Protocol to evaluate the effectiveness and cost-effectiveness of an environmental nutrition and physical activity intervention in nurseries (Nutrition and Physical Activity Self Assessment for Child Care - NAP SACC UK): a multicentre cluster randomised controlled trial.

BACKGROUND: One in seven UK children have obesity when starting school, with higher prevalence associated with deprivation. Most pre-school children do not meet UK recommendations for physical activity and nutrition. Formal childcare settings provide opportunities to deliver interventions to improve nutritional quality and physical activity to the majority of 3-4-year-olds. The nutrition and physical activity self-assessment for childcare (NAP SACC) intervention has demonstrated effectiveness in the USA with high acceptability in the UK. The study aims to evaluate the effectiveness and cost-effectiveness of the NAP SACC UK intervention to increase physical activity, reduce sedentary time and improve nutritional intake. METHODS: Multi-centre cluster RCT with process and economic evaluation. Participants are children aged 2 years or over, attending UK early years settings (nurseries) for ≥ 12 h/week or ≥ 15 h/week during term time and their parents, and staff at participating nurseries. The 12-month intervention involves nursery managers working with a Partner (public health practitioner) to self-assess policies and practices relating to physical activity and nutrition; nursery staff attending one physical activity and one nutrition training workshop and setting goals to be achieved within 6 months. The Partner provides support and reviews progress. Nursery staff receive a further workshop and new goals are set, with Partner support for a further 6 months. The comparator is usual practice. Up to 56 nurseries will be stratified by area and randomly allocated to intervention or comparator arm with minimisation of differences in level of deprivation. PRIMARY OUTCOMES: accelerometer-assessed mean total activity time on nursery days and average total energy (kcal) intake per eating occasion of lunch and morning/afternoon snacks consumed within nurseries. SECONDARY OUTCOMES: accelerometer-assessed mean daily minutes of moderate-to-vigorous physical activity and sedentary time per nursery day, total physical activity on nursery days compared to non-nursery days, average serving size of lunch and morning/afternoon snacks in nursery per day, average percentage of core and non-core food in lunch and morning/afternoon snacks, zBMI, proportion of children who are overweight/obese and child quality-of-life. A process evaluation will examine fidelity, acceptability, sustainability and context. An economic evaluation will compare costs and consequences from the perspective of the local government, nursery and parents. TRIAL REGISTRATION: ISRCTN33134697, 31/10/2019.

Mediation and moderation of genetic risk of obesity through eating behaviours in two UK cohorts.

BACKGROUND: The mechanisms underlying genetic predisposition to higher body mass index (BMI) remain unclear. METHODS: We hypothesized that the relationship between BMI-genetic risk score (BMI-GRS) and BMI was mediated via disinhibition, emotional eating and hunger, and moderated by flexible (but not rigid) restraint within two UK cohorts: the Genetics of Appetite Study (GATE) (n = 2101, 2010-16) and the Avon Longitudinal Study of Parents and Children (ALSPAC) (n = 1679, 2014-18). Eating behaviour was measured by the Adult Eating Behaviour Questionnaire and Three-Factor Eating Questionaire-51. RESULTS: The association between BMI-GRS and BMI were partially mediated by habitual, emotional and situational disinhibition in the GATE/ALSPAC meta-mediation [standardized betaindirect 0.04, 95% confidence interval (CI) 0.02-0.06; 0.03, 0.01-0.04; 0.03, 0.01-0.04, respectively] external hunger and internal hunger in the GATE study (0.02, 0.01-0.03; 0.01, 0.001-0.02, respectively). There was evidence of mediation by emotional over/undereating and hunger in the ALSPAC study (0.02, 0.01-0.03; 0.01, 0.001-0.02; 0.01, 0.002-0.01, respectively). Rigid or flexible restraint did not moderate the direct association between BMI-GRS and BMI, but high flexible restraint moderated the effect of disinhibition subscales on BMI (reduction of the indirect mediation by -5% to -11% in GATE/ALSPAC) and external hunger (-5%) in GATE. High rigid restraint reduced the mediation via disinhibition subscales in GATE/ALSPAC (-4% to -11%) and external hunger (-3%) in GATE. CONCLUSIONS: Genetic predisposition to a higher BMI was partly explained by disinhibition and hunger in two large cohorts. Flexible/rigid restraint may play an important role in moderating the impact of predisposition to higher BMI.

Advertisement of unhealthy commodities in Bristol and South Gloucestershire and rationale for a new advertisement policy.

