Secular trends in mental health problems among young people in Norway: a review and meta-analysis.

There is a growing concern that the mental health of recent generations of youth is deteriorating, yet the etiology of these secular changes is not fully understood. We aimed to review the evidence on trends in mental health problems among young people in Norway. Seven large-scale repeated cross-sectional studies were included in this study, comprising 35 cross-sectional data collections between 1992 and 2019, with a total sample of 776,606 young people. Our study found a clear increase in mental health problems among young females in Norway over the past few decades, while the trends were less marked for males. The proportion of individuals scoring above the problematic symptom score threshold increased on average by 11.2% (range 2.2% to 21.9%) for females and 5.2% (range - 0.9% to 11.1%) for males, based on data from the individual studies. The results from a meta-regression analysis showed that across all surveys, mean symptom scores increased by 17% (95% CI 12 to 21%) among females and 5% (95% CI 1 to 9%) among males from 1992 to 2019. Overall, mental health problems have increased continually since the early 1990s among young people, especially among young females. The cause of these secular changes remains unknown but likely reflect the interplay of several factors at the individual and societal level.Protocol registration: Open science framework, November 8, 2021 ( https://osf.io/g7w3v ).

Associations between family structure and adolescents' food habits.

OBJECTIVE: To investigate family structure differences in adolescents' consumption of fruit, vegetables, sweets and sugar-added soft drinks with adjustments for socio-demographic and socio-economic variables. DESIGN: Cross-sectional data from the Health Behaviour in School-aged Children survey. SETTING: Norwegian primary and secondary schools. PARTICIPANTS: Adolescents (n 4475) aged 11, 13, 15 and 16 years. RESULTS: After adjusting for covariates, living in a single-mother family was associated with lower vegetable consumption (OR 0·76, 95 % CI 0·63, 0·91) and higher soft drink consumption (OR 1·29, 95 % CI 1·06, 1·57). Living in a mother and stepfather family was negatively associated with fruit (OR 0·71, 95 % CI 0·54, 0·95) and vegetable (OR 0·72, 95 % CI 0·54, 0·97) consumption. Living in a single-father family was associated with lower sweets consumption (OR 0·48, 95 % CI 0·32, 0·72). No significant interactions were demonstrated between family structure and socio-demographic or socio-economic covariates. CONCLUSIONS: The study suggests that an independent association between family structure and adolescents' food habits exists.

Mental health symptoms during the first months of the COVID-19 outbreak in Norway: A cross-sectional survey study.

BACKGROUND: The COVID-19 pandemic has led to major social and economic changes that could impact public mental health. The main aim of the current study was to investigate mental health in Norway during the COVID-19 outbreak (since the first confirmed case on 26 February 2020). METHODS: The results are from the first wave of the data collection (1 April-2 June 2020), which took place during the outbreak along with its initial restrictions. A total of 19,372 (11,883 students) people participated in a cross-sectional web-based survey. RESULTS: A total of 21.8% scored above the cut-off for depression and 23.7% for anxiety. Severity of symptoms was associated with the accumulation of risk factors, such as possible/confirmed infection for oneself or one's family, female/other sex, students, having mental health problems, increased use of tobacco, increased use of alcohol, less exercise, losing one's job, suffering economic impact and lower education. CONCLUSIONS: COVID-19 could have a negative association with public mental health, especially for certain risk groups. Future data-collection waves will provide further insight into the development of symptoms following the pandemic.

How to evaluate the effect of seven years of the Norwegian School Fruit Scheme (2007-2014) on fruit, vegetable and snack consumption and weight status: A natural experiment.

Aim: From August 2007 to June 2014, the Norwegian School Fruit Scheme (NSFS) legally established that all pupils in junior high and combined schools (275,000 pupils every year), but not those in primary schools (343,000 pupils every year), were entitled to a free piece of fruit or vegetable every school day. The NSFS is a natural experiment, unique in terms of scope and lengthiness. Such governmental efforts to improve the diet of the public are rarely evaluated. Thus, an evaluation of the comprehensive, well-designed NSFS is warranted. The aim was to describe how the NSFS can be evaluated using existing data sets. Methods: Four data sets have been identified for the evaluation of the NSFS: (a) the Nord-Trøndelag Health Study, (b) the Norwegian Mother and Child Cohort Study, (c) the Norwegian Child Growth Study/Growth in Teenagers and (d) Health Behaviour in School Aged Children. These comprehensive studies have collected cross-sectional or longitudinal data providing information about children's dietary consumption and/or weight status, which can be utilised in the evaluation of the NSFS. Both short- and long-term effects of the NSFS related to dietary habits and weight status and the potential effect of moderators such as socio-economic status, sex, ethnicity and the age of children and adolescents can be studied. Conclusions: Worldwide, there is a lack of well-designed, long-term studies evaluating the impact of governmental efforts to improve public diet. The present study describes how the NSFS can be evaluated using data from four large data sets on eating habits and weight status.

