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Purpose Previous studies showed that patients with lower weight loss after bariatric surgery could be identified based on early postoperative weight loss. However, these studies had only 12–36-month follow-up. This study aimed to explore whether patients in the lowest weight loss quartile at 3 months had lower weight loss trajectories up to 5 years after Roux-en-Y gastric bypass (RYGB), banded Roux-en-Y gastric bypass (BRYGB), and sleeve gastrectomy (SG) surgery. Methods Weight was assessed preoperatively, and 3, 6, 9, 12, 24, 36, 48, and 60 months postoperatively. Patients were grouped into four categories based on quartiles of percentage total weight loss (%TWL) at 3-month follow-up. Results were compared between the lowest %TWL quartile group and other quartile groups. Results Patients underwent either RYGB (n=13,106; 72%), SG (n=3585; 20%), or BRYGB (n=1391, 8%) surgery. Weight loss trajectories of patients in the lowest %TWL quartile group remained lower than that of other quartile groups throughout a 5-year follow-up, for all three types of surgery. Patients in the lowest %TWL quartile group had higher age at surgery, higher baseline BMI, and were more likely to be male (in the SG group), and to suffer from diabetes, hypertension, dyslipidemia, and osteoarthritis. Conclusion This study showed a positive association between weight loss at 3 and 12 to 60 months after bariatric surgery. Weight loss at 3 months after surgery could be used to identify patients whose anticipated weight loss trajectories are below average, to potentially improve their outcomes through early behavioral or medical interventions. Graphical Abstract

Objective: Behaviour change maintenance seems to be difficult for many people. To prevent people from relapsing, insight into determinants of relapse is needed. We synthesized the evidence on predictors of lapse and relapse in physical activity and dietary behaviour change. Design: Prospective studies in adults aged ≥18 years were identified from systematic searches in PsycINFO, PubMed and Cinahl. Methodological quality was analysed, and data were synthesized narratively. Main outcome measures: Lapse and relapse in physical activity and dietary behaviour. Results: 37 articles were included. For several predictors, evidence for an association was found, with self-efficacy as the only consistent predictor across the different outcomes, predicting both lapse and relapse in physical activity, and relapse in dietary behaviour. For most other variables, evidence for prospective relationships with lapse and relapse was insufficient. Conclusion: Most predictors on lapse and relapse were not examined frequently enough to draw conclusions from; many predictors were studied only once or had inconclusive evidence. To be able to provide more substantiated conclusions, more high-quality research is needed. Practitioners and intervention programs could focus on sustainability of behaviour change, by targeting the outcome of interest and its relevant predictors by using behaviour change techniques that have proven effective.

Background: Preventing people from relapsing into unhealthy habits requires insight into predictors of relapse in weight loss maintenance behaviors. We aimed to explore predictors of relapse in physical activity and dietary behavior from the perspectives of health practitioners and persons who regained weight, and identify new predictors of relapse beyond existing knowledge. Methods: We used concept mapping to collect data, by organizing eight concept mapping sessions among health practitioners (N=39, five groups) and persons who regained weight (N=21, three groups). At the start of each session, we collected participants’ ideas on potential predictors. Subsequently, participants individually sorted these ideas by relatedness and rated them on importance. We created concept maps using principal component analysis and cluster analysis. Results: 43 predictors were identified, of which the majority belonged to the individual domain rather than the environmental domain. Although the majority of predictors were mentioned by both stakeholder groups, both groups had different opinions regarding their importance. Also, some predictors were mentioned by only one of the two stakeholder groups. Practitioners indicated change in daily structure, stress, maladaptive coping skills, habitual behavior, and lack of self-efficacy regarding weight loss maintenance as most important recurrent (mentioned in all groups) predictors. Persons who regained weight indicated lifestyle imbalance or experiencing a life event, lack of perseverance, negative emotional state, abstinence violation effect, decrease in motivation and indulgence as most important recurrent predictors. Conclusions: For several predictors associations with relapse were shown in prior research; additionally, some new predictors were identified that have not been directly associated with relapse in weight loss maintenance behaviors. Our finding that both groups differed in opinion regarding the importance of predictors or identified different predictors, may provide an opportunity to enhance lifestyle coaching by creating more awareness of these possible discrepancies and including both points of view during coaching.

Background When losing weight, most individuals find it difficult to maintain a healthy diet. Social environmental conditions are of pivotal importance in determining dietary behavior. To prevent individuals from lapsing, insight in social environmental predictors of lapse in dietary behavior is needed. Purpose Identify social environmental predictors of lapse in dietary behavior, using ecological momentary assessment (EMA) amongst Dutch adults trying to lose weight. Methods Adults (N = 81) participated in two 7-day EMA weeks. Six times a day semi-random prompts were sent. At each prompt, participants indicated whether a lapse had occurred and responded to questions assessing social support, descriptive norm, injunctive norm, social pressure, presence of others, and current location. Generalized estimating equations were used to examine associations with lapse. Results Injunctive norm (OR = 1.07, 95% CI = 1.03-1.11), descriptive norm (OR = 1.04, 95% CI = 1.02-1.07), and social pressure (OR = 1.09, 95% CI = 1.05-1.14), all toward diverting from diet plans, predicted lapses. Social support toward sticking to diet plans and presence of others did not predict lapses. When controlling for a prior lapse, all other associations became nonsignificant. Lapses occurred most often at home and gradually occurred more often during the day. Conclusions Traditional public health perspectives have mainly focused on individual choice and responsibility for overweight related unhealthy lifestyles. This study shows that there may be opportunities to enhance intervention programs by also focusing on social norms and social pressure. The involvement of partners or housemates may create more awareness of the impact of (unintentional) social pressure on risk of lapsing, and reduce the level of exerted social pressure.Lay Summary When losing weight, most individuals find it difficult to maintain a healthy diet. As social environmental conditions are of pivotal importance in determining dietary behavior, insight in social environmental predictors of lapse in dietary behavior is needed to prevent individuals from lapsing. Therefore, this study identified social environmental predictors of lapse in dietary behavior, using ecological momentary assessment (EMA) amongst Dutch adults trying to lose weight. A total of 81 participants took part in two 7-day EMA weeks, in which six times a day semi-random prompts were sent. At each prompt, participants indicated whether a lapse had occurred and responded to questions assessing social support, descriptive norm, injunctive norm, social pressure, presence of others, and current location. The results show that injunctive norm, descriptive norm, and social pressure, all toward diverting from diet plans, predicted dietary lapses. Social support toward sticking to diet plans and presence of others did not predict dietary lapses. Additionally, lapses occurred most often at home and gradually occurred more often during the day. This study shows that there may be opportunities to enhance intervention programs by also focusing on social norms and social pressure.

