Is the effect of menu energy labelling on consumer behaviour equitable? A pooled analysis of twelve randomized control experiments.

Menu energy labelling has been implemented as a public health policy to promote healthier dietary choices and reduce obesity. However, it is unclear whether the influence energy labelling has on consumer behaviour differs based on individuals' demographics or characteristics and may therefore produce inequalities in diet. Data were analysed from 12 randomized control trials (N = 8508) evaluating the effect of food and drink energy labelling (vs. labelling absent) on total energy content of food and drink selections (predominantly hypothetical) in European and US adults. Analyses examined the moderating effects of participant age, sex, ethnicity/race, education, household income, body mass index, dieting status, food choice motives and current hunger on total energy content of selections. Energy labelling was associated with a small reduction (f2 = 0.004, -50 kcal, p < 0.001) in total energy selected compared to the absence of energy labelling. Participants who were female, younger, white, university educated, of a higher income status, dieting, motivated by health and weight control when making food choices, and less hungry, tended to select menu items of lower energy content. However, there was no evidence that the effect of energy labelling on the amount of energy selected was moderated by any of the participants' demographics or characteristics. Energy labelling was associated with a small reduction in energy content of food selections and this effect was similar across a range of participants' demographics and characteristics. These preliminary findings suggest that energy labelling policies may not widen existing inequalities in diet.

Gender diversity and autism spectrum conditions in children and adolescents: A narrative review of the methodologies used by quantitative studies.

AIM: This narrative review aimed to analyse the methodologies used by quantitative studies to evaluate their evidence for the association between gender diversity and autism spectrum conditions (ASC) in child and adolescent population samples. METHOD: A systematic search was conducted for papers published between 2010 and 2020. RESULTS: Fifteen papers met the inclusion criteria; all reported associations between their defined versions of gender diversity and ASC. Gender diversity was characterised as "dysphoria", "variance", and/or "diverse", and was correlated across ASC categories of "symptoms", "traits", or "empathising and systemising styles of thinking". Multiple diagnostic criteria and/or nonspecific, adult administrated measures were used to quantify youth gender experiences and ASCs. CONCLUSION: Interpretations of the findings are discussed in relation to critical appraisal of methodologies used including data collection and deduction, the characteristics of the sample population, the usage of comparison groups, and the overall quality of statistical reporting amongst others.

Dishware size and snack food intake in a between-subjects laboratory experiment.

OBJECTIVE: The use of smaller dishware as a way of reducing food consumption has intuitive appeal and is recommended to the general public. Recent experimental studies have failed to find an effect of plate size on food intake, although the methods used across studies have varied. The aim of the present study was to examine the effect that bowl size had on snack food consumption in a 'typical' snacking context (snacking while watching television). DESIGN: Between-subjects. SETTING: Laboratory experiment. SUBJECTS: Sixty-one adult participants served themselves and ate popcorn while watching television. Participants were randomly assigned to serve themselves with and eat from either a small or a large bowl. RESULTS: The use of a smaller bowl size did not reduce food consumption. Unexpectedly, participants in the small bowl condition tended to consume more popcorn (34·0 g) than participants in the large bowl condition (24·9 g; 37 % increase, d=0·5), although the statistical significance of this difference depended on whether analyses were adjusted to account for participant characteristics (e.g. gender) associated with food intake (P=0·02) or not (P=0·07). CONCLUSIONS: Counter to widely held belief, the use of a smaller bowl did not reduce snack food intake. Public health recommendations advising the use of smaller dishware to reduce food consumption are premature, as this strategy may not be effective.

Demographics of referrals to a specialist gender identity service in the UK between 2017 and 2020.

