Energy and nutrient intake by 11-13-year-old young adolescents attending private schools in Delhi, India.

There are no high-quality data on dietary behavior of adolescents in India. This study aimed to assess the intake of energy (E), macronutrients and selected micronutrients in a sample of 11-13-year-old schoolchildren in Delhi, India. Participants from private schools (n=10) recorded dietary intake using a 3-day food diary. Information was entered into the dietary assessment tool, Intake24, to ascertain portion size and convert data into nutrient intake through integrated food tables. Of the 514 consenting participants, 393 (76.4%) (169 girls, 224 boys) aged 11.4 (± 1.8) years completed the study. The median (interquartile range (IQR) daily E intake was 2580 (2139.3-2989.8) kcal [10.8 (9.0 -12.5) MJ] for girls, and 2941.5 (2466.7- 3599.3) kcal [12.3 (10.3- 15.2) MJ] for boys. The median (IQR) daily nutrient intakes for girls and boys respectively were: protein 64.6 (54.8-79.3) g, 74.4 (61.4; 89.4) g; carbohydrate 336.5 (285.3- 393.6) g, 379.6 (317.8-461.8) g; and saturated fat 45.6 (34.8-58.3) g, 54.6 (41.9-69.5) g. There were no significant between-gender differences in percent E from protein (10.2 (9.2 - 11.4)), or carbohydrate (52.4 (48.7- 56.7)). Girls obtained less percent E from saturated fat (16.1 (11.0-18.2) compared with boys 16.3 (14.2 - 19.1) (P<0.05). E from saturated fat was above Food and Agriculture Organization recommendations in >74% participants. The EAR for iron was achieved by < 40% of girls. In conclusion, strategies to optimize dietary intake of adolescents in India should focus on preventing excess intakes of E and saturated fat, and improving iron intake in girls.

The impact of yoga on stress, metabolic parameters, and cognition of Indian adolescents: Cluster randomized controlled trial.

Background: This project aimed to assess the impact of yoga on stress, metabolic parameters and cognition (attention & concentration) in adolescents, aged 13-15 years from public and private schools in two cities (Chennai and New Delhi) in India. Methods: The study recruited 2000 adolescents from 24 schools in a cluster randomized controlled trial design. The yoga group participants underwent 17 yoga sessions, which included: pranayama, basic asanas, meditation and relaxation exercises. Yoga sessions, were held in the school premises once a week. A total of five awareness talks on healthy lifestyle were delivered once a month to the education group. ADOlescence Stress Scale (ADOSS), salivary cortisol, metabolic and clinical parameters and Letter Cancellation Test (LCT) score were measured at baseline and post-intervention (5-6 months). Results: The yoga group showed statistically significant differences in the mean ADOSS score, metabolic parameters, salivary cortisol, and LCT scores compared to the education group. In the intention- to- treat analysis, a significant reduction [5.11, 95% CI (4.78, 5.36), p = 0.001] in ADOSS score was seen in the yoga group compared to education. Conclusion: Implementation of a 17-week standardized yoga program at the school level significantly decreased stress, improved attention and concentration, metabolic and clinical parameters in Indian adolescents. Trial registration: Clinical Trials Registry, India (CTRI/2017/08/009203).

Can Peer-based Interventions Improve Adolescent Sexual and Reproductive Health Outcomes? An Overview of Reviews.

PURPOSE: An overview of reviews was conducted to summarize the evidence and synthesize the results from systematic reviews. METHODS: The Cochrane and Preferred Reporting Items for Overviews of Reviews reporting guidelines were followed and the protocol was registered. Electronic and manual searches were conducted to identify systematic reviews, published between January 1990 and July 2022. Studies with outcomes relating to all areas of adolescent sexual and reproductive health (SRH) (changes in knowledge, attitudes, beliefs, skills, and practices) were considered. The ROBIS (Risk of Bias in Systematic Reviews) tool was used to assess quality. RESULTS: A total 1849 articles were retrieved, and eight reviews met the inclusion criteria. Three of the eight reviews included meta-analyses. All three of these reviews demonstrated a significant improvement in HIV knowledge. One reported improved attitudes toward people living with HIV but none found any statistically significant effect on condom use or other SRH behaviors. The remaining five reviews included reports of positive individual study outcomes related to knowledge and attitudes and provided narrative syntheses with regard to recruitment, training, support, and participation of peers. Five of the eight reviews were judged to have a low risk of bias. DISCUSSION: Our overview demonstrates that peer-based interventions can improve SRH knowledge and attitudes. Evidence of their effectiveness in promoting healthier SRH behaviors is less certain. Any future studies need to investigate which adolescent health outcomes peer-based programs could reasonably be expected to improve using robust methodologies. Additionally, peers need to be meaningfully engaged and acknowledged as experience-based experts.

