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The urban environment has been criticized for promoting 'nature-deficit' and 'child-nature disconnectedness'. Keeping in mind the importance of nature exposure and its extensive health benefits, many environmental programs around the world hope to (re)connect children with nature. To evaluate the effectiveness of such efforts, valid tools to measure Connectedness to Nature (CN) are needed but do not exist today, especially for use with pre-schoolers. The original CN Index was modified and tested among the Parents of Preschool Children (CNI-PPC) in an urban setting (Hong Kong) for its internal consistency (n = 299) and external validity (n = 194). The 'Strength and Difficulties Questionnaire' (SDQ) was chosen for divergent and convergent analysis. Conventional recommendations for test adaptation and translation were used. Confirmatory factor analysis (CFA) revealed that the 16-item scale adequately captured four major dimensions: enjoyment of nature, empathy for nature, responsibility toward nature, and awareness of nature (Cronbach's α were respectively .86, .87, .75 and .80). When tested against the SDQ, a validated measure for child psychological functioning, and identification of children's problem behaviours, three CNI-PPC factors influenced the SDQ outcomes: (1) the more enjoyment of nature children displayed the less overall distress and impairment they exhibited (β = -.64); (2) greater responsibility toward nature in children was associated with less hyperactivity (β = -.50), fewer behavioural and peer difficulties (β = -.62 and β = -.65 respectively) and improved prosocial behaviour (β = .77); (3) the more aware children were of nature, the less emotional difficulties they exhibited (β = -.51). The variance explained was large (range R2 = .42 to .80). Thus, CNI-PPC factors have meaningful and substantive associations with the strengths and difficulties parents perceive in their children. This indicates that the CNI-PPC is a valid and reliable instrument to measure CN at an age when children cannot respond for themselves. Further, this simple tool can help researchers/practitioners to better understand how connectedness to nature affects child psychological functioning and wellbeing. ClinicalTrials.gov Identifier: NCT02715544. Registered 8 March 2016.

Due to rapid urbanization, children today have fewer opportunities to interact with nature and this may result in a greater risk for developing stress and depression. Outdoor nature-related activities can enhance general well-being. However, the underlying mechanisms are not fully delineated. Here we recruited 54 preschool children to participate in a 10-week structured nature-related “Play&Grow” program. Following the intervention, children were assessed for connectedness to nature and perceived stress levels using validated questionnaires. Moreover, fecal serotonin level and gut microbiota profiles were measured by ELISA and 16S rDNA amplicon sequencing, respectively. Children were significantly more connected to nature after the intervention. Their gut microbiota altered, especially by modulating the abundance of Roseburia and the fecal-serotonin level. Moreover, we also observed a reduction in the overall perceived stress, particularly in the frequency of anger among these children. This study is the first to demonstrate the impact of nature-related activities on gut microbiota, fecal serotonin and psychosocial behaviour of preschool children. However, further mechanistic studies are needed to confirm the functional role of gut microbiota in the association between connectedness to nature and improved psychosocial behavior.

Background The Children's Eating Behaviour Questionnaire (CEBQ) is a multi-dimensional, parent-reported questionnaire measuring children's eating behaviours related to obesity risk, i.e. 'enjoyment of food', 'food responsiveness', 'slowness in eating' and 'satiety responsiveness'. It has not previously been validated in a Swedish population, neither on children under the age of 2 years. In the present study we examined the factor structure and the reliability of the Swedish version of the CEBQ, for use in an obesity intervention programme targeting preschool children 1-6 years. Further, the associations between eating behaviours and children's age, gender and relative weight (BMI SDS) and parental weight were investigated. Methods Parents to 174 children aged 1-6 years (50% girls, mean age 3.8 years), recruited from five kindergartens in Stockholm, completed the Swedish version of the CEBQ. Data on children's weight and height, parental weight, height and educational level was collected. Children's relative weight was calculated for a subpopulation (mean BMI SDS -0.4, n = 47). Factorial validation (Principal Component Analysis) on all CEBQ items was performed. Differences in eating behaviours by age, gender and parental weight were examined. Correlations between eating behaviours and the child's BMI SDS were analysed controlling for age, gender, parental weight and education in linear regression analyses. Results The factor analysis revealed a seven factor solution with good psychometric properties, similar to the original structure. The behaviour scales 'overeating'/'food responsiveness', 'enjoyment of food' and 'emotional undereating' decreased with age and 'food fussiness' increased with age. Eating behaviours did not differ between girls and boys. The children's relative weight was not related to any of the eating behaviours when controlling for age, gender, parental weight and education, and only associated with parental weight status. Conclusions Our results support the use of the CEBQ as a psychometric instrument for assessing children's eating behaviours in Swedish children aged 1-6 years. Measuring obesity related eating behaviours in longitudinal and interventional studies would offer opportunities for studying causal effects of eating behaviours in the development of obesity in children.

