Red and processed meat consumption and purchasing behaviours and attitudes: impacts for human health, animal welfare and environmental sustainability.

OBJECTIVE: Higher intakes of red and processed meat are associated with poorer health outcomes and negative environmental impacts. Drawing upon a population survey the present paper investigates meat consumption behaviours, exploring perceived impacts for human health, animal welfare and the environment. DESIGN: Structured self-completion postal survey relating to red and processed meat, capturing data on attitudes, sustainable meat purchasing behaviour, red and processed meat intake, plus sociodemographic characteristics of respondents. SETTING: Urban and rural districts of Nottinghamshire, East Midlands, UK, drawn from the electoral register. SUBJECTS: UK adults (n 842) aged 18-91 years, 497 females and 345 males, representing a 35·6 % response rate from 2500 randomly selected residents. RESULTS: Women were significantly more likely (P60 years) were more likely to hold positive attitudes towards animal welfare (P<0·01). Less than a fifth (18·4 %) of the sample agreed that the impact of climate change could be reduced by consuming less meat, dairy products and eggs. Positive attitudes towards animal welfare were associated with consuming less meat and a greater frequency of 'higher welfare' meat purchases. CONCLUSIONS: Human health and animal welfare are more common motivations to avoid red and processed meat than environmental sustainability. Policy makers, nutritionists and health professionals need to increase the public's awareness of the environmental impact of eating red and processed meat. A first step could be to ensure that dietary guidelines integrate the nutritional, animal welfare and environmental components of sustainable diets.

UK health visitors' role in identifying and intervening with infants at risk of developing obesity.

Childhood obesity is associated with a number of modifiable risk factors that can be identified during infancy or earlier. In the UK, health visitors advise parents about infant feeding, but little is known about their role in obesity prevention. The aim of this study was to investigate the beliefs and current practices of UK health visitors in relation to recognising and intervening with infants at risk of developing obesity. Thirty members of the health visiting team were interviewed. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was applied using an interpretative, inductive approach. Health visitors were aware of some of the modifiable risk factors for childhood obesity such as infant feeding practices. They felt they had a role in advising parents about diet but did not formally identify and/or intervene with larger infants. Infant overweight was considered a sensitive issue that was difficult to raise with parents. They believed some parents preferred larger infants and were unaware that their feeding practices might be contributing to obesity risk. A need for training and guidance was identified together with strategies to overcome system barriers. Health visitors do not currently target parents of infants at risk of obesity largely because they do not perceive they have appropriate guidance and skills to enable them to do so. There is an urgent need for tools and training to enable all health care professionals to recognise and manage infants at risk of developing obesity without creating a sense of blame.

The dilemma of healthy eating and environmental sustainability: the case of fish.

OBJECTIVE: Despite widespread concern over exploitation of the European Union's fish stocks, dietary guidelines in the UK continue to recommend two portions of fish per week. The present study sought to investigate whether health and/or sustainability are motivating factors when purchasing and consuming fish and whether there are sociodemographic trends. DESIGN: A structured, self-completion postal questionnaire exploring consumers' attitudes towards purchasing fish, their dietary intake, stated purchasing behaviour and sociodemographic information. SETTING: Nottinghamshire, UK. SUBJECTS: Adults from 842 households randomly selected from the electoral register. RESULTS: Over half of the participants (57·0 %) were aware of the health benefits of fish consumption and reported health as a primary motivator for purchasing fish; however, only 26·8 % actively sought to purchase fish from a sustainable source (e.g. Marine Stewardship Council (MSC) certified fish). Only 30·6 % of participants met current dietary recommendations for fish intake. Older respondents (>60 years of age) were more likely to report purchasing fish for health reasons and to buy MSC fish. Participants were significantly less likely to report MSC purchases if they agreed with the statement 'I am confused about which type of fish I should be eating to protect fish stocks' (P < 0·001). CONCLUSIONS: The number of consumers purchasing fish for health reasons was more than those seeking sustainably sourced fish; yet, they still failed to meet the recommended intake set by the Food Standards Agency. Dietary advice to the public to increase consumption of fish conflicts with the prevailing pressure on fish stocks. Clear advice should be communicated enabling consumers to meet nutritional needs while protecting fish stocks.

Preventing childhood obesity during infancy in UK primary care: a mixed-methods study of HCPs' knowledge, beliefs and practice.

