Program Obesity Zero (POZ) – a community-based intervention to address overweight primary-school children from five Portuguese municipalities

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  Program Obesity Zero (POZ) – a community-based intervention to address overweight primary-school children from five Portuguese municipalities
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  Public Health Nutrition: 16(6), 1043–1051  doi:10.1017/S1368980013000244 Program Obesity Zero (POZ) – a community-based interventionto address overweight primary-school children from fivePortuguese municipalities Ana Isabel Rito 1, *, Maria Ana Carvalho 2 , Carlos Ramos 2 and Joa˜o Breda 3 1 INSA – National Institute of Health Doutor Ricardo Jorge IP, Av. Padre Cruz, 1649-016 Lisbon, Portugal: 2 Department of Nutrition Sciences, University Atlaˆntica, Oeiras, Portugal:  3 Division of NoncommunicableDiseases and Health Promotion, WHO Regional Office for Europe, Copenhagen, Denmark Submitted 9 March 2012: Final revision received 29 November 2012: Accepted 6 December 2012: First published online 6 March 2013  Abstract Objective:  Results of the WHO European Childhood Obesity Surveillance Initiativeindicated that on average one out of four primary-school children is overweight orobese. Portugal presented one of the highest prevalences of obesity. Childhoodobesity prevention and treatment should be a top priority. The aim of the presentstudy was to evaluate the effectiveness of Program Obesity Zero (POZ), a multi-component, community-, family- and school-based childhood obesity intervention. Design:  Parents and children attended four individual nutrition and physicalactivity counselling sessions, a one-day healthy cooking workshop and two schoolextracurricular sessions of nutrition education. Waist circumference, BMI, physicalactivity level, sedentary behaviours, and nutrition and physical activity knowledge,attitudes and behaviour were assessed at baseline and after 6 months. Diet wasassessed using two 24h recalls, at baseline and at 6 months. Setting:  Five Portuguese municipalities and local communities. Subjects:  Two hundred and sixty-six overweight children (BMI $ 85th percentile)aged 6–10 years, from low-income families in five Portuguese municipalities, wereassigned to the intervention. Results:  Children showed reductions in waist circumference ( 2 2 ? 0cm;  P  , 0 ? 0001),mean BMI ( 2 0 ? 7kg/m 2 ;  P  , 0 ? 0001) and BMI-for-age percentile ( 2 1 ? 7;  P  , 0 ? 0001)at 6 months. Overall, children’s intake of fruit and vegetables was  , 400g/dthroughout the intervention. After 6 months, higher fibre consumption and anapparent decrease in sugary soft drinks intake to a quarter of that observed atbaseline (mean intake: 198ml/d at baseline), with improvements in physical activity levels and screen time , 2h/d, were also observed. Conclusions:  The findings suggested that POZ is a promising interventionprogramme, at municipality level, to tackle childhood overweight and obesity. Keywords ChildrenPrimary schoolsOverweightMunicipalitiesFamily The prevalence of overweight and obesity has beenincreasing consistently throughout the WHO EuropeanRegion. Preliminary results of the first round of theEuropean Childhood Obesity Surveillance Initiative from WHO European Region indicated that on average 24% of children aged 6– 9 years are overweight or obese (1) , withPortugal (8 ? 9%) (2) and Italy (12 ? 3%) (3) presenting thehighest prevalences of obesity. Childhood obesity preven-tion and treatment should be a top priority. Following the WHO European Charter on Counteracting Obesity and theEuropean Commission White Paper entitled  A Strategy for Europe on Nutrition, Overweight and Obesity related Health Issues  (4,5) , it is essential to build partnerships betweenstakeholders across all levels (national, sub-national andlocal) highlighting the role of local authorities, which havegreat potential in creating the environments and opportu-nities for healthy living. Action should be taken at bothmicro and macro levels and in different settings such ashome