Behaviour change during dietary Type 2 diabetes remission: a longitudinal qualitative evaluation of an intervention using a very low energy diet.

AIM: To understand the process of behaviour change through the experiences of people with Type 2 diabetes engaged in an 8-month diabetes remission intervention including a 2-month weight loss phase with the use of a very low energy diet (VLED), and a 6-month, structured weight maintenance phase. METHODS: Data were collected in three semi-structured interviews at baseline, week 8 (end of the weight loss phase), and month 8 (end of the weight maintenance phase). Longitudinal inductive thematic analysis was used to analyse participants' narratives and identify change over time. RESULTS: Eleven of 18 participants completed all three interviews. The following themes of change were identified in their narratives: (1) 'Building behavioural autonomy' as a process of growing confidence to engage in health behaviours that are independent of those of other people; (2) 'Behavioural contagion' describing how one's new health behaviours tend to affect those of other people; (3) 'From rigid to flexible restraint', reflecting the changes in attitudes and behaviours required for a successful adaptation from weight loss to weight maintenance; and (4) 'Shift in identity', representing changes in the participants' perceptions of themselves. CONCLUSIONS: This longitudinal qualitative study provided new insights into how behaviour change is experienced by people with Type 2 diabetes engaged on a weight management intervention using VLED, contributing to theoretical and practical understanding of weight management behaviours. The themes identify potential areas in which individuals can be supported in achieving dietary diabetes remission and long-term maintenance of weight loss.

Birth weight and adolescent blood pressure measured at age 12 years in the Gateshead Millennium Study.

Birth weight and early growth have been associated with later blood pressure. However, not all studies consistently find a significant reduction in blood pressure with an increase in birth weight. In addition, the relative importance of birth weight and of other lifestyle and environmental factors is often overlooked and the association is rarely studied in adolescents. We investigated early life predictors, including birth weight, of adolescent blood pressure in the Gateshead Millennium Study (GMS). The GMS is a cohort of 1029 individuals born in 1999-2000 in Gateshead in Northern England. Throughout infancy and early childhood, detailed information were collected, including birth weight and measures of height and weight. Assessments of 491 returning participants at age 12 years included measures of body mass and blood pressure. Linear regression and path analysis were used to determine predictors and their relative importance on blood pressure. Birth weight was not directly associated with blood pressure at the age of 12. However, after adjustment for contemporaneous body mass index (BMI), an inverse association of standardized birth weight on systolic blood pressure was significant. The relative importance of birth weight on later systolic blood pressure was smaller than other contemporaneous body measures (height and BMI). There was no independent association of birth weight on blood pressure seen in this adolescent population. Contemporaneous body measures have an important role to play. Lifestyle factors that influence body mass or size, such as diet and physical activity, where interventions are directed at early prevention of hypertension should be targeted.

Development of the MapMe intervention body image scales of known weight status for 4-5 and 10-11 year old children.

Background: Parents tend to visually assess children to determine their weight status and typically underestimate child body size. A visual tool may aid parents to more accurately assess child weight status and so support strategies to reduce childhood overweight. Body image scales (BIS) are visual images of people ranging from underweight to overweight but none exist for children based on UK criteria. Our aim was to develop sex- and age-specific BIS for children, based on British growth reference (UK90) criteria. Methods: BIS were developed using 3D surface body scans of children, their associated weight status using UK90 criteria from height and weight measurements, and qualitative work with parents and health professionals. Results: Height, weight and 3D body scans were collected (211: 4-5 years; 177: 10-11 years). Overall, 12 qualitative sessions were held with 37 participants. Four BIS (4-5-year-old girls and boys, 10-11-year-old girls and boys) were developed. Conclusions: This study has created the first sex- and age-specific BIS, based on UK90 criteria. The BIS have potential for use in child overweight prevention and management strategies, and in future research. This study also provides a protocol for the development of further BIS appropriate to other age groups and ethnicities.

Acceptability of a very-low-energy diet in Type 2 diabetes: patient experiences and behaviour regulation.

