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Abstract Background Healthy sleep is crucial for the physical and mental wellbeing of adolescents. However, many adolescents suffer from poor sleep health. Little is known about how to effectively improve adolescent sleep health as it is shaped by a complex adaptive system of many interacting factors. This study aims to provide insights into the system dynamics underlying adolescent sleep health and to identify impactful leverage points for sleep health promotion interventions. Methods Three rounds of single-actor workshops, applying Group Model Building techniques, were held with adolescents (n = 23, 12–15 years), parents (n = 14) and relevant professionals (n = 26). The workshops resulted in a multi-actor Causal Loop Diagram (CLD) visualizing the system dynamics underlying adolescent sleep health. This CLD was supplemented with evidence from the literature. Subsystems, feedback loops and underlying causal mechanisms were identified to understand overarching system dynamics. Potential leverage points for action were identified applying the Action Scales Model (ASM). Results The resulting CLD comprised six subsystems around the following themes: (1) School environment; (2) Mental wellbeing; (3) Digital environment; (4) Family & Home environment; (5) Health behaviors & Leisure activities; (6) Personal system. Within and between these subsystems, 16 reinforcing and 7 balancing feedback loops were identified. Approximately 60 potential leverage points on different levels of the system were identified as well. Conclusions The multi-actor CLD and identified system dynamics illustrate the complexity of adolescent sleep health and supports the need for developing a coherent package of activities targeting different leverage points at all system levels to induce system change.

Abstract System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10–14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system’s structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice.

ObjectiveInvestigate the cross-sectional association between the psychosocial status of mothers and fathers and the BMI z-scores of their 10 to 12-year-old children. Explore whether this association is mediated by children's diet, physical activity, screen time and sleep. Analyze the moderating effect of the educational levels of both the mother and father on the association.DesignIn a cross-sectional study design, children's height and weight were measured following a standardized protocol. Parents completed the validated Depression Anxiety and Stress questionnaire, while diet quality, sports participation, time spent in bed and screen time were assessed through child-report using previously validated questions.ParticipantsThe data for this study were obtained from the Amsterdam Born Children and their Development study, involving children aged 10 to 12 years and both of their parents (N = 1315).ResultsThe majority, 80%, of the parents were highly educated and born in the Netherlands, and 68% of the children had a healthy BMI. Maternal or paternal psychosocial status was not significantly associated with children's BMI z-score (maternal β -0.0037; 95% CI: -0.008 to 0.0007, paternal β 0.0028; 95% CI: -0.007 to 0.002). Screen time mediated the association between paternal psychosocial status and children's BMI z-score (β = 0.010, 95% CI: 0.002; 0.020). Children's diet, physical activity, and sleep did not mediate the association between paternal psychosocial status and children's BMI z-score. Parental educational level was not a moderator.ConclusionsThis research is unique in including four energy balance behaviors and including both mothers and fathers' psychosocial status. Children withfathers experiencing poorer psychosocial status engaged in more screen time which partly explained their higher BMI z-score.

Abstract Objective: To investigate whether financial constraint and perceived stress modify the effects of food-related taxes on the healthiness of food purchases. Design: Moderation analyses were conducted with data from a trial where participants were randomly exposed to: a control condition with regular food prices, an sugar-sweetened beverage (SSB) tax condition with a two-tiered levy on the sugar content in SSB (5–8 g/100 ml: €0·21 per l and ≥8 g/100 ml: €0·28 per l) or a nutrient profiling tax condition where products with Nutri-Score D or E were taxed at a 20 percent level. Outcome measures were overall healthiness of food purchases (%), energy content (kcal) and SSB purchases (litres). Effect modification was analysed by adding interaction terms between conditions and self-reported financial constraint or perceived stress in regression models. Outcomes for each combination of condition and level of effect modifier were visualised. Setting: Virtual supermarket. Participants: Dutch adults (n 386). Results: Financial constraint or perceived stress did not significantly modify the effects of food-related taxes on the outcomes. Descriptive analyses suggest that in the control condition, the overall healthiness of food purchases was lowest, and SSB purchases were highest among those with moderate/high levels of financial constraint. Compared with the control condition, in a nutrient profiling tax condition, the overall healthiness of food purchases was higher and SSB purchases were lower, especially among those with moderate/high levels of financial constraint. Such patterns were not observed for perceived stress. Conclusion: Further studies with larger samples are recommended to assess whether food-related taxes differentially affect food purchases of subgroups.

BackgroundThe concept of “positive health” emerged from the need for a holistic and more dynamic perspective on health, emphasising the ability of individuals to adapt and self-manage. The positive health conversation tool helps understand how people score on six positive health dimensions. However, skills within these dimensions to maintain or improve health have not yet been described. This is important for enabling individuals to put health advice into practise. Therefore, this paper aims to define and suggest skills for maintaining and improving positive health.SubsectionsSuggestions for definitions of skills within the positive health dimensions are described using the functional, interactive, and critical health literacy framework. Additionally, executive functions and life skills were incorporated. Moreover, the environment's role in these individual skills was noted, mentioning organisational health literacy that emphasises organisations' responsibility to provide comprehensible health information to all individuals. We propose that health promotion interventions can incorporate the proposed skills in practical exercises while aligning intervention materials and implementation tools with end-users and implementers.Discussion and conclusionThe suggested skills for maintaining and improving positive health are a first step towards a more comprehensive understanding and open to discussion. These skills may also be applied to other practical conversation tools for maintaining or improving health. Increasing positive health through the defined skills may be especially relevant to those with a lower socioeconomic position who also have limited health literacy and thereby may contribute to reducing health inequalities. Taken together, strengthening the defined skills may hopefully contribute to allowing people to flourish in life.