BACKGROUND: Bristol City Council introduced a new advertisement policy in 2021/2022 which included prohibiting the advertising of unhealthy food and drink (HFSS), alcohol, gambling and payday loans across council-owned advertising spaces. This mixed methods study is part of the BEAR study, and aimed to explore the rationale and the barriers and facilitators to implementing the policy, and describe the perceived advertising environment prior to implementation. METHODS: Semi-structured interviews were carried out with seven stakeholders involved in the design and implementation of the advertising policy. A stakeholder topic guide was developed before interviews took place to help standardise the lines of inquiry between interviewees. A resident survey was developed to collect socio-demographic data and, for the purpose of this study, information regarding observations of advertising for HFSS products, alcohol and gambling. RESULTS: Fifty-eight percent of respondents residing in Bristol and South Gloucestershire reported seeing advertisements for unhealthy commodities in the week prior to completing the survey. This was highest for HFSS products (40%). 16% of residents reported seeing HFSS product advertisements specifically appealing to children. For HFSS products in particular, younger people were more likely to report seeing adverts than older people, as were those who were from more deprived areas. An advertisement policy that restricts the advertisement of such unhealthy commodities, and in particular for HFSS products, has the potential to reduce health inequalities. This rationale directly influenced the development of the advertisement policy in Bristol. Implementation of the policy benefitted from an existing supportive environment following the 'health in all policies' initiative and a focus on reducing health inequalities across the city. CONCLUSIONS: Unhealthy product advertisements, particularly for unhealthy food and drinks, were observed more by younger people and those living in more deprived areas. Policies that specifically restrict such advertisements, therefore, have the potential to reduce health inequalities, as was the hope when this policy was developed. Future evaluation of the policy will provide evidence of any public health impact.

Assessing exposure to outdoor advertisement for products high in fat, salt and sugar (HFSS); is self-reported exposure a useful exposure metric?

BACKGROUND: Exposure to advertising of unhealthy commodities such as fast-food and gambling is recognised as a risk factor for developing non-communicable diseases. Assessment of the impact of such advertisement and the evaluation of the impact of any policies to restrict such advertisements on public health are reliant on the quality of the exposure assessment. A straightforward method for assessing exposure is to ask people whether they noticed any such advertisements in their neighbourhoods. However, the validity of this method is unclear. We assessed the associations between measured exposure to outdoor advertising, self-reported exposure, and self-reported consumption. METHODS: We collected exposure information in January-March 2022 using two methods: (i) through a resident survey investigating advertising and consumption of unhealthy products, distributed across Bristol and neighbouring South Gloucestershire, and (ii) through in-person auditing. Self-reported exposure was obtained from the resident survey (N = 2,560) and measured exposure from photos obtained for all Council owned advertisement sites (N = 973 bus stops). Both data sources were geographically linked at lower-super-output-area level. Reporting ratios (RRs), 95% confidence intervals (CIs), and Cohen's kappas, are presented. RESULTS: 24% of advertisements displayed food and/or drink advertising. Bristol respondents in neighbourhoods displaying food/drink adverts were more likely to also report seeing these adverts compared to those in neighbourhoods without food/drink adverts (59% vs. 51%, RR = 1.15, 95%CI 1.01-1.31). There was no such association in South Gloucestershire (26% vs. 32%, RR = 0.82, 95%CI 0.58-1.14). Respondents in both Bristol and South Gloucestershire who recalled seeing advertising for unhealthy food and drink products were more likely to consume them (e.g. for fast-food: 22% vs. 11%, RR = 2.01, 95%CI 1.68-2.42). There was no such association between measured food and drink adverts in respondents' local areas and self-reported consumption of HFSS product (90.1% vs. 90.7%, RR = 0.99, 95%CI 0.96-1.03). CONCLUSIONS: Self-reported outdoor advertisement exposure is correlated with measured exposure, making this a useful methodology for population studies. It has the added advantage that it correlates with consumption. However, given that measurement error can be significant and self-reported exposure is known to be susceptible to various biases, inferences from studies using this exposure metric should be made with caution.

Protocol to evaluate the effectiveness and cost-effectiveness of an environmental nutrition and physical activity intervention in nurseries (Nutrition and Physical Activity Self Assessment for Child Care - NAP SACC UK): a multicentre cluster randomised controlled trial.

