Impact of a Multicomponent Program on Sleep Duration and Depressive Symptoms in Overweight Adolescents in Schools in the Northeast Brazil

doi:10.21203/rs.3.rs-4271287/v1

The health promotion in our schools represents a tool of great importance for public health, and the development of some intervention actions to promote healthy habits has been encouraged, especially after the COVID-19 pandemic. Therefore, the present study aimed to analyze the effects of a multicomponent intervention on the duration and quality of sleeping, eating disorders and depressive symptoms in obese adolescents from full-time schools in the city of Fortaleza, CE. This cluster is a randomized controlled trial with 127 (50.4% female) adolescents from the 7th to 9th grade in public schools in Fortaleza, Northeast Brazil. After agreement, three schools were randomly selected for intervention or control groups (3 schools in each group), and all eligible students were invited to participate in the study. The "Fortaleça sua saúde" program was carried out during a school year and included three main components: Teacher training (including face-to-face meetings, a social media platform, and a handbook with lesson plans); improvements in the physical activity environment in schools; and educational strategies. The control schools continued with their traditional schedule. Baseline and post-intervention evaluations included: subjective sleep quality, measured by the Pittsburgh Sleep Quality Index; depressive symptoms, assessed by the Population Screening Scale for Depression; and eating disorders, evaluated using the Eating Attitudes Test-26. The results of this study identified an increase in sleep duration among adolescents in the intervention group (7.42 vs. 7.79; p = 0.018) and a significant decrease (13.5 vs. 12.0; p = 0.003) in depressive symptom scores compared to those in the control group (14.0 vs. 12.5; p = 1.00). Additionally, adolescents who participated in the program showed a 2.32 times greater chance (1.01 – 5.40; p = 0.049) of not presenting depressive symptoms. The results of this study suggest that interventions in the scholar environment can lead to an improvement in health indicators among obese adolescents.

The growing prevalence of obesity in children and adolescents was initially identified in the United States in the mid-1970s. Data records from 1967 to 2017, including 9 million children and adolescents, showed an increment of 1.7 in severe obesity prevalence comparing recent periods with earlier periods (2006–2017 and 1967–2007), respectively (Pinhas Hamiel et al., 2022). In Brazil, the Ministry of Health (2021) estimated that 6.4 million children are overweight, and 3.1 million have already progressed to obesity. According to the Global Obesity Atlas and the World Health Organization – WHO, Brazil is projected to be in the 5th position in the ranking of countries with the highest number of obese children and adolescents by 2030 (Lobstein et al., 2022).

Obesity, besides being considered a chronic disease, can exacerbate the development of other physical and mental health conditions, like depression. The global prevalence of depression among adolescents is increasing internationally, with an 18% increase between 2005 and 2015 (Mojtabai et al., 2016). However, the prevalence of depression symptoms (21.73%) in overweight/obese children/adolescents has been significantly higher than in children/adolescents (17.96%) without overweight/non-obese (Wang et al., 2019).

In addition to the increasing prevalence of obesity and depressive symptoms during adolescence, there is a rise in sedentary behavior (Zou et al., 2023; Bridges Hamilton et al., 2023), especially due to the use of cell phones (Sumi et al., 2022; Park et al., 2022; Souza et al., 2020), which, consequently, may contribute to a decrease in sleep hours, also considered a serious health issue (Dutil et al., 2022; Wheaton & Claussen, 2021).

Among the recommendations for preventing obesity, depression, and short sleep duration during adolescence, the multicomponent interventions in the school environment are encouraged (Ilić., 2022; Jebeile et al., 2022; Ahmed et al., 2023). Therefore, the present study aimed to investigate the effects of an intervention on the sleep, depressive symptoms, and eating habits of obese adolescents in the city of Fortaleza, Northeast Brazil.

Study Design and Sample

The present study is a cluster-randomized controlled trial in which schools were the sample selection units. The authorization of the participants’ parents or guardians, through the signing of free and informed consent forms, was a criterion for participation in the research.

This study was carried out in Fortaleza, Northeastern Brazil. All six full-time schools with adolescents enrolled in grades 7–9 and allied to the School Health Program (Programa Saúde na Escola, PSE) were considered eligible for the study. The Programa Saúde na Escola (Federal Decree N^o. 6286) aims to provide comprehensive prevention, health promotion and care for children and adolescents who attend schools in the public education system. Further methodological details of the study, including a description of the sample size estimate and the flowchart of the sample selection, can be found elsewhere [Barbosa Filho et al., 2015].

The schools were randomly allocated to each group, with three in the intervention group and three in the control group. A total of 1272 adolescents (639 in intervention schools and 633 in control schools) were enrolled in grades 7–9 of eligible schools at the beginning of the study. Of these, 125 (9,8%) adolescents were obesity (72 and 53 of the adolescents in the intervention and control schools, respectively)

Description of the Intervention

The full description of the intervention can be observed in previous publications (Barbosa Filho et al., 2015; Barbosa Filho et al., 2016) The intervention was based on socio ecological theory (Bronfenbrenner, 1994) and socio-cognitive theory (Bandura et al., 2004), as well as allied with the concept of Health Promoting Schools (Guedes & Lopes, 2007). The control group schools maintained their regular routine of activities. Strategies regarding the intervention were focused on three components: teacher training, health education environmental changes and Physical Education class more active which are shown in the table 1.