Insufficient sleep duration among adolescents is a widespread public health problem. Gaining better insight into social-cognitive determinants associated with adolescent sleep duration is necessary for developing effective preventive interventions to support healthy sleep. This study aimed to explore whether social-cognitive determinants regarding sufficient sleep duration were associated with sleep duration, and if these associations were mediated by collective sleep hygiene practices. Furthermore, we examined these associations for social-cognitive determinants related to not using media before bedtime and doing relaxing activities and considered whether these associations were mediated by specific sleep hygiene practices. Data were collected amongst second- and third-grade adolescents from 10 Dutch high schools. A total of 878 adolescents (mean [SD] age 13.3 [0.71] years) completed data on sleep duration, social-cognitive determinants of the Theory of Planned Behaviour (i.e., attitude, subjective norms from parents, subjective norms from peers, perceived behavioural control, intention), and sleep hygiene practices. Single- and multivariable path models were constructed and mediation by sleep hygiene practices was analysed by Monte Carlo simulation. All social-cognitive determinants except for subjective norms from peers were associated with longer sleep duration (p < 0.01). Sleep hygiene practices mediated all associations between social-cognitive determinants and sleep duration (mediation ranging from 16% to 72%). Although some of the significant associations and mediation disappeared in the multivariable model, behavioural arousal was the strongest mediator, but collective sleep hygiene practices and cognitive/emotional arousal also explained parts of the associations. The findings indicate that social-cognitive factors should not be overlooked when targeting adolescent sleep duration.

BACKGROUND: Little research has taken individual variability in weight loss into account. Furthermore, physical activity (PA) and eating style (ES) have been linked only sporadically to weight loss longitudinally.OBJECTIVES: Identify and describe latent classes of weight loss, change of PA, and change of ES up to 5 years after surgery and investigate whether these trajectories are interrelated.SETTING: Multicenter outpatient clinic.METHODS: This is a retrospective study of data collected during standard treatment before and up to 5 years after surgery. Latent class growth analysis was used to identify trajectories of weight loss (percent total weight loss), PA (Baecke questionnaire), and ES (Dutch Eating Behavior Questionnaire).RESULTS: A total of 2785 patients were included. Follow-up rate was 84% at 1 year and 34% at 5 years. Analyses revealed 5 weight loss trajectories. Most patients followed an average, fairly stable weight loss trajectory (48%) or an above-average partial-regain trajectory (36%). Other patients followed a low-responder trajectory (9%), a rapid weight loss and weight regain trajectory (6%), or a continued weight loss trajectory (2%). Patients in the most favorable weight loss trajectory were more likely to also follow the most favorable ES trajectories. Patients following the most unfavorable weight loss trajectory were never also in the PA trajectory with an initial great increase in PA.CONCLUSION: This study distinguishes demographic and behavioral factors that may influence long-term weight loss trajectories after bariatric surgery. Trajectories varied mainly in magnitude and less in the pattern of weight loss over time, suggesting that very deviant patterns are rare.

Objective: To provide insight into the motivational working mechanisms (i.e. mediators) of an effective physical activity (PA) intervention for adults aged over fifty. Design: The mediation model (N = 822) was investigated in an RCT for the total intervention population, participants who were not norm-active at baseline (targeting PA initiation) and norm-active participants (targeting PA maintenance) separately. Main Outcome Measures: Potential mediators (attitude, self-efficacy, intention, action planning and coping planning) of the effect on PA (6-months) were assessed at baseline, 3 and/or 6 months. Results: The intervention resulted in a decrease in intention (B= −.209; p=.017), and an increase in action planning (B=.214; p=.018) and PA (B=.220; p=.002). Intention and action planning did not mediate the effect on PA. Self-efficacy, although not significantly influenced by the intervention, was found to be the only motivational variable that predicted change in PA (B=.164; p=.007). These results were confirmed among participants initiating PA. Among norm-active participants no significant intervention effects were identified. Conclusion: The motivational factors cannot explain the intervention effect on PA. Most likely, the effect can be explained by an interaction between the motivational factors together. Differences between participants initiating versus maintaining PA, highlight the importance of performing mediation analyses per subgroup.

To use computed tomography (CT) to assess the validity and reliability of the posterior landmarks, spinous processes (SP), transverse processes (TP), and centre of lamina (COL), as compared to the Cobb angle to assess the curve severity and progression of adolescent idiopathic scoliosis (AIS).A consecutive series of CT examinations of severe AIS patients were included retrospectively. SP, TP, and COL angles were measured for all curves and compared to the Cobb angle.One hundred and five patients were included. The mean Cobb versus SP, TP, and COL angles were, 54° versus 37°, 49°, and 51° in the thoracic curves and 34° versus 26°, 31°, and 34° in the (thoraco)lumbar curves. Intraclass correlation coefficient values for intra-rater measurements of the SP, TP, and COL angles were 0.93, 0.97, and 0.95 and 0.70, 0.90, and 0.88 for inter-rater measurements. The correlations between the Cobb angle and SP, TP, and COL angles in thoracic and (thoraco)lumbar curves were 0.79 and 0.66, 0.87 and 0.84, and 0.80 and 0.70.The posterior spinal landmarks can be used for assessment of scoliosis severity in AIS; however, they show a systematic underestimation, but a strong correlation with the coronal Cobb angle. TP and COL angles had the highest validity.