Associations between family structure and young people's physical activity and screen time behaviors.

BACKGROUND: Identifying factors that can influence young peoples' physical activity and sedentary behaviors is important for the development of effective interventions. The family structure in which children grow up may be one such factor. As the prevalence of single parent and reconstituted families have increased substantially over the last decades, the objective of this study was to examine whether these family structures are differentially associated with young people's MVPA, participation in organized sports and screen-time activities (screen-based passive entertainment, gaming, other screen-based activities) as compared to traditional nuclear families. METHODS: The data stem from the 2013/2014 "Health Behaviour in School- aged Children (HBSC) study". A large Norwegian sample of 11-16 years old students (n = 4509) participated. Cluster-adjusted regression models were estimated using full information maximum likelihood with robust standard errors (MLR). RESULTS: After adjusting for covariates, living with a single parent was negatively associated with days/week with 60 min MVPA (b = -.39, 95%CI: -.58, -.20), and positively associated with hours/weekday of total screen time (b = .50, 95%CI: .08, .93). Young people living with a single parent were also more likely to report no participation in organized sports (OR = 1.40, 95%CI: 1.09, 1.79). Living in a reconstituted family was negatively associated with days/week with 60 min MVPA (b = -.31, 95%CI: -.53, -.08), and positively associated with hours/weekday of total screen time (b = .85, 95%CI: .37, 1.33). For all outcomes, the interaction effects of family structure with sex, and with having siblings were not statistically significant. For material affluence, a significant interaction effect was found for participation in organized sports (χ2 [4] =13.9, p = .008). Those living in a reconstituted family with low or high material affluence had an increased risk for not participating in organized sports whereas those with medium material affluence did not. CONCLUSION: This study suggests that living with a single parent or in reconstituted families was unfavorably associated with physical activity, sport participation and screen-based behaviors among Norwegian youth. The findings indicate that family structure could be an important factor to take into account in the development and testing of interventions. More in-depth research is needed to identify the mechanisms involved.

Daily Smoking and Subjective Health Complaints in Adolescence.

INTRODUCTION: Using data from the Health Behaviour in School-aged Children survey, this study used a repeated cross-sectional design to examine associations between daily smoking, gender, and self-reported health complaints in five cohorts of adolescents over a 16-year period. METHODS: Data were from nationally representative cohorts of 15-year-old youth in Norway in 1993/1994, 1997/1998, 2001/2002, 2005/2006, and 2009/2010 (n total = 7761). Dependent variables were psychological, somatic, and total health complaints. A mixed GLM model examined main and interaction effects of smoking (daily, intermittent, nonsmoking), year, and gender in predicting complaints. Time periods were segmented to compare trends across smoking groups in specific periods. RESULTS: Prevalence of daily smoking declined from 15.5% (1993/1994) to 6.0% (2009/2010). All health complaint scores were significantly higher for smokers and for girls (vs. boys). Smoking status by year interactions were significant for all complaint variables during the period of sharpest decline of daily smoking prevalence (2001/2002-2005/2006), with daily smokers experiencing increases in health complaints while intermittent and nonsmokers did not. Smoking status by gender interactions were significant for all health complaint variables, indicating that the main effect for gender (females higher) was even stronger among smokers compared with nonsmokers. Using year as unit of analysis, the size of mean differences between daily smokers and intermittent/nonsmokers in total complaints was significantly negatively correlated with daily smoking prevalence (-.963, n = 5, p < .01). CONCLUSIONS: As prevalence of daily smoking declined, daily smokers reported higher levels of complaints, suggesting increasing health problems within this group. Girls who smoke daily had particularly elevated levels of complaints. IMPLICATIONS: This study indicates that the relationship between daily smoking and concurrent health symptomatology in adolescents is changing over time, with higher levels of health complaints reported as overall smoking prevalence declines. To our knowledge, this finding has not previously been reported. If youth are smoking to cope with distress, pain, or other health concerns, tobacco control objectives will be increasingly difficult to achieve with adolescents. Levels of health complaints are particularly high among girls who are daily smokers. The findings suggest that restrictive measures and persuasive communications may not be sufficient tobacco prevention strategies for adolescent populations. Young smokers may need counseling and support.

