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EuropeaN Energy balance Research to prevent excessive weight Gain among Youth

Final Report Summary - ENERGY (European energy balance research to prevent excessive weight gain among youth)

Executive summary:

In Europe as well as other affluent regions of the world, close to or more than half of the population is overweight or obese. Because overweight and obesity in adulthood are predicted by childhood and adolescent overweight, obesity prevention should start early in life. One important target group is school-aged children, and there is an urgent need to develop effective approaches to improve obesity prevention in this age-group.

The school environment is regarded as a good setting for health promotion interventions among school-age children. For obesity prevention, schools have additional relevance as a health promotion setting, because most children eat a significant amount of food at school and schools offer physical education as well as other physical activity opportunities. Furthermore, schools can set a standard for good health behaviour, which can transfer to the family environment and can have an influence on other family members.

The ENERGY project was developed through the cooperation of fifteen partners across Europe. ENERGY is derived from European energy balance research to prevent excessive weight gain among youth. The aim of this project is to promote healthy energy balance-related behaviours in children across Europe.

Preparing the cross-sectional study, we systematically reviewed the literature: we found that parents physical activity, doing physical activities with parents and parental logistic support are the most important predictors of physical activity in children. A lack of parental rules is the strongest predictor of sedentary behaviour at home.

Our findings from the literature also suggest a positive relationship between soft drink availability at home and consumption. Soft drink availability and consumption at school are the most important school-based correlates of soft drink consumption.

Within the ENERGY project, we conducted a cross-European large-scale survey among over one thousand children aged 10 to 12 years in each of seven European countries: Norway, the Netherlands, Belgium, Spain, Greece, Hungary and Slovenia. The surveys were conducted in 2010 and included measurement of children's height and weight, and questions about a range of energy-balance related behaviours, including key dietary behaviours, physical activity and sedentary behaviour.

We found high levels of obesity and overweight among Europe's children, with nearly one in twenty children obese and a further four in twenty overweight, averaged across all seven countries surveyed. Lowest levels were found in Norway where only one child in seventy is obese, and highest levels in Greece where one child in ten is obese. Children in Greece have the lowest levels of sports activities, children in Hungary watch the most television, and children in the Netherlands consume the most sugared drinks. Girls tend to be slimmer than boys, but girls also tend to participate in sports less than boys. Boys watch more television and drink more soft drinks. Sedentary activities such as TV viewing and computer-time were abundant across Europe, in all participating countries.

The reasons for these variations are likely to be complex and possibly different in each country.

Social differences are also important. Generally, children of more highly educated parents tend to engage in more favourable energy-balance related behaviours, and also tend to be slimmer, except in Greece and Spain. Children in families with non-native ethnicity are more likely to be overweight and obese, tend to consume more soft drinks, to skip regular meals such as breakfast more often, and watch more television and participate in less sporting activity. However, they also walk to school more often.

Further analyses of the data show that obesogenic behaviours are associated with a range of important potential determinants, at the individual, home and school environment levels. Especially, the impact of parents, as role models, facilitators, by setting rules and boundaries, and by means of specific parenting behaviours, appears of crucial importance.

It is apparent that interventions to make changes in behaviour need to be sensitive to these differences. In particular, cultural and lifestyle differences need to be set in the context of family resources, including skills and education but also financial resources and access to support and health information. Within the ENERGY project, an intervention specifically aiming to reduce sedentary behaviour was developed and tested in five countries (i.e. Belgium, Germany, Greece, Hungary, Norway). The intervention was well-liked and appreciated by the stakeholders (children, teachers, school staff), evidence that the intervention resulted in more often breaking up of sitting time, but a reduction in total sitting time could not be established.

The results of the ENERGY project provide important data for stakeholders in the health domain, working towards more effective obesity prevention for a healthy Europe.

Project context and objectives:

Childhood overweight and obesity

In Europe as well as other affluent regions of the world, close to or more than half of the population is overweight or obese. Obesity is one of the main determinants of avoidable chronic disease. In the absence of effective, low-cost, long-term obesity treatment, and because the ill-health effects of obesity are not fully reversible, a focus on obesity prevention is recommended. Because overweight and obesity in adulthood are predicted by childhood and adolescent overweight, obesity prevention should start early in life. One important target group is school-aged children, and there is an urgent need to develop effective approaches to improve obesity prevention in this age-group.

School-based interventions and the family environment

The school environment is regarded as a good setting for health promotion interventions among school-age children. Schools offer an environment where almost all children can be reached repeatedly and continuously, and where health education can be combined with health promoting structural environmental changes. For obesity prevention, schools have additional relevance as a health promotion setting, because most children eat a significant amount of food at school and schools offer physical education as well as other physical activity opportunities. Furthermore, schools can set a standard for good health behaviour, which can transfer to the family environment and can have an influence on other family members.