The aim of the present study was to explore potential factors of inadequate sleep health (i.e. sleep duration, quality, and timing) of school-aged children. Data were collected among 382 primary school children (aged 4-13 years) and their parents. Personal characteristics (i.e. age, sex), individual lifestyle behaviours (i.e. screen use, sleep hygiene behaviour), social and community factors (i.e. parental sleep-related practices, parental barriers, perceived ethnicity), and living conditions (i.e. parental educational level, sleep environment) were assessed with a parental questionnaire. Sleep duration, quality, and timing were assessed with a sleep diary. Associations were analysed using linear mixed models and logistic regression analyses. In total, 332 children, with a mean (range) age of 7.5 (4-13) years, were included in the analyses. The mean sleep duration was 632 min/night, the mean sleep quality score was 40, on a scale from 10 to 50, and 25% had a bedtime that varied >40 min between weekdays. Factors negatively associated with children's sleep health included older age, perceived non-Dutch cultural background, lower parental pre-sleep emotional support, the parental barrier to get their child to bed on time when siblings have a later bedtime, high parental educational level, sleeping in a darkened bedroom, and being brought to bed after falling asleep. On average, children in the present study had adequate sleep health. The factors found to be associated with children's sleep health are useful for future healthy sleep research and intervention development.

Background Nicotine dependence during adolescence increases the risk of continuing smoking into adulthood. The magnitude of nicotine dependence among adolescents in the European Union (EU) has not been established. We aimed to estimate the number of nicotine dependent 15-year-old adolescents in the EU, and identify high-risk groups. Methods The number of nicotine dependent 15-year-olds in the EU was derived combining: (i) total number of 15-year-olds in the EU (2013 Eurostat), (ii) smoking prevalence among 15-year-olds (2013/2014 HBSC survey) and (iii) proportion of nicotine dependent 15-year-olds in six EU countries (2013 SILNE survey). Logistic regression analyses identified high-risk groups in the SILNE dataset. Results We estimated 172 636 15-year-olds were moderately to highly nicotine dependent (3.2% of all 15 years old; 35.3% of daily smokers). In the total population, risk of nicotine dependence was higher in males, adolescents with poor academic achievement, and those with smoking parents or friends. Among daily smokers, only lower academic achievement and younger age of smoking onset were associated with nicotine dependence. Conclusion According to our conservative estimates, more than 172 000 15-year-old EU adolescents were nicotine dependent in 2013. Prevention of smoking initiation, especially among adolescents with poor academic performance, is necessary to prevent a similar number of adolescents getting addicted to nicotine each consecutive year.

Objectives To measure the length, width and area of the urogenital hiatus (UH), and the length and mean echogenicity (MEP) of the puborectalis muscle (PRM), automatically and observer‐independently, in the plane of minimal hiatal dimensions on transperineal ultrasound (TPUS) images, by automatic segmentation of the UH and the PRM using deep learning. Methods In 1318 three‐ and four‐dimensional (3D/4D) TPUS volume datasets from 253 nulliparae at 12 and 36 weeks' gestation, two‐dimensional (2D) images in the plane of minimal hiatal dimensions with the PRM at rest, on maximum contraction and on maximum Valsalva maneuver, were obtained manually and the UH and PRM were segmented manually. In total, 713 of the images were used to train a convolutional neural network (CNN) to segment automatically the UH and PRM in the plane of minimal hiatal dimensions. In the remainder of the dataset (test set 1 (TS1); 601 images, four having been excluded), the performance of the CNN was evaluated by comparing automatic and manual segmentations. The performance of the CNN was also tested on 117 images from an independent dataset (test set 2 (TS2); two images having been excluded) from 40 nulliparae at 12 weeks' gestation, which were acquired and segmented manually by a different observer. The success of automatic segmentation was assessed visually. Based on the CNN segmentations, the following clinically relevant parameters were measured: the length, width and area of the UH, the length of the PRM and MEP. The overlap (Dice similarity index (DSI)) and surface distance (mean absolute distance (MAD) and Hausdorff distance (HDD)) between manual and CNN segmentations were measured to investigate their similarity. For the measured clinically relevant parameters, the intraclass correlation coefficients (ICCs) between manual and CNN results were determined. Results Fully automatic CNN segmentation was successful in 99.0% and 93.2% of images in TS1 and TS2, respectively. DSI, MAD and HDD showed good overlap and distance between manual and CNN segmentations in both test sets. This was reflected in the respective ICC values in TS1 and TS2 for the length (0.96 and 0.95), width (0.77 and 0.87) and area (0.96 and 0.91) of the UH, the length of the PRM (0.87 and 0.73) and MEP (0.95 and 0.97), which showed good to very good agreement. Conclusion Deep learning can be used to segment automatically and reliably the PRM and UH on 2D ultrasound images of the nulliparous pelvic floor in the plane of minimal hiatal dimensions. These segmentations can be used to measure reliably UH dimensions as well as PRM length and MEP. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Relative anterior spinal overgrowth (RASO) was proposed as a generalized growth disturbance and a potential initiator of adolescent idiopathic scoliosis (AIS). However, anterior lengthening was also observed in neuromuscular (NM) scoliosis, was shown to be restricted to the apical areas and to be located in the intervertebral discs, not in the bone. In this study the goal was to determine if other scoliotic curves of known origin exhibit the similar mechanism of anterior lengthening without changes in the vertebral body. Therefore CT-scans of 18 patients in whom a short segment congenital malformation had led to a long thoracic compensatory curve without bony abnormality were included. Of each vertebral body and intervertebral disc in the compensatory curve, the anterior and posterior length was measured on CT-scans in the exact mid-sagittal plane, corrected for deformity in all three planes. The total AP% of the compensatory curve in congenital scoliosis showed a lordosis (+1.8%) that differed from the kyphosis in non-scoliotic controls (-3.0%; p0.001), and was comparable to AIS (+1.2%) and NM scoliosis (+0.5%). This anterior lengthening was not located in the bone; the vertebral body AP% showed a kyphosis (-3.2%), similar to non-scoliotic controls (-3.4%), as well as AIS (-2.5%) and NM scoliosis (-4.5%; p=1.000). However, the disc AP% showed a lordosis (+24.3%), which sharply contrasts to the kyphotic discs of controls (-1.5%; p0.001), but was similar to AIS (+17.5%) and NM scoliosis (+20.5%). The results demonstrate that anterior lengthening is part of the three-dimensional deformity in different types of scoliosis and is exclusively located in the intervertebral discs. The bony vertebral bodies maintain their kyphotic shape, which indicates that there is no active bony overgrowth. Anterior lengthening appears to be a passive result of any scoliotic deformity, rather than being related to the specific cause of AIS.

