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BackgroundDespite the well-known beneficial health effects of physical activity (PA), the majority of Dutch primary school children do not meet the recommended PA guidelines. Although there is growing evidence on the effectiveness of exergames for PA in children, there is limited evidence on their effect on health outcomes, such as cardiovascular health and health-related quality of life (HRQOL), and on factors influencing their effectiveness and feasibility. The exergame BOOSTH uses a wrist-worn activity tracker to measure steps per day. As a reward for the performed PA, children can unlock levels in the online BOOSTH game. In addition, “BOOSTH battle” enables competition between groups. ObjectiveThis protocol describes a cluster randomized controlled trial in 16 primary schools in the Netherlands investigating the effect of BOOSTH on moderate-to-vigorous PA (MVPA) using accelerometry. Secondary aims are to investigate the feasibility of BOOSTH (mixed methods: questionnaires and focus group interviews) and its effect on cardiovascular risk factors (anthropometrics, blood pressure, and retinal microvasculature) and HRQOL. MethodsStratification variables and relevant variables related to outcomes (such as BMI [z-score], sex, age, and parenting style) and/or missingness will be taken into account. Measurements will be performed at baseline and after 3, 6, and 12 months. ResultsThe study has received funding from Province Limburg (SAS-2015-04956) and received ethical approval from the Medical Ethics Committee of Maastricht University Medical Centre (METC172043/NL64324.068.17). The results of the analyses are expected to be published in 2021. ConclusionsWith this study, the ability of the exergame BOOSTH to increase PA and improve health in children of primary school age will be investigated. The insights into effectiveness and feasibility will result in scientific and societal recommendations, which could potentially contribute to widespread implementation of exergames for children. Trial RegistrationClinicalTrials.gov NCT03440580; https://clinicaltrials.gov/ct2/show/NCT03440580. International Registered Report Identifier (IRRID)DERR1-10.2196/24035

Objective/design: Information regarding school-based health-promoting interventions' potential effects in the home environment is scarce. Gaining more insight into this is vital to optimise interventions' potential. The Healthy Primary School of the Future (HPSF) is a Dutch initiative aiming to improve children's health and well-being by providing daily physical activity sessions and healthy school lunches. This qualitative study examines if and how HPSF influenced children's and parents' physical activity and dietary behaviours at home., Method: In 2018-2019, 27 semi-structured interviews were conducted with parents from two HPSF schools. Interviews were recorded and transcribed, and data were coded and interpreted through thematic analysis., Results: HPSF resulted in various behavioural changes at home, initiated by both children and parents. Parents reported improvements in healthy behaviours, as well as compensatory, unhealthy behaviours. Reasons for behavioural change included increased awareness, perceived support to adopt healthy behaviours, and children asking for the same healthy products at home. Barriers to change included no perceived necessity for change, lack of HPSF-related information provision, and time and financial constraints., Conclusion: Both child-to-adult intergenerational learning and parent-initiated changes play an important role in the transfer of health behaviours from school to home and are therefore key mechanisms to maximise school-based health-promoting interventions' impact.

