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Background A healthy lifestyle decreases the risk of developing type 2 diabetes mellitus. The current cross-sectional study aimed to describe self-reported lifestyle behaviours and compare them to current health guidelines in European Feel4Diabetes-families at risk for developing type 2 diabetes across six countries (Belgium, Finland, Spain, Greece, Hungary and Bulgaria). Methods Parents and their children were recruited through primary schools located in low socio-economic status areas. Parents filled out the FINDRISC-questionnaire (eight items questioning age, Body Mass Index, waist circumference, PA, daily consumption of fruit, berries or vegetables, history of antihypertensive drug treatment, history of high blood glucose and family history of diabetes), which was used for the risk assessment of the family. Sociodemographic factors and several lifestyle behaviours (physical activity, sedentary behaviour, water consumption, fruit and vegetable consumption, soft drink consumption, sweets consumption, snack consumption, breakfast consumption) of both adults and children were assessed by parental questionnaires. Multilevel regression analyses were conducted to investigate families’ lifestyle behaviours, to compare these levels to health guidelines and to assess potential differences between the countries. Analyses were controlled for age, sex and socio-economic status. Results Most Feel4Diabetes-families at risk (parents and their children) did not comply with the guidelines regarding healthy behaviours, set by the WHO, European or national authorities. Less than half of parents and children complied with the physical activity guidelines, less than 15% of them complied with the fruit and vegetable guideline, and only 40% of the children met the recommendations of five glasses of water per day. Clear differences in lifestyle behaviours in Feel4Diabetes-families at risk exist between the countries. Conclusions Countries are highly recommended to invest in policy initiatives to counter unhealthy lifestyle behaviours in families at risk for type 2 diabetes development, taking into account country-specific needs. For future research it is of great importance to focus on families at risk in order to counter the development of type 2 diabetes and reduce health inequity.

Summary The Feel4Diabetes project conducted a 2-year intervention aiming to encourage healthy behaviours in families in six European countries. Within this paper, the intervention effect was evaluated after the first intervention year on 24-hour physical behaviour composition in Belgian families at risk for type 2 diabetes. Parents’ and children’s levels of physical activity (PA) and sedentary behaviour (SB) were objectively measured and sleep duration was self-reported. Valid data were obtained in 82 children (mean age: 8.2 ± 0.84; 50.0% boys) and 72 parents (mean age: 40.1 ± 5.5; 27.8% fathers). Data were analysed using a compositional data approach, and mixed models were used to take clustering into account. Results showed that for children, the mean baseline composition of the 24-hour day in sleep, SB, light and moderate-to-vigorous PA for the intervention group was (11 hours 18 minutes; 6 hours 33 minutes; 5 hours 02 minutes, 1 hour 08 minutes) and for the control group (11 hours 18 minutes; 6 hours 35 minutes; 5 hours 04 minutes; 1 hour 06 minutes), respectively. For parents, the mean baseline composition was for the intervention group (8 hours 12 minutes; 9 hours 36 minutes; 5 hours 43 minutes; 27 minutes) and for the control group (8 hours 00 minute; 9 hours 00 minute; 6 hours 27 minutes; 33 minutes). No significant intervention effects were found on 24-hour physical behaviour composition of either parents or children (p = 0.19 and p = 0.21, respectively). A relatively small study population and a poor attendance rate among parents could maybe explain the lack of effectiveness. More effective strategies are needed to retain vulnerable families in interventions. Furthermore, future approaches to improve the 24-hour physical behaviour composition should maybe focus more specifically on PA, SB and sleep, and involve teachers, children and parents in the design of the intervention. Trial registration: NCT02393872 in ClinicalTrials.gov.

