Efficacy of a compulsory homework programme for increasing physical activity and improving nutrition in children: a cluster randomised controlled trial.

BACKGROUND: Most physical activity interventions in children focus on the school setting; however, children typically engage in more sedentary activities and spend more time eating when at home. The primary aim of this cluster randomised controlled trial was to investigate the effects of a compulsory, health-related homework programme on physical activity, dietary patterns, and body size in primary school-aged children. METHODS: A total of 675 children aged 7-10 years from 16 New Zealand primary schools participated in the Healthy Homework study. Schools were randomised into intervention and control groups (1:1 allocation). Intervention schools implemented an 8-week applied homework and in-class teaching module designed to increase physical activity and improve dietary patterns. Physical activity was the primary outcome measure, and was assessed using two sealed pedometers that monitored school- and home-based activity separately. Secondary outcome measures included screen-based sedentary time and selected dietary patterns assessed via parental proxy questionnaire. In addition, height, weight, and waist circumference were measured to obtain body mass index (BMI) and waist-to-height ratio (WHtR). All measurements were taken at baseline (T0), immediately post-intervention (T1), and 6-months post-intervention (T2). Changes in outcome measures over time were estimated using generalised linear mixed models (GLMMs) that adjusted for fixed (group, age, sex, group x time) and random (subjects nested within schools) effects. Intervention effects were also quantified using GLMMs adjusted for baseline values. RESULTS: Significant intervention effects were observed for weekday physical activity at home (T1 [P < 0.001] and T2 [P = 0.019]), weekend physical activity (T1 [P < 0.001] and T2 [P < 0.001]), BMI (T2 only [P = 0.020]) and fruit consumption (T1 only [P = 0.036]). Additional analyses revealed that the greatest improvements in physical activity occurred in children from the most socioeconomically deprived schools. No consistent effects on sedentary time, WHtR, or other dietary patterns were observed. CONCLUSIONS: A compulsory health-related homework programme resulted in substantial and consistent increases in children's physical activity - particularly outside of school and on weekends - with limited effects on body size and fruit consumption. Overall, our findings support the integration of compulsory home-focused strategies for improving health behaviours into primary education curricula. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618000590268 . Registered 17 April 2018.

A Cross-Sectional Description of Parental Perceptions and Practices Related to Risky Play and Independent Mobility in Children: The New Zealand State of Play Survey.

The potential for risky play and independent mobility to increase children's physical activity, and enhance cognitive development and emotional wellbeing has been recognised for some time. The aim of this study was to describe the attitudes of New Zealand parents towards such risky play practices and independent mobility, the barriers preventing them from allowing their children to participate, and how often their children engaged in risky play activities. An online survey comprised mostly of validated scales and standardised questions was completed by a nationally representative sample of 2003 parents. We found that parents had neutral feelings about the risk of injury to their child through play, rather they were concerned about road safety and "stranger danger". There was strong agreement that there are multiple benefits to be gained from exposure to risk and challenge, and that health and safety rules are too strict. However, 73% of respondents stated that their 5⁻12 year old child seldom or never engaged in four or more risky activities, and only 14.3% engaged in four or more often or always. While parents agree that their child is likely to benefit from risky play, they do not have the confidence to allow their children to engage in such activities. Future research should address barriers and fears when implementing strategies to facilitate risky play.

A 12-week low-carbohydrate, high-fat diet improves metabolic health outcomes over a control diet in a randomised controlled trial with overweight defence force personnel.

Overweight, obesity, and poor health is becoming a global concern for defence force personnel. Conventional nutrition guidelines are being questioned for their efficacy in achieving optimal body composition and long-term health. This study compared the effects of a 12-week low-carbohydrate, high-fat diet with a conventional, high-carbohydrate, low-fat diet on weight reduction and metabolic health outcomes in at-risk New Zealand Defence Force personnel. In this randomised controlled trial, 41 overweight personnel were assigned to intervention and control groups. Weight, waist circumference, fasting lipids, and glycaemic control were assessed at baseline and at 12 weeks. Within-group change scores were analysed using the t statistic and interpreted using a p < 0.05 level of statistical significance. Between-group mean differences and confidence intervals were analysed using effect sizes and magnitude-based inferences. Twenty-six participants completed the trial (14 intervention, 12 control). Both groups showed statistically significant weight and waist circumference reductions; the intervention group significantly reduced triglycerides and serum glucose and significantly increased high-density lipoprotein cholesterol (HDLc). Relative to control, the intervention group showed small, possibly to likely beneficial effects for weight, triglycerides, glucose, insulin, and homeostasis model assessment of insulin resistance; moderate, likely beneficial effects for HDL cholesterol, triglyceride:HDLc ratio and HbA1c; and a small, likely harmful effect for low-density lipoprotein cholesterol. This dietary approach shows promise for short-term weight loss and improved metabolic health outcomes conditions compared with mainstream recommendations. It should be offered to defence force personnel at least as a viable alternative means to manage their weight and health.

