Trick or Treat?

The only trick to Halloween is how you are going to decipher manufacturer labels on candy products to make smart diabetes lifestyle choices.

When it comes to nutrition I’m constantly learning, just like you. Reading labels really is an important part of that education process.

Do you read labels? Here’s a few label reading pointers:

There are several important things I try to remember when I look at labels.

The first is that I better check out how many servings are in that candy bar my child brought home in his treat bag and I am about to consume in the closet with the light out. Sure it says 120 calories per serving, but if I look in the teeny tiny print, it also says two servings per bar. Two servings? Who eats half a candy bar?

Most labels are based on the daily nutritional value of a person who is on a 2000 or 2,500 calorie diet. Again my incredulity radar goes off. Who eats a 2,000 calorie diet? The Weight Loss Center says a 2000 calorie diet is appropriate for a large man. Terrific. So when I read that I am consuming 31 grams of carbohydrates and it is only 10% of my recommended daily nutritional intake of carbohydrates…I need to remember that they are talking to a large man on a 2000 calorie diet.

Sound complex and confusing. It can be.

Here are a few sites to help unscramble the American food labeling system.

• From the FDA: How to Understand and Use the Nutrition Facts Label
• RealAge: Food Labels
• Mayo Clinic: Nutrition Fact:Reading the Food Label
  

Reading Food Labels is available for purchase from the American Diabetes Online Store.

Read more

               

The lifestyle of the young is not good for the heart

The trend is disturbing. More and more children and young people are having cardiovascular problems. And the causes can be traced to unhealthy lifestyles.

Lack of proper nutrition

Project EAT, a study conducted by the University of Minnesota looked at 2,500 teenage girls over a 5-year period. Their findings show that 62.7% of female teens engage in unhealthy weight control strategies which include taking diet pills, laxatives, drugs that induce vomiting, as well as regularly skipping meals. The use of diet pills is especially popular. Ironically, these weight control behaviour can actually produce the opposite results. Girls who engage in such strategies are 3 times more likely to be overweight. This creates a vicious cycle of dieting, weight gain and eating disorders.

Lack of exercise

How many hours do your children in front of a screen - be it a TV screen, a computer screen or any other game console? Canadian researcher Dr. Ian Michael Janssen tells Reuters that adolescents nowadays “spend more hours daily in front of a screen than they do in a classroom in a given year.” This translates to lack of physical activity that leads to rising rates of obesity among adolescents. It is estimated that about 50% of Canadian children aged 5 to 17 years old do not get enough exercise. 26% of these children are overweight or obese. Excess weight and obesity are risk factors for heart disease and type 2 diabetes.

Lack of sleep

In this study funded by the National Institutes of Health (NIH), researchers found a link between poor sleep quality and shorter sleep duration in teens and elevated blood pressure. Poor sleep quality or low sleep efficiency is defined as having “trouble falling to sleep at night or who wake up too early.”

The study looked at 238 adolescents (123 boys and 115 girls) ages 13 to 16 years old. Data on sleep habits and blood pressure were collected. Adolescents with less than 85% sleep efficiency had nearly three times the likelihood of having elevated high blood pressure.

Researchers say the culprit is technology present in bedrooms, be it in the form of phones, music, computers and other multimedia gadgets.

Childhood hypertension shouldn’t be underestimated, ignored or taken for granted. The likelihood of it developing to a full blown adult hypertension and then a serious cardiovascular disease is very high.

The study authors recommend:

“Adolescents need nine hours of sleep. Parents should optimize sleep quality for their family with regular sleep and wake times and bedrooms should be kept quiet, dark and conducive to sleep.”

 

Photo credit: nookiez at stock.xchng

               

Resource post for September: Fibers for our health

What are fibers?

Fibers come from plant materials. Our body cannot digest or absorb fibers. They seldom provide vitamins and nutrients. Yet, fibers in our diet are very important to our health.  A lot of fibers are actually in carbohydrates that you eat - yes, carbs - that dreaded word that seems to give weight watchers nightmares. Don’t worry. Fibers are special.

Why are fibers so important?

Fibers help in the digestion process. As they move through the digestive tract, they facilitate the absorption of water but block the absorption of cholesterol and other fats. Foodstuffs rich in fibers are usually low in calories, yet they are very filling making them ideal foodstuff for dieters!

