Parents' perception of health promotion: What do parents think of a healthy lifestyle in parenting and the impact of the school environment? A qualitative research in the Netherlands.

PURPOSE: This study aimed at gaining insight into parents' perceptions towards health behaviour in parenting and the impact of the school environment. Healthcare professionals experience barriers to discuss health behaviour in families where levels of overweight and obesity are elevated. There is a need to understand parents' perception and perceived significance of health behaviour. DESIGN AND METHODS: Sixty-three semi-structured interviews were conducted with parents of children from three primary schools located in two different neighbourhoods in Zwolle, the Netherlands. Parents were asked to formulate their top three priority goals in parenting, additionally supplemented with 15 predetermined goals, including a health behaviour related goal. Parents ranked the goals in order of importance and gave an explanation. Finally, parents shared their opinions regarding the school environment in promoting health behaviour, according to the EnrG framework. RESULTS: In 8 out of 63 interviews, health was reported in the top three self-formulated goals. Other goals considered important were happiness and being respectful to others. When health was ranked as less important in parenting, routine of health behaviour, own beliefs and religion were given as explanations. The physical school environment and teachers were mentioned as important factors in promoting health behaviour. CONCLUSIONS: Parents indicate health behaviour as a key-element in parenting, even when health behaviour is not considered as the most important priority. PRACTICE IMPLICATIONS: Since school is perceived as a logical and powerful environment, healthcare professionals should collaborate with school staff to empower their own, teachers' and parents' roles to address health promotion.

Maternal stress and depressive symptoms and adolescents' body mass index: a prospective study.

BACKGROUND: Growing evidence suggests that maternal mental health issues are associated with (young) children's weight outcomes. However, most studies have been limited by cross-sectional designs and have been aimed at (younger) children. The current prospective study focuses on the link between maternal mental health (i.e., psychological stress and depressive symptoms) and adolescents' zBMI development. METHODS: The participants in the present study were part of wave 1 and 2 of a longitudinal study on Dutch adolescents' and their parents' health behavior. Adolescents (aged 10-14) and their parents were recruited through six secondary schools in the South and the East of the Netherlands. For this study, we only included biological mothers and their adolescent children who participated in both waves, with data on the main measures in both waves, leaving a final sample of 336 biological mother-child dyads. Adolescents height and weight were measured, and both parents and adolescents filled in validated questionnaires on perceived stress and depressive symptoms and answered additional questions concerning domain-specific stress. Regression analyses were performed in R to examine longitudinal links between maternal stress and depressive symptoms at baseline (T1) and adolescents' BMI standard deviation scores (zBMI) 6 months later (T2), corrected for baseline zBMI and covariates. RESULTS: Maternal general perceived stress (ß = .20, p = .002) at T1 preceded higher adolescents' zBMI at T2, after controlling for baseline zBMI and other covariates, whereas maternal depressive symptoms at T1 (ß = -.05, p = .44) and other domain-specific stress did not (maternal financial stress, maternal stress at work, maternal stress at home). Additionally, lower educational level among adolescents (ß = .16, p = .001) and adolescent depressive symptoms (ß = .16, p = .001) was associated with a higher zBMI at T2. CONCLUSIONS: Results suggest that maternal general stress, but not depressive symptoms, may influence adolescents' weight development. Our findings warrant future investigation on whether and how general stress among mothers may predict weight increases of their adolescent offspring.

The training and support needs of 22 programme directors of community-based childhood obesity interventions based on the EPODE approach: an online survey across programmes in 18 countries.

BACKGROUND: Tackling childhood obesity is complex and requires a community-based approach implemented in multiple environments. It is known from literature that knowledgeable and skilled professionals are essential to implement such an approach successfully. The aim of the present study was to assess the need for training and support among a global network of programme directors implementing a Community-Based Childhood Obesity Intervention (CBCOI) based on the EPODE approach, in order to assist them in optimising the implementation process. METHODS: An online survey was sent to 40 programme directors representing programmes implementing a CBCOI based on the EPODE approach. The survey consisted of statements on a 5-point Likert scale and multiple-choice questions about attitude towards and usefulness of training and support, and preferences for some predefined training types and training topics. In total, 22 programme directors responded to the survey (55% response rate). Data were analysed using descriptive statistics to describe the need for support in order to improve successful implementation. RESULTS: Respondents strongly agreed that continually updating skills and learning how to make their programmes more effective and sustainable at the start and during the implementation was important. On-site training was preferred most at the commencement of a programme, while a 2-day training course was most valued during implementation. Monitoring, measuring and programme evaluation was identified as the most valuable training topic. CONCLUSIONS: The results indicate a continuing and significant need for support and training among programme directors implementing a CBCOI. The findings give directions regarding topics and types of training and support in order to improve the implementation process.

