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The CO-CREATE project focuses on the need for research on obesity prevention in adolescents to move away from studies of single interventions, toward the investigation of systems-based research incorporating youth involvement. This paper provides an overview of the project, presenting the objectives, design, and novel methodologies applied, as well as findings to date and anticipated outcomes. Adolescents (16–18 years old) in five European countries participated. Methods applied in the project include monitoring and benchmarking of policies, systematic literature reviews, epidemiological surveillance, linking observed overweight and obesity trends to observed policy landscapes, group model building to identify perceived drivers of obesity, alliance building with adolescents, dialog with stakeholders, and system dynamics modelling to explore the potential impact of policy options. Outcomes include tools for developing policy ideas and investigation of prevention strategies with adolescents, including policy databases, system maps of drivers of obesity, protocols for organizing youth alliances, an intergenerational policy dialog tool, and system dynamic models exploring the impacts of cocreated policy ideas. These outcomes make an important contribution to building a pan-European infrastructure for designing and evaluating policies and for providing youth with the opportunity to make their voices heard in the development and implementation of obesity prevention measures. publishedVersion

The Norwegian authorities started a nationwide free school fruit program in 2007, implemented in all secondary schools (grades 8–10) and combined schools (grades 1–10) in Norway. The program ended in 2014. This study evaluates the effect of ending the nationwide free school fruit program on the consumption of fruit, vegetables, and unhealthy snacks among Norwegian sixth and seventh graders. The study sample consists of pupils at 18 schools that participated in all data collections in the Fruits and Vegetables Make the Marks project (FVMM), initiated in 2001, with new data collections in 2008 and 2018. Four of the schools were combined schools, therefore children in sixth and seventh grade at these schools received free fruit in 2008 (intervention schools), and fourteen schools did not (control schools). Between 2008 and 2018, pupils at the intervention schools ate a lower proportion of fruits and vegetables per school week, and the consumption of unhealthy snacks increased compared to the control schools. Completion of the free fruit program was not significantly different for boys and girls, or low and high parental education. The results indicate that the end of the free school fruit program resulted in less healthy eating habits among children.

The CO-CREATE project aims to collaborate with adolescents across Europe in developing policy ideas that contribute to overweight and obesity prevention. In this paper, we present the theoretical basis and methodological approach to recruitment and engagement in the project. The principles of youth-led participatory action research were employed to design Youth Alliances in which adolescents and adults could collaborate. These Alliances should serve to promote and support adolescent participation and to develop policy ideas that would contribute to obesity prevention. Alliance members were recruited in two local geographical areas per country with a focus on reaching out to underrepresented youth. We started with fieldwork to assess locally relevant forms of inclusion and exclusion. The methodology entailed a handbook combining existing tools which could be used flexibly, a collaborative organization, and budgets for the alliances. Engagement started in local organizations, that is, schools and scouts, and with peers. Health- and overweight-related challenges were addressed in their immediate surroundings and supported the inclusion of experiential knowledge. Adolescents were then supported to address the wider obesogenic system when designing policy ideas. The CO-CREATE Alliances provide a concrete example of how to engage youth in public health, in a manner that strives to be participatory, transformative, and inquiry based.

Ana Rito - Departamento de Alimentação e Nutrição, INSA. Engaging youth in obesity prevention research and policy action is essential to develop strategies that are relevant and sensitive to their needs. Research with young people requires critical reflection to safeguard their rights, dignity, and wellbeing. The CO-CREATE project used various methods to engage approximately 300 European youth aged 15–19 years in the development of policies to prevent adolescent obesity. This paper discusses ethical considerations made in the project pertaining to the youth's voluntary participation, their protection from obesity stigma, respect for their time, data privacy and confidentiality, power balance, and equality of opportunity to participate in the research. We describe measures implemented to prevent or limit the emergence of ethical challenges in our interaction with youth and discuss their relevance based on our experience with implementation. While some challenges seemingly were prevented, others arose related to the youth's voluntary participation, time burdens on them, and the sustainability of participation under the Covid-19 pandemic. Concrete and ongoing ethical guidance may be useful in projects aiming to interact and build collaborative relationships with youth for long periods of time. European Commission, Grant/Award Number: 774210; European Union info:eu-repo/semantics/publishedVersion