Relative anterior spinal overgrowth (RASO) was proposed as a generalized growth disturbance and a potential initiator of adolescent idiopathic scoliosis (AIS). However, anterior lengthening was also observed in neuromuscular (NM) scoliosis, was shown to be restricted to the apical areas and to be located in the intervertebral discs, not in the bone. In this study the goal was to determine if other scoliotic curves of known origin exhibit the similar mechanism of anterior lengthening without changes in the vertebral body. Therefore CT-scans of 18 patients in whom a short segment congenital malformation had led to a long thoracic compensatory curve without bony abnormality were included. Of each vertebral body and intervertebral disc in the compensatory curve, the anterior and posterior length was measured on CT-scans in the exact mid-sagittal plane, corrected for deformity in all three planes. The total AP% of the compensatory curve in congenital scoliosis showed a lordosis (+1.8%) that differed from the kyphosis in non-scoliotic controls (-3.0%; p

Background Healthy sleep duration is essential to health and well-being in childhood and later life. Unfortunately, recent evidence shows a decline in sleep duration among children. Although effective interventions promoting healthy sleep duration require insight into its predictors, data on these factors are scarce. This study therefore investigated (i) which individual (lifestyle), social and cultural factors, and living conditions and (ii) which changes in these factors might be associated with the changes in sleep duration of Dutch primary schoolchildren observed over time. Method Data from the ChecKid study was used, a dynamic cohort study among 4–13-year-old children living in the city of Zwolle, the Netherlands. Associations between changes in sleep duration and individual (lifestyle) factors (i.e., age, sex, physical activity behavior, sugar-sweetened beverage consumption, screen behavior), social and cultural factors (i.e., parental rules, ethnicity), and living conditions (i.e., parental education, presence of screens in the bedroom, household size) were analyzed using multivariable linear regression. Results A total of 1180 children participated, aged 6.6 ± 1.4 years in 2009. Mean sleep duration decreased from 11.4 ± 0.5 h/night in 2009 to 11.0 ± 0.5 h/night in 2012. Older children, boys, children who used screens after dinner, children with greater computer/game console use, and children whose parents had low levels of education had a greater decrease in sleep duration. Conclusions This article reports on one of the first large, longitudinal cohort studies on predictors of child sleep duration. The results of the study can inform future interventions aimed at promoting healthy sleep in primary schoolchildren.

An increasing number of children experience inadequate sleep, which negatively effects their health. To promote healthy sleep among children, it is essential to understand the underlying determinants. This online concept mapping study therefore explores potential determinants of children&rsquo, s inadequate sleep as perceived by professionals with expertise in the sleep health of children aged 4&ndash, 12 years. Participants (n = 27) were divided in three groups: (1) doctors (n = 9), (2) nurses (n = 11), (3) sleep experts (n = 7). Participants generated potential determinants (i.e., ideas) of children&rsquo, s inadequate sleep. Subsequently, they sorted all ideas by relatedness and rated their importance. These data were analysed using multidimensional scaling and hierarchical cluster analysis. The results of all three groups were combined and validated by an additional group of professionals (n = 16). A large variety of perceived determinants were identified. The most important determinants perceived by all groups belonged to the categories psychosocial determinants (i.e., worrying, a change in daily life), daytime and evening activities (i.e., screen use before bedtime, stimulating game play before bedtime, inadequate amount of daytime physical activity), and pedagogical determinants (i.e., inconsistent sleep schedule, lack of a bedtime routine). These perspectives are valuable for future longitudinal studies on the determinants of children&rsquo, s sleep and the development of future healthy sleep interventions.

Background Sugar-Sweetened Beverages (SSBs) taxes have been implemented in several countries, however, little is known on how an SSBs tax may impact on low and high socioeconomic groups differently. Therefore, the aim of this study was to gain insight into the perceptions of different stakeholder groups in the Netherlands on (1) the contribution of an SSBs tax to socioeconomic inequalities in diet and health and (2) the mechanisms via which an SSBs tax may influence these inequalities. Methods Semi-structured interviews were held in the Netherlands in March-May 2019 with 27 participants from the following stakeholder groups: health and consumer organisations, health professional associations, advisory bodies, scientists, trade organisations, policy makers, and politicians. Interview transcripts were analysed following a thematic content approach. Results Participants from all stakeholder groups indicated that an SSBs tax would have a larger impact on the budget and SSB consumption of lower socioeconomic groups. With that, an SSBs tax could have larger health benefits among lower socioeconomic groups as a result of cutting down on SSBs. A few participants - from science and a health professional association - discussed possible unwanted effects of an SSBs tax (e.g. lower socioeconomic groups may compensate their lower SSB consumption with other unhealthy behaviour). Some participants emphasised that an SSB tax should only be introduced when accompanied by other measures (e.g. educational efforts, offering healthy alternatives). Conclusions Our results imply that most stakeholders agree that an SSBs tax could contribute to a reduction of socioeconomic inequalities in diet and health. However, in order to be effective and to prevent that an SSBs tax leads to a widening of inequalities, it is important to carefully monitor behavioural changes of socioeconomic groups in response to an SSBs tax, and to implement an SSBs tax as part of a comprehensive policy approach. Key messages An SSBs tax could contribute to a reduction of socioeconomic inequalities in health, according to Dutch stakeholders. It is important to carefully monitor behavioural changes of socioeconomic groups in response to an SSBs tax, and to implement an SSBs tax as part of a comprehensive policy approach.

Background Public acceptability of a sugar-sweetened beverages (SSBs) tax is important for governments in the decision-making process. Therefore, the aim of the present study was to investigate the level of public acceptability of an SSBs tax and its associated factors. Methods Dutch adults representative of the Dutch population for age, sex, educational level and location (n = 500) completed an online self-administered questionnaire. The acceptability of an SSBs tax was measured on a 7-point Likert scale. Associations between acceptability and sociodemographic factors, body mass index, SSB consumption, and beliefs about effectiveness (9 items, e.g. 'An SSBs tax would reduce people's SSB consumption'), appropriateness (7 items), socioeconomic and economic benefit (5 items), implementation (1 item) and trust (3 items) were assessed using multivariable linear regression analyses. Results Of the participants, 40% supported and 43% opposed an SSBs tax in general. Moreover, 42% supported (43% opposed) an SSBs tax as a strategy to reduce overweight and 55% supported (32% opposed) an SSBs tax if revenue is used for health initiatives. Participants with a low educational level (B=-0.82;95%CI = [-1.31,-0.32]), overweight (B=-0.49;95%CI = [-0.89,-0.09]), moderate or high SSB consumption (B=-0.86;95%CI = [-1.30,-0.43] and B=-1.01;95%CI = [-1.47,-0.56], respectively) and households with adolescents (B=-0.57;95%CI = [-1.09,-0.05]) reported lower acceptability of an SSBs tax than their counterparts. Beliefs about effectiveness, appropriateness, socioeconomic and economic benefit, implementation and trust were associated with acceptability (P Conclusions Public acceptability of an SSBs tax tends to be higher if revenue is used for health initiatives. Sociodemographic factors, body mass index, SSB consumption and several beliefs about effectiveness, appropriateness, socioeconomic and economic benefit, implementation and trust are associated with acceptability. Key messages It should be considered to include a recommendation to use revenue for health initiatives in global guidelines for SSBs taxes. Targeting population subgroups with low levels of support might be an effective strategy for communication campaigns.