Abstract Background Understanding the perceptions of lower socioeconomic groups towards workplace health promotion is important because they are underrepresented in workplace health promotion activities and generally engage in unhealthier lifestyle behaviour than high SEP groups. This study aims to explore interest in workplace health promotion programmes (WHPPs) among employees with a low and medium level of education regarding participation and desired programme characteristics (i.e. the employer’s role, the source, the channel, the involvement of the social environment and conditions of participation). Methods A mixed-methods design was used, consisting of a questionnaire study (n = 475) and a sequential focus group study (n = 27) to enrich the questionnaire’s results. Multiple logistic regression analysis was performed to analyse the associations between subgroups (i.e. demographics, weight status) and interest in a WHPP. The focus group data were analysed deductively through thematic analysis, using MAXQDA 2018 for qualitative data analysis. Results The questionnaire study showed that 36.8% of respondents were interested in an employer-provided WHPP, while 45.1% expressed no interest. Regarding subgroup differences, respondents with a low level of education were less likely to express interest in a WHPP than those with a medium level of education (OR = .54, 95%, CI = .35–.85). No significant differences were found concerning gender, age and weight status. The overall themes discussed in the focus groups were similar to the questionnaires (i.e. the employer’s role, the source, the channel, the involvement of the social environment and conditions of participation). The qualitative data showed that participants’ perceptions were often related to their jobs and working conditions. Conclusions Employees with a medium level of education were more inclined to be interested in a WHPP than those with a low level of education. Focus groups suggested preferences varied depending on job type and related tasks. Recommendations are to allow WHPP design to adapt to this variation and facilitate flexible participation. Future research investigating employers’ perceptions of WHPPs is needed to enable a mutual understanding of an effective programme design, possibly contributing to sustainable WHPP implementation.

Introduction and MethodsTo develop an understanding of the dynamics driving obesity-related behaviours in adolescents, we conducted systems-based analysis on a causal loop diagram (CLD) created from a multi-actor perspective, including academic researchers, adolescents and local stakeholders.ResultsThe CLD contained 121 factors and 31 feedback loops. We identified six subsystems with their goals: (1) interaction between adolescents and the food environment, with profit maximisation as goal, (2) interaction between adolescents and the physical activity environment, with utility maximisation of outdoor spaces as goal, (3) interaction between adolescents and the online environment, with profit maximisation from technology use as goal, (4) interaction between adolescents, parenting and the wider socioeconomic environment, with a goal focused on individual parental responsibility, (5) interaction between healthcare professionals and families, with the goal resulting in treating obesity as an isolated problem, and (6) transition from childhood to adolescence, with the goal centring around adolescents’ susceptibility to an environment that stimulates obesity-related behaviours.DiscussionAnalysis showed that inclusion of the researchers’ and stakeholders’ perspectives contributed to an understanding of how the system structure of an environment works. Integration of the adolescents’ perspective enriched insights on how adolescents interact with that environment. The analysis further showed that the dynamics driving obesity-related behaviours are geared towards further reinforcing such behaviours.

BackgroundReducing health inequalities is a challenge for policymakers and civil society. A multisectoral and multilevel approach is most promising to reduce those inequalities. Previous research showed what key elements of Zwolle Healthy City, an integrated community-based approach aimed at reducing socioeconomic health inequalities, are. To fully understand approaches that are complex and context dependent, questions as 'how does the intervention work' and 'in what context does it work' are just as important as 'what works'. The current study aimed to identify mechanisms and contextual factors associated with the key elements of Zwolle Healthy City, using a realist evaluation perspective.MethodsTranscripts of semi-structured interviews with a wide range of local professionals were used (n = 29). Following realist evaluation logic in the analysis of this primary data, context-mechanism-outcome configurations were identified and thereafter discussed with experts (n = 5).ResultsHow mechanisms (M) in certain contexts (C) were of influence on the key elements (O) of the Zwolle Healthy City approach are described. For example, how, in the context of the responsible aldermen embracing the approach (C), regular meetings with the aldermen (M) increased support for the approach among involved professionals (O). Or, how, in the context of available financial resources (C), assigning a program manager (M) contributed positively to coordination and communication (O). All 36 context-mechanism-outcome configurations can be found in the repository.ConclusionThis study showed what mechanisms and contextual factors are associated with the key elements of Zwolle Healthy City. By applying realist evaluation logic in the analysis of primary qualitative data we were able to disentangle the complexity of processes of this whole system approach and show this complexity in a structured manner. Also, by describing the context in which the Zwolle Healthy City approach is implemented, we contribute to the transferability of this approach across different contexts.

