Factors affecting continuous participation in follow-up evaluations during a lifestyle intervention programme for type 2 diabetes prevention: The Feel4Diabetes-study.

AIMS: Community- and school-based lifestyle interventions are an efficient method of preventing type 2 diabetes in vulnerable populations. Many participants, however, fail to complete the necessary follow-ups. We investigated factors affecting the continuous participation in follow-up evaluations during the Feel4Diabetes-study, a multilevel intervention programme implemented across Europe. METHODS: Socioeconomic, sociodemographic and clinical factors were assessed for 2702 participants within six participating countries: Bulgaria and Hungary (low-to-middle-income countries, LMIC), Belgium and Finland (high-income countries, HIC) and Greece and Spain (high-income countries under austerity measures, HICAM). RESULTS: Statistically significant differences were detected with respect to sex, control group, education level, employment status, BMI and blood pressure measurements (systolic and diastolic blood pressure). Post hoc analysis revealed significant differences within socioeconomic regions. Higher levels of education were associated with significantly lower attrition in HIC (p < 0.05) and HICAM (p < 0.001), higher employment status was associated with lower attrition in HICAM (p < 0.001) and being female was associated with lower attrition in LMIC (p < 0.001). Surprisingly, the intervention group exhibited higher-than-expected attrition in HIC (p < 0.001) and HICAM (p = 0.003), and lower attrition in LMIC (p = 0.007). When tested together in the same multivariable predictive model, all sociodemographic and socioeconomic variables along with higher BMI retained their statistical significance, while systolic and diastolic blood pressure failed to remain significant. CONCLUSIONS: Key socioeconomic and sociodemographic factors along with BMI play a significant role in determining continuous participation in follow-up evaluations during school- and community-based intervention programmes.

Physical activity in relation to metabolic health and obesity: The Feel4Diabetes study.

AIM: To examine physical activity levels in association with metabolic health and estimate the stability of metabolically healthy obese (MHO) phenotypes over a 2-year period. METHODS: In total, 2848 men and women from families at risk of the development of diabetes were recruited. Participants were classified as obese or non-obese and metabolic health was defined using five existing definitions. Physical activity was estimated with the International Physical Activity Questionnaire and pedometers. RESULTS: Prevalence of the MHO phenotype varied among definitions (0% to 20.2%). Overall, the MHO were more active than the metabolically unhealthy obese (MUO). Daily sitting hours (odds ratio [OR] = 1.055, 95% confidence interval [CI]: 1.009-1.104) and daily steps (per 500; OR = 0.934, 95% CI: 0.896-0.973) were remarkable predictors of metabolic health in individuals with obesity; and likewise, in individuals without obesity. After 2 years, 44.1% of baseline MHO adults transitioned to MUO, while 84.0% of the MUO at baseline remained at the same phenotype. Although physical activity was not a major determinant in phenotype transitioning, daily steps were associated with the maintenance of metabolic health over time in the non-obese group. CONCLUSION: A universally accepted definition for MHO is needed. Being physically active can contribute to a metabolically healthy profile even in the presence of obesity; still, MHO is a transient condition and physical activity alone may not be an adequate factor for its maintenance.

Parental practices and children's lifestyle correlates of childhood overweight/obesity in Europe: The Feel4Diabetes study.

BACKGROUND: Parental influences on children's eating and physical activity (PA) and consequently on their weight are fundamental. The present study aimed to identify the predominant correlates of childhood overweight/obesity among a variety of parental practices and children's lifestyle indices in a large sample of children in Europe. METHODS: Families from low socio-economic status regions were recruited through schools, located in six European countries (Belgium, Finland, Greece, Spain, Bulgaria and Hungary). Seven thousand three hundred ninety-seven children 4-12 years old and their parents were selected using the FINDRISC-questionnaire. Parental practices assessed included parental role modelling, permissiveness and reward. Children's dietary intake and lifestyle behaviours were assessed through parent-reported questionnaires. RESULTS: Regarding parental practices, it was revealed that being sometimes (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.10-1.43) or rarely (OR = 1.43; 95% CI = 1.21-1.69) physically active with the child was associated with greater overweight/obesity risk, whereas rare permission of computer/mobile/tablet (OR = 0.81; 95% CI = 0.67-0.98) and sometimes (OR = 0.77; 95% CI = 0.68-0.88) or rare (OR = 0.77; 95% CI = 0.66-0.91) reward with PA were associated with lower risk. Regarding children's lifestyle factors, consuming > 3 cups/week fresh fruit juices (OR = 1.28; 95% CI = 1.13-1.45), skipping breakfast (OR = 1.37; 95% CI = 1.17-1.61), absence of 1 h of daily PA (OR = 1.40; 95% CI = 1.24-1.58) and increased daily screen time (ST) (OR = 1.23; 95% CI = 1.09-1.39) were associated with greater overweight/obesity risk. All the variables were adjusted for maternal education, child's sex and age. CONCLUSIONS: These findings emphasize the necessity of family-centered approaches in health promotion and obesity prevention programs for children. Such programs should focus on parents as the primary role models in exerting positive influence and encouraging healthy eating habits, PA, and ST behaviors in their children, which in turn, may have a substantial impact on children's overall weight status.

