Caregivers' Role in the Effectiveness of Two Dutch School-Based Nutrition Education Programmes for Children Aged 7-12 Years Old.

Childhood eating behaviours can track into adulthood. Therefore, programmes that support early healthy eating, including school-based nutrition education programmes, are important. Although school-based programmes may be beneficial in improving nutrition knowledge, impact on actual fruit and vegetable (FV) intake is generally limited as FV intake is also influenced by the home environment. The current study includes secondary analyses of data from an evaluation study on Dutch nutrition education and examined the role of caregivers' health promotion behaviours (HPB) in influencing healthy eating behaviours in primary school children (n = 1460, aged 7-12 years) and whether caregivers' HPB contribute to programme effectiveness. Children's nutrition knowledge, FV intake and caregivers' HPB (FV/sugar-sweetened beverages/sweets provision to take to school, cooking together and talking about healthy food at home) were measured by child-reported questionnaires at baseline, during, and 6 months post-programme. Results indicated that caregivers' HPB was positively associated with children's healthy eating behaviours and that programme effectiveness was highest in those in the lower HPB subcategory. In conclusion, children with less encouragement to eat healthily at home potentially benefit more from school-based nutrition education programmes than children receiving more encouragement. This highlights the important role of the home environment in supporting healthy eating behaviour in children.

Education or Provision? A Comparison of Two School-Based Fruit and Vegetable Nutrition Education Programs in the Netherlands.

A healthy diet is important for optimal child growth and development. School-based opportunities to encourage children to achieve healthy eating behaviors should be explored. Nutrition education programs can provide school children with classroom-based nutrition education and access to fruits and vegetables (FV). However, the effectiveness of specific program components implemented separately has not yet been comprehensively evaluated. The current study examined effectiveness of individual components of two programs targeting primary school children (n = 1460, n = 37 schools) aged 7-12 years. Nutrition knowledge and FV consumption were measured using a student questionnaire, and presence of school food policies was measured in the teachers' questionnaire. A quasi-experimental design with three arms compared: (1) schools that implemented both programs: FV provision + education (n = 15), (2) schools that implemented the FV provision program only (n = 12), (3) schools that did not implement either program (n = 10). Outcomes were assessed pre-intervention (T0), during the intervention (T1), and 6 months post-intervention (T2). Results indicated a significant increase in nutrition knowledge for children attending schools that had participated in both programs, compared to control schools (p < 0.01), but no significant increase in FV intake. In schools without food policies, FV provision alone contributed to an increase in child FV intake (p < 0.05).

Hungry for an intervention? Adolescents' ratings of acceptability of eating-related intervention strategies.

BACKGROUND: Effective interventions promoting healthier eating behavior among adolescents are urgently needed. One factor that has been shown to impact effectiveness is whether the target population accepts the intervention. While previous research has assessed adults' acceptance of eating-related interventions, research on the opinion of adolescents is lacking. The current study addressed this gap in the literature. METHODS: Two thousand seven hundred sixty four adolescents (aged 10-17 years) from four European countries answered questions about individual characteristics (socio-demographics, anthropometrics, and average daily intake of healthy and unhealthy foods) and the acceptability of ten eating-related intervention strategies. These strategies varied in type (either promoting healthy eating or discouraging unhealthy eating), level of intrusiveness, setting (home, school, broader out-of-home environment), and change agent (parents, teacher, policy makers). RESULTS: Based on adolescents' acceptability ratings, strategies could be clustered into two categories, those promoting healthy eating and those discouraging unhealthy eating, with acceptability rated significantly higher for the former. Acceptability of intervention strategies was rated moderate on average, but higher among girls, younger, overweight and immigrant adolescents, and those reporting healthier eating. Polish and Portuguese adolescents were overall more accepting of strategies than UK and Dutch adolescents. CONCLUSIONS: Adolescents preferred intervention strategies that promote healthy eating over strategies that discourage unhealthy eating. Level of intrusiveness affected acceptability ratings for the latter type of strategies only. Various individual and behavioral characteristics were associated with acceptability. These findings provide practical guidance for the selection of acceptable intervention strategies to improve adolescents' eating behavior.

The association of eating styles with weight change after an intensive combined lifestyle intervention for children and adolescents with severe obesity.

