Comparing self-reported energy intake using an online dietary tool with energy expenditure by an activity tracker.

OBJECTIVE: The aim of this study was to compare self-reported total energy intake (TEI) collected using an online multiple-pass 24-h dietary recall tool (Intake24) with total energy expenditure (TEE) estimated from Fitbit Charge 2-improved algorithms in adults from the NoHoW trial (12-mo weight maintenance after free-living weight loss). METHODS: Bland-Altman plots were used to assess the level of agreement between TEI and TEE at baseline and after 12 mo. The ratio of TEI to TEE was also calculated. RESULTS: Data from 1323 participants (71% female) was included in the analysis (mean ± SD: age 45 ± 12 y, body mass index 29.7 ± 5.4 kg/m2, initial weight loss 11.5 ± 6.5 kg). The TEI was lower than TEE on average by 33%, with limits of agreement ranging from -91% to +25%. Men, younger individuals, those with higher body mass index, those with the greater weight loss before enrollment, and those who gained weight during the study underestimated to a greater extent. CONCLUSIONS: These findings contribute to the ongoing research examining the validity of technology-based dietary assessment tools.

Are motivational and self-regulation factors associated with 12 months' weight regain prevention in the NoHoW study? An analysis of European adults.

PURPOSE: Preventing weight regain can only be achieved by sustained changes in energy balance-related behaviors that are associated with weight, such as diet and physical activity. Changes in motivation and self-regulatory skills can support long-term behavioral changes in the context of weight loss maintenance. We propose that experiencing a supportive climate care is associated with enhanced satisfaction of basic psychological needs, intrinsic goals, and autonomous motivation. These factors are expected to be associate with the utilization of self-regulation skills, leading to more sustained behavior changes and ultimately preventing weight regain. This hypothesis was tested in this ancillary analysis of the NoHoW trial, where the study arms were pooled and followed for 12 months. METHODS: The NoHoW was a three-center, large-scale weight regain prevention full factorial trial. In this longitudinal study, data were collected in adults who lost > 5% weight in the past year (N = 870, complete data only, 68.7% female, 44.10 ± 11.86 years, 84.47 ± 17.03 kg) during their participation in a 12-month digital behavior change intervention. Weight and validated measures of motivational- and self-regulatory skills-related variables were collected at baseline, six- and 12 months. Change variables were used in Mplus' path analytical models informed by NoHoW's logic model. RESULTS: The bivariate correlations confirmed key mediators' potential effect on weight outcomes in the expected causal direction. The primary analysis showed that a quarter of the variance (r2 = 23.5%) of weight regain prevention was achieved via the mechanisms of action predicted in the logic model. Specifically, our results show that supportive climate care is associated with needs satisfaction and intrinsic goal content leading to better weight regain prevention via improvements in self-regulatory skills and exercise-controlled motivation. The secondary analysis showed that more mechanisms of action are significant in participants who regained or maintained their weight. CONCLUSIONS: These results contribute to a better understanding of the mechanisms of action leading to behavior change in weight regain prevention. The most successful participants used only a few intrinsic motivation-related mechanisms of action, suggesting that habits may have been learned. While developing a digital behavior change intervention, researchers and practitioners should consider creating supportive climate care to improve needs satisfaction and intrinsic goal contents. TRIAL REGISTRATION: ISRCTN, ISRCTN88405328 , registered 12/22/2016.

Evidence for the protein leverage hypothesis in preschool children prone to obesity.

