Differences in weight status among Australian children and adolescents from priority populations: a longitudinal study.

BACKGROUND AND SIGNIFICANCE: Australia has a high level of cultural and linguistic diversity, including Aboriginal and Torres Strait Islander peoples. Children from specific cultural and ethnic groups may be at greater risk of overweight and obesity and may bear the additional risk of socioeconomic disadvantage. Our aim was to identify differences in body-mass index z-score (zBMI) by: (1) Cultural and ethnic groups and; (2) Socioeconomic position (SEP), during childhood and adolescence. SUBJECTS/METHODS: We used data from the Longitudinal Study of Australian children (n = 9417) aged 2-19 years with 50870 longitudinal measurements of zBMI. Children were classified into 9 cultural and ethnic groups, based on parent and child's country of birth and language spoken at home. These were: (1) English-speaking countries; (2) Middle East & North Africa; (3) East & South-East Asia; (4) South & Central Asia; (5) Europe; (6) Sub-Saharan Africa; (7) Americas; (8) Oceania. A further group (9) was defined as Aboriginal and Torres Strait Islander from self-reported demographic information. Longitudinal cohort analyses in which exposures were cultural and ethnic group and family socioeconomic position, and the outcome was zBMI estimated using multilevel mixed linear regression models. We stratified our analyses over three periods of child development: early childhood (2-5 years); middle childhood (6-11 years); and adolescence (12-19 years). RESULTS: Across all three periods of child development, children from the Middle East and North Africa, the Americas and Oceania were associated with higher zBMI and children from the two Asian groups were associated with lower zBMI, when compared to the referent group (English). zBMI was socioeconomically patterned, with increasingly higher zBMI associated with more socioeconomic disadvantage. CONCLUSIONS: Our findings identified key population groups at higher risk of overweight and obesity in childhood and adolescence. Prevention efforts should prioritize these groups to avoid exacerbating inequalities in healthy weight in childhood.

Parental smoking in the first two years of a child's life and its associations with breastfeeding.

BACKGROUND: Exclusive breastfeeding for the first 6 months followed by ongoing breastfeeding to 12 months and beyond is associated with multiple benefits for both mother and child. Maternal smoking is associated with a reduction in breastfeeding. Little is known about the effect of partner smoking on breastfeeding. AIMS: This study explores the smoking behaviour of mothers and their partners in the first two years of a child's life and its associations with breastfeeding practice. MATERIALS AND METHODS: We performed a secondary data analysis using survey data on 1155 mothers from their third trimester of pregnancy and at six, 12 and 24 months after delivery. Survey questions included smoking status of both mother and partner and breastfeeding intention and practice. Logistic regression models were conducted at each time point. FINDINGS: Where the mother or both parents smoke, babies were less likely to be breastfed at six months of age (adjusted odds ratio (aOR) 0.29, 95% CI: 0.13-0.66) compared with families where neither parent smoked. Non-smoking mothers with smoking partners were less likely to intend to breastfeed (aOR 0.29, 95% CI: 0.11-0.82) and their babies were less likely to be breastfed at six and 12 months of age (aOR 0.64, 95% CI: 0.42-0.98 and 0.64, 95% CI: 0.43-0.95 respectively). There was no difference in breastfeeding behaviour between smoking and non-smoking parents at 24 months. CONCLUSION: Smoking parents are less likely to breastfeed their babies at ages six and 12 months. Breastfeeding promotion should target both smoking mothers and smoking partners.

"What concerns me or what is most interesting to me": A qualitative study about what influences adolescent engagement with public health issues.

ISSUES ADDRESSED: Promoting public health messages in adolescence may influence future health outcomes. A better understanding of what influences adolescent engagement with public health issues is needed. METHODS: Adolescents aged 13-19 years from New South Wales, Australia, were recruited via study advertisements to participate in an online focus group. All provided informed consent and completed a short survey including demographics and selection of leading public health issues of concern. Participants attended a 75-90 min focus group conducted through Zoom teleconference that explored top public health issues of concern to participants, and barriers/enablers to engage with these issues. Qualitative data was thematically analysed using NVivo. A working group reached consensus on final themes. RESULTS: Out of 18 participants (mean 15.4 [SD: 2.2] years; 50% female), most attended high school (83%), spoke predominantly English at home (89%), and resided in metropolitan areas (94%). The top public health issues of concern selected were mental health (56%) and the environment/climate change (56%). From the thematic analysis, underlying drivers of adolescent engagement with public health issues included: personal connection to these issues, broader societal impact, and exposure to public health issues on digital media. Barriers included feeling unempowered, and a lack of support and opportunities. CONCLUSIONS: This study provides insights on the barriers and enablers of adolescents engaging with public health issues of concern to them. SO WHAT?: Understanding this may help health professionals and researchers to design more influential public health campaigns and interventions, including through co-design processes, which may improve future health outcomes.

