Sleep behavioral outcomes of school-based interventions for promoting sleep health in children and adolescents aged 5 to 18 years: a systematic review.

Study Objectives: Insufficient sleep is common among children and adolescents, and can contribute to poor health. School-based interventions potentially could improve sleep behavior due to their broad reach, but their effectiveness is unclear. This systematic review focused on the effects of school-based interventions on sleep behavior among children and adolescents aged 5 to 18 years. Methods: Five electronic databases were searched for randomized controlled trials of sleep health interventions initiated or conducted in school settings and in which behavioral sleep outcomes were measured. Cochrane risk of bias tools were used to assess study quality. Results: From the 5303 database records and two papers from other sources, 21 studies (22 papers) met the inclusion criteria for this review. These studies involved 10 867 children and adolescents at baseline from 13 countries. Most studies (n = 15) were conducted in secondary schools. Sleep education was the most common intervention, either alone (n = 13 studies) or combined with other initiatives (stress management training, n = 2; bright light therapy, n = 1; health education, n = 1). Interventions were typically brief in terms of both the intervention period (median = 4 weeks) and exposure (median = 200 minutes). Behavioral outcomes included actigraphy-measured and self-reported sleep patterns, and sleep hygiene. All outcomes had high risk of bias or some concerns with bias. Sleep education interventions were typically ineffective. Later school start times promoted longer sleep duration over 1 week (1 study, high risk of bias). Conclusions: Current evidence does not provide school-based solutions for improving sleep health, perhaps highlighting a need for complex, multi-component interventions (e.g. whole-of-school approaches) to be trialed.

Clinical practice guidelines for the management of overweight and obesity published internationally: A scoping review.

With the increasing prevalence of obesity placing additional demands on healthcare systems, many jurisdictions and professional bodies have developed clinical practice guidelines to support practitioners in the management of people with overweight and obesity. This scoping review aimed to identify key features of contemporary guidelines for the clinical management of overweight and obesity. Searches of MEDLINE, Guidelines International Network's international guidelines library, and other grey literature sources identified 38 guidelines of 18 countries and one region published since 2010. Guidelines were developed by committees (n = 36, 95%) that comprised knowledgeable experts (n = 36, 95%) and were multidisciplinary (n = 33, 87%), with limited consumer representation (n = 11, 29%). Guideline documentation incorporated review questions (n = 23, 61%), systematic reviews (n = 25, 66%), evidence grading systems (n = 33, 87%), processes for reaching consensus (n = 19, 50%), and guideline review details (n = 28, 74%). Treatment approaches included in most guidelines were nutrition and physical activity (n = 38, 100%), psychology (n = 37, 97%), pharmacotherapy (n = 32, 84%), and bariatric surgery (n = 31, 82%). Most guidelines targeted populations based on age (n = 30, 79%). Guidelines contained recommendations for pregnancy (n = 12, 32%), older adults (n = 9, 24%), and people with eating disorders (n = 8, 21%). Future guidelines would benefit from involvement of consumers including groups known to be at increased risk of overweight and obesity, targeted guidance for at risk groups, and consideration of weight bias and stigma.

Using the Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM) Approach to Assess the Strength of Evidence on Associations between Dietary Patterns and All-Cause Mortality.

Dietary guidelines should be underpinned by high-quality evidence. Quality assessment methods that reflect traditional evidence hierarchies prioritise evidence from randomised controlled trials (RCTs). The Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM) approach is an alternative quality assessment method for research questions that for practical and/or ethical reasons, cannot be answered using RCTs. The aim of this study was to investigate how the HEALM approach could be used to assess the strength of evidence on associations between dietary patterns and all-cause mortality (a research question that is difficult to answer using RCTs). Two data sources were used: an existing systematic review of dietary patterns and all-cause mortality that synthesised evidence from observational studies; and an overview of reviews that was conducted to summarise relevant evidence from mechanistic and intervention studies. A set of four criteria were developed and used in the application of HEALM. Using different datasets in combination, the strength of evidence was rated as 'Grade B: moderate/suggestive' or 'Grade C: insufficient/inconclusive'. HEALM is a novel approach for integrating and assessing the strength of evidence from mechanistic, intervention, and observational studies. Further research is needed to address the practical challenges that were identified in the application of HEALM.

Mums on the Move: A pilot randomised controlled trial of a home-based physical activity intervention for mothers at risk of postnatal depression.

