Experiences and Attitudes of Parents Reducing Carbohydrate Intake in the Management of Their Child's Type 1 Diabetes: A Qualitative Study.

Reducing carbohydrate (CHO) intake is being used as an approach to manage type 1 diabetes (T1D) in children. This study aimed to investigate the experiences and attitudes of parents of children with T1D who are reducing CHO intake to help manage blood glucose levels (BGLs). Semi-structured interviews were conducted with the parents of children with T1D for >1 year who reported implementing a low CHO approach to manage BGLs. Data were analysed using a constant comparative analysis approach. Participants (n = 14) were parents of children (6.6 ± 2.0 years) with T1D in Western Australia. All parents reported different methods of CHO restriction and all perceived that benefits outweighed challenges. Parents reported feeling less worried, had improved sleep and felt their child was safer when using a low CHO approach due to more stable BGLs. Reported challenges included: increased cost and time spent preparing food; perceived judgement from others; and child dissatisfaction with restricted food choices. Parents reported accessing information and support through social media networks. Parents reported a desire for more research into this approach. Understanding the promoters and barriers for this dietary approach may inform strategies to better engage and support families with approaches that align with current evidence while considering their concerns around safety and hyperglycaemia.

Healthy and Sustainable Diet Index: Development, Application and Evaluation Using Image-Based Food Records.

There are limited methods to assess how dietary patterns adhere to a healthy and sustainable diet. The aim of this study was to develop a theoretically derived Healthy and Sustainable Diet Index (HSDI). The HSDI uses 12 components within five categories related to environmental sustainability: animal-based foods, seasonal fruits and vegetables, ultra-processed energy-dense nutrient-poor foods, packaged foods and food waste. A maximum of 90 points indicates the highest adherence. The HSDI was applied to 4-day mobile food records (mFRTM) from 247 adults (18−30 years). The mean HSDI score was 42.7 (SD 9.3). Participants who ate meat were less likely to eat vegetables (p < 0.001) and those who ate non-animal protein foods were more likely to eat more fruit (p < 0.001), vegetables (p < 0.05), and milk, yoghurt and cheese (p < 0.05). After adjusting for age, sex and body mass index, multivariable regression found the strongest predictor of the likelihood of being in the lowest total HSDI score tertile were people who only took a bit of notice [OR (95%CI) 5.276 (1.775, 15.681) p < 0.005] or did not pay much/any attention to the health aspects of their diet [OR (95%CI) 8.308 (2.572, 26.836) p < 0.0001]. HSDI provides a new reference standard to assess adherence to a healthy and sustainable diet.

The Nutritional Quality of Kids' Menus from Cafés and Restaurants: An Australian Cross-Sectional Study.

Australian families increasingly rely on eating foods from outside the home, which increases intake of energy-dense nutrient-poor foods. 'Kids' Menus' are designed to appeal to families and typically lack healthy options. However, the nutritional quality of Kids' Menus from cafes and full-service restaurants (as opposed to fast-food outlets) has not been investigated in Australia. The aim of this study was to evaluate the nutritional quality of Kids' Menus in restaurants and cafés in metropolitan Perth, Western Australia. All 787 cafes and restaurants located within the East Metropolitan Health Service area were contacted and 33% had a separate Kids' Menu. The validated Kids' Menu Healthy Score (KIMEHS) was used to assess the nutritional quality of the Kids' Menus. Almost all Kids' Menus (99%) were rated 'unhealthy' using KIMEHS. The mean KIMEHS score for all restaurants and cafés was -8.5 (range -14.5 to +3.5) which was lower (i.e., more unhealthy) than the mean KIMEHS score for the top 10 most frequented chain fast-food outlets (mean -3.5, range -6.5 to +3). The findings highlight the need for additional supports to make improvements in the nutritional quality of Kids' Menus. Local Government Public Health Plans provide an opportunity for policy interventions, using locally relevant tools to guide decision making.

Demographic and psychosocial correlates of measurement error and reactivity bias in a four-day image-based mobile food record among adults with overweight and obesity.