Background The World Cancer Research Fund International's (WCRF International) analysis of global research shows a strong link between diet, physical activity, and risk of cancer. To address this, WCRF International has developed a package of policy resources to promote healthy diets and physical activity to support reporting, categorising and monitoring of policy actions. The MOVING policy framework was developed as a complement to the well-established NOURISHING framework of diet-related policies-outlining a comprehensive set of areas in which governments should take action to promote physical activity. The new framework forms the basis for the MOVING database of implemented policy actions. Methods For the MOVING framework, literature reviews were undertaken, and the results were distilled into policy categories on which academics and policy experts provided feedback. The framework is the basis for a specific inclusion criteria and search strategy to determine how policy actions will be collected, reviewed and categorised for the MOVING database. A comprehensive scanning methodology was designed to identify all relevant policies across the MOVING policy areas. Relevant policies are then verified with in-country experts and uploaded to the database. This methodology was tested, refined and will be applied to 27 European countries. Results The MOVING policy framework comprises six policy areas within four policy domains and details the areas where governments should take action to promote physical activity. The framework forms the structure for a new database of global physical activity policies, which was launched in the summer of 2020. The MOVING database currently includes 234 policy actions from 12 countries. The MOVING database is a logical and practical tool, allowing users to search for policy actions categorised in the structure of the MOVING framework. Conclusion The MOVING physical activity framework and database are innovative tools that support reporting, categorising and monitoring of physical activity policy actions that will work alongside the NOURISHING framework and database. These physical activity policy tools allow stakeholders such as researchers, civil society organizations and policy makers to quickly identify both gaps and strengths in government action and therefore assess where there is scope for improvement within and across countries.

Background Global research shows a strong link between physical activity and risk of developing non-communicable diseases. To increase physical activity levels, governments must design and implement a comprehensive set of policy actions across a range of areas. To aid governments in this process, the MOVING benchmarking tool was developed to assess the strength of policies across three domains that make up a comprehensive approach to physical activity policy. Methods The MOVING benchmarking tool, which was developed using a consultative process that reviewed evidence on physical activity policy design and existing benchmarking tools, built on the policy areas of the MOVING framework. It values the strength of policy design, based on evidence-informed and aspirational attributes of effective policy-making that impacts health-related behaviours, with a focus on adolescents. The tool was applied to a set of physical activity policies from five countries: Netherlands, Norway, Poland, Portugal and UK. These countries were selected based on their participation in the EU-funded CO-CREATE project, which focuses on prevention of overweight and obesity among adolescents. Relevant physical activity policies in each participating country were identified based on a comprehensive scan, with a set methodology. Results The MOVING benchmarks assessed the strengths and weaknesses in the design of policies across the policy areas of the MOVING policy framework. They produced an overall assessment of policy environments for physical activity across the five countries, as well as an assessment of each individual policy area within the framework, such as walking and cycling infrastructure and active transport. Further, by allowing a fast assessment of many physical activity policies, the benchmarking tool enabled an analysis of the interplay of single policies and drawing conclusions about the overall policy environment in the five countries. Conclusion The MOVING benchmarking tools can identify gaps and assess the strength of actions taken by national governments to promote physical activity, and can be used by policymakers, researchers and civil society to inform advocacy for and design of policies. The scores generated by the benchmarking tool will be amalgamated into an overall policy index for 27 European countries.

Background Global research shows a strong link between physical activity and risk of developing non-communicable diseases. To increase physical activity levels, governments must design and implement a comprehensive set of policy actions across a range of areas. To aid governments in this process, the MOVING benchmarking tool was developed to assess the design and strength of countries' policies in promoting physical activity, as well as gaps in policy action. Methods The MOVING benchmarking tool was developed using a consultative process that reviewed evidence on physical activity policy design, existing benchmarking tools and built on the policy areas of the MOVING framework. The tool values the strength of policy design based on policy attributes that are evidence-based and aspirational - regardless of whether any countries have implemented them. The tool was applied to a set of physical activity policies from five countries participating in? CO-CREATE?, a European Commission-funded project: Netherlands, Norway, Poland, Portugal and UK. Physical activity policies that are currently implemented in these countries were identified based on a comprehensive country scan, with a set methodology. A set of policies from each country corresponding to benchmarks on access to quality public open space and green spaces and community and mass participation initiatives were analysed. The policies were assessed by applying the benchmark corresponding to the relevant policy area Results The benchmarking tools easily identified the strengths and weaknesses in the design of each policy. Thus, the benchmarking tool identified where there was scope for improvement in specific policy area for each country, such as walking and cycling infrastructure and active transport. It also allowed comparisons between countries for specific policy areas. Further, by allowing a fast assessment of many physical activity policies, the benchmarking tool enabled an analysis of the interplay of single policies and draw conclusions about the overall policy environment in the selected countries. Conclusion The MOVING benchmarking tool can inform the development and implementation of policies which promote physical activity. It can be used by government policy-makers, researchers and civil society organisations to identify areas of physical activity policy that require government action. The scores generated by the benchmarking tool will be amalgamated into an overall policy index for 27 European countries.