Inequalities in energy-balance related behaviours and family environmental determinants in European children: changes and sustainability within the EPHE evaluation study.

BACKGROUND: Increasing social inequalities in health across Europe are widening the gap between low and high socio-economic groups, notably in the prevalence of obesity. Public health interventions may result in differential effects across population groups. Therefore, the EPHE (EPODE for the Promotion of Health Equity) project analysed the added value of community-based programmes, based on the EPODE (Ensemble Prévenons l'Obésité Des Enfants-Together Let's Prevent Obesity) model, to reduce socio-economic inequalities in energy balance-related behaviours of children and their family-environmental related determinants in seven European communities. This study presents the changes between baseline and follow-up after the one-year interventions and their sustainability one year after. METHODS: This is a prospective study with a one school-year intervention, followed by one year of follow-up. In all, 1266 children (age 6-8 years) and their families from different socio-economic backgrounds were recruited at baseline. For 1062 children, information was available after one year (T1) and for 921 children after two years (T2). A self-reported questionnaire was completed by the parents to examine the children's energy balance-related behaviours and family- environmental determinants. Socio-economic status was defined by the educational level of the mother. The Wilcoxon signed-rank test for paired data was used to test the differences between baseline and intermediate, and between intermediate and final, measurements for each of the socio-economic status groups. RESULTS: Post-intervention effects in energy-balance related behaviours showed the following improvements among the low socio-economic status groups: increased fruit consumption (Netherlands), decreased fruit juices amount consumed (Romania) and decreased TV time on weekdays (Belgium). Whereas in only the latter case the behavioural change was accompanied with an improvement in a family-environmental determinant (monitoring the time the child watches TV), other improvements in parental rules and practices related to soft drinks/fruit juices and TV exposure were observed. A few of those effects were sustainable, notably in the case of Belgium. CONCLUSIONS: Inequalities in obesity-related behaviours could be potentially reduced when implementing community-based interventions, tailored to inequality gaps and using the EPODE methodology. Within-group changes varied widely, whereas monitoring of interventions and process evaluation are crucial to understand the observed results.

Identifying developmental trajectories of body mass index in childhood using latent class growth (mixture) modelling: associations with dietary, sedentary and physical activity behaviors: a longitudinal study.

BACKGROUND: To date, many epidemiologic studies examining associations between obesity and dietary and sedentary/physical activity behaviors have focused on assessing Body Mass Index (BMI) at one point in time. Recent developments in statistical techniques make it possible to study the potential heterogeneity in the development of BMI during childhood by identifying distinct subpopulations characterized by distinct developmental trajectories. Using Latent Class Growth (Mixture) Modelling (LCGMM) techniques we aimed to identify BMI trajectories in childhood and to examine associations between these distinct trajectories and dietary, sedentary and physical activity behaviors. METHODS: This longitudinal study explored BMI standard deviation score (SDS) trajectories in a sample of 613 children from 4 to 12 years of age. In 2006, 2009 and 2012 information on children's health related behaviors was obtained by parental questionnaires, and children's height and weight were measured. Associations with behaviors were investigated with logistic regression models. RESULTS: We identified two BMI SDS trajectories; a decreasing BMI SDS trajectory (n = 416; 68 %) and an increasing BMI SDS trajectory (n = 197; 32 %). The increasing BMI SDS trajectory consisted of more participants of lower socio-economic status (SES) and of non-western ethnicity. Maternal overweight status was associated with being in the increasing BMI SDS trajectory at both baseline and follow-up six years later (2006: Odds Ratio (OR), 2.9; 95 % confidence interval (CI) 1.9 to 4.3; 2012 OR, 1.8; 95 % CI 1.2 to 2.6). The increasing BMI SDS trajectory was associated with the following behaviors; drinking sugared drinks > 3 glasses per day, participation in organized sports < 1 h per week, and TV viewing > 2 h per day, though participation in organized sports at follow-up was the only significant result. CONCLUSIONS: Our results indicate the importance of healthy lifestyle behaviors at a young age, and indicate that maternal BMI is a very important risk factor for the development of childhood overweight. Comprehension of heterogeneity in the development of BMI and associations with modifiable health related behaviors is interesting for prevention by targeting high risk behaviors in early childhood, especially in low SES children, children of non-western ethnicity and children whose mother is overweight.

