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.

Negative associations between step-up height and waist circumference in 8-year-old children and their parents.

AIM: To study cross-sectional relationships between step-up height and waist circumference (WC), a potential proxy for sarcopenic obesity, in Swedish children and parents. METHODS: Participants were recruited from Swedish schools in disadvantaged areas in 2017. Height, body weight, WC and maximal step-up height were measured in 67 eight-year-old children and parents: 58 mothers, with a mean age of 38.5 and 32 fathers, with a mean age of 41.3. Sedentary time and physical activity were registered by an accelerometer. Associations between maximal step-up height and WC were analysed using Pearson's correlation and adjusted linear regression. RESULTS: Abdominal obesity, WC ≥ 66 centimetres (cm) in children, ≥88 cm in women and ≥102 cm in men, was observed in 13% and 35% of girls and boys, and in 53% and 34% among mothers and fathers, respectively. Negative associations between maximal step-up height and WC were found for children (r = -0.37, p = 0.002) and adults (mothers r = -0.58, p < 0.001, fathers r = -0.48, p = 0.006). The associations remained after adjustments for height, body mass index (BMI) and physical activity in adults. Reduced muscle strength clustered within families (r = 0.54, p < 0.001). CONCLUSION: Associations between reduced muscle strength and abdominal obesity were observed in children and parents. Sarcopenic obesity may need more attention in children. Our findings support family interventions.

Effects of Universal School-Based Parental Support for Children's Healthy Diet and Physical Activity-the Healthy School Start Plus Cluster-Randomised Controlled Trial.

Health promotion from an early age is key to preventing unhealthy weight development in childhood, and parental involvement is essential. The school-based Healthy School Start intervention aims to promote healthy dietary and activity habits in the home environment and prevent child obesity through parental support. This study evaluated the effectiveness of the third iteration of the programme on children's dietary and activity behaviours, and body composition through a cluster-randomised controlled trial. The trial included 17 schools (8 intervention) in disadvantaged areas in mid-Sweden with 353 families with 5- to 7-year-old children. The primary outcomes were intake of selected healthy and unhealthy foods and beverages measured using photography. Secondary outcomes were physical activity and sedentary time measured by accelerometry, and measured weight and height. All outcomes were assessed at baseline and post-intervention (8 months). Linear multi-level regression showed significant favourable effects of the intervention for intake of sweet beverages (b = - 0.17, p = 0.04), intake of healthy foods (b = 0.11, p = 0.04), and more time in moderate to vigorous physical activity during weekdays (b = 5.68, p = 0.02). An unfavourable sub-group effect of the intervention was found for children from families with low education regarding sedentary time on weekends (b = 23.04, p = 0.05). The results align with the previous two trials of the programme, indicating that school-based parental support is a useful approach for health promotion in young children in disadvantaged areas. Trial registration: ClinicalTrials.gov: No. NCT03390725, retrospectively registered on January 4, 2018, https://clinicaltrials.gov/ct2/show/NCT03390725 .

Adolescents' experiences of a school-based health promotion intervention in socioeconomically advantaged and disadvantaged areas in Sweden: a qualitative process evaluation study.

BACKGROUND: Adolescence is a transition period in which positive experiences of physical activity have the potential to last into later adulthood. These experiences are influenced by socioeconomic determinants, leading to health inequalities. This study aims to explore adolescents' experiences and participation in a multi-component school-based intervention in schools located in socioeconomically advantaged and disadvantaged areas in Sweden. METHODS: A qualitative design was used to evaluate how participants experienced the intervention. The intervention was a multi-component school-based intervention. It was conducted in six schools (four control and two intervention schools) with a total of 193 students and lasted one school year. It was teacher-led and consisted of three 60-minute group sessions per week: varied physical activities, homework support with activity breaks, and walks while listening to audiobooks. In total, 23 participant observations were conducted over eight months and 27 students participated in focus groups. A content analysis was conducted. RESULTS: The results describe a main category 'Engaging in activities depending on socioeconomic status' and three generic categories: 1. Variations in participation in PA together with classmates and teachers; 2. Variations in engagement in PA after school; and 3. Differences in time and place allocated to do homework and listen to audiobooks. These categories illustrate how participants looked forward to the physical activities but used the time spent during the walks and homework support differently depending on how busy they were after school. Frequently, those who were busiest after school were also those from the advantaged area, and those who had little to do after school were from the disadvantaged area. CONCLUSION: Socioeconomic factors influence participants' possibilities to engage in the intervention activities as well as how they use their time in the activities. This study showed that it is crucial to support adolescents' participation in physical activities by providing structure and engaging well-known teachers in the activities, especially in schools located in disadvantaged areas.

