Surveying the Knowledge and Practices of Primary Care Residents in Managing Adult Patients with Obesity.

BACKGROUND: The prevalence of obesity is increasing worldwide at an alarming rate, yet obesity remains under-addressed during clinic encounters. A lack of training in how to treat obesity is one crucial factor contributing to this deficiency. OBJECTIVE: This study explored resident physicians' perceptions of their education on obesity and its relationship with confidence and practice behaviors when caring for patients with obesity. DESIGN: A survey was distributed to residency directors to share with residents in their programs. Participation was voluntary and anonymous. Data was collected over a 3-month period. PARTICIPANTS: Residents in Family Medicine and Internal Medicine programs in West Virginia and Indiana who saw adult patients in an ambulatory care setting. MAIN MEASURES: The electronic survey queried the presence of a formal curriculum on Obesity Medicine (OM) and each resident's knowledge, confidence, practice behaviors, and attitudes pertaining to OM. KEY RESULTS: The survey was distributed to 490 residents in 12 programs. Response rate was 22.9% (112 resident physicians). All respondents felt that medical training in obesity should be strengthened. Residents who reported having a formal curriculum on OM were more likely than those without a curriculum to rate their confidence as "high" when discussing weight (35.0% vs. 16.7%, p = 0.03) and when counseling patients about diet and nutrition (37.5% vs. 18.1%, p = 0.02). They also more frequently reported learning enough from faculty to manage obesity (65.0% vs. 29.2%, p < 0.001). Residents with an OM curriculum reported discussing obesity as a problem with patients (100.0% vs. 86.1%, p = 0.01), and completing motivational interviews (90.0% vs. 58.3%, p = < 0.001), more frequently than their peers without a curriculum. CONCLUSIONS: Residents with a formal OM curriculum were more confident in addressing and discussing obesity with patients. Formal training in OM will strengthen resident training to better address and treat patients with obesity.

How long does it take to scale-up obesity prevention interventions?

OBJECTIVE: The scale-up of evidence-based interventions is necessary to reverse high rates of obesity. However, scale-up doesn't occur frequently nor in a timely manner. While it has been estimated that takes 14-17 years for research translation to occur, the time taken to scale-up prevention interventions is largely unknown. This study examined the time taken to scale-up obesity prevention interventions across four scale-up pathways. METHODS: A sample of obesity prevention interventions that had been scaled-up or implemented at scale were found using a structured search strategy. Included interventions were mapped against four scale-up pathways and timeframes associated with each stage of the scale-up pathway were identified to determine the time taken to scale-up. RESULTS: Of the 90 interventions found that were scaled-up to at least a city-wide level, less than half reported a comprehensive research pathway to scale-up and a third did not report any evidence of efficacy or effectiveness prior to scale-up. The time taken to scale-up ranged from 0 to 5 years depending on the pathway taken. Those following a comprehensive pathway took approximately 5 years to scale-up, while interventions that had only one evidence generating step took between 1 and 1.5 years to scale-up. For the remaining interventions, scale-up occurred immediately post-development without evidence generation. CONCLUSIONS: Our findings indicate that the scale-up of obesity prevention interventions can occur more quickly than previous estimates of 14-17 years. Our findings support previous research that scale-up of interventions occurs through a variety of pathways and often scale-up occurs in absence of prior evidence of effectiveness.

Evaluation of the population-level impacts of the LiveLighter® obesity prevention campaign from 2012 to 2019 based on serial cross-sectional surveys.