Abstract Background Prior research indicates a positive association between socioeconomic position and health literacy levels. We hypothesize comparable socioeconomic gradients for food literacy. This study aims to determine the level of self-perceived food literacy and health promotion literacy among adults with a low and medium level of education and from various subgroups, as well as the association between these food and health literacy levels. Furthermore, this study aims to explore the associations of self-perceived food literacy (SPFL) and health promotion literacy (HPL) in BMI. Methods A cross-sectional study was conducted among employees with a low and medium level of education. Descriptive analyses were performed to compute SPFL and HPL levels. Analyses of variance were performed to test differences between subgroups. The correlation between SPFL and HPL was computed by Pearson’s r. Multivariate linear regression analyses were used to explore 1) the association between SPFL and HPL adjusted for demographic characteristics 2) the associations between SPFL and HPL in BMI. Results The majority (63.1%) of all participants (n = 222) scored low on SPFL and 34.5% scored inadequate or problematic on HPL. No significant educational or weight-status differences were found in SPFL or HPL levels. On most levels, women compared to men and older compared to younger employees scored significantly higher. A small positive correlation between the two mean levels was found, r = .25, P

Abstract Background Taxation of sugar-sweetened beverages (SSBs), as a component of a comprehensive strategy, has emerged as an apparent effective intervention to counteract the rising prevalence of overweight and obesity. Insight into the political and public acceptability may help adoption and implementation in countries with governments that are considering an SSBs tax. Hence, we aimed to conduct a systematic review and meta-analysis to synthesize the existing qualitative and quantitative literature on political and public acceptability of an SSBs tax. Methods Four electronic databases (PubMed, Embase, Scopus, Web of Science) were searched until November 2018. The methodological quality of the included studies was assessed using the Mixed Methods Appraisal Tool. Qualitative studies were analyzed using a thematic synthesis. Quantitative studies were analyzed using a random-effects meta-analysis for the pooling of proportions. Results Thirty-seven articles reporting on forty studies were eligible for inclusion. Five themes derived from the thematic synthesis: (i) beliefs about effectiveness and cost-effectiveness, (ii) appropriateness, (iii) economic and socioeconomic benefit, (iv) policy adoption and implementation, and (v) public mistrust of the industry, government and public health experts. Results of the meta-analysis indicated that of the public 42% (95% CI = 0.38–0.47) supports an SSBs tax, 39% (0.29–0.50) supports an SSBs tax as a strategy to reduce obesity, and 66% (0.60–0.72) supports an SSBs tax if revenue is used for health initiatives. Conclusions Beliefs about effectiveness and cost-effectiveness, appropriateness, economic and socioeconomic benefit, policy adoption and implementation, and public mistrust of the industry, government and public health experts have important implications for the political and public acceptability of an SSBs tax. We provide recommendations to increase acceptability and enhance successful adoption and implementation of an SSBs tax: (i) address inconsistencies between identified beliefs and scientific literature, (ii) use raised revenue for health initiatives, (iii) communicate transparently about the true purpose of the tax, and (iv) generate political priority for solutions to the challenges to implementation.

Introduction: The Netherlands Nutrition Centre developed guidelines to improve the availability and accessibility of healthier food products in Dutch canteens. This paper describes the development of an implementation plan to facilitate implementation of Guidelines for Healthier Canteens in Dutch secondary schools.Materials and Methods: In cooperation with stakeholders (i.e., school/caterer managers/employees, school canteen advisors, researchers) and based on theory, we developed an implementation plan in three steps. First, we identified factors that impede/facilitate stakeholders to create a healthier school canteen during 14 interviews. Second, 25 experts discussed and prioritized these identified factors in an expert meeting. Third, we translated these factors into tools to be included in the implementation plan, by making use of behavior change taxonomies and evidence-based implementation strategies.Results: The plan aims to support stakeholders in implementing healthier school canteens and consists of five tools: (1) tailored advice based on an online questionnaire to assess schools' and stakeholders' context and the Canteen Scan (i.e., an online tool to assess the availability and accessibility of food/drink products); (2) communication materials with information and examples; (3) online community for support by sharing experiences/questions; (4) digital newsletter as reminder/support; (5) fact sheet with students' needs/wishes to tailor the canteen.Discussion: This study illustrates how collaboration between science, policy and practice resulted in a tailored implementation plan aimed to support schools to adhere to school canteen policy. This development serves as a good example for researchers, health promotion policymakers, and practitioners how to create an implementation plan that fits the needs of stakeholders.