Psychometric properties of the five-item version of the Mindful Awareness Attention Scale (MAAS) in Norwegian adolescents.

OBJECTIVES: The aim of the present study was to examine the factor structure, model-based reliability, measurement invariance and concurrent validity of the five-item version of the Mindfulness Attention Awareness Scale (MAAS) in Norwegian adolescents. METHODS: An initial pilot study was carried out using a sample of 77 fifteen year olds. For the main analyses, a sample of 2140 Norwegian adolescents was used who participated in the cross-sectional Health Behaviour in School-Aged Children (HBSC) study. All participants were asked to complete a questionnaire. RESULTS: Confirmatory factor analyses found support for the one-factor structure of the five-item version of the MAAS. Acceptable model fit was found in both the pilot sample (χ2=6.48, df=5, p=0.26; root mean square error of approximation [RMSEA]=0.06; comparative fit index [CFI]=0.99; standardised root mean square residual [SRMR]=0.03) and the HBSC sample (χ2=27.1, df=4, p<0.001; RMSEA=0.05; CFI=0.99; SRMR=0.01). The model-based reliability of the scale was good (ω=0.84 and ω=0.81, respectively). Scalar measurement invariance was established for sex, age and material affluence. Finally, the five-item MAAS displayed concurrent validity through moderate negative associations with health complaints ( r=-0.44; p<0.001) and school stress ( b=-0.44, p<0.001), and a positive moderate correlation with life satisfaction ( r=0.26; p<0.001). CONCLUSIONS: The five-item version of the MAAS is an adequate measure of mindfulness in Norwegian adolescents. Due to the brief nature of the scale, it can easily be included in epidemiological and clinical studies with an interest for trait mindfulness. The five-item MAAS may therefore have great potential to facilitate more knowledge about the role of mindfulness in adolescent health.

Reduction in sick leave by a workplace educational low back pain intervention: A cluster randomized controlled trial.

AIMS: The aim of this study was to investigate whether a workplace educational low back pain intervention had an effect on sick leave at the individual level and to identify possible predictors of the effect of intervention. METHODS: Work units in two municipalities were cluster randomized to (a) educational meetings and peer support (45 units), (b) educational meetings, peer support and access to an outpatient clinic if needed (48 units) or (c) a control group (42 units). Both intervention groups attended educational meetings with information about back pain based on a non-injury model. A peer adviser was selected from among their colleagues. The outcome was days of sick leave at the individual level at 3, 6, 9 and 12 months, adjusting for previous sick leave at the unit level. As a result of similar effects on sick leave, the two intervention groups were merged (n=646) and compared with the control group (n=211). The predictors were different levels of belief in back pain myths, pain-related fear, helplessness/hopelessness and low back pain. RESULTS: The intervention group had significantly less days of sick leave at the three month (4.9 days, p=0.001) and six month (4.4 days, p=0.016) follow ups compared with the control group. At three months, a low level of pain-related fear was the only predictor for the intervention effect (8.0 less days of sick leave, p<0.001). CONCLUSIONS A WORKPLACE EDUCATIONAL BACK PAIN INTERVENTION HAD AN EFFECT ON SICK LEAVE FOR UP TO SIX MONTHS A LOW SCORE ON PAIN-RELATED FEAR WAS A PREDICTOR OF THE INTERVENTION EFFECT.

The assessment of ongoing community-based interventions to prevent obesity: lessons learned.