AIMS: To evaluate the acceptability of an 8-week very-low-energy diet for remission of Type 2 diabetes, and to identify barriers and facilitators of adherence and behaviour-regulation strategies used by participants in the Counterbalance study. METHODS: Eighteen of 30 participants in the Counterbalance study (ISRCTN88634530) took part in semi-structured interviews. Of these, 15 participants were interviewed before and after the 8-week very-low-energy diet intervention. Thematic analysis was used to analyse the narratives. RESULTS: The prospect of diabetes remission, considerable weight loss, and long-term health improvement provided participants with substantial initial motivation. This motivation was sustained through the experience of rapid weight loss, improvements in blood glucose levels, social support and increased physical and psychological well-being. Overall, adherence to the very-low-energy diet for 8 weeks was perceived as much easier than anticipated, but required personal effort. Participants addressed challenges by removing food from the environment, planning, avoidance of tempting situations or places, and self-distraction. Weight loss and improvements in blood glucose levels lead to a sense of achievement and improvements in physical and psychological wellbeing. CONCLUSIONS: Dietary treatment for reversal of Type 2 diabetes is acceptable and feasible in motivated participants, and the process is perceived as highly gratifying. Research outside of controlled trial settings is needed to gauge the generalisability of these findings.

Longitudinal study of the associations between change in sedentary behavior and change in adiposity during childhood and adolescence: Gateshead Millennium Study.

BACKGROUND: Sedentary time (ST) has been reported to have a range of negative health effects in adults, however, the evidence for such effects among children and adolescents is sparse. The primary aim of the study was to examine associations between changes in sedentary behavior (time and fragmentation) and changes in adiposity across childhood and adolescence. METHODS: Participants were recruited as part of the Gateshead Millennium Study. Measures were taken at age 7 (n=502), 9 (n=506), 12 (n=420) and 15 years (n=306). Participants wore an ActiGraph GT1M and accelerometer epochs were 'sedentary' when recorded counts were ⩽25 counts per 15 s. ST was calculated and fragmentation (SF) was assessed by calculating the number of sedentary bouts per sedentary hour. Associations of changes in ST and SF with changes in adiposity (body mass index (BMI), and fat mass index (FMI)) were examined using bivariate linear spline models. RESULTS: Increasing ST by 1% per year was associated with an increase in BMI of 0.08 kg m-2 per year (95% CI: 0.06-0.10; P<0.001) and FMI of 0.15 kg m-2 per year (0.11-0.19; P<0.001). Change in SF was associated with BMI and FMI (P<0.001). An increase of 1 bout per sedentary hour per year (that is, sedentary time becoming more fragmented) was associated with an increase in BMI of 0.07 kg m-2 per year (0.06-0.09; P<0.001) and an increase in FMI of 0.14 kg m-2 per year (0.10-0.18; P<0.001) over the 8 years period. However, an increase in SF between 9-12 years was associated with a 0.09 kg m-2 per year decrease in BMI (-0.18-0.00; P=0.046) and 0.11 kg m-2 per year decrease in FMI (-0.22-0.00; P=0.049). CONCLUSIONS: Increased ST and increased SF from 7-15 years were associated with increased adiposity. This is the first study to show age-specific associations between change in objectively measured sedentary behavior and adiposity after adjustment of moderate-to-vigorous-intensity physical activity in children and adolescents. The study suggests that, targeting sedentary behavior for obesity prevention may be most effective during periods in which we see large increases in ST.

Mothers' perceptions of child weight status and the subsequent weight gain of their children: a population-based longitudinal study.

BACKGROUND: There is a plethora of cross-sectional work on maternal perceptions of child weight status showing that mothers typically do not classify their overweight child as being overweight according to commonly used clinical criteria. Awareness of overweight in their child is regarded as an important prerequisite for mothers to initiate appropriate action. The gap in the literature is determining whether, if mothers do classify their overweight child's weight status correctly, this is associated with a positive outcome for the child's body mass index (BMI) at a later stage. OBJECTIVE: To explore longitudinal perceptions of child weight status from mothers of a contemporary population-based birth cohort (Gateshead Millennium Study) and relationships of these perceptions with future child weight gain. METHODS: Data collected in the same cohort at 7, 12 and 15 years of age: mothers' responses to two items concerning their child's body size; child's and mother's BMI; pubertal maturation; demographic information. RESULTS: Mothers' perceptions of whether their child was overweight did not change markedly over time. Child BMI was the only significant predictor of mothers' classification of overweight status, and it was only at the extreme end of the overweight range and in the obese range that mothers reliably described their child as overweight. Even when mothers did appropriately classify their child as overweight at an earlier stage, this was not related to relatively lower child BMI a few years later. CONCLUSIONS: Mothers tend to classify their child as overweight in only more extreme cases. It is an important finding that no beneficial impact was shown on later child BMI in overweight children whose mothers classified their child's weight status as overweight at an earlier stage.

