Exploring the long-term sustainability of school-based nutrition and food programs: What works, where and why?

ISSUE ADDRESSED: Most food and nutrition programs cease within 2 years. Understanding the determinants of program sustainability is crucial to maximise output from funding, whilst allowing sufficient time for program benefits to be achieved. This study applied the Consolidated Framework for Implementation Research (CFIR) to map the barriers and enablers of successful long-term implementation of school-based nutrition and food programs. METHODS: Qualitative methods with purposive and snowball sampling were used to recruit experts who were identified as being influential in implementing and sustaining long-term (>2 years) school-based food and nutrition programs. Semi-structured interviews with global experts were conducted, transcribed verbatim and coded deductively (by applying the CFIR constructs) and inductively when required. Thematic analysis informed the development of themes. RESULTS: Interviews were conducted with 11 experts including researchers, government employees, and a consultant of an international agency, from seven countries. Forty-eight deductive codes and eight inductive codes identified six main themes: (1) funding and integrity of its source; (2) political landscape; (3) nutrition policies and their monitoring; (4) involvement of community actors; (5) adaptability of the program and (6) effective program evaluation. Themes related mainly to the 'outer setting' domain of the CFIR. CONCLUSIONS: The CFIR highlighted pertinent factors that influence the successful long-term implementation of school-based food and nutrition programs. SO WHAT?: The findings suggest that to sustain program implementation beyond its initial funding, relationships across government departments, local organisations and communities, need to be nurtured and prioritised from the outset.

A Missed Opportunity? Meal Provision in Early Childhood Education and Care Services in the Context of Socioeconomic Disadvantage.

OBJECTIVES: Early childhood education and care (ECEC) services are attended by most children before school entry, reaching many living in circumstances of poverty and providing opportunity to support their nutrition. In this study, we examine the extent to which this opportunity is being met, comparing two common types of service provision: centre- versus family- provided food. METHODS: Intensive in-situ observations were undertaken across 10 ECEC services in highly disadvantaged Australian communities. All meals provided to children aged 3.5-5 years across an ECEC day (N = 48), of which 11% were experiencing severe food insecurity, were photographed and analysed to assess nutritional adequacy with reference to national dietary standards. RESULTS: Meals provided did not meet national dietary recommendations for quality or quantity. Nutrition was least adequate in services with policies of family-provided food. These services were also those that served families experiencing the highest levels of severe food insecurity (29%). CONCLUSIONS: In the absence of policies for the provision of food in ECEC, services are not realising their potential to support child nutrition in the context of poverty presenting increased risk to lifetime trajectories of health and wellbeing. System level policy interventions are required to facilitate equitable access to nutritious food and attendant life chances.

Healthier Together: Implementation and evaluation of a co-designed, culturally tailored childhood obesity community prevention program for Maori and Pacific Islander children and families.

ISSUE ADDRESSED: Co-designed and culturally tailored preventive initiatives delivered in childhood have high potential to close the cross-cultural gap in health outcomes of priority populations. Maori and Pacific Islander people living in Australia exhibit a higher prevalence of overweight and obesity and higher rates of multimorbidity, including heart disease, cancer and diabetes. METHODS: This mixed-methods, pilot implementation and evaluation study, aimed to evaluate the implementation of a community-based, co-designed and culturally tailored childhood obesity prevention program, using quantitative (pre-post anthropometric measurement, pre-post health behaviour questionnaire) and qualitative (semi-structured interview) methods. Sessions relating to healthy eating, physical activity and positive parenting practices were delivered to families residing in Brisbane (Australia) over 8-weeks. RESULTS: Data were collected from a total of 66 children (mean age 11, SD 4) and 38 parents (mean age 40, SD 8) of Maori and Pacific Islander background, from July 2018 to November 2019. Anthropometric changes included a reduction in Body Mass Index (BMI) z-score among 59% of children (median change -0.02, n = 38, p = 0.17) and BMI among 47% of adults (median change +0.06 kg/m2 , n = 18, p = 0.64). Significant improvements (p < 0.05) in self-reported health behaviours from pre- to post-program included increased vegetable consumption among children, decreased discretionary food intake of children, decreased discretionary drink consumption among both children and adults, increased minutes of daily physical activity among adults and increased parental confidence in the healthy diets of their children. Qualitative data revealed participants valued the inclusion of all family members, learning of practical skills and cultural tailoring delivered by the Multicultural Health Coaches. CONCLUSIONS: This study provides preliminary evidence that the Healthier Together program improved self-reported health behaviours and physical activity levels among Maori and Pacific Islander children and their families in the short-term; however, due to the small sample size, these results must be interpreted carefully. The program empowered change via cultural tailoring and accessibility; however, long-term implementation and evaluation with a larger cohort is needed to validate the observed health behaviour improvements and their sustainability. SO WHAT?: The co-design framework that informed program development and key learnings of implementation will provide guidance to health practitioners, health workers, public health professionals and policy makers to develop inclusive and pragmatic co-design solutions for priority cultural populations in Australia. Health outcomes will improve as a result, promoting health equity for future generations.