BACKGROUND & AIMS: The protein leverage hypothesis (PLH) proposed that strict regulation of protein intake drives energy overconsumption and obesity when diets are diluted by fat and/or carbohydrates. Evidence about the PLH has been found in adults, while studies in children are limited. Thus, we aimed to test the PLH by assessing the role of dietary protein on macronutrients, energy intake, and obesity risk using data from preschool children followed for 1.3 years. METHODS: 553 preschool children aged 2-6 years from the 'Healthy Start' project were included. EXPOSURES: The proportion of energy intake from protein, fat, and carbohydrates collected from a 4-day dietary record. OUTCOMES: Energy intake, BMI z-score, fat mass (FM) %, waist- (WHtR) and hip-height ratio (HHtR). Power function analysis was used to test the leverage of protein on energy intake. Mixture models were used to explore interactive associations of macronutrient composition on all these outcomes, with results visualized as response surfaces on the nutritional geometry. RESULTS: Evidence for the PLH was confirmed in preschool children. The distribution of protein intake (% of MJ, IQR: 3.2) varied substantially less than for carbohydrate (IQR: 5.7) or fat (IQR: 6.3) intakes, suggesting protein intake is most tightly regulated. Absolute energy intake varied inversely with dietary percentage energy from protein (L = -0.14, 95% CI: -0.25, -0.04). Compared to children with high fat or carbohydrate intakes, children with high dietary protein intake (>20% of MJ) had a greater decrease in WHtR and HHtR over the 1.3-year follow-up, offering evidence for the PLH in prospective analysis. But no association was observed between macronutrient distribution and changes in BMI z-score or FM%. CONCLUSIONS: In this study in preschool children, protein intake was the most tightly regulated macronutrient, and energy intake was an inverse function of dietary protein concentration, indicating the evidence for protein leverage. Increases in WHtR and HHtR were principally associated with the dietary protein dilution, supporting the PLH. These findings highlight the importance of protein in children's diets, which seems to have significant implications for childhood obesity risk and overall health.

Testing motivational and self-regulatory mechanisms of action on device-measured physical activity in the context of a weight loss maintenance digital intervention: A secondary analysis of the NoHoW trial.

BACKGROUND: To date, few digital behavior change interventions for weight loss maintenance focusing on long-term physical activity promotion have used a sound intervention design grounded on a logic model underpinned by behavior change theories. The current study is a secondary analysis of the weight loss maintenance NoHoW trial and investigated putative mediators of device-measured long-term physical activity levels (six to 12 months) in the context of a digital intervention. METHODS: A subsample of 766 participants (Age = 46.2 ± 11.4 years; 69.1% female; original NoHoW sample: 1627 participants) completed all questionnaires on motivational and self-regulatory variables and had all device-measured physical activity data available for zero, six and 12 months. We examined the direct and indirect effects of Virtual Care Climate on post intervention changes in moderate-to-vigorous physical activity and number of steps (six to 12 months) through changes in the theory-driven motivational and self-regulatory mechanisms of action during the intervention period (zero to six months), as conceptualized in the logic model. RESULTS: Model 1 tested the mediation processes on Steps and presented a poor fit to the data. Model 2 tested mediation processes on moderate-to-vigorous physical activity and presented poor fit to the data. Simplified models were also tested considering the autonomous motivation and the controlled motivation variables independently. These changes yielded good results and both models presented very good fit to the data for both outcome variables. Percentage of explained variance was negligible for all models. No direct or indirect effects were found from Virtual Care Climate to long term change in outcomes. Indirect effects occurred only between the sequential paths of the theory-driven mediators. CONCLUSION: This was one of the first attempts to test a serial mediation model considering psychological mechanisms of change and device-measured physical activity in a 12-month longitudinal trial. The model explained a small proportion of variance in post intervention changes in physical activity. We found different pathways of influence on theory-driven motivational and self-regulatory mechanisms but limited evidence that these constructs impacted on actual behavior change. New approaches to test these relationships are needed. Challenges and several alternatives are discussed. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN88405328. Registered December 16, 2016, https://www.isrctn.com/ISRCTN88405328.

Attained body mass index among children attending rural outdoor or urban conventional kindergartens.

