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Multifactorial evidence based approach using behavioural models in understanding and promoting fun, healthy food, play and policy for the prevention of obesity in early childhood: ToyBox

Final Report Summary - TOYBOX (Multifactorial evidence based approach using behavioural models in understanding and promoting fun, healthy food, play and policy for the prevention of obesity in early childhood: ToyBox)

Executive Summary:
Early childhood is a critical period for addressing obesity prevention since behaviours, psychological traits and physiological processes are largely developed or formed at this young age. The development and adoption of the desired behaviours will help to ensure optimum growth during childhood and increase the likelihood of long-term health in adulthood.

The ToyBox-study (www.toybox-study.eu) aimed to expand our knowledge and understanding of young children’s behaviours and their determinants leading to early childhood obesity. Taking into consideration the cultural, legislative and infrastructural diversities in the participating countries, a kindergarten-based, family-involved intervention was developed to promote healthy food and fun and active play in kindergarten settings throughout Europe.

A multidisciplinary team of scientists/researchers from 10 countries joined forces to accomplish this task based on a systematic stepwise approach that combined the use of PRECEDE-PROCEED Model and Intervention Mapping protocol. The ToyBox-study applied this approach for the first time on a European-scale aiming to promote healthy energy balance related behaviours for the prevention of obesity in early childhood.

During the four years of its implementation, ToyBox-study:
Step 1. Identified young children’s key-behaviours and their determinants related to early childhood obesity through systematic reviews, secondary analyses and focus group research; evaluated existing behavioural models and educational strategies that best support behavioural change in this age group through systematic and narrative reviews; and assessed school environment, policies and legislation affecting the implementation of kindergarten-based health promotion activities via documents from national databases and websites which were retrieved.
Step 2. Based on the findings of Step 1, a kindergarten-based, family-involved intervention was developed to influence obesity-related behaviours in 4-6 year olds and their families, adjusting for cultural, legislative and infrastructural diversities in the participating countries;
Step 3. Implemented the ToyBox-intervention in 6 European countries, assessed its process, impact and outcomes and estimated its cost-effectiveness;
Step 4. Disseminated the results and made recommendations for European public health policy.

In total, 309 kindergartens and 7,056 preschool children and their families, stratified by socioeconomic level, participated in the ToyBox-intervention. The process evaluation showed that the stakeholders (children, parents/caregivers, teachers) found the ToyBox-intervention attractive and appropriate for preschool age. The impact evaluation, based on the measurements obtained at baseline and follow-up, revealed that various energy balance related behaviours among the children and their families in the intervention group were significantly improved during the intervention period. Specifically, an increase of children’s water consumption, a decrease of children’s consumption of sweets, pre-packed juices and sugar-sweetened beverages and a lower increase of the time children spent on computer/video games were observed in the intervention group compared to the control group. Regarding the changes of children’s social and physical environment, it was found that parents/caregivers in the intervention group decreased their own consumption of sweets/candies, whereas the percentage of parents/caregivers setting as a rule for their children to consume soft drinks/pre-packed juices only on certain occasions (e.g. birthdays) and the proportion of parents/caregivers serving water to their children during their meals increased in the intervention group compared to the control group. Moreover, the proportion of parents/caregivers allowing their child to watch TV for as long as (s)he wants and the proportion of parents/caregivers thinking that viewing activities are beneficial and educational for their child were decreased in the intervention group compared to the control group over the intervention period.
Regarding the outcome evaluation, no significant differences in BMI z-score and in the prevalence of overweight/obesity between the intervention and the control kindergartens were observed at the end of the intervention, which was expected due to the short period of evaluation. More follow-up assessments in the following years would potentially provide further insights on the longer-term impact and outcome of this intervention.
Since the analysis of data is still ongoing regarding the effectiveness of the ToyBox-intervention and the mediators and moderators affecting its magnitude, more outcomes will be revealed and disseminated in the short future.

