A design thinking-led approach to develop a responsive feeding intervention for Australian families vulnerable to food insecurity: Eat, Learn, Grow.

BACKGROUND: Design thinking is an iterative process that innovates solutions through a person-centric approach and is increasingly used across health contexts. The person-centric approach lends itself to working with groups with complex needs. One such group is families experiencing economic hardship, who are vulnerable to food insecurity and face challenges with child feeding. OBJECTIVE: This study describes the application of a design thinking framework, utilizing mixed methods, including co-design, to develop a responsive child-feeding intervention for Australian families-'Eat, Learn, Grow'. METHODS: Guided by the five stages of design thinking, which comprises empathizing, defining, ideating, prototyping, and testing. We engaged with parents/caregivers of a child aged 6 months to 3 years through co-design workshops (n = 13), direct observation of mealtimes (n = 10), a cross-sectional survey (n = 213) and semistructured interviews (n = 29). Findings across these methods were synthesized using affinity mapping to clarify the intervention parameters. Parent user testing (n = 12) was conducted online with intervention prototypes to determine acceptability and accessibility. A co-design workshop with child health experts (n = 9) was then undertaken to review and co-design content for the final intervention. RESULTS: Through the design thinking process, an innovative digital child-feeding intervention was created. This intervention utilized a mobile-first design and consisted of a series of short and interactive modules that used a learning technology tool. The design is based on the concept of microlearning and responds to participants' preferences for visual, brief and plain language information accessed via a mobile phone. User testing sessions with parents and the expert co-design workshop indicated that the intervention was highly acceptable. CONCLUSIONS: Design thinking encourages researchers to approach problems creatively and to design health interventions that align with participant needs. Applying mixed methods-including co-design- within this framework allows for a better understanding of user contexts, preferences and priorities, ensuring solutions are more acceptable and likely to be engaged.

"You just have to spread it thin": Perceptions and feeding experiences of Australian fathers of young children living with disadvantage.

The role of fathers in feeding is an emerging field within child feeding literature. Fathers have unique contributions to make to family mealtimes and child eating behaviours. However, qualitative research on fathers' experiences is limited, especially in the context of disadvantage. This study explored fathers' perceptions of their roles and feeding practices and their lived experience of disadvantage through a symbolic interactionism lens. Twenty-five Australian fathers of children aged six months to five years who experienced socioeconomic disadvantage participated in semi-structured interviews. Five themes were constructed from reflexive thematic analysis: (i) responsibilities for foodwork are based on strengths, opportunities, and values, (ii) negotiating fatherhood identity from a place of tension to acceptance, (iii) struggling with financial and mental strain, and food insecurity, (iv) managing adversity whist prioritising feeding children, and (v) paternal feeding practices are driven by values, adversity, and emotions. The division of foodwork was contingent on family capability and employment, maternal gatekeeping, paternal attitudes and values, and intergenerational, cultural and gender norms around earning and childrearing. Economic, environmental, and emotional stressors triggered changes to fathers' feeding practices, often contradicting their ideals (e.g., providing alternative meals, using rewards and electronic devices, unstructured settings). Fathers described income and food-based strategies to protect children's food intake, which may involve caregivers forgoing meals. These findings provide insight into fathers' feeding experiences through recognising personal, interpersonal, and systemic enablers and barriers. Promoting optimal feeding practices should include targeted feeding support and broader structural interventions to address inequality. Fathers' experiences as they navigate child mealtime interactions within a context of adversity can be used to inform child feeding interventions to improve child health and development.

Dietary patterns and child, parental, and societal factors associated with being overweight and obesity in Vietnamese children living in Ho Chi Minh city.