BackgroundSince 2010, the Zwolle Healthy City approach, an integrated community-based approach, has been implemented in the Dutch municipality of Zwolle. This approach is proven successful in reducing health inequalities. However, the key elements of this approach are not clear. The current study aimed to identify key elements of this successful local community-based approach, according to the perspectives of various stakeholders.MethodsSemi-structured interviews were carried out with 29 professionals who were involved in the approach in the period 2010-2018 and have occupations at the strategic (n = 4), tactical (n = 17) and operational level (n = 8). Data was analyzed using the thematic analysis approach.ResultsWe identified nine perceived key elements that contributed to the success of the approach aimed at reducing socioeconomic health inequalities. The respondents indicated the following key elements: (1) collaboration between a variety of local organizations that want to have impact on the health of citizens; (2) support for the approach on the strategic, tactical and operational level of involved organizations; (3) proper communication and coordination, both for the network and within the organizations; (4) embeddedness in organizations' policies and processes and (5) collaboration with private organizations is of added value, although there is no "one size fits all". Other key elements are (6) collaboration with citizens, (7) profiling the approach like a brand and (8) moving along with and taking advantage of opportunities. Finally, (9) continuous monitoring and evaluating goals and processes, and learning from the results, is important.ConclusionNine key elements were identified that, according to various stakeholders, contributed to the success of the Zwolle Healthy City approach. These insights are important to further strengthen the Zwolle Healthy City approach but may also help and inspire other local integrated community-based approaches aimed at reducing socioeconomic health inequalities, to improve and adapt the approach within their specific local and dynamic context.

Abstract Background Physical activity (PA) is important in combating childhood obesity. Parents, and thus parental PA, could influence PA in young children. We examined whether the time spent at different intensities of PA and the type of parental PA are associated with the PA of children aged 4–7 years, and whether the associations between child-parent pairs were sex-specific. Methods All the participants were recruited from the Groningen Expert Center for Kids with Obesity (GECKO) birth cohort (babies born between 1 April 2006 and 1 April 2007 in Drenthe province, the Netherlands) and were aged 4–7 years during measurement. PA in children was measured using the ActiGraph GT3X (worn at least 3 days, ≥10 h per day). PA in parents was assessed using the validated SQUASH questionnaire. Results Of the N = 1146 children with valid ActiGraph data and 838 mothers and 814 fathers with valid questionnaire data, 623 child-parent pairs with complete data were analysed. More leisure time PA in mothers was associated with more time spent in moderate-to-vigorous PA (MVPA) in children (Spearman r = 0.079, P

Objective: To examine changes in generic and weight-related, health-related quality of life (HRQoL) in children and adolescents with severe obesity participating in intensive lifestyle treatment, and to examine whether changes in SDS-BMI were associated with changes in HRQoL. Methods: In this prospective observational study, a referred sample of 120 children and adolescents (8-19 years) with severe obesity (SDS-BMI ≥ 3.0, or ≥ 2.3 in combination with obesity-related comorbidity) received an intensive 1-year lifestyle treatment with an inpatient period in a specialized childhood obesity center. A weight-related (IWQOL-Kids) and three generic (KIDSCREEN-52, PedsQL 4.0, and EuroQol) HRQoL questionnaires were administered at baseline (T0), after treatment (T1), and 1 year later (T2). Generalized Linear Mixed Models and partial correlations were used to analyze changes in HRQoL and associations with changes in SDS-BMI. Results: Statistically significant improvements in generic and weight-related HRQoL overall and domain scores were observed at T1and at T2 in comparison with T0, despite partial weight regain from T1 to T2. Larger weight loss at T2 was correlated with larger improvements in physical HRQoL domains. Conclusion: Children and adolescents with severe obesity experienced long-term improvements in generic and weight-related HRQoL after participating in intensive lifestyle treatment, despite partial weight regain.

Abstract Background To date, population based surveys aimed at gaining insight in health related behaviour of children have often used either child self-reports or parent proxy reports. It remains unclear however, if surveys using different sources of information from either parents or children are comparable. In addition, (over)weight status of children can lead to under- and over reporting by parents and children as a result of social desirability bias. We aimed at gaining insight in the level of agreement between parents and child reports regarding aspects of certain dietary, physical activity and sedentary behaviours, and whether there are differences in agreement between parents and child reports in healthy-weight and overweight children. Methods Weighted kappa was used to determine the level of agreement between child and parent reports on health-related behaviour in 1998 parent-child dyads. We also stratified for weight status of the children. Information on children’s health related behaviours was obtained by parental and children’s questionnaires, and children’s height and weight were measured. Associations between children’s weight status and children reporting less, reporting more and reporting the same amount of health behaviour as their parents were investigated with multinomial logistic regression analysis. Results The Cohen’s kappa coefficients ranged from almost perfect agreement for the variable means of transportation, fair for the variables breakfast consumption and frequency of outside play to slight for the variables duration of outside play, frequency and duration of TV/DVD viewing and family dinner. Overweight children were significantly more likely to report less breakfast consumption (OR = 2.6 (95% CI: 1.3 – 5.1)) and lower frequency of outside play than their parents (OR = 1.8 (95% CI: 1.1 – 2.9)). Conclusion There can be considerable disagreement between the health related behaviours of children as reported by parents or the children themselves. Based on the present study, it cannot be concluded whether parents’ or children’s reports are more accurate. For future studies, social desirability and recall bias would be best demonstrated in a validation study comparing child and parent self-reports with more objective measures of physical activity and food intake.

