The effect of a cluster randomised control trial on objectively measured sedentary time and parental reports of time spent in sedentary activities in Belgian preschoolers: the ToyBox-study.

BACKGROUND: In preschoolers, high levels of sedentary behaviour are associated with several adverse health outcomes. The purpose of this study is to report the effects of the ToyBox-intervention (a European 24-week cluster randomised controlled trial) on sedentary behaviour in preschoolers. METHODS: In Belgium, 859 preschoolers from 27 kindergartens (15 intervention and 12 control) wore an accelerometer to objectively measure their sedentary time and 1715 parents/caregivers completed a questionnaire to assess sedentary activities in which preschoolers participate at home. Main outcomes were objectively measured sedentary time, time spent watching TV, using the computer and time spent in quiet play. Multilevel repeated measures analyses were conducted to take clustering into account. Intention to treat analysis was used to handle missing data. RESULTS: A sample of 859 (29.5% of all contacted children) preschoolers (4.4 ± 0.6 years, 54.4% boys) provided valid accelerometer data at either baseline or follow-up and parents of 1715 (58.9% of all contacted children) preschoolers (4.4 ± 0.5 years, 52.5% boys) completed a questionnaire at either baseline or follow-up. No intervention effects were found on objectively and subjectively measured total sedentary time in the total sample. However, some effects on objectively and subjectively measured sedentary time were found in specific subgroups. Preschoolers from the intervention group from high SES kindergartens and preschoolers with high levels of sedentary time at baseline decreased their sedentary time, while preschoolers from the control group increased their sedentary time. Girls in the intervention group decreased their TV viewing time during weekend days (-5.83 min/day), while girls' &TV viewing in the control group increased (+4.15 min/day). In low SES kindergartens, a smaller increase for computer time during weekend days was found in preschoolers in intervention kindergartens (+6.06 min/day) than in control kindergartens (+12.49 min/day). CONCLUSION: While some small positive effects were found in some sub-groups, the ToyBox-intervention had no effect on objectively and subjectively measured sedentary time in the total sample. A longer period to implement the intervention and a more active involvement of parents/caregivers might enhance intervention effects. The ToyBox-study is registered with the clinical trials registry clinicaltrials.gov, ID: NCT02116296.

The translation of preschoolers' physical activity guidelines into a daily step count target.

This study aimed at translating the physical activity (PA) guideline (180 min of total PA per day) into a step count target in preschoolers. 535 Flemish preschoolers (mean age: 4.41 ± 0.58) wore an ActiGraph accelerometer (GT1M, GT3X and GT3X+) - with activated step count function - for four consecutive days. The step count target was calculated from the accelerometer output using a regression equation, applying four different cut-points for light-to-vigorous PA: Pate, Evenson, Reilly, and Van Cauwenberghe. The present analysis showed that 180 min of total PA per day is equivalent to the following step count targets: 5,274 steps/day using the Pate cut-point, 4,653 steps/day using the Evenson cut-point, 11,379 steps/day using the Reilly cut-point and 13,326 steps/day using the Van Cauwenberghe cut-point. Future studies should focus on achieving consensus on which cut-points to use in preschoolers before a definite step count target in preschoolers can be proposed. Until then, we propose to use a provisional step count target of 11,500 steps/day as this step count target is attainable, realistic and helpful in promoting preschoolers' PA.

The effect of a kindergarten-based, family-involved intervention on objectively measured physical activity in Belgian preschool boys and girls of high and low SES: the ToyBox-study.