Background One in seven UK children have obesity when starting school, with higher prevalence associated with deprivation. Most pre-school children do not meet UK recommendations for physical activity and nutrition. Formal childcare settings provide opportunities to deliver interventions to improve nutritional quality and physical activity to the majority of 3-4-year-olds. The nutrition and physical activity self-assessment for childcare (NAP SACC) intervention has demonstrated effectiveness in the USA with high acceptability in the UK. The study aims to evaluate the effectiveness and cost-effectiveness of the NAP SACC UK intervention to increase physical activity, reduce sedentary time and improve nutritional intake. Methods Multi-centre cluster RCT with process and economic evaluation. Participants are children aged 2 years or over, attending UK early years settings (nurseries) for ≥ 12 hours/week or ≥ 15 hours/week during term time and their parents, and staff at participating nurseries. The 12-month intervention involves nursery managers working with a Partner (public health practitioner) to self-assess policies and practices relating to physical activity and nutrition; nursery staff attending one physical activity and one nutrition training workshop and setting goals to be achieved within six months. The Partner provides support and reviews progress. Nursery staff receive a further workshop and new goals are set, with Partner support for a further six months. The comparator is usual practice. Up to 56 nurseries will be stratified by area and randomly allocated to intervention or comparator arm with minimisation of differences in level of deprivation. PRIMARY OUTCOMES: accelerometer-assessed mean total activity time on nursery days and average total energy (kcal) intake per eating occasion of lunch and morning/afternoon snacks consumed within nurseries. SECONDARY OUTCOMES: accelerometer-assessed mean daily minutes of moderate-to-vigorous physical activity and sedentary time per nursery day, total physical activity on nursery days compared to non-nursery days, average serving size of lunch and morning/afternoon snacks in nursery per day, average percentage of core and non-core food in lunch and morning/afternoon snacks, zBMI, proportion of children who are overweight/obese and child quality-of-life. A process evaluation will examine fidelity, acceptability, sustainability and context. An economic evaluation will compare costs and consequences from the perspective of the local government, nursery and parents. TRIAL REGISTRATION: ISRCTN33134697.

Using social networks to scale up and sustain community-based programmes to improve physical activity and diet in low-income and middle-income countries: a scoping review.

BACKGROUND: Community-based programmes [CBPs], targeting increased physical activity and/or healthier eating, have been used in the prevention and management of non-communicable diseases. However, CBPs are only useful, insofar as they can be scaled up and sustained in some meaningful way. Social networks-defined as "social structures that exists between actors, individuals or organizations"-may serve as an important tool to identify underlying mechanisms that contribute to this process. This scoping review aimed to map and collate literature on the role of social network research in scaling-up and sustaining physical activity and/or diet CBPs in low-and middle-income countries [LMICs]. METHODS: Arksey and O'Malley's framework and its enhancement were followed. Inclusion criteria were peer-reviewed articles exploring the role of social networks in scaled-up and/or sustained physical activity and/or diet CBPs in adult populations, published in English since 2000, and based in a LMIC. Databases searched were PubMed, Cochrane, Scopus, Web of Science, CINAHL, SocIndex, International Bibliography of the Social Sciences, and Google Scholar. Books, conference abstracts, and programmes focused on children were excluded. Two reviewers independently selected and extracted eligible studies. Included publications were thematically analysed using the Framework Approach. RESULTS: Authors identified 12 articles for inclusion, covering 13 CBPs. Most were based in Latin America, with others in the Caribbean, the Pacific Islands, Iran, and India. All articles were published since 2009. Only three used social network analysis methods (with others using qualitative methods). Five main social network themes were identified: centralisation, cliques, leaders, quality over quantity, and shared goals. Contextual factors to be considered when scaling-up programmes in LMICs were also identified. CONCLUSIONS: This review has shown that the evidence of the use of social network research in programme scale-up has not yet caught up to its theoretical possibilities. Programmes aiming to scale should consider conducting social network research with identified network themes in mind to help improve the evidence-base of what network mechanisms, in what contexts, might best support the strengthening of networks in physical activity and diet programmes. Importantly, the voice of individuals and communities in these networks should not be forgotten.

Using group model building to frame the commercial determinants of dietary behaviour in adolescence - proposed methods for online system mapping workshops.