BACKGROUND: Halting and reversing the upward trend in obesity requires sustained implementation of comprehensive, evidence-based strategies at the population-level. The LiveLighter® program targets adults using a range of public education strategies, including mass media campaigns, to support healthy lifestyle changes to attain or maintain a healthy weight and reduce the risk of chronic disease. LiveLighter® has been implemented in Western Australia (WA) since 2012 and, to our knowledge, includes the longest running adult-targeted mass media campaign for healthy weight and lifestyle promotion and education globally. This evaluation assessed the impact of LiveLighter® on WA adults' knowledge, intentions and behaviours as they relate to healthy eating and body weight from 2012 to 2019. METHODS: LiveLighter® mass media campaigns, which are TV-led and aired statewide, depict genuine, graphic imagery of visceral fat around internal organs to raise awareness about the link between excess body weight and chronic diseases; demonstrate how unhealthy food and drink consumption can contribute to unhealthy weight gain; and recommend healthy alternatives. Cross-sectional telephone surveys were conducted at baseline and following each campaign phase with an independent, randomly selected sample of WA adults aged 25 to 49 years (n = 501 to n = 1504 per survey) to assess their knowledge of the link between excess body weight and chronic diseases, and their intentions and behaviours related to healthy eating and weight. Multivariable logistic regression models were undertaken to assess differences in responses between baseline and each post-campaign survey. RESULTS: Compared to baseline, there were significant increases in the proportion of respondents reporting knowledge of excess body weight as a risk factor for certain cancers and type 2 diabetes, intentions to eat more fruit and vegetables and drink less sugar sweetened beverages (SSBs) in the next seven days, and the proportion of respondents who reported meeting guidelines for daily vegetable intake. Reported consumption of SSBs significantly decreased. CONCLUSIONS: LiveLighter® is associated with improvements in knowledge of the health risks associated with excess body mass, increased vegetable intake and reduced SSB consumption in WA adults. These findings support the use of sustained, well-designed healthy lifestyle promotion and education programs as part of a comprehensive obesity prevention strategy.

Application of the extended parallel process model and risk perception attitude framework to obesity knowledge and obesity prevention behaviors among Korean adults.

BACKGROUND: Perceiving oneself as obese has been associated with weight loss attempts. However, such a perception may not sufficiently drive significant weight reduction in many individuals. Hence, relying solely on the traditionally emphasized perceived risk of behavioral changes in obesity is challenging. This study used an extended parallel process model and a risk perception attitude framework to explore the influence of perceived risk and perceived efficacy on individual obesity knowledge and obesity prevention behaviors. METHODS: Data were obtained from 1,100 Korean adults aged 40-69 years through an online survey conducted in October 2022. Multinomial logistic regression and analysis of variance were employed to assess the relationships among perceived risk, perceived efficacy, obesity knowledge, and obesity prevention behaviors. RESULTS: Sex was associated with being underweight, overweight, and obese. Moreover, perceived severity was associated with obesity, whereas perceived susceptibility was associated with overweight and obese. Response efficacy was related to being overweight alone, whereas self-efficacy was associated with being underweight, overweight, and obese. The main effects of sex and perceived risk, and their interaction effect were statistically significant for obesity knowledge. Additionally, the main effects of sex, perceived risk, and perceived efficacy on obesity prevention behaviors were statistically significant. CONCLUSIONS: The extended parallel process model and risk perception attitude framework proved effective in classifying obesity based on body mass index, obesity knowledge, and obesity prevention behaviors.

Universal healthy school start intervention reduced the body mass index of young children with obesity.

AIM: To evaluate the effect of a universal, school-based family support programme on body mass index (BMI) of children aged 5-7 years, using pooled data from three trials. METHODS: The programme has three to four components and is delivered during the first school year. It aims to promote healthy dietary and physical activity behaviours, and secondarily prevent unhealthy weight gain. Three cluster-randomised controlled trials were conducted between 2010 and 2018 in low and mixed socioeconomic status areas in Sweden. Weight and height were measured. Multiple mixed linear regression analysis was performed on the pooled data. RESULTS: In total, 961 children were included (50% girls, mean age 6.3 years). The post-intervention effect on BMI z-score in all children was small, but in those with obesity at baseline, we observed a significant, clinically relevant, decrease in BMI z-score (-0.21). This was most pronounced in children with a non-Nordic born parent (-0.24). Five to six months after the intervention, decreases were no longer statistically significant. CONCLUSION: The intervention resulted in changes in BMI comparable to obesity treatment programmes focusing on behaviour change. However, the effect attenuated with time suggesting the programme should be sustained and evaluated for a longer time.

Assessing the acceptability of a culturally adapted group-based pediatric intervention, Kokajjiriri, for Marshallese mothers and infants to improve nutrition and prevent childhood obesity.

