Tools for a systematic appraisal of integrated community-based approaches to prevent childhood obesity.

BACKGROUND: Evaluation and monitoring methods are often unable to identify crucial elements of success or failure of integrated community-wide approaches aiming to tackle childhood overweight and obesity, yet difficult to determine in complex programmes. Therefore, we aimed to systematically appraise strengths and weaknesses of such programmes and to assess the usefulness of the appraisal tools used. METHODS: To identify strengths and weaknesses of the integrated community-based approaches two tools were used: the Good Practice Appraisal tool for obesity prevention programmes, projects, initiatives and intervention (GPAT), a self-administered questionnaire developed by the WHO; and the OPEN tool, a structured list of questions based on the EPODE theory, to assist face-to-face interviews with the principle programme coordinators. The strengths and weaknesses of these tools were assessed with regard to practicalities, quality of acquired data and the appraisal process, criteria and scoring. RESULTS: Several strengths and weaknesses were identified in all the assessed integrated community-based approaches, different for each of them. The GPAT provided information mostly on intervention elements whereas through the OPEN tool information on both the programme and intervention levels were acquired. CONCLUSION: Large variability between integrated community-wide approaches preventing childhood obesity in the European region was identified and therefore each of them has different needs. Both tools used in combination seem to facilitate comprehensive assessment of integrated community-wide approaches in a systematic manner, which is rarely conducted. Nonetheless, the tools should be improved in line to their limitations as recommended in this manuscript.

Development of the 'Canteen Scan': an online tool to monitor implementation of healthy canteen guidelines.

BACKGROUND: To improve the availability and accessibility of healthier food and drinks in schools, sports and worksites canteens, national Guidelines for Healthier Canteens were developed by the Netherlands Nutrition Centre. Until now, no tool was available to monitor implementation of these guidelines. This study developed and assessed the content validity and usability of an online tool (the 'Canteen Scan') that provides insight into and directions for improvement of healthier food products in canteens. METHODS: The Canteen Scan was developed using a three-step iterative process. First, preliminary measures and items to evaluate adherence to the guidelines were developed based on literature, and on discussions and pre-tests with end-users and experts from science, policy and practice. Second, content validity of a paper version of the Canteen Scan was assessed among five end-users. Third, the online Canteen Scan was pilot tested among end-users representing school canteens. Usability was measured by comprehensibility, user-friendliness, feasibility, time investment, and satisfaction. RESULTS: The content validity of the Canteen Scan was ensured by reaching agreement between stakeholders representing science, policy and practice. The scan consists of five elements: 1) basic conditions (e.g. encouragement to drink water and availability of policy regarding the guidelines), 2) product availability offered on displays (counter, shelf) and 3) in vending machines, 4) product accessibility (e.g. promotion and placement of products), and 5) an overall score based on the former elements and tailored feedback for creating a healthier canteen. The scan automatically classifies products into healthier or less healthy products. Pilot tests indicated good usability of the tool, with mean scores of 4.0-4.6 (5-point Likert scale) on the concepts comprehensibility, user-friendliness and feasibility. CONCLUSION: The Canteen Scan provides insight into the extent to which canteens meet the Dutch Guidelines for Healthier Canteens. It also provides tailored feedback to support adjustments towards a healthier canteen and with the scan changes over time can be monitored. Pilot tests show this tool to be usable in practice.

Cross-sectional associations between maternal parenting styles, physical activity and screen sedentary time in children.