The Feel4Diabetes-study has received funding from the European Union's Horizon 2020 research and innovation programme [Grant Agreement: n degrees 643708]. The content of this article reflects only the authors' views and the European Community is not liable for any use that may be made of the information contained therein., Background: This study investigated the effect of the Feel4Diabetes-intervention, a 2-year multilevel intervention, on energy balance-related behaviors among European families at risk for developing type 2 diabetes. Intervention effects on self-reported physical activity, sedentary behavior and eating behaviors were investigated across and within the participating countries: Belgium, Finland, Greece, Spain, Hungary and Bulgaria. Methods: Families were recruited through schools, located in low socio-economic status areas. In total, 4484 families at risk for developing type 2 diabetes were selected using the FINDRISC-questionnaire. Parents' and children's energy balance-related behaviors data were collected by questionnaires at three time points (baseline, mid- and post intervention). Families assigned to the intervention group were invited to participate in a 2-year school-, community-, and family-based intervention to promote a healthier lifestyle, including counseling sessions (first intervention year) and text messages (second intervention year). Families assigned to the control group received standard care, including medical check-up results and recommendations and tips regarding a healthy lifestyle. To assess the intervention-effects, Mixed Models were conducted using the R-Package "lmer "with R v3.2. Results: Significant intervention effects were found on a certain number of families' lifestyle behaviors. Significant favorable intervention effects were detected on parents' water consumption and consumption of fruit and vegetables, and on children's consumption of sweets and moderate-to-vigorous physical activity. Analyses by country revealed significant favorable intervention effects on water consumption and on moderate-to-vigorous physical activity in Belgian parents and on fruit and vegetable consumption among Belgian children, on sweets consumption among Spanish parents and children, and on moderate-to-vigorous physical activity among Finnish children. Unfavorable intervention effects were found on the consumption of soft drinks and sugar-containing juices among Hungarian children and parents, while when examining the intervention effects for the overall population and per country, 10 from the 112 investigated outcome variables were improved in the intervention group compared to the control group (9%). Conclusions: The Feel4Diabetes-intervention managed to improve a certain number of targeted lifestyle behaviors while the intervention was not effective on a large number of targeted lifestyle behaviors. The findings of the current study are encouraging, but further research is needed on how we can further improve effectiveness of lifestyle interventions to prevent type 2 diabetes in families at risk., European Union's Horizon 2020 research and innovation programme 643708

BackgroundThe study aimed to investigate the effectiveness of the European Feel4Diabetes intervention, promoting a healthy lifestyle, on physical activity and its correlates among families at risk for type 2 diabetes mellitus (based on the Finnish Diabetes Risk Score) in Belgium.MethodsThe Feel4Diabetes intervention involved three components: family, school and community component, with the family component consisting of 6 counseling sessions for families at risk. Main outcomes were objectively measured physical activity levels and its subjectively measured correlates. The final sample consisted of 454 parents (mean age 39.4 years; 72.0% women) and 444 children (mean age 8.0 years; 50.1% girls). Multilevel repeated measures analyses were performed to assess intervention effectiveness after 1 year.ResultsIn parents, there was no significant intervention effect. In children, there were only significant negative effects for moderate to vigorous physical activity (p = 0.05; ηp2 = 0.008) and steps (p = 0.03; ηp2 = 0.006%) on weekdays, with physical activity decreasing (more) in the intervention group.ConclusionsThe F4D-intervention lacks effectiveness on high-risk families’ physical activity and its correlates in Belgium. This could partially be explained by low attendance rates and a large drop-out. To reach vulnerable populations, future interventions should invest in more appropriate recruitment (e.g. more face-to-face contact) and more bottom-up development of the intervention (i.e. co-creation of the intervention with the target group).Trial registrationThe Feel4Diabetes-study was prospectively registered at clinicaltrials.gov asNCT02393872on 20 March 2015.