BACKGROUND: Marshallese Pacific Islanders experience higher rates of obesity than other racial and/or ethnic communities. Despite the obesity rates experienced in this community, there are currently no childhood obesity prevention interventions designed for Marshallese Pacific Islanders in the United States. The purpose of this study is to assess the acceptability and feasibility of a culturally adapted group-based pediatric intervention, Kokajjiriri, with Marshallese mothers to improve nutrition and reduce childhood obesity. METHODS: A multi-methods design was used to culturally adapt the Kokajjiriri intervention for Marshallese mothers in Arkansas (n = 17). In phase one, we conducted 24-h dietary recalls with 20 Marshallese mothers to inform the cultural adaptation of the group-based pediatric intervention, and then in phase two, we culturally adapted and piloted three sessions of the intervention to determine the acceptability and feasibility of the intervention. RESULTS: Participants found the adapted intervention to be acceptable and feasible, found the location to be convenient and found the facilitator to be knowledgeable. Four themes emerged from the qualitative data: (1) Lactation Support; (2) Introducing Healthy Solids; (3) Rice Portion Control; and (4) Finding Resources. CONCLUSIONS: This is the first study to assess the acceptability and feasibility of a culturally adapted group-based pediatric intervention, Kokajjiriri, with Marshallese mothers to improve nutrition and reduce childhood obesity. The results from this culturally adapted group-based pediatric intervention, Kokajjiriri, will be used to inform future adaptations and implementation of the full intervention for Marshallese women and children.

Advancing Inclusive Communication: Implementing an Audit to Center Equity in SNAP-Ed Programming.

Public health interventions rely on information exchange to influence health outcomes. Increasingly, practitioners are working to be intentional with public health messaging. The language used to communicate program objectives and health recommendations should reflect the community's lived experience and avoid perpetuating health and social inequities. Words and tone matter, and both should be inclusive and non-stigmatizing. Prioritizing a health equity lens for communication may require a critical review and revision of existing materials. This Practice Note highlights the development and implementation of an audit tool designed to systematically review a cookbook created to support healthy eating for families and individuals experiencing low income and participating in a Supplemental Nutrition Assistance Program-Education (SNAP-Ed) intervention in Maine. The purpose of the audit tool and the collaborative review process was to revise the cookbook content to ensure a weight-neutral, empowering approach to supporting the community's nutritional needs. The audit process resulted in a comprehensive methodology to examine intervention resources for inclusive communication approaches that avoid deficit framing, use person-first language, and do not overemphasize limited resources or appropriate cultures. The instrument and methodology are conceptually replicable and adaptable. In sharing the process and audit results, the authors seek to provide an example for practitioners to draw from for similar critical reviews of public health intervention resources and promotional materials.

Assessing the implementation of healthy eating and physical activity policies and practices in Early Childhood Education and Care in New South Wales, Australia: A cross-sectional study.

ISSUE ADDRESSED: Australian children are not meeting the recommended physical activity (PA) and healthy eating (HE) guidelines. Health behaviour practices implemented in community settings such as early education services can improve child's health outcomes and are therefore key to help meet guidelines. This study aimed to measure the implementation of HE and PA policies and practices in Early Childhood Education and Care (ECEC) services in New South Wales (NSW), Australia, and to examine their association with service characteristics. METHODS: A random sample of 1122 centre-based ECEC services were invited to a cross-sectional survey measuring HE and PA policy and practice implementation. Regression analyses were conducted to assess the relationship between the service characteristics and implementation of policies/practices. RESULTS: In total, 565 ECEC services completed the survey. Results show that while some practices are implemented, the implementation of practices promoting HE and PA education is low. Practices related to educator training for HE (18%) and PA (13%) were poorly implemented. The implementation of practices such as 'providing educator training around child PA', 'engaging families in activities to increase child PA' and 'encouraging supportive feeding practices' were significantly higher in services located in major cities than regional/remote services. 'Having a PA policy' and the practice of 'limiting the use of screen time' was significantly higher in long day care services than in preschools. The implementation of 'providing educator-led PA', 'providing free play opportunities' and 'having a PA policy' was significantly lower in private not-for-profit community managed services than in private for-profit services. CONCLUSIONS: Implementation of various HE and PA policies and practices in regional/remote services, private not-for-profit services and preschools across NSW could be improved. SO WHAT?: Future research should be prioritised towards identifying factors influencing the implementation of these policies and practices to best tailor implementation support efforts for those who need it the most.