Dietary Strategies for Obesity.

Overweight and obesity remains an important health focus internationally, due to the strong link to many noncommunicable diseases, such as cardiovascular disease, non-alcoholic fatty liver disease, diabetes mellitus and mental health conditions [...].

Applying the Integrated Sustainability Framework to explore the long-term sustainability of nutrition education programmes in schools: a systematic review.

OBJECTIVE: This review aimed to identify and synthesise the enablers and barriers that influence the long-term (≥ 2 years) sustainment of school-based nutrition programmes. DESIGN: Four databases (PubMed, Cochrane Library, Embase and Scopus) were searched to identify studies reporting on the international literature relating to food and nutrition programmes aimed at school-age (5-14 years) children that had been running for ≥ 2 years (combined intervention and follow-up period). Eligible studies were analysed using the Integrated Sustainability Framework (ISF), which involved deductive coding of programme enablers and barriers. A quality assessment was completed, using the Mixed-Methods Appraisal Tool and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. SETTING: International school-based nutrition programmes. SUBJECTS: Individuals involved with the implementation of school-based nutrition programmes. RESULTS: From the 7366 articles identified, thirteen studies (seven qualitative, five mixed methods and one quantitative descriptive) were included, from which the enablers and barriers of eleven different nutrition-related programmes were analysed. Thirty-four factors across the five domains of the ISF were identified that influenced the sustained implementation of programmes. The most common barrier was a lack of organisational readiness and resources, whereas the most common enabler was having adequate external partnerships and a supportive environment. CONCLUSIONS: These findings have application during the initiation and implementation phases of school-based nutrition programmes. Paying attention to the 'outer contextual factors' of the ISF including the establishment and maintenance of robust relationships across whole of government systems, local institutions and funding bodies are crucial for programme sustainment.

Mealtimes in the context of poverty: Comparison of ECEC services providing food and those requiring food provided from home.

BACKGROUND: In developed economies, most children attend Early Childhood Education and Care (ECEC) services before school entry, many from early life and across long days. For this reason, ECEC services present significant potential to provide food environments that positively influence eating behaviours and food preferences with attendant effect on life course trajectories of health and wellbeing. Yet there is evidence that feeding practices that limit optimal ongoing nutrition, such as pressure and restriction, are amplified in ECEC services serving disadvantaged communities. We sought to identify underlying explanatory mechanisms through observation of children's feeding experiences and educator explanations comparing, family-provided and service-provided meals. METHOD: This study used qualitative analyses of educator interviews and observation records from 55 mealtimes in 10 ECEC services: 5 providing food and 5 requiring family food provision. RESULTS: High levels of concern drove educator's controlling feeding practices at mealtimes but presented differently across meal provision modes. In centres that provided food, educators' concern focused on food variety, manifesting in pressure to 'try' foods. In centres requiring family-provided food, concern focused on nutrition quantity and quality and manifested as control of order of food consumption and pacing of intake to ensure food lasted across the day. Interview data suggested that conflict aversion limited optimal nutrition. In centres providing food, this was seen in menus that prioritized child food preferences. In centres requiring family meal provision, conflict aversion was seen as reticence to discuss lunchbox contents with families. CONCLUSION: The findings direct attention to public health intervention. Currently, ECEC face significant barriers to realizing their potential to support child nutrition and establish positive life course trajectories of nutrition. To do so requires targeted supports that enable sufficient supply and quality of food in the context of poverty.

