***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Pathways , a multisite school-based study aim ed at promoting healthful eating and increasing physical activity , was a r and omized field trial including 1704 American Indian third to fifth grade students from 41 schools ( 21 intervention , 20 controls ) in seven American Indian communities . METHODS The intervention schools received four integrated components : a classroom curriculum , food service , physical activity , and family modules . The curriculum and family components were based on Social Learning Theory , American Indian concepts , and results from formative research . Process evaluation data were collected from teachers ( n=235 ) , students ( n=585 ) , and families .  Knowledge , Attitudes , and Behavior Question naire data were collected from 1150 students including both intervention and controls . RESULTS There were significant increases in knowledge and cultural identity in children in intervention compared to control schools with a significant retention of knowledge over the 3 years , based on the results of repeating the third and fourth grade test items in the fifth grade . Family members participated in Family Events and take-home activities , with fewer participating each year . CONCLUSION A culturally appropriate school intervention can promote positive changes in knowledge , cultural identity , and self-reported healthful eating and physical activity in American Indian children and environmental change in school food service OBJECTIVE To assess the effects of a comprehensive , integrated community-based lifestyle intervention on diet , physical activity and smoking in two Iranian communities . METHODS Within the framework of the Isfahan Healthy Heart Program , a community trial was conducted in two intervention counties ( Isfahan and Najaf-Abad ) and a control area ( Arak ) .  Lifestyle interventions targeted the urban and rural population s in the intervention counties but were not implemented in Arak . In each community , a r and om sample of adults was selected yearly by multi-stage cluster sampling . Food consumption , physical exercise and smoking behaviours were quantified and scored as 1 ( low-risk ) or 0 ( other ) at baseline ( year 2000 ) and annually for 4 years in the intervention areas and for 3 years in the control area . The scores for all behaviours were then added to derive an overall lifestyle score . FINDINGS After 4 years , changes from baseline in mean dietary score differed significantly between the intervention and control areas ( + 2.1 points versus -1.2 points , respectively ; P < 0.01 ) , as did the change in the percentage of individuals following a healthy diet ( + 14.9 % versus -2.0 % , respectively ; P < 0.001 ) . Daily smoking had decreased by 0.9 % in the intervention areas and by 2.6 % in the control area at the end of the third year , but the difference was not significant . Analysis by gender revealed a significant decreasing trend in smoking among men ( P < 0.05 ) but not among women . Energy expenditure for total daily physical activities showed a decreasing trend in all areas , but the mean drop from baseline was significantly smaller in the intervention areas than in the control area ( -68 metabolic equivalent task ( MET ) minutes per week versus -114 MET minutes per week , respectively ; P < 0.05 ) . Leisure time devoted to physical activities showed an increasing trend in all areas . A significantly different change from baseline was found between the intervention areas and the control area in mean lifestyle score , even after controlling for age , sex and baseline values . CONCLUSION The results suggest that community-based lifestyle intervention programmes can be effective in a developing country setting The primary aim of the Trial of Activity in Adolescent Girls ( TAAG ) is to test an intervention to reduce by half the age-related decline in moderate to vigorous physical activity  ( MVPA ) in middle school girls . The intervention will be evaluated using a group-r and omized trial involving 36 middle schools . The primary endpoint is the mean difference in intensity-weighted minutes ( i.e. , MET-minutes ) of MVPA between intervention and comparison schools assessed using accelerometry . The TAAG study design calls for two cross-sectional sample s , one drawn from 6th grade rs at the beginning of the study and the second drawn from 8th grade rs at the end of the study following the 2-year implementation of the intervention . An important strength of this design over a cohort design is the consistency with the goals of TAAG , which focus on environmental-level rather than individual-level interventions to produce change . The study design specifies a recruitment rate of 80 % and a smaller sample of girls at baseline ( n=48 per school ) than at follow-up ( n=96 per school ) . A two-stage model will be used to test the primary hypothesis . In the first stage , MET-weighted minutes of MVPA will be regressed on school , time ( baseline or follow-up ) , their interaction , ethnicity and week of data collection . The second stage analysis will be