COVID-19 induced changes in physical activity patterns, screen time and sleep among Swedish adolescents - a cohort study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic had a huge impact on daily life, even in countries such as Sweden where the restrictions were relatively mild. This paper assesses the effects of the COVID-19 pandemic restrictions on physical activity (PA) patterns, screen time, and sleep among Swedish adolescents. The exposures explored include gender, parental education, anthropometrics, and cardiovascular fitness (CVF). METHODS: Cohort data were collected from September 26th to December 6th, 2019, and from April 12th to June 9th, 2021. Participants were 13-14 years-old (7th graders) at baseline with 585 participating at both baseline and follow-up. At both baseline and follow-up PA and sedentary time were measured with accelerometers, and sleep and screen time with questionnaires. The exposure variables (gender, parental education, anthropometrics and CVF) were collected at baseline. Multilevel linear regression analyses were performed. RESULTS: Moderate-to-vigorous-physical activity (MVPA) remained unchanged while light physical activity (LiPA) decreased and sedentary time increased. Sleep duration decreased and screen time increased. Girls, adolescents with overweight/obesity (BMI and percent body fat), and those with lower CVF at baseline had less favourable changes in PA patterns, sleep and screen time. CONCLUSIONS: Although no significant (α = 0.05) changes were seen in MVPA, both LiPA and sedentary time as well as sleep and screen time changed in unfavourable ways. More intense activities are often organised and seem to have withstood the pandemic, while less intense activities decreased. Some groups were more vulnerable and will need directed intervention in the post-pandemic period as well as when future pandemics hit.

Parents' experiences of participating in the Healthy School Start Plus programme - a qualitative study.

BACKGROUND: The rise in overweight and obesity among children is a global problem and effective prevention interventions are urgently required. Parents play an important role in children's lifestyle behaviours and body weight development and therefore there is a great need to investigate how to involve parents effectively in health promotion and prevention programmes. The aim of the study was to describe parents' experiences of barriers and facilitators of participating in the Healthy School Start Plus (HSSP) intervention study. METHODS: HSSP is a parental support programme, conducted in Sweden, with the aim to promote a healthy diet, physical activity and preventing obesity in 5-7-year-old children starting school. In total 20 parents from 7 schools participated in semi-structured telephone-based interviews. The data was analysed using qualitative content analysis, with a deductive approach based on the Consolidated Framework for Implementation Research (CFIR). RESULTS: Parental experiences of barriers and facilitators informing the implementation of the HSSP intervention were identified within all five domains of the CFIR. Two additional constructs, not included in the CFIR were identified: Social factors and Cooperation. The findings of parental experiences of barriers and facilitators related to the importance of (1) adaptation of the intervention to fit the abilities of the parents with different social and cultural backgrounds; (2) the need for continuous delivery of information related to healthy behaviours; (3) the commitment and efforts of the deliverers of the intervention; (4) the need for repetition of information related to healthy behaviours given by the deliverers of the intervention; (5) encouragement and facilitation of the involvement of the family and key people around them through the intervention activities and by the deliverers of the intervention; (6) awareness of unexpected impacts and social and cultural conditions complicating the execution of the intervention and; (7) cooperation and a well-functioning interaction between parents and school staff. CONCLUSIONS: Barriers and facilitators indicated by the parents highlighted that interventions like the HSSP need to be adapted to fit the parents' abilities, with reminders, follow-ups and delivery of relevant information. Variations in social and cultural conditions need to be taken into consideration. The commitment of the school and the interaction between the school staff and the family as well as key people around them appears to be important. TRIAL REGISTRATION: The Healthy School Start Plus trial was retrospectively registered in the International Standard Randomised Controlled Trial Number Registry on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725.

Associations between organised sports participation, general health, stress, screen-time and sleep duration in adolescents.

