Pharmacological Interventions for the Prevention of Antipsychotic-Induced Weight Gain in People With Schizophrenia: A Cochrane Systematic Review and Meta-Analysis.

Patients with schizophrenia are burdened by higher rates of obesity, cardiovascular disease and reduced life expectancy than the general population. In addition to illness, genetic and lifestyle factors, the associated weight gain and metabolic adverse effects of antipsychotic (AP) medications are known to exacerbate and accelerate these cardiometabolic problems significantly. Given the detrimental consequences of weight gain and other metabolic disturbances, there is an urgent need for safe and effective strategies to manage these issues as early on as possible. This review summarizes the literature of adjunctive pharmacological interventions aimed at preventing AP-induced weight gain.

Pharmacological interventions for prevention of weight gain in people with schizophrenia.

BACKGROUND: Antipsychotic-induced weight gain is an extremely common problem in people with schizophrenia and is associated with increased morbidity and mortality. Adjunctive pharmacological interventions may be necessary to help manage antipsychotic-induced weight gain. This review splits and updates a previous Cochrane Review that focused on both pharmacological and behavioural approaches to this problem. OBJECTIVES: To determine the effectiveness of pharmacological interventions for preventing antipsychotic-induced weight gain in people with schizophrenia. SEARCH METHODS: The Cochrane Schizophrenia Information Specialist searched Cochrane Schizophrenia's Register of Trials on 10 February 2021. There are no language, date, document type, or publication status limitations for inclusion of records in the register. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) that examined any adjunctive pharmacological intervention for preventing weight gain in people with schizophrenia or schizophrenia-like illnesses who use antipsychotic medications. DATA COLLECTION AND ANALYSIS: At least two review authors independently extracted data and assessed the quality of included studies. For continuous outcomes, we combined mean differences (MD) in endpoint and change data in the analysis. For dichotomous outcomes, we calculated risk ratios (RR). We assessed risk of bias for included studies and used GRADE to judge certainty of evidence and create summary of findings tables. The primary outcomes for this review were clinically important change in weight, clinically important change in body mass index (BMI), leaving the study early, compliance with treatment, and frequency of nausea. The included studies rarely reported these outcomes, so, post hoc, we added two new outcomes, average endpoint/change in weight and average endpoint/change in BMI. MAIN RESULTS: Seventeen RCTs, with a total of 1388 participants, met the inclusion criteria for the review. Five studies investigated metformin, three topiramate, three H2 antagonists, three monoamine modulators, and one each investigated monoamine modulators plus betahistine, melatonin and samidorphan. The comparator in all studies was placebo or no treatment (i.e. standard care alone). We synthesised all studies in a quantitative meta-analysis. Most studies inadequately reported their methods of allocation concealment and blinding of participants and personnel. The resulting risk of bias and often small sample sizes limited the overall certainty of the evidence. Only one reboxetine study reported the primary outcome, number of participants with clinically important change in weight. Fewer people in the treatment condition experienced weight gains of more than 5% and more than 7% of their bodyweight than those in the placebo group (> 5% weight gain RR 0.27, 95% confidence interval (CI) 0.11 to 0.65; 1 study, 43 participants; > 7% weight gain RR 0.24, 95% CI 0.07 to 0.83; 1 study, 43 participants; very low-certainty evidence). No studies reported the primary outcomes, 'clinically important change in BMI', or 'compliance with treatment'. However, several studies reported 'average endpoint/change in body weight' or 'average endpoint/change in BMI'. Metformin may be effective in preventing weight gain (MD -4.03 kg, 95% CI -5.78 to -2.28; 4 studies, 131 participants; low-certainty evidence); and BMI increase (MD -1.63 kg/m2, 95% CI -2.96 to -0.29; 5 studies, 227 participants; low-certainty evidence). Other agents that may be slightly effective in preventing weight gain include H2 antagonists such as nizatidine, famotidine and ranitidine (MD -1.32 kg, 95% CI -2.09 to -0.56; 3 studies, 248 participants; low-certainty evidence) and monoamine modulators such as reboxetine and fluoxetine (weight: MD -1.89 kg, 95% CI -3.31 to -0.47; 3 studies, 103 participants; low-certainty evidence; BMI: MD -0.66 kg/m2, 95% CI -1.05 to -0.26; 3 studies, 103 participants; low-certainty evidence). Topiramate did not appear effective in preventing weight gain (MD -4.82 kg, 95% CI -9.99 to 0.35; 3 studies, 168 participants; very low-certainty evidence). For all agents, there was no difference between groups in terms of individuals leaving the study or reports of nausea. However, the results of these outcomes are uncertain given the very low-certainty evidence. AUTHORS' CONCLUSIONS: There is low-certainty evidence to suggest that metformin may be effective in preventing weight gain. Interpretation of this result and those for other agents, is limited by the small number of studies, small sample size, and short study duration. In future, we need studies that are adequately powered and with longer treatment durations to further evaluate the efficacy and safety of interventions for managing weight gain.