BACKGROUND: Postnatal women are commonly physically inactive, and, when coupled with depressive symptoms, barriers to physical activity can be heightened. This study aimed to 1) examine the feasibility and acceptability of a multi-component home-based physical activity intervention delivered to mothers at risk of postnatal depression, and 2) examine changes in health behaviours (physical activity, sedentary behaviour, sleep, diet) and indicators of mental health. METHODS: Sixty-two mothers (3 - 9 months postpartum) who at baseline were insufficiently active and experiencing heightened depressive symptoms were recruited into a 12-week randomised controlled trial in 2018. Participants were randomised into either a) Intervention group (receiving a theoretically underpinned multi-component program including free exercise equipment at home, access to smartphone web-app, and an online forum); or b) Control group (usual routine). Primary outcomes were program feasibility and acceptability. Secondary outcomes included self-reported and accelerometer-assessed physical activity and sedentary behavior, sleep, diet, determinants of physical activity, and mental health (depressive and anxiety symptoms), measured at baseline and follow-up (12-weeks), with self-reported physical activity, sedentary behaviour and depressive symptoms also measured at weeks 4 and 8. Qualitative data was analysed following inductive content analysis, and quantitative data using linear mixed models. RESULTS: Exercise equipment use in the home was shown to be a feasible strategy to re-engage postnatal women in physical activity. Other components of the program (e.g. web-app, online forum) had low compliance. The program had high acceptability, predominately due to its accessibility, flexibility and ability to overcome key barriers to physical activity. The program resulted in improvements in short-term self-reported physical activity (increased 162min/week at 4 weeks, 95% CI: 37.7, 286.2), behavioural skills (B=0.4, 95% CI: 0.0, 0.8) and perceived barriers to physical activity. However, accelerometer measured physical activity decreased in the intervention group, compared to control group at week 12 (B=-1.3, 95% CI:-2.5, -0.1). There were no changes in other outcomes. CONCLUSIONS: A home-based physical activity program involving free exercise equipment is acceptable and feasible amongst women experiencing heightened postnatal depressive symptoms. Such programs may be effective in increasing engagement in physical activity, yet additional strategies may be needed to enhance maintenance of physical activity and improvements in mental health.

An evaluation of SecondBite® 's FoodMate® , a nutrition education and skill-building program aimed at reducing food insecurity.

ISSUE ADDRESSED: Enhancing food skills and nutrition knowledge may help promote healthy eating among people who are food insecure. FoodMate® by SecondBite® , an 8-week nutrition education and food hamper program, focuses on developing food skills and independence among Australians at risk of/experiencing food insecurity. This study aimed to explore participants' perceptions of and experiences with FoodMate® over a long-term (up to 2 years) follow-up. METHODS: For evaluation purposes, SecondBite® previously collected data from participants prior to (T1) and following completion (T2) of FoodMate® . This paper reports results from semi-structured telephone interviews conducted in a follow-up study (2016/2017, T3) among 19 adults enrolled in FoodMate® programs delivered in Victoria and New South Wales within the previous two years. Data were analysed using inductive thematic analysis of responses to T3 open-ended questions, and descriptive analysis of closed-ended question responses (T1 vs T2 vs T3). RESULTS: Major qualitative themes included program enjoyment; perceived positive long-term program impact on participants' eating and related attitudes and skills; barriers to cooking; suggested program modifications; and impact on others. In descriptive quantitative analyses, participants' diet; confidence to cook using basic ingredients, follow simple recipes and try new foods; cooking and food-related skills; social engagement and life satisfaction all improved between T1 and T3. CONCLUSIONS: Overall, FoodMate® was well-received and associated with long-term positive changes in a range of outcomes. Wider implementation among vulnerable groups should be considered. SO WHAT?: Future health promotion initiatives could adopt FoodMate® to increase food skills and knowledge among adults experiencing food insecurity.

The association between sedentary behaviour and indicators of stress: a systematic review.

BACKGROUND: Emerging evidence shows sedentary behaviour may be associated with mental health outcomes. Yet, the strength of the evidence linking sedentary behaviour and stress is still unclear. This study aimed to synthesise evidence regarding associations between time spent in sedentary behaviour and stress in adults. METHODS: A systematic search was conducted (January 1990 - September 2019). Following PRISMA guidelines, an evaluation of methodological quality, and best-evidence synthesis of associations between time in sedentary behaviour (including sitting time, TV viewing, computer use) and stress were presented. Twenty-six studies reporting on data from n = 72,795 people (age 18-98y, 62.7% women) were included. RESULTS: Across the studies (n = 2 strong-, n = 10 moderate- and n = 14 weak-quality), there was insufficient evidence that overall time spent in sedentary behaviour and sitting time were associated with stress, particularly when using self-report measures of sedentary behaviour or stress. There was strong evidence of no association between TV viewing, or computer use and stress. Amongst studies using objective measures of sedentary behaviour and/or stress there was also strong evidence of no association. CONCLUSION: Although previous research suggested sedentary behaviour may be linked to mental health outcomes such as depression and anxiety, the evidence for an association between various types of sedentary behaviour and stress is limited in quality, and associations are either inconsistent or null. High-quality longitudinal/interventional research is required to confirm findings and determine the direction of associations between different contexts (i.e. purpose) and domains (i.e. leisure, occupational, transport) of sedentary behaviour and stress.