Improving dietary reporting among people living with obesity is challenging as many factors influence reporting accuracy. Reactive reporting may occur in response to dietary recording but little is known about how image-based methods influence this process. Using a 4-day image-based mobile food record (mFRTM), this study aimed to identify demographic and psychosocial correlates of measurement error and reactivity bias, among adults with BMI 25-40kg/m2. Participants (n=155, aged 18-65y) completed psychosocial questionnaires, and kept a 4-day mFRTM. Energy expenditure (EE) was estimated using ≥4 days of hip-worn accelerometer data, and energy intake (EI) was measured using mFRTM. Energy intake: energy expenditure ratios were calculated, and participants in the highest tertile were considered to have Plausible Intakes. Negative changes in EI according to regression slopes indicated Reactive Reporting. Mean EI was 72% (SD=21) of estimated EE. Among participants with Plausible Intakes, mean EI was 96% (SD=13) of estimated EE. Higher BMI (OR 0.81, 95%CI 0.72-0.92) and greater need for social approval (OR 0.31, 95% CI 0.10-0.96), were associated with lower likelihood of Plausible Intakes. Estimated EI decreased by 3% per day of recording (IQR -14%,6%) among all participants. The EI of Reactive Reporters (n=52) decreased by 17%/day (IQR -23%,-13%). A history of weight loss (>10kg) (OR 3.4, 95% CI 1.5-7.8), and higher percentage of daily energy from protein (OR 1.1, 95%CI 1.0-1.2) were associated with greater odds of Reactive Reporting. Identification of reactivity to measurement, as well as Plausible Intakes, is recommended in community-dwelling studies to highlight and address sources of bias.

Effects of Dietary Fat and Protein on Glucoregulatory Hormones in Adolescents and Young Adults With Type 1 Diabetes.

CONTEXT: Dietary fat and protein impact postprandial hyperglycemia in people with type 1 diabetes, but the underlying mechanisms are poorly understood. Glucoregulatory hormones are also known to modulate gastric emptying and may contribute to this effect. OBJECTIVE: Investigate the effects of fat and protein on glucagon-like peptide (GLP-1), glucagon-dependent insulinotropic polypeptide (GIP) and glucagon secretion. METHODS: 2 crossover euglycemic insulin clamp clinical trials at 2 Australian pediatric diabetes centers. Participants were 12-21 years (n = 21) with type 1 diabetes for ≥1 year. Participants consumed a low-protein (LP) or high-protein (HP) meal in Study 1, and low-protein/low-fat (LPLF) or high-protein/high-fat (HPHF) meal in Study 2, all containing 30 g of carbohydrate. An insulin clamp was used to maintain postprandial euglycemia and plasma glucoregulatory hormones were measured every 30 minutes for 5 hours. Data from both cohorts (n = 11, 10) were analyzed separately. The main outcome measure was area under the curve of GLP-1, GIP, and glucagon. RESULTS: Meals low in fat and protein had minimal effect on GLP-1, while there was sustained elevation after HP (80.3 ± 16.8 pmol/L) vs LP (56.9 ± 18.6), P = .016, and HPHF (103.0 ± 26.9) vs LPLF (69.5 ± 31.9) meals, P = .002. The prompt rise in GIP after all meals was greater after HP (190.2 ± 35.7 pmol/L) vs LP (152.3 ± 23.3), P = .003, and HPHF (258.6 ± 31.0) vs LPLF (151.7 ± 29.4), P < .001. A rise in glucagon was also seen in response to protein, and HP (292.5 ± 88.1 pg/mL) vs LP (182.8 ± 48.5), P = .010. CONCLUSION: The impact of fat and protein on postprandial glucose excursions may be mediated by the differential secretion of glucoregulatory hormones. Further studies to better understand these mechanisms may lead to improved personalized postprandial glucose management.

Substantial Intra-Individual Variability in Post-Prandial Time to Peak in Controlled and Free-Living Conditions in Children with Type 1 Diabetes.