Mothers' sociodemographic factors and use of health professionals for child feeding advice.

This study examined sociodemographic factors associated with mothers seeking child feeding advice from health professionals (HPs). Cross-sectional analysis of survey data from linked randomized controlled trials was conducted. Surveys asked which sources of feeding information mothers used when their child was 6 months and 5 years old. Logistic regression was used to examine associations between sociodemographic characteristics and use of information from HPs. Here, 947 and 405 mothers completed 6-month and 5-year surveys, respectively. At 6 months, multiparous mothers were less likely to seek advice from child and family health nurses (CFHNs) (adjusted odds ratio [AOR]: 0.558, 95% confidence interval [95% CI]: 0.416-0.749) and other HPs (AOR: 0.706, 95% CI: 0.542-0.919), unmarried mothers were less likely to seek advice from other HPs (AOR: 0.582, 95% CI: 0.342-0.990). At 5 years, mothers with household income ≥$80,000 p.a. were less likely to seek advice from CFHNs (AOR: 0.514, 95% CI: 0.302-0.875) and working mothers less likely to seek advice from general practitioners (GPs) (AOR: 0.581, 95% CI: 0.374-0.905). Mothers born in Australia were less likely to seek information from CFHNs (AOR: 0.462, 95% CI: 0.257-0.833) and GPs (AOR: 0.431, 95% CI: 0.274-0.677). There was a greater likelihood that multiparous mothers (AOR: 2.114, 95% CI: 1.272-3.516) and mothers of children whose fathers had not attended university (AOR: 2.081, 95% CI: 1.256-3.449) had never sought advice from CFHNs, and that mothers who had not attended university (AOR: 1.769, 95% CI: 1.025-3.051), multiparous (AOR: 1.831, 95% CI: 1.105-3.035) and employed (AOR: 2.058, 95% CI: 1.135-3.733) mothers had never sought advice from other HPs. Understanding sociodemographic factors associated with seeking child feeding advice from HPs may inform priorities for engaging families in health promotion.

Responsive feeding practices among Arabic and Mongolian speaking migrant mothers in Australia: A qualitative study.

Establishing healthy feeding habits during infancy is crucial for optimal growth. However, certain parental feeding and cultural practices might hinder the development of children's healthy eating behaviours. This research explored responsive feeding practices among migrant mothers in Australia. Semi-structured telephone interviews were conducted in their native language with 20 Arabic and 20 Mongolian-speaking migrant mothers with children under 2 years old or currently pregnant. Thematic analysis was conducted using the framework method. Both cultural groups followed a variety of feeding practices, including on demand responsive feeding or structured schedules. Arabic-speaking mothers tended to demonstrate responsive feeding practices more frequently than Mongolian-speaking mothers, except for those using formula feeding, who consistently followed a fixed feeding routine. When introducing solid foods, mothers from both groups often overlooked their babies' hunger and satiety cues, frequently pressuring their children to finish their entire plate. One cited reason for this was the challenge parents faced in identifying such cues. Arabic-speaking mothers often supplemented with formula top-ups after introducing solid foods, due to the belief that breast milk or solid foods alone might not sufficiently nourish their infants. Additionally, some Arabic-speaking mothers used food-based rewards to encourage eating. Mongolian mothers expressed a cultural preference for chubby babies, a potential reason why they may have been inclined to pressure-feed their children. Moreover, both groups reported using digital devices to distract their children during meals. This study highlights the necessity of tailoring future resources and services related to responsive feeding practices to accommodate diverse literacy levels and cultural backgrounds.

Bayesian network modelling to identify on-ramps to childhood obesity.

BACKGROUND: When tackling complex public health challenges such as childhood obesity, interventions focused on immediate causes, such as poor diet and physical inactivity, have had limited success, largely because upstream root causes remain unresolved. A priority is to develop new modelling frameworks to infer the causal structure of complex chronic disease networks, allowing disease "on-ramps" to be identified and targeted. METHODS: The system surrounding childhood obesity was modelled as a Bayesian network, using data from The Longitudinal Study of Australian Children. The existence and directions of the dependencies between factors represent possible causal pathways for childhood obesity and were encoded in directed acyclic graphs (DAGs). The posterior distribution of the DAGs was estimated using the Partition Markov chain Monte Carlo. RESULTS: We have implemented structure learning for each dataset at a single time point. For each wave and cohort, socio-economic status was central to the DAGs, implying that socio-economic status drives the system regarding childhood obesity. Furthermore, the causal pathway socio-economic status and/or parental high school levels → parental body mass index (BMI) → child's BMI existed in over 99.99% of posterior DAG samples across all waves and cohorts. For children under the age of 8 years, the most influential proximate causal factors explaining child BMI were birth weight and parents' BMI. After age 8 years, free time activity became an important driver of obesity, while the upstream factors influencing free time activity for boys compared with girls were different. CONCLUSIONS: Childhood obesity is largely a function of socio-economic status, which is manifest through numerous downstream factors. Parental high school levels entangle with socio-economic status, and hence, are on-ramp to childhood obesity. The strong and independent causal relationship between birth weight and childhood BMI suggests a biological link. Our study implies that interventions that improve the socio-economic status, including through increasing high school completion rates, may be effective in reducing childhood obesity prevalence.

