Exploring views of members of the public and policymakers on the acceptability of population level dietary and active-travel policies: a qualitative study.

BACKGROUND: There is limited evidence on what shapes the acceptability of population level dietary and active-travel policies in England. This information would be useful in the decision-making process about which policies should be implemented and how to increase their effectiveness and sustainability. To fill this gap, we explored public and policymakers' views about factors that influence public acceptability of dietary and active-travel policies and how to increase public acceptability for these policies. METHODS: We conducted online, semi-structured interviews with 20 members of the public and 20 policymakers in England. A purposive sampling frame was used to recruit members of the public via a recruitment agency, based on age, sex, socioeconomic status and ethnicity. Policymakers were recruited from existing contacts within our research collaborations and via snowball sampling. We explored different dietary and active-travel policies that varied in their scope and focus. Interviews were transcribed verbatim and analysed using thematic reflexive analysis with both inductive and deductive coding. RESULTS: We identified four themes that informed public acceptability of dietary and active-travel policies: (1) perceived policy effectiveness, i.e., policies that included believable mechanisms of action, addressed valued co-benefits and barriers to engage in the behaviour; (2) perceived policy fairness, i.e., policies that provided everyone with an opportunity to benefit (mentioned only by the public), equally considered the needs of various population subgroups and rewarded 'healthy' behaviours rather than only penalising 'unhealthy' behaviours; (3) communication of policies, i.e., policies that were visible and had consistent and positive messages from the media (mentioned only by policymakers) and (4) how to improve policy support, with the main suggestion being an integrated strategy addressing multiple aspects of these behaviours, inclusive policies that consider everyone's needs and use of appropriate channels and messages in policy communication. CONCLUSIONS: Our findings highlight that members' of the public and policymakers' support for dietary and active-travel policies can be shaped by the perceived effectiveness, fairness and communication of policies and provide suggestions on how to improve policy support. This information can inform the design of acceptable policies but can also be used to help communicate existing and future policies to maximise their adoption and sustainability.

A longitudinal study investigating change in BMI z-score in primary school-aged children and the association of child BMI z-score with parent BMI.

BACKGROUND: This paper aims to explore change in BMI z-score through childhood and the association between parent BMI and child BMI z-score. This is important to understand for the development of effective obesity interventions. METHODS: Data from the longitudinal B-ProAct1v study (1837 participants) were analysed. A paired sample t-test examined changes in child BMI z-score between Year 1 and 4. Multivariable linear regression models examined the cross-sectional associations between child BMI z-score and parent BMI in Year 1 and 4. The influence of change in parental BMI between Year 1 and Year 4 on child BMI z-score in Year 4 was explored through regression analyses, adjusted for baseline BMI z-score. RESULTS: There was a strong association between child BMI z-score at Year 1 and 4. Child mean BMI z-score score increased from 0.198 to 0.330 (p = < 0.005) between these timepoints. For every unit increase in parent BMI, there was an increase in child BMI z-score of 0.047 in Year 1 (p = < 0.005) and of 0.059 in Year 4 (p = < 0.005). Parental BMI change was not significantly associated with Year 4 child BMI z-score. CONCLUSION: The key indicator of higher child BMI at Year 4 is high BMI at Year 1. Further studies are needed to explore the impact of parental weight change on child BMI z-score and whether interventions targeted at overweight or obese parents, can improve their child's BMI z-score.

Novel measures of inflammation and insulin resistance are related to obesity and fitness in a diverse sample of 11-14 year olds: The HEALTHY Study.

