Understanding the use of media analysis in public health research through food tax debates (HEALTHEI Project): a scoping review.

BACKGROUND: Poor diet is a major public health concern. In 2021, 63·8% of adults and 22·2% of reception-age children were either overweight or obese in England. Fiscal interventions have become a popular policy measure to reduce obesity and encourage healthy eating. Such measures are highly controversial, leading to media debate promoting pro-tax and anti-tax arguments. To better understand food tax debates and the use of media analysis in public health research, we conducted a scoping review of media analyses using food taxes as a case study. METHODS: In this scoping review, we searched SCOPUS, PubMed, and EBSCOhost databases on Feb 14-22, 2023, using keyword variations for "food", "tax", and "media analysis". Results were restricted to English-only, peer-reviewed journal articles. The initial results were manually screened through an iterative process to exclude articles that did not analyse a food tax, were non-English language, were not peer-reviewed, or did not use media analysis as the primary method. Modelled on Arksey and O'Malley's (2005) five-stage review protocol, two researchers used a coding framework to independently code all articles and checked result quality through regular discussion. Extracted data included article title, author, year, country, tax type, media sources used, identified media frames, and research aims, methods, results, and conclusions. Results are reported according to PRISMA guidelines and data files submitted to FigShare Repository (non-accessible). FINDINGS: Of 1087 articles reviewed, 19 were eligible to be included in the study. Articles were published between 2013 and 2023, with 2021 having the highest concentration of studies carried out mainly in UK and USA. Despite search terms encompassing a range of food products, the retrieved media analyses focused on three types of food product taxes: sugar-sweetened beverages, meat, and groceries. Most articles explored arguments for and against policy implementation, with some investigating stakeholder representation. Results demonstrate that stakeholders' arguments, both positive and negative, are consistent across countries and food products. INTERPRETATION: The consistency of how both pro-tax and anti-tax arguments are presented in the media demonstrates the importance of coordination between stakeholder groups to influence policy adoption. To our knowledge, this is the first study to investigate media analysis across a diverse range of food products. FUNDING: National Institute for Health and Care Research (NIHR).

The Healthy Start scheme in England "is a lifeline for families but many are missing out": a rapid qualitative analysis.

BACKGROUND: Healthy Start (HS) is a government scheme in England, Wales and Northern Ireland that offers a financial payment card and free vitamins to families experiencing low income. Pregnant women and families with children < 4 years can use the HS card to buy fruit, vegetables, cow's milk, infant formula and pulses. HS was fully digitalised in March 2022. While digitalisation has improved the user experience for many families, in the context of the cost-of-living crisis and increasing dietary inequalities, it is important to understand why HS is not reaching more families. This study aimed to (i) assess the perceptions and experiences of HS from stakeholders across the system including those who promote, implement and are eligible for HS, and (ii) identify recommendations to improve the scheme's effectiveness and uptake. METHODS: The study design was a post-implementation rapid qualitative evaluation using stakeholder interviews. Data were collected between January and June 2023 via semi-structured interviews (50% online; 50% in person) with 112 stakeholders, including parents (n = 59), non-government organisations (n = 13), retailers (n = 11) and health and community professionals (n = 29) at national and local levels. Findings were confirmed by a sub-sample of participants. RESULTS: Six core themes cut across stakeholders' perceptions and experiences, and stakeholders collectively outlined seven recommendations they felt could be acted upon to maximise uptake and efficiency of HS, with actions at both national and local levels. A novel finding from this study is that raising awareness about HS alone is unlikely to result automatically or universally in higher uptake rate. Recommendations include: continuing to provide this scheme that is universally valued; the need for many families to be provided with a helping hand to successfully complete the application; reframing of the scheme as a child's right to food and development to ensure inclusivity; improved leadership, coordination and accountability at both national and local levels. CONCLUSIONS: HS provides benefits for child development and family wellbeing. The study's recommendations should be actioned by national and local governments to enable all families eligible for the scheme to benefit from this nutritional safety net.

What shapes parental feeding decisions over the first 18 months of parenting: Insights into drivers towards commercial and home-prepared foods among different socioeconomic groups in the UK.