Twelve-month effectiveness of telephone and SMS support to mothers with children aged 2 years in reducing children's BMI: a randomized controlled trial.

BACKGROUND/OBJECTIVES: Few quality intervention studies have assessed whether a combined telephone and short message service (SMS) intervention to mothers is effective in reducing BMI and obesity risk behaviors of children at 3 years of age. This study aimed to assess effectiveness of telephone and SMS support in reducing children's body mass index (BMI) and obesity risk behaviors. SUBJECTS/METHODS: A randomized controlled trial (RCT) with 662 women of 2-year-old children (with the proportion of overweight and obesity being similar to the general population) was conducted in Sydney, Australia, March 2019-October 2020. The mothers in the intervention group received three telephone support sessions plus SMS messages and mailed-intervention-booklets over a 12 months period i.e., 24-26, 28-30, and 32-34 months of the child's age. Mothers in the control group received usual care and two mailed booklets on information not related to the intervention. The primary outcome was child's BMI at 3 years of age. Secondary outcomes were children's dietary and activity behaviors. All outcome measures were based on mothers' self-report using standardized tools due to COVID-19 pandemic restrictions. RESULTS: 537 (81%) mothers completed the post-intervention assessment at 3 years with only 470 (71%) children having weight and height measures. Multiple imputation analysis showed no statistically significant difference in mean BMI between the groups. Children in the intervention group were more likely not to eat in front of the TV [AOR 1.79 (95% CI 1.17-2.73), P = 0.008], more likely to meet the dietary recommendations [AOR 1.73 (95% CI 0.99-3.02), P = 0.054] and meet the activity recommendations [AOR 1.72 (95% CI 1.11-2.67), P = 0.015] than those in the control group respectively. Among those with an annual household income (

Understanding the pathways between prenatal and postnatal factors and overweight outcomes in early childhood: a pooled analysis of seven cohorts.

BACKGROUND/OBJECTIVES: Childhood overweight and obesity are influenced by a range of prenatal and postnatal factors. Few studies have explored the integrative pathways linking these factors and childhood overweight. This study aimed to elucidate the integrative pathways through which maternal pre-pregnancy body mass index (BMI), infant birth weight, breastfeeding duration, and rapid weight gain (RWG) during infancy are associated with overweight outcomes in early childhood from ages 3 to 5 years. SUBJECTS/METHODS: Pooled data from seven Australian and New Zealand cohorts were used (n = 3572). Generalized structural equation modelling was used to examine direct and indirect associations of maternal pre-pregnancy BMI, infant birth weight, breastfeeding duration, and RWG during infancy with child overweight outcomes (BMI z-score and overweight status). RESULTS: Maternal pre-pregnancy BMI was directly associated with infant birth weight (ß 0.01, 95%CI 0.01, 0.02), breastfeeding duration ≥6 months (OR 0.92, 95%CI 0.90, 0.93), child BMI z-score (ß 0.03, 95%CI 0.03, 0.04) and overweight status (OR 1.07, 95%CI 1.06, 1.09) at ages 3-5 years. The association between maternal pre-pregnancy BMI and child overweight outcomes was partially mediated by infant birth weight, but not RWG. RWG in infancy exhibited the strongest direct association with child overweight outcomes (BMI z-score: ß 0.72, 95%CI 0.65, 0.79; overweight status: OR 4.49, 95%CI 3.61, 5.59). Infant birth weight was implicated in the indirect pathways of maternal pre-pregnancy BMI with RWG in infancy, breastfeeding duration, and child overweight outcomes. The associations between breastfeeding duration (≥6 months) and lower child overweight outcomes were fully mediated by RWG in infancy. CONCLUSIONS: Maternal pre-pregnancy BMI, infant birth weight, breastfeeding duration and RWG in infancy act in concert to influence early childhood overweight. Future overweight prevention interventions should target RWG in infancy, which showed the strongest association with childhood overweight; and maternal pre-pregnancy BMI, which was implicated in several pathways leading to childhood overweight.