Objective: This study aimed to examine whether children in rural outdoor kindergartens had attained a lower body mass index z-score (BMIz) and were at lower risk of overweight after school entrance compared to children in urban conventional kindergartens. Methods: This is a longitudinal observational study of 1,544 children from outdoor kindergartens and 1,640 from conventional kindergartens. The mean age at kindergarten enrolment was 3.5 years (SD: 0.9) in the outdoor kindergartens and 3.6 years (SD: 1.0) in the conventional kindergartens. Anthropometry was measured after school entry by school health nurses when the children were 6 to 8 years old. Attained BMIz was included as the primary outcome. The risk of attaining overweight (including obesity) was included as a secondary outcome. Register-based information was available on potential confounding factors. Linear and logistic regression models were used to assess group differences in outcome measures. Results: Our basic models, with information on outcome, kindergarten type, and birth weight showed a borderline statistically significantly lower attained BMIz (-0.07 [95% CI: -0.14, 0.00], P = 0.060) and a lower risk of overweight (adjusted risk ratio: 0.83 [95% CI: 0.72, 0.97], P = 0.016) among children attending outdoor kindergartens. However, when adjusting for sociodemographic factors and parental BMI, there was no evidence of differences in attained BMIz (P = 0.153) or overweight (P = 0.967). Conclusion: When considering confounding factors, our findings indicate no differences in attained BMIz or risk of overweight after school entry among children attending rural outdoor kindergartens compared to those attending urban conventional kindergartens.

Exploratory analysis of reflective, reactive, and homeostatic eating behaviour traits on weight change during the 18-month NoHoW weight maintenance trial.

Behaviour change interventions for weight management have found varied effect sizes and frequent weight re-gain after weight loss. There is interest in exploring whether differences in eating behaviour can be used to develop tailored weight management programs. This secondary analysis of an 18-month weight maintenance randomised controlled trial (RCT) aimed to investigate the association between individual variability in weight maintenance success and change in eating behaviour traits (EBT). Data was analysed from the NoHoW trial (Scott et al., 2019), which was designed to measure processes of change after weight loss of ≥5% body weight in the previous year. The sample included 1627 participants (mean age = 44.0 years, SD = 11.9, mean body mass index (BMI) = 29.7 kg/m2, SD = 5.4, gender = 68.7% women/31.3% men). Measurements of weight (kg) and 7 EBTs belonging to domains of reflective, reactive, or homeostatic eating were taken at 4 time points up to 18-months. Increases in measures of 'reactive eating' (binge eating, p < .001), decreases in 'reflective eating' (restraint, p < .001) and changes in 'homeostatic eating' (unlimited permission to eat, p < .001 and reliance on hunger and satiety cues, p < .05) were significantly and independently associated with concomitant weight change. Differences in EBT change were observed between participants who lost, maintained, or re-gained weight for all EBTs (p < .001) except for one subscale of intuitive eating (eating for physical reasons, p = .715). Participants who lost weight (n = 322) exhibited lower levels of reactive eating and higher levels of reflective eating than participants who re-gained weight (n = 668). EBT domains can identify individuals who need greater support to progress in weight management interventions. Increasing reflective eating and reducing reactive eating may enhance weight management success.

Types of kindergarten and their relationship with parental and children's socio-demographic characteristics in Denmark.

In Danish outdoor kindergartens, children are spending most of the day outdoors often in forests or similar nature environments. These children are assumed to be healthier than children attending conventional kindergartens, however, factors related to choosing a specific type of kindergarten may explain the differences. To better understand this, we aimed to investigate parents reasons for choosing either outdoor or conventional kindergartens based on a mixed-method participatory Concept Mapping approach, and further if parental socio-demographics and early child characteristics differed prior to enrolling children to either type of kindergarten using a cohort register-based approach. Parents of children attending outdoor kindergartens (n = 23) weighed reasons such as "physical setting, outdoor life, and freedom of movement" high, whereas "a good first impression of the kindergarten" was an important reason for parents choosing a conventional kindergarten (n = 22). In the register-based approach, 2434 and 2643 children attended outdoor or conventional kindergartens, respectively. The parents choosing outdoor kindergartens as well as their children differed according to most investigated characteristics, including origin (maternal non-Western: 4.2% vs. 21.9%, p < .0001), educational level (maternal long education: 45.6% vs. 33.0%, p < .0001), prematurity (5.1% vs. 7.1%, p = 0.004) and sex (females: 43.5% vs. 48.6%, p = <0.0013). In conclusion, parental reasons for choosing kindergarten as well as parental socio-demographics differed substantially among kindergarten type. These differences might cause selection bias if not considering when comparing health outcomes among children attending different kinds of kindergartens.