Children's food choices are highly dependent on patterns of parenting practices and food availability at home in families at high risk for type 2 diabetes in Europe: Cross-sectional results from the Feel4Diabetes study.

BACKGROUND: Food parenting practices, behaviours and food availability at home are associated with children's food choices; however, these associations have been mainly studied for each parenting practice separately and focused mostly on healthy populations. The aim of the study was to identify patterns of parenting practices (including data regarding food availability at home, food and physical activity-related behaviours and rewards) and to investigate their cross-sectional associations with children's food choices in families at high risk for type 2 diabetes (T2D). METHODS: Data of parents and children (n = 2278), from the Feel4Diabetes study conducted in six European countries, were collected using validated questionnaires. The data analysed included children's food choices, food availability at home and food and physical activity-related parenting practices. Four patterns of parenting practices were identified using principal component analysis, and associations between those components and children's food choices were assessed using adjusted, individual linear regressions. RESULTS: Parenting patterns focusing on unhealthy habits, such as allowing unhealthy snacks and unlimited screen time, providing higher availability of unhealthy foods at home, rewarding with snacks and screen time, were positively associated with children's unhealthy food choices (consumption of savoury/sweet snacks, fizzy drinks, etc.). The parenting patterns providing fruit/vegetables at home, consuming fruit, and being physically active with the child were positively associated with children's healthier food choices (consumption of fruit, vegetables, whole grain cereals, etc.). CONCLUSIONS: Public health initiatives should focus on high-risk families for T2D, assisting them to adopt appropriate parenting practices and behaviours to promote healthier food choices for children.

A lifestyle pattern characterised by high consumption of sweet and salty snacks, sugar sweetened beverages and sedentary time is associated with blood pressure in families at risk for type 2 diabetes mellitus in Europe. The Feel4Diabetes Study.

BACKGROUND: Individuals from families at high-risk for type 2 diabetes mellitus (T2DM) are also at high risk for hypertension (HTN) and cardiovascular disease. Studies identifying lifestyle patterns (LPs) combining dietary, physical activity or sedentary variables and examining their possible role with respect to developing blood pressure (BP) are limited. The present study aimed to examine the association of different LPs with BP levels in families at high risk for T2DM in Europe. METHODS: In total, 1844 adults (31.6% males) at high-risk for T2DM across six European countries were included in this cross-sectional study using data from the baseline assessment of the Feel4Diabetes Study. BP measurements and dietary and physical activity assessments were conducted, and screen times were surveyed. LPs were revealed with principal component analysis of various data regarding diet, physical activity, screen time and smoking. RESULTS: Three LPs were identified. LP3 (high consumption of sweet and salty snacks, sugar sweetened soft drinks and juices, and high amount of screen time) was positively associated with diastolic BP (B, 0.52; 95% confidence interval = 0.05-0.99) and the existence of HTN (odds ratio = 1.12; 95% confidence interval = 1.00-1.25). Participants in the highest tertile of LP3 spent mean 3 h of screen time, consumed 1.5 portions of sweet and/or salty snacks and 1 L of soft drinks on a daily basis, were associated with 12% higher risk of HTN. CONCLUSIONS: Focusing on the combination of eating and lifestyle behaviours may more accurately identify, and therefore guide preventive measures tailored to the specific needs of high-risk populations.

Familial Partial Lipodystrophy: Clinical Features, Genetics and Treatment in a Greek Referral Center.