UNLABELLED: The main purpose of this prospective intervention study was to determine whether eating styles after an intensive, partly inpatient, one year combined lifestyle intervention are associated with weight change in the following year in severely obese children and adolescents. A total of 120 participants (8-19 years) with an average SDS-BMI of 3.41 (SD = 0.38) was included. Measurements were conducted at baseline (T0), at the end of treatment (T12) and at the end of follow up two years after baseline (T24). The primary outcome measurement was the ΔSDS-BMI between T12 and T24. As primary determinant of weight change after treatment, the participants eating styles were evaluated with the Dutch Eating Behavior Questionnaire - child report that measures external, emotional and restraint eating. The association between outcome and determinant was assessed in linear regression analyses. Complete data were available for 76 of the 120 participants. This study shows that for girls a higher score on restraint eating at T12 and a higher score on external eating at T12 were associated with more weight (re)gain in the year after treatment. No statistically significant association with emotional eating at T12 was found. In addition for girls a higher score on external eating at T0 was associated with more weight (re)gain in the year after treatment. Furthermore, the observed changes in eating styles suggest that on average it is possible to influence these with treatment, although the detected changes were different for girls and boys and for the different eating styles. More generally, this study indicates that for girls the levels of restraint and external eating after treatment were associated with the weight change during the following year. TRIAL REGISTRATION: Netherlands Trial Register (NTR1678, registered 20-Feb-2009).

The habitual nature of unhealthy snacking: How powerful are habits in adolescence?

Many adolescents engage in unhealthy snacking behavior, and the frequency and amount of unhealthy consumption is increasing further. In this study, we aim to investigate the role that habit strength plays in unhealthy snacking during adolescence and whether self-regulation strategies can overcome habitual snacking. A total of 11,392 adolescents aged 10-17 years from nine European countries completed a cross-sectional survey about healthy eating intentions, snacking habit strength, eating self-regulation strategies, and daily intake of unhealthy snacks. The results showed that habit strength was positively associated with intake of unhealthy snack foods, also when healthy eating intentions were accounted for. Use of self-regulation strategies was negatively associated with unhealthy snacking. The interaction effect of habit strength and use of self-regulation strategies was significant. Strong snacking habits were associated with higher consumption, but this effect could be attenuated by use of temptation-oriented self-regulation strategies. The present study highlights that habit strength is associated with unhealthy snacking already in adolescents. The findings suggest that teaching self-regulation strategies may help adolescents to overcome unhealthy snacking habits.

Communicating eating-related rules. Suggestions are more effective than restrictions.

BACKGROUND: A common social influence technique for curbing unhealthy eating behavior is to communicate eating-related rules (e.g. 'you should not eat unhealthy food'). Previous research has shown that such restrictive rules sometimes backfire and actually increase unhealthy consumption. In the current studies, we aimed to investigate if a milder form of social influence, a suggested rule, is more successful in curbing intake of unhealthy food. We also investigated how both types of rules affected psychological reactance. METHOD: Students (N = 88 in Study 1, N = 51 in Study 2) completed a creativity task while a bowl of M&M's was within reach. Consumption was either explicitly forbidden (restrictive rule) or mildly discouraged (suggested rule). In the control condition, consumption was either explicitly allowed (Study 1) or M&M's were not provided (Study 2). Measures of reactance were assessed after the creativity task. Subsequently, a taste test was administered where all participants were allowed to consume M&M's. RESULTS: Across both studies, consumption during the creativity task did not differ between the restrictive- and suggested-rule-conditions, indicating that both are equally successful in preventing initial consumption. Restrictive-rule-condition participants reported higher reactance and consumed more in the free-eating taste-test phase than suggested-rule-condition participants and control-group participants, indicating a negative after-effect of restriction. DISCUSSION: RESULTS show that there are more and less effective ways to communicate eating-related rules. A restrictive rule, as compared to a suggested rule, induced psychological reactance and led to greater unhealthy consumption when participants were allowed to eat freely. It is important to pay attention to the way in which eating-related rules are communicated.

The home food environment of overweight gatekeepers in the Netherlands.