BACKGROUND: The ToyBox-study developed an evidence- and theory-based intervention to improve preschoolers' energy balance-related behaviours - including physical activity (PA) - by targeting the kindergarten environment and involving their parents/caregivers. The present study aimed to examine the effect of the ToyBox-intervention on increasing Belgian preschoolers' objectively measured PA levels. METHODS: A sample of 472 preschoolers (4.43 ± 0.55 years; 55.1% boys) from 27 kindergartens (15 intervention, 12 control kindergartens) in Flanders, Belgium were included in the data analyses. Preschoolers wore an ActiGraph accelerometer for six consecutive days and were included in the data analyses if they had a minimum of two weekdays and one weekend day, both at baseline and follow-up (one year later). Preschoolers' PA outcomes were estimated for an average day, weekday, weekend day, during school hours, and during after school hours. To assess intervention effects, multilevel repeated measures analyses were conducted for the total sample, and for sub-groups (according to sex, kindergarten levels of socio-economic status (SES) and risk groups (low levels of PA at baseline)) of preschoolers. RESULTS: Small intervention effects were found in the total sample. Most intervention effects were found in boys and in preschoolers from high SES kindergartens. Boys from the intervention group had an increase in vigorous PA (ß=1.47, p=0.03) and moderate-to-vigorous PA (ß=1.27, p=0.03) from baseline to follow-up, whereas PA levels in boys from the control group stagnated or decreased. In preschoolers from high SES kindergartens, the largest effects were found for PA outcomes during school hours and during after school hours. CONCLUSION: The results from the Belgian sample demonstrate that effects of the PA-component of the ToyBox-intervention on objectively measured PA were found in preschool boys and in preschoolers from high SES kindergartens, which means that the ToyBox-intervention was mainly effective in those sub-groups. Future interventions should search for alternative strategies to increase preschoolers' PA levels in preschool girls and preschoolers from low SES kindergartens, as these are the most important at-risk groups regarding PA.

Using the intervention mapping protocol to reduce European preschoolers' sedentary behavior, an application to the ToyBox-Study.

BACKGROUND: High levels of sedentary behavior are often measured in preschoolers, but only a few interventions have been developed to counteract this. Furthermore, detailed descriptions of interventions in preschoolers targeting different forms of sedentary behavior could not be located in the literature. The aim of the present paper was to describe the different steps of the Intervention Mapping Protocol used towards the development of an intervention component of the ToyBox-study focusing on decreasing preschoolers' sedentary behavior. The ToyBox-study focuses on the prevention of overweight in 4- to 6-year-old children by implementing a multi-component kindergarten-based intervention with family involvement in six different European countries. METHODS: Applying the Intervention Mapping Protocol, six different steps were systematically completed for the structured planning and development of the intervention. A literature search and results from focus groups with parents/caregivers and kindergarten teachers were used as a guide during the development of the intervention and the intervention materials. RESULTS: The application of the different steps in the Intervention Mapping Protocol resulted in the creation of matrices of change objectives, followed by the selection of practical applications for five different intervention tools that could be used at the individual level of the preschool child, at the interpersonal level (i.e., parents/caregivers) and at the organizational level (i.e., kindergarten teachers). No cultural differences regarding preschoolers' sedentary behavior were identified between the participating countries during the focus groups, so cultural and local adaptations of the intervention materials were not necessary to improve the adoption and implementation of the intervention. CONCLUSIONS: A systematic and evidence-based approach was used for the development of this kindergarten-based family-involved intervention targeting preschoolers, with the inclusion of parental involvement. The application of the Intervention Mapping Protocol may lead to the development of more effective interventions. The detailed intervention matrices that were developed as part of the ToyBox-study can be used by other researchers as an aid in order to avoid repetitive work for the design of similar interventions.

Physical activity and beverage consumption in preschoolers: focus groups with parents and teachers.