Effect of an educational intervention on diet and physical activity among school-aged adolescents in Delhi -The i-PROMISe (PROMoting health literacy in Schools) Plus Study.

Purpose: Emerging lifestyle changes due to rapid urbanization have led to an epidemiological transition and the rising prevalence of obesity is responsible for major non-communicable diseases (NCDs) which have further aggravated due to the COVID-19 pandemic. This study aims to assess the effectiveness of a comprehensive school-based intervention on diet and physical activity-related behavior of adolescents. Methods: In 2019, a cluster-randomized controlled trial was conducted in randomly selected (n = 8) private schools. A 2-year intervention program was implemented over consecutive academic years (2019-2020 and 2020-2021) with students who were in the 6th and 7th grades when the study began. Four schools were randomly assigned to the intervention (n = 794) and four schools to the control group (n = 774). Results: The difference in changes in diet and physical-activity-related behaviors of the students between the intervention and control schools were not significant in the intention to treat analysis probably due to the large drop-out due to COVID-19 measures: 304 students were available for follow-up in the intervention group and 122 in the control group (391 cases were excluded to make data comparable with baseline survey). The intake of vegetables (once a day) [ß = 0.35, OR = 1.42, 95% CI (1.03, 1.95)] in the per-protocol analysis has increased among adolescents in the intervention group as compared to the control group. Conclusion: The findings of this study indicated a positive effect of the intervention on diet and physical-activity-related changes in the expected direction and highlights the importance of addressing such behavior to prevent obesity among adolescents and thus NCDs in the later stage of life.

Changes in tobacco depictions after implementation of tobacco-free film and TV rules in Bollywood films in India: a trend analysis.

BACKGROUND: India's tobacco-free film and TV rules were implemented from 2012. To assess the effect of the rules, we studied tobacco depictions in top-grossing Bollywood films released between 2006 and 2017 and rule compliance after 2012. METHODS: Tobacco incidents and brand appearances were coded in 240 top-grossing Bollywood films (2006-2017) using the Breathe California method. Trends in number of tobacco incidents per film per year were studied before and after implementation of the rules using Poisson regression analysis. Compliance with rules over the years was studied using Pearson product-moment correlations. RESULTS: Forty-five films were U-rated (all ages), 162 were UA-rated (below age 12 years must be adult-accompanied), and 33 were A-rated (age 18+ years only). Before implementation of the rules, the number of tobacco incidents per film was increasing by a factor of 1.1/year (95% CI 1.0 to 1.2, p=0.002). However, beginning year 2013, the number of incidents per film started falling significantly by a factor of 0.7/year (95% CI 0.6 to 0.9; p=0.012) compared with the previous increasing trend. The percentage of youth-rated (U and UA) films with any tobacco incidents also declined from a peak of 76% in 2012 to 35% in 2017. The percentage of films complying with the rules (audio-visual disclaimers, health spots, static warnings) did not change significantly from 2012 to 2017. CONCLUSION: India's 2012 rules were followed by a reduction in tobacco depictions in Bollywood films. Enhanced monitoring of compliance is needed to ensure the continued effectiveness of the rules.

Accelerating policy response to curb non-communicable diseases: an imperative to mitigate the dual public health crises of non-communicable diseases and COVID-19 in India.