INSERT TABLE 1

Questionnaires and measurements

Sleep Quality

The Pittsburgh Sleep Quality Index - PSQI-BR (Bertolazi et al., 2009) was applied to assess sleep quality, in which scores above 5 were classified as "poor sleep."

Eating Disorders

The Eating Attitudes Test (EAT-26), validated for Portuguese by Bighetti (2003), was adopted. The EAT-26 is a self-report instrument that indicates the presence of abnormal eating patterns. It consists of 26 self-administered questions with six response options: always, very often, often, sometimes, rarely, and never. These questions are related to three aspects: diet - 13 items reflecting a refusal to eat high-calorie foods and concerns about physical appearance; bulimia nervosa - 6 items identifying thoughts about food and bulimic attitudes; oral control - 7 items related to self-control regarding food and recognition of social pressures to gain weight.

The assessment of responses is done using a Likert scale ranging from always (3 points) to often (1 point), with the remaining responses not being scored (sometimes, rarely, and never). An exception is question 4, where the points are reversed, and "sometimes," "rarely," and "never" score 1, 2, and 3 points, respectively. The EAT-26 cutoff point is 21 points, and a score equal to or above that point indicates the possibility of developing an eating attitude disorder.

Depressive Symptoms

A questionnaire consisting of 20 items considered representative of the main symptoms of depression was used to measure these signs in the general population. Individuals rate each item using a frequency scale (0 = rarely, 1 = for a short time, 2 = for a moderate amount of time, or 3 = for most of the time) considering the week before. The score is a simple sum, ranging from 0 to 60, with a cutoff point of 16 points (or higher) typically used to distinguish individuals with a higher likelihood of having depression.

Statistical analysis

For data analysis, initially, the Kolmogorov-Smirnov test was conducted, which did not confirm the normality of the collected data. Descriptive statistics were used in terms of absolute values, percentages, medians, and interquartile range. The comparison of sleep duration, sleep quality scores, eating disorders, and depressive symptoms at the initial and final stages within the groups was performed using the Wilcoxon test. For the comparison between groups at the final stage, the Mann-Whitney test was employed. The relationship between the percentage of adolescents with short sleep duration, poor sleep quality, eating disorders, and depressive symptoms with participation in the intervention was assessed using the Chi-square test. The McNemar test was chosen for within-group and between-group differences at the final stage of the study, considering p < 0.05.

To identify the odds ratio of the studied circumstances (sleep duration, sleep quality, participation in the intervention, and eating disorders) in not presenting depressive symptoms at the end of the intervention, the Odds Ratio (OR) was applied through logistic regression, with a 95% confidence interval. Variables with a p value ≤ 0.05 were considered factors associated with the outcomes. The data were analyzed using IBM SPSS software, version 20.0 (IBM Corp., Armonk, United States).

Ethical approval

The ethics committee of University Federal of Ceará reviewed and approved the study protocol and consent forms. All participants provided written informed consent for the project and subsequent research.

The study sample consisted of 125 obese adolescents, with 72 in the intervention group. The majority were female (50.4%), aged 13 to 14 years (60.0%), and in the 7th grade (60.0%). The characteristics of this population are presented in Table 2. About 69.6% of the subjects had short sleep duration, while 26.4% reported poor sleep quality. On the other hand, 61.3% and 57.4% of them did not have eating disorders and depressive symptoms, respectively. Statistically, there was no significant difference observed between the adolescents in the intervention and control groups for the variables analyzed at baseline (p > 0.05).

INSERT TABLE 2

Figure 1A shows an increase in sleep duration among adolescents in the intervention group (7.42 vs. 7.79; p = 0.018) compared to the control group (7.50 vs. 7.50; p = 0.450). However, at the final stage, there was no difference between the groups (p > 0.05). Figure 1C presents a significant decrease (13.5 vs. 12.0; p = 0.003) in CES-D scores among adolescents in the intervention group compared to those in the control group (14.0 vs. 12.5; p = 1.00). There was no significant difference in sleep quality and eating disorders, as shown in Figure 1 (B and C) (p > 0.05).

INSERT FIGURE 1

Table 3 presents the results of the intervention on the proportion of adolescents with short sleep duration or poor sleep quality, as well as with eating disorders and depressive symptoms. The intervention had a positive impact on reducing the number of individuals showing depressive signs (p = 0.039).

INSERT TABLE 3

Regarding factors associated with depressive symptoms in obese adolescents, the present study found that individuals who participated in the intervention program have a 2.32 (1.01 - 5.40; p = 0.049) higher chance of not presenting these symptoms. It was also found that individuals with longer and better sleep duration, without a diagnosis of eating disorders, have a greater chance of not experiencing the mentioned symptoms, but without significant risks (p > 0.05), as shown in Table 4.

INSERT TABLE 4

This study demonstrates the beneficial effects on sleep duration and depressive symptoms in obese adolescents who participated in a multicomponent school-based intervention. To the best of our knowledge, this is the first study on the impact of a multicomponent intervention regarding sleep duration and depressive symptoms in obese adolescents from the Northeast region of Brazil. Most previous studies in adolescents focused only on exercise as an intervention to reduce sleep-related issues (Mendelson et al., 2015; Santiago et al., 2015; AWAD et al., 2013) or educational actions on sleep (Gruber et al., 2016; Wang et al., 2015; Hendricks et al., 2014; Moseley & Gradisar, 2009), and often these studies did not focus only on obese students.

