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Background The aim of this study was to investigate bidirectional associations between (prolonged) sitting time and sleep duration in 12- to 14-year-old adolescents using a between-subjects and within-subjects analyses approach. Methods Observational data were used from 108 adolescents (53% girls; mean age 12.9 (SD 0.7) years) from six schools in Flanders, Belgium. The Axivity AX3 triaxial accelerometer, worn on the thigh, was used to assess daily total sitting time and daily time spent in sedentary bouts of ≥30 min (as a proxy for prolonged sitting time). The Fitbit Charge 3 was used to assess nightly sleep duration. Both monitors were worn on schooldays only (ranging from 4 to 5 days). Linear mixed models were conducted to analyse the associations, resulting in four models. In each model, the independent variable (sleep duration, sitting time or prolonged sitting time) was included as within- as well as between-subjects factor. Results Within-subjects analyses showed that when the adolescents sat more and when the adolescents spent more time sitting in bouts of ≥30 min than they usually did on a given day, they slept less during the following night (p = 0.01 and p = 0.05 (borderline significant), respectively). These associations were not significant in the other direction. Between-subjects analyses showed that adolescents who slept more on average, spent less time sitting (p = 0.006) and less time sitting in bouts of ≥30 min (p = 0.004) compared with adolescents who slept less on average. Conversely, adolescents who spent more time sitting on average and adolescents who spent more time sitting in bouts of ≥30 min on average, slept less (p = 0.02 and p = 0.003, respectively). Conclusions Based on the between-subjects analyses, interventions focusing on reducing or regularly breaking up sitting time could improve adolescents’ sleep duration on a population level, and vice versa. However, the within-subjects association was only found in one direction and suggests that to sleep sufficiently during the night, adolescents might limit and regularly break up their sitting time the preceding day. Trial registration Data have been used from our trial registered at ClinicalTrials.gov (NCT04327414; registered on March 11, 2020).

Background Recent 24-h movement guidelines for the early years established recommendations for physical activity (PA), screen time (ST), and sleep. To date, few studies have focused on compliance with meeting the guidelines and their associations with health outcomes. Thus, we aimed to investigate: 1) compliance with the 24-h movement guidelines, and 2) associations between compliance and anthropometry in Finnish preschoolers. Methods We utilized DAGIS survey data that were collected in 2015–2016 (N = 864). PA was assessed 24 h/day over 7 days using a waist-worn ActiGraph wGT3X-BT accelerometer. ST and sleep were reported by the parents during the same 7 days. Anthropometry was assessed using body mass index (BMI, kg/m2) and waist circumference (WC, cm). Children were classified as meeting the guidelines if they averaged ≥180 min/day of PA, which consisted of ≥60 min of moderate-to-vigorous intensity; ≤60 min/day of ST; and 10–13 h/day of sleep. In total, 778 children (51% boys, mean age: 4.7 ± 0.9 years) were included in the study. The compliance with meeting the 24-h movement guidelines was calculated for each behavior separately and in combinations. Adjusted linear regression analyses were applied to examine associations of compliance with BMI and WC. Results Children were physically active on average 390 (±46.2) min/day and spent 86 (±25.5) min/day in moderate-to-vigorous PA. They spent 76 (±37.4) min/day on ST and had on average 10:21 (±0:33) h:min/day of sleep. The compliance rate in meeting all three movement guidelines overall was 24%. The highest compliance rate was found for PA (85%), followed by sleep (76%) and ST (35%). Meeting guidelines separately for PA or sleep, or for both, were associated with lower WC (PA: B = -1.37, p p = 0.009; PA + Sleep: B = -1.03, p p = 0.027; PA + Sleep: B = -0.30, p = 0.007). There were no significant associations found regarding ST. Conclusions Meeting recommendations for PA and sleep may have an important role in supporting a healthy weight status in young children. However, there is still a need to improve compliance with the 24-h movement guidelines, especially for ST.

Background Many individuals aspire to attain various goals in life, such as committing to a healthful diet to slim down or saving for retirement to enhance future welfare. While these behaviors (weight loss and saving) share the common denominator of self-regulation, it is unclear whether success in one domain is related to the other. Therefore, we examined the relationship between long term weight loss (LTWL) success and monetary savings among U.S. adults who at one point in life diverged from normal weight status. Methods Data on 1994 adults with a maximum BMI ≥ 25 kg/m2 and with an annual household income equal or less than 200% poverty level. Data were derived from a U.S. population-based study (NHANES). The independent variable was LTWL success (loss maintained for at least 1 year), which was operationalized as Results Multivariable analysis revealed that adjusting for income, education and other covariates, being in the highest LTWL category (≥20.00%) significantly reduced the likelihood of monetary savings in comparison to the reference group (OR = 0.55, 95%CI = 0.34–0.91). This relationship was not observed in the lower LTWL category (10.00–19.99%). Conclusions Adults who in the past were overweight or obese and who presently exhibit high levels of LTWL, were markedly less successful when it came to their finances. This might stem from significant cognitive-affective resources exerted during the weight loss process coupled with a paucity of financial resources which impede financial decision making. This supposition, however, warrants future research.

Background Tobacco use is one of the world-leading preventable killers. There was a varied prevalence of tobacco use and cigarette smoking across different areas. The aim of the study was to assess the prevalence and factors associated with current tobacco use among adults residing in Arba Minch health and demographic surveillance site (HDSS). Methods A community-based cross-sectional study was conducted among adults residing in Arba Minch HDSS in 2017. The estimated sample size was 3368 individuals which were selected by simple random sampling techniques using Arba Minch HDSS dataset. Data collection tools were obtained from the WHO STEPwise. Current use of tobacco, which defined as the current use of smoked and/or smokeless tobacco, was considered as the dependent variable. A binary logistic regression model was used to identify candidate variables for the multivariable logistic regression model. An adjusted odds ratio (AOR) at a p-value of less than 0.05 was used to determine a statistically significant association between independent and dependent variables. Result The prevalence of tobacco use among adults was 20.2% (95% CI: 18.9–21.6%). The current use of smoked and smokeless tobacco were 17.1% (95%CI: 15.8–18.4%) and 9.7% (95%CI: 8.8–10.8%), respectively. The current use of tobacco was significantly associated with sex (female [AOR 0.54; 95%CI: 0.42–0.68] compared to men), age group (35–44 [AOR 1.57; 95%CI: 1.14–2.17], 45–54 [AOR 1.99; 95%CI: 1.45–2.74], and 55–64 [AOR 3.26; 95%CI: 2.37–4.48] years old compared to 25–35 years old), physical activity (moderate physical activity level [AOR 0.65; 95%CI: 0.44–0.96] compared with low) and residency (highland [AOR 4.39; 95% CI: 3.21–6.01] compared with at lowlander). Also, heavy alcohol consumption (AOR 3.97; 95% CI: 3.07–5.12), and Khat chewing (AOR 3.07(95%CI: 1.64–5.77) were also associated with the use of tobacco among the study participants. Conclusion Nearly one in five adults used tobacco currently in the study area, which is more than the national reports. Interventions for the reduction of tobacco use need to give due attention to men, older adults, uneducated, poor, and highlanders.

BackgroundNeighbourhood safety has repeatedly been shown to be associated with the health and well-being of the residents. Criminality is often seen as one of the key factors affecting neighbourhood safety. However, the relationship between crime, fear of crime and feelings of safety remains underexplored.MethodsData on socio-demographic, health and safety perceptions was extracted from the Maastricht municipality survey (the Netherlands) (n = 9656 adults) and merged with data on official neighbourhood crime rates from the Police Registry. Pearson correlation coefficients and multilevel logistic regression models were computed to assess the association between aspects of objective and perceived criminality, individuals’ feelings of safety and health.ResultsThe correlation between the police recorded crime and residents’ perceptions of the neighbourhood crime rates was weak (0.14–0.38), with the exception of violent crime (0.59), which indicates that other factors contribute to the perceptions of safety. In turn, the perception of higher rates of violent crime and more nuisance (on the scale 0–10) but not other types of crime or nuisance was positively associated with feeling unsafe (OR 1.27 [1.22;1.32] and 1.39 [1.33;1.46], respectively). Lower general feelings of safety at both the individual and neighbourhood level were consistently associated with worse self-rated health. Among different indicators of safety, the general feelings of safety had the most pronounced association with health, while subjective or objective measures of crime showed limited to no direct relationship with health.ConclusionsPublic health policies targeting safety as a social determinant of health should consider prioritizing areas of violent crime and nuisance to improve general feelings of safety. Further research is needed to understand which factors aside from criminality are driving residents’ feelings of safety.

Background Despite the current obesogenic environment creating challenges weight management, some people succeed in maintaining a normal weight. This study explored lifelong weight management from the life course perspective. We aimed to gain an insight into the issues related to the pathways of individuals of normal weight from childhood to adulthood, and how their experiences and social connections influence their weight management. Methods We approached the research topic using qualitative methods. Two age groups (30–45; 55–70 years, men and women), forming a total of 39 individuals, participated in theme interviews. Thematic analysis resulted in two main categories, namely (1) adoption of lifestyle and (2) maintenance of lifestyle. Results Childhood family played a central role in the formation of lifestyle: food-upbringing created the basis for the interviewees’ current diet, and their lives had always been characterized by an active lifestyle. High perceived self-efficacy was vital in weight management. The interviewees were confident about their routines and trusted their abilities to recognize and handle situations that threatened their lifestyles. They possessed skills for adjusting their lifestyle to altered environments, and showed a high level of coping self-efficacy. The interviewees also highlighted the importance of habits for weight management. They had improved their adopted lifestyle through constant learning. New routines had become more internalized through active repetition, finally turning into habitual practices, which simplified weight management. Conclusions Based on our interviews, we conclude that childhood was important in the development of the health-promoting lifestyle of our interviewees. However, weight management was described as a journey over the life course, and success also encouraged skills of identifying risks and adjusting actions to cope with challenging situations.