Familial partial lipodystrophy (FPLD) is a rare syndrome in which a patient's phenotype is not merely dependent on the specific genetic mutation, but it is also defined by a combination of other demographic, environmental and genetic factors. In this prospective observational study in a Greek referral center, we enrolled 39 patients who fulfilled the clinical criteria of FPLD. A genetic analysis was conducted, which included sequence and deletion/duplication analyses of the LMNA and PPRARG genes, along with anthropometric and metabolic parameters. The treatment responses of patients who were eligible for treatment with metreleptin were evaluated at 3 and 12 months. In most of the patients, no significant changes were detected at the exon level, and any mutations that led to changes at the protein level were not associated with the lipodystrophic phenotype. On the contrary, various changes were detected at the intron level, especially in introns 7 and 10, whose clinical significance is considered unknown. In addition, treatment with metreleptin in specific FPLD patients significantly improved glycemic and lipidemic control, an effect which was sustained at the 12-month follow-up. More large-scale studies are necessary to clarify the genetic and allelic heterogeneity of the disease, along with other parameters which could predict treatment response.

Contribution of home availability, parental child-feeding practices and health beliefs on children's sweets and salty snacks consumption in Europe: Feel4Diabetes-Study.

Adoption of healthy dietary and snacking habits could support optimum physical and mental development in children as they define health in adulthood. This study assessed parameters associated with children's snacking such as food home availability, parenting practices, and parents' health beliefs. In this cross-sectional study 12 039 children, 49·4% boys 5-12 years, participating in the European Feel4Diabetes-Study were included. Children's weekly consumption of sweets and salty snacks, home availability of snacks, food parenting practices, and health beliefs were assessed via questionnaires. Logistic regression was applied to explore associations of a) home availability of snacks, b) food parenting practices (permissiveness and rewarding with snacks) and c) parent's opinions on deterministic health beliefs with children's consumption of sweets and salty snacks. Results showed that home availability (sweets: ORadj: 4·76, 95 % CI: 4·32, 5·23; salty snacks: ORadj: 6·56, 95 % CI: 5·64, 7·61), allowing to consume (sweets: ORadj: 3·29, 95 % CI: 2·95, 3·67; salty snacks: ORadj: 3·41, 95 % CI: 2·98, 3·90) and rewarding with sweets/salty snacks (sweets: ORadj: 2·69, 95 % CI: 2·23, 3·24; salty snacks: ORadj: 4·34, 95 % CI: 3·57, 5·28) 'sometimes/or less frequently' compared to 'always/or often' were associated with lower weekly consumption of sweets and snacks. Parents' disagreement compared to agreement with deterministic health beliefs and inattentive eating were associated with lower consumption of salty snacks and sweets in children. Overall, the findings of this study indicate that attempts to promote healthy snacking habits in children should aim to improve parental dietary habits, food parenting practices, health beliefs, and reducing home availability of unhealthy foods and snacks.

Sociodemographic, anthropometric, and lifestyle correlates of prediabetes and type 2 diabetes in europe: The Feel4Diabetes study.

BACKGROUND AND AIMS: The current work aimed to identify the predominant correlates of prediabetes and T2DM among a variety of socio-demographic, anthropometric and lifestyle indices, in a large sample of adults from families at high risk for T2DM. METHODS AND RESULTS: In this cross-sectional study, 2816 adults were recruited from low-socioeconomic areas in high-income countries (HICs) (Belgium-Finland), HICs under austerity measures (Greece-Spain), and low/middle-income countries (LMICs) (Bulgaria-Hungary). A positive association between the male sex (OR, 95% C.I.2.77 (1.69-4.54)) and prediabetes was revealed compared to females, while there was a negative association between younger age (<45 years) (OR, 95% C.I. 0.58 (0.37-0.92)), and low/medium levels of waist circumference (OR, 95% C.I. 0.44 (0.22-0.89)) with prediabetes compared to older age and high levels of waist circumference, respectively. Concerning T2DM, 0-0.5 cups/day of fruits and berries (OR, 95% C.I.2. 13 (1.16-3.91)) and 150-300 g fish/week (OR, 95% C.I. 2.55 (1.01-6.41)) have a positive association compared to higher consumptions, respectively. Conversely, <1 cup/week legumes (OR, 95% C.I. 0.55 (0.31-0.99) as well as 0-0.5 servings (OR, 95% C.I. 0.34 (0.12-0.95) and 0.5-1 servings (OR, 95% C.I. 0.37 (0.19-0.71) of full-fat dairy/day have a negative association compared to higher consumptions, respectively. CONCLUSION: These findings indicate the need for diabetes prevention measures targeting young adults and especially men, above 45 years of age, with central obesity and poor dietary habits and prioritize vulnerable groups and populations living in LMICs. NATIONAL CLINICAL TRIAL NUMBER: NCT02393872.

