Randomised Controlled Trial of a Customised Text Messaging and Activity Monitor Program for Lifestyle Improvement after Gestational Diabetes.

Gestational diabetes (GDM) is associated with a long-term risk of diabetes. We aimed to determine whether a text-messaging-based lifestyle support program would improve diabetes risk factors following GDM. Women with GDM were randomised following delivery to receive four text messages per week supporting a healthy lifestyle and parenting for 6 months, with feedback from an activity monitor (intervention), or to receive the activity monitor only (control). The primary outcome was a composite of weight, physical activity and dietary goals. There were 177 women randomised, with 88 intervention and 89 control participants. All the participants experienced COVID-19 lockdowns during the study. Six-month primary outcome data were obtained for 57 intervention participants and 56 controls. There were 7/57 (12%) intervention and 6/56 (11%) control participants who met the primary outcome (relative risk, 1.08; 95%CI, 0.63-1.85; p = 0.79). Two intervention participants met the dietary goals compared to none of the control participants (p = NS). The intervention participants were more likely to record >1000 steps/day (on 102 ± 59 vs. 81 ± 59 days, p = 0.03). When analysed monthly, this was not initially different but became significant 3-6 months post-partum. Interviews and surveys indicated that with the Intervention, healthier choices were made, but these were negatively impacted by COVID-19 restrictions. Participants found the messages motivational (74%) and the activity monitor useful (71%). In conclusion, no improvement in the diabetes risk factors occurred among the women receiving the text messaging intervention when affected by COVID-19 restrictions.

Household Food Insecurity and Changes in BMI Z-Score in a Pediatric Obesity Management Clinic.

BACKGROUND: Multicomponent lifestyle interventions are fundamental in pediatric obesity management. However, whether household food insecurity influences the efficacy of such interventions remains undocumented. OBJECTIVES: The objective was to compare changes in BMI z-score (BMIz) among children whose family received lifestyle counseling at a pediatric obesity management clinic in Montréal (Canada) according to their household food security status. METHODS: This is a retrospective, longitudinal analysis of medical records of children (2-17 y) with overweight or obesity who received lifestyle counseling at a pediatric obesity management clinic. The number of visits at the clinic and the duration of the follow-up were individualized. Household food security status was assessed using the Health Canada's Household Food Security Survey Module at the first visit at the clinic. BMIz was calculated and updated at each visit. A reduction of ≥0.25 in BMIz between the last and the first visit at the clinic was considered clinically meaningful. Statistical significance was considered at P < 0.05. RESULTS: Among the 214 children included in the study, 83 (38.8%) lived in a food insecure household. In multivariable-adjusted analyses, differences in BMIz between the last and the first appointment tended to be smaller among children who lived in a food insecure household than those in children living in a food secure household [ΔBMIzfood insecurity = -0.432 (95% CI: -0.672, -0.193) compared with ΔBMIzfood security = -0.556 (95% CI: -0.792, -0.319; P = 0.14)]. Differences were most notable in the first 6 mo of follow-up. The OR of achieving a clinically significant reduction in BMIz over follow-up associated with household food insecurity, compared with household food security, was 0.57 (95% CI: 0.31, 1.05; P = 0.07). CONCLUSIONS: In this sample of children followed up at a pediatric obesity clinic, those who lived in a food insecure household experienced smaller BMIz reductions than those who lived in a food secure household.

Two decades of diabetes prevention efforts: A call to innovate and revitalize our approach to lifestyle change.

The impact of global diabetes prevention efforts has been modest despite the promise of landmark diabetes prevention trials nearly twenty years ago. While national and regional initiatives show potential, challenges remain to adapt large-scale strategies in the real-world that fits individuals and their communities. Additionally, the sedentary lifestyle changes during the COVID-19 pandemic and guidelines that now call for earlier screening (e.g., US Preventative Task Force) will increase the pool of eligible adults worldwide. Thus, a more adaptable, person-centered approach that expands the current toolkit is urgently needed to innovate and revitalize our approach to diabetes prevention. This review identifies key priorities to optimize the population-level delivery of diabetes prevention based on a consensus-based evaluation of the current evidence among experts in global translational programs; key priorities identified include (1) participant eligibility, (2) intervention intensity, (3) delivery components, (4) behavioral economics, (5) technology, and (6) the role of pharmacotherapy. We offer a conceptual framework for a broader, person-centered approach to better address an individual's risk, readiness, barriers, and digital competency.