There are various research designs and approaches to investigate how health-promoting activities are implemented in complex, real-world systems, and to identify potential health effects that might occur following implementation. Although literature describes guidelines to perform and report about implementation research and effect evaluations, no specific guidelines exist on analysing and reporting about the combination of effectiveness data and implementation data collected as part of intervention evaluation in complex and diverse settings. This paper describes the evaluation of primary school-based health-promoting activities in complex systems. Furthermore, an approach for data categorization inspired by Rogers' Diffusion of Innovations theory is presented that can facilitate structuring the study's results and relating the degree of implementation to any impact on effectiveness outcomes that might be observed. Researchers interested in using this approach for data categorization have to ensure that the following three conditions are met: (i) data on an intervention's efficacy in a controlled setting with optimal implementation is available; (ii) key points that define an intervention's optimal implementation are available and (iii) an evaluation study is performed, collecting both effectiveness data and implementation data in a real-world context. This data categorization approach can be useful to generate more insight into an intervention's effectiveness under varying circumstances, and optimal support and advice can be provided to stakeholders to achieve maximum impact of population-based health-promoting interventions in complex, real-world systems. However, the proposed approach is a first suggestion and further testing and adaptation is necessary to increase its usefulness. Knowledge and experience sharing among researchers performing comparable research can increase the knowledge base regarding this subject., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: Lifestyle preferences are inculcated in childhood and once established, persist into adulthood. The Project PROMoting Health LIteracy in School (i-PROMISe) aims to promote a healthy lifestyle among students for the universal prevention of non-communicable diseases (NCDs) like diabetes., Study Design: Qualitative study using focus-group-discussions (FGDs) and In-Depth Interviews (IDI)., Method: Project was undertaken in two-phases in two private schools in New Delhi, India. In phase-one, FGDs with students (grades IV to VIII) and IDIs with teachers were conducted to ascertain their perceptions of diabetes prevention and management according to the Health Belief Model. The data was analyzed using a thematic framework method. In phase-two, the resources were pre-tested and participants' feedback was requested on the duration, quality, and understanding of the resources., Results: In total, 89 students and 17 teachers participated in phase-one (n = 54 [in FGDs] and n = 5 [in IDIs]) and phase-two (n = 35 students and n = 12 teachers in FGDs). In phase-one, themes that emerged included: diabetes was considered a disease of the elderly; misconceptions about susceptibility to these diseases were common; children were largely aware of measures to prevent these diseases, but barriers to adopting a healthy lifestyle existed. Based on the findings, a comprehensive module was developed, which consisted of a teacher's manual with interactive activities and short films. The resources (teacher's manual and short films) were well received and contributed to a better understanding of diabetes and other NCDs; myths/misconceptions were clarified., Conclusion: Development of resources using participatory approach can be effective in promoting and reinforcing healthy behaviours among school going children to prevent and control NCDs in schools., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. None to declare., (© 2022 The Authors.)

Background: The World Health Organization designed a minimum set of interventions, the World Health Organization Package of Essential Noncommunicable disease interventions (WHO PEN), for detection, prevention, treatment, and care of Non-communicable diseases (NCDs) in resource constraint settings. This intervention study examines the effectiveness of the integration of components of WHO PEN protocols on improved clinical outcomes among patients of cardiovascular disease and diabetes mellitus in urban and rural primary health care settings., Methods: In this quasi-experimental study (pre-test post-test control group design), trained non-physician health workers will provide behavior change interventions regarding four major NCD risk factors, i.e., tobacco use, excessive alcohol intake, physical inactivity, an unhealthy diet; using 'Brief Advice' to the NCD patients enrolled in the experimental arm. The health centers in the control arm will provide the usual care to all the NCD patients. The intervention will last for six months, and the two groups will be followed up at two months, four months, and six months since enrolment in the study., Results: The primary outcome is improved mean blood pressure levels and the proportion of patients with controlled blood pressure levels. The secondary outcomes assess medication adherence, self-reported reductions in tobacco and alcohol intake, consumption of a heart-healthy diet, and regular physical activity., Discussion: This intervention trial will provide evidence for the utility of individual-level behavioral interventions for adequate management of NCDs., Trial Registration: Clinical Trial Registry of India: CTRI/2018/12/016707., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Information regarding school-based health-promoting interventions' potential effects in the home environment is scarce. Gaining more insight into this is vital to optimise interventions' potential. The Healthy Primary School of the Future (HPSF) is a Dutch initiative aiming to improve children's health and well-being by providing daily physical activity sessions and healthy school lunches. This qualitative study examines if and how HPSF influenced children's and parents' physical activity and dietary behaviours at home. In 2018-2019, 27 semi-structured interviews were conducted with parents from two HPSFs. Interviews were recorded and transcribed, and data were coded and interpreted through thematic analysis. HPSF resulted in various behavioural changes at home, initiated by both children and parents. Parents reported improvements in healthy behaviours, as well as compensatory, unhealthy behaviours. Reasons for behavioural change included increased awareness, perceived support to adopt healthy behaviours, and children asking for the same healthy products at home. Barriers to change included no perceived necessity for change, lack of HPSF-related information provision, and time and financial constraints. Both child-to-adult intergenerational learning and parent-initiated changes play an important role in the transfer of health behaviours from school to home and are therefore key mechanisms to maximise school-based health-promoting interventions' impact.

