"Over-preoccupation with healthy food is perceived as worship of the body": Food, culture and beliefs in Ultra-Orthodox Jewish families.

BACKGROUND: Eating behaviours vary by culture and religion, and an understanding of attitudes and practices are essential for providing culturally competent nutritional guidance. The Ultra-orthodox Jewish community is characterized by poor diet, high rates of obesity, anemia and diabetes. This study aimed to acquire insights that could influence the promotion of healthier eating in the Ultra-orthodox and other closed religious communities, particularly regarding children's eating habits and the food they consume. METHODS: In depth face-to-face recorded interviews were conducted with 20 information-rich participants: religious leaders, opinion leaders and education/health professionals from Gur and Chabad, two Ultra-orthodox Jewish religious communities in Israel. The focus was on exploring young family eating behaviours and perceived challenges to encouraging healthier nutrition in the community. Interviews were transcribed and thematic analysis employed using grounded theory. RESULTS: Seven themes were identified with findings that had clear implications for the promotion of health at both the community and individual level. These included spiritual aspects of eating, deficits in knowledge and awareness, less relevance of kashrut than previously thought, the centrality of motherhood and family meals, the quality of food in educational institutions, the significance and sensitivity of Sabbath and festive meals and pragmatic considerations. DISCUSSION AND CONCLUSIONS: By illuminating attitudes and behaviors, the study broadens and enhances our understanding of the Ultra-orthodox communities' perspectives on eating behaviours in the family. The findings have the potential to contribute to strengths-based health promotion for children's nutrition. Recommendations regarding culturally competent guidance and implications for other secluded religious communities are discussed.

The impact of HENRY on parenting and family lifestyle: A national service evaluation of a preschool obesity prevention programme.

OBJECTIVES: One in five children in England are overweight/obese at school entry. Tackling obesity is therefore a priority. Right from the Start with HENRY is a widely-commissioned programme delivered by trained facilitators to small groups of parents over eight weekly sessions. It is designed to provide parents of infants and preschool children with the skills, knowledge and confidence required for a healthier family lifestyle. The aim of this work was to investigate programme impact using data collected routinely for quality control purposes. STUDY DESIGN: Analysis of routinely collected pre-post data from programmes delivered in the UK from January 2012 to February 2014. METHODS: Data were analysed from 144 programmes, including questionnaires relating to parenting, family eating behaviours, dietary intake, and physical activity/screen time. RESULTS: Over 24 months, 1100 parents attended programmes running in 86 locations. 788 (72%) completed >5 sessions of whom 624 (79%) provided baseline and completion questionnaires. Parents reported increases in healthiness of family lifestyle, parenting attributes, and emotional wellbeing following attendance (all P < .001). Both parents and children were reported to have increased their daily fruit/vegetable consumption, and reduced their consumption of high fat/sugar foods (both P < .001). There were also positive changes in eating behaviours, physical activity (P < .001) and children's screen time (P < .001). CONCLUSIONS: Significant changes were reported in all domains similar to those reported in a previous, smaller study in locations selected for experience and quality. The HENRY approach appears to have a beneficial impact even when delivered at scale in non-selected locations. Such changes, if maintained, may serve to protect against later obesity.

"It's like giving him a piece of me.": Exploring UK and Israeli women's accounts of motherhood and feeding.

OBJECTIVE: The present study explored how Israeli and UK mothers integrate feeding into their conceptualisations of mothering 2-6 months post-partum. BACKGROUND: The nature and importance of motherhood is subject to differential contextual, cultural, political and historical influences. We set out to compare experiences of motherhood and feeding between these two countries using a qualitative approach. METHODS: Forty one women (mean age 36.4 ± 2.7 years) from Israel and the UK, mostly married or in a committed relationship were interviewed about their experience of pregnancy, motherhood and feeding. Data were analysed thematically. RESULTS: The experience of motherhood in the early postnatal period was dominated, for all mothers, by the experience of breastfeeding and clustered around three representations of mothering, namely; 1) a devoted mother who ignores her own needs; 2) a mother who is available for her infant but acknowledges her needs as well; and 3) a struggling mother for whom motherhood is a burden. Such representations existed within both cultural groups and sometimes coexisted within the same mothers. UK women described more struggles within motherhood whereas a tendency towards idealising motherhood was observed for Israeli women. CONCLUSION: There are similarities in the ways that UK and Israeli women experienced motherhood and feeding. Where family life is strongly emphasized, mothers reported extremes of idealism and burden and associated an "ideal" mother with a breastfeeding mother. Where motherhood is represented as just one of many roles women take up, they are more likely to represent a "good enough" approach to mothering. Understanding the experience of motherhood and feeding in different cultural settings is important to provide the context for postnatal care specifically where mothers are reluctant to share problems or difficulties encountered.