Diet quality in association to lipidaemic profile in adults of families at high-risk for type 2 diabetes in Europe: The Feel4Diabetes study.

BACKGROUND AND AIMS: The role of diet in blood lipids is scarcely investigated in adults at risk of Type 2 Diabetes Mellitus (T2DM) and even less studied regarding their socioeconomic status (SES). This study aimed to investigate the associations of diet quality with blood lipids in adults from families at high-risk for developing T2DM from six European countries, considering their SES. METHODS AND RESULTS: In total 2049 adults (67% women) from relatively low-SES regions and high T2DM risk families were enrolled. Dietary habits, sedentary behaviour and sociodemographic characteristics were assessed using standardised questionnaires. The associations of tertiles of healthy diet score (HDS) with blood lipids were tested by univariate analysis of variance (UNIANOVA). HDL-Cholesterol (HDL-C) was positively (B 1.54 95%CI 0.08 to 2.99) and LDL-Cholesterol (LDL-C) (B -4.15 95%CI -7.82 to -0.48), ratio of total cholesterol to HDL-C (B -0.24 95%CI -0.37 to -0.10), ratio of LDL-C to HDL-C (B -0.18 95%CI -0.28 to -0.08) and Atherogenic Index of Plasma (B -0.03 95%CI -0.06 to 0.00) inversely associated with the highest tertile of diet score compared to the lowest tertile independently of age, sex, Body Mass Index, total screen time and smoking. In sub-analysis of education (<14 and ≥ 14 years of education), these findings were only significant in the high-SES group. CONCLUSION: While diet quality was poorer in the low-SES group, an association between diet quality and lipidemic profile was not found, as increased central obesity and smoking prevalence might have confounded this association. These findings indicate the need for tailor-made interventions, guided by the specific risk factors identified per population sub groups.

Parental insulin resistance is associated with unhealthy lifestyle behaviours independently of body mass index in children: The Feel4Diabetes study.

Parental health is associated with children's health and lifestyles. Thus, the aim of the present study was to assess lifestyle behaviours of children of parents with insulin resistance (IR) and at risk of type 2 diabetes. 2117 European families from the Feel4Diabetes-study were identified as being at risk for diabetes with the FINDRISC questionnaire and included in the present study. One parent and one child per family were included. Parental IR was considered when homeostasis model assessment (HOMA) was equal or higher than 2.5. Children's screen-time, physical activity and diet were assessed and clustered by K-means. Weight and height were measured and children's body mass index (BMI) was calculated. For children, a Healthy Diet Score (HDS) was calculated. Linear regression and multilevel logistic regression analyses were performed to assess the associations between parental IR and children's lifestyle behaviours in 2021. Children of parents with IR had higher BMI (p < 0.001) and spent more screen time (p = 0.014) than those of non-IR parents. Children of parents with IR had a lower value in the breakfast and vegetable components of the HDS (p = 0.008 and p = 0.05). Four lifestyle clusters were found. Children of IR parents had higher odds of being in a non-healthy cluster (OR: 1.19; 95%CI: 1.001-1.437). CONCLUSION: Having an IR parent was associated with a high screen time and an increased probability of having an unhealthy lifestyle pattern in children. These data point out that children's lifestyles should be assessed in families with IR parents to provide tailored interventions. WHAT IS KNOWN: • Children with diabetic or insulin-resistant parents could also develop this condition. • Unhealthy lifestyles are directly related with insulin resistance even in children. WHAT IS NEW: • Children from parents with insulin resistance have higher chances of unhealthy lifestyles. • A higher BMI was found for those children with an insulin-resistant parent.

Can food parenting practices explain the association between parental education and children's food intake? The Feel4Diabetes-study.