With rapid urbanization and the Indian nutrition transition, Indian adolescents face a high risk of developing an energy imbalance. This study aims to assess the prevalence of excessive weight, underweight, and associated knowledge and lifestyle behaviors among private school-going adolescents in Delhi. A cross-sectional study was conducted in students (6th-7th grades) of eight randomly selected private schools in Delhi, India in 2019. A self-administered survey was used to assess students' dietary-and-physical-activity-related knowledge and behavior. Anthropometric measurements (height, weight, and waist circumference) were also conducted. Out of 1567 participants, 7.2% were underweight, 61.3% normal, and 31.5% excess in weight. Underweight was associated with significantly more eating whilst studying for exams (relative risk ratio (RRR) 1.7 (1.0-2.9)). Excessive weight was associated with less incorrect knowledge on behaviors causing overweight (RRR 0.7 (0.5-0.9)), more often reading nutritional labels of packed food items (RRR 0.6 (0.4-0.9)), and less frequent vegetable-intake (RRR 0.7 (0.4-0.9)). Underweight students showed more suboptimal knowledge and unhealthy behaviors, whilst students with excessive weight showed more correct knowledge and healthy behaviors. This study highlights the immediate need for effective health-promoting interventions focused on the importance of healthy lifestyle at least in underweight adolescents.

Mere exposure is an often-described strategy to increase children's food familiarity, preferences, and intake. Research investigating this method in less controlled settings is scarce. This study investigates the effects of repeated fruit and vegetable (FV) exposure through the Healthy Primary School of the Future (HPSF) on children's FV familiarity, preferences, and intake. The study had a longitudinal quasi-experimental design comparing two full HPSFs (focus: nutrition and physical activity) with two partial HPSFs (focus: physical activity) in the Netherlands. Annual measurements (child-reported questionnaires) were conducted during 2015-2019 in 833 7-12-year-old children. The study was registered on ClinicalTrials.gov (NCT02800616). After correction for baseline, full HPSFs had, on average, a lower number of unfamiliar vegetable items after one (effect size (ES) = -0.28) and three years (ES = -0.35) and a higher number of disliked vegetable items after one year (ES = 0.24) than partial HPSFs. Unfavorable intervention effects were observed for fruit intake after one (odds ratio (OR) = 0.609) and four years (OR = 0.451). Repeated FV exposure had limited effects on children's FV familiarity, preferences, and intake, likely due to insufficient taste exposure. Considering the widespread implementation of school-based mere exposure efforts, it is highly relevant to further investigate under which circumstances mere exposure effectively contributes to improvements in (determinants of) FV intake.

Introduction: Physical activity (PA) plays an important role in the prevention of cardiovascular diseases, especially in children. Previous studies which investigated the role of PA and sedentary time (ST) in cardiovascular disease used different measurements and found inconsistent results. The current study used recommended standardized measures and provides an overview of PA and ST among Dutch primary school children and their associations with cardiovascular risk factors., Methods: 503 children (55% girls, mean age (± SD) 10 ± 1y) were included. PA (total PA, lightPA and moderate to vigorous PA (MVPA)) and ST were measured with the Actigraph GT3X accelerometer. PA in different domains was measured with the BAECKE questionnaire. Cardiovascular risk factors included BMI z-score, waist circumference, blood pressure (z-score) and estimated cardiorespiratory fitness (CRF) as measured with the 20 meter shuttle run test., Results: Children spent 57 ± 20 min/day (8%) on MVPA and 42% of the children reached the MVPA guideline of 60 min/day. Total PA and MVPA (h/day) were negatively associated with BMI z-score (B = -0.452, p = 0.011) and waist circumference (B = -3.553, p = 0.011) and positively associated with CRF (B = 2.527, p = <0.001). ST was positively associated with BMI z-score (B = 0.108, p = 0.048) and waist circumference (B = 0.920, p = 0.033). No significant associations were found between total PA or PA intensities and blood pressure., Conclusion: This study used standardized measures of PA and therefore created an accurate overview of PA, ST and their associations with cardiovascular risk factors. PA and ST were associated with BMI z-score, waist circumference and CRF. The findings emphasize the importance of promoting MVPA in children, but also highlight the potential benefits of reducing ST to improve cardiovascular risk factors., Trial Registration: ClinicalTrials.gov NCT03440580., Competing Interests: The authors have declared that no competing interests exist.