A qualitative study of the drivers of socioeconomic inequalities in men's eating behaviours.

BACKGROUND: Men of low socioeconomic position (SEP) are less likely than those of higher SEP to consume fruits and vegetables, and more likely to eat processed discretionary foods. Education level is a widely used marker of SEP. Few studies have explored determinants of socioeconomic inequalities in men's eating behaviours. The present study aimed to explore intrapersonal, social and environmental factors potentially contributing to educational inequalities in men's eating behaviour. METHODS: Thirty Australian men aged 18-60 years (15 each with tertiary or non-tertiary education) from two large metropolitan sites (Melbourne, Victoria; and Newcastle, New South Wales) participated in qualitative, semi-structured, one-on-one telephone interviews about their perceptions of influences on their and other men's eating behaviours. The social ecological model informed interview question development, and data were examined using abductive thematic analysis. RESULTS: Themes equally salient across tertiary and non-tertiary educated groups included attitudes about masculinity; nutrition knowledge and awareness; 'moralising' consumption of certain foods; the influence of children on eating; availability of healthy foods; convenience; and the interplay between cost, convenience, taste and healthfulness when choosing foods. More prominent influences among tertiary educated men included using advanced cooking skills but having relatively infrequent involvement in other food-related tasks; the influence of partner/spouse support on eating; access to healthy food; and cost. More predominant influences among non-tertiary educated men included having fewer cooking skills but frequent involvement in food-related tasks; identifying that 'no-one' influenced their diet; having mobile worksites; and adhering to food budgets. CONCLUSIONS: This study identified key similarities and differences in perceived influences on eating behaviours among men with lower and higher education levels. Further research is needed to determine the extent to which such influences explain socioeconomic variations in men's dietary intakes, and to identify feasible strategies that might support healthy eating among men in different socioeconomic groups.

Can an incentive-based intervention increase physical activity and reduce sitting among adults? the ACHIEVE (Active Choices IncEntiVE) feasibility study.

BACKGROUND: Despite recent interest in the potential of incentivisation as a strategy for motivating healthier behaviors, little remains known about the effectiveness of incentives in promoting physical activity and reducing sedentary behavior, and improving associated health outcomes. This pre-post-test design study investigated the feasibility, appeal and effects of providing non-financial incentives for promoting increased physical activity, reduced sedentary time, and reduced body mass index (BMI) and blood pressure among inactive middle-aged adults. METHODS: Inactive men (n = 36) and women (n = 46) aged 40-65 years were recruited via a not-for-profit insurance fund and participated in a 4 month pre-post design intervention. Baseline and post-intervention data were collected on self-reported physical activity and sitting time (IPAQ-Long), BMI and blood pressure. Participants were encouraged to increase physical activity to 150 mins/week and reduce sedentary behavior by 150 mins/week in progressive increments. Incentives included clothing, recipe books, store gift vouchers, and a chance to win one of four Apple iPad Mini devices. The incentive component of the intervention was supported by an initial motivational interview and text messaging to encourage participants and provide strategies to increase physical activity and reduce sedentary behaviors. RESULTS: Only two participants withdrew during the program, demonstrating the feasibility of recruiting and retaining inactive middle-aged participants. While two-thirds of the sample qualified for the easiest physical activity incentive (by demonstrating 100 mins physical activity/week or 100 mins reduced sitting time/week), only one third qualified for the most challenging incentive. Goals to reduce sitting appeared more challenging, with 43% of participants qualifying for the first incentive, but only 20% for the last incentive. More men than women qualified for most incentives. Mean leisure-time physical activity increased by 252 mins/week (leisure-time), with 65% of the sample achieving at least 150 mins/week; and sitting time decreased by 3.1 h/day (both p < 0.001) between baseline and follow-up. BMI, systolic and diastolic (men only) blood pressure all significantly decreased. Most participants (50-85%) reported finding the incentives and other program components helpful/motivating. CONCLUSIONS: Acknowledging the uncontrolled design, the large pre-post changes in behavioral and health-related outcomes suggest that the ACHIEVE incentives-based behavior change program represents a promising approach for promoting physical activity and reducing sitting, and should be tested in a randomized controlled trial. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry IDACTRN12616000158460 , registered 10/2/16.