BACKGROUND: Qualitative research is a method in which new ideas and strategies can be discovered. This qualitative study aimed to investigate parents' and teachers' opinions on physical activity and beverage consumption of preschool children. Through separate, independent focus groups, they expressed their perceptions on children's current physical activity and beverage consumption levels, factors that influence and enhance these behaviours, and anticipated barriers to making changes. METHODS: Multi-cultural and multi-geographical focus groups were carried out in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain). In total, twenty-four focus groups with 122 parents and eighteen focus groups with 87 teachers were conducted between October 2010 and January 2011. Based on a semi-structured interview guide, questions on preschoolers' physical activity (opinions on preschoolers' physical activity, how to increase physical activity, facilitators and barriers of physical activity) and beverage consumption (rules and policies, factors influencing promotion of healthy drinking, recommendations for future intervention development) were asked. The information was analyzed using qualitative data analysis software (NVivo8). RESULTS: The focus group results indicated misperceptions of caregivers on preschoolers' physical activity and beverage consumption levels. Caregivers perceived preschoolers as sufficiently active; they argue that children need to learn to sit still in preparation for primary school. At most preschools, children can drink only water. In some preschools sugar-sweetened beverages like chocolate milk or fruit juices, are also allowed. It was mentioned that sugar-sweetened beverages can be healthy due to mineral and vitamin content, although according to parents their daily intake is limited. These opinions resulted in low perceived needs to change behaviours. CONCLUSIONS: Although previous research shows need of change in obesity-related behaviours, the participants in the current study didn't perceive such. The awareness of parents and teachers needs to be raised concerning their shared responsibility about healthy behaviours in preschoolers. Providing preschool teachers with ready-to-use classroom material will encourage them to change physical activity and beverage consumption, and to implement related activities in the classroom. Involvement in activities that their children perform at preschool will motivate parents to extend these behaviours to the home environment.

Reproducibility and relative validity of a semiquantitative food frequency questionnaire in European preschoolers: The ToyBox study.

OBJECTIVES: The aim of this study was to examine the reproducibility and relative validity of a semiquantitative food frequency questionnaire (FFQ) in assessing food group estimates. METHODS: Food group estimates were assessed via a 37-item FFQ and a 3-d food record (FR). Pearson's correlation coefficients for log-transformed values were calculated to assess the reproducibility and Spearman's rank correlation coefficients for log-transformed values were calculated to assess the validity. Kindergartens from six European countries participated in the preparatory substudies of the ToyBox intervention study; data from preschool children 4 to 6 y of age (n = 196, reproducibility study; n = 324, validation study) were obtained. RESULTS: In the reproducibility study, positive Pearson's correlation coefficients for single and aggregated food groups ranged from 0.14 for pasta and rice to 0.90 for cooked vegetables. In the validation study, the FR gave higher estimates of 40 of the 50 food items (single and aggregated) examined compared with those obtained from the FFQ. Positive crude Spearman rank correlation coefficients ranged from 0.01 for total beverages (added sugar) and rice to 0.62 for tea. Corrections for the deattenuation effect did not improve observed correlations. Quartiles and tertiles were calculated for a small number of food groups (N = 14) owing to zero consumption in the rest of the groups. CONCLUSIONS: Moderately good reproducibility and low-moderate relative validity of the FFQ used in preschool children was observed. Relative validity, however, varied by food and beverage group; for some of the "key" foods/drinks targeted in the ToyBox intervention (e.g., biscuits), the validity was good. The findings should be considered in future epidemiologic and intervention studies in preschool children.

Parental Influences on Preschoolers' TV Viewing Time: Mediation Analyses on Australian and Belgian Data.

BACKGROUND: Television viewing is highly prevalent in preschoolers (3-5 years). Because of the adverse health outcomes related to this behavior, it is important to investigate associations and mediators of young children's television viewing time. This study investigated whether parental rules regarding television viewing time and parental concerns about screen viewing activities mediated the association between parents' and preschoolers' television viewing time. METHODS: Mediation analyses were performed with the product-of-coefficient test on data derived from the Australian HAPPY study (n = 947) and the Belgian sample of the ToyBox-study (n = 1527). Parents reported their own and their child's television viewing time, their rules regarding television viewing and concerns about their child's screen viewing activities. RESULTS: Parents' television viewing time was directly associated with preschoolers' television viewing time and parental rule for television viewing time mediated this association in both samples (14.4% and 8.1% in the Australian and Belgian samples, respectively). CONCLUSIONS: This study is unique in examining the mediating pathway of parental television viewing and a rule limiting TV viewing time and whether this is consistent in different samples. Due to the consistent importance, both parents' television viewing time and rules should be targeted in interventions to decrease preschoolers' television viewing time.

Validity of the Omron pedometer and the actigraph step count function in preschoolers.