As health literacy (HL) is hypothesized to develop throughout life, enhancement during childhood will improve HL and health during life. There are few valid, age-appropriate tools to assess children's HL. The German-language European Health Literacy Survey Questionnaire Adapted for Children (HLS-Child-Q15-DE) is a self-report questionnaire adapted from the adult European Health Literacy Survey Questionnaire. This study aims to translate the HLS-Child-Q15 to Dutch and explore the sample's HL distribution. The HLS-Child-Q15-DE was translated following WHO guidelines and administered digitally to 209 Dutch schoolchildren (eight-to-eleven-year-olds). Its psychometric properties were assessed and the sample's HL distribution was explored by demographic characteristics. The HLS-Child-Q15-NL had high internal consistency (α = 0.860) and moderate to strong item-total correlations (mean = 0.499). For 6 of the 15 items, >10% of participants answered "do not know", indicating comprehension problems. Higher HL scores were observed for ten-to-eleven-year-olds (compared with eight-to-nine-year-olds; p = 0.021) and fourth-grade students (compared with third-grade; p = 0.019). This supports the idea that HL evolves throughout life and the importance of schools in this process. With the HLS-Child-Q15-NL, a Dutch measurement instrument of children's HL is available, although it needs further tailoring to the target group. More research is needed to decrease comprehension problems and to investigate retest reliability and construct validity.

Objective: To study school lifestyle interventions for elementary school children (The Healthy Primary School of the Future)., Research Question: What are the effects of the introduction of increased physical activity with or without healthy nutrition on health behaviour and BMI of young children and what are the costs of this program?, Design: Prospective controlled non-randomized study with nearly 1700 children in Parkstad (South-East Netherlands)., Results: Preliminary results after two years show that the combination of increased physical activity and healthy nutrition result in a decreased BMIz-score (-0.036), increased physical activity alone in hardly any change (-0.10) while in the control group the BMIz-score increased (0.052). The net societal costs of the combination of physical activity and health nutrition costs were 1 euro per child per day., Conclusion: The study contributes to the increasing amount of evidence proving that lifestyle interventions are effective in reducing the obesity epidemic. Future studies will show whether a weight reduction in children will result in the prevention of chronic disease later on in life and what the cost reduction related to this result will be.

Background: This study examines the social return on investment (SROI) of the "Healthy Primary School of the Future" initiative after 2 years. Methods: Healthy Primary Schools of the Future (HPSF) provide a healthy lunch and daily structured physical activity sessions, whereas Physical Activity Schools (PAS) focus on physical activity only. We evaluated the 2-years investments and effects ( N = 1,676 children) of both school environments (four schools) compared to control schools (four schools). Investments and outcomes were grouped within the healthcare, education, household & leisure, and labor & social security sector. Outcomes that could be expressed in monetary terms were used for the calculation of social return on investment. Results: HPSF and PAS created outcomes for the healthcare sector by favorable changes in health behaviors, body mass index [both significant], and medical resource use [not significant]. Outcomes for the education sector included a favorable impact on perceived social behaviors and school satisfaction, and absenteeism from school [latter not significant], and more engagement with the community was experienced. The per child investments, €859 (HPSF) and €1017 (PAS), generated a benefit of €8 (HPSF) and €49 (PAS) due to reduced school absenteeism and medical resource use. Conclusions: Within 2 years of intervention implementation, the HPSF initiative created outcomes in several sectors, but the benefits did not outweigh the investments. Follow-up assessments as well as modeling long-term outcomes are needed to assess the total value of the interventions. Until then, the SROI framework can inform strategies for obtaining stakeholder support and intervention implementation. Trial registration: The study was registered in the ClinicalTrials.gov database on 14 June 2016 (NCT02800616)., (Copyright © 2020 Oosterhoff, van Schayck, Bartelink, Bosma, Willeboordse, Winkens and Joore.)

