Baby Food Pouches, Baby-Led Weaning, and Iron Status in New Zealand Infants: An Observational Study.

Iron deficiency in infants can impact development, and there are concerns that the use of baby food pouches and baby-led weaning may impair iron status. First Foods New Zealand (FFNZ) was an observational study of 625 New Zealand infants aged 6.9 to 10.1 months. Feeding methods were defined based on parental reports of infant feeding at "around 6 months of age": "frequent" baby food pouch use (five+ times per week) and "full baby-led weaning" (the infant primarily self-feeds). Iron status was assessed using a venepuncture blood sample. The estimated prevalence of suboptimal iron status was 23%, but neither feeding method significantly predicted body iron concentrations nor the odds of iron sufficiency after controlling for potential confounding factors including infant formula intake. Adjusted ORs for iron sufficiency were 1.50 (95% CI: 0.67-3.39) for frequent pouch users compared to non-pouch users and 0.91 (95% CI: 0.45-1.87) for baby-led weaning compared to traditional spoon-feeding. Contrary to concerns, there was no evidence that baby food pouch use or baby-led weaning, as currently practiced in New Zealand, were associated with poorer iron status in this age group. However, notable levels of suboptimal iron status, regardless of the feeding method, emphasise the ongoing need for paying attention to infant iron nutrition.

Hunger Training as a Self-regulation Strategy in a Comprehensive Weight Loss Program for Breast Cancer Prevention: A Randomized Feasibility Study.

Weight losses >10% favorably modulate biomarkers of breast cancer risk but are not typically achieved by comprehensive weight loss programs, including the Diabetes Prevention Program (DPP). Combining the DPP with hunger training (HT), an evidence-based self-regulation strategy that uses self-monitored glucose levels to guide meal timing, has potential to enhance weight losses and cancer-related biomarkers, if proven feasible. This two-arm randomized controlled trial examined the feasibility of adding HT to the DPP and explored effects on weight and metabolic and breast cancer risk biomarkers. Fifty postmenopausal women [body mass index (BMI) >27 kg/m2)] at risk of breast cancer were randomized to the DPP+HT or DPP-only arm. Both arms followed a 16-week version of the DPP delivered weekly by a trained registered dietitian. Those in the DPP+HT also wore a continuous glucose monitor during weeks 4-6 of the program. Feasibility criteria were accrual rates >50%, retention rates >80%, and adherence to the HT protocol >75%. All a priori feasibility criteria were achieved. The accrual rate was 67%, retention rate was 81%, and adherence to HT was 90%. Weight losses and BMI reductions were significant over time as were changes in metabolic and breast cancer risk biomarkers but did not vary by group. This trial demonstrated that HT was feasible to add to comprehensive weight management program targeted toward postmenopausal women at high risk of breast cancer, though upon preliminary examination it does not appear to enhance weight loss or metabolic changes. PREVENTION RELEVANCE: This study found that it was feasible to add a short glucose-guided eating intervention to a comprehensive weight management program targeting postmenopausal women at high risk of breast cancer. However, further development of this novel intervention as a cancer prevention strategy is needed.

Energy, Sugars, Iron, and Vitamin B12 Content of Commercial Infant Food Pouches and Other Commercial Infant Foods on the New Zealand Market.

There has been an important shift in the New Zealand infant food market over the past decade, with the majority of complementary foods now sold in "pouches". Along with the increasing market share of commercial infant food pouches internationally, there have been growing concerns about their nutritional quality. However, research examining the nutritional quality of these pouches compared to other forms of commercial infant foods in New Zealand has not been undertaken. Nor have any studies reported the free sugars or added sugars content of these foods. To address this knowledge gap, a cross-sectional survey of infant foods sold in New Zealand supermarkets was conducted in 2019-2020. Recipes and nutrient lines were developed for the 266 foods identified (133 food pouches). The energy, iron, vitamin B12, total sugars, free sugars, and added sugars content of infant food pouches and other forms of commercial infant foods per 100 g were compared, both within food groups and by age group. Infant food pouches contained similar median amounts of energy, iron, and vitamin B12 to other forms of commercial infant foods but contained considerably more total sugars (8.4 g/100 g vs. 2.3 g/100 g). However, median free sugars and added sugars content was very low across all food groups except for "dairy" and "sweet snacks". All "dry cereals" were fortified with iron whereas none of the infant food pouches were. Therefore, consuming food pouches to the exclusion of other commercial infant foods may place infants at risk of iron deficiency if they do not receive sufficient iron from other sources.