Engaging adolescents in obesity prevention is a main objective of the CO-CREATE project. This paper presents the development of a questionnaire to assess readiness for action and attitudes toward obesity prevention among adolescents. The questionnaire was developed based on literature searches and internal discussions with experts in the CO-CREATE consortium. The questionnaire was translated, back translated, and pretested for time and comprehensiveness by adolescents from five countries (the Netherlands, Norway, Poland, Portugal, and the United Kingdom). Exploratory factor analysis was performed, and internal reliability of the resulting factors was determined using baseline data from Poland and Norway. Furthermore, test–retest reliability was assessed in a sample of Norwegian adolescents. The exploratory factor analysis on readiness for action identified four factors. Analysis on attitudes toward obesity prevention identified four factors on responsibility and five factors on drivers of behavior. Six of the factors had a Cronbach's alpha value above 0.70, five factors had a value between 0.60–0.70, whereas the remaining two factors were below 0.60. The test–retest correlation ranged from 0.46 to 0.87. The exploratory factor analyzes on readiness for action identified the same factors as hypothesized in the development of the questionnaire, whereas attitudes toward obesity prevention identified more factors than initially assumed. The questionnaire is considered reliable as a tool for measuring adolescents' readiness for action and attitudes toward obesity prevention.

Background: Considering the large health burden of physical inactivity, effective physical activity promotion is a “best buy” for noncommunicable disease and obesity prevention. The MOVING policy framework was developed to promote and monitor government policy actions to increase physical activity as part of the EU Horizon 2020 project “Confronting Obesity: Co-creating policy with youth (CO-CREATE).” Method: A scanning exercise, documentary review of key international policy documents, and thematic analysis of main recommendations were conducted. Themes were reviewed as part of a consultation with physical activity experts. Results: There were 6 overarching policy framework areas: M—make opportunities and initiatives that promote physical activity in schools, the community, and sport and recreation; O—offer physical activity opportunities in the workplace and training in physical activity promotion across multiple professions; V—visualize and enact structures and surroundings that promote physical activity; I—implement transport infrastructure and opportunities that support active societies; N—normalize and increase physical activity through public communication that motivates and builds behavior change skills; and G—give physical activity training, assessment, and counseling in health care settings. Conclusions: The MOVING framework can identify policy actions needed, tailor options suitable for populations, and assess whether approaches are sufficiently comprehensive.

Public health research and practice is increasingly employing systems thinking to help grapple with complex issues, from obesity to HIV treatment. At the same time, there is growing recognition that to address a given problem it is essential collaborate with those most at risk of or affected by it. Group model building (GMB), a process grounded in system dynamics, combines systems thinking and participatory methods to structure and address complex issues. As part of the CO-CREATE project we conducted GMB sessions with young people in six countries to create causal loop diagrams showing the factors that they believe drive obesity. This paper describes the background to GMB and the process we used to construct causal loop diagrams; it discusses how GMB contributed to generating noteworthy and useful findings, and the strengths and limitations of the method. Using GMB, we identified areas of concern to adolescents in relation to obesity that have so far had little attention in obesity research and policy: mental health and online activity. In using GMB, we also helped answer calls for a more participatory approach to youth involvement in research and policy development. publishedVersion

While in the Nordic countries we have well-developed welfare policies and several structural, statutory measures in place aiming to promote public health, studies from these countries are often absent from systematic reviews of research literature assessing the effects of policy measures designed to promote health. Using adolescent health promotion and efforts related to primary prevention of obesity as an example, this short commentary aims to illustrate the paucity of well-designed studies investigating the effects of public health policies affecting adolescents. This paper argues that the Nordic research community is in a good position to help fill this gap, and to contribute more widely to the international literature on evaluation of policy interventions.

Overweight and obesity increase the risk of a range of poor physiological and psychosocial health outcomes. Previous work with well-defined cohorts has explored the determinants of obesity and employed various methods and measures; however, less is known on the broader societal drivers, beyond individual-level influences, using a systems framework with adolescents. The aim of this study was to explore the drivers of obesity from adolescents’ perspectives using a systems approach through group model building in four South African schools. Group model building was used to generate 4 causal loop diagrams with 62 adolescents aged 16–18 years. These maps were merged into one final map, and the main themes were identified: (i) physical activity and social media use; (ii) physical activity, health-related morbidity, and socio-economic status; (iii) accessibility of unhealthy food and energy intake/body weight; (iv) psychological distress, body weight, and weight-related bullying; and (v) parental involvement and unhealthy food intake. Our study identified meaningful policy-relevant insights into the drivers of adolescent obesity, as described by the young people themselves in a South African context. This approach, both the process of construction and the final visualization, provides a basis for taking a novel approach to prevention and intervention recommendations for adolescent obesity.