Exploring the long-term sustainability of school-based nutrition and food programs: What works, where and why?

ISSUE ADDRESSED: Most food and nutrition programs cease within 2 years. Understanding the determinants of program sustainability is crucial to maximise output from funding, whilst allowing sufficient time for program benefits to be achieved. This study applied the Consolidated Framework for Implementation Research (CFIR) to map the barriers and enablers of successful long-term implementation of school-based nutrition and food programs. METHODS: Qualitative methods with purposive and snowball sampling were used to recruit experts who were identified as being influential in implementing and sustaining long-term (>2 years) school-based food and nutrition programs. Semi-structured interviews with global experts were conducted, transcribed verbatim and coded deductively (by applying the CFIR constructs) and inductively when required. Thematic analysis informed the development of themes. RESULTS: Interviews were conducted with 11 experts including researchers, government employees, and a consultant of an international agency, from seven countries. Forty-eight deductive codes and eight inductive codes identified six main themes: (1) funding and integrity of its source; (2) political landscape; (3) nutrition policies and their monitoring; (4) involvement of community actors; (5) adaptability of the program and (6) effective program evaluation. Themes related mainly to the 'outer setting' domain of the CFIR. CONCLUSIONS: The CFIR highlighted pertinent factors that influence the successful long-term implementation of school-based food and nutrition programs. SO WHAT?: The findings suggest that to sustain program implementation beyond its initial funding, relationships across government departments, local organisations and communities, need to be nurtured and prioritised from the outset.

The impacts of an mHealth intervention targeting parents on health service usage and out-of-pocket costs in the first 9 months of life: The Growing healthy app.

Mobile health (mHealth) interventions provide a low-cost, scalable approach to supporting parents with infant feeding advice with the potential to reduce health care visits and associated costs for infant feeding support. This Australian study examined the impact of the Growing healthy (GH) app on health service utilisation and out-of-pocket costs for families in the first 9 months of their infants life. A quasi-experimental study with a comparison group was conducted in 2015-2016 with an mHealth intervention group (GH app, n = 301) and a nonrandomized usual care group (n = 344). The GH app aimed to support parents of young infants with healthy infant feeding behaviours from birth to 9 months of age. App-generated notifications directed parents to age-and feeding-specific content within the app. Both groups completed surveys at baseline when infants were less than 3 months old (T1), at 6 months (T2) and 9 months (T3) of age. At T3, participants reported health services used and any out-of-pocket costs for advice on infant feeding, growth or activity. App users had lower odds (odds ratio: 0.38 95% confidence interval: 0.25, 0.59) of using one or more services and had lower number of visits to a general practitioner (1.0 vs. 1.5 visits, p = 0.003) and paediatrician (0.3 vs. 0.4 visits, p = 0.049) compared to the usual care group. There was no difference in out-of-pocket costs between groups. Provision of an evidenced-based infant feeding app may provide substantial savings to the health system and potentially to parents through fewer primary health care and paediatrician visits.

Are U.S. food and beverage companies now advertising healthy products to children on television? An evaluation of improvements in industry self-regulation, 2017-2021.