A prediction model for childhood obesity in New Zealand.

Several early childhood obesity prediction models have been developed, but none for New Zealand's diverse population. We aimed to develop and validate a model for predicting obesity in 4-5-year-old New Zealand children, using parental and infant data from the Growing Up in New Zealand (GUiNZ) cohort. Obesity was defined as body mass index (BMI) for age and sex ≥ 95th percentile. Data on GUiNZ children were used for derivation (n = 1731) and internal validation (n = 713). External validation was performed using data from the Prevention of Overweight in Infancy Study (POI, n = 383) and Pacific Islands Families Study (PIF, n = 135) cohorts. The final model included: birth weight, maternal smoking during pregnancy, maternal pre-pregnancy BMI, paternal BMI, and infant weight gain. Discrimination accuracy was adequate [AUROC = 0.74 (0.71-0.77)], remained so when validated internally [AUROC = 0.73 (0.68-0.78)] and externally on PIF [AUROC = 0.74 [0.66-0.82)] and POI [AUROC = 0.80 (0.71-0.90)]. Positive predictive values were variable but low across the risk threshold range (GUiNZ derivation 19-54%; GUiNZ validation 19-48%; and POI 8-24%), although more consistent in the PIF cohort (52-61%), all indicating high rates of false positives. Although this early childhood obesity prediction model could inform early obesity prevention, high rates of false positives might create unwarranted anxiety for families.

Pharmacological Augmentation in Unipolar Depression: A Guide to the Guidelines.

BACKGROUND: Pharmacological augmentation is a recommended strategy for patients with treatment-resistant depression. A range of guidelines provide advice on treatment selection, prescription, monitoring and discontinuation, but variation in the content and quality of guidelines may limit the provision of objective, evidence-based care. This is of importance given the side effect burden and poorer long-term outcomes associated with polypharmacy and treatment-resistant depression. This review provides a definitive overview of pharmacological augmentation recommendations by assessing the quality of guidelines for depression and comparing the recommendations made. METHODS: A systematic literature search identified current treatment guidelines for depression published in English. Guidelines were quality assessed using the Appraisal of Guidelines for Research and Evaluation II tool. Data relating to the prescription of pharmacological augmenters were extracted from those developed with sufficient rigor, and the included recommendations compared. RESULTS: Total of 1696 records were identified, 19 guidelines were assessed for quality, and 10 were included. Guidelines differed in their quality, the stage at which augmentation was recommended, the agents included, and the evidence base cited. Lithium and atypical antipsychotics were recommended by all 10, though the specific advice was not consistent. Of the 15 augmenters identified, no others were universally recommended. CONCLUSIONS: This review provides a comprehensive overview of current pharmacological augmentation recommendations for major depression and will support clinicians in selecting appropriate treatment guidance. Although some variation can be accounted for by date of guideline publication, and limited evidence from clinical trials, there is a clear need for greater consistency across guidelines to ensure patients receive consistent evidence-based care.

Consistent use of bedtime parenting strategies mediates the effects of sleep education on child sleep: secondary findings from an early-life randomized controlled trial.