The NOURISHING database is a repository of more than 1000 verified nutrition anddiet-related governmental policy actions currently in effect globally. The database isa unique and rich data source on governmental policy actions with a potential fordeveloping tools that capture the overall policy efforts in a country, identify policygaps, and enable cross-national comparisons. Policy actions from a sample of fiveEuropean countries have been benchmarked against aspirational standards using theNOURISHING benchmarking tool. This paper presents the results of the pilot testingfrom the benchmarking process for the construction of the NOURISHING policyindex. The development of the index was guided by existing tools for developingcomposite indicators. The findings from the pilot test indicate that the NOURISHINGpolicy index can identify both policy gaps and cross-national policy differences. Theseresults demonstrate that the policy index merits testing on a larger sample to identifypotential refinements. Pilot test of the NOURISHING policy index—Assessing governmental nutrition policies in five European countries

The Childhood Obesity Surveillance Initiative (COSI) routinely measures height andweight of primary school children aged 6–9 years and calculates overweight andobesity prevalence within the World Health Organization (WHO) European Regionusing a standard methodology. This study examines the trends in the prevalence ofoverweight and obesity from the first round of COSI carried out in 2007/2008 to thelatest of 2015/2017 in 11 European countries in which data were collected for atleast three rounds. In total 303,155 children were measured. In general, the preva-lence of overweight and obesity among boys and girls decreased in countries withhigh prevalence (Southern Europe) and remained stable or slightly increased in North-ern European and Eastern European countries included in the analysis. Among boys, the highest decrease in overweight (including obesity) was observed in Portugal (from40.5% in 2007/2008 to 28.4 in 2015/2017) and in Greece for obesity (from 30.5% in2009/2010 to 21.7% in 2015/2017). Lithuania recorded the strongest increase in theproportion of boys with overweight (from 24.8% to 28.5%) and obesity (from 9.4% to12.2%). The trends were similar for boys and girls in most countries. Several countriesin Europe have successfully implemented policies and interventions to counteract theincrease of overweight and obesity, but there is still much to be done. The authors gratefully acknowledge support through a grant from the Russian Government in the context of the WHO European Office for the Prevention and Control of NCDs. The Ministries of health of Austria, Croatia, Greece, Italy, Malta, Norway, and the Russian Federation provided financial support for the meetings at which the protocol, data collection procedures, and analyses were discussed. Data collection in the countries included in this study was made possible through funding from: Bulgaria: Ministry of Health, National Center of Public Health and Analyses, and WHO Regional Office for Europe; Czechia: WHO grants AZV MZČR 17-31670 A MZČR-RVO EÚ 00023761, World Health Organization Regional Office for Europe, and WHO country office; Greece: International Hellenic University and Hellenic Medical Association for Obesity; Ireland: Health Service Executive; Italy: Ministry of Health and Italian National Institute of Health; Latvia: Ministry of Health and Centre for Disease Prevention and Control; Lithuania: Science Foundation of Lithuanian University of Health Sciences, Lithuanian Science Council, and WHO; Norway: Ministry of Health and Norwegian Institute of Public Health; Portugal: Ministry of Health Institutions, the National Institute of Health, Directorate General of Health, Regional Health Directorates, and the kind technical support from the Center for Studies and Research on Social Dynamics and Health (CEIDSS); Slovenia: Ministry of Education and Science and Sport of the Republic of Slovenia within the SLOfit surveillance system; and Spain: Spanish Agency for Food Safety and Nutrition (AESAN). info:eu-repo/semantics/publishedVersion

In order to develop effective public health initiatives aimed at promoting healthy weight development, identifying the interventions/combination of interventions with the highest beneficial effect on body weight is vital. The study aimed to estimate the mean BMI at age 13 under hypothetical interventions targeting dietary behavior, physical activity and screen time at age 11. We used data from a school-based cohort study of 530 participants followed between the ages of 11 and 13. We used g-computation, a causal modeling method, to estimate the impact of single and combined hypothetical behavioral interventions at age 11 on BMI at age 13. Of the hypothetical interventions, the one with the largest population mean difference in BMI was the one combining all interventions (dietary behavior, physical activity and screen time interventions) and assuming 100% intervention adherence, with a population mean differences of − 0.28 (95% CI − 0.59, 0.07). Isolated behavioral interventions had a limited impact on BMI. This study demonstrated that a combination of healthy dietary behavior and physical activity promotion, as well as screen time reduction interventions at age 11 could have the highest beneficial effect on the reduction of BMI at age 13, although the change in BMI was small. The findings highlight the importance of a systems approach to obesity prevention focusing on multicomponent interventions.

