Theory-informed nutrition education curriculum Tools For Feeling Good promotes healthy eating patterns among fifth grade pupils: cross-sectional study.

BACKGROUND: The eating patterns of school-aged children rarely meet recommendations: meal frequency is irregular and the consumption of vegetables is lower and sugar-sweetened products higher than recommended. Although school is an excellent arena for nutrition education to support pupils eating patterns, teachers usually lack efficient tools. The present study aimed to develop a curriculum for nutrition education to be used by teachers and to examine its efficacy in the school environment with respect to the eating patterns of pupils. METHODS: The curriculum was developed in collaboration with school teachers using self-determination theory as a theoretical standpoint. The Health at Every Size concept and sensory-based food education were utilised in the curriculum. Self-reported questionnaires were used to assess the feasibility and impact of the curriculum. Fourteen teachers implemented the curriculum during 2012-2013 with 194 pupils aged 10-13 years (fifth and sixth grades). The control schools included 140 pupils of the same age not following the curriculum. RESULTS: The teachers reported that the curriculum was easy to integrate in the school environment. The fifth graders improved their breakfast frequency, increased their consumption of vegetables and reduced their consumption of ice cream, sweets and sugar-sweetened drinks. No improvement was found in the fifth graders at the control schools. In the sixth graders, no dietary changes were detected in the intervention or control schools. CONCLUSIONS: The pupils in the fifth grade appeared to comprise a responsive target group for nutrition education at schools. The curriculum offers a promising approach for developing healthy eating patterns among fifth graders. Collaboration with teachers in developing the curriculum likely enhanced its feasibility and teacher commitment for implementation.

Intergenerational transmission of overweight among Finnish adolescents and their parents: a 16-year follow-up study.

OBJECTIVE: Previous studies have shown strong parental influences on adolescent overweight. However, longitudinal data is scarce on gender-specific effects of parental body mass index (BMI) on offspring overweight. The objective of this study was to examine the associations of parental pre-pregnancy BMI, weight change, BMI and BMI class transition 16 years after pregnancy with the BMI of their 16-year-old children. SUBJECTS AND METHODS: The study population was derived from the general population-based Northern Finland Birth Cohort 1986. A total of 4788 child-mother-father trios (2325 boys, 2463 girls) were analysed. Weight and height of the adolescents were measured and overweight and obesity defined according to the International Obesity Task Force. For the parents, self-reported data were obtained and overweight and obesity defined according to the World Health Organization. Associations of parental BMI status and weight change with offspring BMI were assessed using binary logistic regression analyses stratified by gender and adjusted for parental age and education. RESULTS: Children whose both parents were overweight or obese both before pregnancy and after 16-year follow-up had a strikingly high risk of overweight at age 16 years (boys odds ratio (OR) 5.66 95% confidence interval (CI) 3.12, 10.27; girls OR 14.84 95% CI 7.41, 29.73). Parental pre-pregnancy obesity strongly predicted offspring overweight (mother-son OR 4.36 95% CI 2.50, 7.59; mother-daughter OR 3.95 95% CI 2.34, 6.68; father-son OR 3.17 95% CI 1.70, 5.92; father-daughter OR 5.58 95% CI 3.09, 10.07). CONCLUSION: Parental overweight conveys a major risk for overweight in children for which both parents' long-term overweight (BMI ≥25 kg m(-2) before pregnancy and after 16-year follow-up) was the strongest single predictor. Preventing intergenerational transmission of obesity by helping parents to maintain a healthy weight is an essential target for public health.

Long-term efficacy of group-based treatment for childhood obesity compared with routinely given individual counselling.

OBJECTIVE: We investigated the long-term efficacy of two childhood obesity treatment programs, routine counselling (two appointments for children) and group treatment (15 sessions separately for children and parents) in a randomised controlled trial. As published earlier, group treatment was more effective than routine counselling in the treatment of 7-9 year-old obese children in the short term. DESIGN: The children's heights and weights were measured 2 and 3 years after the beginning of the intervention and changes in weight for height, body mass index (BMI) and BMI standard deviation scores were used as outcome measures. RESULTS: There were no significant differences between the treatment arms in the changes of outcome measures from baseline to 2- or 3-years follow-up visits. CONCLUSION: In conclusion, novel efforts are needed for the improvement of the long-term results of childhood obesity treatment programs.

Clinical efficacy of group-based treatment for childhood obesity compared with routinely given individual counseling.