Qualitative Evaluation of a Comprehensive Online Wellness Program (MENTOR) Among People With Spinal Cord Injury.

People with spinal cord injury (SCI) experience a plethora of health conditions that hinder their health and wellness. This qualitative retrospective evaluation describes the perceptions of 14 peoples with SCI, several months after they completed an eight-week telewellness community program (MENTOR-Mindfulness, Exercise and Nutrition To Optimize Resilience). The program offered daily online classes that covered three core wellness domains (mindfulness, exercise, nutrition) and one health coaching session to introduce participants to eight other wellness domains (sleep, self-care, core values, arts & leisure, outdoor time in nature; spiritual practice, relationships, contribution to others). Qualitative analysis resulted in 4 themes related to program benefits, likes, and improvement recommendations. First, participants valued the program for the social support provided by a sense of community and relationship building with peers. Second, self-regulation was facilitated by the comprehensiveness of the program components, easy online access, and shared lifestyle goals for self-improvement among peers. Third, participants reported improved psychological wellbeing and adopted healthy behaviors that were maintained long after the program. Last, future programs should include flexible class times, post-program support, specific exercise adaptations for people with limited arm function, and supplementary in-person meetings. These preliminary findings demonstrate that MENTOR may benefit the wellbeing of people with SCI and warrant further study.

Development and Evaluation of a Measure for Social Support Provided by Friends during Lifestyle Management Programs.

Obesity is a public health crisis that contributes to chronic disease prevalence, morbidity, and mortality. Nutrition and physical activity are risk factors for many chronic diseases including cancer and cardiovascular disease, the leading causes of death in the United States. Lifestyle management programs to address obesity and potential sequelae such as chronic conditions have shown efficacy, with social support an important factor in interventions. Instruments that assess social support specifically provided by friends are lacking but could be important predictors of program success. The purpose of this study was to examine the reliability and validity of the 10-item Social Support to Eat Better and Move More instrument that was developed and designed to measure support from friends that influence dietary and physical activity behaviors during lifestyle management programs. Data were collected during a cross-sectional study using purposive sampling strategies among adult residents of two southern states. Statistical analysis was conducted to examine latent factors, internal consistency, and convergent and predictive validity. These preliminary results indicated that the Social Support to Eat Better and Move More instrument had excellent internal consistency for the overall measure (α = 0.96) as well as for informational support (α = 0.97), emotional support (α = 0.96), and encouragement (α = 0.97). The tool related well to another general social support measure as well as to diet, physical activity, and health-related variables, and it can be a useful measure in lifestyle management studies.

A randomized trial of a brief behavioral health lifestyle program for outpatient cardiology clinics.

Research on lifestyle programs for patients with coronary artery disease (CAD) has largely recruited from hospitals and/or recruited following acute coronary syndrome. By contrast, this study evaluated a 3-session behavioral health program for patients with stable CAD treated in an outpatient cardiology clinic. Thirty-three patients were randomized to the behavioral lifestyle intervention or to Treatment as Usual (TAU). A priori feasibility and acceptability criteria were met, and reliable change analyses revealed that at post-treatment and 30-day follow-up, significantly more intervention participants than TAU participants exhibited increased self-efficacy compared with baseline.

Evaluation of the Small Changes, Healthy Habits Pilot Program: Its Influence on Healthy Eating and Physical Activity Behaviors of Adults in Louisiana.

The community-based Small Changes, Healthy Habits (SCHH) program was developed to teach skills and techniques to help adults in Louisiana make and maintain small behavioral changes in their food selection, preparation, and consumption, and in physical activity routines. The content of this four-week program included habit formation and goal setting techniques; physical activity guidance; strategies for a healthier home food environment; a grocery store tour focused on label reading for healthier food selections; basic knife and cooking skills. The program was piloted at ten sites throughout the state. A survey with 14 core items was applied before and after the program to evaluate participant acquisition of skills and behaviors associated with topic areas. A total of 47 participants provided complete data sets. Post-program, these participants reported increased confidence in preparing healthy meals at home (p = 0.04); changes in fats (p = 0.03) and salt (p = 0.01) intake; increased frequency of reading nutrition labels (32%); decreased frequency of meals eaten outside the home (Improvement Index = 0.27); and decreased time/day spent sitting (p < 0.05). These short-term results suggest that the SCHH program has potential to positively affect healthy eating and to reduce sedentary behaviors, both of which are fundamental to good health and wellness.

