How to reduce parental provision of unhealthy foods to 3- to 8-year-old children in the home environment? A systematic review utilizing the Behaviour Change Wheel framework.

BACKGROUND AND OBJECTIVE: The effectiveness of obesity prevention interventions to improve children's diet can be enhanced. Deconstructing past interventions can identify components with potential to change behaviour. This systematic review using the Behaviour Change Wheel aimed to examine the behaviour change content of interventions supporting parents of 3- to 8-year olds to reduce provision of unhealthy foods to children. METHODS: Ebscohost, Ovid, Scopus and Web of Science were searched. Eligible studies included controlled interventions with active parent involvement, at least one intervention strategy and outcome measure for unhealthy foods ≥3 months from baseline. Seventeen interventions were included describing 18 intervention arms. RESULTS: Interventions frequently targeted parents' reflective motivation (n = 17) and psychological capability (n = 15), through education (n = 15) or enablement (n = 15) intervention functions and service provision (n = 18) policy category. Only 24 of the 93 behaviour change techniques were used with an average of five techniques used per intervention. CONCLUSIONS: Existing interventions achieving small reductions in unhealthy food intake are homogenous in approach. There is potential to utilize untapped behaviour change techniques, through comprehensive intervention design and behavioural analysis guided by the Behaviour Change Wheel. Interventions targeting opportunity through persuasion, modelling or environmental restructuring, and using different policy categories are urgently needed to provide an evidence base to inform policy and practice.

The adaptation and translation of the PEACH™ RCT intervention: the process and outcomes of the PEACH™ in the community trial.

OBJECTIVE: To describe the process and report selected outcomes of translating an effective child weight management initiative (PEACH™) from a randomised controlled trial intervention to a community health programme. STUDY DESIGN AND METHODS: Pre-post study design utilising the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) evaluation framework. Adaptation of PEACH™ required significant promotional activity and consideration of legal, ethical and financial issues. PEACH™ components were revised and an evaluation design based on the RE-AIM framework was developed. Facilitator training workshops were made available to South Australian health or education professionals initially, then opened up to new graduates, interstate dietitians and others interested in professional development. Facilitators completed pretraining and post-training questionnaires and a third questionnaire following programme delivery. Data were collected from families by facilitators and returned to university staff for assessment of change (baseline to programme end) in body mass index (BMI) and waist circumference (WC) z-scores. RESULTS: Changes to organisational and political environments prevented maximum programme reach and adoption. Nonetheless, data indicated that PEACH™ was effective at improving facilitators' confidence (P < 0.05) and children's (n = 37) BMI z-score (-0.17, 95% confidence interval [CI]: 0.03:0.30, P = 0.016), WC z-score (-0.14, 95% CI: -0.02:0.30, P = 0.09) and lifestyle behaviours. Collection of maintenance data was prevented due to time and financial constraints. CONCLUSIONS: Translational research needs to develop ways to effectively and efficiently bridge the gap between behavioural research and practice to improve the adoption of evidence-based approaches to child weight management. Nutrition educators and researchers can drive these nutrition-focussed translational research efforts forward. Funding bodies and health service organisations are encouraged to provide financial and structural support for such activity.

Validity of short food questionnaire items to measure intake in children and adolescents: a systematic review.

BACKGROUND: Short food questions are appealing to measure dietary intakes. METHODS: A review of studies published between 2004 and 2016 was undertaken and these were included in the present study if they reported on a question or short item questionnaire (≤50 items, data presented as ≤30 food groups) measuring food intake or food-related habits, in children (aged 6 months to 18 years), and reported question validity or reliability. Thirty studies met the inclusion criteria. RESULTS: Most questions assessed foods or food groups (n = 29), with the most commonly assessed being fruit (n = 22) or vegetable intake (n = 23), dairy foods and discretionary foods (n = 20 studies each). Four studies assessed food habits, with the most common being breakfast and meal frequency (n = 4 studies). Twenty studies assessed reliability, and 25 studies determined accuracy and were most commonly compared against food records. Evaluation of question performance relied on statistical tests such as correlation. CONCLUSIONS: The present study has identified valid and reliable questions for the range of key food groups of interest to public health nutrition. Questions were more likely to be reliable than accurate, and relatively few questions were both reliable and accurate. Gaps in repeatable and valid short food questions have been identified that will provide direction for future tool development.

Australasian nutrition research for prevention and management of child obesity: innovation and progress in the last decade.

