Effectiveness of the Walking in ScHools (WISH) Study, a peer-led walking intervention for adolescent girls: results of a cluster randomised controlled trial.

BACKGROUND: Most adolescent girls fail to meet current physical activity guidelines. Physical activity behaviours track from childhood into adulthood and providing adolescent girls with opportunities to be physically active may have health benefits beyond childhood. The effects of walking interventions on adult cardiometabolic health are known, however less is understood about the potential of walking to promote physical activity in adolescents. Following the Walking In ScHools (WISH) feasibility study, this definitive trial aimed to evaluate the effectiveness of a novel, low-cost, school-based walking intervention at increasing physical activity levels of adolescent girls (aged 12-14 years). METHODS: Female pupils were recruited from eighteen schools across the border region of Ireland and in Northern Ireland. In intervention schools (n = 9), girls aged 15-18 years, were trained as walk leaders, and led the younger pupils in 10-15 min walks before school, at break and lunch recess. All walks took place in school grounds and pupils were encouraged to participate in as many walks as possible each week. The primary outcome measure was accelerometer determined total physical activity (counts per minutes, cpm). RESULTS: In total, 589 pupils were recruited to the study. At baseline, pupils engaged in a median (interquartile range (IQR)) 35.7 (21.2) mins moderate-vigorous physical activity (MVPA) per day and only 12% (n = 66) of participants met physical activity guidelines (60 min MVPA per day). The intervention was delivered for a mean (standard deviation (SD)) 19.9 ± 0.97 weeks. The mean post-intervention total physical activity for the intervention group was 676 cpm and 710 cpm in the control group. Post-intervention total physical activity did not statistically differ between groups when adjusted for age, body mass index z-scores and baseline physical activity (mean difference, -33.5, 95% CI = -21.2 to 88.1; p = 0.213). CONCLUSIONS: 'Scaling-up' physical activity interventions is challenging and despite a promising feasibility study, the results of this fully powered trial suggest that in this context, the WISH intervention did not increase device measured physical activity. Since the COVID-19 pandemic, school environments have changed and although pupils enjoyed the programme, attendance at walks was low, indicating that there is a need to better understand how to implement interventions within schools. TRIAL REGISTRATION: ISRCTN; ISRCTN12847782; Registered 2nd July 2019.

A peer-led walking intervention for adolescent girls (the WISH study): a cluster-randomised controlled trial.

BACKGROUND: Adolescent girls in the UK and Ireland fail to meet physical activity (PA) guidelines. PA behaviours track from childhood into adulthood. The effects of walking interventions on adult health are known; however, the potential of walking to promote PA in adolescents is less known. This study evaluated the effectiveness of a novel, school-based walking intervention aimed at increasing PA levels of adolescent girls. METHODS: In this cluster-randomised controlled trial, female pupils aged 12-14 years were recruited from 18 (mixed or single-sex) schools across the border region of Ireland and Northern Ireland. Schools were randomly assigned to either the control group (usual physical activity; n=9) or the intervention group (n=9) by independent faculty staff using an online randomisation tool (randomization.com). In intervention schools, female pupils aged 15-18 years were trained as walk leaders and led the younger pupils in 10-15 min walks before school, at break, and at lunchtime. Walks were in school grounds and pupils were encouraged to join as many walks as possible. The intervention was delivered for a full school year excluding holidays (for a total of 18-21 weeks). Accelerometers measured PA, and the primary outcome was total PA (counts per minute [cpm]). Ethics approval was granted by Ulster University Research Ethics Committee and written informed consent (parent or guardian) and assent (pupils) was obtained. This study is registered with the ISRCTN Registry, 12847782. FINDINGS: The study took place from Sept 1, 2021, to May 31, 2023. In total, 589 pupils were recruited (n=286 in intervention group; n=303 in control group). Median moderate-vigorous PA (MVPA) at baseline was 36·1 min/day (IQR 23·0) for the intervention group and 35·3 min/day (19·8) for the control group. Only 37 (15%) girls in the intervention group and 29 (10%) girls in the control group met PA guidelines (60 min/day of MVPA). The mean total PA after intervention was 676 cpm (SD 18·7) for the intervention group and 710 cpm (SD 17·7) for the control group. Post-intervention total PA did not differ between groups when adjusted for age, body-mass index, z-scores, and baseline PA (mean difference -33·5, 95% CI -21·2 to 88·1; p=0·213). INTERPRETATION: Scaling up PA interventions is challenging. Despite a promising feasibility study, the results of this fully powered trial indicate that in this context, the walking programme did not increase PA. Since the COVID-19 pandemic, school environments have changed, and although pupils enjoyed the programme, attendance at walks was low. There is a need to better understand the implementation of interventions such as this within schools. FUNDING: Cross-border Healthcare Intervention Trials in Ireland Network (CHITIN).