Abstract Background In literature, not much emphasis has been placed on methods for analyzing repeatedly measured independent variables, even less so for the use in prediction modeling specifically. However, repeated measurements could especially be interesting for the construction of prediction models. Therefore, our objective was to evaluate different methods to model a repeatedly measured independent variable and a long-term fixed outcome variable into a prediction model. Methods Six methods to handle a repeatedly measured predictor were applied to develop prediction models. Methods were evaluated with respect to the models’ predictive quality (explained variance R 2 and the area under the curve (AUC)) and their properties were discussed. The models included overweight and BMI-standard deviation score (BMI-SDS) at age 10 years as outcome and seven BMI-SDS measurements between 0 and 5.5 years as longitudinal predictor. Methods for comparison encompassed developing models including: all measurements; a single (here: the last) measurement; a mean or maximum value of all measurements; changes between subsequent measurements; conditional measurements; and growth curve parameters. Results All methods, except for using the maximum or mean, resulted in prediction models for overweight of similar predictive quality, with adjusted Nagelkerke R 2 ranging between 0.230 and 0.244 and AUC ranging between 0.799 and 0.807. Continuous BMI-SDS prediction showed similar results. Conclusions The choice of method depends on hypothesized predictor-outcome associations, available data, and requirements of the prediction model. Overall, the growth curve method seems to be the most flexible method capable of incorporating longitudinal predictor information without loss in predictive quality.

Background: Considering the large economic consequences of severe childhood obesity for the society, we aimed to conduct an economic evaluation comparing two intensive 1-year lifestyle treatments with varying inpatient periods for severely obese children and adolescents with regard to standard deviation score BMI (SDS-BMI) and quality-adjusted life years (QALYs). Methods: An economic evaluation from a societal perspective accompanying a randomized controlled trial with a 24-month follow-up. 80 participants (8-19 years) with severe obesity were included. Participants received an intensive 1-year lifestyle treatment with an inpatient period of 2 months (short-stay group) or 6 months (long-stay group). Data were collected at baseline, 6, 12 ,and 24 months and included SDS-BMI and QALYs. Results: SDS-BMI decreased in the first 6 months of treatment, stabilized in the second 6 months, and increased during the 2nd year in both groups. After 24 months, SDS-BMI was similar in both groups, but remained lower than baseline values (mean difference -0.24, 95% CI -0.42; -0.06). There was no difference in QALYs between the groups after 24 months. For SDS-BMI, the probability of the short-stay treatment being cost-effective in comparison with the long-stay treatment was 1 at a willingness-to-pay of 0 EUR/unit of effect, which slowly decreased to 0.54 for larger willingness-to-pay values. Conclusions: Based on the results of this study, the short-stay treatment is considered to be more cost-effective from the societal perspective in comparison with the long-stay treatment. Future research should provide insight in whether the short-stay treatment is cost-effective in comparison with usual care.

Introduction: To encourage healthier food/drink choices, the “Guidelines for Healthier Canteens” were developed by the Netherlands Nutrition Centre. This paper describes (1) how we developed a plan to support implementation of the “Guidelines for Healthier Canteens” in Dutch secondary schools, and (2) how we will evaluate this plan on process and effect level.Materials and Methods: The implementation plan (consisting of several tools) was developed in cooperation with stakeholders. Barriers/facilitators to implement the guidelines were identified by 14 interviews and prioritized during one expert meeting. Thereafter, these barriers were translated into implementation tools using behavioral change methods and implementation strategies. The implementation plan consists of the tools: tailored advice provided via an advisory meeting and report, based on a questionnaire about the stakeholders'/school's context and the “Canteen Scan,” an online tool to assess the product availability and accessibility; communication materials; an online community; newsletters; a factsheet with students' wishes/needs. This implementation plan will be evaluated on process and effect in a 6-month quasi-experimental controlled design with 10 intervention and 10 matched control schools. Process outcomes will be measured: (1) factors affecting implementation and (2) the quality of implementation, both collected via a questionnaire among involved stakeholders. Effect outcomes will be collected pre/post-intervention with: (1) self-reported purchase behavior among around 100 students per school; (2) the “health level” of the school canteen. Linear and linear/logistic two-level regression analyses will be performed.Discussion: The implementation tools are developed by combining a theory and practice-based approach, with input from different stakeholders. If these tools are evaluated positive, it will support schools/stakeholders to create a healthier school canteen.Trial Registration: Dutch Trial register no.: NTR5922, date of registration June 20, 2016; METC no.: 2015.331; EMGO+ project number: WC2015-008.