Project Context and Objectives:
The prevalence of obesity in childhood has been increasing worldwide while the mean prevalence of childhood overweight and obesity in Europe is about 20% and 5% respectively at preschool age, reaching much higher rates in the Southern European regions. These high rates of childhood obesity and their subsequent cardiometabolic or psychosocial health effects in adulthood call for appropriate preventive measures and effective policies to be taken early in life. Early childhood is a critical period for addressing obesity prevention since behaviours, psychological traits and physiological processes are largely developed or formed at this young age. The development and adoption of the desired behaviours will help to ensure optimum growth during childhood and increase the likelihood of long-term health in adulthood.

To be successful in preventing childhood obesity, an intervention programme needs to adopt a holistic, multifactorial and cost-effective approach guided by an appropriate socio-ecological framework. ToyBox-study (www.toybox-study.eu) aimed to expand our knowledge and understanding of young children’s behaviours and their determinants leading to early childhood obesity. Taking into consideration the cultural, legislative and infrastructural diversities in the participating countries, a kindergarten- based, family-involved intervention was developed to promote healthy food and fun and active play in kindergarten settings throughout Europe.

A multidisciplinary team of scientists/researchers from 10 countries joined forces to accomplish this task based on a systematic stepwise approach that combines the use of PRECEDE-PROCEED Model and Intervention Mapping protocol. The ToyBox-study applied this approach for the first time on a European-scale aiming to promote healthy weight and healthy energy balance related behaviours for the prevention of obesity in early childhood.

During the four years of its implementation, ToyBox-study:
Step 1. Identified young children’s key-behaviours and their determinants related to early childhood obesity; evaluated existing behavioural models and educational strategies that best support behavioural change in this age group; assessed school environment, policies and legislation affecting the implementation of kindergarten-based health promotion activities.
Step 2. Based on the findings of Step 1, a kindergarten-based, family-involved intervention was developed to influence obesity-related behaviours in 4-6 year olds and their families, adjusting for cultural, legislative and infrastructural diversities in the participating countries;
Step 3. Implemented the ToyBox-intervention in 6 European countries, assessed its process, impact and outcomes and estimated its cost-effectiveness;
Step 4. Disseminated the results and made recommendations for European public health policy.

In order to identify young children’s key-behaviours and their determinants related to early childhood obesity, systematic reviews, secondary analyses and focus group research were conducted.
Obesity prevalence was found to be higher in low-socioeconomic groups and in Southern European countries. Snacking, drinking, physical activity and sedentary behaviours were identified as the key-behaviours related to obesity at preschool age. Regarding the determinants of these behaviours, it was observed that attending a rural preschool is positively associated with higher levels of physical activity, preschoolers are less physically active and more sedentary on weekdays, watching TV is associated with higher consumption of snacks and sweet beverages, and weather conditions and parental habits at home influence children’s screen time (TV/DVD viewing and computer use).

In order to evaluate existing behavioural models and educational strategies that best support behavioural change in this age group, systematic and narrative reviews were performed.
The use of the social cognitive theory/social learning theory in the development of interventions was found to be the most effective. Combining high levels of parental involvement and use of interactive school-based learning, targeting physical activity and dietary change and long-term follow up, were characteristics of the most effective school-based obesity prevention interventions. Moreover, the inclusion of physical activity sessions with a minimum duration of 30 minutes, the use of portable play equipment and teachers’ training can be effective strategies to promote physical activity in preschools. Regarding the strategies to improve preschool children’s eating behaviour, five to ten repeated tastes to increase acceptance of healthy foods, rewarding healthy eating, increasing portion sizes of healthier foods especially in the beginning of the meal, parents’ use of moderate food restriction as a parental feeding practice and the active positive social modeling were found to be effective.

In order to assess school environment, policies and legislation affecting the implementation of kindergarten-based health promotion activities, documents from national databases and websites were retrieved.
According to the results, only few policies and legislations exist in the ToyBox-intervention countries. Some ongoing health promotion activities of good methodological approach were only observed at regional level in Belgium, Germany and Spain.