Infants born into families experiencing socioeconomic disadvantage follow a high-risk trajectory for obesity and poor health in later life. Differences in early childhood food experiences may be contributing to these inequalities. This study aimed to explore the factors that influence parental decisions on when, how and what food to introduce over the first 18 months of their child's life and identify differences according to families' social position. Particular attention was given to social and environmental determinants within and outside the home. This research utilised a longitudinal qualitative methodology, with interviews and photo-elicitation exercises completed by participants when their children were 4-6; 10-12 and 16-18 months of age. Participants were parents (61 mothers; 1 father), distributed across low, medium and high socioeconomic position (SEP). During analysis, observable differences in factors directing parents to home-prepared or commercial foods were identified. Factors that undermined the provision of home-prepared meals included lack of time after returning to work, insufficient support from partners, uncertainty around infant and young child feeding (defined as the introduction and provision of solids) and an implicit trust in the messaging on branded products. These factors directed parents towards commercial foods and were most persistent among families experiencing socioeconomic disadvantage due to barriers accessing formal childcare, less flexible working conditions and fathers being less involved in infant feeding. To facilitate an enabling environment for healthy infant and young child feeding practices and address dietary inequalities, immediate steps that policy makers and healthcare providers can take include: i) changing the eligibility criteria for shared parental leave, ii) aligning claims on commercial infant food labels with international best practices, and iii) improving access to formal childcare.

UK government's new placement legislation is a 'good first step': a rapid qualitative analysis of consumer, business, enforcement and health stakeholder perspectives.

BACKGROUND: The current food system in England promotes a population diet that is high in fat, sugar and salt (HFSS). To address this, the UK government has implemented legislation to restrict the promotion of HFSS products in prominent locations (e.g. store entrances, checkouts) in qualifying retailers since October 2022. This study investigated the perceived impact of the legislation for affected stakeholders. METHODS: A pre-implementation rapid qualitative evaluation of stakeholder interviews. One hundred eight UK stakeholders participated in the study including 34 consumers, 24 manufacturers and retailers, 22 local authority enforcement officers and 28 academic and charitable health representatives. A participatory conference was used to enable policy recommendations to be confirmed by stakeholders. RESULTS: Stakeholders perceived the legislation to be a 'good first step' towards improving population diet but recognised this needed to be considered amongst a range of long-term obesity policies. Areas of further support were identified and these are presented as six recommendations for government to support the successful implementation of the legislation: (1) provide a free central HFSS calculator, (2) refine legislation to enhance intent and clarity, (3) conduct a robust evaluation to assess intended and unintended outcomes, (4) provide greater support for smaller businesses, (5) provide ring-fenced resources to local authorities and (6) create and communicate a long-term roadmap for food and health. CONCLUSIONS: This legislation has the potential to reduce impulse HFSS purchases and makes a solid start towards creating healthier retail outlets for consumers. Immediate government actions to create a freely accessible HFSS calculator, support smaller businesses and provide additional resources to local authorities would support successful implementation and enforcement. Independent evaluation of the implementation of the legislation will enable monitoring of potential unintended consequences identified in this study and support refinement of the legislation. A long-term roadmap is necessary to outline strategies to support equal access to healthier and sustainable food across the whole food system within the next 20-30 years.

Real-life experiments in supermarkets to encourage healthy dietary-related behaviours: opportunities, challenges and lessons learned.

BACKGROUND: Supermarkets are the primary source of food for many people yet their full potential as a setting to encourage healthy dietary-related behaviours remains underutilised. Sharing the experiences from research groups who have worked with supermarket chains to evaluate strategies that promote healthy eating could improve the efficiency of building such relationships and enhance the design quality of future research studies. METHODS: A collective case study approach was used to synthesise experiences of engaging and sustaining research collaborations with national supermarket chains to test the effectiveness of health-focused in-store interventions. The collective narrative covers studies conducted in three high-income countries: Australia, the Netherlands and the United Kingdom. RESULTS: We have distilled our experiences and lessons learned into six recommendations for conducting high quality public health research with commercial supermarket chains. These include: (i) using personal contacts, knowledge of supermarket activities and engaging executive management to establish a partnership and allowing time to build trust; (ii) using scientifically robust study designs with appropriate sample size calculations; (iii) formalising data exchange arrangements and allocating adequate resource for data extraction and re-categorisation; (iv) assessing effects at individual/households level where possible; (v) designing a mixed-methods process evaluation to measure intervention fidelity, dose and unintended consequences; and (vi) ensuring scientific independence through formal contract agreements. CONCLUSIONS: Our collective experiences of working in non-financial partnerships with national supermarket chains could be useful for other research groups looking to develop and implement supermarket studies in an efficient manner. Further evidence from real-life supermarket interventions is necessary to identify sustainable strategies that can improve population diet and maintain necessary commercial outcomes.