BACKGROUND: Unhealthy lifestyles in early childhood are a major global health challenge. These lifestyles often persist from generation to generation and contribute to a vicious cycle of health-related and social problems. This design article presents a study evaluating the effects of two novel healthy school interventions. The main outcome measure will be changes in children's body mass index (BMI). In addition, lifestyle behaviours, academic achievement, child well-being, socio-economic differences, and societal costs will be examined.METHODS: In close collaboration with various stakeholders, a quasi-experimental study was developed, for which children of four intervention schools (n = 1200) in the southern part of the Netherlands are compared with children of four control schools (n = 1200) in the same region. The interventions started in November 2015. In two of the four intervention schools, a whole-school approach named 'The Healthy Primary School of the Future', is implemented with the aim of improving physical activity and dietary behaviour. For this intervention, pupils are offered an extended curriculum, including a healthy lunch, more physical exercises, and social and educational activities, next to the regular school curriculum. In the two other intervention schools, a physical-activity school approach called 'The Physical Activity School', is implemented, which is essentially similar to the other intervention, except that no lunch is provided. The interventions proceed during a period of 4 years. Apart from the effectiveness of both interventions, the process, the cost-effectiveness, and the expected legal implications are studied. Data collection is conducted within the school system. The baseline measurements started in September 2015 and yearly follow-up measurements are taking place until 2019.DISCUSSION: A whole-school approach is a new concept in the Netherlands. Due to its innovative, multifaceted nature and sound scientific foundation, these integrated programmes have the potential to form a template for primary schools worldwide. The effects of this approach may extend further than the outcomes associated with well-being and academic achievement, potentially impacting legal and cultural aspects in our society.TRIAL REGISTRATION: The study protocol was registered in the database ClinicalTrials.gov on 14-06-2016 with the reference number NCT02800616 .

Background The increase in adiposity problems among United States adolescents has been accompanied by persistently high prevalence of unhealthy dieting behaviours (UDBs) such as fasting, taking diet pills/powders/liquids, and vomiting/taking laxatives. This study aimed to examine the associations of self-perceptions of weight status, weight change intentions (WCIs) and UDBs with sex, age and race, as well as trends of UDBs in American adolescents across the weight spectrum. Methods Data come from the biennial cross-sectional, school-based surveys, the Youth Risk Behaviour Surveillance System (1999–2013, n = 113,542). The outcome measures were the self-reported UDBs: fasting for 24 h or more; taking diet pills/powders/liquids; and vomiting/taking laxatives. Sex-stratified logistic regressions assessed relationships between weight status misperceptions across all weight statuses, race and WCIs with UDBs. Differential trends between races were assessed using race*year interaction terms. Results In males, all non-White races had higher odds of fasting and vomiting/taking laxatives than Whites (except fasting in Hispanic/Latinos), with Adjusted Odds Ratios (AORs) between 1.44 and 2.07. In females, Black/African Americans and Hispanic/Latinos had lower odds of taking diet pills/powders/liquids compared to Whites (AORs 0.50 and 0.78 respectively). Racial disparities persisted throughout the study period. Prevalence of fasting and vomiting/taking laxatives did not change between 1999 and 2013 for all races, while taking diet pills/powders/liquids decreased. Compared to individuals of normal weight who were accurate weight status perceivers, individuals of almost all other combinations of weight status and weight status perception had significantly higher odds of displaying any UDB outcome. Overestimation of weight status was found to be the strongest determinant of UDBs. Compared to individuals endorsing "not wanting to do anything" about their weight, individuals endorsing all other WCIs (including wanting to gain weight) also showed significantly higher odds for every UDB outcome, with wanting to lose weight having AORs of the greatest magnitudes. Conclusions Prevalence of UDBs is persistently high, and highest among females across all racial groups. UDBs may elevate undesired weight gain and weight loss in individuals who are obese/overweight and underweight respectively. Further research into weight status perceptions among adolescents may inform efforts to reduce UDBs.

Objectives: Sufficient fruit consumption is beneficial for a healthy live. While many Dutch adults intent to eat the recommended amount of fruit, only 5-10% of the population actually adheres to the recommendation. One mechanism that can help to narrow this gap between intention and actual fruit consumption is action planning. However, action planning is only assumed to be effective if plans are enacted. This study assessed which action plans are made and enacted, and further aimed to investigate two main hypotheses: 1. the effect of action planning (at T1) on fruit consumption (at T2) is mediated by plan enactment (at T3); 2. positive intentions (2a), high self-efficacy (2b) and a strong habit to eat fruit (2c) enhance the mediation of plan enactment, whereas a strong habit to eat snacks (2d) hinders the mediation of plan enactment.Methods: This study was a self-reported longitudinal online survey study. A total of 428 participants filled in a survey, measuring demographic factors (e. g. gender, age, education level), several socio-cognitive constructs (i. e. attitudes, self-efficacy, habit, action planning, plan enactment), and fruit consumption, at three points in time (baseline, after 1 month, and after 3 months). Mediation and moderated mediation analyses were used to investigate the planningplan enactment-fruit consumption relationship.Results: Up to 70% of the participants reported to have enacted their T1 action plans at T2. Action planning on fruit consumption was fully mediated by plan enactment (Hypothesis 1). All four proposed moderators (i. e. intention, selfefficacy, habit to consume fruit, and habit to consume snacks) significantly influenced the mediation (Hypotheses 2a-2d). Mediation of plan enactment was only present with high levels of intention, high levels of self-efficacy, strong habits to eat fruit, and weak habits to eat snacks.Conclusion: The study suggests the importance of plan enactment for fruit consumption. Furthermore, it emphasizes the necessity of facilitating factors. High levels of intention, self-efficacy and a strong habit to consume fruit clearly aid the enactment of action plans. This suggests that when these factors are moderately low, plan enactment may fail and thus an intervention may require first steps to foster these moderating factors.

Background This study aims to review all published systematic reviews on the prevalence of modifiable cardiovascular disease risk factors among women from the Gulf Cooperation Council countries (GCC). This is the first review of other systematic reviews that concentrates on lifestyle related diseases among women in GCC countries only. Method Literature searches were carried out in three electronic databases for all published systematic reviews on the prevalence of cardiovascular disease risk factors in the GCC countries between January 2000 and February 2016. Results Eleven systematic reviews were identified and selected for our review. Common reported risk factors for cardiovascular disease were obesity, physical inactivity, diabetes, metabolic syndrome and hypertension. In GCC countries, obesity among the female population ranges from 29 to 45.7%, which is one of the highest rates globally, and it is linked with physical inactivity, ranging from 45 to 98.7%. The prevalence of diabetes is listed as one of the top ten factors globally, and was reported with an average of 21%. Hypertension ranged from 20.9 to 53%. Conclusions The high prevalence of lifestyle-related diseases among women population in GCC is a ticking time bomb and is reaching alarming levels, and require a fundamental social and political changes. These findings highlight the need for comprehensive work among the GCC to strengthen the regulatory framework to decrease and control the prevalence of these factors.

Background: Recent research has illustrated the need for cross-sector partnerships to tackle multidimensional problems such as health inequalities and sport and physical activity promotion. Capacity building is based on partnerships and has demonstrated effectiveness in tackling these multidimensional problems. This study aims to explain how cross-sector partnerships build capacity at the practitioner, organisational and partnership levels. The subject of this study is a community sport program (CSP) that aims to increase sport participation rates and physical activity levels. Methods: The study examined multiple cases in four disadvantaged communities in Antwerp, Belgium where the CSP was implemented. Forty-four face-to-face interviews were held with leaders from sport, social, health, culture and youth organisations that collaborated with the CSP. Results: Thirteen elements of cross-sector partnerships were identified as critical to building capacity at each of the different levels. These include: process evaluation, trust, mutuality, policy support, partner complementarity and fit, diversity of activities and period of collaboration-time. Trust in turn was fostered by a longer period of collaboration-time, better personal contact, clearer coordination and an external focus. Policy support was developed by support of partners and establishing clear metrics of success. Conclusion: Insight into the key elements of cross-sector partnerships that build capacity is given and several practical recommendations are suggested for practitioners and policy makers.