ENERGY project

The ENERGY project was developed through the cooperation of fifteen partners across Europe. ENERGY is derived from European energy balance research to prevent excessive weight gain among youth.

The overall aim of the ENERGY project was the development of a new theory- and evidence-based multi-component intervention scheme ready to be implemented across Europe promoting the adoption or continuation of health behaviours that contribute to a healthy energy balance. We developed an intervention scheme that is both school-based and family involved, and aimed at the age group of 10-12 year olds, in the transition between childhood and adolescence.

To achieve this, within the ENERGY project, we conducted the following:

1. Performed a thorough multidisciplinary analysis of the most important behaviours contributing to energy balance of children, and their most important modifiable intrinsic and extrinsic determinants, including personal and, social-cultural, physical financial-economic environmental factors, with a specific focus on the family setting and the school setting.
2. Identified successful intervention schemes and strategies and the factors mediating and moderating these successful schemes in different sub-populations based on age, gender and socio-economic status, including the exploration of financial intervention strategies that can be implemented in schools.
3. Carefully designed a multi-component school-based and family-involved intervention using obtained insights from the above mentioned analyses.
4. Evaluated the multi-component intervention implemented in a controlled settings.
5. Prepared a large-scale implementation and a monitoring plan for dissemination of the intervention scheme.

Findings: prevention issues

Preventing overweight and obesity and promoting healthy dietary patterns, healthy physical activity and reduced sedentary behaviour (together referred to here as energy-balance related behaviours) during childhood are important health policy priorities in Europe and beyond. To curb the obesity epidemic, data on the prevalence of overweight and obesity, and on children's current energy-balance related behaviour is needed in order to identify groups at highest risk for overweight and the forms of intervention, which might be appropriate. In earlier reports large differences in childhood overweight and obesity between European countries have been found, but data for these studies come from a range of different investigations, conducted in different years, with different age groups and using different methods, such as self-reported versus measured weight and height. Within the ENERGY project we conducted a large-scale cross-European cross-sectional study.

Findings: from the literature

Preparing the cross-sectional study, we systematically reviewed the literature: we found that parents' physical activity, doing physical activities with parents and parental logistic support are the most important predictors of physical activity in children. A lack of parental rules is the strongest predictor of sedentary behaviour at home.

Our findings from the literature also suggest a positive relationship between soft drink availability at home and consumption. Soft drink availability and consumption at school are the most important school-based correlates of soft drink consumption.

Findings: how do European children do?

The present document presents results and conclusions from the ENERGY-project which included a survey of over one thousand children aged 10 to 12 years in each of seven European countries: Norway, the Netherlands, Belgium, Spain, Greece, Hungary and Slovenia. The surveys were conducted in 2010 and included measurement of children's height and weight, and questions about a range of energy-balance related behaviours, including key dietary behaviours, physical activity and sedentary behavior.

Too fat?

In summary, obesity and overweight are at high levels among Europe's children, with nearly one in twenty children obese and a further four in twenty overweight, averaged across all seven countries surveyed. Lowest levels were found in Norway where only one child in seventy is obese, and highest levels in Greece where one child in ten is obese. The reasons for this variation are likely to be complex and possibly different in each country.

(Un)healthy behaviours

Children in Greece have the lowest levels of sports activities, children in Hungary watch the most television, and children in the Netherlands consume the most sugared drinks. Girls tend to be slimmer than boys, but girls also tend to participate in sports less than boys. Boys watch more television and drink more soft drinks. Sedentary activities such as TV viewing and computer-time were abundant across Europe, in all participating countries.

Social differences

Social differences are also important. Generally, children of more highly educated parents tend to engage in more favourable energy-balance related behaviours, and also tend to be slimmer, except in Greece and Spain. Children in families with non-native ethnicity are more likely to be overweight and obese, tend to consume more soft drinks, to skip regular meals such as breakfast more often, and watch more television and participate in less sporting activity. However, they also walk to school more often.

Other correlates of (un)healthy behaviours

Further analyses of the data show that obesogenic behaviours are associated with a range of important potential determinants, at the individual, home and school environment levels. Especially the impact of parents, as role models, facilitators, by setting rules and boundaries, and by means of specific parenting behaviours, appears of crucial importance.

Interventions

It is apparent that interventions to make changes in behaviour need to be sensitive to these differences. In particular, cultural and lifestyle differences need to be set in the context of family resources, including skills and education but also financial resources and access to support and health information. Within the ENERGY project an intervention specifically aiming to change one key obesogenic behaviour was developed and tested in five countries (i.e. Belgium, Germany, Greece, Hungary, Norway). This intervention was aimed at reducing sedentary behaviours because this is the obesogenic behaviour most under-studied. The intervention was well-liked and appreciated by the stakeholders (children, teachers, school staff), evidence that the intervention resulted in more often breaking up of sitting time, but a reduction in total sitting time could not be established.