BACKGROUND: There is a strong rationale for intervening in early childhood to prevent obesity. Over a quarter of infants gain weight more rapidly than desirable during the first six months of life putting them at greater risk of obesity in childhood. However, little is known about UK healthcare professionals' (HCPs) approach to primary prevention. This study explored obesity-related knowledge of UK HCPs and the beliefs and current practice of general practitioners (GPs) and practice nurses in relation to identifying infants at risk of developing childhood obesity. METHOD: Survey of UK HCPs (GPs, practice nurses, health visitors, nursery, community and children's nurses). HCPs (n = 116) rated their confidence in providing infant feeding advice and completed the Obesity Risk Knowledge Scale (ORK-10).Semi-structured interviews with a sub-set of 12 GPs and 6 practice nurses were audio recorded, taped and transcribed verbatim. Thematic analysis was applied using an interpretative, inductive approach. RESULTS: GPs were less confident about giving advice about infant feeding than health visitors (p = 0.001) and nursery nurses (p = 0.009) but more knowledgeable about the health risks of obesity (p < 0.001) than nurses (p = 0.009). HCPs who were consulted more often about feeding were less knowledgeable about the risks associated with obesity (r = -0.34, n = 114, p < 0.001). There was no relationship between HCPs' ratings of confidence in their advice and their knowledge of the obesity risk.Six main themes emerged from the interviews: 1) Attribution of childhood obesity to family environment, 2) Infant feeding advice as the health visitor's role, 3) Professional reliance on anecdotal or experiential knowledge about infant feeding, 4) Difficulties with recognition of, or lack of concern for, infants "at risk" of becoming obese, 5) Prioritising relationship with parent over best practice in infant feeding and 6) Lack of shared understanding for dealing with early years' obesity. CONCLUSIONS: Intervention is needed to improve health visitors and nursery nurses' knowledge of obesity risk and GPs and practice nurses' capacity to identify and manage infants' at risk of developing childhood obesity. GPs value strategies that maintain relationships with vulnerable families and interventions to improve their advice-giving around infant feeding need to take account of this. Further research is needed to determine optimal ways of intervening with infants at risk of obesity in primary care.

Parents' beliefs about appropriate infant size, growth and feeding behaviour: implications for the prevention of childhood obesity.

BACKGROUND: A number of risk factors are associated with the development of childhood obesity which can be identified during infancy. These include infant feeding practices, parental response to infant temperament and parental perception of infant growth and appetite. Parental beliefs and understanding are crucial determinants of infant feeding behaviour; therefore any intervention would need to take account of their views. This study aimed to explore UK parents' beliefs concerning their infant's size, growth and feeding behaviour and parental receptiveness to early intervention aimed at reducing the risk of childhood obesity. METHOD: Six focus groups were undertaken in a range of different demographic localities, with parents of infants less than one year of age. The focus groups were audio-recorded, transcribed verbatim and thematic analysis applied using an interpretative, inductive approach. RESULTS: 38 parents (n=36 female, n=2 male), age range 19-45 years (mean 30.1 years, SD 6.28) participated in the focus groups. 12/38 were overweight (BMI 25-29.99) and 8/38 obese (BMI>30). Five main themes were identified. These were a) parental concern about breast milk, infant contentment and growth; b) the belief that the main cause of infant distress is hunger is widespread and drives inappropriate feeding; c) rationalisation for infants' larger size; d) parental uncertainty about identifying and managing infants at risk of obesity and e) intentions and behaviour in relation to a healthy lifestyle. CONCLUSIONS: There are a number of barriers to early intervention with parents of infants at risk of developing obesity. Parents are receptive to prevention prior to weaning and need better support with best practice in infant feeding. In particular, this should focus on helping them understand the physiology of breast feeding, how to differentiate between infant distress caused by hunger and other causes and the timing of weaning. Some parents also need guidance about how to recognize and prepare healthy foods and facilitate physical activity for their infants.

Communicating about obesity and weight-related topics with children with a physical disability and their families: spina bifida as an example.

