Adaptation and Validation of the MapMe Body Image Scales in Spanish Parents of Schoolchildren.

Childhood overweight and obesity is a worldwide problem and to treat it parents' detection has to be improved. The MapMe Body Image Scales (BIS) are a visual tool developed to improve parental perception of child weight in the United Kingdon (UK) based on British growth reference criteria. The aim of this study was to make a transcultural adaptation and validation of the MapMe BIS in Spain based on International Obesity Task Force (IOTF) cut offs A descriptive cross-sectional study was done. First, a translation and cultural adaptation was carried out. A total of 155 10-11-year-old children and their parents participated in this study. Children were measured to calculate their weight status, Body Mass Index (BMI), Body Fat Percentage (BFP) and Waist Circumference (WC), and their parents completed a purpose designed questionnaire about their perception and satisfaction of child's body weight status using the adapted BIS. Test-retest reliability, criterion validity and concurrent validity of the adapted BIS were analyzed. This study shows that the adapted MapMe BIS has good psychometric properties and is a suitable visual scale to assess parental perception of weight status in 10 and 11-year-old children in Spain.

5-year follow-up of the randomised Diabetes Remission Clinical Trial (DiRECT) of continued support for weight loss maintenance in the UK: an extension study.

BACKGROUND: In DiRECT, a randomised controlled effectiveness trial, weight management intervention after 2 years resulted in mean weight loss of 7·6 kg, with 36% of participants in remission of type 2 diabetes. Of 36 in the intervention group who maintained over 10 kg weight loss at 2 years, 29 (81%) were in remission. Continued low-intensity dietary support was then offered up to 5 years from baseline to intervention participants, aiming to maintain weight loss and gain clinical benefits. This extension study was designed to provide observed outcomes at 5 years. METHODS: The DiRECT trial took place in primary care practices in the UK. Participants were individuals aged 20-65 years who had less than 6 years' duration of type 2 diabetes, a BMI greater than 27 kg/m2, and were not on insulin. The intervention consisted of withdrawal of antidiabetic and antihypertensive drugs, total diet replacement (825-853 kcal per day formula diet for 12-20 weeks), stepped food reintroduction (2-8 weeks), and then structured support for weight-loss maintenance. After sharing the 2-year results with all participants, UK National Health Service data were collected annually until year 5 from remaining intervention participants who received low-intensity dietary support, intervention withdrawals, and the original randomly allocated groups. The primary outcome was remission of type 2 diabetes; having established in the DiRECT trial that sustained weight loss was the dominant driver of remission, this was assumed for the Extension study. The trial is registered with the ISRCTN registry, number 03267836. FINDINGS: Between July 25, 2014, and Aug 5, 2016, 149 participants were randomly assigned to the intervention group and 149 were assigned to the control group in the original DiRECT study. After 2 years, all intervention participants still in the trial (101 [68%] of 149) were approached to receive low-intensity support for a further 3 years. 95 (94%) of 101 were able to continue and consented and were allocated to the DiRECT extension group. 54 participants were allocated to the non-extension group, where intervention was withdrawn. At 5 years, DiRECT extension participants (n=85) lost an average of 6·1 kg, with 11 (13%) of 85 in remission. Compared with the non-extension group, DiRECT extension participants had more visits with HbA1c <48 mmol/mol (<6·5%; 36% vs 17%, p=0·0004), without glucose-lowering medication (62% vs 30%, p<0·0001), and in remission (34% vs 12%, p<0·0001). Original control participants (n=149) had mean weight loss 4·6 kg (n=82), and 5 (5%) of 93 were in remission. Compared with control participants, original intervention participants had more visits with weight more than 5% below baseline (61% vs 29%, p<0·0001), HbA1c below 48 mmol/mol (29% vs 15%, p=0·0002), without antidiabetic medication (51% vs 16%, p<0·0001), and in remission (27% vs 4%, p<0·0001). Of those in remission at year 2, 26% remained in remission at 5 years. Serious adverse events in the original intervention group (4·8 events per 100 patient-years) were under half those in the control group (10·2 per 100 patient-years, p=0·0080). INTERPRETATION: The extended DiRECT intervention was associated with greater aggregated and absolute weight loss, and suggested improved health status over 5 years. FUNDING: Diabetes UK.