Summary The aim of this overview of systematic reviews was to summarize evidence from up-to-date reviews of the effectiveness of interventions aimed at preventing overweight and obesity in adolescents aged 10 to 19 years. We searched nine databases for systematic reviews published between January 2008 and November 2019. We used A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 to assess the quality of reviews, excluding those of critically low quality, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to grade the certainty of included evidence. We included 13 reviews. Three reviews focused on dietary behaviour, six on physical activity, and four on both types of behaviours. Individual-oriented and school-based interventions dominated. Results across reviews showed little or no effect on body mass index, or physical activity levels of adolescents, whereas results from a couple of reviews suggest possibly beneficial effects of public health interventions on dietary behaviours (i.e., consumption of sugar-sweetened beverages). The certainty of evidence was low to very low for all outcomes. Overall, the evidence base for the effect of primary interventions to prevent overweight and obesity in adolescents is weak. In particular, there is a lack of reviews assessing the impact of environmental interventions targeting adolescents, and reviews addressing social inequality are virtually absent from this body of literature.

First page of both questionnaires (24â h-recall and FFQ) (PDF-file). (PDF 7 kb)

The intake of fruit and vegetables is associated with beneficial health outcomes, and studies aimed at increasing fruit and vegetable intake lack long-term follow-up. The primary objective of this study was to evaluate the long-term (14-year) effects of a multicomponent school-based educational intervention targeted to increase fruit and vegetable intake in children. The secondary objective was to evaluate the potential synergistic effect between free school fruit and the educational program. A cluster randomized school-based intervention was initiated in 2001 in Norway, known as the Fruit and Vegetable Make the Marks study. In total, 38 schools were randomized; for the intervention (n = 18) and as control schools (n = 20). A subsample of the intervention schools (n = 9) were additionally given free school fruit, resulting in two intervention groups - one with and one without free fruit. Participants completed questionnaires in September 2001 (baseline, mean age 11.8), May 2002 (at the end of the intervention), May 2003, May 2005, September 2009 and throughout 2016 (mean age 26.5). Of 1950 participants, 982 (50.4%) completed the 14-year follow-up and were considered as the current study sample. Analysis yielded no 14-year effects of the educational program on fruit and vegetable intake. A synergistic effect between the educational program and free fruit was not observed either. Future studies might benefit from increased focus on more extensive parental involvement, increased home availability, and a longer intervention period. However, more long-term studies are needed to evaluate the effects of school-based interventions into adulthood. Trial registration number: Ethical approval and research clearance was obtained from The National Committees for Research Ethics in Norway (file number S-01076) and The Norwegian Centre for Research Data (file number 12395).

Table: Overall difference mean/percentage between 1 ≥ missing and no missing within the intervention and control group (word-file). (DOCX 16 kb)

CONSORT flow chart (word-file). (DOC 53 kb)

In a cluster-randomized trial conducted in 22 government secondary schools in Uganda, effects of a school-based intervention aimed at improving aspects of parent/caregiver-adolescent communication on sexuality were examined. The intervention comprised classroom-based education sessions, take home assignments for students to discuss with parents/caregivers and parenting workshops. Baseline and post intervention questionnaires were completed by students and by parents/caregivers. Effect estimates were significant for both students and parents/caregivers on sexuality communication frequency and quality, and for positive and negative attitudes towards sex-related communication, all in the desired direction with effect sizes ranging from 0.17 to 0.38. Effects on four sum scores related to general parenting proved significant only for parents'/caregivers' legitimacy with regard to rule setting (parents'/caregivers' reports only). These results suggest that in Uganda, using schools as gateways, parent/caregiver-adolescent communication can be improved through modification of existing school curricula, training teachers in learner-centred approaches and through mobilization and training of parents/caregivers.