BACKGROUND: The assessment of real-life, community-based interventions to tackle obesity is an important step in the development of effective policies. Especially multi-level interventions have a high likely effectiveness and potential reach in counteracting the obesity epidemic. Although much can be learned from these initiatives, performing an evaluation of such interventions is challenging. The aim of the current article is to provide a descriptive overview of the data collection process and general results of an assessment of ongoing multi-level obesity prevention community interventions for adults in Europe, and the lessons learned from this effort. METHODS: The data collection was divided into two main phases: a) finding the ongoing obesity prevention interventions by contacting key informants in each of the European Union countries and the European Economic Area, and searching existing databases; and b) collecting detailed information (including the reach, effectiveness, adoption, implementation and maintenance (RE-AIM)) of the selected interventions using questionnaires for informants in each of the interventions. RESULTS: A total of 78 interventions from 24 European countries were included in the final sample. The number of identified interventions varied greatly per country. The interventions covered various implementation levels (national, regional or local) and determinants (physical, sociocultural, economic, political), mostly addressing both nutrition and physical activity behaviours. CONCLUSIONS: We found that many multi-level obesity prevention interventions among adults are currently active in Europe, although we found relatively few in Southern and Eastern Europe. Identifying interventions and obtaining detailed information proved to be a difficult, time consuming and painstaking process. We discuss some of the reasons why this might be the case and present recommendations based on our experiences. We suggest that future research uses a step-wise approach, keeping participant burden to a minimum. The use of personalised and tailored strategies is recommended, led by researchers who exercise flexibility, tact and patience during the data collection process.

Are associations between electronic media use and BMI different across levels of physical activity?

BACKGROUND: The use of electronic media has been found to be a risk factor for higher BMI and for being overweight. Physical activity has been found to be associated with lower BMI and lower risk for being overweight. Little is known about whether the associations between physical activity and electronic media use are additive or interactive in predicting BMI and risk for overweight among adolescents. METHODS: The data used in this study stem from the 2009/2010 survey of "Health Behaviour in School-aged Children (HBSC) study: A WHO Cross-National Survey. The sample consisted of 107184 13 and 15 year students from 30 different countries. Multilevel regression models were used to produce the presented estimates. RESULTS: Overall, 18% of boys and 11% of girls were classified as overweight. EM use was found to be associated with increased BMI z-scores and odds for overweight among both boys and girls who did not comply with physical activity guidelines. Among physically active adolescents, EM was found to be significantly associated with BMI or odds for overweight among girls, but not among boys. CONCLUSION: While the usage of EM appear to be inconsequential for BMI and the risk of overweight among physically active boys, we find evidence indicating that EM use is associated with BMI and risk for overweight among girls, including those who report complying with MVPA guidelines.

Trend analyses in the health behaviour in school-aged children study: methodological considerations and recommendations.

BACKGROUND: This article presents the scope and development of the Health Behaviour in School-aged Children (HBSC) study, reviews trend papers published on international HBSC data up to 2012 and discusses the efforts made to produce reliable trend analyses. METHODS: The major goal of this article is to present the statistical procedures and analytical strategies for upholding high data quality, as well as reflections from the authors of this article on how to produce reliable trends based on an international study of the magnitude of the HBSC study. HBSC is an international cross-sectional study collecting data from adolescents aged 11-15 years, on a broad variety of health determinants and health behaviours. RESULTS: A number of methodological challenges have stemmed from the growth of the HBSC-study, in particular given that the study has a focus on monitoring trends. Some of those challenges are considered. When analysing trends, researchers must be able to assess whether a change in prevalence is an expression of an actual change in the observed outcome, whether it is a result of methodological artefacts, or whether it is due to changes in the conceptualization of the outcome by the respondents. CONCLUSION: The article present recommendations to take a number of the considerations into account. The considerations imply methodological challenges, which are core issues in undertaking trend analyses.

Cross-national trends in perceived school pressure by gender and age from 1994 to 2010.

BACKGROUND: Pressure within school can be a critical component in understanding how the school experience influences young people's intellectual development, physical and mental health and future educational decisions. METHODS: Data from five survey rounds (1993/1994, 1997/1998, 2001/2002, 2005/2006 and 2009/2010) were used to examine time-, age- and gender-related trends in the amounts of reported school pressure among 11-, 13- and 15-year-olds, in five different regions (North America, Great Britain, Eastern Europe, Nordic and Germanic countries). RESULTS: Across the regions the reported perceptions of school pressure did not change between 1994 and 2010, despite a temporary increase in 2002 and 2006. With the exception of children at 11 years of age, girls reported higher levels of school pressure than boys (Cohen's d from 0.12 to 0.58) and school pressure was higher in older age groups. These findings were consistent across countries. Regionally, children in North America reported the highest levels of school pressure, and students in the Germanic countries the lowest. CONCLUSION: Factors associated with child development and differences in societal expectations and structures, along with the possible, albeit, differential impact of the Programme for International Student Assessment (PISA), may partially explain the differences and trends found in school pressure. School pressure increases alongside the onset of adolescence and the shift from elementary school to the higher demanding expectations of secondary education. Time-related increases in school pressure occurred in the years following the release of the PISA results, and were larger in those regions in which results were less positive.

