‘Fat but fit’ – Lessons in the language of a press release

This week a paper from the EPIC-CVD which I co-authored was published in the European Heart Journal. Unfortunately the article was subsequently promoted in the press with the headline ‘Fat but fit’ still risk heart disease, encouraging a belief that physical activity offers no heart health benefit to those that are overweight.

This headline is misleading because most people understand ‘fit’ to mean physically activity, however the paper didn’t measure physical fitness. Instead it measured metabolic health (ie, high blood pressure, cholesterol and blood glucose) which some term ‘medical fitness’, and is often shortened to ‘fitness’. Hence the confusion.

What the paper really shows is that being overweight and having poor metabolic health both contribute to increasing risk of coronary heart disease (CHD), or a heart attack, to put it more simply. If you group people based on their weight status and metabolic health then the risk of having a heart attack increases in the following order:

 

 

 

 

 

 

To provide some context to these numbers, we know that having a heart attack is more common in older people – that risk increases with age by about 10% per year. Being overweight and healthy notionally makes you 2 ½ years older (in terms of heart disease risk) than a normal weight and healthy person. Whilst being obese and unhealthy notionally makes you 15 ½ years older!

My take home message from these figures is that having poor metabolic health is much worse than being overweight or obese on its own; however people carrying excess weight still don’t get off scot-free. So, if you can improve your metabolic health (whether you are normal weight or overweight or obese) you can substantially reduce your risk of CHD. Equally if you can reduce your weight (whether you have good or bad metabolic health) you can reduce the likelihood of a heart attack even further.

What about being fit, ‘physically active’ fit?  

If you are overweight and are physically active then this will more than likely be good for your health – we know that physical activity has beneficial effects on metabolic health. The long-standing fat-fit hypothesis states that the health benefits of being physically active can cancel out the increased risk of being overweight, so it’s possible to live just as long if you are fat as long as you are fit. Does our work say anything about that idea? Not really, not without a lot of inference and assumptions. You’d need a study of physical fitness and weight and metabolic health to get to the bottom of that one (a study like this).

What is apparent from this analysis is that grouping people based on continuous measures of health is spurious. If you look at the ‘apparently healthy’ overweight or obese group you’ll see that their blood pressure, cholesterol, blood glucose, etc are actually still higher than the supposedly equally healthy normal weight group. To me this suggests that metabolically healthy obesity doesn’t really exist, not long-term. The people in the healthy obese group just didn’t quite meet the cut-offs for being defined as ‘unhealthy’ yet, suggesting it’s only a matter of time before they cross over to the unhealthy group.

So what’s the point of putting people in boxes, we are all individuals after all, with our own unique profile of risk factors. I’d say let’s try and keep continuous risk factors continuous and aim for lowering them across the whole range using whatever methods have been shown to work in the past. Physical activity and diet can both help in different ways, to either improve metabolic health or promote weight loss, so aiming for a healthier lifestyle is as important as it ever was.

This blog was written by Dr Laura Johnson, a Lecturer in Public Health Nutrition in the Centre for Exercise, Nutrition and Health Science, School for Policy Studies.

 

 

 

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Back to school for MyHeart Beat

Dr Laura Johnson, is a Nutritional Epidemiologist and Senior Lecturer in Public Health Nutrition. Her research focuses on establishing the role of overall dietary and eating patterns in the prevention and treatment of obesity, diabetes and coronary heart disease as well as understanding the factors that influence food intake and appetite control. In this blog, she reflects on a recent visit to Malaysia to research adolescent lifestyle in conjunction with the MyHeart Beat project.

In April, this year I went back to school, some things were just the same as I remembered but others were very different, mainly because I was in school in Malaysia. I had found myself in Kuala Lumpur for work and I was visiting schools to find out exactly how big a task we had taken on for our new collaborative research project MyHeart Beat (Malaysian Health and Adolescents longitudinal Research Team Behavioural Epidemiology and Trial).

MyHeart Beat is funded by the UK Medical Research Council and Academy of Sciences Malaysia (Newton Ungku Omar Fund). The project aims to explore how changes to diet and physical activity could improve heart health in Malaysian adolescents. It’s a collaboration between researchers in the University of Bristol’s Centre for Exercise, Nutrition and Health Sciences and the University of Malaya’s Faculty of Medicine. Our aim is to find ways for Malaysian teens to be more active and eat better, which will help them in the future to avoid obesity, type 2 diabetes, and cardiovascular disease, chronic conditions that are affecting ever increasing numbers of people in Malaysia.