Background: The obesity epidemic presents a major public health challenge, and a poor diet quality has been identified as one of the most important contributing factors. Whereas a sufficient fruit and vegetable consumption has been associated with several positive health outcomes, the long-term effect on overweight and obesity is unclear. Thus, the aims of this study were to investigate if one year with free school fruit had any effect on weight status 14 years later, and if it affected the birth weight of the participants’ children. Methods: In 2001, 10 -12-year old Norwegian children, received one year of free school fruit in the intervention study “Fruits and Vegetables Make the Marks” (FVMM) and in 2016, a total of 1081 participants of 2049 eligible responded to a follow-up survey. Multilevel logistic regression was used to investigate if one year of free school fruit was associated with weight status and with birthweight status of the offspring. The analyses were adjusted for gender, educational level, and the offspring analysis also for parents’ weight status, and the nested design (child/parent). Results: The odds ratios of being overweight (OR: 0.93, 95% CI: 0.70, 1.24) or having a child with high or low birth weight (OR: 0.52, 95% CI: 0.21, 1.30) in the intervention group compared to the control group were not statistically significant, 14 years after the intervention period. Conclusions: One year of free school fruit did not have an effect on weight status on the participants or birth weight of their offspring, 14 years after the intervention period. Although, results from the present study contribute to fill the knowledge gaps concerning long-term effects of public health efforts on weight status, more follow-up studies with larger samples are warranted.

Increased use of antibiotics and a higher rate of injury in May for 19-year-olds have been described earlier. We examined whether 19-year-olds also demonstrate greater use of general practitioner services at the time of russefeiring – celebrations in connection with completion of upper secondary school.The study is based on data from the Directorate of Health’s system for the control and payment of reimbursements to healthcare providers (KUHR) for all consultations in the general practitioner services for age group 18 – 20 years in the period 2012 – 15. The number of consultations per month and age group were analysed using Poisson regression, with 19-year-olds in March as a reference group. The incidence rate ratio (IRR) was the outcome measure.All calendar years showed a sharp increase in the number of consultations among 19-year-olds in May in all calendar years compared with other calendar months and the cohorts above and below. The incidence rate ratio for consultations with GPs and emergency departments was 1.40 (95 % confidence interval (CI) 1.38 – 1.41) and 2.07 (95 % CI 2.02 – 2.13). The increase was greatest for respiratory infections (IRR 3.64, 95 % CI 3.55 – 3.73). The incidence rate ratio for injuries was 1.21 (95 % CI 1.16 – 1.27). The increase commenced in the three weeks before 17 May (Constitution Day) and persisted in the following two weeks.The sharp increase in the number of consultations for 19-year-olds in the general practitioner services is associated timewise with celebrations in connection with completion of upper secondary school (russefeiring). More frequent contact with these services lasts well into the ensuing examination period.

Background Increased use of antibiotics and a higher rate of injury in May for 19-year-olds have been described earlier. We examined whether 19-year-olds also demonstrate greater use of general practitioner services at the time of russefeiring – celebrations in connection with completion of upper secondary school. Material and method The study is based on data from the Directorate of Health’s system for the control and payment of reimbursements to healthcare providers (KUHR) for all consultations in the general practitioner services for age group 18 – 20 years in the period 2012 – 15. The number of consultations per month and age group were analysed using Poisson regression, with 19-year-olds in March as a reference group. The incidence rate ratio (IRR) was the outcome measure. Results All calendar years showed a sharp increase in the number of consultations among 19-year-olds in May in all calendar years compared with other calendar months and the cohorts above and below. The incidence rate ratio for consultations with GPs and emergency departments was 1.40 (95 % confidence interval (CI) 1.38 – 1.41) and 2.07 (95 % CI 2.02 – 2.13). The increase was greatest for respiratory infections (IRR 3.64, 95 % CI 3.55 – 3.73). The incidence rate ratio for injuries was 1.21 (95 % CI 1.16 – 1.27). The increase commenced in the three weeks before 17 May (Constitution Day) and persisted in the following two weeks. Interpretation The sharp increase in the number of consultations for 19-year-olds in the general practitioner services is associated timewise with celebrations in connection with completion of upper secondary school (russefeiring). More frequent contact with these services lasts well into the ensuing examination period.

Background: The importance of family meals to the consumption of healthful food choices has been stated in recent reviews. However, little information is available on barriers that interfere with regular family meal patterns during childhood.Objective: Describe family meal patterns among 11-year-old children across Europe and identify correlates of irregular family breakfast and dinner consumption.Design: Cross-sectional survey involving samples of 13,305 children from nine European countries in 2003.Results: The proportions of children who regularly ate family breakfast and dinner were 62% and 90%, respectively. Correlates of irregular family breakfasts and dinners were less vegetable consumption, and irregular family breakfasts were associated with more television viewing. Social differences in the consumption of family breakfasts were observed.Discussion: Strengths of this study are the large sample size and validated research method. Limitations are the cross-sectional design and self-reported data.Conclusion: The majority of 11-year-old children regularly ate breakfast and dinner with their families. More television viewing and less vegetable consumption were associated with irregular family breakfasts and dinners, respectively. Social differences were observed in the regularity of family breakfasts. Promoting family meals across social class may lead to healthier eating and activity habits, sustainable at the population level.

