Community nutrition and physical activity

Forskargrupp Community nutrition and activity, 2017

Dietary habits and physical activity are among the most important determinants of health and well-being. An unhealthy diet and a sedentary lifestyle greatly increase the risk for chronic diseases like cardiovascular diseases, obesity, type 2 diabetes, cancer and premature death. Improving dietary habits and physical activity can contribute to achievement of the Sustainable Development Goals. 

Research areas

The main aim of the group’s research is to contribute to equality in health through high quality studies regarding dietary habits and physical activity. The research covers multilevel and mixed-methods health promotion research regarding dietary habits and physical activity with a universal or targeted approach. It is carried out in settings such as child health care, preschools, schools and in residences for adults with disabilities. 

The group is conducting research in the following areas:

  • Epidemiological studies of dietary habits and physical activity and their determinants, in relation to health outcomes.
  • Multidisciplinary research on the development, implementation and evaluation of interventions to promote healthy and sustainable eating habits, physical activity and prevent obesity and chronic diseases.
  • Commissioned assignments from external partners within the groups research competence.

The group members participate in third-level education at undergraduate, graduate and doctoral level in the areas of public health nutrition and physical activity,  theory and practice of intervention and implementation research. 

Knowledge exchange and cooperation

Our research group collaborates with the Public Health Agency of Sweden, the National Food Agency, the National Board of Health and Welfare, the Swedish Association for Local Authorities and Regions, Stockholm County Council, non-governmental organisations, municipalities and other research groups in Sweden and abroad. We participate in knowledge exchange within the European Union and the World Health Organization. Many of our researchers have a dual affiliation with the Stockholm County Council, which facilitates the bridging gap between research and practice.

Research projects

A Healthy School Start

Social inequalities regarding unhealthy diets, physical inactivity and obesity are seen from early age to the disadvantage of low socioeconomic groups. Parents play a crucial role in promoting children’s health-related behaviors.

Aim
To develop and evaluate a multi-component parental support programme to promote a healthy diet and physical activity and prevent overweight and obesity in children starting school.

The programme
The program is based on Social Cognitive Theory and includes three components:
1. Health information sent home to parents
2. Motivational Interviewing with the parents
3. Teacher-led classroom activities with the children

Outcomes:
* Physical activity of children measured objectively
* Dietary habits assessed by a validated questionnaire
* Measured body weight and height
* Parental self-efficacy assessed by a validated questionnaire

Process evaluation:
Quantitative and qualitative methods are used to identify barriers and facilitators of implementation, and to monitor fidelity and acceptance to the program components. 

Implementation
The 6-month program has been implemented in middle-to-low income areas in Stockholm County with high prevalence of overweight and obesity in two cluster-randomized controlled trials.

Results and further work
The effects have so far been modest and further program development is needed in order to increase effectiveness and sustain the effects long-term. We have now started a new study called A Healthy School Start Plus.

Publications: 
- Effectiveness of a universal parental support programme to promote health behaviours and prevent overweight and obesity in 6-year-old children in disadvantaged areas, the Healthy School Start Study II, a cluster-randomised controlled trial. Nyberg G, Norman A, Sundblom E, Zeebari Z, Elinder LS. Int J Behav Nutr Phys Act. 2016;13(1):4.


Psychometric properties of a scale to assess parental self-efficacy for influencing children’s dietary, physical activity, sedentary, and screen time behaviours in disadvantaged areas. Norman Å, Bohman B, Nyberg G, Elinder LS.
Health Education & Behavior. 2017. DOI:10.1177/1090198117699506.


Factors influencing the implementation of a school-based parental support programme to promote health-related behaviours-interviews with teachers and parents. Bergstrom H, Haggard U, Norman A, Sundblom E, Schafer Elinder L, Nyberg G. BMC Public Health. 2015;15:541.

Effectiveness of a universal parental support programme to promote healthy dietary habits and physical activity and to prevent overweight and obesity in 6-year-old children: the Healthy School Start study, a cluster-randomised controlled trial. Nyberg G, Sundblom E, Norman A, Bohman B, Hagberg J, Elinder LS. PLoS One. 2015;10(2):e0116876.

One size does not fit all – qualitative process evaluation of a parental support programme to prevent overweight and obesity among children in disadvantaged areas in Sweden. Norman Å, Berlin A, Nyberg G, Elinder LS. BMC Public Health. 2016;16(1):37.

- Low socioeconomic status associated with unhealthy weight in six-year-old Swedish children despite higher levels of physical activity. Beckvid Henriksson G, Franzen S, Elinder LS, Nyberg G. Acta Paediatr. 2016 Mar 23.