School-based health promotion is a crucial tool for public health, and the development of multicomponent interventions to promote healthy habits has been encouraged by various international organizations (BRASIL, 2022; CDC, 2019; Okan et al., 2020).

A study conducted in Spain with 121 school adolescents (55 in the intervention group) aimed to investigate the impact of a multicomponent intervention (educational sessions, educational material, and dietary guidance based on the Mediterranean diet) in a school setting over two and a half months. They identified positive effects on dietary behavior and physical activity during the weekend. However, there were no improvements in sleep duration. The authors justified these results based on two hypotheses: the lack of family commitment, as parents can help establish bedtime routines and monitor technology use, as well as the need for a greater emphasis on sleep in the sessions that were conducted (Tapia & Serrano, 2021).

On the other hand, a systematic review aimed at investigating the effects of multicomponent interventions on the sleep of children (0 to 5 years) found an increase in sleep duration among those children who participated in the intervention. It is important to note that most of the interventions involved parents and educational programs (Fangupo et al., 2021).

In contrast, multicomponent interventions in a school setting have not clearly indicated their specific effects on overweight students. This could be because multicomponent school-based studies are still scarce, especially in Brazil (Jacob et al., 2021; Karacabeyle et al., 2018), or interventions are still carried out specifically to reduce sedentary behavior (Zhang et al., 2022), increase physical activity levels (Calcattera; Zucoti, 2022), or make dietary changes (Rose et al., 2021; Morel-Azanza et al., 2019).

Thus, it is believed that the improvements in sleep duration in this study can be attributed to the increase in physical activity in the school environment. In addition to the increase in active activities in physical education classes, toys and balls were made available for use during recess and after lunch. Furthermore, the tasks suggested in physical education classes encouraged physical activity on weekends. This also reinforces the importance of school actions that include obese adolescents alongside non-obese ones, as the literature has already presented the benefits of physical activity on sleep among adolescents, but outside the school environment (Bello et al., 2023).

This intervention had a significant impact on reducing the percentage of adolescents with depressive symptoms. Additionally, in the univariate analysis, an association was observed between participation in the intervention and the absence of depressive symptoms. These results are consistent with the literature (Yu et al., 2022; Mehra et al., 2022; Paul & Usha, 2021; Tejada-Gallardo et al., 2020).

An intervention study conducted in 75 Indian schools (15,832 students) over two years (2015-2016) divided its actions into two groups: a) training a school counselor, and b) training teachers so that they could conduct classes on gender and sexuality, sexually transmitted diseases, and positive relationships for ninth-grade students. In addition, some actions involved the entire school, as well as parents and the community. The authors found an improvement in mental health (a decrease in depressive symptoms) in students, regardless of which group they participated in (Shinde et al., 2020).

In this intervention, in addition to curriculum content aimed at improving lifestyle, the increase in physical activity in the school environment may have contributed to the reduction of depressive symptoms, as the literature indicates physical activity as beneficial for the physical and mental health of obese adolescents (Hale et al., 2021; Recchia et al., 2023; Sluijs et al., 2021). Thus, the use of physical activity in multicomponent school-based interventions is reinforced, as preliminary evidence suggests that school-based interventions provide a feasible means to prevent the worsening of depressive symptoms in youth (Filia et al., 2021).

However, even though physical activity is recommended and environmental changes and inclusion of related content in school-based interventions for the prevention and reduction of mental health problems, designing an intervention can be a complex process. The success of school interventions has been sporadic, perhaps due to the lack of collaboration and contribution from the main stakeholders, students and schools. After all, developing an intervention for young people would require their commitment, which would help to ensure an effective implementation (Neill et al., 2022).

In this study, no effects of the intervention on eating disorders were identified. This may have occurred due to the recommended form of treatment, which includes psychological approaches, including cognitive-behavioral therapy, interpersonal psychotherapy, and dialectical behavior therapy (Mangione et al., 2022). Furthermore, there are few multicomponent school-based studies aiming to reduce eating disorders.

In the present intervention, the nutritional status of adolescents did not change, and these results corroborate the literature (Berria, 2017; Amini et al., 2015). Intervention studies conducted in a school environment that provided only an increase in physical activity levels (Liu et al., 2022), eating habits changes (Raynor et al., 2021), or both simultaneously (Recasens et al., 2019; Wolf et al., 2018) managed to observe a decrease in body mass indices. However, recommendations for the prevention and treatment of childhood and adolescent obesity suggest the commitment of parents, changes in the school environment, nutritional education, and the promotion of long-term physical activity interventions (Denova-Gutiérrez et al., 2023; Tugault-Lafleur et al., 2023; Smit et al., 2023; Jacob et al., 2021) to avoid the need for surgical interventions in early life. It is also important to note the use of digital media in interventions among adolescents due to its greater acceptance and previously identified results (Vilardell-Dávila et al., 2023; Lee et al., 2023).