MyHeart Beat builds on MyHearts (Malaysian Health and Adolescents longitudinal Research Team study) an excellent project by researchers at the University of Malaya, in collaboration with researchers from Queen’s University of Belfast, who have spent the last 5 years following more than 1000 teenagers from the age of 13 to 17 years in 3 Malaysian states. MyHearts has collected detailed information on diet, activity, lifestyle and health and has shown that 15% of adolescents are overweight and a further 9% are obese. Physical inactivity is rife (64% of teens are inactive) and breakfast habits are erratic (25% of teens never or only occasionally eat breakfast). We’re planning more analyses of this rich data to find out about the patterns of behaviour related to obesity and heart health.

I’ve previously explored patterns of food intake associated with obesity and shown that it’s a combination of high-fat, low fibre and energy density that is important rather than any single aspect of diet. Key foods part of an obesogenic dietary pattern in the UK include fruits, vegetables, and high-fibre bread (not eating enough of them) and white bread, crisps, sweets, and processed meat (eating too much of them). We expect the most common foods eaten in Malaysia to be different to the UK but in principle whatever foods there that make a diet energy dense, low in fibre and high in fat are still likely to be those most important for preventing obesity. In MyHeart Beat we will apply the same method for finding patterns of behaviour (reduced rank regression, RRR). RRR is a statistical technique that, for dietary patterns, adds up intakes of all foods after giving some foods more emphasis than other (by giving pattern loadings). RRR works out how much emphasis to give different foods by trying lots of options until it settles on the one where foods are combined in such a way that the energy density, fibre and fat content of the whole diet can be predicted best. You end up with pattern loadings (numbers) for each food and the larger the loading the more important that food is for predicting the obesogenic features of diet. Using the loadings, it’s then possible to rank foods in order of importance and identify exactly what foods to change to make diets less likely to lead to obesity. With our analyses, we hope to find out not only what the most important foods are but also what activities are best for maintaining health throughout adolescence. Once we know what the high-risk behaviours are we can start working out ways to help teenagers to change.

Although, even when you know what to change you then have the task of working out how to change it. There are many different routes we can take to change behaviour; the sheer number of options can be challenging but is also what makes the project fascinating. The MyHeart Beat team has lots of experience trying to change behaviour in children in the UK, Europe and Malaysia. For changing diet we’ve attempted intensive programs led by dietitians as well as computer based courses supervised by teachers. Innovative strategies we’ve tried for increasing physical activity have included after school clubs led by teaching assistants; dance workshops and harnessing the power of social networks to spread positive physical activity messages. In Malaysia, the MyBFF@school program (My Body is Fit and Fabulous) has been designed specifically to help overweight and obese adolescents control their weight and provides a valuable platform on which to build a broader program that could help all adolescents stay healthy.

A starting point for designing an intervention is simple logistics. What is even possible to change within Malaysian schools? So that’s what brought me to Kuala Lumpur, to visit schools and see for myself how life works for adolescents at school over there. I realised that the biggest difference compared with my school in the UK was the timing. In Malaysia, school starts at 7 am and ends at 1 pm, break time is for 20 minutes between 0930-1030 (depending on which year you are in) and this is the time when the cafeteria is open for hot meals and cold drinks.

The school canteen offers lots of fried and sweet snacks like burgers, sausages, chicken and samosas, not so different to school food I remember. But more traditional meals, made of rice, noodles, eggs, fish or meat with sauce, were also for sale.

Some schools had fruit snacks suggesting it may be possible to alter the range of foods available. There were vats of ice-cold drinks like fruit squash and Milo and iced tea, all sugar-sweetened. Water wasn’t freely accessible but water bottles were sometimes brought in from home.

Touring the rest of the school, I saw that there were plenty of spaces for physical activity, a school gym, hall, basketball courts and a playing field. But the heat was high as was the humidity, I was sweating just standing still! I had no desire to be physically active in those conditions, which made me wonder what the kids thought about that.    

