Preconception health and care policies, strategies and guidelines in the UK and Ireland: a scoping review.

BACKGROUND: Preconception health has the potential to improve parental, pregnancy and infant outcomes. This scoping review aims to (1) provide an overview of the strategies, policies, guidelines, frameworks, and recommendations available in the UK and Ireland that address preconception health and care, identifying common approaches and health-influencing factors that are targeted; and (2) conduct an audit to explore the awareness and use of resources found in the scoping review amongst healthcare professionals, to validate and contextualise findings relevant to Northern Ireland. METHODS: Grey literature resources were identified through Google Advanced Search, NICE, OpenAire, ProQuest and relevant public health and government websites. Resources were included if published, reviewed, or updated between January 2011 and May 2022. Data were extracted into Excel and coded using NVivo. The review design included the involvement of the "Healthy Reproductive Years" Patient and Public Involvement and Engagement advisory panel. RESULTS: The searches identified 273 resources, and a subsequent audit with healthcare professionals in Northern Ireland revealed five additional preconception health-related resources. A wide range of resource types were identified, and preconception health was often not the only focus of the resources reviewed. Resources proposed approaches to improve preconception health and care, such as the need for improved awareness and access to care, preconceptual counselling, multidisciplinary collaborations, and the adoption of a life-course approach. Many behavioural (e.g., folic acid intake, smoking), biomedical (e.g., mental and physical health conditions), and environmental and social (e.g., deprivation) factors were identified and addressed in the resources reviewed. In particular, pre-existing physical health conditions were frequently mentioned, with fewer resources addressing psychological factors and mental health. Overall, there was a greater focus on women's, rather than men's, behaviours. CONCLUSIONS: This scoping review synthesised existing resources available in the UK and Ireland to identify a wide range of common approaches and factors that influence preconception health and care. Efforts are needed to implement the identified resources (e.g., strategies, guidelines) to support people of childbearing age to access preconception care and optimise their preconception health.

The effect of increased fruit and vegetable consumption on blood pressure and lipids: a pooled analysis of six randomised controlled fruit and vegetable intervention trials.

BACKGROUND: Increasing fruit and vegetable (FV) consumption is associated with reduced cardiovascular disease risk in observational studies but with little evidence from randomised controlled trials (RCTs). The impact of concurrent pharmacological therapy is unknown. OBJECTIVE: To pool data from six RCTs to examine the effect of increasing FV intake on blood pressure (BP) and lipid profile, also exploring whether effects differed by medication use. DESIGN: Across trials, dietary intake was assessed by diet diaries or histories, lipids by routine biochemical methods and BP by automated monitors. Linear regression provided an estimate of the change in lipid profile or BP associated with a one portion increase in self-reported daily FV intake, with interaction terms fitted for medication use. RESULTS: The pooled sample included a total of 554 participants (308 males and 246 females). Meta-analysis of regression coefficients revealed no significant change in either systolic or diastolic BP per portion FV increase, although there was significant heterogeneity across trials for systolic BP (I2 = 73%). Neither adjusting for change in body mass index, nor analysis according to use of anti-hypertensive medication altered the relationship. There was no significant change in lipid profile per portion FV increase, although there was a significant reduction in total cholesterol among those not on lipid-lowering therapy (P < 0.05 after Bonferroni correction). CONCLUSION: Pooled analysis of six individual FV trials showed no impact of increasing intake on BP or lipids, but there was a total cholesterol-lowering effect in those not on lipid-lowering therapy.

Effectiveness and cost-effectiveness of a 12-month automated text message intervention for weight management in postpartum women with overweight or obesity: protocol for the Supporting MumS (SMS) multisite, parallel-group, randomised controlled trial.