What impact does community service learning have on medical students' appreciation of population health?

OBJECTIVES: The Bar Ilan Faculty of Medicine places public health as a priority in its medical curriculum, emphasizing its importance by strategically placing the required course as first on entry into medical school. Students are introduced to the importance of population health and community engagement through participatory community learning experiences. This study aims to examine how participatory community teaching methods impact students' understanding and attitudes towards community health. STUDY DESIGN: Mixed quantitative and qualitative design. METHODS: 75 first year students completed the required public health course utilizing participatory community methods, including community visits, Team Based Learning, an ethnic forum, and lifestyle medicine. Evaluation comprised skills assessment through project work, analysis of reflective notes and comparison of assessment scores with students in the previous year who experienced a formal lecture-only based curriculum. RESULTS: Students acquired public health skills, including conducting a needs assessment, searching for research evidence and designing an evaluation framework. Reflective notes revealed in-depth understanding not only of course aims, but an appreciation of the social determinants of health and the local community. Test marks indicated public health knowledge reached a comparable standard (83 ± 7.3) to the previous year (85 ± 9.3; P = 0.431). CONCLUSIONS: Participatory community learning equips students with public health skills, knowledge, and enhanced understanding of communities. It offers a way to effectively teach public health, while emphasizing the extended role and societal responsibilities of doctors.

An investigation into the dental health of children with obesity: an analysis of dental erosion and caries status.

AIM: To investigate whether children with obesity experienced more erosion and caries than children with normal weight. METHODS: This study involved children aged 7-15 years. The study and control group comprised 32 children with BMI > 98th centile and 32 healthy children with normal BMI-for-age, respectively. O'Sullivan Erosion Index and WHO Caries Index were used in the examination of erosion and caries, respectively. Stimulated salivary flow rate, buffering capacity, Streptococcus mutans and lactobacilli counts (CFU/ml) were evaluated. A cross-sectional questionnaire survey was employed to collect information on participant's demographic background, oral health history and habits, and utilisation of dental care services. RESULTS: Children with obesity were more likely to have erosion than healthy children (p < 0.001), and had more erosion in terms of severity (p < 0.0001) and area affected (p < 0.0001), but not in the number of surfaces affected (p = 0.167). Posterior teeth were less likely than anterior teeth to be affected by erosion (OR 0.32, 95 % CI 0.012-0.082). Gender had no effect on erosion. There were no statistically significant differences in the DMFT, saliva profiles or questionnaire responses between the groups. CONCLUSIONS: Children with obesity may have high risk of dental erosion, but do not necessarily have higher risk of dental caries than children with normal weight.

Combating child obesity: impact of HENRY on parenting and family lifestyle.

BACKGROUND: One-quarter of children in England are overweight/obese at school entry. We investigated the impact of a programme designed to provide parents of infants and preschool children with the skills required for a healthier family lifestyle. METHOD: A cohort of families was followed across the 8-week HENRY (Health Exercise Nutrition for the Really Young) parent course at nine locations in England. Seventy-seven parents enrolled on the course, of which 71 agreed to complete questionnaires addressing eating behaviours, dietary intake and parental self-efficacy. Pre- and post-course data was available from 60 (84.5%) parents (8-week follow-up data from 58 parents) and was analysed using repeated measures analyses. RESULTS: Significant changes were observed, with most sustained at follow-up. Parents reported increased self-efficacy and ability to encourage good behaviour (P < 0.001). Increased consumption of fruits and vegetables was reported in both children and adults, together with reduced consumption of sweets, cakes and fizzy drinks in adults (all P < 0.01). There were also positive changes in eating behaviours (e.g., frequency of family mealtimes and eating while watching television or in response to negative emotion [P < 0.01] ) and reduced screen time in adults (P < 0.001). DISCUSSION: The results build upon earlier evaluation, indicating that the HENRY intervention has a beneficial impact upon the families of infants and preschool children. Furthermore, the findings suggest that positive changes inspired by the programme can be maintained beyond its completion. Such changes may serve to protect against later obesity.