"We'd be really motivated to do something about it": A qualitative study of parent and clinician attitudes towards predicting childhood obesity in practice.

ISSUE ADDRESSED: In Australia, one in four (24.9%) children live with overweight or obesity (OW/OB). Identifying infants at risk of developing childhood OW/OB is a potential preventive pathway, but its acceptability is yet to be investigated in Australia. This study aimed to (1) investigate the acceptability of predicting childhood OW/OB with parents of infants (aged 0-2 years) and clinicians and (2) explore key language to address stigma and maximise the acceptability of predicting childhood OW/OB in practice. METHODS: This was a cross-sectional and qualitative design, comprising individual semi-structured interviews. Participants were multidisciplinary paediatric clinicians (n = 18) and parents (n = 13) recruited across public hospitals and health services in Queensland, Australia. Data were analysed under the Framework Method using an inductive, thematic approach. RESULTS: Five main themes were identified: (1) Optimism for prevention and childhood obesity prediction, (2) parent dedication to child's health, (3) adverse parent response to risk for childhood obesity, (4) language and phrasing for discussing weight and risk and (5) clinical delivery. Most participants were supportive of using a childhood OW/OB prediction tool in practice. Parents expressed dedication to their child's health that superseded potential feelings of judgement or blame. When discussing weight in a clinical setting, the use of sensitive (ie, "overweight", "above average", "growth" versus "obesity") and positive, health-focused language was mostly supported. CONCLUSIONS: Multidisciplinary paediatric clinicians and parents generally accept the concept of predicting childhood OW/OB in practice in Queensland, Australia. SO WHAT?: Clinicians, public health and health promotion professionals and policymakers can act now to implement sensitive communication strategies concerning weight and obesity risk.

What Do Health Professionals and Parents Want as Part of an Online Childhood Obesity Prevention Program?

Background: There are limited evidence-based programs for children living in Queensland, Australia, who are at risk of overweight or obesity. Despite the known importance of prevention initiatives, an online, locally relevant program supporting sustainable health behaviors does not exist. This study aimed to understand the perspectives of parents/guardians and health professionals regarding important aspects of an online childhood obesity prevention program. Methods: This pragmatic, mixed-methods study was conducted from March to December 2020. Recruitment included participants from two groups involved with children aged 2-17 years, health professionals, and parents/guardians. Phase 1 involved dissemination of an online survey. Questions addressed program structure, content delivery (including nutrition, physical activity, and parenting practices), program evaluation, and information dissemination. Descriptive statistics were used to describe survey data to inform the delivery of Phase 2, where two focus groups further explored the topics. Thematic analysis was used to investigate the qualitative data. Results: Twenty-eight health professionals and 11 parents/guardians completed the survey, and 14 health professionals and 6 parents/guardians participated in the focus groups. Participants believed that the most beneficial approach would target younger children with family-based interventions, via a nontraditional structure. There was a strong preference for interactive content, gamification, and practical resources to translate knowledge into practice. Parents emphasized that there should be no assumption of basic knowledge, and that decision fatigue is a barrier to engagement. Conclusion: Participants provided clear direction regarding key aspects for future development of an online prevention program, highlighting the importance of codesign to tailor the program to identified needs.

A Rapid Review of the Impact of Family-Based Digital Interventions for Obesity Prevention and Treatment on Obesity-Related Outcomes in Primary School-Aged Children.