The intake of selected foods by six-year-old Swedish children differs according to parental education and migration status. Safsten E, Nyberg G, Elinder LS, Norman A, Patterson E. Acta paediatrica. 2016;105(4):421-6.


Effectiveness of universal parental support interventions addressing children’s dietary habits, physical activity and bodyweight: a systematic review. Kader, M, Sundblom E, Elinder LS. Preventive Medicine 2015;77:52-67.

Aspects influencing the implementation of a parental support programme to promote health-related behaviours in a school setting according to teachers and parents. Bergström H, Haggård U, Norman Å, Sundblom E, Elinder LS, Nyberg G. BMC Public Health 2015, 15:541

Stuck in a vicious circle of stress – parental concerns and barriers to changing children’s dietary habits and physical activity.  Norman Å, Berlin A, Sundblom E, Elinder LS, Nyberg G. Appetite. 2015 Apr;87:137-42.

Validity and Reliability of a Parental Self-Efficacy Instrument in the Healthy School Start Prevention Trial of Childhood Obesity. Bohman B, Nyberg G, Sundblom E, Schäfer Elinder L. Health Educ Behav. 2013 Dec 25.

A healthy school start - parental support to promote healthy dietary habits and physical activity in children: design and evaluation of a cluster-randomised intervention. Nyberg G, Sundblom E, Norman A, Elinder LS. BMC Public Health. 2011 Mar 25;11:185.

Project contact person: Gisela Nyberg

A Healthy School Start Plus for children and parents in disadvantaged areas - prevention of obesity and type 2-diabetes

This 3-year project is a further development of our Healthy School Start intervention runs from 2017-2019, funded by the Swedish Research Council Forte and the Kamprad Family Foundation. https://enfriskskolstartplus.se
High-quality evaluation of a program to promote healthy dietary habits and physical activity and prevent obesity and chronic diseases in children and their parents in disadvantaged areas with great health needs. 

The programme
The program is based on social cognitive theory and includes four components:
1) Health information to parents
2) Motivational Interviewing with the parents concerning their child
3) Teacher-led classroom activities with the children
4) A test of type-2 diabetes risk by parents with follow-up in primary health care 

Outcomes:
* Dietary habits and physical activity of the children
* Body weight and height of children
* Parental self-efficacy to improve the child’s health
* Parental feeding styles and practices
* Parents’ risk of type-2 diabetes

Process evaluation:
Quantitative and qualitative methods are used to identify barriers and facilitators of implementation, and to monitor fidelity and acceptance to the programme components. 

Study design
A cluster-randomized controlled trial with 20 schools and 600 families in disadvantaged areas of Stockholm County. 

Project contact person: Åsa Norman

Intervention for adults with intellectual disabilities

Adults with intellectual disabilities have an increased risk of developing physical as well as mental ill-health. This target group on average has poor dietary habits, low physical activity and a higher prevalence of obesity compared to the general population. Effective health programmes for this target group are lacking.

Aim 
To develop and evaluate a multi-component programme to promote physical activity and healthy diet among adults with intellectual disabilities targeting both residents and staff in community residences.

The programme
The 12-month programme includes three components:
1. A
ppointment of a health ambassador among staff
2. 
A study circle for staff - where they discuss health promotion work routines and practices
3. 
A health course for the residents

Outcomes:
* Work routines in residences assessed by questionnaire
* Physical activity of residents measured objectively
* Diet quality of residents assessed by digital photography
* Anthropometry of residents
Satisfaction with life of residents assessed by structured interview

Process evaluation:
Interviews are conducted with managers and health ambassadors to assess barriers and facilitators of implementation, and fidelity to the program components is monitored. 

Implementation
The programme has been implemented in 30 community residences in Stockholm County and has been evaluated in a cluster-randomized controlled trial. In another quasi-experimental study including 84 residences in 8 municipalities we have assessed the implementation of the study circle for staff component and its effect on work routines. 

Results and further work
Results have been encouraging regarding physical activity, but further development is needed regarding improvements in diet. A manual (in Swedish) has been produced and the programme is being implemented in several municipalities throughout Sweden. A new intervention targeting young adults with ID is in the planning stage. 

Publications:

Manual. Hälsofrämjande gruppbostad. Ett program för att främja bra mat- och rörelsevanor i gruppbostäder och servicebostäder (Manual. Health promotion in community residences. A program to promote healthy dietary habits and physical activity in community residences – a manual). Centre for Epidemiology and Community Medicine, Stockholm county Council. Stockholm 2014.