Costing a pilot complex community-based childhood obesity intervention.

BACKGROUND: Childhood obesity has significant impact on future health and economic consequences. Evidence of effectiveness of interventions is developing, although little is known about costs. Therefore, the direct costs to health care and other public sector agencies of a pilot community-based childhood obesity treatment programme were estimated. METHODS: The present study comprised a retrospective review of resource use of an intervention drawing resources from local government and primary care sectors and delivered across multiple settings. Ninety-six children, aged 8-16 years old; body mass index (BMI) >98th centile; mean BMI SD 3.1 and low quality of life scores attended a 12-month programme delivered by nonhealth professionals. Direct costs to health care and other public sector agencies were assessed. RESULTS: Total programme direct costs were £82,380 (€94,736, $123,569) in the base case or £120,474 (€138,546, $180,713) when venues were treated as real additional costs, and varied only slightly with the number of participants in the programme. Costs per participant were £858 (€987, $1287) in the base case or £1255 (€1443, $1883) when venues were treated as additional costs. Costs per participant were sensitive to the number of participants, varying between £691 (€795, $1037) and £2026 (€2330, $3039) when venue costs were zero and between £1009 (€1160, $1514) and £2978 (€3425, $4467) with venue costs added. CONCLUSIONS: It is possible to provide a community-based service at reasonable cost, and probably less than for health professional delivered services. Further work is required to assess the possible effects of the programme on wider service resource use, on users' costs and on programme effectiveness.

How good are BMI charts for monitoring children's attempts at obesity reduction?

INTRODUCTION: Body mass index (BMI) is the pragmatic measure to assess children's obesity clinically and BMI charts are widely used for counselling families about children's weight management over time. AIMS: To explore the variability in clinicians' interpretation of BMI patterns and to ascertain the diagnostic accuracy of their judgement by relating it to change in body composition by dual-emission x-ray absorptiometry (DXA). METHODS: Data from 70 children who participated in a trial of a weight management programme for obese children were analysed. BMI was plotted on UK 1990 charts at baseline, 6 months and 12 months, and four clinicians experienced in obesity management independently scored the charts on a five-point scale for how successful children were in tackling their obesity over a 6-month period. Scores were compared with change in BMI, fat mass and lean mass z-scores as measured by DXA. RESULTS: 54 children (aged 8-15 years; BMI z-score 2.93 (SD 0.48)) had simultaneous BMI and DXA scans performed, giving 104 pairs of measurements 6 months apart. There was good consistency between clinicians' scores for weight management and these related well to change in BMI and fat mass z-scores, but not lean mass z-score. They reported that measurement proximity to centile lines and crossing of lines influenced their confidence in making a decision and change in severe obesity was harder to judge as higher centile lines are so far apart. CONCLUSIONS: BMI charts are useful for assessing children's attempts at weight management, and provide a reasonably accurate indication of change in body fat. Recommendations are made regarding BMI chart design and guidance in interpreting measurements.

Training community practitioners to work more effectively with parents to prevent childhood obesity: the impact of HENRY upon Children's Centres and their staff.