The ENERGY project

We have provided up-to-date prevalence rates over overweight, obesity and (un)healthy behaviours in European children. Factors that play an important role and factors that need to be addressed when curbing the obesity epidemic have been identified, and further explorations for interventions have been conducted. The results of the ENERGY project provide important data for stakeholders in the health domain, working towards more effective obesity prevention for a healthy Europe.

Further research

Further research is necessary to develop, test and disseminate true multilevel, participatory interventions that include children, their family and wider social and physical environments. This requires a systems-based approach and participatory research involving all key stakeholders.

Project results:

Main results and foreground

A.1. Scientific results - Results of literature reviews in preparation of the cross-sectional and intervention study

Several reviews of the scientific literature were undertaken as part of the ENERGY project, focusing on scientific evidence relating to interventions that target children aged 10 - 12 years. Findings can be summarised as follows:

Specific factors influencing children's energy-balance related behaviours

A review of the scientific literature found that parents' physical activity, doing physical activities with parents and parental logistic support were identified as the most important predictors of physical activity in children. A lack of parental rules was the strongest predictor of sedentary behaviour at home. Socio-economic status was positively related to physical activity and negatively related to sedentary behaviour. The available studies suggested a positive relationship between soft drink availability at home and consumption. Soft drink availability and consumption at school were the most important school-based correlates of soft drink consumption. A permissive parenting style was related to more soft drink consumption and less breakfast consumption. Little research has been done to identify school-environmental correlates of energy-balance related behaviours and more needs to be done.

(1) Breakfast consumption

Since breakfast is an event that happens most of the times at home, parents play a major role. Having breakfast together with the parents at age 10 - 12 is an important determinant of breakfast consumption and is influenced by rules set by the parents to create a routine of having breakfast every morning. Children with overweight parents and children from low social-economic status families tend to have breakfast less often, although children from a single-parent high socio-economic status household also have breakfast less often.

(2) Soft drink consumption

The availability of soft drinks at home at age 10 - 12 is a very important determinant of soft drink consumption, and parents are the main decision-makers for purchases for home consumption. If soft drinks are available at home, parental rules can control how frequently a child is able to take a soft drink. Soft drink consumption is also determined by the availability of such drinks in the school and near-school environment, and there is evidence that restrictions on soft drinks at elementary school can lower soft drink consumption.

(3) Physical activity

The most important family-based determinants of physical activity are parental activity, parental attitude towards physical activity and parental encouragement and logistic support (parents pay fees, transport their child to the activities, provide equipment and clothing and shoes, etc.). Parents who perceived more barriers for their child to be physically active at age 10 had children that were less totally physically active, participated less in sports and did less active transportation at age 16.

Solutions to tackle barriers need to be offered to the parents, and schools can be involved in this: for example organising joint sporting events and offering the use of school facilities and coaching during non-school hours. Schools also need to recognise the psycho-social aspects of encouraging physical activity: for example the need to increase children's feelings of self-efficacy might be encouraged through individualised or cooperative activities rather than through competitive activities, and to offer skills acquisition (e.g. self-defense, dance, yoga) rather than repetitive games playing.

(4) Sedentary behaviour

Reviews of the literature indicated that the higher the parental BMI, the greater the extent of children's sedentary behaviour. Children from low socio-economic status families are also at greater risk of high levels of sedentary behaviour, as are those children that have repeated a class in elementary school. Parental rules/restrictions of screen-based behaviours, the number of TVs in the home and parental role modelling of sedentary behaviour were the three most important correlates of screen time.

(5) Incentives that motivate behaviour

A systematic search of the literature found evidence that price incentives are effective for altering consumption in the school setting. Other types of economic incentives have been used in combined intervention schemes, but the inclusion of a mix of intervention elements makes it difficult to draw conclusions about the effectiveness of the economic incentive instruments per se in these studies.

(6) The mediators involved in changes in behaviour

A review of the literature was undertaken in order to identify psycho-social and environmental mediators that can be used in interventions to change energy-balance related behaviours in young people. There was strong evidence for self-efficacy and moderate evidence for intention as mediators of physical activity interventions. Indications were found for attitude, knowledge and habit strength to be mediators of dietary behaviour interventions. There were too few sedentary behaviour interventions reporting on mediating effects to reach a conclusion.