Virtual delivery of obesity prevention and treatment programs may be effective for supporting children and families to adopt healthy lifestyle changes while enhancing program accessibility. This rapid review aimed to summarize the impact of family-based digital interventions for childhood obesity prevention and treatment. Four databases were searched up to February 2021 for trials of interactive digital programs aimed to prevent and/or treat obesity in children aged 5-12 years and reported diet, physical activity, sedentary behavior, sleep, or weight-related outcomes in children. A total of 23 publications (from 18 interventions) were included. Behavior change theories were used in 13 interventions with "Social Cognitive Theory" applied most frequently (n = 9). Interventions included websites (n = 11), text messaging (n = 5), video gaming (n = 2), Facebook (n = 3), and/or mobile applications (n = 2). Studies reported changes in body mass index (BMI; n = 11 studies), diet (n = 11), physical activity (n = 10), screen time (n = 6), and/or sleep (n = 1). Significant improvements were reported for diet (n = 5) or physical activity (n = 4). Two of the six interventions were effective in reducing screen time. Digital interventions have shown modest improvements in child BMI and significant effectiveness in diet and physical activity, with emerging evidence supporting the use of social media and video gaming to enhance program delivery.

Watch me grow integrated (WMG-I): protocol for a cluster randomised controlled trial of a web-based surveillance approach for developmental screening in primary care settings.

INTRODUCTION: The increasing prevalence of developmental disorders in early childhood poses a significant global health burden. Early detection of developmental problems is vital to ensure timely access to early intervention, and universal developmental surveillance is recommended best practice for identifying issues. Despite this, there is currently considerable variation in developmental surveillance and screening between Australian states and territories and low rates of developmental screening uptake by parents. This study aims to evaluate an innovative web-based developmental surveillance programme and a sustainable approach to referral and care pathways, linking primary care general practice (GP) services that fall under federal policy responsibility and state government-funded child health services. METHODS AND ANALYSIS: The proposed study describes a longitudinal cluster randomised controlled trial (c-RCT) comparing a 'Watch Me Grow Integrated' (WMG-I) approach for developmental screening, to Surveillance as Usual (SaU) in GPs. Forty practices will be recruited across New South Wales and Queensland, and randomly allocated into either the (1) WMG-I or (2) SaU group. A cohort of 2000 children will be recruited during their 18-month vaccination visit or opportunistic visit to GP. At the end of the c-RCT, a qualitative study using focus groups/interviews will evaluate parent and practitioner views of the WMG-I programme and inform national and state policy recommendations. ETHICS AND DISSEMINATION: The South Western Sydney Local Health District (2020/ETH01625), UNSW Sydney (2020/ETH01625) and University of Queensland (2021/HE000667) Human Research Ethics Committees independently reviewed and approved this study. Findings will be reported to the funding bodies, study institutes and partners; families and peer-reviewed conferences/publications. TRIAL REGISTRATION NUMBER: ANZCTR12621000680864.

Precision Public Health for Non-communicable Diseases: An Emerging Strategic Roadmap and Multinational Use Cases.

Non-communicable diseases (NCDs) remain the largest global public health threat. The emerging field of precision public health (PPH) offers a transformative opportunity to capitalize on digital health data to create an agile, responsive and data-driven public health system to actively prevent NCDs. Using learnings from digital health, our aim is to propose a vision toward PPH for NCDs across three horizons of digital health transformation: Horizon 1-digital public health workflows; Horizon 2-population health data and analytics; Horizon 3-precision public health. This perspective provides a high-level strategic roadmap for public health practitioners and policymakers, health system stakeholders and researchers to achieving PPH for NCDs. Two multinational use cases are presented to contextualize our roadmap in pragmatic action: ESP and RiskScape (USA), a mature PPH platform for multiple NCDs, and PopHQ (Australia), a proof-of-concept population health informatics tool to monitor and prevent obesity. Our intent is to provide a strategic foundation to guide new health policy, investment and research in the rapidly emerging but nascent area of PPH to reduce the public health burden of NCDs.

Characteristics and treatment outcomes of children and adolescents accessing treatment in Child and Youth Mental Health Services.