Introduction: Exposure to poor environmental conditions has been associated with deterioration of physical and mental health, and with reduction of cognitive performance. Environmental conditions may also influence cognitive development of children, but epidemiological evidence is scant. In developed countries, children spend 930 hours per year in a classroom, second only to time spent in their bedroom. Using continuous sensing technology, we investigate the relationship between indoor environmental quality (IEQ) and cognitive performance of school-aged children. The proposed study will result in a better understanding of the effects of environmental characteristics on cognitive performance, thereby paving the way for experimental studies., Methods and Analysis: A study protocol is presented to reliably measure IEQ in schools. We will monitor the IEQ of 280 classrooms for 5 years, covering approximately 10 000 children. Each classroom in the sample is permanently equipped with a sensor measuring air quality (carbon dioxide and coarse particles), temperature, relative humidity, light intensity and noise levels, all at 1 min intervals. The location of sensing equipment within and across rooms has been validated by a pilot study. Academic performance of school-aged children is measured through standardised cognitive tests. In addition, a series of health indicators is collected (eg, school absence and demand for healthcare), together with an extensive set of sociodemographic characteristics (eg, parental income, education, occupational status)., Ethics and Dissemination: Medical Ethical Approval for the current study was waived by the Medical Ethical Committee azM/UM (METC 2018-0681). In addition, data on student performance and health stems from an already existing data infrastructure that are granted with ethical approval by the Ethical Review Committee Inner City faculties (ERCIC&#95;092&#95;12&#95;07&#95;2018). Health data are obtained from the 'The Healthy Primary School of the Future' (HPSF) project. Medical Ethical Approval for HPSF was waived by the Medical Ethical Committee of Zuyderland, Heerlen (METC 14 N-142). The HPSF study protocol was registered in the database ClinicalTrials.gov on 14-06-2016 with reference number NCT02800616, this study is currently in the Results stage. Data collection from Gemeentelijke Gezondheidsdienst Zuid-Limburg (GGD-ZL) is executed by researchers of HPSF, this procedure has been fully approved by the Medical Ethical Committee of Zuyderland. The questionnaires on level of comfort will be filled in anonymously by students and teachers. The study will follow the EU General Data Protection Regulation (EU GDPR) and Dutch data protection law to ensure protection of personal data, as well as maintain proper data management and anonymisation.The protocol discussed in this paper includes significant efforts focused on integrating results and making them available to both the scientific community and the wider public, including policy makers. The results will lead to multiple scientific articles that will be disseminated through peer-reviewed international journals, as well as through conference presentations. In addition, we will exploit ongoing collaboration with project stakeholders and project partners to disseminate information to the target audience. For example, the results will be presented to school boards in the Netherlands, through engagement with the Coalition for Green Schools, as well as to school boards in USA, through engagement with the Center for Green Schools., Trial Registration Number: NCT02800616; Results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Schools play an important role in promoting healthy behaviours in children and can offer perspective in the ongoing obesity epidemic. The 'Healthy Primary School of the Future' (HPSF) aims to improve children's health and well-being by enhancing school health promotion. The current study aims to assess the effect of HPSF on children's body mass index (BMI) z-score after 1 and 2 years follow-up and to investigate whether HPSF has different effects within specific subgroups of children., Design: A longitudinal quasi-experimental design., Setting: Four intervention and four control schools participated; located in a low socioeconomic status region in the Netherlands., Participants: 1676 children (aged 4-12 years)., Interventions: HPSF uses a contextual systems approach and includes health-promoting changes in the school. Central to HPSF is the provision of a daily healthy lunch and structured physical activity sessions each day. Two intervention schools implemented both changes (full HPSF), two intervention schools implemented only the physical activity change (partial HPSF)., Main Outcome Measures: BMI z-score, determined by measurements of children's height and weight at baseline, after 1 and 2 years follow-up., Results: The intervention effect was significant after 1-year follow-up in the partial HPSF (standardised effect size (ES)=-0.05), not significant in the full HPSF (ES=-0.04). After 2 years follow-up, BMI z-score had significantly decreased in children of both the full HPSF (ES=-0.08) and the partial HPSF (ES=-0.07) compared with children of the control schools, whose mean BMI z-score increased from baseline to 2 years. None of the potential effect modifiers (gender, baseline study year, socioeconomic status and baseline weight status) were significant., Conclusions: HPSF was effective after 1 and 2 years follow-up in lowering children's BMI z-scores. No specific subgroups of children could be identified who benefitted more from the intervention., Trial Registration Number: NCT02800616., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Context: Childhood obesity increases the risk of diseases as diabetes, cardiovascular disease, and nonalcoholic fatty liver disease., Objective: To evaluate the prevalence of comorbidities in school-age children with obesity and to compare its prevalence and the effect of a lifestyle intervention between children in primary and secondary school and between boys and girls., Design: Cross-sectional analysis and lifestyle intervention., Setting: Centre for Overweight Adolescent and Children's Healthcare., Patients: Comorbidities were evaluated in 149 primary and 150 secondary school children with (morbid) obesity (162 girls). The effect of lifestyle intervention was studied in 82 primary and 75 secondary school children., Intervention: One-year interdisciplinary lifestyle intervention., Results: Insulin resistance (37%), impaired glucose tolerance (IGT) (3%), dyslipidemia (48%), hypertension (7%), and elevated liver transaminase levels (54%) were already common in primary school children. Glomerular hyperfiltration and insulin resistance were more prevalent in secondary school children. IGT was more prevalent in girls. The change in body mass index z score after intervention was greater in primary school children (primary vs secondary: -0.25 ± 0.32 vs -0.11 ± 0.47), even as the change in low-density lipoprotein cholesterol concentrations [primary vs secondary: -0.30 (interquartile range, -0.70 to 0.10) vs -0.10 (interquartile range, -0.40 to 0.30)] and systolic blood pressure z score (primary vs secondary: -0.32 ± 1.27 vs 0.24 ± 1.3). The change in body mass index z score, but not in comorbidities, was greater in boys (boys vs girls: -0.33 ± 0.45 vs -0.05 ± 0.31)., Conclusions: The presence of comorbidities is already evident in primary school children with obesity. The effect of a lifestyle intervention on these comorbidities is greater in primary compared with secondary school children, stressing the need for early interventions., (Copyright © 2019 Endocrine Society.)

