Evaluating the Change4Life Food Scanner app in reducing children's sugar intake: a randomised pilot and feasibility study.

BACKGROUND: The Change4Life Food Scanner app displays nutritional information using visual images alongside traffic light labels. The app's effectiveness for improving dietary choices is unknown. This study investigated the feasibility and acceptability of evaluating the effectiveness of the Food Scanner app in reducing children's sugar intake in the UK. METHODS: Adopting a non-blinded parallel trial design, we randomly assigned (1:1) 126 parents of children aged 4-11 years through block randomisation sequences into a 3-month intervention consisting of exposure to the Change4Life Food Scanner app (version 1.6; ie, the intervention group [n=62]) or no intervention (ie, the control group [n=64]). Participants completed baseline and 3-month post-intervention measures of dietary intake (3-day food diary) and trial acceptability measures. The intervention group completed fortnightly app engagement measures. Ethical approval was obtained by the University of Sheffield Research Ethics Committee (026380). FINDINGS: 64 (51%) of 126 participants completed the study (29 [45%] in the intervention group and 35 [55%] in the control group). 51 (80%) of 64 reported that the study was easy to complete and 62 (97%) found receiving task completion reminders helpful. App engagement decreased throughout the study (eg, mean engagement time was 18·01 min [SD 27·15] in week 2, and 6·76 min [11·56] in week 12). 18 (64%) of 28 participants reported high overall app acceptability; however, seven (25%) did not find the app helpful. 24 (86%) of 28 reported high acceptability for the app's use of sugar cube images, which were rated as easy to understand and useful to supplement front of package nutritional labels. Six (21%) of 28 did not find sugar cube images helpful and 20 (71%) had low acceptability of the app aiding food purchasing decisions. 45 (73%) of 62 were willing to continue with the study for a 12-month trial. INTERPRETATION: Despite a high attrition rate, study procedures were considered acceptable by most participants. Acceptability of the Food Scanner app was varied, and participants did not find the app helpful for food purchases. Analysis of preliminary efficacy of the intervention is ongoing, which will inform design parameters for a future large-scale trial. FUNDING: Wellcome Trust.

Timing of energy intake and BMI in children: differential impacts by age and sex.

Body weight regulation may be influenced by the timing of food intake. The relationship between children's BMI and their daily pattern of energy consumption was investigated using data from the UK National Diet and Nutrition Survey 2008-2019. The sample included 6281 children aged 4-18 years. Linear and logistic regression models investigated the timing of energy intake (103 kJ) as a predictor of BMI (kg/m2) and healthy weight status. The models showed that children aged 4-10 years who consume more energy content after 20:00, in comparison with less energy content, had a significantly higher BMI (young girls: ß = 0·159; 95 % CI 0·003, 0·315; P = 0·05; young boys: ß = 0·166; 95 % CI 0·028, 0·304; P = 0·02). Similar findings were also present for boys aged 11-18 years (ß = 0·091; 95 % CI 0·003, 0·180; P = 0·04), though logistic regression findings were contradictory (OR = 0·9566; 95 % CI 0·926, 0·989; P = 0·009). However, older girls who consumed more energy content in the morning had a significantly lower BMI (ß = -0·464; 95 % CI -0·655, -0·273; P < 0·001) and a lower probability of non-healthy weight (OR = 0·901; 95 % CI 0·826, 0·982; P = 0·02). Physical activity reduced the likelihood of unhealthy weight status. The data suggest that food consumption later in the day in childhood and into adolescence may increase the risk of a higher BMI, especially for less active children. Developing guidance on appropriate meal timings and recommended energy distribution throughout the day could promote healthier lifestyles. Doing so may help increase parental awareness of timing of food intake and its potential impact on BMI.

Predictors of Physician Recommendation for Ethically Controversial Medical Procedures: Findings from an Exploratory National Survey of American Muslim Physicians.