BACKGROUND: Through the Children's Food and Beverage Advertising Initiative (CFBAI), U.S. food companies pledge to only advertise healthier products in children's television (TV) programming, but previous research shows that highly advertised products do not qualify as nutritious according to independent nutrition criteria. In 2020, the CFBAI implemented stricter nutrition criteria for products that may be advertised to children, but the potential impact of these changes has not been assessed. This observational study evaluates (1) improvements in energy and individual nutrient composition of products that companies indicated may be advertised to children (i.e., CFBAI-listed products) in 2020 versus 2017, (2) amount of advertising on children's TV for CFBAI-listed versus other products in 2021, and 3) the nutrition quality of advertised versus non-advertised CFBAI-listed products. METHODS: Data include energy, saturated fat, sodium, and sugar content and overall nutrition quality (Nutrition Profile Index [NPI] scores) of CFBAI-listed products in 2017 (n = 308) and 2020 (n = 245). Nielsen data provided total ad spending and children's exposure to ads on children's TV channels for all foods and beverages in 2021. RESULTS: From 2017 to 2021, energy, saturated fat and sugar declined for CFBAI-listed products in three of six food categories (yogurt, sweet and salty snacks). Although CFBAI-listed products accounted for 79% of food ads viewed by children on children's TV channels, just 50% of CFBAI-listed food and 36% of drink brands were advertised on children's TV. Moreover, advertised products were significantly less nutritious than non-advertised CFBAI-listed products. CONCLUSION: Despite revised nutrition standards and improvements in nutrient content of some product categories, participating companies continued to primarily advertise nutritionally poor food and beverages on children's TV. CFBAI companies have not delivered on their promises to advertise healthier products to children.

Evaluation of a cluster-randomized controlled trial: Communities for Healthy Living, family-centered obesity prevention program for Head Start parents and children.

BACKGROUND: This study reports the outcomes of Communities for Healthy Living (CHL), a cluster randomized obesity prevention trial implemented in partnership with Head Start, a federally-funded preschool program for low-income families. METHODS: Using a stepped wedge design, Head Start programs (n = 16; Boston, MA, USA) were randomly assigned to one of three intervention start times. CHL involved a media campaign and enhanced nutrition support. Parents were invited to join Parents Connect for Healthy Living (PConnect), a 10-week wellness program. At the beginning and end of each school year (2017-2019), data were collected on the primary outcome of child Body Mass Index z-score (BMIz) and modified BMIz, and secondary outcomes of child weight-related behaviors (diet, physical activity, sleep, media use) and parents' weight-related parenting practices and empowerment. Data from 2 years, rather than three, were utilized to evaluate CHL due to the COVID-19 pandemic. We used mixed effects linear regression to compare relative differences during intervention vs. control periods (n = 1274 vs. 2476 children) in (1) mean change in child BMIz and modified BMIz, (2) the odds of meeting child health behavior recommendations, (3) mean change in parenting practices, and (4) mean change in parent empowerment. We also compared outcomes among parents who chose post-randomization to participate in PConnect vs. not (n = 55 vs. 443). RESULTS: During intervention periods (vs. control), children experienced greater increases in BMIz and modified BMIz (b = 0.06, 95% CI = 0.02,0.10; b = 0.07, 95% CI = 0.03, 0.12), yet were more likely to meet recommendations related to three of eight measured behaviors: sugar-sweetened beverage consumption (i.e., rarely consume; Odds Ratio (OR) = 1.5, 95% CI = 1.2,2.3), water consumption (i.e., multiple times per day; OR = 1.6, 95% CI = 1.2,2.3), and screen time (i.e., ≤1 hour/day; OR = 1.4, 95% CI = 1.0,1.8). No statistically significant differences for intervention (vs. control) periods were observed in parent empowerment or parenting practices. However, parents who enrolled in PConnect (vs. not) demonstrated greater increases in empowerment (b = 0.17, 95% CI = 0.04,0.31). CONCLUSIONS: Interventions that emphasize parent engagement may increase parental empowerment. Intervention exposure was associated with statistically, but not clinically, significant increases in BMIz and increased odds of meeting recommendations for three child behaviors; premature trial suspension may explain mixed results. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03334669 , Registered October 2017.

A Pilot Randomized Trial of an Obesity Prevention Program for High-Risk Infants in Primary Care.