A Randomised Control Trial Investigating the Efficacy of the MapMe Intervention on Parental Ability to Correctly Categorise Overweight in Their Child and the Impact on Child BMI Z-Score Change at 1 Year.

Research suggests parental ability to recognise when their child has overweight is limited. It is hypothesised that recognition of child overweight/obesity is fundamental to its prevention, acting as a potential barrier to parental action to improve their child's health-related behaviours and/or help seeking. The purpose of this study was to investigate the efficacy of an intervention (MapMe) to improve parental ability to correctly categorise their child as having overweight one-month post-intervention, and reduce child body mass index (BMI) z-score 12 months post-intervention. MapMe consists of body image scales of known child BMI and information on the consequences of childhood overweight, associated health-related behaviours and sources of support. We conducted a three-arm (paper-based MapMe, web-based MapMe and control) randomised control trial in fifteen English local authority areas with parents/guardians of 4-5- and 10-11-year-old children. Parental categorisation of child weight status was assessed using the question 'How would you describe your child's weight at the moment?' Response options were: underweight, healthy weight, overweight, and very overweight. Child weight status and BMI z-scores were calculated using objectively measured height and weight data and UK90 clinical thresholds. There was no difference in the percentage of parents correctly categorising their child as having overweight/very overweight (n = 264: 41% control, 48% web-based, and 43% paper-based, p = 0.646). BMI z-scores were significantly reduced for the intervention group at 12 months post-intervention compared to controls (n = 338, mean difference in BMI z-score change -0.11 (95% CI -0.202 to -0.020, p = 0.017). MapMe was associated with a decrease in BMI z-score 12 months post-intervention, although there was no direct evidence of improved parental ability to correctly categorise child overweight status. Further work is needed to replicate these findings in a larger sample of children, investigate mechanisms of action, and determine the use of MapMe as a public health initiative.

Changes and differences in school food standards (2010-2021) and free school meal provision during COVID-19 across the UK: Potential implications for children's diets.

This paper explores changes to school food standards from 2010, free school meal provision during the COVID-19 pandemic across the UK and potential implications for children's diets. To obtain information on UK school food policies and free school meal provision methods we reviewed several sources including news articles, policy documents and journal articles. School food is an important part of the UK's health agenda and commitment to improving children's diets. Each UK nation has food-based standards implemented, however, only Scotland and Wales also have nutrient-based standards. School food standards in each nation have been updated in the last decade. Universal free school meals are available for children in the first 3 years of primary school in England and the first 5 years of primary school in Scotland, with plans announced for implementation of free school meals for all primary schoolchildren in Scotland and Wales. There is a lack of consistent monitoring of school food across the UK nations, and a lack of reporting compliance to the standards. Each nation differed in its response and management of free school meals during COVID-related school closures. Further, there are issues surrounding the monitoring of the methods to provide free school meal support during school closures. The role of school food has been highlighted during COVID-19, and with this, there have been calls for a review of free school meal eligibility criteria. The need for improved and consistent monitoring of school food across the UK remains, as does the need to evaluate the impact of school food on children's diets.

The Effect of a Product Placement Intervention on Pupil's Food and Drink Purchases in Two Secondary Schools: An Exploratory Study.

Limited research exists on the effectiveness of product placement in secondary schools. We explored the impact of re-positioning sweet-baked goods, fruit, sugar-sweetened beverages (SSBs) and water on pupil's lunchtime purchases in two secondary schools in North-East England. We employed a stepped-wedge design with two clusters and four time periods. The intervention(s) involved re-positioning selected food and drinks to increase and decrease accessibility of 'healthier' and 'less healthy' items, respectively. Unidentifiable smartcard data measured the change in number of pupil's purchasing the above items. McNemar tests were undertaken on paired nominal data in Stata(v15). In School A, pupils purchasing fruit pots from control to intervention increased (n = 0 cf. n = 81; OR 0, 95% CI 0 to 0.04); post-intervention, this was not maintained. In School B, from control to intervention pupil's purchasing sweet-baked goods decreased (n = 183 cf. n = 147; OR 1.2, 95% CI 1 to 1.6). This continued post-intervention (n = 161 cf. n = 122; OR 1.3, 95% CI 1.0 to 1.7) and was similar for SSBs (n = 180 cf. n = 79; OR 2.3, 95% CI 1.7 to 3.0). We found no evidence of other changes. There is some evidence that product placement may positively affect pupil's food and drink purchases. However, there are additional aspects to consider, such as, product availability, engaging canteen staff and the individual school context.