AIM: Physical activity patterns in adolescents have been associated with general health. Stress, screen-time and sleep are other factors associated with physical activity that influence health in adolescents. Physical activity accounts for several health benefits; however, the impact of organised sports participation to achieve the same health benefits are less explored. This study explored the associations of organised sports participation with general health, stress, screen-time and sleep-duration in adolescents. METHODS: For this cross-sectional study, data from 1139 adolescents (age 13-14 years) from 34 schools were analysed. Data were collected during autumn 2019. Data collection consisted of self-reported questionnaires and standard methods for height and weight measurements. RESULTS: Adolescents with organised sports participation ≥3 times/week were twice as likely to report better general health (OR: 2.11, CI: 1.45-3.07) and lower screen-time (OR: 1.98, CI: 1.43-2.74). Adolescents with organised sports participation ≥3 times/week were less likely to meet the recommended sleep-duration on weekdays (OR: 0.43, 95% CI: 0.29-0.65). CONCLUSIONS: Adolescents with frequent organised sports participation had better general health, lower amounts of screen-time and shorter sleep-duration on weekdays than those with no participation. Although the causal relationships remain unknown, these results can be relevant when developing strategies promoting physical activity and health in adolescents.

Effects of prolonged sitting and physical activity breaks on measures of arterial stiffness and cortisol in adolescents.

AIM: In adults, prolonged periods of sitting have been linked to acute negative effects on vascular structure and function. The aim of this study was to evaluate the acute effects of physical activity (PA) breaks during prolonged sitting on arterial stiffness, cortisol and psychological factors in adolescents. METHODS: Adolescents underwent different short (3-min) breaks starting every 20 min, during 80 min of sitting on three separate days. Breaks were (A) social seated breaks (SOC), (B) low-intensity simple resistance activity PA breaks (SRA) and (C) moderate-intensity step-up PA breaks (STEP). The arterial stiffness measures were augmentation index (AIx), AIx@75 and pulse wave velocity (PWV). Cortisol was measured from saliva. Psychological factors were self-reported. RESULTS: Eleven girls and six boys (average age 13.6 ± 0.7 years) participated, with average baseline heart rates of 72 ± 11 bpm, systolic/diastolic blood pressure 111 ± 7/64 ± 6 mmHg and cortisol 10.9 ± 5.8 nmoL/L. PWV, cortisol and psychological factors did not change after any of the conditions. AIx@75 increased significantly (4.9 ± 8.7-9.2 ± 13.2) after the STEP intervention compared with SOC and SRA (time × condition p < 0.05). CONCLUSION: Arterial stiffness increased after prolonged sitting with frequent, short step-up activity breaks. The results indicate potential important intensity-dependent effects of physical activity on vascular regulation in youth.

Vitamin D status and associations with diet, objectively measured physical activity patterns and background characteristics among adolescents in a representative national cross-sectional survey.

OBJECTIVE: To report on vitamin D status, measured as plasma 25-hydroxyvitamin D concentration (25(OH)D), the prevalence of vitamin D insufficiency and deficiency, and to explore associations between vitamin D status and background characteristics. DESIGN: Data were collected in a National Dietary Survey, Riksmaten adolescents 2016-2017. The participants completed dietary assessments and questionnaires on the web and wore accelerometers. (25(OH)D) was measured with a MS method. SETTING: Representative survey conducted in schools throughout Sweden. PARTICIPANTS: Participants attended school years 5 (Y5, mean age 12. 5 years), 8 (Y8, mean age 14. 5 years) and 11 (Y11, mean age 18 years), and included 1100 participants. RESULTS: Overall, there was no difference in plasma 25(OH)D between girls and boys. Vitamin D insufficiency differed between the three school years. The prevalence of insufficiency in Y5 was 32 (boys) and 48 (girls) percent, while in Y11 62 (boys) and 43 (girls) percent. The prevalence of deficiency in Y11 was 16 and 15 % in boys and girls, respectively. Being born outside of Sweden was associated with a 10-fold increased risk of being vitamin D deficient. Deficiency was also associated with longer time spent in sedentary intensity, a lower consumption of fortified dairy products and fats and oils. CONCLUSIONS: Vitamin D deficiency was most common in the oldest age group and being born outside of Sweden increased the risk of being deficient. The present study will form a baseline for future follow-up studies of the implementation of a new mandatory vitamin D fortification policy in 2018.

Leisure-time organised physical activity and dietary intake among Swedish adolescents.