Does attendance in outdoor kindergartens reduce the use of antibiotics in children?

AIM: The aim of this study was to determine whether children enrolled in rural outdoor kindergartens had a lower risk of redeeming at least one prescription for antibiotics compared with children enrolled in urban conventional kindergartens, and if type of antibiotics prescribed differed according to kindergarten type. METHODS: Two Danish municipalities provided data including civil registration numbers from children enrolled in a rural outdoor kindergarten in 2011-2019, and a subsample of all children enrolled in urban conventional kindergartens in the same period. Civil registration numbers were linked to individual-level information on redeemed prescriptions for antibiotics from the Danish National Prescription Registry. Regression models were performed on 2132 children enrolled in outdoor kindergartens, and 2208 children enrolled in conventional kindergartens. RESULTS: There was no difference between groups in risk of redeeming at least one prescription for all types of antibiotics (adjusted risk ratio: 0.97 [95% confidence intervals 0.93, 1.02, p = 0.26]). Similarly, there were no differences between kindergarten type and risk of redeeming at least one prescription for systemic, narrow-spectrum systemic antibacterial, broad-spectrum systemic antibacterial or topical antibiotics. CONCLUSION: Compared with children who were enrolled in conventional kindergartens, children who were enrolled in outdoor kindergartens did not have a lower risk of redeeming prescriptions for any type of antibiotics.

Can change in phase angle predict the risk of morbidity and mortality during an 18-year follow-up period? A cohort study among adults.

Introduction: Phase angle (PhA, degrees), measured via bioimpedance (BIA, 50 kHz), is an index that has been used as an indicator of nutritional status and mortality in several clinical situations. This study aimed to determine the relationship between 6-year changes in PhA and total mortality as well as the risk of incident morbidity and mortality from cardiovascular disease (CVD) and coronary heart disease (CHD) during 18 years of follow-up among otherwise healthy adults. Methods: A random subset (n = 1,987) of 35-65 years old men and women was examined at the baseline in 1987/1988 and 6 years later in 1993/1994. Measures included weight, height, and whole-body BIA, from which PhA was calculated. Information on lifestyle was obtained through a questionnaire. The associations between 6-year PhA changes (ΔPhA) and incident CVD and CHD were assessed by Cox proportional hazard models. The median value of ΔPhA was used as the reference value. The hazard ratio (HR) model and confidence intervals (CIs) of incident CVD and CHD were used according to the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles of ΔPhA. Results: During 18 years of follow-up, 205 women and 289 men died. A higher risk of both total mortality and incident CVD was present below the 50th percentile (Δ = -0.85°). The highest risk was observed below the 5th percentile (ΔPhA = -2.60°) in relation to total mortality (HR: 1.55; 95% CI: 1.10-2.19) and incident CVD (HR: 1.52; 95% CI: 1.16-2.00). Discussion: The larger the decrease in PhA, the higher the risk of early mortality and incident CVD over the subsequent 18 years. PhA is a reliable and easy measure that may help identify those apparently healthy individuals who may be at increased risk of future CVD or dying prematurely. More studies are needed to confirm our results before it can be definitively concluded that PhA changes can improve clinical risk prediction.

Outdoor Kindergartens: A Structural Way to Improve Early Physical Activity Behaviour?

BACKGROUND: Studies have shown that outdoor play in nature is associated with a higher physical activity level than indoor play. We aimed to examine the effect of outdoor versus conventional kindergartens on objectively measured physical activity. METHOD: Using a pre-test-post-test design, we collected data in four kindergartens that provided a rotating outdoor and conventional kindergarten setting. Step counts were measured during one week in the outdoor setting and one week in the conventional setting. Differences in step counts between the outdoor and conventional setting were analysed using a paired t-test. RESULTS: In total, 74 children were included. There was no statistically significant difference in total daily step counts between children in the two settings. When we looked at step counts during kindergarten hours, we saw that children were more physically active in the outdoor setting compared to the conventional setting (mean difference: 1089, p < 0.0001). When we looked at activity during time outside the kindergarten, we discovered that children had a lower step count in the outdoor setting as compared to the conventional setting (mean difference -652, p = 0.01). CONCLUSION: This study indicates that children are more physically active during the time they spend in outdoor kindergartens compared to conventional kindergartens, but may compensate with more inactivity outside kindergarten hours.