and families, communities and schools (6) . Increasingevidence shows that the most successful interventionsare multi-component, adapted to the local context, using theexisting local structures of a community and involving theparticipants in the planning and implementation stages (7) .Using this sort of approach and involving multiple partnerscontributes to community empowerment and aff ords theopportunity to reach a large number of people (8) . Inter-national recommendations agree that interventions used within a childhood obesity approach should essentially rely upon behaviour modification regarding diet andphysical activity  (9,10) . The aim of the present study was to * Corresponding author:  Email ana.rito@insa.min-saude.pt  r The Authors 2013  evaluate the effectiveness of Program Obesity Zero (POZ),a multi-component, community-, family- and school-basedintervention at municipality level, which targeted low-income families with overweight and obese children. Methods POZ was implemented during the year 2009 in fivemunicipalities from the five Portuguese regions thatapplied to the programme – Melgac¸o (North), Cascais(Lisbon and Tagus Valley), Mealhada (Centre), Beja(Alentejo) and Silves (Algarve) – in partnership with thelocal health centre. In line with recommendations fromthe National Health Plan 2011–2016 (11) , POZ prioritizedlow-income families, acknowledging that counteractingchildhood obesity should be particularly oriented forthe less affluent groups of the population. POZ was anintegrated, multi-component healthy lifestyle programmebased on the principles of nutrition and physical activity from psychology, learning and social cognitive theoriesand the study of therapeutic processes.The goal was then to target low-income families withoverweight children (6–10 years old) through a set of activities in order to reverse the trend. This project wasthe first in Portugal to put forward an approach to treatobesity in children with the involvement of community players.The programme engaged families in the process of childhood obesity management (decreasing adiposity andBMI) by addressing components necessary for individual-level behavioural change. The intervention targetedfive behavioural changes: (i) decreasing the consumptionof foods high in fat, salt and sugar; (ii) increasing theconsumption of fruits and vegetables and wholegrainproducts; (iii) decreasing television viewing; (iv) increasingphysical activity levels; (v) and increasing knowledge,positive attitudes about nutrition and healthy diet, andrelated behaviour change.  Participant selection Each municipality and health centre conducted an initialchildhood nutritional status survey targeting all primary-school children (6–10 years old) registered in the school year 2008/2009. Potential participants (with overweight orobesity) were recruited and an invitation was forwarded tothe families through the local health authorities followingadvice from the family doctor regarding income statusand eligibility of the family. In order to have homogeneousguidance of the project, the national team developedseveral training sessions for the local stakeholders aboutanthropometric measurements and nutritional counselling.In addition, each municipality had the help of a nutritionist who was responsible for coordinating the activities. Fromthe 2226 children measured, 482 were eligible since thesechildren were overweight (BMI $ 85th percentile) (12) ,enrolled in a primary school and had no apparentclinical problems, co-morbidities, physical disabilities orlearning difficulties. Most of the measurements (97%) wereperformed in schools and the rest at the health centres.Informed consent was obtained from the parents afterprovision of explanation of the study objectives andmethods in several local meetings conducted by nutri-tionists. Two hundred and sixty-six (55 ? 1%) familiesaccepted to participate.  