This study aimed to investigate associations between participation in leisure-time organised physical activity (LTOPA) and dietary intake in a large representative sample of Swedish adolescents participating in the national dietary survey Riksmaten Adolescents 2016-2017. A sample of 2807 participants aged 11-12, 14-15 and 17-18 years were included. Information about LTOPA and dietary intake were collected through questionnaires and two 24-hour recalls on the web (RiksmatenFlex). For dietary intake, overall healthy eating index, intake of fruit, vegetables, candy, sugar-sweetened beverages, and the proportion of added sugar to total energy intake were analysed. Significance-testing for associations was performed with analysis of covariance. LTOPA was associated with lower sugar-sweetened beverages intake among adolescent boys (p < 0.001, ηp2 = 0.012) and girls (p = 0.007, ηp2 = 0.005), higher fruit intake among boys (p = 0.043, ηp2 = 0.003), and lower vegetable intake among girls (p < 0.001, ηp2 = 0.009). However, LTOPA was unrelated to the overall healthy eating index, candy intake, and the proportion of added sugar to total energy intake (p > 0.05). LTOPA was only associated with some healthy eating behaviours, and there is much room for improvement in the diets of Swedish adolescents.

Children's experiences of participating in a school-based health promotion parental support programme - a qualitative study.

BACKGROUND: Children's voices are seldom heard in process evaluations concerning health promotion programmes. A Healthy School Start Plus (HSSP) is a parental support programme, conducted in Sweden, with the aim of promoting healthy diet, physical activity and preventing obesity in preschool class children. The 6-month programme includes: (1) Health information to parents; (2) Motivational Interviewing with parents by school nurses; (3) Classroom activities and home assignments for children; (4) A self-test of type-2 diabetes risk for parents. We aimed to describe children's experiences of the third component regarding barriers and facilitators of participating in and learning from the classroom activities in the HSSP. METHODS: In total 36 children from 7 schools in Sweden, mean age 6 years, participated in 7 focus group discussions. Purposeful sampling with maximum variation was used to collect the data. The focus groups were audio-recorded, transcribed and analysed using qualitative content analysis. RESULTS: Four categories were identified; (1) Time available to work on intervention activities; (2) Others' interest; (3) Abilities and interests in intervention activities; and (4) Practicing the concept of health. CONCLUSIONS: The findings may improve the HSSP and other similar interventions that include classroom-based learning regarding health by highlighting the following points to consider: aiming for homework to be an integrated part of the school-setting to enhance parental involvement; using flexible material, tailored to the children's abilities and giving children adequate time to finish the intervention activities; and making teachers and parents aware of the importance of verbal and body language regarding intervention activities. TRIAL REGISTRATION: The Healthy School Start Plus trial was retrospectively registered in the International Standard Randomised Controlled Trial Number Registry on January 4, 2018 and available online at ClinicalTrials.gov: No. NCT03390725 .

Sedentary activity bout length was associated with BMI and waist circumference in Swedish children aged 5-7 years.

AIM: This study examined the pattern of sedentary behaviour during the week and on weekends and associations with health outcomes among children aged 5-7 years in Sweden. METHODS: This cross-sectional study used data from 342 children, many of whom had at least one parent born outside the Nordic region. Physical activity and sedentary time were measured by accelerometry. A sedentary bout was defined as 1-4 and 5-9 min. Diet, time in front of television or computer screen, sleep and physical activity behaviour were measured via parental reports, and anthropometric data by research staff. RESULTS: The number of sedentary bouts was higher on weekends than on weekdays. Compared to girls, boys had more 1-4 min bouts on both weekdays and weekend days, and more 5-9 min bouts on weekends. A higher number of 5-9 min bouts was associated with a higher body mass index and waist circumference. CONCLUSION: This study showed an association between sedentary activity and weight status in children as young as 5-7 years. Reducing time, especially longer bouts, spent in sedentary activities may encourage healthy weight development in children.

Self-reported physical activity and sedentary behaviour amongst adolescents in Sweden vary depending on sex, age and parental education.

AIM: The aim of this study was to investigate self-reported physical activity and sedentary behaviour by sex, age and parental education in a large representative sample of Swedish adolescents. METHODS: This study is based on data from the national dietary survey Riksmaten Adolescents, which was conducted by the Swedish Food Agency in 2016-2017. In total, 3477 students from grade five (11-12 years), eight (14-15 years) and eleven (17-18 years) were included. A web questionnaire was used to collect information about physical activity and sedentary behaviour. RESULTS: In total, 53% reported active transport to and from school, 93% that they usually participate in the physical education, 76% reported a physically active leisure time, and 66% reported that they participated in organised physical activities. In addition, 12% and 6% reported two hours or less of screen time on weekdays and weekends, respectively. Participation in physical activity was generally lower amongst girls, older adolescents and for those from families with low-parental education. CONCLUSION: This study provide reference values for self-reported physical activities and sedentary behaviours amongst adolescents in Sweden. Strategies to increase physical activity and reduce screen time are needed, particularly amongst girls, older adolescents and amongst those with low-parental education.