BACKGROUND: One in four children in England is overweight/obese upon starting school. HENRY (Health Exercise Nutrition for the Really Young) offers a novel, preventive approach to this problem by training practitioners to work more effectively with the parents of preschool children around obesity and lifestyle issues. The programme is being delivered to all Sure Start Children's Centres (the UK government initiative providing family support and childcare in disadvantaged areas) in Leeds, UK. METHODS: The evaluation covered the first 12 Centres to be trained (these had a reach of approximately 5000 families). A series of semi-structured interviews were conducted with Centre managers, and 'drop boxes' were provided for all staff to leave their comments. Interviews took place up to 11 months post-training, allowing a consideration of any long-term impact. RESULTS: Data from 12 interviews and 106 comment slips indicated that HENRY training was associated with considerable changes to the Centre environment. Immediate effects included changes to Centre policy and practice, including the provision of age-appropriate portion sizes and the introduction of healthy snacks; a strengthening of team working and increased staff confidence around tackling lifestyle change; and enhanced skills when working with families. Training also induced changes within the staff's personal lives (e.g. increased physical activity and family mealtimes). CONCLUSIONS: The findings suggest that positive and lasting lifestyle effects can be achieved by brief training courses involving Children's Centre staff teams. Both staff and attendant families appear to benefit. The effect on levels of preschool obesity across the city once HENRY has extended to the remaining Centres is yet to be seen.

Identifying infants at risk of becoming obese: can we and should we?

OBJECTIVES: Increased understanding of the risk factors for childhood obesity has raised the possibility of identifying infants who are at risk of becoming overweight or obese, enabling early intervention for infants at high risk. This paper considers the known risk factors, describes statistical work aimed at identifying risk, and considers the ethical and practical issues of such a development. STUDY DESIGN AND METHODS: An overview of the published evidence for risk factors in the early development of overweight and obesity, and a statistical assessment of the practicality of developing a simple obesity risk assessment tool (ORT) for use in the primary care setting. RESULTS: Analysis of data from two currently available UK birth cohort studies suggests that an ORT based on these data does not provide acceptable levels of specificity and sensitivity for use in a primary care setting. CONCLUSION: Further development of an ORT using additional data and enhanced statistical analysis may lead to a practical tool. However the practical, ethical and legal issues involved in its use, and the public health policy considerations that follow must be resolved.

HENRY: development, pilot and long-term evaluation of a programme to help practitioners work more effectively with parents of babies and pre-school children to prevent childhood obesity.

BACKGROUND: Despite epidemic numbers of obese and overweight pre-school children, professionals report a lack of confidence and self-efficacy in working with parents around lifestyle change. HENRY--Health Exercise Nutrition for the Really Young--trains health and community practitioners to work more sensitively and effectively with parents of babies and pre-school children around obesity and lifestyle concerns. Underpinned by the Family Partnership Model, reflective practice and solution-focused techniques, it offers face-to-face training and e-learning. This paper describes the development, pilot and evaluation of HENRY Sure Start Children's Centres. METHODS: Twelve Children's Centres in Oxfordshire took part in the pilot involving 137 staff. Questionnaires were administered at the end of training courses. Self-reported confidence ratings were obtained before and after training. Postal questionnaires were sent to Centre managers 2-6 months later to ascertain long-term effects. Nine managers participated in in-depth interviews. A further 535 learners completed the e-learning course and online feedback. RESULTS: One hundred and thirty-one staff (96%) completed the training course and valued it as a way of enhancing skills and knowledge. Mean (±SD) self-reported confidence ratings increased (4.1 ± 0.7 to 7.2 ± 0.7; P < 0.00001). An influence on personal as well as professional lives was apparent. Long-term follow-up indicated ongoing impact attributed to HENRY on both Centres and staff. All 535 e-learners successfully completed: 98% would recommend HENRY; 94% thought it enhanced their skills as well as knowledge. CONCLUSIONS: HENRY is an innovative approach that offers some promise in tackling obesity through training community and health practitioners to work more effectively with parents of very young children. It appears to have an effect on participants' personal lives as well as professional work. A large-scale long-term study would be required to ascertain if there is the desired impact on young children's lifestyles and risk of obesity.

Weighing and measuring primary school children: evaluation of the TRENDS model for implementation of Department of Health guidelines.