Physician religiosity can influence their ethical attitude toward medical procedures and can thereby impact healthcare delivery. Using a national survey of American Muslim physicians, we explored the association between physician recommendation of three controversial medical procedures--tubal ligation, abortion, and porcine-based vaccine--and their (1) religiosity, (2) utilization of bioethics resources, and (3) perception of whether the procedure was a medical necessity and if the scenario represented a life threat. Generally, multivariate models found that physicians who read the Qur'an more often as well as those who perceived medical necessity and/or life threat had a higher odds recommending the procedures, whereas those who sought Islamic bioethical guidance from Islamic jurists (or juridical councils) more often had a lower odds. These associations suggest that the bioethical framework of Muslim physicians is influenced by their reading of scripture, and the opinions of Islamic jurists and that these influences may, paradoxically, be interpreted to be in opposition over some medical procedures.

Economic and health impacts of the Change4Life Food Scanner app: Findings from a randomized pilot and feasibility study.

Introduction: The UK Government developed the Change4Life Food Scanner app to provide families with engaging feedback on the nutritional content of packaged foods. There is a lack of research exploring the cost-effectiveness of dietary health promotion apps. Methods: Through stakeholder engagement, a conceptual model was developed, outlining the pathway by which the Food Scanner app leads to proximal and distal outcomes. The conceptual model informed the development of a pilot randomized controlled trial which investigated the feasibility and acceptability of evaluating clinical outcomes in children and economic effectiveness of the Food Scanner app through a cost-consequence analysis. Parents of 4-11 years-olds (n = 126) were randomized into an app exposure condition (n = 62), or no intervention control (n = 64). Parent-reported Child Health Utility 9 Dimension (CHU9D) outcomes were collected alongside child healthcare resource use and associated costs, school absenteeism and parent productivity losses at baseline and 3 months follow up. Results for the CHU9D were converted into utility scores based on UK adult preference weights. Sensitivity analysis accounted for outliers and multiple imputation methods were adopted for the handling of missing data. Results: 64 participants (51%) completed the study (intervention: n = 29; control: n = 35). There was a mean reduction in quality adjusted life years between groups over the trial period of -0.004 (SD = 0.024, 95% CI: -0.005; 0.012). There was a mean reduction in healthcare costs of -£30.77 (SD = 230.97; 95% CI: -£113.80; £52.26) and a mean reduction in workplace productivity losses of -£64.24 (SD = 241.66, 95% CI: -£147.54; £19.07) within the intervention arm, compared to the control arm, over the data collection period. Similar findings were apparent after multiple imputation. Discussion: Modest mean differences between study arms may have been due to the exploration of distal outcomes over a short follow-up period. The study was also disrupted due to the coronavirus pandemic, which may have confounded healthcare resource data. Although measures adopted were deemed feasible, the study highlighted difficulties in obtaining data on app development and maintenance costs, as well as the importance of economic modeling to predict long-term outcomes that may not be reliably captured over the short-term. Clinical trial registration: https://osf.io/, identifier 62hzt.

Quality of Life in Children and Young People With Congenital Adrenal Hyperplasia-UK Nationwide Multicenter Assessment.

CONTEXT: Quality of life (QoL) has been inconsistently reported in children and young people (CYP) with congenital adrenal hyperplasia (CAH). OBJECTIVE: Assess QoL in CYP with CAH in the UK alongside biometric and androgen profiles. DESIGN: To define the evidence base for health care delivery, we conducted a cross-sectional study in CYP with CAH in the UK. Questionnaire results were compared with normative data and between groups, and modelled for association with sex, height, weight, body mass index, or steroid biomarkers of CAH control. SETTING: Tertiary care in 14 UK centers. PATIENTS: Results from 104 patients, 55% female, mean age 12.7 years (SD 3.0), paired responses from parents. INTERVENTIONS: Strengths and Difficulties questionnaire (SDQ) and pediatric QoL questionnaire. MAIN OUTCOME MEASURE: Total QoL scores as assessed by SDQ and a pediatric QoL questionnaire in comparison to normative data. RESULTS: Total scores were worse in parents than normative data, but similar in patients. Patient QoL was rated better in social functioning but worse in emotional, school, and peer domains by patients, and worse in total scores and domains of peer problems, and psychosocial, emotional, and school functioning by parents. Parents consistently scored QoL of their children lower than their child. Larger height-SD score and lower weight-SD score were associated with better QoL. Girls with lower steroid biomarkers had worse SDQ scores. CONCLUSIONS: In CYP with CAH, reduced height, increased weight, and hormonal biomarkers consistent with overtreatment were associated with worse QoL; addressing these problems should be prioritized in clinical management.Clinical Trials Registration Number: SCH/15/088.