"We were all together"- families' experiences of the health-promoting programme - A Healthy Generation.

BACKGROUND: Healthy lifestyle habits, including physical activity (PA), are associated with a broad range of positive psychosocial and physical health benefits. However, there are challenges involved in reaching vulnerable groups in socioeconomically disadvantaged areas. There is a lack of research on family-based PA interventions, specifically considering psychosocial health. The purpose of this study was to explore how families experienced psychosocial aspects of health after participation in a family-based programme, A Healthy Generation. METHODS: A Healthy Generation is a health-promoting, family-based programme delivered in collaboration with local municipalities and sport associations in socioeconomically disadvantaged areas in Sweden. Families with children in grade 2 (8-9 years), including siblings, participate in health-promoting activities, including activity sessions, healthy meals, health information and parental support groups. Data was collected through interviews with parents and children (n = 23) from a controlled pilot trial of the programme. Interviews were audio recorded, transcribed and analysed using a phenomenological hermeneutical method. RESULTS: Three themes and seven sub-themes emerged. The themes were: "A sense of belonging", "Awareness of one's role as a parent" and "Inspiration towards new and healthier behaviours". In terms of A sense of belonging, participation in the programme was the families own free zone, where they also had the opportunity of being together with other families in the programme. For participants that were isolated and lacked a social network, their participation helped them towards social participation. During the programme, parents created an Awareness of one's role as a parent, with new insights on how to act as a parent and they also negotiated differences between each other. Participation in the programme contributed to Inspiration towards new and healthier behaviours such as experience-based insights and healthy lifestyle changes. CONCLUSIONS: This study highlights the importance of co-participation in family-based health-promoting programmes to enhance psychosocial health among families in socioeconomically disadvantaged areas. The results give new insights into participants' experiences of psychosocial aspects of health after participation in a family-based PA programme. This knowledge can contribute to the understanding of how to design health-promoting, family-based interventions to promote psychosocial health in socioeconomically disadvantaged areas. TRIAL REGISTRATION: ISRCTN ISRCTN11660938 . Retrospectively registered 23 September 2019.

Effectiveness of a family intervention on health-related quality of life-a healthy generation, a controlled pilot trial.

BACKGROUND: Physical activity is associated with better health, but knowledge about health promoting interventions, including physical activity for families in disadvantaged areas and the impact on health-related quality of life (HRQOL) is sparse. The aim of this study was to assess HRQOL in children and their parents after participation in the programme "A Healthy Generation". METHODS: The programme is delivered in socioeconomically disadvantaged areas in Sweden and offers physical activity and a healthy meal or fruit twice a week from August to May to families with children in grade 2. Children (n = 67), aged 8-9 years, and their parents (n = 90) participated in this controlled study conducted in four schools, two control and two intervention schools. HRQOL of children and adults was assessed at baseline and follow-up after the intervention with the Pediatric Quality of Life Inventory (PedsQL) 4.0 and the Gothenburg Quality of Life scale, respectively. Analyses of covariance (ANCOVAs), linear regression and Pearson's correlation were conducted. RESULTS: There were no significant differences between intervention and control in HRQOL among children or adults after the intervention. However, in a subgroup of children (n = 20) and adults (n = 29) with initial low HRQOL scores at baseline, there was a significant difference between the intervention group and control group after the intervention (children (total score): p = 0.02; adults (social domain) p = 0.04). Furthermore, within the intervention group, there was a significant relationship between level of participation in "A Healthy Generation" and the physical domain of HRQOL among girls (r = 0.44, p = 0.01), but not boys (r = - 0.07, p = 0.58). CONCLUSION: Participation in the programme "A Healthy Generation" did not show a significant intervention effect on HRQOL in general. However, the findings suggest that HRQOL may be increased for children and adults with low HRQOL in disadvantaged areas. This knowledge can contribute to the development of health promoting interventions in such areas, and to more equitable health. TRIAL REGISTRATION: ISRCTN ISRCTN11660938. Retrospectively registered 23 September 2019.

A national survey showed low levels of physical activity in a representative sample of Swedish adolescents.

