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We took four measurements, with a one-minute interval.
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We used the mean of the last three measurements for analyses. Serum was then visually inspected for residues and centrifugation was repeated if residue was present. Serum samples were analyzed for constituents related to traditional risk factors for NCDs, such as insulin, glucose and the standard lipid panel triglycerides, total cholesterol, high density lipoprotein cholesterol HDL and low density lipoprotein cholesterol LDL using standard laboratory methods.
Baseline and post intervention samples were analyzed at the same time in one batch at an ISO certificated laboratory. Analyses of low molecular weight metabolites and lipoprotein distribution was performed for serum samples using proton nuclear magnetic resonance 1H-NMR spectroscopy. The proton NMR profiles of low molecular metabolites fatty acids and amino acids were obtained by using a standard experimental set-up [ 37 ].
For lipoproteins we made a minor modification to the experimental protocol used by Mihaleva et. FAMEs will be extracted and analyzed by gas chromatography as described in Gudbrandsen et al. Chromatographic areas are corrected by empirical response factors calculated from the GLC mixture. The amounts of FAs are thereafter quantified by means of the internal standard. Mode of transport to school, levels of leisure time physical activity, sedentary behavior and psycho-social and environmental correlates of physical activity were assessed with a questionnaire developed for youths also used in a large national representative surveillance study of physical activity among Norwegian children and youth [ 41 , 42 ].
The Kidscreen questionnaire was developed simultaneously in several European countries, and has been validated in Norwegian children aged 10 [ 44 ] and 8—18 [ 45 ] In order to assess well-being at school and predictors for this, we also used the teacher and classmate support scale [ 46 ]. Physical activity preferences were assessed with a questionnaire created by the ASK group. The children rated their preferences for each of 28 different activities on a scale from one to ten. We assessed physical activity habits, physical activity in leisure time and everyday living with a questionnaire developed for adults [ 42 ].
This questionnaire also assessed background variables ethnic background, income, education and job description , as well as psychological, social and environmental determinants of physical activity. More recent studies have identified a item factor that describes child behavioral self-regulation in a classroom setting [ 49 ]. The CBRS is a reliable and valid tool that has been used in multiple studies in Western countries [ 50 , 51 ]. After the intervention period, the teachers from the I-schools were asked to provide a self-report survey evaluation of the ASK intervention.
The purpose was to obtain an in-depth understanding of pedagogical processes taking place in the ASK study. More specifically, we identified purposive sample of classes from two I-schools and two C-schools. All children participated in a drawing and writing task and one group interview. The students were also observed by the researcher during one PE lesson.
We conducted in-depth interviews and field observations including short video recordings with 32 children. Teachers were interviewed individually and in groups and observed; we also interviewed two groups of parents. Data i. Developing in-depth knowledge is an iterative process where preliminary interpretations of the empirical material are brought together with discussions on theoretical significance in increasing detail. Thus our approach differed from a more conventional approach where empirical data are seen as separate from theory, but are used to guide and validate theory development.
In addition, this gives us a basis to discuss the teaching and learning processes, the possible benefits and pitfalls in the intervention, as well as to evaluate whether the intervention and the ASK study as a whole might serve as tools towards creating an improved atmosphere for learning in the schools in the future.
We assessed the extent to which the intervention was implemented dose , the quality of the implementation fidelity , as well as feasibility as perceived by teachers and others. Blinding of children and schools was not possible due to the nature of the experiment. However, only the project management group has formal knowledge of group assignment.
The data manager and statisticians are blinded to group allocation until analyses are conducted. For secondary outcomes we assume an ICC of 0. Accepting the assumptions above, the target sample size allowed us to detect a significant difference between the groups for variables reaching an effect size of 0.
Our main analysis in order to assess the effectiveness of the ASK intervention are based on and intention to treat analysis [ 57 , 58 ]. We also acknowledge the importance of conducting per-protocol analyses to determine efficacy based on schools that showed fidelity to the model and performed the physical activity intervention as intended [ 59 ].
We describe missing data using appropriate flow charts [ 60 ] that also allowed for investigation of missing data mechanisms and assumptions that underpin statistical analyses. Missing data was imputed from all available relevant variables by means of multiple imputation using a Markov Chain Monte Carlo procedure with 20 iterations, with an assumption that data are missing at random.