INTRODUCTION: The reproductive years can increase women's weight-related risk. Evidence for effective postpartum weight management interventions is lacking and engaging women during this life stage is challenging. Following a promising pilot evaluation of the Supporting MumS intervention, we assess if theory-based and bidirectional text messages to support diet and physical activity behaviour change for weight loss and weight loss maintenance, are effective and cost-effective for weight change in postpartum women with overweight or obesity, compared with an active control arm receiving text messages on child health and development. METHODS AND ANALYSIS: Two-arm, parallel-group, assessor-blind randomised controlled trial with cost-effectiveness and process evaluations. Women (n=888) with body mass index (BMI) ≥25 kg/m2 and within 24 months of giving birth were recruited via community and National Health Service pathways through five UK sites targeting areas of ethnic and socioeconomic diversity. Women were 1:1 randomised to the intervention or active control groups, each receiving automated text messages for 12 months. Data are collected at 0, 6, 12 and 24 months. The primary outcome is weight change at 12 months from baseline, compared between groups. Secondary outcomes include weight change (24 months) and waist circumference (cm), proportional weight gain (>5 kg), BMI (kg/m2), dietary intake, physical activity, infant feeding and mental health (6, 12 and 24 months, respectively). Economic evaluation examines health service usage and personal expenditure, health-related quality of life and capability well-being to assess cost-effectiveness over the trial and modelled lifetime. Cost-utility analysis examines cost per quality-adjusted life-years gained over 24 months. Mixed-method process evaluation explores participants' experiences and contextual factors impacting outcomes and implementation. Stakeholder interviews examine scale-up and implementation. ETHICS AND DISSEMINATION: Ethical approval was obtained before data collection (West of Scotland Research Ethics Service Research Ethics Committee (REC) 4 22/WS/0003). Results will be published via a range of outputs and audiences. TRIAL REGISTRATION NUMBER: ISRCTN16299220.

Text Messages With Financial Incentives for Men With Obesity: A Randomized Clinical Trial.

Importance: Effective weight loss interventions are needed for men with obesity. Objective: To determine whether an intervention that combined text messaging with financial incentives attained significant weight loss at the 12-month follow-up compared with the control group and whether an intervention of text messaging alone attained significant weight loss at the 12-month follow-up compared with the control group. Design, Setting, and Participants: An assessor-blinded randomized clinical trial conducted in Belfast, Bristol, and Glasgow areas in the UK. A total of 585 men with body mass index (BMI) of 30 or more were enrolled between July 2021 and May 2022. Final follow-up occurred June 2023. Interventions: Participants were randomly assigned to 12 months of behavioral focused text messages combined with financial incentives (n = 196), 12 months of behavioral focused text messages alone (n= 194), or a waiting list (control group; n= 195). The financial incentive consisted of a monetary reward that was lost if weight loss targets were not met. All participants received weight management information and a pedometer at baseline. Main Outcomes and Measures: The 2 primary comparisons were the 12-month comparison of within-participant weight change between the text messaging with financial incentive group and the control group and the comparison between the text messaging alone group and the control group (minimum clinically important difference, 3%). The P value defined for statistical significance was P < .025 for each comparison. Results: Of the 585 men (mean [SD] age, 50.7 [13.3] years; mean weight, 118.5 [19.9] kg; mean BMI, 37.7 [5.7]; 525 [90%] White), 227 (39%) lived in postal code areas with lower socioeconomic status, and 426 (73%) completed the 12-month follow-up. At the 12-month follow-up, compared with the control group, the mean percent weight change was significantly greater in the text messaging with financial incentive group (mean difference, -3.2%; 97.5% CI, -4.6% to -1.9%; P < .001) but was not significantly greater in the text messaging alone group (mean difference, -1.4%; 97.5% CI, -2.9% to 0.0, P = .05). The mean (SD) weight changes were -5.7 (7.4) kg for the text messaging with financial incentives group, -3.0 (7.5) kg for the text messaging alone group, and -1.5 (6.6) kg for the control group. The 12-month mean (SD) percentage weight changes from baseline were -4.8% (6.1%) for the text messaging with financial incentives group, -2.7% (6.3%) for text messaging alone group, and -1.3% (5.5%) for the control group. Of 366 adverse events reported, the most common were infections (83 [23%]). Of the 23 serious adverse events (6.3%), 12 (52%) occurred in the text messaging with financial incentives group, 5 (22%) in the texts messaging alone group, and 6 (26%) in the control group. None were considered related to participating in a trial group. Conclusion and Relevance: Among men with obesity, an intervention with text messaging with financial incentive significantly improved weight loss compared with a control group, whereas text messaging alone was not significantly better than the control condition. These findings support text messaging combined with financial incentives to attain weight loss in men with obesity. Trial Registration: isrctn.org Identifier: ISRCTN91974895.

Identifying the top 10 research priorities for the school food system in the UK: a priority setting exercise.