The intervention The programme consisted of three different types of intervention delivered over a 6-month period in differentsettings. Health centres – individual counselling sessions  Each child, and at least one parent, were invited to parti-cipate in four individual counselling sessions performedby trained nutritionists (two days of training), who wereprovided with identical materials and manuals which con-tained detailed methods for the delivery of all sessions.These sessions (each individual counselling session lasting60min) consisted of nutrition education with healthy eatingadvice customized for overweight and obese children.The traffic light diet method was followed (13) . The sessionsalso included healthy eating tips in the form of achievable weekly and monthly targets. A ‘non-dieting’ philosophy  was advocated throughout the intervention; thereforechildren were discouraged from weighing themselves andencouraged to make small lifestyle changes to improvehealth rather than achieve rapid weight loss. A behaviouralapproach was adopted, focused on teaching parents andchildren to apply different techniques such as stimuluscontrol, goal setting, reinforcement and response preven-tion to establish a health-promoting home environment (14) . All children were encouraged to undertake at least 1h of physical activity daily. Family ‘healthy cooking’ workshops  In order to actively involve families and the schoolenvironment, in each municipality children and families were invited to participate in a one-day healthy cooking workshop (each healthy cooking workshop lasting 3h),performed by a certified and renowned ‘chef’ in a schoolkitchen. The workshop was under the guidance of anutritionist where nutrition education focused not only on the provision of nutrition information, but also on thedevelopment of skills and behaviours related to areassuch as food preparation, food preservation and storage,social and cultural aspects of food and eating, and otherconsumer aspects. All of  these areas are conduciveto healthier food choices (15) . A ‘healthy meals/recipesPOZ book’, developed particularly to achieve children’sdietary needs, was provided to families where they learnthow to prepare low-budget healthy meals and how toprepare these recipes at home. 1044 AI Rito  et al  .  School intervention   All school classes that had children enrolled in POZ wereselected. Two intervention initiatives were developed atschool level, one oriented to children in the classroom(each lasting 6h) and another one targeting parents(each lasting 3h). The focus of the intervention was onencouraging healthy eating and increased levels of physicalactivity in all children rather than highlighting weight orobesity as issues, although participants (children, familiesand schools) were not blinded to the fact that it wasan obesity prevention initiative. In the classroom, eachnutritionist encouraged all children (the participants andnon-participants from each class) to be more physically active every day by increasing the variety and opportunitiesfor physical activity beyond those which were currently provided in each school, i.e. to increase non-curricularactivity at recess, lunchtimes and after school, with aparticular focus on less traditional sports and more lifestyle-based activities such as outdoor games, cycling, beachhikes and children’s games. Another intervention initiativeincluded the development of a resource called ‘nutritionand physical activity sheets’ for teachers to facilitateadditional initiatives in classrooms. These activities werepredominantly nutrition based and focused on reducingthe intake of sugary drinks and on increasing fruitand vegetable consumption. Objectives for the parents’component focused on stimulating awareness and gainingparental support to encourage variety in the diet andavailability of healthy foods at home. Methods used inclu-ded a presentation, discussion and brochures given in onesession meeting.  