Childhood overweight and obesity are rapidly increasing in urban Vietnam. Dietary patterns are understudied for their association with obesity risk in these children, and it is unclear which parental and societal factors should be targeted in prevention efforts. The study assessed child characteristics, dietary patterns, parental and societal factors for associations with childhood overweight and obesity status in Ho Chi Minh City, Vietnam. A sample of 221 children aged 9-11 years was randomly selected from four Ho Chi Minh City primary schools. Weight, height and waist circumference were measured using standardized methods. Three 24-h dietary recalls were collected from 124 children, which were used to assess dietary patterns using principal component analysis (PCA). Parents completed a questionnaire about child, parental and societal factors. The overall prevalence of obesity was 31.7% and of combined overweight and obesity 59.3%. Three main dietary patterns from 10 food groups were identified by PCA: traditional (grains, vegetables, meat and meat alternatives), discretionary (snacks and sweetened beverages), and industrialized (fast food and processed meat). Children with higher discretionary diet scores had higher odds of being overweight. Being a boy, screen time over 2 h/day, parental underestimation of child weight status, father's obesity, and household income in the lowest quintile were positively associated with childhood obesity. Future intervention programmes in Vietnam need to consider targeting children's unhealthy diets and parental perceptions of child weight status, as well as focusing on upstream approaches that reduce inequities contributing to childhood obesity and concomitant dietary patterns.

Social and ecological disparities in anaemia among adolescent girls 15-19 years old in Nepal.

OBJECTIVE: Adolescent girls are at risk of anaemia due to increased nutrient demands because of growth, menstrual blood loss and possible pregnancies. Sociocultural and household conditions influence their anaemia risk. We aimed to identify the sociocultural and economic factors associated with anaemia among adolescent girls in Nepal. DESIGN: The Nepal Demographic and Health Surveys (NDHS) conducted in 2006, 2011 and 2016 were pooled for secondary analysis. We used data on haemoglobin measurements for anaemia and conducted bivariate and multivariable logistic regression analyses to identify factors associated with anaemia. SETTING: Nationally representative NDHS households with adolescent girls 15-19 years of age. PARTICIPANTS: Non-pregnant adolescent girls 15-19 years, with a haemoglobin measurement (n = 3731). RESULTS: The overall prevalence of anaemia among adolescent girls was 39·6 %. Adolescents from socially disadvantaged caste/ethnicity groups were 1·42 times (95 % CI: 1·13, 1·78) more likely to have anaemia compared with those from Brahmin/Chhetri households. We found a counter-intuitive association between socio-economic status and anaemia where adolescents from the middle (adjusted OR (aOR) 1·37, 95 % CI: 1·01, 1·85) and highest (aOR 1·74, 95 % CI: 1·18, 2·56) quintiles were at increased odds of anaemia. Relative geographical inequality was observed where adolescents from the Terai region had 3·5 times (95 % CI: 2·32, 5·33) higher odds of anaemia. CONCLUSIONS: The disparities in the distribution of anaemia among adolescents by caste/ethnicity groups, wealth quintiles and geographical regions are evident. Reducing the anaemia burden will require addressing the social determinants of anaemia by allocating resources and expanding anaemia prevention programmes to target adolescents at higher risk.

A review of the prevalence, trends, and determinants of coexisting forms of malnutrition in neonates, infants, and children.

OBJECTIVE: Coexisting Forms of Malnutrition (CFM) refers to the presence of more than one type of nutritional disorder in an individual. Worldwide, CFM affects more than half of all malnourished children, and compared to standalone forms of malnutrition, CFM is associated with a higher risk of illness and death. This review examined published literature for assessing the prevalence, trends, and determinants of CFM in neonates, infants, and children. METHODS: A review of community-based observational studies was conducted. Seven databases, (CINAHL, Cochrane Library, EMBASE, Medline, PubMed, Scopus, and Web of Science) were used in December-2021 to retrieve literature. Google, Google Scholar and TROVE were used to search for grey literature. Key stakeholders were also contacted for unpublished documents. Studies measuring the prevalence, and/or trends, and/or determinants of CFM presenting in individuals were included. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools for prevalence and longitudinal studies. RESULTS: The search retrieved 14,207 articles, of which 24 were included in this review. The prevalence of CFM varied by geographical area and specific types. In children under 5 years, the coexistence of stunting with overweight/obesity ranged from 0.8% in the United States to over 10% in Ukraine and Syria, while the prevalence of coexisting wasting with stunting ranged from 0.1% in most of the South American countries to 9.2% in Niger. A decrease in CFM prevalence was observed in all countries, except Indonesia. Studies in China and Indonesia showed a positive association between rurality of residence and coexisting stunting with overweight/obesity. Evidence for other risk and protective factors for CFM is too minimal or conflicting to be conclusive. CONCLUSION: Evidence regarding the prevalence, determinants and trends for CFM is scarce. Apart from the coexistence of stunting with overweight/obesity, the determinants of other types of CFM are unclear. CFM in any form results in an increased risk of health adversities which can be different from comparable standalone forms, thus, there is an urgent need to explore the determinants and distribution of different types of CFM.