Promoting health equity in European children: design and methodology of the prospective EPHE (Epode for the Promotion of Health Equity) evaluation study.

BACKGROUND: Reducing health inequalities is a top priority of the public health agendas in Europe. The EPHE project aims to analyse the added value of a community-based interventional programme based on EPODE methodology, adapted for the reduction of socio-economic inequalities in childhood obesity. The interventions that will be implemented by this project focus on four energy balance-related behaviours (fruit and vegetable consumption, tap water intake, physical inactivity, sleep duration) and their determinants. This article presents the design of the effect evaluation of the EPHE project. METHODS/DESIGN: This is a prospective two-year follow-up evaluation study, which will collect data on the energy balance-related behaviours and potential environmental determinants of 6-8 year olds, depending on the socio-economic status of the parents. For this purpose a parental self-reported questionnaire is constructed. This assesses the socio-economic status of the parents (5 items) and the dietary (12 items), sedentary (2 items) and sleeping (4 items) behaviour of the child. Alongside potential family-environmental determinants are assessed. The EPHE parental questionnaire will be disseminated in schools of a selected medium-sized city in seven European countries (Belgium, Bulgaria, France, Greece, Portugal, Romania, The Netherlands). DISCUSSION: This study will evaluate the effects of the EPHE community-based interventional programmes. Furthermore, it will provide evidence for children's specific energy balance-related behaviours and family environmental determinants related to socio-economic inequalities, in seven European countries.

Two-Year Results of a Five-Year Personalized Integrative Obesity Coaching Program (IBO) Based upon a Systems Health Perspective and an Evolutionary Longitudinal Study Approach.

This study presents the outcomes of a 5-year personalized integrative coaching program for adults with obesity (body mass index BMI ≥ 30 kg/m2), based upon a systems health perspective, during the first 2 years. This longitudinal study, which had an evolutionary design, included all adults who enrolled in the program. Health-related quality of life (HRQoL) was measured with the Short Form-36 (SF-36), and physical outcomes included weight, waist circumference, aerobic capacity, lipid profile, and HbA1c. Subsequently, participants completed questionnaires (e.g., the Symptom Checlist-90 (SCL-90) and the Checklist Individual Strength (CIS)). Seventy-nine adults with a mean BMI of 39.5 kg/m2 (SD 5.3) were included. Forty-four participants completed 2 years in the program. Compared to baseline, there were significant improvements in the SF-36 subscales 'physical functioning' (MD 9.9 points, 95% CI: 2.1-17.5, p = 0.013) and 'general health perceptions' (MD 9.3 points, 95% CI 2.9-15.7, p = 0.006). Furthermore, significant improvements in physical outcomes and psychosocial questionnaires (e.g., weight loss (MD 3.5 kg, 95% CI: 1.2-5.7, p = 0.003), waist circumference (MD 5.1 cm, 95% CI: 2.4-7.8, p < 0.001), and CIS fatigue (MD 6.8, 95% CI: 3.1-10.5, p = 0.001) were observed. This study highlights the importance of a systems health perspective supporting the development of a personalized integrative coaching program for adults with obesity in a 'real-world' setting.

Children's sedentary behaviour: descriptive epidemiology and associations with objectively-measured sedentary time.

