Development of the VEGANScreener, a Tool for a Quick Diet Quality Assessment among Vegans in Europe.

BACKGROUND: Plant-based diets are not inherently healthy. Similar to omnivorous diets, they may contain excessive amounts of sugar, sodium, and saturated fats, or lack diversity. Moreover, vegans might be at risk of inadequate intake of certain vitamins and minerals commonly found in foods that they avoid. We developed the VEGANScreener, a tool designed to assess the diet quality of vegans in Europe. METHODS: Our approach combined best practices in developing diet quality metrics with scale development approaches and involved the following: (a) narrative literature synthesis, (b) evidence evaluation by an international panel of experts, and (c) translation of evidence into a diet screener. We employed a modified Delphi technique to gather opinions from an international expert panel. RESULTS: Twenty-five experts in the fields of nutrition, epidemiology, preventive medicine, and diet assessment participated in the first round, and nineteen participated in the subsequent round. Initially, these experts provided feedback on a pool of 38 proposed items from the literature review. Consequently, 35 revised items, with 17 having multiple versions, were suggested for further consideration. In the second round, 29 items were retained, and any residual issues were addressed in the final consensus meeting. The ultimate screener draft encompassed 29 questions, with 17 focusing on foods and nutrients to promote, and 12 addressing foods and nutrients to limit. The screener contained 24 food-based and 5 nutrient-based questions. CONCLUSIONS: We elucidated the development process of the VEGANScreener, a novel diet quality screener for vegans. Future endeavors involve contrasting the VEGANScreener against benchmark diet assessment methodologies and nutritional biomarkers and testing its acceptance. Once validated, this instrument holds potential for deployment as a self-assessment application for vegans and as a preliminary dietary screening and counseling tool in healthcare settings.

Preconception diet in adolescence and its association with hypertensive disorders of pregnancy and preterm birth. Results from the HUNT study.

Our aim was to estimate associations of adolescent dietary patterns and meal habits with hypertensive disorders of pregnancy (HDP) and preterm birth. We used data from a prospective cohort study (Norwegian Young-HUNT1) where dietary information was collected during adolescence and pregnancy outcomes were obtained through record linkage to the Norwegian national birth registry. The outcomes were HDP, hypertension, pre-eclampsia/eclampsia, and preterm birth in the first pregnancy and in any pregnancy. Diet was self-reported from validated questionnaires, and exposures were dietary indexes (healthy; unhealthy; fruit and vegetable; fibre index) and meal habits. Recruitment took place in schools. Eligible participants were females aged 13-19 years at the time of dietary assessment with a subsequent singleton pregnancy (n 3622). Women who reported a higher fibre intake in adolescence had a lower risk of pre-eclampsia in the first pregnancy (Relative Risk: 0·84; 95 % CI 0·7, 1·0), although this was weaker in sensitivity analyses. Regular meal habits in mid-adolescence (aged 13-15 years), particularly breakfast and lunch, were weakly associated with a lower risk of hypertension in pregnancy. Our results are the first to indicate an association between aspects of diet and dietary behaviour in mid-adolescence and subsequent HDP. More evidence is needed from larger studies to replicate the results and from alternative study designs to disentangle causality.

Home-delivered meal boxes in a family setting: a qualitative study investigating reasons for use and perceived impact on meal practices.

BACKGROUND: Cooking and consuming a homemade meal is associated with health benefits. Home-delivered meal boxes can support families in cooking this fresh meal. The current study aimed to gain a deeper understanding of the determinants of meal box use, and of the perceived impact on meal practices of parents with younger (i.e., aged 6-12 years) and older children (i.e., 13-18 years). METHODS: Four focus groups were conducted (n = 19); two with parents of younger children, and two with parents of older children. A semi-structured interview guide was developed and interviews were recorded and transcribed. Reflexive thematic analysis was performed using NVivo 1.4. RESULTS: Most parents mentioned practical reasons like saving time and money, as well as inspiration, as reasons to choose a home-delivered meal box. Also, tastiness and menu variation were often mentioned as determining factors by both parent groups. However, a few parents stated to stop using the meal boxes because of returning menus or too small portion sizes. Meal box providers were chosen based on the price, the freshness and the quality of the products. Moreover, positive effects on parents' perceived cooking skills and knowledge were reported. Also, some parents mentioned positively changed attitudes towards vegetarian dishes. Lastly, parents reported healthier eating due to more appropriate portion sizes and more vegetables. A prominent difference between parent groups was that older children played a role in continuing the use of meal boxes, and helped to prepare the meals (contrary to younger children). CONCLUSIONS: Home-delivered meal boxes might be promising to enhance families' meal practices. This study could inform social marketeers and health promotors to adopt an optimal strategy to reach families.