Eating Disorders In weight-related Therapy (EDIT) Collaboration: rationale and study design.

The cornerstone of obesity treatment is behavioural weight management, resulting in significant improvements in cardio-metabolic and psychosocial health. However, there is ongoing concern that dietary interventions used for weight management may precipitate the development of eating disorders. Systematic reviews demonstrate that, while for most participants medically supervised obesity treatment improves risk scores related to eating disorders, a subset of people who undergo obesity treatment may have poor outcomes for eating disorders. This review summarises the background and rationale for the formation of the Eating Disorders In weight-related Therapy (EDIT) Collaboration. The EDIT Collaboration will explore the complex risk factor interactions that precede changes to eating disorder risk following weight management. In this review, we also outline the programme of work and design of studies for the EDIT Collaboration, including expected knowledge gains. The EDIT studies explore risk factors and the interactions between them using individual-level data from international weight management trials. Combining all available data on eating disorder risk from weight management trials will allow sufficient sample size to interrogate our hypothesis: that individuals undertaking weight management interventions will vary in their eating disorder risk profile, on the basis of personal characteristics and intervention strategies available to them. The collaboration includes the integration of health consumers in project development and translation. An important knowledge gain from this project is a comprehensive understanding of the impact of weight management interventions on eating disorder risk.

Associations of dietary and sedentary behaviours of pregnant women with their children's birth weight: findings from the CHAT trial in Australia.

OBJECTIVE: To examine the associations of pregnant women's dietary and sedentary behaviours with their children's birth weight. DESIGN: Secondary data analysis was conducted using data from a randomised controlled trial, Communicating Healthy Beginnings Advice by Telephone, conducted in Australia. Information on mothers' socio-demographics, dietary and sedentary behaviours during pregnancy was collected by telephone survey at the third trimester. Birth weight data were extracted from the child's health record book. Multinomial logistic regression models were built to examine the associations of pregnant women's dietary and sedentary behaviours with children's birth weight. SETTING: Participating families. PARTICIPANTS: Pregnant women and their children. RESULTS: A total of 1132 mother-child dyads were included in the analysis. The majority of infants (87 %, n 989) were of normal birth weight (2500 g to <4000 g), 4 % (n 50) had low birth weight (<2500 g) and 8 % (n 93) had macrosomia (≥4000 g). Mothers who ate processed meat during pregnancy were more likely to have macrosomia (adjusted risk ratio (ARR) 1·80, 95 % CI (1·12, 2·89)). The risk of macrosomia decreased as the number of dietary recommendations met by mothers increased (ARR 0·84, 95 % CI (0·71, 0·99)). Children's birth weight was not associated with mothers' sedentary time. Children's low birth weight was not associated with mothers' dietary and sedentary behaviours during pregnancy. CONCLUSION: Maternal consumption of processed meat during pregnancy was associated with an increased risk of macrosomia. Increasing number of dietary recommendations met by mothers was associated with a lower risk of macrosomia. The findings suggested encouraging pregnancy women to meet dietary recommendation will benefit children's birth weight.

Role of Pediatricians in Promoting and Supporting Breastfeeding: A Position Paper of the International Pediatric Association Strategic Advisory Group on Infant, Child, and Adolescent Nutrition.

BACKGROUND: Promoting and supporting breastfeeding is an important public health intervention with multiple benefits for both infants and mothers. Even modest increases in the prevalence and duration of breastfeeding could significantly reduce healthcare costs and improve maternal and child health outcomes. However, widespread adoption of breastfeeding recommendations remains poor in most settings, which contributes to widening health and social inequalities. Pediatricians have a duty to advocate for improving child health, including promoting and supporting breastfeeding. SUMMARY: This paper, from the International Pediatric Association Special Advisory Group on Nutrition, considers common barriers to breastfeeding and addresses how pediatricians can better promote and support breastfeeding, both at an individual level and by influencing practice and policy. All pediatricians need to understand the basics of breastfeeding, including lactation physiology, recognize common breastfeeding problems, and advise mothers or refer them for appropriate support; training curricula for general pediatricians and all pediatric subspecialties should reflect this. Even in the situation where their day-to-day work does not involve direct contact with mothers and infants, pediatricians can have an important influence on policy and practice. They should support colleagues who work directly with mothers and infants, ensuring that systems and environments are conducive to breastfeeding and, where appropriate, milk expression. Pediatricians and pediatric organizations should also promote policies aimed at promoting and supporting breastfeeding at local, regional, national, and international levels. KEY MESSAGES: Pediatricians have a duty to promote and support breastfeeding, regardless of their day-to-day role and responsibilities. Pediatric training curricula should ensure that all trainees acquire a good understanding of breastfeeding so they are able to effectively support mothers in their personal practice but also influence breastfeeding practice and policy at a local, regional, national, and international level.