OBJECTIVE: Rapid infant weight gain is associated with later obesity. Novel interventions to prevent rapid infant weight gain that are accessible to infants and families are needed, especially for those at the highest risk. Our aims were to examine: (a) feasibility and acceptability of a responsive parenting intervention delivered via Integrated Behavioral Health (IBH) in pediatric primary care and (b) preliminary effects on infant weight gain from birth to 6 (post-treatment) and 9 (follow-up) months. METHODS: A parallel design, proof-of-concept randomized control trial was conducted with 65 mother-infant dyads (32 randomized to intervention, 33 randomized an IBH attention control focused on promoting healthy mental health), in which the majority identify as Black (80%) and low income (91% receiving Medicaid). Participants and assessors were masked to treatment condition. Outcomes included feasibility (enrollment), acceptability (retention and adherence), and conditional weight gain (CWG), an indicator of rapid weight gain. RESULTS: The intervention was feasible (90% of eligible families enrolled) and acceptable (89% of families retained), with 81% receiving ≥3 of 4 treatment sessions. A medium effect was found on CWG (d = -0.54 post-treatment, d = -0.57 follow-up), with the infants in the treatment group showing significantly lower CWG (mean = -0.27, 95% CI, -0.63, 0.09) compared to the control group (mean = 0.29, 95% CI, -0.17, 0.76) at 9 months (p = .04). CONCLUSIONS: This study demonstrates the feasibility of implementing a responsive parenting obesity prevention intervention within primary care. Delivery in pediatric primary care is advantageous for implementation and reaching at-risk populations. The preliminary effects on CWG are promising and support testing in a larger trial.

Designing a childhood obesity preventive intervention using the multiphase optimization strategy: The Healthy Bodies Project.

BACKGROUND/AIMS: Preventing the development of childhood obesity requires multilevel, multicomponent, comprehensive approaches. Study designs often do not allow for systematic evaluation of the efficacy of individual intervention components before the intervention is fully tested. As such, childhood obesity prevention programs may contain a mix of effective and ineffective components. This article describes the design and rationale of a childhood obesity preventive intervention developed using the multiphase optimization strategy, an engineering-inspired framework for optimizing behavioral interventions. Using a series of randomized experiments, the objective of the study was to systematically test, select, and refine candidate components to build an optimized childhood obesity preventive intervention to be evaluated in a subsequent randomized controlled trial. METHODS: A 24 full factorial design was used to test the individual and combined effects of four candidate intervention components intended to reduce the risk for childhood obesity. These components were designed with a focus on (a) improving children's healthy eating behaviors and nutrition knowledge, (b) increasing physical activity and reducing sedentary activity in the childcare setting, (c) improving children's behavioral self-regulation, and (d) providing parental web-based education to address child target outcomes. The components were tested with approximately 1400 preschool children, ages 3-5 years in center-based childcare programs in Pennsylvania, the majority of which served predominantly Head-Start eligible households. Primary child outcomes included healthy eating knowledge, physical and sedentary activity, and behavioral self-regulation. Secondary outcomes included children's body mass index and appetitive traits related to appetite regulation. RESULTS: Four intervention components were developed, including three classroom curricula designed to increase preschool children's nutrition knowledge, physical activity, and behavioral, emotional, and eating regulation. A web-based parent education component included 18 lessons designed to improve parenting practices and home environments that would bolster the effects of the classroom curricula. A plan for analyzing the specific contribution of each component to a larger intervention was developed and is described. The efficacy of the four components can be evaluated to determine the extent to which they, individually and in combination, produce detectable changes in childhood obesity risk factors. The resulting optimized intervention should later be evaluated in a randomized controlled trial, which may provide new information on promising targets for obesity prevention in young children. CONCLUSION: This research project highlights the ways in which an innovative approach to the design and initial evaluation of preventive interventions may increase the likelihood of long-term success. The lessons from this research project have implications for childhood obesity research as well as other preventive interventions that include multiple components, each targeting unique contributors to a multifaceted problem.

Controlled trial of a workplace sales ban on sugar-sweetened beverages.