Background To prevent people from relapsing into unhealthy habits, insight into predictors of relapse in physical activity and dietary behavior is needed. Therefore, we aimed to explore predictors of relapse in physical activity and dietary behavior from the perspectives of health practitioners and the key population (i.e. adults who recently lost weight and experienced relapse). Methods We used concept mapping to collect data among five groups of health practitioners (N = 39) and three key population groups (N = 21). First participants’ ideas on potential predictors were collected. Subsequently, these ideas were individually sorted by relatedness and rated on importance. Concept maps were created for each group using principal component analysis and cluster analysis. Results In total 43 predictors were identified, of which the majority belonged to the individual domain compared to the environmental domain. Although the majority of perceived predictors were mentioned by both stakeholder groups, both groups had different opinions regarding the importance of predictors. Also, few predictors were mentioned by all practitioner groups, but not by the key population, and vice versa. Practitioners indicated change in daily structure, stress, lack of effective coping skills, habitual behavior, and lack of self-efficacy regarding losing weight as most important recurrent (i.e. mentioned in all practitioner groups) predictors. The key population indicated lifestyle imbalance or experiencing a life event, lack of perseverance, negative emotional state, abstinence violation effect, decrease in motivation and indulgence as most important recurrent predictors. Conclusions Both stakeholder groups predominantly rated individual factors as most important perceived predictors of relapse. The finding that both groups differed in opinion regarding importance of predictors or identified different predictors, may provide an opportunity to enhance lifestyle coaching by ensuring it is patient-centered and tailored.

Purpose: Sleeve gastrectomy (SG) is the most popular type of bariatric surgery. It has often been compared to Roux-en-Y gastric bypass (RYGB) in terms of clinical outcomes. However, health-related quality of life (HRQoL) has been sparsely studied after SG. The goal was to study HRQoL after SG using a generic (RAND-36) and an obesity-specific (impact of weight on quality of life-lite, IWQOL-lite) questionnaire and to compare the results with RYGB. Methods: HRQoL and weight were measured before and 9, 15, and 24 months after surgery. RAND-36 physical health summary (PHS) and mental health summary (MHS), and IWQOL-lite total score were calculated. A mixed model analysis was conducted to study the change in HRQoL and compare SG with RYGB. Results: A total of 219 patients (8.7%) underwent a SG and 2309 patients (91.3%) a RYGB. PHS, MHS, and IWQOL-lite significantly improved after SG when comparing baseline to all follow-up moments (p < 0.001 in all). There were no significant differences when comparing SG with RYGB: change in PHS (β − 0.10, 95% CI − 1.24 to 1.04, p = 0.861), MHS (β − 0.51, 95% CI − 1.56 to 0.52, p = 0.330), and IWQOL-lite (β 0.310, 95% CI − 0.85 to 1.47, p = 0.601). Conclusion: HRQoL significantly improved after SG. In the included populations, weight loss was comparable and the extent to which HRQoL improved did not differ between SG and RYGB, when measured with the RAND-36 or IWQOL-lite. This might be partly caused by the fact that these questionnaires do not assess specific bariatric HRQoL and/or complaints.

ObjectiveThe present study aimed to explore the mediating role of family-related determinants on the effects of the ToyBox-intervention on pre-school children’s consumption of healthy and unhealthy snacks.DesignThe ToyBox-intervention was a kindergarten-based, family-involved intervention with a cluster-randomized design, aiming to promote healthy lifestyle behaviours to prevent obesity at pre-school age.SettingKindergartens (n 309) in six European countries.SubjectsA total of 6290 pre-schoolers and their families participated in the ToyBox-intervention in 2012–2013 and data from 5212 pre-schoolers/families were included in the current analyses.ResultsEven though the total effect of the ToyBox-intervention on healthy and unhealthy snacking was not significant, the ToyBox-intervention significantly improved parental rule setting on children’s unhealthy snack consumption (i.e. restriction of snacking while watching television and permission only at certain occasions) and parental consumption of unhealthy snacks, while it increased parental knowledge on snacking recommendations. Regarding healthy snacking, the ToyBox-intervention improved children’s attitude towards fruit and vegetables (F&V). All previously mentioned family-related determinants mediated the intervention effects on pre-schoolers’ consumption of healthy and unhealthy snacks. Almost all family-related determinants examined in the study were independently associated with pre-schoolers’ consumption of healthy and unhealthy snacks.ConclusionsThe intervention was effective in improving relevant family-related determinants. Interventions aiming to promote F&V consumption and limit the consumption of unhealthy snacks in pre-schoolers should target on these mediators, but also identify new family-, school- or peer-related determinants, to enhance their effectiveness.

Introduction The prevalence and clinical significance of weight regain after bariatric surgery remains largely unclear due to the lack of a standardized definition of significant weight regain. The development of a clinically relevant definition of weight regain requires a better understanding of its clinical significance. Objectives To assess rates of weight regain 5 years after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), applying six definitions and investigating their association with clinical outcomes. Methods Patients were followed up until 5 years after surgery and weight regain was calculated. Regression techniques were used to assess the association of weight regain with health-related quality of life (HRQoL) and the presence of comorbidities. Results A total of 868 patients participated in the study, with a mean age of 46.6 (± 10.4) years, of which 79% were female. The average preoperative BMI was 44.8 (± 5.9) kg/m2 and the total maximum weight loss was 32% (± 8%). Eighty-seven percent experienced any regain. Significant weight regain rates ranged from 16 to 37% depending on the definition. Three weight regain definitions were associated with deterioration in physical HRQoL (p Conclusion These results indicate that identifying one single categorical definition of clinically significant weight regain is difficult. Additional research into the clinical significance of weight regain is needed to inform the development of a standardized definition that includes all dimensions of surgery success: weight, HRQoL, and comorbidity remission.