Schools can help to improve children's health. The 'Healthy Primary School of the Future' (HPSF) aims to sustainably integrate health and well-being into the school system. This study examined the effects of HPSF on children's dietary and physical activity (PA) behaviours after 1 and 2 years' follow-up. The study ( n = 1676 children) has a quasi-experimental design with four intervention schools, i.e., two full HPSF (focus: nutrition and PA) and two partial HPSF (focus: PA), and four control schools. Accelerometers and child- and parent-reported questionnaires were used at baseline, after 1 (T1) and 2 (T2) years. Mixed-model analyses showed significant favourable effects for the full HPSF versus control schools for, among others, school water consumption (effect size (ES) = 1.03 (T1), 1.14 (T2)), lunch intake of vegetables (odds ratio (OR) = 3.17 (T1), 4.39 (T2)) and dairy products (OR = 4.43 (T1), 4.52 (T2)), sedentary time (ES = -0.23 (T2)) and light PA (ES = 0.22 (T2)). Almost no significant favourable effects were found for partial HPSF compared to control schools. We conclude that the full HPSF is effective in promoting children's health behaviours at T1 and T2 compared with control schools. Focusing on both nutrition and PA components seems to be more effective in promoting healthy behaviours than focusing exclusively on PA., Competing Interests: The authors declare no conflicts of interests. None of the funding bodies had a role in the design of the study or the writing of this manuscript, nor a role in the data collection, analysis, interpretation of data, and writing of publications.

Background: Schools can play an important role in promoting children's health behaviours. A Dutch initiative, 'The Healthy Primary School of the Future', aims to integrate health and well-being into the school system. We use a contextual action-oriented research approach (CARA) to study the implementation process. Properties of CARA are its focus on contextual differences and the use of monitoring and feedback to support and evaluate the process of change. The aim of this article is to describe the use of the approach. Methods: Four schools (each with 200⁻300 children, aged 4⁻12 years) were included; all located in low socio-economic status areas in the south of the Netherlands. Data collection methods include interviews, observations, questionnaires, and health and behavioural measurements. Research contributions include giving feedback and providing schools with a range of possibilities for additional changes. The contextual data we examine include schools' health promoting elements, practices of teachers and parents, dominating organisational issues, and characteristics of the student population; process data include the presence of potential barriers to changes. Discussion: CARA is an adaptive research approach that generates knowledge and experiences on how to deal with health promotion in complex systems. We think this approach can set an example for research efforts in comparable initiatives.