AIM: This study investigated objectively measured physical activity and sedentary time by sex, age and socioeconomic status in a large representative sample of Swedish adolescents. METHODS: In this cross-sectional national survey between 2016 and 2017, students aged 11-12, 14-15 and 17-18 years from 131 schools were invited to participate. Physical activity and sedentary time were measured objectively with accelerometers for seven consecutive days. Socioeconomic status (parental education) and country of birth were self-reported in a questionnaire. Weight and height were measured by trained staff. RESULTS: A total of 3477 adolescents participated in the study, and 2419 (73%) had at least 3 days of valid accelerometer data. The results showed that 43% of boys and 23% of girls reached the recommendation of 60 minutes of daily moderate-to-vigorous physical activity. Boys were more physically active than girls in all age groups. Girls with high socioeconomic status were more physically active than girls with low socioeconomic status (P < .001), and this difference was not found in boys. CONCLUSION: The majority of Swedish adolescents did not reach the physical activity recommendation, and boys were more active than girls. Effective strategies to increase physical activity, especially among girls with low socioeconomic status, are urgently needed.

Organised physical activity during leisure time is associated with more objectively measured physical activity among Swedish adolescents.

AIM: The aim of this study was to investigate associations between participation in organised physical activity (PA), such as sport and exercise during leisure time, and objectively measured PA and sedentary time in a large representative sample of Swedish adolescents. METHODS: This study was part of the school-based cross-sectional Swedish national dietary survey Riksmaten Adolescents 2016-17. Data from 3477 adolescents aged 11-12, 14-15 and 17-18 years were used in the analyses. Participation in organised PA and parental education were reported in questionnaires. PA and sedentary time were objectively measured through accelerometry during seven consecutive days. RESULTS: Adolescents who participated in organised PA had significantly higher total PA (14%, P < .001), more time spent on moderate-to-vigorous PA (MVPA) (8 minutes, P < .001) and had less sedentary time (15 minutes, P < .001). Those who participated in organised PA were more likely to reach recommended PA levels. Total PA and MVPA did not differ by parental education among those who participated in organised PA. CONCLUSION: Adolescents who participated in organised PA were more physically active, less sedentary and more likely to reach PA recommendations than those who did not.

Managing Implementation of a Parental Support Programme for Obesity Prevention in the School Context: The Importance of Creating Commitment in an Overburdened Work Situation, a Qualitative Study.

Health-related behaviours in children can be influenced by parental support programmes. The aim of this study was to explore barriers to and facilitators for the implementation of a parental support programme to promote physical activity and healthy dietary habits in a school context. We explored the views and experiences of 17 coordinating school nurses, non-coordinating school nurses, and school principals. We based the interview guide on the Consolidated Framework for Implementation Research. We held four focus group discussions with coordinating and non-coordinating school nurses, and conducted three individual interviews with school principals. We analysed data inductively using qualitative content analysis. We identified "Creating commitment in an overburdened work situation" as an overarching theme, emphasising the high workload in schools and the importance of creating commitment, by giving support to and including staff in the implementation process. We also identified barriers to and facilitators of implementation within four categories: (1) community and organisational factors, (2) a matter of priority, (3) implementation support, and (4) implementation process. When implementing a parental support programme to promote physical activity and healthy dietary habits for 5- to 7-year-old children in the school context, it is important to create commitment among school staff and school nurses. The implementation can be facilitated by political support and additional funding, external guidance, use of pre-existing resources, integration of the programme into school routines, a clearly structured manual, and appointment of a multidisciplinary team. The results of this study should provide useful guidance for the implementation of similar health promotion interventions in the school context.

Parental support in promoting children's health behaviours and preventing overweight and obesity - a long-term follow-up of the cluster-randomised healthy school start study II trial.