Non-communicable Diseases (NCDs) are a threat to public health and sustainable development. NCDs were equated to being a 'pandemic' before COVID-19 originated. Globally, NCDs caused approximately 74% of deaths (2019). India accounted for nearly 14.5% of these deaths. NCDs and COVID-19 have a lethal bi-directional relationship with both exacerbating each other's impact. Health systems and populations, particularly in Low- and Middle-Income Countries (LMICs) like India have among the highest burden of COVID-19. This narrative review tracks key policy and programmatic developments on NCD prevention and control in India, with a focus on commercially-driven risk factors (tobacco and alcohol use, unhealthy diet, physical inactivity, and air pollution), and the corresponding NCD targets. It identifies lacunae and recommends urgent policy-focussed multi-dimensional action, to ameliorate the dual impact of NCDs and COVID-19. India's comprehensive response to NCDs can steer national, regional and global progress towards time-bound NCD targets and NCD-related Sustainable Development Goals (SDGs). Funding: This work is supported by the Commonwealth Foundation. None of the authors were paid to write this article by a pharmaceutical company or other agency. The authors were not precluded from accessing data and accept responsibility to submit for publication.

How to promote a healthy lifestyle among schoolchildren: Development of an intervention module (i-PROMISe).

Objective: Lifestyle preferences are inculcated in childhood and once established, persist into adulthood. The Project PROMoting Health LIteracy in School (i-PROMISe) aims to promote a healthy lifestyle among students for the universal prevention of non-communicable diseases (NCDs) like diabetes. Study design: Qualitative study using focus-group-discussions (FGDs) and In-Depth Interviews (IDI). Method: Project was undertaken in two-phases in two private schools in New Delhi, India. In phase-one, FGDs with students (grades IV to VIII) and IDIs with teachers were conducted to ascertain their perceptions of diabetes prevention and management according to the Health Belief Model. The data was analyzed using a thematic framework method. In phase-two, the resources were pre-tested and participants' feedback was requested on the duration, quality, and understanding of the resources. Results: In total, 89 students and 17 teachers participated in phase-one (n = 54 [in FGDs] and n = 5 [in IDIs]) and phase-two (n = 35 students and n = 12 teachers in FGDs). In phase-one, themes that emerged included: diabetes was considered a disease of the elderly; misconceptions about susceptibility to these diseases were common; children were largely aware of measures to prevent these diseases, but barriers to adopting a healthy lifestyle existed. Based on the findings, a comprehensive module was developed, which consisted of a teacher's manual with interactive activities and short films. The resources (teacher's manual and short films) were well received and contributed to a better understanding of diabetes and other NCDs; myths/misconceptions were clarified. Conclusion: Development of resources using participatory approach can be effective in promoting and reinforcing healthy behaviours among school going children to prevent and control NCDs in schools.

Impact of closure of educational institutions due to COVID-19 lockdown on overall subjective wellbeing of adolescents and youth: Cross-sectional survey, India.

Background: Students were confined to their homes due to the national closure of educational institutions during the COVID 19 pandemic, thus presenting an unprecedented risk to children's education, protection, and wellbeing. Aim: This study aimed to understand the determinants of subjective wellbeing of adolescents and youth (aged 11-21 years) during the COVID-19 pandemic in India. Materials and methods: A cross-sectional web-based survey was adapted, pre-tested, and finalized to obtain the participant's responses from schools and colleges. Participants aged 11-17 years were engaged through schools. Consent procedures were followed. The survey link was disseminated through social media for the participants aged 18-21 years. The survey was made available in English and Hindi. The data was collected from March-June, 2021. Results: Overall, 1,596 students completed the survey. Out of 1,596 students, 1252 (78%) were below 18 years and 344 (21.5%) participants were 18 years and above. Results suggest a statistically significant (p < 0.01) difference in the level of student's life satisfaction before and during the COVID-19 pandemic. Of the students who were dissatisfied with their general life during the pandemic, nearly 63.4% felt sadness followed by other feelings, i.e., boredom (around 60.5%), loneliness (63.7%), and anxiety (62.2%). Conclusion: This study highlights the need for innovative strategies for adolescents and parents to adopt and promote overall subjective wellbeing, especially during public health crises such as the COVID-19 pandemic.