BACKGROUND: Group model building (GMB) is a participatory approach whereby diverse stakeholders can share their views about a problem to create a collective understanding of a complex system. In this article we report our methodological approach to adapt face-to-face GMB processes to an online format to explore the mechanisms by which commercial drivers influence adolescents' dietary behaviour. We use our experiences to make recommendations on how online GMB could be delivered. METHODS: We planned, adapted, piloted, delivered, and evaluated a series of online GMB workshops with adolescents, policymakers and public health practitioners to create a system map of the commercial determinants of dietary behaviour in adolescence. We adapted face-to-face GMB workshops to a series of 3 online GMB workshops with 11 adolescents (16-18 years) living in the Southwest of England, and one GMB workshop with policymakers and public health practitioners. RESULTS: In our experience, adapting, and delivering GMB online is feasible, engaging, cost-saving and an enjoyable experience. Participants gave positive feedback in terms of engagement and enjoyment, and it allowed them to recognise different points of view about the same problem. Participants became familiarised with system thinking and system dynamics concepts, developed a shared understanding of a complex issue and portrayed it in a system map that depicted the most important factors in a causal structure as well as their interactions at various levels. CONCLUSIONS: We recommend using process mapping to understand the overall GMB process in an online environment and piloting the workshops to test the timings and flow between online platforms. For facilitation and delivery, facilitators need to ensure they can create an inviting and engaging online environment, even for participants who decide to have their cameras off. Separating GMB activities into different workshops allowed participants to reflect on the problem being discussed and bring new ideas to subsequent workshops. Evaluating the workshops enabled us to build evidence on the trade-offs between the effectiveness, quality and efficiency of online GMB workshops, and how this might be enhanced to identify leverage points and achieve systemic changes in complex issues. ETHICAL APPROVAL: The research was approved by the University of Bristol's Faculty of Health Sciences Research Ethics Committee (Ref: 99,003) and written consent was received from all participants.

Exploring dietitians' practice and views of giving advice on dietary patterns to patients with type 2 diabetes mellitus: A qualitative study.

BACKGROUND: Dietary guidelines for type 2 diabetes mellitus (T2DM) emphasise weight management and individualised total carbohydrate intake. Evidence on the most effective dietary patterns (DPs) for T2DM management is mixed, potentially leading to variations in the advice that dietitians provide. The present study aimed to explore dietitians' practice of DP advice provision to adults with T2DM, as well as understand their views when advising their patients on the DPs deemed effective for glycaemic management or recommended by current guidelines. METHODS: Semi-structured interviews were conducted with 12 UK-registered dietitians, with experience in consulting adults with T2DM. Dietitians were asked for their views on five DPs recommended for glycaemic management of T2DM. Interview transcripts were analysed using deductive and inductive thematic analysis. RESULTS: Nine themes were identified that draw attention to DP advice provision practices, the five DPs (low-carbohydrate, low-fat, low-glycaemic index, Mediterranean diet and Dietary Approaches to Stop Hypertension diet), other DPs, the barriers and facilitators to DP advice provision and following this advice, and the factors affecting the provision of DP advice. Participants' current practice of DP advice provision to patients with T2DM was perceived to be individualised and patient-centred. Participants discussed their current practice and perceptions of available evidence and how patients respond to advice on the DPs shown to be effective for glycaemic management. Several barriers to providing advice on specific DPs, including safety and compliance challenges, were identified. Participants also highlighted factors that would facilitate the provision of advice on specific DPs and would help patients to follow this advice, including social support, educational resources and more robust scientific evidence. CONCLUSIONS: The findings of the present study provide important insights regarding dietitians' views of promoting whole DPs to patients with T2DM. Emerged barriers and facilitators should be considered when developing future guidance for dietetic practice to support patients with following whole DPs for T2DM management.

Where and when are portion sizes larger in young children? An analysis of eating occasion size among 1·5-5-year-olds in the UK National Diet and Nutrition Survey (2008-2017).

OBJECTIVE: To identify eating occasion-level and individual-level factors associated with the consumption of larger portions in young children and estimate their relative importance. DESIGN: Cross-sectional. SETTING: Data from parent-reported 4-d food diaries in the UK National Diet and Nutrition Survey (2008-2017) were analysed. Multilevel models explored variation in eating occasion size (kJ) within (n 48 419 occasions) and between children (n 1962) for all eating occasions. Eating contexts: location, eating companion, watching TV, and sitting at a table and individual characteristics: age, gender, ethnicity and parental socio-economic status were explored as potential correlates of eating occasion size. PARTICIPANTS: Children aged 1·5-5 years. RESULTS: Median eating occasion size was 657 kJ (IQR 356, 1117). Eating occasion size variation was primarily attributed (90 %) to differences between eating occasions. Most (73 %) eating occasions were consumed at home. In adjusted models, eating occasions in eateries were 377 kJ larger than at home. Eating occasions sitting at a table, v. not, were 197 kJ larger. Eating in childcare, with additional family members and friends, and whilst watching TV were other eating contexts associated with slightly larger eating occasion sizes. CONCLUSIONS: Eating contexts that vary from one eating occasion to another are more important than demographic characteristics that vary between children in explaining variation in consumed portion sizes in young children. Strategies to promote consumption of age-appropriate portion sizes in young children should be developed, especially in the home environment, in eating contexts such as sitting at the table, eating with others and watching TV.