Trends in clinical referrals to specialist gender services historically comprised more assigned male at birth young people. In the last decade, this has shifted in adolescent samples to more assigned female young people. An updated review of the current patterns of referrals is important to better understand the potential changing needs of clinically referred gender-diverse children and adolescents. We assessed the demographics of referrals to the Gender Identity Development Service (GIDS) and their attendance patterns from 2017 to 2020. During this period, 9555 referrals were received in total, most were in adolescence (n = 7901, 82.7%), and more assigned female (age range = 1-18 years; M = 14.05; SD = 2.5) were referred than assigned male young people overall (n = 6823, 71.4%). A larger proportion of assigned female adolescents (assigned female: n = 5835, 62.3%, assigned male: n = 1897, 20.3%) and assigned female children (n = 988, 10.6%, assigned male: n = 640, 6.8%) were referred. For 2%, sex assigned at birth was unrecorded, 83.4% were White British and 36.6% had an unidentified ethnicity. Only 4% did not attend a first appointment, indicating the need for care from this specialist service. With more young people presenting to gender services, understanding the demographics of young people seeking gender care is vital for service provision. Future research should explore how to increase access to gender care for ethnic minorities, and how to support those accessing services.

Exploring navigation of gender in a sample of clinically referred young people attending the gender identity development service.

BACKGROUND: Gender-diverse young people experience a cisnormative world and are subject to unique minority stressors, which have been found to contribute to adverse mental health. This research aims to understand the social and personal context unique to gender-diverse people that young people navigate prior to attending specialised services. METHODS: The baseline measure of a newly developed questionnaire, the GIDS Gender Questionnaire (GIDS-GQ), was sent to all young people (or caregivers for those aged under 12) attending the Gender Identity Development Service (GIDS). Eighty-four young people and caregivers completed the questionnaire, with eighty-one included in the final sample (M = 15.77 years, SD = 1.83, range = 9-17; assigned female at birth = 72, assigned male at birth = 9). Questionnaires were emailed to participants via an online survey between one and three appointments with the Service. Data were collected between April 2021 and February 2022. RESULTS: All young people had initiated a social transition, with 75.3% categorised as fully socially transitioned. More young people reported experiencing transphobic bullying (64.2%) and a lack of acceptance of their gender identity (85.1%) in the past (lifetime) than in the 6 months prior to attending the service (transphobic bullying: 12.3%; non-acceptance: 49.4%). 94.5% of the sample reported disliked body parts, most commonly breasts (80.8%), genitals (37%), and hips (31.5%). Participants most commonly reported a decrease in their mood (61.25%) and most areas of social connectedness. CONCLUSIONS: The majority of this sample had socially transitioned, were supported in their identification, and had experienced less transphobic bullying and non-acceptance prior to commencing services. However, young people continued to dislike their bodies, and experience low mood and social connectedness. Future research is needed to understand how clinical support can help reduce the impact of these external/distal minority stressors by promoting social connectedness, incorporating such learnings into clinical practice and subsequent policy in clinical work with gender-diverse young people.

Impact of Hormone Treatment on Psychosocial Functioning in Gender-Diverse Young People.

Purpose: Few studies have assessed the effects of hormonal treatments such as gonadotropin-releasing hormone agonists (GnRHa) and gender-affirming hormones (GAH) on mental health outcomes in clinically referred gender-diverse young people from a younger age. Where this research has been conducted, findings have been mixed. This study investigated a cohort of young people before treatment, 1 year into GnRHa, and 1 year into GAH treatment to understand psychological and behavioral impacts over time. Methods: Thirty-eight young people (28 assigned female and 10 assigned male) referred to endocrinology, younger than 15 years at/beyond Tanner stage two, who received GnRHa followed by GAH treatment, were assessed in a retrospective analysis study. Young people completed the Youth Self Report (YSR), the Body Image Scale, and the Utrecht Gender Dysphoria Scale, while caregivers completed the Child Behavior Checklist (CBCL) and the Social Responsiveness Scale-2 at all time points. Results: Dissatisfaction with primary sexual characteristics (p = 0.02), gender dysphoria (p = 0.01), and social motivation (p = 0.04) improved significantly over time. Self-harm and suicidality also showed a general decrease. Caregivers reported a significant reduction in internalizing (p = 0.03) behaviors on the CBCL after GnRHa. Other subcategories of the YSR and CBCL were within normal ranges with no significant difference (p > 0.05). Conclusion: These findings demonstrate some improvements in psychological and behavioral outcomes in young people concurrently receiving psychosocial support and hormone treatment. Future research with larger and more diverse samples is warranted to further understand generalizability.