Background Effective interventions on screen-time behaviours (television, video games and computer time) are needed to prevent non-communicable diseases in low- and middle-income countries. The present manuscript investigates the effect of a school-based health promotion intervention on screen-time behaviour among 12- to 15-year-old adolescents. We report the effect of the trial on screen-time after two stages of implementation. Methods We performed a cluster-randomised pair matched trial in urban schools in Cuenca-Ecuador. Participants were adolescents of grade eight and nine (mean age 12.8 ± 0.8 years, n = 1370, control group n = 684) from 20 schools (control group n = 10). The intervention included an individual and environmental component tailored to the local context and resources. The first intervention stage focused on diet, physical activity and screen-time behaviour, while the second stage focused only on diet and physical activity. Screen-time behaviours, primary outcome, were assessed at baseline, after the first (18 months) and second stage (28 months). Mixed linear models were used to analyse the data. Results After the first stage (data from n = 1224 adolescents; control group n = 608), the intervention group had a lower increase in TV-time on a week day (β = −15.7 min; P = 0.003) and weekend day (β = −18.9 min; P = 0.005), in total screen-time on a weekday (β = −25.9 min; P = 0.03) and in the proportion of adolescents that did not meet the screen-time recommendation (β = −4 percentage point; P = 0.01), compared to the control group. After the second stage (data from n = 1078 adolescents; control group n = 531), the TV-time on a weekday (β = 13.1 min; P = 0.02), and total screen-time on a weekday (β = 21.4 min; P = 0.03) increased more in adolescents from the intervention group. No adverse effects were reported. Discussion and Conclusion A multicomponent school-based intervention was only able to mitigate the increase in adolescents’ television time and total screen-time after the first stage of the intervention or in other words, when the intervention included specific components or activities that focused on reducing screen-time. After the second stage of the intervention, which only included components and activities related to improve healthy diet and physical activity and not to decrease the screen-time, the adolescents increased their screen-time again. Our findings might imply that reducing screen-time is only possible when the intervention focuses specifically on reducing screen-time. Trial registration Clinicaltrials.gov identifier NCT01004367.

Background The assessment of real-life, community-based interventions to tackle obesity is an important step in the development of effective policies. Especially multi-level interventions have a high likely effectiveness and potential reach in counteracting the obesity epidemic. Although much can be learned from these initiatives, performing an evaluation of such interventions is challenging. The aim of the current article is to provide a descriptive overview of the data collection process and general results of an assessment of ongoing multi-level obesity prevention community interventions for adults in Europe, and the lessons learned from this effort. Methods The data collection was divided into two main phases: a) finding the ongoing obesity prevention interventions by contacting key informants in each of the European Union countries and the European Economic Area, and searching existing databases; and b) collecting detailed information (including the reach, effectiveness, adoption, implementation and maintenance (RE-AIM)) of the selected interventions using questionnaires for informants in each of the interventions. Results A total of 78 interventions from 24 European countries were included in the final sample. The number of identified interventions varied greatly per country. The interventions covered various implementation levels (national, regional or local) and determinants (physical, sociocultural, economic, political), mostly addressing both nutrition and physical activity behaviours. Conclusions We found that many multi-level obesity prevention interventions among adults are currently active in Europe, although we found relatively few in Southern and Eastern Europe. Identifying interventions and obtaining detailed information proved to be a difficult, time consuming and painstaking process. We discuss some of the reasons why this might be the case and present recommendations based on our experiences. We suggest that future research uses a step-wise approach, keeping participant burden to a minimum. The use of personalised and tailored strategies is recommended, led by researchers who exercise flexibility, tact and patience during the data collection process. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1563-2) contains supplementary material, which is available to authorized users.

BACKGROUND: People with low socioeconomic status (SES) and some ethnic minorities are often underrepresented in lifestyle programmes. Therefore, a lifestyle programme was developed especially targeting these groups. Developing this lifestyle programme and designing an intervention study to test the effectiveness of this programme was an informative process in which several obstacles were encountered and choices had to be made. Study protocols, however, rarely describe these obstacles encountered in the protocol design process, and it is not always clear why researchers made certain choices. Therefore, the aim of this article is to describe both the final MetSLIM study protocol and the considerations and choices made in designing this study protocol. METHODS/DESIGN: The developed MetSLIM study has a quasi-experimental design, targeting 30- to 70-year-old adults with an elevated waist circumference, living in deprived neighbourhoods, of Dutch, Turkish or Moroccan descent. The intervention group participates in a 12-month lifestyle programme consisting of individual dietary advice, four group sessions and weekly sports lessons. The control group receives written information about a healthy lifestyle and one group session provided by a dietician. The study contains an elaborate effect, process and economic evaluation. Outcome measures are, among other things, change in waist circumference and the other components of the metabolic syndrome. DISCUSSION: Matching the preferences of the target group, such as their preferred setting, has implications for the entire study protocol. The process evaluation of the MetSLIM study will provide insight into the consequences of the choices made in the MetSLIM study protocol in terms of reach, acceptability and delivery of the programme, and the effect and economic evaluation will provide insight into the (cost)effectiveness of the lifestyle programme in order to reduce waist circumference among individuals with low SES of different ethnic origins. TRIAL REGISTRATION: Netherlands Trial Register NTR3721 (since November 27, 2012).

Background: The SI! Program promotes cardiovascular health through a multilevel school-based intervention on four lifestyle-related components: diet, physical activity, understanding the body and heart, and management of emotions. We report here the development and validation of the KAH (knowledge, attitudes and habits)-questionnaire adapted for elementary school children (6-7 years old) as a tool for the forthcoming evaluation of the SI! Program, where the KAH scoring will be the primary outcome. The efficacy of such an intervention will be based on the improvements in children's KAH towards a healthy lifestyle. Methods: The questionnaire validation process started with a pool of items proposed by the pedagogical team who developed the SI! Program for elementary school. The questionnaire was finalized by decreasing the number of items from 155 to 48 using expert panels and statistical tests on the responses from 384 children (ages 6-7). A team of specialized psychologists administered the questionnaire at schools providing standard directions for the final administration. The internal consistency was assessed using Cronbach's a coefficients. Reliability was measured through the split-half method, and problematic items were detected applying the item response theory. Analysis of variance and Tukey's test of additivity were used for multiple comparisons. Results: The final KAH-questionnaire for elementary school children should be administered to children individually by trained staff. The 48 items-questionnaire is divided evenly between the 4 components of the intervention, with an overall Cronbach's a = 0.791 (a = 0.526 for diet, a = 0.537 for physical activity, a = 0.523 for human body and heart, and a = 0.537 for management of emotions). Conclusions: The KAH-questionnaire is a reliable instrument to assess the efficacy of the SI! Program on instilling healthy lifestyle-related behaviors in elementary school children. This work is supported by the SHE Foundation (Foundation for Science, Health and Education) and the Daniel and Nina Carasso Foundation. Sí

Background Research suggests an inverse association between parental rules and screen time in pre-adolescents, and that parents’ style of communication with their children is related to the children’s time spent watching TV. The aims of this study were to examine associations of parental rules and parental style of communication with children’s screen time and perceived excessive screen time in five European countries. Methods UP4FUN was a multi-centre, cluster randomised controlled trial with pre- and post-test measurements in each of five countries; Belgium, Germany, Greece, Hungary and Norway. Questionnaires were completed by the children at school and the parent questionnaire was brought home. Three structural equation models were tested based on measures of screen time and parental style of communication from the pre-test questionnaires. Discussion Of the 152 schools invited, 62 (41 %) schools agreed to participate. In total 3325 children (average age 11.2 years and 51 % girls) and 3038 parents (81 % mothers) completed the pre-test questionnaire. The average TV/DVD times across the countries were between 1.5 and 1.8 h/day, while less time was used for computer/games console (0.9–1.4 h/day). The children’s perceived parental style of communication was quite consistent for TV/DVD and computer/games console. The presence of rules was significantly associated with less time watching TV/DVD and use of computer/games console time. Moreover, the use of an autonomy-supportive style was negatively related to both time watching TV/DVD and use of computer/games console time. The use of a controlling style was related positively to perceived excessive time used on TV/DVD and excessive time used on computer/games console. With a few exceptions, results were similar across the five countries. Conclusions This study suggests that an autonomy-supportive style of communicating rules for TV/DVD or computer/ games console use is negatively related to children’s time watching TV/DVD and use of computer/games console time. In contrast, a controlling style is associated with more screen time and with more perceived excessive screen time in particular. Longitudinal research is needed to further examine effects of parental style of communication on children’s screen time as well as possible reciprocal effects. Trial registration International Standard Randomized Controlled Trial Number Register, registration number: ISRCTN34562078 . Date applied29/07/2011, Date assigned11/10/2011.

Background Tackling inequalities in overweight, obesity and related determinants has become a top priority for the European research and policy agendas. Although it has been established that such inequalities accumulate from early childhood onward, they have not been studied extensively in children. The current article discusses the results of an explorative analysis for the identification of inequalities in behaviours and their determinants between groups with high and low socio-economic status. Methods This study is part of the Epode for the Promotion of Health Equity (EPHE) evaluation study, the overall aim of which is to assess the impact and sustainability of EPODE methodology to diminish inequalities in childhood obesity and overweight. Seven community-based programmes from different European countries (Belgium, Bulgaria, France, Greece, Portugal, Romania, The Netherlands) participate in the EPHE study. In each of the communities, children aged 6–8 years participated, resulting in a total sample of 1266 children and their families. A parental self-administrated questionnaire was disseminated in order to assess the socio-economic status of the household, selected energy balance-related behaviours (1. fruit and vegetable consumption; 2. soft drink/ fruit juices and water consumption; 3. screen time and 4. sleep duration) of the children and associated family environmental determinants. The Mann–Whitney U test and Pearson’s chi-square test were used to test differences between the low and high education groups. The country-specific median was chosen as the cut-off point to determine the educational level, given the different average educational level in every country. Results Children with mothers of relatively high educational level consumed fruits and vegetables more frequently than their peers of low socio-economic status. The latter group of children had a higher intake of fruit juices and/or soft drinks and had higher screen time. Parental rules and home availability were consistently different between the two socio-economic groups in our study in all countries. However we did not find a common pattern for all behaviours and the variability across the countries was large. Conclusions Our findings are indicative of socio-economic inequalities in our samples, although the variability across the countries was large. The effectiveness of interventions aimed at chancing parental rules and behaviour on health inequalities should be studied. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-2540-5) contains supplementary material, which is available to authorized users.