Does an inflammatory diet affect mental well-being in late childhood and mid-life? A cross-sectional study.

Inflammatory diets are increasingly recognised as a modifiable determinant of mental illness. However, there is a dearth of studies in early life and across the full mental well-being spectrum (mental illness to positive well-being) at the population level. This is a critical gap given that inflammatory diet patterns and mental well-being trajectories typically establish by adolescence. We examined the associations of inflammatory diet scores with mental well-being in 11-12-year-olds and mid-life adults. Throughout Australia, 1759 11-12-year-olds (49 % girls) and 1812 parents (88 % mothers) contributed cross-sectional population-based data. Alternate inflammatory diet scores were calculated from a twenty-six-item FFQ, based on the prior literature and prediction of inflammatory markers. Participants reported negatively and positively framed mental well-being via psychosocial health, quality of life and life satisfaction surveys. We used causal inference modelling techniques via generalised linear regression models (mean differences and risk ratios (RR)) to examine how inflammatory diets might influence mental well-being. In children and adults, respectively, a 1 sd higher literature-derived inflammatory diet score conferred between a 44 % (RR 95 % CI 1·2, 1·8) to 57 % (RR 95 % CI 1·3, 2·0) and 54 % (95 % CI 1·2, 2·0) to 86 % (RR 95 % CI 1·4, 2·4) higher risk of being in the worst mental well-being category (i.e. <16th percentile) across outcome measures. Results for inflammation-derived scores were similar. BMI mediated effects (21-39 %) in adults. Inflammatory diet patterns were cross-sectionally associated with mental well-being at age 11-12 years, with similar effects observed in mid-adulthood. Reducing inflammatory dietary components in childhood could improve population-level mental well-being across the life course.

Protocol for a randomised controlled trial of a family strengthening program to prevent unhealthy weight gain among 5 to 11-year-old children from at-risk families: the Strong Families Trial.

BACKGROUND: Obesity is an increasing health concern in Australia among adult and child populations alike and is often associated with other serious comorbidities. While the rise in the prevalence of childhood obesity has plateaued in high-income countries, it continues to increase among children from disadvantaged and culturally diverse backgrounds. The family environment of disadvantaged populations may increase the risk of childhood obesity through unhealthy eating and lifestyle practices. The Strong Families Trial aims to assess the effectiveness of a mixed behavioural and lifestyle intervention for parents and carers of at-risk populations, i.e. families from culturally diverse and disadvantaged backgrounds, in preventing unhealthy weight gain among children aged 5 to 11 years. METHODS: Eight hundred families from low socio-economic areas in Greater Western Sydney, NSW, and Melbourne, VIC, will be recruited and randomised into a lifestyle intervention or control group. The intervention comprises 90-minute weekly sessions for 6 weeks (plus two-booster sessions) of an integrated, evidence-based, parenting and lifestyle program that accounts for the influences of family functioning. Primary (anthropometric data) and secondary (family functioning, feeding related parenting, physical activity, consumption of healthy foods, health literacy, family and household costs) outcome measures will be assessed at baseline, immediately following the intervention, and 12 months post-intervention. DISCUSSION: This study will elucidate methods for engaging socially disadvantaged and culturally diverse groups in parenting programs concerned with child weight status. TRIAL REGISTRATION: This study is registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12619001019190 ). Registered 16 July 2019.

Interactivity, Quality, and Content of Websites Promoting Health Behaviors During Infancy: 6-Year Update of the Systematic Assessment.

BACKGROUND: As of 2021, 89% of the Australian population are active internet users. Although the internet is widely used, there are concerns about the quality, accuracy, and credibility of health-related websites. A 2015 systematic assessment of infant feeding websites and apps available in Australia found that 61% of websites were of poor quality and readability, with minimal coverage of infant feeding topics and lack of author credibility. OBJECTIVE: We aimed to systematically assess the quality, interactivity, readability, and comprehensibility of information targeting infant health behaviors on websites globally and provide an update of the 2015 systematic assessment. METHODS: Keywords related to infant milk feeding behaviors, solid feeding behaviors, active play, screen time, and sleep were used to identify websites targeting infant health behaviors on the Google search engine on Safari. The websites were assessed by a subset of the authors using predetermined criteria between July 2021 and February 2022 and assessed for information content based on the Australian Infant Feeding Guidelines and National Physical Activity Recommendations. The Suitability Assessment of Materials, Quality Component Scoring System, the Health-Related Website Evaluation Form, and the adherence to the Health on the Net code were used to evaluate the suitability and quality of information. Readability was assessed using 3 web-based readability tools. RESULTS: Of the 450 websites screened, 66 were included based on the selection criteria and evaluated. Overall, the quality of websites was mostly adequate. Media-related sources, nongovernmental organizations, hospitals, and privately owned websites had the highest median quality scores, whereas university websites received the lowest median score (35%). The information covered within the websites was predominantly poor: 91% (60/66) of the websites received an overall score of ≤74% (mean 53%, SD 18%). The suitability of health information was mostly rated adequate for literacy demand, layout, and learning and motivation of readers. The median readability score for the websites was grade 8.5, which is higher than the government recommendations (

Trial collaborators' perceptions of the process of delivering Healthy Beginnings advice via telephone calls or text messages.