Among the limitations of this study, it should be mentioned that the subjective assessment of variables through self-report has greater imprecision, especially in the younger population (Alves et al., 2020); however, the use of objective measures was beyond the scope of this study. Additionally, the intervention conducted had a relatively short duration, lasting approximately four months, as well as the post-intervention follow-up period, making it challenging to assess long-term objectives.

Nevertheless, some practical implications for the school context can be suggested based on the development of this study. Implementing strategies that involve different school contexts (classroom, school management) and components (teachers, students, parents) may be essential for promoting health in the young population. Investing in rest areas in full-time schools could be relevant to prevent students from becoming idle. Furthermore, topics related to sleep could be included in the curriculum to provide students with more information about the importance of sleep for their health.

Author Contribution

E.A.S. participated in all stages of the study, including design, planning, analyze the data, implementation and supervision of the program. M.A.M. and T.B.M. have been involved in drafting the manuscript or revising it critically for important intellectual content. P.F.C.B. have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. The final version of the manuscript was approved by all authors.

Acknowledgement

We thank the Municipal Education Department for technical support and authorization to the study execution. We thank all members of the school community (managers, teachers, parents and adolescents) who were involved in this study. We thank the Fortaleça sua Saúde Working Group, which is detailed in a previous publication (http://www.biomedcentral.com/1471-2458/15/1212).