Trajectories of transgender adolescents referred for endocrine intervention in England.

OBJECTIVES: Some gender-diverse young people (YP) who experience clinically significant gender-related distress choose to pursue endocrine treatment alongside psychotherapeutic support to suppress pubertal development using gonadotropin-releasing hormone analogues (GnRHa), and then to acquire the secondary sex characteristics of their identified gender using gender affirming hormones (GAH). However, little is known about the demographics of transgender adolescents accessing paediatric endocrinology services while under the specialist Gender Identity Development Service (GIDS) in England. DESIGN: Demographics of referrals from the GIDS to affiliated endocrinology clinics to start GnRHa or GAH between 2017 and 2019 (cohort 1), with further analysis of a subgroup of this cohort referred in 2017-2018 (cohort 2) were assessed. RESULTS: 668 adolescents (227 assigned male at birth (AMAB) and 441 assigned female at birth (AFAB)) were referred to endocrinology from 2017 to 2019. The mean age of first GIDS appointment for cohort 1 was 14.2 (±2.1) years and mean age of referral to endocrinology postassessment was 15.4 (±1.6) years. Further detailed analysis of the trajectories was conducted in 439 YP in cohort 2 (154 AMAB; 285 AFAB). The most common pathway included a referral to access GnRHa (98.1%), followed by GAH when eligible (42%), and onward referral to adult services when appropriate (64%). The majority (54%) of all adolescents in cohort 2 had a pending or completed referral to adult services. CONCLUSIONS: This study highlights the trajectories adolescents may take when seeking endocrine treatments in child and adolescent clinical services and may be useful for guiding decisions for gender-diverse YP and planning service provision.

Service user engagement by ethnicity groups at a children's gender identity service in the UK.

OBJECTIVES: Gender service utilisation according to ethnicity is largely under-researched. The present research looked at demographics and service user-engagement according to ethnicity of young people accessing a gender service for children. METHOD: A total of 2063 (M = 14.19 years, SD = 2.59, assigned male = 556, 1495 assigned female = 1495, no-specification=12) referrals were included in the analysis. Self-defined ethnicity in financial years (FY) 2016-2017, 2018-2019, and referrer-defined ethnicity in FY 2020-2021 were compared between years, to the national UK-population, and child and adolescent mental health service (CAMHS) averages. Numbers of offered, attended and non-attended appointments were compared across the White and the ethnic minority population (EMP). RESULTS: Across years 93.35% young people identified as White (higher than the CAMHS and national population averages); 6.65% as EMP. Service utilisation was similar in FY 2016-2017. In FY 2018-2019, the EMP subgroup was offered and attended more appointments compared to the White subgroup, 'did not attended' average was similar. CONCLUSIONS: The majority of young people self-identified with a White ethnic-background. Service engagement was comparable between the EMP and White ethnicity subgroups in 2016-2017, while the EMP group was offered and attended more appointments in 2018-2019. Due to the low EMP group numbers, findings need to be interpreted with caution.

Key socio-demographic characteristics of children and adolescents with gender dysphoria: A British Isles surveillance study.

The present research used linked surveillance systems (British Paediatric Surveillance Unit; and the Child and Adolescent Psychiatry Surveillance System) over a 19 month period (1 November 2011-31 May 2013) to notify of young people (4-15.9 years) presenting to secondary care (paediatrics or child and adolescent mental health services) or specialist gender services with features of gender dysphoria (GD). A questionnaire about socio-demographic, mental health, and GD features was completed. Presence of GD was then assessed by experts in the field using then-current criteria (DSM-IV-TR). Incidence across the British Isles was 0.41-12.23 per 100,000. 230 confirmed cases of GD were noted; the majority were white (94%), aged ≥12 years (75.3%), and were assigned female at birth (57.8%). Assigned males presented most commonly in pre-adolescence (63.2%), and assigned females in adolescence (64.7%). Median age-of-onset of experiencing GD was 9.5 years (IQR 5-12); the majority reported long-standing features (2-5 years in 36.1%, ≥5 years in 26.5%). Only 82.5% attended mainstream school. Bullying was reported in 47.4%, previous self-harm in 35.2%, neurodiversity in 16%, and 51.5% had ≥1 mental health condition. These findings suggest GD is rare within this age group but that monitoring wellbeing and ensuring support for co-occurring difficulties is vital.