'Including us, talking to us and creating a safe environment'-Youth patient and public involvement and the Walking In ScHools (WISH) Study: Lessons learned.

BACKGROUND: Young people have the right to be informed and consulted about decisions affecting their lives. Patient and public involvement (PPI) ensures that research is carried out 'with' or 'by' young people rather than 'to', 'about' or 'for' them. The aim of this paper is to outline how youth PPI can be embedded within a physical activity intervention, reflect on the impact of PPI and provide recommendations for future PPI in a similar context. METHODS: A Youth Advisory Group (YAG) was set up within the Walking In ScHools (WISH) Study to involve adolescent girls in the delivery, implementation and dissemination of a physical activity intervention targeted at adolescents. Schools invited pupils aged 12-14 years and 15-18 years to YAG meetings (n3, from 2019 to 2023). Participative methods were used to inform recruitment strategies and data collection methods for the WISH Study. RESULTS: Across the three YAG meetings, n51 pupils from n8 schools were involved. Pupils enjoyed the YAG meetings, felt that their feedback was valued and considered the meetings a good way to get young people involved in research. The YAG advised on specific issues and although measuring impact was not the primary aim of the YAG meetings, over the course of the study there were many examples of the impact of PPI. Recruitment targets for the WISH Study were exceeded, the attrition rate was low and pupils were engaged in data collection. CONCLUSION: Youth PPI is a developing field and there are few physical activity studies that report the PPI work undertaken. Within the WISH Study, three YAG meetings were held successfully, and the views of adolescent girls were central to the development of the study. Considering the specific issues that the YAG advised on (study recruitment, attrition and data collection), there was evidence of a positive impact of PPI. PATIENT OR PUBLIC CONTRIBUTION: Pupils from post-primary schools interested/participating in the WISH Study were invited to attend YAG meetings. YAG meetings were set up to consult adolescent girls on the delivery, implementation and dissemination of the WISH intervention.

Factors that influence food choices in secondary school canteens: a qualitative study of pupil and staff perspectives.

Background: Adolescence is recognised as a period of nutritional vulnerability, with evidence indicating that United Kingdom adolescents have suboptimal dietary intakes with many failing to meet dietary recommendations. Additionally, adolescence is a time of transition when they become more independent in their dietary choices and begin to develop their own sense of autonomy and are less reliant on their parent's guidance, which is reported to lead to less favourable dietary behaviours. Reducing the prevalence of poor dietary intakes and the associated negative health consequences among this population is a public health priority and schools represent an important setting to promote positive dietary behaviours. The aim of this school-based study was to explore the factors and barriers which influence food choices within the school canteen and to identify feasible strategies to promote positive dietary behaviours within this setting. Methods: Thirteen focus groups with 86 pupils in Year 8 (n = 37; aged 11-12 years) and Year 9 (n = 49; aged 12-13 years) in six secondary schools across Northern Ireland, United Kingdom were conducted. Additionally, one-to-one virtual interviews were conducted with 29 school staff [principals/vice-principals (n = 4); teachers (n = 17); and caterers (n = 7)] across 17 secondary schools and an Education Authority (EA) senior staff member (n = 1). Focus groups and interviews were audio-recorded, transcribed, and analysed following an inductive thematic approach. Results: Using the ecological framework, multiple factors were identified which influenced pupils' selection of food in the school canteen at the individual (e.g., time/convenience), social (e.g., peer influence), physical (e.g., food/beverage placement), and macro environment (e.g., food provision) level. Suggestions for improvement of food choices were also identified at each ecological level: individual (e.g., rewards), social (e.g., pupil-led initiatives), physical (e.g., labelling), and macro environment (e.g., whole-school approaches). Conclusion: Low-cost and non-labour intensive practical strategies could be employed, including menu and labelling strategies, placement of foods, reviewing pricing policies and whole-school initiatives in developing future dietary interventions to positively enhance adolescents' food choices in secondary schools.