OBJECTIVE: The aim of the present study was to gain insight into (i) processed snack-food availability, (ii) processed snack-food salience and (iii) the size of dinnerware among households with overweight gatekeepers. Moreover, associations between gatekeepers' characteristics and in-home observations were determined. DESIGN: A cross-sectional observation of home food environments was conducted as part of a baseline measurement of a larger study. SETTING: Home food environments of overweight and obese gatekeepers in the Netherlands. SUBJECTS: Household gatekeepers (n 278). Mean household size of the gatekeepers was 3.0 (SD 1.3) persons. Mean age of the gatekeepers was 45.7 (SD 9.2) years, 34.9% were overweight and 65.1% were obese. Of the gatekeepers, 20.9% had a low level of education and 42.7% had a high level of education. RESULTS: In 70% of the households, eight or more packages of processed snack foods were present. In 54% of the households, processed snack foods were stored close to non-processed food items and in 78% of households close to non-food items. In 33% of the households, processed snack foods were visible in the kitchen and in 15% of the households processed snack foods were visible in the living room. Of the dinnerware items, 14% (plates), 57% (glasses), 78% (dessert bowls), 67% (soup bowls) and 58% (mugs) were larger than the reference norms of the Netherlands Nutrition Centre Foundation. Older gatekeepers used significantly smaller dinnerware than younger gatekeepers. CONCLUSIONS: Environmental factors endorsing overconsumption are commonly present in the home environments of overweight people and could lead to unplanned eating or passive overconsumption.

PortionControl@HOME: results of a randomized controlled trial evaluating the effect of a multi-component portion size intervention on portion control behavior and body mass index.

BACKGROUND: Food portion sizes influence energy intake. PURPOSE: The purpose of this paper is to determine effectiveness of the "PortionControl@HOME" intervention on body mass index and portion control behavior. METHODS: A randomized controlled trial among 278 overweight and obese participants was conducted. PortionControl@HOME aimed to increase: portion size awareness, portion control behavior, portion control cooking skills, and to create a home environment favoring portion control. RESULTS: Intention-to-treat multi-level regression analysis indicated statistically significant effects of the intervention on portion control behavior at 3, 6, and 12 months follow-up. The effect on body mass index was significant only at 3 months follow-up and when outliers (n = 3) were excluded (B = -0.45; 95%CI = -0.88 to -0.04). The intervention effect on body mass index was mediated by portion control behavior. CONCLUSIONS: The intervention improves portion control behavior, which in turn influence body mass index. Once the intervention ceased, sustained effects on body mass index were no longer evident. (Current-Controlled-Trials ISRCTN12363482).

Navigating the obesogenic environment: how psychological sensitivity to the food environment and self-regulatory competence are associated with adolescent unhealthy snacking.

PURPOSE: Living in an obesogenic environment may not affect all adolescents to the same extent, depending on their psychological sensitivity to the food environment and their self-regulatory competence. The purpose of the current study was to examine associations of these two factors with unhealthy snacking among adolescents. We also investigated whether self-regulatory competence could attenuate the negative effects of being sensitive to the food environment. METHODS: A survey was completed by 11,392 European adolescents (10-17years old). The survey measured psychological sensitivity to the food environment, self-regulatory competence and self-reported unhealthy snack intake. RESULTS: Higher food environment sensitivity and lower self-regulatory competence were associated with more unhealthy snacking. The two factors also interacted, with self-regulatory competence attenuating the influence of high food environment sensitivity. DISCUSSION: Adolescents who are sensitive to the food environment reported higher unhealthy snack intake. More frequent use of self-regulation strategies on the other hand was associated with lower unhealthy snack intake. Moreover, self-regulatory competence was found to moderate the influence of psychological sensitivity to the food environment on unhealthy snacking, although the effect size was small. Fostering adolescents' self-regulatory competence can help enable them to better navigate the obesogenic environment.

Identifying the 'if' for 'if-then' plans: combining implementation intentions with cue-monitoring targeting unhealthy snacking behaviour.