BACKGROUND: Little is known regarding the patterning and socio-demographic distribution of multiple sedentary behaviours in children. The aims of this study were to: 1) describe the leisure-time sedentary behaviour of 9-10 year old British children, and 2) establish associations with objectively-measured sedentary time. METHODS: Cross-sectional analysis in the SPEEDY study (Sport, Physical activity and Eating behaviour: Environmental Determinants in Young people) (N=1513, 44.3% boys). Twelve leisure-time sedentary behaviours were assessed by questionnaire. Objectively-measured leisure-time sedentary time (Actigraph GT1M, <100 counts/minute) was assessed over 7 days. Differences by sex and socioeconomic status (SES) in self-reported sedentary behaviours were tested using Kruskal-Wallis tests. The association between objectively-measured sedentary time and the separate sedentary behaviours (continuous (minutes) and categorised into 'none' 'low' or 'high' participation) was assessed using multi-level linear regression. RESULTS: Sex differences were observed for time spent in most sedentary behaviours (all p ≤ 0.02), except computer use. Girls spent more time in combined non-screen sedentary behaviour (median, interquartile range: girls: 770.0 minutes, 390.0-1230.0; boys: 725.0, 365.0 - 1182.5; p = 0.003), whereas boys spent more time in screen-based behaviours (girls: 540.0, 273.0 - 1050.0; boys: 885.0, 502.5 - 1665.0; p < 0.001). Time spent in five non-screen behaviours differed by SES, with higher values in those of higher SES (all p ≤ 0.001). Regression analyses with continuous exposures indicated that reading (ß = 0.1, p < 0.001) and watching television (ß = 0.04, p < 0.01) were positively associated with objectively-measured sedentary time, whilst playing board games (ß = -0.12, p < 0.05) was negatively associated. Analysed in categorical form, sitting and talking (vs. none: 'low' ß = 26.1,ns; 'high' 30.9, p < 0.05), playing video games (vs. none: 'low' ß = 49.1, p < 0.01; 'high' 60.2, p < 0.01) and watching television (vs. lowest tertile: middle ß = 22.2,ns; highest ß = 31.9, p < 0.05) were positively associated with objectively-measured sedentary time whereas talking on the phone (vs. none: 'low' ß = -38.5, p < 0.01; 'high' -60.2, p < 0.01) and using a computer/internet (vs. none: 'low' ß = -30.7, p < 0.05; 'high' -4.2,ns) were negatively associated. CONCLUSIONS: Boys and girls and children of different socioeconomic backgrounds engage in different leisure-time sedentary behaviours. Whilst a number of behaviours may be predictive of total sedentary time, collectively they explain little overall variance. Future studies should consider a wide range of sedentary behaviours and incorporate objective measures to quantify sedentary time where possible.

Barriers, facilitators and attitudes influencing health promotion activities in general practice: an explorative pilot study.

BACKGROUND: The number of chronically ill patients increases every year. This is partly due to an unhealthy lifestyle. However, the frequency and quality of (evidence-based) health promotion activities conducted by Dutch general practitioners (GPs) and practice nurses (PNs) are limited. The aim of this pilot study was to explore which lifestyle interventions Dutch GPs and PNs carry out in primary care, which barriers and facilitators can be identified and what main topics are with respect to attitudes towards health promoting activities. These topic areas will be identified for a future, larger scale study. METHOD: This qualitative study consisted of 25 semi-structured interviews with sixteen GPs and nine PNs. ATLAS.ti was used to analyse the transcripts of the interviews. RESULTS: All GPs and PNs said they discuss lifestyle with their patients. Next to this, GPs and PNs counsel patients, and/or refer them to other disciplines. Only few said they refer patients to specific lifestyle programs or interventions in their own practice or in the neighbourhood. Several barriers and facilitators were identified. The main topics as barriers are: a lack of patients' motivation to make lifestyle changes, insufficient reimbursement, a lack of proven effectiveness of interventions and a lack of overview of health promoting programs in their neighbourhood. The most cited facilitators are availability of a PN, collaboration with other disciplines and availability of interventions in their own practice. With respect to attitudes, six different types of GPs were identified reflecting the main topics that relate to attitudes, varying from 'ignorer' to 'nurturer'. The topics relating to PNs attitudes towards health promotion activities, were almost unanimously positive. CONCLUSION: GPs and PNs all say they discuss lifestyle issues with their patients, but the health promotion activities that are organized in their practice vary. Main topics that hinder or facilitate implementation are identified, including those that relate to attitudes of GPs and PNs.

The influence of the macro-environment on physical activity: a multilevel analysis of 38 countries worldwide.