BACKGROUND/OBJECTIVE: The Food and Nutrition stream of Australasian Child and Adolescent Obesity Research Network (ACAORN) aims to improve the quality of dietary methodologies and the reporting of dietary intake within Australasian child obesity research (http://www.acaorn.org.au/streams/nutrition/). METHODS/RESULTS: With 2012 marking ACAORN's 10th anniversary, this commentary profiles a selection of child obesity nutrition research published over the last decade by Food and Nutrition Stream members. In addition, stream activities have included the development of an online selection guide to assist researchers in their selection of appropriate dietary intake methodologies (http://www.acaorn.org.au/streams/nutrition/dietary-intake/index.php). CONCLUSIONS: The quantity and quality of research to guide effective child obesity prevention and treatment has increased substantially over the last decade. ACAORN provides a successful case study of how research networks can provide a collegial atmosphere to foster and coordinate research efforts in an otherwise competitive environment.

Dietary patterns of Australian children aged 14 and 24 months, and associations with socio-demographic factors and adiposity.

BACKGROUND/OBJECTIVES: Previous research has shown, in predominantly European populations, that dietary patterns are evident early in life. However, little is known about early-life dietary patterns in Australian children. We aimed to describe dietary patterns of Australian toddlers and their associations with socio-demographic characteristics and adiposity. SUBJECTS/METHODS: Principal component analysis was applied to 3 days (1 × 24-h recall and 2 × 24-h record) data of 14 (n=552)- and 24 (n=493)-month-old children from two Australian studies, NOURISH and South Australian Infant Dietary Intake (SAIDI). Associations with dietary patterns were investigated using regression analyses. RESULTS: Two patterns were identified at both ages. At 14 months, the first pattern was characterised by fruit, grains, vegetables, cheese and nuts/seeds ('14-month core foods') and the second pattern was characterised by white bread, milk, spreads, juice and ice-cream ('basic combination'). Similarly, at 24 months the '24-month core foods' pattern included fruit, vegetables, dairy, nuts/seeds, meat and water, whereas the 'non-core foods' included white bread, spreads, sweetened beverages, snacks, chocolate and processed meat. Lower maternal age and earlier breastfeeding cessation were associated with higher 'basic combination' and 'non-core foods' pattern scores, whereas earlier and later solid introduction were associated with higher 'basic combination' and '24-month core foods' pattern scores, respectively. Patterns were not associated with body mass index (BMI) z-score. CONCLUSIONS: Dietary patterns reflecting core and non-core food intake are identifiable in Australian toddlers. These findings support the need to intervene early with parents to promote healthy eating in children and can inform future investigations on the effects of early diet on long-term health.

Sleep duration or bedtime? Exploring the association between sleep timing behaviour, diet and BMI in children and adolescents.

OBJECTIVE: To determine whether sleep timing behaviour is associated with energy intake and diet quality in children and adolescents. DESIGN: Cross-sectional analysis of nationally representative survey data. SAMPLE: A total of 2200 participants of the 2007 Australian National Children's Nutrition and Physical Activity Survey aged 9-16 years with 2 days of food intake data, 4 days of use of time data and complete anthropometry. Participants were grouped into one of four sleep-wake behaviour categories: early bed-early rise (EE); early bed-late rise (EL); late bed-early rise (LE) and late bed-late rise (LL). The four categories were compared for body mass index (BMI) z-score, energy intake and diet quality assessed using the Dietary Guideline Index for Children and Adolescents. Analyses were adjusted for survey design, sociodemographic characteristics, sleep duration and physical activity level (PAL). RESULTS: In adjusted multivariate regression models with sleep timing behaviour group as the independent variable, the 'LL' category compared with the 'EE' category had a higher BMI z-score (ß=0.20, 95% confidence interval (CI) 0.06 to 0.34, P=0.007), and lower diet quality (ß=-4.0, 95% CI -5.7 to -2.3, P<0.001). Children and adolescents who went to bed late also had a higher intake of extra foods (that is, energy-dense, nutrient-poor foods) while those whom went to bed early consumed more fruit and vegetables. Energy intake was associated with sleep duration (ß=-4.5 kJ, 95% CI -6.7 to -2.4, P<0.001), but not sleep timing behaviour. CONCLUSION: Late bedtimes and late wake up times are associated with poorer diet quality, independent of sleep duration, PAL and child and sociodemographic characteristics.

The quality of dietary intake methodology and reporting in child and adolescent obesity intervention trials: a systematic review.