Participant experiences in the Diabetes REmission Clinical Trial (DiRECT).

INTRODUCTION: The Diabetes REmission Clinical Trial (DiRECT) has shown that sustained remission of type 2 diabetes in primary care is achievable through weight loss using total diet replacement (TDR) with continued behavioural support. Understanding participants' experiences can help optimise the intervention, support implementation into healthcare, and understand the process of behaviour change. METHODS: Thirty-four DiRECT participants were recruited into this embedded qualitative evaluation study. In-person and telephone interviews were conducted before the TDR; at week 6-8 of the TDR; 2 weeks into food reintroduction (FR); and at 1 year, to learn about participant experiences with the programme. Transcribed narratives were analysed thematically, and we used interpretation to develop overarching themes. RESULTS: Initiation of the TDR and transition to FR were challenging and required increased behavioural support. In general, adhering to TDR proved easier than the participants had anticipated. Some participants chose the optional extension of TDR. Rapid weight loss and changes in diabetes markers provided ongoing motivation. Further weight loss, behavioural support and occasional use of TDR facilitated weight loss maintenance (WLM). A process of behaviour adaptation to change following regime disruption was identified in three stages: (1) expectations of the new, (2) overcoming difficulties with adherence, and (3) acceptance of continuous effort and establishment of routines. CONCLUSIONS: The DiRECT intervention was acceptable and regularity, continuity, and tailoring of behavioural support was instrumental in its implementation in primary care. The adaptation process accounts for some of the individual variability of experiences with the intervention and highlights the need for programme flexibility.

Failure to Launch: Predictors of Unfavourable Physical Activity and Sedentary Behaviour Trajectories from Childhood to Adolescence: The Gateshead Millennium Study.

In a previous study based on this cohort, only 15% of the participants belonged to a favourable physical activity/sedentary behaviour trajectory group (characterised by relatively high moderate-vigorous intensity physical activity and relatively low sedentary behaviour across childhood and adolescence). Since this favourable trajectory is protective against obesity, we aimed to identify factors associated with membership of this group. In this longitudinal study, 671 participants were assessed at ages 7, 9, 12 and 15 years. Participants' demographics, socio-economic status (SES) and physical activity environment such as, sports club participation and commuting school were assessed at ages 7, 9 and 12 and analysed with favourable trajectory membership as an outcome using multinomial logistic regression. Sex (male) and SES (higher) were the non-modifiable factors associated with favourable trajectory group. Of the modifiable factors, commuting to school at age 7, a safe environment to play at age 7 and sports club participation at age 12 were all associated with more than 2.0 times increased probability of being in the most favourable trajectory. Future interventions to promote a favourable trajectory could focus on girls and participants with low SES. Promoting active commuting, safe local spaces to play and sports participation should also help lead to a favourable trajectory for physical activity and sedentary behaviour across childhood and adolescence.

Moderate-To-Vigorous Intensity Physical Activity and Sedentary Behaviour across Childhood and Adolescence, and Their Combined Relationship with Obesity Risk: A Multi-Trajectory Analysis.