The optimal time to bolus insulin for meals is challenging for children and adolescents with type 1 diabetes (T1D). Current guidelines to control glucose excursions do not account for individual differences in glycaemic responses to meals. This study aimed to examine the within- and between-person variability in time to peak (TTP) glycaemic responses after consuming meals under controlled and free-living conditions. Participants aged 8-15 years with T1D ≥ 1 year and using a continuous glucose monitor (CGM) were recruited. Participants consumed a standardised breakfast for six controlled days and maintained their usual daily routine for 14 free-living days. CGM traces were collected after eating. Linear mixed models were used to identify within- and between-person variability in the TTP after each of the controlled breakfasts, free-living breakfasts (FLB), and free-living dinners (FLD) conditions. Thirty participants completed the study (16 females; mean age and standard deviation (SD) 10.5 (1.9)). The TTP variability was greater within a person than the variability between people for all three meal types (between-person vs. within-person SD; controlled breakfast 18.5 vs. 38.9 min; FLB 14.1 vs. 49.6 min; FLD 5.7 vs. 64.5 min). For the first time, the study showed that within-person variability in TTP glycaemic responses is even greater than between-person variability.

Additional Insulin Is Required in Both the Early and Late Postprandial Periods for Meals High in Protein and Fat: A Randomized Trial.

CONTEXT: The pattern and quantity of insulin required for high-protein high-fat (HPHF) meals is not well understood. OBJECTIVE: This study aimed to determine the amount and delivery pattern of insulin required to maintain euglycemia for 5 hours after consuming a HPHF meal compared with a low-protein low-fat (LPLF) meal. METHODS: This randomized crossover clinical trial, conducted at 2 Australian pediatric diabetes centers, included 10 patients (12-21 years of age) with type 1 diabetes for ≥ 1 year. Participants were randomized to HPHF meal (60 g protein, 40 g fat) or LPLF meal (5 g protein, 5 g fat) with identical carbohydrate content (30 g). A modified insulin clamp technique was used to determine insulin requirements to maintain postprandial euglycemia for 5 hours. Total mean insulin requirements over 5 hours were measured. RESULTS: The total mean insulin requirements for the HPHF meal were significantly greater than for the LPLF meal (11.0 [CI 9.2, 12.8] units vs 5.7 [CI 3.8, 7.5] units; P = 0.001). Extra intravenous insulin was required for HPHF: 0 to 2 hours (extra 1.2 [CI 0.6, 1.6] units/h), 2 to 4 hours (extra 1.1 [CI 0.6, 1.6] units/h), and 4 to 5 hours (extra 0.6 [CI 0.1, 1.1] units/h) after the meal. There were marked inter-individual differences in the quantity of additional insulin (0.3 to 5 times more for HPHF) and the pattern of insulin delivery (0%-85% of additional insulin required in the first 2 hours). CONCLUSION: The addition of protein and fat to a standardized carbohydrate meal almost doubled the mean insulin requirement, with most participants requiring half of the additional insulin in the first 2 hours.

Correction: Improving Nutrition and Activity Behaviors Using Digital Technology and Tailored Feedback: Protocol for the Tailored Diet and Activity (ToDAy) Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/12782.].

Improving Nutrition and Activity Behaviors Using Digital Technology and Tailored Feedback: Protocol for the Tailored Diet and Activity (ToDAy) Randomized Controlled Trial.