Substituting sedentary time with sleep or physical activity and subsequent weight-loss maintenance.

OBJECTIVE: In this study, the associations between the substitution of sedentary time with sleep or physical activity at different intensities and subsequent weight-loss maintenance were examined. METHODS: This prospective study included 1152 adults from the NoHoW trial who had achieved a successful weight loss of ≥5% during the 12 months prior to baseline and had BMI ≥25 kg/m2 before losing weight. Physical activity and sleep were objectively measured during a 14-day period at baseline. Change in body weight was included as the primary outcome. Secondary outcomes were changes in body fat percentage and waist circumference. Cardiometabolic variables were included as exploratory outcomes. RESULTS: Using isotemporal substitution models, no associations were found between activity substitutions and changes in body weight or waist circumference. However, the substitution of sedentary behavior with moderate-to-vigorous physical activity was associated with a decrease in body fat percentage during the first 6 months of the trial (-0.33% per 30 minutes higher moderate-to-vigorous physical activity [95% CI: -0.60% to -0.07%], p = 0.013). CONCLUSIONS: Sedentary behavior had little or no influence on subsequent weight-loss maintenance, but during the early stages of a weight-loss maintenance program, substituting sedentary behavior with moderate-to-vigorous physical activity may prevent a gain in body fat percentage.

Motivational and self-efficacy reciprocal effects during a 12-month' weight regain prevention program.

OBJECTIVE: Weight regain prevention is a critical public health challenge. Digital behaviour change interventions provide a scalable platform for applying and testing behaviour change theories in this challenging context. This study's goal was to analyse reciprocal effects between psychosocial variables (i.e., needs satisfaction, eating regulation, self-efficacy) and weight over 12 months using data from a large sample of participants engaged in a weight regain prevention trial. METHODS: The NoHoW study is a three-centre, large-scale weight regain prevention trial. Adults who lost >5% of their weight in the past year (N = 1627, 68.7% female, 44.10 ± 11.86 years, 84.47 ± 17.03 kg) participated in a 12-month' digital behaviour change-based intervention. Weight and validated measures of basic psychological needs satisfaction, eating regulation and self-efficacy were collected at baseline, six- and 12 months. Correlational, latent growth models and cross-lagged analysis were used to identify potential reciprocal effects. RESULTS: Baseline higher scores of needs satisfaction and self-efficacy were associated with six- and 12-month' weight loss. Baseline weight was linked to all psychosocial variables at six months, and six-months weight was associated with needs satisfaction and self-efficacy at 12 months. During the 12 months, increases in eating regulation, needs satisfaction and self-efficacy were associated with weight loss over the same period, and reciprocal effects were observed between the variables, suggesting the existence of Weight Management Cycles. CONCLUSIONS: While further studies are needed, during long-term weight regain prevention, weight decrease, needs satisfaction and self-efficacy may lead to Weight Management Cycles, which, if recurrent, may provide sustained prevention of weight regain.

Comparison of Motor Difficulties Measured in the First Year of School among Children Who Attended Rural Outdoor or Urban Conventional Kindergartens.