BACKGROUND: Children's activity level, including physical activity (PA) and screen sedentary time (SST), is influenced by environmental factors in which parents play a critical role. Different types of parenting styles may influence children's activity level. Inconsistent results were found on the association between parenting styles and PA, and few studies tested the association between parenting styles and SST. This study examined the association between parenting styles, PA and SST and the modifying effect of children's gender and maternal educational level on these associations. METHODS: Cross-sectional data were collected from parents of children aged 8-11 years old who completed a web-based non-standardized questionnaire (N = 4047). Since 85% of the questionnaires were filled in by mothers, parenting styles are mainly reported by mothers. Multiple linear regression techniques were used to assess the associations between parenting styles (authoritative, permissive, authoritarian and neglectful), and PA and SST (mean min/day). The modifying effect of children's gender and maternal educational level on these associations was explored. P values ≤.0125 were considered as statistically significant based on the Bonferroni correction for four primary analyses. RESULTS: The neglectful parenting style was most widely used (35.3%), while the authoritarian style was least common (14.8%). No significant association was found between parenting styles and PA level. As regards SST, an authoritative parenting style was significantly associated with lower SST in boys while a neglectful parenting style was significantly associated with higher SST in both boys and girls. When the mother had a medium educational level, an authoritative parenting style was significantly associated with lower SST while neglectful parenting was significantly associated with higher SST. CONCLUSIONS: No association was found between parenting styles and PA. However, an authoritative parenting style was associated with a reduction in SST and a neglectful parenting style with an increase in SST, especially in boys and in children whose mother had a medium education level. Future studies of parenting practices are needed to gain more insight into the role of parents in children's PA and SST levels, as a basis for the development of interventions tailored to support parents in stimulating PA and reducing SST in children.

Adult adiposity susceptibility loci, early growth and general and abdominal fatness in childhood: the Generation R Study.

BACKGROUND: Genome-wide association studies in adults have identified genetic loci associated with adiposity measures. Little is known about the effects of these loci on growth and body fat distribution from early childhood onwards. METHODS: In a population-based prospective cohort study among 4144 children, we examined the associations of weighted risk scores combining 29 known genetic markers of adult body mass index (BMI) and 14 known genetic markers of adult waist-hip ratio (WHR) with peak weight velocity, peak height velocity, age at adiposity peak and BMI at adiposity peak in early infancy and additionally with BMI, total fat mass, android/gynoid fat ratio and preperitoneal fat area at the median age of 6.0 years (95% range 5.7, 7.8). RESULTS: A higher adult BMI genetic risk score was associated with a higher age at adiposity peak in infancy and a higher BMI, total fat mass, android/gynoid fat ratio and preperitoneal fat area in childhood (P=0.05, 1.5 × 10(-24), 3.6 × 10(-18), 4.0 × 10(-11) and 1.3 × 10(-5), respectively), with the strongest association for childhood BMI with a 0.04 higher s.d. score BMI (95% confidence interval 0.03, 0.05) per additional risk allele. A higher adult WHR genetic risk score was not associated with infant growth measures or childhood BMI and total fat mass, but was associated with childhood android/gynoid fat ratio and preperitoneal fat area (P<0.05). CONCLUSION: Genetic variants associated with BMI and WHR in adults influence growth patterns and general and abdominal fat development from early childhood onwards.

Dutch teachers and parents about overweight prevention in pre-vocational schools.

Healthier lifestyles may contribute to prevent overweight in adolescents. Although school-based interventions show promising results, adoption and implementation by secondary schools and involvement of parents is difficult. Our study aims to gain a better understanding of the problem awareness and beliefs of school staff and parents regarding adolescents' overweight and energy balance-related behaviour, their motivation for health-promoting activities and suggested actions in the school environment. Focus group interviews were conducted with three groups of parents and three groups of school staff at three pre-vocational schools in the Netherlands. Comments concerning awareness, motivation to intervene and possible actions were analysed with the Atlas.ti program. Results showed that school staff and parents were aware of overweight as a health problem, but underestimated the prevalence and impact of overweight and unhealthy behaviour in their school. Health-related behaviour of adolescents was considered primarily the responsibility of parents, but the school staff also had a pedagogical responsibility. Parents and school staff agreed that health promotion efforts would have more impact on adolescents' behaviour, when school-based activities were supported by parents and parental efforts were supported by school health promotion. Therefore, parental efforts and school-based activities should be aligned by developing and expressing shared norms about healthy behaviour and parents should be taught how to discuss healthy dietary and physical activity behaviour with their children. To tackle peer group culture and the obese environment, parents' and school staff's efforts should be part of an integrated community approach.

Association between TV viewing, computer use and overweight, determinants and competing activities of screen time in 4- to 13-year-old children.