Effects of the Health-Awareness-Strengthening Lifestyle Program in a Randomized Trial of Young Adults with an At-Risk Mental State.

BACKGROUND: Increasing health awareness in health promotion is considered as one of the less stigmatized interventions for improving help-seeking behaviors and total well-being. This study aimed to explore the short-term and long-term effectiveness of the health-awareness-strengthening lifestyle (HASL) program on Taiwanese young adults with at-risk mental state. METHODS: A pre- and post-test randomized trial was conducted on 92 young adults with at-risk mental state. The HASL program was provided to the experimental group as intervention, and it was only provided to the control group passively by request after the post-test for ethical reasons. The program was conducted once every six weeks, 60-90 min per session, for a total of three times. Mental health risk, anxiety level, health promotion lifestyles, quality of life, physiological index, and physical exercises were assessed one week before and after the program for both groups and followed up to 6 and 12 months for experimental group only. RESULTS: Compared to the control group, those in the experimental group showed significant improvements regarding anxiety level, health promotion lifestyles, and quality of life one week after participating in the program. Furthermore, the experimental group also showed an additional long-term positive effect on mental risk, physical exercises, and physical health after the follow-ups. CONCLUSIONS: The outcomes highlighted the interventions of the HASL program leading to more positive health effects on young adults with at-risk mental state. The implementation of similar clinical service is recommended for young adults with at-risk mental state.

Keeping our staff in mind: Dietary results of a lifestyle intervention targeting mental health staff.

ISSUES ADDRESSED: 1) Describe the dietary intake of mental health staff within South Eastern Sydney Local Health District and 2) Evaluate the impact of an individualised staff lifestyle program on the following nutrition parameters; (i) energy, (ii) core food groups and (iii) discretionary foods. METHODS: This was a pragmatic single-arm intervention study, conducted for all staff working in a public mental health service, in Sydney, Australia. A five-session individualised lifestyle intervention delivered over 5 weeks incorporated nutritional counselling delivered by a dietitian. Participants were assessed at baseline, following the intervention, and at follow-up using diet history to assess dietary intake. RESULTS: Eighty-eight staff completed the dietary intervention and follow-up. An intake of core food groups significantly below national recommendations was reported for total vegetables (-1.75 ± 0.14 serves, P < .001), fruit (-0.29 ± 0.11 serves, P = .01), grains (-1.25 ± 0.20 serves, P < .001) and dairy servings (-1.00 ± 1.08 serves, P < .001), and protein-based foods were significantly above national recommendations (0.2 ± 0.09 serves, P = .03). At completion of the program, energy from discretionary foods was reduced by 460 kJ (95% CI -635 to -285, P < .001), and the serves of total vegetables (0.91 serves, 95% CI 0.59-1.22, P < .001) and dairy (0.31 serves, 95% CI 0.11-0.50, P < .001) were increased significantly. CONCLUSIONS: A workplace-based well-being program for staff working in the mental health setting coincided with dietary improvements. SO WHAT: Mental health staff can act as positive role models for clients to promote developing positive physical health behaviours.

The Effect of a Family-Based Lifestyle Education Program on Dietary Habits, Hepatic Fat and Adiposity Markers in 8-12-Year-Old Children with Overweight/Obesity.