OBJECTIVES: To validate the GT1M actigraph accelerometer step count function, and the Omron Walking Style Pro pedometer against accelerometer-based activity counts, and to compare pedometer-based and accelerometer-based steps in preschoolers. DESIGN: A sample of 41 preschoolers (21 boys, mean age 5.43±0.63 years) from one preschool in Flanders, Belgium, was included in data analysis. METHODS: Accelerometer-based and pedometer-based steps were simultaneously collected in this Flemish sample of preschool children. Preschoolers wore two motion sensors (accelerometer and pedometer) for four consecutive days. Pearson correlations were calculated to compare accelerometer activity counts with accelerometer-based steps, accelerometer activity counts with pedometer-based steps and accelerometer-based steps with pedometer-based steps. Bland-Altman analysis was carried out to investigate the agreement between the pedometer-based and the accelerometer-based steps. RESULTS: Accelerometer-based steps correlated moderately high with accelerometer activity counts per hour (r=0.77) and per day (r=0.82). Pedometer-based steps correlated moderately high with accelerometer activity counts per hour (r=0.65) and per day (r=0.64). High correlations were revealed between steps from both devices (hourly: r=0.92; daily: r=0.89). The Bland-Altman analysis showed a bias of 221.81 (±1679.78) and the limits of agreement ranged from -3070.57 to 3514.18 steps per day. CONCLUSIONS: Both the accelerometer-based as pedometer-based step counts are valid estimates of preschoolers' physical activity levels during free-living activities based on group estimates. High agreement between both step counts justifies combining and comparing pedometer- and accelerometer-based step counts.

Differences in energy balance-related behaviours in European preschool children: the ToyBox-study.

BACKGROUND: The aim of the current study was to compare levels of energy balance-related behaviours (physical activity, sedentary behaviour, and dietary behaviours (more specifically water consumption, sugar-sweetened beverage consumption and unhealthy snacking)) in four- to six-year-old preschoolers from six European countries (Belgium, Bulgaria, Germany, Greece, Poland, and Spain) within the ToyBox cross-sectional study. METHODS: A sample of 4,045 preschoolers (4.77 ± 0.43 years; 52.2% boys) had valid physical activity data (steps per day), parents of 8,117 preschoolers (4.78 ± 0.46 years; 53.0% boys) completed a parental questionnaire with questions on sedentary behaviours (television viewing, computer use, and quiet play), and parents of 7,244 preschoolers (4.77 ± 0.44 years; 52.0% boys) completed a food frequency questionnaire with questions on water consumption, sugar-sweetened beverage consumption and unhealthy snacking. RESULTS: The highest levels of physical activity were found in Spain (12,669 steps/day on weekdays), while the lowest levels were found in Bulgaria and Greece (9,777 and 9,656 steps/day on weekdays, respectively). German preschoolers spent the least amount of time in television viewing (43.3 min/day on weekdays), while Greek preschoolers spent the most time in television viewing (88.5 min/day on weekdays). A considerable amount of time was spent in quiet play in all countries, with the highest levels in Poland (104.9 min/day on weekdays), and the lowest levels in Spain (60.4 min/day on weekdays). Belgian, German, and Polish preschoolers had the lowest intakes of water and the highest intakes of sugar-sweetened beverages. The intake of snacks was the highest in Belgian preschoolers (73.1 g/day) and the lowest in Greek preschoolers (53.3 g/day). CONCLUSIONS: Across six European countries, differences in preschoolers' energy balance-related behaviours were found. Future interventions should target European preschoolers' energy balance-related behaviours simultaneously, but should apply country-specific adaptations.

The impact of a teacher-led structured physical activity session on preschoolers' sedentary and physical activity levels.