OBJECTIVE: TV viewing and computer use is associated with childhood overweight, but it remains unclear as to how these behaviours could best be targeted. The aim of this study was to determine to what extent the association between TV viewing, computer use and overweight is explained by other determinants of overweight, to find determinants of TV viewing and computer use in the home environment and to investigate competing activities. METHOD: A cross-sectional study was carried out among 4072 children aged 4-13 years in the city of Zwolle, the Netherlands. Data collection consisted of measured height, weight and waist circumference, and a parental questionnaire on socio-demographic characteristics, child's nutrition, physical activity (PA) and sedentary behaviour. Associations were studied with logistic regression analyses, for older and younger children, boys and girls separately. RESULTS: The odds ratio (OR) of being overweight was 1.70 (95% confidence interval (CI): 1.07-2.72) for viewing TV >1.5 h among 4- to 8-year-old children adjusted for all potential confounders. Computer use was not significantly associated with overweight. Determinants of TV viewing were as follows: having >2 TVs in the household (OR: 2.38; 95% CI: 1.66-3.41), a TV in the child's bedroom and not having rules on TV viewing. TV viewing and computer use were both associated with shorter sleep duration and not with less PA. CONCLUSION: Association between TV viewing and overweight is not explained by socio-demographic variables, drinking sugared drinks and eating snacks. Factors in the home environment influence children's TV viewing. Parents have a central role as they determine the number of TVs, rules and also their children's bedtime. Therefore, interventions to reduce screen time should support parents in making home environmental changes, especially when the children are young.

Association between sleep duration and overweight: the importance of parenting.

OBJECTIVE: Sleep duration has been related to overweight in children, but determinants of sleep duration are unclear. The aims were to investigate the association between sleep duration and childhood overweight adjusted for family characteristics and unhealthy behaviours, to explore determinants of sleep duration and to determine with sleep competing activities. METHOD: A cross-sectional study was carried out in 2006 among 4072 children aged 4-13 years in the city of Zwolle, The Netherlands. In these children, data were available on measured height, weight and waist circumference, and from a parental questionnaire, on socio-demographic characteristics, child's sleep duration, nutrition, physical activity and sedentary behaviour. Associations were studied in 2011 using logistic and linear regression analyses, adjusted for potential confounders. RESULTS: Short sleep duration was associated with overweight for 4-8-year-old boys (odds ratio (OR):3.10; 95% confidence interval (CI):1.15-8.40), 9-13-year-old boys (OR:4.96; 95% CI:1.35-18.16) and 9-13-year-old girls (OR:4.86; 95% CI:1.59-14.88). Among 4-8-year-old girls no statistically significant association was found. Determinants for short sleep duration were viewing television during a meal, permission to have candy without asking, not being active with their caregiver and a late bedtime. For all children, short sleep duration was strongly associated with more television viewing and computer use. CONCLUSIONS: Association between sleep duration and overweight is not explained by socio-demographic variables, drinking sugared drinks and eating snacks. Parents have a key role in stimulating optimal sleep duration. Improving parenting skills and knowledge to offer children more structure, and possibly with that, increase sleeping hours, may be promising in prevention of overweight.

[Breastfeeding in a multi-ethnic population: changes between 2009 and 2015]. / Borstvoeding in een multi-etnische populatie.

OBJECTIVE: To examine changes in breastfeeding rates in 0 to 6 month old infants in Amsterdam, the Netherlands, over the period from 2009 to 2015, for the total population as well as for various ethnic groups. DESIGN: Cross-sectional study. METHOD: Breastfeeding rates were examined for the period from 2009 to 2015 in 165,420 registrations of 75,543 infants at the ages of 2 weeks, 3 months and 6 months for the entire Amsterdam population and for various ethnic groups. Differences were analysed using χ2 tests. RESULTS: The weighted percentage of total breastfeeding (exclusive breastfeeding as well as a combination of breast and formula feeding) increased in the entire Amsterdam study population over the period from 2009 to 2015 (2 weeks: 87.8% to 89.1%; 3 months: 61.6% to 63.6%; 6 months: 39.5% to 42.2%). Increases were mainly the result of increases in weighted percentages for exclusive breastfeeding. The highest exclusive breastfeeding rates were observed among the Turkish ethnic group, the lowest among the Antillean/Aruban and Surinamese groups. CONCLUSION: Percentages for total breastfeeding as well as exclusive breastfeeding in Amsterdam rose over the period from 2009 to 2015, but there is room for improvement. Breastfeeding promotion, whether or not in combination with formula feeding, may be of particular benefit to children of Surinam or Antillean/Aruban descent. Before ethnicity-specific interventions can be implemented, more insight is needed in the reasons for the low breastfeeding rates in specific groups.