Intervention strategies to promote healthy and sustainable food choices among parents with lower and higher socioeconomic status.

BACKGROUND: A global shift towards more healthy and sustainable diets is necessary for the prevention of obesity and chronic diseases, as well as for the growing pressure on our ecosystems. Given that parents are important actors in affecting dietary behaviors of their children, developing intervention strategies targeting families and their practices is promising to reach positive behavior change among children. Also, it is important to tailor these interventions to the needs of parents with different socioeconomic statuses (SES), given that health inequalities continue to grow. This study aims to investigate perspectives of lower and higher SES parents on the usability and acceptability of various innovative intervention strategies. METHODS: Fourteen focus groups and four individual interviews (n = 78, nlowerSES = 17; nhigherSES = 61) were conducted in Belgium. A semi-structured interview guide was used to facilitate the discussions. The interviews were recorded, transcribed, and analyzed via thematic content analysis using NVivo. RESULTS: To encourage healthy and sustainable food choices, interventions via online food shopping platforms and nudging strategies in grocery stores were mostly cited by higher SES parents, but these were less applicable for lower SES parents as they buy less online and mainly consider the price of products. Mobile applications that provide inspiration for healthy and sustainable recipes and easily accessible shopping lists received moderate support among lower and higher SES parents. Furthermore, both lower and higher SES parents showed interest in meal boxes delivered at home, but lower SES parents have not yet tried such meal boxes because of their higher prices. Still, both groups of SES parents mentioned many advantages of these meal boxes, such as the convenience and time-saving component, as well as the cooking inspiration aspect. CONCLUSION: Our study reveals the preferences of lower and higher SES parents for practical intervention strategies, providing insight in what features these strategies should have to be acceptable and useful. Hence, the findings can inform the development of a tailored family-based intervention strategy to improve parental food choices in favor of increased health and sustainability.

Determinants of healthy and sustainable food choices in parents with a higher and lower socioeconomic status: A qualitative study.

Establishing healthy and sustainable dietary habits in childhood is necessary for the prevention of obesity and chronic diseases, as well as for the growing pressure on our ecosystems. Considering that parents are the most important actors in affecting dietary behaviors of their children, and that there is a social gradient for obesity, this study aims to investigate differences in determinants of both healthy and sustainable food choices among parents with a higher and lower socioeconomic status (SES). Fifteen focus groups and four individual interviews (n = 78) with parents of children aged 6 to 12 were conducted in Belgium. A semi-structured interview guide based on a socioecological model was used. The interviews were recorded, transcribed and thematic content analysis was performed using NVivo 1.0. Findings indicate some differences in determinants of healthy and sustainable food choices among higher and lower SES parents. Generally, higher SES parents reported more barriers for sustainable than for healthy food choices. They showed more positive attitudes towards healthy than sustainable food choices, and reported low knowledge and self-efficacy to make sustainable food choices, while a lack of time was a barrier to cook both healthy and sustainable meals. Lower SES parents, like higher SES parents, showed more positive attitudes towards healthy food choices. They reported high prices and a lack of inspiration and skills as barriers for both food choices, while also being influenced by their cultural backgrounds. For both SES types of parents, children had a strong influence on their healthy and sustainable food choices. The findings suggest socioeconomic differences in determinants of healthy and sustainable food choices. Hence, these differences should be taken into account when developing intervention strategies to improve food choices in parents.

The conceptual framework for a combined food literacy and physical activity intervention to optimize metabolic health among women of reproductive age in urban Uganda.