Healthier movement behavior profiles are associated with higher psychological wellbeing among emerging adults attending post-secondary education.

BACKGROUND: Emerging adulthood is a stressful time fraught with new challenges while attending higher education. Identifying protective factors to help reduce the psychological burden that many will experience during this period is therefore important. This study aimed to identify whether emerging adults attending post-secondary education can be classified into distinct profiles based on their 24-h movement behaviors, evaluate correlates of profile membership, and examine relationships between profile membership and indicators of mental health. METHODS: This cross-sectional study used data from Cycle 1 of the Canadian Campus Wellbeing Survey. Emerging adults (N = 15,080; 67.6 % female; mean age = 20.78 ± 2.00) from 20 post-secondary institutions in Canada self-reported their movement behaviors - moderate-to-vigorous physical activity (MVPA), recreational screen time (ST) and sleep - and completed measures of psychological distress and mental wellbeing. Latent profile analysis was employed. RESULTS: Five profiles were identified: low ST with very high (12.6 %), high (24.4 %) and low MVPA (51.2 %) as well as high ST with high (2.3 %) and low MVPA (9.4 %). Profiles had similar sleep patterns and were thus characterized by differences in MVPA and ST. Several socio-demographic variables were associated with profile membership. Profiles characterized by healthier combinations of MVPA, ST and sleep generally reported more favorable scores for indicators of mental health. LIMITATIONS: Cross-sectional data limits causal inference, whereas self-reports may be biased. CONCLUSIONS: Campus-based interventions should focus on getting students to engage in a healthy balance of physical activity and recreational screen use as it has the potential to reduce the mental health burden on emerging adults attending post-secondary education.

If You Pay, Will They Come? Evaluating the Impact of Subsidies on Cessation Outcomes in the Walk or Run to Quit Program.

Introduction: Exercise interventions may assist smoking cessation attempts. One such publicly available 10-week program, Walk or Run to Quit (WRTQ), demonstrated success in smoking cessation and physical activity (PA) outcomes. However, initial WRTQ participants (2016-2017) were fairly homogenous in their demographic profile. To increase diversity, subsidies for participation were offered in 2018. This study assessed how the subsidies affected participant demographics, running frequency, smoking cessation, intention to quit, and program attendance and completion. Methods: The $70 registration fee was subsidized for 41% of participants in 2018. A pre-postdesign was used, with participants completing surveys on their demographics and smoking and physical activity behaviours. Descriptive statistics compared the year subsidies were available (2018) and unsubsidized years (2016-2017) and subsidized and unsubsidized participants' data from 2018. Results: The 2018 participants had lower average attendance and program completion rates compared to 2016-2017 and no statistically significant differences in demographics or smoking cessation and PA outcomes. There were no differences in smoking cessation, run frequency, or demographic variables between the subsidized and unsubsidized participants in 2018. Conclusions: Offering subsidies did not diversify the participant profile. Subsidies did not have a negative impact on attendance nor primary outcomes. Subsidies may not have addressed barriers that prevented a more diverse sample from participating in WRTQ, such as program location, timing, and design. Equitable access to smoking cessation programs remains essential. As subsidies may play a role in reducing financial barriers disproportionately faced by marginalized groups, the implementation of, and recruitment for, such subsidized programs requires further investigation.

Are early increases in physical activity a behavioral marker for successful antidepressant treatment?