Background: Fruit and vegetable intake is crucial in health promotion and disease prevention. Inadequate intake is found among adult populations worldwide. Aims: To assess fruit and vegetable intake among Portuguese mothers and to examine its association with sociodemographic determinants. Methods: A national cross-sectional survey was performed in Portugal as part of the Pro Children study. Data from self-administrated precoded 24-hour recall and food frequency questionnaires answered by 1,853 mothers of 11- to 13-year-old children were analyzed. Descriptive analysis of the data was followed by logistic regression to assess associations between daily fruit and vegetable intake and sociodemographic determinants. Results: The mean fruit and vegetable intake was 221.2 and 170.0 g/day, respectively. Only 46% of the mothers met the WHO recommendations (≥400 g fruit and vegetables/day). Daily fruit intake was significantly higher among mothers who live with a spouse/partner, and who belong to a higher social class. For vegetables, daily intake was significantly higher among mothers with a higher education and social class. Conclusions: This study shows that the mean intake of fruit and vegetables among Portuguese mothers is far below international recommendations. Effective strategies to promote fruit and vegetable intake are needed, especially for mothers belonging to lower social classes and educational levels.

PurposeThis paper's aim is to assess vegetable soup intake and its contribution to total vegetable intake among mothers of Portuguese schoolchildren as well as to examine the association between relative vegetable soup intake and sociodemographic characteristics.Design/methodology/approachA cross‐sectional survey was carried out in Portugal as part of the Pro Children study. In total 1,673 women, mothers of 11‐13 year old children, took part in the study. The vegetable intake and sociodemographic characteristics were collected with a self‐administered questionnaire in which a precoded 24‐hour recall was applied. The analysed sociodemographic characteristics were the number of people and composition of household, educational level, social class and region of residence. The associations between preferential or exclusive consumer mothers of vegetable soup (i.e. ≥50 per cent of total vegetable intake) and sociodemographic characteristics were analysed by a logistic regression model.FindingsThe mean intake of vegetable soup was 76.1 g/d and its contribution to total vegetable intake was approximately 45 per cent. The percentage of mothers that were preferential or exclusive consumers of vegetable soup was 41 per cent. Preferential or exclusive vegetable soup intake was less likely among mothers when the number of people in the household was less than four (vs 4; OR: 0.734, 95 per cent CI: 0.577‐0.934) and that did not live with their spouse/partner (OR: 0.617, 95 per cent CI: 0.424‐0.878).Originality/valueThe paper focuses on the consumption of vegetable soup, a traditional culinary preparation among Portuguese people. Also, it identifies factors associated with its consumption.

ObjectiveThe present study investigates the changes and tracking of dietary behaviours in Norwegian 11-year-olds and examines the association between parental education and dietary tracking over a time period of 20 months.DesignLongitudinal data from the Norwegian HEalth In Adolescents (HEIA) cohort study followed up at three time points (2007–2009).SettingIntakes of fruits, vegetables and snacks were assessed by frequency and intakes of sugar-sweetened soft drinks and squash were assessed by frequency and amount. Tracking of dietary behaviours was assessed by adolescents’ relative position in rank over time and Cohen's kappa was used to measure tracking coefficients. Multinomial logistic regression analyses were performed to assess the association between parental education and the tracking of dietary behaviours.SubjectsIn total, 885 adolescents from the HEIA cohort study participated by answering Internet-based questionnaires at three time points.ResultsThe results indicated that boys and girls maintained their relative position in rank of dietary intake over time, when grouped by baseline consumption. Fair to moderate tracking coefficients of dietary variables were observed. An inverse association was found between parental education and stability of soft drink and squash consumption during the 20 months.ConclusionsThe observed tracking pattern indicates the importance of promoting healthy dietary behaviours at an even earlier age. Furthermore, interventions should focus particularly on adolescents from families with low parental education and their consumption of sugar-sweetened beverages.