BACKGROUND: The UK Department of Health for England and Wales has issued guidance to all local Primary Care Trusts (PCTs), who have responsibility for school nursing services, for the annual weighing and measuring of all children on entry to primary school and in Year 6 (age 5 and 11 years respectively), known as the National Child Measurement Programme. The guidance places the responsibility for implementation and funding of this scheme onto the PCTs. METHOD: This paper describes the conduct and evaluation of the 2006 monitoring exercise in a 10% sample of Leeds primary schools. RESULTS: The evaluation showed that the exercise can be carried out with little disruption in schools and minimal distress for children. CONCLUSIONS: Recommendations include: adequate staff training in measuring children, along with anticipation of the issues and problems they may encounter and best practice for dealing with them. A good working relationship must be established between the team and school before the measuring day. Schools need to ensure the availability of suitable accommodation and a screen to maintain privacy. Lightweight but robust and accurate scales conforming to the European Union standard should be used and routinely checked for accuracy. Where possible, children should not be lined up, but seen individually. This is considered essential for the older Year 6 children.

Pilot of "Families for Health": community-based family intervention for obesity.

OBJECTIVE: To develop and evaluate "Families for Health", a new community based family intervention for childhood obesity. DESIGN: Programme development, pilot study and evaluation using intention-to-treat analysis. SETTING: Coventry, England. PARTICIPANTS: 27 overweight or obese children aged 7-13 years (18 girls, 9 boys) and their parents, from 21 families. INTERVENTION: Families for Health is a 12-week programme with parallel groups for parents and children, addressing parenting, lifestyle change and social and emotional development. MAIN OUTCOME MEASURES: Change in baseline BMI z score at the end of the programme (3 months) and 9-month follow-up. Attendance, drop-out, parents' perception of the programme, child's quality of life and self-esteem, parental mental health, parent-child relationships and lifestyle changes were also measured. RESULTS: Attendance rate was 62%, with 18 of the 27 (67%) children completing the programme. For the 22 children with follow-up data (including four who dropped out), BMI z score was reduced by -0.18 (95% CI -0.30 to -0.05) at 3 months and -0.21 (-0.35 to -0.07) at 9 months. Statistically significant improvements were observed in children's quality of life and lifestyle (reduced sedentary behaviour, increased steps and reduced exposure to unhealthy foods), child-parent relationships and parents' mental health. Fruit and vegetable consumption, participation in moderate/vigorous exercise and children's self-esteem did not change significantly. Topics on parenting skills, activity and food were rated as helpful and used with confidence by most parents. CONCLUSIONS: Families for Health is a promising new childhood obesity intervention. Definitive evaluation of its clinical effectiveness by randomised controlled trial is now required.

Monitoring trends in childhood obesity: a simple school-based model.

BACKGROUND: The UK Government has set a target of halting the rise in childhood obesity by 2010. However, at the time the target was set, no monitoring process existed. The English Department of Health has now issued guidelines to primary care trusts for the annual weighing and measuring of all children on entry to primary school and in year 6. AIM: Development of an inexpensive school-based monitoring scheme for trends in childhood obesity suitable for national implementation. METHOD: The methodology was developed in 10 pilot schools in 2004 and implemented in 25 primary schools and three secondary schools in 2005. Specially trained healthcare support workers (HCSWs) recorded height and weight measurements of primary school children in reception and year 4, and secondary school children in year 8 (aged 5, 8 and 13 years, respectively, on average). The ethnic and socio-economic profile of the sample was compared with census data, and the levels of obesity were calculated using standard age cut-offs. RESULTS: While monitoring in primary schools was achieved with no evidence of disruption to the schools or distress to the subjects, monitoring in secondary schools was deemed to be impractical. Cost analysis indicated an estimated cost of less than 1.50 UK pounds per primary school child measured. CONCLUSIONS: The model provides a viable means of monitoring childhood obesity trends. Monitoring should be confined to primary schools and should be conducted by specially trained HCSWs rather than school nurses.

Dietary patterns, toothbrushing habits and caries experience of schoolchildren in West Yorkshire, England.