Healthy lifestyle education programs are recommended for obesity prevention and treatment. However, there is no previous information on the effects of these programs on the reduction of hepatic fat percentage. The aims were (i) to examine the effectiveness of a 22-week family-based lifestyle education program on dietary habits, and (ii) to explore the associations of changes in dietary intake with percent hepatic fat reduction and adiposity in children with overweight/obesity. A total of 81 children with overweight/obesity (aged 10.6 ± 1.1 years, 53.1% girls) and their parents attended a 22-week family based healthy lifestyle and psychoeducational program accompanied with (intensive group) or without (control) an exercise program. Hepatic fat (magnetic resonance imaging), adiposity (dual energy X-ray absorptiometry) and dietary habits (two non-consecutive 24 h-recalls) were assessed before and after the intervention. Energy (p < 0.01) fat (p < 0.01) and added sugar (p < 0.03) intake were significantly reduced in both groups at the end of the program, while, in addition, carbohydrates intake (p < 0.04) was reduced exclusively in the control group, and simple sugar (p < 0.05) and cholesterol (p < 0.03) intake was reduced in the exercise group. Fruit (p < 0.03) and low-fat/skimmed dairy consumption (p < 0.02), the adherence to the Mediterranean Diet Quality Index for children and teenagers (KIDMED, p < 0.01) and breakfast quality index (p < 0.03) were significantly higher in both control and intervention groups after the intervention. Moreover, participants in the exercise group increased the adherence to the Dietary Approaches to Stop Hypertension (DASH) diet (p < 0.001), whereas the ratio of evening-morning energy intake was significantly lower exclusively in the control group after the program (p < 0.02). Changes in energy intake were significantly associated with changes in fat mass index (FMI) in the exercise group, whereas changes in sugar-sweetened beverages (SSB) consumption was associated with percent hepatic fat reduction (p < 0.05) in the control group. A 22-week family-based healthy lifestyle program seems to be effective on improving diet quality and health in children with overweight/obesity and these should focus on SSB avoidance and physical activity.

The impact of health vs. non-health goals on individuals' lifestyle program choices: a discrete choice experiment approach.

BACKGROUND: Goals play an important role in the choices that individuals make. Yet, there is no clear approach of how to incorporate goals in discrete choice experiments. In this paper, we present such an approach and illustrate it in the context of lifestyle programs. Furthermore, we investigate how non-health vs. health goals affect individuals' choices via non-goal attributes. METHODS: We used an unlabeled discrete choice experiment about lifestyle programs based on two experimental conditions in which either a non-health goal (i.e., looking better) or a health goal (i.e., increasing life expectancy) was presented to respondents as a fixed attribute level for the goal attribute. Respondents were randomly distributed over the experimental conditions. Eventually, we used data from 407 Dutch adults who reported to be overweight (n = 212 for the non-health goal, and n = 195 for the health goal). RESULTS: Random parameter logit model estimates show that the type of goal significantly (p < 0.05) moderates the effect that the attribute diet has on lifestyle program choice, but that this is not the case for the attributes exercise per week and expected weight loss. CONCLUSIONS: A flexible diet is more important for individuals with a non-health goal than for individuals with a health goal. Therefore, we advise policy makers to use information on goal interactions for developing new policies and communication strategies to target population segments that have different goals. Furthermore, we recommend researchers to consider the impact of goals when designing discrete choice experiments.

"I'm Still on Track": A Qualitative Exploration of Participant Experiences of a Weight Loss Maintenance Program.

Qualitative evidence of participants' experiences of real-life weight loss maintenance programs is important for ongoing participant engagement and can inform program improvements. The purpose of this study was to understand how participants account for their engagement with a weight loss maintenance program and the role of the program in their weight management. A qualitative study using semi-structured interviews with 17 participants of a weight loss maintenance program was conducted; common themes were identified using a thematic inductive approach. Many participant narratives incorporated recurrent descriptions of their program experiences as a weight management journey. Our analysis generated four themes: returning to real life as a threat, the personal responsibility imperative, the program supporting agency and the program supporting self-regulation. The program, which provides external support and strategies, overlapped with the context of returning to real life and the personal responsibility imperative. Participant accounts of their journey at this intersection include the program supporting both agency and self-regulation which influences ongoing weight management. The interplay between themes identified and the maintenance program services allows compatibility between participants' sense of personal responsibility and the program components to help participants to 'stay on track' or 'get back on track'. In providing sufficient structure, opportunities to revisit successful strategies, and accountability, participants are empowered to overcome real-life threats and make positive health choices.