ISSUE ADDRESSED: One in four Australian children aged between the ages of two and four are affected by overweight. In New South Wales, the Communicating Healthy Beginnings Advice by Telephone (CHAT) trial delivered an intervention to pregnant women and women with infants via telephone calls and text messages. The focus of the intervention was on infant feeding and establishing healthy habits for infants by building the capacity of mothers. This study investigates trial collaborators' perspectives concerning the implementation of this intervention, to obtain insights that will support future translation and scale-up. METHODS: This research was undertaken during the intervention phase of the trial. Twenty trial collaborators involved in the planning, implementation or delivery of the CHAT trial were invited to participate. Qualitative interviews were conducted with collaborators using open-ended questions based on Steckler and Linnan's process evaluation framework and the Consolidated Framework for Implementation Research. Inductive thematic analysis was employed to identify themes from the interview data. RESULTS: Fourteen trial collaborators were interviewed. Collaborators included child and family health nurses (intervention providers), nurse managers with extensive child and family health nursing experience, a paediatrician, dietitians, health promotion experts, health service managers, health and nursing executives, program personnel (project coordinator, research fellow and evaluation officer) and university researchers. Following coding of qualitative data, themes were realised from the data as a result of active co-production on the part of the researcher. Five themes were identified: (a) context (organisational support, engagement and partnerships, communication and project leadership); (b) program receipt, benefit and reach; (c) program delivery (intervention providers' experience and skills, mode of intervention delivery, referral to other services, support and training for intervention providers); (d) implementation (program delivered as planned); (e) opportunities for scale-up. Collaborators perceived that the program was implemented and delivered as planned. This specific research addresses the success of the process of implementing and delivering interventions for infant feeding and establishing healthy habits for children by building the capacity of mothers. Collaborators attributed successful program implementation to contextual factors: strong support by the host organisation; good project leadership; clear communication; collaborative internal and external partnerships; intervention provision by experienced nurses. Remote delivery was convenient to program participants and participants were able to resolve other personal concerns in addition to direct immediate benefits. Because of their capacity to influence policy decisions, the absence of policymakers at project meetings was a shortcoming. Collaborative partnerships with health and research partners, understanding of contextual issues and consumer involvement could lead to program expansion. The program has the potential to be scaled up through integration with existing services and gradual expansion into other health districts prior to state-wide rollout. CONCLUSIONS: The CHAT trial delivered the Healthy Beginnings intervention which resulted in improvements in infant feeding, active play and sedentary behaviours. This evaluation demonstrated that the involvement of key stakeholders from early planning stages through to implementation of the program and the partnerships that evolved contributed to the successful implementation of the program. An unintended benefit to participants from this program was the social support that was provided. Intervention delivery via telephone and text messages enabled easy access to the program. Most importantly, the program has the potential to be scaled up through integration into existing services and gradual expansion prior to state-wide rollout. SO WHAT?: Strong internal and external partnerships, effective communication systems and integration with existing services create the context for potential translation and scaling up of the program to other health promotion settings.

Infant feeding and growth trajectories in early childhood: the application and comparison of two longitudinal modelling approaches.