Satiety responsiveness in toddlerhood predicts energy intake and weight status at four years of age.

The aim of this study was to examine whether maternal-report of child eating behaviour at two years predicted self-regulation of energy intake and weight status at four years. Using an 'eating in the absence of hunger' paradigm, children's energy intake (kJ) from a semi-standardized lunch meal and a standardized selection of snacks were measured. Participants were 37 mother-child dyads (16 boys, Median child age=4.4years, Inter-quartile range=3.7-4.5years) recruited from an existing longitudinal study (NOURISH randomised controlled trial). All participants were tested in their own home. Details of maternal characteristics, child eating behaviours (at age two years) reported by mothers on a validated questionnaire, and measured child height and weight (at age 3.5-4years) were sourced from existing NOURISH trial data. Correlation and partial correlation analyses were used to examine longitudinal relationships. Satiety responsiveness and Slowness in eating were inversely associated with energy intake of the lunch meal (partial r=-.40, p=.023, and partial r=-.40, p=.023) and the former was also negatively associated with BMI-for-age Z score (partial r=-.42, p=.015). Food responsiveness and Enjoyment of food were not related to energy intake or BMI Z score. None of the eating behaviours were significantly associated with energy intake of the snacks (i.e., eating in the absence of hunger). The small and predominantly 'healthy weight' sample of children may have limited the ability to detect some hypothesized effects. Nevertheless, the study provides evidence for the predictive validity of two eating behaviours and future research with a larger and more diverse sample should be able to better evaluate the predictive validity of other children's early eating behaviour styles.

Assessing the relationship of maternal short stature with coexisting forms of malnutrition among neonates, infants, and young children of Pakistan.

Evidence from previous studies suggests a strong association between pediatric undernutrition and maternal stature. However, there's a scarcity of evidence regarding the relationship between maternal stature and pediatric coexisting forms of malnutrition (CFM). This study examined the prevalence and trends of CFM at the individual, household, and community levels, using data from the Demographic & Health Surveys (DHS) of Pakistan. Furthermore, this study assessed the association between pediatric CFM and short maternal stature while adjusting for multiple covariates. A panel cross-sectional analysis was conducted using data from the 2012-2013 and 2017-2018 Pakistan Demographic & Health Survey (PDHS). We included data from 6194 mother-child dyads aged 15-49 years and 0-59 months, respectively, while excluding data from pregnant mothers and dyads with incomplete anthropometric variables and anthropometric outliers. Across the two survey periods, our findings reveal a significant decline in pediatric malnutrition, including CFM, alongside a concurrent increase in maternal overweight/obesity. Three out of four households had either a malnourished mother, and/or a malnourished child, and/or both. Our study demonstrates that short maternal stature increased the odds of various forms of pediatric undernutrition by two-to-threefolds (p < .041), but we did not find an association with wasting, overweight/obesity, and nutritional paradox. This underscores the heightened vulnerability of children born to short-stature mothers to various forms of pediatric undernutrition. Addressing the high prevalence of pediatric undernutrition among children of short-stature mothers necessitates a comprehensive approach that considers an individual's nutritional status throughout their entire life cycle.

Food Insecurity and Feeding Experiences Among Parents of Young Children in Australia: An Exploratory Qualitative Study.