Pinhas-Hamiel, O., Hamiel, U., Bendor, C. D., Bardugo, A., Twig, G., & Cukierman-Yaffe, T. (2022). The global spread of severe obesity in toddlers, children, and adolescents: a systematic review and meta-analysis. Obesity facts, 15(2), 118-134. https://doi.org/10.1159/000521913
Lobstein, T., Brinsden, H., & Neveux, M. (2022). World obesity atlas 2022. Retrieved from https://policycommons.net/artifacts/2266990/world_obesity_atlas_2022_web/3026660/?utm_medium=email&utm_source=transaction on 06 Oct 2023. CID: 20.500.12592/74dsjp.
Mojtabai, R., Olfson, M., & Han, B. (2016). National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics, 138(6). https://doi.org/10.1542/peds.2016-1878
Wang, F., & Boros, S. (2021). The effect of physical activity on sleep quality: a systematic review. European Journal of Physiotherapy, 23(1), 11-18. https://doi.org/10.1080/21679169.2019.1623314
Zou, L., Wang, T., Herold, F., Ludyga, S., Liu, W., Zhang, Y., Healy, S., Zhang, Z., Kuang, J., Taylor, A., Kramer, A. F., Chen, S., Tremblay, M. S., & Hossain, M. M. (2023). Associations between sedentary behavior and negative emotions in adolescents during home confinement: Mediating role of social support and sleep quality. International journal of clinical and health psychology : IJCHP, 23(1), 100337. https://doi.org/10.1016/j.ijchp.2022.100337
Bridges Hamilton, C. N., Ylitalo, K. R., Wende, M. E., Sharkey, J. R., & Umstattd Meyer, M. R. (2023). Depressive Symptoms and Their Longitudinal Impact on Physical Activity and Sedentary Behaviors Among Mexican-Heritage Youth. Family & community health, 10.1097/FCH.0000000000000388. Advance online publication. https://doi.org/10.1097/FCH.0000000000000388
Sumi, Y., Masuda, F., Kadotani, H., & Ozeki, Y. (2022). The prevalence of depression in isolated/idiopathic rapid eye movement sleep behavior disorder: A systematic review and meta-analysis. Sleep medicine reviews, 101684. https://doi.org/10.1016/j.smrv.2022.101684
Park, I. Y., Speer, R., Whitfield, D. L., Kattari, L., Walls, E. N., & Christensen, C. (2022). Predictors of bullying, depression, and suicide attempts among youth: The intersection of race/ethnicity by gender identity. Children and youth services review, 139, 106536. https://doi.org/10.1016/j.childyouth.2022.106536
Souza, E. A. D., Pinto, J. C. B. D. L., & Alves, F. R. (2020). Cell phone use before bedtime: A risk factor for excessive sleepiness in adolescents from military schools. Jornal Brasileiro de Psiquiatria, 69, 111-116. https://doi.org/10.1590/0047-2085000000265
Dutil, C., Podinic, I., Sadler, C. M., da Costa, B. G., Janssen, I., Ross-White, A., Saunders, T. J., Tomasone, J. R., & Chaput, J. P. (2022). Sleep timing and health indicators in children and adolescents: a systematic review. Horaire de sommeil et indicateurs de santé chez les enfants et les adolescents : revue systématique. Health promotion and chronic disease prevention in Canada :research, policy and practice, 42(4), 150–169. https://doi.org/10.24095/hpcdp.42.4.04
Wheaton, A. G., & Claussen, A. H. (2021). Short Sleep Duration Among Infants, Children, and Adolescents Aged 4 Months-17 Years - United States, 2016-2018. MMWR. Morbidity and mortality weekly report, 70(38), 1315–1321. https://doi.org/10.15585/mmwr.mm7038a1
Ilić, A., Rumbak, I., Brečić, R., Barić, I. C., & Bituh, M. (2022). Increasing Fruit and Vegetable Intake of Primary School Children in a Quasi-Randomized Trial: Evaluation of the Three-Year School-Based Multicomponent Intervention. Nutrients, 14(19), 4197. https://doi.org/10.3390/nu14194197
Jebeile, H., Kelly, A. S., O'Malley, G., & Baur, L. A. (2022). Obesity in children and adolescents: epidemiology, causes, assessment, and management. The lancet Diabetes & endocrinology. https://doi.org/10.1016/S2213-8587(22)00047-X
Ahmed, K. R., Horwood, S., & Khan, A. (2023). Effects of a School-Based Physical Activity Intervention on Adolescents’ Mental Health: A Cluster Randomized Controlled Trial. Journal of Physical Activity and Health (published online ahead of print 2023). Retrieved Oct 6, 2023, from https://doi.org/10.1123/jpah.2023-0062
Barbosa Filho, V. C., Lopes, A.daS., Lima, A. B., de Souza, E. A., Gubert, F.doA., Silva, K. S., Vieira, N. F., Trompieri Filho, N., de Araújo, T. S., de Bruin, P. F., Mota, J., & “Fortaleça sua Saúde” Working Group (2015). Rationale and methods of a cluster-randomized controlled trial to promote active and healthy lifestyles among Brazilian students: the "Fortaleça sua Saúde" program. BMC public health, 15, 1212. https://doi.org/10.1186/s12889-015-2543-2
Filho, V. C. B., da Silva, K. S., Mota, J., Beck, C., & da Silva Lopes, A. (2016). A Physical Activity Intervention for Brazilian Students From Low Human Development Index Areas: A Cluster-Randomized Controlled Trial. Journal of Physical Activity and Health, 13(11), 1174-1182. Retrieved Oct 6, 2023, from https://doi.org/10.1123/jpah.2016-0113
Bronfenbrenner, U. (1994). Ecological models of human development. International encyclopedia of education, 3(2), 37-43.
Bandura, A. Health promotion by social cognitive means. Health Educ. Behav. 2004, 31, 143–164.
Guedes, D.P.; Lopes, C.C. Validação da versão brasileira do Youth Risk Behavior Survey 2007. Revista de Saúde Pública 2010
Bertolazi, A. N., Fagondes, S. C., Hoff, L. S., Pedro, V. D., Menna Barreto, S. S., & Johns, M. W. (2009). Portuguese-language version of the Epworth sleepiness scale: validation for use in Brazil. Jornal Brasileiro de Pneumologia, 35, 877-883. https://doi.org/10.1590/S1806-37132009000900009
Bighetti, F. (2003). Tradução e validação do Eating Attitudes Test (EAT-26) em adolescentes do sexo feminino na cidade de Ribeirão Preto-SP (Doctoral dissertation, Universidade de São Paulo).
Mendelson, M., Borowik, A., Michallet, A. S., Perrin, C., Monneret, D., Faure, P., ... & Flore, P. (2016). Sleep quality, sleep duration and physical activity in obese adolescents: effects of exercise training. Pediatric obesity, 11(1), 26-32. https://doi.org/10.1111/ijpo.12015