Based on the information obtained from “Step 1”, we proceeded with “Step 2”, i.e. the development of the ToyBox-intervention programme and the relevant material. More specifically, the Intervention Mapping Table was created and provided the basis for the development of the multi-component school-based family-involved intervention programme and the relevant material, which comprised of:

A) Material for the class
1) One handbook (“Teacher’s General Guide”) to guide the teachers on how to implement the programme, including the timeplan for the implementation of classroom activities and the distribution of the intervention material to the parents
2) Four handbooks (i.e. one for each targeted behaviour) for the implementation of classroom activities by the teacher (“Classroom Activities Guide SNACKING”, “Classroom Activities Guide DRINKING”, “Classroom Activities Guide PHYSICAL ACTIVITY”, “Classroom Activities Guide SEDENTARY BEHAVIOUR”)

B) Material for home
1) Nine newsletters (i.e. one newsletter to introduce ToyBox to parents and two newsletters for each behaviour)
2) Eight tip-cars (i.e. two tip-cards for each behaviour)
3) Four posters (i.e. one for each behaviour)

The ToyBox-intervention was implemented in six European countries (Belgium, Bulgaria, Germany, Greece, Spain and Poland) during the academic year 2012-2013. Three teachers’ training sessions were conducted in all intervention countries by trained researchers, following standardized procedures. In total, 309 kindergartens and 7,056 children/families participated in the ToyBox--intervention. The process, impact and outcome evaluation and cost-effectiveness of the ToyBox-study was assessed in all intervention countries, using standard equipment, questionnaires and procedures.

The process evaluation showed that the stakeholders (children, parents/caregivers, teachers) found the ToyBox-intervention attractive and appropriate for preschool age. The impact evaluation, based on the measurements obtained at baseline and follow-up, revealed that various energy balance related behaviours among the children and their families in the intervention group were significantly improved during the intervention period. Specifically, an increase of children’s water consumption, a decrease of children’s consumption of sweets, pre-packed juices and sugar-sweetened beverages and a lower increase of the time children spent on computer/video games were observed in the intervention group compared to the control group. Regarding the changes of children’s social and physical environment, it was found that parents/caregivers in the intervention group decreased their own consumption of sweets/candies, whereas the percentage of parents/caregivers setting as a rule for their children to consume soft drinks/pre-packed juices only on certain occasions (e.g. birthdays) and the proportion of parents/caregivers serving water to their children during their meals increased in the intervention group compared to the control group. Moreover, the proportion of parents/caregivers allowing their child to watch TV for as long as (s)he wants and the proportion of parents/caregivers thinking that viewing activities are beneficial and educational for their child were decreased in the intervention group compared to the control group over the intervention period.
Regarding the outcome evaluation, no significant differences in BMI z-score and in the prevalence of overweight/obesity between the intervention and the control kindergartens were observed at the end of the intervention, which was expected due to the short period of evaluation. More follow-up assessments in the following years would potentially provide further insights on the longer-term impact and outcome of this intervention.
Since the analysis of data is still ongoing regarding the effectiveness of the ToyBox-intervention and the mediators and moderators affecting its magnitude, more outcomes will be revealed and disseminated in the short future.

Project Results:
A) Scientific results

Results of the systematic reviews, secondary analyses and focus group research conducted within the ToyBox-study.
In order to identify young children’s key-behaviours and their determinants related to early childhood obesity, systematic reviews, secondary analyses and focus group research were conducted. Obesity prevalence was found to be higher in low-socioeconomic groups and in Southern European countries. Snacking, drinking, physical activity and sedentary behaviours were identified as the key-behaviours related to obesity at preschool age. Regarding the determinants of these behaviours, it was observed that attending a rural preschool is positively associated with higher levels of physical activity, preschoolers are less physically active and more sedentary on weekdays, watching TV is associated with higher consumption of snacks and sweet beverages, and weather conditions and parental habits at home influence children’s screen time (TV/DVD viewing and computer use).