BACKGROUND: The aim of this study was to examine whether changes in physical activity predicted reductions in depression during the 8 weeks of antidepressant treatment with vortioxetine. METHODS: One hundred individuals were recruited for the (THINC-it ®)-sensitivity to change study. Self-reported moderate-to-vigorous physical activity (MVPA) and depression severity were assessed at baseline, week 4 and week 8. Linear mixed model analyses were performed to examine whether increases in MVPA were associated with reduction in depression severity over the course of treatment and hierarchical logistic regression analyses were performed to assess whether treatment response (responders vs. non-responders) at week 8 was predicted by early change in physical activity (MVPA at week 4), after controlling for individuals' demographics (sex, age, race, education level, BMI) and baseline MVPA and depression severity. RESULTS: After controlling for individuals' demographics, a significant increase in MVPA predicted reduction in depression severity, ß = -2.06, 95% CI -3.18, -0.94, p <0.001. Individuals with more physical activity at week 4 relative to baseline had higher odds of treatment response at endpoint, OR 1.97, 95% CI 1.11 - 3.48, p <0.05. Twenty-one percent of total variance of depression severity was explained by change in MVPA. CONCLUSIONS: The study suggests that early increases in physical activity may be a behavioral marker of antidepressant treatment response. The inclusion of physical activity measures in future clinical treatment trials of depression is recommended to explore whether changes in physical activity mediate or moderate reductions in depression severity associated with the primary treatment.

Exercise interventions for smoking cessation.

BACKGROUND: Taking regular exercise, whether cardiovascular-type exercise or resistance exercise, may help people to give up smoking, particularly by reducing cigarette withdrawal symptoms and cravings, and by helping to manage weight gain. OBJECTIVES: To determine the effectiveness of exercise-based interventions alone, or combined with a smoking cessation programme, for achieving long-term smoking cessation, compared with a smoking cessation intervention alone or other non-exercise intervention. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register for studies, using the term 'exercise' or 'physical activity' in the title, abstract or keywords. The date of the most recent search was May 2019. SELECTION CRITERIA: We included randomised controlled trials that compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme alone or another non-exercise control group. Trials were required to recruit smokers wishing to quit or recent quitters, to assess abstinence as an outcome and have follow-up of at least six months. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison, as either smoking cessation or relapse prevention. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models. MAIN RESULTS: We identified 24 eligible trials with a total of 7279 adult participants randomised. Two studies focused on relapse prevention among smokers who had recently stopped smoking, and the remaining 22 studies were concerned with smoking cessation for smokers who wished to quit. Eleven studies were with women only and one with men only. Most studies recruited fairly inactive people. Most of the trials employed supervised, group-based cardiovascular-type exercise supplemented by a home-based exercise programme and combined with a multi-session cognitive behavioural smoking cessation programme. The comparator in most cases was a multi-session cognitive behavioural smoking cessation programme alone. Overall, we judged two studies to be at low risk of bias, 11 at high risk of bias, and 11 at unclear risk of bias. Among the 21 studies analysed, we found low-certainty evidence, limited by potential publication bias and by imprecision, comparing the effect of exercise plus smoking cessation support with smoking cessation support alone on smoking cessation outcomes (RR 1.08, 95% CI 0.96 to 1.22; I2 = 0%; 6607 participants). We excluded one study from this analysis as smoking abstinence rates for the study groups were not reported. There was no evidence of subgroup differences according to the type of exercise promoted; the subgroups considered were: cardiovascular-type exercise alone (17 studies), resistance training alone (one study), combined cardiovascular-type and resistance exercise (one study) and type of exercise not specified (two studies). The results were not significantly altered when we excluded trials with high risk of bias, or those with special populations, or those where smoking cessation intervention support was not matched between the intervention and control arms. Among the two relapse prevention studies, we found very low-certainty evidence, limited by risk of bias and imprecision, that adding exercise to relapse prevention did not improve long-term abstinence compared with relapse prevention alone (RR 0.98, 95% CI 0.65 to 1.47; I2 = 0%; 453 participants). AUTHORS' CONCLUSIONS: There is no evidence that adding exercise to smoking cessation support improves abstinence compared with support alone, but the evidence is insufficient to assess whether there is a modest benefit. Estimates of treatment effect were of low or very low certainty, because of concerns about bias in the trials, imprecision and publication bias. Consequently, future trials may change these conclusions.

The Protective Effects of School Connectedness on Substance Use and Physical Activity.