OBJECTIVE: This study aimed to investigate the mediating role of food parenting practices (FPP), including home availability of different types of foods and drinks, parental modelling of fruit intake, permissiveness and the use of food as a reward in the relationship between parental education and dietary intake in European children. DESIGN: Single mediation analyses were conducted to explore whether FPP explain associations between parents' educational level and children's dietary intake measured by a parent-reported FFQ. SETTING: Six European countries. PARTICIPANTS: Parent-child dyads (n 6705, 50·7 % girls, 88·8 % mothers) from the Feel4Diabetes-study. RESULTS: Children aged 8·15 ± 0·96 years were included. Parental education was associated with children's higher intake of water, fruits and vegetables and lower intake of sugar-rich foods and savoury snacks. All FPP explained the associations between parental education and dietary intake to a greater or lesser extent. Specifically, home availability of soft drinks explained 59·3 % of the association between parental education and sugar-rich food intake. Home availability of fruits and vegetables was the strongest mediators in the association between parental education and fruit and vegetable consumption (77·3 % and 51·5 %, respectively). Regarding savoury snacks, home availability of salty snacks and soft drinks was the strongest mediators (27·6 % and 20·8 %, respectively). CONCLUSIONS: FPP mediate the associations between parental education and children's dietary intake. This study highlights the importance of addressing FPP in future interventions targeting low-educated populations.

Parental food consumption and diet quality and its association with children's food consumption in families at high risk of type 2 diabetes: the Feel4Diabetes-study.

OBJECTIVE: To examine the parental food consumption and diet quality and its associations with children's consumption in families at high risk for developing type 2 diabetes mellitus across Europe. Also, to compare food frequency consumption among parents and children from high-risk families to the European Dietary guidelines/recommendations. DESIGN: Cross-sectional study using Feel4diabetes FFQ. SETTING: Families completed FFQ and anthropometric measures were obtained. Linear regression analyses were applied to investigate the relations between parental food consumption and diet quality and their children's food consumption after consideration of potential confounders. PARTICIPANTS: 2095 European families (74·6 % mothers, 50·9 % girls). The participants included parent and one child, aged 6-8 years. RESULTS: Parental food consumption was significantly associated with children's intake from the same food groups among boys and girls. Most parents and children showed under-consumption of healthy foods according to the European Dietary Guidelines. Parental diet quality was positively associated with children's intake of 'fruit' (boys: ß = 0·233, P < 0·001; girls: ß = 0·134, P < 0·05) and 'vegetables' (boys: ß = 0·177, P < 0·01; girls: ß = 0·234, P < 0·001) and inversely associated with their 'snacks' consumption (boys: ß = -0·143, P < 0·05; girls: ß = -0·186, P < 0·01). CONCLUSION: The present study suggests an association between parental food consumption and diet quality and children's food intake. More in-depth studies and lifestyle interventions that include both parents and children are therefore recommended for future research.

Fathers' daily intake of fruit and vegetables is positively associated with children's fruit and vegetable consumption patterns in Europe: The Feel4Diabetes Study.

BACKGROUND: Past research has focused on the relationship between mothers' and children's eating habits, although little is known about fathers as potential agents. The present study aimed to investigate the relationship between fathers' and children's fruit and vegetable (FV) intake in the context of fathers' education level and family income insecurity. METHODS: Cross-sectional analysis using baseline data from the multicentre Feel4Diabetes Study were collected in 2016. Participants were parent-dyads (fathers, n = 10,038) and school children (n = 12,041) from six European countries. Socio-demographic and dietary data were collected using questionnaires. Associations were assessed applying the multinomial logistic regression model. RESULTS: Overall, European children have low FV intake, especially in Southern European countries (Greece, Spain and Hungary). Children with fathers consuming FV daily were more likely to consume fresh fruit (odds ratio [OR] = 2.75; 95% confidence interval [CI] = 1.95-3.88) and vegetables (OR = 2.55; 95% CI = 1.80-3.60) 1-2 times per day. After adjusting for paternal educational level and family income insecurity significant associations remained for fresh fruit (ORadj = 2.59; 95% CI = 1.82-3.69) and vegetables (ORadj = 1.98; 95% CI = 1.38-2.86). Country differences showed that fathers' educational level and income insecurity might be important factors worth considering for FV intake in Greece. CONCLUSIONS: The present study showed that fathers' FV intake was positively associated with children's daily intake of these foods. Implementation of future population-based strategies promoting FV intake not only in mothers, but also in fathers could be an effective public health initiative to increase FV intake in children. Policy-makers should give special attention to families dwelling in Southern European regions.