PURPOSE: The purpose of this study was to explore the experiences of children with spina bifida (SB), their families and healthcare professionals (HCPs) when discussing weight-related topics. METHOD: In-depth qualitative interviews were conducted with HCPs from Canadian outpatient SB clinics (n = 13), children aged 6-18 years with SB (n = 17) and their parents (n = 20). Data were analyzed using a phenomenological approach within an interpretative paradigm. RESULTS: Many HCPs were not confident talking about weight, concerned that they would damage relationships with children and families. Parents wanted routine weight surveillance, but were worried about their children's self-esteem if their weight was discussed. They wanted HCPs to acknowledge the challenges of weight management in children with a physical disability and provide specialized solutions. Children wanted a positively framed and tailored approach to weight discussions, although this had generally not been their experience. CONCLUSIONS: Stakeholders describe therapeutic relationships that are currently disconnected around the issue of weight and obesity. However, children, parents and HCPs all believed that discussing this topic was critical. Positively framed, strengths-based and tailored approaches to weight-related discussions are warranted. Implications for Rehabilitation Rates of overweight and obesity in children and youth with physical disabilities are substantially higher than their typically developing peers. Healthcare professionals, children with physical disabilities and families often find weight-related discussions challenging and disconnected. Weight-related discussions should be tailored to the child and family's circumstances and priorities. Positively framed and strengths-based approaches to weight-related discussions are warranted.

Antenatal weight management: Diet, physical activity, and gestational weight gain in early pregnancy.

OBJECTIVE: to investigate women's physical activity levels, diet and gestational weight gain, and their experiences and motivations of behavior change. DESIGN: analysis of cross-sectional data collected during a longitudinal, cohort study examining physiological, psychological, sociodemographic, and self-reported behavioural measures relating to bodyweight. SETTING: women recruited from routine antenatal clinics at the Nottingham University Hospitals NHS Trust. PARTICIPANTS: 193 women ≤27 weeks gestation and aged 18 years or over. MEASUREMENTS & FINDINGS: measurements included weight and height, the Dietary Instrument for Nutrition Education (Brief Version), the International Physical Activity Questionnaire (Short Form), and open questions of perceptions of behaviour change. 50.3% (n=97) were overweight/obese, and women gained 0.26kg/wk (IQR 0.34kg/wk) since conception. The majority consumed low levels of fat (n=121; 63.4%), high levels of unsaturated fat (n=103; 53.9%), and used a dietary supplement (n=166; 86.5%). However, 41% (n=76) were inactive, 74.8% (n=143) did not consume high levels of fibre, and 90.0% (n=171) consumed less than 5 portions of fruit and vegetables a day. Body mass index category was not associated with diet, physical activity levels, or gestational weight gain. Themes generated from open-questions relating to behaviour change were: (1) Risk management, (2) Coping with symptoms, (3) Self-control, (4) Deviation from norm, (5) Nature knows best. CONCLUSIONS: early pregnancy is a period of significant and heterogeneous behaviour change, influenced by perceptions of risk and women's lived experience. Behaviour was influenced not only by perceptions of immediate risk to the fetus, but also by the women's lived experience of being pregnant. IMPLICATIONS FOR PRACTICE: There are exciting opportunities to constructively reframe health promotion advice relating to physical activity and diet in light of women's priorities. The need for individualized advice is highlighted, and women across all body mass index categories would benefit from improved diet and physical activity levels.

Validation, Optimal Threshold Determination, and Clinical Utility of the Infant Risk of Overweight Checklist for Early Prevention of Child Overweight.

BACKGROUND: Previous research has demonstrated the predictive validity of the Infant Risk of Overweight Checklist (IROC). This study further establishes the predictive accuracy of the IROC using data from the Avon Longitudinal Study of Parents and Children (ALSPAC) and examines the optimal threshold for determining high risk of childhood overweight. METHODS: Using the IROC algorithm, we calculated the risk of being overweight, based on International Obesity Task Force criteria, in the first year of life for 980 children in the ALSPAC cohort at 5 years. Discrimination was assessed by the area under the receiver operating curve (AUC c-statistic). Net reclassification index (NRI) was calculated for risk thresholds ranging from 2.5% to 30%, which determine cutoffs for identifying infants at risk of becoming overweight. RESULTS: At 5 years of age, 12.3% of boys and 19.6% of girls were categorized overweight. Discrimination (AUC c-statistic) ranged from 0.67 (95% confidence interval [CI], 0.62-0.72) when risk scores were calculated directly to 0.93 (95% CI, 0.88-0.98) when the algorithm was recalibrated and missing values of the risk factor algorithm were imputed. The NRI showed that there were positive gains in reclassification using risk thresholds from 5% to 20%, with the maximum NRI being at 10%. CONCLUSIONS: This study confirms that the IROC has moderately good validity for assessing overweight risk in infants and offers an optimal threshold for determining high risk. The IROC algorithm has been imbedded into a computer program for Proactive Assessment of Obesity Risk during Infancy, which facilitates early overweight prevention through communication of risk to parents.