Evaluation and interpretation of latent class modelling strategies to characterise dietary trajectories across early life: a longitudinal study from the Southampton Women's Survey.

There is increasing interest in modelling longitudinal dietary data and classifying individuals into subgroups (latent classes) who follow similar trajectories over time. These trajectories could identify population groups and time points amenable to dietary interventions. This paper aimed to provide a comparison and overview of two latent class methods: group-based trajectory modelling (GBTM) and growth mixture modelling (GMM). Data from 2963 mother-child dyads from the longitudinal Southampton Women's Survey were analysed. Continuous diet quality indices (DQI) were derived using principal component analysis from interviewer-administered FFQ collected in mothers pre-pregnancy, at 11- and 34-week gestation, and in offspring at 6 and 12 months and 3, 6-7 and 8-9 years. A forward modelling approach from 1 to 6 classes was used to identify the optimal number of DQI latent classes. Models were assessed using the Akaike and Bayesian information criteria, probability of class assignment, ratio of the odds of correct classification, group membership and entropy. Both methods suggested that five classes were optimal, with a strong correlation (Spearman's = 0·98) between class assignment for the two methods. The dietary trajectories were categorised as stable with horizontal lines and were defined as poor (GMM = 4 % and GBTM = 5 %), poor-medium (23 %, 23 %), medium (39 %, 39 %), medium-better (27 %, 28 %) and best (7 %, 6 %). Both GBTM and GMM are suitable for identifying dietary trajectories. GBTM is recommended as it is computationally less intensive, but results could be confirmed using GMM. The stability of the diet quality trajectories from pre-pregnancy underlines the importance of promotion of dietary improvements from preconception onwards.

The beer component hordenine inhibits alcohol addiction-associated behaviours in mice.

Alcohol consumption is a widespread behaviour that may eventually result in the development of alcohol use disorder (AUD). Alcohol, however, is rarely consumed in pure form but in fruit- or corn-derived preparations, like beer. These preparations add other compounds to the consumption, which may critically modify alcohol intake and AUD risk. We investigated the effects of hordenine, a barley-derived beer compound on alcohol use-related behaviours. We found that the dopamine D2 receptor agonist hordenine (50 mg/kg) limited ongoing alcohol consumption and prophylactically diminished relapse drinking after withdrawal in mice. Although not having reinforcing effects on its own, hordenine blocked the establishment of alcohol-induced conditioned place preference (CPP). However, it independently enhanced alcohol CPP retrieval. Hordenine had a dose-dependent inhibitory effect on locomotor activity. Chronic hordenine exposure enhanced monoamine tissue levels in many brain regions. Further characterization revealed monoaminergic binding sites of hordenine and found a strong binding on the serotonin and dopamine transporters, and dopamine D3 , and adrenergic α1A and α2A receptor activation but no effects on GABAA receptor or glycinergic signalling. These findings suggest that natural ingredients of beer, like hordenine, may work as an inhibitory and use-regulating factor by their modulation of monoaminergic signalling in the brain.

Development of a measure of dietary quality for the UK Biobank.