PURPOSE: Cross-sectional evidence suggests that school connectedness is an important correlate of health-related behaviors among adolescents, but prospective studies are needed to strengthen the case for a causal relationship. This study investigated the prospective relationship between school connectedness and four health-related behaviors: cigarette smoking, marijuana use, binge drinking, and physical activity. METHODS: We analyzed 4 years of data from the COMPASS study. Participants included in this analysis were 33,313 students who provided information on sociodemographic, school connectedness, and the four health-related behaviors for at least two consecutive years. Generalized Estimating Equation models were used to examine whether the change in school connectedness scores predicted the change in an individual child's trajectory of health-related behaviors across 9th, 10th, 11th, and 12th grades. RESULTS: As students moved to higher grades, school connectedness decreased, and the likelihood of being a less frequent smoker, marijuana user, and binge drinker, and meeting physical activity guidelines declined. An increase in school connectedness scores was associated with an increased likelihood of meeting physical activity recommendations (OR = 1.06, p < .01), being a less frequent smoker, marijuana user, and binge drinker (OR = 1.30, 1.17, 1.10, respectively; p's < .0001) across the 4 years. CONCLUSIONS: This study provides prospective evidence supporting the protective effects of school connectedness on substance abuse and physical activity, and highlights the importance of fostering school connectedness to support healthy adolescent development.

Active living in Saskatchewan: A review of official community plans.

OBJECTIVE: Municipal policies may have a significant impact on the development of environments that provide sustainable opportunities for individuals to engage in healthy, active lifestyles. Little is known about how explicitly community planning in Canada integrates strategies to promote physical activity. In the context of Active Saskatchewan 2020 (AS2020), the strategic plan of Saskatchewan in motion, such an analysis would create a basis for identifying policy gaps and ongoing monitoring. The objective of this study was to review the official community plan (OCP) of each city in the province of Saskatchewan, Canada and identify policies supportive of physical activity. METHODS: A conventional content analysis was completed of the OCPs of the 17 cities in Saskatchewan. Each OCP was reviewed and text extracted that related to supporting physical activity. Extracted text was thematically organized within and across cities, creating a set of indicators for ongoing monitoring. RESULTS: Overall, 17 indicators were identified. The frequency of inclusion of these indicators within the 17 OCPs varied from 17.6% to 82.4%. The mean frequency of indicators identified per OCP was 7.4. The most commonly included indicators included residential neighbourhood plans associated with active living, downtown cycling and pedestrian plans, and joint-use agreements between communities and schools. CONCLUSIONS: Most Saskatchewan OCPs make little direct reference to policies supportive of physical activity. Impacting community-level policy is an expected outcome of AS2020/Saskatchewan in motion. This study identifies a range of indicators for monitoring this process and highlights potential areas for policy development within OCPs.

Smoking and binge-drinking among adolescents, Ontario, Canada: Does the school neighbourhood matter?

This study examines whether access to alcohol and tobacco around the school relates to higher or lower odds of cigarette smoking and binge-drinking among Ontario high school students. The 2013 Ontario Student Drug Use and Health Survey provides data on self-reported smoking and drinking, individual covariates and subjective socio-economic status for 6142 students (grades 9-12) in Ontario, Canada. Locations of schools were geocoded and 1.6km network buffers defined the school neighbourhoods. Multi-level logistic regression examines individual and school neighbourhood factors with smoking and binge drinking as the dependent variable. Higher density of retail outlets increased the odds of smoking, but not the odds of binge-drinking. Older age, lower SES and being male increased the odds of smoking; while older age and being male also increased the odds of binge-drinking. Lower SES and higher population density decreased the odds of binge-drinking. Proximity to tobacco and alcohol outlets was not significant. Findings showed that a greater number of outlets in the school neighbourhood is significantly associated with higher odds of smoking, but not binge-drinking. School neighbourhood access to tobacco outlets should be considered when formulating policy interventions to reduce smoking for adolescents.

Looking beyond cigarettes: Are Ontario adolescents with asthma less likely to smoke e-cigarettes, marijuana, waterpipes or tobacco cigarettes?

OBJECTIVES: The purpose of this paper is to examine whether high school students in Ontario with asthma smoke cigarettes, waterpipes, marijuana or e-cigarettes more or less than those without asthma. METHODS: The 2013 Ontario Student Drug Use and Health Survey provides self-report data on tobacco cigarettes, waterpipes, marijuana and e-cigarette smoking and asthma rates from 109 high schools in Ontario, Canada. Individual and social characteristics were also collected. Multiple binary logistic regression models measures the association with the various types of smoking in relation to asthma. RESULTS: Adolescents with asthma have higher odds of smoking e-cigarettes or smoking any type including either cigarettes, waterpipes, marijuana or e-cigarettes. Respondents of lower socio-economic status had a higher odds of smoking marijuana or any type. Boys were more likely to smoke waterpipes, e-cigarettes or any type, while students in higher grades had a higher odds of smoking cigarettes, waterpipes, marijuana or any type. CONCLUSIONS: Results from this study suggest that adolescents with asthma have a higher odds of smoking e-cigarettes than those without asthma, but no relationship was found for cigarettes, waterpipes or marijuana. Findings present some new challenges as technology changes how adolescents can smoke. Public health campaigns should target adolescents, especially those with asthma, to raise their awareness of the risks of all types of smoking including e-cigarettes.