Abstract Background To date, many epidemiologic studies examining associations between obesity and dietary and sedentary/physical activity behaviors have focused on assessing Body Mass Index (BMI) at one point in time. Recent developments in statistical techniques make it possible to study the potential heterogeneity in the development of BMI during childhood by identifying distinct subpopulations characterized by distinct developmental trajectories. Using Latent Class Growth (Mixture) Modelling (LCGMM) techniques we aimed to identify BMI trajectories in childhood and to examine associations between these distinct trajectories and dietary, sedentary and physical activity behaviors. Methods This longitudinal study explored BMI standard deviation score (SDS) trajectories in a sample of 613 children from 4 to 12 years of age. In 2006, 2009 and 2012 information on children’s health related behaviors was obtained by parental questionnaires, and children’s height and weight were measured. Associations with behaviors were investigated with logistic regression models. Results We identified two BMI SDS trajectories; a decreasing BMI SDS trajectory (n = 416; 68 %) and an increasing BMI SDS trajectory (n = 197; 32 %). The increasing BMI SDS trajectory consisted of more participants of lower socio-economic status (SES) and of non-western ethnicity. Maternal overweight status was associated with being in the increasing BMI SDS trajectory at both baseline and follow-up six years later (2006: Odds Ratio (OR), 2.9; 95 % confidence interval (CI) 1.9 to 4.3; 2012 OR, 1.8; 95 % CI 1.2 to 2.6). The increasing BMI SDS trajectory was associated with the following behaviors; drinking sugared drinks > 3 glasses per day, participation in organized sports 2 h per day, though participation in organized sports at follow-up was the only significant result. Conclusions Our results indicate the importance of healthy lifestyle behaviors at a young age, and indicate that maternal BMI is a very important risk factor for the development of childhood overweight. Comprehension of heterogeneity in the development of BMI and associations with modifiable health related behaviors is interesting for prevention by targeting high risk behaviors in early childhood, especially in low SES children, children of non-western ethnicity and children whose mother is overweight.

Background. Integrated community-wide intervention approaches (ICIAs) are implemented to prevent childhood obesity. Programme evaluation improves these ICIAs, but professionals involved often struggle with performance. Evaluation tools have been developed to support Dutch professionals involved in ICIAs. It is unclear how useful these tools are to intended users. We therefore researched the facilitators of and barriers to ICIA programme evaluation as perceived by professionals and their experiences of the evaluation tools. Methods. Focus groups and interviews with 33 public health professionals. Data were analysed using a thematic content approach. Findings. Evaluation is hampered by insufficient time, budget, and experience with ICIAs, lack of leadership, and limited advocacy for evaluation. Epidemiologists are regarded as responsible for evaluation but feel incompetent to perform evaluation or advocate its need in a political environment. Managers did not prioritise process evaluations, involvement of stakeholders, and capacity building. The evaluation tools are perceived as valuable but too comprehensive considering limited resources. Conclusion. Evaluating ICIAs is important but most professionals are unfamiliar with it and management does not prioritise process evaluation nor incentivize professionals to evaluate. To optimise programme evaluation, more resources and coaching are required to improve professionals’ evaluation capabilities and specifically the use of evaluation.

INTRODUCTION: The global increase in childhood overweight and obesity has been ascribed partly to increases in children's screen time. Parents have a large influence on their children's screen time. Studies investigating parenting and early childhood screen time are limited. In this study, we investigated associations of parenting style and the social and physical home environment on watching TV and using computers or game consoles among 5-year-old children. METHODS: This study uses baseline data concerning 5-year-old children (n = 3067) collected for the 'Be active, eat right' study. RESULTS: Children of parents with a higher score on the parenting style dimension involvement, were more likely to spend >30 min/day on computers or game consoles. Overall, families with an authoritative or authoritarian parenting style had lower percentages of children's screen time compared to families with an indulgent or neglectful style, but no significant difference in OR was found. In families with rules about screen time, children were less likely to watch TV>2 hrs/day and more likely to spend >30 min/day on computers or game consoles. The number of TVs and computers or game consoles in the household was positively associated with screen time, and children with a TV or computer or game console in their bedroom were more likely to watch TV>2 hrs/day or spend >30 min/day on computers or game consoles. CONCLUSION: The magnitude of the association between parenting style and screen time of 5-year-olds was found to be relatively modest. The associations found between the social and physical environment and children's screen time are independent of parenting style. Interventions to reduce children's screen time might be most effective when they support parents specifically with introducing family rules related to screen time and prevent the presence of a TV or computer or game console in the child's room.

OBJECTIVE: This study reported on correlates of parental perception of their child's weight status. Associations between parental misperception (i.e., underestimation of the child's weight) and parental intention to improve their child's overweight-related health behaviors and their child meeting guidelines regarding these behaviors were also investigated. METHODS: Baseline data from the population-based 'Be active, eat right study' were used. The population for analysis consisted of 630 overweight and 153 obese five year-old children and their parents. Questionnaires were used to measure parental perception of the child's weight status, correlates of misperception (i.e., child age, child gender, child BMI, parental age, parental gender, parental country of birth, parental educational level and parental weight status), overweight-related health behaviors (i.e., child playing outside, having breakfast, drinking sweet beverages, and watching TV), and parental intention to improve these behaviors. Height and weight were measured using standardized protocols. Multivariable logistic regression analyses were performed. RESULTS: In total, 44.40% of the parents misperceived their child's weight status. Parental misperception was associated with lower child BMI, the parent being the father, a foreign parental country of birth, and a lower parental education level (p