Outcome measurements Data were collected at baseline and 6 months thereafter,i.e. at the first and fourth individual counselling sessionand visit to the health centre, respectively, by a trainednutritionist in each municipality. Nutritional status  Body weight, height and waist circumference were obtainedfor every child, following standardized procedures (16) . BMI was subsequently calculated. The 2000 growth reference of the Centers for Disease Control and Prevention (12)  was usedto describe children’s nutritional status. Children wereclassified as overweight if their BMI-for-age was  $ 85thpercentile, pre-obese and obese if their BMI-for-age was $ 85th and  , 95th and  $ 95th percentile, respectively. The75th percentile was used as the cut-off point for risk of abdominal obesity using Fernandez  et al  .’s reference (17) . Socio-economic classification  Social class was based on the occupation of the parents inaccordance with the Standard Occupational Classificationfrom the National Institute of Statistics (18) . Mothers’ andfathers’ socio-occupational status was then categorizedinto three groups. The ‘high’ category included women ormen in management positions (Class I); only 7 ? 8% of menand 6 ? 2% of women were from this class. Office workers,service workers and skilled manual workers constitutedthe ‘middle’ category (Class II and III). The majority of the parents were from the ‘low’ category, i.e. 61 ? 2%of men and 55 ? 4% of women were unskilled workers orunemployed (Class IV and V). Dietary intake – 24h recall  From the age of about 7–8 years there is a fairly rapidincrease in the ability of children to participate in unassistedrecall, but only for food eaten in the immediate past and forno longer than the previous 24h (19) . For Andersen  et al. (20) ,the 24h recall would be the first choice of method forchildren as is logistically simple, applicable for cross-culturalsurveys and less burdensome for the respondents. Further-more, the 24h recall method has been shown to be reliableand valid in children as young as 7–8 years old (21) . Two24h dietary recalls (at baseline and after 6 months) wereadministered to children and assisted by parents and trainednutritionists in each municipality. Recall records werereviewed by nutritionists from the national programme teambefore analysis of food and nutrient data. The 20- to 30-mininterview was conducted privately and focused on food andbeverage intake during the previous 24h period. Informa-tion on macro- and micronutrients was obtained using thesoftware Food Processor SQL s , version 9 ? 7 ? 0. Physical activity and sedentary behaviours  Habitual free-living physical activity was measured withthe use of a pedometer (vertical impact measure only) worn around the waist, which provided an assessment of the daily number of steps. Children were instructed to puton the pedometer as soon as they woke up and to takeit off just before bed. Physical activity and the amountof sedentary behaviours were also assessed using a non- validated questionnaire administered by the nutritionistto parents and children. The questionnaire includedthe number and duration of physical vigorous activities(e.g. sports) and the time spent on sedentary activities(television watching, video games/computer use), which was assessed separately for weekdays and weekend days.It also evaluated the number of hours of sleep. Nutrition and physical activity knowledge, attitudes and behaviour   A validated questionnaire (22) for Portuguese children thatincluded questions regarding nutrition knowledge, attitudesand behaviours was completed by the children with thehelp of the nutritionists. The final instrument comprisedthirteen questions. A score system gave one point to eachcorrect answer, positive attitude and behaviour.  Statistical analysis  All analyses were conducted using the statistical softwarepackage SPSS 20 ? 0 for Windows. Descriptive analyses POZ – a community-based intervention 1045  (mean values, standard deviations and percentages) of childcharacteristics and 95% confidence intervals were calculated.The paired-samples  t   test was calculated after testingfor normality and the Wilcoxon test was used as a non-parametric alternative. The McNemar test was used forcategorical variables. Statistical significance was set at P  , 0 ? 