BACKGROUND: Kindergartens can potentially contribute substantially to the daily level of physical activity and development of motor skills and might be an ideal setting for improving these as a public health initiative. We aimed to examine whether children from rural outdoor kindergartens had a lower risk of motor difficulties than children from urban conventional kindergartens. METHODS: Motor test results were measured during the first school year by school health nurses using a six-item test of gross- and fine motor skills (jumping, handle a writing tool, cutting with a scissor following a line, one-leg stand on each leg, throwing and grabbing). Register-based information was available on potential confounding factors. RESULTS: We included 901 children from outdoor kindergartens and 993 from conventional kindergartens with a mean (SD) age of 6.5 years (0.4). The children from the two types of kindergarten differed according to demographic information, with outdoor kindergarten children more often being from more affluent families (long maternal education level: 47.5% vs. 31.0%, p < 0.0001) and fewer girls attending the outdoor kindergartens (42.7% vs. 49.5%, p = 0.003). In the adjusted models, we found no evidence of differences in the risk of motor difficulties between children attending either type of kindergarten (OR: 0.95, 95%CI: 0.71; 1.27, p = 0.72). CONCLUSION: Our results do not support outdoor kindergartens as a potential intervention to improve motor abilities among children. Randomized controlled trials are needed to confirm these findings.

Association between intake of marine fat and adiposity development among children ages 2 to 6 y: Substitution analyses from the Healthy Start intervention study.

OBJECTIVES: A few previous studies have described a potential role of Ω-3 long-chain polyunsaturated fatty acids from marine animals in obesity in children, but the results are conflicting. The objectives of this study were to examine if intake of marine fat was related to less gain in body mass index (BMI) and body fat (BF) over a 15-mo period among Danish children age 2 to 6 y, and if potential associations depended on which types of fatty acids were replaced. METHODS: A total of 355 children age 2 to 6 y were included in the study. Weight, height, and BF percentage (BF%) assessed by bioimpedance were measured by trained research personnel. Multivariable linear regression models were used to investigate associations between marine fat intake and changes in BMI or BF% over the subsequent 15 mo. To investigate substitution effects, we constructed regression models that included marine fat and all other energy yielding dietary components, except for the nutrient to be substituted for either all fats or specific subgroups (saturated, monounsaturated, or other polyunsaturated fatty acids). RESULTS: No significant associations were observed between intake of marine fat and development in BMI or BF% in any of the analyses, either with or without specified substitutions. Furthermore, the results were independent on whether intake was expressed in g/d or percentage of energy, and were not modified by age or BMI status. CONCLUSIONS: This study suggests that marine fat intake and fat composition in a diet may have little or no effect on weight and adiposity development among preschool-aged children.

Effects of the healthy start randomized intervention on psychological stress and sleep habits among obesity-susceptible healthy weight children and their parents.

Poor sleep and psychological stress are obesity determinants that are rarely included in obesity prevention programs. The aim was to report the effects of the Healthy Start randomized intervention on the secondary outcomes psychological stress and sleep duration and onset latency. Data was obtained from the Healthy Start randomized intervention conducted in 2009-2012 among Danish healthy weight children aged 2-6 years, who had either a high birth weight (>4,000 g), high maternal pre-pregnancy body mass index (>28 kg/m2), or low maternal educational level (≤10 years of schooling) and their parents. The intervention was designed to deliver improvements in diet and physical activity habits, optimization of sleep habits, and reduction of psychological family stress. The average intervention period was 15 months. Children with information on a 7-day sleep record, sleep onset latency, Strengths and Difficulties Questionnaire (SDQ), and a modified version of Parenting Stress Index (PSI) were included. The effects of the intervention on sleep habits, PSI scores, SDQ Total Difficulties (SDQ-TD) and Pro-social Behavior scores, and 95% Confidence Intervals (95% CI) were analyzed using linear regression intention-to-treat (n = 543 (intervention group n = 271, control group n = 272)) analyses. No statistically significant effects on sleep duration, sleep onset latency, PSI score, or SDQ Pro-social Behavior score were observed. Values both before and after the intervention were within the normal range both for children in the intervention and children in the control group. Mean change in SDQ-TD was 0.09 points (95% CI -0.57;0.59) in the intervention group, and -0.69 points (95% CI -1.16; -0.23) in the control group (p = 0.06). In conclusion, there were no intervention effects in relation to sleep duration, sleep onset latency, PSI score, or SDQ Pro-social behavior. There was an indication that children in the intervention group had slightly more behavioral problems than the control group after the intervention, but values were within normal range both before and after the intervention, and the difference is not considered to be clinically meaningful.

Physical Activity and Subsequent Change in Body Weight, Composition and Shape: Effect Modification by Familial Overweight.