BACKGROUND: As indicated by the ANGELO framework and similar models, various environmental factors influence population levels of physical activity (PA). To date attention has focused on the micro-level environment, while evidence on the macro-level environment remains scarce and mostly limited to high-income countries. This study aims to investigate whether environmental factors at macro-level are associated with PA among a broader range of countries. METHODS: Data from the World Health Survey (WHS) was used to analyze 177,035 adults from 38 (mostly low and middle income) countries. The International Physical Activity Questionnaire-Short Form (IPAQ-S) was used to measure PA. Respondents were classified as active or inactive for vigorous PA, moderate PA and walking. Multilevel logistic regression was performed to assess associations between macro-level environmental factors and the prevalence of PA, with control for individual-level socioeconomic factors. RESULTS: The prevalence of PA varied widely between countries and types of PA (5.0%-93.8%). A negative association was found between gross domestic product and PA, odds ratios for men were 0.76 (95% CI: 0.65-0.89) for moderate PA and 0.79 (95% CI: 0.63-0.98) for walking. A higher temperature was associated with less PA (all types) and higher urbanization was associated with less vigorous and moderate PA. More gender equality was also associated with more walking for women. Governmental functioning and literacy rate were not found to be associated with any type of PA. CONCLUSIONS: This exploratory study indicates that factors such as climate, economic development and cultural factors are determinants of the level of overall PA at national levels. This underlines the suggestion that the macro-environment should be regarded as an important influence on PA.

Developing a Personalized Integrative Obesity-Coaching Program: A Systems Health Perspective.

Current obesity management strategies are failing to achieve sustainable and favorable long-term results. We propose a more personalized, dynamic, and systemic perspective on the interactions of key determinants and coaching advice on obesity. The aim of this study was to use a systems view on overweight, complexity science, and a transdisciplinary process to develop a five-year personalized integrative obesity-coaching and research program. Managers, medical specialists, clinical psychologists, dieticians, physical- and psychomotor therapists, and lifestyle coaches aligned their perspectives and objectives with experts in systems thinking and systems biology. A systems health model of obesity was used to identify the causal relations of variables with the most influence on obesity. The model helped to align and design a personalized integrative obesity-coaching program and to identify the key variables to monitor the progress and to adjust the personalized program, depending on the goals and needs of the participant. It was decided to use subtyping of participants by a systems biologist, based on traditional Chinese medicine symptoms, as a novel method to personalize the intervention. The collaborative transdisciplinary approach based upon a systems view on obesity was successful in developing a personalized and adaptive five-year obesity-coaching and research program.

The role of performance pressure, loneliness and sense of belonging in predicting burnout symptoms in students in higher education.

Student burnout is raising an increasing amount of concern. Burnout often leads to psychosocial problems and drop-out. In this study multiple regression analysis was used to examine the impact of performance pressure, loneliness, and sense of belonging on the underlying dimensions of burnout in 3,134 university students in the Netherlands. Results suggest that sense of belonging could be targeted as a way to enhance student wellbeing, in order to improve the ability to cope with the high demands in student life and the prevention of burnout.

The prevalence of overweight and obesity and its determinants in children with and without disabilities.

OBJECTIVES: To compare the prevalence of overweight and obesity and nutrition and physical activity behavior between primary school children with and without disabilities. STUDY DESIGN: Body weight and height were measured in 4072 children from regular primary schools in the city of Zwolle, the Netherlands, and in 85 children from a school for children with disabilities. Furthermore, parents completed a questionnaire on the child's nutrition and physical activity behavior. A χ(2) analysis was used to test categorical variables between groups, and analysis of variance was used for continuous variables. RESULTS: The prevalence of overweight and obesity among disabled children was 30.6% and 10.6%, respectively, which is three and six times higher than in nondisabled children (P < .001). Furthermore, our study shows statistically significant differences in nutrition and physical activity behavior between disabled and nondisabled children. CONCLUSIONS: There is a need to promote a healthy lifestyle and to reduce the prevalence of overweight and obesity in disabled children.

Impact of a Nurse-Led Health Promotion Intervention in an Aging Population: Results From a Quasi-Experimental Study on the "Community Health Consultation Offices for Seniors".