The beneficial short-term effects of a high-protein/low-carbohydrate diet on glycaemic control assessed by continuous glucose monitoring in patients with type 1 diabetes.

AIM: To compare the effects of three different but isocaloric dietary patterns, high-protein/low-carbohydrate (HPD) with 20% of calories as carbohydrates, Mediterranean/low glycaemic index (MED) with 40% carbohydrates, and a reference diet (REF) with 50% carbohydrates, in patients with type 1 diabetes (T1D). MATERIALS AND METHODS: In a randomized crossover study, 15 patients with T1D were assigned to the three dietary patterns for three separate weeks, with 7-day washout periods in between. Continuous glucose monitoring was applied during the intervention periods. The primary outcome was glycaemic control, as measured by the percentage of time patients spent within the euglycaemic range (TIR70-140 mg/dl ). Other key glycaemic metrics were also investigated as secondary outcomes. RESULTS: TIR70-140 was not statistically different between HPD, MED and REF (p = .105). Pairwise analysis revealed a statistically significant difference between HPD and REF at the .05 level, which was not retained after applying Bonferroni correction (54.87% ± 14.11% vs. 48.33% ± 13.72%; p = .018). During the HPD period, 11 out of 15 participants spent more time within TIR70-140 compared with either the REF or MED. The HPD performed significantly better than the REF in terms of TIR70-180 (74.33% ± 12.85% vs. 67.53% ± 12.73%; p = .012), glycaemic variability (coefficient of variation: 36.18% ± 9.30% vs. 41.48% ± 8.69%; p = .016) and time spent in the hypoglycaemic range (TBR70 mg/dl ; median: 12, IQR: 16 vs. median: 14, IQR: 20; p = .007), whereas no statistically significant differences were observed between MED and HPD or REF. CONCLUSIONS: Compared with REF and MED, an HPD plan may have a positive impact on glycaemic control in patients with T1D. During the HPD, patients spent a shorter time in hypoglycaemia and exhibited lower glycaemic variability.

Cost-effectiveness analysis of a school- and community-based intervention to promote a healthy lifestyle and prevent type 2 diabetes in vulnerable families across Europe: the Feel4Diabetes-study.

The Feel4Diabetes-study implemented a school- and community-based intervention to promote healthy lifestyle and prevent type 2 diabetes mellitus (T2DM) in six European countries. The intervention included a special focus on families at increased T2DM risk. The current study evaluates the intervention's cost-effectiveness. A Markov-type health economic model was developed to predict the incidence of T2DM and its complications. Incremental cost-effectiveness ratios (lifetime horizon, societal perspective) were calculated based on the overall intervention effect on health behaviour, and stratified for low- and high-risk families. Sensitivity analyses captured input parameters uncertainty. A budget impact analysis was performed. The increase in children's water consumption and physical activity led to a modest gain in quality adjusted life years (QALYs) at a low intervention cost and budget impact. Medical cost savings due to avoided illness could only be achieved on the very long-term (>30 years). The intervention in its entirety was cost-effective (more QALYs at a reasonable investment) in Belgium, Finland, Bulgaria, and Hungary, while being dominant (net savings and more QALYs) in Greece and Spain. Results were cost-effective for the low-risk families, who only received the school- and community-based intervention component. Results for the high-risk families were only cost-effective (with considerable uncertainty) in Greece and Spain, but not when the intervention would need to be repeated. The Feel4Diabetes-intervention is potentially cost-effective, especially in countries with a high overweight and obesity prevalence, at a limited budget impact. The incremental financial investments to reach and support high-risk families did not result in the hoped-for health benefits.

European Childhood Obesity Risk Evaluation (CORE) index based on perinatal factors and maternal sociodemographic characteristics: the Feel4Diabetes-study.