BACKGROUND: GlycA is a novel serum marker of systemic inflammation. There is no information on GlycA in pediatric populations, how it differs by gender or its association with body mass index (BMI) or fitness. Lipoprotein insulin resistance index (LP-IR) is a serum measure of insulin resistance, which is related to changes in BMI group in adolescents, but its relationship with fitness is unknown. The current study examined the independent associations between fitness and BMI with GlycA and LP-IR among US adolescents. METHODS: Participants were 1664 US adolescents from the HEALTHY study with complete 6th and 8th grade BMI, fitness and blood data. GlycA and LP-IR were measured by nuclear magnetic resonance spectroscopy. Three BMI groups and three fitness groups were created. Linear mixed models examined associations between GlycA, LP-IR, fitness and BMI. RESULTS: LP-IR decreased between 6th and 8th grade. GlycA increased among girls but decreased among boys. At 8th grade, median GlycA values were 27 (7.6%) µmol l(-1) higher (381 versus 354) for girls than boys. Median GlycA 6th grade values were 9% higher in obese girls than healthy weight girls. Overall, there was strong evidence (P<0.001) that GlycA was higher in higher BMI groups. Fitness was negatively associated with GlycA (r=-0.37 and -0.35) and LP-IR (r=-0.34 and -0.18) at the 6th and 8th grade assessments. As BMI category increased and fitness category decreased, GlycA and LP-IR levels increased. Lowest GlycA was found in the low BMI/high fitness group. CONCLUSIONS: GlycA was associated with BMI and fitness among in US adolescents. These findings suggest that there are independent effects for BMI and fitness group with both GlycA and LP-IR. Future studies should validate the role of GlycA and LP-IR to evaluate the effects of interventions to modify obesity and fitness to improve systemic inflammation and insulin resistance.

Process evaluation of the Bristol girls dance project.

BACKGROUND: The Bristol Girls Dance Project was a cluster randomised controlled trial that aimed to increase objectively measured moderate-to-vigorous physical activity (MVPA) levels of Year 7 (age 11-12) girls through a dance-based after-school intervention. The intervention was delivered in nine schools and consisted of up to forty after-school dance sessions. This paper reports on the main findings from the detailed process evaluation that was conducted. METHODS: Quantitative and qualitative data were collected from intervention schools. Dose and fidelity were reported by dance instructors at every session. Intervention dose was defined as attending two thirds of sessions and was measured by attendance registers. Fidelity to the intervention manual was reported by dance instructors. On four randomly-selected occasions, participants reported their perceived level of exertion and enjoyment. Reasons for non-attendance were self-reported at the end of the intervention. Semi-structured interviews were conducted with all dance instructors who delivered the intervention (n = 10) and school contacts (n = 9) in intervention schools. A focus group was conducted with girls who participated in each intervention school (n = 9). RESULTS: The study did not affect girls' MVPA. An average of 31.7 girls participated in each school, with 9.1 per school receiving the intervention dose. Mean attendance and instructors' fidelity to the intervention manual decreased over time. The decline in attendance was largely attributed to extraneous factors common to after-school activities. Qualitative data suggest that the training and intervention manual were helpful to most instructors. Participant ratings of session enjoyment were high but perceived exertion was low, however, girls found parts of the intervention challenging. CONCLUSIONS: The intervention was enjoyed by participants. Attendance at the intervention sessions was low but typical of after-school activities. Participants reported that the intervention brought about numerous health and social benefits and improved their dance-based knowledge and skills. The intervention could be improved by reducing the number of girls allowed to participate in each school and providing longer and more in-depth training to those delivering the intervention. TRIAL REGISTRATION: ISRCTN52882523 Registered 25th April 2013.

Lessons learned from the AFLY5 RCT process evaluation: implications for the design of physical activity and nutrition interventions in schools.