BACKGROUND/OBJECTIVES: The role of infant feeding practices in longitudinal growth trajectories in children remains equivocal. This study utilised two longitudinal approaches to examine the associations of infant feeding mode (breastfeeding, mixed feeding, formula feeding), breastfeeding duration, and the timing of solid foods introduction with body mass index (BMI) z-score in early childhood. SUBJECTS/METHODS: Secondary analyses of data from the Healthy Beginnings Trial were conducted. Infant feeding practices were reported by mothers at 6, 12, and 24 months of child age. Child weight and length were measured at birth, 12, 24, 42, and 60 months. Two longitudinal approaches: linear spline multilevel model (LSMM) and group-based trajectory modelling (GBTM) were used to describe BMI z-score trajectories and assess its associations with infant feeding practices. RESULTS: The LSMM approach demonstrated that the breastfeeding group showed lower BMI z-scores from ages 12 to 60 months than the mixed feeding and formula feeding groups. Children who were breastfed for ≥ 6 versus < 6 months exhibited a lower BMI z-score trajectory from ages 12 to 60 months. Results from the GBTM approach revealed that the mixed feeding (OR: 1.83, 95%CI 1.04, 3.21) and the formula feeding group (OR: 2.00, 95%CI 0.67, 5.92) showed a tendency for higher odds of following the "High BMIz" trajectory than the breastfeeding group. Breastfeeding duration ≥6 versus < 6 months was linked with lower odds of following the "High BMIz" trajectory (OR 0.65, 95%CI 0.43, 0.98). Both approaches revealed no evidence of an association between the timing of solid foods introduction and BMI z-score trajectory. CONCLUSIONS: The two longitudinal approaches revealed similar findings that infant feeding mode and breastfeeding duration, but not the timing of solid foods introduction, were associated with BMI z-score trajectory in early childhood. The findings provide robust longitudinal evidence to encourage and support extended breastfeeding for childhood obesity prevention.

Looking backwards and forwards: tracking and persistence of weight status between early childhood and adolescence.

BACKGROUND/OBJECTIVE: Many studies have shown that child BMI or weight status tracks over time, but the demographic predictors of high tracking have not been investigated. Our objective was to identify demographic predictors of persistence (duration) of healthy weight and overweight/obesity throughout childhood, and to examine whether tracking was age dependent. METHODS: We conducted secondary data analysis of 4606 children from the Birth cohort and 4983 children from the Kindergarten cohort of the Longitudinal Study of Australian Children with follow-up to age 12/13 and 16/17 years, respectively. Retrospective and prospective tracking were examined descriptively. Time-to-event analysis determined demographic predictors of persistence of healthy weight and overweight/obesity beyond age 4-5 years, after controlling for child BMI z-score. Weight status was determined using WHO methods. RESULTS: Tracking of healthy weight was consistently higher than that of overweight/obesity, and incident overweight was equally likely throughout childhood and adolescence. Tracking of overweight was lower for children under 7 years than in middle childhood and adolescence (2-year probability 65%, compared with 80%; 2-year resolution of overweight 35 and 20%). Children of lower socioeconomic position, those from culturally and linguistically diverse backgrounds, and girls were more likely to move into overweight (hazard ratios [95%CI] for incident overweight: 1.39 [1.26-1.52], 1.16 [1.02-1.31] and 1.12 [1.02-1.23], respectively) and less likely to resolve their overweight (hazard ratios for resolution of overweight/obesity: 0.77 [0.69-0.85], 0.8 [0.69-0.92] and 0.79 [0.71-0.81], respectively) during childhood. However, persistence of weight status was not significantly affected by rurality or Indigenous status (P > 0.05). CONCLUSIONS: Lowest tracking and highest natural resolution of overweight in children under 7 years suggests this may be an opportune time for interventions to reduce overweight. Primary and secondary prevention programmes during the school years should be designed with special consideration for lower socioeconomic communities, for culturally and linguistically diverse populations and for girls.

Process evaluations of early childhood obesity prevention interventions delivered via telephone or text messages: a systematic review.

BACKGROUND: Increasingly, public health interventions are delivered via telephone and/or text messages. Recent systematic reviews of early childhood obesity prevention interventions have not adequately reported on the way interventions are delivered and the experiences/perceptions of stakeholders. We aimed to summarise the literature in early childhood obesity prevention interventions delivered via telephone or text messages for evidence of application of process evaluation primarily to evaluate stakeholders' acceptability of interventions. METHODS: A systematic search of major electronic databases was carried out using the Population, Intervention, Comparison, Outcomes framework. Studies were included if interventions were delivered via telephone/text messages; aimed at changing caregivers' behaviours to prevent early childhood obesity; with one or more outcomes related to early obesity risk factors such as breastfeeding, solid feeding, tummy time, sleep and settling, physical activity and screen time; published from inception to May 2020. All eligible studies were independently assessed by two reviewers using the Cochrane Collaboration tool for assessing risk of bias. Qualitative studies were assessed using the Consolidated Criteria for Reporting Qualitative Research and Standards for Reporting Qualitative Research tools. RESULTS: Twenty-four studies were eligible, and the overall risk of bias was low. Eight studies (33%) had evidence of process evaluation that examined participants' perceptions of interventions. Participants appreciated the convenience of receiving interventions via telephone or text messages. 63% of all studies in this review showed improvement in one or more behaviours related to childhood obesity prevention. Participants were likely to modify behaviours if they received information from a credible source such as from health professionals. CONCLUSION: There is limited reporting of stakeholders' experiences in early obesity prevention studies delivered by telephone or text messages. Only one-third of studies examined participants' acceptability and the potential for delivery of childhood obesity prevention interventions conveniently using this mode of delivery. Interventions delivered remotely via telephone or text messages have the potential to reach equal or a greater number of participants than those delivered via face-to-face methods. Future research should build in process evaluation alongside effectiveness measurements to provide important insight into intervention reach, acceptability and to inform scale up. TRIAL REGISTRATION: PROSPERO registration: CRD42019108658.