According to the British Nutrition Foundation:

Diets naturally high in fibre can be considered to bring about five main physiological consequences:

improvements in gastrointestinal health;

improvements in glucose tolerance and the insulin response;

reduction of hyperlipidaemia, hypertension and other coronary heart disease (CHD) risk factors;

reduction in the risk of developing some cancers;

increased satiety and hence some degree of weight management.

There are 2 kinds of fibers in our diet: soluble and insoluble fiber.

Insoluble fiber goes through the digestive tract largely undigested and is important in the functioning of the digestive system. This type of fiber can be found in whole-grain cereals, leguminous vegetables, and fruits eaten with skin.

Soluble or viscous fiber on the other hand, is transformed in the intestine into a gel-like substance and is especially important for cardiovascular health. It hinders the absorption of cholesterol and fats through the walls of the digestive tract. By simply increasing your daily fiber intake, you are decreasing the the level of LDL cholesterol in your blood.

How much fiber do we need in our diet?

Different health authorities have different recommendations as to how much dietary fiber we need on a daily basis. It all depends mainly on age and calorie intake.

The American Dietetic Association (ADA) recommends a daily allowance of 30 to 38 grams dietary fiber for men and 21 to 25 grams for women. The ADA’s recommendation for children should be calculated as the child’s age plus 5 grams per day.

The British Nutrition Foundation recommends a minimum fiber intake of 18 g per day for healthy adults.

The American Heart Association (AHA) recommends the following dietary fiber intake for children:

Gender/Age	Fiber (grams)
1 to 3 years	19
4 to 8 years	25
9 to 13 years
Female	26
Male	31
14 to 18 years
Female	29
Male	38

The National Academy of Sciences’ Institute of Medicine recommends 38 grams of fiber for men aged 50 and below and 25 grams for women of the same age. Those older than 20 are recommended to have 30 and 25 grams for men and women, respectively.

It is however a general observation that the majority of the population’s daily intake of dietary fiber is far below these recommendation.

How do we increase our fiber intake?

Although an increase in dietary fiber intake is recommended, a sudden change in diet can lead to stomach problems such as cramps and bloating. Increasing fiber in the diet should therefore be done gradually. Here are some tips from the National Heart, Lung, and Blood Institute (NHLBI):

• For breakfast, eat whole grain cereals such as oatmeal or bran.
• Add fruit to cereals such as apple, bananas, and berries. Eat fruit together with the skin whenever possible. A large portion of fruit fiber is in the skin.
• Eat whole, unprocessed fruit instead of or in addition to drinking fruit juice. A whole orange has six times more fiber than 1 glass of orange juice.
• Add more fresh vegetables in your diet. For salads, add beans such as white, black, kidney beans or lentils.
• Eat whole grain bread instead of white bread.

What are the main sources of dietary fiber?

The table below provided by NHLBI summarizes the most common food sources of fiber:

 

Reading resources:

Dietary Fiber: An Important Link in the Fight Against Heart Disease (ADA)

Barley: A Healthy Heart Solution (ADA)

Whole Grains Made Easy (ADA)

Cholesterol, Fiber and Oat Bran (AHA)

Fiber and Children’s Diets (AHA)

Dietary fiber: An essential part of a healthy diet (Mayo Clinic)

 

Photo credits

Cereal 1 by blackcat79

Bread by alexkalina

Beans by biearwicke

 

               

Check out what your drink does to your heart

Heart experts from all over Europe and the world met in Munich, Germany last August 30 to September 3 to share the latest research findings on cardiovascular sciences at the European Society of Cardiology (ESC) Congress 2008. Today and in the coming days, I will be presenting some extracts from reports presented at the Congress.

One of the most interesting presentations under the topic “Cardiovascular Disease Prevention - Risk Assessment and Management” is entitled “The gourmand’s heart - a bitter sweet relationship?” where Spanish heart expert S.S. Menendez summarized the latest updates on the health effects of four common food and drinks in the Western diet, namely tea, coffee, wine and chocolate.

Tea

Dutch researchers reported that tea showed beneficial effects on cardiovascular health in many studies (but not all) conducted in Europe. The substances responsible for the positive effects are most likely the strong oxidants flavonols and catechins found in tea.