(7) The moderators which influence behaviour change

A literature survey found that gender, ethnicity, age, baseline values of outcomes, initial weight status and socio-economic status were the most frequently studied potential moderators. The moderator with the most convincing evidence was gender: school-based interventions appear to work better for girls than for boys. However, many studies reported non-significant moderating effects, and the methodological quality of most studies was poor, and consequently there is lack of insight into what interventions work for whom.

(8) Role of parents and families in school-based interventions

A survey of scientific publications found evidence for positive effects of parental involvement in changing children's behaviour and changing the determinants of that behaviour. When interventions addressed several home-related determinants and practices concerning eating and physical activity behaviours simultaneously, the effects were stronger. However, no conclusive evidence could be provided concerning the added value of parent involvement, and there is a need for more studies comparing school-based interventions with and without a parental component.

(9) Parents' views

A series of discussion groups were undertaken with parents of children aged 10-15 years, in order to understand the best procedures to encourage parental participation in school interventions to promote healthy behaviour. Variation in parental socio-economic status and parental school involvement was taken into account when recruiting the parents. The discussions showed that physical activity was considered to be a joint responsibility of school and parents, while nutrition was parent's responsibility but supported by the school, and prevention of sedentary behaviour (e.g. TV watching, screen-games playing) as parent's sole responsibility.

Parents suggested that the best way of being involved was through interactive and practical activities undertaken together with their child, including cooking, food tasting and nutrition workshops, walking or cycling tours, and sport initiatives together with their child. Activities should be cheap, at a convenient time, focused on their children and not on themselves, not tutoring, not theoretical, and could be either school-or home-based.

A.2. Scientific results - Cross-sectional study

In Europe as well as other affluent regions of the world, close to or more than half of the population is overweight or obese. Obesity is one of the main determinants of avoidable chronic disease. In the absence of effective, low-cost, long-term obesity treatment, and because the ill-health effects of obesity are not fully reversible, a focus on obesity prevention is recommended. Because overweight and obesity in adulthood are predicted by childhood and adolescent overweight, obesity prevention should start early in life. One important target group is school-aged children, and there is an urgent need to develop effective approaches to improve obesity prevention in this age-group.

The school environment is regarded as a good setting for health promotion interventions among school-age children. Schools offer an environment where almost all children can be reached repeatedly and continuously, and where health education can be combined with health promoting structural environmental changes. For obesity prevention, schools have additional relevance as a health promotion setting, because most children eat a significant amount of food at school and schools offer physical education as well as other physical activity opportunities. Furthermore, schools can set a standard for good health behaviour which can transfer to the family environment and can have an influence on other family members.

Preventing overweight and obesity and promoting healthy dietary patterns, healthy physical activity and reduced sedentary behaviour (together referred to here as energy-balance related behaviours) during childhood are important health policy priorities in Europe and beyond. To curb the obesity epidemic, data on the prevalence of overweight and obesity, and on children's current energy-balance related behaviour is needed in order to identify groups at highest risk for overweight and the forms of intervention which might be appropriate. In earlier reports large differences in childhood overweight and obesity between European countries have been found, but data for these studies come from a range of different investigations, conducted in different years, with different age groups and using different methods, such as self-reported vs measured weight and height.

The present document presents data from the ENERGY project which included a survey of over one thousand children aged 10 to 12 years in each of seven European countries. The countries were: Norway, the Netherlands, Belgium, Spain, Greece, Hungary and Slovenia. The surveys were conducted in 2010 and included measurement of children's height and weight, and questions about a range of energy-balance related behaviours, including key dietary behaviours, physical activity and sedentary behaviour. The surveys aimed to answer the following questions:

What are the distributions and differences in body mass index (BMI), waist circumference (WC), overweight and obesity in schoolchildren aged 10 - 12 years in seven countries across Europe?

What are the distribution and differences in dietary intake, physical activity, sedentary behaviour and sleeping duration among these children?

What are differences in anthropometrics and energy-balance related behaviours according to gender, parental education and ethnicity across different countries in Europe?

The results are shown in the set of maps on in the appendix (uploaded), drawn from the scientific reports of the study. They show large differences in many of the measures and indicate significant variation between different countries, and between different social groupings defined by parental educational level and by ethnicity.

The prevalence of overweight (including obesity) pooled across all seven countries from different regions in Europe was 25.8 % and 21.8 % for boys and girls respectively. Although some studies have suggested that overweight has ceased to rise in some countries, the present prevalence remains higher than desirable and unacceptably high in some countries.

Across all countries children engaged frequently in dietary intake, physical activity behaviours and sedentary behaviour that are regarded as potential risk behaviours for becoming overweight / obese, with large differences between countries. Many children skipped breakfast on one or more days per week, especially in Greece and Slovenia, and the mean intakes of sugar-sweetened beverages in the Netherlands, Hungary and Slovenia was high. Low levels of active transport were reported especially in Belgium, Slovenia and Hungary, while low levels of sports were reported in Greece. Norwegian children reported the most minutes of cycling and walking to school.