Prevalence of Excessive Weight and Underweight and Its Associated Knowledge and Lifestyle Behaviors among Urban Private School-Going Adolescents in New Delhi.

With rapid urbanization and the Indian nutrition transition, Indian adolescents face a high risk of developing an energy imbalance. This study aims to assess the prevalence of excessive weight, underweight, and associated knowledge and lifestyle behaviors among private school-going adolescents in Delhi. A cross-sectional study was conducted in students (6th-7th grades) of eight randomly selected private schools in Delhi, India in 2019. A self-administered survey was used to assess students' dietary-and-physical-activity-related knowledge and behavior. Anthropometric measurements (height, weight, and waist circumference) were also conducted. Out of 1567 participants, 7.2% were underweight, 61.3% normal, and 31.5% excess in weight. Underweight was associated with significantly more eating whilst studying for exams (relative risk ratio (RRR) 1.7 (1.0-2.9)). Excessive weight was associated with less incorrect knowledge on behaviors causing overweight (RRR 0.7 (0.5-0.9)), more often reading nutritional labels of packed food items (RRR 0.6 (0.4-0.9)), and less frequent vegetable-intake (RRR 0.7 (0.4-0.9)). Underweight students showed more suboptimal knowledge and unhealthy behaviors, whilst students with excessive weight showed more correct knowledge and healthy behaviors. This study highlights the immediate need for effective health-promoting interventions focused on the importance of healthy lifestyle at least in underweight adolescents.

Tobacco imagery in on-demand streaming content popular among adolescents and young adults in India: implications for global tobacco control.

BACKGROUND: India implemented tobacco-free film and TV rules (Rules) to protect adolescents and young adults from tobacco exposure. OBJECTIVE: To assess tobacco imagery in online series popular among adolescents and young adults. METHODS: Ten popular online series on streaming platforms were identified after discussions with participants (aged 15-24 years) in New Delhi, and content-coded for tobacco imagery following the Breathe California protocol. Incidents of tobacco use and brand appearances in each series episode were counted, and compliance with Indian Rules was recorded. RESULTS: 188 episodes across 10 series on Netflix and Amazon Prime Video were coded. Seven series were rated age 16+, two were 18+ and one was 13+. The median number of tobacco incidents per episode in foreign productions was as follows: Amazon's 'The Marvellous Mrs Maisel' (87.5, IQR 62.0-116.0) and Netflix's 'The Crown' (29.0, 18.0-36.0) were higher than Indian productions: Netflix's 'Sacred Games' (9.0, 0.5-14.5) and Amazon's 'Mirzapur' (7.0, 4.0-11.0) (p=0.84). Tobacco incidents per hour ranged from 0 (Bodyguard, Riverdale, 13 Reasons Why) to 106.1 (The Marvellous Mrs Maisel). Seven of 10 series had tobacco imagery and none were compliant with the Rules. CONCLUSION: Contrary to Section 5 of India's Cigarettes and Other Tobacco Products Act, its Rules are not being complied with by the streaming platforms. US-produced streaming media contains more tobacco incidents than Indian-produced media. There is an urgent need for better enforcement of existing Rules on streaming platforms in India, and modernisation of the WHO Framework Convention on Tobacco Control, Article 13 guidelines to account for new streaming platforms to protect youth from tobacco imagery globally.

Adolescent and adult perceptions of the effects of larger size graphic health warnings on conventional and plain tobacco packs in India: A community-based cross-sectional study.