Using social networks to scale up and sustain community-based programmes to improve physical activity and diet in low-income and middle-income countries: a scoping review protocol.

INTRODUCTION: The World Health Organisation endorses community-based programmes as a cost-effective, feasible and a 'best buy' in the prevention and management of non-communicable diseases (NCDs). These programmes are particularly successful when the community actively participates in its design, implementation and evaluation. However, they may be only useful insofar as they can be scaled up and sustained in some meaningful way. Social network research may serve as an important tool for determining the underlying mechanisms that contribute to this process. The aim of this planned scoping review is to map and collate literature on the role of social networks in scaling-up and sustaining community-based physical activity and diet programmes in low-income and middle-income countries. METHODS AND ANALYSIS: This scoping review protocol has been planned around the Arksey and O'Malley framework and its enhancement. Inclusion criteria are peer-reviewed articles and grey literature exploring the role of social networks in the scale-up and/or sustainability of NCD prevention community-based programmes in adult populations. Studies must have been published since 2000, in English, and be based in a low-income or middle-income country. The following databases will be used for this review: PubMed, Cochrane, Scopus, Web of Science, CINAHL, SocIndex, the International Bibliography of the Social Sciences, Google and Google Scholar. Books, conference abstracts and research focused only on children will be excluded. Two reviewers will independently select and extract eligible studies. Included publications will be thematically analysed using the Framework Approach. ETHICS AND DISSEMINATION: Ethical approval will not be sought for this review as no individual-level data or human participants will be involved. This protocol is registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/KG7TX). The findings from the review will be published in an accredited journal. The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews checklist will be used to support transparency and guide translation of the review.

Conceptualizing the commercial determinants of dietary behaviors associated with obesity: A systematic review using principles from critical interpretative synthesis.

INTRODUCTION: Unhealthy diet is an important preventable risk factor for overweight and obesity. Identifying the key drivers of an unhealthy diet is an important public health aim. "Big Food" has been identified as an influential factor shaping dietary behavior and obesity, and their practices have broadly been labeled as the "commercial determinants of obesity," but there is a lack of definitions and conceptualizations for these terms. This review aimed to synthesize literature on the commercial determinants of dietary behavior associated with obesity. It presents the development of an integrative definition and a conceptual framework involving potential influences on dietary behavior, and it examines the prevalence of certain narratives within papers that focus on children and adolescents. METHODS: Four electronic databases (Ovid MEDLINE, PubMed, Web of Science, and Scopus) were searched up to December 2020. Eighty-one articles met the inclusion criteria: they were published in a peer-reviewed academic journal, described a practice from the food/beverage industry in relation to dietary behavior or obesity. Data were integrated using critical interpretative synthesis. RESULTS: The commercial determinants of dietary behavior are conceptualized in terms of three corporate spheres of action-political and legal; production, processing and design; and marketing and preference shaping-which enable powerful food industry to successfully pursue their business, market, and political objectives. The most frequently reported sphere of action targeting children and adolescents was marketing and preference shaping. CONCLUSIONS: In the included literature, the commercial determinants of dietary behavior associated with obesity have been conceptualized as being part of a complex system where corporate practices are enabled by power structures. The proposed framework can facilitate a structured identification and systematic study of the impact of specific aspects of food industry's strategies and increase opportunities for primary prevention by anticipating industry responses and by discouraging corporate practices that harm health.

Perceptions of eating practices and physical activity among Malaysian adolescents in secondary schools: a qualitative study with multi-stakeholders.