BACKGROUND: The current study examined the associations between active commuting to school, cognitive performance, and academic achievement in Dutch adolescents. In addition, it was explored whether these associations were moderated by sex and mediated by depressive symptoms. METHODS: Students in grades 7 and 9 (N = 270; mean age 13.4 years; 53% boys) were included. Active commuting to school was measured objectively by an ActivPAL3 accelerometer. Cognitive performance was measured by the d2 Test of attention (key components of executive functioning) and the Symbol Digit Modalities Test (information-processing speed). Academic achievement was determined by the mean of the school grades obtained in Dutch, mathematics and English. Depressive symptoms were self-reported. RESULTS: Active commuting to school constituted 28% of the total amount of time spent moving per week. Active commuting to school was not significantly associated with cognitive performance and academic achievement, overall. However, active commuting to school was positively associated with performance on the d2 Test of attention in girls (beta = .17, p = .037), but not in boys (beta = -.03, p = .660). The associations were not mediated by depressive symptoms. CONCLUSIONS: The associations between active commuting to school and cognitive performance and academic achievement are weak and might be moderated by sex, while the greatest benefits on cognition due to active commuting to school might be with regard to executive functioning. Future studies might make use of experimental designs, because causal relations between active commuting to school and cognitive performance or academic achievement would provide important implications for both education and public health.

Background Screen-related behaviours are highly prevalent in schoolchildren. Considering the adverse health effects and the relation of obesity and screen time in childhood, efforts to affect screen use in children are warranted. Parents have been identified as an important influence on children’s screen time and therefore should be involved in prevention programmes. The aim was to examine the mediating role of family-related factors on the effects of the school-based family-focused UP4FUN intervention aimed at screen time in 10- to 12-year-old European children (n child–parent dyads = 1940). Methods A randomised controlled trial was conducted to test the six-week UP4FUN intervention in 10- to 12-year-old children and one of their parents in five European countries in 2011 (n child–parent dyads = 1940). Self-reported data of children were used to assess their TV and computer/game console time per day, and parents reported their physical activity, screen time and family-related factors associated with screen behaviours (availability, permissiveness, monitoring, negotiation, rules, avoiding negative role modeling, and frequency of physically active family excursions). Mediation analyses were performed using multi-level regression analyses (child-school-country). Results Almost all TV-specific and half of the computer-specific family-related factors were associated with children’s screen time. However, the measured family-related factors did not mediate intervention effects on children’s TV and computer/game console use, because the intervention was not successful in changing these family-related factors. Conclusion Future screen-related interventions should aim to effectively target the home environment and parents’ practices related to children’s use of TV and computers to decrease children’s screen time. Trial registration The study is registered in the International Standard Randomised Controlled Trial Number Register (registration number: ISRCTN34562078 ).

Background: This study assessed the role of habits and previous behavior in predicting fruit consumption as well as their additional predictive contribution besides socio-demographic and motivational factors. In the literature, habits are proposed as a stable construct that needs to be controlled for in longitudinal analyses that predict behavior. The aim of this study is to provide empirical evidence for the inclusion of either previous behavior or habits. Methods. A random sample of 806 Dutch adults (>18 years) was invited by an online survey panel of a private research company to participate in an online study on fruit consumption. A longitudinal design (N = 574) was used with assessments at baseline and after one (T2) and two months (T3). Multivariate linear regression analysis was used to assess the differential value of habit and previous behavior in the prediction of fruit consumption. Results: Eighty percent of habit strength could be explained by habit strength one month earlier, and 64% of fruit consumption could be explained by fruit consumption one month earlier. Regression analyses revealed that the model with motivational constructs explained 41% of the behavioral variance at T2 and 38% at T3. The addition of previous behavior and habit increased the explained variance up to 66% at T2 and to 59% at T3. Inclusion of these factors resulted in non-significant contributions of the motivational constructs. Furthermore, our findings showed that the effect of habit strength on future behavior was to a large extent mediated by previous behavior. Conclusions: Both habit and previous behavior are important as predictors of future behavior, and as educational objectives for behavior change programs. Our results revealed less stability for the constructs over time than expected. Habit strength was to a large extent mediated by previous behavior and our results do not strongly suggest a need for the inclusion of both constructs. Future research needs to assess the conditions that determine direct influences of both previous behavior and habit, since these influences may differ per type of health behavior, per context stability in which the behavior is performed, and per time frame used for predicting future behavior. © 2014 de Vries et al.; licensee BioMed Central Ltd.

The purpose of this article is to give an integrative insight into the theoretical and empirical-based development of the Online Pestkoppenstoppen (Stop Bullies Online/Stop Online Bullies). This intervention aims to reduce the number of cyberbully victims and their symptoms of depression and anxiety (program goal), by teaching cyberbully victims how to cope in an adequate and effective manner with cyberbully incidents (program’s outcomes). In developing the program the different steps of the Intervention Mapping protocol are systematically used. In this article we describe each step of Intervention Mapping. Sources used for the development were a literature review, a Delphi study among experts, focus group interviews with the target group, and elements from a proven effective anti-bullying program. The result is a fully automated web-based tailored intervention for cyberbully victims (12-15 years) consisting of three web-based advice sessions delivered over three months. The first advice aims to teach participants how behavior is influenced by the thoughts they have, how to recognize and dispute irrational thoughts and how to form rational thoughts. In the second advice, participants will learn about the way bullying emerges, how their behavior influences bullying and how they can use effective coping strategies in order to stop (online) bullying. In the third advice, participants receive feedback and will learn how to use the Internet and mobile phones in a safe manner. Each advice is tailored to the participant’s personal characteristics (e.g., personality, self-efficacy, coping strategies used and (ir)rational thoughts). To ensure implementation of the program after testing it for effectiveness, the intervention was pretested in the target-population and an implementation plan was designed. Finally, we will elaborate on the planned randomized controlled trial in which the intervention will be compared to a general information group and waiting list control group. This evaluation will provide insight into the intervention’s efficacy to reduce cyberbullying and its negative effects. Intervention Mapping is a time consuming but profound way to ensure that each step of developing an intervention is taken, and resulted in three web-based tailored pieces of advices that teach adolescents how to cope more effectively with cyberbullying experiences. NTR3613 , 14-09-2012

Background: Health inequalities can be tackled with appropriate health and social policies, involving all community groups and governments, from local to global. The objective of this study was to carry out a scoping review on social and health policies or interventions to tackle health inequalities in European cities published in scientific journals.Methods: Scoping review. The search was done in "PubMed" and the "Sociological Abstracts" database and was limited to articles published between 1995 and 2011. The inclusion criteria were: interventions had to take place in European cities and they had to state the reduction of health inequalities among their objectives.Results: A total of 54 papers were included, of which 35.2% used an experimental design, and 74.1% were carried out in the United Kingdom. The whole city was the setting in 27.8% of them and 44.4% were based on promoting healthy behaviours. Adults and children were the most frequent target population and half of the interventions had a universal approach and the other half a selective one. Half of the interventions were evaluated and showed positive results.Conclusions: Although health behaviours are not the main determinants of health inequalities, the majority of the selected documents were based on evaluations of interventions focusing on them.

Background: Health inequalities can be tackled with appropriate health and social policies, involving all community groups and governments, from local to global. The objective of this study was to carry out a scoping review on social and health policies or interventions to tackle health inequalities in European cities published in scientific journals. Methods: Scoping review. The search was done in “PubMed” and the “Sociological Abstracts” database and was limited to articles published between 1995 and 2011. The inclusion criteria were: interventions had to take place in European cities and they had to state the reduction of health inequalities among their objectives. Results: A total of 54 papers were included, of which 35.2% used an experimental design, and 74.1% were carried out in the United Kingdom. The whole city was the setting in 27.8% of them and 44.4% were based on promoting healthy behaviours. Adults and children were the most frequent target population and half of the interventions had a universal approach and the other half a selective one. Half of the interventions were evaluated and showed positive results. Conclusions: Although health behaviours are not the main determinants of health inequalities, the majority of the selected documents were based on evaluations of interventions focusing on them. This article has been partially funded by the project INEQ-CITIES, “Socioeconomic inequalities in mortality: evidence and policies of cities of Europe”; project funded by the Executive Agency for Health and Consumers (Commission of the European Union), project n°2008 12 13

Background Exhaled breath temperature has been suggested as a new method to detect and monitor pathological processes in the respiratory system. The putative mechanism of this approach is based upon changes in the blood flow. So far potential factors that influence breath temperature have not been studied in the general population. Methods The exhaled breath temperature was measured in 151 healthy non-smoking elderly (aged: 60–80 years) at room temperature with the X-halo device with an accuracy of 0.03°C. We related exhaled breath temperature by use of regression models with potential predictors including: host factors (sex, age) and environmental factors (BMI, physical activity, and traffic indicators). Results Exhaled breath temperature was lower in women than in men and was inversely associated with age, physical activity. BMI and daily average ambient temperature were positively associated with exhaled breath temperature. Independent of the aforementioned covariates, exhaled breath temperature was significantly associated with several traffic indicators. Residential proximity to major road was inversely associated with exhaled breath temperature: doubling the distance to the nearest major intense road was observed a decrease of 0.17°C (95% CI: -0.33 to -0.01; p = 0.036). Conclusions Exhaled breath temperature has been suggested as a noninvasive method for the evaluation of airway inflammation. We provide evidence that several factors known to be involved in proinflammatory conditions including BMI, physical activity and residential proximity to traffic affect exhaled breath temperature. In addition, we identified potential confounders that should be taken into account in clinical and epidemiological studies on exhaled breath temperature including sex, age, and ambient temperature.