INTRODUCTION: The school food system varies widely between schools and across the UK. There is a need to understand evidence gaps in school food research to allow the development, implementation and evaluation of policies and interventions to support children's healthy eating at school. This study aimed to conduct a priority setting exercise to co-produce research priorities in relation to the UK school food system. METHODS: The James Lind Alliance process informed this priority setting exercise; all key steps engaged a wide range of UK school food stakeholders (including teachers, parents, principals, school governors, policymakers, caterers). An initial online stakeholder survey identified perceived research priorities. In a second survey, stakeholders were asked to rank these priorities. Lastly, an online priority setting workshop with stakeholders elicited the most important research priorities. RESULTS: In 2021, school food stakeholders (n=1280) completed the first survey, from which 136 research priorities were identified. In the second survey, participants (n=107) ranked these research priorities regarding their importance. Lastly, 30 workshop participants discussed and reached consensus on the research priorities. After final refinement by the research team, 18 priorities resulted, with the top 10 being related to the provision of free school meals (effectiveness of cost-effectiveness of different levels of eligibility, including universal provision), implementation of policy (including improving uptake) and food standards, issues around procurement, leadership, inequalities, social norms, the eating environment, food culture throughout the school setting and healthy eating. CONCLUSION: The top 10 research priorities were elicited through a rigorous approach, including a wide range of stakeholders across the UK. These should be considered by policymakers, researchers and others to inform research, evidence-based policy development and, ultimately, improve the UK school food system.

Exploring the world of food with families: perspectives of low-income families on factors influencing their food choices.

OBJECTIVE: The aim of this study was to investigate the social and environmental factors involved in the food decision-making processes of families living on lower incomes on the Island of Ireland. DESIGN: A qualitative design was employed for this study, using photovoice and creative mapping methods. Parents were requested to take photos and draw maps of their food environments. Interviews were then conducted with parents, using the materials produced by parents as a cue to discuss their food environments, influences and decision-making processes around food choices. SETTING: The participants were interviewed online via Microsoft Teams. PARTICIPANTS: The participants were parents or guardians of children between the ages of 2 and 18 who self-defined as 'living on a tight budget'. RESULTS: Twenty-eight participants were recruited and interviewed for this study, including twelve parents in Northern Ireland and sixteen in the Republic of Ireland. The findings were mapped on to Bronfenbrenner's Ecological Systems Theory and showed that multiple, overlapping and intersecting factors at the individual, micro-, meso-, exo-, macro- and chrono-system were implicated in family food choices. Upstream factors in particular, including structural, policy and commercial determinants, appear to be significant drivers of behaviour. CONCLUSIONS: While the findings suggest that a complex range of factors are involved in family food choices, it is clear that policy measures and regulations are needed to stave off the impacts of rising social inequality and food poverty. Health promoters should strive to find non-stigmatising interventions to bridge the nutritional divide experienced by lower-income families.

The feasibility and acceptability of a rewards system based on food purchasing behaviour in secondary school cashless canteens: the Eat4Treats (E4T) cluster feasibility, non-randomised, controlled intervention study.

BACKGROUND: Using rewards may be an effective method to positively influence children's eating behaviour but evidence to date is limited, particularly in older children. The cashless canteen systems in schools provides a unique opportunity to implement a food-based reward scheme but intervention development work and feasibility testing is needed. The overall aim of the E4T feasibility study was to examine the feasibility and acceptability of implementing a rewards scheme based on the food purchasing behaviour of pupils in cashless canteens in secondary schools. METHODS: A non-randomised, controlled, parallel-group cluster feasibility study conducted in four secondary schools (two intervention and two control) serving areas of the highest social deprivation in Northern Ireland. During the 4-month trial, pupils earned points for foods purchased at the school canteen, with better nutritional choices having a higher value. Pupils could exchange the points they earned for rewards (e.g. stationery, vouchers, sports equipment) via the E4T website. Qualitative and quantitative data was collected from year 9 and 10 pupils (boys and girls aged 12-14 years), teachers and canteen staff to address the feasibility questions. RESULTS: Two intervention (one urban, one rural) and one control (urban) school completed the study. Seventy-one percent of 12-14-year-old pupils consented to take part; 1% of parents opted their child out of the study. Questionnaire completion rates were high (6 and 11% of questionnaires were partially completed at baseline and follow-up respectively). Collecting data on food consumed in the canteen was challenging logistically. Focus groups with pupils indicated that the overall concept of E4T was well received and there was a high degree of satisfaction with the rewards available. Pupils and teachers made several suggestions for improvements. CONCLUSIONS: E4T was successfully implemented as a result of collaboration between schools, school canteens and cashless canteen providers working with a multidisciplinary research team. It was acceptable to pupils, teachers and canteen staff. The findings suggest a few areas for refining implementation and evaluation processes that would need to be considered in the design of a larger trial, particularly resources required to streamline implementation and ways to optimise pupil engagement. TRIAL REGISTRATION: Under review with https://www. CLINICALTRIALS: gov (retrospective registration-reg number and weblink to be added).