OBJECTIVES: The purpose of this observational study was to examine differences in preschoolers' sedentary time and physical activity (PA) participation between preschool-attending weekdays with and without a teacher-led structured PA session. DESIGN: A sample of 200 preschoolers (5.3±0.4y; 113 boys) from 26 preschools in Flanders, Belgium were included in data analysis. METHODS: Participants wore a GT1M ActiGraph accelerometer on one preschool-attending weekday with and on one preschool-attending weekday without the provision of a teacher-led structured PA session. Preschoolers' sedentary time, light PA, and moderate-to-vigorous physical activity (MVPA) during the time in preschool (08:00-16:00h) and after preschool (16:00-20:00h) were estimated. To assess differences in the outcome measures between both days, multi-level linear regression models were conducted. RESULTS: During the time at preschool, lower sedentary levels (ß=13.0min; SE=1.6; p<0.001) and higher light PA (ß=2.9min; SE=0.7 p<0.001) and MVPA levels (ß=10.1min; SE=1.1; p<0.001) were prevalent on days with a structured PA session compared to days without a structured PA session in both boys and girls. After preschool, no differences were found between both days in sedentary time (ß=0.7; SE=1.4; p>0.05), light PA (ß=0.3; SE=0.5; p>0.05), and MVPA (ß=0.3; SE=0.9; p>0.05). CONCLUSIONS: The results demonstrate that no compensatory changes were found after preschool for the structured PA session during the preschool hours. Therefore, a teacher-led structured PA session integrated in the preschool curriculum is a promising mean to decrease sedentary time and to increase PA in preschool-aged boys and girls.

Validity of the ActivPAL™ and the ActiGraph monitors in preschoolers.

PURPOSE: This study aimed to compare three objective measures (GT1M ActiGraph, ActivPAL™, and direct observation) of sedentary behavior in preschoolers. METHODS: Fifty-two 4- to 6-yr-old preschoolers wore an ActivPAL™ and a GT1M ActiGraph for five consecutive days and were videotaped for 1 h during classroom activities at preschool. The area under the receiver operating characteristic curve was calculated to assess the criterion validity of the ActivPAL™ (sitting/lying, with and without standing still) and the GT1M ActiGraph (<100 counts per minute) to estimate sedentary behavior (directly observed sitting behaviors). A two-way repeated-measures ANOVA was used to define the convergent validity of the ActivPAL™ and the GT1M ActiGraph sedentary behavior estimates across the measurement days. The practical utility of the ActivPAL™ was tested in the same sample by asking the parents how their child perceived wearing the ActivPAL™. RESULTS: Results indicated a poor classification accuracy for both devices (area under the receiver operating characteristic curve, 0.6) to measure sedentary behavior based on the direct observation, with and without the inclusion of standing. Time defined as sedentary behavior (sitting/lying) was lower for the ActivPAL™ compared with the GT1M ActiGraph (mean bias, 7.7%; limits of agreement, -29.01% to 13.6%). According to the parental reports, 38% of the preschoolers had skin irritation due to wearing the ActivPAL™ for consecutive days. CONCLUSIONS: Low classification accuracy was found for the ActivPAL™ and the GT1M ActiGraph to measure sedentary behavior in preschoolers. No correction factor can be suggested to make the sedentary estimates of the GT1M ActiGraph and the ActivPAL™ convergent as no systematic bias and wide limits of agreement were found. Furthermore, the practical utility of the ActivPAL™ was perceived to be lower compared with the ActiGraph accelerometer in preschoolers.

Influencing factors of sedentary behavior in European preschool settings: an exploration through focus groups with teachers.

BACKGROUND: Sedentary behavior refers to activities involving sitting down and reclining (eg, watching TV, using the computer) and has been associated with different health outcomes. In preschool, children are sedentary for 50% to 80% of the time, in the classroom as well as during recess. Because of the absence of qualitative studies examining influencing factors of preschoolers' sedentary behavior in preschool settings, this study explored teachers' opinions on potentially influencing factors of this behavior. METHODS: Eighty-seven teachers of 4- to 6-year-old preschoolers from 6 European countries participated in a total of 18 focus groups between October 2010 and January 2011. Key findings were reported separately by country, and were independently analyzed by 2 researchers using qualitative content analysis. RESULTS: Teachers perceive the lack of play space and small classroom size as being influential factors on preschoolers' sedentary behavior; increasing play equipment and using teachers' prompts are mentioned as ways to stimulate children to be less sedentary on the playground. Computer use is reported to be more common in preschool than watching TV. CONCLUSION: Interventions should focus on increasing teachers' awareness of how sedentary preschoolers are during the preschool day. Teachers also should be informed about strategies to decrease sedentariness in the classroom and on the playground.