Aim Weight loss success is highly variable among individuals. Cluster analysis contributes to future intervention development by recognising this individual variability and identifying different weight loss patterns. Identifying determinants that differentiate between these patterns would explain the source of variability. Thus, we aimed to identify weight loss patterns and their determinants in adults with overweight and obesity. Methods The present study is a secondary analysis of data from the PortionControl@HOME study. The weight of 175 adults was measured at 0, 3 and 12 months and potential determinants were self-reported using validated questionnaires at 0 and 3 months. Weight loss patterns were identified based on percent weight change during Phase 1 (0-3 months) and Phase 2 (3-12 months) using cluster analysis. Determinants were assessed using multinomial logistic regression. Results We identified three weight loss patterns: (i) low success, demonstrating low weight loss achievement, (ii) moderate success, demonstrating successful weight loss in Phase 1 followed by partial regain in Phase 2 and (iii) high success, demonstrating weight loss in Phase 1 followed by continued weight loss in Phase 2. Compared to the moderate success pattern, the low success pattern was negatively associated with power of food at baseline (i.e. the appetitive drive to consume highly palatable food) (odds ratio, OR = 0.42, 95% CI = 0.21-0.86) and change in portion control behaviour (i.e. the use of behavioural strategies to control the amount of food consumed) (OR = 0.28, 95% CI = 0.10-0.78). Conclusions Three weight loss patterns were identified in adults with overweight and obesity. Adults with greater power of food and increased portion control behaviour were less likely to exhibit an unsuccessful weight loss pattern.

Background Discerning the determinants of weight loss maintenance is important in the planning of future interventions and policies regarding overweight and obesity. We have therefore systematically synthesized recent literature on determinants of weight loss maintenance for individuals with overweight and obesity. Methods With the use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, prospective studies were identified from searches in PubMed and PsycINFO from 2006 to 2016. We included articles investigating adults with overweight and obesity undergoing weight loss without surgery or medication. Included articles were scored on their methodological quality, and a best-evidence synthesis was applied to summarize the results. Results Our search resulted in 8,222 articles of which 67 articles were selected. In total, 124 determinants were identified of which 5 were demographic, 59 were behavioural, 51 were psychological/cognitive and 9 were social and physical environmental determinants. We found consistent evidence that demographic determinants were not predictive of weight loss maintenance. Behavioural and cognitive determinants that promote a reduction in energy intake, an increase in energy expenditure and monitoring of this balance are predictive determinants. Conclusion This review identifies key determinants in weight loss maintenance. However, more research regarding cognitive and environmental determinants of weight loss maintenance is needed to advance our knowledge on determinants of weight loss maintenance.

Objectives The introduction of three‐dimensional (3D) analysis of the puborectalis muscle (PRM) for diagnostic purposes into daily practice is hindered by the need for appropriate training of observers. Automatic segmentation of the PRM on 3D transperineal ultrasound may aid its integration into clinical practice. The aims of this study were to present and assess a protocol for manual 3D segmentation of the PRM on 3D transperineal ultrasound, and to use this for training of automatic 3D segmentation method of the PRM. Methods The data used in this study were derived from 3D transperineal ultrasound sequences of the pelvic floor acquired at 12 weeks' gestation from nulliparous women with a singleton pregnancy. A manual 3D segmentation protocol was developed for the PRM based on a validated two‐dimensional segmentation protocol. For automatic segmentation, active appearance models of the PRM were developed, trained using manual segmentation data from 50 women. The performances of both manual and automatic segmentation were analyzed by measuring the overlap and distance between the segmentations. Intraclass correlation coefficients (ICCs) and their 95% CIs were determined for mean echogenicity and volume of the puborectalis muscle, in order to assess inter‐ and intraobserver reliabilities of the manual method using data from 20 women, as well as to compare the manual and automatic methods. Results Interobserver reliabilities for mean echogenicity and volume were very good for manual segmentation (ICCs 0.987 and 0.910, respectively), as were intraobserver reliabilities (ICCs 0.991 and 0.877, respectively). ICCs for mean echogenicity and volume were very good and good, respectively, for the comparison of manual vs automatic segmentation (0.968 and 0.626, respectively). The overlap and distance results for manual segmentation were as expected, showing an average mismatch of only 2–3 pixels and reasonable overlap. Based on overlap and distance, five mismatches were detected for automatic segmentation, resulting in an automatic segmentation success rate of 90%. Conclusions This study presents a reliable manual segmentation protocol and automatic 3D segmentation method for the PRM, which will facilitate future investigation of the PRM, allowing for the reliable measurement of potentially clinically valuable parameters such as mean echogenicity. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology Published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To evaluate the effectiveness of guanfacine extended-release (GXR) versus placebo as adjunct therapy to usual care stimulant therapy in improving executive function in children aged 6 to 12 years diagnosed with ADHD. Method: In this single center, double-blind placebo-controlled crossover trial, subjects continued to take their psychostimulant and were randomly assigned at baseline to receive active treatment or placebo first. Efficacy measures included Behavioural Rating Inventory of Executive Function (BRIEF-P), ADHD Rating Scale IV (ADHD-RS IV), and Clinical Global Impressions of Severity of Illness (CGI-S) and Improvement (CGI-I) scales. Safety measures included adverse events and vital signs. Results: Significant benefits of GXR plus psychostimulant were observed on BRIEF-P ( p value = .0392), ADHD-RS-IV ( p < .0001), CGI-S ( p = .0007), and CGI-I ( p = .003). There were no serious adverse events and no new safety signals. Conclusion: Use of GXR as adjunctive therapy to stimulant therapy significantly improves executive function in children with ADHD.

These longitudinal studies in older adults targeted mediated relationships between habit and physical activity (PA). In The Netherlands two independent studies were conducted among 1976 (Study 1: Mage = 63.63, SD = 8.66, 30% functional limitations) and 2140 (Study 2: Mage = 62.75, SD = 8.57, 45% functional limitations) adults aged 50 years or older. Cross-lagged panel designs were applied to examine whether habit mediates the relationship between prior and later PA and whether PA simultaneously mediates the relationship between prior and later habit. Data on habit and PA were collected by means of questionnaires at baseline (t0) and at 6 (t1) and 12 (t2) months after baseline measurement. Results of structural equation modeling analyses were not unambiguous. Indications for the existence of both hypothesized mediation effects were found, but no clear, unequivocal pattern appeared. Somewhat more support was found for the PA-habit-PA path than for the habit-PA-habit path. More research is needed to draw more definitive conclusions.