Objective: The study evaluated the nurse-led intervention "Community Health Consultation Offices for Seniors (CHCO)" on health-related and care needs-related outcomes in community-dwelling older people (⩾60 years). Method: With a quasi-experimental design, the CHCO intervention was evaluated on health-related and care needs-related outcomes after 1-year follow-up. Older people who received the intervention were frail, overweight, or were smoking. The comparison group received care as usual. In both groups, similar data were collected on health status, falls and fractures, and care needs. In the intervention group, additional data were collected on biometric measures and health-related behavior. Results: The intervention group and the care-as-usual group included 403 seniors and 984 seniors, respectively. Health-related outcomes, behaviors, and biometric measures, remained stable. After 1 year, care needs increased for both groups, but at a lower rate for the care-as-usual group. Discussion: The CHCO intervention showed no significant improvement on health-related outcomes or stability in care needs-related outcomes.

Age, period and cohort effects on body weight and body mass index in adults: The Doetinchem Cohort Study.

OBJECTIVE: To study the development of body weight with ageing, in a general adult population, taking into account possible period and cohort effects. DESIGN: A prospective cohort study with 11 years of follow-up. At baseline and after 6 and 11 years, body weight and height were measured. SETTING: The Doetinchem Cohort Study, consisting of inhabitants of Doetinchem, a town in a rural area of The Netherlands. SUBJECTS: In total, 4070 healthy men and women aged 20-59 years at baseline. RESULTS: Increase in BMI with ageing was less profound based on cross-sectional data than based on longitudinal data. More recent-born cohorts had a higher BMI at a given age than cohorts who were born earlier. Increase in mean BMI with ageing was observed in all age groups and was similar for groups with a different educational level. Highest increase in BMI over 11 years was observed in the youngest group, aged 20-29 years at baseline (2.2 [95 % CL 2.0, 2.3] kg/m2), and lowest increase in the oldest group, aged 50-59 years at baseline (1.1 [1.0, 1.3] kg/m2). CONCLUSIONS: Findings of the present study using longitudinal data suggest that increase in BMI with ageing is underestimated in all age groups by studying cross-sectional data only. Further, weight gain is present in all educational levels and does not stop at middle age.

Experiences and views of older people on their participation in a nurse-led health promotion intervention: "Community Health Consultation Offices for Seniors".

BACKGROUND: The growing number of community-dwelling older adults and the increased risks of adverse health events that accompany ageing, call for health promotion interventions. Nurses often lead these interventions. The views and experiences of older adults participating in these interventions have rarely been studied. To understand the views of targeted older adults, qualitative studies are essential. The aim of this study was to investigate the views and experiences of older adults on their participation in a nurse-led intervention, taking into account their views on healthy aging. METHODS: In a qualitative study, nineteen Dutch older adults aged 62 to 92 years participated in semi-structured interviews. These were transcribed verbatim and coded with the Qualitative Data Analysis Miner software program. The Qualitative Analysis Guide of Leuven was used for data analysis. RESULTS: Based on the analysis of the interviews, the following main themes emerged from the data reflecting the experiences of the participants: 1) awareness of aging, 2) experienced interaction with the nurse, and 3) perception of the consultations as a check-up and/or personal support. CONCLUSIONS: This study underscores the importance of nurse-led interventions that match older adults' personal views concerning healthy living, and their views and experiences concerning these interventions. Older adults' holistic views of healthy living were not always assessed and valued by the nurses. Also, our study shows a wide variety of expectations, views and experiences among the participating older adults. This implies that health professionals should adjust their working and communication methods to the older adult's views on life.

Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300 000 persons.

BACKGROUND: The extent to which moderate overweight (body mass index [BMI], 25.0-29.9 [calculated as weight in kilograms divided by height in meters squared]) and obesity (BMI, >/= 30.0) are associated with increased risk of coronary heart disease (CHD) through adverse effects on blood pressure and cholesterol levels is unclear, as is the risk of CHD that remains after these mediating effects are considered. METHODS: Relative risks (RRs) of CHD associated with moderate overweight and obesity with and without adjustment for blood pressure and cholesterol concentrations were calculated by the members of a collaboration of prospective cohort studies of healthy, mainly white persons and pooled by means of random-effects models (RRs for categories of BMI in 14 cohorts and for continuous BMI in 21 cohorts; total N = 302 296). RESULTS: A total of 18 000 CHD events occurred during follow-up. The age-, sex-, physical activity-, and smoking-adjusted RRs (95% confidence intervals) for moderate overweight and obesity compared with normal weight were 1.32 (1.24-1.40) and 1.81 (1.56-2.10), respectively. Additional adjustment for blood pressure and cholesterol levels reduced the RR to 1.17 (1.11-1.23) for moderate overweight and to 1.49 (1.32-1.67) for obesity. The RR associated with a 5-unit BMI increment was 1.29 (1.22-1.35) before and 1.16 (1.11-1.21) after adjustment for blood pressure and cholesterol levels. CONCLUSIONS: Adverse effects of overweight on blood pressure and cholesterol levels could account for about 45% of the increased risk of CHD. Even for moderate overweight, there is a significant increased risk of CHD independent of these traditional risk factors, although confounding (eg, by dietary factors) cannot be completely ruled out.