BACKGROUND: Metabolic health of urban Ugandans, mostly women, has increasingly become sub-optimal. As women are strategic for family behavioral change and do not meet WHO recommendations regarding dietary and physical activity (PA), there is an urgent need for science-based interventions to tackle unhealthy dietary and PA behaviors. OBJECTIVE: To develop a food literacy and PA promotion intervention to optimise metabolic health among women of reproductive age in urban Uganda. METHODOLOGY: Steps 1- 6 of the Intervention Mapping protocol were used to design the intervention. RESULTS: Notable determinants from Step 1 were health/beauty paradox, nonfactual nutrition information, socio-cultural misconceptions around moderate PA, fruits, and vegetables. Others included gaps in food/PA knowledge, skills, and self-efficacy. We hypothesised that changing the overall existing behaviours in one intervention may meet strong resistance. Thus, we decided to go for gradual stepwise changes. Hence in step 2, three behavioural intervention objectives were formulated; (1) women evaluate the accuracy of nutrition and PA information., (2) engage in moderate intensity PA for at least 150 min a week, and (3) consume at least one portion of vegetables and one portion of fruit every day. Based on the food literacy model, intervention objectives were formulated into performance objectives and matrices of change objectives. In step 3 a combination of eleven behavioural change techniques were selected and translated into practical strategies to effect changes in determinants. In step 4, intervention components and materials were developed. The intervention consists of five interactive group sessions, 150 min each. Infographics on benefits/recommendations, vegetable recipes, and practical tips to eat more fruits, vegetables, and to engage more in PA are included. Personalised goals and action plans tailored to personal metabolic health and lifestyle needs, and environmental opportunities form the basis of the intervention. A randomized controlled trial is being conducted to evaluate the intervention ( https://clinicaltrials.gov/ct2/show/NCT04635332 ). CONCLUSIONS: The intervention is novel, based on a holistic food literacy model. The intervention is built on determinants specific to urban Uganda, evidence based behavioural change theoretical models and techniques, detailing the hypothesised behavioural change mechanism. If effective, an evidence-based intervention will become available for reference in urban Uganda.

Effect of a Parent-Focused eHealth Intervention on Children's Fruit, Vegetable, and Discretionary Food Intake (Food4toddlers): Randomized Controlled Trial.

BACKGROUND: In Western countries, children's diets are often low in fruits and vegetables and high in discretionary foods. Diet in early life tends to track through childhood and youth and even into adulthood. Interventions should, therefore, be delivered in periods when habitual traits are established, as in toddlerhood when children adapt to their family's diet. OBJECTIVE: In this study, we assessed the effect of the Food4toddlers eHealth intervention, which aimed to enhance toddlers' diets by shaping their food and eating environment. METHODS: The Food4toddlers randomized controlled trial was conducted in Norway in 2017-2018. Parent-child dyads were recruited through social media. In total, 298 parents completed an online questionnaire at baseline (mean child age 10.9 months, SD 1.2). Postintervention questionnaires were completed immediately after the intervention (ie, follow-up 1; mean child age 17.8 months, SD 1.3) and 6 months after the intervention (ie, follow-up 2; mean child age 24.2 months, SD 1.9). The intervention was guided by social cognitive theory, which targets the linked relationship between the person, the behavior, and the environment. The intervention group (148/298, 49.7%) got access to the Food4toddlers website for 6 months from baseline. The website included information on diet and on how to create a healthy food and eating environment as well as activities, recipes, and collaboration opportunities. To assess intervention effects on child diet from baseline to follow-up 1 and from baseline to follow-up 2, we used generalized estimating equations and a time × group interaction term. Between-group differences in changes over time for frequency and variety of fruits and vegetables and frequency of discretionary foods were assessed. RESULTS: At follow-up 1, a significant time × group interaction was observed for the frequency of vegetable intake (P=.02). The difference between groups in the change from baseline to follow-up 1 was 0.46 vegetable items per day (95% CI 0.06-0.86) in favor of the intervention group. No other significant between-group differences in dietary changes from baseline to follow-up 1 or follow-up 2 were observed. However, there is a clear time trend showing that the intake of discretionary foods increases by time from less than 1 item per week at baseline to more than 4 items per week at 2 years of age (P<.001), regardless of group. CONCLUSIONS: A positive intervention effect was observed for the frequency of vegetable intake at follow-up 1 but not at follow-up 2. No other between-group effects on diet were observed. eHealth interventions of longer duration, including reminders after the main content of the intervention has been delivered, may be needed to obtain long-terms effects, along with tailoring in a digital or a personal form. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 92980420; https://doi.org/10.1186/ISRCTN92980420.