BACKGROUND: Responsive feeding is a reciprocal process between caregiver and child that is primarily child-led. It is linked to the development of positive eating behaviors and food preferences. There is evidence that household chaos, family dynamics, the quality of mealtime routines, financial hardship, and food insecurity can impact the feeding relationship. OBJECTIVE: This study explored factors influencing feeding experiences among Australian parents with young children experiencing financial hardship, including household chaos and food insecurity. DESIGN: This qualitative semi-structured interview study was conducted as a component of a larger research program to design and evaluate a parent program to support responsive feeding practices in Australian families experiencing financial hardship and food insecurity. PARTICIPANTS/SETTING: Participants were caregivers of a child aged 6 months to 3 years (n = 29), living in Australia, who self-identified as experiencing financial hardship. Interviews were conducted in person and via telephone between August 2021 and January 2022. ANALYSIS: Transcripts were analyzed using the Framework Method of thematic analysis. RESULTS: Five key themes were generated: family tensions heightened through hardship, making tradeoffs and sacrifices, the unseen mental load, the inescapable impact of COVID-19, and resiliency and being creative. Despite facing multiple hardships and challenges with feeding the family, parents demonstrated resilience and capabilities through creative food resource management and organizational skills. Parents experienced a high mental load through the cognitive and emotional work of planning, adapting, anticipating, and caring for the family's needs through meals and child feeding. CONCLUSIONS: Programs to support child feeding need to consider the high mental load families with food insecurity experience and how this can impact parents' capacity. Program content should be contextually sensitive to the experience of food insecurity and consider the constraints inherent in families and communities while building on capabilities and strengths.

Designing Child Nutrition Interventions to Engage Fathers: Qualitative Analysis of Interviews and Co-Design Workshops.

BACKGROUND: Fathers play a pivotal role in parenting and child feeding, but they remain underrepresented in intervention studies, especially those focused on disadvantaged populations. A better understanding of fathers' experiences and needs regarding support access and child nutrition information in the context of disadvantage can inform future interventions engaging fathers. OBJECTIVE: This study aims to explore fathers' experiences; perceived enablers; and barriers to accessing support and information related to parenting, child feeding, and nutrition and to co-design principles for tailoring child nutrition interventions to engage fathers. METHODS: Australian fathers of children aged 6 months to 5 years with lived experience of disadvantage participated in semistructured interviews and co-design workshops, primarily conducted via videoconference. Creative analogies were used to guide the ideation process in the workshops. RESULTS: A total of 25 interviews and 3 workshops (n=10 participants) were conducted, with data analyzed using reflexive thematic analysis and the Capability, Opportunity, and Motivation-Behavior model. The interview data illuminated factors influencing fathers' initiation in seeking support for parenting, child feeding, and nutrition, including their experiences. It highlighted fathers' diverse information needs and the importance of an inclusive environment and encouragement. Enablers and barriers in accessing support related to parenting and child nutrition were identified at the individual (eg, personal goals and resource constraints), interpersonal (family support and false beliefs about men's caregiving role), organizational (inadequate fathering support), and systemic levels (father-inclusive practice and policy). Digital data collection methods enabled Australia-wide participation, overcoming work and capacity barriers. Videoconferencing technology was effectively used to engage fathers creatively. Key principles for engaging fathers were co-designed from the workshop data. Interventions and resources need to be father specific, child centered, and culturally appropriate; promote empowerment and collaboration; and provide actionable and accessible strategies on the what and how of child feeding. Fathers preferred multiformat implementation, which harnesses technology-based design (eg, websites and mobile apps) and gamification. It should be tailored to the child's age and targeted at fathers using comprehensive promotion strategies. CONCLUSIONS: Fathers faced barriers to accessing support and information related to parenting and feeding that may not adequately address their needs. Future interventions could integrate the co-designed principles to engage fathers effectively. These findings have implications for health service delivery and policy development, promoting father-inclusive practice.

Dads at Mealtimes: Associations between Food Security, Household and Work Chaos, and Paternal Feeding Practices among Australian Fathers Living with Disadvantage.