Soft drink consumption ranged from more than 600 ml/day among Hungarian and Dutch boys to less than 150 ml/day in Greek and Spanish girls. In all countries except Hungary, boys had significantly higher intakes than girls. Fruit juice intake was high in Dutch boys, bringing their mean sugary drinks consumption to more than one litre/day.

Children of lower educated parents reported less favourable intakes regarding soft drink, fruit juice, and breakfast than children of higher educated parents. Children whose parents were born in a different country consumed greater quantities of soft drinks than children whose parents were born in the country of current residence.

With an average of more than 40 minutes/week, children in Norway and the Netherlands spent much more time cycling to school than children in other countries. In general, girls cycled significantly fewer days per week to school than boys, but no significant gender differences in weekly minutes of cycling were found. Spanish and Norwegian girls reported the most minutes of walking to school. In general, girls reported more weekly minutes of walking to school than boys.

For engagement in sport activities, boys reported on average 260 minutes/week ranging from more than 300 minutes/week in Norway to less than 200 minutes/week in Greece. Girls reported on average almost 200 minutes/week, ranging from 250 minutes/ week in Slovenia to less than 150 minutes/week in Greece. Girls reported lower engagement in sport across all countries. Children of higher educated parents participated significantly more in sports than those from lower educated parents.

For sedentary behaviours, screen activities were high in all countries, with children spending on average more than 2 hours/day in TV and computer activities. Across the countries, boys reported spending about 3 hours 15 minutes a day in screen-viewing activities (TV and computer-time combined). The figure was a little lower for girls, with girls in Spain showing the lowest levels at 2 hours 40 minutes a day. Children of higher educated parents and children of parents born in the country of current residence reported less screen time than those from lower educated parents or of parents born elsewhere. The results also indicate that for every hour of TV viewing, another 30-40 minutes of computer screen viewing occurs, indicating that interventions to reduce sedentary behaviour should not be restricted to television viewing only.

In summary, obesity and overweight are at record levels among Europe's children, with nearly one in twenty children obese and a further four in twenty overweight, averaged across all seven countries surveyed. Lowest levels were found in Norway where only one child in seventy is obese, and highest levels in Greece where one child in ten is obese. The reasons for this variation are likely to be complex and possibly different in each country. Children in Greece have the lowest levels of sports activities, children in Hungary watch the most television, and children in the Netherlands consume the most sugared drinks. Girls tend to be slimmer than boys, but girls also tend to participate in sports less than boys. Boys watch more television and drink more soft drinks.

Social differences are also important. Generally, children of more highly educated parents tend to engage in more favourable energy-balance related behaviours, and also tend to be slimmer, except in Greece and Spain. Children in families with non-native ethnicity are more likely to become overweight and obese, tend to consume more soft drinks, to skip regular meals such as breakfast more often, and watch more television and participate in less sporting activity. However, they also walk or cycle to school more often.

It is apparent that interventions to make changes in behaviour need to be sensitive to these differences. In particular, cultural and lifestyle differences need to be set in the context of family resources, including skills and education but also financial resources and access to support and health information.

A.3. Scientific results - Intervention study

The previous section outlined the evidence-base for developing an intervention to reduce children's sedentary behaviour. The ENERGY project was designed to develop a pilot intervention scheme for 10 - 12 year old children. The form of intervention which was piloted in the ENERGY project was a six-week school-based, family-involving initiative to reduce and break up sitting time.

As indicated earlier, sedentary behaviour is a neglected area of research and yet can be a significant point of access for changing energy-balance related behaviour overall. Prior to the current survey, there were few figures for children's sedentary behaviour in Europe but data from other countries indicate that children can spend 2 to 4 hours a day watching screens and up to 10 hours a day in sedentary behaviour. Children tend to sit more during weekends and sitting time increases throughout adolescence. The ENERGY project survey results indicate that children across Europe are spending an average of over three hours a day watching screens (TV and computer screens combined) with highest levels found among boys in Hungary, who spent on average very nearly four hours a day watching screens.

In school, breaking up sitting time may help improve children's concentration and learning. Reducing screen time at home may also improve school performance, including improved grades and results on numeracy and literacy tests. Having a bedroom television may reduce hours of sleep and impair day-time concentration as well as influence school performance negatively. Multiple TVs in the home and having TV in the bedroom may also increase children's TV viewing, and children who watch more TV at a young age are likely to continue to do so as they get older. Analyses within ENERGY also confirmed that parental and peer modelling are influential: children are more likely to watch more TV when their parents and peers do so too. Parental rules are also important: TV and PC time is considerably lower in families where parents have put rules in place regarding TV and PC time. Furthermore, the pattern of sitting time is important for health not just the amount of accumulated sitting time throughout the day, so it is important to consider interventions which break up the periods of sitting.