Background This paper describes the systematic development of a text-driven and a video-driven web-based computer-tailored intervention aimed to prevent obesity among normal weight and overweight adults. We hypothesize that the video-driven intervention will be more effective and appealing for individuals with a low level of education. Methods and Design The Intervention Mapping protocol was used to develop the interventions, which have exactly the same educational content but differ in the format in which the information is delivered. One intervention is fully text-based, while in the other intervention in addition to text-based feedback, the core messages are provided by means of videos. The aim of the interventions is to prevent weight gain or achieve modest weight loss by making small changes in dietary intake or physical activity. The content of the interventions is based on the I-Change Model and self-regulation theories and includes behavior change methods such as consciousness raising, tailored feedback on behavior and cognitions, goal setting, action and coping planning, and evaluation of goal pursuit. The interventions consist of six sessions. In the first two sessions, participants will set weight and behavioral change goals and form plans for specific actions to achieve the desired goals. In the remaining four sessions, participants’ will evaluate their progress toward achievement of the behavioral and weight goals. They will also receive personalized feedback on how to deal with difficulties they may encounter, including the opportunity to make coping plans and the possibility to learn from experiences of others. The efficacy and appreciation of the interventions will be examined by means of a three-group randomized controlled trial using a waiting list control group. Measurements will take place at baseline and six and twelve months after baseline. Primary outcome measures are body mass index, physical activity, and dietary intake. Discussion The present paper provides insight into how web-based computer-tailored obesity prevention interventions consisting of self-regulation concepts and text-driven and video-driven messages can be developed systematically. The evaluation of the interventions will provide insight into their efficacy and will result in recommendations for future web-based computer-tailored interventions and the additional value of using video tailoring. Trial registration NTR3501.

Background: Running is associated with desirable lifestyle changes. Therefore several initiatives have been undertaken to promote running. Exact data on the health effects as a result of participating in a short-term running promotion program, however, is scarce. One important reason for dropout from a running program is a running-related injury (RRI). The incidence of RRIs is high, especially in novice runners. Several studies examined potential risk factors for RRIs, however, due to the often underpowered studies it is not possible to reveal the complex mechanism leading to an RRI yet.The primary objectives are to determine short- and long-term health effects of a nationwide "Start to Run" program and to identify determinants for RRIs in novice runners. Secondary objectives include examining reasons and determinants for dropout, medical consumption and economical consequences of RRIs as a result of a running promotion program. Methods/design. The NLstart2run study is a multi-center prospective cohort study with a follow-up at 6, 12, 24 and 52 weeks. All participants that sign up for the Start to Run program in 2013, which is offered by the Dutch Athletics Federation, will be asked to participate in the study.During the running program a digital running log will be completed by the participants every week to administer exposure and running related pain. After the running program the log will be completed every second week. An RRI is defined as any musculoskeletal ailment of the lower extremity or back that the participant attributed to running and hampers running ability for at least one week. Discussion. The NLstart2run study will provide insight into the short- and long-term health effects as a result of a short-term running promotion program. Reasons and determinants for dropout from a running promotion program will be examined as well. The study will result in several leads for future RRI prevention and as a result minimize dropout due to injury. This information may increase the effectiveness of future running promotion programs and will thereby contribute positively to public health. Trial registration. The Netherlands National Trial Register NTR3676. The NTR is part of the WHO Primary Registries.

Background: The existing literature on weight management interventions targeting physical activity and healthy eating in mental health care appears to provide only limited evidence. The aim of the study was to examine the effectiveness of a 10-week health promotion intervention, followed by a 6-month follow-up period in individuals with mental disorders living in sheltered housing in the Flanders region (Belgium). Methods: The study had a cluster preference randomized controlled design. Twenty-five sheltered housing organisations agreed to participate (16 in the intervention group, nine in the control group). In the intervention group, 225 individuals agreed to participate, while in the control group 99 individuals entered into the study. The main outcomes were changes in body weight, Body Mass Index, waist circumference and fat mass. Secondary outcomes consisted of changes in physical activity levels, eating habits, health-related quality of life and psychiatric symptom severity. Results: A significant difference was found between the intervention group and the control group regarding body weight (−0.35 vs. +0.22 kg; p=0.04), Body Mass Index (−0.12 vs. +0.08 kg/m 2 ; p=0.04), waist circumference (−0.29 vs. + 0.55 cm; p

Background High infection rates of STIs are found among the different ethnic communities living in the Netherlands, especially among the Surinamese and Dutch-Antilleans. Only limited effective interventions that promote STI/HIV testing among these communities are available in the Netherlands. In the present study we identified the determinants of the intention to get tested for STI/HIV of the sexually active Surinamese and Dutch-Antilleans living in the Netherlands. Secondly, this study assesses which determinants should be addressed when promoting STI/HIV testing among these communities. Methods In total, 450 Surinamese and 303 Dutch-Antillean respondents were recruited through Dutch Internet panels and group activities. The questionnaire used in the online survey was based on the concepts of the Health Belief Model, the Social Cognitive Theory, and Theory of Planned behavior. To correct for multiple outcome testing, we considered differences as statistically significant at p

Background Overweight and obesity in youth has increased dramatically. Therefore, overweight prevention initiatives should start early in life and target modifiable energy balance-related behaviours. Parental participation is often advocated as important for school-based interventions, however, getting parents involved in school-based interventions appears to be challenging based on earlier intervention experiences. The purpose of this study was to get insight into the determinants of and perspectives on parental participation in school-interventions on energy balance-related behaviours (physical activity, healthy eating, sedentary behaviours) in parents of ten- to twelve-year olds in order to develop an effective parental module for school-based interventions concerning energy balance-related behaviours. Methods Four countries (Belgium, Hungary, Norway and Spain) conducted the focus group research based on a standardised protocol and a semi-structured questioning route. A variation in parental socio-economic status (SES) and parental school involvement was taken into account when recruiting the parents. The audio taped interviews were transcribed, and a qualitative content analysis of the transcripts was conducted in each country. Results Seventeen focus group interviews were conducted with a total of 92 parents (12 men, 80 women). Physical activity was considered to be a joint responsibility of school and parents, nutrition as parent's responsibility but supported by the school, and prevention of sedentary behaviours as parent's sole responsibility. Parents proposed interactive and practical activities together with their child as the best way to involve them such as cooking, food tasting, nutrition workshops, walking or cycling tours, sport initiations together with their child. Activities should be cheap, on a convenient moment, focused on their children and not on themselves, not tutoring, not theoretical, and school-or home-based. Conclusions Parents want to be involved in activities related to energy balance-related behaviours if this implies 'doing things together' with their child at school or at home.

Background Sedentary behaviors (involving prolonged sitting time) are associated with deleterious health consequences, independent of (lack of) physical activity. To inform interventions, correlates of prevalent sedentary behaviors need to be identified. We examined associations of socio-demographic, home-environmental and psychosocial factors with adults' TV viewing time and leisure-time Internet use; and whether psychosocial and environmental correlates differed according to gender, age and educational attainment. Methods This cross-sectional study was conducted in Ghent, Belgium, between March and May 2010. Respondents to a mail-out survey (n = 419; 20-65 years; mean age 48.5 [12.1] years; 47.3% men) completed a questionnaire on sedentary behaviors and their potential socio-demographic, psychosocial and home environmental correlates. Statistical analyses were performed using multiple linear regression models. Results The independent variables explained 31% of the variance in TV viewing time and 38% of the variance in leisure-time Internet use. Higher education, greater perceived pros of and confidence about reducing TV time were negatively associated with TV viewing time; older age, higher body mass index, larger TV set size and greater perceived cons of reducing TV time showed positive associations. Perceived pros of and confidence about reducing Internet use were negatively associated with leisure-time Internet use; higher education, number of computers in the home, positive family social norms about Internet use and perceived cons of reducing Internet use showed positive associations. None of the socio-demographic factors moderated these associations. Conclusions Educational level, age, self-efficacy and pros/cons were the most important correlates identified in this study. If further cross-sectional and longitudinal research can confirm these findings, tailored interventions focusing on both psychosocial and environmental factors in specific population subgroups might be most effective to reduce domestic screen time.