The impact of diet during adolescence on the neonatal health of offspring: evidence on the importance of preconception diet. The HUNT study.

Emerging evidence suggests that parents' nutritional status before and at the time of conception influences the lifelong physical and mental health of their child. Yet little is known about the relationship between diet in adolescence and the health of the next generation at birth. This study examined data from Norwegian cohorts to assess the relationship between dietary patterns in adolescence and neonatal outcomes. Data from adolescents who participated in the Nord-Trøndelag Health Study (Young-HUNT) were merged with birth data for their offspring through the Medical Birth Registry of Norway. Young-HUNT1 collected data from 8980 adolescents between 1995 and 1997. Linear regression was used to assess associations between adolescents' diet and later neonatal outcomes of their offspring adjusting for sociodemographic factors. Analyses were replicated with data from the Young-HUNT3 cohort (dietary data collected from 2006 to 2008) and combined with Young-HUNT1 for pooled analyses. In Young-HUNT1, there was evidence of associations between dietary choices, meal patterns, and neonatal outcomes, these were similar in the pooled analyses but were attenuated to the point of nonsignificance in the smaller Young-HUNT3 cohort. Overall, energy-dense food products were associated with a small detrimental impact on some neonatal outcomes, whereas healthier food choices appeared protective. Our study suggests that there are causal links between consumption of healthy and unhealthy food and meal patterns in adolescence with neonatal outcomes for offspring some years later. The effects seen are small and will require even larger studies with more state-of-the-art dietary assessment to estimate these robustly.

Corrigendum: Environmentally Sustainable Food Consumption: A Review and Research Agenda From a Goal-Directed Perspective.

[This corrects the article DOI: 10.3389/fpsyg.2020.01603.].

Fat-soluble nutrients and Omega-3 fatty acids as modifiable factors influencing preterm birth risk.

Preterm birth is a leading cause of child morbidity and mortality, so strategies to reduce early birth must remain a priority. One key approach to enhancing birth outcomes is improving maternal dietary intake. Therefore, the purpose of this review is to discuss mechanisms on perinatal status of fat-soluble nutrients (carotenoids, retinol, tocopherols) and omega-3 fatty acids and how they impact risk for preterm birth. Literature review demonstrates that maternal dietary intake and biological (blood and placental tissue) levels of fat-soluble nutrients during pregnancy may provide antioxidative, anti-inflammatory, and immunomodulatory health benefits. Omega-3 fatty acids also promote increased production of specialized pro-resolving mediators, subsequently mediating inflammation resolution. Combined effects of these nutrients support appropriate placental organogenesis and function. Consequently, fat-soluble nutrients and omega-3 fatty acids serve as strong influencers for preterm birth risk. As dietary intake remains a modifiable factor, future intervention would benefit from a focus on optimizing perinatal status of these specific nutrients.

Effect of a free healthy school meal on fruit, vegetables and unhealthy snacks intake in Norwegian 10- to 12-year-old children.

BACKGROUND: Norwegian children have a lower intake of fruit, vegetables, and a higher intake of unhealthy snacks compared to dietary guidelines. Such dietary inadequacies may be detrimental for their current and future health. Schools are favorable settings to establish healthy eating practices. Still, no school meal arrangement is provided in Norway, and most children typically bring packed lunches from home. The aim of this study was to investigate whether serving a free healthy school meal for one year resulted in a higher intake of fruit and vegetables and a lower intake of unhealthy snacks in total among 10-12-year-olds in Norway. METHODS: The School Meal Project in Southern Norway was a non-randomized trial in two elementary schools in rural areas in the school year 2014/2015. The study sample consisted of 10- to 12-year-old children; an intervention group (N = 55) and a control group (N = 109) resulting in a total of 164 school children at baseline. A food frequency questionnaire was completed by the children at baseline, at five months follow-up and after one year to assess fruit, vegetable, and snacks intake. Multiple linear regression analyses were performed to assess intervention effects on overall intake of fruit and vegetables and unhealthy snacks. RESULTS: Serving of a free healthy school meal for one year was associated with a higher weekly intake of vegetables on sandwiches in the intervention group compared to the control group, adjusted for baseline intake (B: 1.11 (95% CI: .38, 1.85)) at the end of the intervention. No other significant intervention effects were found for the remaining fruit and vegetables measures. Serving of a free healthy school meal was not associated with a lower weekly intake of unhealthy snacks (i.e. potato chips, candy, sugar sweetened beverages) in the intervention group compared to the control group. CONCLUSIONS: A free healthy school meal was associated with a higher weekly intake of vegetables on sandwiches but did not significantly change any other investigated dietary behaviors. However, given the inadequate intake of vegetables among children and that even moderate improvements have public health relevance, a free healthy school meal for all school children could be beneficial. TRIAL REGISTRATION: ISRCTN61703361 . Date of registration: December 3rd, 2018. Retrospectively registered.