The aim of this study was to develop and examine the predictive accuracy of an index that estimates obesity risk in childhood based on perinatal factors and maternal sociodemographic characteristics. Analysis was conducted by using cross-sectional and retrospective data collected from a European cohort of 2775 schoolchildren and their families participating in the Feel4Diabetes-study. The cohort was randomly divided by using two-thirds of the sample for the development of the index and the remaining one third for assessing its predictive accuracy. Logistic regression analyses determined a prediction model for childhood obesity. The area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were calculated. Cut-off analysis was applied to identify the optimal value of the index score that predicts obesity with the highest possible sensitivity and specificity. Eight factors were found to be significantly associated with obesity and were included as components in the European "Childhood Obesity Risk Evaluation" (CORE) index: region of residence, maternal education, maternal pre-pregnancy weight status, gestational weight gain, maternal smoking during pregnancy, birth weight for gestational age, infant growth velocity, and exclusive breastfeeding during the first 6 months. Risk score ranged from 0 to 22 corresponding to a risk from 0.9 to 54.6%. The AUC-ROC was 0.725 with optimal cut-off ≥9 (sensitivity = 74.1%, specificity = 61.0%, PPV = 11.3%, NPV = 97.2%).Conclusion: The European CORE index can be used as a screening tool for the identification of infants at high-risk for becoming obese at 6-9 years. This tool could assist healthcare professionals in initiating preventive measures from the early life.Trial registration: The Feel4Diabetes-intervention is registered at https://clinicaltrials.gov/ ; number, CT02393872; date, March 20, 2015. What is Known: • As prevention of obesity should start early in life, there is a compelling rationale for the early identification of high-risk children to facilitate targeted intervention. What is New: • This study developed and assessed the predictive accuracy of an index for the Childhood Obesity Risk Evaluation (CORE), combining certain perinatal factors and maternal sociodemographic characteristics in a large European cohort. • The European CORE index can be used as a screening tool for identifying infants at high-risk for becoming obese at 6-9 years and assist health professionals in initiating early prevention strategies.

Methodological procedures followed in a school-and community-based intervention to prevent type 2 diabetes in vulnerable families across Europe: the Feel4Diabetes-study.

Feel4Diabetes (standing for: Families across Europe following a hEalthy Lifestyle for Diabetes prevention, http://feel4diabetes-study.eu/) is a school and community based intervention program, aiming to prevent type 2 diabetes (T2D) among families from vulnerable population groups, in six European countries, by promoting healthy lifestyle. In the current issue of BMC Endocrine Disorders, three reviews and three papers providing a detailed description of the methodology used to obtain measurements related to the trial conduction, as well as two papers using original data collected in the Feel4Diabetes-study are presented.

Effective strategies for childhood obesity prevention via school based, family involved interventions: a critical review for the development of the Feel4Diabetes-study school based component.

BACKGROUND: Although there are many interventions targeting childhood obesity prevention, only few have demonstrated positive results. The current review aimed to gather and evaluate available school-based intervention studies with family involvement targeting dietary, physical activity and sedentary behaviors among primary schoolchildren and their families, in order to identify the most effective strategies. METHODS: Studies published between 2000 and January 2015 were retrieved from scientific electronic databases and grey literature. The databases used included MEDLINE/PubMed, Web-of-Science, CINAHL and Scopus. Included studies had to be experimental controlled studies and had duration over 1 school year, had family involvement, combined PA and dietary behaviors and were implemented in school setting. A complementary search was executed to update the review to cover the period from February 2015 to January 2019. RESULTS: From the studies examined (n = 425), 27 intervention programs (33 publications) fulfilled the inclusion criteria. Among these, 15 presented significant effect on weight status and/ or overweight/ obesity or clinical indices, 3 presented significant effect on most energy balance-related behaviors (EBRBs) while 9 presented significant effect on some/few EBRBs or determinants. Strategies implemented in effective interventions were: teachers acting as role-models and being actively involved in the delivery of the intervention, school policies supporting the availability of healthy food and beverage choices and limiting unhealthy snacks, changes in the schoolyard, in the recess rules and in the physical education classes to increase physical activity, and involving parents in the intervention via assignments, meetings, informative material and encouraging them to improve the home environment. Use of incentives for children, social marketing techniques, collaboration with local stakeholders were found to increase effectiveness. Programs that focused only on educational sessions and material for parents, without promoting relevant environmental and policy changes, were found to be less effective. Cultural adaptations have been suggested to increase the intervention's acceptance in specific or vulnerable population groups. CONCLUSIONS: Several effective strategies were identified in the reviewed programs. Outcomes of the current review were taken into account in developing the Feel4Diabetes-intervention and summed up as recommendations in the current work in order to facilitate other researchers designing similar childhood obesity prevention initiatives.