We performed sensitivity analyses to evaluate the stability of results under various assumptions of missing data. We used a mixed-effects model to test the between-group difference intervention vs. The per-protocol analysis was adjusted for differences between groups as appropriate. We conducted defined moderator-mediator analyses a priori to evaluate characteristics of children and pathways that could influence the effect of the intervention on academic performance.
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We identified potential moderators that include both characteristics of the children and baseline values for specific secondary outcomes. We included change in executive function, motor skills, physical activity, physical fitness, adiposity and other risk factors for lifestyle-related non-communicable diseases in mediation-analyses. We used a similar strategy to evaluate moderators and mediators of secondary outcomes.
For mediation analyses we used structural equation modeling. We also used multivariate linear regression and exploratory analyses [ 61 , 62 ] to evaluate associations between secondary outcomes and academic performance, and to explore associations among independent variables. Importantly, school-based models will be more likely to be sustained if they are anchored and supported by policy within the school system [ 64 ]. We carried out a four-stage plan to achieve this.
This educational forum was established in in Sogn and Fjordane County as an arena to discuss, translate and integrate educational policies regarding school quality and school development. The forum includes professional executives of the most important educational authorities and organizations in the Sogn and Fjordane, and it is highly respected by school administrators and teachers in the county.
We also clearly described the measurement protocol and procedures and addressed any questions. We emphasized that children were free to withdraw from the study or from any measurements at any time, without providing an explanation. Fourth, we carried out an extensive anchoring process with the ASK teachers in the I-schools.
The ASK study adopted a population-based approach that focuses on- and treats all children equally and considerately. Reporting are anonymous and it is not be possible to identify individual participants in any published materials. The school setting offers a unique opportunity for structured physical activity for children; it may well be the ideal environment for population-based physical activity interventions.
Most children and adolescents, aged six to 16, spend most of their day in school. No other institution has possibly as much influence on children during the first two decades of their lives [ 66 ]. As the physical activity is mandatory in the 28 I-schools in the ASK study, all children were involved in a physical activity intervention, and not only the motivated children.
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Additionally, the school offers a safe environment and facilities in an arena designed for learning. This creates an optimal context to support increased physical activity levels of children. A comprehensively designed and appropriately powered RCT of elementary school-based physical activity with a long enough intervention and an adequate dose delivered by trained teachers in order to enhance physical activity of students would provide Level I evidence to support the effectiveness of such models.
High recruitment levels and carefully selected and implemented measures such as objectively measured physical activity also enhance the quality of the ASK study.
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The trial is important for a number of reasons and may have an impact in a number of ways. Second, schools could be considered key sites for preventive public health initiatives that are adaptable, feasible and embedded within school culture.
Academic performance and public health initiatives are interrelated. It is clear that if schools are to play a role in the prevention of NCDs and other public health problems in the future, the approach to achieving this must be anchored and accepted among the larger school community parents, teachers, administrators.
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For schools to adopt this role and redefine themselves, the pathway to this is likely through enhanced academic performance through physical activity. Importantly, if classroom teachers receive comprehensive education beyond qualification, the ASK model can be inexpensively disseminated to schools. In national and international contexts, the ASK study has the potential to extend current evidence and inform the political and scientific debate as to whether embedding physical activity into school culture is an effective next step toward meeting both educational and health goals.
Competing interests. All authors participated in the writing of the paper and approved the final version. Katrine N Aadland 1 , katrine.
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Aadland hisf. Yngvar Ommundsen 4 , yngvar. Lars B Andersen 4 , lboandersen health. Willem van Mechelen 5 , w. Susi Kriemler 6 , susi. Mjos kj. Tarja AR Kvalheim 2 , tarja. Tone F Bathen 8 , tone. Oien hisf.
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Inger J Solheim 9 , inger. Lerum hisf. Gjoroy hisf. Frode O Haara 1 , frode. Tom R Kongelf 1 , tom. Kyrkjebo hisf. Geir K Resaland, Email: on. Vegard Fusche Moe, Email: on. Eivind Aadland, Email: on.