05. Results Of the 266 participating children, 199 completed theintervention (41% of the srcinal sample). Major reasonsfor dropping out were absence or parental refusal to thepre-scheduled sessions.  Effects on nutritional status The characteristics of the study population at baseline and6 months after are shown in Table 1. The effect on outcome variables after 6 months of intervention is also shown inTable 1. Mean height and weight were significantly higher by respectively 2 ? 6 (95% CI 2 ? 3, 2 ? 9) cm and 0 ? 8 (95% CI 0 ? 5,0 ? 1) kg (both  P  , 0 ? 001) after 6 months. Changes in BMI didnot result from variation in weight but rather from differ-ences in relative height over time. Waist circumference, meanBMI and BMI-for-age percentile were significantly lower at6 months: by  2 2 ? 0cm;  2 1 ? 7kg/m 2 and  2 1 ? 7, respectively (all  P  , 0 ? 001). After 6 months, 9 ? 1% of the children movedout of the obese category (59 ? 4% to 50 ? 3%), 1 ? 6% (40 ? 6%to 42 ? 2%) moved into the pre-obese category and 7 ? 5%moved into the healthy weight category (Table 1).  Effects on dietary intake  Analysis of data from repeated 24h recalls indicatedsignificantly higher fibre consumption (2 ? 5g; 95% CI 0 ? 7,4 ? 2g;  P  5 0 ? 005; Table 2) after 6 months of intervention. Although total energy, protein, carbohydrate, sugar andtotal fat consumption showed lower values, these differ-ences were not statistically significant (Table 2). Analyses of children’s food intake reported in the 24hrecall showed that, at baseline, ‘semi-skimmed milk’ (14 ? 2%), Table 1  Descriptive characteristics of the study population at baseline and after 6 months of intervention: overweight children aged6–10 years from low-income families in five Portuguese municipalities, 2009CharacteristicBaseline 6 months DifferenceMean  SD  Mean  SD  n   Mean 95% CI  P   value n   266 199 NA NA NAAge (years) 8 ? 6 1 ? 4 8 ? 9 1 ? 3 NA NA NASexMale 126 96 NA NA NAFemale 140 103 NA NA NAHeight (cm) 137 ? 3 9 ? 9 139 ? 5 9 ? 8 199 2 ? 6 2 ? 3, 2 ? 9  , 0 ? 001*Weight (kg) 43 ? 3 1 ? 0 44 ? 1 10 ? 1 199 0 ? 8 0 ? 5, 1 ? 1  , 0 ? 001 - BMI (kg/m 2 ) 22 ? 8 3 ? 0 22 ? 4 2 ? 9 199  2 0 ? 4  2 0 ? 6,  2 0 ? 2  , 0 ? 001 - Waist circumference (cm) 75 ? 1 8 ? 4 73 ? 1 8 ? 9 198  2 2 ? 0  2 2 ? 7,  2 1 ? 3  , 0 ? 001 - BMI-for-age percentile 95 ? 0 3 ? 8 93 ? 4 5 ? 5 199  2 1 ? 7  2 2 ? 2,  2 1 ? 3  , 0 ? 001 - Normal weight (%) NA 7 ? 5 NA NA NAPre-obesity (%) 40 ? 6 42 ? 2 NA NA NAObesity (%) 59 ? 4 50 ? 3 NA NA NA NA, not applicable.Data are presented as number, mean and standard deviation, or percentage.*Paired-samples  t   test. - Wilcoxon test. Table 2  Estimated differences in daily dietary intake at baseline and after 6 months of intervention: overweight children aged 6–10 yearsfrom low-income families in five Portuguese municipalities, 2009DifferenceBaseline 6 months Mean 95% CI  P   valueTotal energy intake (kJ) 6908 6738  2 171  2 227, 569 0 ? 397*Total energy intake (kcal) 1651 ? 0 1610 ? 5  2 40 ? 9  2 54 ? 2, 136 ? 1 0 ? 397*Protein (g) 81 ? 2 71 ? 0  2 10 ? 2  2 28 ? 7, 8 ? 3 0 ? 674 - Carbohydrates (g) 244 ? 2 236 ? 5  2 7 ? 7  2 24 ? 4, 9 ? 1 0 ? 368*Sugar (g) 90 ? 2 82 ? 8  2 7 ? 4  2 16 ? 4, 1 ? 7 0 ? 233 - Total fat (g) 51 ? 9 50 ? 8  2 1 ? 1  2 5 ? 9, 3 ? 7 0 ? 485 - Fibre (g) 16 ? 7 19 ? 2 2 ? 5 0 ? 7, 4 ? 2 0 ? 005 - *Unpaired  t   test. - Mann–Whitney test. 1046 AI Rito  et al  .  ‘vegetable soup’ (8 ? 4%) and soft dinks such as ‘ice tea’(5 ? 3%), ‘tropical fruit flavour soda’ (3 ? 3%) and ‘coke’ (1 ? 6%) were the foods/beverages that contributed most to totaldaily energy intake. On average, at baseline, childrenreported an intake of 286 ? 7g of fruit and vegetables (fruit,153 ? 7g; vegetables, 133 ? 0g) and consumption of 198mlof sugar-rich drinks on the previous day, with ‘ice tea’accounting for 53 ? 0% and coke for 14 ? 7% of total softdrinks consumption reported. After 6 months of interven-tion, milk was the item that contributed most to total energy intake (semi-skimmed milk, 19 ? 3%; skimmed milk, 5 ? 