Background: The clinical and economic burden of type 2 diabetes mellitus on society is rising. Effective and efficient preventive measures may stop the increasing prevalence, given that type 2 diabetes mellitus is mainly a lifestyle-driven disease. The Feel4Diabetes-study aimed to tackle unhealthy lifestyle (unhealthy diet, lack of physical activity, sedentary behaviour, and excess weight) of families with a child in the first grades of elementary school. These schools were located in regions with a relatively low socio-economic status in Belgium, Bulgaria, Finland, Greece, Hungary and Spain. Special attention was paid to families with a high risk of developing type 2 diabetes mellitus. Methods: The aim of this paper is to describe the detailed methodology of the intervention’s cost-effectiveness analysis. Based on the health economic evaluation of the Toybox-study, both a decision analytic part and a Markov model have been designed to assess the long-term (time horizon of 70 year with one-year cycles) intervention’s value for money. Data sources used for the calculation of health state incidences, transition probabilities between health states, health state costs, and health state utilities are listed. Intervention-related costs were collected by questionnaires and diaries, and attributed to either all families or high risk families only. Conclusions: The optimal use of limited resources is pivotal. The future results of the health economic evaluation of the Feel4Diabetes-study will contribute to the efficient use of those resources., Publication of this supplement was funded by the European Union’s Horizon 2020 research and innovation programme under grant agreement n° 643708.

Background Feel4Diabetes was a school and community based intervention aiming to promote healthy lifestyle and tackle obesity for the prevention of type 2 diabetes among families in 6 European countries. We conducted this literature review in order to guide the development of evidence-based implementation of the Feel4Diabetes intervention. We focused on type 2 diabetes prevention strategies, including all the phases from risk identification to implementation and maintenance. Special focus was given to prevention among vulnerable groups and people under 45 years. Methods Scientific and grey literature published between January 2000 and January 2015 was searched for relevant studies using electronic databases. To present the literature review findings in a systematic way, we used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. A complementary literature search from February 2015 to December 2018 was also conducted. Results The initial review included 27 studies with a follow-up ≥12 months and 9 studies with a follow-up ≥6 months and with a participant mean age Conclusion This narrative review highlighted several important aspects that subsequently guided the development of the Feel4Diabetes high-risk intervention. Research on diabetes prevention interventions targeted at younger adults or vulnerable population groups is still relatively scarce. Feel4Diabetes is a good example of a project aiming to fill this research gap. Trial registration clinicaltrials.gov NCT02393872, registered 20th March 2015.

Background: This study aimed to investigate whether the relationship between psychosocial and perceived environmental factors and physical activity (PA) in adults at risk for type 2 diabetes is influenced by educational level. Methods: Based on the Finnish Diabetes Risk Score questionnaire, this study selected 164 adults (Mage: 38 (5.34) y, 13.4% men) at type 2 diabetes risk from 11 low socioeconomic neighborhoods in Flanders (Belgium). Participants filled out questionnaires on psychosocial and perceived environmental factors and wore an ActiGraph accelerometer for 5 consecutive days. Statistical analyses were performed using analysis of covariance in SPSS. Results: Educational level significantly influenced the association between perception of body weight and light PA (P = .01) and total PA (P = .03) on weekend days. Educational level did not influence the associations between other psychosocial and perceived environmental factors (ie, perceived social influence; environmental, time and attitudinal barriers, perceived self-efficacy; knowledge and fatalism) and PA. Conclusions: Educational level did not influence the relationship between most psychosocial and perceived environmental factors and PA in this sample of adults at type 2 diabetes risk. This suggests that addressing different psychosocial and perceived environmental correlates in lower and higher educated participants might not be necessary. However, more research in this specific population is needed.