A Call to Action: Setting the Research Agenda for Addressing Obesity and Weight-Related Topics in Children with Physical Disabilities.

BACKGROUND: Pediatric obesity is a world-wide challenge. Children with physical disabilities are particularly at risk of obesity, which is worrisome because obesity can result in serious secondary conditions that decrease health status, reduce independence, and increase impact on healthcare systems. However, the determinants of obesity and the health promotion needs of children with physical disabilities are relatively unexplored compared with their typically developing peers. METHODS: This white paper describes a Canadian multi-stakeholder workshop on the topic of obesity and health in children with physical disabilities and provides recommendations for future research in this understudied area. RESULTS: Seventy-one knowledge gaps identified by attendees using a modified nominal group technique clustered into six themes: (1) early, sustained engagement of families; (2) rethinking determinants of obesity and health; (3) maximizing impact of research; (4) inclusive integrated interventions; (5) evidence-informed measurement and outcomes; and (6) reducing weight biases. Attendees worked together to develop research plans in more detail for three areas identified through consensus as high priority: "early, sustained engagement of families;" "rethinking determinants of obesity and health;" and "evidence informed measurement and outcomes." CONCLUSIONS: Using the workshop described here as a call to action, Canadian researchers are now well positioned to work toward a greater understanding of weight-related topics in children with physical disabilities, with the aim of developing evidence-based and salient obesity prevention and treatment approaches.

Obesity prevention for children with physical disabilities: a scoping review of physical activity and nutrition interventions.

PURPOSE: Children with disabilities are at higher risk of obesity, engage in less physical activity and report poorer quality dietary habits than their non-disabled peers. This study reviewed current evidence on interventions designed to facilitate weight management and/or weight-related behaviors (i.e. physical activity and/or healthy eating habits) in children with physical disabilities. METHODS: A scoping review was performed using established methodology. Data from studies meeting specific inclusion criteria were extracted and analyzed using summary statistics, and common characteristics thematically identified. RESULTS: Thirty-four articles were included in the synthesis. No long-term obesity prevention interventions were identified. The majority of research focused upon children with cerebral palsy, and had case study, quasi- or non-experimental designs. All interventions reporting positive outcomes (n = 18) addressed physical activity, with common themes including using motivational strategies for the child and child self-direction. Incremental increases in workload and engaging in strength training for longer than 15 minutes were also effective. Interventions targeting body weight/composition did not report success in the long term. CONCLUSIONS: A robust evidence base is lacking for long-lasting obesity interventions for children with physical disabilities. Current research provides some insights into the specific components that should be considered when planning such interventions in the future.

Talking about obesity with clients: preferred terms and communication styles of U.K. pre-registration dieticians, doctors, and nurses.

OBJECTIVE: To describe trainee healthcare professionals' preferred terms when talking about obesity, their beliefs about initiating discussions about weight, and their confidence about consulting with obese people. METHODS: A self-completed questionnaire collected data on demographics, preferred terms, beliefs about initiation of discussions, confidence and training needs from 1036 pre-registration dieticians, nurses and doctors. RESULTS: Participants' preferred terms when raising the issue of obesity with clients were BMI (mean=.96), weight (mean=.71) and unhealthy BMI (mean=.43). When defining a client's bodyweight, students endorsed the euphemism 'your weight may be damaging your health' (67.6%). A proactive, collaborative communication style was preferred by 34.9% of participants. 58.2% of participants felt confident about discussing obesity with clients and 95.1% felt that that more training would be useful. CONCLUSION: It is reassuring that U.K. trainee healthcare professionals avoid value-laden terms and broadly endorse words preferred by people with obesity. It is, however, concerning that the majority of participants did not favor a proactive, collaborative communication style. PRACTICE IMPLICATIONS: Educators of tomorrow's healthcare professionals could take advantage of students' desire for more training on how to effectively talk to clients with obesity about their weight. Such training would, however, require the development of clear guidelines on terminology and communication styles.

Estimating overweight risk in childhood from predictors during infancy.