OBJECTIVE AND METHOD: The present study followed a group of 608 children, aged 7-11 years from six primary schools, for whom detailed dietary information was available. These children were traced four years later when they were in secondary school. The aim of the study was to investigate the relationship between the original dietary pattern, current dietary pattern, toothbrushing habit and oral health. Of the original children, 500 were traced to 32 secondary schools over a wide geographic area. For logistical reasons those in 18 schools were selected and positive consent and full data was obtained for 315 together with an additional group of 122 of their classmates. Three-day, self-reported dietary data was obtained, together with information on toothbrushing habits. A dental examination was carried out using BASCD survey methodology. RESULTS: The children in this study had a lower DMFT (0.82) than found in the most recent survey for the area (1.39). No significant relationship was found between sugar-sweetened foods or drinks at age 7-11 and caries in the first permanent molar teeth at age 11-15 years, however a significant relationship was found between current sugar-sweetened drinks consumption and caries. Significantly less caries was associated with the reported moderate consumption of dairy products by the children when aged 11-15 years. The bedtime consumption of NMES drinks at 7-11 was significantly associated with an increase in caries as was the bedtime consumption of non-milk extrinsic sugars (NMES) foods at 11-15 years. A significant inverse relationship was found between claimed toothbrushing frequency and caries. Of those children aged 11-15 years claiming to brush at least once a day, 69% were caries-free with a mean DMFT of 0.69. Of the children who claimed to brush only occasionally or never, 52% were caries-free and they had a mean DMFT of 1.05. CONCLUSION: The reported consumption of sugar-sweetened drinks and the lack of regular toothbrushing were found to be the factors most strongly linked to caries and this finding is consistent with other recent studies.

The TRENDS Project: development of a methodology to reliably monitor the obesity epidemic in childhood.

AIMS: The government has set a target to halt the rise in childhood obesity in those aged under 11 by 2010, but no system is in place to ascertain if this has been achieved. We aimed to develop a simple and reproducible methodology to monitor trends in childhood obesity. METHODS: A purposive sample of 10 primary schools and three secondary schools was selected. Children were measured with parental "opt out" consent in reception class, year 4, and year 8 (ages 5, 9, and 13 years, respectively). Measurements were compared with those obtained locally in 1996-2001. Calculations were then performed to ascertain the sample size required to confidently identify a halt in the rise in obesity using three growth measures. RESULTS: A total of 999 children were measured with ascertainment of 95% in primary and 85% in secondary schools. The proportion of overweight and obese children aged 9 and 13 years had increased since 1996-2001, although only 9 year olds showed a significant rise. A general trend of an increase in obesity was observed with increasing age. Calculations showed that 1900-2400 children per age group are needed to detect a halt in the rise in obesity based on mean body mass index (BMI) standard deviation scores (SDS) by 2010 with 90% power, whereas 4200-10 500 children are needed for other measures. CONCLUSION: We have developed a simple, cost effective methodology for accurately measuring the epidemic and recommend the use of mean BMI SDS for demonstrating if a halt has been achieved.

What is the long term outcome for children who fail to thrive? A systematic review.

AIMS: To ascertain the long term outcomes in children diagnosed as having failure to thrive (FTT). METHODS: Systematic review of cohort studies. Medline, Psychinfo, Embase, Cinahl, Web of Science, Cochrane, and DARE databases were searched for potentially relevant studies. INCLUSION CRITERIA: cohort studies or randomised controlled trials in children <2 years old with failure to thrive defined as weight <10th centile or lower centile and/or weight velocity <10th centile, with growth, development, or behaviour measured at 3 years of age or older. RESULTS: Thirteen studies met the inclusion criteria; eight included a comparison group, of which five included children identified in community settings. Two were randomised controlled trials. Attrition rates were 10-30%. Data from population based studies with comparison groups and which reported comparable outcomes in an appropriate form were pooled in a random effects meta-analysis. Four studies report IQ scores at follow up and the pooled standardised mean difference was -0.22 (95% CI -0.41 to -0.03). Two studies reported growth data as standard deviation scores. Their pooled weighted mean difference for weight was -1.24 SDS (95% CI -2.00 to -0.48), and for height -0.87 SDS (95% CI -1.47 to -0.28). No studies corrected for parental height, but two reported that parents of index children were shorter. CONCLUSIONS: The IQ difference (equivalent to approximately 3 IQ points) is of questionable clinical significance. The height and weight differences are larger, but few children were below the 3rd centile at follow up. It is unclear to what extent observed differences reflect causal relations or confounding due to other variables. In the light of these results the aggressive approach to identification and management of failure to thrive needs reassessing.