INTRODUCTION: We studied adolescent and adult perceptions of the effects of larger size, 85% versus 40%, Graphic Health Warnings (GHWs) on conventional and plain tobacco packs, in India. METHODS: A cross-sectional survey was conducted with 2121 participants (aged ≥13 years), during the period 2015-16, in Delhi and Telangana, India. Four categories of GHWs on tobacco packs were shown: A - 40% existing (April 2013-April 2016), B - 40% new (April 2016-present), C - 85% new, and D - plain packs (85% new). Regression models tested percentage differences in choice of categories for eight outcomes, adjusted for gender, area of residence, socioeconomic status, age, and tobacco use. RESULTS: Of the total 2121 participants, 1120 were from Delhi, 1001 from Telangana, 50% were males, 62% were urban residents, 12% were adolescents, and 72% had never used tobacco. Among packs shown, the majority of participants perceived the 85% size GHWs more effective than the 40% size GHWs across all outcomes. The perceived increase in noticeability of GHWs was 45% for category C (p<0.05) and 43.5% for category D (p<0.05) versus category B. In Delhi, participants perceived plain packs to be most effective in motivating quitting, preventing initiation and conveying the health message. In Telangana, adolescents believed GHWs on plain packs were most noticeable, most effective for quitting and preventing initiation. CONCLUSIONS: The larger size 85% GHWs were perceived to be more effective in increasing noticeability of warnings, motivating cessation, preventing initiation, and conveying the intended health message. Support for plain packaging was higher in Delhi and among adolescents in Telangana.

School policies, built environment and practices for non-communicable disease (NCD) prevention and control in schools of Delhi, India.

OBJECTIVE: To assess school policies, built environment and practices for prevention and control of non-communicable diseases in schools of Delhi, India. METHODS: School built environments and policies were assessed using a structured observation checklist in 10 private and 9 government schools which were randomly selected from all 184 co-educational schools with primary to senior secondary level education in Delhi, India. A self-administered questionnaire was also completed by teachers from each school (n = 19) to capture information specific to school policies. Surveys were also conducted with parent of students in class II (aged 6-7 years; n = 574) and student in class XI (aged 15-16 years, n = 755) to understand school practices. RESULTS: The majority of government (88.9%; n = 8) and private (80%; n = 8) schools reported having comprehensive school health policy. In terms of specific health behaviours, policies related to diet and nutrition in government schools were mostly restricted to primary levels with provision of the mid-day meal programme. All schools had two physical education periods per week of about 45-50 minutes. Most schools were compliant with tobacco-free school guidelines (n = 15 out of 19) and had alcohol control policies (n = 13 out of 19). Parent and student reports of practices indicated that school policies were not consistently implemented. CONCLUSION: Most schools in Delhi have policies that address health behaviours in students, but there was considerable variation in the types and number of policies and school environments. Government schools are more likely to have policies in place than private schools. Further work is needed to evaluate how these policies are implemented and to assess their impact on health outcomes.

Improving the school experience of children with diabetes: Evaluation of the KiDS project.

BACKGROUND: The International Diabetes Federation (IDF) launched the Kids and Diabetes in School (KiDS) project in collaboration with the International Society for Paediatric and Adolescent Diabetes (ISPAD) and Sanofi Diabetes to inform and teach school staff, children and parents on the management of diabetes in school. Brazil and India were chosen as pilot countries. METHODS: The evaluation was conducted using a qualitative methodology using semi-structured face to face in-depth interviews. Five out of fifteen schools were selected, where teachers and parents of children with and without diabetes were interviewed. Interviews took place one and three months after the implementation of KiDS. FINDINGS: Diabetes knowledge among the school staff and parents of children without diabetes was very limited prior to the KiDS Project in both countries. After introducing the KiDS information pack both groups mentioned increased knowledge on the management of diabetes. This was reflected through healthier food choices at school and the encouragement of physical activities. Increased awareness and understanding in the school staff were observed by parents of children with diabetes. INTERPRETATION: The KiDS project received positive feedback on the educational materials. The pack was deemed informative, interesting and engaging, creating increased awareness and understanding among school staff, parents and children. The project has created a demand for diabetes intervention in schools. The pack has been translated into fourteen languages and was downloaded over 17,000 times by November 2018.

Plain packaging of tobacco products: the logical next step for tobacco control policy in India.