Results of the systematic reviews and narrative reviews conducted within the ToyBox-study.
In order to evaluate existing behavioural models and educational strategies that best support behavioural change in this age group, systematic and narrative reviews were performed. The use of social cognitive theory/social learning theory in the development of interventions was found to be the most effective. Combining high levels of parental involvement and use of interactive school-based learning, targeting physical activity and dietary change and long-term follow up, were characteristics of the most effective school-based obesity prevention interventions. Moreover, the inclusion of physical activity sessions with a minimum duration of 30 minutes, the use of portable play equipment and teachers’ training can be effective strategies to promote physical activity in preschools. Regarding the strategies to improve preschool children’s eating behaviour, five to ten repeated tastes to increase acceptance of healthy foods, rewarding healthy eating, increasing portion sizes of healthier foods especially in the beginning of the meal, parents’ use of moderate food restriction as a parental feeding practice and the active positive social modeling were found to be effective.

Results of the research regarding school environment, policies and legislation conducted within the ToyBox-study.
In order to assess school environment, policies and legislation affecting the implementation of kindergarten-based health promotion activities, documents from national databases and websites were retrieved. According to the results, only few policies and legislations exist in the ToyBox-intervention countries. Some ongoing health promotion activities of good methodological approach were only observed at regional level in Belgium, Germany and Spain.

Results of the ToyBox-intervention process, impact and outcome evaluation and cost-effectiveness assessment.
The process evaluation showed that the stakeholders (children, parents/caregivers, teachers) found the ToyBox-intervention attractive and appropriate for preschool age. The impact evaluation, based on the measurements obtained at baseline and follow-up, revealed that various energy balance related behaviours among the children and their families in the intervention group were significantly improved during the intervention period. Specifically, an increase of children’s water consumption, a decrease of children’s consumption of sweets, pre-packed juices and sugar-sweetened beverages and a lower increase of the time children spent on computer/video games were observed in the intervention group compared to the control group. Regarding the changes of children’s social and physical environment, it was found that parents/caregivers in the intervention group decreased their own consumption of sweets/candies, whereas the percentage of parents/caregivers setting as a rule for their children to consume soft drinks/pre-packed juices only on certain occasions (e.g. birthdays) and the proportion of parents/caregivers serving water to their children during their meals increased in the intervention group compared to the control group. Moreover, the proportion of parents/caregivers allowing their child to watch TV for as long as (s)he wants and the proportion of parents/caregivers thinking that viewing activities are beneficial and educational for their child were decreased in the intervention group compared to the control group over the intervention period.
Regarding the outcome evaluation, no significant differences in BMI z-score and in the prevalence of overweight/obesity between the intervention and the control kindergartens were observed at the end of the intervention, which was expected due to the short period of evaluation. More follow-up assessments in the following years would potentially provide further insights on the longer-term impact and outcome of this intervention.
Since the analysis of data is still ongoing regarding the effectiveness of the ToyBox-intervention and the mediators and moderators affecting its magnitude, more outcomes will be revealed and disseminated in the short future.

B) Foreground

1) ToyBox cross-sectional study datasets
These datasets refer to the data collected at baseline (May/June 2012) in the six intervention countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain) and include:
- Anthropometric measurements of children (weight, height, waist circumference)
- Self-reported anthropometric measurements of parents/caregivers (weight, height)
- Pedometer data (for children’s objective physical activity assessment)
- Food frequency questionnaire: regarding children’s consumption of various foods (completed by their parents/caregivers)
- Core-questionnaire: regarding various family socio-economic characteristics, children’s and parental energy balance related behaviours (breakfast consumption, drinking, snacking, physical activity and sedentary behaviours), children’s perinatal characteristics, children’s sleep duration, parental perceptions of their children’s body weight, children’s medical history questionnaire
- Audit-questionnaire: for the evaluation of kindergartens’ food and physical activity environment (including physical environment, policies/legislations, rules, etc)