A school based study of time trends in food habits and their relation to socio-economic status among Norwegian adolescents, 2001-2009.

BACKGROUND: In recent years, adolescents' food habits have become a major source of concern, and substantial policy and intervention efforts have been made to influence adolescents to consume more fruit and vegetables and less sweets and soft drink. Particular attention has been devoted to the social gradient in food habits, aiming to reduce dietary inequality. However, few internationally published studies have evaluated trends in teenagers' food habits, or investigated how dietary inequalities develop. METHODS: We used Norwegian cross-sectional data from the international Health Behaviour in School-Aged Children (HBSC) study, collected via three nationally representative and comparable questionnaire surveys in 2001, 2005 and 2009. Food habits were identified by students' consumption of fruit, vegetables, sweets and sugar rich soft drink. Socio-economic status (SES) was measured with the Family Affluence Scale (FAS). Multilevel logistic regression was used to analyze the data. RESULTS: The analyses indicated an overall positive trend in food habits among adolescents in Norway. Students were more likely to consume fruit (OR 1.76, CI 1.61-1.92) and vegetables (OR 1.51, CI 1.37-1.66) daily in 2005 as compared to 2001, and were less likely to consume sweets (OR 0.58, CI 0.51-0.66 resp. OR 0.77, CI 0.67-0.90) and soft drink (OR 0.55, CI 0.49-0.62 resp. OR 0.84, CI 0.73-0.96) daily when comparing, respectively, 2005 with 2001 and 2009 with 2005. Across all survey years, students with higher SES were more likely to eat fruit (OR 1.47, CI 1.32-1.65) and vegetables (OR 1.40, CI 1.24-1.58) daily than did students with lower SES. Our analyses indicated that the socio-economic differences were stable in the period 2002 - 2010, with uniform improvement in fruit and vegetable consumption across all SES levels. No significant associations between SES and intake of sweets and sugar-added soft drink were found. CONCLUSION: The study identifies an overall improvement in diet among adolescents over a period characterized by onset of as well as ongoing initiatives targeting young people's food habits. However, the observed socio-economic gradient in fruit and vegetable consumption remained unchanged.

Family structure and the association with physical activity-Findings from 40 countries participating in the Health Behaviour in School-aged Children (HBSC) study.

BACKGROUND: The family has been acknowledged as central to developing physical activity (PA) beliefs and behaviours. However, increased diversity in family structures has developed over the last decades. This study examines the association between family structure and PA among adolescents and cross-national variations in the associations. METHODS: The data are from the 2013/14 Health Behaviours in School-Aged Children study, involving nationally representative samples of 11-, 13- and 15-year-olds (n = 211,798) from 40 countries. Multilevel Poisson regression analysis was used to examine the associations between family structure and moderate to vigorous physical activity (MVPA) and vigorous physical activity (VPA) by age, gender, socioeconomic status (SES), and geographic region. RESULTS: Living with one versus two parents was associated with a reduced likelihood of daily 60 min MVPA for boys (IRR = 0.96, 95% CI: 0.92, 0.99) and ≥ 4 times/week VPA (IRR 0.93, 95% CI: 0.91, 0.95). This impact on MVPA differed across individual-level SES (high SES; IRR = 0.92, (p <0.05), low SES; IRR = 1.04, (ns)), and was for VPA only significant for those with siblings (IRR = 0.93, 95% CI: 0.91, 0.96). Cross-country variations in the association between living with one versus two parents were observed, most pronounced for VPA. These differences varied by region, primarily explained by country-level SES differences between regions. The likelihood of daily 60 min MVPA also increased with siblings in the main house (IRR 1.11, 95% CI: 1.07, 1.14), and ≥ 4 times/week VPA decreased with grandparents in the main house (IRR 0.91, 95% CI: 0.89,0.94). CONCLUSIONS: Family structure correlated with PA, but cross-country differences exist. The findings are relevant for the development of policies and programs to facilitate PA, especially in countries where living with one versus two parents was unfavourable. Additional country-specific research is needed to identify challenges for engaging in PA related to family structure.