The combined role of objectively assessed moderate-vigorous intensity physical activity (MVPA) and sedentary behaviour (SB) is unclear in obesity prevention. This study aimed to identify latent groups for MVPA and SB trajectories from childhood to adolescence and examine their relationship with obesity risk at adolescence. From the Gateshead Millennium Study, accelerometer-based trajectories of time spent in MVPA and SB at ages 7, 9, 12, and 15 were derived as assigned as the predictor variable. Fat mass index (FMI), using bioelectrical impedance at age 15, was the outcome variable. From 672 children recruited, we identified three distinct multiple trajectory groups for time spent in MVPA and SB. The group with majority membership (54% of the cohort) had high MVPA and low SB at childhood, but MVPA declined and SB increased by age 15. One third of the cohort (31%) belonged to the trajectory with low MVPA and high time spent sedentary throughout. The third trajectory group (15% of the cohort) that had relatively high MVPA and relatively low SB throughout had lower FMI (-1.7, 95% CI (-3.4 to -1.0) kg/m2, p = 0.034) at age 15 compared to the inactive throughout group. High MVPA and low SB trajectories when combined are protective against obesity.

A comparison of food portion size estimation methods among 11-12 year olds: 3D food models vs an online tool using food portion photos (Intake24).

BACKGROUND: Technology has advanced bringing new cost-effective methods to measure food intake. The aim of the study was to compare food and drink portion estimates from a traditional portion estimation method using 3D food models with portion estimates using an online dietary recall tool, Intake24. METHODS: 11-12 year old children were recruited from secondary schools in Newcastle upon Tyne. Each pupil completed a two-day food diary followed by an interview during which pupils estimated food portion sizes using a range of 3D food models. They also completed Intake24 for the same 2 days. Bland Altman analyses were used to compare mean intake for each method. RESULTS: Seventy pupils completed both portion estimation methods. There was good agreement in food weight estimations between the two methods (geometric mean ratio 1.00), with limits of agreement ranging from minus 35% to plus 53%. Intake24 provided estimates of energy intake that were 1% lower on average than estimates of energy intake using the food models. Mean intakes of all macro and micronutrients using Intake24 were within 6% of the food model estimates. CONCLUSIONS: The findings suggest that there was little difference in portion estimations from the two methods, allowing comparisons to be made between Intake24 data and food diary data collected from same age pupils using 3D food models in previous years.

The Biological and Social Determinants of Childhood Obesity: Comparison of 2 Cohorts 50 Years Apart.

OBJECTIVE: To determine whether the same relationships between early-life risk factors and socioeconomic status (SES) with childhood body mass index (BMI) are observed in a modern cohort (2000) compared with a historic cohort (1947). STUDY DESIGN: The relationships between early-life factors and SES with childhood BMI were examined in 2 prospective birth cohorts from the same region, born 50 years apart: 711 children in the 1947 Newcastle Thousand Families Study (NTFS) and 475 from the 2000 Gateshead Millennium Study (GMS). The associations between birth weight, breastfeeding, rapid infancy growth (0-12 months), early-life adversity (0-12 months), and parental SES (birth and childhood) with childhood BMI z-scores and whether overweight/obese (BMI >91st percentile using UK 1990 reference) aged 9 years were examined using linear regression, path analyses, and logistic regression. RESULTS: In the NTFS, the most advantaged children were taller than the least (+0.91 height z-score, P = .001), whereas in GMS they had lower odds of overweight/obese than the least (0.35 [95% CI 0.14-0.86]). Rapid infancy growth was associated with increased BMI z-scores in both cohorts, and with increased likelihood of overweight/obese in GMS. CONCLUSIONS: This study suggests that children exposed to socioeconomic disadvantage or who have rapid infancy growth in modern environments are now at lower risk of growth restriction but greater risk of overweight.

Implementation of Universal Infant Free School Meals: a pilot study in NE England exploring the impact on Key Stage 1 pupil's dietary intake.