Improving adolescents' dietary behaviours in the school-setting: challenges and opportunities.

Adolescence is a critical time of physical, psychological and social development, and thus, optimal nutritional intakes are required during this life stage. Despite this, adolescence is recognised as a period of nutritional vulnerability, with many reportedly failing to meet current dietary guidelines. The school-setting presents a favourable environment to intervene and promote positive dietary behaviours and is also inclusive regardless of socio-economic status. However, a lack of consensus exists on how best to utilise schools to facilitate improvements in dietary behaviours among this age group. Whilst previous research has focused on identifying the factors motivating dietary choices within the school-setting, less is known on the optimum strategies to enhance these dietary choices which could positively contribute to the design of future interventions. It is reported that adolescents have good nutritional knowledge, although this does not appear to be a central consideration when making their dietary choices. Alternative factors at the individual (taste, visual appeal, familiarity, food quality, price, portion size, value for money, time/ convenience), social (peer influence), physical (product placement) and macro environment (food availability) levels have been frequently cited as important influences on adolescents' dietary choices in school. Although school-based interventions have shown potential in achieving positive dietary change among adolescents, more research is needed to determine the most effective methods in improving dietary behaviours in schools. This review summarises the key factors which influence adolescents' school-based dietary choices and the effectiveness of previously conducted interventions, identifying promising components for consideration when developing future dietary interventions within the school-setting.

"When You Move You Have Fun": Perceived Barriers, and Facilitators of Physical Activity From a Child's Perspective.

In Northern Ireland (NI), many children do not meet the recommended levels of physical activity (PA). To reduce the prevalence of physical inactivity and associated health conditions, it is important to understand the influences on children's PA, which in turn has the potential to inform future intervention design. The purpose of this formative study was to examine the current views, barriers, facilitators, experiences, and perceptions of children in relation to PA in the classroom, school, and home environments, and to assess the acceptability of components for a school-based intervention. Write and draw tasks and semi-structured focus groups (n = 10) were conducted with 50 children aged 7-9 years (22 boys, 28 girls) from six primary schools. Focus groups were recorded, transcribed, and analyzed thematically. Pen profiles were constructed from the transcripts in a deductive manner and represent key emergent themes. Results indicated that children's perception and knowledge of PA was mainly structured and sport-based, while some referred to fun, play and health. Fun, social support and outdoor activity were identified as key facilitators. Barriers included parental restrictions, lack of time and space in the different environments. The acceptability of intervention components was examined, children recognized the potential benefits of additional movement in the classroom, but opinions differed on the sit-to-stand desks. Findings contribute to a more detailed understanding of children's perceptions of context specific PA, the barriers they face, in addition to factors that support them to lead a physically active lifestyle, which may inform future PA promotion strategies.

The Effectiveness of School-Based Interventions on Obesity-Related Behaviours in Primary School Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

School-based interventions are promising for targeting a change in obesity-related behaviours in children. However, the efficacy of school-based interventions to prevent obesity remains unclear. This review examined the effectiveness of school-based interventions at changing obesity-related behaviours (increased physical activity, decreased sedentary behaviour and improved nutrition behaviour) and/or a change in BMI/BMI z-score. Following PRISMA guidelines, seven databases were systematically searched from 1 January 2009 to 31 December 2020. Two review authors independently screened studies for eligibility, completed data extraction and assessed the risk of bias of each of the included studies. Forty-eight studies met the inclusion criteria and were included in a narrative synthesis. Thirty-eight studies were eligible for inclusion in a meta-analysis. The findings demonstrate that interventions in children when compared to controls resulted in a small positive treatment effect in the control group (2.14; 95% CI = 0.77, 3.50). There was no significant effect on sedentary behaviour, energy intake and fruit and vegetable intake. Significant reductions were found between groups in BMI kg/m2 (-0.39; 95% CI = -0.47, -0.30) and BMI z-score (-0.05; 95% CI = -0.08, -0.02) in favour of the intervention. The findings have important implications for future intervention research in terms of the effectiveness of intervention components and characteristics.