OBJECTIVE: The aim of this study was to develop and validate a risk score algorithm for childhood overweight based on a prediction model in infants. METHODS: Analysis was conducted by using the UK Millennium Cohort Study. The cohort was divided randomly by using 80% of the sample for derivation of the risk algorithm and 20% of the sample for validation. Stepwise logistic regression determined a prediction model for childhood overweight at 3 years defined by the International Obesity Task Force criteria. Predictive metrics R(2), area under the receiver operating curve (AUROC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: Seven predictors were found to be significantly associated with overweight at 3 years in a mutually adjusted predictor model: gender, birth weight, weight gain, maternal prepregnancy BMI, paternal BMI, maternal smoking in pregnancy, and breastfeeding status. Risk scores ranged from 0 to 59 corresponding to a predicted risk from 4.1% to 73.8%. The model revealed moderately good predictive ability in both the derivation cohort (R(2) = 0.92, AUROC = 0.721, sensitivity = 0.699, specificity = 0.679, PPV = 38%, NPV = 87%) and validation cohort (R(2) = 0.84, AUROC = 0.755, sensitivity = 0.769, specificity = 0.665, PPV = 37%, NPV = 89%). CONCLUSIONS: Using a prediction algorithm to identify at-risk infants could reduce levels of child overweight and obesity by enabling health professionals to target prevention more effectively. Further research needs to evaluate the clinical validity, feasibility, and acceptability of communicating this risk.

Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy.

OBJECTIVE: To determine risk factors for childhood overweight that can be identified during the first year of life to facilitate early identification and targeted intervention. DESIGN: Systematic review and meta-analysis. SEARCH STRATEGY: Electronic database search of MEDLINE, EMBASE, PubMed and CAB Abstracts. ELIGIBILITY CRITERIA: Prospective observational studies following up children from birth for at least 2 years. RESULTS: Thirty prospective studies were identified. Significant and strong independent associations with childhood overweight were identified for maternal pre-pregnancy overweight, high infant birth weight and rapid weight gain during the first year of life. Meta-analysis comparing breastfed with non-breastfed infants found a 15% decrease (95% CI 0.74 to 0.99; I(2)=73.3%; n=10) in the odds of childhood overweight. For children of mothers smoking during pregnancy there was a 47% increase (95% CI 1.26 to 1.73; I(2)=47.5%; n=7) in the odds of childhood overweight. There was some evidence associating early introduction of solid foods and childhood overweight. There was conflicting evidence for duration of breastfeeding, socioeconomic status at birth, parity and maternal marital status at birth. No association with childhood overweight was found for maternal age or education at birth, maternal depression or infant ethnicity. There was inconclusive evidence for delivery type, gestational weight gain, maternal postpartum weight loss and 'fussy' infant temperament due to the limited number of studies. CONCLUSIONS: Several risk factors for both overweight and obesity in childhood are identifiable during infancy. Future research needs to focus on whether it is clinically feasible for healthcare professionals to identify infants at greatest risk.

Asthma as a barrier to children's physical activity: implications for body mass index and mental health.

OBJECTIVES: The purpose of this work was to identify barriers to physical activity in children with asthma and to compare their customary activity levels, BMI and emotional well-being with that of children with other medical conditions. It was hypothesized that children with asthma would have higher BMI and lower levels of customary activity. PATIENTS AND METHODS: We studied children aged 7 to 14 years attending hospital outpatient clinics for either asthma (asthma group: n = 56) or for otorhinolaryngology or dermatological conditions (nonasthma group: n = 61). In this cross-sectional survey, children's weight and height were recorded and their BMI classified according to International Obesity Task Force classification of obesity. Child mental health was assessed by the parent-rated Strengths and Difficulties Questionnaire. The child-rated Physical Activity Questionnaire assessed total sedentary and physical activities during the previous 24 hours. RESULTS: The asthma group had a higher mean BMI (20.78 vs 18.82) and higher rates of obesity (21.4% vs 6.6%). Children with asthma reported fewer physical activities than the nonasthma group (median 4 per day vs 6 per day) but comparable levels of sedentary activities. Asthma was the strongest predictor of lower activity scores, followed by younger age. The asthma group had higher levels of emotional difficulties and, within this group, more active children had better mental health. More parents in the asthma group identified the child's health as a barrier to exercise (60.7% vs 11%). The same was true of children (66.1% vs 11.5%). CONCLUSIONS: We found that children attending a hospital clinic for asthma were more likely to be obese and were significantly less active than a comparison group with other medical conditions. Asthma was identified as a barrier to exercise by parents and children. Strategies to promote exercise within pediatric asthma care are needed to protect both mental and physical health.