What is the alternative to sitting? Light physical activity includes most activities carried out in a non-sitting posture, such as walking while talking, getting the mail, undertaking household chores such as washing dishes, tidying a room and helping prepare meals. Examples of standing activities could be reading, talking in the phone and even playing computer games while standing. The more time children spend in light physical activity, the less time they spend sitting. Getting out of the home may help: although there is seasonal variation, children may spend more than 90 % of their waking hours indoors, whereas being outside may increase the opportunities for standing and walking activities.

Research has shown that parental encouragement and support are important when modifying children's sitting time. Children in families with clear rules about screen time also spend less time watching screens. As children grow older, intrinsic motivation is likely to cause more lasting changes because the motives are then in line with the person's own values and interests. For a child to become intrinsically motivated they should feel that they are capable of doing what is needed (have competence), they should feel they have a choice to do it or not (autonomy) and they should feel they are in a supportive environment and situation where they belong (relatedness). If any of these are not in place the motivation may be diminished.

In order to evaluate the effectiveness of the intervention, the pilot intervention was tested in the autumn of 2011 in a cluster randomised controlled trial with a pre- and post-test design in five countries across Europe: Belgium, Germany, Greece, Hungary and Norway. The children were aged between 10 and 12 years, with two grade levels participating in the intervention.

Measures of sedentary behaviour along with attitudes and knowledge about a range of factors that might influence sedentary behaviour were assessed in the intervention and control schools.

The results show that, compared with children in non-intervention schools, an effect of the intervention was observed on:

- the number of breaks during watching TV/DVD and using computer / games consoles;
- the attitude towards, and liking / preferences for breaking up continuous sitting time.

No effects of the intervention were observed for total screen time, either for watching TV/DVD or using computer / games consoles.

A few determinants of screen time were affected by the intervention, but this appeared to be related to an increase in the accuracy of the perceptions after the intervention, since the intervention children were more likely to agree that it is hard not watching TV/DVD, and their parents reported an increased number of games consoles at home. It is possible that the intervention triggered greater awareness about the problem of screen time use in adolescents; i.e. that the children became more aware of how hard it really is to not watch TV/DVD, and the parents became more aware of the actual numbers of games consoles present at home as part of the homework in week 4.

The process evaluation of the intervention showed that the implementation of the intervention was good for some parts of the intervention, especially the handing out of bracelets and stickers by the teachers, and also the handing out of the newsletters (News). However, the News received by the parents decreased throughout the intervention period indicating that increasing numbers of pupils did not deliver the News at home.

Most of the intervention classes registered the sitting time, the steps and undertook activity breaks at school. Fewer children did the drawing of when they sit and what they do, wrote a list of alternative non-sitting things they like to do at home, took the challenge to reduce sitting time, made a poster at school for active recess activities, or took the family challenge, but there were country variations in these numbers.

Teachers and parents believed that the intervention had only a moderate or low effect on reducing child sitting time. However, the children, parents and teachers reported that they liked the project, and in particular, the activities regarding the usage of pedometers (for step counting) and the activity breaks. The activity breaks were also conducted at home by several children. This might explain the effect seen in increased breaks during sitting time in the intervention group.

The family fun event / family challenge was not implemented in all five countries. In general, the intervention did not appear to trigger the amount of family interaction that was intended. (See comments in 'What the participants said' section below)

Country differences were observed in the process evaluation, and Greek children, parents and teachers rated the project the best and implemented the largest number of the intervention components. However, analysing the effect of the intervention for separate countries did not show a larger effect of the intervention in Greece than in the other countries.

B. Foreground

B.1. Data bases from WP7 and WP9

Within WP7 we have collected data among more than 7000 children and their parents during a school-based cross-sectional survey in 2010 in seven different European countries; Belgium, Greece, Hungary, the Netherlands, Norway, Slovenia, and Spain.

This has resulted in several data bases, including:

- anthropometric measure of children (i.e. height, weight, waist circumference);
- child and parent questionnaires assessing energy balance-related behaviours (e.g. soft drink consumption, data on sedentary behaviour) and potential personal, family and school environmental correlates of these behaviours including the social-cultural, physical, political, and economic environmental factors;
- school-staff questionnaires and school observations.

In addition, a selection of countries conducted accelerometer measurements to objectively assess physical activity and sedentary behaviour, and collected blood samples to assess several biomarkers of metabolic function.