Effect and Process Evaluation of a Structural Health Intervention in Community Residences for Adults with Intellectual Disabilities. Elinder LS, Sundblom E, Zeebari Z, Bergström H. (Accepted for publication 2017).

Understanding the implementation process of a multi-component health promotion intervention for adults with intellectual disabilities in Sweden. Sundblom E, Bergström H, Elinder LS.Journal of Appl Res Intellect Disabil. 2015 Dec;41(4):392-396.  


Barriers and facilitators in health education for adults with intellectual disabilities--a qualitative study. Bergström H, Elinder LS, Wihlman U. Health Educ Res. 2014 Apr;29(2):259-71.

Promoting health of people with intellectual disabilities: Views of professionals working in group homes. Wahlström L, Bergström H, Marttila A. J Intellect Disabil. 2014 Mar 4;18(2):113-128.

A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: a cluster randomised controlled trial. Bergström H, Hagströmer M, Hagberg J, Elinder LS. Res Dev Disabil. 2013 Nov;34(11):3847-57. 

Psychometric evaluation of a scale to assess satisfaction with life among people with intellectual disabilities living in community residences. Bergström H, Hochwälder J, Kottorp A, Elinder LS. J Intellect Disabil Res. 2013 Mar;57(3):250-6.

The role of staff in health promotion in community residences for people with intellectual disabilities: variation in views among managers and caregivers. Bergström H, Wihlman U. J Intellect Disabil. 2011 Sep;15(3):167-76.

Validation of personal digital photography to assess dietary quality among people with intellectual disabilities. Elinder LS, Brunosson A, Bergström H, Hagströmer M, Patterson E. J Intellect Disabil Res. 2012 Feb;56(2):221-6.

Promoting a healthy diet and physical activity in adults with intellectual disabilities living in community residences: design and evaluation of a cluster-randomized intervention. Elinder LS, Bergström H, Hagberg J, Wihlman U, Hagströmer M. BMC Public Health. 2010 Dec 13;10:761.

Project contact person: Liselotte Schäfer-Elinder

School Food Sweden (SkolmatSverige)

School meals are provided free of cost for all children aged 6-16 years in Sweden and since 2011 the law states that school meals should also be “nutritious”.

Aim
We have developed and validated a novel web-based system called SkolmatSverige (School food Sweden) which was launched in 2012. It is currently used by almost 40% of all primary schools in Sweden, and it allows continuous evaluation of school meal quality as well as research relating school meal quality to health and educational outcomes.

Web-based system
SkolmatSverige consists of an instrument to be completed by the school, usually by the head of catering. The instrument covers six different domains. In addition, the school can choose to administer two questionnaires to pupils and staff at the school. The six domains are:
* Food choice and provision
* Nutritional adequacy
* Safe and hygienic food
* Service and the pedagogic lunch
* Environmental impact
* Organisation and policy

Automatic feedback to the school showing their strengths and weaknesses in the different areas is provided. This feedback, plus encouragement, to create an action plan is intended to help them improve their school meal quality. 

Results and further work
Two years after the new law was introduced we could see small but significant positive results. Preliminary analysis suggests that repeated use of the instrument is also helping schools to improve their school meal quality. The data gathered makes it also possible to conduct research on potential systematic differences in school meal quality in the country and on the health and educational effects of school meals. See www.skolmatsverige.se for more results in Swedish.

Publications:
Improvements in school meal quality in Sweden after the introduction of new legislation – a two-year follow-up. Patterson E, Elinder LS.Eur J Public Health. 2014 Nov 12.


Design, testing and validation of an innovative web-based instrument to evaluate school meal qualityPatterson E, Quetel AK, Lilja K, Simma M, Olsson L, Elinder LS. Public Health Nutr. 2013 Jun;16(6):1028-36.

SkolmatSverige – verktyget som bidrar till utveckling av skolmåltidens kvalitet. Patterson E, Elinder LS. Nordisk Nutrition nr 1, 2016.


Project contact person: Emma Patterson

Optimat Sweden

The Swedish school meal scheme offers a unique opportunity to foster healthy and sustainable dietary habits among the young generation. This 3-year research project running from 2016 - 2020 is financed by the Swedish Research Council Formas.

Aim
To develop a holistic model for a health-promoting, affordable, and socially acceptable school meal plan optimized for environmental sustainability (green-house gas emissions). The project constitutes collaboration between Karolinska Institute, the National Food Agency Sweden, and the Metropolitan University College, Copenhagen.