Environmentally Sustainable Food Consumption: A Review and Research Agenda From a Goal-Directed Perspective.

The challenge of convincing people to change their eating habits toward more environmentally sustainable food consumption (ESFC) patterns is becoming increasingly pressing. Food preferences, choices and eating habits are notoriously hard to change as they are a central aspect of people's lifestyles and their socio-cultural environment. Many people already hold positive attitudes toward sustainable food, but the notable gap between favorable attitudes and actual purchase and consumption of more sustainable food products remains to be bridged. The current work aims to (1) present a comprehensive theoretical framework for future research on ESFC, and (2) highlight behavioral solutions for environmental challenges in the food domain from an interdisciplinary perspective. First, starting from the premise that food consumption is deliberately or unintentionally directed at attaining goals, a goal-directed framework for understanding and influencing ESFC is built. To engage in goal-directed behavior, people typically go through a series of sequential steps. The proposed theoretical framework makes explicit the sequential steps or hurdles that need to be taken for consumers to engage in ESFC. Consumers need to positively value the environment, discern a discrepancy between the desired versus the actual state of the environment, opt for action to reduce the experienced discrepancy, intend to engage in behavior that is expected to bring them closer to the desired end state, and act in accordance with their intention. Second, a critical review of the literature on mechanisms that underlie and explain ESFC (or the lack thereof) in high-income countries is presented and integrated into the goal-directed framework. This contribution thus combines a top-down conceptualization with a bottom-up literature review; it identifies and discusses factors that might hold people back from ESFC and interventions that might promote ESFC; and it reveals knowledge gaps as well as insights on how to encourage both short- and long-term ESFC by confronting extant literature with the theoretical framework. Altogether, the analysis yields a set of 33 future research questions in the interdisciplinary food domain that deserve to be addressed with the aim of fostering ESFC in the short and long term.

Process Evaluation of an eHealth Intervention (Food4toddlers) to Improve Toddlers' Diet: Randomized Controlled Trial.

BACKGROUND: Parents seek trustworthy information online to promote healthy eating for their toddlers. Such information must be perceived as relevant and easy to implement and use. OBJECTIVE: The objectives of this study were to conduct a process evaluation of the electronic health (eHealth) intervention (Food4toddlers) targeting food environment, parental feeding practices, and toddlers' diet and to examine possible differences in these areas according to education and family composition. METHODS: A 2-armed randomized controlled trial, including 298 parent-toddler dyads from Norway, was conducted in 2017. In total, 148 parents in the intervention group received access to an intervention website for 6 months. Data on website usage were retrieved from the learning management platform used (NEO). Participants' satisfaction with the intervention was asked for in a postintervention questionnaire. Chi-square and t tests were used to examine differences in usage and satisfaction between education and family composition groups. RESULTS: Most participants were mothers (144/148, 97.2%), lived in two-adult households (148/148, 100%), and were born in Norway (132/148, 89.1%). Mean parental age was 31.5 years (SD 4.2). More than 87.8% (129/147) had a university education degree and 56.5% (83/147) had over 4 years of university education. Most (128/148, 86.5%) intervention participants entered the website at least once (mean days of access 7.4 [SD 7.1]). Most parents reported the website as appropriate to the child's age (71/83, 86%) and self-explanatory (79/83, 95%) and appreciated the interface (52/83, 63%) and layout (46/83, 55%). In total, 61% (51/83) stated that they learned something new from the intervention. Parents with over 4 years of university education and in 1-child households used the intervention website more than those with 4 years or less of university education (8.4 vs 5.9 days in total, P=.04) and households with more than 1 child (8.3 vs 5.8 days in total, P=.04), respectively. CONCLUSIONS: The Food4toddlers intervention website was found to be relevant by most participants in the intervention group, although usage of the website differed according to educational level and family composition. For eHealth interventions to be effective, intervention materials such as websites must be used by the target group. Our results highlight the need to include users from different groups when developing interventions. TRIAL REGISTRATION: ISRCTN Registry ISRCTN92980420; http://www.isrctn.com/ISRCTN92980420.