B.2. Materials of the UP4FUN project

- A file is uploaded, showing part of the materials used in the UP4FUN intervention
- Letter for parents (information about the project and a consent form for participation)
- Handout for teacher training
- Teacher's manual (including manual activity breaks)
- Binder for teacher's material
- CD (electronic copy of material) (not shown)
- Forms for pupils
- Sitting time registration card
- Classroom poster frame for recess activity ideas
- Stepcounters / pedometers (not shown)
- Stickers for pupils
- Silicon bracelets with UP4FUN embossed
- Newsletters for parents
- Software Adobe InDesign C S6 to edit newsletters

See the UP4FUN website materials at http://site.up4fun.eu/up4fun/up4fun-material

A user-friendly protocol explaining how the intervention should be implemented.

Potential impact and main dissemination activities

Potential impact - Recommendations for interventions

The ENERGY project consisted of a series of systematic reviews of the scientific literature along with the design of the UP4FUN project and its pilot testing in five countries. Much of this work is being reported in scientific journals (see other sections of our reporting).

From this work, it is possible to give recommendations for implementing interventions that aim at preventing overweight and obesity in children with a focus on reducing sedentary behaviour, particularly sitting time, elsewhere in Europe.

As a point of principle, it is important to recognise the need to design interventions on the basis of evidence and scientific understanding of the theories of behaviour change and methods for achieving this. Resources provided for interventions need to be used responsibly and professionally, and the project proposals need to be justifiable and feasible and the results timely and measurable. Within this context some flexibility is needed to ensure that an intervention is suitable for the local context and the participants concerns.

Addressing multiple behaviours

In order to make an intervention with a great impact on preventing excessive weight gain, multiple behaviours need to be addressed. Some of these behaviours have been identified in the ENERGY project: eating breakfast, drinking sugar containing drinks, using active transport, participating in sports, and sedentary behaviours. Other factors to consider are the consumption of fruit and vegetables and unhealthy snacks.

Measures to reduce sedentary behaviour are reported to be effective in reducing children's risk of obesity, and therefore a focus on sedentary behaviour aimed at increasing the frequency of breaks as well as reducing the duration of sitting time is recommended. As we have indicated, the UP4FUN project material can be used to develop the part of such an intervention targeting sedentary behaviour.

Breaking up sitting time

The UP4FUN project was able to break up sitting time, and strengthened children's awareness of the need for activity breaks and increased their liking of such breaks, in a six-week intervention run during normal school timetables and with modest family involvement. These parts of the intervention are strongly recommended to be included in an intervention to prevent excessive weight gain and promote healthy energy-balance related behaviours among school children in Europe.

Use of incentives

The process evaluation of the intervention indicates that age-appropriate incentives were important to support motivation and increase enjoyment of such a project for children. The step counters (pedometers), colourful stickers and bracelets, were liked very much by the pupils. Particularly the use of the step counters appeared to be a valuable factor for increasing motivation and interest in taking breaks and assessing light physical activity.

Involving the family

An important barrier for interventions that target a behaviour that is mostly performed at home, such as sitting during leisure-time activities, is the difficulty in reaching the family, particularly the parents. The UP4FUN pilot intervention did not reach the parents to the extent that had been intended. Parents were asked in focus groups carried out within the ENERGY project how they wanted to be engaged in family involved projects like UP4FUN. These findings and results from the literature were used to develop an approach to reach the parents using newsletters including tasks at home to be done by the child involving other family members, a family fun event, incentives (bracelets for the whole family) and a website. Nevertheless, this did not seem to be sufficient to ensure adequate access to and participation by the parents. Future projects need to consider how to overcome these barriers.

Allowing for adaptation

One intervention does not seem to fit all: the process evaluation showed clear country differences in the implementation of the intervention. Even though screen time activities were high in all countries surveyed in the cross sectional study and varied little between the countries, the UP4FUN intervention was implemented and enjoyed in varying degrees in the different countries. This shows that one intervention package might not fit all cultures in Europe and points towards the need to develop country-specific or culture-specific interventions and ensure there is sufficient flexibility to allow for local adaptations of a core intervention. Also schools should be able to adapt an intervention in order to make it fit with the school's focus, interest and curriculum, the school's environment and the needs of parents and pupils.

Involvement of teachers

It should not need to be said, but it is always important to remember that the timely planning, preparation and provision of materials is important for a successful project, and so too is the preparation by the school if the project is a school-based initiative. In particular, teachers need to know as much as a semester in advance what changes to their normal timetables, teaching procedures and curriculum might need to be accommodated.

It is of utmost importance that teachers are motivated to participate in the project: They need to feel that the project is worthwhile and of benefit to their pupils if they are being asked to make changes to their normal routines and have to accept an extra work load. Flexibility is important, and teachers need to be able to adapt the core elements of a project so that they fit comfortably into their normal practices. Furthermore, teachers know their pupils' abilities and interests and therefore should actively participate in the project design process and this can further improve the teachers' motivation to participate and improve the chances of successful outcomes.