That leads me back to what MyHeart Beat aims to do in the next 18 months. We plan to find out what staff and students think about different options for changing diet and activities – because ultimately it’s the people whose behaviour you are trying to change that know best what will work for them. We’re also aware of some local initiatives by state nutrition divisions starting this year to make improvements to the school food supply e.g. in Perak, parents/teachers are asked to report if the canteen is selling unhealthy food. To find out more about what the adolescents, teachers and Ministry of Education officials think about what can and should change, we’re planning some interviews and focus groups to ask them directly. From this we’ll work out the options that will be most feasible for changing. Then we’ll develop an intervention (set of changes) that we hope will improve diet and physical activity and ultimately cardiovascular and metabolic health. Our approach follows the UK Medical Research Council (MRC) recommendations for designing interventions. We hope that by building on a strong evidence base and crucially talking to the local people, we’ll ensure the intervention we design will be a success.

Towards the end of 2018 we’ll be taking our intervention out to some schools to test it out. This small pilot project is the ultimate aim of all of the different parts of the project and will tell us if the plans we’ve made will work in practice. I’m looking forward to visiting Malaysia again at that stage, and getting some more fabulous hospitality from the MyHeart Beat researchers over there!

To Shooka, Shafina and Fadzrel, Terima Kasih (Thank You) for having me.

 

 

 

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If all the evidence points to a Mediterranean diet… Why do UK Dietary Guidelines insist on a low-fat diet?

Dr Angeliki Papadaki, Lecturer in Public Health Nutrition at the Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, argues on the need for UK dietary guidance to loosen the low-fat advice and embrace higher-fat but healthier dietary patterns, like the Mediterranean diet.

olive-oil-photoI come from Crete. I grew up in a house where everything revolved around the kitchen. Most of my childhood memories involve my mother preparing meals from scratch, using olive oil. Meals were accompanied with vegetables and we had a legume soup (like lentils, beans, chickpeas) twice a week. All of them were a pleasure to eat; they just needed olive oil and a slice of bread to scoop up the juices to receive a cook’s highest reward: empty plates.

I’ve lived in the UK for 10 years and I still can’t enjoy vegetables or salad unless I prepare them myself. They are boiled and boring, with uninspiring dressings, and no tomato sauce or sautéing with olive oil and onions to give them some flavour. It’s no wonder that 70% of adults in the UK do not eat enough fruits and vegetables and that on average they consume 14g of legumes a day (half the amount consumed in the traditional diet of Crete).

The argument that olive oil, as one of the most important Mediterranean diet foods, helps the consumption of higher amounts of vegetables and legumes is not new. Yet UK dietary guidance has a long tradition of recommending a low-fat diet. Up to recently, the Eatwell Plate recommended to “eat just a small amount of foods high in fat” and made only one reference to olive oil: “When you’re cooking, use just a small bit of unsaturated oil such as sunflower, rapeseed or olive, rather than butter, lard or ghee”.greek-salad-photo

Granted, the revised Eatwell Guide differentiates unsaturated oils from other high-fat foods, but still emphasises that these foods “should be limited in the diet”, without defining this limit. Again, olive oil comes third in line, after vegetable and rapeseed oil. To contrast this, the Mediterranean diet recommendations suggest that olive oil should be the main source of fat in the diet and used in every main meal. A recent randomised controlled study showed that for each 10 g/day increase in extra-virgin olive oil consumption, cardiovascular disease incidence and mortality decrease by 10% and 7%.

The concern about moving from a low-fat diet recommendation to a higher-fat one (even with the ‘right’ fats) might come from fear of promoting obesity. Yet, despite the advice to limit fats, more than half adults in the UK are overweight or obese. At the same time, diabetes is on the increase and heart disease is one of the most common causes of death. In contrast, and despite its higher fat content, the Mediterranean diet does not cause weight gain, and even if some heart disease risk factors are higher in Mediterranean countries, actual diagnosis of the disease is lower than in the UK. High-fat diets were recently shown to improve risk factors for heart disease among people with diabetes, compared to low-fat diets. The Spanish landmark PREDIMED study also recently showed that following a Mediterranean diet, with high amounts of olive oil (≥4 tablespoons recommended every day), reduces risk of cardiovascular events by 30%, compared to a low-fat diet usually recommended for the prevention of cardiovascular disease.