Coffee

The caffeinholics among us will immediately ask - what about coffee? Greek researchers reported that coffee does not increase the long-term risk for developing cardiovascular disease. Nor does it worsen existing conditions of CVD. However, coffee consumption may increase blood pressure and interact with cigarette smoking, leading to adverse effects. Also, the health effects of coffee may differ depending on the type of coffee and the way it is prepared.

Chocolate

Researchers from the land of chocolate - Switzerland - reported about the positive effects of cocoa. Cocoa benefits cardiovascular health by “lowering blood pressure, improved endothelial function, improved insulin sensitivity and platelet function.” However, these effects are only true for unprocessed cocoa from the cacao beans but not necessarily for the chocolate goodies you see in Swiss confectionaries. Processing of cacao may lead to loss of its antioxidant properties.

Wine

Now, the list won’t be complete without touching on wine. Italian researchers reported that moderate alcohol consumption reduces CVD risk, CVD mortality and total mortality in healthy people and in patients with a history of CVD. Wine, especially, should be alcoholic drink of your choice. For maximum cardiovascular protection, 1 to 2 glasses per day for women and 2 to 4 glasses per day for men are recommended. However, overconsumption of alcohol can lead to major health problems as discussed in a previous post.

In conclusion, tea, cocoa, and wine showed beneficial effects on cardiovascular health but the effect of coffee is not clear. As parting shot, the author gives the following prudent recommendation:

Take a coffee or cocoa drink for breakfast, drink green tea during the day, a glass of wine in the evening and … a piece of dark chocolate before going to bed !!!

Photo credits:

woodsy at stock.xchng

wine at stock.xchng

               

The Olympic diet: what do athletes eat?

We all know that our diet is a key factor to being and keeping healthy. It is the food we eat that provides us the energy to perform our daily activities - it is what keeps our heart pumping. Now, we get to wonder, what do high performance athletes eat? What gives them the energy, the power to run, swim, jump or lift weights faster and better than non-athletic people like you and me?

Here are some examples of what Olympic athletes eat on a normal day.

Gymnastics

Gymnastics is an example of anaerobic physical activity. The gymnasts need strong spurts of energy for short periods of time to jump, flip, swing and perform somersaults.

In this msnbc report, gymnasts like Stephen McCain go for the low-carbohydrate, high-protein diet.

Most gymnasts try to get between 60 percent and 70 percent of their calories from proteins (like meats and cheeses), the rest from carbs (like whole-grain pasta, fruits, vegetables) and fats (like oils from peanuts).

Of course gymnastics is a special sports where weight is highly relevant to performance. Gymnasts have to closely watch their calorie intake to keep down their weight.

Other anaerobic sport sports such as weight lifting and shot put, put less emphasis on weight but more muscle growth and therefore have other dietary requirements. The American College of Sports Medicine (ACSM), for example, recommends body builders to eat

“…a pre-exercise snack that includes a combination of carbs (for energy) and protein (for muscle building): cereal with milk, yogurt and a banana, bagel with peanut butter, trail mix (nuts and dried fruit), or a turkey sandwich”.

In addition, ACSM warns of the danger of undereating, especially among female athletes who strictly control their weight. Undereating can lead to shortage of calories needed for strenuous exercise, resulting in amenorrhea (irregular menstrual cycle) and iron deficiency anemia

Swimming

Now, how about eating a thousand calories every hour? Unthinkable? Well, that´s what Michael Phelps, winner of 8 gold medals in swimming require during rigorous training and competition, according to a report at WebMD. On a normal day, he can easily take in 6000 to 8000 calories in pizza and pasta.

Unlike gymnastics, swimming is an aerobic sports that requires prolonged energy output. High calorie, high carbohydrate diet is what endurance athletes like Phelps need. However, they need to make sure that calories intake is well-distributed all throughout the day and certainly no big intake immediately before a race. High calorie foods with small volume are especially recommended so that “granola with fruit and yogurt would be a better choice than flake cereal with milk.”

Nutritional requirements of athletes differ from those of “mere mortals” like us. For more information about good dietary habits, check out The Dietary Guidelines for Americans published jointly every 5 years by the Department of Health and Human Services (HHS) and the Department of Agriculture (USDA).

 

Photo credit

               

CVD News Watch for the Weekend August 15

Looking forward to your second Olympics weekend? Be aware, though, that watching stressful sports events might just not be good for your heart. Happy reading!