Results From Canada's 2016 ParticipACTION Report Card on Physical Activity for Children and Youth.

BACKGROUND: The ParticipACTION Report Card on Physical Activity for Children and Youth is the most comprehensive assessment of child and youth physical activity in Canada and provides an update or "state of the nation" that assesses how Canada is doing at promoting and facilitating physical activity opportunities for children and youth. The purpose of this paper is to summarize the results of the 2016 ParticipACTION Report Card. METHODS: Twelve physical activity indicators were graded by a committee of experts using a process that was informed by the best available evidence. Sources included national surveys, peer-reviewed literature, and gray literature such as government and nongovernment reports and online content. RESULTS: Grades were assigned to Daily Behaviors (Overall Physical Activity: D-; Organized Sport and Physical Activity Participation: B; Active Play: D+; Active Transportation: D; Physical Literacy: D+; Sleep: B; Sedentary Behaviors: F), Settings and Sources of Influence (Family and Peers: C+; School: B; Community and Environment: A-), and Strategies and Investments (Government: B-; Nongovernment: A-). CONCLUSIONS: Similar to previous years of the Report Card, Canada generally received good grades for indicators relating to investment, infrastructure, strategies, policies, and programming, and poor grades for behavioral indicators (eg, Overall Physical Activity, Sedentary Behaviors).

Ten-year trends in overweight/obesity among Ontario middle and high school students and their use in establishing baseline measures for government reduction targets.

OBJECTIVES: Public health concern about increasing levels of child/youth overweight and obesity has resulted in initiatives to address this issue. In 2012, the Ontario Ministry of Health and Long-Term Care (MOHLTC) established a target to reduce childhood obesity by 20% within five years. In this paper, we examine trends and establish baseline levels of overweight/obesity to assess the impacts of population-level interventions. METHODS: We analyzed 10 years (2003-2013) of data accumulated from six cycles of the Ontario Student Drug Use and Health Survey using logistic regression to assess trends in the prevalence of overweight/obesity among middle and high school students. The 2013 data are used to begin monitoring progress toward achieving the MOHLTC target. RESULTS: From 2003 through 2013, the prevalence of overweight/obesity among middle school students in the province remained stable overall and among all subgroups except 7th-grade females, who showed a significant linear decline. Among high school students, the prevalence of overweight/obesity showed a significant linear increase and an increase among 11th graders, females, and 10th- and 11th-grade females specifically. The prevalence remained stable but elevated among 9th- and 12th-grade females as well as among males in all grades. In 2013 (baseline for the MOHLTC target), 25.1% of students in grades 7-12 were overweight or obese, implying a presumed 2018 target of 20.1%. CONCLUSION: Ten-year trends in overweight/obesity indicate stability among males and significant linear increases in some female subgroups. Also, baseline data (2013) will facilitate the monitoring of future interventions aimed at achieving the 2018 MOHLTC target.

The Feasibility of Financial Incentives to Increase Exercise Among Canadian Cardiac Rehabilitation Patients.

PURPOSE: To examine the feasibility of conducting a randomized controlled trial investigating the effectiveness of financial incentives for exercise self-monitoring in cardiac rehabilitation (CR). METHODS: A 12-week, 2 parallel-arm, single-blind feasibility study design was employed. A volunteer sample of CR program graduates was randomly assigned to an exercise self-monitoring intervention only (control; n = 14; mean age ± SD, 62.7 ± 14.6 years), or an exercise self-monitoring plus incentives approach (incentive; n = 13; mean age ± SD, 63.6 ± 11.8 years). Control group participants received a "home-based" exercise self-monitoring program following CR program completion (exercise diaries could be submitted online or by mail). Incentive group participants received the "home-based" program, plus voucher-based incentives for exercise diary submissions ($2 per day). A range of feasibility outcomes is presented, including recruitment and retention rates, and intervention acceptability. Data for the proposed primary outcome of a definitive trial, aerobic fitness, are also reported. RESULTS: Seventy-four CR graduates were potentially eligible to participate, 27 were enrolled (36.5% recruitment rate; twice the expected rate), and 5 were lost to followup (80% retention). Intervention acceptability was high with three-quarters of participants indicating that they would likely sign up for an incentive program at baseline. While group differences in exercise self-monitoring (the incentive "target") were not observed, modest but nonsignificant changes in aerobic fitness were noted with fitness increasing by 0.23 mL·kg-·min- among incentive participants and decreasing by 0.68 mL·kg-·min- among controls. CONCLUSION: This preliminary study demonstrates the feasibility of studying incentives in a CR context, and the potential for incentives to be readily accepted in the broader context of the Canadian health care system.