BACKGROUND: Systematic reviews have highlighted that school-based diet and physical activity (PA) interventions have had limited effects. This study used qualitative methods to examine how the effectiveness of future primary (elementary) school diet and PA interventions could be improved. METHODS: Data are from the Active For Life Year 5 (AFLY5) study, which was a cluster randomised trial conducted in 60 UK primary schools. Year 5 (8-9 years of age) pupils in the 30 intervention schools received a 12-month intervention. At the end of the intervention period, interviews were conducted with: 28 Year 5 teachers (including 8 teachers from control schools); 10 Headteachers (6 control); 31 parents (15 control). Focus groups were conducted with 70 year 5 pupils (34 control). Topics included how the AFLY5 intervention could have been improved and how school-based diet and PA interventions should optimally be delivered. All interviews and focus groups were transcribed and thematically analysed across participant groups. RESULTS: Analysis yielded four themes. Child engagement: Data suggested that programme success is likely to be enhanced if children feel that they have a sense of autonomy over their own behaviour and if the activities are practical. School: Finding a project champion within the school would enhance intervention effectiveness. Embedding diet and physical activity content across the curriculum and encouraging teachers to role model good diet and physical activity behaviours were seen as important. Parents and community: Encouraging parents and community members into the school was deemed likely to enhance the connection between schools, families and communities, and "create a buzz" that was likely to enhance behaviour change. Government/Policy: Data suggested that there was a need to adequately resource health promotion activity in schools and to increase the infrastructure to facilitate diet and physical activity knowledge and practice. DISCUSSION AND CONCLUSIONS: Future primary school diet and PA programmes should find ways to increase child engagement in the programme content, identify programme champions, encourage teachers to work as role models, engage parents and embed diet and PA behaviour change across the curriculum. However, this will require adequate funding and cost-effectiveness will need to be established. TRIAL REGISTRATION: ISRCTN50133740.

Combined influence of healthy diet and active lifestyle on cardiovascular disease risk factors in adolescents.

To investigate the combined influence of diet quality and physical activity on cardiovascular disease (CVD) risk factors in adolescents, adolescents (n = 1513; 12.5-17.5 years) participating in the Healthy Lifestyle in Europe by Nutrition in Adolescence study were studied. Dietary intake was registered using a 24-h recall and a diet quality index was calculated. Physical activity was assessed by accelerometry. Lifestyle groups were computed as: healthy diet and active, unhealthy diet but active, healthy diet but inactive, and unhealthy diet and inactive. CVD risk factor measurements included cardiorespiratory fitness, adiposity indicators, blood lipid profile, blood pressure, and insulin resistance. A CVD risk score was computed. The healthy diet and active group had a healthier cardiorespiratory profile, fat mass index (FMI), triglycerides, and high-density lipoprotein cholesterol (HDL-C) levels and total cholesterol (TC)/HDL-C ratio (all P ≤ 0.05). Overall, active adolescents showed higher cardiorespiratory fitness, lower FMI, TC/HDL-C ratio, and homeostasis model assessment index and healthier blood pressure than their inactive peers with either healthy or unhealthy diet (all P ≤ 0.05). Healthy diet and active group had healthier CVD risk score compared with the inactive groups (all P ≤ 0.02). Thus, a combination of healthy diet and active lifestyle is associated with decreased CVD risk in adolescents. Moreover, an active lifestyle may reduce the adverse consequences of an unhealthy diet.

Changes in reported food intake in adults with type 2 diabetes in response to a nonprescriptive dietary intervention.

OBJECTIVES: There is a lack of published data about the food intake of patients with type 2 diabetes and the changes that they make in response to patient-centred dietary advice. The present study describes the changes reported in response to a nonprescriptive dietary intervention based upon UK dietary guidelines. METHODS: Two hundred and sixty-two patients (87 women and 175 men) from the Early ACTivity in Diabetes (ACTID) trial who received the dietary intervention returned 4 days food diaries at baseline and 6 months. Nonparametric tests were used to examine changes in meal patterns, total energy intake and energy from food groups between baseline and 6 months. RESULTS: Mean (SD) number of reported meals day(-1) was 3.0 (0.3) and mean (SD) number of snacks was 1.1 (0.6) at both baseline and 6 months for men and women. Men reported decreasing energy intake by a mean (SD) of 912 (1389) KJ/day [218 (332) kcal day(-1) ] (P < 0.001) and women by 515 (1130) KJ/day [123 (270) kcal day(-1) ] (P < 0.001). Men reported reducing energy from alcoholic drinks [-234 (527) KJ day(-1) ; P < 0.001], white bread [-113 (402) KJ day(-1) ; P = 0.001], biscuits [i.e. cookies -67 (205) KJ day(-1) ; P < 0.001] and cakes [-50 (410) KJ day(-1) ; P = 0.0012]. Women reported reducing energy from mixed main meals [-134 (456) KJ day(-1) ; P = 0.036], pasta and rice [-79 (326) KJ day(-1) ; P = 0.019], high-energy drinks [-59 (159) KJ day(-1) ; P = 0.001] and white bread [-59 (368) KJ day(-1) ; P = 0.042]. CONCLUSIONS: Men and women in the Early ACTID study reported small changes in higher-energy and lower-fibre foods and drinks in response to patient-centred dietary advice.