BACKGROUND: Previous studies of the UK Biobank have examined intake of single food items and their association with health outcomes. Our aim was to develop a dietary quality score and examine the relationship between this score and markers of cardiometabolic health. METHODS: Principal component analysis was performed on dietary data from UK Biobank participants. Linear regression was used to analyse the relationship between diet and cardiometabolic health. RESULTS: The first component explained 14% of the variation in the dietary data. It was characterised by high consumption of meat and low fibre carbohydrates, and a low intake of fruit and vegetables. A higher score, indicative of healthier diet, was associated with lower systolic and diastolic blood pressure (ß -0.81, 95% CI -1.0, -0.62; ß - .61, 95% CI -0.72, -0.5) and a healthier lipid profile (lower levels of cholesterol ß -0.05, 95% CI -0.06, -0.04, triglycerides ß -0.05, 95% CI -0.06, -0.03, and higher HDL cholesterol ß 0.01, 95% CI 0, 0.01). CONCLUSIONS: The dietary quality score was a good approximation of overall dietary quality. An unhealthy diet was associated with markers of poorer cardiometabolic health.

The interplay between social and food environments on UK adolescents' food choices: implications for policy.

Factors from social and food environments can influence the food choices of adolescents in ways not experienced during childhood. Evidence suggests these two environments influence adolescents' food choices independently, but there is limited knowledge of how the interplay between these environments influence adolescents' diets. An enhanced understanding of this interplay surrounding adolescent food choice could aid the development of more nuanced interventions and policies. This qualitative study involved 13 online focus groups with adolescents (n = 45) aged 11-18 years, attending secondary school or college in England, UK. Data were analysed using thematic analysis. Social experiences which accompanied eating were perceived as more important than the food itself, and fast-food outlets were described as uniquely suited to facilitating these interactions. Young people wanted to spend their money on foods they considered worthwhile, but this did not always relate to the most affordable foods. Adolescents wanted to put little effort into making food decisions and appreciated factors that helped them make quick decisions such as prominent placement and eye-catching promotions on foods they wanted to buy. Chain food outlets were valued as they offered familiar and frequently advertised foods, which minimized the effort needed for food decisions. Adolescents' sense of autonomy underpinned all themes. Participants described having limited opportunities to make their own food choices and they did not want to waste these buying unappealing 'healthy' foods. Interventions and government policies should align with adolescents' experiences and values relating to food choice to ensure that they are effective with this important age group.

Longitudinal dietary trajectories from preconception to mid-childhood in women and children in the Southampton Women's Survey and their relation to offspring adiposity: a group-based trajectory modelling approach.

BACKGROUND: Rates of childhood obesity are increasing globally, with poor dietary quality an important contributory factor. Evaluation of longitudinal diet quality across early life could identify timepoints and subgroups for nutritional interventions as part of effective public health strategies. OBJECTIVE: This research aimed to: (1) define latent classes of mother-offspring diet quality trajectories from pre-pregnancy to child age 8-9 years, (2) identify early life factors associated with these trajectories, and (3) describe the association between the trajectories and childhood adiposity outcomes. DESIGN: Dietary data from 2963 UK Southampton Women's Survey mother-offspring dyads were analysed using group-based trajectory modelling of a diet quality index (DQI). Maternal diet was assessed pre-pregnancy and at 11- and 34-weeks' gestation, and offspring diet at ages 6 and 12 months, 3, 6-7- and 8-9-years using interviewer-administered food frequency questionnaires. At each timepoint, a standardised DQI was derived using principal component analysis. Adiposity age 8-9 years was assessed using dual-energy X-ray absorptiometry (DXA) and BMI z-scores. RESULTS: A five-trajectory group model was identified as optimal. The diet quality trajectories were characterised as stable, horizontal lines and were categorised as poor (n = 142), poor-medium (n = 667), medium (n = 1146), medium-better (n = 818) and best (n = 163). A poorer dietary trajectory was associated with higher maternal pre-pregnancy BMI, smoking, multiparity, lower maternal age and lower educational attainment. Using linear regression adjusted for confounders, a 1-category decrease in the dietary trajectory was associated with higher DXA percentage body fat (0.08 SD (95% confidence interval 0.01, 0.15) and BMI z-score (0.08 SD (0.00, 0.16) in the 1216 children followed up at age 8-9 years. CONCLUSION: Mother-offspring dietary trajectories are stable across early life, with poorer diet quality associated with maternal socio-demographic and other factors and childhood adiposity. The preconception period may be an important window to promote positive maternal dietary changes in order to improve childhood outcomes.

Altering product placement to create a healthier layout in supermarkets: Outcomes on store sales, customer purchasing, and diet in a prospective matched controlled cluster study.