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. Electronic supplementary material The online version of this article (10.1186/s12966-019-0843-0) contains supplementary material, which is available to authorized users.

Purpose: To gain more insight into the optimal strategy to achieve weight loss and weight loss maintenance in overweight and obese cancer survivors after completion of initial treatment, this systematic review aimed to provide an overview of the literature on intervention effects on weight, to describe intervention components used in effective interventions, to identify and synthesize behaviour change techniques (BCTs) and to assess the frequency with which these BCTs were used in effective interventions. Methods: Six databases were searched for original research articles describing weight changes in adult overweight cancer survivors after participation in a lifestyle intervention initiated after completion of initial treatment. Two researchers independently screened the retrieved papers and extracted BCTs using the BCT Taxonomy version 1. Results: Thirty-two papers describing 27 interventions were included. Interventions that were evaluated with a robust study design (n = 8) generally showed

Objectives Physical activity is associated with many health benefits that are important for older adults. These health benefits can only be obtained and preserved when physical activity is maintained over a long period of time. Habit formation has been proposed as a way to ensure long-term maintenance of physical activity. Intention, action planning, and physical activity are suggested to be determinants of physical activity habits. However, how they determine physical activity habits in older adults is largely unknown. This study examined whether the relationship between intention and habit is mediated by action planning and/or physical activity. Design A four-wave prospective design was used. Methods Two independent studies were conducted in 469 (Study 1; Mage = 63.07, SDage = 7.61) and 322 (Study 2; Mage = 64.31, SDage = 9.39) older adults. Study 2 was conducted with the aim of replicating findings of Study 1. In both studies the older adults completed questionnaires on intention, physical activity, and habit at baseline, action planning at three months, physical activity at six months, and habit at twelve months. Results Structural equation modeling analyses showed significant intention-physical activity-habit paths, nonsignificant intention-action planning-habit paths, and nonsignificant intention-action planning-physical activity-habit paths in both studies. Conclusions The relationship between physical activity habit and intention was mediated by physical activity. Intention was neither associated with habit via action planning as a single mediator, nor via action planning and physical activity as sequential mediators. Possible conditions under which intention-action planning-habit paths and intention-action planning-physical activity-habit paths exist are discussed.

Purpose: To assess the feasibility of deep learning-based high resolution synthetic CT generation from MRI scans of the lower arm for orthopedic applications. Methods: A conditional Generative Adversarial Network was trained to synthesize CT images from multi-echo MR images. A training set of MRI and CT scans of 9 ex vivo lower arms was acquired and the CT images were registered to the MRI images. Three-fold cross-validation was applied to generate independent results for the entire dataset. The synthetic CT images were quantitatively evaluated with the mean absolute error metric, and Dice similarity and surface to surface distance on cortical bone segmentations. Results: The mean absolute error was 63.5 HU on the overall tissue volume and 144.2 HU on the cortical bone. The mean Dice similarity of the cortical bone segmentations was 0.86. The average surface to surface distance between bone on real and synthetic CT was 0.48 mm. Qualitatively, the synthetic CT images corresponded well with the real CT scans and partially maintained high resolution structures in the trabecular bone. The bone segmentations on synthetic CT images showed some false positives on tendons, but the general shape of the bone was accurately reconstructed. Conclusions: This study demonstrates that high quality synthetic CT can be generated from MRI scans of the lower arm. The good correspondence of the bone segmentations demonstrates that synthetic CT could be competitive with real CT in applications that depend on such segmentations, such as planning of orthopedic surgery and 3D printing., Comment: This work has been accepted at the SPIE Medical Imaging 2019, Image Processing conference, paper 10949-54

We evidence the impact of small angle light scattering on Differential Mode Attenuation (DMA) in few-mode fibers. Based on this finding, we design and fabricate a weakly-coupled 6-LP-mode fiber with low DMA.

Many children do not meet the recommendations for healthy sleep, which is concerning given the potential negative effects on children&rsquo, s health. To promote healthy sleep, it is crucial to understand its determinants. This concept mapping study therefore explores perspectives of children and parents on potential determinants of children&rsquo, s inadequate sleep. The focus lies on 9&ndash, 12 year old children (n = 45), and their parents (n = 33), from low socioeconomic neighbourhoods, as these children run a higher risk of living in a sleep-disturbing environment (e.g., worries, noise). All participants generated potential reasons (i.e., ideas) for children&rsquo, s inadequate sleep. Next, participants sorted all ideas by relatedness and rated their importance. Subsequently, multidimensional scaling and hierarchical cluster analyses were performed to create clusters of ideas for children and parents separately. Children and parents both identified psychological (i.e., fear, affective state, stressful situation), social environmental (i.e., sleep schedule, family sleep habits), behavioural (i.e., screen behaviour, physical activity, diet), physical environmental (i.e., sleep environment such as temperature, noise, light), and physiological (i.e., physical well-being) determinants. These insights may be valuable for the development of future healthy sleep interventions.

To develop evidence-based healthy sleep interventions for children, this review provides insight into the behavioral determinants of sleep behavior. Hence the objective of this review is to systematically review the longitudinal evidence on determinants of children's sleep behavior. Studies were identified from searches in PubMed, PsycINFO, and Web of Science, until January 2017. Longitudinal studies investigating the association between potential determinants and sleep behavior (duration, quality and timing) in healthy children aged 4–12 years were included. The methodological quality was scored and the results were summarized using a best-evidence synthesis. We followed the PRISMA statement guidelines in order to summarize the evidence accurately and reliably. Twelve of the 45 included studies were rated as ‘high quality’. We found strong evidence for child age and moderate evidence for screen time, past sleep behavior, and a difficult temperament as determinant of sleep duration. For determinants of sleep quality, evidence was either insufficient or inconsistent. We found moderate evidence for week schedule as a determinant of sleep timing, with later bed- and wake times in weekends. More high quality studies, which are extensive, collaborative, and multidisciplinary, are needed into the determinants of all dimensions of sleep behavior.