Background Variability in health behaviours is an important cause of socioeconomic health disparities. Socioeconomic differences in health behaviours are poorly understood. Previous studies have examined whether (single) stressors or psychosocial resources mediate the relationship between socioeconomic position and health or mortality. This study examined: 1) whether the presence of stressors and the absence of resources can be represented by a single underlying factor, and co-occur among those with lower education, 2) whether stressors and resources mediated the relation between education and health behaviours, and 3) addressed the question whether an aggregate measure of stressors and resources has an added effect over the use of individual measures. Methods Questionnaire data on sociodemographic variables, stressors, resources, and health behaviours were collected cross-sectionally among inhabitants (n = 3050) of a medium-sized Dutch city (Utrecht). Descriptive statistics and bootstrap analyses for multiple-mediator effects were used to examine the role of stressors and resources in mediating educational associations with health behaviours. Results Higher levels of stressors and lower levels of resources could be represented by a single underlying factor, and co-occurred among those with lower educational levels. Stressors and resources partially mediated the relationship between education and four health- behaviours (exercise, breakfast frequency, vegetable consumption and smoking). Financial stress and poor perceived health status were mediating stressors, and social support a strong mediating resource. An aggregate measure of the stressors and resources showed similar associations with health behaviours compared to the summed individual measures. Conclusions Lower educated groups are simultaneously affected by the presence of various stressors and absence of multiple resources, which partially explain socioeconomic differences in health behaviours. Compared to the direct associations of stressors and resources with health behaviours, the association with socioeconomic status was modest. Therefore, besides addressing structural inequalities, interventions promoting financial management, coping with chronic disease, and social skills training have the potential to benefit large parts of the population, most notably the lower educated. Further research is needed to clarify how stressors and resources impact health behaviours, why this differs between behaviours and how these disparities could be alleviated.

Background Smoking, high alcohol consumption, unhealthy eating habits and physical inactivity often lead to (chronic) diseases, such as cardiovascular diseases and cancer. Tailored online interventions have been proven to be effective in changing health behaviours. The aim of this study is to test and compare the effectiveness of two different tailoring strategies for changing lifestyle compared to a control group using a multiple health behaviour web-based approach. Methods In our Internet-based tailored programme, the five lifestyle behaviours of smoking, alcohol intake, fruit consumption, vegetable consumption, and physical activity are addressed. This randomized controlled trial, conducted among Dutch adults, includes two experimental groups (i.e., a sequential behaviour tailoring condition and a simultaneous behaviour tailoring condition) and a control group. People in the sequential behaviour tailoring condition obtain feedback on whether their lifestyle behaviours meet the Dutch recommendations. Using a step-by-step approach, they are stimulated to continue with a computer tailored module to change only one unhealthy behaviour first. In the course of the study, they can proceed to change a second behaviour. People in the simultaneous behaviour tailoring condition receive computer tailored feedback about all their unhealthy behaviours during their first visit as a stimulation to change all unhealthy behaviours. The experimental groups can re-visit the website and can then receive ipsative feedback (i.e., current scores are compared to previous scores in order to give feedback about potential changes). The (difference in) effectiveness of the different versions of the programme will be tested and compared to a control group, in which respondents only receive a short health risk appraisal. Programme evaluations will assess satisfaction with and appreciation and personal relevance of the intervention among the respondents. Finally, potential subgroup differences pertaining to gender, age and socioeconomic status regarding the behaviour effects and programme evaluation will be assessed. Discussion Research regarding multiple behaviour change is in its infancy. We study how to offer multiple behaviour change interventions optimally. Using these results could strengthen the effectiveness of web-based computer-tailoring lifestyle programmes. This study will yield new results about the need for differential lifestyle approaches using Internet-based expert systems and potential differences in subgroups concerning the effectiveness and appreciation. Trial registration Dutch Trial Register NTR2168.

Background Obesity treatment is by large ineffective long term, and more emphasis on the prevention of excessive weight gain in childhood and adolescence is warranted. To inform energy balance related behaviour (EBRB) change interventions, insight in the potential personal, family and school environmental correlates of these behaviours is needed. Studies on such multilevel correlates of EBRB among schoolchildren in Europe are lacking. The ENERGY survey aims to (1) provide up-to-date prevalence rates of measured overweight, obesity, self-reported engagement in EBRBs, and objective accelerometer-based assessment of physical activity and sedentary behaviour and blood-sample biomarkers of metabolic function in countries in different regions of Europe, (2) to identify personal, family and school environmental correlates of these EBRBs. This paper describes the design, methodology and protocol of the survey. Method/Design A school-based cross-sectional survey was carried out in 2010 in seven different European countries; Belgium, Greece, Hungary, the Netherlands, Norway, Slovenia, and Spain. The survey included measurements of anthropometrics, child, parent and school-staff questionnaires, and school observations to measure and assess outcomes (i.e. height, weight, and waist circumference), EBRBs and potential personal, family and school environmental correlates of these behaviours including the social-cultural, physical, political, and economic environmental factors. 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. Discussion The ENERGY survey is a comprehensive cross-sectional study measuring anthropometrics and biomarkers as well as assessing a range of EBRBs and their potential correlates at the personal, family and school level, among 10-12 year old children in seven European countries. This study will result in a unique dataset, enabling cross country comparisons in overweight, obesity, risk behaviours for these conditions as well as the correlates of engagement in these risk behaviours.

Background The implementation project of the national diabetes prevention programme in Finland, FIN-D2D, was carried out in primary health care in the area of five hospital districts during 2003-2007. Methods The population strategy of FIN-D2D was primarily aimed at increasing the awareness of type 2 diabetes and preventing obesity. To investigate the effects of this strategy, we studied the changes in the prevalence of obesity, overweight, and central obesity among a random independent sample of individuals aged 45-74 years in the FIN-D2D area; and assessed whether they differed from a sample of individuals in the control area, which consisted of four geographical areas not participating in FIN-D2D (FINRISK study). Data was obtained for 5850/ 6406 (in the beginning/ in the end) individuals. The duration of the observation period varied from three to five years. Results The mean body weight decreased from 78.7 to 78.1 kg (p = 0.041) in the FIN-D2D area, and from 78.7 to 78.0 kg (p = NS) in the control area. The prevalence of obesity (BMI ≥30 kg/m2) decreased in the FIN-D2D area (26.5% vs. 24.4%, p = 0.015), and in the control area (28.4% vs. 25.2%, p = 0.005). The prevalence of morbid obesity (BMI ≥40 kg/m2) remained unchanged in the FIN-D2D area, but increased in the control area (1.2% vs. 2.3%, p = 0.007). The mean waist circumference remained unchanged in the FIN-D2D area, but increased in the control area (92.8 vs. 94.0 cm, p = 0.005). Conclusions The prevalence of obesity may be decreasing among 45-74 year old Finns. We still need a longer time perspective and future studies to see whether this favourable trend can be sustained in Finland. The actions of this implementation project can at least partly explain the differences in the mean waist circumference and the prevalence of morbid obesity between the intervention and control areas.

Background To improve a sustainable healthy working life, we have developed the intervention 'Staying healthy at work', which endeavours to enhance work participation of employees aged 45 years and older by increasing their problem-solving capacity and stimulating their awareness of their role and responsibility towards a healthy working life. This research study aims to evaluate the process and the effectiveness of the intervention compared with care as usual. Methods/design The study is a cluster-randomized controlled trial design (randomized at the supervisor level), with a 1-year follow-up. Workers aged 45 years and older have been enrolled in the study. Workers in the intervention group are receiving the intervention 'Staying healthy at work'. The main focus of the intervention is to promote a healthy working life of ageing workers by: (1) changing workers awareness and behaviour, by emphasizing their own decisive role in attaining goals; (2) improving the supervisors' ability to support workers in taking the necessary action, by means of enhancing knowledge and competence; and (3) enhancing the use of the human resource professionals and the occupational health tools available within the organization. The supervisors in the intervention group have been trained how to present themselves as a source of support for the worker. Workers in the control group are receiving care as usual; supervisors in the control group have not participated in the training. Measurements have been taken at baseline and will be followed up at 3, 6 and 12 months. The primary outcome measures are vitality, work ability and productivity. The secondary outcomes measures include fatigue, job strain, work attitude, self-efficacy and work engagement. A process evaluation will be conducted at both the supervisor and the worker levels, and satisfaction with the content of the intervention will be assessed. Discussion The intervention 'Staying healthy at work' has the potential to provide evidence-based knowledge of an innovative method to promote a sustainable healthy working life in the older working population. The results of the study will be relevant for workers, employers, occupational health professionals and human resource professionals. Trial registration The trial is registered with the Dutch Trial Register under number NTR2270.