BACKGROUND: Previous product placement trials in supermarkets are limited in scope and outcome data collected. This study assessed the effects on store-level sales, household-level purchasing, and dietary behaviours of a healthier supermarket layout. METHODS AND FINDINGS: This is a prospective matched controlled cluster trial with 2 intervention components: (i) new fresh fruit and vegetable sections near store entrances (replacing smaller displays at the back) and frozen vegetables repositioned to the entrance aisle, plus (ii) the removal of confectionery from checkouts and aisle ends opposite. In this pilot study, the intervention was implemented for 6 months in 3 discount supermarkets in England. Three control stores were matched on store sales and customer profiles and neighbourhood deprivation. Women customers aged 18 to 45 years, with loyalty cards, were assigned to the intervention (n = 62) or control group (n = 88) of their primary store. The trial registration number is NCT03518151. Interrupted time series analysis showed that increases in store-level sales of fruits and vegetables were greater in intervention stores than predicted at 3 (1.71 standard deviations (SDs) (95% CI 0.45, 2.96), P = 0.01) and 6 months follow-up (2.42 SDs (0.22, 4.62), P = 0.03), equivalent to approximately 6,170 and approximately 9,820 extra portions per store, per week, respectively. The proportion of purchasing fruits and vegetables per week rose among intervention participants at 3 and 6 months compared to control participants (0.2% versus -3.0%, P = 0.22; 1.7% versus -3.5%, P = 0.05, respectively). Store sales of confectionery were lower in intervention stores than predicted at 3 (-1.05 SDs (-1.98, -0.12), P = 0.03) and 6 months (-1.37 SDs (-2.95, 0.22), P = 0.09), equivalent to approximately 1,359 and approximately 1,575 fewer portions per store, per week, respectively; no differences were observed for confectionery purchasing. Changes in dietary variables were predominantly in the expected direction for health benefit. Intervention implementation was not within control of the research team, and stores could not be randomised. It is a pilot study, and, therefore, not powered to detect an effect. CONCLUSIONS: Healthier supermarket layouts can improve the nutrition profile of store sales and likely improve household purchasing and dietary quality. Placing fruits and vegetables near store entrances should be considered alongside policies to limit prominent placement of unhealthy foods. TRIAL REGISTRATION: ClinicalTrials.gov NCT03518151 (pre-results).

Development of a short food frequency questionnaire to assess diet quality in UK adolescents using the National Diet and Nutrition Survey.

BACKGROUND: UK adolescents consume fewer fruits and vegetables and more free sugars than any other age group. Established techniques to understand diet quality can be difficult to use with adolescents because of high participant burden. This study aimed to identify key foods that indicate variation in diet quality in UK adolescents for inclusion in a short food frequency questionnaire (FFQ) and to investigate the associations between adolescent diet quality, nutritional biomarkers and socio-demographic factors. METHODS: Dietary, demographic and biomarker data from waves 1-8 of the National Diet and Nutrition Survey rolling programme were used (n=2587; aged 11-18 years; 50% boys; n=≤997 biomarker data). Principal component analysis (PCA) was applied to 139 food groups to identify the key patterns within the data. Two diet quality scores, a 139-group and 20-group, were calculated using the PCA coefficients for each food group and multiplying by their standardised reported frequency of consumption and then summing across foods. The foods with the 10 strongest positive and 10 strongest negative coefficients from the PCA results were used for the 20-group score. Scores were standardised to have a zero mean and standard deviation of one. RESULTS: The first PCA component explained 3.0% of variance in the dietary data and described a dietary pattern broadly aligned with UK dietary recommendations. A correlation of 0.87 was observed between the 139-group and 20-group scores. Bland-Altman mean difference was 0.00 and 95% limits of agreement were - 0.98 to 0.98 SDs. Correlations, in the expected direction, were seen between each nutritional biomarker and both scores; results attenuated slightly for the 20-group score compared to the 139-group score. Better diet quality was observed among girls, non-white populations and in those from higher socio-economic backgrounds for both scores. CONCLUSIONS: The diet quality score based on 20 food groups showed reasonable agreement with the 139-group score. Both scores were correlated with nutritional biomarkers. A short 20-item FFQ can provide a meaningful and easy-to-implement tool to assess diet quality in large scale observational and intervention studies with adolescents.