OBJECTIVE: To examine the effectiveness of a workplace sugar-sweetened beverage (SSB) sales ban on reducing SSB consumption in employees, including those with cardiometabolic disease risk factors. DESIGN: A controlled trial of ethnically diverse, full-time employees who consumed SSB heavily (sales ban n 315; control n 342). Outcomes included standardised measures of change in SSB consumption in the workplace (primary) and at home between baseline and 6 months post-sales ban. SETTING: Sutter Health, a large non-profit healthcare delivery system in Northern California. PARTICIPANTS: Full-time employees at Sutter Health screened for heavy SSB consumption. RESULTS: Participants were 66·1 % non-White. On average, participants consumed 34·7 ounces (about 1 litre) of SSB per d, and the majority had an elevated baseline BMI (mean = 29·5). In adjusted regression analyses, those exposed to a workplace SSB sales ban for 6 months consumed 2·7 (95 % CI -4·9, -0·5) fewer ounces of SSB per d while at work, and 4·3 (95 % CI -8·4, -0·2) fewer total ounces per d, compared to controls. Sales ban participants with an elevated BMI or waist circumference had greater post-intervention reductions in workplace SSB consumption. CONCLUSIONS: Workplace sales bans can reduce SSB consumption in ethnically diverse employee populations, including those at higher risk for cardiometabolic disease.

Ecological system theory and community participation to promote healthy food environments for obesity and non-communicable diseases prevention among school-age children.

OBJECTIVES: To implement and evaluate the effectiveness of the community participatory program between school and family based on ecological system theory and participatory action research. The intervention covers three levels at the individual, family and school levels and involves educating students and parents by using technology, reducing sedentary behaviours, increasing exercise and changing to healthy food environments at school and at home. DESIGN: A quasi-experimental design was used in this study. SETTING: Public primary school in Thailand. SUBJECTS: The participants in the study included 138 school-age children in grades 2-6 with their parents/guardians. The control group consisted of 134 school-age children at a school of the same size with their parents/guardians. RESULTS: Results show that nutritional status was significantly improved within the experimental group (P value = 0·000) and between groups during follow-up (P value = 0·032). Students' knowledge about obesity and non-communicable chronic diseases (NCD) prevention, as well as physical activity and exercise behaviours, in the experimental group was significantly higher than that in the control group (P value = 0·000 and 0·044, respectively). Parents' perceptions of child obesity and family modelling behaviours in the experimental group were also significantly higher than that in the control group; P value = 0·013 and 0·000, respectively). CONCLUSION: The community participation program was found to be successful. Not only students, families and schools improved health behaviours and healthy food environments at home and school, but the students' long-term nutritional status also improved.

Protocol to evaluate the effectiveness and cost-effectiveness of an environmental nutrition and physical activity intervention in nurseries (Nutrition and Physical Activity Self Assessment for Child Care - NAP SACC UK): a multicentre cluster randomised controlled trial.

BACKGROUND: One in seven UK children have obesity when starting school, with higher prevalence associated with deprivation. Most pre-school children do not meet UK recommendations for physical activity and nutrition. Formal childcare settings provide opportunities to deliver interventions to improve nutritional quality and physical activity to the majority of 3-4-year-olds. The nutrition and physical activity self-assessment for childcare (NAP SACC) intervention has demonstrated effectiveness in the USA with high acceptability in the UK. The study aims to evaluate the effectiveness and cost-effectiveness of the NAP SACC UK intervention to increase physical activity, reduce sedentary time and improve nutritional intake. METHODS: Multi-centre cluster RCT with process and economic evaluation. Participants are children aged 2 years or over, attending UK early years settings (nurseries) for ≥ 12 h/week or ≥ 15 h/week during term time and their parents, and staff at participating nurseries. The 12-month intervention involves nursery managers working with a Partner (public health practitioner) to self-assess policies and practices relating to physical activity and nutrition; nursery staff attending one physical activity and one nutrition training workshop and setting goals to be achieved within 6 months. The Partner provides support and reviews progress. Nursery staff receive a further workshop and new goals are set, with Partner support for a further 6 months. The comparator is usual practice. Up to 56 nurseries will be stratified by area and randomly allocated to intervention or comparator arm with minimisation of differences in level of deprivation. PRIMARY OUTCOMES: accelerometer-assessed mean total activity time on nursery days and average total energy (kcal) intake per eating occasion of lunch and morning/afternoon snacks consumed within nurseries. SECONDARY OUTCOMES: accelerometer-assessed mean daily minutes of moderate-to-vigorous physical activity and sedentary time per nursery day, total physical activity on nursery days compared to non-nursery days, average serving size of lunch and morning/afternoon snacks in nursery per day, average percentage of core and non-core food in lunch and morning/afternoon snacks, zBMI, proportion of children who are overweight/obese and child quality-of-life. A process evaluation will examine fidelity, acceptability, sustainability and context. An economic evaluation will compare costs and consequences from the perspective of the local government, nursery and parents. TRIAL REGISTRATION: ISRCTN33134697, 31/10/2019.