OBJECTIVE: To consider the principal effect of an interaction between year (pre- and post-Universal Infant Free School Meals (UIFSM)) and school on pupil's dietary intakes. DESIGN: A repeated cross-sectional survey using dietary data from 2008 to 2009 (pre-) and 2017 to 2018 (post-UIFSM). SETTING: Two primary schools, NE England. PARTICIPANTS: Pupils aged 4-7 years (2008-2009 n 121; 2017-2018 n 87). RESULTS: At lunchtime, there was a statistically significant decrease in pupils non-milk extrinsic sugars intake (%E NMEs) pre- to post-UIFSM (mean change -4·6 %; 95 % CI -6·3, -2·9); this was reflected in total diet (-3·8 %; -5·2, -2·7 %). A year and school interaction was found for mean Ca intakes: post-UIFSM pupils in School 2 had a similar mean intake as pre; in School 1 intakes had increased (difference of difference: -120 mg; 95 % CI -179, -62); no reflection in total diet. Post-UIFSM mean portions of yogurt decreased in School 2 and remained similar in School 1 (-0·25; -0·46, -0·04); this was similar for 'cake/pudding' and fruit. CONCLUSIONS: Within the limitations, these findings highlight positives and limitations following UIFSM implementation and demonstrate the role of school-level food practices on pupil's choices. To facilitate maximum potential of UIFSM, national levers, such as discussions on updating school food standards, including sugars, could consider removing the daily 'pudding' option and advocate 'fruit only' options 1 d/week, as some schools do currently. Small school-level changes could maximise positive health impacts by decreasing NMEs intake. A more robust evaluation is imperative to consider dietary impacts, equitability and wider effects on schools and families.

Supporting a Healthier Takeaway Meal Choice: Creating a Universal Health Rating for Online Takeaway Fast-Food Outlets.

Digital food ordering platforms are used by millions across the world and provide easy access to takeaway fast-food that is broadly, though not exclusively, characterised as energy dense and nutrient poor. Outlets are routinely rated for hygiene, but not for their healthiness. Nutritional information is mandatory in pre-packaged foods, with many companies voluntarily using traffic light labels to support making healthier choices. We wanted to identify a feasible universal method to objectively score takeaway fast-food outlets listed on Just Eat that could provide users with an accessible rating that can infer an outlet's 'healthiness'. Using a sample of takeaway outlets listed on Just Eat, we obtained four complete assessments by nutrition researchers of each outlet's healthiness to create a cumulative score that ranged from 4 to 12. We then identified and manually extracted nutritional attributes from each outlet's digital menu, e.g., number of vegetables that have the potential to be numerated. Using generalized linear modelling we identified which attributes were linear predictors of an outlet's healthiness assessment from nutritional researchers. The availability of water, salad, and the diversity of vegetables were positively associated with academic researchers' assessment of an outlet's healthiness, whereas the availability of chips, desserts, and multiple meal sizes were negatively associated. This study shows promise for the feasibility of an objective measure of healthiness that could be applied to all outlet listings on Just Eat and other digital food outlet aggregation platforms. However, further research is required to assess the metric's validity, its desirability and value to users, and ultimately its potential influence on food choice behaviour.

The Food provision, cUlture and Environment in secondary schooLs (FUEL) study: protocol of a mixed methods evaluation of national School Food Standards implementation in secondary schools and their impact on pupils' dietary intake and dental health.

INTRODUCTION: Excess free sugar intake is associated with obesity and poor dental health. Adolescents consume substantially more free sugar than is recommended. National (UK) School Food Standards (SFS) are in place but are not mandatory in all schools, and their impact on the diets of secondary school pupils is unknown. We aim to evaluate how SFS and wider healthy eating recommendations (from the national School Food Plan (SFP)) are implemented in secondary schools and how they influence pupils' diets and dental health. METHODS AND ANALYSIS: Secondary-level academies/free schools in the West Midlands, UK were divided into two groups: SFS mandated and SFS non-mandated. Using propensity scores to guide sampling, we aim to recruit 22 schools in each group. We will compare data on school food provision and sales, school food culture and environment, and the food curriculum from each group, collected through: school staff, governor, pupil, parent surveys; school documents; and observation. We will explore the implementation level for the SFS requirements and SFP recommendations and develop a school food typology. We aim to recruit 1980 pupils aged 11-15 years across the 44 schools and collect dietary intake (24-hour recall) and dental health data through self-completion surveys. We will compare free sugar/other dietary intake and dental health across the two SFS groups and across the identified school types. School type will be further characterised in 4-8 case study schools through school staff interviews and pupil focus groups. Evaluation of economic impact will be through a cost-consequence analysis and an exploratory cost-utility analysis. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of Birmingham Ethical Review Committee (ERN_18-1738). Findings will be disseminated to key national and local agencies, schools and the public through reports, presentations, the media and open access publications. TRIAL REGISTRATION NUMBER: ISRCTN 68757496 (registered 17 October 2019).