BACKGROUND: Excess weight is a major risk factor for chronic diseases. In Australia, over 60% of adults are overweight or obese. The overconsumption of energy-dense nutrient-poor (EDNP) foods and low physical activity (PA) levels are key factors contributing to population obesity. New cost-effective approaches to improve population diet and PA behaviors are needed. OBJECTIVE: This 1-year randomized controlled trial (6-month intervention and 6-month follow-up) aims to investigate whether a tailored intervention using mobile technology can improve diet and PA behaviors leading to weight loss in adults (aged 18-65 years) who are overweight or obese and recruited through a social marketing campaign (LiveLighter). METHODS: All eligible participants will provide data on demographics and lifestyle behaviors online at baseline, 6 months, and 12 months. Using two-stage randomization, participants will be allocated into one of three conditions (n=200 per group): tailored feedback delivered via email at seven time points, informed by objective dietary (mobile food record app) and activity (wearable activity monitor) assessment; active control receiving no tailored feedback, but undergoing the same objective assessments as tailored feedback; and online control receiving no tailored feedback or objective assessments. Primary outcome measures at 6 and 12 months are changes in body mass, EDNP food and beverage consumption, and daily moderate-to-vigorous PA (measured via accelerometry). Secondary outcomes include change in fruit and vegetable consumption, daily sedentary behaviors, and cost effectiveness. RESULTS: Enrolment commenced in August 2017. Primary outcomes at 12 months will be available for analysis from September 2019. CONCLUSIONS: Tailored email feedback provided to individuals may deliver a cost-effective strategy to overcome existing barriers to improving diet and PA. If found to be successful and cost effective, upscaling this intervention for inclusion in larger-scale interventions is highly feasible. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617000554369; https://www.anzctr.org.au /Trial/Registration/TrialReview.aspx?id=371325&isReview=true. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12782.

Image-Based Dietary Assessment and Tailored Feedback Using Mobile Technology: Mediating Behavior Change in Young Adults.

Assessing the implementation of nutrition interventions is important to identify characteristics and dietary patterns of individuals who benefit most. The aim was to report on young adults' experiences of receiving dietary feedback text messaging intervention. Diet was captured using an image-based 4-day mobile food recordTM application (mFRTM) and assessed to formulate two tailored feedback text messages on fruit and vegetables and energy-dense nutrient-poor (EDNP) foods and beverages. At 6-months 143 participants completed a second mFRTM and a questionnaire evaluating the dietary feedback. Participants who agreed the text messages made them think about how much vegetables they ate were more likely to increase their intake by at least half a serve than those who disagreed [odds ratio (OR) = 4.28, 95% Confidence Interval (CI): 1.76 to 10.39]. Those who agreed the text messages made them think about how much EDNP foods they ate, were twice as likely to decrease their intake by over half a serve (OR = 2.39, 95%CI: 1.12 to 5.25) than those who disagreed. Undertaking detailed dietary assessment ensured the tailored feedback was constructive and relevant. Personal contemplation about vegetable and EDNP food intake appears to be a mediator of dietary change in young adults.

Healthy and sustainable diets: Community concern about the effect of the future food environments and support for government regulating sustainable food supplies in Western Australia.

OBJECTIVE: To determine the level of community concern about future food supplies and perception of the importance placed on government regulation over the supply of environmentally friendly food and identify dietary and other factors associated with these beliefs in Western Australia. DESIGN: Data from the 2009 and 2012 Nutrition Monitoring Survey Series computer-assisted telephone interviews were pooled. Level of concern about the effect of the environment on future food supplies and importance of government regulating the supply of environmentally friendly food were measured. Multivariate regression analysed potential associations with sociodemographic variables, dietary health consciousness, weight status and self-reported intake of eight foods consistent with a sustainable diet. SETTING: Western Australia. SUBJECTS: Community-dwelling adults aged 18-64 years (n = 2832). RESULTS: Seventy nine per cent of Western Australians were 'quite' or 'very' concerned about the effect of the environment on future food supplies. Respondents who paid less attention to the health aspects of their diet were less likely than those who were health conscious ('quite' or 'very' concerned) (OR = 0.53, 95% CI [0.35, 0.8] and 0.38 [0.17, 0.81] respectively). The majority of respondents (85.3%) thought it was 'quite' or 'very' important that government had regulatory control over an environmentally friendly food supply. Females were more likely than males to rate regulatory control as 'quite' or 'very' important' (OR = 1.63, 95% CI [1.09, 2.44], p = .02). Multiple regression modeling found that no other factors predicted concern or importance. CONCLUSIONS: There is a high level of community concern about the impact of the environment on future food supplies and most people believe it is important that the government regulates the issue. These attitudes dominate regardless of sociodemographic characteristics, weight status or sustainable dietary behaviours.