Aims: The aim of the study is to investigate the influence of the school food environment on the dietary behaviours of 11-year-old Norwegian children in elementary schools. Methods: Baseline data from a school-based intervention study: the Health In Adolescents study was used. A total of 1425 11-year-old children from 35 schools from the eastern part of Norway were included. School administrators provided information on the physical, political, and sociocultural school food environment and students reported their intake of fruits, vegetables, sugar-sweetened beverages (SSB), and snacks. Multilevel modelling was used to assess the school-level variance in dietary behaviours and to investigate the association of school food environmental factors with these dietary behaviours. Results: After adjustment for student characteristics, the school level accounted for a small proportion (1.1%–3.0%) of the variance in the dietary behaviours investigated. None of the investigated school food environmental factors were found to be related to the children’s reported intake of fruits, vegetables, snacks or SSB. Conclusions: Most of the variance in the dietary behaviours investigated was at the personal level. Thus in this sample, the investigated school-level factors do not appear to exert a strong influence on the dietary behaviours of children. Longitudinal studies using validated measures of the school food environment are needed.

ObjectiveTo analyse (i) differences in beverage pattern among Norwegian children in 2001 and 2008; (ii) beverage intake related to gender, parental education and family composition; and (iii) potential disparities in time trends among the different groups.DesignWithin the Fruits and Vegetables Make the Marks (FVMM) project, 6th and 7th grade pupils filled in a questionnaire about frequency of beverage intake (times/week) in 2001 and 2008.SettingTwenty-seven elementary schools in two Norwegian counties.SubjectsIn 2001 a total of 1488 and in 2008 1339 pupils participated.ResultsBetween 2001 and 2008, a decreased consumption frequency of juice (from 3·6 to 3·4 times/week, P = 0·012), lemonade (from 4·8 to 2·5 times/week, P < 0·001) and regular soft drinks (from 2·7 to 1·6 times/week, P < 0·001), but an increased consumption frequency of diet soft drinks (from 1·2 to 1·6 times/week, P < 0·001), were observed. From 2001 to 2008, boys increased their frequency of juice consumption (from 3·1 to 3·3 times/week) whereas girls decreased their frequency of juice consumption (3·8 to 3·4 times/week; interaction time × gender P = 0·02). Children with higher educated parents increased their frequency of juice consumption (3·6 to 3·8 times/week) whereas those with lower educated parents decreased their frequency of juice consumption (3·3 to 3·0 times/week; interaction time × parental education P = 0·04).ConclusionA lower frequency of consumption of sugar-sweetened beverages was observed among pupils in 2008 than in 2001. This is in accordance with the Norwegian health authority's goals and strategies for this time period, and is an important step to improve the dietary health of adolescents.

This paper has the following aims: (i) to explore the extent to which students who received an intervention involving HIV/AIDS and sexuality perceived that their teacher cared for their health and well-being, (ii) to investigate the characteristics of students who reported to have caring teachers and (iii) to document the association between students' perceptions of care and reported onset of sexual activity. Data were obtained from the second follow-up survey of a prospective study carried out among high school students in South Africa (Cape Town and Mankweng). We analyzed data from 3483 students who met the inclusion criteria. Students from the intervention group perceived greater care from teachers than students in the control group. Female students and students from Cape Town perceived having received more care, and their perception of care was associated with the number of lessons received, how often students expressed their opinions in class and how often teachers talked about HIV/AIDS, condoms and abstinence. Students who perceived that their teacher cared for their health and well-being were less likely to initiate sexual intercourse. This is the first paper to demonstrate the salience of the concept of care in studies of school-based HIV/AIDS prevention programs in sub-Saharan Africa.

The aim of this study was to examine modifiable biological, psychological, behavioral and social-environmental correlates of physical activity among 1129 Norwegian 11-year-old children within a cross-sectional sample from the HEalth In Adolescents study. Physical activity was assessed by accelerometer, and weight and height were measured objectively. Age- and gender-specific cut-off points proposed by the International Obesity Task Force were used to define body mass index. Social-environmental variables were self-reported by questionnaire. Hierarchical regression (linear mixed models) revealed that normal weight children scored higher on percentage daily moderate-to-vigorous physical activity [% daily moderate to vigorous physical activity (MVPA)] than overweight/obese children (P

In this paper we explore the perceived desirable characteristics of South African Life Orientation teachers for teaching sexuality and HIV/AIDS. We also investigate the extent to which these characteristics can be understood as parts of a role script for teaching HIV/AIDS and sexuality. Data were collected from teachers who taught Grade Eight and Grade Nine students in South African public high schools. The teachers particularly emphasised the importance of personality and life experience as important characteristics for teaching sexuality and HIV/AIDS. In addition, they felt that it was challenging to create an open dialogue in the classroom and at the same time maintain classroom discipline. The teachers did not perceive that teaching about sexuality and HIV/AIDS was a role that a teacher could step in and out of. On the other hand, they were accustomed to playing different roles with respect to the students, such as parent, friend, counsellor and social worker.