Stakeholders' perceptions and experiences of the National Health Service diabetes prevention programme in England: qualitative study with service users, intervention providers and deliverers, commissioners and referrers.

BACKGROUND: The National Health Service diabetes prevention programme in England, (NHS DPP) aims to identify people at high risk of type 2 diabetes (T2D) and offer them a face-to-face, group-based, behaviour change intervention for at least 9 months. The NHS DPP was rolled out in phases. We aimed to elicit stakeholders' perceptions and experiences of the factors influencing implementation of, and participation in, the programme during the development phase. METHODS: Individual, semi-structured telephone interviews were conducted with 50 purposively sampled stakeholders: service users (n = 20); programme commissioners (n = 7); referrers (n = 8); and intervention deliverers (n = 15). Topic guides were structured using a pragmatic, theory-informed approach. Analysis employed the framework method. RESULTS: We identified factors that influenced participation: Risk communication at referral - stakeholders identified point of referral as a window of opportunity to offer brief advice, to provide an understanding of T2D risk and information about the programme; Perceived impact of the NHS DPP - service users highlighted the positive perceived impact on their behaviour change, the peer support provided by participating in the programme, the option to involve a relative, and the 'knock on' effect on others. Service users also voiced disappointment when blood test results still identified them at high risk after the programme; and Behavioural maintenance - participants highlighted the challenges linked to behavioural maintenance (e.g. discontinuation of active support). Factors influencing implementations were also identified: Case finding - stakeholders suggested that using community involvement to identify service users could increase reach and ensure that the workload was not solely on GP practices; Adaptability: intervention deliverers acknowledged the need to tailor advice to service users' preferences and needs; Accountability - the need to acknowledge who was responsible for what at different stages of the NHS DPP pathway; and Fidelity - stakeholders described procedures involved in monitoring service users' satisfaction, outcome data collection and quality assurance assessments. CONCLUSIONS: The NHS DPP offers an evidence-informed behavioural intervention for T2D prevention. Better risk communication specification could ensure consistency at the referral stage and improve participation in the NHS DPP intervention. Cultural adaptations and outreach strategies could ensure the NHS DPP contributes to reducing health inequalities.

The 'Voice' of Key Stakeholders in a School Food and Drink Intervention in Two Secondary Schools in NE England: Findings from a Feasibility Study.

Background: Overweight/obesity affects one-third of UK 11-15-year olds. Individually focussed interventions alone have limited effectiveness. Food choice architecture approaches increase the visibility and convenience of foods to facilitate the choice of 'healthier' foods and reduce 'unhealthy' foods. This qualitative component of a School Food Architecture (SFA) study aimed to determine the perceptions of pupils and staff in relation to school food provision and their perceptions of the intervention. Methods: Pupil focus groups and staff one-to-one interviews. Topic guides were developed from literature and in consultation with a Young Person's Advisory Group. Thematic analysis was applied. Results: Focus group (n = 4) themes included: dining hall practices, determinants of choice, and aspects of health. Interview themes (n = 8) included: catering practices, health awareness, education, and knowledge of intervention. Pupils liked to purchase hand-held, quick to purchase foods potentially limiting the access to fruits and vegetables. Pupils were aware of 'healthier' food choices but would choose other options if available. Conclusions: Schools provide a daily school meal for large numbers of pupils, with time and dining environment constraints. Pupils consume 35-40% of their daily energy intake at school, therefore interventions enabling healthier eating in school are essential, including making healthier choices readily available and accessible.

Validity and reliability of an online self-report 24-h dietary recall method (Intake24): a doubly labelled water study and repeated-measures analysis.