AIM: To provide insight into the characteristics and treatment outcomes of children and adolescents accessing outpatient Child and Youth Mental Health Services (CYMHS), and to explore whether outcomes differ by age, sex, and ancestry background. This information can guide how to optimize the treatment delivered at these services. METHODS: An observational retrospective study was performed based on data from 3098 children and adolescents between age 5 and 18 who received treatment at Brisbane, Australia, community CYMHS between 2013-2018. Patient characteristics, service use, and clinician and parent rated Routine Outcome Measures (ROM) were extracted from electronic health records. RESULTS: Anxiety and mood disorders were the most common mental disorders (37% and 19%). In 1315 children and adolescents (42%), two or more disorders were diagnosed, and the far majority (88%) had experienced at least one psychosocial stressor. The ROM scores improved between start and end of treatment with Cohen's d effect sizes of around 0.9. However, ~50% of the children still scored in the clinical range at the end of treatment. Outcomes did not differ over gender and Indigenous status. CONCLUSIONS: Children and adolescents accessing CYMHS have severe and complex mental disorders as reflected by high rates of comorbidity, exposure to adverse circumstances and high symptom scores at the start of treatment. Despite the clinically relevant and substantial improvement, end ROM scores indicated the presence of residual symptoms. As this increases the risk for relapse, services should explore ways to improve treatment to further reduce mental health symptoms.

Addressing childhood obesity in Queensland: Aboriginal and Torres Strait Islander Health Worker perspectives and practices.

ISSUE ADDRESSED: Obesity disproportionately impacts Aboriginal and Torres Strait Islander children compared to non-Indigenous children. Aboriginal and Torres Strait Islander Health Workers (AHWs) in Queensland support the health of Aboriginal and Torres Strait Islander peoples. However, little is known about their perspectives and practices on addressing childhood obesity. The aim of this study was to investigate AHW perspectives and clinical practice behaviours with Aboriginal and Torres Strait Islander children and their families. METHODS: In a cross-sectional mixed-methods approach, a purpose-developed online survey (25 items) was distributed to the AHW workforce in Queensland (~100 AHWs). The survey explored [1] role characteristics, [2] current attitudes and beliefs about childhood obesity, [3] barriers to discussing weight management, [4] clinical practice behaviours and [5] demographic characteristics. Eight AHWs responding to the survey also participated in semi-structured telephone interviews to discuss their survey responses. RESULTS: Fifty-five AHWs responded and 45 completed the survey. While the majority of respondents (91%) agreed that addressing childhood obesity was an important part of their role, fewer (67%) agreed that obesity was an issue in Aboriginal and Torres Strait Islander peoples. Over half (55%) found it difficult to discuss overweight and obesity with children and families and only 22.5% reported measuring height and weight often. Key themes included a willingness to address childhood obesity, with experience and training being key enablers to discussing the issue. There was a perceived lack of culturally appropriate programs to support AHWs working with families. CONCLUSIONS: AHWs report a willingness to address childhood obesity within their roles, however many find it difficult to raise the issue with families, with even fewer routinely undertaking obesity assessment practices. SO WHAT?: These findings could inform training initiatives for AHWs to optimise screening, identification, referral, and treatment of childhood obesity in Aboriginal and Torres Strait Islander communities.

Empowerment Approaches in Childhood Weight Management: A Systematic Review.

