients. We recruited 41 participants and randomized them into an intervention group (IG) (n=20) and a control group (CG) (n = 21). The intervention consisted of five sessions within 12 weeks, a booster session after 22 weeks and a pedometer. Primary outcome was PA assessed by accelerometer (minutes per day) and pedometer (steps per day). Secondary outcomes were weight, body mass index, blood pressure, haemoglobin A1c and total cholesterol. After 12 weeks, the IG increased with more than 2000 steps day(-1) compared with the CG, whereas sedentary behaviour decreased more than 1 hour day(-1) in the IG and showed no change in the CG. There was no intervention effect on the accelerometer-based PA nor on health measurements. After 1 year, the increase in steps per day remained significant in the IG, but sedentary activity increased again to baseline levels. This pilot study showed that the combination of a 12-week cognitive-behavioural intervention and a pedometer has a significant short-term impact on daily steps and sedentary behaviour but that the effects on total PA and long-term effects were limited.

Environmental factors: opportunities and barriers for physical activity, and healthy eating among children and adolescents.

While genetic factors play a role in the development of obesity, the dramatic increase of its prevalence in the past years strongly suggests that environmental factors are largely responsible. The wealth and variety of food supply available 24h/day and throughout the year, the change in dietary habits due to time constraints and the change in physical activity due to technological advances all create a 'toxic' environment responsible for obesity and eating habit disorders. This manuscript describes and discusses the results of a systematic review of environmental opportunities & obstacles for physical activity and dietary intake influencing the obesity epidemic among children and adolescents. Although evidence clearly shows the impact of the environment on obesity related lifestyle factors, evidence for effective strategies combating this obesogenic environment is very scarce. Interventions aiming to change environmental factors in order to reduce obesity may include taxes/subsidies encouraging healthy eating or physical activity, extra provision of sporting facilities, efforts to improve safety and accessibility of walking, cycling or play areas or attempting to influence social meanings/values attached to weight, food or physical activity. It is clear that some level of institutionalization of systems that support the desired changes is required to sustain environmental and social changes in the long-term. At last, it is important to note that better-designed and -conducted research on the true importance of the interaction between environmental factors and psychosocial factors, including the micro- and the macro-level, for obesogenic behavioral change is needed to reassure the success of large-scale environmental change interventions.