OBJECTIVE: The aim of the study was to compare the efficacy of group treatment stressing a health-promoting lifestyle with routine counseling in the treatment of childhood obesity. DESIGN AND SUBJECTS: Seventy obese children (weight for height 115-182%) aged 7-9 years were randomized either to routine counseling (two appointments for children) or to family-based group treatment (15 separate sessions for parents and children). These sessions included nutrition education, physical activity education and behavioral therapy. OUTCOME MEASURES: Children's weights and heights were measured at baseline, after the 6-month intervention and after the 6-month follow-up. The change of weight for height based on Finnish growth charts was used as the primary, and changes in body mass index (BMI) and BMI standard deviation scores (BMI-SDS) as secondary outcome measures. RESULTS: Children attending the group treatment lost more weight for height (6.8%) than children receiving routine counseling (1.8%) (P=0.001). The difference was significant when the data were analyzed in four groups by the cut-off limits of 0, -5 and -10% for the change in weight for height. The respective decreases in BMI were 0.8 vs 0.0 (P=0.003) and in BMI-SDS 0.3 vs 0.2 (P=0.022). The results remained similar in adjusted analyses. Both group and routine programs were feasible with a high, 87-99%, participation rate in sessions and appointments and very low, 3% or less, attrition rate from the programs. Six months after the intervention, beneficial effects were partly lost, but for changes in weight for height and BMI, the differences between the two treatment programs still were significant, and for BMI-SDS, there was a trend. CONCLUSIONS: Family-based group treatment that stresses a health-promoting lifestyle and is given separately for parents and children, offers an effective mode of therapy to treat obese school-aged children.

Parent-child relationship of physical activity patterns and obesity.

OBJECTIVE: To study differences in physical activity between normal-weight and obese children, as well as parent-child associations of obesity and physical activity. DESIGN: Cross-sectional study. SUBJECTS: 129 obese children (67 girls and 62 boys), 142 normal-weight controls (81 boys and 61 girls), and mothers (n = 245) and fathers (n = 222) of the children. METHODS: Physical activity was assessed by a 3-day physical activity record (children and parents), by a questionnaire (children), and by one question on habitual physical activity (parents). The data were analysed by stepwise linear and logistic regressions. Obesity was assessed from relative weight (children) and BMI (parents). RESULTS: Parent inactivity was a strong and positive predictor of child inactivity (beta-coefficients 0.25 and 0.16, P<0.001, for mother and father inactivity, respectively). Scores of parent activity were somewhat weaker predictors of child vigorous activity hours and total physical activity level (beta-coefficients 0.13-0.25, P = 0.003-0.08). Child obesity was negatively associated with child habitual physical activity (odds ratio 0.88, P<0.001). In addition, parent obesity (body mass index > or =30 kg/m2) was another strong predictor of child obesity (odds ratio 2.38-3.50, P<0.002). CONCLUSIONS: The present study underscores the parents' role in childhood activity patterns and obesity. A novel finding was that the parent-child relationship of inactivity appeared to be stronger than that of vigorous activity. Hence, parents who want to reduce their children's inactivity may have to pay attention to their own lifestyle.

Diet and nutritional status in children with cow's milk allergy.

OBJECTIVE: The purpose of this study was to investigate the nutritional status and adequacy of the diet in the children with cow's milk allergy (CMA). DESIGN AND SUBJECTS: 18 children with challenge-proven CMA and 20 healthy children were investigated in the cross-sectional study. The mean (range) age of the children was 2.0 (1.0-3.5) years. The healthy children were matched by age and sex with the allergic children. Food consumption data were collected by the six-day food record method. The weight and height of both groups and laboratory indices of children with CMA were measured to study the nutritional status. RESULTS: Thirteen (72%) of the children with CMA used a formula based on soy or casein hydrolysate. The amounts of these formulas consumed by the allergic children were smaller (371 ml vs 559 ml; P < 0.01) than the amount of milk and milk products consumed by the healthy children. There was no difference in energy intake between the groups. Protein intake by the allergic children was lower (39 g vs 48 g; P < 0.05) and fat intake higher (47 g vs 39 g; P < 0.05) than that of the healthy children. The mean intakes of energy and zinc in both groups, and the intake of iron in the healthy children, were below the RDAs. The diet in the allergic children was supplemented with calcium and in 11 children with vitamins A and D. Fourteen healthy children had vitamin A and D supplement. The height-for-age was lower in the children with CMA (-0.6 vs +0.2 s.d. units; P < 0.05) as compared to healthy children. Serum biochemical measurements were within the reference range in the allergic children, and no nutritional problems were found. CONCLUSIONS: For the eliminated foods children with CMA substituted nutritionally corresponding food items which resulted in adequate mean intakes of nutrients. Specific formulas contributed substantially to the nutrient intake. Children with CMA need intensive nutritional counselling and regular monitoring of growth.