Can Parenting Practices Moderate the Relationship between Reward Sensitivity and Adolescents' Consumption of Snacks and Sugar-Sweetened Beverages?

BACKGROUND: Reward sensitivity has been associated with adolescents' intake of unhealthy snacks and sugar-sweetened beverages. However, so far, there are no studies published describing the impact of parenting practices on this relationship. The present study will, therefore, investigate whether food parenting practices can moderate the association between reward sensitivity and diet intakes. METHOD: A cross-sectional research study was conducted among 14- to 16-year old Flemish adolescents (n = 867, age 14.7 ± 0.8 y, 48.1% boys) and a subset of their parents (n = 131), collecting data on daily intakes, reward sensitivity, and food parenting practices. Linear regression was used to assess the moderation effect of parenting practices (both adolescent- and parent-reported) on the relationship between reward sensitivity, and diet using SPSS 25.0. RESULTS: In the main analysis (adolescent-reported), no significant moderation effects were found for parenting practices on the relationship between reward sensitivity and diet. However, the sensitivity analysis (parent-reported) showed a moderation effect for health-reducing parenting practices on the association between reward sensitivity and unhealthy snack intake (ß = 0.297, 95% CI = 0.062, 0.531, p = 0.01). CONCLUSION: Given the difference in the effect of parenting practices between the adolescent- and parent-reported data, our inconclusive findings warrant more research in larger adolescent-parent dyad samples.

Disposition-Content Congruency in Adolescents' Alcohol-Related Social Media (Self-) Effects: The Role of the Five-Factor Model.

OBJECTIVE: Accumulating evidence indicates that social networking sites play an increasingly important role in young people's drinking behavior. The present study adds to this research by assessing the conditionality of the relationships between exposure to and self-sharing of alcohol-related content on social media and adolescents' drinking behavior. Specifically, the moderating role of the five-factor model of personality is determined. METHOD: A cross-sectional survey study was conducted among 866 mid-adolescents (Msubsample = 14.85 years, SD = 0.71, 57.5% girls). Polynomial regression analysis with response surface modeling was used to test the interactions. RESULTS: Exposure, but not self-sharing, was directly associated with more alcohol consumption. However, it appeared that the act of sharing was more important than the frequency of sharing. Next, the relationship between exposure and consumption was not found to be moderated by personality. In contrast, there were significant linear and nonlinear interactions between self-sharing and all five personality traits. Individuals who are predisposed to engage in more alcohol consumption experience a stronger association between self-sharing and their drinking behavior. CONCLUSIONS: Social media can play a role in adolescents' drinking behavior, but this role is partially dependent on temperamental predispositions.

Free school meals as an approach to reduce health inequalities among 10-12- year-old Norwegian children.