OBJECTIVE: Using data from a randomized controlled trial, this study investigated whether parent's consistent use of recommended bedtime strategies with infants was a mediating mechanism for improved child sleep. METHODS: Expectant mothers were allocated to 4 groups: usual care (Control); additional support regarding Food, (physical) Activity, and Breastfeeding (FAB); advice on infant sleep through 1 group educational session during the antenatal period and 1 home visit when the child was 3 weeks of age (Sleep), or both FAB and Sleep interventions (Combination). An index relating to parent's consistent use of strategies to encourage infant sleep self-settling was developed from data collected when infants were 4 and 6 months of age. Child sleep self-control was measured at 3.5 years of age through a behavior rating scale. Child overnight sleep duration was measured using accelerometers at 1, 2, 3.5, and 5 years of age. Analyses examined whether any association between intervention group and child sleep self-control or sleep duration was mediated by consistent use of bedtime strategies at 4 and 6 months. RESULTS: Compared to Controls, Sleep group parents had significantly higher odds of using more intervention strategies consistently (1.63; 95% confidence interval [CI] 1.14-2.33), as did Combination group parents (1.45; 95% CI 1.01-2.07). Consistent strategy use was significantly associated with a decrease in child bedtime behavioral difficulties (0.97; 95% CI 0.95-0.98) and increased sleep duration (0.152; SE = 0.017). Sleep group assignment reduced child sleep self-control difficulties and improved sleep duration indirectly via parent's consistent use of bedtime strategies. DISCUSSION: Consistent use of appropriate bedtime strategies in infancy is an important factor that influences child sleep self-control in later development.

Sleep, nutrition, and physical activity interventions to prevent obesity in infancy: follow-up of the Prevention of Overweight in Infancy (POI) randomized controlled trial at ages 3.5 and 5 y.

Background: Our Prevention of Overweight in Infancy (POI) study suggested that a brief sleep intervention in infancy reduced the risk of obesity at age 2 y. In contrast, we observed no benefit from the nutrition and activity intervention. Objective: The objective of the study was to determine how these interventions influenced growth at ages 3.5 and 5 y compared with usual care (Control). Design: A follow-up of a parallel, 4-arm, single-blind, 2-y, randomized controlled trial in 802 women (86% European, 48% primiparous) recruited in pregnancy (58% response rate) was undertaken. All groups received standard Well-Child care with additional support for 3 intervention groups: FAB (promotion of breastfeeding, healthy eating, physical activity: 8 contacts, antenatal, 18 mo); Sleep (prevention of sleep problems: antenatal, 3 wk); Combination (both interventions). Follow-up measures were collected by staff blinded to group allocation. The primary outcome was child body mass index (BMI) z score, and secondary outcomes were prevalence of obesity (BMI ≥95th percentile), self-regulation (psychological measures), sleep, physical activity (accelerometry, questionnaires), and dietary intake (food-frequency questionnaire). Analyses were conducted through the use of multiple imputation. Results: Retention was 77% at age 3.5 y and 69% at age 5 y. Children in the FAB group had significantly higher BMI z scores than did Controls at age 5 y (adjusted difference: 0.25; 95% CI: 0.04, 0.47) but not at age 3.5 y (0.15; 95% CI: -0.04, 0.34). Children who received the Sleep intervention (Sleep and Combination groups) had significantly lower BMI z scores at age 3.5 y (-0.24; 95% CI: -0.38, -0.10) and at age 5 y (-0.23; 95% CI: -0.38, -0.07) than children who did not (Control and FAB groups). Conclusions: A conventional intervention had unexpected adverse long-term weight outcomes, whereas positive outcomes from a less conventional sleep intervention remained promising at age 5 y. More intensive or extended sleep intervention might have larger or longer-lasting effects and should be investigated. This trial was registered at clinicaltrials.gov as NCT00892983.

Impact of a modified version of baby-led weaning on iron intake and status: a randomised controlled trial.