Methods for the economic evaluation of obesity prevention dietary interventions in children: A systematic review and critical appraisal of the evidence.

OBJECTIVES: We aim to describe and provide a discussion of methods used to conduct economic evaluations of dietary interventions in children and adolescents, including long-term modelling, and to make recommendations to assist health economists in the design and reporting of such evaluations. METHODS: A systematic review was conducted in 11 bibliographic databases and the grey literature with searches undertaken between January 2000 and December 2021. A study was included if it (1) was an economic evaluation or modelling study of an obesity-prevention dietary intervention and (2) targeted 2- to 18-year-olds. RESULTS: Twenty-six studies met the inclusion criteria. Twelve studies conducted an economic evaluation alongside a clinical trial, and 14 studies modelled long-term health and cost outcomes. Four overarching methodological challenges were identified: modelling long-term impact of interventions, measuring and valuing health outcomes, cost inclusions and equity considerations. CONCLUSIONS: Variability in methods used to predict, measure and value long-term benefits in adulthood from short-term clinical outcomes in childhood was evident across studies. Key recommendations to improve the design and analysis of future economic evaluations include the consideration of weight regain and diminishing intervention effects within future projections; exploration of wider intervention benefits not restricted to quality-of-life outcomes; and inclusion of parental or caregiver opportunity costs.

An Assessment of Behavior Change Techniques in Two Versions of a Dietary Mobile Application: The Change4Life Food Scanner.

The Change4Life Food Scanner app is a UK Government dietary app designed to provide feedback on the nutritional content of packaged foods to parents and their children. To understand its intended mechanism of behavior change and how Behavior Change Technique (BCT) content evolves with app updates, this research aimed to map out the BCTs of two versions of the Change4Life Food Scanner app. Two coders undertook a descriptive comparative analysis of the use of BCTs in the Food Scanner app using the Behavior Change Technique Taxonomy [both the outdated (v1.6) and updated (v2.0) versions of the app were coded]. Results showed that both versions encompass the BCTs "goal setting (behavior)", "feedback on behavior", "social support (unspecified)", "instruction on how to perform behavior", "salience of consequences", "prompts/cues" and "credible source". The outdated version contained the BCT "behavior substitution" which had been dropped in the updated version. The updated version featured the additional BCTs "information about social and environmental consequences", "information about emotional consequences", "social reward" and "social incentive" and was comparatively more BCT intensive in terms of content and occurrence. The BCT content of the Food Scanner app resembles that of existing dietary apps and incorporates several BCTs which have previously been found to be effective. Future work to evaluate the effectiveness of the app is recommended. This will provide insight into whether the combination of BCTs used in the Change4Life Food Scanner app are effective in improving dietary choices.

Health status of children and young persons with congenital adrenal hyperplasia in the UK (CAH-UK): a cross-sectional multi-centre study.

Objective: There is limited knowledge on the onset of comorbidities in congenital adrenal hyperplasia (CAH) during childhood. We aimed to establish the health status of children with CAH in the UK. Design and methods: This cross-sectional multicentre study involved 14 tertiary endocrine UK units, recruiting 101 patients aged 8-18 years with classic 21-hydroxylase deficiency and 83 controls. We analysed demographic, clinical and metabolic data, as well as psychological questionnaires (Strengths and Difficulties (SDQ), Paediatric Quality of Life (PedsQL)). Results: Patient height SDS in relation to mid-parental height decreased with age, indicating the discrepancy between height achieved and genetic potential height. Bone age was advanced in 40.5% patients, with a mean difference from the chronological age of 1.8 (±2.3) years. Patients were more frequently overweight (27%) or obese (22%) compared to controls (10.8% and 10.8%, respectively, P < 0.001). No consistent relationship between glucocorticoid dose and anthropometric measurements or hormonal biomarkers was detected. A small number of patients had raised total cholesterol (3.0%), low HDL (3.0%), raised LDL (7.0%) and triglycerides (5.0%). SDQ scores were within the 'high' and 'very high' categories of concern for 16.3% of patients. 'School functioning' was the lowest PedsQL scoring dimension with a median (interquartile range) of 70 (55-80), followed by 'emotional functioning' with a median of 75 (65-85). Conclusions: Our results show an increased prevalence of problems with growth and weight gain in CAH children and suggest reduced quality of life. This highlights the urgent need to optimise management and monitoring strategies to improve long-term health outcomes.