Background Promotion of healthy lifestyles in children focuses predominantly on proper nutrition and physical activity, elements now widely recognised as essential for a healthy life. Systematic reviews have shown that nature-related activities also enhance general well-being as reflected in increased physical activity, a healthier diet, reduced stress and better sleep. Recent research suggests that many young children in Hong Kong between the ages of two and four in Hong Kong are more sedentary than recommended and seldom participate in active play, placing them at risk of becoming overweight or obese. The proposed project aims to investigate whether connecting families to nature positively influences physical activity (i.e., active playtime) and healthy eating routines in children aged 2 to 4. Methods We recently conducted a pilot study in Hong Kong to develop a programme, Play & Grow, based on the most successful evidence-based international preschool interventions. In addition to adopting the healthy eating and physical activity elements of these interventions, this project will additionally include a third novel element of Connectedness to nature: discovering nature through games and awareness of sounds, touch, smells, and temperature. To test the effectiveness of this modified intervention, a randomised controlled trial (RCT) involving 240 families with children aged 2 to 4 will be conducted. Families and children will take part in weekly one-hour activity sessions for 10-weeks. Lifestyle-related habits will be assessed before and immediately after the 10-week intervention, with follow up testing at 6 and 12 months’ post intervention. Discussion A novel measuring tool created specifically for assessing Connectedness to nature, Nature Relatedness Scale (NRS), will be validated and tested for reliability prior to the RCT. The results of the RCT are intended to be used to understand which components of the intervention are most effective. The objectives of this project will be achieved over a 30-month period and will contribute to the research that examines key components of successful healthy lifestyle promotion programmes during early childhood. We predict that the inclusion of Connectedness to nature will significantly improve recognised preschool interventions. Finally, the aim of targeting family involvement will hopefully increase the sustainability of longer-term lifestyle modifications in children. Trial registration ClinicalTrials.gov, NCT02715544 . Registered 22 March 2016

A “proof-of-concept” study to examine the feasibility of wearing an Actigraph GT3X+ at the Chest (resembling a neck pendant) for physical activity measurement. A convenience sample of 45 healthy adults (23 male, mean age 20.0±4.5 years) was included in data analysis. Participants simultaneously wore three GT3X+ accelerometers, on the Waist, Wrist, and Chest and completed 8 bouts of slow (.67, .89, 1.11m/s), average (1.33, 1.56, 1.78m/s) and fast (2.00, 2.22m/s) walking on a treadmill. Paired t-test, correlations and absolute percentage errors (APE) of accelerometer output (vector magnitude, VM) were computed for the key pairs: Waist–Wrist; and Waist–Chest. The Wrist-site overestimated VM to a greater extent at all speeds in comparison to the Chest. Pearson's r correlations were weaker for Waist–Wrist (<.80) in comparison to the Waist–Chest (>.85). The APE's were much lower (i.e. higher agreement) for the Chest (9.23–15.5%) compared to the Wrist (19.7–54.9%). Participants also felt the Chest-site was more acceptable than the Waist-site. PA measurements recorded by a Chest worn GT3X+ more closely resembled PA measurements recorded at the traditional Waist site than when compared to the Wrist site. When combined with high Chest site preference, the findings of our study suggest that the Chest is a feasible site for accelerometer wear.

Background Eating behaviours have been suggested relating to obesity development. The Children's Eating Behaviour Questionnaire (CEBQ) is a parent-report measure constructed to assess multiple dimensions of eating behavior for children. This study aimed to test the validity of the Chinese version of Children's Eating Behaviour Questionnaire (CEBQ) in Chinese children aged 12-18 months. We examined factor structure and the reliability of the Chinese version of the CEBQ, the associations between children's eating behaviours and children's weight (BMI SDS) were assessed. Methods 219 questionnaires were filled out by the caregivers, approached in community health care centers in two cities in China. BMI of each child was calculated and converted to BMI SDS. Factor validation (Principal Component Analysis, exploratory factor analysis) on all CEBQ items was performed and gender difference in eating behaviours was examined. Correlations between eating behaviours and the child's BMI SDS were analyzed by linear regression analysis controlling for gender, parental combined weight, and education. Results The factor analysis revealed a seven-factor solution, with factor 'food responsiveness' (FR) split into two. 'Satiety responsiveness' (SR) and 'Enjoyment of food' (EF) factors were not detected. Interestingly, boys scored higher than girls in the FR scales, whereas girls had a higher score in 'food fussiness' (FF) scale. Conclusions We conclude that although a valuable psychometric instrument, CEBQ might be affected by age and cultural differences. Therefore, adjusting it in order to fit the Chinese population was suggested. We did not find an association between eating behaviours and children's BMI SDS, when it was controlled for gender and parental weight.