Assessing dietary intake is important in evaluating childhood obesity intervention effectiveness. The purpose of this review was to evaluate the dietary intake methods and reporting in intervention studies that included a dietary component to treat overweight or obese children. A systematic review of studies published in the English language, between 1985 and August 2010 in health databases. The search identified 2,295 papers, of which 335 were retrieved and 31 met the inclusion criteria. Twenty-three studies reported energy intake as an outcome measure, 20 reported macronutrient intakes and 10 studies reported food intake outcomes. The most common dietary method employed was the food diary (n = 13), followed by 24-h recall (n = 5), food frequency questionnaire (FFQ) (n = 4) and dietary questionnaire (n = 4). The quality of the dietary intake methods reporting was rated as 'poor' in 15 studies (52%) and only 3 were rated as 'excellent'. The reporting quality of FFQs tended to be higher than food diaries/recalls. Deficiencies in the quality of dietary intake methods reporting in child obesity studies were identified. Use of a dietary intake methods reporting checklist is recommended. This will enable the quality of dietary intake results to be evaluated, and an increased ability to replicate study methodology by other researchers.

The impact of replacing regular- with reduced-fat dairy foods on children's wider food intake: secondary analysis of a cluster RCT.

BACKGROUND/OBJECTIVES: The effect of changing one aspect of diet needs to be considered within the context of total diet. The study aim was to evaluate the changes in children's overall food intake following replacement of regular-fat with reduced-fat dairy foods. SUBJECTS/METHODS: Secondary analysis of a cluster Randomized Controlled Trial where families were received parental behavioral nutrition education to change to reduced-fat dairy foods (intervention) or reduce screen time (comparison control). Food intake was assessed via multiple 24-h recalls at baseline, week 12 (end of the intervention) and week 24. Participants were parents and their children (4-13 years, N=145) who were regular-fat dairy food consumers. The intervention effect was based on mixed model analysis adjusted for covariates, and baseline food intake. RESULTS: At week 24, total dairy servings per day were similar between groups and servings of reduced-fat dairy foods were higher in the intervention group (0.8 servings per day 95% confidence interval (CI) 0.5-1.1, P<0.0001). Fruit intake was higher in the intervention group (0.5 servings per day 95% CI 0.02-0.9, P=0.040), with no other statistically significant differences in food intake. In the intervention group, the contribution of core food groups to saturated fat intake was 45% at baseline and 31% at week 24, with 'extra foods' being the largest contributor to total energy (28%) and saturated fat (40%) intake at follow-up. CONCLUSIONS: Changing children's dairy food choices to reduced-fat varieties did not adversely affect overall food intake. Replacing energy-dense foods with nutrient-rich foods should be the focus of interventions to lower in saturated fat.

Associations between dietary patterns at 6 and 15 months of age and sociodemographic factors.

BACKGROUND/OBJECTIVES: Data from the Avon Longitudinal Study of Parents and Children (ALSPAC) have previously shown that dietary patterns are observable by 3 years. However, it is not clear when dietary patterns emerge. We aimed to describe dietary patterns in early life and their associations with maternal and infant sociodemographic characteristics. SUBJECTS/METHODS: Principal component analysis was applied to diet questionnaires of ALSPAC participants at 6 months (n = 7052) and 15 months (n = 5610) to extract dietary patterns. The sociodemographic factors associated with dietary patterns were investigated using regression analyses. RESULTS: Four dietary patterns were extracted at both 6 and 15 months. A traditional-style pattern characterized by home-prepared meats, vegetables and desserts, a second pattern characterized by ready-prepared baby foods and a third pattern characterized by discretionary foods such as biscuits, sweets and crisps were identified at both ages. At 6 months, the fourth pattern was characterized predominantly by breastfeeding and at 15 months, by contemporary-style foods including herbs, legumes, nuts, raw fruit and vegetables. Higher maternal age and education, number of siblings and lower body mass index (BMI) was associated with higher scores on the breastfeeding or meat, vegetables and desserts patterns, whereas higher discretionary food pattern scores were associated with younger maternal age, lower education, higher BMI and more siblings. Associations between sociodemographic factors and the ready-prepared baby food pattern scores were inconsistent across ages. CONCLUSIONS: Dietary patterns emerge from infancy and are associated with sociodemographic characteristics.

Interventions that involve parents to improve children's weight-related nutrition intake and activity patterns - what nutrition and activity targets and behaviour change techniques are associated with intervention effectiveness?