The impact of interventions to promote healthier ready-to-eat meals (to eat in, to take away or to be delivered) sold by specific food outlets open to the general public: a systematic review.

INTRODUCTION: Ready-to-eat meals sold by food outlets that are accessible to the general public are an important target for public health intervention. We conducted a systematic review to assess the impact of such interventions. METHODS: Studies of any design and duration that included any consumer-level or food-outlet-level before-and-after data were included. RESULTS: Thirty studies describing 34 interventions were categorized by type and coded against the Nuffield intervention ladder: restrict choice = trans fat law (n = 1), changing pre-packed children's meal content (n = 1) and food outlet award schemes (n = 2); guide choice = price increases for unhealthier choices (n = 1), incentive (contingent reward) (n = 1) and price decreases for healthier choices (n = 2); enable choice = signposting (highlighting healthier/unhealthier options) (n = 10) and telemarketing (offering support for the provision of healthier options to businesses via telephone) (n = 2); and provide information = calorie labelling law (n = 12), voluntary nutrient labelling (n = 1) and personalized receipts (n = 1). Most interventions were aimed at adults in US fast food chains and assessed customer-level outcomes. More 'intrusive' interventions that restricted or guided choice generally showed a positive impact on food-outlet-level and customer-level outcomes. However, interventions that simply provided information or enabled choice had a negligible impact. CONCLUSION: Interventions to promote healthier ready-to-eat meals sold by food outlets should restrict choice or guide choice through incentives/disincentives. Public health policies and practice that simply involve providing information are unlikely to be effective.

'I'm not trusted in the kitchen': food environments and food behaviours of young people attending school and college.

BACKGROUND: Food behaviours are important in the context of health and obesity. The aim was to explore the environments and food behaviours of a sample of young people in the North East of England to further understanding of the relationship between eating behaviours and environmental context. METHODS: Focus groups were conducted with four groups of young people aged 16-20 years (n = 40; 28 male, 12 female) between November 2006 and June 2007. Analysis was informed by grounded theory methods and was an iterative process of identifying themes across the transcripts. RESULTS: Topics explored included: their main environment, home food responsibility and cooking, food outside of the home, where food was purchased/obtained and where food was eaten and with whom. Emergent themes included: the value for money in food purchases, time convenience, the car as a means of accessing food and health perceptions. CONCLUSIONS: The complexities of the food environment were illustrated. This work has highlighted the importance of the home food environment and parents, and indicated the importance of factors such as time and cost in this age group's food choices. The behavioural norms around food behaviours merit further exploration for this population in transition between adolescence and adulthood.

Serum 25-hydroxyvitamin D concentration and its determinants in the very old: the Newcastle 85+ Study.

SUMMARY: Data on vitamin D status in very old adults are lacking. The aim of this study was to assess 25-hydroxyvitamin D [25(OH)D] concentrations and its predictors in 775 adults aged 85 years old living in North-East England. Low 25(OH)D was alarmingly high during winter/spring months, but its biological significance is unknown. INTRODUCTION: Despite recent concerns about the high prevalence of vitamin D deficiency in much of the British adult and paediatric population, there is a dearth of data on vitamin D status and its predictors in very old adults. The objective of the present study was to describe vitamin D status and its associated factors in a broadly representative sample of very old men and women aged 85 years living in the North East of England (55° N). METHODS: Serum concentrations of 25-hydroxyvitamin D [25(OH)D] were analysed in 775 participants in the baseline phase of the Newcastle 85+ cohort study. Season of blood sampling, dietary, health, lifestyle and anthropometric data were collected and included as potential predictors of vitamin D status in ordinal regression models. RESULTS: Median serum 25(OH)D concentrations were 27, 45, 43 and 33 nmol/L during spring, summer, autumn and winter, respectively. The prevalence of vitamin D deficiency according to North American Institute of Medicine guidelines [serum 25(OH)D <30 nmol/L] varied significantly with season with the highest prevalence observed in spring (51%) and the lowest prevalence observed in autumn (23%; P < 0.001). Reported median (inter-quartile range) dietary intakes of vitamin D were very low at 2.9 (1.2-3.3) µg/day. In multivariate ordinal regression models, non-users of either prescribed or non-prescribed vitamin D preparations and winter and spring blood sampling were associated with lower 25(OH)D concentrations. Dietary vitamin D intake, disability score and disease count were not independently associated with vitamin D status in the cohort. CONCLUSION: There is an alarming high prevalence of vitamin D deficiency (<30 nmol/L) in 85-year-olds living in North East England at all times of the year but particularly during winter and spring. Use of vitamin D containing preparations (both supplements and medications) appeared to be the strongest predictor of 25(OH)D concentrations in these very old adults.