Implementation intentions aimed at changing unwanted habits require the identification of personally relevant cues triggering the habitual response in order to be effective. To facilitate successful implementation intention formation, in the present study, planning was combined with cue-monitoring, a novel way to gain insight into triggers for unhealthy snacking. It was tested whether keeping a cue-monitoring diary and tailoring implementation intentions accordingly improves plan effectiveness. A 2 Monitoring (cue-monitoring, control) × 2 Planning (implementation intention, goal intention) between subjects design was adopted. Participants (N = 161) monitored their unhealthy snacking behaviour for a week using either a cue-monitoring or a control diary. Participants then formulated a goal intention or an implementation intention tailored to their personal cue. Snacking frequency and caloric intake from unhealthy snacks were examined using a seven-day snack diary. The results did not indicate an interaction but yielded a main effect of Monitoring. Cue-monitoring either or not combined with implementation intentions reduced unhealthy snacking behaviour compared with control. Findings emphasise the effectiveness of cue-monitoring, suggesting that on the short term, cue-monitoring suffices to decrease unhealthy snacking, without additional benefit from planning. Future research should examine whether supplementing cue-monitoring with implementation intentions is required to establish long-term behaviour change maintenance.

How norms work: self-identification, attitude, and self-efficacy mediate the relation between descriptive social norms and vegetable intake.

BACKGROUND: The current studies aim to show that descriptive social norms influence vegetable intake and to investigate three potentially underlying processes (self-identification, attitude, and self-efficacy). METHODS: In two studies, descriptive social norms regarding vegetable intake were manipulated (majority vs. minority norm). Study 1 investigated both the relation between baseline vegetable intake and self-identification, attitude, and self-efficacy, as well as the effect of the norm manipulation on vegetable intake over a one-week period. Study 2 investigated potential mediation of the effect of the manipulation on vegetable intake intentions through self-identification, attitude, and self-efficacy. RESULTS: Study 1 showed that the proposed mediators were related to a baseline measure of vegetable intake. Moreover, in participants identifying strongly with the norm referent group, majority norms led to higher vegetable consumption than minority norms. Study 2 showed that the direct effect of the social norm manipulation on vegetable intake intentions was partly mediated by self-identification, attitude, and self-efficacy. CONCLUSIONS: These studies shed first light on processes underlying the effect of descriptive social norms on health behavior. A norm describing the behavior of a salient social group leads people to identify more with, have more positive attitudes toward, and feel more self-efficacious regarding that behavior.

Behavioural strategies to control the amount of food selected and consumed.

Several factors within the food environment may stimulate overconsumption. The present study aimed to (1) identify behavioural strategies to cope with this environment to control the amount of food consumed, (2) examine the feasibility and usefulness of the strategies, and (3) evaluate the association between the strategies and body mass index (BMI). After the literature was screened for evidence of factors that contribute to the consumption of large amounts of food, 32 behavioural strategies were identified to overcome these influences (study 1). Subjectively reported feasibility and usefulness of the 32 behavioural strategies in weight management were explored using a pretest post-test study (study 2: n = 52). Additionally, two cross-sectional questionnaire studies (study 3a: n = 120 and study 3b: n = 278) were conducted to evaluate the association between the 32 behavioural strategies and BMI. The strategies were subjectively reported as feasible and useful in weight management. Frequent use of strategies discriminated non-overweight from overweight individuals, but did not discriminate overweight from obese individuals. In conclusion, the findings provided preliminary evidence for the acceptability and validity of the strategies. The effectiveness of the strategies for controlling the amount consumed should be further investigated, especially in overweight and obese participants.

Motivational interviewing within the different stages of change: an analysis of practice nurse-patient consultations aimed at promoting a healthier lifestyle.

Combining the Stages of Change (SOC) model with Motivational Interviewing (MI) is seen as a helpful strategy for health care providers to guide patients in changing unhealthy lifestyle behaviour. SOC suggests that people are at different stages of motivational readiness for engaging in health behaviours and that intervention methods are most useful when tailored to a person's stage of change. However, it is unknown whether practice nurses (PNs) actually adapt their MI and more generic communication skills to a particular stage during real-life face-to-face consultations with their patients. The aim of this study was to explore whether and how PNs apply MI and general communication skills to the different SOC of patients, targeting behaviour change about smoking, alcohol use, dietary habits and/or physical activity. Real-life consultations between nineteen Dutch PNs and 103 patients were recorded on video between June 2010 and March 2011. All consultations focused on a discussion of patients' lifestyle behaviour. The Behaviour Change Counselling Index (BECCI) was used to code PNs' MI skills. Generic communication skills were rated with the MAAS-global. Patients' SOC was assessed for each consultation by observing the communication between patient and PN regarding the patient's current lifestyle behaviour. Multilevel analyses revealed that PNs adapt their MI skills to a patient's SOC to some extent. On average PNs apply MI skills more to patients in the preparation stage (P < 0.05) than during the other stages of change. PNs adjusted three MI skills and one generic communication skill to patients' SOC. This explorative study suggests that, at least to some extent, PNs intuitively assess the stage of patients' readiness to change and tailor their communication accordingly. However, differences between the stages were small. By teaching PNs to explicitly identify patients' SOC they could further enhance and adapt their MI and general communication skills to the individual.