Online self-reported 24-h dietary recall systems promise increased feasibility of dietary assessment. Comparison against interviewer-led recalls established their convergent validity; however, reliability and criterion-validity information is lacking. The validity of energy intakes (EI) reported using Intake24, an online 24-h recall system, was assessed against concurrent measurement of total energy expenditure (TEE) using doubly labelled water in ninety-eight UK adults (40-65 years). Accuracy and precision of EI were assessed using correlation and Bland-Altman analysis. Test-retest reliability of energy and nutrient intakes was assessed using data from three further UK studies where participants (11-88 years) completed Intake24 at least four times; reliability was assessed using intra-class correlations (ICC). Compared with TEE, participants under-reported EI by 25 % (95 % limits of agreement -73 % to +68 %) in the first recall, 22 % (-61 % to +41 %) for average of first two, and 25 % (-60 % to +28 %) for first three recalls. Correlations between EI and TEE were 0·31 (first), 0·47 (first two) and 0·39 (first three recalls), respectively. ICC for a single recall was 0·35 for EI and ranged from 0·31 for Fe to 0·43 for non-milk extrinsic sugars (NMES). Considering pairs of recalls (first two v. third and fourth recalls), ICC was 0·52 for EI and ranged from 0·37 for fat to 0·63 for NMES. EI reported with Intake24 was moderately correlated with objectively measured TEE and underestimated on average to the same extent as seen with interviewer-led 24-h recalls and estimated weight food diaries. Online 24-h recall systems may offer low-cost, low-burden alternatives for collecting dietary information.

Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial.

BACKGROUND: The DiRECT trial assessed remission of type 2 diabetes during a primary care-led weight-management programme. At 1 year, 68 (46%) of 149 intervention participants were in remission and 36 (24%) had achieved at least 15 kg weight loss. The aim of this 2-year analysis is to assess the durability of the intervention effect. METHODS: DiRECT is an open-label, cluster-randomised, controlled trial done at primary care practices in the UK. Practices were randomly assigned (1:1) via a computer-generated list to provide an integrated structured weight-management programme (intervention) or best-practice care in accordance with guidelines (control), with stratification for study site (Tyneside or Scotland) and practice list size (>5700 or ≤5700 people). Allocation was concealed from the study statisticians; participants, carers, and study research assistants were aware of allocation. We recruited individuals aged 20-65 years, with less than 6 years' duration of type 2 diabetes, BMI 27-45 kg/m2, and not receiving insulin between July 25, 2014, and Aug 5, 2016. The intervention consisted of withdrawal of antidiabetes and antihypertensive drugs, total diet replacement (825-853 kcal per day formula diet for 12-20 weeks), stepped food reintroduction (2-8 weeks), and then structured support for weight-loss maintenance. The coprimary outcomes, analysed hierarchically in the intention-to-treat population at 24 months, were weight loss of at least 15 kg, and remission of diabetes, defined as HbA1c less than 6·5% (48 mmol/mol) after withdrawal of antidiabetes drugs at baseline (remission was determined independently at 12 and 24 months). The trial is registered with the ISRCTN registry, number 03267836, and follow-up is ongoing. FINDINGS: The intention-to-treat population consisted of 149 participants per group. At 24 months, 17 (11%) intervention participants and three (2%) control participants had weight loss of at least 15 kg (adjusted odds ratio [aOR] 7·49, 95% CI 2·05 to 27·32; p=0·0023) and 53 (36%) intervention participants and five (3%) control participants had remission of diabetes (aOR 25·82, 8·25 to 80·84; p<0·0001). The adjusted mean difference between the control and intervention groups in change in bodyweight was -5·4 kg (95% CI -6·9 to -4·0; p<0·0001) and in HbA1c was -4·8 mmol/mol (-8·3 to -1·4 [-0·44% (-0·76 to -0·13)]; p=0·0063), despite only 51 (40%) of 129 patients in the intervention group using anti-diabetes medication compared with 120 (84%) of 143 in the control group. In a post-hoc analysis of the whole study population, of those participants who maintained at least 10 kg weight loss (45 of 272 with data), 29 (64%) achieved remission; 36 (24%) of 149 participants in the intervention group maintained at least 10 kg weight loss. Serious adverse events were similar to those reported at 12 months, but were fewer in the intervention group than in the control group in the second year of the study (nine vs 22). INTERPRETATION: The DiRECT programme sustained remissions at 24 months for more than a third of people with type 2 diabetes. Sustained remission was linked to the extent of sustained weight loss. FUNDING: Diabetes UK.