Determinants of changes in sedentary time and breaks in sedentary time among 9 and 12 year old children.

The current study aimed to identify the determinants of objectively measured changes in sedentary time and sedentary fragmentation from age 9- to age 12 years. Data were collected as part of the Gateshead Millennium Birth Cohort study from September 2008 to August 2009 and from January 2012 to November 2012. Participants were 9.3 (± 0.4) years at baseline (n = 508) and 12.5 (± 0.3) years at follow-up (n = 427). Sedentary behaviour was measured using an ActiGraph GT1M accelerometer. Twenty potential determinants were measured, within a socio-ecological model, and tested for their association with changes in sedentary time and the extent to which sedentary behaviour is prolonged or interrupted (fragmentation index). Univariate and multivariate linear regression analyses were conducted. Measurements taken during winter and a greater decrease in moderate-to-vigorous intensity physical activity (MVPA) over time were associated with larger increases in sedentary time (seasonality ß: - 3.03; 95% CI: - 4.52, - 1.54; and change in MVPA ß: - 1.68; 95% CI: - 1.94, - 1.41). Attendance at sport clubs was associated with smaller increases in sedentary time (- 1.99; - 3.44, - 0.54). Girls showed larger decreases in fragmentation index (- 0.52; - 1.01, - 0.02). Interventions aimed at decreasing the decline in MVPA and increasing/maintaining sport club attendance may prevent the rise in sedentary time as children grow older. In addition, winter could be targeted to prevent an increase in sedentary time and reduction in sedentary fragmentation during this season.

Reducing the cost of dietary assessment: self-completed recall and analysis of nutrition for use with children (SCRAN24).

BACKGROUND: Self-Completed Recall and Analysis of Nutrition (scran24) is a prototype computerised 24-h recall system for use with 11-16 year olds. It is based on the Multiple Pass 24-h Recall method and includes prompts and checks throughout the system for forgotten food items. METHODS AND RESULTS: The development of scran24 was informed by an extensive literature review, a series of focus groups and usability testing. The first stage of the recall is a quick list where the user is asked to input all the foods and drinks they remember consuming the previous day. The quick list is structured into meals and snacks. Once the quick list is complete, additional information is collected on each food to determine food type and to obtain an estimate of portion size using digital images of food. Foods are located within the system using a free text search, which is linked to the information entered into the quick list. A time is assigned to each eating occasion using drag and drop onto a timeline. The system prompts the user if no foods or drinks have been consumed within a 3-h time frame, or if fewer than three drinks have been consumed throughout the day. The food composition code and weight (g) of all items selected are automatically allocated and stored. Nutritional information can be generated automatically via the scran24 companion Access database. CONCLUSIONS: scran24 was very well received by young people and was relatively quick to complete. The accuracy and precision was close to that of similar computer-based systems currently used in dietary studies.

Developing an interactive portion size assessment system (IPSAS) for use with children.

Novel methods of assessing dietary intake are required to reduce the participant burden in dietary surveys, improve participation rates and thereby improve the representativeness of the sample and minimise the impact of measuring dietary intake on a subject's food intake during the recording period. One method of reducing the burden placed on participants in recording dietary intake is to replace weighing of foods with estimation of portion size using tools such as food photographs. The interactive portion size assessment system (IPSAS) is an interactive portion size assessment system for use in assessing portion sizes of foods consumed by children aged 18 months to 16 years. The system is computer-based and is designed to be administered during an interview for a food diary or 24-h recall. The portion sizes depicted are age-specific and based on the weights of foods served to children during the UK National Diet and Nutrition Surveys. The system displays digital images of food used to estimate the amount of each food served to the child and the amount of any food left over. Foods are categorised within the system using a three-tier structure. Twenty-seven food group icons are used with two further drop-down menus to select first the food group, then the food category and, finally, the actual food product. Each food is linked to UK food composition codes and all photographs are linked to the weight of the food depicted. Nutritional output is via a companion database. The present study describes the development of the IPSAS and the structure of the system.