BACKGROUND: Children spend a considerable amount of time at school and consume at least one meal/day. This study aimed to investigate if a free, healthy school meal every day for one school year was associated with children's intake of healthy foods at school, weight status and moderating effects of socio-economic status. METHODS: A non-randomized study design with an intervention and a control group was used to measure change in children's dietary habits at lunchtime. In total, 164 children participated; 55 in the intervention group and 109 in the control group (baseline). Intervention-children were served a free, healthy school meal every school day for one year. Participating children completed a food frequency questionnaire at baseline, at five months follow-up and after one year. Children's anthropometrics were measured at all three timepoints. Intervention effects on children's Healthy food score, BMI z-scores, and waist circumference were examined by conducting a Repeated Measures Multivariate ANOVA. Moderating effects of children's gender and parental socio-economic status were investigated for each outcome. RESULTS: A significant intervention effect on children's outcomes (multivariate) between baseline and after one year (F = 2.409, p < 0.001), and between follow-up 1 at five months and after one year (F = 8.209, p < 0.001) compared to the control group was found. The Univariate analyses showed a greater increase in the Healthy food score of the intervention group between baseline and follow-up 1 (F = 4.184, p = 0.043) and follow-up 2 (F = 10.941, p = 0.001) compared to the control group. The intervention-children had a significant increase in BMI z-scores between baseline and follow-up 2 (F = 10.007, p = 0,002) and between follow-up 1 and 2 (F = 22.245, p < 0.001) compared to a decrease in the control-children. The intervention-children with lower socio-economic status had a significantly higher increase in Healthy food score between baseline and follow-up 2 than the control-children with lower socio-economic status (difference of 2.8 versus 0.94), but not among children with higher socio-economic status. CONCLUSIONS: Serving a free school meal for one year increased children's intake of healthy foods, especially among children with lower socio-economic status. This study may contribute to promoting healthy eating and suggests a way forward to reduce health inequalities among school children. TRIAL REGISTRATION: ISRCTN61703361 . Date of registration: December 3rd, 2018. Retrospectively registered.

The Food4toddlers study - study protocol for a web-based intervention to promote healthy diets for toddlers: a randomized controlled trial.

BACKGROUND: Eating habits are established during childhood and track into adolescence and later in life. Given that these habits have a large public health impact and influence the increasing rates of childhood obesity worldwide, there is a need for effective, evidence-based prevention trials promoting healthy eating habits in the first 2 years of life. The aim of this study was to develop and evaluate the effect of an eHealth intervention called Food4toddlers, aiming to promote healthy dietary habits in toddlers by targeting parents' awareness of their child's food environment (i.e., how food is provided or presented) and eating environment (e.g., feeding practices and social interaction). This paper describes the rationale, development, and evaluation design of this project. METHODS/DESIGN: We developed a 6-month eHealth intervention, with the extensive user involvement of health care nurses and parents of toddlers. This intervention is in line with the social cognitive theory, targeting the interwoven relationship between the person, behavior, and environment, with an emphasis on environmental factors. The intervention website includes recipes, information, activities, and collaboration opportunities. The Food4toddlers website can be used as a mobile application. To evaluate the intervention, a two-armed pre-post-follow-up randomized controlled trial is presently being conducted in Norway. Parents of toddlers (n = 404) were recruited via social media (Facebook) and 298 provided baseline data of their toddlers at age 12 months. After baseline measurements, participants were randomly allocated to an intervention group or control group. Primary outcomes are the child's diet quality and food variety. All participants will be followed up at age 18 months, 2 years, and 4 years. DISCUSSION: The results of this trial will provide evidence to increase knowledge about the effectiveness of an eHealth intervention targeting parents and their toddler's dietary habits. TRIAL REGISTRATION: ISRCTN92980420 . Registered 13 September 2017. Retrospectively registered.

Feasibility and impact study of a reward-based mobile application to improve adolescents' snacking habits.

OBJECTIVE: Adolescents' snacking habits are driven by both explicit reflective and implicit hedonic processes. Hedonic pathways and differences in sensitivity to food rewards in addition to reflective determinants should be considered. The present study evaluated the feasibility and impact of a mobile phone-delivered intervention, incorporating explicit reflective and implicit rewarding strategies, on adolescents' snack intake. DESIGN: Adolescents (n 988; mean age 14·9 (sd 0·70) years, 59·4 % boys) completed a non-randomized clustered controlled trial. Adolescents (n 416) in the intervention schools (n 3) were provided with the intervention application for four weeks, while adolescents (n 572) in the control schools (n 3) followed the regular curriculum. Outcomes were differences in healthy snacking ratio and key determinants (awareness, intention, attitude, self-efficacy, habits and knowledge). Process evaluation data were collected via questionnaires and through log data of the app. RESULTS: No significant positive intervention effects on the healthy snack ratio (b=-3·52 (se 1·82), P>0·05) or targeted determinants were observed. Only 268 adolescents started using the app, of whom only fifty-five (20·5 %) still logged in after four weeks. Within the group of users, higher exposure to the app was not significantly associated with positive intervention effects. App satisfaction ratings were low in both high and low user groups. Moderation analyses revealed small positive intervention effects on the healthy snack ratio in high compared with low reward-sensitive boys (b=1·38 (se 0·59), P<0·05). CONCLUSIONS: The intervention was not able to improve adolescents' snack choices, due to low reach and exposure. Future interventions should consider multicomponent interventions, teacher engagement, exhaustive participatory app content development and tailoring.