Background: This study assesses socio-economic health inequalities (SEHI) over primary school-age (4- to 12-years old) across 13 outcomes (i.e. body-mass index [BMI], handgrip strength, cardiovascular fitness, current physical conditions, moderate to vigorous physical activity, sleep duration, daily fruit and vegetable consumption, daily breakfast, exposure to smoking, mental strengths and difficulties, self-efficacy, school absenteeism and learning disabilities), covering four health domains (i.e. physical health, health behaviour, mental health and academic health)., Methods: Multilevel mixed effect (linear and logistic) regression analyses were applied to cross-sectional data of a Dutch quasi-experimental study that included 1403 pupils from nine primary schools. Socioeconomic background (high-middle-low) was indicated by maternal education (n = 976) and parental material deprivation (n = 784)., Results: Pupils with higher educated mothers had lower BMIs, higher handgrip strength and higher cardiovascular fitness; their parents reported more daily fruit and vegetable consumption, daily breakfast and less exposure to smoking. Furthermore these pupils showed less mental difficulties and less school absenteeism compared with pupils whose mothers had a lower education level. When using parental material deprivation as socio-economic indicator, similar results were found for BMI, cardiovascular fitness, sleep duration, exposure to smoking and mental strengths and difficulties. Socio-economic differences in handgrip strength, cardiovascular fitness and sleep duration were larger in older than in younger pupils., Conclusions: Childhood SEHI are clearly found across multiple domains, and some are larger in older than in younger pupils. Interventions aiming to tackle SEHI may therefore need a comprehensive and perhaps more fundamental approach.

Background: Asthma and obesity are highly prevalent in children, and are interrelated resulting in a difficult-to-treat asthma-obesity phenotype. The exact underlying mechanisms of this phenotype remain unclear, but decreased physical activity (PA) could be an important lifestyle factor. We hypothesize that both asthma and overweight/obesity decrease PA levels and interact on PA levels in asthmatic children with overweight/obesity., Methods: School-aged children (n = 122) were divided in 4 groups (healthy control, asthma, overweight/obesity and asthma, and overweight/obesity). Children were asked to perform lung function tests and wear an activity monitor for 7 days. PA was determined by: step count, active time, screen time, time spent in organized sports and active transport forms. We used multiple linear regression techniques to investigate whether asthma, body mass index-standard deviation score (BMI-SDS), or the interaction term asthma x BMI-SDS were associated with PA. Additionally, we tested if asthma features (including lung function and medication) were related to PA levels in asthmatic children., Results: Asthma, BMI-SDS and the interaction between asthma x BMI-SDS were not related to any of the PA variables (p ≥ 0.05). None of the asthma features could predict PA levels (p ≥ 0.05). Less than 1 in 5 children reached the recommended daily step count guidelines of 12,000 steps/day., Conclusion: We found no significant associations between asthma, overweight and PA levels in school-aged children in this study. However, as PA levels were worryingly low, effective PA promotion in school-aged children is necessary.

Background: There is increasing evidence that obesity is related to asthma development and severity. However, it is largely unknown whether weight reduction can influence asthma management, especially in children., Objective: To determine the effects of a multifactorial weight reduction intervention on asthma management in overweight/obese children with (a high risk of developing) asthma., Methods: An 18-month weight-reduction randomized controlled trial was conducted in 87 children with overweight/obesity and asthma. Every six months, measurements of anthropometry, lung function, lifestyle parameters and inflammatory markers were assessed. Analyses were performed with linear mixed models for longitudinal analyses., Results: After 18 months, the body mass index-standard deviation score decreased by -0.14±0.29 points (p<0.01) in the intervention group and -0.12±0.34 points (p<0.01) in the control group. This change over time did not differ between groups (p>0.05). Asthma features (including asthma control and asthma-related quality of life) and lung function indices (static and dynamic) improved significantly over time in both groups. The FVC% predicted improved over time by 10.1 ± 8.7% in the intervention group (p<0.001), which was significantly greater than the 6.1 ± 8.4% in the control group (p<0.05)., Conclusions & Clinical Relevance: Clinically relevant improvements in body weight, lung function and asthma features were found in both the intervention and control group, although some effects were more pronounced in the intervention group (FVC, asthma control, and quality of life). This implies that a weight reduction intervention could be clinically beneficial for children with asthma., Trial Registration: ClinicalTrials.gov NCT00998413.