OBJECTIVE: An overweight prevention protocol was used in the 'Be active, eat right' study; parents of overweight children (5 years) were offered healthy lifestyle counseling by youth health care professionals. Effects of the protocol on child BMI and waist circumference at age 7 years were evaluated. METHODS: A cluster RCT was conducted among nine youth health care centers in the Netherlands. Parents of overweight, not obese, children received lifestyle counseling and motivational interviewing according to the overweight prevention protocol in the intervention condition (n = 349) and usual care in the control condition (n = 288). Measurements were made of child height, weight and waist circumference at baseline and at a two-year follow-up; parents completed questionnaires regarding demographic characteristics. Linear mixed models were applied; interaction terms were explored. RESULTS: The analyzed population consisted of 38.1% boys; mean age 5.7 [sd: 0.4] years; mean BMI 18.1 [sd: 0.6], the median number of counseling sessions in the intervention condition was 2. The regression model showed no significant difference in BMI increase between the research conditions at follow-up (beta -0.16; 95% CI:-0.60 to 0.27; p = 0.463). There was a significant interaction between baseline BMI and research condition; children with a baseline BMI of 17.25 and 17.50 had a smaller increase in BMI at follow-up when allocated to the intervention condition compared to control condition (estimated adjusted mean difference -0.67 [se: 0.30] and -0.52 [se: 0.36]). CONCLUSION: Mildly overweight children (baseline BMI 17.25 and 17.50) in the intervention condition showed a significantly smaller increase in BMI at follow-up compared to the control condition; there was no overall difference between intervention and control condition. Future research may explore and evaluate improvements of the prevention protocol. TRIAL REGISTRATION: Current Controlled Trials ISRCTN04965410.

BACKGROUND: Limited studies have reported on associations between overweight, and physical and psychosocial health outcomes among younger children. This study evaluates associations between overweight, obesity and underweight in 5-year-old children, and parent-reported health outcomes at age 7 years. METHODS: Data were used from the 'Be active, eat right' study. Height and weight were measured at 5 and 7 years. Parents reported on child physical and psychosocial health outcomes (e.g. respiratory symptoms, general health, happiness, insecurity and adverse treatment). Regression models, adjusted for potential confounders, were fitted to predict health outcomes at age 7 years. RESULTS: The baseline study sample consisted of 2,372 children mean age 5.8 (SD 0.4) years; 6.2% overweight, 1.6% obese and 15.0% underweight. Based on parent-report, overweight, obese and underweight children had an odds ratio (OR) of 5.70 (95% CI: 4.10 to 7.92), 35.34 (95% CI: 19.16; 65.17) and 1.39 (95% CI: 1.05 to 1.84), respectively, for being treated adversely compared to normal weight children. Compared to children with a low stable body mass index (BMI), parents of children with a high stable BMI reported their child to have an OR of 3.87 (95% CI: 1.75 to 8.54) for visiting the general practitioner once or more, an OR of 15.94 (95% CI: 10.75 to 23.64) for being treated adversely, and an OR of 16.35 (95% CI: 11.08 to 24.36) for feeling insecure. CONCLUSION: This study shows that overweight, obesity and underweight at 5 years of age is associated with more parent-reported adverse treatment of the child. Qualitative research examining underlying mechanisms is recommended. Healthcare providers should be aware of the possible adverse effects of childhood overweight and also relative underweight, and provide parents and children with appropriate counseling.

BACKGROUND: TV time and total sedentary time have been positively related to biomarkers of cardiometabolic risk in adults. We aim to examine the association of TV time and computer time separately with cardiometabolic biomarkers in young adults. Additionally, the mediating role of waist circumference (WC) is studied. METHODS AND FINDINGS: Data of 634 Dutch young adults (18-28 years; 39% male) were used. Cardiometabolic biomarkers included indicators of overweight, blood pressure, blood levels of fasting plasma insulin, cholesterol, glucose, triglycerides and a clustered cardiometabolic risk score. Linear regression analyses were used to assess the cross-sectional association of self-reported TV and computer time with cardiometabolic biomarkers, adjusting for demographic and lifestyle factors. Mediation by WC was checked using the product-of-coefficient method. TV time was significantly associated with triglycerides (B = 0.004; CI = [0.001;0.05]) and insulin (B = 0.10; CI = [0.01;0.20]). Computer time was not significantly associated with any of the cardiometabolic biomarkers. We found no evidence for WC to mediate the association of TV time or computer time with cardiometabolic biomarkers. CONCLUSIONS: We found a significantly positive association of TV time with cardiometabolic biomarkers. In addition, we found no evidence for WC as a mediator of this association. Our findings suggest a need to distinguish between TV time and computer time within future guidelines for screen time.

BackgroundComplications of overweight amplify with age, and irreversible damage already exists in young persons. Identifying the most sensitive age interval(s) for adult overweight is relevant for primary prevention. The aim of the study was to assess the relative contribution of body mass index (BMI) changes between 0 and 18 years to adult overweight, and to identify the earliest critical growth period.Methods and findingsData from 762 subjects in the Terneuzen Birth Cohort with an average of 21 growth measurements per subject from birth until 18 years were used. The main outcome measure was the BMI standard deviation score (SDS) at young adulthood. For each subject BMI SDS was fitted by a piecewise linear model at eight different ages and correlated to adult BMI SDS. The age intervals in between are considered critical according to three criteria, tested by respectively Students' t-tests, multiple linear regression analyses and Pearson's correlation tests. In the age intervals 4 months(m) -1 year(y), 2-6 y, 6-10 y and 10-18 y the BMI SDS change differs between adults with and without overweight (PConclusions/significanceThe age interval from 2 y to 6 y is the earliest and most critical growth period for adult overweight. Therefore, primary prevention of adult overweight seems most likely to be successful if targeted at this specific age interval. By identifying those with an upwards centile crossing between 2 and 6 years, the development towards adult overweight might be reversed.