Discharge outcome analysis of 1089 transgender young people referred to paediatric endocrine clinics in England 2008-2021.

INTRODUCTION: The destination of transgender and gender variant young people referred by the National Health Service (NHS) Gender Identity Development Service (GIDS) to, and discharged from the two English paediatric endocrine liaison clinics is not known. METHODS: 1151 young people referred after full assessment by the GIDS; 827 to University College London Hospital since 2008; 324 to Leeds Children's Hospital since 2013. Discharge categorisation was by agreed criteria. Eleven emigrated and 51 self-discharged. 1089 had known outcomes. RESULTS: 999/1089 (91.7%) continued identifying as gender variant. 867/999 (86.8%) were discharged to adult gender identity clinics (GICs). 166/867 (19.1%) of these were <16 years and 701/867 (80.9%) ≥16 years at initial endocrine referral. No sex differences were seen. 38/999 (3.8%) opted for non-NHS services.90/1089 ceased identifying as gender variant. In 32/1089 (2.9%), this was subsequent to their first clinic appointment.58/1089 (5.3%) stopped treatment either with the gonadotropin releasing hormone analogue (GnRHa) or gender-affirming hormones (GAH) and reverted to their birth gender: <16 years (20/217; 9.2%); ≥16 years (38/872; 4.4%).Subdividing further, 16/217 (7.4%) <16 years ceased GnRHa and 4/217 (1.8%) after GAH. Of those ≥16 years, 33/872 (3.8%) ceased GnRHa and 5/872 (0.6%) GAH. CONCLUSIONS: At discharge, 91.7% continued as transgender or gender variant, 86.8% sought ongoing care through NHS GICs. 2.9% ceased identifying as transgender after an initial consultation prior to any endocrine intervention and 5.3% stopped treatment either with GnRHa or GAH, a higher proportion in the <16 year compared with the ≥16 year groups.

A Longitudinal Study of Features Associated with Autism Spectrum in Clinic Referred, Gender Diverse Adolescents Accessing Puberty Suppression Treatment.

Literature has documented inflated rates of features associated with autism spectrum (AS) in clinic referred, gender diverse young people. This study examined scores on the Social Responsiveness Scale, Second Edition (SRS-2) over time in a group of clinic referred, gender diverse adolescents accessing gonadotropin-releasing hormone analogues (GnRHa) to supress puberty. Primary caregivers of 95 adolescents presenting to the Gender Identity Development Service (GIDS) completed the SRS-2 prior to receiving endocrine input (mean age: 13.6 ± SEM: 0.11) and after approximately one year of accessing GnRHa (mean age: 14.6 ± SEM: 0.13). No significant differences in SRS-2 scores over time and between birth assigned sex were found. No interactions between time and birth assigned sex were established for SRS-2 subscales or total scores.

Gender identity development in children and young people: A systematic review of longitudinal studies.

BACKGROUND: Children are presenting in greater numbers to gender clinics around the world. Prospective longitudinal research is important to better understand outcomes and trajectories for these children. This systematic review aims to identify, describe and critically evaluate longitudinal studies in the field. METHOD: Five electronic databases were systematically searched from January 2000 to February 2020. Peer-reviewed articles assessing gender identity and psychosocial outcomes for children and young people (<18 years) with gender diverse identification were included. RESULTS: Nine articles from seven longitudinal studies were identified. The majority were assessed as being of moderate quality. Four studies were undertaken in the Netherlands, two in North America and one in the UK. The majority of studies had small samples, with only two studies including more than 100 participants and attrition was moderate to high, due to participants lost to follow-up. Outcomes of interest focused predominantly on gender identity over time and emotional and behavioural functioning. CONCLUSIONS: Larger scale and higher quality longitudinal research on gender identity development in children is needed. Some externally funded longitudinal studies are currently in progress internationally. Findings from these studies will enhance understanding of outcomes over time in relation to gender identity development in children and young people.

Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK.

BACKGROUND: In adolescents with severe and persistent gender dysphoria (GD), gonadotropin releasing hormone analogues (GnRHa) are used from early/middle puberty with the aim of delaying irreversible and unwanted pubertal body changes. Evidence of outcomes of pubertal suppression in GD is limited. METHODS: We undertook an uncontrolled prospective observational study of GnRHa as monotherapy in 44 12-15 year olds with persistent and severe GD. Prespecified analyses were limited to key outcomes: bone mineral content (BMC) and bone mineral density (BMD); Child Behaviour CheckList (CBCL) total t-score; Youth Self-Report (YSR) total t-score; CBCL and YSR self-harm indices; at 12, 24 and 36 months. Semistructured interviews were conducted on GnRHa. RESULTS: 44 patients had data at 12 months follow-up, 24 at 24 months and 14 at 36 months. All had normal karyotype and endocrinology consistent with birth-registered sex. All achieved suppression of gonadotropins by 6 months. At the end of the study one ceased GnRHa and 43 (98%) elected to start cross-sex hormones. There was no change from baseline in spine BMD at 12 months nor in hip BMD at 24 and 36 months, but at 24 months lumbar spine BMC and BMD were higher than at baseline (BMC +6.0 (95% CI: 4.0, 7.9); BMD +0.05 (0.03, 0.07)). There were no changes from baseline to 12 or 24 months in CBCL or YSR total t-scores or for CBCL or YSR self-harm indices, nor for CBCL total t-score or self-harm index at 36 months. Most participants reported positive or a mixture of positive and negative life changes on GnRHa. Anticipated adverse events were common. CONCLUSIONS: Overall patient experience of changes on GnRHa treatment was positive. We identified no changes in psychological function. Changes in BMD were consistent with suppression of growth. Larger and longer-term prospective studies using a range of designs are needed to more fully quantify the benefits and harms of pubertal suppression in GD.

Does acute or habitual protein deprivation influence liking for monosodium glutamate?

The umami flavour generated by monosodium glutamate (MSG) has been proposed as the marker for the presence of protein in foods. As protein is the most closely regulated macronutrient in the diet, the present study addressed whether acute protein deprivation, habitual protein intake or a combination of the two influenced liking for the taste of MSG. 24 low-restraint male participants (mean age: 22; BMI: 23) consumed either their habitual breakfast (baseline), a low protein breakfast (breakfast meal with low protein milk and milkshake) or a high protein breakfast (breakfast meal with high protein milk and milkshake) on three different days, and then evaluated the acceptability of umami (MSG), salty (NaCl) or sweet (Acesulphame K) tastes at low or high concentrations in a soup context at lunchtime. Participants also completed a habitual protein intake questionnaire (39-item protein Food Frequency Questionnaire). Liking for all tastes was higher on the low than on the high protein day, and NaCl and Acesulphame K were liked less on both protein manipulation days when compared to the no added flavour control. Habitual protein intake was not related to liking for MSG stimuli alone but habitual high protein consumers rated a high concentration of MSG as more pleasant than any other taste when in protein deficit. Overall, these findings suggest that liking for high MSG concentrations may be moderated by nutritional need in high protein consumers.

The effect of heightened awareness of observation on consumption of a multi-item laboratory test meal in females.

Human eating behaviour is often studied in the laboratory, but whether the extent to which a participant believes that their food intake is being measured influences consumption of different meal items is unclear. Our main objective was to examine whether heightened awareness of observation of food intake affects consumption of different food items during a lunchtime meal. One hundred and fourteen female participants were randomly assigned to an experimental condition designed to heighten participant awareness of observation or a condition in which awareness of observation was lower, before consuming an ad libitum multi-item lunchtime meal in a single session study. Under conditions of heightened awareness, participants tended to eat less of an energy dense snack food (cookies) in comparison to the less aware condition. Consumption of other meal items and total energy intake were similar in the heightened awareness vs. less aware condition. Exploratory secondary analyses suggested that the effect heightened awareness had on reduced cookie consumption was dependent on weight status, as well as trait measures of dietary restraint and disinhibition, whereby only participants with overweight/obesity, high disinhibition or low restraint reduced their cookie consumption. Heightened awareness of observation may cause females to reduce their consumption of an energy dense snack food during a test meal in the laboratory and this effect may be moderated by participant individual differences.