Feasibility of working with a wholesale supplier to co-design and test acceptability of an intervention to promote smaller portions: an uncontrolled before-and-after study in British Fish & Chip shops.

OBJECTIVES: To explore the feasibility of working with a wholesale supplier to co-design and deliver, and to assess the acceptability of, an intervention to promote smaller portions in Fish & Chip shops. DESIGN: Uncontrolled before-and-after study. SETTING: Fish & Chip shops in northern England, 2016. PARTICIPANTS: Owners (n=11), a manager and customers (n=46) of Fish & Chip shops; and intervention deliverers (n=3). INTERVENTION: Supplier-led, three-hour engagement event with shop owners and managers, highlighting the problem of excessive portion sizes and potential ways to reduce portion sizes; provision of box packaging to serve smaller portions; promotional posters and business incentives. DATA COLLECTION: In-store observations and sales data collected at baseline and postintervention. Exit survey with customers. Semistructured interviews with owners/managers and intervention deliverers postintervention. RESULTS: Twelve Fish & Chip shops were recruited. Observational data were collected from eight shops: at baseline, six shops did not promote the availability of smaller portion meals; at follow-up, all eight did and five displayed the promotional poster. Seven out of 12 shops provided sales data and all reported increased sales of smaller portion meals postintervention. Of 46 customers surveyed: 28% were unaware of the availability of smaller portion meals; 20% had bought smaller portion meals; and 46% of those who had not bought these meals were interested to try them in the future. Interviews revealed: owners/managers found the intervention acceptable but wanted a clearer definition of a smaller portion meal; the supplier valued the experience of intervention co-production and saw the intervention as being compatible with their responsibility to drive innovation. CONCLUSIONS: The co-design of the intervention with a supplier was feasible. The partnership facilitated the delivery of an intervention that was acceptable to owners and customers. Sales of smaller meal packaging suggest that promotion of such meals is viable and may be sustainable.

Non-linear longitudinal associations between moderate-to-vigorous physical activity and adiposity across the adiposity distribution during childhood and adolescence: Gateshead Millennium Study.

OBJECTIVE: Insufficient moderate-to-vigorous intensity physical activity (MVPA) is harmful for youth; however, the evidence for differential effects by weight status is limited. The study aimed to examine associations between MVPA and adiposity by weight status across childhood and adolescence. METHODS: Participants were from the Gateshead Millennium Study. Physical activity and body composition measures were taken at age 7 y (n = 502; measures taken between October 2006 and December 2007), 9 y (n = 506; October 2008-September 2009), 12 y (n = 420; October 2011-September 2012), and 15 y (n = 306; September 2014-September 2015). Participants wore an ActiGraph GT1M and epochs were classified as MVPA when accelerometer counts were ≥574 counts/15 s. Weight and height were measured using standardized methods and fat mass using bioelectrical impedance. Associations between MVPA and changes in BMI and FMI were examined by weight status using quantile regression. RESULTS: Higher MVPA was associated with lower FMI for the 25th, 50th, 75th, and 90th percentile and lower BMI at the 50th, 75th, and 90th percentile, independent of accelerometer wear time, sex, and sedentary time. The association between MVPA and change in adiposity was stronger in the higher than lower FMI and BMI percentiles (e.g., 1 h/day more MVPA was associated with a 1.5 kg/m2 and 2.7 kg/m2 lower FMI at the 50th and 90th FMI percentiles, respectively). CONCLUSIONS: The effect of MVPA on adiposity in the higher adiposity percentiles is stronger than reported to date. Given overweight and obese children are the highest risk group for later obesity, targeting MVPA might be a particularly effective obesity prevention strategy.

Erratum: Validity and reliability of an online self-report 24-hour dietary recall method (Intake24): A doubly-labelled water study and repeated measures analysis - CORRIGENDUM.

[This corrects the article DOI: 10.1017/jns.2019.20.].