The prevention of overweight and obesity in children and adolescents: a review of interventions and programmes.

Overweight and obesity are serious, large-scale, global, public health concerns requiring population-based childhood overweight and obesity prevention. The overall objective of this review is to identify aspects of successful childhood overweight prevention programmes. This objective will be met by assessing existing interventions quantitatively as well as qualitatively, identifying efficacy, effectiveness and implementation, and evaluating potential adverse effects of previous studies. This review was limited to school-based studies with a quantitative evaluation using anthropometric outcomes and that intervene on diet or activity-related behaviours. Quantitative and qualitative approaches are used to identify factors related to successful interventions as well as adverse consequences. Sixty-eight per cent of the interventions, or 17 of the 25, were 'effective' based on a statistically significant reduction in body mass index (BMI) or skin-folds for the intervention group. Four interventions were effective by BMI as well as skin-fold measures. Of these, two targeted reductions in television viewing. The remaining two studies targeted direct physical activity intervention through the physical education programme combined with nutrition education. Of the interventions reported here, one was effective in reducing childhood overweight but was also associated with an increase in underweight prevalence. Few other studies reported outcomes for underweight. The majority of overweight/obesity prevention programmes included in this review were effective. Physical education in schools and reducing television viewing are two examples of interventions that have been successful. Because few studies report on underweight prevalence, this review recommends giving more attention to preventing adverse outcomes by reporting the intervention impact on the frequency distribution for both BMI and adiposity measures.

[Lessons learned from the implementation of Dutch national healthcare guidelines on childhood obesity]. / Lessen geleerd van de implementatie van Zorgstandaard Obesitas voor kinderen.

OBJECTIVE: To describe the implementation and feasibility of the national healthcare guidelines on childhood obesity in a region with a high prevalence of overweight and obesity in children. DESIGN: Descriptive, implementation study. METHOD: The implementation of the guidelines took place in the borough Amsterdam West. In total, 17 general practitioners (GP) from the Academic General Practice Network (ANH) of the VU University Medical Center, Amsterdam, participated in the study, along with 19 child healthcare practitioners and 3 paediatricians. A number of measures were taken to promote implementation. Feasibility was evaluated using both qualitative and quantitative methods. RESULTS: The participating healthcare providers found the training in application of the guidelines and case study discussions useful. GPs found that their role as central caregiver was not feasible. All participants expressed a preference for child healthcare practitioners as the central caregiver. A total of 327 obese children were invited to attend the GP's surgery; only 65 of them participated in the study and only 28 children were monitored for a whole year. Collaboration agreements between involved healthcare providers were rarely fulfilled. CONCLUSION: Implementation of the national healthcare guidelines on childhood obesity in the current form appears not to be feasible in Amsterdam West, despite the many implementation-enhancing measures that were applied. It is questionable whether the national healthcare guidelines on childhood obesity in its current form can contribute to addressing the societal problem of overweight and obesity in children.

Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice.

OBJECTIVE: To assess the long-term effectiveness of a quality improvement program on care provided and patient outcomes in patients with diabetes. RESEARCH DESIGN AND METHODS: A nonrandomized trial was performed with 312 patients with type 2 diabetes in the intervention group and 77 patients with type 2 diabetes in the reference group. The follow-up period was 42 months. The quality improvement program focused on improving both the provision of diabetes care and the patient outcomes. The program consisted of clinical practice guidelines, postgraduate education, audit and feedback, templates to register diabetes care, and a recall system. Data on the care provided were abstracted from medical records. Main outcomes on the provision of care were annual number of patient visits, blood pressure, and HbA(1c) and blood lipid levels. Main patient outcomes were blood pressure and HbA(1c) and blood lipid levels. Multilevel analysis was used to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices. RESULTS: Patients in the intervention group received care far more in accordance with the guidelines than patients in the reference group. Odds ratios ranged from 2.43 (95% CI 1.01-5.82) for the measurement of urine albumin to 12.08 (4.70-31.01) for the measurement of blood pressure. No beneficial effect was found on any patient outcome. CONCLUSIONS: The quality improvement program improved the provision of diabetes care, but this was not accompanied by any effect on patient outcomes.

Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review.

OBJECTIVE: To review the effectiveness of interventions targeted at health care professionals and/or the structure of care in order to improve the management of diabetes in primary care, outpatient, and community settings. RESEARCH DESIGN AND METHODS: A systematic review of controlled trials evaluating the effectiveness of interventions targeted at health care professionals and aimed at improving the process of care or patient outcomes for patients with diabetes was performed. Standard search methods of the Cochrane Effective Practice and Organization of Care Group were used. RESULTS: A total of 41 studies met the inclusion criteria. The studies identified were heterogeneous in terms of interventions, participants, settings, and reported outcomes. In all studies, the interventions were multifaceted. The interventions were targeted at health care professionals only in 12 studies, at the organization of care only in 9 studies, and at both in 20 studies. Complex professional interventions improved the process of care, but the effect on patient outcomes remained less clear because such outcomes were rarely assessed. Organizational interventions that facilitated the structured and regular review of patients also showed a favorable effect on process measures. Complex interventions in which patient education was added and/or the role of a nurse was enhanced led to improvements in patient outcomes as well as the process of care. CONCLUSIONS: Multifaceted professional interventions and organizational interventions that facilitate structured and regular review of patients were effective in improving the process of care. The addition of patient education to these interventions and the enhancement of the role of nurses in diabetes care led to improvements in patient outcomes and the process of care.

Associations between the home environment and children's sweet beverage consumption at 2-year follow-up: the 'Be active, eat right' study.

BACKGROUND: This study evaluates the association between home environmental characteristics and sweet beverage consumption (i.e. beverages that contain sugar) of 7-year-old children. METHODS: The population for analysis consisted of n = 2047 parents and their children from the population-based 'Be active, eat right' study. Data on sociodemographic characteristics, parental beliefs, parenting practices and child's sweet beverage consumption were obtained by parental report with questionnaires. We performed linear and multinomial regression analyses evaluating associations between characteristics at age 5 years and (i) consumption at 7 years and (ii) consumption patterns between age 5 and 7 years with reference category 'low consumption'. RESULTS: Based on the report from their parents, 5-year-old children drank on average 3.0 (SD:1.4) sweet beverage per day. Children consumed less sweet beverages at age 7 years (beta -0.16, 95% confidence interval [CI] -0.24 to -0.09) when there were less sweet beverages available at home. The multinomial regression model showed that children with parents who discouraged sweet beverage consumption were more likely to decrease their sweet beverage consumption over the study period (odds ratio: 1.24, 95% CI 1.07 to 1.43). Moreover, when there were less sweet beverages available at home, children were less likely to increase their consumption or have a high consumption over the study period (odds ratio: 0.70, 95% CI 0.59 to 0.83 and 0.61, 95% CI 0.54 to 0.70, respectively). CONCLUSIONS: The results showed that characteristics of the home environment are associated with the consumption of sweet beverages among children. Specifically, the availability of sweet beverages at home is associated with the child's sweet beverage consumption.

Home environmental determinants of children's fruit and vegetable consumption across different SES backgrounds.

OBJECTIVE: To investigate the association between home environmental determinants of fruit and vegetable consumption with childhood overweight separately for low, medium and high social economic status (SES) families. METHOD: A cross-sectional study was carried out in 2006 among 4072 children aged 4-13 years in the city of Zwolle, the Netherlands. Of these children, data were available on measured height and weight, and from a parental questionnaire, on sociodemographic characteristics and children's fruit and vegetables intake. Associations were studied using logistic regression analyses. RESULTS: Not eating the recommended amounts of vegetables daily was associated with overweight for children with a low SES background (odds ratio [OR]: 1.17; 95% confidence interval [CI]: 0.66-2.07) and medium SES background (OR: 1.73; 95% CI: 1.20-2.49). Eating < 2 pieces of fruit daily was associated with a lower OR for overweight among children with a high SES background (OR: 0.66; 95% CI: 0.50-0.88). Determinants of eating vegetables < 7 d were: permission to take candy without asking, eating at the table < 7 d per week, eating a takeaway meal ≥ 1 d per week, eating a home cooked meal < 6 d per week and cooking together with caregiver less than 5 d per week. CONCLUSION: Interventions regarding vegetable consumption should be tailored to families with low and medium SES background. The most promising avenues for intervention seem to be (i) to prevent eating takeaway meals on a weekly basis and, (ii) to promote eating a home cooked meal at the table and (iii) to involve children in the cooking process. Interventions should support parents in making these home environmental changes.

Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings.

BACKGROUND: Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care. OBJECTIVES: To assess the effects of different interventions, targeted at health professionals or the structure in which they deliver care, on the management of patients with diabetes in primary care, outpatient and community settings. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register (Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999), Cinahl (1982-1999), and reference lists of articles. SELECTION CRITERIA: Randomised trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) analyses of professional, financial and organisational strategies aimed at improving care for people with Type 1 or Type 2 diabetes. The participants were health care professionals, including physicians, nurses and pharmacists. The outcomes included objectively measured health professional performance or patient outcomes, and self-report measures with known validity and reliability. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Forty-one studies were included involving more than 200 practices and 48,000 patients. Twenty-seven studies were RCTs, 12 were CBAs, and two were ITS. The studies were heterogeneous in terms of interventions, participants, settings and outcomes. The methodological quality of the studies was often poor. In all studies the intervention strategy was multifaceted. In 12 studies the interventions were targeted at health professionals, in nine they were targeted at the organisation of care, and 20 studies targeted both. In 15 studies patient education was added to the professional and organisational interventions. A combination of professional interventions improved process outcomes. The effect on patient outcomes remained less clear as these were rarely assessed. Arrangements for follow-up (organisational intervention) also showed a favourable effect on process outcomes. Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients' health outcomes. REVIEWER'S CONCLUSIONS: Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes. Organisational interventions that improve regular prompted recall and review of patients (central computerised tracking systems or nurses who regularly contact the patient) can also improve diabetes management. The addition of patient-oriented interventions can lead to improved patient health outcomes. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment.

[Insulin resistance and diabetes type 2 in overweight children]. / Insulineresistentie en diabetes mellitus type 2 bij kinderen met overgewicht.

The prevalence of overweight and obesity in children is increasing significantly. This increase is attended by an increase in diabetes type 2 in children and adolescents. The most important risk factor for the rise of insulin resistance amongst young people is overweight. The diagnostic criteria for diabetes mellitus in young people are: (a) symptoms of diabetes mellitus and a random plasma-glucose concentration of > or = 11.1 mmol/l, or (b) fasting plasma-glucose concentration of > or = 7.0 mmol/l, or (c) 2-hour plasma-glucose levels following an oral glucose-tolerance test > or = 11.1 mmol/l. Treatment involves lowering the glucose concentration by changes in lifestyle such as more physical exercise and dieting. In the US, metformin is registered for use in young people. Insulin is indicated in cases of serious hyperglycaemia or diabetic ketoacidosis. Early detection is very useful in obese children with two additional risk factors: diabetes type 2 in first- and second-degree relatives, members of certain ethnic groups or indications of insulin resistance.

[Overweight and obesity in children and adolescents and preventative measures]. / Overgewicht en obesitas bij kinderen en adolescenten en preventieve maatregelen.

The prevalence of overweight and obesity in children is increasing rapidly. This is alarming because obesity is associated with severe chronic diseases, such as type 2 diabetes mellitus. Obesity at young age is related to obesity at adult age. Consequently, the prevention of overweight from childhood onwards is an important issue. Apart from diabetes mellitus type 2 there is an increased risk of orthopaedic complications, respiratory problems, fertility problems, cardiovascular diseases and psychosocial consequences in the form of a negative self-image, emotional and behavioural problems and depression. Environmental and behavioural factors are regarded as the most important causes of the rapid increase in the prevalence of overweight and as the most important starting points for prevention. Most prevention programmes are still in the initial stages. Prevention programmes aimed at stimulating breast feeding and daily physical activity (playing outside) and the restriction of sweetened drinks and watching TV are very promising. With such preventive measures the involvement of both the school and the parents is important.

