4. Discussion
obesity, sedentary behaviors
OBESITY, CHILDHOOD OBESITY
This study reports the results of a multicomponent educational intervention on the level of PA and sedentary behavior among schoolchildren based upon the use of digital media and face-to-face activities with the schoolchildren and their parents, and the school community in general, along with the use of visual material at school. The results indicate that a reduction in the average exposure to screen time was achieved at the end of the intervention with one year of follow-up. This reduction was more significant in participants whose parents were more involved with the intervention. This could indicate two relevant factors: (1) the importance of involving the families of schoolchildren in educational activities which are aimed at behavioral changes in support of a healthy lifestyle; and (2) once the message has been delivered, behavioral changes leading to a healthy lifestyle can be achieved. Regarding the latter, a multi-component strategy with various communication channels, such as that used in this study, increases the probability of exposure to information promoting a healthy lifestyle. However, the intervention did not show an effect on the minutes/week that schoolchildren spend performing MVPA; perhaps it would be necessary to include the participation of the school so that physical exercise and sports activities can be offered as extracurricular activities as a complement to the educational intervention. Several interventions have been proposed that are aimed at changing the habits related to sedentary behaviors to prevent excess weight and obesity in children. In this study, an intervention with multiple components achieved a decrease in screen exposure time, achieving a reduction of approximately half an hour per day in the IG. This result is consistent with those reported by other authors who found reductions of between 5 and 60 min/d [The present study’s baseline data show that the schoolchildren spent an average of 180 min/d watching screens. There is no currently defined consensus on the maximum period of screen time to which school-age children can be exposed without presenting changes in their health. The American Academy of Pediatrics previously established a recommendation that children older than 2 years should not spend more than 2 h a day in front of screens. Currently, the importance of creating a plan for the use of digital media, personalized for each family, and established according to the characteristics, needs, and values of the family is stressed [In this study, the children performed MVPA 150 min/week on average during follow-up. Therefore, the WHO’s recommendation to perform MVPA for at least 60 min/d [Varied results have been reported regarding the use of digital media as part of educational interventions aimed at changing habits. Knowlden et al. used a web portal to transmit information to mothers and the observed decrease was not significant between groups, even though there was an overall decrease of 27.6 min/d in screen time [In this study, the effect on screen time was observed until the 12 months of follow-up, unlike other community interventions, where the effects on the IG are usually observed earlier and then diminish as follow-up progresses. However, the investigation by Martin et al. found that the effects on the reduction in time in sedentary behaviors were usually still observed at 3 months and could be continued up to 12 months in interventions aimed at adults [Having observed different behaviors in the variables of interest, MVPA and time in front of screens, the importance of addressing physical inactivity and sedentary lifestyle independently is confirmed [Among the strengths of this study is the proposal of a practical strategy to implement an educational intervention conducted in primary schools which involves both children and parents. It is feasible to implement the different means of communication used in the strategy on a larger scale. The results presented reflect the 12-month follow-up, while most studies report shorter follow-up times [Despite the afore mentioned, this study has certain limitations. An individual randomization process was not performed, as randomization was performed by school. Contacting participants within the schools did not make randomization feasible without contamination of the study groups. Additionally, measuring the variables of interest through a questionnaire may not correctly reflect the sedentary activities and PA of participants and resulting data are susceptible to information and memory bias. Social stigmatization of physical inactivity may also have caused an underestimation of screen time or an overestimation of PA because of what is considered as more appropriate behavior. Other weaknesses of the study include the high percentage of losses to follow-up (50%), which is one of the disadvantages of follow-up studies; however, the main losses were due to the fact that the participants did not return the questionnaire that the children took to their parents to answer, and they had to return it to the schools and give it to the researchers. In addition, other sedentary behaviors apart from screen time were not considered. Furthermore, the outcome measurements and exposure to the intervention were reported by the parents and not through reports by the children themselves, which is made difficult by age. Young children usually have trouble quantifying the timeframe of their activities and recalling them objectively [Due to the afore mentioned, continued research efforts are required to improve the educational strategies that impact risk behaviors which lead to childhood excess weight and obesity. These investigations should consider more objective parameters for measuring PA and sedentary lifestyle (e.g., accelerometers, inclinometers, pedometers, etc.). Studies that assess the impact of these educational strategies on a larger scale and include the measurement of long-term effects are also needed. Cost-effectiveness studies need to be conducted and evaluated in other cultural, socioeconomic, and geographic contexts. Finally, it is important to mention that, although this study took place several years ago, this type of intervention is especially relevant in the current times, when the recent pandemic caused important modifications in the lifestyles of both young and old people around the world, shifting many work and recreational activities into more sedentary alternatives and significantly increasing time spent in front of screens. Due to the significant increase in sedentary behaviors and the increase in the prevalence of childhood obesity, it is necessary to carry out research on interventions aimed at promoting more active and healthy lifestyles. Further research is needed to constantly update data concerning the physical activity of school-age children, adolescents, and adults and the sedentary behavior of these groups, as well as the use of digital media to perform physical activity, such as on-line recorded or live classes, the use of applications with plans structured for physical activity, applications to measure and intervene in times of sedentary lifestyle, to have active pauses in activities in school or at work, etc., in order to update the information to generate or adapt different interventions for specific populations.