conducted on the 72 adjusted means from the first stage . In the main-effects model , we will regress the follow-up school mean MET-weighted minutes of MVPA on study condition , adjusting for the baseline school mean . The TAAG study addresses an important health behavior , and also advances the field of group-r and omized trials through the use of a study design and analysis plan tailored to serve the main study hypothesis Background : Population -based studies directed at promoting physical activity in youth have shown limited success in obesity prevention . Objective : To assess whether an intervention integrating environmental changes to induce sustained changes in physical activity , prevents overweight in adolescents . Design : Four-year r and omized trial started in 2002 in eight middle schools of Eastern France . The intervention , r and omized at school level , was design ed to promote physical activity by changing attitudes through debates and attractive activities , and by providing social support and environmental changes encouraging physical activity . Subjects : Nine hundred and fifty four 12-year-old six- grade rs . Measurements : Body mass index ( BMI ) , body composition , physical activity by question naire , plasma lipids and glucose , insulin resistance . Results : Intervention students had a lower increase in BMI ( P=0.01 ) and age- and gender-adjusted BMI ( P<0.02 ) over time than controls . The differences across groups of the age- and gender-adjusted BMI changes ( 95 % confidence interval ( CI ) ) were −0.29 ( −0.51 ; −0.07 ) kg/m2 at 3 years , −0.25 ( −0.51 ; 0.01 ) kg/m2 at 4 years . An interaction with baseline weight status was noted . The intervention had a significant effect throughout the study in initially non-overweight adolescents ( −0.36 ( −0.60;−0.11 ) kg/m2 for adjusted BMI at 4 years ) , corresponding to a lower increase in fat mass index ( P<0.001 ) . In initially overweight adolescents , the differences observed across groups at 2 years ( –0.40 ( −0.94 ; 0.13 ) kg/m2 for adjusted BMI ) did not persist over time . At 4 years , 4.2 % of the initially non-overweight adolescents were overweight in the intervention schools , 9.8 % in the controls ( odds ratio=0.41 ( 0.22 ; 0.75 ) ; P<0.01 ) . Independent of initial weight status , compared with controls , intervention adolescents had an increase in supervised physical activity ( P<0.0001 ) , a decrease of TV/video viewing ( P<0.01 ) and an increase of high-density cholesterol concentrations ( P<0.0001 ) . Conclusion : Enhancing physical activity with a multilevel program prevents excessive weight gain in non-overweight adolescents . Our study provides evidence that prevention of obesity in youth is feasible Background Recent systematic review s have suggested that pedometers may be effective motivational tools to promote walking . However , studies tend to be of a relatively short duration , with small clinical based sample s. Further research is required to demonstrate their effectiveness in adequately powered , community based studies . Objective Using a r and omized controlled trial design , this study assessed the impact of a 12-week graduated pedometer-based walking intervention on daily step-counts , self-reported physical activity and health outcomes in a Scottish community sample not meeting current physical activity recommendations . MethodS ixty-three women and 16 men ( 49.2 years ± 8.8 ) were r and omly assigned to either an intervention ( physical activity consultation and 12-week pedometer-based walking program ) or control ( no action ) group . Measures for step-counts , 7-day physical activity recall , affect , quality of life ( n = 79 ) , body mass , BMI , % body fat , waist and hip circumference ( n = 76 ) , systolic/diastolic blood pressure , total cholesterol and HDL cholesterol ( n = 66 ) were taken at baseline and week 12 . Analyses were performed on an intention to treat basis using 2-way mixed factorial analyses of variance for parametric data and Mann Whitney and Wilcoxon tests for non-parametric data . Results Significant increases were found in the intervention group for step-counts ( p < .001 ) , time spent in leisure walking ( p = .02 ) and positive affect ( p = .027 ) . Significant decreases were found in this group for time spent in weekday ( p = .003 ) , weekend ( p = .001 ) and total sitting ( p = .001 ) with no corresponding changes in the control group . No significant changes in any other health outcomes were found in either group . In comparison with the control group at week 12 , the intervention group reported a significantly greater number of minutes spent in leisure time ( p = .008 ) , occupational ( p = .045 ) and total walking ( p = .03 ) , and significantly fewer minutes in time spent in weekend ( p = .003 ) and total sitting ( p = .022 ) . Conclusion A pedometer-based walking program , incorporating a physical activity consultation , is effective in promoting walking and improving positive affect over 12 weeks in community based individuals . The discussion examines possible explanations for the lack of significant changes in health