2) ToyBox-intervention datasets
These datasets refer to the complete data (i.e. children’s anthropometric data and 75% complete core-questionnaire data) collected at baseline and at follow-up (May/June 2012 and May/June 2013) in the six intervention countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain) and include:
- Anthropometric measurements of children (weight, height, waist circumference)
- Pedometer data (for children’s objective physical activity assessment)
- Self-reported anthropometric measurements of parents/caregivers (weight, height)
- Food frequency questionnaire: regarding children’s consumption of various foods (completed by their parents/caregivers)
- Core-questionnaire: regarding various family socio-economic characteristics, children’s and parental energy balance related behaviours (breakfast consumption, drinking, snacking, physical activity and sedentary behaviours), children’s sleep duration,
- Process evaluation data
- Cost-effectiveness data
- Audit-questionnaire: for the evaluation of kindergartens’ food and physical activity environment (including physical environment, policies/legislations, rules, etc)

3) ToyBox-intervention material
The ToyBox-intervention material comprised of:

A) Material for the class
1) One handbook (“Teacher’s General Guide”) to guide the teachers on how to implement the programme, including the timeplan for the implementation of classroom activities and the distribution of the intervention material to the parents
2) Four handbooks (i.e. one for each targeted behaviour) for the implementation of classroom activities by the teacher (“Classroom Activities Guide SNACKING”, “Classroom Activities Guide DRINKING”, “Classroom Activities Guide PHYSICAL ACTIVITY”, “Classroom Activities Guide SEDENTARY BEHAVIOUR”)

B) Material for home
1) Nine newsletters (i.e. one newsletter to introduce ToyBox to parents and two newsletters for each behaviour)
2) Eight tip-cars (i.e. two tip-cards for each behaviour)
3) Four posters (i.e. one for each behaviour)

Potential Impact:
Within ToyBox-study a multi-component kindergarten-based and family-involved intervention was developed and implemented, aiming to facilitate the local needs within a European scale approach. The intervention was applied in a selected number of European countries and a comprehensive (process, impact, outcome and cost effectiveness) evaluation was performed. Children/families and kindergartens from three socio-economic groups participated in the ToyBox-intervention.

The results of ToyBox-study are continuously disseminated among key stakeholders including scientists, health promotion specialists, teachers, policy makers and the general population. In that sense, ToyBox-study supports decision making for public health policy by providing all necessary information for policy makers and health promotion coordinators while the material and/or the intervention plan can be adapted on a pan-European scale.

The results of the ToyBox-study have been disseminated through public, professional and scientific media and via the ToyBox-website (www.toybox-study.eu). More specifically, regarding the:

Policy and professional dissemination: one major policy document was prepared, following discussions in a meeting of researchers, NGOs and EU officials at the ToyBox Stakeholder meeting in Brussels, April 2014. This document – a Policy Briefing Paper, attracted publicity in the public health media and a feature piece in the EU Parliament Magazine. ToyBox was also presented at a meeting of the DG Sanco Platform on Diet, Physical Activity and Health, in November 2013. Further articles in professional newsletters for nutritionists and school health educators are in press.

Scientific dissemination: The results of the systematic reviews, secondary analyses, focus group research and societal assessment which guided the development of the ToyBox-intervention, the methods and design of the ToyBox-intervention and intervention material, as well as the procedures followed and tools developed for the evaluation of the impact, outcome, process and cost-effectiveness of the ToyBox-intervention have been presented in two Supplement issues published in Obesity Reviews. Moreover, two International Scientific Symposia were organized by the ToyBox–study group, one at the meeting of ISBNPA in Ghent, Belgium (May 2013), and one at the meeting of the ICN in Granada, Spain (September 2013). A ToyBox Stakeholder policy meeting was conducted in April 2014, attended by officials from DG Sanco, DG Research, and the EC Joint Research Centre.

List of Websites:
http://www.toybox-study.eu/