Fat distribution, physical activity and cardiovascular risk among adolescent girls.

BACKGROUND AND AIMS: It is not clear whether changes in waist circumference (WC), sums of skinfold thickness (SSF), or levels of physical activity (PA) during adolescence are associated with cardiovascular risk factors, or if associations are independent or interactive. METHODS AND RESULTS: In a US cohort of adolescent girls (n = 617-904) girls, examined at ages 12 and 14, WC, SSF, PA, systolic and diastolic blood pressure (SBP & DBP) were assessed. Fasting blood samples were used to determine concentrations of triglycerides (TG), cholesterol (TC), high and low density lipoproteins (HDL-C and LDL-C), and apolipoprotein A1 and B (Apo-A1 and Apo-B). After adjustment for change in SSF and PA, increases in WC were associated with change in TG (z = 1.73, 95% CI = 0.77, 2.69), TC (z = 0.45, 95% CI = 0.01, 0.90), HDL-C (z = -0.18, 95% CI = -0.37, -0.01), LDL-C (z = 0.41, 95% CI = 0.03, 0.80), Apo-A1 (z = -0.52, 95% CI = -1.02, -0.02), Apo-B (z = 0.60, 95% CI = 0.24, 0.97) and SBP levels (z = 0.31, 95% CI = 0.15, 0.47). Associations between changes in SSF and PA with cardiovascular risk were eliminated after adjustment for WC, and all interactions between WC, SSF and PA were non-significant at conventional levels. CONCLUSIONS: Changes in WC were independently associated with the development of cardiovascular risk factors, whereas changes in SSF and PA were not. Clinicians should consider the routine screening of WC to monitor cardiovascular health in adolescent girls.

How does physical activity and fitness influence glycaemic control in young people with Type 1 diabetes?

AIMS: To assess physical activity and fitness levels of young people with Type 1 diabetes compared with siblings without diabetes, and to investigate the association between physical activity, physical fitness and glycaemic control (HbA(1c)) in those young people with diabetes. METHODS: The study consisted of 97 young people aged 8 to 16 years (62% male) from a Paediatric Diabetes Service in South West England. Sixty participants (67% male) had Type 1 diabetes and 37 participants (54% male) were siblings without diabetes (control group). We measured weight, height and waist circumference, calculated BMI and waist-height ratio and recorded pubertal status, blood pressure and current insulin regimen information. We assessed physical activity by accelerometry, from which we calculated light and moderate-to-vigorous intensity activity. We measured physical fitness by multistage sub-maximal bicycle ergometer test. We obtained HbA(1c) by venipuncture. RESULTS: There were no differences between the young people with diabetes and siblings without diabetes in body composition, blood pressure, physical activity and fitness. Moderate-to-vigorous physical activity was associated with better glycaemic control, accounting for 30-37% (R(2) = 0.295-0.374) of the variance for HbA(1c). Physical fitness was not associated with HbA(1c). CONCLUSIONS: Moderate-to-vigorous physical activity was associated with better glycaemic control while fitness was not. Findings suggest that developing strategies to increased moderate-to-vigorous physical activity may prove an effective method of improving glycaemic control in young people with diabetes.

Developing parent involvement in a school-based child obesity prevention intervention: a qualitative study and process evaluation.