Background Overweight and obesity have a dramatic negative impact on children's health not only during the childhood but also throughout the adult life. Preventing the development of obesity in children is therefore a world-wide health priority. There is an obvious urge for sustainable and evidenced-based interventions that are suitable for families with young children, especially for families with overweight or obese parents. We have developed a prevention program, Early STOPP, combating multiple obesity-promoting behaviors such unbalanced diet, physical inactivity and disturbed sleeping patterns. We also aim to evaluate the effectiveness of the early childhood obesity prevention in a well-characterized population of overweight or obese parents. This protocol outlines methods for the recruitment phase of the study. Design and methods This randomized controlled trial (RCT) targets overweight and/or obese parents with infants, recruited from the Child Health Care Centers (CHCC) within the Stockholm area. The intervention starts when infants are one year of age and continues until they are six and is regularly delivered by a trained coach (dietitian, physiotherapist or a nurse). The key aspects of Early STOPP family intervention are based on Swedish recommendations for CHCC, which include advices on healthy food choices and eating patterns, increasing physical activity/reducing sedentary behavior and regulating sleeping patterns. Discussion The Early STOPP trial design addresses weaknesses of previous research by recruiting from a well-characterized population, defining a feasible, theory-based intervention and assessing multiple measurements to validate and interpret the program effectiveness. The early years hold promise as a time in which obesity prevention may be most effective. To our knowledge, this longitudinal RCT is the first attempt to demonstrate whether an early, long-term, targeted health promotion program focusing on healthy eating, physical activity/reduced sedentary behaviors and normalizing sleeping patterns could be effective. If proven so, Early STOPP may protect children from the development of overweight and obesity. Trial registration The protocol for this study is registered with the clinical trials registry clinicaltrials.gov, ID: ES-2010)

To provide an update on current practices and policy development status concerning breastfeeding in the WHO European Region. National surveys and studies conducted by national health institutions were prioritized. Sub-national data were included where no national data or studies existed. Information on national breastfeeding policies was collected mainly from the WHO Seventh Meeting of Baby-Friendly Hospital Initiative Coordinators and European Union projects. Owing to the different data sources and methods, any comparisons between countries must be made with caution. WHO European Member States. Data from fifty-three WHO European Member States were investigated; however, a large proportion had not reported any data. Rates of early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding to 1 year all varied considerably within the WHO European Region. Exclusive breastfeeding rates declined considerably after 4 months, and were low in infants under 6 months and at 6 months of age. The majority of the countries with existing data reported having a national infant and young child feeding policy and the establishment of a national committee on breastfeeding or infant and young child feeding. The majority of the countries with existing data reported having baby-friendly hospitals, although the proportion of baby-friendly hospitals to the total number of national hospitals with maternity units was low in most countries. Breastfeeding practices within the WHO European Region, especially exclusive breastfeeding rates, are far from complying with the WHO recommendations. There are marked differences between countries in breastfeeding practices, infant and young child feeding policy adoption and proportion of baby-friendly hospitals.

Objectives Many obesity-related chronic diseases originate from unhealthy childhood habits. The aim of this study was to describe 9-month-old infants’ physical activity levels and patterns and to examine the correlates. Understanding these factors is necessary for improving the effectiveness of physical activity intervention programs for infants. Methods In total, 143 infant–mother dyads from Macau, SAR China, participated in this study. Physical activity (PA) was assessed by using the Actigraph GT3X+ accelerometer and the demographic variables were collected by questionnaires. Results The most important findings were that: (1) infants had more screen time during weekdays (p = .044); (2) infants and mothers were least active at 8 a.m. (both weekdays and weekends) in the morning and most active at 7 p.m. (weekdays) and 8 p.m. (weekends) in the evening; (3) infants’ PA levels significantly correlated with their mothers’ PA intensities during the weekends (r = .192, p = .036), especially the mothers’ lower intensities in the mornings and evenings; (4) maternal BMI predicted the PA levels of the 9-month-old infants’ (R2 = .06, β = 29.188, p = .009). Conclusions for Practice Physical activity promotion programs for infants should be time-specific starting from early infancy. This study was one of the first to examine 9-month-old infants’ PA levels, patterns and correlates. The results may be helpful in improving the effectiveness of future healthy lifestyle intervention programs for infants in Macau and in the region in general.

As global population growth continues, the rapidly increasing demand for food and the environmental impact of this demand is a growing concern. Most food in Hong Kong is imported, which has implications for the associated environmental footprint. The carbon and water footprints (CF and WF) of the average Hong Kong diet were estimated from available sources and compared to well-accepted sustainable diets to characterize environmental sustainability. The total CF was 5701.90 g CO2-eq per capita/day, and the WF was 4782.31 L per capita/day. While meat products contributed only 22% to the weight, they were responsible for 57% and 53% of the total CF and WF, respectively. The impacts of the Hong Kong diet were greater than those of well-accepted sustainable diets, possibly due to the heavy consumption of meat and the import of foods. This confirms an urgency to increase environmental awareness among Hong Kong’s consumers and make interventions toward the adoption of sustainable, plant-based diets.