Change of School Playground Environment on Bullying: A Randomized Controlled Trial.

OBJECTIVE: To investigate whether increasing risk and challenge in primary school playgrounds influences interactions between children. METHODS: In a 2-year cluster-randomized controlled trial, 8 control schools were asked to not change their play environment, whereas 8 intervention schools increased opportunities for risk and challenge (eg, rough-and-tumble play), reduced rules, and added loose parts (eg, tires). Children (n = 840), parents (n = 635), and teachers (n = 90) completed bullying questionnaires at baseline, 1 (postintervention), and 2 (follow-up) years. RESULTS: Intervention children reported higher odds of being happy at school (at 2 years, odds ratio [OR]: 1.64; 95% confidence interval [CI]: 1.20-2.25) and playing with more children (at 1 year, OR: 1.66; 95% CI: 1.29-2.15) than control children. Although intervention children indicated they were pushed/shoved more (OR: 1.33; 95% CI: 1.03-1.71), they were less likely to tell a teacher (OR: 0.69; 95% CI: 0.52-0.92) at 2 years. No significant group differences were observed in parents reporting whether children had "ever" been bullied at school (1 year: P = .23; 2 years: P = .07). Intervention school teachers noticed more bullying in break time at 1 year (difference in scores: 0.20; 95% CI: 0.06-0.34; P = .009), with no corresponding increase in children reporting bullying to teachers (both time points, P ≥ .26). CONCLUSIONS: Few negative outcomes were reported by children or parents, except for greater pushing/shoving in intervention schools. Whether this indicates increased resilience as indicated by lower reporting of bullying to teachers may be an unanticipated benefit.

Family-centered brief intervention for reducing obesity and cardiovascular disease risk: A randomized controlled trial.

OBJECTIVE: To assess the effects of a family-centered, physical activity and nutrition "brief" intervention (time-limited contact) on body weight and related health outcomes in primary health care patients with an elevated 5-year cardiovascular disease (CVD) risk. METHODS: This study implemented a cluster randomized controlled trial design with two treatment conditions: a CVD risk assessment and one-time consultation ("usual care" control) and a CVD risk assessment and up to five home sessions that aimed to reduce obesity by encouraging physical activity and healthy eating (intervention). Three hundred and twenty patients aged 35 to 65 years from 16 primary health care clinics in Auckland, New Zealand, participated in the study. Intervention effects on BMI, waist circumference, blood pressure, blood cholesterol, triglycerides, 5-year CVD risk, physical activity, and dietary patterns were assessed using generalized linear mixed models. RESULTS: When compared with the control group, the intervention resulted in a significant but relatively modest decrease in BMI between baseline and the 12-month follow-up (-0.633 kg m-2 , Padj = 0.048). Significant decreases were also observed for total cholesterol at 4 and 12 months, the total cholesterol to high-density lipoprotein cholesterol ratio at 4 months, 5-year CVD risk at 4 months, and fast food consumption at 12 months. CONCLUSIONS: Our findings show that a family-centered brief intervention targeting physical activity and nutrition can generate slightly better obesity-related health outcomes than usual care alone.

Neighbourhoods for Active Kids: study protocol for a cross-sectional examination of neighbourhood features and children's physical activity, active travel, independent mobility and body size.