Exercise can provoke asthma symptoms, such as dyspnoea, in children with asthma. Exercise-induced bronchoconstriction (EIB) is prevalent in 40-90% of children with asthma. Conversely, exercise can improve physical fitness. The purpose of this paper is to provide a systematic review of the literature regarding the effects of exercise training in children with asthma, particularly in relation to: EIB, asthma control, pulmonary function, cardiorespiratory parameters and parameters of underlying pathophysiology. A systematic search in several databases was performed. Controlled trials that undertook a physical training programme in children with asthma (aged 6-18 years) were selected. Twenty-nine studies were included. Training had positive effects on several cardiorespiratory fitness parameters. A few studies demonstrated that training could improve EIB, especially in cases where there was sufficient room for improvement. Peak expiratory flow was the only lung function parameter that could be improved substantially by training. The effects of training on asthma control, airway inflammation and bronchial hyper-responsiveness were barely studied. Owing to the overall beneficial effects of training and the lack of negative effects, it can be concluded that physical exercise is safe and can be recommended in children with asthma. A training programme should have a minimum duration of 3 months, with at least two 60 min training sessions per week, and a training intensity set at the (personalised) ventilatory threshold. Further research is recommended regarding the effects of exercise on underlying pathophysiological mechanisms and asthma control in children with asthma., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Obesity has been identified as a risk factor for asthma in children. However, in the Netherlands, the obesity prevalence is rising while the asthma prevalence in children is stabilising. The aim of this study is to clarify the association between asthma and Body Mass Index (BMI) in children and whether this association is influenced by sex., Study Design: Parents of 39,316 children (6-16 years) in the south of the Netherlands were invited to complete an online questionnaire on respiratory symptoms, anthropometric variables and several potential confounding factors for asthma and obesity (including sex, birth weight and breastfeeding). Data was analysed by multivariable logistic regression models and an ordinal regression model., Results: The response rate was 24% (n boys= 4,743, n girls= 4,529). The prevalence of asthma, overweight and obesity was 8%, 15% and 2% respectively. Body mass index--standard deviation Score (BMI-SDS) was related to current asthma (adjusted OR: 1.29; 95%CI: 1.14-1.45, p ≤ 0.001). When stratified for sex, asthma and BMI-SDS were only related in girls (Girls: adjusted OR: 1.31; 95%CI: 1.13-1.51, p ≤ 0.001. Boys: adjusted OR: 1.01; 95%CI: 0.91-1.14, p=0.72)., Conclusions: The positive association between BMI-SDS and asthma is only present in girls, not boys. Future studies into obesity and asthma should correct for sex in their analyses.

Background: In children, the prevalence's of both obesity and asthma are disconcertingly high. Asthmatic children with obesity are characterised by less asthma control and a high need for asthma medication. As the obese asthmatic child is becoming more common in the clinical setting and the disease burden of the asthma-obesity phenotype is high, there is an increasing need for effective treatment in these children. In adults, weight reduction resulted in improved lung function, better asthma control and less need for asthma medication. In children this is hardly studied. The Mikado study aims to evaluate the effectiveness of a long term multifactorial weight reduction intervention, on asthma characteristics in children with asthma and a high body weight., Methods/design: The Mikado study is a two-armed, randomised controlled trial. In total, 104 participants will be recruited via online questionnaires, pulmonary paediatricians, the youth department of the Municipal Health Services and cohorts of existing studies. All participants will be aged 6-16 years, will have current asthma, a Body Mass Index in the overweight or obesity range, and no serious comorbidities (such as diabetes, heart diseases). Participants in the intervention arm will receive a multifactorial intervention of 18 months consisting of sessions concerning sports, parental involvement, individual counselling and lifestyle advices including dietary advices and cognitive behavioural therapy. The control group will receive usual care. The primary outcome variables will include Forced Expiratory Volume in one second and Body Mass Index - Standard Deviation Score. Secondary outcomes will include other lung function parameters (including dynamic and static lung function parameters), asthma control, asthma-specific quality of life, use of asthma medication and markers of systemic inflammation and airway inflammation., Discussion: In this randomised controlled trial we will study the potential of a multifactorial weight reduction intervention to improve asthma-related outcome measures in asthmatic children with overweight. Moreover, it will provide information about the underlying mechanisms in the relationship between asthma and a high body weight in children. These findings can contribute to optimal management programs and better clinical guidelines for children with asthma and overweight., Trial Registration: Clinicaltrial.gov NCT00998413.