The Feel4Diabetes intervention was a school and community-based intervention aiming to promote healthy lifestyle and tackle obesity and obesity-related metabolic risk factors for the prevention of type 2 diabetes (T2D) among families at risk of developing this disease. The current study aims to present the results on lifestyle behaviors obtained from parents during the first year of the Feel4Diabetes intervention. This multicomponent intervention had a cluster randomized design and was implemented in Belgium, Bulgaria, Finland, Greece, Hungary and Spain over two years (2016&ndash, 2018). Standardized protocols and procedures were used by the participating centers in all countries to collect data on parents&rsquo, lifestyle behaviors (diet, physical activity, sedentary behavior). The Feel4Diabetes intervention was registered at clinicaltrials.gov (registration number: NCT02393872). In total, 2110 high-risk parents participated in the baseline and 12-month follow-up examination measurements. Participants allocated to the intervention group reduced their daily consumption of sugary drinks (p = 0.037) and sweets (p = 0.031) and their daily screen time (p = 0.032), compared with the control group. In addition, participants in the intervention group in Greece and Spain increased their consumption of breakfast (p = 0.034) and fruits (p = 0.029), while in Belgium and Finland they increased their water intake (p = 0.024). These findings indicate that the first year of the Feel4Diabetes intervention resulted in the improvement of certain lifestyle behaviors in parents from high-risk families.

Background This study aimed to investigate the effect of integrating a video intervention “Movie Models” within the Feel4Diabetes-study on specific parenting practices and related parental self-efficacy regarding children’s physical activity, screen-time and eating behaviour in vulnerable families (i.e. families living in low socioeconomic municipalities and at risk for developing type 2 diabetes). Additionally, there was examination of how the intervention was perceived by the parents. Methods Within randomly selected low socioeconomic municipalities in Belgium, families were recruited through primary schools. Families at risk for developing type 2 diabetes were identified using the FINDRISC questionnaire (n = 457). Afterwards, the municipalities were randomly assigned to the intervention or control condition. At risk families assigned to the intervention group were invited to participate in six Feel4Diabetes counselling sessions in which families were encouraged to adopt a healthier lifestyle. The “Movie Models” videos were integrated within two sessions by using a face-to-face group discussion approach. Parenting-related factors were assessed before and after the integration of the videos, using a questionnaire. After integrating the videos, some extra evaluation questions were assessed. In total, 126 families were included in a per protocol evaluation and Repeated Measures ANOVAs were conducted to evaluate the potential intervention effects. Results Some favourable intervention effects were found on parenting practices and related parental self-efficacy regarding children’s eating behaviours, however almost no effects were found on parenting-related factors regarding children’s physical activity and screen-time. In total, 60.0% of the participants indicated that they applied tips regarding parenting practices and 52.0% indicated that discussions with other participants regarding the videos were useful for them. Conclusion The integration of “Movie Models” within the Feel4Diabetes-study was effective in improving some parenting-related factors regarding children’s health behaviours, however most parenting-related factors could not be improved. The implementation of “Movie Models” as a face-to-face group discussion approach was relatively well received and may be a promising way to improve parenting-related factors in vulnerable families. Trial registration ClinicalTrials.gov NCT02278809.

This study is part of the ToyBox-study, which is conducted in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain), aiming to develop a cost-effective kindergarten-based, family-involved intervention to prevent overweight and obesity in four- to six-year-old preschool children. In the current study, we aimed to examine and compare preschoolers’ step count patterns, across the six European countries. A sample of 3578 preschoolers (mean age: 4.8 ± 0.4) was included. Multilevel analyses were performed to take clustering of measurements into account. Based on the average hourly steps, step count patterns for the six European countries were created for weekdays and weekend days. The step count patterns during weekdays were related to the daily kindergarten schedules. Step count patterns during weekdays showed several significant peaks and troughs (p < 0.01) and clearly reflected the kindergartens’ daily schedules, except for Germany. For example, low numbers of steps were observed during afternoon naptimes and high numbers of steps during recess. In Germany, step count patterns did not show clear peaks and troughs, which can be explained by a less structured kindergarten schedule. On weekend days, differences in step count patterns were observed in the absolute number of steps in the afternoon trough and the period in which the evening peak occurred. Differences in step count patterns across the countries can be explained by differences in (school) policy, lifestyle habits, and culture. Therefore, it might be important to respond to these step count patterns and more specifically to tackle the inactive periods during interventions to promote physical activity in preschoolers.