Participatory design

The teachers are not the only group who can have a valuable role to play in shaping the intervention. Children themselves, and their parents, will have useful insights into what will be interesting to them, what might act as an incentive and increase motivation, what they might resist or find difficult or embarrassing, and what might be unnecessary, e.g. if sedentary behaviour is already at a lower than average level. Parental involvement a key aspect of making changes in the family environment where most sedentary behaviour occurs may be increased by including parents in the design of the intervention, and parents may even be able to take on some of the roles in implementing the project in the community, for example motivating other parents, helping to reduce the dependence on external resources and potentially increase the sustainability of the initiative.

As we suggested in the start of this report, projects are more likely to be successful if their design has been shared and developed with all participants: teachers and school staff, children and parents. Furthermore, participants should be encouraged to provide feedback as the project develops.

Choosing the appropriate duration of the intervention

An intervention of only six weeks could be predicted to be too short to result in large changes in behaviour. However, the teachers' motivation and the number of News reaching the parents appeared to decrease throughout the intervention period, and both these changes indicated that it may be difficult to motivate the participants to engage with a longer intervention. However, the decrease in implementation of some elements of the intervention could at least be partly explained by the overload of work the teachers reported during the intervention period, which made them not being able to skip their regular classes in order to carry out the intervention teaching. More participation in the project design, and greater flexibility of adaptation by the teachers, may strengthen the long term sustainability of the project. In some situations it may be possible for teachers to design the project so that it fits into their curriculum.

Making structural changes

Behavioural change interventions like the UP4FUN project often aim to change cognitive determinants such as attitudes and self-efficacy. In addition, the UP4FUN project had a strong focus on the home environment and aimed to address the parents' understanding and actions to reduce children's sedentary behaviour. However, behaviour change is difficult and takes time. Therefore in order to achieve longer-lasting effects, structural changes, such as reducing the numbers of screens at home, or instituting family rules for watching TV/DVD or using of computers, or having class-room breaks on a routine basis, may require more specific, environment-focused and policy-focused interventions than achieved by a single school-based project such as the UP4FUN initiative.

Furthermore, as children live in a highly obesogenic environment in virtually all locations in Europe, the changes being instituted in homes and schools need to be supported by policy changes at community and national level. Many examples can be given:

- incentives to schools to encourage more breaks and activity periods, changes to the curriculum so that nutrition and physical activity are part of the teaching role (and are taught in teacher training colleges),
- incentives to parents to reduce the screens in homes, to provide the right example and to establish rules regarding maximum screen time,
- incentives for community improvements to increase street safety and personal security so that parents are comfortable allowing children out, and the provision of attractive environments clubs and play areas (without screens), organised activities and use of school facilities out of hours as alternatives to sitting at home.

Reaching all children

Lastly, it is important to recognise the need to reach children who might benefit most from reduced sedentary behaviour and improvements in energy balance related behaviours generally. Interventions are often taken up more enthusiastically by children and families with better resources, better educational levels, greater time flexibility and a willingness to focus on obesity prevention and health promotion. Children and parents from lower income households, or ethnic immigrant families or one-parent families or families enduring other forms of social or financial stress may find it harder to participate, yet these children may be the ones who would benefit most. Such disparities can serve to widen the health inequalities seen in Europe and shown in the ENERGY project surveys. Furthermore, language barriers can exacerbate the problem if, for example, newsletters and activity sheets are not easily comprehended by parents, or parents do not feel they can participate in teacher-parent meetings. Also the capabilities of the pupils have to be considered in intervention development and allow for flexible adaptation by the teachers: not all children benefit equally from one type of intervention: for example some may not benefit if the contents are to be conveyed in a very cognitive manner and not in a more appropriate playful, practical and motivating manner.

Projects need to be designed with these issues in mind. Interventions which lead to structural changes in school routines are more likely to benefit all pupils, whereas interventions which rely on individual child or family motivation outside the school may enhance inequality. Interventions which lead to structural changes in the community can benefit all members of the community, especially if the provision of community facilities is effectively communicated and can be easily accessed by all families who might use them. This requires considerable further exploration.


Main dissemination activities

For the description of the main dissemination activities of the ENERGY project, we would also like to refer to WP10 and those as uploaded (A2 dissemination activities). WP10 was dedicated to the preparation of an implementation and dissemination plan. Within WP10 we have focused on the promotion of dissemination of the publicly available deliverables and results from the ENERGY project to the main stake holders.

Project website: http://www.projectenergy.eu