BACKGROUND: Little is known about the effectiveness of parent involvement in school-based obesity prevention interventions. METHODS: A qualitative study with parents of children aged 9-10 years was conducted to identify possible methods to involve them in a school-based obesity prevention intervention, followed by a process evaluation of homework and school newsletters to involve parents. RESULTS: Qualitative study: parents supported the use of homework and school newsletters to involve them and overcome the main barriers of their work and time. Process evaluation: Ten homeworks and inserts for the school newsletter about the obesity prevention intervention were developed and delivered. The majority of homeworks were given out (73%), completed by children (84%) and recalled by parents (60-68%). The majority of homeworks were enjoyed by parents and children. All the schools put information about the project in the newsletter and this was recalled by parents. Most parents felt the homeworks were a practical way of involving them. CONCLUSIONS: Homeworks are routinely given to children and provide a means of engaging potentially all parents if parental support is required. Homeworks which are novel, fun and involve activities and social contact are enjoyed by parents and children and may increase awareness of healthy diet and physical activity.

Early-stage studies to larger-scale trials: investigators' perspectives on scaling-up childhood obesity interventions.

BACKGROUND: Pilot/feasibility studies play an important role in the development and refinement of behavioral interventions by providing information about feasibility, acceptability, and potential efficacy. Despite their importance and wide-spread use, the approaches taken by behavioral scientists to scale-up early-stage studies to larger-scale trials has received little attention. The aim of our study was to understand the role that pilot studies play in the development and execution of larger-scale trials. METHODS: We conducted interviews with childhood obesity researchers who had published pilot behavioral interventions and larger-scale trials of the same or similar interventions. Questions were asked about the role of pilot studies in developing larger-scale trials and the challenges encountered when scaling-up an intervention based upon pilot findings. Data were coded and analyzed using an inductive analytic approach to identify themes. RESULTS: Twenty-four interventionists (54% women, 37-70 years old, mean 20 years since terminal degree) completed a total of 148 pilot studies across their careers (mean 6.4, range 1-20), of which 59% were scaled-up. Scaling was described as resource intensive and pilot work was considered essential to successfully competing for funding by 63% of the sample (n = 15). When asked to define a high-quality pilot study, interventionists described studies that allowed them to evaluate two independent factors: components of their intervention (e.g., acceptability, feasibility) and study parameters (e.g., sample size, measures). Interventionists expressed that more process implementation measures, different study designs, and additional iterations could improve decisions to scale-up. Most agreed that pilot studies were likely to produce inflated estimates of potential efficacy though only nine interventionists provided potential solutions for decreasing inflated measures of efficacy. Suggested major causes of inflated effects included high levels of oversight in pilot studies (e.g., researcher support), reliance on subjective measures, and utilizing convenience or highly motivated samples. Potential solutions included designing pilots for real-world implementation, only conducting randomized controlled pilot studies, and pre-registering pilot studies. CONCLUSIONS: Pilot studies purposes are multifaceted and deemed essential to obtaining funding for larger-scale trials. Clarifying the form and function of preliminary, early-stage research may enhance the productive utilization of early-stage studies and reduced drops in efficacy when transitioning to larger scale studies.

Obesogenic diet and physical activity: independent or associated behaviours in adolescents?

OBJECTIVE: Associations between diet and physical activity may identify behaviours that could be changed together to prevent childhood obesity. The present study examines associations between physical activity and obesogenic dietary behaviours in a large UK adolescent cohort. DESIGN: Cross-sectional analysis of a UK cohort. Adolescents aged 10-11 years completed three 1 d diet diaries. Average daily energy consumption, percentage energy from fat and carbohydrate, energy density and grams of fruit and vegetables were estimated. To assess physical activity participants wore an accelerometer for three or more days. Regression models were run by sex to examine the extent to which dietary variables predicted physical activity before and after controlling for pubertal status, maternal education and adiposity. SETTING: The Avon Longitudinal Study of Parents and Children (ALSPAC), south-west England. SUBJECTS: Adolescents who provided diet data at age 10 years and physical activity data at age 11 years. RESULTS: Among boys, percentage energy from fat was consistently negatively associated with accelerometer-determined indicators of physical activity (standardized beta (beta) = -0.055 to -0.101, P < 0.05) while total energy (beta = 0.066 to 0.091, P < 0.05) and percentage energy from carbohydrate (beta = 0.054 to 0.106, P < 0.05) were positively associated before and after adjustment for confounders. For girls fruit and vegetable intake was consistently positively associated with physical activity (beta = 0.056 to 0.074, P < 0.005). However all associations were weak. Associations were broadly comparable when participants with non-plausible dietary reports were included or excluded from the analyses. CONCLUSIONS: Obesogenic diet and physical activity behaviours were weakly associated, suggesting that interventions should focus on implementing strategies that are independently successful at changing diet or physical activity behaviours either separately or in combination.