Perception v. actual intakes of junk food and sugar-sweetened beverages in Australian young adults: assessed using the mobile food record.

OBJECTIVE: To determine perception v. actual intakes of energy-dense nutrient-poor 'junk food' (JF) and sugar-sweetened beverages (SSB) in young adults, using the mobile food record (mFR). DESIGN: Before-and-after eating images using a 4 d mFR were assessed for standardised 600 kJ (143 kcal) servings of JF and SSB (excluding diet drinks). Participants reported their concern about the health aspects of their diet, perceptions and intentions regarding JF and SSB. SETTING: Perth, Western Australia. SUBJECTS: Adults (n 246) aged 18-30 years. RESULTS: The mean (sd) intake of JF+SSB was 3·7 (2·0) servings/d. Women thinking about drinking less SSB consumed more SSB servings/d (1·5 (1·2)) than men (0·7 (0·5); P<0·05) who were thinking about drinking less. Men not thinking about cutting down JF consumed more servings/d (4·6 (2·4)) than women (2·5 (0·7); P<0·01) who were not thinking about cutting down. Those who paid a lot of attention to the health aspects of their diet consumed less JF+SSB than those who took only a bit of notice (P<0·001), were not really thinking much about it (P<0·001) or who didn't think at all about the health aspects of food (P<0·01). CONCLUSIONS: Perceptions and attitudes regarding JF and SSB were associated with level of consumption. Those not thinking about cutting down their intake of these foods represent an important target group as they consume more than their peers. Further research is needed to identify how amenable young adults are to changing their intake, particularly given the lack of attention paid to the health aspects of their diet.

BMI is Associated with the Willingness to Record Diet with a Mobile Food Record among Adults Participating in Dietary Interventions.

Image-based dietary assessment methods have the potential to address respondent burden and improve engagement in the task of recording for dietary interventions. The aim of this study was to assess factors associated with the willingness of adults to take images of food and beverages using a mobile food record (mFR) application. A combined sample of 212 young adults and 73 overweight and obese adults completed a 4-day mobile food record on two occasions and a follow-up usability questionnaire. About 74% of participants stated they would record using the mFR for a longer period compared with a written record (29.4 ± 69.3 vs. 16.1 ± 42.6 days respectively; p < 0.0005). Multivariable logistic regression was used to identify those who were more likely to record mFR in the top tertile (≥14 days). After adjusting for age and gender, those with a BMI ≥ 25 were 1.68 times more likely (Odds Ratio 95% Confidence Interval: 1.02-2.77) than those with BMI < 25 to state a willingness to record with the mFR for ≥ 14 days. The greater willingness of overweight and obese individuals to record dietary intake using an mFR needs further examination to determine if this translates to more accurate estimates of energy intake.

The connecting health and technology study: a 6-month randomized controlled trial to improve nutrition behaviours using a mobile food record and text messaging support in young adults.

BACKGROUND: Early adulthood represents the transition to independent living which is a period when changes in diet and body weight are likely to occur. This presents an ideal time for health interventions to reduce the effect of health problems and risk factors for chronic disease in later life. As young adults are high users of mobile devices, interventions that use this technology may improve engagement. The Connecting Health and Technology study aimed to evaluate the effectiveness of tailored dietary feedback and weekly text messaging to improve dietary intake of fruit, vegetables and junk food over 6 months among a population-based sample of men and women (aged 18-30 years). METHODS: A three-arm, parallel, randomized control trial was conducted. After baseline assessments, participants were randomized to one of three groups: A) dietary feedback and weekly text messages, B) dietary feedback only or C) control group. Dietary intake was assessed using a mobile food record App (mFR) where participants captured images of foods and beverages consumed over 4-days at baseline and post-intervention. The primary outcomes were changes in serves of fruits, vegetables, energy-dense nutrient-poor (EDNP) foods and sugar-sweetened beverages (SSB). The intervention effects were assessed using linear mixed effect models for change in food group serves. RESULTS: Young adults (n = 247) were randomized to group A (n = 82), group B (n = 83), or group C (n = 82). Overall, no changes in food group serves for either intervention groups were observed. An unanticipated outcome was a mean weight reduction of 1.7 kg (P = .02) among the dietary feedback only. Men who received dietary feedback only, significantly reduced their serves of EDNP foods by a mean of 1.4 serves/day (P = .02). Women who received dietary feedback only significantly reduced their intake of SSB (P = .04) by an average of 0.2 serves/day compared with controls. CONCLUSIONS: Tailored dietary feedback only resulted in a decrease in EDNP foods in men and SSB in women, together with a reduction in body weight. Using a mobile food record for dietary assessment and tailored feedback has great potential for future health promotion interventions targeting diet and weight in young adults. TRIAL REGISTRATION: Australian Clinical Trials Registry Registration number: ACTRN12612000250831 .