Feel4Diabetes healthy diet score: development and evaluation of clinical validity.

BACKGROUND: The aim of this paper is to present the development of the Feel4Diabetes Healthy Diet Score and to evaluate its clinical validity. METHODS: Study population consisted of 3268 adults (63% women) from high diabetes risk families living in 6 European countries. Participants filled in questionnaires at baseline and after 1 year, reflecting the dietary goals of the Feel4Diabetes intervention. Based on these questions the Healthy Diet Score was constructed, consisting of the following components: breakfast, vegetables, fruit and berries, sugary drinks, whole-grain cereals, nuts and seeds, low-fat dairy products, oils and fats, red meat, sweet snacks, salty snacks, and family meals. Maximum score for each component was set based on its estimated relative importance regarding T2DM risk, higher score indicating better quality of diet. Clinical measurements included height, weight, waist circumference, heart rate, blood pressure, and fasting blood sampling, with analyses of glucose, total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides. Analysis of (co) variance was used to compare the Healthy Diet Score and its components between countries and sexes using baseline data, and to test differences in clinical characteristics between score categories, adjusted for age, sex and country. Pearson's correlations were used to study the association between changes from baseline to year 1 in the Healthy Diet Score and clinical markers. To estimate reproducibility, Pearson's correlations were studied between baseline and 1 year score, within the control group only. RESULTS: The mean total score was 52.8 ± 12.8 among women and 46.6 ± 12.8 among men (p <  0.001). The total score and its components differed between countries. The change in the Healthy Diet Score was significantly correlated with changes in BMI, waist circumference, and total and LDL cholesterol. The Healthy Diet Score as well as its components at baseline were significantly correlated with the values at year 1, in the control group participants. CONCLUSION: The Feel4Diabetes Healthy Diet Score is a reproducible method to capture the dietary information collected with the Feel4Diabetes questionnaire and measure the level of and changes in the adherence to the dietary goals of the intervention. It gives a simple parameter that associates with clinical risk factors in a meaningful manner. TRIAL REGISTRATION: Clinicaltrials.gov NCT02393872. Registered March 20, 2015.

Obtaining evidence base for the development of Feel4Diabetes intervention to prevent type 2 diabetes - a narrative literature review.

BACKGROUND: Feel4Diabetes was a school and community based intervention aiming to promote healthy lifestyle and tackle obesity for the prevention of type 2 diabetes among families in 6 European countries. We conducted this literature review in order to guide the development of evidence-based implementation of the Feel4Diabetes intervention. We focused on type 2 diabetes prevention strategies, including all the phases from risk identification to implementation and maintenance. Special focus was given to prevention among vulnerable groups and people under 45 years. METHODS: Scientific and grey literature published between January 2000 and January 2015 was searched for relevant studies using electronic databases. To present the literature review findings in a systematic way, we used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. A complementary literature search from February 2015 to December 2018 was also conducted. RESULTS: The initial review included 27 studies with a follow-up ≥12 months and 9 studies with a follow-up ≥6 months and with a participant mean age < 45 years. We found out that interventions should be targeted at people at risk to improve recruiting and intervention effectiveness. Screening questionnaires (primarily Finnish Diabetes Risk Score FINDRISC) and blood glucose measurement can both be used for screening; the method does not appear to affect intervention effectiveness. Screening and recruitment is time-consuming, especially when targeting lower socioeconomic status and age under 45 years. The intervention intensity is more important for effectiveness than the mode of delivery. Moderate changes in several lifestyle habits lead to good intervention results. A minimum of 3-year follow-up seemed to be required to show a reduction in diabetes risk in high-risk individuals. In participants < 45 years, the achieved results in outcomes were less pronounced. The complementary review included 12 studies, with similar results regarding intervention targets and delivery modes, as well as clinical significance. CONCLUSION: This narrative review highlighted several important aspects that subsequently guided the development of the Feel4Diabetes high-risk intervention. Research on diabetes prevention interventions targeted at younger adults or vulnerable population groups is still relatively scarce. Feel4Diabetes is a good example of a project aiming to fill this research gap. TRIAL REGISTRATION: clinicaltrials.gov NCT02393872, registered 20th March 2015.