Validation of a short dietary questionnaire and a qualitative fat index for the assessment of fat intake.

In connection with a population-based study on familial and non-familial determinants of serum total cholesterol an interviewer-administered short questionnaire, including 21 food items, and a qualitative fat index based on four questions were developed. Subjects for the validation study, 51 women and 31 men, aged 16-71 years, were selected from the population-based study (n = 892). The short questionnaire and the qualitative fat index were validated with a 3 day food record as the reference method. The short questionnaire captured 90-97% of the mean intakes of total fat, saturated, monounsaturated and polyunsaturated fatty acids and cholesterol. The Pearson correlation coefficients between the fat intakes based on the questionnaire and the diet records were strongest for the intake of total fat (r = 0.80). The qualitative fat index was based on four questions concerning type of fat: the higher the scores the higher the intakes of polyunsaturated fatty acids. The Spearman correlation coefficients between the qualitative fat index and the intakes based on the diet records were -0.55 for saturated, 0.34 for monounsaturated and 0.52 for polyunsaturated fatty acids. The respective correlation for the P/S ratio (total amounts of polyunsaturated fatty acids/saturated fatty acids) and the PM/S ratio (total amounts of polyunsaturated and monounsaturated fatty acids/saturated fatty acids) were 0.50 and 0.53. An inverse association between serum total cholesterol and the qualitative fat index was found in the whole study population, suggesting the impact of dietary fat on serum cholesterol in this study population. In conclusion, the short questionnaire proved to be accurate in measuring the intake of different fatty acids at the group level, whereas the simpler fat index measured the quality of fat quite well.

Long-term effects of weight reduction on serum lipids and plasma insulin in obese children.

The long-term metabolic effects of weight reduction on serum lipids and plasma insulin were evaluated in 32 obese children with a mean (+/- SD) relative weight of 160.9 +/- 20.1% before and after active treatment for 1 y and after observation for another 4 y. The obese subjects had higher serum triglyceride and plasma insulin concentrations initially but lower high-density-lipoprotein (HDL)-cholesterol concentrations and a lower ratio of HDL cholesterol to total cholesterol (TC) than 29 normal-weight children. There was a decrease of 15.8% in relative weight over the first year with a parallel decrease in serum triglyceride and plasma insulin, whereas HDL cholesterol and the ratio of HDL cholesterol to TC increased (P < 0.001). These changes remained stable over the second year. At 5 y the obese subjects still had a reduced weight (12.8% lower than initially) and higher HDL cholesterol. These results indicate that weight reduction in obese children is associated with a change in serum lipids toward normal and reduced peripheral hyperinsulinemia.

Weight loss, body composition and risk factors for cardiovascular disease in obese children: long-term effects of two treatment strategies.

Two treatment strategies were compared to determine their effects on weight loss, body composition and risk factors for cardiovascular disease (CVD) in 32 obese children (relative weight > 120%) aged 6-15 years. Modes of therapy included individual (Group I) or group treatment (Group II). The children were treated for 1 year and observed during the second year. Relative body weight decreased by 16.6% in Group I (p < 0.001) and by 15.8% (p < 0.01) in Group II during the first year; in both groups the lower relative body weight was maintained during the year of observation. No changes were observed in linear growth or lean body mass. Weight reduction was accompanied by increased high-density lipoprotein cholesterol (HDL-C) levels, increased ratio of HDL-C to total cholesterol, and reduced triglyceride concentrations in both groups. Fasting plasma insulin concentrations decreased significantly in Group I. In conclusion, intensive treatment produced significant weight loss, improved serum lipid profile and reduced hyperinsulinemia. These changes, if sustained, may reduce the risk of CVD later in life.

Predictors of weight reduction in obese children.

The characteristics of successful and unsuccessful weight losers were studied in 48 obese children (relative weight > 120%) aged 6-15 years who were treated for 1 year and observed for another. Successful weight loss was defined as a decrease in relative weight of > or = 0.8 in the standard deviation score (SDS) at the end of the study. Thirty-two children were treated intensively, 16 with individual counselling and 16 in group therapy, while the remaining 16 children were treated conventionally in a school health care setting. Three children dropped out of the study. In 2 years, the relative body weight decreased by 1.7 SDS in those who were successful weight losers (n = 21, 47%), but remained unchanged in those who had been unsuccessful (n = 24). At baseline there were no differences between the two groups. At 1 year, the successful weight losers had lower body weight (P < 0.05), less lean body mass (0.05) and lower fasting concentrations of circulating insulin (P < 0.01) than the unsuccessful children did. A decrease in mothers' body mass index (BMI) and in documented energy intake over the first year as well as energy intake at 1 year were significant predictors of success at 2 years. The combination of these three predictors resulted in correct classification of about 3/4 of the cases as successful or unsuccessful weight losers. It appears, however, difficult to develop a clinically useful model for predicting the treatment outcome in obese children.

