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  • 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

    http://www.google.gr/url?sa=i&rct=j&q=hua+logo&source=images&cd=&cad=rja&docid=g5Z3sczTfiRH0M&tbnid=h_MTbSZdC6m4aM:&ved=0CAUQjRw&url=http://commons.wikimedia.org/wiki/File:Hua_logo.jpg&ei=AhaRUbetFoWJtQagxYGgDA&bvm=bv.46340616,d.Yms&psig=AFQjCNE836VALJ1cDVngHC9rc0F0cJOlmA&ust=1368549240057711

  • 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

    http://www.cdc.gov/

  • WATER CONSUMPTION AND EATING HABITS

  • Children’s water consumption (portions/day)

    (1.26)

    (1.23)

    (1.21)

    (1.25)

    p

  • Parents serving water to their children during meals

    p

  • 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

  • Parental sweets/candies consumption (portions/day)

    (2.52)

    (2.56)

    (2.91)

    p

  • PHYSICAL ACTIVITY AND SEDENTARY BEHAVIOUR