Using Online Photovoice to Explore Food Decisions of Families on Low Income: Lessons Learnt During the COVID-19 Pandemic.

The method of photovoice has been previously used to effectively engage with socioeconomically disadvantaged groups and explore their eating behaviours. In this methodological article, we draw on our experiences from using photovoice through online interviews with families on low income about their food decisions. A purposive recruitment approach targeted parents of children 2-17 years old who lived on a tight budget across the island of Ireland. Participants provided demographic information and were invited to take photographs of food-related decisions and activities for 1 week during the COVID-19 lockdown. The photographs were then discussed through an online communication platform to generate qualitative data. A total of 28 parents participated in the photo-elicited interviews and shared a total of 642 photographs of factors that influenced their food decisions. Following the interviews, the researchers documented their reflections which focused on (1) participants' engagement with the online photo-elicitation and (2) practical aspects around participant consent and data safety. The participants in our study engaged well with the online photovoice method and shared a variety of photos which provided ample material to facilitate the conversations around their food environment and its impact on their food decisions. Our experiences can provide novel insights into using photovoice in a virtual environment and useful considerations around ethics and data collection for researchers who work with socioeconomically disadvantaged groups. Photo-elicited interviews offer an engaging and flexible data collection technique that can highlight issues informing future priorities of healthcare policy.

Effects of PROtein enriched MEDiterranean Diet and EXercise on nutritional status and cognition in adults at risk of undernutrition and cognitive decline: the PROMED-EX Randomised Controlled Trial.

INTRODUCTION: Undernutrition leading to unplanned weight loss is common in older age and has been linked to increased dementia risk in later life. Weight loss can precede dementia by a decade or more, providing a unique opportunity for early intervention to correct undernutrition and potentially prevent or delay cognitive impairment. The combined effects of diet and exercise on undernutrition have not yet been evaluated. The objective of this trial is to determine the effect of a protein-enriched Mediterranean diet, with and without exercise, on nutritional status and cognitive performance in older adults at risk of undernutrition and cognitive decline. METHODS: One hundred and five participants aged 60 years and over at risk of undernutrition and with subjective cognitive decline will be recruited to participate in a 6-month, single-blind, parallel-group randomised controlled trial. Participants will be block randomised into one of three groups: group 1-PROMED-EX (diet+exercise), group 2-PROMED (diet only) and group 3-standard care (control). The primary outcome is nutritional status measured using the Mini Nutritional Assessment. Secondary outcomes include cognitive function, nutritional intake, body composition, physical function and quality of life. Mechanistic pathways for potential diet and exercise-induced change in nutritional status and cognition will be explored by measuring inflammatory, metabolic, nutritional and metabolomic biomarkers. ETHICS AND DISSEMINATION: The study is approved by the UK Office for Research Ethics Committee (ref: 21/NW/0215). Written informed consent will be obtained from participants prior to recruitment. Research results will be disseminated to the public via meetings and media and the scientific community through conference presentations and publication in academic journals. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT05166564).

Exploring Health Behaviours, Attitudes and Beliefs of Women and Men during the Preconception and Interconception Periods: A Cross-Sectional Study of Adults on the Island of Ireland.

Preconception health is increasingly seen as a key target for improving population health in the UK and Ireland, yet little is known about the attitudes and beliefs of adults regarding preconception care strategies. This online cross-sectional survey aimed to explore the health behaviours, attitudes and beliefs of adults of reproductive age in regard to preconception health and care. The survey was developed by reviewing the previous literature and engaging with those from the target group. It is one of the first surveys to assess the attitudes and beliefs of adults of reproductive age across the Island of Ireland regarding preconception health and care. Results from 386 individuals with a mean age of 29.9 ± 10.3 years were included. A variety of health behaviours, attitudes and beliefs were investigated, with differences being identified between women and men and between participants with or without children (i.e., in the preconception or interconception stage). The majority of respondents held beliefs that preconception care was important, but there was greater emphasis on women than men in terms of the need to engage in health-promoting preconception health behaviours. This study highlights the need to improve preconception health awareness in women and men in the preconception and interconception stage. Findings indicate that efforts to improve preparation for pregnancy among adults of childbearing age are needed, to ensure optimal engagement in preconception health behaviours, with efforts being tailored based on sex and parental status.

Capturing the whole-school food environment in primary schools.