Measurement of Salivary Adrenal-Specific Androgens as Biomarkers of Therapy Control in 21-Hydroxylase Deficiency.

BACKGROUND: Monitoring of hormonal control represents a key part of the management of congenital adrenal hyperplasia (CAH). Monitoring strategies remain suboptimal because they rely on frequent blood tests and are not specific for adrenal-derived hormones. Recent evidence suggests the crucial role of adrenal-specific 11-oxygenated-C19 androgens in the pathogenesis of CAH. OBJECTIVE: To establish a correlation between plasma and salivary adrenal-specific androgens in CAH as a noninvasive monitoring strategy. DESIGN: This prospective cross-sectional study recruited patients between 2015 and 2018. SETTING: Multicenter study including 13 tertiary centers in the United Kingdom. PARTICIPANTS: Seventy-eight children with CAH and 62 matched healthy controls. METHODS: Using liquid chromatography-tandem mass spectrometry, plasma and salivary concentrations of five steroids were measured: 17-hydroxyprogesterone (17OHP), androstenedione (A4), testosterone (T), 11-hydroxyandrostenedione (11OHA4), and 11-ketotestosterone (11KT). The correlation between plasma and salivary steroids was analyzed to assess their use in clinical practice. RESULTS: Strong correlations between plasma and salivary steroid concentrations in patients with CAH were detected: 17OHP (rs = 0.871; P < 0.001), A4 (rs = 0.931; P < 0.001), T (rs = 0.867; P < 0.001), 11OH4A (rs = 0.876; P < 0.001), and 11KT (rs = 0.944; P < 0.001). These results were consistent for patient subgroups based on sex and age. Analysis of patient subgroups based on 17OHP concentrations established clear correlations between plasma and salivary concentrations of the adrenal-specific androgen 11KT. CONCLUSIONS: The current study identified tight correlations between plasma and saliva for the adrenal-derived 11-oxygenated C19 androgen 11KT, as well as 17OHP and A4, which are widely used for monitoring treatment in CAH. This combination of steroid hormones will serve as an improved noninvasive salivary test for disease monitoring in patients with CAH.

Intentions to Prevent Weight Gain in Older and Younger Adults; The Importance of Perceived Health and Appearance Consequences.

OBJECTIVES: This study investigates whether health and appearance consequences predict intentions to prevent weight gain and whether these relationships differ in younger versus older adults and in men versus women. METHODS: UK adults aged 18-26 years (younger adults; n = 584) or >45 years (older adults; n = 107) participated in an online survey. Logistic regression assessed associations between intentions to avoid gaining weight and age, gender as well as perceived negative consequences of weight gain for health and appearance. Co-variates were ethnicity, education, weight perception and perceived weight gain vulnerability. Interactions between age, gender and perceived health and appearance consequences of weight gain were also tested. RESULTS: Perceived negative appearance consequences of weight gain predicted weight gain prevention intentions (OR = 9.3, p < 0.001). Health concerns were not a significant predictor of intentions overall but were a strong predictor for older adults (age × health concern interaction: OR = 13.6, p > 0.01). CONCLUSION: Concerns about feeling unattractive predict intentions to prevent weight gain. However, health consequences of weight gain are only important motivators for older adults. Future research should identify ways to shift the focus of young people from appearance concerns towards the health benefits of maintaining a healthy weight.