Patterns of objectively measured sedentary time in 10- to 12-year-old Belgian children: an observational study within the ENERGY-project.

BACKGROUND: This study examined the frequency of and differences in sedentary bouts of different durations and the total time spent in sedentary bouts on a weekday, a weekend day, during school hours, during after-school hours and in the evening period in a sample of 10- to 12-year-old Belgian children. METHODS: Accelerometer data were collected as part of the ENERGY-project in Belgium (n = 577, 10.9 ± 0.7 years, 53% girls) in 2011. Differences in total sedentary time, sedentary bouts of 2-5, 5-10, 10-20, 20-30 and ≥30 min and total time accumulated in those bouts were examined on a weekday, a weekend day, during school hours, during after-school hours and in the evening period, using multilevel analyses in MLwiN 2.22. RESULTS: More than 60% of the participants' waking time was spent sedentary. Children typically engaged in short sedentary bouts of 2-5 and 5-10 min, which contributed almost 50% towards their total daily sedentary time. Although the differences were very small, children engaged in significantly fewer sedentary bouts of nearly all durations during after-school hours compared to during school hours and in the evening period. Children also engaged in significantly fewer sedentary bouts of 5-10, 10-20, and 20-30 min per hour on a weekend day than on a weekday. CONCLUSIONS: Although primary school children spend more than 60% of their waking time sedentary, they generally engaged in short sedentary bouts. Children's sedentary bouts were slightly longer on weekdays, particularly during school hours and in the evening period, although the differences were very small. These results suggest that in this age group, interventions focusing on reducing total sedentary time rather than interrupting prolonged sedentary time are needed.

Parent engagement and attendance in PEACH™ QLD - an up-scaled parent-led childhood obesity program.

BACKGROUND: Parenting, Eating and Activity for Child Health (PEACH™) is a multicomponent treatment program delivered over ten group sessions to parents of overweight/obese primary school-aged children. It has been shown to be efficacious in an RCT and was recently translated to a large-scale community intervention funded by the Queensland (Australia) Government. Engagement (enrolment and attendance) was critical to achieving program outcomes and was challenging. The purpose of the present study was to examine sample characteristics and mediating factors that potentially influenced program attendance. METHODS: Data collected from parents who attended at least one PEACH™ Queensland session delivered between October 2013 and October 2015 (47 programs implemented in 29 discrete sites), was used in preliminary descriptive analyses of sample characteristics and multilevel single linear regression analyses. Mediation analysis examined associations between socio-demographic and parent characteristics and attendance at group sessions and potential mediation by child and parent factors. RESULTS: 365/467 (78%) enrolled families (92% mothers) including 411/519 (79%) children (55% girls, mean age 9 ± 2 years) attended at least one session (mean 5.6 ± 3.2). A majority of families (69%) self-referred to the program. Program attendance was greater in: advantaged (5.9 ± 3.1 sessions) vs disadvantaged families (5.4 ± 3.4 sessions) (p < 0.05); partnered (6.1 ± 3.1 sessions) vs un-partnered parents (5.0 ± 3.1 sessions) (p < 0.01); higher educated (6.1 ± 3.0 sessions) vs lower educated parents (5.1 ± 3.3 sessions) (p = 0.02); and self-referral (6.1 ± 3.1) vs professional referral (4.7 ± 3.3) (p < 0.001). Child (age, gender, pre-program healthy eating) and parent (perceptions of child weight, self-efficacy) factors did not mediate these relationships. CONCLUSIONS: To promote reach and effectiveness of up-scaled programs, it is important to identify ways to engage less advantaged families who carry higher child obesity risk. Understanding differences in referral source and parent readiness for change may assist in tailoring program content. The influence of program-level factors (e.g. facilitator and setting characteristics) should be investigated as possible alternative mediators to program engagement.