The aim of this study was to examine the mediating effects of specific parenting practices on the association between family socio-economic status (SES) and screen-time of 6- to 9-year-old children from families with an increased risk of developing type 2 diabetes. This cross-sectional study, focusing on families with an increased risk of developing type 2 diabetes, used the Belgian baseline data of the Movie Models intervention, integrated within the European Feel4Diabetes intervention, and included 247 parents (57.6% lower SES family, 78.0% mothers) who completed a questionnaire. Mediating effects were tested using MacKinnon&rsquo, s product-of-coefficients test via multilevel linear regression analyses. Being consistent concerning rules about gaming (&beta, = 0.127, standard error = 0.055, 95% CI = 0.020, 0.234) and avoiding negative role modeling concerning TV-time (&beta, = &minus, 0.082, standard error = 0.040, 95% CI = &minus, 0.161, &minus, 0.003) significantly mediated the inverse association between family SES and children&rsquo, s screen-time. Parents from lower SES families were more consistent concerning rules about gaming and watched more TV nearby their child compared to parents from higher SES families, and these parenting practices were related to more screen-time. No other parenting practices were found to mediate this association. Thus, parents from lower SES families with a higher risk for developing type 2 diabetes might limit their own TV-time nearby their child to reduce their child&rsquo, s screen-time. Future research should examine other possible mediating factors to develop effective interventions targeting this important at-risk group.

Physical inactivity is one of the major risk factors for poor health in the world. Therefore, effective interventions that promote physical activity are needed. Hence, we developed an eHealth intervention for adults, i.e., ‘MyPlan 1.0’, which includes self-regulation techniques for behaviour change. This study examined the effect of ‘MyPlan 1.0’ on physical activity (PA) levels in general practice. 615 adults (≥18 years) were recruited in 19 Flemish general practices, for the intervention group (n = 328) or for the wait-list control group (n = 183). Participants in the intervention group received the web-based intervention ‘MyPlan 1.0’ and were prompted to discuss their personal advice/action plan with their general practitioner. Participants in the wait-list control group only received general advice from the website. Self-reported physical activity was assessed with the International Physical Activity Questionnaire (IPAQ) at baseline and after one month. A three-level (general practice, adults, time) regression analysis was conducted in MLwiN. Significant intervention effects were found for total PA and moderate to vigorous PA with an increase for the intervention group compared to a decrease in the control condition. However, there was a high dropout rate in the intervention group (76%) and the wait-list control group (57%). Our self-regulation intervention was effective in increasing physical activity levels in adults. Future studies should consider strategies to prevent the large dropout from participants.

This study investigated barriers towards health behaviours (physical activity, limiting sedentary behaviour and healthy dietary habits) experienced by young European families living in vulnerable areas, from multiple perspectives (parents, teachers, local community workers). Focus groups were conducted in six European countries (Belgium, Bulgaria, Finland, Hungary, Greece and Spain). In each country, three focus groups were conducted with parents, one with teachers and one with local community workers. Data were analysed using a deductive framework approach with a manifest content analysis using the software NVivo. The present study identified barriers on four levels (individual, interpersonal, organisational and macro level) of a socio-ecological model of health behaviour. From parents’ perspectives, both general barriers (e.g., financial limitations and lack of time) and country-specific barriers (e.g., organisational difficulties and inappropriate work environment) were identified. Additional barriers (e.g., lack of parental knowledge and lack of parental skills) were provided by other stakeholders (i.e., teachers and local community workers). The results of this study demonstrate the additional value of including multiple perspectives when developing a lifestyle intervention aiming to prevent type 2 diabetes in vulnerable groups. Future lifestyle interventions are recommended to include multiple components (family, school, and community) and could be implemented across European countries if country-specific adaptations are allowed.