BACKGROUND: We recently reported the age interval 2-6y being the earliest and most critical for adult overweight. We now aim to determine which age intervals are predictive of cardiometabolic risk at young adulthood. METHODS AND FINDINGS: We analyzed data from 642 18-28 years olds from the Terneuzen Birth Cohort. Individual BMI SDS trajectories were fitted by a piecewise linear model. By multiple regression analyses relationships were assessed between subsequent conditional BMI SDS changes and components of the metabolic syndrome (MetS), skinfold thickness and hsCRP at young adulthood. Results were adjusted for gender and age, and other confounders. Gender was studied as an effect modifier. All BMI SDS changes throughout childhood were related to waist circumference and skinfold thickness. No other significant relationship was found before the age of 2 years, except between the BMI SDS change 0-1y and hsCRP. Fasting blood glucose was not predicted by any BMI SDS change. BMI SDS change 2-6y was strongly related to most outcome variables, especially to waist circumference (ß 0.47, SE 0.02), systolic and diastolic blood pressure (ß 0.20 SE 0.04 and ß 0.19 SE 0.03), and hsCRP (ß 0.16 SE 0.04). The BMI SDS change 10-18y was most strongly related to HDL cholesterol (ß -0.10, SE 0.03), and triglycerides (ß 0.21, SE 0.03). To a lesser degree, the BMI SDS change 6-10y was related to most outcome variables. BMI SDS changes 2-6y and 10-18y were significantly related to MetS: the OR was respectively 3.39 (95%CI 2.33-4.94) and 2.84 (95%CI 1.94-4.15). CONCLUSION: BMI SDS changes from 2y onwards were related to cardiometabolic risk at young adulthood, the age interval 2-6y being the most predictive. Monitoring and stabilizing the BMI SDS of children as young as 2-6y may not only reverse the progression towards adult overweight, but it may also safeguard cardiometabolic status.

Energy balance-related behavior on schooldays and beliefs about school-based interventions may differ between students in different educational levels, sexes, and BMI (body mass index) categories. In Zwolle (the Netherlands), 1,084 adolescents (13-15 years) at 9 secondary schools completed a questionnaire. Overweight prevalence (boys 18.1%, girls 19.3%) increased with decreasing educational level, especially in boys. Girls reported healthier behavior than boys regarding daily consumption of fruit (35% vs. 29%), vegetables (58% vs. 48%), =1 snack/candy (36% vs. 26%), =3 glasses of sugared drinks (80% vs. 73%; all p < 0.05). Unhealthier dietary behaviors were associated with lower educational level, except for eating sugary and savory snacks. Snacks and sugared drinks consumed at school were mostly brought from home (61.6% and 68.5%, respectively). Overweight students reported less frequent consumption of daily breakfast, snacks, and sugared drinks than non overweight students. Of all students, 40% spent =1 hour per day cycling to school. Lower educational level students reported less organized sports activities than higher level students, but more outside play and other activities. Overweight was associated with cycling to school (boys) and participating in organized sports (girls). More girls than boys were interested in lessons about healthy nutrition (44.4% vs. 31.7%). To stimulate physical activity, boys suggested more physical education classes (63%), girls advised more variation (47%) and choice (43%). A healthy school canteen (57%) and offering free fruit (67%) were suggested as promising interventions to stimulate healthy behavior. Educational and environmental interventions to tackle unhealthy dietary and physical activity behavior should be developed in collaboration with parents and tailored to educational level and gender.

Objective: Investigate the cross-sectional association between the psychosocial status of mothers and fathers and the BMI z-scores of their 10 to 12-year-old children. Explore whether this association is mediated by children's diet, physical activity, screen time and sleep. Analyze the moderating effect of the educational levels of both the mother and father on the association. Design: In a cross-sectional study design, children's height and weight were measured following a standardized protocol. Parents completed the validated Depression Anxiety and Stress questionnaire, while diet quality, sports participation, time spent in bed and screen time were assessed through child-report using previously validated questions. Participants: The data for this study were obtained from the Amsterdam Born Children and their Development study, involving children aged 10 to 12 years and both of their parents (N = 1315). Results: The majority, 80%, of the parents were highly educated and born in the Netherlands, and 68% of the children had a healthy BMI. Maternal or paternal psychosocial status was not significantly associated with children's BMI z-score (maternal β -0.0037; 95% CI: -0.008 to 0.0007, paternal β 0.0028; 95% CI: -0.007 to 0.002). Screen time mediated the association between paternal psychosocial status and children's BMI z-score (β = 0.010, 95% CI: 0.002; 0.020). Children's diet, physical activity, and sleep did not mediate the association between paternal psychosocial status and children's BMI z-score. Parental educational level was not a moderator. Conclusions: This research is unique in including four energy balance behaviors and including both mothers and fathers' psychosocial status. Children withfathers experiencing poorer psychosocial status engaged in more screen time which partly explained their higher BMI z-score. [ABSTRACT FROM AUTHOR]