Short-term weight trajectories and long-term weight outcomes from a lifestyle intervention in real-world clinical practice.

Centers for Disease Control and Prevention aligned lifestyle change programs are effective in promoting weight loss among those with elevated cardiometabolic risk; yet, variability in weight outcomes among participants is high. Little is known about heterogeneity of short-term weight changes among participants in real-world clinical practice. We sought to identify short-term weight trajectory clusters among lifestyle change program participants in real-world clinical practice and to examine the relationship between cluster membership and long-term weight outcomes. We identified participants from the electronic health records (2010-2017) with weight measured ≤30 days prior to program initiation (baseline) and in four intervals (3-week segments) in the 12 weeks after baseline. Clustering analysis was performed to identify distinct trajectories in percent weight change over 12 weeks. Cluster-specific differences in weight change at 12 and 52 weeks were assessed. Among 1,148 participants, across 18 clinic sites, three clusters were identified: minimal-to-no weight loss (MWL), delayed-minimal weight loss (DWL), and steady-moderate weight loss (SWL), corresponding to mean weight changes of 0.4%, -2.3%, and -4.8% at 12 weeks follow-up, respectively. Mean weight changes were 0.4%, -1.8%, and -5.1% for MWL, DWL, and SWL clusters, respectively, at 52 weeks follow-up, which correlated in direction and magnitude with short-term weight changes. Clustering analysis reveals heterogeneous, short-term weight trajectories among lifestyle change program participants in real-world clinical practice. Given the relationship between the magnitudes of short- and long-term weight change, individual participant weight trajectories may be useful in identifying potential non-responders in need of adjunctive or alternative therapy.

Feasibility of a Group-Based, Facilitator-Directed Online Family Lifestyle Program.

OBJECTIVE: This study aimed to overcome barriers to access and attendance, and improve recruitment and engagement, through delivery and evaluation of the Parenting, Eating and Activity for Child Health (PEACH) child weight management program, as a facilitated group-based online healthy lifestyle program, PEACH Lifestyle. METHODS: Pre-post feasibility study of an online intervention comprising a website with 10 self-directed learning modules and 6 facilitated group-based video conferencing sessions with parents (n = 79) of children (7.9 ± 2.9 years, 25% healthy weight, 23% obese). RESULTS: Three enrollees were from remote locations. Half of the parents (n = 38) attended ≥1 video conferencing session (median = 3 participants per session [Range, 0-7]). Thirty percent (n = 7 of 21) completed all 10 online modules. Technical issues, time, and family commitments were barriers to engagement. CONCLUSIONS AND IMPLICATIONS: Reframing and delivering a weight management program as a healthy lifestyle program online in real-time did not address barriers to engagement in PEACH Lifestyle.

Telemedicine-Assisted Self-Management Program for Type 2 Diabetes Patients.

Background: Lifestyle interventions with personalized self-management programs have shown benefits for patients with type 2 diabetes mellitus (T2DM), a devastating highly prevalent disease worldwide. Despite advances in drug therapy and nonpharmacological strategies achieved in the past recent years, self-management programs to be implemented in everyday life are needed. The aim of the present prospective study was to evaluate the effects, in terms of glycated hemoglobin (HbA1c) values and self-management behavior, of a telemedicine-assisted self-management program offered to T2DM patients by a large private health insurance company. Methods: Participants with T2DM included 60 adults in the intervention group (M = 59.4 years) and 55 adults in the control group (M = 58.4 years). In the beginning of the study, the intervention group was provided with a tablet computer, a glucometer, and a step counter. Additionally, they received an individual need-based telephone coaching to address and improve motivation and diabetes self-management in daily life. The control group received care as usual and were not offered additional treatment. The study examined the results of a diabetes lifestyle program after 3 months. Results: The intervention resulted in significantly greater declines in HbA1c compared with the control group. In addition, tele-assisted participants showed significant improvements in Diabetes Self-Management scale score and body mass index compared with usual care participants. Conclusions: Patients with T2DM can benefit from telemedicine-assisted self-management programs, which may offer new options for treatment and prevention of disease progression. More follow-up and research is needed to assess feasibility and effectiveness on a larger scale.