OBJECTIVE: The school food environment (SFE) is an ideal setting for encouraging healthy dietary behaviour. We aimed to develop an instrument to assess whole-SFE, test the instrument in the school setting and demonstrate its use to make food environment recommendations. DESIGN: SFE literature and UK school food guidance were searched to inform instrument items. The instrument consisted of (i) an observation proforma capturing canteen areas systems, food presentation and monitoring of food intake and (ii) a questionnaire assessing food policies, provision and activities. The instrument was tested in schools and used to develop SFE recommendations. Descriptive analyses enabled narrative discussion. SETTING: Primary schools. PARTICIPANTS: An observation was undertaken at schools in urban and rural geographical regions of Northern Ireland of varying socio-economic status (n 18). School senior management completed the questionnaire with input from school caterers (n 16). RESULTS: The instrument captured desired detail and potential instrument modifications were identified. SFE varied. Differences existed between food policies and how policies were implemented and monitored. At many schools, there was scope to enhance physical eating environments (n 12, 67 %) and food presentation (n 15, 83 %); emphasise healthy eating through food activities (n 7, 78 %) and increase parental engagement in school food (n 9, 56 %). CONCLUSIONS: The developed instrument can measure whole-SFE in primary schools and also enabled identification of recommendations to enhance SFE. Further assessment and adaptation of the instrument are required to enable future use as a research tool or for self-assessment use by schools.

Preconception health and care policies, strategies and guidelines in the UK and Ireland: a scoping review protocol.

INTRODUCTION: Preconception care can significantly improve maternal and infant outcomes, and thus optimise intergenerational health. The aims of this scoping review are to (1) provide an up-to-date summary of preconception health and care strategies, policies, guidelines, frameworks and recommendations across the UK and Ireland and (2) explore preconception health and care services and interventions in Northern Ireland as a case study. METHODS AND ANALYSIS: This scoping review of grey literature will be conducted as per the Scoping Review Methods Manual by the Joanna Briggs Institute and the Arksey-O'Malley framework for scoping studies, and reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Searches were conducted on Google Advanced Search, OpenAire, NICE, ProQuest and relevant public health websites in May 2022. Only results published, reviewed or updated between January 2011 and the time of the searches (May 2022) were considered for inclusion. In addition, searches on interventions and services provided in Northern Ireland will be supplemented by consultations and audits with key stakeholders to validate findings, identify other potentially eligible resources and ensure breadth of coverage. Data will be extracted into Excel and coded using NVivo, and ≥10% of the data will be double-coded. A narrative approach with content analysis highlighting key themes and concepts will be used to report findings.Throughout the research cycle, members of the wider public will be involved and engaged with to provide feedback. ETHICS AND DISSEMINATION: Ethical approval is not required as analyses will be conducted on data available in the public domain. Findings will be shared with relevant stakeholders with the aim to inform future research, practice and decision-making, and disseminated through a peer-reviewed publication, conference presentations and infographics. Dissemination plans will be informed by the 'Healthy Reproductive Years' patient and public involvement and engagement advisory panel.

A peer support dietary change intervention for encouraging adoption and maintenance of the Mediterranean diet in a non-Mediterranean population (TEAM-MED): lessons learned and suggested improvements.

Peer support interventions for dietary change may offer cost-effective alternatives to interventions led by health professionals. This process evaluation of a trial to encourage the adoption and maintenance of a Mediterranean diet in a Northern European population at high CVD risk (TEAM-MED) aimed to investigate the feasibility of implementing a group-based peer support intervention for dietary change, positive elements of the intervention and aspects that could be improved. Data on training and support for the peer supporters; intervention fidelity and acceptability; acceptability of data collection processes for the trial and reasons for withdrawal from the trial were considered. Data were collected from observations, questionnaires and interviews, with both peer supporters and trial participants. Peer supporters were recruited and trained to result in successful implementation of the intervention; all intended sessions were run, with the majority of elements included. Peer supporters were complimentary of the training, and positive comments from participants centred around the peer supporters, the intervention materials and the supportive nature of the group sessions. Attendance at the group sessions, however, waned over the intervention, with suggested effects on intervention engagement, enthusiasm and group cohesion. Reduced attendance was reportedly a result of meeting (in)frequency and organisational concerns, but increased social activities and group-based activities may also increase engagement, group cohesion and attendance. The peer support intervention was successfully implemented and tested, but improvements can be suggested and may enhance the successful nature of these types of interventions. Some consideration of personal preferences may also improve outcomes.

First-trimester glycaemic markers as predictors of gestational diabetes and its associated adverse outcomes: A prospective cohort study.