Mothers' judgements about their child's weight: distinguishing facts from values.

BACKGROUND: Mothers' responses to questionnaire items assessing their child's weight status typically do not correspond to conventional clinical classifications based on body mass index (BMI). From this observation health professionals infer that mothers do not recognize overweight in their child. But the questions used have generally confounded factual judgements with values, so it is not clear whether the mothers are making factual errors, or differ from professionals in their values. METHODS: Cross-sectional study of population-based birth cohort at 6-8 years and their mothers (n = 540). An objective BMI matching task was used to determine the accuracy of mothers' recognition of their child's weight. Mothers matched their child to sex- and age-specific images of children of known BMI ranging from very thin to obese, and chose a descriptor of their child's weight of the kind used in previous research. RESULTS: Mothers tended to underestimate their child's BMI on the matching task. Matching errors significantly predicted mothers' description of their child's weight; those who overestimated their child's BMI on the matching task were more likely to say their child was overweight, while those who underestimated it were less likely to, independently of their child's actual BMI. CONCLUSIONS: Educational programmes aimed at parents of young primary school children need to address separately the factual and the evaluative components of their assessment of child weight.

Parental perceptions of weight status in children: the Gateshead Millennium Study.

OBJECTIVES: To investigate parents' perceptions of weight status in children and to explore parental understanding of and attitudes to childhood overweight. DESIGN: Questionnaires and focus groups within a longitudinal study. SUBJECTS: 536 parents of Gateshead Millennium Study children, of which 27 attended six focus groups. MAIN OUTCOME MEASURES: Parents' perception of their child's weight status according to actual weight status as defined by International Obesity Taskforce (IOTF) cutoffs. Focus group outcomes included parental awareness of childhood overweight nationally and parental approaches to identifying overweight children. RESULTS: The sensitivity of parents recognising if their child was overweight was 0.31. Prevalence of child overweight was underestimated: 7.3% of children were perceived as 'overweight' or 'very overweight' by their parents, 23.7% were identified as overweight or obese using IOTF criteria. 69.3% of parents of overweight or obese children identified their child as being of 'normal' weight. During focus groups parents demonstrated an awareness of childhood overweight being a problem nationally but their understanding of how it is defined was limited. Parents used alternative approaches to objective measures when identifying overweight in children such as visual assessments and comparisons with other children. Such approaches relied heavily on extreme and exceptional cases as a reference point. The apparent lack of relevance of childhood overweight to their child's school or own community along with scepticism towards both media messages and clinical measures commonly emerged as grounds for failing to engage with the issue at a personal level. CONCLUSION: Parents' ability to identify when their child was overweight according to standard criteria was limited. Parents did not understand, use or trust clinical measures and used alternative approaches primarily reliant on extreme cases. Such approaches underpinned their reasoning for remaining detached from the issue. This study highlights the need to identify methods of improving parental recognition of and engagement with the problem of childhood overweight.

When do mothers think their child is overweight?

OBJECTIVE: To quantify how overweight children have to be for their mothers to classify them as overweight and to express concern about future overweight, and to investigate the adiposity cues in children that mothers respond to. DESIGN: Cross-sectional. SUBJECTS: A total of 531 children from the Gateshead Millennium Study cohort at 6-8 years and their mothers. MEASUREMENTS: In the mother: responses to two questions concerning the child's adiposity; height; weight; educational qualifications; and economic status. In the child: height; weight; waist circumference; skinfold thicknesses; bioelectrical impedance; and bone frame measurements. RESULTS: The body mass index (BMI) at which half the mothers classify their child as overweight was 21.3 (in the obese range for children of this age). The BMI at which half the mothers were concerned about their child becoming overweight in the future was 17.1 (below the overweight range). Waist circumference and skinfolds contributed most to mothers' responses. Although BMI and fat scores were important predictors individually, they did not contribute independently once waist circumference and skinfolds (their most visible manifestations) were included in the regression equations. Mothers were less likely to classify girls as overweight. Mothers with higher BMIs were less likely to classify their child as overweight, but were more likely to be concerned about future overweight. CONCLUSION: Health promotion efforts directed at parents of young primary school children might better capitalise on their concern about future overweight in their child than on current weight status, and focus on mothers' response to more visible characteristics than the BMI.