CVD healthcare watch

Coronary CTA costs less than standard of care for triaging women with acute chest pain

Would you believe it, non-invasive CTA - short for coronary CT angiography seems to be cheaper than standard diagnostic care which consists of stress tests and cardiac enzymes screening - at least for women with low-risk profiles but acute chest pains. This is according to a report by the American Roentgen Ray Society.

CVD cholesterol watch

People with heart disease still have trouble controlling blood lipid levels

Researchers at the University of California at Irvine report that current cholesterol level management among heart disease patients is not enough to keep total blood lipid profile in control. It seems that it is not enough to lower the bad LDL cholesterol. Other lipids such as HDL cholesterol and triglycerides should be monitored as well.

CVD weight loss watch

Scientists identify another piece of the weight-control puzzle

Is it all in the brain? Neuroscientists at the Beth Israel Deaconess Medical Center (BIDMC) in Boston have identified that the neurotransmitter GABA may play a role in weight control. Read more about this research which will be published in Nature Neuroscience.

CVD nutrition watch

ViaViente demonstrates cardiovascular benefits in new human trial

ViaVente - this anti-oxidant product in the form of fruity beverage seems to show benefits to cardiovascular health in this new study in humans. The study was conducted by Bell Ventures.

CVD drug watch

Multaq (dronedarone) granted FDA priority review for patients with atrial fibrillation

The new drug application for dronedarone (commercial name Multaq) is now under priority review by the US FDA. Dronedarone is indicated for the treatment of atrial fibrillation or flutter. It has been developed by the French pharmaceutical company sanofi-aventis. According to the company’s press release:

“Atrial fibrillation is a major cause of hospitalisation and mortality and affects about 2.5 million people in the United States, as well as 4.5 million people in the European Union and is emerging as a growing public health concern due to an aging population. Patients suffering from atrial fibrillation have twice the risk of death, an increased risk of stroke and cardiovascular complications, including congestive heart failure. Furthermore atrial fibrillation considerably impairs patients’ lives, mainly because of their inability to perform normal daily activities due to complaints of palpitations, chest pain, dyspnoea, fatigue or light-headedness.“

 CVD pollution watch

Air pollution damages more than lungs: Heart and blood vessels suffer too

Right in the wake of the Beijing Olympics, California researchers will publish in the August  issue Journal of the American College of Cardiology (JACC) an article that reports how air pollution can injure the heart and the blood vessels in the short- and long-term.

               

CVD News Watch for the Weekend 8 August

Enjoying your summer? Here’s some new items to read over the weekend.

CVD nutrition watch

Eating fish may prevent memory loss and stroke in old age

This study which looked at 3,660 people age 65 and above, reports that eating fish rich in omega-3 fatty acids lowers the risk for stroke and cognitive decline in the elderly.

The study found that people who ate broiled or baked tuna and other fish high in omega-3 fatty acids (called DHA and EPA) three times or more per week had a nearly 26 percent lower risk of having the silent brain lesions that can cause dementia and stroke compared to people who did not eat fish regularly. Eating just one serving of this type of fish per week led to a 13 percent lower risk. The study also found people who regularly ate these types of fish had fewer changes in the white matter in their brains. (Source: American Academy of Neurology)

CVD BP watch

Blood Pressure Is So Much More than Brachial

Check out this video at Medscape to know more about other types of blood pressure (other than the usual measurements on the cuff and arm), what they tell us and why are they important.

CVD infection watch

HIV infection increases risk for aortic stiffness and CAC

This study reports a link between cardiovascular health and HIV infection. The researchers specifically looked at “aortic stiffness and coronary artery calcification, two subclinical markers of atherosclerosis.”

CVD healthcare watch

Average ER waiting time nears 1 hour, CDC says

The average time you have to reckon with when waiting in an ER in the US is almost 60 minutes - up from 38 minutes of previous years. This is because the number of ER cases is up but the number of ERs is down, thus creating a bottleneck, Physorg reports.

CDC reports:

At least 10% of emergent cases (those in which patients should be seen in less than 15 minutes) and 20% of urgent cases (should be seen in 15–60 minutes) had to wait longer than 1 hour to see a physician. Blacks and Hispanics were more likely to wait for more than 1 hour in all cases other than emergent.

