Food frequency questionnaire was especially designed in France  to assess the adherence to French guidelines  for fruits and vegetables, dairy products, starchy food, drinks, sugar foods, meat, and fish. The IPAQ assessed the frequency days per week and duration minutes of walking and moderate and vigorous physical activity during the previous 7 days.
Physical activity level was defined as low, moderate or high according the IPAQ scoring guidelines . For sitting time, the frequency days per week and duration minutes and context school days, weekend, school, transportation, screen-viewing, other leisure-time were assessed. A sedentary behavior was defined by the daily number of hours spent sitting. Scores were calculated and the cut-off values used are those recommended by the authors.
The HAD scale  ,  has acceptable psychometric properties in the general population . The total score was the sum of the scores on the 14 items, and for each of the 2 subscales, the score was the sum of the scores for the respective 7 items. The Kidscreen  provided a global perceived health appreciation on a Likert scale ranging from 1 to 5 excellent to bad and a item quality of life score. High score on the 0— scale indicates good quality of life.
To facilitate interpretation, all health scores were normalized to a 0— scale. Outcomes transition questions provided the adolescents' perception of change and were answered on a Likert scale ranging from 1 to 5 much better to much worse or yes a lot to not at all.
According to the characteristics of the participating high schools, approximately students attended grade 10 each academic year. Under these conditions, we expected to be able to include adolescents over 2 years: in the A. S group, in the LA. S group and in the LA. Thus, the smallest detectable difference SDD was calculated with this sample size. For the first comparison of the primary objective A.
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S vs LA. S , we were able to detect an absolute true difference of 0. For the second comparison A. For the first comparison LA. Given the insufficient inclusion rate during the first academic year — , to reach the expected sample size, adolescents attending grade 9 in the 13 committed middle schools were incorporated in the inclusion process and we added a third inclusion wave — The prevalence of overweight and obesity was determined among all adolescents attending grades 9 and 10 who were measured at the inclusion session.
Baseline social inequalities in health social gradient were investigated among eligible adolescents who completed the questionnaire and participated in the medical visit to confirm the hypothesis of important social inequalities in health and overweight among state-run school adolescents. Among adolescents proposed for inclusion, comparing included and not included adolescents written parental refusal aimed to seek for the existence of a selection bias related to parental ability to accept or refuse this kind of intervention.
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Statistical comparison involved use of Student t -test, Mann—Whitney U test, Wilcoxon signed ranks test for continuous or discrete variables and Pearson chi-square test for categorical variables as appropriate, and use of logistic or linear multivariate regression models using a stepwise variable selection method. Adolescents' participation over the intervention and follow-up period will be described by a flow chart according to the CONSORT statement  and analyzed for possible selection bias especially along with social status.
The first comparison of the primary objective analysis A. S will consist of an equivalence test. For the second and third comparisons A. S and LA.
S , superiority analyses will involve mixed models accounting for the potential confounding factors identified in the previous steps and the hierarchical possible school and wave random effects and longitudinal nature of the data. An unstructured correlation matrix will be initially specified and the existence of a more appropriate specific correlation structure based on the data at hand will be.
Additional analyses concerning changes in secondary outcomes anthropometric, nutritional, attitudes and behaviors, health, transition questions will involve models similar to those specified for the primary outcomes. Post-intervention T2—T1 analyses will involve the same model to investigate the sustainability of the intervention effects.
All statistical analyses involve use of SAS v9. The flow chart of the inclusion process is in Fig. A total of 10, adolescents were attending grades 9 and 10 in the 35 schools during the inclusion period. Among the latter adolescents, Of these, attended the medical visit and A total of adolescents were definitively included, with weight excess according to BMI whatever the WC and exclusively according to WC and 61 only on health or demand criteria. S, LA. The proportion of parental refusal did not differ by intervention groups.
Indicators for state-run adolescents in the Vosges department were estimated among all adolescents with available measures Table 2. The mean SD waist circumference was Corpulence indicators were higher for girls than boys Boys and girls did not differ in overweight and obesity prevalence. Regarding the school type, all indicators were significantly higher for adolescents attending vocational high school than thus attending general high school or middle school. The FAS score was categorized in 5 classes: [0—2] highly less advantaged; [3,4] less advantaged, [5,6] intermediate, [7,8] advantaged and  highly advantaged Table 3.
Mean FAS score decreased consistently from 6. The social gradient was striking for the benefits of advantaged adolescents. Among the adolescents, 72 3. High social origins reflect better mastery of corpulence. The higher the social level, the lower the BMI from No social gradient was evidence for sitting time duration, health disorders and anxiety risk.
Among the adolescents proposed for inclusion, were not included because of parental refusal Written parental refusal was significantly associated, in multivariate regression, with age odds ratio [OR] 0. The probability of parental refusal was lower among adolescents with high eating disorder risks. Food consumption frequency, physical activity practice, sedentary behavior and other health indicators smoking status, perceived general health and anxiety and depression risks did not predict written parental refusal.