[Television watching and some eating habits of 6-14-year-old children in Amsterdam, the Netherlands; a cross-sectional study]. / Televisiekijken en enkele eetgewoonten bij Amsterdamse 6-14-jarigen; een transversaal onderzoek.

OBJECTIVE: To describe the time spent by children between the ages of 6-14 years watching television during a weekday and to examine associated factors. DESIGN: Cross-sectional questionnaire study. METHOD: Data were collected during a vaccination campaign against meningococci C in Amsterdam in September 2002. From a sample of 2910 parents of 6-14-year-old children 1775 agreed to participate in the study. Socio-demographic characteristics and data on television viewing the previous day, the presence of a television in the child's bedroom and on eating habits were collected by short interviews. RESULTS: In total 1587 children were included in the analyses, 805 boys and 782 girls. In total 40.1% of the boys and 36.5% of the girls had watched television for > or = 2 h during the previous day. Among the children < or = 10 years 28.7% had a television in their bedroom, among children > 10 years this was 45.7%. Age (> 10 years), ethnicity (notably Surinam origin) and having a television in the bedroom was related to spending more time watching television. Having parents with a high socioeconomic status (SES) was associated with less television viewing than having parents with a lower SES. Children who had not eaten fresh fruit or who had visited a snackbar the previous day had been watching television for > or = 2 h more often than children who had eaten fresh fruit (p < 0.001) or who had not visited a snackbar (p < 0.05). CONCLUSION: Children spent a lot of time watching television. In view of the relation between television viewing and overweight this is an alarming development. Possibilities for the prevention of overweight by reducing television viewing must be investigated.

Factors associated with the timing of introduction of complementary feeding: the Generation R Study.

BACKGROUND/OBJECTIVES: Many parents do not follow recommendations for the timing of introduction of complementary feeding. The aim of this study was to identify determinants associated with the timing of introduction of complementary feeding in a multiethnic birth cohort. SUBJECTS/METHODS: Subjects were 3561 mothers and infants participating in a prospective cohort study. The timing of introduction of complementary feeding and maternal and infant characteristics were obtained by parent-derived questionnaires. Regression analyses were performed to identify determinants for the timing of introduction of complementary feeding (<3, 3-6 and ≥ 6 months). RESULTS: In total, 62% of infants were introduced to complementary feeding before the age of 6 months. Determinants for very early (<3 months) introduction were being a single parent and infant day care attendance. Determinants for early (3-6 months) introduction were young maternal age, multiple parities, no infant family history of asthma, atopy and no infant history of allergy to cow's milk. Determinants for both very early and early introduction were low educational level and not fully breastfeeding for 4 months. Maternal educational level was only significantly associated with the timing of introduction in mothers of Western origin. CONCLUSIONS: This study confirmed determinants for the timing of introduction of complementary feeding that have been identified by previous studies, which may be appropriate targets for education and guidance. Moreover, mothers whose infants attend day care and have a family history of asthma, atopy or allergy to cow's milk may need guidance to follow infant feeding recommendations.

Body size and growth in 0- to 4-year-old children and the relation to body size in primary school age.

Excess weight in early life is believed to increase susceptibility to obesity, and in support of such theory, excess weight and fast weight gain in early childhood have been related to overweight later in life. The aim of this study was to review the literature on body size and growth in 0- to 4-year-old children and the association with body size at age 5-13 years. In total, 43 observational studies on body size and/or growth were included, of which 24 studies had been published in 2005 or later. Twenty-one studies considered body size at baseline, and 31 studies considered growth which all included assessment of weight gain. Eight (38%) studies on body size, and 15 (48%) on weight gain were evaluated as high-quality studies. Our results support conclusions in previous reviews of a positive association between body size and weight gain in early childhood, and subsequent body size. Body size at 5-6 months of age and later and weight gain at 0-2 years of age were consistently positively associated with high subsequent body size. Results in this review were mainly based on studies from developed Western countries, but seven studies from developing countries showed similar results to those from developed countries.