Changes in Physical Activity, Sleep, Mental Health, and Social Media Use During COVID-19 Lockdown Among Adolescent Girls: A Mixed-Methods Study.

BACKGROUND: To suppress the transmission of coronavirus, many governments, including that of the island of Ireland, implemented a societal lockdown, which included school closures, limits on social gatherings, and time outdoors. This study aimed to evaluate changes in physical activity (PA), mental health, sleep, and social media use among adolescent girls during lockdown. METHODS: 281 female pupils (12-14 y) taking part in the ongoing Walking In Schools study on the island of Ireland self-reported PA, mental health, sleep, and social media use before (September-October 2019) and during lockdown (May-June 2020), via questionnaires. These were supplemented with open-ended structured interviews conducted with 16 girls during lockdown. RESULTS: During the period of lockdown and school closures, pupils tried new forms of PA and undertook PA with family, but there was no significant change in self-reported PA. There was a decline in health-related quality of life and motivation for exercise; however, self-efficacy for walking and happiness with appearance increased. There was no change in sleep quality or social media usage. CONCLUSIONS: Despite the many challenges that schools face as they reopen, there is a need to continue to prioritize PA and motivation for exercise to support health and well-being in adolescent girls.

Development and Feasibility of a Family-Based Health Behavior Intervention Using Intelligent Personal Assistants: Randomized Controlled Trial.

BACKGROUND: Intelligent personal assistants such as Amazon Echo and Google Home have become increasingly integrated into the home setting and, therefore, may facilitate behavior change via novel interactions or as an adjunct to conventional interventions. However, little is currently known about their potential role in this context. OBJECTIVE: This feasibility study aims to develop the Intelligent Personal Assistant Project (IPAP) and assess the acceptability and feasibility of this technology for promoting and maintaining physical activity and other health-related behaviors in both parents and children. METHODS: This pilot feasibility study was conducted in 2 phases. For phase 1, families who were attending a community-based weight management project were invited to participate, whereas phase 2 recruited families not currently receiving any additional intervention. Families were randomly allocated to either the intervention group (received a smart speaker for use in the family home) or the control group. The IPAP intervention aimed to promote positive health behaviors in the family setting through utilization of the functions of a smart speaker and its linked intelligent personal assistant. Data were collected on recruitment, retention, outcome measures, intervention acceptability, device interactions, and usage. RESULTS: In total, 26 families with at least one child aged 5 to 12 years were recruited, with 23 families retained at follow-up. Across phase 1 of the intervention, families interacted with the intelligent personal assistant a total of 65 times. Although device interactions across phase 2 of the intervention were much higher (312 times), only 10.9% (34/312) of interactions were coded as relevant (related to diet, physical activity or well-being). Focus groups highlighted that the families found the devices acceptable and easy to use and felt that the prompts or reminders were useful in prompting healthier behaviors. Some further intervention refinements in relation to the timing of prompts and integrating feedback alongside the devices were suggested by families. CONCLUSIONS: Using intelligent personal assistants to deliver health-related messages and information within the home is feasible, with high levels of engagement reported by participating families. This novel feasibility study highlights important methodological considerations that should inform future trials testing the effectiveness of intelligent personal assistants in promoting positive health-related behaviors. TRIAL REGISTRATION: ISRCTN Registry ISRCTN16792534; http://www.isrctn.com/ISRCTN16792534.

A Novel Urinary Biomarker Approach Reveals Widespread Exposure to Multiple Low-Calorie Sweeteners in Adults.