Parental perspectives on negotiations over diet and physical activity: how do we involve parents in adolescent health interventions?

OBJECTIVE: To identify the ways in which parental involvement can be incorporated into interventions to support adolescent health behaviour change. DESIGN: Data from semi-structured interviews were analysed using inductive thematic analysis. SETTING: Southampton, Hampshire, UK. PARTICIPANTS: A convenience sample of twenty-four parents of adolescents. RESULTS: Parents consider themselves to play an important role in supporting their adolescents to make healthy choices. Parents saw themselves as gatekeepers of the household and as role models to their adolescents but recognised this could be both positive and negative in terms of health behaviours. Parents described the changing dynamics of the relationships they have with their adolescents because of increased adolescent autonomy. Parents stated that these changes altered their level of influence over adolescents' health behaviours. Parents considered it important to promote independence in their adolescents; however, many described this as challenging because they believed their adolescents were likely to make unhealthy decisions if not given guidance. Parents reported difficulty in supporting adolescents in a way that was not viewed as forceful or pressuring. CONCLUSIONS: When designing adolescent health interventions that include parental components, researchers need to be aware of the disconnect between public health recommendations and the everyday reality for adolescents and their parents. Parental involvement in adolescent interventions could be helpful but needs to be done in a manner that is acceptable to both adolescents and parents. The findings of this study may be useful to inform interventions which need to consider the transitions and negotiations which are common in homes containing adolescents.

Women's perceptions of factors influencing their food shopping choices and how supermarkets can support them to make healthier choices.

OBJECTIVES: To examine women's perceptions of factors that influence their food shopping choices, particularly in relation to store layout, and their views on ways that supermarkets could support healthier choices. DESIGN: This qualitative cross-sectional study used semi-structured telephone interviews to ask participants the reasons for their choice of supermarket and factors in-store that prompted their food selections. The actions supermarkets, governments and customers could take to encourage healthier food choices were explored with women. Thematic analysis was conducted to identify key themes. SETTING: Six supermarkets across England. PARTICIPANTS: Twenty women customers aged 18-45 years. RESULTS: Participants had a median age of 39.5 years (IQR: 35.1, 42.3), a median weekly grocery spend of £70 (IQR: 50, 88), and 44% had left school aged 16 years. Women reported that achieving value for money, feeling hungry, tired, or stressed, and meeting family members' food preferences influenced their food shopping choices. The physical environment was important, including product quality and variety, plus ease of accessing the store or products in-store. Many participants described how they made unintended food selections as a result of prominent placement of unhealthy products in supermarkets, even if they adopted more conscious approaches to food shopping (i.e. written or mental lists). Participants described healthy eating as a personal responsibility, but some stated that governments and supermarkets could be more supportive. CONCLUSIONS: This study highlighted that in-store environments can undermine intentions to purchase and consume healthy foods. Creating healthier supermarket environments could reduce the burden of personal responsibility for healthy eating, by making healthier choices easier. Future research could explore the interplay of personal, societal and commercial responsibility for food choices and health status.

Preconception health in England: a proposal for annual reporting with core metrics.

There is growing interest in preconception health as a crucial period for influencing not only pregnancy outcomes, but also future maternal and child health, and prevention of long-term medical conditions. Successive national and international policy documents emphasise the need to improve preconception health, but resources and action have not followed through with these goals. We argue for a dual intervention strategy at both the public health level (eg, by improving the food environment) and at the individual level (eg, by better identification of those planning a pregnancy who would benefit from support to optimise health before conception) in order to raise awareness of preconception health and to normalise the notion of planning and preparing for pregnancy. Existing strategies that target common risks factors, such as obesity and smoking, should recognise the preconception period as one that offers special opportunity for intervention, based on evidence from life-course epidemiology, developmental (embryo) programming around the time of conception, and maternal motivation. To describe and monitor preconception health in England, we propose an annual report card using metrics from multiple routine data sources. Such a report card should serve to hold governments and other relevant agencies to account for delivering interventions to improve preconception health.