Planned sub-studies
* School lunches, their contribution ti overall dietary intake and relation to school meal quality - a cross sectional study
* Development of an acceptable, affordable, health promoting, and nutritious food basket optimzed for minimum environmental impact
* Effect of new meal plans on dietary intake and acceptability among students: An intervention study
* Implementation of the new menu plan - a qualitative process evaluation

Project contact person: Emma Patterson

Health promotion in schools

Schools are one of the most important settings for health promotion with the potential to reduce social inequalities in health. There is good evidence for the effectiveness of multi-component programs, and for sustainability reasons a participatory approach in planning, implementation and evaluation is preferred. This project was conducted 2009-2013.

Aim
To develop and evaluate a model intervention to promote healthy eating habits, physical activity, and self-esteem, and promote a healthy body weight in children aged 6-16 years (SCIP-school). 

Implementation
Schools are provided with a self-assessment tool (KEY) in order to identify, prioritize, plan and implement health promotion work. 

Results and further work
Positive changes in school health promotion practices were found as a result of the intervention, but no changes in health behaviors or overweight and obesity were found at student level. Implementation of the intervention was found to be weak. Further developmental work is in progress to improve implementation and achieve sustainability of schools’ health promotion work. 

Publications:
Longitudinal changes in health behaviours and body weight among Swedish school children - associations with age, gender and parental education - the SCIP school cohort. Elinder LS, Heinemans N, Zeebari Z, Patterson E. BMC Public Health. 2014 Jun 23;14(1):640.

A participatory and capacity-building approach to healthy eating and physical activity- SCIP-school: a 2-year controlled trial. Elinder LS, Heinemans N, Hagberg J, Quetel AK, Hagströmer M. Int J Behav Nutr Phys Act. 2012 Dec 17;9:145.

Project contact person: Liselotte Schäfer-Elinder 

Doctoral Students

  • Helena Bergström:  Health promotion for adults with intellectual disabilities. Evaluation of a multi-component intervention in community residences. Dissertation September 2014
  • Åsa Norman: Effectiveness of a universal theory-based parental support programme to promote healthy dietary habits and physical activity and prevent overweight and obesity. Dissertation December 2016.
  • Patricia Eustachio Colombo: Fostering sustainable dietary habits through optimzed school meals - OPTIMAT. Dissertation expected 2021.

Scientific Publications

Please see under relevant project above

Other Publications

Publication Author

 Evidensbaserat folkhälsoarbete (Studentlitteratur)

Elinder LS, Kwak L (eds)

Food and nutrition. In: J. Mackenbach and M. McKee (eds). Successes and failures of health policy in Europe over four decades. Open University Press McGraw Hill - Education; 2013.

Elinder LS, Bollars C

”Sverige behöver nationell strategi för nutrition och fysisk aktivitet (Debattartikel i Läkartidningen)” 

 Elinder LS, Patterson E, Nyberg G, Säfsten E, Sundblom E

Hur kan vi jobba mer evidensbaserat med att främja hälsosamma matvanor i framtiden? Nordisk Nutrition nr 1, 2016.

Elinder LS

Insatser för att främja hälsosamma matvanor och fysisk aktivitet – en kartläggande översikt över systematiska kunskapsöversikter (Promotion of healthy dietary habits and physical activity – a review of systematic reviews and Nordic primary studies). Karolinska Institutet, 2017.
Bilaga 1
Bilaga 2
Bilaga 3

Bergström H, Rahman S, Lynch C, Elinder LS

Global region of birth is an independent risk factor for type 2 diabetes in Stockholm, Sweden. European Journal of Public Health

Elinder LS, Hakimi S, Lager A, Patterson E

Group members

Mathias AhlqvistResearch assistant
Susanne AndermoPostdoc
Helena BergströmAssociated
Patricia Eustachio ColomboPhD student, Graduate Student
Karin KjellenbergResearch assistant
Mahnoush MalekR&D trainee
Åsa NormanPostdoc
Gisela NybergAssociated
Emma PattersonAssociated
Ylva RodvallAssociated
Liselotte Schäfer ElinderAdjunct professor
My SjunnestrandResearch assistant

Contact

Research group leader

Adjunct professor

Liselotte Schäfer Elinder

Phone: +46-(0)72-526 69 91
Organizational unit: Social Medicin
E-mail: Liselotte.Schafer-Elinder@ki.se

NutritionObesityPhysical activityPublic HealthSocial Medicine