Background Childhood obesity has reached epidemic proportions in developed countries. Sedentary screen-based activities such as video gaming are thought to displace active behaviors and are independently associated with obesity. Active video games, where players physically interact with images onscreen, may have utility as a novel intervention to increase physical activity and improve body composition in children. The aim of the Electronic Games to Aid Motivation to Exercise (eGAME) study is to determine the effects of an active video game intervention over 6 months on: body mass index (BMI), percent body fat, waist circumference, cardio-respiratory fitness, and physical activity levels in overweight children. Methods/Design Three hundred and thirty participants aged 10–14 years will be randomized to receive either an active video game upgrade package or to a control group (no intervention). Discussion An overview of the eGAME study is presented, providing an example of a large, pragmatic randomized controlled trial in a community setting. Reflection is offered on key issues encountered during the course of the study. In particular, investigation into the feasibility of the proposed intervention, as well as robust testing of proposed study procedures is a critical step prior to implementation of a large-scale trial. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12607000632493

Background Screening invitations have traditionally been brief, providing information only about population benefits. Presenting information about the limited individual benefits and potential harms of screening to inform choice may reduce attendance, particularly in the more socially deprived. At the same time, amongst those who attend, it might increase motivation to change behavior to reduce risks. This trial assesses the impact on attendance and motivation to change behavior of an invitation that facilitates informed choices about participating in diabetes screening in general practice. Three hypotheses are tested: 1. Attendance at screening for diabetes is lower following an informed choice compared with a standard invitation. 2. There is an interaction between the type of invitation and social deprivation: attendance following an informed choice compared with a standard invitation is lower in those who are more rather than less socially deprived. 3. Amongst those who attend for screening, intentions to change behavior to reduce risks of complications in those subsequently diagnosed with diabetes are stronger following an informed choice invitation compared with a standard invitation. Method/Design 1500 people aged 40–69 years without known diabetes but at high risk are identified from four general practice registers in the east of England. 1200 participants are randomized by households to receive one of two invitations to attend for diabetes screening at their general practices. The intervention invitation is designed to facilitate informed choices, and comprises detailed information and a decision aid. A comparison invitation is based on those currently in use. Screening involves a finger-prick blood glucose test. The primary outcome is attendance for diabetes screening. The secondary outcome is intention to change health related behaviors in those attenders diagnosed with diabetes. A sample size of 1200 ensures 90% power to detect a 10% difference in attendance between arms, and in an estimated 780 attenders, 80% power to detect a 0.2 sd difference in intention between arms. Discussion The DICISION trial is a rigorous pragmatic denominator based clinical trial of an informed choice invitation to diabetes screening, which addresses some key limitations of previous trials. Trial registration Current Controlled Trials ISRCTN73125647

Background Higher prevalence rates of unhealthy behaviours among lower socioeconomic groups contribute substantially to socioeconomic inequalities in health in adults. Preventing the development of these inequalities in unhealthy behaviours early in life is an important strategy to tackle socioeconomic inequalities in health. Little is known however, about health promotion strategies particularly effective in lower socioeconomic groups in youth. It is the purpose of project TEENAGE to improve knowledge on the prevention of socioeconomic inequalities in physical activity, diet, smoking and alcohol consumption among adolescents in Europe. This paper describes the background, design and methods to be used in the project. Methods/design Through a systematic literature search, existing interventions aimed at promoting physical activity, a healthy diet, preventing the uptake of smoking or alcohol, and evaluated in the general adolescent population in Europe will be identified. Studies in which indicators of socioeconomic position are included will be reanalysed by socioeconomic position. Results of such stratified analyses will be summarised by type of behaviour, across behaviours by type of intervention (health education, environmental interventions and policies) and by setting (individual, household, school, and neighbourhood). In addition, the degree to which effective interventions can be transferred to other European countries will be assessed. Discussion Although it is sometimes assumed that some health promotion strategies may be particularly effective in higher socioeconomic groups, thereby increasing socioeconomic inequalities in health-related behaviour, there is little knowledge about differential effects of health promotion across socioeconomic groups. Synthesizing stratified analyses of a number of interventions conducted in the general adolescent population may offer an efficient guidance for the development of strategies and interventions to prevent socioeconomic inequalities in health early in life.

Background Lower socioeconomic position is generally associated with higher rates of smoking and alcohol consumption and lower levels of physical activity. Health-related behaviour is usually established during late childhood and adolescence. The aim of this study is to explore changes in health-related behaviour in a cohort of adolescents aged between 15 and 19, overall and by socioeconomic position. Methods The sample consisted of 844 first-year students (42.8% males, baseline in 1998 – mean age 14.9, follow-up in 2002 – mean age 18.8) from 31 secondary schools located in Kosice, Slovakia. This study focuses on changes in adolescents' smoking, alcohol use, experience with marijuana and lack of physical exercise with regard to their socioeconomic position. Four indicators of socioeconomic position were used – adolescents' current education level and employment status, and the highest education level and highest occupational status of their parents. We first made cross tabulations of HRB with these four indicators, using McNemar's test to assess differences. Next, we used logistic regression to assess adjusted associations, using likelihood ratio tests to assess statistical significance. Results Statistically significant increases were found in all health-related behaviours. Among males, the most obvious socioeconomic gradient was found in smoking, both at age 15 and at 19. Variations in socioeconomic differences in health-related behaviour were more apparent among females. Although at age 15, almost no socioeconomic differences in health-related behaviour were found, at age 19 differences were found for almost all socioeconomic indicators. Among males, only traditional socioeconomic gradients were found (the lower the socioeconomic position, the higher the prevalence of potentially harmful health-related behaviour), while among females reverse socioeconomic gradients were also found. Conclusion We confirmed an increase in unhealthy health-related behaviour during adolescence. This increase was related to socioeconomic position, and was more apparent in females.

Background Cross-sectional studies have reported associations between social support and health, but prospective evidence is less conclusive. This study aims to investigate the associations of positive and negative experiences of social support with current and future lifestyle factors, biological risk factors, self-perceived health and mental health over a 10-year period. Methods Data were from 4,724 Dutch men and women aged 26-65 years who participated in the second (1993-1997) and in the third (1998-2002) or fourth (2003-2007) study round of the Doetinchem Cohort Study. Social support was measured at round two using the Social Experiences Checklist. Health was assessed by several indicators such as smoking, alcohol consumption, physical activity, fruit and vegetable intake, overweight, hypertension, hypercholesterolemia, self-perceived health and mental health. Tertiles of positive and negative experiences of social support were analysed in association with repeated measurements of prevalence and incidence of several health indicators using generalised estimating equations (GEE). Results Positive and negative experiences of social support were associated with prevalence and incidence of poor mental health. For the lowest tertile of positive support, odds ratios were 2.74 (95% CI 2.32-3.23) for prevalent poor mental health and 1.86 (95% CI 1.39-2.49) for incident poor mental health. For the highest tertile of negatively experienced support, odds ratios for prevalent and incident poor mental health were 3.28 (95% CI 2.78-3.87) and 1.60 (95% CI 1.21-2.12), respectively. Low levels of positive experiences of social support were also associated with low current intake of fruits and vegetables, but not with future intake. Negative experiences of social support were additionally associated with current smoking, physical inactivity, overweight and poor self-perceived health. Furthermore, high levels of negative experiences of social support were associated with future excessive alcohol consumption (OR 1.42; 95% CI 1.10-1.84), physical inactivity (95% CI 1.28; 1.03-1.58) and poor self-perceived health (OR 1.36; 95% CI 1.01-1.82). Conclusions This study showed that social support might have a beneficial effect on lifestyle and health, with negative experiences of social support affecting lifestyle and health differently from positive experiences of social support.

Background The increasing prevalence of type 2 diabetes poses both clinical and public health challenges. Cost-effective approaches to prevent progression of the disease in primary care are needed. Evidence suggests that intensive multifactorial interventions including medication and behaviour change can significantly reduce cardiovascular morbidity and mortality among patients with established type 2 diabetes, and that patient education in self-management can improve short-term outcomes. However, existing studies cannot isolate the effects of behavioural interventions promoting self-care from other aspects of intensive primary care management. The ADDITION-Plus trial was designed to address these issues among recently diagnosed patients in primary care over one year. Methods/Design ADDITION-Plus is an explanatory randomised controlled trial of a facilitator-led, theory-based behaviour change intervention tailored to individuals with recently diagnosed type 2 diabetes. 34 practices in the East Anglia region participated. 478 patients with diabetes were individually randomised to receive (i) intensive treatment alone (n = 239), or (ii) intensive treatment plus the facilitator-led individual behaviour change intervention (n = 239). Facilitators taught patients key skills to facilitate change and maintenance of key behaviours (physical activity, dietary change, medication adherence and smoking), including goal setting, action planning, self-monitoring and building habits. The intervention was delivered over one year at the participant's surgery and included a one-hour introductory meeting followed by six 30-minute meetings and four brief telephone calls. Primary endpoints are physical activity energy expenditure (assessed by individually calibrated heart rate monitoring and movement sensing), change in objectively measured dietary intake (plasma vitamin C), medication adherence (plasma drug levels), and smoking status (plasma cotinine levels) at one year. We will undertake an intention-to-treat analysis of the effect of the intervention on these measures, an assessment of cost-effectiveness, and analyse predictors of behaviour change in the cohort. Discussion The ADDITION-Plus trial will establish the medium-term effectiveness and cost-effectiveness of adding an externally facilitated intervention tailored to support change in multiple behaviours among intensively-treated individuals with recently diagnosed type 2 diabetes in primary care. Results will inform policy recommendations concerning the management of patients early in the course of diabetes. Findings will also improve understanding of the factors influencing change in multiple behaviours, and their association with health outcomes. Trial registration ISRCTN: ISRCTN99175498

Background Increasing cycling for transport can contribute to improve public health among adults. Micro-environmental factors (i.e. small-scaled street-setting features) may play an important role in affecting the street’s appeal to cycle for transport. Understanding about the interplay between individuals and their physical environment is important to establish tailored environmental interventions. Therefore, the current study aimed to examine whether specific subgroups exist based on similarities in micro-environmental preferences to cycle for transport. Methods Responses of 1950 middle-aged adults (45–65 years) on a series of choice tasks depicting potential cycling routes with manipulated photographs yielded three subgroups with different micro-environmental preferences using latent class analysis. Results Although latent class analysis revealed three different subgroups in the middle-aged adult population based on their environmental preferences, results indicated that cycle path type (i.e. a good separated cycle path) is the most important environmental factor for all participants and certainly for individuals who did not cycle for transport. Furthermore, only negligible differences were found between the importances of the other micro-environmental factors (i.e. traffic density, evenness of the cycle path, maintenance, vegetation and speed limits) regarding the two at risk subgroups and that providing a speed bump obviously has the least impact on the street’s appeal to cycle for transport. Conclusions Results from the current study indicate that only negligible differences were found between the three subgroups. Therefore, it might be suggested that tailored environmental interventions are not required in this research context. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3471-5) contains supplementary material, which is available to authorized users.