OBJECTIVE: To determine the iron intake and status of infants following a version of baby-led weaning (BLW) modified to prevent iron deficiency (Baby-Led Introduction to SolidS; BLISS) compared with those of infants following traditional spoon-feeding. DESIGN, PARTICIPANTS AND INTERVENTION: This randomised controlled trial included 206 participants assigned to control (n=101) or BLISS (n=105) groups. Both groups received standard midwifery and 'Well Child' care. BLISS participants received eight additional visits (from before birth to 9 months) providing education and support on the BLISS approach to complementary feeding (ie, BLW modified to increase iron intake). The primary outcome of the BLISS study (growth) has been previously reported. This paper reports the key prespecified secondary outcomes, iron intake and iron status. OUTCOME MEASURES: Intake of iron and key absorption modifiers were assessed using weighed 3-day diet records at 7 and 12 months. A venipuncture blood sample was collected at 12 months to determine plasma ferritin, haemoglobin, soluble transferrin receptor, C-reactive protein and α1-acid glycoprotein concentrations; and body iron was calculated. RESULTS: Differences in median dietary iron intakes between the control and BLISS groups were not significant at 7 (difference 0.6 mg/day; 95% CI -1.0 to 2.3) or 12 (-0.1 mg/day; -1.6 to 1.4) months of age. Similarly, there were no significant differences in plasma ferritin concentration (difference -2.6 µg/L; 95% CI -10.9 to 5.8), body iron (0.04 mg/kg; -1.1 to 1.2) or the prevalence of depleted iron stores, early functional iron deficiency or iron deficiency anaemia (all p≥0.65) at 12 months of age. CONCLUSIONS: A baby-led approach to complementary feeding does not appear to increase the risk of iron deficiency in infants when their parents are given advice to offer 'high-iron' foods with each meal. TRIAL REGISTRATION NUMBER: ACTRN12612001133820; Pre-results.

Determining how best to support overweight adults to adhere to lifestyle change: protocol for the SWIFT study.

BACKGROUND: Physical activity plays a critical role in health, including for effective weight maintenance, but adherence to guidelines is often poor. Similarly, although debate continues over whether a "best" diet exists for weight control, meta-analyses suggest little difference in outcomes between diets differing markedly in macronutrient composition, particularly over the longer-term. Thus a more important question is how best to encourage adherence to appropriate lifestyle change. While brief support is effective, it has on-going cost implications. While self-monitoring (weight, diet, physical activity) is a cornerstone of effective weight management, little formal evaluation of the role that self-monitoring technology can play in enhancing adherence to change has occurred to date. People who eat in response to hunger have improved weight control, yet how best to train individuals to recognise when true physical hunger occurs and to limit consumption to those times, requires further study. METHODS/DESIGN: SWIFT (Support strategies for Whole-food diets, Intermittent Fasting, and Training) is a two-year randomised controlled trial in 250 overweight (body mass index of 27 or greater) adults that will examine different ways of supporting people to make appropriate changes to diet and exercise habits for long-term weight control. Participants will be randomised to one of five intervention groups: control, brief support (monthly weigh-ins and meeting), app (use of MyFitnessPal with limited support), daily self-weighing (with brief monthly feedback), or hunger training (four-week programme which trains individuals to only eat when physically hungry) for 24 months. Outcome assessments include weight, waist circumference, body composition (dual-energy x-ray absorptiometry), inflammatory markers, blood lipids, adiponectin and ghrelin, blood pressure, diet (3-day diet records), physical activity (accelerometry) and aerobic fitness, and eating behaviour. SWIFT is powered to detect clinically important differences of 4 kg in body weight and 5 cm in waist circumference. Our pragmatic trial also allows participants to choose one of several dietary (Mediterranean, modified Paleo, intermittent fasting) and exercise (current recommendations, high-intensity interval training) approaches before being randomised to a support strategy. DISCUSSION: SWIFT will compare four different ways of supporting overweight adults to lose weight while following a diet and exercise plan of their choice, an aspect we believe will enhance adherence and thus success with weight management. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12615000010594. Registered 8th January 2015.

Development and pilot testing of Baby-Led Introduction to SolidS--a version of Baby-Led Weaning modified to address concerns about iron deficiency, growth faltering and choking.