outcomes . Continued follow-up of this study will examine adherence to the intervention and possible result ing effects on health outcomes Background Ageing is associated with a decrease in physical activity . This decrease particularly occurs during specific transitional life stages . Especially during adolescence and young adulthood a steep decrease in physical activity is observed . Inactive people are often not aware of their inactivity . Providing feedback on the actual physical activity level by an activity monitor can increase awareness and may in combination with an individually tailored physical activity advice stimulate a physically active lifestyle . Methods In a r and omized controlled trial the effectiveness of providing an activity monitor in combination with a personal physical activity advice through the Internet will be examined . Outcome measures are level of physical activity , determinants of physical activity , quality of life , empowerment , aerobic fitness and body composition .  Participants are relatively inactive adolescents and young adults who are measured at baseline , after 3 months intervention and 5 months after the end of the intervention . In addition , facilitating and hindering factors for implementation of the intervention will be investigated . Discussion The use of a personal activity monitor in combination with web-based assisted individually tailored health promotion offers a good opportunity to work interactively with large groups of adolescents and young adults and provide them with advice based on their actual activity level . It has great potential to motivate people to change their behaviour and to our knowledge has not been evaluated before Background We report the main results , among adults , of a cluster-r and omised-trial of Well London , a community-engagement programme  promoting healthy eating , physical activity and mental well-being in deprived neighbourhoods . The hypothesis was that benefits would be neighbourhood-wide , and not restricted to intervention participants . The trial was part of a multicomponent process/ outcome evaluation which included non-experimental components ( self-reported behaviour change amongst participants , case studies and evaluations of individual projects ) which suggested health , well-being and social benefits to participants . Methods Twenty matched pairs of neighbourhoods in London were r and omised to intervention/control condition . Primary outcomes ( five portions fruit/vegetables/day ; 5 × 30 m of moderate intensity physical activity/week , abnormal General Health Question naire (GHQ)-12 score and Warwick – Edinburgh Mental Well-being Scale ( WEMWBS ) score ) were measured by postintervention question naire survey , among 3986 adults in a r and om sample of households across neighbourhoods . Results There was no evidence of impact on primary outcomes : healthy eating ( relative risk [ RR ] 1.04 , 95 % CI 0.93 to 1.17 ) ; physical activity ( RR:1.01 , 95 % CI 0.88 to 1.16 ) ; abnormal GHQ12 ( RR:1.15 , 95 % CI 0.84 to 1.61 ) ; WEMWBS ( mean difference [ MD ] : −1.52 , 95 % CI −3.93 to 0.88 ) . There was evidence of impact on some secondary outcomes : reducing unhealthy eating-score ( MD : −0.14 , 95 % CI −0.02 to 0.27 ) and increased perception that people in the neighbourhood pulled together ( RR : 1.92 , 95 % CI 1.12 to 3.29 ) . Conclusions The trial findings do not provide evidence supporting the conclusion of non-experimental components of the evaluation that intervention improved health behaviours , well-being and social outcomes . Low participation rates and population churn likely compromised any impact of the intervention . Imprecise estimation of outcomes and sampling bias may also have influenced findings . There is a need for greater investment in refining such programmes before implementation ; new methods to underst and , longitudinally different pathways residents take through such interventions and their outcomes , and new theories of change that apply to each pathway OBJECTIVES We sought to determine the effects of a community-based , culturally tailored diabetes lifestyle intervention on risk factors for diabetes complications among African Americans and Latinos with type 2 diabetes . 
    Output:
    
Generally , the better design ed studies showed no improvement in the primary outcome measure of physical activity at a population level .
Some program level effect was observed with more people walking in the intervention community , however this result was not evident in the whole community .
Overall , there was a noticeable absence of reporting of benefit in  physical activity  for community wide interventions in the included studies .
However , as a group , the interventions undertaken in China appeared to have the greatest possibility of success with high participation rates reported .
The body of evidence in this review does not support the hypothesis that the multi-component community wide interventions studied effectively increased physical activity for the population , although some studies with environmental components observed more people walking