The ToyBox-study – a European kindergarten-based, family-involved intervention

aiming to prevent obesity in early childhood

Yannis Manios Associate Professor

School of Health Sciences & Education Department of Nutrition & Dietetics

Harokopio University, Athens, Greece

Med Clin N Amer 2000 84(2)

School based interventions

Large contact time / access

to large cohorts

Available infrastructure

and human resources

Do school based interventions work?

Flynn et al (2006) Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with ‘best practice’ recommendations Obesity Reviews

Do school based interventions work?

Flynn et al (2006) Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with ‘best practice’ recommendations Obesity Reviews

Inconclusive results on their effectiveness

Do school based interventions work?

Flynn et al (2006) Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with ‘best practice’ recommendations Obesity Reviews

Inconclusive results on their effectiveness

Majority of studies low-mid methodological quality

Do school based interventions work?

Flynn et al (2006) Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with ‘best practice’ recommendations Obesity Reviews

6/11 improved body composition indices

8/11 improved dietary/ p.a. indices

Inconclusive results on their effectiveness

Majority of studies low-mid methodological quality

Learning from previous programmes & existing literature for effective interventions

– Be rooted in behaviour change theories & not being too general

– Identify and target specific behaviours and their determinants

– Take into account stakeholders’ views, contextual factors and policy framework

– Target school and home social & physical environment

– Have a minimum duration of one academic year

– Be low in cost and use available human and infrastructure resources

– Perform a process evaluation

Waters E et al Cochrane Database Syst Rev 2011

Gonzalez-Suarez C et al Am J Prev Med 2009

Sharma M Obes Rev 2007

Summerbell CD et al Cochrane Database Syst Rev 2005

Key-learnings from previous studies guided ToyBox-study

Started: early 2010

Aims • The primary aim of ToyBox-study was to prevent obesity in early childhood

(3.5-5.5 years old and their families)

ToyBox study is a EU funded project

(Project Number: 245200, FP7-KBBE-2009-3)

Coordinator: Yannis Manios, Harokopio University

Aims • The primary aim of ToyBox-study was to prevent obesity in early childhood

(3.5-5.5 years old and their families)

• By creating a supportive social and physical environment at kindergartens and home to facilitate desired behaviours

ToyBox study is a EU funded project

(Project Number: 245200, FP7-KBBE-2009-3)

Coordinator: Yannis Manios, Harokopio University

Aims • The primary aim of ToyBox-study was to prevent obesity in early childhood

(3.5-5.5 years old and their families)

• By creating a supportive social and physical environment at kindergartens and home to facilitate desired behaviours

• Using a low-cost and potentially cost effective approach

ToyBox study is a EU funded project

(Project Number: 245200, FP7-KBBE-2009-3)

Coordinator: Yannis Manios, Harokopio University

ToyBox-study

Academic Research Institutes

Harokopio University, HUA (GR)

Ludwig-Maximilians University of Munich, LMU (DE)

State Institute of Early Childhood Research, IFP (DE)

Ghent University, Ugent (BE)

VU University Medical Centre, Vumc (NL)

University of Zaragoza, UniZar (ES)

Akershus University College, HIAK (NO)

Durham University, UDUR (UK)

Roehampton University, RoU (UK)

Children’s Memorial Health Institute, CMHI (PL)

Medical Universityof Varna, MUV (BG)

University of Luxembourg (ULU) (LUX)

International / Health Promotion Organisations

International Association for the Study of Obesity,

IASO (UK)

Netherlands Institute for Health Promotion and

Disease Prevention, NIGZ (NL)