Weight loss success is highly variable among individuals. Cluster analysis contributes to future intervention development by recognising this individual variability and identifying different weight loss patterns. Identifying determinants that differentiate between these patterns would explain the source of variability. Thus, we aimed to identify weight loss patterns and their determinants in adults with overweight and obesity.The present study is a secondary analysis of data from the PortionControl@HOME study. The weight of 175 adults was measured at 0, 3 and 12 months and potential determinants were self-reported using validated questionnaires at 0 and 3 months. Weight loss patterns were identified based on percent weight change during Phase 1 (0-3 months) and Phase 2 (3-12 months) using cluster analysis. Determinants were assessed using multinomial logistic regression.We identified three weight loss patterns: (i) low success, demonstrating low weight loss achievement, (ii) moderate success, demonstrating successful weight loss in Phase 1 followed by partial regain in Phase 2 and (iii) high success, demonstrating weight loss in Phase 1 followed by continued weight loss in Phase 2. Compared to the moderate success pattern, the low success pattern was negatively associated with power of food at baseline (i.e. the appetitive drive to consume highly palatable food) (odds ratio, OR = 0.42, 95% CI = 0.21-0.86) and change in portion control behaviour (i.e. the use of behavioural strategies to control the amount of food consumed) (OR = 0.28, 95% CI = 0.10-0.78).Three weight loss patterns were identified in adults with overweight and obesity. Adults with greater power of food and increased portion control behaviour were less likely to exhibit an unsuccessful weight loss pattern.

Predicting pseudo CT images from MRI data has received increasing attention for use in MRI-only radiation therapy planning and PET-MRI attenuation correction, eliminating the need for harmful CT scanning. Current approaches focus on voxelwise mean absolute error (MAE) and peak signal-to-noise-ratio (PSNR) for optimization and evaluation. Contextual losses such as structural similarity (SSIM) are known to promote perceptual image quality. We investigate the use of these contextual losses for optimization. Patch-based 3D fully convolutional neural networks (FCN) were optimized for prediction of pseudo CT images from 3D gradient echo pelvic MRI data and compared to ground truth CT data of 26 patients. CT data was non-rigidly registered to MRI for training and evaluation. We compared voxelwise L1 and L2 loss functions, with contextual multi-scale L1 and L2 (MSL1 and MSL2), and SSIM. Performance was evaluated using MAE, PSNR, SSIM and the overlap of segmented cortical bone in the reconstructions, by the dice similarity metric. Evaluation was carried out in cross-validation. All optimizations successfully converged well with PSNR between 25 and 30 HU, except for one of the folds of SSIM optimizations. MSL1 and MSL2 are at least on par with their single-scale counterparts. MSL1 overcomes some of the instabilities of the L1 optimized prediction models. MSL2 optimization is stable, and on average, outperforms all the other losses, although quantitative evaluations based on MAE, PSNR and SSIM only show minor differences. Direct optimization using SSIM visually excelled in terms subjective perceptual image quality at the expense of a voxelwise quantitative performance drop. Contextual loss functions can improve prediction performance of FCNs without change of the network architecture. The suggested subjective superiority of contextual losses in reconstructing local structures merits further investigations.

Lack of physical activity (PA) and high levels of sedentary behaviour (SB) have been associated with health problems. This systematic review evaluates the effectiveness of school-based interventions to increase PA and decrease SB among 15–19-year-old adolescents, and examines whether intervention characteristics (intervention length, delivery mode and intervention provider) and intervention content (i.e. behaviour change techniques, BCTs) are related to intervention effectiveness. A systematic search of randomised or cluster randomised controlled trials with outcome measures of PA and/or SB rendered 10 results. Risk of bias was assessed using the Cochrane risk of bias tool. Intervention content was coded using Behaviour Change Technique Taxonomy v1. Seven out of 10 studies reported significant increases in PA. Effects were generally small and short-term (Cohen's d ranged from 0.132 to 0.659). Two out of four studies that measured SB reported significant reductions in SB. Interventions that increased PA included a higher number of BCTs, specific BCTs (e.g., goal setting, action planning and self-monitoring), and were delivered by research staff. Intervention length and mode of delivery were unrelated to effectiveness. More studies are needed that evaluate long-term intervention effectiveness and target SBs among older adolescents.

BACKGROUND: The ToyBox-intervention has increased preschool children's water consumption. This study aimed to examine if family-related determinants mediate the effects of the ToyBox-intervention on preschoolers' water consumption. METHODS: Overall, 6290 preschoolers and their families from 6 European countries participated in the ToyBox-intervention and returned parental questionnaires in May/June 2012 and 2013. This study included the 3725 preschoolers/families who had complete data on water consumption, all mediators, and confounders. Mediation effects were assessed with bootstrapping procedure. RESULTS: Regarding the intervention effects on family-related determinants, the ToyBox-intervention significantly increased water availability during meals, parental water consumption, parental encouragement to their children to drink water, and parental knowledge on water recommendations. In the multiple mediator model, all factors were independently associated with preschoolers' water consumption and mediated the intervention effect on preschoolers' water consumption (total mediation effect = 40%). After including all mediators into the model, the direct intervention effect remained significant. CONCLUSIONS: The effect of the ToyBox-intervention on preschool children's water consumption was mediated by most family-related determinants examined in this study (ie, availability, parental modeling, parental encouragement, and parental knowledge). Interventions aiming to promote water in preschoolers should target these mediators to enhance their effectiveness.

Objectives: This study aims to describe the time devoted to sedentary and physical activities at school in five European countries and to examine differences according to country, sex, ethnicity, parental education and weight status. Design: cross-European cross-sectional survey. Methods: Primary schoolchildren (n=1025) aged 10-12 years in Belgium, Greece, Hungary, the Netherlands, and Switzerland wore accelerometers for at least six consecutive days. Only weekdays were used for this study to calculate the percentages of school-time spent in sedentary activities and moderate to vigorous intensity activity. Trained research assistants measured height and weight. Sex and date of birth were self-reported by the child and parental education and ethnicity were parent-reported. Results: European schoolchildren spent on average 65% of their time at school in sedentary activities and 5% on moderate to vigorous intensity activities, with small differences between countries. Girls spent a significant larger amount of school-time in sedentary activities (67%) than boys (63%; p