OBJECTIVE: Gestational diabetes mellitus (GDM) is associated with excessive fetal growth in later gestation. Recent data suggest accelerated growth may begin before 28 weeks' gestation when GDM is typically diagnosed. The identification of pregnancies at risk of early fetal growth would enable early intervention. We assessed the use of early pregnancy HbA1c in predicting excessive fetal growth. RESEARCH DESIGN AND METHODS: Women were recruited at antenatal booking from a major maternity unit in the UK. HbA1c was measured at <14 weeks gestation in 1243 women at risk of GDM as defined by UK NICE risk factors of whom 1115 underwent OGTT. Women with previous GDM were excluded. Comprehensive fetal ultrasound was performed at 28 weeks' gestation alongside 75 g OGTT in 976 of these women. GDM was defined using WHO criteria. Pregnancy outcomes were extracted from the regional maternity care database. RESULTS: Two hundred and thirty-six women screened positive for GDM. At diagnosis, GDM pregnancies demonstrated higher adjusted fetal weight percentile than non-GDM pregnancies: (51.8 vs. 46.3, p = 0.008). This was driven by increases in the fetal abdominal circumference percentile in GDM compared with non-GDM pregnancies (55.3 vs. 46.2, p = <0.001). Early pregnancy HbA1c was higher in the GDM versus non-GDM group: (35.7 mmol/mol vs. 32.9 mmol/mol p = <0.01). A threshold for predicting excessive fetal growth was not identified in this cohort. CONCLUSIONS: Accelerated fetal growth is evident prior to the diagnosis of GDM. There remains a need for suitable methods of early identification of pregnancies at high risk for early accelerated fetal growth due to GDM. First-trimester HbA1c was not useful in identifying these pregnancies. NOVELTY STATEMENT: WHAT IS ALREADY KNOWN?: Recent research suggests excessive growth associated with GDM may begin prior to 28 weeks' gestation, when GDM is typically tested for WHAT THIS STUDY HAS FOUND?: Pregnancies affected by GDM are already subject to accelerated fetal growth in comparison to non-GDM pregnancies by way of higher estimated fetal weight and fetal abdominal circumference Neither first-trimester HbA1c nor plasma glucose was useful predictors of these outcomes WHAT ARE THE IMPLICATIONS OF THIS STUDY?: Highlights the emergence of excessive growth prior to detection of GDM Reinforces need for suitable methods of identifying such pregnancies in earlier gestation.

Investigating the feasibility and acceptability of using Instagram to engage post-graduate students in a mass communication social media-based health intervention, #WeeStepsToHealth.

BACKGROUND: Instagram's popularity among young adults continues to rise, and previous work has identified diffusion of unhealthy messages and misinformation throughout the platform. However, we know little about how to use Instagram to promote health messages. This study aims to assess the feasibility and acceptability of using Instagram to engage post-graduate students in a mass communication social media (SM)-based health intervention. METHODS: A 4-week intervention targeting post-graduate students with physical activity (PA), nutrition, and general wellbeing messages was conducted via Instagram. Feasibility and acceptability were assessed using SM metrics (likes, comments, and shares), pre- and post-intervention online surveys (knowledge, attitude, and behavioural outcomes), and a focus group conducted with a sample of individuals in the target population (to assess intervention recall, feedback on message framing, and acceptability of Instagram). RESULTS: The two independent samples captured by online surveys (pre-intervention, n = 43, post-intervention, n = 41, representing 12.3% and 11.7% of Instagram followers, respectively) were predominantly female (88.4%, 80.5%) aged 18-34 (95.4%, 95.1%). Respondents in the second survey reported higher weekly PA levels (+ 13.7%) and more frequent nutritional behaviours including consumption of five or more fruits and vegetables (+ 23.3%) and looking at nutritional labels (+ 10.3%). However, respondents in the second survey also reported less frequent meal preparation (- 18.0%) and a small increase in fast food consumption (+ 2.8% consuming fast food 3-4 days a week). A total of 247 'likes' were collected from 28 Instagram posts (mean 8.8 likes per post). Humorous posts achieved a moderately higher level of engagement than non-humorous posts (median 10 and 8 likes, respectively). Focus group participants liked the campaign content and trusted the information source. CONCLUSIONS: Findings indicate that Instagram could be a feasible and acceptable platform for engaging post-graduate students in a SM-based mass communication health intervention, and that humour may have the potential to encourage further engagement.

An online survey of dietary quality during complementary feeding; associations with maternal feeding self-efficacy and adherence to dietary recommendations.