BACKGROUND: Observational investigations into the health impacts of low-calorie sweeteners (LCSs) in humans fail to adequately identify or fully characterize LCS consumption. OBJECTIVES: We aimed to utilize a novel biomarker approach to investigate exposure to 5 LCSs and to test whether reported low-calorie sweetened beverage (LCSB) consumption effectively identifies exposure to LCSs in adults. METHODS: In this cross-sectional analysis, 2 population studies were conducted in adults. Urinary excretions of 5 LCSs, namely acesulfame-K, saccharin, cyclamate, sucralose, and steviol glycosides, were simultaneously determined using LC tandem-MS. In Study 1, previously collected 24-h urine samples (n = 357) were analyzed. In Study 2, previously collected 24-h urine samples (n = 79) were analyzed to compare urinary excretions of LCSs with self-reported LCSB consumption for identifying LCS exposure. Exposure to LCSs was characterized using descriptive statistics and chi-square tests were performed to assess associations between age-groups and LCS excretion, and to assess the proportion of individuals identified as LCS consumers using biomarker data or reported LCSB consumption. RESULTS: A total of 341 adults (45% men) and 79 adults (39% men) were included in the final analysis of Studies 1 and 2, respectively. In Study 1, >96% of samples contained ≥1 LCS and almost 60% contained ≥3 LCSs. A greater proportion of younger adults (<40 y old) excreted ≥3 LCSs than older adults (>40 y old) (P < 0.001). In Study 2, a much higher prevalence of LCS consumption was observed using biomarker data (92%) than reported LCSB consumption (6%) (P < 0.001). CONCLUSIONS: This work indicates widespread exposure to LCSs, suggesting that population-based research to date into LCS exposure and health may be flawed. Therefore, a urinary biomarker approach offers considerable potential for more robust investigations in this area.

A study protocol for a clustered randomised controlled trial to evaluate the effectiveness of a peer-led school-based walking intervention on adolescent girls' physical activity: the Walking In ScHools (WISH) study.

BACKGROUND: Adolescent girls in the UK and Ireland are failing to meet current physical activity guidelines. Physical activity behaviours track from childhood to adulthood and it is important that adolescent girls are provided with opportunities to be physically active. Walking has been a central focus for physical activity promotion in adults and may effectively increase physical activity levels among younger people. Following on from a pilot feasibility trial, the purpose of this cluster randomised controlled trial (c-RCT) is to evaluate the effectiveness of a novel, low-cost, peer-led school-based walking intervention delivered across the school year at increasing physical activity levels of adolescent girls. METHODS: The Walking In ScHools (WISH) Study is a school-based c-RCT conducted with girls aged 12-14 years from eighteen schools across the Border Region of Ireland / Northern Ireland. Following baseline data collection, schools will be randomly allocated to intervention or control group. In intervention schools, female pupils aged 15-18 years will be invited to train as walk leaders and will lead younger pupils in 10-15 min walks before school, at break and lunch recess. All walks will take place in school grounds and pupils will be encouraged to participate in as many walks as possible each week. The intervention will be delivered for the whole school year (minimum 20-22 weeks). The primary outcome measure is accelerometer-measured total physical activity (counts per minute) (end of intervention). Secondary outcomes will include time spent in sedentary behaviour, light, moderate and vigorous intensity physical activity, anthropometry measures, social media usage and sleep. A mixed-methods process evaluation will also be undertaken. DISCUSSION: The WISH Study will examine the effectiveness of a low-cost, school-based, peer-led walking intervention in increasing physical activity in adolescent girls when delivered across the school year. If the intervention increases physical activity, it would benefit adolescent girls in the defined target area with potential for wider adoption by schools across the UK and Ireland. TRIAL REGISTRATION: ISRCTN; ISRCTN12847782; Registered 2nd July 2019.

Expert consensus on low-calorie sweeteners: facts, research gaps and suggested actions.

A consensus workshop on low-calorie sweeteners (LCS) was held in November 2018 where seventeen experts (the panel) discussed three themes identified as key to the science and policy of LCS: (1) weight management and glucose control; (2) consumption, safety and perception; (3) nutrition policy. The aims were to identify the reliable facts on LCS, suggest research gaps and propose future actions. The panel agreed that the safety of LCS is demonstrated by a substantial body of evidence reviewed by regulatory experts and current levels of consumption, even for high users, are within agreed safety margins. However, better risk communication is needed. More emphasis is required on the role of LCS in helping individuals reduce their sugar and energy intake, which is a public health priority. Based on reviews of clinical evidence to date, the panel concluded that LCS can be beneficial for weight management when they are used to replace sugar in products consumed in the diet (without energy substitution). The available evidence suggests no grounds for concerns about adverse effects of LCS on sweet preference, appetite or glucose control; indeed, LCS may improve diabetic control and dietary compliance. Regarding effects on the human gut microbiota, data are limited and do not provide adequate evidence that LCS affect gut health at doses relevant to human use. The panel identified research priorities, including collation of the totality of evidence on LCS and body weight control, monitoring and modelling of LCS intakes, impacts on sugar reduction and diet quality and developing effective communication strategies to foster informed choice. There is also a need to reconcile policy discrepancies between organisations and reduce regulatory hurdles that impede low-energy product development and reformulation.