Energy Balance-Related Behavior and Anthropometric Measures Among Adolescents Across Three Educational Levels: A Cross-Sectional Study in Dutch Schools.

Energy balance-related behavior on schooldays and beliefs about school-based interventions may differ between students in different educational levels, sexes, and BMI (body mass index) categories. In Zwolle (the Netherlands), 1,084 adolescents (13-15 years) at 9 secondary schools completed a questionnaire. Overweight prevalence (boys 18.1%, girls 19.3%) increased with decreasing educational level, especially in boys. Girls reported healthier behavior than boys regarding daily consumption of fruit (35% vs. 29%), vegetables (58% vs. 48%), ≤1 snack/candy (36% vs. 26%), ≤3 glasses of sugared drinks (80% vs. 73%; all p < .05). Unhealthier dietary behaviors were associated with lower educational level, except for eating sugary and savory snacks. Snacks and sugared drinks consumed at school were mostly brought from home (61.6% and 68.5%, respectively). Overweight students reported less frequent consumption of daily breakfast, snacks, and sugared drinks than nonoverweight students. Of all students, 40% spent ≥1 hour per day cycling to school. Lower educational level students reported less organized sports activities than higher level students, but more outside play and other activities. Overweight was associated with cycling to school (boys) and participating in organized sports (girls). More girls than boys were interested in lessons about healthy nutrition (44.4% vs. 31.7%). To stimulate physical activity, boys suggested more physical education classes (63%), girls advised more variation (47%) and choice (43%). A healthy school canteen (57%) and offering free fruit (67%) were suggested as promising interventions to stimulate healthy behavior. Educational and environmental interventions to tackle unhealthy dietary and physical activity behavior should be developed in collaboration with parents and tailored to educational level and gender.

Agreement between parent and child report of physical activity, sedentary and dietary behaviours in 9-12-year-old children and associations with children's weight status.

BACKGROUND: To date, population based surveys aimed at gaining insight in health related behaviour of children have often used either child self-reports or parent proxy reports. It remains unclear however, if surveys using different sources of information from either parents or children are comparable. In addition, (over)weight status of children can lead to under- and over reporting by parents and children as a result of social desirability bias. We aimed at gaining insight in the level of agreement between parents and child reports regarding aspects of certain dietary, physical activity and sedentary behaviours, and whether there are differences in agreement between parents and child reports in healthy-weight and overweight children. METHODS: Weighted kappa was used to determine the level of agreement between child and parent reports on health-related behaviour in 1998 parent-child dyads. We also stratified for weight status of the children. Information on children's health related behaviours was obtained by parental and children's questionnaires, and children's height and weight were measured. Associations between children's weight status and children reporting less, reporting more and reporting the same amount of health behaviour as their parents were investigated with multinomial logistic regression analysis. RESULTS: The Cohen's kappa coefficients ranged from almost perfect agreement for the variable means of transportation, fair for the variables breakfast consumption and frequency of outside play to slight for the variables duration of outside play, frequency and duration of TV/DVD viewing and family dinner. Overweight children were significantly more likely to report less breakfast consumption (OR = 2.6 (95% CI: 1.3 - 5.1)) and lower frequency of outside play than their parents (OR = 1.8 (95% CI: 1.1 - 2.9)). CONCLUSION: There can be considerable disagreement between the health related behaviours of children as reported by parents or the children themselves. Based on the present study, it cannot be concluded whether parents' or children's reports are more accurate. For future studies, social desirability and recall bias would be best demonstrated in a validation study comparing child and parent self-reports with more objective measures of physical activity and food intake.