Background Looking out on and being in the green elements of the landscape around us seem to affect health, well-being and feelings of social safety. This article discusses the design of a research program on the effects of green space in the living environment on health, well-being and social safety. Methods/design The program consists of three projects at three different scales: at a macro scale using data on the Netherlands as a whole, at an intermediate scale looking into the specific effect of green space in the urban environment, and at micro scale investigating the effects of allotment gardens. The projects are observational studies, combining existing data on land use and health interview survey data, and collecting new data through questionnaires and interviews. Multilevel analysis and GIS techniques will be used to analyze the data. Discussion Previous (experimental) research in environmental psychology has shown that a natural environment has a positive effect on well-being through restoration of stress and attentional fatigue. Descriptive epidemiological research has shown a positive relationship between the amount of green space in the living environment and physical and mental health and longevity. The program has three aims. First, to document the relationship between the amount and type of green space in people's living environment and their health, well-being, and feelings of safety. Second, to investigate the mechanisms behind this relationship. Mechanisms relate to exposure (leading to stress reduction and attention restoration), healthy behavior and social integration, and selection. Third, to translate the results into policy on the crossroads of spatial planning, public health, and safety. Strong points of our program are: we study several interrelated dependent variables, in different ordinary settings (as opposed to experimental or extreme settings), focusing on different target groups, using appropriate multilevel methods.

Background: The Qatar Biobank aims to collect extensive lifestyle, clinical, and biological information from up to 60,000 men and women Qatari nationals and long-term residents (individuals living in the country for ≥15 years) aged ≥18 years (approximately one-fifth of all Qatari citizens), to follow up these same individuals over the long term to record any subsequent disease, and hence to study the causes and progression of disease, and disease burden, in the Qatari population. Methods: Between the 11th-December-2012 and 20th-February-2014, 1209 participants were recruited into the pilot study of the Qatar Biobank. At recruitment, extensive phenotype information was collected from each participant, including information/measurements of socio-demographic factors, prevalent health conditions, diet, lifestyle, anthropometry, body composition, bone health, cognitive function, grip strength, retinal imaging, total body dual energy X-ray absorptiometry, and measurements of cardiovascular and respiratory function. Blood, urine, and saliva were collected and stored for future research use. A panel of 66 clinical biomarkers was routinely measured on fresh blood samples in all participants. Rates of recruitment are to be progressively increased in the coming period and the recruitment base widened to achieve a cohort of consented individuals broadly representative of the eligible Qatari population. In addition, it is planned to add additional measures in sub-samples of the cohort, including Magnetic Resonance Imaging (MRI) of the brain, heart and abdomen. Results: The mean time for collection of the extensive phenotypic information and biological samples from each participant at the baseline recruitment visit was 179 min. The 1209 pilot study participants (506 men and 703 women) were aged between 28–80 years (median 39 years); 899 (74.4 %) were Qatari nationals and 310 (25.6 %) were long-term residents. Approximately two-thirds of pilot participants were educated to graduate level or above. Conclusions: The pilot has proven that recruitment of volunteers into the Qatar Biobank project with intensive baseline measurements of behavioural, physical, and clinical characteristics is well accepted and logistically feasible. Qatar Biobank will provide a powerful resource to investigate the major determinants of ill-health and well-being in Qatar, providing valuable insights into the current and future public health burden that faces the country. Qatar Foundation for Education, Science and Community Development and the Supreme Council of Health

Background Body mass index (BMI) is associated with subjective well-being. Higher BMI is believed to be related with lower well-being. However, the association may not be linear. Therefore, we investigated whether a nonlinear (U-shaped) trend would better describe this relationship, and whether eating disorders might account for the association in young adults. Methods FinnTwin16 study evaluated multiple measures of subjective well-being, including life satisfaction, General Health Questionnaire (GHQ-20), satisfaction with leisure time, work, and family relationships, and satisfaction with sex life in young adulthood in the 1975–79 birth cohorts of Finnish twins (n=5240). We studied the relationship between indicators of subjective well-being and BMI both in full birth cohorts and in subgroups stratified by lifetime DSM-IV eating disorders. Results We found an inverse U-shaped relationship between all indicators of subjective well-being and BMI in men. There was no overall association between BMI and subjective well-being in women. However, there was an inverse U-shaped relationship between BMI and indicators of subjective well-being in women with a lifetime eating disorder and their healthy female co-twins. Subjective well-being was optimal in the overweight category. Conclusions Both underweight and obesity are associated with impaired subjective well-being in young men. The BMI reflecting optimal subjective well-being of young men may be higher than currently recognized. Categorization of body weight in terms of BMI may need to be reassessed in young men. BMI and subjective well-being are related in women with a lifetime eating disorder, but not in the general population of young women.

BACKGROUND: Evidence is lacking on the screen-based behaviour of adolescents with a chronic condition. The aim of our study was to analyse differences in screen-based behaviour of adolescents by long-term illness, asthma and learning disabilities.METHODS: We used data from the cross-sectional Health Behaviour of School-aged Children study collected in 2014 among Slovak adolescents (age 13 to 15 years old, N = 2682, 49.7 % boys). We analysed the associations between screen-based behaviour and long-term illness, asthma and learning disabilities using logistic regression models adjusted for gender.RESULTS: We found no associations between screen-based behaviour and long-term illness, except that children with asthma had a 1.60-times higher odds of excessively playing computer games than healthy children (95 % confidence interval of odds ratio (CI): 1.11-2.30). Children with learning disabilities had 1.71-times higher odds of risky use of the Internet (95 % CI: 1.19-2.45).CONCLUSION: Adolescents with a long-term illness or with a chronic condition or a learning disability do not differ from their peers in screen-based activities. Exceptions are children with asthma and children with learning disabilities, who reported more risky screen-based behaviour.

Effective interventions that target socioeconomic status (SES) differences to avoid the potential widening of inequalities in health are needed. Children at preschool age is a valuable intervention target since sedentary behaviors, physical activity (PA), dietary behaviors, and sleep habits, jointly called the energy balance-related behaviors (EBRBs), are established in early childhood and tend to persist later in life. The interventions are most effective, when they focus on evidence-based factors. One potential factor associated with EBRBs and SES is children’s stress regulation, which receives special attention in this study. Based on the socioecological approach, the combinations of multiple levels (e.g. individual, environmental, societal) of analysis and diverse methodologies (e.g. surveys, observations, biological measurements) are used to assess the healthfulness of environments (e.g. social, physical, learning, policy) in preschool and family settings. The intervention aimed to diminish SES differences in EBRBs is then conducted in the preschool setting. The DAGIS study is divided into two phases. The first phase comprises focus group interviews and a cross-sectional survey. Parents and preschool personnel in low SES neighborhoods participated in interviews about children’s sedentary behaviors, dietary behaviors, and PA in 2014. In the cross-sectional survey beginning in autumn 2015, preschools will be recruited from a random sample of preschools in 3–5 municipalities in Southern Finland. A total of 800 children will wear an accelerometer for seven days. Children’s hair and saliva samples will be taken. Parents and preschool personnel will complete questionnaires on EBRBs, social and physical environments and SES factors. The quality of preschool environment is also observed. In the second phase, an intervention targeting to narrowing SES differences in EBRBs is conducted. The effects of the intervention will be evaluated in randomised controlled trial. The implementation of the intervention will also be evaluated. If effective, this unique preschool-based study will be able to narrow the SES differences in preschool children’s EBRBs. This study is anticipated to identify the most important modifiable factors in preschool and family environmental settings associated with children’s EBRBs, especially in children from low SES backgrounds. ISRCTN57165350 (January, 8th, 2015).

Background Although strength exercises evidently have both physiological and psychological health benefits across all ages, they are erroneously considered to adversely affect health status in youngsters. The aim of this study was to examine parental attitudes towards their child’s physical activity in general, as well as aerobic and strength exercises in particular. Methods In total, 314 parents from an online panel representative of the Dutch population completed an online survey about their own physical activity and that of their child (12–15 years old). The study also explored reasons for non-participation, and attitudes about the parents’ own and their child’s physical activity level. Results Parents consistently reported a positive attitude towards aerobic exercises, but a less positive attitude regarding strength exercises. Parents were more likely to indicate that their child was not allowed to participate in strength exercises (29.6 %) than aerobic exercises (4.0 %). They thought that strength exercises could interfere with optimal physical development. Conclusions This study consistently shows that parents have a positive attitude towards aerobic exercises, but a less positive attitude regarding strength exercises. We suggest testing interventions to increase parental understanding of the advantages of and possibilities for (e.g., facilities) strength training on their child’s health. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-2328-7) contains supplementary material, which is available to authorized users.