OBJECTIVE: To conduct formative research using qualitative methods among stakeholders of secondary schools to explore their perceptions, barriers and facilitators related to healthy eating and physical activity (PA) among Malaysian adolescents. DESIGN: A qualitative study involving eight focus groups and twelve in-depth interviews. Focus groups and interviews were recorded and transcribed verbatim. An inductive thematic analysis approach was used to analyse the data. SETTING: Four secondary schools in Perak and Selangor states (two urban and two rural schools) in Malaysia. PARTICIPANTS: Focus groups were conducted with seventy-six adolescents aged 13-14 years, and in-depth interviews were conducted with four headmasters, four PA education teachers and four food canteen operators. RESULTS: Stakeholders thought that adolescents' misperceptions, limited availability of healthy options, unhealthy food preferences and affordability were important challenges preventing healthy eating at school. Low-quality physical education (PE) classes, limited adolescent participation and teachers' commitment during lessons were perceived as barriers to adolescents being active at school. Affordability was the main challenge for adolescents from rural schools. Stakeholders perceived that a future school-based intervention should improve the availability and subsidies for healthy foods, provide health education/training for both adolescents and PE teachers, enhance active adolescent participation in PE and develop social support mechanisms to facilitate engagement with PA. CONCLUSIONS: These findings provide important insights into developing school-based lifestyle interventions to improve healthy eating and strengthening PA of Malaysian adolescents.

School-Based Intervention to Improve Healthy Eating Practices Among Malaysian Adolescents: A Feasibility Study Protocol.

Introduction: School environments can influence students' dietary habits. Hence, implementing a healthy canteen intervention programme in schools is a recommended strategy to improve students' dietary intake. This study will evaluate the feasibility of providing healthier food and beverage options in selected secondary schools in Malaysia by working with canteen vendors. It also will assess the changes in food choices before and after the intervention. Methods: A feasibility cluster randomised controlled study will be conducted in six secondary schools (intervention, n = 4; control, n = 2) comprising of rural and urban schools located in Selangor and Perak states in Malaysia. Four weeks of intervention will be conducted among Malaysian adolescents aged 15 years old. Two interventions are proposed that will focus on providing healthier food options in the canteen and convenience shops in the selected schools. Interventions 1 and 2 will entail training the canteen and school convenience shop operators. Intervention 2 will be applied to subsidise the cost of low energy-dense kuih (traditional cake), vegetables, and fruits. The control group will continue to sell the usual food. Trained dietitians will audit the canteen menu and food items sold by the school canteen and convenience shops in all schools. Anthropometric measurements, blood pressure and dietary assessment will be collected at baseline and at the end of 4-week intervention. Focus group discussions with students and in-depth interviews with headmasters, teachers, and school canteen operators will be conducted post-intervention to explore intervention acceptability. Under this Healthy School Canteen programme, school canteens will be prohibited from selling "red flag" foods. This refers to foods which are energy-dense and not nutritious, such as confectionery and deep-fried foods. They will also be prohibited from selling soft drinks, which are sugar-rich. Instead, the canteens will be encouraged to sell "green flag" food and drinks, such as fruits and vegetables. Conclusion: It is anticipated that this feasibility study can provide a framework for the conception and implementation of nutritional interventions in a future definitive trial at the school canteens in Malaysia.

Future Directions for Integrative Objective Assessment of Eating Using Wearable Sensing Technology.

Established methods for nutritional assessment suffer from a number of important limitations. Diaries are burdensome to complete, food frequency questionnaires only capture average food intake, and both suffer from difficulties in self estimation of portion size and biases resulting from misreporting. Online and app versions of these methods have been developed, but issues with misreporting and portion size estimation remain. New methods utilizing passive data capture are required that address reporting bias, extend timescales for data collection, and transform what is possible for measuring habitual intakes. Digital and sensing technologies are enabling the development of innovative and transformative new methods in this area that will provide a better understanding of eating behavior and associations with health. In this article we describe how wrist-worn wearables, on-body cameras, and body-mounted biosensors can be used to capture data about when, what, and how much people eat and drink. We illustrate how these new techniques can be integrated to provide complete solutions for the passive, objective assessment of a wide range of traditional dietary factors, as well as novel measures of eating architecture, within person variation in intakes, and food/nutrient combinations within meals. We also discuss some of the challenges these new approaches will bring.

Cardiometabolic Risk Factors and Physical Activity Patterns Maximizing Fitness and Minimizing Fatness Variation in Malaysian Adolescents: A Novel Application of Reduced Rank Regression.

Patterns of physical activity (PA) that optimize both fitness and fatness may better predict cardiometabolic health. Reduced rank regression (RRR) was applied to identify combinations of the type (e.g., football vs. skipping), location and timing of activity, explaining variation in cardiorespiratory fitness (CRF) and Body Mass Index (BMI). Multivariable regressions estimated longitudinal associations of PA pattern scores with cardiometabolic health in n = 579 adolescents aged 13-17 years from the Malaysian Health and Adolescent Longitudinal Research Team study. PA pattern scores in boys were associated with higher fitness (r = 0.3) and lower fatness (r = -0.3); however, in girls, pattern scores were only associated with higher fitness (r = 0.4) (fatness, r = -0.1). Pattern scores changed by ß = -0.01 (95% confidence interval (CI) -0.04, 0.03) and ß = -0.08 (95% CI -0.1, -0.06) per year from 13 to 17 years in boys and girls respectively. Higher CRF and lower BMI were associated with better cardiometabolic health at 17 years, but PA pattern scores were not in either cross-sectional or longitudinal models. RRR identified sex-specific PA patterns associated with fitness and fatness but the total variation they explained was small. PA pattern scores changed little through adolescence, which may explain the limited evidence on health associations. Objective PA measurement may improve RRR for identifying optimal PA patterns for cardiometabolic health.