Body-related concerns and participation in physical education among adolescent students: the mediating role of motivation.

Background: There is a need to understand better factors influencing participation in physical education (PE) and the mechanisms involved. The adolescent years are characterised by increasing levels of body-related concerns. In PE, the body is judged for its physical abilities and subject to social comparisons and body judgements. Grounded in the Self-Determination Theory, this study aimed to explore whether body-related factors were associated with adolescents' involvement in PE and whether types of motivation mediated this relationship. Methods: The study involved 2,140 (54.5% girls) secondary students (15-16-year-olds) from Norway participating in the nationally representative "Health Behaviour in School-aged Children (HBSC) study: a WHO collaborative cross-national study." Body-related factors included Body Mass Index (BMI), health complaints, body perception and dietary behaviours. Gender, age, and socioeconomic status (family affluence) were control variables. Motivation for PE was assessed with the Perceived Locus of Causality (PLOCQ) scale measuring three distinct factors: autonomous motivation, controlled motivation and amotivation. PE involvement was self-reported as weekly participation in PE classes and time spent in moderate-to-vigorous physical activity (MVPA) during PE. Results: Gender (girl), family affluence, health complaints, not being on a diet but wanting to lose weight, and body perception (too fat) were negatively associated with weekly PE participation when adjusting for other variables. This association was largely explained by students' autonomous motivation in the case of health complaints and partly in the case of dietary behaviour and body perception. Similar results were observed for MVPA during PE lessons. Additionally, gender was associated with MVPA through amotivation. Conclusion: The study adds new knowledge to the understanding of the relationship between body-related factors and PE, supporting that autonomous motivation is a central mechanism and an avenue for further research. The results should be considered in planning high-quality PE classes and suggest that an autonomous supportive learning climate sensitive to body-related concerns should be a priority to increase adolescent involvement in PE.

Ethical considerations in engaging young people in European obesity prevention research: The CO-CREATE experience.

Engaging youth in obesity prevention research and policy action is essential to develop strategies that are relevant and sensitive to their needs. Research with young people requires critical reflection to safeguard their rights, dignity, and well-being. The CO-CREATE project used various methods to engage approximately 300 European youth aged 15-19 years in the development of policies to prevent adolescent obesity. This paper discusses ethical considerations made in the project pertaining to the youth's voluntary participation, their protection from obesity stigma, respect for their time, data privacy and confidentiality, power balance, and equality of opportunity to participate in the research. We describe measures implemented to prevent or limit the emergence of ethical challenges in our interaction with youth and discuss their relevance based on our experience with implementation. While some challenges seemingly were prevented, others arose related to the youth's voluntary participation, time burdens on them, and the sustainability of participation under the Covid-19 pandemic. Concrete and ongoing ethical guidance may be useful in projects aiming to interact and build collaborative relationships with youth for long periods of time.

Understanding the dynamics emerging from the interplay among poor mental wellbeing, energy balance-related behaviors, and obesity prevalence in adolescents: A simulation-based study.

Both obesity and poor mental wellbeing have a high prevalence in European youth. Adolescents in six countries identified mental wellbeing factors as main drivers of youth obesity through systems mapping. This study sought to (1) explore the dynamics of the interplay between poor mental wellbeing, energy balance-related behaviors, and adolescent overweight and obesity prevalence and (2) test the effect of intervention point scenarios to reduce adolescent obesity. Drawing on the youth-generated systems maps and a literature synthesis, we built a simulation model that represents the links from major feedback pathways for poor mental wellbeing to changes in dietary, physical activity, and sleep behaviors. The model was calibrated using survey data from Norway, expert input, and literature and shows a good fit between simulated behavior and available statistical data. The simulations indicate that adolescent mental wellbeing is harmed by socio-cultural pressures and stressors, which trigger reinforcing feedback mechanisms related to emotional/binge eating, lack of motivation to engage in physical activity, and sleep difficulty. Targeting a combination of intervention points that support a 25% reduction of pressure on body image and psychosocial stress showed potentially favorable effects on mental wellbeing-doubling on average for boys and girls and decreasing obesity prevalence by over 4%.