Understanding how fathers engage in feeding while experiencing disadvantage is important for family-focused interventions. A cross-sectional online survey involving 264 Australian fathers was conducted to explore feeding involvement and the relationships between feeding practices, food insecurity, and household and work chaos. Practices related to coercive control, structure, and autonomy support were measured for two age groups (<2 years and 2-5 years). Multivariable linear regression was used to examine the associations for each practice. Three-quarters of the sample were food insecure, impacting adults more than children, and correlated with household chaos. Food insecurity was associated with increased 'persuasive feeding' and 'parent-led feeding' in younger children. Household chaos was positively associated with coercive control practices in both younger and older child groups, with the strongest associations for 'using food to calm' and 'overt restriction', respectively. In older child groups, household chaos was negatively associated with 'offer new foods' and 'repeated presentation of new foods'. Structure practices had no significant relationships with any factors, and work chaos did not predict any feeding practices. These findings emphasize a need for societal and structural support to address food insecurity and household chaos. Tailored strategies are crucial to support fathers in responsive feeding.

Utility of the waist-to-height ratio as an instrument to measure parental perception of body weight in children and its use in a population-based survey of children.

OBJECTIVE: To investigate which anthropometric measure of overweight status, BMI or waist-to-height ratio (WHtR), is most closely associated with parents' perception of their child's overweight status. DESIGN: The sensitivity and specificity of parental perception against child-specific BMI and WHtR definitions of overweight were tested. SETTING: Primary schools in Queensland, Australia. SUBJECTS: Boys and girls aged 9·00-11·99 years (n 1431). RESULTS: Of the 138 boys and 202 girls who were classified as overweight according to BMI, only 27·5 % (boys) and 22·7 % (girls) were also perceived as overweight by their parents. Using WHtR, 206 boys and 333 girls were classified as overweight, of whom only 21·9 % and 13·8 %, respectively, were perceived as overweight. Perception of overweight was underestimated in approximately 15 % of boys and 21 % of girls when compared with BMI. Underestimation was higher when compared with WHtR: 25 % (boys) and 39 % (girls). Overweight prevalence was significantly lower according to perception than according to BMI or WHtR. Mother's education level was significantly associated with accurate perception of overweight status (P < 0·001). CONCLUSIONS: The sensitivity of parental perception of child overweight was higher when BMI was used. However, emphasis needs to be placed on using WHtR as an actual measure of overweight because high central adiposity is associated with increased risk of CVD. The combined use of WHtR, body-shape images rather than word responses regarding perception and public health messages that educate parents and children about body shape and associated health risks may be the best combination in improving parents' perception of their child's overweight status.

Use of the waist-height ratio to predict metabolic syndrome in obese children and adolescents.

AIM: To demonstrate that the waist-height ratio (WHtR) is a simple and effective screening tool that could be used to identify obese children with the metabolic syndrome. METHODS: Data from 109 obese boys and girls, aged 10.00-16.50 years, who were recruited as part of the Eat Smart study were analysed. Systolic (SBP) and diastolic (DBP) blood pressure, blood lipids (total cholesterol, triglycerides (TG), high- and low-density lipoproteins), insulin, glucose, height, weight and waist circumference (WC) were collected. These measurements were used to calculate WHtR, body mass index (BMI), Z-scores for BMI, WC, weight and homeostatic model assessment for insulin resistance (HOMA-IR). Correlations between anthropometric measures and blood pressure, lipids, insulin, glucose and HOMA-IR were assessed. Binary logistic regression was used to test which anthropometric measure was a significant predictor of the metabolic syndrome. RESULTS: Among boys, WHtR was negatively correlated with glucose (P < 0.05); WHtR and BMI Z-score were positively correlated with insulin, HOMA-IR and TG (P < 0.05) and WC Z-score was significantly correlated with age. Among girls, WHtR, BMI Z-score and WC Z-score were positively correlated with insulin and HOMA-IR and negatively correlated with high-density lipoprotein-cholesterol (P < 0.05), whereas BMI Z-score was significantly correlated with SBP and DBP Z-scores. Twenty per cent of subjects were classified as having the metabolic syndrome, with WHtR, BMI Z-score and HOMA-IR being significant predictors. CONCLUSION: The WHtR is a significant predictor of the metabolic syndrome in obese youth. The WHtR is the simplest index to calculate and interpret, making it an ideal non-invasive screening tool to use in clinical practice.