Santiago, L. D. C. S., Lyra, M. J., Cunha Filho, M., Cruz, P. W. D. S., Santos, M. A. M. D., & Falcão, A. P. S. T. (2015). Effect of a session of strength training on the quality adolescents sleeping. Revista Brasileira de Medicina do Esporte, 21, 148-152. https://doi.org/10.1590/1517-869220152101144430
Awad, K. M., Drescher, A. A., Malhotra, A., & Quan, S. F. (2013). Effects of exercise and nutritional intake on sleep architecture in adolescents. Sleep and Breathing, 17, 117-124. https://doi.org/10.1007/s11325-012-0658-6
Gruber, R., Somerville, G., Bergmame, L., Fontil, L., & Paquin, S. (2016). School-based sleep education program improves sleep and academic performance of school-age children. Sleep medicine, 21, 93-100. https://doi.org/10.1016/j.sleep.2016.01.012
Wang, Y., Cai, L., Wu, Y., Wilson, R. F., Weston, C., Fawole, O., ... & Segal, J. (2015). What childhood obesity prevention programmes work? A systematic review and meta‐analysis. Obesity reviews, 16(7), 547-565 https://doi.org/10.1111/obr.12277
Hendricks, M. C., Ward, C. M., Grodin, L. K., & Slifer, K. J. (2014). Multicomponent cognitive-behavioural intervention to improve sleep in adolescents: a multiple baseline design. Behavioural and Cognitive Psychotherapy, 42(3), 368-373. https://doi.org/10.1017/S1352465813000623
Moseley, L., & Gradisar, M. (2009). Evaluation of a school-based intervention for adolescent sleep problems. Sleep, 32(3), 334-341. https://doi.org/10.1093/sleep/32.3.334
Brasil. Ministério da Saúde. Caderno temático do Programa Saúde na Escola: alimentação saudável e prevenção da obesidade. Brasília, DF: Ministério da Saúde; 2022.
Centers for Disease Control and Prevention. Increasing Physical Education and Physical Activity: A Framework for Schools; 2019
Okan, O., Paakkari, L., & Dadaczynski, K. (2020). Health literacy in schools. State of the Art.
Tapia-Serrano, M. A., Esteban-Cornejo, I., Rodriguez-Ayllon, M., Vaquero-Solís, M., Sánchez-Oliva, D., & Sánchez-Miguel, P. A. (2021). Adherence to the Mediterranean diet and academic performance in adolescents: Does BMI status moderate this association?. Clinical Nutrition, 40(6), 4465-4472. https://doi.org/10.1016/j.clnu.2020.12.036
Fangupo, L. J., Haszard, J. J., Reynolds, A. N., Lucas, A. W., McIntosh, D. R., Richards, R., ... & Taylor, R. W. (2021). Do sleep interventions change sleep duration in children aged 0–5 years? A systematic review and meta-analysis of randomised controlled trials. Sleep Medicine Reviews, 59, 101498. https://doi.org/10.1016/j.smrv.2021.101498
Jacob, C. M., Hardy-Johnson, P. L., Inskip, H. M., Morris, T., Parsons, C. M., Barrett, M., ... & Baird, J. (2021). A systematic review and meta-analysis of school-based interventions with health education to reduce body mass index in adolescents aged 10 to 19 years. International Journal of Behavioral Nutrition and Physical Activity, 18, 1-22. https://doi.org/10.1186/s12966-020-01065-9
Karacabeyli, D., Allender, S., Pinkney, S., & Amed, S. (2018). Evaluation of complex community‐based childhood obesity prevention interventions. Obesity reviews, 19(8), 1080-1092. https://doi.org/10.1111/obr.12689
Zhang, M., Wang, W., Li, M., Sheng, H., & Zhai, Y. (2022). Efficacy of mobile health applications to improve physical activity and sedentary behavior: a systematic review and meta-analysis for physically inactive individuals. International Journal of Environmental Research and Public Health, 19(8), 4905. https://doi.org/10.3390/ijerph19084905
Calcaterra, V., Vandoni, M., Rossi, V., Berardo, C., Grazi, R., Cordaro, E., ... & Zuccotti, G. (2022). Use of physical activity and exercise to reduce inflammation in children and adolescents with obesity. International Journal of Environmental Research and Public Health, 19(11), 6908. https://doi.org/10.3390/ijerph19116908
Rose, K., O'Malley, C., Eskandari, F., Lake, A. A., Brown, L., & Ells, L. J. (2021). The impact of, and views on, school food intervention and policy in young people aged 11–18 years in Europe: a mixed methods systematic review. Obesity Reviews, 22(5), e13186. https://doi.org/10.1111/obr.13186
Morell-Azanza, L., Ojeda-Rodríguez, A., Ochotorena-Elicegui, A., Martín-Calvo, N., Chueca, M., Marti, A., & Julian, A. S. (2019). Changes in objectively measured physical activity after a multidisciplinary lifestyle intervention in children with abdominal obesity: A randomized control trial. BMC pediatrics, 19(1), 1-8. https://doi.org/10.1186/s12887-019-1468-9
Bello, B., Mohammed, J., & Useh, U. (2023). Effectiveness of physical activity programs in enhancing sleep outcomes among adolescents: a systematic review. Sleep and Breathing, 27(2), 431-439. https://doi.org/10.1007/s11325-022-02675-2
Yu, T., Xu, J., Jiang, Y., Hua, H., Zhou, Y., & Guo, X. (2022). School educational models and child mental health among K-12 students: a scoping review. Child and adolescent psychiatry and mental health, 16(1), 1-16. https://doi.org/10.1186/s13034-022-00469-8
Mehra, D., Lakiang, T., Kathuria, N., Kumar, M., Mehra, S., & Sharma, S. (2022, February). Mental health interventions among adolescents in India: a scoping review. In Healthcare (Vol. 10, No. 2, p. 337). MDPI. https://doi.org/10.3390/healthcare10020337
Paul, B., & Usha, K. V. (2021). Effect of a Multicomponent depression prevention Intervention on depressive Symptoms, Anxiety and well-being among adolescents with risk for depression: A Pilot Study. International Journal of Nursing Education and Research, 9(1), 17-23. https://doi.org/ 10.5958/2454-2660.2021.00005.3
Tejada-Gallardo, C., Blasco-Belled, A., Torrelles-Nadal, C., & Alsinet, C. (2020). Effects of school-based multicomponent positive psychology interventions on well-being and distress in adolescents: A systematic review and meta-analysis. Journal of Youth and Adolescence, 49(10), 1943-1960. https://doi.org/10.1007/s10964-020-01289-9