BACKGROUND: In Baby-Led Weaning (BLW), infants are offered 'finger' foods from the start of the complementary feeding period instead of being spoon-fed. Healthcare professionals have expressed concerns about adequacy of iron and energy intake, and about choking, for infants following Baby-Led Weaning. METHODS: We developed a modified version of BLW, Baby-Led Introduction to SolidS (BLISS), to address these concerns. In a 12-week pilot study, families who had chosen to use a BLW approach were assigned to BLISS (n = 14) or BLW (n = 9). BLISS participants received 2 intervention visits, resources and on-call support. BLW participants received no intervention. Participants were interviewed weekly for 12 weeks and completed a three-day weighed record or three 24-h iron questionnaires. RESULTS: Compared to the BLW group, the BLISS group were more likely to introduce iron containing foods during the first week of complementary feeding, and to offer more serves per day of iron containing foods at 6 months (2.4 vs 0.8 serves/day; P = 0.001); and less likely to offer high-choking-risk foods (3.24 vs 0.17 serves/day; P = 0.027). CONCLUSIONS: This pilot study suggests BLISS may result in higher iron intakes and lower choking risk than unmodified BLW. However, the results need to be confirmed in a large randomised controlled trial.

Impact of an early-life intervention on the nutrition behaviors of 2-y-old children: a randomized controlled trial.

BACKGROUND: Despite an extensive well-child health service, 30% of New Zealand's 2- to 4-y old children are overweight or obese. This suggests that additional intervention is necessary to establish healthy nutrition behaviors. OBJECTIVE: The aim of this study was to assess the effect of intervention from 0 to 18 mo of age on food and nutrient intake, eating behaviors, and parental feeding practices in 18- to 24-mo-old children. DESIGN: In total, 802 families with healthy infants were randomly allocated to 1 of 4 groups: Usual Care (UC); Food, Activity, and Breastfeeding (FAB); Sleep; or FAB and Sleep (Combination). All groups received standard "well-child" care. The FAB intervention comprised 7-8 additional contacts for education and support around breastfeeding, food, and activity. The Sleep intervention comprised 2 additional contacts for guidance about sleeping habits. Combination families received both interventions. A validated food-frequency questionnaire assessed food intake at 2 y. A questionnaire assessed eating behaviors and parental feeding practices at 18 and 24 mo. RESULTS: At 2 y, there were no statistically significant differences in food and nutrient intake or eating behaviors in the groups receiving the FAB intervention (FAB, Combination; 325 children) compared with the groups who did not (Sleep, UC; 341 children). With the use of a 5-point scale, small but statistically significant differences in parental feeding practices were observed in the groups receiving the FAB intervention: greater child control over eating (difference: 0.14; 95% CI: 0.02, 0.26) and less pressure to eat (difference: 0.18; 95% CI: 0.04, 0.32) at 18 mo, as well as greater encouragement of nutrient-dense foods at 24 mo (difference: 0.16; 95% CI: 0.03, 0.30). No statistically significant differences were observed between the groups who received the Sleep intervention (Sleep, Combination; 313 children) and those who did not, except higher meat intake in the former (11 g/d). CONCLUSION: Additional education and support for parents from birth did not improve nutrition behaviors in this population at 2 y of age. This trial was registered at clinicaltrials.gov as NCT00892983.

Lactation Consultant Support from Late Pregnancy with an Educational Intervention at 4 Months of Age Delays the Introduction of Complementary Foods in a Randomized Controlled Trial.

BACKGROUND: Although the WHO recommends that complementary feeding in infants should begin at 6 mo of age, it often begins before this in developed countries. OBJECTIVE: Our objective was to determine whether lactation consultant (LC) support, with educational resources given at 4-mo postpartum, can delay the introduction of complementary foods until around 6 mo of age. METHODS: A total of 802 mother-infant pairs were recruited from the single maternity hospital serving Dunedin, New Zealand (59% response rate) and randomly assigned to the following: 1) usual care (control group); 2) infant sleep education intervention (Sleep); 3) food, activity, and breastfeeding intervention (FAB); or 4) combination (both) intervention (Combo). Certified LCs delivered 3 intervention sessions (late pregnancy and 1-wk and 4-mo postpartum). The 4-mo contact used educational resources focused on developmental readiness for complementary foods. Age when complementary foods were introduced was obtained from repeated interviews (monthly from 3- to 27-wk postpartum). RESULTS: A total of 49.5% and 87.2% of infants received complementary foods before 5 and 6 mo of age, respectively. There was evidence of group differences in the number of infants introduced to complementary foods before 5 mo (P = 0.006), with those receiving support and resources (FAB and Combo groups combined; 55.6%) more likely to wait until at least 5 mo compared with controls (control and Sleep groups combined; 43.3%) (OR: 1.52; 95% CI: 1.08, 2.16). However, there was no evidence they were more likely to wait until 6 mo of age (P = 0.52). Higher maternal age, higher parity, and a less positive attitude toward breastfeeding were positively associated, and drinking alcohol during pregnancy was negatively associated, with later age of introduction of complementary foods. CONCLUSIONS: Providing an LC and educational resources at 4-mo postpartum to predominantly well-educated, mainly European, women can delay the introduction of complementary foods until 5 mo of age, but not until the WHO recommendation of 6 mo. This trial was registered at clinicaltrials.gov as NCT00892983.