Physically active families - de-bunking the myth? A qualitative study of family participation in physical activity.

BACKGROUND: The benefits of physical activity for reducing obesity and related chronic diseases are well known. The need for more family-based interventions to increase physical activity is frequently cited in the literature; however, little is known about if and how families are physically active together, and what factors might influence family-based participation in regular physical activity. This study examined the types of activities (physical and sedentary) engaged in as a family and explored parents' perceptions of the importance, frequency, nature and barriers to family physical activity. METHODS: Semi-structured telephone interviews were conducted with 30 parents (26 female, four male) of 10- to 11-year-old schoolchildren who attended either low, middle or high socio-economic status schools in Bristol, UK. Interviews were transcribed verbatim, anonymized and analysed using conventional content analysis. RESULTS: The majority of parents rated family engagement in physical activity as important, and identified benefits such as increased parent-child communication, spending time together, enjoyment, enhanced mental health, weight control and physical fitness. Despite these benefits most parents reported their families did little or no physical activity together as a family unit during the week, and any activities performed together were usually sedentary in nature. They reported increased family physical activity on the weekends but rarely including the full family unit simultaneously. Parents in two-parent households commonly paired off with one or more children because of complexities of schedules. Commonly reported barriers were busy lifestyles, diverse ages and interests of children and adults, bad weather, and lack of access to facilities, transportation and money to support activities. CONCLUSIONS: Family-based interventions might be more effective if they are designed to accommodate the complex demands and needs of two-parent and single-parent families and provide affordable, diverse activities appealing to a wide range of interests.

Rationale, design and methods of the HEALTHY study physical education intervention component.

The HEALTHY primary prevention trial was designed to reduce risk factors for type 2 diabetes in middle school students. Middle schools at seven centers across the United States participated in the 3-year study. Half of them were randomized to receive a multi-component intervention. The intervention integrated nutrition, physical education (PE) and behavior changes with a communications strategy of promotional and educational materials and activities. The PE intervention component was developed over a series of pilot studies to maximize student participation and the time (in minutes) spent in moderate-to-vigorous physical activity (MVPA), while meeting state-mandated PE guidelines. The goal of the PE intervention component was to achieve > or =150 min of MVPA in PE classes every 10 school days with the expectation that it would provide a direct effect on adiposity and insulin resistance, subsequently reducing the risk of type 2 diabetes in youth. The PE intervention component curriculum used standard lesson plans to provide a comprehensive approach to middle school PE. Equipment and PE teacher assistants were provided for each school. An expert in PE at each center trained the PE teachers and assistants, monitored delivery of the intervention and provided ongoing feedback and guidance.

Histological assessment of ß-amyloid precursor protein immunolabelled rectal biopsies aids diagnosis of equine grass sickness.