ShopSmart 4 Health: results of a randomized controlled trial of a behavioral intervention promoting fruit and vegetable consumption among socioeconomically disadvantaged women.

BACKGROUND: Behavioral interventions show potential for promoting increased fruit and vegetable consumption in the general population. However, little is known about their effectiveness or cost-effectiveness among socioeconomically disadvantaged groups, who are less likely to consume adequate fruit and vegetables. OBJECTIVE: This study investigated the effects and costs of a behavior change intervention for increasing fruit and vegetable purchasing and consumption among socioeconomically disadvantaged women. DESIGN: ShopSmart 4 Health was a randomized controlled trial involving a 3-mo retrospective baseline data collection phase [time (T) 0], a 6-mo intervention (T1-T2), and a 6-mo no-intervention follow-up (T3). Socioeconomically disadvantaged women who were primary household shoppers in Melbourne, Australia, were randomly assigned to either a behavior change intervention arm (n = 124) or a control arm (n = 124). Supermarket transaction (sales) data and surveys measured the main outcomes: fruit and vegetable purchases and self-reported fruit and vegetable consumption. RESULTS: An analysis of supermarket transaction data showed no significant intervention effects on vegetable or fruit purchasing at T2 or T3. Participants in the behavior change intervention arm reported consumption of significantly more vegetables during the intervention (T2) than did controls, with smaller intervention effects sustained at 6 mo postintervention (T3). Relative to controls, vegetable consumption increased by ∼0.5 serving · participant(-1) · d(-1) from baseline to T2 and remained 0.28 servings/d higher than baseline at T3 among those who received the intervention. There was no intervention effect on reported fruit consumption. The behavior change intervention cost A$3.10 (in Australian dollars) · increased serving of vegetables(-1) · d(-1)CONCLUSIONS: This behavioral intervention increased vegetable consumption among socioeconomically disadvantaged women. However, the lack of observed effects on fruit consumption and on both fruit and vegetable purchasing at intervention stores suggests that further investigation of effective nutrition promotion approaches for this key target group is required. The ShopSmart 4 Health trial was registered at www.isrctn.com as ISRCTN48771770.

Nutrition promotion approaches preferred by Australian adolescents attending schools in disadvantaged neighbourhoods: a qualitative study.

BACKGROUND: Links between socioeconomic disadvantage and unhealthy eating behaviours among adolescents are well established. Little is known about strategies that might support healthy eating among this target group. This study aimed to identify potential strategies and preferred dissemination methods that could be employed in nutrition promotion initiatives focussed on improving eating behaviours among socioeconomically disadvantaged adolescents. METHODS: Semi-structured interviews were conducted in 2011 among 22 adolescents (12-15 years) recruited from secondary schools in disadvantaged neighbourhoods in Victoria, Australia. RESULTS: Strategies suggested by adolescents to support healthy eating included increasing awareness about healthy eating; greater cooking involvement; greater parental and peer support; frequent family meal participation; greater parental and peer role-modelling of healthy eating; increased availability of healthy foods and decreased availability of unhealthy foods in homes and schools. Adolescents preferred electronic media, adolescent-specific recipe books, and school-based methods for distributing nutrition promotion messages and strategies. CONCLUSIONS: A number of suggested strategies and methods identified in the present investigation have been employed with success in previous nutrition promotion interventions targeting socioeconomically disadvantaged adolescents. The present study also contributes novel insights into potential strategies and methods that could be employed in initiatives aiming to improve eating behaviours in this vulnerable group, and particularly highlights the importance of incorporating strategies involving parents and modifying the home food environment.

Socio-economic differences in predictors of frequent dairy food consumption among Australian adolescents: a longitudinal study.