Thus the participation was all the more so as the needs increased. The 3 arms baseline characteristics are displayed in Table 5. Overall, S group, less advantaged adolescents were included either in the LA. The mean SD age was S group, which was mostly composed of girls Among them, Compared to advantaged adolescents, less-advantaged adolescents were older mean age S and S and more often attended vocational high schools, lived in single-parent family and had parents who were mostly workers.
They also exhibited more important weight excess whatever indicators , a higher consumption of sugary foods and a lower physical activity level. Other health indicators were less favorable for less-advantaged than advantaged adolescents. Socio-demographic, body size, behavior and health description of the 3 study arms. Formal statistical comparison p of advantaged and less advantaged groups.
Although school-based interventions are not scarce  ,  ,  ,  , the reduction of social inequalities is not systematically addressed and when addressed, the usual approaches are observational studies describing inequalities  or targeted interventions implemented in low-income communities schools  ,  ,  ,  or universal interventions with effects compared by socioeconomic status  ,  , .
The final aim was to determine whether overweight interventions adapted to socioeconomic status could reduce or at least avoid the aggravation of social inequalities as compared with universalism prevention . In this perspective, the best design appeared to be as follows:. Easy collection of socioeconomic status near the adolescents themselves.
Nevertheless, during the follow-up course, the interventions might be further adapted to the social status during the MDT meetings. The main comparison of advantaged adolescents receiving standard-care to less-advantaged adolescents receiving standard care plus strengthened-care management could only and obviously be quasi-experimental the socioeconomic status cannot be changed by the researchers, the interventions and their implementation are controlled by the researchers and had to be formulated as an equivalence comparison doing as well.
The experimental comparison randomized assignment to standard or strengthened care within the less-advantaged group only allowed for detecting the superiority of the strengthened activities among less-advantaged adolescents. Finally, a quasi-experimental comparison of advantaged and less-advantaged adolescents receiving the same standard universal intervention intended to confirm whether advantaged adolescents benefit more from interventions.
Initially scheduled over 2-year waves and only in high school grade 10 , the trial has been extended over 3 years and to middle school students grade 9 because the first-year inclusion rate was lower than expected. The main reason was the disappointing height and weight declaration prerequisite leading to numerous overweight adolescents being missed. From the second year, the declaration was eliminated and all adolescents were invited to be measured.
Additionally, middle schools were committed. The modification of the strategy of inclusion after the first year did not change the implementation of activities but allowed for achieving the sample size. A good quality of the inclusion and follow-up data was warranted because of the unified procedure for collecting anthropometric, self-administered questionnaire and medical visit data.
The computer-assisted questionnaire completion was easier than the paper version and also, the adolescents are assisted by a trained technician. Including a medical examination with BMI and WC measurements can help avoid misclassification and the proposition to participate in an inappropriate program. Thus, after information dissemination, only a written parental refusal was the final non-inclusion criterion.
Such usual-care research facilitated access to the program especially for less-advantaged adolescents because it did not require double parental consent. The non-requirement of parental consent associated with specific oral information given to LAS. Moreover, the LAS. S group and Thus clear, oral and non-intrusive information appears to be a key to better inclusion acceptance in health promotion program directed to less-advantaged adolescents. The prevalence of overweight and obesity was, as expected, stable and was even slightly lower than in the previous study  and in French national surveys  and European surveys .
During the last decades, the surveillance of child and adolescent overweight and major public health strategies to reduce the prevalence of overweight and obesity at every age  has resulted in a plateau stability of adolescent overweight and obesity prevalence during the s in France, and the situation seems fairly favorable. However, this prevalence hides strong social inequalities in overweight and obesity  and related behaviors and health status among adolescents, which are consistent with the cultural and behavioral approach of health inequalities .
The difference in adolescents overweight prevalence between social classes reflects differences in health-related behaviors such as diet  and physical activity  , and our findings agreed, except for sedentary behavior. Indeed, we did not find any social gradient of sedentary behavior, as was suggested by Meilke et al. Measuring health social gradient requires an optimal measure of social status with validated tools such as the FAS.
The proportionate universalism approach considers the people not only at the bottom of the health gradient, but also all over the gradient, thereby ensuring that the impact is proportionately greater at the bottom end of the gradient . One of the mechanisms by which the observed widening of health inequalities may operate in universal health interventions is social and cultural differences between health professionals delivering the intervention and the target audience.
For adolescents, one way to counteract this social and cultural gap is by reaching adolescents of low socioeconomic status with similar peers in addition to interventions by health professionals, this was the basis of peer education  , . Some adjustments were made to adapted activities strengthened-care management during the intervention. For example, the UNSS coupon, which was given to adolescents by their physician just after the medical visit during the first year, is then directly mailed to the adolescent's home.
The sporting good was initially given as a Euros voucher and then adolescents were asked to choose the good, which was brought to them by the trial group.