SME

AOK- Verlag GmbH (DE) GREECE

SPAIN BULGARIA

ENGLAND

NORWAY

POLAND GERMANY

HOLLAND

BELGIUM

LUXEMBURG

April 2010 2011 2012 2013 2014

Multi-stage sampling procedure

MUNICH

ATHENS

VARNA

WARSAW

ZARAGOZA

GHENT

April 2010 2011 2012 2013 2014

ToyBox-study

2010 2011 2012-2013 2014

• Systematic reviews

• Secondary analysis

• Focus groups

Key-behaviours & their

determinants

Changes kindergarten environment

Implement the behaviours Conduct interactive activities Target/Involve parents via

newsletters/tip-cards/posters

IM Table

Targeted behaviours • Water consumption

• Snacking • Physical activity

• Sedentary behaviour

1st Behaviour: Water consumption

Change of kindergarten

environment

Implementation of behaviour Every 30-40

minutes

2nd Behaviour: Snacking

Change of kindergarten

environment

Implementation of behaviour

Morning snack

3rd Behaviour: Physical activity

Change of kindergarten

environment

Implementation of behaviour At least 2

times/week

4th Behaviour: Sedentary behaviour

Change of kindergarten

environment

Implementation of behaviour Every 30-40

minutes

For all behaviours:

classroom activities

Intervention at home Oct Nov Dec Jan Feb Mar Apr May Jun

Water

consumption

Newsletter

Tip-card

Poster

Physical

activity

Newsletter

Tip-card

Poster

Snacking

Newsletter

Tip-card

Poster

Sedentary

behaviour

Newsletter

Tip-card

Poster

Water

consumption

Newsletter

Tip-card

Poster

Physical

activity

Newsletter

Tip-card

Poster

Snacking

Newsletter

Tip-card

Poster

Sedentary

behaviour

Newsletter

Tip-card

Poster

All

behaviours

Newsletter

Tip-card

Poster

• 9 Newsletters

• 8 Tip-cards

• 4 Posters

FIRST RESULTS OF TOYBOX-INTERVENTION

Complete baseline & follow up data

GERMANY

GREECE

BULGARIA

POLAND

SPAIN

BELGIUM

Country Kindergartens Children/ Parents

Belgium 26 1032

Bulgaria 19 792

Germany 55 954

Greece 92 854

Poland 49 1065

Spain 30 853

Total 271 5550

% Overweight/obesity changes

14,3%

13,9%

13,4% 13,3%

12,8%

13,0%

13,2%

13,4%

13,6%

13,8%

14,0%

14,2%

14,4%

Baseline Follow-up

Intervention

Control

Interaction effect = 0.892

p < 0.672

p < 0.881

Boys: 2 - 20 yrs

www.cdc.gov

“Adiposity rebound” & BMI

WATER CONSUMPTION AND EATING HABITS

Children’s water consumption (portions/day)

(1.26)

(1.23)

(1.21)

(1.25)

p<0.001

p<0.001

Interaction effect = 0.017

Parents serving water to their children during meals

p<0.001

p=0.309

Interaction effect = 0.023

Children’s sweets consumption (portions/day)

(sd: 1,61) 2.16

1.94

2.12

2.05

1,8

1,9

1,9

2,0

2,0

2,1

2,1

2,2

2,2

Baseline Follow-up

Intervention

Control

(1.44)

(1.40)

(1.44)

p<0.001

p=0.055 Interaction effect = 0.010

(1.61)

Parental sweets/candies consumption (portions/day)

(2.52)

(2.56)

(2.91)

p<0.001

p=0.309

Interaction effect = 0.002 (3.09)

PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR

Parental vigorous PA (% ≥3 times/week)

p<0.001

p=0.274 Interaction

effect=0.006

0.22

0.3

0.41

0.59

0.18

0.3

0.37

0.6

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

Baseline Follow-up Baseline Follow-up

Weekdays Weekend days

Intervention

Control

Children’s screen time (PC/video games) (hours/day)

(0.47) (0.37)

(0.49) (0.51)

Interaction effect = 0.016

Interaction effect = 0.032

(0.74) (0.62)

(0.79) (0.78)

p<0.001

p<0.001

p<0.001

p<0.001

% Children >10.000steps/day (pedometers)