CVD weight loss watch

Adults who eat eggs for breakfast lose 65 percent more weight

How about eggs for breakfast? You can add a bagel on top and won’t be hungry again for hours. This new, low-calorie, high protein diet may be the next diet craze. Check out the reviews about it here.

               

CVD News Watch for the Weekend, August 1

It’s Friday again and I am bringing you good and not-so-good news from the CVD front.

CVD biotech watch

New research on pre-eclampsia in mice may have important implications for humans

Researchers at the University of Texas-Houston Medical School were able to induce pre-eclampsia in mice by injecting the animals with certain human autoantibodies isolated from women with the disorder. The researchers were able to reverse the symptoms by giving the mice drugs that blocked the autoantibodies. This breakthrough can lead to new therapies for the prevention and management of pre-eclampsia.

CVD patient watch

Overweight elderly Americans contribute to financial burdens of the US health care system

Overweight people incur higher healthcare costs than those with normal weight, according to reports published in Health Services Research. Over a lifetime, an overweight or obese elderly person will cost Medicare 6 to 17% more than a person of similar age but of normal weight. Obesity is major risk factor for cardiovascular disorder and type 2 diabetes.

CVD drug watch

Federal authorities seize xiadafil vip tablets after company refuses to recall product

This drug is sold as nutritional supplements but actually contains hydroxyhomosildenafil, which is very similar to sildenafil, otherwise commonly known as Viagra, the popular prescription drugs against erectile dysfunction (ED).

ED is a common problem in men who have diabetes, high blood pressure, high cholesterol, or heart disease. Because they may have been advised against taking ED drugs, men with these conditions may seek alternative products like Xiadafil VIP tablets because they are marketed as “all natural” or as not containing the active ingredients in approved, prescribed ED drugs. Furthermore, because the manufacturing source of the active ingredients in many of these alternative products is unknown, consumers should also be aware that the safety, efficacy, and purity of these ingredients have not been verified by the FDA.

CVD nutrition watch

Iron intake linked to blood pressure

Intake of total and non-haem iron which is found in vegetables has a positive effect on blood pressure (BP), according to researchers at the Imperial College London. However, no link was found between BP and dietary haem iron from animal sources.

CVD legislation watch

Statement by American Heart Association President Timothy J. Gardner, M.D. in response to Senate vote on STOP Stroke Act omnibus package

The American Heart Association expressed disappointment over the House of Senate’s vote on the STOP Stroke Act omnibus package. According to AHA President,

“…the Senate vote is a huge setback for stroke patients, caregivers and healthcare providers in our ongoing battle against this debilitating and costly disease…Our lawmakers missed an opportunity to help Americans get appropriate and timely care to minimize the devastating consequences of a stroke.”

Photo credit

               

CVD News Watch for the Weekend, July 25

 

Have a great weekend!

CVD nutrition watch

Margarine, pastry producers slow to reduce trans-fat levels: task force

Some food companies are resistant to lowering the trans-fat content of the food they sell, according to a task force formed by Health Canada and the Heart and Stroke Foundation of Canada. Some of these food companies are listed in this CBC News report.

 

CVD pollution watch

Beijing pollution may trigger heart attacks, strokes among spectators

In this podcast, two professors of medicine at the Northwestern University, Dr. Gokhan Mutlu and Dr. Scott Budinger discuss the health risks that visitors to the Beijing Olympics might encounter. It’s not only the athletes who are in danger, it’s the spectators as well.

 

CVD biotech watch

Researchers grow human blood vessels in mice from adult progenitor cells

Another first! Researchers at Harvard have developed human blood vessels from adult blood and bone marrow stem cells for the first time. And they work. The blood vessels have been successfully implanted in mice.

 

CVD weight loss watch

Limiting fructose may boost weight loss

Researchers at the UT Southwester Medical Center report that less fructose in our diet can help get rid of those extra pounds. Fructose occurs naturally in fruits and has always been thought to be a healthier alternative to table sugar. Some food products, especially beverages use this as artificial sweetener. Now we know better.

 

CVD fitness watch

Exercise could be the heart’s fountain of youth

Previous research studies have shown that exercise can delay, even reverse aging. It is also known that the heart deteriorates with age. Researchers at the Washington University School of Medicine studied how exercise can affect the heart - with very encouraging results. Endurance exercise seems to keep the heart younger! More about exercise next week.