A Novel Dietary Assessment Method to Measure a Healthy and Sustainable Diet Using the Mobile Food Record: Protocol and Methodology.

The world-wide rise in obesity parallels growing concerns of global warming and depleting natural resources. These issues are often considered separately but there may be considerable benefit to raising awareness of the impact of dietary behaviours and practices on the food supply. Australians have diets inconsistent with recommendations, typically low in fruit and vegetables and high in energy-dense nutrient-poor foods and beverages (EDNP). These EDNP foods are often highly processed and packaged, negatively influencing both health and the environment. This paper describes a proposed dietary assessment method to measure healthy and sustainable dietary behaviours using 4-days of food and beverage images from the mobile food record (mFR) application. The mFR images will be assessed for serves of fruit and vegetables (including seasonality), dairy, eggs and red meat, poultry and fish, ultra-processed EDNP foods, individually packaged foods, and plate waste. A prediction model for a Healthy and Sustainable Diet Index will be developed and tested for validity and reliability. The use of the mFR to assess adherence to a healthy and sustainable diet is a novel and innovative approach to dietary assessment and will have application in population monitoring, guiding intervention development, educating consumers, health professionals and policy makers, and influencing dietary recommendations.

How willing are adolescents to record their dietary intake? The mobile food record.

BACKGROUND: Accurately assessing the diets of children and adolescents can be problematic. Use of technologies, such as mobile apps designed to capture food and beverages consumed at eating occasions with images taken using device-embedded cameras, may address many of the barriers to gathering accurate dietary intake data from adolescents. OBJECTIVE: The objectives of this study were to assess the willingness of adolescents to take images of food and beverages at their eating occasions using a novel mobile food record (mFR) and to evaluate the usability of the user confirmation component of the mFR app, referred to as the "review process." METHODS: Mixed methods combining quantitative and qualitative protocols were used in this study. Adolescents (11-15-year olds) attending a summer camp were recruited to participate in the study. First, the participants were asked to take images of foods and beverages consumed as meals and snacks for 2 consecutive days using the mFR app running on an iPhone and the number of images taken was noted. This was followed by focus group sessions to evaluate usability, which was analyzed by content and themes. After using the mFR, a think-aloud method was used to evaluate the usability of the mFR method for reviewing system-identified foods (ie, the review process). A usability questionnaire was administered at the end of all activities. RESULTS: The mFR was accepted by the majority of the 24 boys and 17 girls (n=41) but varied according to gender and eating occasion. Girls were significantly more likely than boys to capture images of their eating occasions (Fisher exact test, P=.03). Participants were more likely to take images of their breakfasts (90%, 36/40) and lunches (90%, 72/80) and least likely to capture afternoon and evening snacks, 54% (43/80) and 40% (32/80), respectively. The major themes from the focus groups with regard to using the mFR were games, rewards, and the need to know more about why they were using the app. Results of the usability questionnaire indicated that including a game component would be important to increase willingness to use the mFR, and a high majority of the participants indicated a willingness to use the mFR for 7 days or more. The image review process was found to be easy to use except for some confusion with overlapping markers on the screen. CONCLUSIONS: The adolescents' experiences with and feedback about the mFR highlighted the importance of increased training, reminders, entertainment (eg, games), and training with practice in using the device to capture complete dietary intake as part of their active lifestyles.