Interaction effect =0.874 Interaction effect = 0.590

62,3% 62,4%

44,0% 38,4%

49,8% 50,5%

42,1%

35,0%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

Baseline Follow up Baseline Follow up

Weekdays Weekend

Intervention

Control

p<0.929

p<0.795 p<0.002

p<0.004

Physical environment

Athens, Greece Ghent, Belgium

High SES municipality in Athens

Physical environment

Low-medium SES municipality in Athens

Physical environment

Summary of findings

Based on the preliminary analyses some positive findings can be seen for IG vs. CG. group for:

- children’s PC/video games

- children’s water consumption

- children’s and parents’ sweet consumption

- parents’ vigorous physical activity

Summary of findings

Based on the preliminary analyses some positive findings can be seen for IG vs. CG. group for:

- children’s PC/video games

- children’s water consumption

- children’s and parents’ sweet consumption

- parents’ vigorous physical activity

Next steps: - Have those primarily in need for the intervention, been benefited?

Multi-stage sampling procedure

MUNICH

ATHENS

VARNA

WARSAW

ZARAGOZA

GHENT

•6 Regions

Country Kinder-gartens

Children

Belgium 26 1327

Bulgaria 34 964

Germany 58 1217

Greece 110 1229

Poland 49 1430

Spain 32 889

Total 309 7056

April 2010 2011 2012 2013 2014

20,8%

15,4%

13,4% 12,9%

11,1% 9,6%

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

Greece Spain Bulgaria Poland Belgium Germany

Overweight/obesity

Prevalence of overweight/obesity among preschool children in Europe

20,8%

15,4%

13,4% 12,9%

11,1%

9,6%

12,8%

4,1%

6,5% 6,3%

3,5%

1,5%

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

Greece Spain Bulgaria Poland Belgium Germany

Overweight/obesity Screen time >2 hours per day

Prevalence of overweight/obesity and screen time > 2 hours per day among preschool children in Europe

20,8%

15,4% 13,4% 12,9%

11,1% 9,6%

12,8%

4,1% 6,5% 6,3%

3,5% 1,5%

29,9% 32,3%

37,1% 36,6% 36,4%

46,2%

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

30,0%

35,0%

40,0%

45,0%

50,0%

Greece Spain Bulgaria Poland Belgium Germany

Overweight/obesity Screen time >2 hours per day Meeting daily step count recommendations

Prevalence of overweight/obesity, screen time > 2 hours per day and meeting recommendations for daily steps among preschool children in Europe

20,8%

15,4% 13,4% 12,9%

11,1% 9,6%

12,8%

4,1% 6,5% 6,3%

3,5% 1,5%

29,9% 32,3%

37,1% 36,6% 36,4%

46,2%

22,0% 20,0%

18,0%

8,0%

3,0% 2,0%

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

30,0%

35,0%

40,0%

45,0%

50,0%

Greece Spain Bulgaria Poland Belgium Germany

Overweight/obesity Screen time >2 hours per day Meeting daily step count recommendations Watching TV at lunch

Prevalence of overweight/obesity, screen time > 2 hours per day, meeting recommendations for daily steps and watching TV at lunch among preschool

children in Europe

Prevalence of overweight/obesity, screen time > 2 hours per day, meeting recommendations for daily steps, watching TV at lunch and watching TV at dinner

among preschool children in Europe

20,8%

15,4% 13,4% 12,9%

11,1% 9,6%

12,8%

4,1% 6,5% 6,3%

3,5% 1,5%

29,9% 32,3%

37,1% 36,6% 36,4%

46,2%

22,0% 20,0%

18,0%

8,0%

3,0% 2,0%

19,0%

38,0%

47,0%

21,0%

9,0% 7,0%

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

30,0%

35,0%

40,0%

45,0%

50,0%

Greece Spain Bulgaria Poland Belgium Germany

Overweight/obesity Screen time >2 hours per day Meeting daily step count recommendations Watching TV at lunch Watching TV at dinner