 

CVD patient watch

Heart Surgery Survivor Looks Forward to Motherhood

Heart surgery survivor Rebecca Venis was diagnosed with a bad aortic valve at the age of 8. She underwent human aortic valve transplant in 2000. The graft started leaking and she underwent another surgery, this time a pig valve replacement. This one seems to work well and Rebecca is back to running and mountain climbing. It might even now be possible for her to get pregnant.

 

CVD treatment watch

Scientists suspect omega-3 fatty acids could slow acute wound healing

They are supposedly good for the heart, but this popular fish oil used by many as nutritional supplement seems to slow down wound healing, according to researchers at the Ohio State University. In their research, they compared the healing process of blister wounds of people taking omega-3 supplements compared to those taking only placebo. Although healing seemed to have proceeded almost at the same time in the two groups, something different was observed at the cellular level. There were more proteins associated with initiating and sustaining inflammation observed in the blister fluid of those who were taking the active supplement. The researchers expected exactly the opposite and are still trying to figure out the mechanisms behind this.

These findings are very significant because many heart patients are on omega-3 supplementation. If healing is indeed slowed down by these supplements, then such supplements are not suitable for patients scheduled for surgery.

 

Photo credit

               

School diet program helped children in controlling weight problems

In some parts of the world, children are dying of hunger; in other parts, children are dying from obesity-related health problems. Such irony.

Childhood obesity is becoming a major problem in the developed world. In the US alone, 16.9% of boys and 15.6% of girls aged 6 to 11 years among non-Hispanic whites are overweight. Among non-Hispanic blacks, it’s 17.2% of boys and 24.8%of girls in the same age group. For Mexican Americans, it’s 25.6% of boys and 16.6% of girls. (Source: American Heart Association (AHA)). Obesity is a major risk factor in cardiovascular health as well as type 2 diabetes.

Many studies point to the causes of these weight problems - poor nutrition and lack of exercise. The American Academy of Pediatrics (AAP) and the American Heart Association have issued guidelines on how to clinically monitor and control cholesterol levels in children who are overweight or obese.

However, health solutions that go beyond the clinical settings are necessary to stem this rapidly growing problem.

Schools are one of the ideal places to start with. After all, children spend a large part of their daily routine at school. This study led by the Center for Obesity Research and Education, Temple University examined

the effects of a multicomponent, School Nutrition Policy Initiative on the prevention of overweight … and obesity … among children in grades 4 through 6 over a 2-year period.

1,349 pupils from 10 Philadelphia elementary schools were involved in the study. 5 schools implemented the School Nutrition Policy Initiative and 5 schools did not and served as conrol. The schools who had implemented the policy drastically changed the food available at school, be it at the cafeteria or in the vending machines. Sodas were replaced with fruit juices, low-fat milk, or water. Candies and sweets were banned and snacks were scaled down in terms of fat and sugar content. In addition, rewards in the form of raffle tickets for sports equipment were given to those who made wise food choices. In addition, the pupils were encouraged to perform physical exercises at break times. The children were monitored, their weight and height measured and their eating and exercise habits were checked with a questionnaire. The school staff who organized the study was specially trained in nutrition education.

The schools also stepped on nutrition and health education. Nutrition education is incorporates as much as possible in all school subjects. Special classes were organized not only for the pupils but for teachers and parents as well.

Social marketing on nutrition was also employed. Slogans and posters on healthy lifestyle were posted everywhere.

And here are the results:

The intervention resulted in a 50% reduction in the incidence of overweight. Significantly fewer children in the intervention schools (7.5%) than in the control schools (14.9%) became overweight after 2 years. The prevalence of overweight was lower in the intervention schools. No differences were observed in the incidence or prevalence of obesity or in the remission of overweight or obesity at 2 years.

This means that after two years, the number of overweight pupils at the five “nutrition-friendly” schools dropped while the number of overweight children in control schools increased. Also fewer new overweight children were observed at the “nutrition-friendly” schools.

Unfortunately, no such significant difference has been observed in the incidence of obesity in the 2 school groups. Also, remission or the tendency to gain back lost pounds did not significantly decrease.

In conclusion, special interventions such as used in this study do help in controlling the problem of overweight among children. However, it doesn’t seem to be enough. Other measures have to be taken including implementation of such initiative earlier. In addition, future initiatives should focus on other aspects of the school environment such as PE classes as well as environments outside the school - at home!

Photo credit

               

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