BACKGROUND: An accurate, minimally invasive, ante-mortem diagnostic test for equine grass sickness (EGS) is currently lacking. Although histological examination of haematoxylin and eosin-stained rectal biopsies for chromatolytic neurons is insensitive as a diagnostic test for EGS, we hypothesised that its diagnostic accuracy could be improved by immunolabelling for ß-amyloid precursor protein (ß-APP), which has increased expression in cranial cervical ganglia (CCG) neuronal perikarya in EGS. OBJECTIVES: To develop a grading scheme for assessing the distribution and intensity of ß-APP immunoreactivity within individual rectal submucosal neurons and subsequently to determine the value of the distribution of different grades of neurons in EGS diagnosis. STUDY DESIGN: Retrospective case-control diagnostic accuracy study. METHODS: Initially, a standardised grading scheme was developed and ß-APP immunoreactivity in individual neuronal perikarya and axons was compared in sections of CCG and ileum from EGS and control horses. The grading scheme was then refined before being blindly applied to submucosal neurons in rectal biopsies derived from 21 EGS and 23 control horses. RESULTS: ß-APP immunoreactivity was increased in neuronal perikarya and axons in sections of CCG, ileum and rectum from EGS horses compared with controls. For rectal biopsies, a mean immunoreactivity grade exceeding 1.1 was 100% specific and sensitive for EGS, and the presence of at least one neuron with diffuse labelling of the entire cytoplasm (grade 3) was 95% sensitive and 100% specific for EGS. MAIN LIMITATIONS: Although the diagnostic criteria facilitated the discrimination of the EGS and control biopsies evaluated in this study, further prospective validation using a larger sample set is required. CONCLUSIONS: Histological assessment of ß-APP immunolabelled rectal biopsies is more sensitive than conventional histological examination in EGS diagnosis. Further validation is required before this technique can be advocated for use in clinical decision making.

Neurodegeneration in equine grass sickness is not attributable to niacin deficiency.

BACKGROUND: The aetiology of equine grass sickness (EGS) is currently unknown. We hypothesised that an acute deficiency of niacin (vitamin B3), which plays a key role in neural homeostasis, may contribute to neurodegeneration in EGS. Niacin deficiency can potentially result from ingestion of niacin antagonists produced by pasture mycotoxigenic fungi. OBJECTIVES: To compare the niacin status of EGS and control grazing horses. A secondary objective was to compare blood concentrations of vitamins B1, B2 and B6 in EGS and control grazing horses to determine if the status of these vitamins was altered in EGS. STUDY DESIGN: Case-control study. METHODS: Indices of niacin status, namely the erythrocyte nicotinamide adenine dinucleotide:nicotinamide adenine dinucleotide phosphate ratio (NAD:NADP ratio) and erythrocyte concentrations of NAD and NADP, were compared in blood collected from EGS and healthy control grazing horses. Blood concentrations of vitamins B1, B2 and B6 were also compared. RESULTS: There was no significant intergroup difference in the NAD:NADP ratio, the main index of functional niacin status (control group: median 2.1, interquartile range [IQR] 1.8-2.6; EGS group: median 2.1, IQR 1.9-2.6). EGS horses had significantly higher (median value increased by 25%) concentrations of NADP. There were no intergroup differences in blood concentrations of vitamins B1, B2 and B6. MAIN LIMITATIONS: The interpretation of data was limited by the lack of previously defined equine reference ranges for many of the analytes. Sample size was low. CONCLUSIONS: Niacin deficiency does not contribute to EGS neurodegeneration.

NAP SACC UK: protocol for a feasibility cluster randomised controlled trial in nurseries and at home to increase physical activity and healthy eating in children aged 2-4 years.

INTRODUCTION: Systematic reviews have identified the lack of intervention studies with young children to prevent obesity. This feasibility study examines the feasibility and acceptability of adapting the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) intervention in the UK to inform a full-scale trial. METHODS AND ANALYSIS: A feasibility cluster randomised controlled trial in 12 nurseries in England, with 6 randomly assigned to the adapted NAP SACC UK intervention: nursery staff will receive training and support from an NAP SACC UK Partner to review the nursery environment (nutrition, physical activity, sedentary behaviours and oral health) and set goals for making changes. Parents will be invited to participate in a digital media-based home component to set goals for making changes in the home. As this is a feasibility study, the sample size was not based on a power calculation but will indicate the likely response rates and intracluster correlations. Measures will be assessed at baseline and 8-10 months later. We will estimate the recruitment rate of nurseries and children and adherence to the intervention and data. Nursery measurements will include the Environmental Policy Assessment and Observation score and the nursery staff's review of the nursery environment. Child measurements will include height and weight to calculate z-score body mass index (zBMI), accelerometer-determined minutes of moderate-to-vigorous physical activity per day and sedentary time, and diet using the Child and Diet Evaluation Tool. Questionnaires with nursery staff and parents will measure mediators. A process evaluation will assess fidelity of intervention delivery and views of participants. ETHICS AND DISSEMINATION: Ethical approval for this study was given by Wales 3 NHS Research Ethics Committee. Findings will be made available through publication in peer-reviewed journals, at conferences and to participants via the University of Bristol website. Data will be available from the University of Bristol Research Data Repository. TRIAL REGISTRATION NUMBER: ISRCTN16287377.