Association of Infant Feeding Indicators and Infant Feeding Practices with Coexisting Forms of Malnutrition in Children under Six Months of Age.

Breastmilk is the only recommended source of nutrition for infants below six months of age. However, a significant proportion of children are either on supplemental breastfeeding (SBF) or weaned due to the early introduction of solid/semi-solid/soft food and liquids (SSF) before six months of age. There is good evidence that exclusive breastfeeding (EBF) in infants below six months of age protects them from preventable illnesses, including malnutrition. The relationship between infant feeding practices and coexisting forms of malnutrition (CFMs) has not yet been explored. This study examined the association of different feeding indicators (continuation of breastfeeding, predominant feeding, and SSF) and feeding practices (EBF, SBF, and complete weaning) with CFM in infants aged below six months in Pakistan. National and regional datasets for Pakistan from the last ten years were retrieved from the Demographic Health Surveys (DHS) and UNICEF data repositories. In Pakistan, 34.5% of infants have some form of malnutrition. Among malnourished infants, 44.7% (~15.4% of the total sample) had a CFM. Continuation of breastfeeding was observed in more than 85% of infants, but less than a quarter were on EBF, and the rest were either SBF (65.4%) or weaned infants (13.7%). Compared to EBF, complete weaning increased the odds of coexistence of underweight with wasting, and underweight with both wasting and stunting by 1.96 (1.12-3.47) and 2.25 (1.16-4.36), respectively. Overall, breastfed children had lower odds of various forms of CFM (compared to non-breastfed), except for the coexistence of stunting with overweight/obesity. Continuation of any breastfeeding protected infants in Pakistan from various types of CFM during the first six months of life.

Parental Feeding Practices in Families Experiencing Food Insecurity: A Scoping Review.

Parental feeding practices and styles influence child diet quality and growth. The extent to which these factors have been assessed in the context of disadvantage, particularly household food insecurity (HFI), is unknown. This is important, as interventions designed to increase responsive practices and styles may not consider the unique needs of families with HFI. To address this gap, a scoping review of studies published from 1990 to July 2021 in three electronic databases was conducted. A priori inclusion criteria were, population: families with children aged 0-5 years experiencing food insecurity and/or disadvantage; concept: parental feeding practices/behaviours/style; and context: high income countries. The search identified 12,950 unique papers, 504 full-text articles were screened and 131 met the inclusion criteria. Almost all the studies (91%) were conducted in the United States with recruitment via existing programs for families on low incomes. Only 27 papers assessed feeding practices or styles in the context of HFI. Of the eleven interventions identified, two assessed the proportion of participants who were food insecure. More research is required in families outside of the United States, with an emphasis on comprehensive and valid measures of HFI and feeding practices. Intervention design should be sensitive to factors associated with poverty, including food insecurity.

Development and Validation of the Vietnamese Children's Short Dietary Questionnaire to Evaluate Food Groups Intakes and Dietary Practices among 9-11-Year-Olds Children in Urban Vietnam.

This study aims to develop and assess the reproducibility and validity of the Vietnamese Children's Short Dietary Questionnaire (VCSDQ) in evaluating food groups intakes and dietary practices among school-aged children 9-11 years old in urban Vietnam. A 26-item questionnaire covering frequency intakes of five core food groups, five non-core food groups, five dietary practices over a week, and daily intakes of fruits, vegetables, and water was developed. Children (n = 144) from four primary schools in four areas of Ho Chi Minh City, Vietnam completed the VCSDQ twice, as well as three consecutive 24 h recalls over a week. Intra-class correlation, Spearman correlation, weighted kappa, cross-classification, and Bland-Altman plots were used to evaluate the reproducibility and validity. The direct validity of food groups from VCSDQ against the 24 h recalls was examined using Wilcoxon-test for trend. The VCSDQ had good reproducibility in 12 out of 15 group items; the ICC ranged from 0.33 (grains) to 0.84 (eating while watching screens). This VCSDQ had low relative validity, two items (instant noodles, eating while watching screens) had a moderate to good agreement (k = 0.43, k = 0.84). There was good direct validity in three core-food groups (fruits, vegetables, dairy) and three non-core food groups (sweetened beverages, instant noodles, processed meat). In addition, the VCSDQ can also be used to classify daily intakes of fruits and vegetables from low to high.