Parent involvement is an important component of obesity prevention interventions. However, the best way to support parents remains unclear. This review identifies interventions targeting parents to improve children's weight status, dietary and/or activity patterns, examines whether intervention content and behaviour change techniques employed are associated with effectiveness. Seventeen studies, in English, 1998-2008, were included. Studies were evaluated by two reviewers for study quality, nutrition/activity content and behaviour change techniques using a validated quality assessment tool and behaviour change technique taxonomy. Study findings favoured intervention effectiveness in 11 of 17 studies. Interventions that were considered effective had similar features: better study quality, parents responsible for participation and implementation, greater parental involvement and inclusion of prompt barrier identification, restructure the home environment, prompt self-monitoring, prompt specific goal setting behaviour change techniques. Energy intake/density and food choices were more likely to be targeted in effective interventions. The number of lifestyle behaviours targeted did not appear to be associated with effectiveness. Intervention effectiveness was favoured when behaviour change techniques spanned the spectrum of behaviour change process. The review provides guidance for researchers to make informed decisions on how best to utilize resources in interventions to support and engage parents, and highlights a need for improvement in intervention content reporting practices.

School lunch and learning behaviour in primary schools: an intervention study.

BACKGROUND/OBJECTIVES: In addition to the nutritional benefits of healthier school food, anecdotes describe improvements in children's behaviour and educational outcomes when school food or the school dining room environment is improved. This study hypothesized that a school food and dining room intervention would improve pupils' learning-related classroom behaviour. SUBJECTS/METHODS: A controlled intervention trial involving six primary schools matched in triplets and randomly assigned to a 12-week intervention (promotion of healthier school food at lunchtime and changes in the school dining environment) or 12-week wait-listed control group. Study outcome was learning-related behaviours measured in a random sample of 146 pupils in years 3-5. RESULTS: On-task and off-task behaviours were observed and used as proxy measures for concentration and disengagement (disruption), respectively. Teacher-pupil on-task engagement was 3.4 times more likely in the intervention schools compared with the control schools (adjusted model odds ratio (OR)=3.40 (95% confidence interval (CI)=1.56, 7.36), P=0.009). However, on-task pupil-pupil behaviour was less likely in the intervention group (adjusted model OR=0.45 (95% CI=0.28, 0.70), P<0.001). Similarly, off-task pupil-pupil behaviour was more likely in the intervention group than in the control group in both the unadjusted model (OR=2.18 (95% CI=1.52, 3.13), P<0.001) and the adjusted model (OR=2.28 (95% CI=1.25, 4.17), P=0.007). CONCLUSIONS: This study offers some support for the hypothesis that a school food and dining room intervention can have a positive impact on pupils' alertness. However, if raised alertness is not channelled and supervised, it may result in increased off-task behaviour when pupils are working together.

Comparison of metabolic syndrome prevalence using six different definitions in overweight pre-pubertal children enrolled in a weight management study.

OBJECTIVES: To assess the implications of variation in Metabolic Syndrome (MS) definition (biochemical and anthropometric indicators) on MS prevalence estimates in a population of overweight and mildly obese children. DESIGN: Cross-sectional study. SUBJECTS: Ninety-nine (64 girls) overweight or mildly obese, but otherwise healthy, pre-pubertal 6-9-year olds recruited for a randomized controlled trial of weight management. MEASURES: Height, weight and waist circumference were measured with BMI and waist z-scores calculated. Fasting cholesterol and fractions, glucose and insulin were measured, together with systolic and diastolic blood pressure (BP). Anthropometric and metabolic indicators were classified as normal or elevated using adult- or child-specific cut points with clustering of MS indicators also assessed using two adult and three child-specific definitions. RESULTS: A total of 0-4% of subjects were classified with MS when adult definitions were applied. This increased to between 39 and 60% using child-specific definitions, varying according to whether hyperinsulinaemia was central to the MS classification. Systolic BP, triglycerides, total cholesterol, high-density lipoprotein cholesterol and waist z-score increased across insulin quartiles (P<0.05). The use of body mass index and waist circumference in the MS definition classified the same subjects. CONCLUSIONS: The classification of MS in children depends strongly on the definition chosen, with MS prevalence estimates higher if insulin is part of the definition and child-specific cut points for metabolic indicators are used. Hyperinsulinaemia and MS are common consequences of childhood obesity but they are not commonly part of the assessment or management plan for weight management in children. There is a need for the establishment of normal insulin ranges and consistent definition of MS in childhood and adolescence.