BACKGROUND: Effects of obesity prevention interventions in early childhood are only meaningful if they are sustained over time, but long-term follow-up studies are rare. The school-based cluster-randomised Healthy School Start (HSS) trial aimed at child health promotion and obesity prevention through parental support was carried out in 31 pre-school classes (378 families) in disadvantaged areas in Sweden during 2012-2013. Post-intervention results showed intervention effects on intake of unhealthy foods and drinks, and lower BMI-sds in children with obesity at baseline. This study aimed to evaluate the long-term effectiveness 4 years post-intervention. METHODS: Data were collected from 215 children in March-June 2017. Child dietary intake, screen time, and physical activity were measured through parental-proxy questionnaires. Child height and weight were measured by the research group. Group effects were examined using Poisson, linear, logistic, and quantile regression for data on different levels. Analyses were done by intention to treat, per protocol, and sensitivity analyses using multiple imputation. RESULTS: No between-group effects on dietary intake, screen time, physical activity, or BMI-sds were found for the entire group at the four-year follow-up. In girls, a significant subgroup-effect was found favouring intervention compared to controls with a lower intake of unhealthy foods, but this was not sustained in the sensitivity analysis. In boys, a significant sub-group effect was found where the boys in the intervention group beyond the 95th percentile had significantly higher BMI-sds compared to boys in the control group. This effect was sustained in the sensitivity analysis. Analyses per protocol showed significant intervention effects regarding a lower intake of unhealthy foods and drinks in the children with a high intervention dose compared to controls. CONCLUSIONS: Four years after the intervention, only sub-group effects were found, and it is unlikely that the HSS intervention had clinically meaningful effects on the children. These results suggest that school-based prevention programmes need to be extended for greater long-term effectiveness by e.g. integration into school routine practice. In addition, results showed that children with a high intervention dose had better long-term outcomes compared to controls, which emphasises the need for further work to increase family engagement in interventions. TRIAL REGISTRATION: ISRCTN, ISRCTN39690370, retrospectively registered March 1, 2013, http://www.isrctn.com/ISRCTN39690370 .

Use of a Web-Based Dietary Assessment Tool (RiksmatenFlex) in Swedish Adolescents: Comparison and Validation Study.

BACKGROUND: A Web-based dietary assessment tool-RiksmatenFlex-was developed for the national dietary survey of adolescents in Sweden. OBJECTIVE: This study aimed to describe the Web-based method RiksmatenFlex and to test the validity of the reported dietary intake by comparing dietary intake with 24-hour dietary recalls (recall interviews), estimated energy expenditure, and biomarkers. METHODS: Adolescents aged 11-12, 14-15, and 17-18 years were recruited through schools. In total, 78 students had complete dietary information and were included in the study. Diet was reported a few weeks apart with either RiksmatenFlexDiet (the day before and a random later day) or recall interviews (face-to-face, a random day later by phone) in a cross-over, randomized design. At a school visit, weight and height were measured and blood samples were drawn for biomarker analyses. Students wore an accelerometer for 7 days for physical activity measurements. Dietary intake captured by both dietary methods was compared, and energy intake captured by both methods was compared with the accelerometer-estimated energy expenditure (EEest). Intake of whole grain wheat and rye and fruit and vegetables by both methods was compared with alkylresorcinol and carotenoid concentrations in plasma, respectively. RESULTS: The mean of the reported energy intake was 8.92 (SD 2.77) MJ by RiksmatenFlexDiet and 8.04 (SD 2.67) MJ by the recall interviews (P=.01). Intake of fruit and vegetables was 224 (169) g and 227 (150) g, and whole grain wheat and rye intake was 12.4 (SD 13.2) g and 12.0 (SD 13.1) g, respectively; the intakes of fruit and vegetables as well as whole grain wheat and rye did not differ between methods. Intraclass correlation coefficients ranged from 0.57 for protein and carbohydrates to 0.23 for vegetables. Energy intake by RiksmatenFlexDiet was overreported by 8% (P=.03) but not by the recall interviews (P=.53) compared with EEest. The Spearman correlation coefficient between reported energy intake and EEest was 0.34 (P=.008) for RiksmatenFlexDiet and 0.16 (P=.21) for the recall interviews. Spearman correlation coefficient between whole grain wheat and rye and plasma total alkylresorcinol homologs was 0.36 (P=.002) for RiksmatenFlexDiet and 0.29 (P=.02) for the recall interviews. Spearman correlations between intake of fruit and vegetables and plasma carotenoids were weak for both dietary tools. The strongest correlations were observed between fruit and vegetable intake and lutein/zeaxanthin for RiksmatenFlexDiet (0.46; P<.001) and for recall interviews (0.28; P=.02). CONCLUSIONS: RiksmatenFlexDiet provides information on energy, fruit, vegetables, and whole grain wheat and rye intake, which is comparable with intake obtained from recall interviews in Swedish adolescents. The results are promising for cost-effective dietary data collection in upcoming national dietary surveys and other studies in Sweden. Future research should focus on how, and if, new technological solutions could reduce dietary reporting biases.