Developing waist-to-height ratio cut-offs to define overweight and obesity in children and adolescents.

OBJECTIVE: The waist-to-height ratio (WHtR) assesses abdominal adiposity and has been proposed to be of greater value in predicting obesity-related cardiovascular health risks in children than BMI. The present study aims to develop WHtR cut-offs for overweight and obesity based on the 85th and 95th percentiles for the percentage body fat (%BF) in a cohort of children and adolescents. DESIGN: Waist circumference (WC), height, triceps and subscapular skinfolds were used to calculate WHtR and %BF. Correlations between WHtR and %BF and WHtR/mid-abdominal skinfold were made. Receiver-operating characteristic (ROC) curve analysis was used to select WHtR cut-offs to define overweight and obesity. Subjects were grouped by WHtR cut-offs, and mean values for anthropometry, blood lipids and blood pressure (BP) variables were compared. SETTING: Australian primary and secondary schools. SUBJECTS: A total of 2773 male (M) and female (F) subjects of the 1985 Australian Health and Fitness Survey, aged 8-16 years. RESULTS: Correlation coefficients between WHtR and %BF were M: r = 0.73, F: r = 0.60, P < 0.01 and WHtR/mid-abdominal skinfold were M: r = 0.78, F: r = 0.65, P < 0.01. WHtR of 0.46(M) and 0.45(F) best identified subjects with > or = 85th percentile for %BF and 0.48(M) and 0.47(F) identified subjects with > or = 95th percentile for %BF. When comparing the highest WHtR group to the lowest, both sexes had significantly higher means for weight, WC, %BF, TG (male subjects only), systolic BP (female subjects only) and lower means for HDL cholesterol (P < 0.05). CONCLUSIONS: WHtR is useful in clinical and population health as it identifies children with higher %BF at greater risk of developing weight-related CVD at an earlier age.

Validating the waist-height ratio and developing centiles for use amongst children and adolescents.

AIM: To assess the statistical validity of the waist-height ratio (WHtR) as an appropriate method of adjusting waist circumference (WC) for height in children and adolescents. INTRODUCTION: Recently, WHtR has been proposed to be of greater value than body mass index (BMI), in predicting obesity-related cardiovascular co-morbidities in children. This index, however, is yet to be extensively validated within the paediatric population. METHODS: Height and WC in centimetres, were measured in 3597 children from grades 1 (5-7 years), 5 (9-11 years) and 10 (15-17 years). Log regression analyses using WC and height were performed to determine appropriate powers (p) to raise height, to completely adjust the index for height, by sex and grade. Correlations between WHtR and height were assessed. RESULTS: Statistically, the WHtR is only valid for use among grade 1 boys and girls (p = 1.09 [95%CI 0.95-1.23] and p = 1.07 [95%CI 0.92-1.22], respectively) and grade 10 girls p = 0.85 (95%CI 0.62-1.08). However, the error (0.25%-1.85%), associated with the use of this index, in all ages and both sexes is clinically and biologically acceptable. CONCLUSION: The WHtR is a clinically and biologically valid index to use among Australian children and adolescents.

Childhood overweight and obesity amongst primary school children in Hai Phong City, Vietnam.