INTRODUCTION: New Zealand children's physical activity, including independent mobility and active travel, has declined markedly over recent decades. The Neighbourhoods for Active Kids (NfAK) study examines how neighbourhood built environments are associated with the independent mobility, active travel, physical activity and neighbourhood experiences of children aged 9-12 years in primary and intermediate schools across Auckland, New Zealand's largest city. METHODS AND ANALYSIS: Child-specific indices of walkability, destination accessibility and traffic exposure will be constructed to measure the built environment in 8 neighbourhoods in Auckland. Interactive online-mapping software will be used to measure children's independent mobility and transport mode to destinations and to derive measures of neighbourhood use and perceptions. Physical activity will be measured using 7-day accelerometry. Height, weight and waist circumference will be objectively measured. Parent telephone interviews will collect sociodemographic information and parent neighbourhood perceptions. Interviews with school representative will capture supports and barriers for healthy activity and nutrition behaviours at the school level. Multilevel modelling approaches will be used to understand how differing built environment variables are associated with activity, neighbourhood experiences and health outcomes. DISCUSSION: We anticipate that children who reside in neighbourhoods considered highly walkable will be more physically active, accumulate more independent mobility and active travel, and be more likely to have a healthy body size. This research is timely as cities throughout New Zealand develop and implement plans to improve the liveability of intensifying urban neighbourhoods. Results will be disseminated to participants, local government agencies and through conventional academic avenues.

Evaluation of a primary care-based programme designed to increase exercise and improve nutrition in patients at risk.

INTRODUCTION: Evidence is limited regarding the effectiveness of brief interventions delivered through primary care to improve healthy living and increase physical activity. The Healthy As programme delivering brief interventions programmes in primary care to promote physical activity, improved nutrition and weight management was developed, implemented and assessed. This study aimed to identify aspects of the programme that worked well, those that presented problems or barriers, along with suggestions for improvement. METHODS: Three provider organisations in Auckland were contracted to deliver the Healthy As intervention in primary care settings. Semi-structured interviews were conducted with those delivering the risk assessments and providing the intervention from each provider organisation. A thematic analysis approach based on grounded theory was used to analyse the emerging key themes. FINDINGS: The emerging themes related to the holistic nature of the programme, its structure, resources used with participants, engagement of the providers with the participants, and whether the programme was effective in changing behaviour. CONCLUSION: Initial engagement of participants was found to be particularly important for the success of the Healthy As programme. For a patient-centred approach, good communication between the patient and health provider is required to facilitate shared decision-making and self-management prior to implementation of an intervention. Patients need to indicate whether they want help to make changes. Advice on healthy eating and exercise should not be given in isolation. Patients may also need help with mental health or other lifestyle issues before they can actively engage in exercise or weight reduction programmes.

Built environment and physical activity in New Zealand adolescents: a protocol for a cross-sectional study.

INTRODUCTION: Built-environment interventions have the potential to provide population-wide effects and the means for a sustained effect on behaviour change. Population-wide effects for adult physical activity have been shown with selected built environment attributes; however, the association between the built environment and adolescent health behaviours is less clear. This New Zealand study is part of an international project across 10 countries (International Physical Activity and the Environment Network-adolescents) that aims to characterise the links between built environment and adolescent health outcomes. METHODS AND ANALYSES: An observational, cross-sectional study of the associations between measures of the built environment with physical activity, sedentary behaviour, body size and social connectedness in 1600 New Zealand adolescents aged 12-18 years will be conducted in 2013-2014. Walkability and neighbourhood destination accessibility indices will be objectively measured using Geographic Information Systems (GIS). Physical activity and sedentary behaviours will be objectively measured using accelerometers over seven consecutive days. Body mass index will be calculated as weight divided by squared height. Demographics, socioeconomic status, active commuting behaviours and perceived neighbourhood walkability will be assessed using the Neighbourhood Environment Walkability Scale for Youth and psychosocial indicators. A web-based computer-assisted personal interview tool Visualisation and Evaluation of Route Itineraries, Travel Destinations, and Activity Spaces (VERITAS) and Global Positioning System (GPS) receivers will be used in a subsample of 300 participants. A qualitative research component will explore barriers and facilitators for physical activity in adolescents with respect to the built and social environment in a subsample of 80 participants. ETHICS AND DISSEMINATION: The study received ethical approval from the Auckland University of Technology Ethics Committee (12/161). Data will be entered and stored into a secure (password protected) database. Only the named researchers will have access to the data. Data will be stored for 10 years and permanently destroyed thereafter. The results papers will be submitted for publication in peer-reviewed journals.

Prevalence of New Zealand children and adolescents achieving current physical activity and television watching recommendations.