OBJECTIVE: Sufficient dairy food consumption during adolescence is necessary for preventing disease. While socio-economically disadvantaged adolescents tend to consume few dairy foods, some eat quantities more in line with dietary recommendations despite socio-economic challenges. Socio-economic variations in factors supportive of adolescents' frequent dairy consumption remain unexplored. The present study aimed to identify cross-sectional and longitudinal associations between intrapersonal, social and environmental factors and adolescents' frequent dairy consumption at baseline and two years later across socio-economic strata, and to examine whether socio-economic position moderated observed effects. DESIGN: Online surveys completed at baseline (2004-2005) and follow-up (2006-2007) included a thirty-eight-item FFQ and questions based on social ecological models examining intrapersonal, social and environmental dietary influences. SETTING: Thirty-seven secondary schools in Victoria, Australia. SUBJECTS: Australian adolescents (n 1201) aged 12-15 years, drawn from a sub-sample of 3264 adolescents (response rate=33%). RESULTS: While frequent breakfast consumption was cross-sectionally associated with frequent dairy consumption among all adolescents, additional associated factors differed by socio-economic position. Baseline dairy consumption longitudinally predicted consumption at follow-up. No further factors predicted frequent consumption among disadvantaged adolescents, while four additional factors were predictive among advantaged adolescents. Socio-economic position moderated two predictors; infrequently eating dinner alone and never purchasing from school vending machines predicted frequent consumption among advantaged adolescents. CONCLUSIONS: Nutrition promotion initiatives aimed at improving adolescents' dairy consumption should employ multifactorial approaches informed by social ecological models and address socio-economic differences in influences on eating behaviours; e.g., selected intrapersonal factors among all adolescents and social factors (e.g., mealtime rules) among advantaged adolescents.

Longitudinal predictors of frequent vegetable and fruit consumption among socio-economically disadvantaged Australian adolescents.

Adequate vegetable and fruit consumption is necessary for preventing nutrition-related diseases. Socio-economically disadvantaged adolescents tend to consume relatively few vegetables and fruits. However, despite nutritional challenges associated with socio-economic disadvantage, a minority of adolescents manage to eat vegetables and fruit in quantities that are more in line with dietary recommendations. This investigation aimed to identify predictors of more frequent intakes of fruits and vegetables among adolescents over a 2-year follow-up period. Data were drawn from 521 socio-economically disadvantaged (maternal education ≤Year 10 of secondary school) Australian adolescents aged 12-15 years. Participants were recruited from 37 secondary schools and were asked to complete online surveys in 2004/2005 (baseline) and 2006/2007 (follow-up). Surveys comprised a 38-item FFQ and questions based on Social Ecological models examining intrapersonal, social and environmental influences on diet. At baseline and follow-up, respectively, 29% and 24% of adolescents frequently consumed vegetables (≥2 times/day); 33% and 36% frequently consumed fruit (≥1 time/day). In multivariable logistic regressions, baseline consumption strongly predicted consumption at follow-up. Frequently being served vegetables at dinner predicted frequent vegetable consumption. Female sex, rarely purchasing food or drink from school vending machines, and usually being expected to eat all foods served predicted frequent fruit consumption. Findings suggest nutrition promotion initiatives aimed at improving eating behaviours among this at-risk population and should focus on younger adolescents, particularly boys; improving adolescent eating behaviours at school; and encouraging families to increase home availability of healthy foods and to implement meal time rules.

Predictors of high-energy foods and beverages: a longitudinal study among socio-economically disadvantaged adolescents.

OBJECTIVE: While socio-economically disadvantaged adolescents tend to have poor dietary intakes, some manage to eat healthily. Understanding how some disadvantaged adolescents restrict high-energy foods and beverages may inform initiatives promoting healthier diets among this population. The present investigation aimed to: (i) identify disadvantaged adolescents' high-energy food and beverage intakes; and (ii) explore cross-sectional and longitudinal associations between intrapersonal, social and environmental factors and disadvantaged adolescents' high-energy food intakes. DESIGN: Longitudinal online surveys were completed at baseline (2004-2005) and follow-up (2006-2007), each comprising a thirty-eight-item FFQ and questions examining intrapersonal, social and environmental factors. SETTING: Thirty-seven secondary schools in metropolitan and non-metropolitan Victoria, Australia. SUBJECTS: Of 1938 adolescents aged 12-15 years participating at both time points, 529 disadvantaged adolescents (whose mothers had low education levels) were included in the present investigation. RESULTS: At baseline and follow-up, respectively 32% and 39% of adolescents consumed high-energy foods less frequently (≤2 high-energy food meals/week); 61% and 65% consumed high-energy beverages less frequently (≤1 time/d). More girls than boys had less frequent high-energy food intakes, and baseline consumption frequency predicted consumption frequency at follow-up. Adolescents with less frequent consumption of high-energy foods and beverages seldom ate fast food for main meals, reported reduced availability of high-energy foods at home and were frequently served vegetables at dinner. CONCLUSIONS: Nutrition promotion initiatives could help improve disadvantaged adolescents' eating behaviours by promoting adolescents and their families to replace high-energy meals with nutritious home-prepared meals and decrease home availability of high-energy foods in place of more nutritious foods.