BACKGROUND: Parents are the gatekeepers of nutrition in early life and their feeding practices form children's dietary behaviours. Although maternal characteristics have been associated with certain feeding practices, their relationship with overall quality of complementary feeding diets has not been explored. This study aimed to: assess dietary quality in complementary feeding age; explore its association with maternal and child characteristics; and evaluate the association between complementary feeding practices and child weight. METHODS: An online cross-sectional survey captured data from a self-selected sample of mothers living in the UK with a healthy full-term child in complementary feeding age. A total of 466 mothers completed a questionnaire on their complementary feeding practices, demographics, anthropometrics, rates of maternal food neophobia, feeding self-efficacy, social support, postnatal depression and infant temperament. Dietary quality was assessed using the Complementary Feeding Utility Index (CFUI). Children were classified into underweight, normal weight, overweight and obese. RESULTS: Majority of participants reported high levels of dietary quality as determined by a mean CFUI score of 80%. High dietary quality was associated with reliance on the NHS recommendation on timing of complementary feeding and maternal self-efficacy in promoting a healthy diet and limiting non-recommended foods. Responsive feeding, longer breastfeeding duration, frequent exposure to fruits and to a high variety of protein-rich animal foods were significantly associated with lighter child weight status. Consumption of sweetened drinks and delayed introduction of lumpy foods were associated with heavier child weight status. CONCLUSIONS: This study provided an evaluation of dietary quality in complementary feeding in a UK sample of children and explored its relationship with maternal and child attributes. Increasing understanding of the current complementary feeding recommendations and strengthening maternal feeding self-efficacy may be key for healthcare professionals and researchers to improving complementary feeding practices.

Evaluation of a Text Messaging Intervention to Promote Preconception Micronutrient Supplement Use: Feasibility Study Nested in the Healthy Life Trajectories Initiative Study in South Africa.

BACKGROUND: Social messaging strategies such as SMS text messaging and radio are promising avenues for health promotion and behavior change in low- to middle-income settings. However, evidence of their acceptability, feasibility, and impact in the context of young women's health and micronutrient deficiencies is lacking. OBJECTIVE: This study aimed to evaluate the feasibility of an automated 2-way text messaging intervention nested in an ongoing preconception health trial, the Healthy Life Trajectories Initiative (HeLTI; HeLTI Bukhali) in Soweto, South Africa. Second, we aimed to evaluate the acceptability of a health promotion radio serial, which aired concurrently in the region. METHODS: In this feasibility study, 120 participants enrolled in HeLTI Bukhali between November 2020 and February 2021 received the 6-month 2-way text messaging intervention. Quantitative and qualitative data on intervention acceptability, usability, interaction, perceived benefit, and fidelity were collected during 5 focus group discussions (FGDs) and from study data logs. During the FGDs, data were collected on the acceptability of the radio serial. Following the text messaging intervention, capillary hemoglobin levels were assessed, and a participant questionnaire provided information on adherence and attitudes toward supplements. The text messaging control group comprised the first 120 women recruited from November 2019 to February 2020, who received the Bukhali intervention but not the text messages. Statistical significance testing and a linear mixed model were used for indicative effect comparisons between the text message-receiving and control groups. RESULTS: The text messaging intervention was found to be acceptable and to have perceived benefits, including being reminded to take supplements, gaining knowledge, and feeling supported by the study team. The use of the 2-way text messaging reply function was limited, with only a 10.8% (13/120) response rate by week 24. Barriers to replying included a lack of interest or phone credit and technical issues. Regarding the indicative effect, participants receiving the text messages had higher self-reported adherence at follow-up than the text messaging control group (42/63, 67% vs 33/85, 39% taking supplements every time; P=.02), and altitude-adjusted hemoglobin increased more between baseline and follow-up in the SMS text message-receiving group than in the text messaging control group (1.03, 95% CI 0.49-1.57; P<.001). The radio serial content was acceptable, although few participants reported exposure before the FGD. CONCLUSIONS: Women reported that the text messaging intervention was useful and described the benefits of receiving the messages. Examination of hemoglobin status indicated a promising beneficial effect of text messaging support on adherence to micronutrient supplementation, requiring further exploration through randomized controlled studies. Health promotion through radio and text messages were both found to be acceptable, although more research into the radio serial reach among young women is needed. TRIAL REGISTRATION: Pan African Clinical Trials Registry (PACTR) PACTR201903750173871; https://tinyurl.com/4x6n32ff.

PROtein enriched MEDiterranean diet to combat undernutrition and promote healthy neuroCOGnitive ageing in older adults: The PROMED-COG consortium project.