Associations between parental feeding practices, problem food behaviours and dietary intake in New Zealand overweight children aged 4-8 years.

OBJECTIVE: Parents report that children's eating behaviours are a major barrier to providing them with a healthy diet. Links between problem eating behaviours and parental feeding practices are not well established and have not previously been examined in overweight children. The aim of the present study was to assess associations between problem food behaviours, dietary intake and parental feeding practices of overweight children aged 4-8 years. DESIGN: Participants were recruited for a lifestyle intervention (n 203). At baseline, children's BMI was measured and parents completed comprehensive questionnaires about the feeding practices they used, the problem food behaviours their children exhibited and the foods their child consumed. A fussy eating scale was developed and associations were determined using correlations and regression analysis, including interactions. SETTING: Dunedin, New Zealand. SUBJECTS: Overweight children aged 4-8 years. RESULTS: Healthy eating guidance and monitoring by parents were related to the consumption of fewer unhealthy foods (B=-0·4, P=0·001 and B=-0·4, P<0·001). Conversely, a lack of parental control (child control) was related to a higher intake of unhealthy foods (B = 0·5, P<0·001). Parents of children who were fussy eaters monitored their child's food intake less (P<0·001) and allowed the child more freedom over what he/she ate (P<0·001). These children consumed fewer fruit and vegetables than those who were not fussy eaters (P<0·001). However, fussy eaters with food-restrictive parents ate more fruit and vegetables (B=2·9, P<0·001). CONCLUSIONS: These results suggest that a more structured food environment might be beneficial for the diet and food behaviours of young overweight children.

Do parents recall and understand children's weight status information after BMI screening? A randomised controlled trial.

OBJECTIVES: As parents of young children are often unaware their child is overweight, screening provides the opportunity to inform parents and provide the impetus for behaviour change. We aimed to determine if parents could recall and understand the information they received about their overweight child after weight screening. DESIGN: Randomised controlled trial of different methods of feedback. SETTING: Participants were recruited through primary and secondary care but appointments took place at a University research clinic. PARTICIPANTS AND INTERVENTION: 1093 children aged 4-8 years were screened. Only overweight children (n=271, 24.7%) are included in this study. Parents of overweight children were randomised to receive feedback regarding their child's weight using best practice care (BPC) or motivational interviewing (MI) at face-to-face interviews typically lasting 20-40 min. 244 (90%) parents participated in a follow-up interview 2 weeks later to assess recall and understanding of information from the feedback session. PRIMARY AND SECONDARY OUTCOME MEASURES: Interviews were audio-taped and transcribed verbatim before coding for amount and accuracy of recall. Scores were calculated for total recall and sub-categories of interest. RESULTS: Overall, 39% of the information was recalled (mean score 6.3 from possible score of 16). Parents given feedback via BPC recalled more than those in the MI group (difference in total score 0.48; 95% CI 0.05 to 0.92). Although 94% of parents were able to correctly recall their child's weight status, fewer than 10 parents could accurately describe what the measurements meant. Maternal education (0.81; 0.25 to 1.37) and parental ratings of how useful they found the information (0.19; 0.04 to 0.35) were significant predictors of recall score in multivariate analyses. CONCLUSIONS: While parents remember that their child's body mass index is higher than recommended, they are unable to remember much of the information and advice provided about the result. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry ACTRN12609000749202.

What factors influence uptake into family-based obesity treatment after weight screening?