The role of self-regulating abilities in long-term weight loss in severely obese children and adolescents undergoing intensive combined lifestyle interventions (HELIOS); rationale, design and methods.

BACKGROUND: Adequate treatment of severe childhood obesity is important given its serious social, psychological and physical consequences. Self-regulation may be a crucial determinant of treatment success. Yet, little is known about the role that self-regulation and other psychosocial factors play in the long-term outcome of obesity treatment in severely obese children and adolescents.In this paper, we describe the design of a study that aims to determine whether the ability to self-regulate predicts long-term weight loss in severely obese children and adolescents. An additional objective is to identify other psychosocial factors that may modify this relation. METHODS/DESIGN: The study is designed as a prospective observational study of 120 severely obese children and adolescents (8-19 years) and their parents/caregivers undergoing an intensive combined lifestyle intervention during one year. The intervention uses behavior change techniques to improve the general ability to self-regulate.Measurements will be taken at three points in time: at baseline (start of treatment), at the end of treatment (1 year after baseline) and at follow-up (2 years after baseline). The primary outcome measurement is the gender and age-specific change in SDS-BMI.The children's general self-regulation abilities are evaluated by two behavioral computer tasks assessing two distinct aspects of self-regulation that are particularly relevant to controlling food intake: inhibitory control (Stop Signal Task) and sensitivity to reward (Balloon Analogue Risk Task). In addition to the computer tasks, a self-report measure of eating-specific self-regulation ability is used. Psychosocial factors related to competence, motivation, relatedness and outcome expectations are examined as moderating factors using several questionnaires for the patients and their parents/caregivers. DISCUSSION: This study will provide knowledge about the relation between self-regulation and long-term weight loss after intensive lifestyle interventions over a two-year period in severely obese children and adolescents, a growing but often overlooked patient group. We aim to investigate to what extent (changes in) the general ability to self-regulate predicts weight loss and weight loss maintenance. This study will also contribute to the knowledge on how this association is modified by other psychosocial factors. The results may contribute to the development of more successful interventions. TRIAL REGISTRATION: Netherlands Trial Register (NTR1678, registered 20-Feb-2009).

Minority talks: the influence of descriptive social norms on fruit intake.

Previous research established that norms describing the behaviour of a majority (e.g. 'many people consume too much alcohol') can have ironic and unwanted effects on health behaviour. To date, no research has addressed the effects of minority descriptive norms (e.g. 'only few people use sunscreen'), while such minority norms are frequently communicated to the public. The current studies investigate the effects of minority and majority norms on intended and actual fruit intake. University students received either minority or majority normative information describing fruit intake behaviour of a referent group. Identification strength with this referent group was measured (Study 1) or manipulated (Study 2). Results showed that, compared to majority norms, minority norms negatively affected fruit intake when participants strongly identify with the referent group. Moreover, absolute negative (minority norm) and positive (majority norm) effects of one-third portion of fruit were found compared to a no-norm condition. Since minority norms are often communicated with the intention of alarming people regarding their low engagement in health protective behaviour, the potential ironic effects of these minority norms should be taken into account when presenting such information to the public.

Should implementation intentions interventions be implemented in obesity prevention: the impact of if-then plans on daily physical activity in Dutch adults.