Prevalence of overweight/obesity by region & SES-group

14,5% 12,7%

10,9% 10,0% 8,9% 8,1%

9,3%

7,2%

3,5% 3,1%

2,0% 1,6%

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

Low SES Mid/High SES Low SES Mid/High SES Low SES Mid/High SES

South (Greece, Spain)

East (Bulgaria, Poland)

Central/North (Belgium, Germany)

Overweight Obesity

P = 0.040

Suggestions for future school based & community intervention programmes

Large differences on the prevalence of obesity throughout EU and within each country (SES groups)

Suggestions for future school based & community intervention programmes

Large differences on the prevalence of obesity throughout EU and within each country (SES groups)

→ Focus in regions/SES groups with the highest prevalence of obesity

Suggestions for future school based & community intervention programmes

Large differences on the prevalence of obesity throughout EU and within each country (SES groups)

→ Focus in regions/SES groups with the highest prevalence of obesity

Very different behaviours, determinants and physical environment throughout EU countries and within

countries/SES groups

Suggestions for future school based & community intervention programmes

Large differences on the prevalence of obesity throughout EU and within each country (SES groups)

→ Focus in regions/SES groups with the highest prevalence of obesity

Very different behaviours, determinants and physical environment throughout EU countries and within

countries/SES groups

→ Develop and implement the “school based family involved intervention” tailor-made to the

“local” needs (one size does not fit all)

Suggestions for future school based & community intervention programmes

Large differences on the prevalence of obesity throughout EU and within each country (SES groups)

→ Focus in regions/SES groups with the highest prevalence of obesity

Very different behaviours, determinants and physical environment throughout EU countries and within

countries/SES groups

→ Develop and implement the “school based family involved intervention” tailor-made to the

“local” needs (one size does not fit all)

Within each school-class some children/families at higher risk for obesity

Suggestions for future school based & community intervention programmes

Large differences on the prevalence of obesity throughout EU and within each country (SES groups)

→ Focus in regions/SES groups with the highest prevalence of obesity

Very different behaviours, determinants and physical environment throughout EU countries and within

countries/SES groups

→ Develop and implement the “school based family involved intervention” tailor-made to the

“local” needs (one size does not fit all)

Within each school-class some children/families at higher risk for obesity

→ Identify these children/families at higher risk. Invite those families (adults) to attend additional

sessions (in municipality settings outside the school) delivered by health care professionals.

Suggestions for future school based & community intervention programmes

Large differences on the prevalence of obesity throughout EU and within each country (SES groups)

→ Focus in regions/SES groups with the highest prevalence of obesity

Very different behaviours, determinants and physical environment throughout EU countries and within

countries/SES groups

→ Develop and implement the “school based family involved intervention” tailor-made to the

“local” needs (one size does not fit all)

Within each school-class some children/families at higher risk for obesity

→ Identify these children/families at higher risk. Invite those families (adults) to attend additional

sessions (in municipality settings outside the school) delivered by health care professionals.

→ Use available facilities, personnel and mobile technologies to lower the cost of intervention

Families across Europe following a hEalthy Lifestyle FOR Diabetes prevention

Feel4Diabetes No. of proposal: 643708 Coordinator: Dr. Yannis Manios Harokopio University, Athens

The Feel4Diabetes-study has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement n° 643708. The content of this article reflects only the authors’ views and the European Community is not liable for any use that may be made of the information contained therein.

Intervention

Municipalities

750 children

150 High-risk families All families

“Targeting high-risk families”

component

Structured lifestyle counselling

sessions

+ “Targeting all families” component

Improvement of school social & physical environment

+

Improvement of home social & physical environment

+

Local municipality initiatives

Randomly selected schools

Second-stage randomization

Screening at school setting: Families’ FINDRISC

Feel4Diabetes-study Design

Yannis Manios, Associate Professor E-mail: manios@hua.gr More information regarding the ToyBox-study: www.toybox-study.eu More information regarding the Feel4Diabetes-study: manios.feel4diabetes@hua.gr

Harokopio University, Athens