Long-term weight control in obese children: persistence of treatment outcome and metabolic changes.

Maintenance of achieved weight loss and clinical and biochemical changes were studied in 48 obese children (relative weight greater than 120%) over a three-year period after active treatment for one year and initial observation for another year. The control group comprised 29 normal weight children (relative weight less than 120%). The children were 6-16 years old at the beginning of the study. The successful weight loser was defined as a child with a decrease of at least 10% in relative weight at the end of the initial two year study period. Twenty-two subjects (49%) were treated successfully while 23 children were unsuccessful. Three obese children dropped out of the study. In successful children the relative body weight decreased by 24.7% (P less than 0.001) during the initial two-year period, and the lower body weight was maintained during the subsequent observation. The relative height also decreased significantly in the successful subjects but was still normal at the end of the study. Success in weight reduction was associated with increased HDL-cholesterol (HDL-C) levels, increased ratio of HDL-C to total cholesterol and reduced concentrations of triglyceride and plasma insulin. All of these changes were maintained throughout the five year study period. In normal weight children concentrations of serum lipids and plasma insulin remained unchanged during the five years. In conclusion, initial success in weight loss was associated with long-term favourable changes in the serum lipid profile and reduced hyperinsulinemia. A majority of the initially successful weight losers (14 of 22) managed to maintain their reduced weight up to five years.

Long-term effects of dietary counselling on nutrient intake and weight loss in obese children.

The effects of dietary counselling on food and nutrient intake and weight loss were studied over a two-year period in 32 obese children (relative weight greater than 120%) with intensive treatment (Group I) and in 16 obese children treated in a school health-care setting (Group II). The control group (Group III) comprised 29 normal-weight children (relative weight less than 120%). The children were 6-16 years old. The obese children were treated for one year and observed for another year. Food consumption data were collected by a four-day food record method. At baseline there were no differences in food consumption or nutrient intake between obese and normal-weight children. During treatment the children in Group I reduced their mean daily fat intake (P less than 0.001) and this reduction was maintained throughout the observation period. In Groups II and III no change was observed in mean daily fat intake. The relative body weight decreased by 16.2% in Group I (P less than 0.001) during the first year and the lower body weight was maintained during the observation year. No significant weight reduction was observed in Group II. The decrease in energy intake was significantly correlated with the reduction in body fat mass over the first year (rs = 0.50; P = 0.05, n = 16) in obese children passing through their pubertal growth spurt and to the reduction in relative weight over the first year (rs = 0.90; P less than 0.05, n = 5), as well as to the decrease in fat mass over the second year (rs = 0.70; P less than 0.05, n = 11) in adolescents beyond their growth spurt. In conclusion, intensive treatment resulted in decreased fat intake and also led to a reduction in relative weight, whereas a conventional approach appeared to be ineffective with regard to nutrient intake and weight loss.

[Treatment of obesity in children and adolescents]. / Behandling av obesitet hos barn och ungdomar.

Weight development was compared in 48 obese children, 6-15 years of age, who during a 12-month period underwent treatment either individually, in groups, or as part of the school health services. Those treated intensively by groups or individually manifested a relative weight reduction of 10-14 per cent at the 12-month follow-up, as compared with seven per cent in those treated by the school health services, but at five-year follow-up relative weight reduction was much the same in all three categories. Thus, group treatment of childhood obesity would appear to be the best alternative as it yields fairly rapid relative weight reduction with beneficial metabolic changes, and entails less investment in personnel resources.

Combined oral and home parenteral nutrition for the short bowel syndrome.

Combined parenteral and peroral nutrition is necessary when a large small bowel resection leads to inadequate intestinal absorption and starvation. We report the case of a 17-year old schoolgirl in whom, following a rupture of the spleen and splenectomy, extensive small bowel necrosis necessitated small bowel resection from the lig. Treitz to the terminal ileum saving the last ten centimeters of the ileum. The serious starvation which developed after the operation was first treated with a one-month course of parenteral nutrition in hospital. Thereafter the patient took care of the infusions herself. Home parenteral nutrition took place during a 10-12 h overnight period 5 times a week. The proportion of peroral dietary intake was increased gradually during the first year, after which a 1 to 1 ratio between peroral and parenteral intake of energy and protein was maintained. The patient's subjective and objective well-being after two-years' of follow-up is good. Regular examinations at 3-6 month intervals are needed for the maintenance of adequate nutritional replacement.