Effect and Process Evaluation of a Cluster Randomized Control Trial on Water Intake and Beverage Consumption in Preschoolers from Six European Countries: The ToyBox-Study

An-Sofie Pinket, Wendy Van Lippevelde, Ilse De Bourdeaudhuij, Benedicte Deforche, Greet Cardon, Odysseas Androutsos, Berthold Koletzko, Luis A Moreno, Piotr Socha, Violeta Iotova, Yannis Manios, Marieke De Craemer, ToyBox-Study Group, Yannis Manios, Berthold Koletzko, Ilse De Bourdeaudhuij, Mai Chin A Paw, Luis Moreno, Carolyn Summerbell, Tim Lobstein, Lieven Annemans, Goof Buijs, John Reilly, Boyd Swinburn, Dianne Ward, Yannis Manios, Odysseas Androutsos, Eva Grammatikaki, Christina Katsarou, Eftychia Apostolidou, Eirini Efstathopoulou, Paraskevi-Eirini Siatitska, Angeliki Giannopoulou, Effie Argyri, Konstantina Maragkopoulou, Athanasios Douligeris, Berthold Koletzko, Kristin Duvinage, Sabine Ibrügger, Angelika Strauß, Birgit Herbert, Julia Birnbaum, Annette Payr, Christine Geyer, Ilse De Bourdeaudhuij, Greet Cardon, Marieke De Craemer, Ellen De Decker, Lieven Annemans, Stefaan De Henauw, Lea Maes, Carine Vereecken, Jo Van Assche, Lore Pil, Mai Chin A Paw, Saskia te Velde, Luis Moreno, Theodora Mouratidou, Juan Fernandez, Maribel Mesana, Pilar De Miguel-Etayo, Esther González, Luis Gracia-Marco, Beatriz Oves, Agneta Yngve, Susanna Kugelberg, Christel Lynch, Annhild Mosdøl, Carolyn Summerbell, Helen Moore, Wayne Douthwaite, Catherine Nixon, Susanne Kreichauf, Andreas Wildgruber, Piotr Socha, Zbigniew Kulaga, Kamila Zych, Magdalena Góźdź, Beata Gurzkowska, Katarzyna Szott, Violeta Iotova, Mina Lateva, Natalya Usheva, Sonya Galcheva, Vanya Marinova, Zhaneta Radkova, Nevyana Feschieva, Tim Lobstein, Andrea Aikenhead, Goof Buijs, Annemiek Dorgelo, Aviva Nethe, Jan Jansen, Otto Gmeiner, Jutta Retterath, Julia Wildeis, Axel Günthersberger, Leigh Gibson, Claus Voegele, An-Sofie Pinket, Wendy Van Lippevelde, Ilse De Bourdeaudhuij, Benedicte Deforche, Greet Cardon, Odysseas Androutsos, Berthold Koletzko, Luis A Moreno, Piotr Socha, Violeta Iotova, Yannis Manios, Marieke De Craemer, ToyBox-Study Group, Yannis Manios, Berthold Koletzko, Ilse De Bourdeaudhuij, Mai Chin A Paw, Luis Moreno, Carolyn Summerbell, Tim Lobstein, Lieven Annemans, Goof Buijs, John Reilly, Boyd Swinburn, Dianne Ward, Yannis Manios, Odysseas Androutsos, Eva Grammatikaki, Christina Katsarou, Eftychia Apostolidou, Eirini Efstathopoulou, Paraskevi-Eirini Siatitska, Angeliki Giannopoulou, Effie Argyri, Konstantina Maragkopoulou, Athanasios Douligeris, Berthold Koletzko, Kristin Duvinage, Sabine Ibrügger, Angelika Strauß, Birgit Herbert, Julia Birnbaum, Annette Payr, Christine Geyer, Ilse De Bourdeaudhuij, Greet Cardon, Marieke De Craemer, Ellen De Decker, Lieven Annemans, Stefaan De Henauw, Lea Maes, Carine Vereecken, Jo Van Assche, Lore Pil, Mai Chin A Paw, Saskia te Velde, Luis Moreno, Theodora Mouratidou, Juan Fernandez, Maribel Mesana, Pilar De Miguel-Etayo, Esther González, Luis Gracia-Marco, Beatriz Oves, Agneta Yngve, Susanna Kugelberg, Christel Lynch, Annhild Mosdøl, Carolyn Summerbell, Helen Moore, Wayne Douthwaite, Catherine Nixon, Susanne Kreichauf, Andreas Wildgruber, Piotr Socha, Zbigniew Kulaga, Kamila Zych, Magdalena Góźdź, Beata Gurzkowska, Katarzyna Szott, Violeta Iotova, Mina Lateva, Natalya Usheva, Sonya Galcheva, Vanya Marinova, Zhaneta Radkova, Nevyana Feschieva, Tim Lobstein, Andrea Aikenhead, Goof Buijs, Annemiek Dorgelo, Aviva Nethe, Jan Jansen, Otto Gmeiner, Jutta Retterath, Julia Wildeis, Axel Günthersberger, Leigh Gibson, Claus Voegele

Abstract

Background: Within the ToyBox-study, a kindergarten-based, family-involved intervention was developed to prevent overweight and obesity in European preschoolers, targeting four key behaviours related to early childhood obesity, including water consumption. The present study aimed to examine the effect of the ToyBox-intervention (cluster randomized controlled trial) on water intake and beverage consumption in European preschoolers and to investigate if the intervention effects differed by implementation score of kindergartens and parents/caregivers.

Method: A sample of 4964 preschoolers (4.7 ± 0.4 years; 51.5% boys) from six European countries (Belgium, Bulgaria, Germany, Greece, Poland, Spain) was included in the data analyses. A standardized protocol was used and parents/caregivers filled in socio-demographic data and a food-frequency questionnaire. To assess intervention effects, multilevel repeated measures analyses were conducted for the total sample and for the six country-specific samples. Based on the process evaluation questionnaire of teachers and parents/caregivers, an implementation score was constructed. To assess differences in water intake and beverage consumption by implementation score in the total sample, multilevel repeated measures analyses were performed.

Results: Limited intervention effects on water intake from beverages and overall beverage consumption were found. However, important results were found on prepacked fruit juice consumption, with a larger decrease in the intervention group compared to the control group. However, also a decline in plain milk consumption was found. Implementation scores were rather low in both kindergartens and parents/caregivers. Nevertheless, more favorable effects on beverage choices were found in preschoolers whose parents/caregivers and kindergarten teachers had higher implementation scores compared to those with lower implementation scores.

Conclusion: The ToyBox-intervention can provide the basis for the development of more tailor-made interventions. However, new strategies to improve implementation of interventions should be created.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Overview process evaluation questions to…
Fig 1. Overview process evaluation questions to calculate the implementation score (total score on 30) for teachers (first focus).
Fig 2. Overview process evaluation questions to…
Fig 2. Overview process evaluation questions to calculate the implementation score (total score on 30) for teachers (repetition period).
Fig 3. Overview process evaluation questions to…
Fig 3. Overview process evaluation questions to calculate the implementation score (score on 18) for parents/caregivers.
Fig 4. Process evaluation results: Implementation score…
Fig 4. Process evaluation results: Implementation score x Plain water intake, Soft drink intake, Prepacked fruit juice intake and Plain milk intake (ml/day).

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