Biomarker approaches to assessing intakes and health impacts of sweeteners: challenges and opportunities.

The term 'sweeteners' encompasses both nutritive and non-nutritive sweeteners, which when added to food/beverages, can enhance the flavour and other functional properties of food/beverage products. This review considers how dietary biomarker approaches may enhance current understanding of nutritive sweetener (namely free sugars) and non-nutritive or low-energy sweetener (LES) intakes and how these may impact health. Recent public health strategies to reduce free sugar consumption will help contribute to challenging sugar intake targets. Robust evaluation is needed to determine the effectiveness of these approaches to reducing free sugar consumption. LES provides a sweet taste without the addition of appreciable energy and can help maintain the palatability of reformulated products. All LES undergo rigorous safety evaluations prior to approval for use. Whilst intervention data suggest LES can be beneficial for health (relating to weight status and glycaemic control), debate persists on their use and findings from population-based research are mixed, in part because of potential contributing factors such as reverse causality. Additionally, assessments often consider only certain sources of LES (e.g. LES-beverages) and/or LES as a homogeneous group despite differing biological fates, thus not adequately capturing intakes of individual LES or allowing for reliable estimation of overall intakes. Urinary biomarker approaches developed/investigated for sweetener consumption have the potential to overcome existing limitations of dietary data by providing more objective intake data, thereby enhancing population-based research. In conclusion, such biomarker approaches to the concomitant study of free sugars and LES intakes are timely and represent interesting developments in an area of significant public health interest.

Nutrition Education and Community Pharmacy: A First Exploration of Current Attitudes and Practices in Northern Ireland.

Community pharmacist is one of the most prominent and accessible healthcare professions. The community pharmacists' role in healthcare is evolving, with opportunities being taken to reduce pressure on primary care services. However, the question remains of how well community pharmacists are equipped for this changing role. This was a sequentially designed study using a mix of methods to explore nutrition education among community pharmacists in Northern Ireland. It consisted of two phases. Phase 1 was a cross-sectional exploration to map the attitudes and practice of Northern Ireland (NI) pharmacists towards diet-related health promotion and disease prevention. An online questionnaire with open and closed questions to gain both quantitative and qualitative responses was developed and distributed to community pharmacists practising in NI. A total of 91% considered nutrition important in reducing the global burden of disease. While the majority (89%) believed patients would value nutritional advice from a pharmacist, 74% were not confident in providing advice to a patient with diabetes. From the consensus gained in Phase 1 a nutrition education intervention (Phase 2) for pre-registration pharmacists was developed using the Hardens 10 question system. The training programme was advertised to pre-registration pharmacy students in NI. It was delivered by nutrition experts who have education qualifications. The intervention was evaluated using a before and after questionnaire that assessed knowledge, attitudes, and practice (KAP). Phase 2 did find sustained improvement from the baseline in KAP but there was a decline from immediately post-training to three months post-training. This suggests the need to further embed nutrition education. The education programme was found to be effective for the target population and sets the stage for the development of an implementation strategy for a wider roll-out with evaluation.

Hyperglycemia and Metformin Use Are Associated With B Vitamin Deficiency and Cognitive Dysfunction in Older Adults.