Empowerment interventions facilitate individuals, organizations, and communities to gain better control over their health. They are distinctly different from traditional behavior change models and encourage participants to set their own health priorities and agenda. Current evidence suggests empowerment interventions are efficacious for smoking, sexual, and mental health outcomes. However, empowerment in childhood obesity (which remains a global public health challenge) is underresearched. This review systematically analyzed the evidence for empowerment approaches in childhood weight management. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A search strategy was applied to six databases from inception to May 25, 2021. Evidence was appraised using The Academy of Nutrition and Dietetics Quality Criteria Checklist and National Health and Medical Research Council Levels of Evidence. Of the 9274 articles identified, 29 articles describing 14 programs met the inclusion criteria. Twenty-five studies rated positive and four rated neutral. Overall, the evidence body rated "B." Seventy-two percent of the 3318 participants were from priority populations, highlighting the unique ability of empowerment interventions to engage those most in need. Results demonstrate small to large improvements in participant body mass index with effect sizes ranging from 0.08 to 1.13. Throughout the literature, empowerment was measured inconsistently and usually with a surrogate marker. All studies were set in America or Canada. This review suggests empowerment should be further investigated in childhood weight management. Empowerment interventions represent a unique opportunity to meaningfully integrate self-determination to clinical childhood weight management practice and overcome current barriers related to priority population engagement.

Associations between food provision and feeding practices in socially disadvantaged childcare centres.

Preschool children consume a large proportion of their daily food intake in their childcare settings. These settings, therefore, provide important opportunities for children to experience food socialisation, and related positive nutrition. Yet, the extent to which these opportunities are taken, particularly in socioeconomically disadvantaged areas where risk of poor nutrition is high, is not well documented. This study focused on 10 childcare centres in socially disadvantaged locations and examined daily feeding practices via direct in-situ observation (n = 189 children observed). Centres were randomly selected based on type of food provision: centre-provided (n = 5 centres) or family-provided (n = 5 centres). Analyses showed that where food was family-provided, educators were significantly more likely to use controlling feeding practices, including pressuring children to eat, restricting food choices and rushing children into finishing meals. These practices were particularly evident during mid-morning meals, where pressuring children to eat healthy foods first, was more often observed. Further research and interventions that target feeding practices in childcare are indicated and should consider how source of food provision impacts upon these practices.

Digital health and precision prevention: shifting from disease-centred care to consumer-centred health.

Digital disruption and transformation of health care is occurring rapidly. Concurrently, a global syndemic of preventable chronic disease is crippling healthcare systems and accelerating the effect of the COVID-19 pandemic. Healthcare investment is paradoxical; it prioritises disease treatment over prevention. This is an inefficient break-fix model versus a person-centred predict-prevent model. It is easy to reward and invest in acute health systems because activity is easily measured and therefore funded. Social, environmental and behavioural health determinants explain ~70% of health variance; yet, we cannot measure these community data contemporaneously or at population scale. The dawn of digital health and the digital citizen can initiate a precision prevention era, where consumer-centred, real-time data enables a new ability to count and fund population health, making disease prevention 'matter'. Then, precision decision making, intervention and policy to target preventable chronic disease (e.g. obesity) can be realised. We argue for, identify barriers to, and propose three horizons for digital health transformation of population health towards precision prevention of chronic disease, demonstrating childhood obesity as a use case. Clinicians, researchers and policymakers can commence strategic planning and investment for precision prevention of chronic disease to advance a mature, value-based model that will ensure healthcare sustainability in Australia and globally.

Cultural adaptation of health interventions including a nutrition component in Indigenous peoples: a systematic scoping review.

BACKGROUND: Indigenous populations throughout the world experience poorer health outcomes than non-indigenous people. The reasons for the health disparities are complex and due in part to historical treatment of Indigenous groups through colonisation. Evidence-based interventions aimed at improving health in this population need to be culturally safe. However, the extent to which cultural adaptation strategies are incorporated into the design and implementation of nutrition interventions designed for Indigenous peoples is unknown. The aim of this scoping review was to explore the cultural adaptation strategies used in the delivery of nutrition interventions for Indigenous populations worldwide. METHODS: Five health and medical databases were searched to January 2020. Interventions that included a nutrition component aimed at improving health outcomes among Indigenous populations that described strategies to enhance cultural relevance were included. The level of each cultural adaptation was categorised as evidential, visual, linguistic, constituent involving and/or socio-cultural with further classification related to cultural sensitivity (surface or deep). RESULTS: Of the 1745 unique records screened, 98 articles describing 66 unique interventions met the inclusion criteria, and were included in the synthesis. The majority of articles reported on interventions conducted in the USA, Canada and Australia, were conducted in the previous 10 years (n = 36) and focused on type 2 diabetes prevention (n = 19) or management (n = 7). Of the 66 interventions, the majority included more than one strategy to culturally tailor the intervention, combining surface and deep level adaptation approaches (n = 51), however, less than half involved Indigenous constituents at a deep level (n = 31). Visual adaptation strategies were the most commonly reported (n = 57). CONCLUSION: This paper is the first to characterise cultural adaptation strategies used in health interventions with a nutrition component for Indigenous peoples. While the majority used multiple cultural adaptation strategies, few focused on involving Indigenous constituents at a deep level. Future research should evaluate the effectiveness of cultural adaptation strategies for specific health outcomes. This could be used to inform co-design planning and implementation, ensuring more culturally appropriate methods are employed.

