Similar to various low and middle income countries (LMICs), in Ecuador, the leading cause death is lifestyle related non-communicable disease (NCDs). Unfortunately preventive action to decrease the incidence of NCDs risk factors during adolescence is scarce. To our knowledge, there are no studies in Ecuador focused on improving the dietary intake, physical activity, physical fitness or sedentary patterns among adolescents. The present doctoral work aims to provide evidence on strategies to promote a healthy lifestyle in Ecuadorian adolescents. For this purpose, first we evaluated the current physical fitness among adolescents, and its association with dyslipidemia as the most prevalent NCD risk factor. Second, we analyzed the effect of a school-based health promotion program on physical fitness, physical activity and sedentary behaviors among adolescents. Finally, we assessed whether adolescents that are already at health risk such as overweight/obese and those with a low fitness level respond differently to the intervention program. In order to study the current state of physical fitness among Ecuadorian adolescents, a cross sectional study in an urban (Cuenca city) and a rural (Nabón canton) area was conducted (Chapter 2.1). In total of 648 adolescents (52.3% boys), attending 8th, 9th and 10th grade of the secondary schools participated in this study. We found that the majority of adolescents (59%) had poor physical fitness according to the FITNESSGRAM standards. Urban participants showed better scores in the majority of EUROFIT tests compared to their rural peers. The physical fitness of the whole population was worse compared to that of adolescents from some other countries e.g. Spain, Belgium, Turkey, Poland and Mexico. These findings indicate the need for specific health promotion programs aiming to improve physical fitness among Ecuadorian adolescents. In this study we also found a weak association between physical fitness and blood lipid profile, even after adjustment for energy intake (Chapter 3). A school-based health promotion program entitled "ACTIVITAL" was designed using the Intervention Mapping protocol and Comprehensive Participatory Planning and Evaluation approach. The program involved an individual and environmental component tailored to the local context and resources. The individual component included the delivery of an educational package organized at classroom level. The environmental component included (i) workshops with parents and staff in school canteens; (ii) social events at school such as an interactive session with famous young athletes and the preparation of a healthy breakfast and (iii) a walking trail that was drawn on the school playground (Chapter 2.2). A total of 1440 from 8th and 9th grade adolescents (intervention: n=700, 48.6%) from 20 schools (intervention: n=10, 50%) participated in the cluster-randomized pair-matched trial that lasted 28 months. Primary outcomes were dietary intake (24 recall questionnaire), physical fitness (EUROFIT battery), physical activity (accelerometers) and sedentary behaviors (screen-time self-reported questionnaire); the BMI, blood pressure, waist circumference were secondary outcomes. Results related to dietary intake, blood pressure and waist circumference were presented in a previous doctoral dissertation. We found that the school-based health promotion program can improve physical fitness, minimize the decline in physical activity levels (Chapter 4) and mitigate the increase in screen-time among Ecuadorian adolescents (Chapter 5). Specifically, the intervention program increased the vertical jump (mean intervention effect=2.5cm; 95%CI 0.8-4.2; P=0.01). Although marginally insignificant, adolescents from the intervention group increased less time for speed shuttle run (mean intervention effect=-0.8s, 95%CI -1.58-0.07; P=0.05). The proportion of students achieving over 60 minutes of moderate-to-vigorous physical activity / day decreased over time with the change in proportion significantly less in the intervention schools (6 vs. 18 percentage points, P<0.01). Adolescents on the intervention group reported watching less television (intervention effect =-14.8 min, 95%CI -27.4 -2.5; P=0.02) and they also showed decreased total screen-time (intervention effect =-25 min, 95%CI -47.9 -2.8; P=0.03) on a weekend day. Our results also suggest that the school-based health promotion program might improve the speed and muscular strength fitness components among low-fit and overweight/obese adolescents (Chapter 6). Specifically, the intervention effect on speed shuttle run was higher in overweight (intervention effect=-1.9 s, 95%CI -3.62 -0.08; P=0.04) adolescents compared to underweight (intervention effect =-1.7 s, 95%CI -6.31 to 2.97; P=0.5) or normal weight (intervention effect =-0.4s, 95%CI -1.63 to 0.93; P=0.6) peers. The intervention effect on vertical jump was higher in adolescents with poor physical fitness (intervention effect =3.7 cm, 95%CI 1.15; 6.28; P=0.005) compared to their fit (intervention effect =1.3 cm, 95%CI -1.77 to 4.32; P=0.4) peers. We conclude that a school-based health promotion program with relatively few intervention objectives, strategies and activities, but refined with stakeholder participation could have an effect on physical fitness, physical activity and screen-time behaviors of Ecuadorian adolescents. Future interventions should try to include the health education program as a part of the official school curriculum as well as try to identify the barriers to parents' participation in order to improve the effectiveness of the program (Chapter 7).
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