Monosodium glutamate delivered in a protein-rich soup improves subsequent energy compensation.

Previous research suggests that monosodium glutamate (MSG) may have a biphasic effect on appetite, increasing appetite within a meal with its flavour-enhancing effect, but enhancing subsequent satiety due to its proposed role as a predictor of protein content. The present study explored this by assessing the impact of a 450 g soup preload differing in MSG concentration (1 % MSG added (MSG+) or no MSG (MSG-)) and nutrient content (low-energy control or high-energy carbohydrate or high-energy protein) on rated appetite and ad libitum intake of a test meal in thirty-five low-restraint male volunteers using a within-participant design. Protein-rich preloads significantly reduced intake at the test meal and resulted in more accurate energy compensation than did carbohydrate-rich preloads. This energy compensation was stronger in the MSG+ protein conditions when compared with MSG+ carbohydrate conditions. No clear differences in rated appetite were seen in MSG or the macronutrient conditions alone during preload ingestion or 45 min after intake. Overall, these findings indicate that MSG may act to further improve energy compensation when provided in a protein-rich context.

Umami flavor enhances appetite but also increases satiety.

BACKGROUND: Monosodium glutamate (MSG) has been shown to increase satiety when combined with protein. Inosine 5'-monophosphate acts synergistically with MSG when tasted, is present in high-protein sources, and may potentially further enhance satiety. OBJECTIVE: We assessed effects of a combination of monosodium glutamate and inosine 5'-monophosphate (MSG/IMP) provided either alone or in a high-energy, high-carbohydrate and -protein soup on appetite during ingestion and postingestive satiety. DESIGN: Fixed portions (450 g) of a low-energy control and high-energy, high-carbohydrate and -protein soup preload with added monosodium glutamate and inosine 5'-monophosphate (MSG/IMP+) or without added monosodium glutamate and inosine 5'-monophosphate (MSG/IMP-) were consumed on 4 nonconsecutive days, and changes in appetite during soup intake and at a subsequent ad libitum lunch were assessed in 26 low-restraint volunteers by using a within-participant design. RESULTS: MSG/IMP+ conditions significantly reduced subsequent intake more than the MSG/IMP- condition did irrespective of energy. The high-carbohydrate and -protein condition also reduced intake independently of MSG/IMP. Energy compensation was greater in the MSG/IMP+ carbohydrate and protein conditions than MSG/IMP- condition. The addition of the MSG/IMP+ also increased the soup pleasantness and caused an immediate increase in appetite when the soup was first tasted. CONCLUSION: The addition of MSG/IMP to a low-energy preload had a biphasic effect on appetite by stimulating appetite during ingestion and enhancing postingestive satiety.

Does monosodium glutamate interact with macronutrient composition to influence subsequent appetite?

The influence of flavour enhancers such as monosodium glutamate (MSG) on satiation and satiety is unclear, and the present study aimed to explore this by examining the effects consumption of soups varying in MSG (1% MSG added or no MSG) and macronutrient content (added carbohydrate, protein or control) had on appetite. 24 non-obese, low-restraint male participants consumed a fixed portion of soup and rated their appetite before, immediately after intake and at 15 minute intervals for 120 min post-ingestion across six sessions. Added MSG significantly increased flavour pleasantness and tended to result in a smaller decrease in hunger immediately after soup ingestion. MSG also reduced rather than enhanced feelings of fullness immediately after ingestion of the high protein soup. As expected, hunger increased, and fullness decreased, over the subsequent 120 min, but the increase in hunger was significantly lower in the MSG than no-MSG conditions with the protein soup between 30 and 60 min post-ingestion. Overall these data suggest that MSG may have a bi-phasic effect on appetite, with reduced satiation mediated by effects on palatability, but potential for enhanced post-ingestive satiety particularly in the context of protein ingestion.