Development of the Health Incentive Program Questionnaire (HIP-Q) in a cardiac rehabilitation population.

The purpose of this study was to develop a questionnaire to facilitate the design of acceptable financial health incentive programs. A multiphase psychometric questionnaire development method was used. Theoretical and literature reviews and three focus groups generated a pool of content areas and items. New items were developed to ensure adequate content coverage. Field testing was conducted with a convenience sample of cardiac rehabilitation (CR) patients (n = 59) to establish face and construct validity (p = 0.021) and reliability (intraclass coefficients = 0.42-0.87). The final questionnaire is comprised of 23 items. This questionnaire builds on previous attempts to explore acceptability by sampling a wider range of instrumental and affective attitudes and by measuring the effect of program features on the likelihood of incentive program participation. Future research is now needed to examine whether tailoring incentives to preferences assessed by the questionnaire improves uptake and effectiveness.

MoveU? Assessing a Social Marketing Campaign to Promote Physical Activity.

OBJECTIVE: MoveU is a social marketing initiative aimed at increasing moderate-to-vigorous physical activity (MVPA) among undergraduate students. Using the Hierarchy of Effects model (HOEM), this study identified awareness of MoveU and examined associations between awareness, outcome expectations, self-efficacy, intentions, and MVPA. PARTICIPANTS: Students (N = 2,784) from a Canadian university in March 2013. METHODS: A secondary analysis of the National College Health Assessment-II survey and measures specific to the MoveU campaign. The main associations were examined in a path analysis. RESULTS: MoveU awareness (36.4%) was lower than other well-established university health campaigns. Younger students, females, and individuals living on campus were more likely to be aware of MoveU. The HOEM was supported, and improvements in model fit were evident, with additional direct relationships between outcome expectancy and intention, and between self-efficacy and MVPA. CONCLUSIONS: The intended population was aware of the campaign. The HOEM was useful in the development and evaluation of the MoveU campaign. Longitudinal studies are needed to further test the efficacy of the HOEM in the social marketing of physical activity.

Food access and children's BMI in Toronto, Ontario: assessing how the food environment relates to overweight and obesity.

OBJECTIVES: The objective was to examine how access to fast food restaurants, less healthy/healthier food outlets and supermarkets relate to measured levels of overweight and obesity among grade 5 and 6 students. METHODS: Measured height and weight data were obtained to measure BMI. The location and type of food outlet were derived from Toronto Public Health. The density of fast food, less healthy/healthy food outlets and supermarkets within a 1-km walk of the child's home was calculated along with the distance to the closest. Logistic regression models examined the relationship between food access and overweight/obesity. RESULTS: Lower income residents were more likely to be overweight or obese, as were boys. Living in an area with a higher density of healthy food outlets and in close proximity to a supermarket decreased the odds of being overweight or obese. CONCLUSIONS: Addressing several limitations in the literature, the findings confirm an association between the food retail environment and body weight. Density of healthy food outlets and distance to the nearest supermarket are important factors to be considered in addressing the childhood obesity pandemic.

Exercise interventions for smoking cessation.