BACKGROUND: Physical activity (PA) has been shown to attenuate the genetic risk of obesity as measured using polygenic risk scores. However, familial obesity history might be an easier predictor. We examined associations between PA and subsequent changes in BMI, body fat percentage (BF%) and waist circumference (WC) among participants with and without adiposity and a familial overweight. METHODS: In total, 1971 participants from the Danish MONICA cohort were included. Mean differences for 6-year changes in BMI, BF% and WC across PA levels were estimated. Association between walking and biking and subsequent change in adiposity were analysed. Effect modification by familial obesity was assessed by adding product terms to the models. RESULTS: We observed weak associations between leisure PA level and changes in WC [participants with low PA: 3.4 cm (95%CI: 2.8;4.0), participants with high PA: 2.4 cm (95%CI: 1.8;3.0)], with no evidence of effect modification by familial obesity. We found effect modification in analyses on walking and biking in relation to changes in BMI (P-interaction<0.01) and BF% (P-interaction=0.04), suggesting lower gain with more hours of activity among participants with adiposity and familial overweight. CONCLUSIONS: The results were modest but suggested that PA, especially walking and biking, may prevent future adiposity.

Intake of n-3 LCPUFA and trans-fatty acids is unrelated to development in body mass index and body fat among children.

BACKGROUND: The number of children and adolescents with obesity has increased worldwide. Some studies have found an increase in the intake of n-3 long-chain polyunsaturated fatty acid (LCPUFA) to be beneficial for weight and obesity status. The objectives of this study were to examine if intake of trans-fatty acids (TFA) and n-3 LCPUFA at school start was associated with weight and body fat development in the following 3 and 7 years, and if substituting other fats for n-3 LCPUFA in regression models influenced weight and body fat development. METHODS: A total of 285 children (boys:130, girls:155) were included in this study. Weight, height and skinfold thickness (SF) of children were measured at age 6, 9 and 13 years by trained research personnel. Multivariate linear regression models were used to investigate the associations between n-3 LCPUFA or TFA intake and subsequent changes in body mass index (BMI) or SF. To investigate substitution effects, we constructed regression models including information on n-3 LCPUFA and all other energy given components of the diet, except for the nutrient to be substituted (all other fats and specific subgroups; saturated fatty acids (SFAs), monounsaturated fatty acids (MUFAs) and other polyunsaturated fatty acids (PUFAs)). RESULTS: No significant associations were observed between intake of TFA or n-3 LCPUFA and changes in BMI and SF. Also, results from regression analysis showed substituting other fats for n-3 LCPUFA did not associate with BMI or SF development. CONCLUSION: The lack of associations between n-3 LCPUFA and TFA and adiposity suggests that fat composition in the diet does not play a major role in obesity development among school-aged children.

Users' Experiences With the NoHoW Web-Based Toolkit With Weight and Activity Tracking in Weight Loss Maintenance: Long-term Randomized Controlled Trial.

BACKGROUND: Digital behavior change interventions (DBCIs) offer a promising channel for providing health promotion services. However, user experience largely determines whether they are used, which is a precondition for effectiveness. OBJECTIVE: The primary aim of this study is to evaluate user experiences with the NoHoW Toolkit (TK)-a DBCI that targets weight loss maintenance-over a 12-month period by using a mixed methods approach and to identify the main strengths and weaknesses of the TK and the external factors affecting its adoption. The secondary aim is to objectively describe the measured use of the TK and its association with user experience. METHODS: An 18-month, 2×2 factorial randomized controlled trial was conducted. The trial included 3 intervention arms receiving an 18-week active intervention and a control arm. The user experience of the TK was assessed quantitatively through electronic questionnaires after 1, 3, 6, and 12 months of use. The questionnaires also included open-ended items that were thematically analyzed. Focus group interviews were conducted after 6 months of use and thematically analyzed to gain deeper insight into the user experience. Log files of the TK were used to evaluate the number of visits to the TK, the total duration of time spent in the TK, and information on intervention completion. RESULTS: The usability level of the TK was rated as satisfactory. User acceptance was rated as modest; this declined during the trial in all the arms, as did the objectively measured use of the TK. The most appreciated features were weekly emails, graphs, goal setting, and interactive exercises. The following 4 themes were identified in the qualitative data: engagement with features, decline in use, external factors affecting user experience, and suggestions for improvements. CONCLUSIONS: The long-term user experience of the TK highlighted the need to optimize the technical functioning, appearance, and content of the DBCI before and during the trial, similar to how a commercial app would be optimized. In a trial setting, the users should be made aware of how to use the intervention and what its requirements are, especially when there is more intensive intervention content. TRIAL REGISTRATION: ISRCTN Registry ISRCTN88405328; https://www.isrctn.com/ISRCTN88405328. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2019-029425.