Enrolment of families with overweight children into a program aimed at reducing childhood obesity with and without a weight criterion: a natural experiment.

BACKGROUND: Difficulties engaging families with overweight children to enrol into programs aimed at reducing childhood obesity have been well documented. During the implementation of the Parenting, Eating and Activity for Child Health Program (PEACH™) over a large geographical area (Queensland (QLD), Australia), a natural experiment developed. This experiment provided an opportunity to observe if there was a difference in enrolment for families with overweight children with a weight criterion (referred to as the period with a Targeted Eligibility Criterion (TEC)) compared to when a weight criterion was removed (the period referred to as Universal Eligibility Criterion (UEC)). We also examined the eligibility criterion's relationship with attendance, parental concern about their child's weight, estimation of overweight and obesity from parent-reported data. METHODS: A secondary analysis of baseline data from 926 overweight/obese children from 817 families enrolled in PEACH™ QLD was performed. Analyses were adjusted to control for the presence of clustered data. Bivariate statistics were performed using Pearson chi-square test with the second-order Rao-Scott correction, and Mann-Whitney U-test for non-parametric continuous variables. Generalized Estimating Equations (GEE) explored the association between weight status-based eligibility criteria and enrolment of overweight children. GEE were adjusted for sex, age and socioeconomic index and stratified for weight category. RESULTS: Compared to obese children, overweight children were almost twice as likely to be enrolled when the program did not have weight status-based eligibility criteria (during UEC period) (OR = 1.90 (CI 95% 1.35-2.68, p <  0.001)). Parents of overweight children enrolled during the UEC period were more likely to regard their child's weight as less of a concern than during the TEC period (UEC 67% vs. TEC 45%, p = 0.036). Children whose parent-reported data underestimated their weight category were more likely to be enrolled while the program did not have weight-related eligibility criteria OR = 2.27 (CI 1.38-3.70, p <  0.01). Program session attendance did not appear to be impacted by the changes in eligibility criteria. CONCLUSIONS: The omission of weight criteria for healthy lifestyle programs is a consideration for health professionals and decision-makers alike when encouraging the enrolment of children who are overweight into healthy lifestyle programs. TRIAL REGISTRATION: ACTRN12617000315314 . Retrospectively registered 28 February 2017.

Experiences from individuals with increased cardiovascular risk participating in a one-year lifestyle program.

OBJECTIVE: The purpose of the current study was to describe the participants' experiences of a structured lifestyle program for persons with high cardiovascular risk. METHOD: Sixteen participants with high cardiovascular risk participating in a one-year structured lifestyle intervention program were interviewed regarding their experiences of the program. The interviews were analyzed using content analyses. RESULTS: The participants' (mean age 58 ± 9) experiences were categorized into three categories: "How to know," based on the participants' experience from both individual counselling and group sessions with tools to strengthen self-care; "Staff who know how," based on experience from the meeting with, and the importance of, competent health professionals; "Why feedback is essential," based on the participants' experience and effects of person-centered feedback. Several factors were deemed important in the structure of the program: an individual visit with shared goal setting, a group education session with interactive discussion, a competent, educated, and respectful health professional who gives continuous feedback, and the right tools to support self-care at home between visits. CONCLUSION: Individuals participating in a structured lifestyle program experienced several factors as important: an individual visit with shared goal setting, a group education session with interactive discussion, a competent, educated, and respectful healthcare professional who gives continuous feedback, and the right tools to support self-care at home between visits.

A Pilot Randomised Controlled Trial of a Text Messaging Intervention with Customisation Using Linked Data from Wireless Wearable Activity Monitors to Improve Risk Factors Following Gestational Diabetes.