Response to 'Systematic reviews do not always capture context of real-world intervention programmes for childhood obesity' by Wild et al., 2021 in BMC Public Health.

In a correspondence to BMC Public Health, Wild et al. respond to our systematic review that synthesised results of interventions to prevent or treat childhood obesity in Maori and Pacific Islanders. Our review included the Whanau Pakari study as one of six included studies - a multidisciplinary intervention for Maori children and adolescents living with obesity led by their research team. Our review suggested that future research can incorporate stronger co-design principles when designing culturally-tailored interventions to maximise cultural specificity, enhance engagement, facilitate program ownership and contribute to improved health and weight-related outcomes. We commend Whanau Pakari and the team of Wild et al. on their sustained commitment to addressing obesity in priority populations and agree that systematic reviews struggle to capture real-world context of interventions for complex diseases such as obesity. In this article, we respond sequentially to the comments made by Wild et al. and (1) clarify the scope of our review article (2) reiterate our commendation of mixed-methods approaches that capture real-world context (3) explain a referencing error that caused a misinterpretation of our results (4) clarify our interpretation of some Whanau Pakari characteristics (5) welcome partnership to facilitate shared learning with Wild et al.

i-PATHWAY: Development and validation of a prediction model for childhood obesity in an Australian prospective birth cohort.

AIM: To develop and validate a model (i-PATHWAY) to predict childhood (age 8-9 years) overweight/obesity from infancy (age 12 months) using an Australian prospective birth cohort. METHODS: The Transparent Reporting of a multivariable Prediction model for individual Prognosis or Diagnosis (TRIPOD) checklist was followed. Participants were n = 1947 children (aged 8-9 years) from the Raine Study Gen2 - an Australian prospective birth cohort - who had complete anthropometric measurement data available at follow up. The primary outcome was childhood overweight or obesity (age 8-9 years), defined by age- and gender-specific cut-offs. Multiple imputation was performed to handle missing data. Predictors were selected using 2000 unique backward stepwise logistic regression models. Predictive performance was assessed via: calibration, discrimination and decision-threshold analysis. Internal validation of i-PATHWAY was conducted using bootstrapping (1000 repetitions) to adjust for optimism and improve reliability. A clinical model was developed to support relevance to practice. RESULTS: At age 8-9 years, 18.9% (n = 367) of children were classified with overweight or obesity. i-PATHWAY predictors included: weight change (0-1 year); maternal pre-pregnancy body mass index (BMI); paternal BMI; maternal smoking during pregnancy; premature birth; infant sleep patterns; and sex. After validation, predictive accuracy was acceptable: calibration slope = 0.956 (0.952-0.960), intercept = -0.052 (-0.063, -0.048), area under the curve = 0.737 (0.736-0.738), optimised sensitivity = 0.703(0.568-0.790), optimised specificity = 0.646 (0.571-0.986). The clinical model retained acceptable predictive accuracy without paternal BMI. CONCLUSIONS: i-PATHWAY is a simple, valid and clinically relevant prediction model for childhood overweight/obesity. After further validation, this model can influence state and national health policy for overweight/obesity screening in the early years.