OBJECTIVES: To determine what factors drive participation in a family-based weight management program for 4- to 8-year-old children following screening for overweight or obesity. STUDY DESIGN: Children (n = 1093) attended a comprehensive screening appointment where parents completed questionnaires on demographics, motivation for healthy lifestyles, feeding practices, and beliefs about child size, prior to feedback about the child's weight. Parents of overweight or obese children (body mass index ≥85th percentile) attended a follow-up interview to assess reactions to feedback and willingness to participate in a 2-year intervention. RESULTS: A total of 271 (24.8%) children were overweight or obese with 197 (72.7%) agreeing to the intervention. Socioeconomic status differed in intervention participants (n = 197) compared with non-participants (n = 74), whereas no differences were observed in parental feeding practices, ineffective parenting practices, or self-determined forms of motivation. However, fewer non-participating parents believed their child to be overweight (23% vs 49%, P < .001) or were concerned about it (16% vs 43%, P < .001), despite children having an average body mass index approximating the 95th percentile. Non-participating parents did not expect their child to be overweight (P = .002) and rated receiving this information as less useful (P = .008) than participating parents. CONCLUSION: Preconceptions about child weight and reactions to feedback determined intervention uptake more than parenting or motivation for health. Many parents agreed to participate in the intervention despite not viewing their child as overweight.

Longitudinal analysis of sleep in relation to BMI and body fat in children: the FLAME study.

OBJECTIVES: To determine whether reduced sleep is associated with differences in body composition and the risk of becoming overweight in young children. DESIGN: Longitudinal study with repeated annual measurements. SETTING: Dunedin, New Zealand. PARTICIPANTS: 244 children recruited from a birth cohort and followed from age 3 to 7. MAIN OUTCOME MEASURES: Body mass index (BMI), fat mass (kg), and fat free mass (kg) measured with bioelectrical impedance; dual energy x ray absorptiometry; physical activity and sleep duration measured with accelerometry; dietary intake (fruit and vegetables, non-core foods), television viewing, and family factors (maternal BMI and education, birth weight, smoking during pregnancy) measured with questionnaire. RESULTS: After adjustment for multiple confounders, each additional hour of sleep at ages 3-5 was associated with a reduction in BMI of 0.48 (95% confidence interval 0.01 to 0.96) and a reduced risk of being overweight (BMI ≥ 85th centile) of 0.39 (0.24 to 0.63) at age 7. Further adjustment for BMI at age 3 strengthened these relations. These differences in BMI were explained by differences in fat mass index (-0.43, -0.82 to -0.03) more than by differences in fat free mass index (-0.21, -0.41 to -0.00). CONCLUSIONS: Young children who do not get enough sleep are at increased risk of becoming overweight, even after adjustment for initial weight status and multiple confounding factors. This weight gain is a result of increased fat deposition in both sexes rather than additional accumulation of fat free mass.

School playgrounds and physical activity policies as predictors of school and home time activity.

BACKGROUND: Previous work has suggested that the number of permanent play facilities in school playgrounds and school-based policies on physical activity can influence physical activity in children. However, few comparable studies have used objective measures of physical activity or have had little adjustment for multiple confounders. METHODS: Physical activity was measured by accelerometry over 5 recess periods and 3 full school days in 441 children from 16 primary schools in Dunedin, New Zealand. The number of permanent play facilities (swing, fort, slide, obstacle course, climbing wall etc) in each school playground was counted on three occasions by three researchers following a standardized protocol. Information on school policies pertaining to physical activity and participation in organized sport was collected by questionnaire. RESULTS: Measurement of school playgrounds proved to be reliable (ICC 0.89) and consistent over time. Boys were significantly more active than girls (P < 0.001), but little time overall was spent in moderate-vigorous physical activity (MVPA). Boys engaged in MVPA for 32 (SD 17) minutes each day of which 17 (10) took place at school compared with 23 (14) and 11 (7) minutes respectively in girls. Each additional 10-unit increase in play facilities was associated with 3.2% (95% CI 0.0-6.4%) more total activity and 8.3% (0.8-16.3%) more MVPA during recess. By contrast, school policy score was not associated with physical activity in children. CONCLUSION: The number of permanent play facilities in school playgrounds is associated with higher physical activity in children, whereas no relationship was observed for school policies relating to physical activity. Increasing the number of permanent play facilities may offer a cost-effective long-term approach to increasing activity levels in children.