Feasibility of a culturally adapted early childhood obesity prevention program among migrant mothers in Australia: a mixed methods evaluation.

INTRODUCTION: Healthy Beginnings is an established nurse-led early childhood obesity prevention program that promotes healthy infant feeding practices and active play in the early years of life. To improve engagement with culturally and linguistically diverse populations, the Healthy Beginnings program delivered by telephone was culturally adapted and implemented with Arabic- and Chinese-speaking mothers in Sydney, Australia. The cultural adaptation process has been published separately. In this article, we aimed to evaluate the feasibility of the culturally adapted program. METHODS: In 2018-2019, the culturally adapted Healthy Beginnings program was implemented with Arabic- and Chinese-speaking women recruited from antenatal clinics in Sydney. At four staged timepoints (from third trimester until 6 months of age), mothers were sent culturally adapted health promotion booklets and text messages and offered four support calls from bi-cultural child and family health nurses in Arabic and Chinese. A mixed methods evaluation included a) baseline and 6-month telephone surveys, followed by b) semi-structured follow-up interviews with a subset of participating mothers and program delivery staff. Main outcomes of this feasibility study were reach (recruitment and retention), intervention dose delivered (number of nurse support calls completed) and acceptability (appropriateness based on cognitive and emotional responses). RESULTS: At recruitment, 176 mothers were eligible and consented to participate. Of 163 mothers who completed the baseline survey, 95% completed the program (n = 8 withdrew) and 83% completed the 6-month survey (n = 70 Arabic- and n = 65 Chinese-speaking mothers). Most mothers (n = 127, 78%) completed at least one nurse support call. The qualitative analysis of follow-up interviews with 42 mothers (22 Arabic- and 20 Chinese-speaking mothers) and 10 program delivery staff highlighted the perceived value of the program and the positive role of bi-cultural nurses and in-language resources. Mothers who completed more nurse support calls generally expressed greater acceptability. CONCLUSIONS: The culturally adapted Healthy Beginnings program was feasible to deliver and acceptable to Arabic- and Chinese-speaking mothers. Our results highlight the importance of in-language resources and individualised bi-cultural nurse support by telephone for supporting culturally and linguistically diverse migrant families with infant feeding and active play. These findings support the potential for program refinements and progression to an effectiveness trial.

The process of culturally adapting the Healthy Beginnings early obesity prevention program for Arabic and Chinese mothers in Australia.

BACKGROUND: Behavioural interventions for the early prevention of childhood obesity mostly focus on English-speaking populations in high-income countries. Cultural adaptation is an emerging strategy for implementing evidence-based interventions among different populations and regions. This paper describes the initial process of culturally adapting Healthy Beginnings, an evidence-based early childhood obesity prevention program, for Arabic and Chinese speaking migrant mothers and infants in Sydney, Australia. METHODS: The cultural adaptation process followed the Stages of Cultural Adaptation theoretical model and is reported using the Framework for Reporting Adaptations and Modifications-Enhanced. We first established the adaptation rationale, then considered program underpinnings and the core components for effectiveness. To inform adaptations, we reviewed the scientific literature and engaged stakeholders. Consultations included focus groups with 24 Arabic and 22 Chinese speaking migrant mothers and interviews with 20 health professionals. With input from project partners, bi-cultural staff and community organisations, findings informed cultural adaptations to the content and delivery features of the Healthy Beginnings program. RESULTS: Program structure and delivery mode were retained to preserve fidelity (i.e. staged nurse calls with key program messages addressing modifiable obesity-related behaviours: infant feeding, active play, sedentary behaviours and sleep). Qualitative analysis of focus group and interview data resulted in descriptive themes concerning cultural practices and beliefs related to infant obesity-related behaviours and perceptions of child weight among Arabic and Chinese speaking mothers. Based on the literature and local study findings, cultural adaptations were made to recruitment approaches, staffing (bi-cultural nurses and project staff) and program content (modified call scripts and culturally adapted written health promotion materials). CONCLUSIONS: This cultural adaptation of Healthy Beginnings followed an established process model and resulted in a program with enhanced relevance and accessibility among Arabic and Chinese speaking migrant mothers. This work will inform the future cultural adaptation stages: testing, refining, and trialling the culturally adapted Healthy Beginnings program to assess acceptability, feasibility and effectiveness.