1%)on the previous day. Regarding wholegrain products,there was a ten times higher reported consumption of  whole-wheat bread after 6 months of intervention (from1% to 10% of children consuming 50g/d). The reportedconsumption of sugary soft drinks on the previous day  was 44ml per child, on average, after the intervention(data not shown).  Effects on physical activity and sedentary behaviours Habitual free-living physical activity was not measuredbecause the daily number of steps was not recorded by thefamilies. The majority of children were not registered in asports club (71 ? 2%) at baseline. After the intervention,5 ? 0% of these children registered in a sports club. Dataindicated an increase in vigorous activity (0 ? 3d/week,95% CI 0 ? 1, 0 ? 5d/week;  P  5 0 ? 008) and an improvement inscreen time, i.e. the percentage of children reporting tele- vision viewing and video games/computer use for , 2h/d(8 ? 8% more during weekdays from baseline to 6 monthsafter;  P  5 0 ? 001; Table 3). Children slept for more hoursduring the weekend than during the week (10 ? 7 and 9 ? 8hat 6 months, respectively). The number of hours of sleepduring the weekend increased from baseline to 6 months(0 ? 3h, 95% CI 0 ? 2, 0 ? 4h) and this difference was statistically significant ( P  , 0 ? 001; Table 3).  Effects on nutrition knowledge and attitudes  Analysis of the children’s knowledge concerning healthy diet and nutrition indicated that, from baseline measures,dietary knowledge increased ( 1 5 ? 8 scale points, 95% CI4 ? 6, 7 ? 1 scale points;  P  , 0 ? 001) after 6 months. There was also an improvement in children’s attitudes regardinghealthy foods such as brown bread, vegetable soup,lettuce, tomato, apple, carrot, orange, broccoli, milk, fish yoghurt and fruit ( 1 1 ? 3 scale points, 95% CI 0 ? 9, 1 ? 6 scalepoints;  P  , 0 ? 001; Table 3). Discussion  POZ was developed as a multi-component intervention inoverweight children from families of low socio-economicstatus, in school and family settings, focusing mainly on thepromotion of healthy lifestyles. Participation in POZ wasassociated with significant improvements in the degree of adiposity which was examined by waist circumference andBMI. Waist circumference was designated as an outcomemeasure since BMI does not distinguish between fat andlean mass and waist circumference is not susceptible to thiseffect, as it does not depend on lean mass. We felt that thisadvantage outweighed the known disadvantages of waistcircumference of greater measurement error and variability over time compared with BMI (23) . Excess abdominal fatin children has been associated with several CVD riskfactors (24,25) . The present findings are therefore encoura-ging since POZ resulted in decreased waist circumference(–2 ? 0cm) in the children at 6 months and furthermoresignificant differences were observed in both mean BMI( 2 1 ? 7kg/m 2 ) and BMI-for-age percentile ( 2 1 ? 7; Table 1). This agrees with results from other studies (26 – 32)  wherecommunity-based programmes proved to be effective andsuccessful in the prevention and/or reduction of over- weight and/or obesity in children at local or municipality  Table 3  Estimated differences in physical activity and sedentary behaviours, nutrition knowledge and attitudes at baseline and after6 months of intervention: overweight children aged 6–10 years from low-income families in five Portuguese municipalities, 2009DifferenceBaseline 6 months Mean 95% CI  P  -valuePhysical activity and sedentary behavioursVigorous activity (d/week) 2 ? 2 2 ? 5 0 ? 3 0 ? 1, 0 ? 5 0 ? 008*Television viewing and video games/computer use (%) , 2h/d, weekdays 84 ? 0 92 ? 8 8 ? 8 0 ? 001 - $ 2h/d, weekdays 16 ? 0 7 ? 2  2 8 ? 8 , 2h/d, weekend days 49 ? 4 51 ? 4 2 ? 0 0 ? 324 - $ 2h/d, weekend days 50 ? 6 48 ? 6  2 2 ? 0Hours of sleepWeekdays 9 ? 9 9 ? 8  2 0 ? 1  2 0 ? 2, 2 0 ? 05 0 ? 005*Weekend days 10 ? 4 10 ? 7 0 ? 3 0 ? 2, 0 ? 4  , 0 ? 001*Nutrition knowledge and attitudesFood and nutrition knowledge 51 ? 8 57 ? 6 5 ? 8 4 ? 6, 7 ? 1  , 0 ? 001*Food attitudes to healthy foods 9 ? 1 10 ? 4 1 ? 3 0 ? 9, 1 ? 6  , 0 ? 001* *Wilcoxon test. - McNemar test. POZ – a community-based intervention 1047
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