Shinde, S., Weiss, H. A., Khandeparkar, P., Pereira, B., Sharma, A., Gupta, R., ... & Patel, V. (2020). A multicomponent secondary school health promotion intervention and adolescent health: an extension of the SEHER cluster randomised controlled trial in Bihar, India. PLoS medicine, 17(2), e1003021. https://doi.org/10.1186/s13034-022-00469-8
Hale, G. E., Colquhoun, L., Lancastle, D., Lewis, N., & Tyson, P. J. (2021). Physical activity interventions for the mental health and well‐being of adolescents–a systematic review. Child and adolescent mental health, 26(4), 357-368. https://doi.org/10.1111/camh.12485
van Sluijs, E. M., Ekelund, U., Crochemore-Silva, I., Guthold, R., Ha, A., Lubans, D., ... & Katzmarzyk, P. T. (2021). Physical activity behaviours in adolescence: current evidence and opportunities for intervention. The Lancet, 398(10298), 429-442. https://doi.org/10.1016/S0140-6736(21)01259-9
Filia, K., Eastwood, O., Herniman, S., & Badcock, P. (2021). Facilitating improvements in young people’s social relationships to prevent or treat depression: A review of empirically supported interventions. Translational Psychiatry, 11(1), 305. https://doi.org/10.1038/s41398-021-01406-7
Recchia F, Bernal JDK, Fong DY, et al. Physical Activity Interventions to Alleviate Depressive Symptoms in Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Pediatr. 2023;177(2):132–140. https://doi:10.1001/jamapediatrics.2022.5090
Mangione, C. M., Barry, M. J., Nicholson, W. K., Cabana, M., Coker, T. R., Davidson, K. W., ... & US Preventive Services Task Force. (2022). Screening for anxiety in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA, 328(14), 1438-1444. https://doi:10.1001/jama.2022.16936
Berria, J. (2017). Intervenção multicomponente na escola: efeito em indicadores de adiposidade em adolescentes, mediadores e preditores de desistência.
Amini, M., Djazayery, A., Majdzadeh, R., Taghdisi, M. H., & Jazayeri, S. (2015). Effect of school-based interventions to control childhood obesity: a review of reviews. International journal of preventive medicine, 6. https://doi:10.4103/2008-7802.162059
Liu, Z., Gao, P., Gao, A. Y., Lin, Y., Feng, X. X., Zhang, F., ... & Wu, Y. F. (2022). Effectiveness of a multifaceted intervention for prevention of obesity in primary school children in China: a cluster randomized clinical trial. JAMA pediatrics, 176(1), e214375-e214375. https://doi:10.1001/jamapediatrics.2021.4375
Raynor, H. A., Mazzeo, S. E., LaRose, J. G., Adams, E. L., Thornton, L. M., Caccavale, L. J., & Bean, M. K. (2021). Effect of a high-intensity dietary intervention on changes in dietary intake and eating pathology during a multicomponent adolescent obesity intervention. Nutrients, 13(6), 1850. https://doi.org/10.3390/nu13061850
Recasens, M. A., Xicola-Coromina, E., Manresa, J. M., Ullmo, P. A., Jensen, B. B., Franco, R., ... & Llargués, E. (2019). Impact of school-based nutrition and physical activity intervention on body mass index eight years after cessation of randomized controlled trial (AVall study). Clinical nutrition, 38(6), 2592-2598.https://doi.org/10.1016/j.clnu.2018.12.029
Wolf, V. L. W., Samur-San-Martin, J. E., Sousa, S. F. D., Santos, H. D. O., Folmann, A. G., Ribeiro, R. R., & Guerra-Júnior, G. (2018). Efetividade de programas de intervenção para obesidade com base em orientações para escolares adolescentes: revisão sistemática. Revista Paulista de Pediatria, 37, 110-120. https://doi.org/10.1590/1984-0462/;2019;37;1;00015
Denova-Gutiérrez, E., González-Rocha, A., Méndez-Sánchez, L., Araiza-Nava, B., Balderas, N., López, G., ... & Rivera, J. A. (2023). Overview of Systematic Reviews of Health Interventions for the Prevention and Treatment of Overweight and Obesity in Children. Nutrients, 15(3), 773. https://doi.org/10.3390/nu15030773
Tugault-Lafleur, C. N., De-Jongh González, O., Macdonald, J., Bradbury, J., Warshawski, T., Ball, G. D., ... & Mâsse, L. (2023). Efficacy of the Aim2Be Intervention in Changing Lifestyle Behaviors Among Adolescents With Overweight and Obesity: Randomized Controlled Trial. Journal of Medical Internet Research, 25, e38545.https://doi.org/doi:10.2196/38545
Jacob, C. M., Hardy-Johnson, P. L., Inskip, H. M., Morris, T., Parsons, C. M., Barrett, M., ... & Baird, J. (2021). A systematic review and meta-analysis of school-based interventions with health education to reduce body mass index in adolescents aged 10 to 19 years. International Journal of Behavioral Nutrition and Physical Activity, 18, 1-22. https://doi.org/10.1186/s12966-020-01065-9
Smit, M. S., Boelens, M., Mölenberg, F. J., Raat, H., & Jansen, W. (2023). The long‐term effects of primary school‐based obesity prevention interventions in children: A systematic review and meta‐analysis. Pediatric obesity, 18(3), e12997. https://doi.org/10.1111/ijpo.12997
Vilardell-Dávila, A., Martínez-Andrade, G., Klünder-Klünder, M., Miranda-Lora, A. L., Mendoza, E., Flores-Huerta, S., ... & Vilchis-Gil, J. (2023). A Multi-Component Educational Intervention for Addressing Levels of Physical Activity and Sedentary Behaviors of Schoolchildren. International Journal of Environmental Research and Public Health, 20(4), 3003. https://doi.org/ 10.3390/ijerph20043003
Lee, H., Oldewage-Theron, W., & Dawson, J. A. (2023). Effects of a Theory-Based, Multicomponent eHealth Intervention for Obesity Prevention in Young Children from Low-Income Families: A Pilot Randomized Controlled Study. Nutrients, 15(10), 2296. https://doi.org/ 10.3390/nu15102296
Alves, F. R., de Souza, E. A., de França Ferreira, L. G., Neto, J. D. O. V., de Bruin, V. M. S., & de Bruin, P. F. C. (2020). Sleep duration and daytime sleepiness in a large sample of Brazilian high school adolescents. Sleep medicine, 66, 207-215.https://doi.org/10.1016/j.sleep.2019.08.019