The Association of Breakfast Frequency and Cardiovascular Disease (CVD) Risk Factors among Adolescents in Malaysia.

Breakfast frequency is associated with cardiovascular disease (CVD) risk in Western populations, possibly via the types of food eaten or the timing of food consumption, but associations in Malaysian adolescents are unknown. While the timing of breakfast is similar, the type of food consumed at breakfast in Malaysia differs from Western diets, which allows novel insight into the mechanisms underlying breakfast-CVD risk associations. We investigated foods eaten for breakfast and associations between breakfast frequency and CVD risk factors in the Malaysian Health and Adolescents Longitudinal Research Team study (MyHeARTs). Breakfast (frequency of any food/drink reported as breakfast in 7-day diet history interviews) and CVD risk factors (body mass index (BMI), waist circumference, fasting blood glucose, triacylglycerol, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and systolic and diastolic blood pressure) were cross-sectionally associated using linear regression adjusting for potential confounders (n = 795, age 13 years). Twelve percent of adolescents never ate breakfast and 50% ate breakfast daily, containing mean (SD) 400 (±127) kilocalories. Commonly consumed breakfast foods were cereal-based dishes (primarily rice), confectionery (primarily sugar), hot/powdered drinks (primarily Milo), and high-fat milk (primarily sweetened condensed milk). After adjustment, each extra day of breakfast consumption per week was associated with a lower BMI (-0.34 kg/m2, 95% confidence interval (CI) -0.02, -0.66), and serum total (-0.07 mmol/L 95% CI -0.02, -0.13) and LDL (-0.07 mmol/L 95% CI -0.02, -0.12) cholesterol concentrations. Eating daily breakfast in Malaysia was associated with slightly lower BMI and total and LDL cholesterol concentrations among adolescents. Longitudinal studies and randomized trials could further establish causality.

High-risk environments for eating foods surplus to requirements: a multilevel analysis of adolescents' non-core food intake in the National Diet and Nutrition Survey (NDNS).

OBJECTIVE: Interventions to reduce adolescents' non-core food intake (i.e. foods high in fat and sugar) could target specific people or specific environments, but the relative importance of environmental contexts v. individual characteristics is unknown. DESIGN: Cross-sectional. SETTING: Data from 4d food diaries in the UK National Diet and Nutrition Survey (NDNS) 2008-2012 were analysed. NDNS food items were classified as 'non-core' based on fat and sugar cut-off points per 100g of food. Linear multilevel models investigated associations between 'where' (home, school, etc.) and 'with whom' (parents, friends, etc.) eating contexts and non-core food energy (kcal) per eating occasion (EO), adjusting for variables at the EO (e.g. time of day) and adolescent level (e.g. gender).ParticipantsAdolescents (n 884) aged 11-18 years. RESULTS: Only 11 % of variation in non-core energy intake was attributed to differences between adolescents. In adjusted models, non-core food intake was 151 % higher (ratio; 95 % CI) in EO at 'Eateries' (2·51; 2·14, 2·95) and 88 % higher at 'School' (1·88; 1·65, 2·13) compared with 'Home'. EO with 'Friends' (1·16; CI 1·03, 1·31) and 'Family & friends' (1·21; 1·07, 1·37) contained 16-21 % more non-core food compared with eating 'Alone'. At the individual level, total energy intake and BMI, but not social class, gender or age, were weakly associated with more non-core energy intake. CONCLUSIONS: Regardless of individual characteristics, adolescents' non-core food consumption was higher outside the home, especially at eateries. Targeting specific eating contexts, not individuals, may contribute to more effective public health interventions.

"In my day "- Parents' Views on Children's Physical Activity and Screen Viewing in Relation to Their Own Childhood.