Parents' recalled experiences of the child centred health dialogue in children with overweight: a qualitative study.

BACKGROUND: Because overweight and obesity are still increasing and prevention of childhood obesity is more likely to be effective when initiated in preschool children, the Child Health Service in the south of Sweden developed a structured child-centred health dialogue model targeting all 4-year-old children and their families. The aim of this study was to describe parents' recalled experiences of this health dialogue in children with overweight. METHODS: A qualitative inductive approach with purposeful sampling was used. Thirteen individual interviews with parents (including 11 mothers and 3 fathers) were conducted and analysed with qualitative content analysis. RESULTS: The analysis resulted in two categories: 'A valuable visit with a subtle individual impact' that described parents' recalled experiences of the health dialogue and 'There is a complex interaction between weight and lifestyle' that reflected the parents' perceptions of the relationship between their children's weight and lifestyle. CONCLUSIONS: Parents recalled the child-centred health dialogue as important and described discussing a healthy lifestyle as one of the obligations of the Child Health Service. Parents wanted confirmation that their family lifestyle was healthy; however, they did not want to discuss the relationship between their family lifestyle and their children's weight. Parents expressed that when their child followed the child's growth curve, then this indicated healthy growth. This study supports using the child-centred health dialogue as a model to provide structure for discussing a healthy lifestyle and growth but highlights the difficulties of discussing body mass index and overweight, especially in the presence of children.

Assessing readiness for childhood obesity prevention in German municipalities: application of the community readiness model.

The World Health Organization has identified childhood obesity as one of the most serious public health problems of the 21st century. Understanding a municipality's readiness to address it is crucial to achieve successful interventions. However, the preparedness of German municipalities to address childhood obesity has not yet been investigated. This study is the first in Germany to apply the community readiness model (CRM) in this context. The purpose was to determine readiness of five municipalities for childhood obesity prevention and to identify factors that influence their readiness. Therefore, 27 semi-structured key informant interviews were conducted. First, the interviews were analysed following the CRM protocol to categorize the municipalities into a readiness level between one and nine. In a second step, a content analysis was carried out for an in-depth interpretation of the readiness scores. The municipalities achieved an average readiness of 3.84, corresponding to the 'Vague Awareness' stage. A lack of prioritization and leadership support, insufficient low-threshold efforts, a lack of knowledge and problem awareness as well as a lack of structures and resources were identified as factors that can determine municipal readiness to prevent childhood obesity. This study not only extends the application of the CRM to childhood obesity in German municipalities but also offers practical implications for professionals in assessing readiness.

Association between early care and education centres policies and practices and children's healthy behaviours.

OBJECTIVE: To examine the impact of nutritional and physical activity (PA) policies and practices at early care and education centres on behavioural changes among children ages 2-5. METHODS: The study population included 586 children from 25 education centres throughout the state of Georgia. Policies and practices were measured using the Georgia Nutrition and PA Assessment at the start of school year in Fall 2017. Survey data were collected at the beginning of school year September/October 2017 and at the end of school year April/May 2018 to measure changes in children's nutritional and PA behaviour over the school year. We used generalised estimating equations to estimate odds ratios and 95% confidence intervals. RESULTS: Children at centres with a high nutrition assessment score had higher odds of increasing vegetable consumption (OR = 2.1; 95% CI: 1.1, 4.0) while the odds of increasing fruit (OR = 1.4; 95% CI: 0.8, 2.4) and water (OR = 1.2; 95% CI: 0.5, 2.7) consumption increased non-significantly. The odds of improving PA were similar between children at centres with a high versus a low PA assessment score. CONCLUSION: The results, though insignificant, indicate that policies and practices could influence children's health behaviours. Further research is warranted to examine whether improvements in policies and practices could explain changes in children's health behaviours, the impact of educator's knowledge on children's health behaviours and the implementation of and adherence to policy and practice improvement plans.