Overweight and obesity prevention for and with adolescents: The "Confronting obesity: Co-creating policy with youth" (CO-CREATE) project.

The CO-CREATE project focuses on the need for research on obesity prevention in adolescents to move away from studies of single interventions, toward the investigation of systems-based research incorporating youth involvement. This paper provides an overview of the project, presenting the objectives, design, and novel methodologies applied, as well as findings to date and anticipated outcomes. Adolescents (16-18 years old) in five European countries participated. Methods applied in the project include monitoring and benchmarking of policies, systematic literature reviews, epidemiological surveillance, linking observed overweight and obesity trends to observed policy landscapes, group model building to identify perceived drivers of obesity, alliance building with adolescents, dialog with stakeholders, and system dynamics modelling to explore the potential impact of policy options. Outcomes include tools for developing policy ideas and investigation of prevention strategies with adolescents, including policy databases, system maps of drivers of obesity, protocols for organizing youth alliances, an intergenerational policy dialog tool, and system dynamic models exploring the impacts of cocreated policy ideas. These outcomes make an important contribution to building a pan-European infrastructure for designing and evaluating policies and for providing youth with the opportunity to make their voices heard in the development and implementation of obesity prevention measures.

Encouraging greater empowerment for adolescents in consent procedures in social science research and policy projects.

The United Nations Convention on the Rights of the Child emphasizes the importance of allowing children and adolescents to influence decisions that are important to them following their age and maturity. This paper explores the principles, practices, and implications around using parental versus child/adolescent consent when participating in social science research and policy development. Experiences from two studies are presented: The Confronting Obesity: Co-creating policy with youth (CO-CREATE) and the Health Behaviour in School-aged Children (HBSC) study, a World Health Organization (WHO) Collaborative Cross-National study. Although parental consent may be an important gatekeeper for protecting children and adolescents from potentially harmful research participation, it may also be considered an obstacle to the empowerment of children and adolescents in case they want to share their views and experiences directly. This paper argues that evaluation of possible harm should be left to ethics committees and that, if no harm related to the research participation processes is identified and the project has a clear perspective on collaborating with the target group, adolescents from the age of 12 years should be granted the legal capacity to give consent to participate in the research project. Collaboration with adolescents in the development of the research project is encouraged.

Family affluence and cultural capital as indicators of social inequalities in adolescent's eating behaviours: a population-based survey.

BACKGROUND: Dietary inequality, via socio-economic inequality, may involve several mechanisms. Different aspects of adolescents' socio-economic circumstances should therefore be considered in order to make effective interventions to promote healthy eating in the young population. Indicators designed to tap socio-economic status among adolescents in particular will facilitate a better understanding of the concept of socio-economic status and how it influences health behaviour among young people. The purpose of this study was to evaluate if material capital and cultural capital individually and independently contribute to the prediction of eating habits in the Norwegian adolescent population. METHODS: The analysis is based on survey data from the Health Behaviour in School-Aged Children study. The Family Affluence Scale (number of cars, holidays, PC and bedrooms) and number of books in the household were used as indicators of socio-economic status, respectively measuring material capital and cultural capital. Their influence on adolescent's consumption of fruit, vegetables, sweets, soft drinks, and consumption of breakfast and dinner was evaluated. Pearson's correlation, logistic regression and ridit transformation analysis were used to analyse the data. RESULTS: Higher family affluence was shown to predict consumption of more fruit (OR 1.52) and vegetables (OR 1.39) and consumption of breakfast (OR 1.61) and dinner (1.35). Cultural capital was significantly associated to consumption of fruit (OR 1.85), vegetables (OR 2.38) sweets (OR .45), sugary soft drinks (OR .26), breakfast (OR 2.13) and dinner (OR 1.54). Cultural capital was the strongest predictor to healthy eating among adolescents in Norway. CONCLUSIONS: Material capital and cultural capital individually and independently contributed to the prediction of healthy eating patterns among adolescents in Norway. Cultural capital is an understudied dimension of the socio-economic status concept and the influence on health behaviour needs to be explored in future studies. Initiatives to promote healthy eating should focus on education, habits and consciousness of a healthy diet, but also at reducing the high cost of fruit and vegetables. There is further a need for developing appropriate indicators for adolescent socio-economic status.