Dementia is a major public health challenge owing to its increasing prevalence and recognised impact on disability among older adults. Observational data indicate that weight loss is associated with increased dementia risk of 30%-40% and precedes a diagnosis of cognitive impairment or dementia by at least one decade. Although relatively little is known about the mechanisms of unintentional weight loss in dementia, this provides a window of opportunity to intervene with strategies to counteract undernutrition and delay, or prevent, the onset of dementia. This article provides an overview of the PROMED-COG project and associated work packages. The project aimes to (1) strengthen the epidemiologic evidence to better understand the potential benefits of combating undernutrition for healthy neurocognitive ageing; (2) increase scientific knowledge on the balance between a protein enriched Mediterranean diet (PROMED) and physical exercise to prevent undernutrition and promote healthy neurocognitive ageing, and generate data on mechanistic pathways; (3) stimulate collaboration and capacity building for nutrition and neurocognitive ageing research in Europe; and (4) develop public and practice recommendations to combat undernutrition and promote healthy neurocognitive ageing in older adults. Findings will provide new and critical insights into the role of undernutrition in neurocognitive ageing, how this role can differ by sex, genetic risk and timing of undernutrition exposure, and how modifications of dietary and physical activity behaviour can reduce the burden of undernutrition and neurodegeneration. The research outcomes will be useful to inform policy and practice about the dietary guidelines of older people and provide insight to industry for the development of food-based solutions to prevent undernutrition.

Effectiveness and cost-effectiveness of text messages with or without endowment incentives for weight management in men with obesity (Game of Stones): study protocol for a randomised controlled trial.

BACKGROUND: Obesity increases the risk of type 2 diabetes, heart disease, stroke, mobility problems and some cancers, and its prevalence is rising. Men engage less than women in existing weight loss interventions. Game of Stones builds on a successful feasibility study and aims to find out if automated text messages with or without endowment incentives are effective and cost-effective for weight loss at 12 months compared to a waiting list comparator arm in men with obesity. METHODS: A 3-arm, parallel group, assessor-blind superiority randomised controlled trial with process evaluation will recruit 585 adult men with body mass index of 30 kg/m2 or more living in and around three UK centres (Belfast, Bristol, Glasgow), purposively targeting disadvantaged areas. Intervention groups: (i) automated, theory-informed text messages daily for 12 months plus endowment incentives linked to verified weight loss targets at 3, 6 and 12 months; (ii) the same text messages and weight loss assessment protocol; (iii) comparator group: 12 month waiting list, then text messages for 3 months. The primary outcome is percentage weight change at 12 months from baseline. Secondary outcomes at 12 months are as follows: quality of life, wellbeing, mental health, weight stigma, behaviours, satisfaction and confidence. Follow-up includes weight at 24 months. A health economic evaluation will measure cost-effectiveness over the trial and over modelled lifetime: including health service resource-use and quality-adjusted life years. The cost-utility analysis will report incremental cost per quality-adjusted life years gained. Participant and service provider perspectives will be explored via telephone interviews, and exploratory mixed methods process evaluation analyses will focus on mental health, multiple long-term conditions, health inequalities and implementation strategies. DISCUSSION: The trial will report whether text messages (with and without cash incentives) can help men to lose weight over 1 year and maintain this for another year compared to a comparator group; the costs and benefits to the health service; and men's experiences of the interventions. Process analyses with public involvement and service commissioner input will ensure that this open-source digital self-care intervention could be sustainable and scalable by a range of NHS or public services. TRIAL REGISTRATION: ISRCTN 91974895 . Registered on 14/04/2021.

Culturally adapting the Mediterranean Diet pattern - a way of promoting more 'sustainable' dietary change?

Average diet quality is low in the UK and is socioeconomically patterned, contributing to the risk of non-communicable disease and poor health. Achieving meaningful dietary change in the long term is challenging, with intervention required on a number of different levels which reflect the multiple determinants of dietary choice. Dietary patterns have been identified which contribute positively to health outcomes; one of these is the Mediterranean diet (MD) which has been demonstrated to be associated with reduced non-communicable disease risk. Most research exploring the health benefits of the MD has been conducted in Mediterranean regions but, increasingly, research is also being conducted in non-Mediterranean regions. The MD is a dietary pattern that could have positive impacts on both health and environmental outcomes, while being palatable, appetising and acceptable. In this review, we consider the studies that have explored transferability of the MD. To achieve long-term dietary change towards a MD, it is likely that the dietary pattern will have to be culturally adapted, yet preserving the core health-promoting elements and nutritional composition, while considering the food system transition required to support changes at population level. Population-specific barriers need to be identified and ways sought to overcome these barriers, for example, key food availability and cost. This should follow a formal cultural adaptation framework. Such an approach is likely to enhance the extent of adherence in the longer term, thus having an impact on population health.