The association between general and central obesity and the risks of coronary heart disease in women with and without a familial predisposition to obesity: findings from the Danish Nurse Cohort.

Several studies show an increased risk of coronary heart disease (CHD) among people with obesity, but it is largely unknown whether this association also depends on a familial predisposition to obesity. This study examined if associations between Body Mass Index (BMI) or waist circumference (WC) and incident CHD differed among Danish female nurses with and without familial overweight and obesity. Analyses were based on data from the Danish Nurse Cohort (n = 20,701). Self-reported height, weight and self-measured WC were assessed in 1999, as was information on familial overweight/obesity, defined as having one or both parents with overweight/obesity. Information on the development of or death from CHD was collected from nationwide Danish registries in 2015. Analyses were based on Cox proportional hazard regression models adjusted for potential confounding factors. Both BMI and WC were directly associated with CHD risk, but we found no evidence of effect modification from familial predisposition to obesity. Hence a familial predisposition to obesity does not seem to influence the risk of CHD associated with general or central obesity.

Effect of PEP flute self-care versus usual care in early covid-19: non-drug, open label, randomised controlled trial in a Danish community setting.

OBJECTIVE: To determine whether positive expiratory pressure (PEP) by PEP flute self-care is effective in reducing respiratory symptoms among community dwelling adults with SARS-CoV-2 infection and early stage covid-19. DESIGN: Non-drug, open label, randomised controlled trial. SETTING: Capital Region and Region Zealand in Denmark from 6 October 2020 to 26 February 2021. PARTICIPANTS: Community dwelling adults, able to perform self-care, with a new SARS-CoV-2 infection (verified by reverse transcription polymerase chain reaction tests) and symptoms of covid-19. INTERVENTION: Participants were randomised to use PEP flute self-care in addition to usual care or have usual care only. Randomisation was based on permuted random blocks in a 1:1 ratio, stratified for sex and age (<60 or ≥60 years). The PEP self-care group was instructed to use a PEP flute three times per day during the 30 day intervention. MAIN OUTCOME MEASURES: Primary outcome was a change in symptom severity from baseline to day 30, as assessed by the self-reported COPD (chronic obstructive pulmonary disease) assessment test (CAT), which was adjusted for baseline values and stratification factors. Participants completed the CAT test questionnaire every day online. Secondary outcomes were self-reported urgent care visits due to covid-19, number of covid-19 related symptoms, and change in self-rated health, all within 30-days' follow-up. RESULTS: 378 participants were assigned to the PEP flute self-care intervention (n=190) or usual care only (n=188). In the PEP self-care group, the median number of days with PEP flute use was 21 days (interquartile range 13-25). For the intention-to-treat population, a group difference was observed in changes from baseline in CAT scores of -1.2 points (95% confidence interval -2.1 to -0.2; P=0.017) in favour of the PEP flute self-care group. At day 30, the PEP flute self-care group also reported less chest tightness, less dyspnoea, more vigour, and higher level of daily activities, but these differences were small, and no consistent effects were seen on the secondary outcomes. No serious adverse events were reported. CONCLUSIONS: In community dwelling adults with early covid-19, PEP flute self-care had a significant, yet marginal and uncertain clinical effect on respiratory symptom severity, as measured by CAT scores. TRIAL REGISTRATION: ClinicalTrials.gov NCT04530435.