Motivational interviewing for screening and feedback and encouraging lifestyle changes to reduce relative weight in 4-8 year old children: design of the MInT study.

BACKGROUND: Because parental recognition of overweight in young children is poor, we need to determine how best to inform parents that their child is overweight in a way that enhances their acceptance and supports motivation for positive change. This study will assess 1) whether weight feedback delivered using motivational interviewing increases parental acceptance of their child's weight status and enhances motivation for behaviour change, and 2) whether a family-based individualised lifestyle intervention, delivered primarily by a MInT mentor with limited support from "expert" consultants in psychology, nutrition and physical activity, can improve weight outcomes after 12 and 24 months in young overweight children, compared with usual care. METHODS/DESIGN: 1500 children aged 4-8 years will be screened for overweight (height, weight, waist, blood pressure, body composition). Parents will complete questionnaires on feeding practices, physical activity, diet, parenting, motivation for healthy lifestyles, and demographics. Parents of children classified as overweight (BMI > or = CDC 85th) will receive feedback about the results using Motivational interviewing or Usual care. Parental responses to feedback will be assessed two weeks later and participants will be invited into the intervention. Additional baseline measurements (accelerometry, diet, quality of life, child behaviour) will be collected and families will be randomised to Tailored package or Usual care. Parents in the Usual care condition will meet once with an advisor who will offer general advice regarding healthy eating and activity. Parents in the Tailored package condition will attend a single session with an "expert team" (MInT mentor, dietitian, physical activity advisor, clinical psychologist) to identify current challenges for the family, develop tailored goals for change, and plan behavioural strategies that best suit each family. The mentor will continue to provide support to the family via telephone and in-person consultations, decreasing in frequency over the two-year intervention. Outcome measures will be obtained at baseline, 12 and 24 months. DISCUSSION: This trial offers a unique opportunity to identify effective ways of providing feedback to parents about their child's weight status and to assess the efficacy of a supportive, individualised early intervention to improve weight outcomes in young children. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609000749202.

Reducing weight gain in children through enhancing physical activity and nutrition: the APPLE project.

OBJECTIVE: Community-based lifestyle intervention may offer the best means of reducing the global epidemic of childhood obesity and its consequences, yet few successful interventions have been reported. The objective was to determine whether increasing extra-curricular levels of activity could reduce weight gain in children. METHODS: A controlled intervention study was conducted using standardised methods to assess outcomes. Two comparable relatively rural communities in Otago, New Zealand formed intervention and control settings. Height, weight, waist circumference and participation in physical activity (by accelerometry) were measured at baseline and at 1 year in 384 children aged 5 to 12 years representing the majority of children in this age group in intervention and control communities. Community Activity Co-ordinators were employed at each school in the intervention area. Their brief was to widen exposure to activity and engage children not interested in traditional sporting activities by encouraging lifestyle-based activities (e.g. walking) and non-traditional sports (e.g. golf and taekwondo) during extra-curricular time at school, after school and during vacations. Simple dietary advice was offered and the wider community was encouraged to participate. RESULTS: Average accelerometry counts at 1 year were 28% (95% CI: 11 to 47%) higher in intervention compared with control children after adjusting for age, sex, baseline values and school. Intervention children spent less time in sedentary activity (ratio 0.91, p = 0.007) and more time in moderate (1.07, p = 0.001) and moderate/vigorous (1.10, p = 0.01) activity. Adjusted mean BMI Z-score was lower in intervention relative to control children by -0.12 units (95% CI: -0.22 to -0.02). CONCLUSION: . An intervention designed to maximise opportunities for physical activity during extra-curricular time at school and during leisure time through the provision of community-based Activity Co-ordinators significantly increased participation in physical activity and slowed unhealthy weight gain in primary school-aged children.