BACKGROUND: Forming implementation intentions (specifying when, where and how to act) has been proposed as a potentially effective and inexpensive intervention, but has mainly been studied in controlled settings for straightforward behaviors. PURPOSE: To examine if forming implementation intentions (II) could be used in large-scale, population-based interventions that aim to promote more complex and clinically relevant behavior change, we tested the impact of different II on increasing daily physical activity (PA) aimed at weight maintenance among 709 Dutch adults. METHODS: At T0, participants were randomly allocated to a control group or to form II for 1) a prescribed action (walking), 2) self-selected activities, 3) self-selected activities and repeat making these II two times. All participants were asked to increase PA by at least two hours a week (15-20 minutes per day). Post-tests took place two weeks (response 85%), three months (response 78%) and six months (response 79%) post-intervention. RESULTS: No main effects of II formation on BMI or physical activity were found. Intention to increase physical activity moderated the effects of repeated II, but not of the other II conditions. Forming repeated II had a positive effect on total PA and number of active days for respondents with strong intentions. CONCLUSION: Implementation intention interventions may not yet be ready for implementation on its own for large-scale obesity prevention in the general public. Future research should test strategies for optimal II formation in both initiating and maintaining behavioral change. TRIAL REGISTRATION: ISRCTN81041724.

Predictors of stage transitions in the precaution adoption process model.

PURPOSE: To explore psychosocial correlates and predictors of stage transitions in the precaution adoption process model (PAPM) for fruit intake. DESIGN: A cohort completed three electronic questionnaires, at baseline (time 0), 35 days later (time 1), and another 32 days later (time 2). SETTING: Secured Internet Web site. SUBJECTS: A cohort of 735 adults was formed from a random sample of an existing Internet panel. The mean age was 37.5 years, 51% were women, and 90% were of Dutch origin. Most respondents (48%) had a medium level of education. MEASURES: Precaution adoption process model stage, risk perception, perception of own fruit intake level, attitude, pros, cons, subjective norms, social support, modeling, self-efficacy, and fruit intake (assessed using a food frequency questionnaire). ANALYSIS: Cross-sectional differences in psychosocial variables and fruit intake across PAPM stages at baseline were analyzed using analysis of variance with Tukey multiple comparisons tests. Predictors of PAPM stage transitions between time 0 and time 1 and between time 1 and time 2 were analyzed using logistic regression analysis. RESULTS: Factors related to attitude and social influences may be important if one is to decide to act, whereas strong self-efficacy may also be required for acting on the decision to act. CONCLUSION: Although the results should be replicated in a larger and more representative sample, the PAPM seems a good framework for studying fruit intake.

Do the transtheoretical processes of change predict transitions in stages of change for fruit intake?

In a longitudinal study, it is examined whether the transtheoretical processes of change do predict stage transitions in fruit intake. A random sample of an existing Internet research panel resulted in a cohort of 735 adults, who were examined three times with electronic questionnaires assessing stages of change, processes of change, and fruit intake. Cross-sectional differences were found for the processes of change between precontemplation and all further stages. Experiential as well as behavioral processes increased from precontemplation to action with similar patterns. Both experiential and behavioral processes predicted forward transition out of precontemplation and forward transition into action, whereas only behavioral processes predicted forward transition out of contemplation. The results indicate that the transtheoretical processes of change predict stage transitions for fruit intake, but that the pattern of relevant processes for fruit intake is not as straightforward as outlined by the transtheoretical model of behavior change.

Do implementation intentions help to turn good intentions into higher fruit intakes?

OBJECTIVE: The present study examined (1) whether respondents who were encouraged to make implementation intentions to eat more fruit increased their fruit intakes, as measured by three measures of fruit intake; (2) whether the effects of implementation intentions on fruit intake were dependent on positive goal intentions at baseline; and (3) the respondents' commitment to perform their implementation intentions. DESIGN: Dutch adults (n = 535) were randomly assigned to either receive implementation intention instructions or not. Two questionnaires were completed with a 1.5-week time interval. Respondents in the implementation intention condition were asked to form implementation intentions to eat an extra serving of fruit per day during one week. RESULTS: Respondents in the implementation intention group reported a high frequency of eating an extra serving of fruit per day. The implementation intention effect on frequency of extra fruit did not depend on goal intention at baseline. The more committed respondents were to carrying out their implementation intention, the more likely they were to increase their fruit intake. CONCLUSION: These results provide some indications that implementation intentions could be a useful strategy to induce a short-term increase in fruit intake.