BACKGROUND: Aims were to investigate sex, ethnicity, and age differences in achieving daily step count and television (TV) watching recommendations in schoolchildren. METHODS: Participants were 615 children (n = 325) and adolescents (n = 290) aged 5 to 16 years. Activity was assessed over 5 days using pedometers; TV time was collected via parental proxy-report and self-report. Ethnic, sex, and age differences in step counts, TV time, and odds of meeting TV and step count recommendations were examined for weekdays, weekend days, and overall using generalized estimation equation modeling. RESULTS: Overall, girls were more active than boys (P < .001). Adolescents were more active than children (P = .044), watched more TV (P = .005), and were less likely to meet TV watching recommendations (P = .004). Non-European children watched significantly more TV (P = .008), and were significantly less likely to meet TV recommendations than non-European children (P = .001). Participants watched more TV and accumulated less steps on weekend days than weekdays. CONCLUSIONS: Multifaceted interventions focusing on both increasing activity and decreasing TV time are needed, especially on weekends. Children and girls may benefit more from activity interventions, while ethnic-specific interventions focusing on TV habits may be most efficacious for adolescents.

Efficacy of a compulsory homework programme for increasing physical activity and healthy eating in children: the healthy homework pilot study.

BACKGROUND: Most physical activity and nutrition interventions in children focus on the school setting; however, evidence suggests that children are less active and have greater access to unhealthy food at home. The aim of this pilot study was to examine the efficacy of a compulsory homework programme for increasing physical activity and healthy eating in children. METHODS: The six-week 'Healthy Homework' programme and complementary teaching resource was developed under the guidance of an intersectoral steering group. Eight senior classes (year levels 5-6) from two diverse Auckland primary schools were randomly assigned into intervention and control groups. A total of 97 children (57 intervention, 40 control) aged 9-11 years participated in the evaluation of the intervention. Daily step counts were monitored immediately before and after the intervention using sealed multiday memory pedometers. Screen time, sports participation, active transport to and from school, and the consumption of fruits, vegetables, unhealthy foods and drinks were recorded concurrently in a 4-day food and activity diary. RESULTS: Healthy Homework resulted in a significant intervention effect of 2,830 steps.day-1 (95% CI: 560, 5,300, P = 0.013). This effect was consistent between sexes, schools, and day types (weekdays and weekend days). In addition, significant intervention effects were observed for vegetable consumption (0.83 servings.day-1, 95% CI: 0.24, 1.43, P = 0.007) and unhealthy food consumption (-0.56 servings.day-1, 95% CI: -1.05, -0.07, P = 0.027) on weekends but not weekdays, with no interactions with sex or school. Effects for all other variables were not statistically significant regardless of day type. CONCLUSIONS: Compulsory health-related homework appears to be an effective approach for increasing physical activity and improving vegetable and unhealthy food consumption in children. Further research in a larger study is required to confirm these initial results.

Understanding the Relationship between Activity and Neighbourhoods (URBAN) Study: research design and methodology.

BACKGROUND: Built environment attributes are recognized as being important contributors to physical activity (PA) engagement and body size in adults and children. However, much of the existing research in this emergent public health field is hindered by methodological limitations, including: population and site homogeneity, reliance on self-report measures, aggregated measures of PA, and inadequate statistical modeling. As an integral component of multi-country collaborative research, the Understanding the Relationship between Activity and Neighbourhoods (URBAN) Study seeks to overcome these limitations by determining the strengths of association between detailed measures of the neighborhood built environment with PA levels across multiple domains and body size measures in adults and children. This article outlines the research protocol developed for the URBAN Study. METHODS AND DESIGN: The URBAN Study is a multi-centered, stratified, cross-sectional research design, collecting data across four New Zealand cities. Within each city, 12 neighborhoods were identified and selected for investigation based on higher or lower walkability and Maori demographic attributes. Neighborhoods were selected to ensure equal representation of these characteristics. Within each selected neighborhood, 42 households are being randomly selected and an adult and child (where possible) recruited into the study. Data collection includes: objective and self-reported PA engagement, neighborhood perceptions, demographics, and body size measures. The study was designed to recruit approximately 2,000 adults and 250 children into the project. Other aspects of the study include photovoice, which is a qualitative assessment of built environment features associated with PA engagement, an audit of the neighborhood streetscape environment, and an individualized neighborhood walkability profile centered on each participant's residential address. Multilevel modeling will be used to examine the individual-level and neighborhood-level relationships with PA engagement and body size. DISCUSSION: The URBAN Study is applying a novel scientifically robust research design to provide urgently needed epidemiological information regarding the associations between the built environment and health outcomes. The findings will contribute to a larger, international initiative in which similar neighborhood selection and PA measurement procedures are utilized across eight countries. Accordingly, this study directly addresses the international priority issues of increasing PA engagement and decreasing obesity levels.