India implemented larger 85% pictorial health warnings on all tobacco products from 1 April 2016. However, to remove the last bit of glamour and attraction from the tobacco packs, it must now embrace plain packaging. Plain packaging prevents tobacco packs from carrying the tobacco industry brand imagery as mobile billboards. Postimplementation of larger 85% pictorial health warnings on all tobacco products, this analysis was undertaken to assess the feasibility of plain packaging as the next logical tobacco control policy measure in India. As part of this analysis, the research team reviewed the available literature on legal and policy challenges to plain packaging as a tobacco control policy initiative for India. Literature from 2010 to 2016 in English language was reviewed, which reveals that, India has taken several preparatory steps implemented by other countries like Australia and the UK that have introduced plain packaging, for example, stronger smoke-free laws, ban on tobacco advertising, promotion and sponsorship, increase in taxes and a report from civil society task force on plain packaging. The trade and investment agreements signed by India are also within the international trade norms relating to public health. A Private Member's Bill on plain packaging is also pending in the Parliament of India. Other potential challenges against such policy decision, for example, freedom of trade, right to property, violation of competition law and other laws including consumer protection laws, were found unsubstantiated by the research team. Plain packaging is the next logical step for tobacco control policy in India.

School environment assessment tools to address behavioural risk factors of non-communicable diseases: A scoping review.

We aimed to identify, describe and analyse school environment assessment (SEA) tools that address behavioural risk factors (unhealthy diet, physical inactivity, tobacco and alcohol consumption) for non-communicable diseases (NCD). We searched in MEDLINE and Web of Science, hand-searched reference lists and contacted experts. Basic characteristics, measures assessed and measurement properties (validity, reliability, usability) of identified tools were extracted. We narratively synthesized the data and used content analysis to develop a list of measures used in the SEA tools. Twenty-four SEA tools were identified, mostly from developed countries. Out of these, 15 were questionnaire based, 8 were checklists or observation based tools and one tool used a combined checklist/observation based and telephonic questionnaire approach. Only 1 SEA tool had components related to all the four NCD risk factors, 2 SEA tools has assessed three NCD risk factors (diet/nutrition, physical activity, tobacco), 10 SEA tools has assessed two NCD risk factors (diet/nutrition and physical activity) and 11 SEA tools has assessed only one of the NCD risk factor. Several measures were used in the tools to assess the four NCD risk factors, but tobacco and alcohol was sparingly included. Measurement properties were reported for 14 tools. The review provides a comprehensive list of measures used in SEA tools which could be a valuable resource to guide future development of such tools. A valid and reliable SEA tool which could simultaneously evaluate all NCD risk factors, that has been tested in different settings with varying resource availability is needed.

An evaluation of outdoor school environments to promote physical activity in Delhi, India.

BACKGROUND: Increasing physical activity in children is an important public health goal in India. Schools may be a target for physical activity promotion, but little is known about outdoor school environments. The purpose of this study was to describe characteristics of the surrounding outdoor school environments that may promote children's physical activity in Delhi, India. METHODS: For this cross-sectional study, we conducted a structured observation of outdoor school environments in a random sample of 16 private schools in Delhi, India using the Sport, Physical activity and Eating behavior: Environmental Determinants in Young people (SPEEDY) audit tool. The SPEEDY school audit measured six categories, including (1) access to the school; (2) surrounding area; (3) school grounds; (4) aesthetics; (5) usage; and (6) overall environment. Six trained data collectors conducted the audit independently in the summer of 2012 while schools were in session. RESULTS: Of the 16 schools, one had cycle lanes separated from the road while two schools had cycle lanes on the road. Two schools had pavement on both sides of the road for pedestrians. One school had marked pedestrian crossings. No schools had school warning signs, road safety signs, or route signs for cyclists that would help calm vehicular traffic. Fifteen schools had playground equipment and nine had courts, an assault course (a sequence of equipment designed to be used together), and a quadrangle (an enclosed or semi-enclosed courtyard) for outdoor physical activity. The majority of schools were shielded from the surrounding area by hedges, trees, or fences (n = 13) and were well maintained (n = 10). One school had evidence of vandalism. Two schools had graffiti, seven had litter, and 15 had murals or art. CONCLUSIONS: The majority of schools did not have infrastructure to support physical activity, such as cycle lanes, marked pedestrian crossings, or traffic calming mechanisms such as school warning signs. However, most had playground equipment, courts, and outdoor play areas. Nearly all were free from vandalism and many had murals or art. These results provide preliminary data for future work examining outdoor school environments, active transport to school, and children's physical activity in India.