How can we best use opportunities provided by routine maternity care to engage women in improving their diets and health?

Pregnancy provides motivation for women to improve their diets and increase their physical activity. Opportunistic brief interventions delivered as part of routine primary care have produced improvements in patients' health behaviour. Consequently, there have been calls for midwives to use contacts during pregnancy in this way. This study explored the experiences of pregnant women and research midwives/nurses of a brief intervention called Healthy Conversation Skills (HCS) being delivered as part of a randomised control trial, assessing the acceptability and feasibility of including this intervention in routine maternity care. Three research questions were addressed using mixed methods to produce four datasets: face-to-face interviews with participants, a focus group with the HCS-trained midwives/nurses, case reports of participants receiving HCS and audio-recordings of mid-pregnancy telephone calls to the women which produced midwife/nurse HCS competency scores. Midwives/nurses used their HCS to support women to make plans for change and set goals. Women welcomed the opportunity to address their own health and well-being as distinct from that of their baby. Midwives/nurses were competent in using the skills and saw healthy conversations as an effective means of raising issues of diet and physical activity. Recent extension of maternity appointment times provides ideal opportunities to incorporate a brief intervention to support behaviour change. Incorporating HCS training into midwifery education and continuing professional development would facilitate this. HCS is a scalable, brief intervention with the potential to improve the diets and physical activity levels of women during pregnancy, and hence the health of themselves and their babies.

Intervention strategies to improve nutrition and health behaviours before conception.

The nutritional status of both women and men before conception has profound implications for the growth, development, and long-term health of their offspring. Evidence of the effectiveness of preconception interventions for improving outcomes for mothers and babies is scarce. However, given the large potential health return, and relatively low costs and risk of harm, research into potential interventions is warranted. We identified three promising strategies for intervention that are likely to be scalable and have positive effects on a range of health outcomes: supplementation and fortification; cash transfers and incentives; and behaviour change interventions. On the basis of these strategies, we suggest a model specifying pathways to effect. Pathways are incorporated into a life-course framework using individual motivation and receptiveness at different preconception action phases, to guide design and targeting of preconception interventions. Interventions for individuals not planning immediate pregnancy take advantage of settings and implementation platforms outside the maternal and child health arena, since this group is unlikely to be engaged with maternal health services. Interventions to improve women's nutritional status and health behaviours at all preconception action phases should consider social and environmental determinants, to avoid exacerbating health and gender inequalities, and be underpinned by a social movement that touches the whole population. We propose a dual strategy that targets specific groups actively planning a pregnancy, while improving the health of the population more broadly. Modern marketing techniques could be used to promote a social movement based on an emotional and symbolic connection between improved preconception maternal health and nutrition, and offspring health. We suggest that speedy and scalable benefits to public health might be achieved through strategic engagement with the private sector. Political theory supports the development of an advocacy coalition of groups interested in preconception health, to harness the political will and leadership necessary to turn high-level policy into effective coordinated action.

A Delphi study to build consensus on the definition and use of big data in obesity research.

BACKGROUND: 'Big data' has great potential to help address the global health challenge of obesity. However, lack of clarity with regard to the definition of big data and frameworks for effectively using big data in the context of obesity research may be hindering progress. The aim of this study was to establish agreed approaches for the use of big data in obesity-related research. METHODS: A Delphi method of consensus development was used, comprising three survey rounds. In Round 1, participants were asked to rate agreement/disagreement with 77 statements across seven domains relating to definitions of, and approaches to, using big data in the context of obesity research. Participants were also asked to contribute further ideas in relation to these topics, which were incorporated as new statements (n = 8) in Round 2. In Rounds 2 and 3 participants re-appraised their ratings in view of the group consensus. RESULTS: Ninety-six experts active in obesity-related research were invited to participate. Of these, 36/96 completed Round 1 (37.5% response rate), 29/36 completed Round 2 (80.6% response rate) and 26/29 completed Round 3 (89.7% response rate). Consensus (defined as > 70% agreement) was achieved for 90.6% (n = 77) of statements, with 100% consensus achieved for the Definition of Big Data, Data Governance, and Quality and Inference domains. CONCLUSIONS: Experts agreed that big data was more nuanced than the oft-cited definition of 'volume, variety and velocity', and includes quantitative, qualitative, observational or intervention data from a range of sources that have been collected for research or other purposes. Experts repeatedly called for third party action, for example to develop frameworks for reporting and ethics, to clarify data governance requirements, to support training and skill development and to facilitate sharing of big data. Further advocacy will be required to encourage organisations to adopt these roles.