Table 1 - Description of the components of the "Fortaleza sua saúde" program

Components

Objectives

Metodology

Target Public

Teacher Training

Develop strategies to combine teaching tools (guided work, tests and assessments, group presentations, among others) with health-related content (physical activity, quality of life, environment and health, among others).

In-person course with a duration of 4 hours;

A manual, was developed, aimed at guiding teachers in the process of integrating the discussion of health topics with elementary school content;

A social media page was created to monitor, assist, and promote activities among the teachers from participating schools in the intervention.

General subjects teachers

Training the Physical Education Teachers

Instruct teachers to structure the Physical Education classes to be predominantly active (with students actively participating for the majority of the total class time).

In-person course with a duration of 4 hours;

A manual with lesson plans and activity proposals was also developed and provided to the teachers. For example, teaching different types of physical activities through relay dynamics.

Physical Education Teachers

School Environment Modifications

Create opportunities for physical activity in the school and encourage its practice throughout the day, while also emphasizing the importance of an active and healthy lifestyle.

Spaces and materials were structured and made available for games and play during school day breaks.

Students

Informational Brochures

Reinforce the content taught in classes and inform parents/family members about health recommendations.

Materials produced in general subjects and in Physical Education classes were displayed on bulletin boards in the courtyard and classrooms so that the school community could view health messages. Distribution of informational brochures about health.

Teachers and students

Table 2 – Characteristics of obese adolescents at baseline according to the group (intervention or control) of the “Fortaleça sua Saúde” program.

Characteristics	Total (n = 125)	Intervention(n=72)	Control (n=53)	p*
Gender
Male	62 (49,6)	36(28,8)	26(20,8)	0,917
Female	63(50,4)	36(28,8)	27(21,6)	0,917
Age (Years)
11 – 12	15(12,0)	11(8,8)	4(3,2)	0,339
13 – 14	75(60,0)	40(32,0)	35(28,0)
> 15	35(28,0)	21(16,8)	14(11,2)
Sleep duration on school days
> 8h	38 (30,4)	22(17,6)	16(12,8)	0,965
< 8h	87 (69,6)	50(40,0)	37(29,6)	0,965
Sleep quality
Good sleep quality	92(73,6)	54(43,2)	38(30,4)	0,679
Bad sleep quality	33(26,4)	18(14,4)	15(12,0)	0,679
Eating Disorders
No eating disorders	65(61,3)	34(32,1)	31(29,2)	0,261
Presenting eating disorders	41(38,7)	26(24,5)	15(14,2)	0,261
Depression Symptoms
No depression symptoms	58(57,4)	36(35,6)	22(21,8)	0,273
Presenting depression symptoms	43(42,6)	22(21,8)	21(20,8)	0,273

* P-values obtained using the chi-square test

Table 3 - Frequency of adolescents with short sleep duration and poor sleep quality, with eating disorders and depressive symptoms before and after the intervention according to the control and intervention groups.

Factors	Intervention			Control
	Start	Final	p*	Start	Final	p*	p**
Short sleep duration	50(69,4)	43(59,7)	0,230	37(69,8)	33(62,8)	0,424	0,774
Bad sleep quality	18(25,0)	13(18,1)	0,267	15(28,3)	11(20,8)	0,424	0,705
Presenting eating disorders	21(38,9)	19(32,5)	0,754	12(28,6)	12(28,6)	1,00	0,593
Presenting depression symptoms	19 (38,0)	12 (24,5)	0,092	20 (51,3)	18 (46,2)	0,754	0,039

* Within-group statistical difference (intervention and control) by the McNemar test

** Statistical difference between the final stages of the groups (intervention and control) by the Chi-square test

Table 4 – Factors associated with depressive symptoms in adolescents participating in the “Fortaleça sua saúde” program before and after the intervention.

	Final
Factors	No depression symptoms (n =75)
Group	OR Raw (CI 95%)	p*	OR adjusted (CI 95%)	p**
Intervention	2,32(1,00 – 5,40)	0,049	2,00 (0,81 – 4,95)	0,132
Sleep Hours
Long duration	1,17 (0,50 – 2,75)	0,711	1,16 (0,42 – 3,21)	0,769
IQSP
Good sleep quality	1,87(0,70 – 4,95)	0,206	2,27 (0,72 – 7,29)	0,165
EAT - 26
No eating disorders	0,45 (0,18 – 1,11)	0,080	2,42 (0,95 – 6,15)	0,062

Odds Ratio – OR Confidence Interval – TR; * p< 0,005 **Analyses adjusted for: sex, age

No competing interests reported.

Impact of a Multicomponent Program on Sleep Duration and Depressive Symptoms in Overweight Adolescents in Schools in the Northeast Brazil

Status:

Version 1

Abstract

Figures

Introduction

Methods

Description of the Intervention

Questionnaires and measurements

Statistical analysis

Ethical approval

Results

Discussion

Declarations

Author Contribution

Acknowledgement

References

Tables

Additional Declarations

Status:

Version 1