Gestational diabetes (GDM) is a highly prevalent disorder of pregnancy which portends a high risk for future type 2 diabetes. Limited evidence indicates lifestyle intervention prevents the development of diabetes, but most previously studied interventions are resource-intensive. Intervention programs that utilise newer technologies may be scalable at lower cost. This 6-month pilot randomized controlled trial tested the delivery of text messages linked to an activity monitor, adaptive physical activity goal setting, and limited face-to-face counseling, as an intervention to improve rates of post-partum glucose tolerance testing and lifestyle behaviours amongst women following a GDM pregnancy. Sixty subjects were randomised 2:1 intervention vs. control. Compared to control subjects, there were trends for intervention subjects to improve diet, increase physical activity, and lose weight. There was no difference between the groups in the rate of glucose tolerance testing. Only 46 (77%) subjects completed some, and 19 subjects completed all the elements of the final evaluation. Feedback regarding the text messages and activity monitor was highly positive. Overall, results suggest that a text message and activity monitor intervention is feasible for a larger study or even as a potentially scalable population health intervention. However, low completion rates necessitate carefully considered modification of the protocol.

Evaluation of the Effectiveness of a 3-Year, Teacher-Led Healthy Lifestyle Program on Eating Behaviors Among Adolescents Living in Day School Hostels in Malaysia.

BACKGROUND: Independence gained during adolescence may be associated with unhealthy eating behaviors. Although malnutrition among adolescents is evident, studies on eating behaviors among adolescents are scarce. OBJECTIVE: To determine the effectiveness of a teacher-led Healthy Lifestyle Program on eating behaviors among adolescents in Malaysia. METHODS: This was a cluster randomized controlled trial (conducted in 2012 to 2014), with 100 schools randomly selected from 721 schools, then assigned to 50 intervention schools and 50 control schools. A Healthy Eating and Be Active among Teens (HEBAT) module was developed for pretrained teachers to deliver a Healthy Lifestyle Program on eating behaviors among adolescents. Eating behaviors of the respondents was determined using Eating Behaviors Questionnaire. Linear Mixed Model analysis and χ2 test were used to determine within- and between-group effects of studied variables. RESULTS: A total of 4277 respondents participated in this study, with 2635 samples involved in the final analysis, comprised of 921 intervention and 1714 control respondents. There were 32.4% (36.4%) males and 67.6% (63.6%) females in the intervention (control) group. Mean age was comparable between the groups (intervention = 12.98 years; control = 12.97 years). Majority of the respondents skipped meals at baseline (intervention = 74.7%; control = 79.5%). After the program, intervention respondents had higher consumption frequency of lunch, dinner, and mid-morning snack but a lower consumption frequency of late-evening snack and meal skipping behaviors than their control counterparts. CONCLUSION: The teacher-led Healthy Lifestyle Program was effective in reducing meal-skipping behaviors among Malaysian adolescents.

Wishes and preferences for an online lifestyle program for brain health-A mixed methods study.

INTRODUCTION: Individuals with subjective cognitive decline (SCD) are at increased risk of Alzheimer's disease and could benefit from a prevention strategy targeting lifestyle factors. Making a program available through the Internet gives a widespread reach at low cost, but suboptimal adherence is a major threat to effectiveness. As a first step in developing an online lifestyle program (OLP), we aimed to identify factors that are barriers and/or facilitators for the use of an OLP in individuals with SCD in three European countries. METHODS: As part of the Euro-SCD project, SCD subjects were recruited at memory clinics in the Netherlands, Germany, and Spain. We combined quantitative and qualitative methods, using a mixed methods approach. We conducted an online 18-item survey on the preferences of SCD patients for an OLP (N = 238). In addition, we held semi-structured interviews (N = 22) to gain in-depth understanding of factors acting as a facilitator and/or barrier for intended use of an OLP. Audio recordings were transcribed verbatim. Content analysis was performed. RESULTS: One hundred seventy-six individuals completed the survey (response rate 74%). Almost all participants regularly use the Internet (97%). Participants reported trustworthiness (93%), user-friendliness (91%), and up-to-date information (88%) as main facilitators, whereas having contact with other users (26%), needing an account (21%), and assignments (16%) were reported as barriers. Barriers differed slightly between countries, but facilitators were largely similar. In-depth interviews revealed that both program characteristics (e.g., trustworthiness, user-friendliness, and personalization) and personal factors (e.g., expectancy to receive negative feedback) are likely to influence the intended use of an OLP. DISCUSSION: Involving users provided in-depth understanding of factors associated with the intended use of an OLP for brain health. Both program characteristics and personal factors are likely to influence the use of an OLP. Based on this input from the end-users, we will develop an OLP for individuals with SCD.