Traditional Greek dip tzatziki

The EU recently invited its Member States to “promote healthy eating, emphasising health promoting diets, such as the Mediterranean diet”. The US Dietary Guidelines have also recently recommended the Mediterranean diet as an example of a healthy eating pattern. The National Institute for Health and Care Excellence, after reviewing the evidence for its draft public health guideline on maintaining a healthy weight, recommended to “follow the principles of a Mediterranean diet, which is a diet predominantly based on vegetables, fruits, beans and pulses, wholegrains, fish and using olive oil instead of other fats”. After review by the Public Health Advisory Committee however, this recommendation was not included in the final guidance, exposing a resistance of UK experts to the Mediterranean diet recommendations.

Yet we know that the Mediterranean diet is tastier and easier to comply with compared to a low-fat diet. We know that, with appropriate nutrition education, it can be transferable to Western populations. Perhaps we need to show its effect on health through randomised controlled trials in the UK before we see UK dietary guidance embrace its recommendations, similar to what our US counterparts did.

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Growing the conversation: how to make Bristol a Child Friendly city

Close up of little boy in canvas shoes drawing with chalks on the sidewalk

Debbie Watson reports as The Bristol ‘Child Friendly City’ Network ran the first Child Friendly Symposium as part of the 2015 Thinking Futures festival.

Inspired by global UNICEF guidelines, the Child Friendly City’s Network aim is to bring together a wide range of partners to campaign strategically and deliver grass roots projects that support child friendly environments. The Child Friendly Symposium brought together around 20 children and young people, as well as 80 adults who worked for and with this demographic, from all over Bristol.

Mayor George Ferguson opened the event and emphasised the need for cities to actively consider children and young people, whether in urban planning decisions, allocation of community resources or in the respect afforded to our youngest citizens. He said: “A child-friendly city is a healthy, happy, liveable and playable city”.

The symposium then saw short presentations delivered by Bristol academics: Dr Angie Page on children’s activity levels and public health outcomes; Dr Helen Manchester on a project which explored young people’s cultural engagement in Bristol; and Dr Debbie Watson on a project which co-developed research capability and awareness with Room13 Hareclive children and artists.

But the main event saw child-led participatory activity to engage adults in the room. Together they made creative banners, highlighting what needs to change in Bristol for it to be truly child friendly. These banners were then showcased, sharing many powerful and provocative messages.

Giving young people from Room 13 Hareclive, Hartcliffe and Felix Road Adventure Playground, Easton, a contributing role in the symposium was an important statement of intent. Harnessing this potential is what Child Friendly Cities (CFC) are all about, holding true to the principle that ‘if a city is successful for children it will be successful for all people’.

“The Thinking Futures Bristol Child Friendly City Symposium was a great opportunity for us to bring together representatives from different backgrounds in the city to share an equal platform: children and young people, academics, organisations working with children and young people, arts and cultural organisations, Bristol’s mayor and Bristol City Council officers.”

We heard compelling arguments from different perspectives – research, local government and children themselves – about why it’s so important for Bristol to be more child friendly. Children and adults identified key calls for change in the city such as ‘free bus travel for children’, ‘safer streets’ and ‘believe and trust in us’, which we all endorsed. It was good to see children and young people, many of them from more disconnected parts of Bristol, sharing thoughts and ideas with academics and practitioners, and vice versa.

This event in partnership with the University of Bristol really helped to raise the profile of Bristol CFC and to consolidate and move on our agenda within the city. We’re excited by the possibility of further collaborative work with academics.” – the Child Friendly City network.

The event is part of a wider strategy to grow the conversation in Bristol, beyond immediate partners and interested parties. Already, impact can be seen across the city through press releases, media coverage, and new partnerships. Bristol and other cities have already been in touch, with potential collaborations stretching as far as Sweden. In late February these interested parties came together at a seminar hosted by Cardiff University’s Children’s social care research and development centre (CASCADE), opened by Dr Sally Holland, the children’s commissioner for Wales.
Ongoing local campaigning includes: a proposal for research impact funding to tackle one key issue with children in the city; organising a young people’s Mayoral hustings in May; and an international conference hosted in Bristol, for the city to truly lead on child friendly policy and practice.

For more information:

Towards a child-friendly city

The Child Friendly City network consists of University of Bristol academics and grassroots organisations Architecture Centre, Playing Out, and Room13 Hareclive.

Debbie Watson is Reader in Childhood Studies in the Centre for Family Policy and Child Welfare.