Examination of how food environment and psychological factors interact in their relationship with dietary behaviours: test of a cross-sectional model.

BACKGROUND: To improve population diet environmental strategies have been hailed the panacea because they require little agency or investment of personal resources; this contrasts with conventional strategies that rely on individuals to engage high levels of agency and make deliberate choices. There is an immediate need to improve understanding of the synergy between the psychological and environmental determinants of diet in order to optimise allocation of precious public health resources. This study examined the synergistic and relative association between a number of food environment and psychological factors and the dietary behaviours of a population sample of women with young children. METHODS: Women in Hampshire were recruited from children's centres and asked about their demographic characteristics, psychological resources, dietary behaviours (food frequency questionnaire) and perceptions of healthy food access and affordability. Three local food environment factors were objectively assessed: i) spatial access to food outlets using activity spaces; ii) healthfulness of the supermarket where women did their main food shop, (based on nine in-store factors including price, placement and promotion on seven healthy and five less healthy foods); iii) nutrition environment of children's centres visited frequently by the women, assessed via staff-administered questionnaire. A theoretical model linking environmental factors to dietary behaviours, both directly and indirectly through three factors representing individual agency (psychological resources, perceived food affordability, perceived food accessibility), was tested using Structural Equation Modelling. RESULTS: Complete data were available for 753 women. The environment of women's main supermarket was indirectly related to their dietary behaviours through psychological resources and perceived food affordability. Shopping at supermarkets classified as having a healthier in-store environment was associated with having greater psychological resources associated with healthy eating (standardised regression weight ß = 0.14SD, p = 0.03) and fewer food affordability concerns (ß = - 0.14SD, p = 0.01), which in turn related to healthier dietary behaviours (ß = 0.55SD, < 0.001 and ß = - 0.15, p = 0.01 respectively). The three food environment factors were not directly associated with dietary behaviour (p > 0.3). The overall model fit was good (CFI = 0.91, RMSEA = 0.05 [0.05, 0.06]). CONCLUSIONS: This pathway analysis identified three focal points for intervention and suggests that high-agency interventions targeting individual psychological resources when combined with low-agency supermarket environment interventions may confer greater benefits on dietary behaviours than either intervention alone.

Greater access to healthy food outlets in the home and school environment is associated with better dietary quality in young children.

OBJECTIVE: To explore associations between dietary quality and access to different types of food outlets around both home and school in primary school-aged children. DESIGN: Cross-sectional observational study. SETTING: Hampshire, UK. SUBJECTS: Children (n 1173) in the Southampton Women's Survey underwent dietary assessment at age 6 years by FFQ and a standardised diet quality score was calculated. An activity space around each child's home and school was created using ArcGIS. Cross-sectional observational food outlet data were overlaid to derive four food environment measures: counts of supermarkets, healthy specialty stores (e.g. greengrocers), fast-food outlets and total number of outlets, and a relative measure representing healthy outlets (supermarkets and specialty stores) as a proportion of total retail and fast-food outlets. RESULTS: In univariate multilevel linear regression analyses, better diet score was associated with exposure to greater number of healthy specialty stores (ß=0·025 sd/store: 95 % CI 0·007, 0·044) and greater exposure to healthy outlets relative to all outlets in children's activity spaces (ß=0·068 sd/10 % increase in healthy outlets as a proportion of total outlets, 95 % CI 0·018, 0·117). After adjustment for mothers' educational qualification and level of home neighbourhood deprivation, the relationship between diet and healthy specialty stores remained robust (P=0·002) while the relationship with the relative measure weakened (P=0·095). Greater exposure to supermarkets and fast-food outlets was associated with better diet only in the adjusted models (P=0·017 and P=0·014, respectively). CONCLUSIONS: The results strengthen the argument for local authorities to increase the number of healthy food outlets to which young children are exposed.