Managing the screen-viewing behaviours of children aged 5-6 years: a qualitative analysis of parental strategies.

OBJECTIVES: The present study used qualitative methods to: (1) examine the strategies that were used by parents of children aged 5-6 years to manage screen viewing; (2) identify key factors that affect the implementation of the strategies and (3) develop suggestions for future intervention content. DESIGN: Telephone interviews were conducted with parents of children aged 5-6 years participating in a larger study. Interviews were transcribed verbatim and analysed using an inductive and deductive content analysis. Coding and theme generation was iterative and refined throughout. SETTING: Parents were recruited through 57 primary schools located in the greater Bristol area (UK). PARTICIPANTS: 53 parents of children aged 5-6 years. RESULTS: Parents reported that for many children, screen viewing was a highly desirable behaviour that was difficult to manage, and that parents used the provision of screen viewing as a tool for reward and/or punishment. Parents managed screen viewing by setting limits in relation to daily events such as meals, before and after school, and bedtime. Screen-viewing rules were often altered depending on parental preferences and tasks. Inconsistent messaging within and between parents represented a source of conflict at times. Potential strategies to facilitate reducing screen viewing were identified, including setting screen-viewing limits in relation to specific events, collaborative rule setting, monitoring that involves mothers, fathers and the child, developing a family-specific set of alternative activities to screen viewing and developing a child's ability to self-monitor their own screen viewing. CONCLUSIONS: Managing screen viewing is a challenge for many parents and can often cause tension in the home. The data presented in this paper provide key suggestions of new approaches that could be incorporated into behaviour change programmes to reduce child screen viewing.

Bodyweight change aids prediction of survival in chronic equine grass sickness.

REASONS FOR PERFORMING STUDY: Objective criteria for predicting survival of chronic grass sickness cases are currently lacking. OBJECTIVES: To determine whether the rate and/or magnitude of bodyweight change during hospitalisation of chronic grass sickness cases can provide an objective predictor of survival to discharge from hospital. Clinicians' recorded indication(s) for euthanasia were also reviewed. STUDY DESIGN: Single centre retrospective observational study. METHODS: Case records of all horses admitted for management of chronic grass sickness to The Dick Vet Equine Hospital between 1998 and 2013 were analysed. Case background, survival to hospital discharge, indication(s) for euthanasia, disease duration at admission and bodyweight changes during the hospitalisation period were analysed, and data for survivors and nonsurvivors compared. Percentage weight change was calculated for 7 day intervals up to 28 days (0-7, 7-14, 14-21, 21-28 days) and for entire periods from the first weight recorded (0-7, 0-14, 0-21, 0-28 days). These results were used to estimate survival probability conditional on weight change. RESULTS: The study sample comprised 213 horses, with 114 survivors (53.5%) and 99 (46.5%) nonsurvivors. Compared with nonsurvivors, survivors had significantly lower median maximum bodyweight loss as a percentage of first weight (survivors 5.9%, interquartile range 1.8-13.5; nonsurvivors 12.7%, 6.4-17.3). Throughout all time periods analysed, survivors had significantly lower median bodyweight loss than nonsurvivors, but no specific time period was more predictive of survival. Highest percentages of total bodyweight loss for individual horses were comparable for survivors (36%) and nonsurvivors (37%). Survival prediction curves reporting percentage survival rates for all time periods analysed provided data to aid prediction of chronic grass sickness survival. CONCLUSIONS: Overall, nonsurvivors had greater bodyweight loss than survivors. Rapidity and magnitude of bodyweight loss were equally predictive of outcome. Percentage survival prediction curves provide objective data to aid discussion of prognosis, but greater predictive specificity with associated sensitivity is required for clinical decision making in individual cases.