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An engaging pilot study: How the PLAN-A study has been built on participant input.

Plan A logoDr Mark Edwards, from the Centre for Exercise, Nutrition and Health Sciences, discusses the value of participant inclusion in project implementation.

Physical activity is a big problem in the UK. We’re not doing enough of it. Lots of evidence suggests that when people are more active they are also healthier, have a greater sense of wellbeing, and help reduce their risk of future disease. So, why isn’t everybody active? This is a difficult question. We could ask why some people still smoke or why we don’t all eat a healthy diet. The potential answers to these questions are complex and multifaceted.

We do know a few things about physical activity however; firstly, females are less active than males at all ages. Secondly, adolescence is a key time when females become less active and the divide between males’ and females’ activity widens; around the beginning of secondary school. Thirdly, when adolescents stop being active, it becomes even more difficult to (re-)engage them. Fourth, being physically active is not a simple as it seems: the choice and ability to be active is wrapped in myriad social and psychological factors.

The PLAN-A team, led by Dr Simon Sebire at the University of Bristol’s Centre for Exercise, Nutrition & Health Sciences, hope to advance our understanding of how we can increase the physical activity of girls during early adolescence. We are testing the feasibility of increasing the activity levels of Year 8 girls (aged 12-13) through a ‘peer-led’ concept that has proved successful in reducing adolescent smoking rates (www.decipher-impact.com/). The basic concept of PLAN-A is: 1) ask all Year 8 girls in a school to nominate who they think are the most influential girls in their year, 2) recruit the top 15% of the girls nominated to attend a training course to be a peer-supporter, 3) train peer-supporters to recognise the importance of being active, how they can overcome barriers commonly faced by teenage girls and incorporate more activity into their friends’ lives, and how to communicate effectively, and 4) send the girls  back to their peer groups to informally encourage their peers to be more active.

A central belief that underpins PLAN-A is that the people taking part – the girls whose behaviour we are trying to change and, to a lesser extent, the trainers who will train the girls – are best placed to know what will work for them. Despite having a diverse range of experience in our team, we are not Year 8 girls, and as such can only go so far to develop an educational experience that meets their expectations. If the PLAN-A intervention is to help increase the physical activity levels of Year 8 girls, it needs to reflect what they find important, speak their language, engage and enthuse and inspire them to encourage their friends to be active. As such, we have continuously engaged our “end users” in the design of the PLAN-A study, as can be seen in the following narrative.

Our stakeholder engagement started when the grant application was being written. A group of adolescent girls from the DECIPHer ALPHA (Advise Leading to Public Health Advancement) group took part in a focus group and gave valuable feedback on the design of a peer-led activity intervention. The intervention we designed expressly adhered to the girls’ suggestions that the training should focus on health, vitality and enjoyment. The girls also wanted the training to equip them with practical skills. We took what the girls said and edited the training and recruitment materials in light of this.

Before we conducted the ‘feasibility’ study we wanted to explore the materials and training we had developed in light of the DECIPHer ALPHA group’s suggestions with more year 8 girls. We hoped that this would provide a further opportunity to tailor the intervention to their preferences. A school in Wiltshire kindly allowed us to pilot the whole of the PLAN-A intervention with their Year 8 girls. As such, we tested the recruitment, peer nomination, pupil briefings and training with these girls. The process was interesting, a little reassuring, and hugely constructive. Children can be good critics!

In total we conducted six focus groups with the Year 8 girls. The first two focus groups sought feedback on our proposed peer-supporter recruitment and training materials, including the study logo. We mainly wanted to know if what we were proposing appealed to Year 8 girls. Although we weren’t too far off, we redesigned elements of the intervention and then invited the girls to two more focus groups to check whether we had done what they asked. Following a few more revisions based on their input, we felt we were ready to rehearse the intervention.

We ran a pilot recruitment drive, which entailed a presentation to all Year 8 girls and an information pack for themselves and their parents. This went well and 95.7 % of girls in the year wanted to take part. We then conducted the peer nomination with the year group. This provided the chance to test the nomination process out. Again, this went smoothly and a few days later we invited the girls who had been nominated as peer supporters to a briefing session. As they suggested in the earlier focus groups, the girls were reminded of the kudos of being identified as one of the most influential people in their year group. Of the 14 girls who were nominated, 12 attended the training.