BACKGROUND: Taking regular exercise may help people give up smoking by moderating nicotine withdrawal and cravings, and by helping to manage weight gain. OBJECTIVES: To determine whether exercise-based interventions alone, or combined with a smoking cessation programme, are more effective than a smoking cessation intervention alone. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2014, and searched MEDLINE, EMBASE, PsycINFO, and CINAHL Plus in May 2014. SELECTION CRITERIA: We included randomized trials which compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme (which we considered the control in this review). Studies were required to recruit smokers or recent quitters and have a follow-up of six months or more. Studies that did not meet the full inclusion criteria because they only assessed the acute effects of exercise on smoking behaviour, or because the outcome was smoking reduction, are summarised but not formally included. DATA COLLECTION AND ANALYSIS: We extracted data on study characteristics and smoking outcomes. Because of differences between studies in the characteristics of the interventions used we summarized the results narratively, making no attempt at meta-analysis. We assessed risk of selection and attrition bias using standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We identified 20 trials with a total of 5,870 participants. The largest study was an internet trial with 2,318 participants, and eight trials had fewer than 30 people in each treatment arm. Studies varied in the timing and intensity of the smoking cessation and exercise programmes offered. Only one included study was judged to be at low risk of bias across all domains assessed. Four studies showed significantly higher abstinence rates in a physically active group versus a control group at end of treatment. One of these studies also showed a significant benefit for exercise versus control on abstinence at the three-month follow-up and a benefit for exercise of borderline significance (p = 0.05) at the 12-month follow-up. Another study reported significantly higher abstinence rates at six month follow-up for a combined exercise and smoking cessation programme compared with brief smoking cessation advice. One study showed significantly higher abstinence rates for the exercise group versus a control group at the three-month follow-up but not at the end of treatment or 12-month follow-up. The other studies showed no significant effect for exercise on abstinence. AUTHORS' CONCLUSIONS: Only two of the 20 trials offered evidence for exercise aiding smoking cessation in the long term. All the other trials were too small to reliably exclude an effect of intervention, or included an exercise intervention which may not have been sufficiently intense to achieve the desired level of exercise. Trials are needed with larger sample sizes, sufficiently intense interventions in terms of both exercise intensity and intensity of support being provided, equal contact control conditions, and measures of exercise adherence and change in physical activity in both exercise and comparison groups.

A longitudinal examination of the interrelationship of multiple health behaviors.

BACKGROUND: Evaluating the interrelationship of health behaviors could assist in the development of effective public health interventions. Furthermore, the ability to identify cognitive mediators that may influence multiple behavioral changes requires evaluation. PURPOSE: To evaluate covariation among health behaviors, specifically alcohol consumption, leisure-time physical activity, and smoking, and examine whether mastery acts as a mediating social-cognitive mechanism that facilitates multiple health behavior change in a longitudinal analysis. METHODS: In 2010, secondary data analysis was conducted on the first seven cycles of the Canadian National Population Health Survey. Data collection began in 1994-1995 and has continued biennially. At the time of this analysis, only seven cycles of data (2006-2007) were available. Parallel process growth curve models were used to analyze covariation between health behaviors and the potential mediating effects of perceived mastery. RESULTS: Increases in leisure-time physical activity were associated with reductions in tobacco use, whereas declines in alcohol consumption were associated with decreases in tobacco use. Covariation between alcohol consumption and leisure-time physical activity did not reach statistical significance. For the most part, mastery was unsuccessful in mediating the interrelationship of multiple behavioral changes. CONCLUSIONS: Health behaviors are not independent but rather interrelated. In order to optimize limited prevention resources, these results suggest that population-level intervention efforts targeting multiple modifiable behavioral risk factors may not need to occur simultaneously.

Outdoor play in children: associations with objectively-measured physical activity, sedentary behavior and weight status.

OBJECTIVES: To determine the amount of time children play outdoors and examine associations with weekday, weekend and after-school physical activity (PA), sedentary behavior (SB), and weight-status (normal-weight, overweight/obese). METHODS: Data were extracted from Project BEAT (Toronto, 2010-2011; www.beat.utoronto.ca). Children's (n=856; mean age=11±0.6years) PA and SB were measured using accelerometry. Outdoor play (OP) was assessed via parental report and collapsed into three categories (<1h/day, 1-2h/day, >2h/day) and differences in anthropometric and PA characteristics were assessed. RESULTS: 55.1%, 37.2%, and 7.7% of children played outdoors for <1h/day, 1-2h/day and >2h/day, respectively, on weekdays. OP was higher on weekends and in boys. OP was associated with SB, light PA and MVPA at all time-points, whereby children attaining <1h/day had lower activity profiles. Boys playing outdoors for <1h/day were more likely to be overweight/obese and had lower PA levels than normal weight boys. However, overweight/obese boys who spent >2h/day playing outdoors had PA profiles similar to normal weight counterparts. CONCLUSION: Encouraging children to spend more time outdoors may be an effective strategy for increasing PA, reducing SB, and preventing excess weight gain (particularly boys' play).