The ToyBox-study a European kindergarten-based, family ... · The ToyBox-study – a European...
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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
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
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: [email protected] More information regarding the ToyBox-study: www.toybox-study.eu More information regarding the Feel4Diabetes-study: [email protected]
Harokopio University, Athens