In the meantime we trained our PLAN-A trainers – the two people who would be training the peer supporters. The trainers received a training course (run by study staff) and then delivered the peer supporter training. We had an experienced observer sit in and watch the training to help identify any issues that may not be apparent to the trainers (and to also check that everything flowed as planned). Immediately after the training, we interviewed each trainer and conducted two focus groups with the girls who took part. We wanted a ‘warts and all’ account of their experience with PLAN-A, and that’s what we got!

In general the girls loved the training (and their trainers). The biggest issue was that there was too much writing and not enough moving. The trainers largely agreed with the girls and raised similar issues. We took this feedback and used it to change as many activities as possible to reflect what the girls wanted. We revised the activities and now have a “final” intervention package that targets the intended learning outcomes using much more activity, less writing and sitting, and more role play. We will be delivering the intervention over the next few months and will, once again, seek detailed feedback on how this was received by the people taking part.

 

This project is funded by the National Institute for Health Research [Public Health Research Programme] (project number 13/90/16). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR PHR Programme or the Department of Health.

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Can after-school dance increase physical activity levels in adolescent girls?

Russ Jago, Professor of Paediatric Physical Activity & Public Health, reports some surprising findings from research conducted at the Centre for Exercise, Nutrition, and Health.

dancers1-500x240

Adolescent girls who attend after-school dance classes are no more likely to be physically active than those who don’t. This is one of the key findings from Active 7, a research project that aims to find out whether after-school dance sessions can help adolescent girls to engage in moderate levels of exercise.

Physical activity is associated with improved physical and mental health, but many adolescents – and particularly adolescent girls – do not engage in recommended levels of physical activity.  A team, led by staff in the Centre for Exercise, Health and Nutrition at the School for Policy Studies aimed to address this issue by examining whether providing dance programmes at secondary schools led to increases in girls’ physical activity. The study took place in 18 secondary schools. In half of the schools, Year 7 girls were provided with a new after-school dance programme for 20 weeks. Girls in the other “control” schools carried on as normal.

The results were surprising.  Much academic research suggests dance is an appealing form of physical activity amongst teenage girls, that extra-curricular periods are better suited to delivering physical activity interventions, and that interventions based on psychological theory (as Active7 was) have more success than non-theory based interventions. However, we found no difference between the physical activity levels of the intervention and control group girls at the end of the programme, or 6-months later. We also found that only a third of girls attended at least two thirds of the sessions provided in their school.

Our earlier work had suggested that girls enjoy dance and as such the lack of a difference in the physical activity levels of the girls was surprising. This could be due to the intensity of the dance sessions. The goal of the project was to increase ‘moderate to vigorous physical activity’ (MVPA), which gets you sweaty and slightly out of breath. The results found that girls who attended Active7 only took part in 4.7 more minutes of MVPA on session days, and therefore the sessions may not have been intensive enough to impact on MVPA.  Only one-third of the girls met the attendance criteria of attending two-thirds of the sessions, suggesting there may be a need to consider alternative forms of physical activity. A final and third explanation is methodological; accelerometers may not be able to capture the nuanced movements inherent in dance, especially when preparing for performances. Thus, levels of MVPA in sessions may have been underrepresented.

The results have implications for how we think about delivering after-school physical activity interventions. We might need to move beyond delivering standardised forms of extra-curricular physical activity and instead find more novel forms of exercise that offer lots of different types of physical activity. Fortunately, the findings from Active7 provide us with new ways of thinking about designing interventions. Offering participants with sufficient ‘choice’ in the design of the intervention is one potential method uncovered in our analysis, whilst delivering tailored interventions that meet a diversity of schools was also suggested as a future recommendation from girls and school contacts. Thus, future research which examines how to engage girls in activity and focusses on the types of activities that they would like to attend, when they would like to attend and how to maximise physical activity during those sessions, is needed.

The project was funded by the National Institute for Health Research Public Health Research (NIHR PHR) Programme (project number 11/3050/01). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR PHR Programme or the Department of Health.

This blog post is based on Jago et al 2015: Effect and cost of an after-school dance programme on the physical activity of Year 7 girls: The Bristol Girls Dance Project, a school-based cluster randomised controlled trial, International Journal of Behavioral Nutrition & Physical Activity, 12:128, 2015

 

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