BACKGROUND AND OBJECTIVES: Childhood obesity is a rising health concern in Vietnam, however, research in this area is not extensive. The aim of this study was to determine the prevalence of childhood overweight and obesity, and to study associations between weight status and selected lifestyle factors, such as diet and physical activity levels, among children aged 6-10 years in Hai Phong City, Vietnam. METHODS AND STUDY DESIGN: Two hundred and seventy-six children from an urban and a rural primary school participated in this cross-sectional study. Data on weight, height and waist circumference were used to calculate BMI, and waist-height ratio to determine the proportion of children who were overweight, obese and had high central adiposity. Information on diet, physical activity and socioeconomic status of families was collected using questionnaires. RESULTS: Prevalences of overweight, obesity and high abdominal adiposity were 11.2%, 10.1% and 19.9%, respectively. Children who completed >=60 minutes of physical activity daily were 50% and 80% less likely to be overweight and have high abdominal adiposity, respectively. Computer usage increased the odds of overweight and high abdominal adiposity by 4.5 and 3.9 times, respectively. Mothers with higher education and income levels increased the risk of their children being overweight (p<0.05). CONCLUSIONS: Physical inactivity and high maternal education and income levels increased the risk of childhood overweight and obesity in this cohort. Future interventions should target parents and their children by providing both with educational modules centred on healthy eating habits, parental feeding practices and strategies for increasing physical activity.

Relative validity of a semi-quantitative food frequency questionnaire for Singaporean toddlers aged 15-36 months.

BACKGROUND: There is presently no simple tool for use in large epidemiological studies to understand the food and nutrient intakes of Asian toddlers. This study aimed to assess the relative validity of a semi-quantitative food frequency questionnaire (sqFFQ) developed for multi-ethnic Singaporean toddlers aged 15-36 months. METHODS: Ninety-one parents completed the sqFFQ and a 2-day weighed food record as the reference method. Intake of energy and 25 nutrients were determined for each method and compared using Pearson correlations corrected for attenuation, Bland-Altman plots, and weighted kappa according to quartiles; sqFFQ calibration was performed using multivariable linear regression. RESULTS: Deattenuated correlations for energy and all nutrients were acceptable (r = ≥0.30, p < 0.001). The sqFFQ was highly reproducible, but significantly overestimated intake of energy and all nutrients except vitamin A. Bland-Altman plots showed wide limits of agreement for energy and all nutrients. Weighted kappa ranged from 0.12 (slight) to 0.53 (moderate). After calibration, deattenuated correlations improved for energy and 10/25 nutrients, with no change or a slight decline for the remainder, including one falling to r = 0.27. Limits of agreement narrowed for energy and all nutrients, and except for DHA, median intakes were not significantly different except for vitamin A, enabling population estimates of absolute intakes. Weighted kappa improved overall; energy and 16 nutrients now had moderate agreement (0.41-0.60), while 9 nutrients had fair agreement (0.21-0.40). CONCLUSIONS: The Singaporean toddler semi-quantitative food frequency questionnaire is suitable for ranking nutrient intakes of Singaporean toddlers in larger epidemiological studies. However, for population estimates of absolute nutrient intakes, it is recommended that a subsample within a cohort complete weighed food records for calibration purposes. TRIAL REGISTRATION: This study was registered retrospectively on clinicaltrials.gov on 3rd May 2017 (identifier code: NCT03138330).

Development of food lists as a first step to develop a food frequency questionnaire for toddlers in a multi-ethnic population.

AIM: Toddlerhood is an important stage of growth, thus understanding the food intake of children in this age group is important. In Singapore, there is currently no simple tool, such as Food Frequency Questionnaire (FFQ), to collect dietary information from this ethnically diverse age group. Generating an appropriate food list is a crucial step in the development of a FFQ and this step is not clearly documented in the literature. The purpose of this study is to generate food lists and portion sizes for toddlers from three major ethnic groups in Singapore and document the processes involved in this first stage. METHODS: A total of 30 mothers (equal number of Malays, Indians and Chinese) of 11-24-month-old children completed three-day food records and participated in the focus group discussion. The reported food items were then categorised into food groups. RESULTS: The food lists varied by ethnic groups with the longest list obtained from Chinese toddlers. There were also other foods that were then classified as common foods for all ethnicities. Commonly used utensils among the three ethnic groups were small-sized bowls, plates, cups and spoons. For portion sizes, these utensils were typically half-filled for the toddlers. CONCLUSIONS: As all Singaporeans have access to the same foods, the ethnic-specific food lists generated in this study could be combined into one list. Together with portion sizes, this information can be used for developing a semi-quantitative FFQ.