Physical activity and screen viewing are associated with cardio-metabolic risk factors, psychological wellbeing, and academic performance among children. Across the last generation, children's physical activity and screen viewing behaviours have changed, coinciding with changes to the home and neighbourhood environment. This study aimed to qualitatively explore parents' views on their 8⁻9-year-old child's childhood and how this compares to experiences from their own childhood, with a specific focus on physical activity and screen viewing behaviours. Semi-structured telephone interviews were conducted with 51 parents (mean age = 41.2 years, range 31.5 to 51.5 years), between July and October 2016. Inductive and deductive content analyses were used to explore parents' perceptions of their child's physical activity and screen viewing behaviours in comparison to their own childhood behaviours. Interview data revealed that compared to the relative freedom they recalled as children, parents restrict their children's independent mobility and outdoor play due to concerns about safety. Despite their children having greater access to structured activities than they did as children, parents feel their children are "missing out," and perceived their own childhood as better with regards to maximising independent and outdoor play and limiting screen viewing. Innovative strategies are needed to change the social norms surrounding children's independent mobility and outdoor play.

Parents' perspectives of change in child physical activity & screen-viewing between Y1 (5-6) & Y4 (8-9) of primary school: implications for behaviour change.

BACKGROUND: The aim of this study was to explore parents' responses to changes in children's physical activity and screen-time between Year 1 (5-6 years) and Year 4 (8-9 years of age) of primary school. A secondary aim was to identify how parents adapt their parenting to rapidly changing screen-based technology. METHODS: Data were from the longitudinal B-Proact1v Study. Semi-structured telephone interviews were conducted between July and October 2016 with a sub-sample of 51 parents who participated in the study at Year 4. The sample was drawn from 1223 families who took part in the B-Proact1v in which the children wore an accelerometer for 5 days and mean minutes of moderate to vigorous intensity physical activity (MVPA) and sedentary minutes per day were derived. This sample was stratified according to the child's MVPA and sedentary (SED) minutes per day, and by child gender. Data were thematically analysed. RESULTS: Analysis yielded five main themes: 1) Parents reported how children's interests change with free play decreasing and structured activity increasing. 2) Parents highlighted how their children's independence and ability to make choices in relation to physical activity and screen-viewing increase, and that parental influence decreased, as the child gets older. 3) Parents reported that the transition from Year 1 to Year 4 appeared to be a time of substantial change in the screen-based devices that children used and the content that they viewed. 4) Parents reported that managing screen-viewing was harder compared to three years ago and a third of parents expressed concerns about the difficulty of managing screen-viewing in the future. 5) Parents reported using general principles for managing children's screen-viewing including engaging the children with rule setting and encouraging self-regulation. CONCLUSIONS: Parents reported that children's physical activity and sedentary screen behaviours change between Year 1 and Year 4 with children obtaining increased licence to influence the type, location and frequency with which they are active or sedentary. These changes and rapid advances in screen-viewing technology are a challenge for parents to negotiate and highlight a need to develop innovative and flexible strategies to help parents adapt to a rapidly changing environment.

Examining the challenges posed to parents by the contemporary screen environments of children: a qualitative investigation.

BACKGROUND: The ubiquity of technology in modern society has led to the American Academy of Pediatrics adapting their screen-viewing (SV) recommendations for children. The revised guidelines encourage families to identify an appropriate balance between SV and other activities. The aims of this study were to explore parents' views of their child's SV time and how important it is for families to achieve a 'digital balance'. METHODS: Semi-structured telephone interviews were conducted with 51 parents of 8-9-year-old children, between July and October 2016. Inductive and deductive content analyses were used to explore parents' perceptions of their child's level of SV (low, medium, high), how parents feel about child SV, and the importance placed on achieving a digital balance. Parent report of child SV behaviours on weekdays and weekend days were assessed via questionnaire. RESULTS: Interview data revealed that because SV is considered the 'norm', parents struggle to limit it, partly because they want their children to be equipped for the modern technological world. While most parents believe SV to have negative effects on children, parents also report advantages to SV. Many parents feel that not all SV is equal, with tablets considered worse than television because of the isolated nature of activities, and educational SV considered more beneficial than non-educational SV. Most parents feel it is important for their family to achieve a digital balance, primarily to spend more quality family time together. Large variation was observed in parents' descriptions of child SV time on weekdays and weekend days. CONCLUSIONS: Parents recognise the importance of digital balance but want their children to fit into the ever-advancing digital world. Parents do not treat all SV equally. Watching television and engaging in educational SV may be encouraged, while 'playing' on tablets is discouraged. These findings highlight the challenge faced by researchers and policy makers to help families achieve a digital balance, and strategies are needed to support parents to plan child SV time.