Packaged food intake by British children aged 0 to 6 years.

The European Union approach to assessing exposure to chemical migrants from plastic food-contact materials has been to assume an intake of 1 kg of food in contact with a particular material, per 60 kg person per day, which equates to 16.7 g kg(-1) body weight. A food packaging surface area-food mass ratio of 6 dm(2)/1 kg is assumed, equivalent to 0.1 dm(2) kg(-1) of body weight. Children might be at increased risk to exposure from migrants as they have higher intakes of food per kg body weight compared with adults. In addition, much of the food marketed for/to children is in small portions and therefore the food-contact material area-food mass ratio is relatively high. To determine if, and how, the European Union model might be modified to ensure specific protection against chemical migration into food marketed for children, data on 4-day food intakes of 297 children aged 0-6 years were collected including information on pack size, pack type and food-contact material area-food mass ratio. The 297 children consumed a total of 1646 kg of food and drink (including tap water), of which 978 kg (59%) was packaged with 67% of this packaged in plastics. Mean intakes of food packaged in plastic ranged from 27 g kg(-1) body weight (for the infants under 1 year) to 51 g kg(-1) body weight (for the 1-4-year-olds). This was higher than the 16.7 g kg(-1) body weight derived from the European Union convention. The mean area of packaging in contact with the food consumed daily per kg body weight were 0.65 dm(2) kg(-1) for the infants under 1 year, 0.81 dm(2) kg(-1) for the 1-4-year-olds, and 0.66 dm(2) kg(-1) for the 4-6-year-olds. All 297 children had intakes that exceeded 0.1 dm(2) of packaging per kg of body weight assumption.

A gamma-ray burst at a redshift of z approximately 8.2.

Long-duration gamma-ray bursts (GRBs) are thought to result from the explosions of certain massive stars, and some are bright enough that they should be observable out to redshifts of z > 20 using current technology. Hitherto, the highest redshift measured for any object was z = 6.96, for a Lyman-alpha emitting galaxy. Here we report that GRB 090423 lies at a redshift of z approximately 8.2, implying that massive stars were being produced and dying as GRBs approximately 630 Myr after the Big Bang. The burst also pinpoints the location of its host galaxy.

Diet, physical activity, sedentary behaviour and perceptions of the environment in young adults.

BACKGROUND: Few studies have explored both food behaviour and physical activity in an environmental context. Most research in this area has focused on adults; the aim of the present study was to describe perceptions of the environment, diet, physical activity and sedentary behaviour patterns in 16-20 year olds in full-time education (Newcastle, UK). METHODS: Participants (n = 73) recruited from a college and sixth-form college completed a UK version of the Youth Neighbourhood Environment Walkability Survey, which included measures of sedentary behaviour. A validated food frequency questionnaire was completed and a factor applied to produce an estimated mean daily frequency of intake of each item, which was converted to nutrient intakes. A rank for Index of Multiple Deprivation (IMD) was assigned to their home postcode. Analysis explored associations between sedentary behaviours and nutrient intake. RESULTS: In this descriptive cross-sectional study, most participants reported being physically active for at least 1 h day(-1) on 3-4 (n = 28) or 5-7 days (n = 31). There were no significant differences in nutrient intake according to sample quartile IMD position. Sedentary behaviours were significantly associated with less healthy eating patterns. Higher total energy (P = 0.02), higher fat (P = 0.005), percentage energy from fat (P = 0.035) and lower carbohydrate intakes (P = 0.004) were significantly associated with more time spent watching DVDs at the weekend. CONCLUSIONS: This combination of sedentary behaviour and less healthy eating patterns has important implications for long-term health (e.g. the tracking of being overweight and obesity from adolescence into adulthood). Understanding behaviour relationships is an important step in developing interventions in this age group.