CONTEXT: Emerging evidence suggests that deficiencies of folate-related B vitamins can arise with metformin treatment and are independently linked with cognitive dysfunction, a comorbidity of diabetes. OBJECTIVE: To determine the impact of hyperglycemia and metformin use on relevant B vitamin biomarkers and cognitive outcomes in older adults. SETTING AND PARTICIPANTS: Community-dwelling older adults (74.1 ± 8.3 years, n = 4160) without dementia, recruited to the Trinity, Ulster and Department of Agriculture cohort study in 2008 to 2012, were classified as normoglycemic (n = 1856) or hyperglycemic, based on HbA1c ≥5.7% (39 mmol/mol), either with (n = 318) or without (n = 1986) metformin treatment. MAIN OUTCOME MEASURES: Biomarkers of folate, vitamin B12, vitamin B6, and riboflavin were measured. Cognitive assessments included the Repeatable Battery for Assessment of Neuropsychological Status (RBANS) and the Frontal Assessment Battery (FAB). RESULTS: Metformin use was associated with higher risk of deficiency of vitamin B12 (combined B12 index ≤-1; OR 1.45; 95% CI, 1.03 to 2.02) and vitamin B6 (plasma pyridoxal 5-phosphate <30.0 nmol/L; OR 1.48; 95% CI, 1.02 to 2.15). Fortified foods when eaten regularly had a positive impact on all relevant B vitamin biomarkers, even with hyperglycemia. After adjustment for relevant covariates, metformin use was associated with an increased risk of cognitive dysfunction as assessed with the RBANS (OR 1.36; 95% CI, 1.03 to 1.80) and FAB (OR 1.34; 95% CI, 1.03 to 1.74). CONCLUSIONS: Use of metformin by older adults is associated with poorer cognitive performance; B vitamin deficiency may be implicated. Fortified foods can optimize B vitamin status and may be beneficial for maintaining better cognitive health in older people with or at risk for diabetes.

Using the School Environment to Promote Walking amongst Adolescent Females: A Mixed-Method Study.

Schools have the potential to promote physical activity (PA) in adolescents through physical education (PE) and extra-curricular PA. The aims of this study were to firstly understand the experiences of adolescent females who participated in a school-based walking programme (the Walking In ScHools (WISH) study) and secondly, to assess the potential for schools to further promote PA outside of structured PE. A sample of female participants (n = 45, mean age 13.1 years) who participated in the WISH study were randomly selected to participate in focus group discussions, to explore their experiences of the intervention. In addition, an online survey was distributed to all post-primary schools (n = 208) in Northern Ireland to assess the provision of extra-curricular PA and further evaluate the feasibility of the WISH study. In total, six focus groups were conducted. Walking during the school day was viewed as an acceptable form of PA by adolescent females, providing an opportunity to be active with friends, and helped participants overcome barriers previously associated with being active at school. Responding schools (n = 59) identified adolescent females and non-sporty pupils as sub-groups who would benefit most from participation in a school-based walking programme. This study has highlighted that the delivery of a walking programme within the school setting is acceptable, warranted and practically feasible from the point of view of adolescent females and key stakeholders within the school setting.

Biomarkers of intake for coffee, tea, and sweetened beverages.

Non-alcoholic beverages are important sources of nutrients and bioactive compounds that may influence human health and increase or decrease the risk of chronic diseases. A wide variety of beverage constituents are absorbed in the gut, found in the systemic circulation and excreted in urine. They may be used as compliance markers in intervention studies or as biomarkers of intake to improve measurements of beverage consumption in cohort studies and reveal new associations with disease outcomes that may have been overlooked when using dietary questionnaires. Here, biomarkers of intake of some major non-alcoholic beverages-coffee, tea, sugar-sweetened beverages, and low-calorie-sweetened beverages-are reviewed. Results from dietary intervention studies and observational studies are reviewed and analyzed, and respective strengths and weaknesses of the various identified biomarkers discussed. A variety of compounds derived from phenolic acids, alkaloids, and terpenes were shown to be associated with coffee intake and trigonelline and cyclo(isoleucylprolyl) showed a particularly high specificity for coffee intake. Epigallocatechin and 4'-O-methylepigallocatechin appear to be the most sensitive and specific biomarkers for green or black tea, while 4-O-methylgallic acid may be used to assess black tea consumption. Intake of sugar-sweetened beverages has been assessed through the measurement of carbon-13 enrichment of whole blood or of blood alanine in North America where sugar from sugarcane or corn is used as a main ingredient. The most useful biomarkers for low-calorie-sweetened beverages are the low-calorie sweeteners themselves. Further studies are needed to validate these biomarkers in larger and independent populations and to further evaluate their specificity, reproducibility over time, and fields of application.

Understanding pre-, peri- and post-menopausal women's intentions to perform muscle-strengthening activities using the Theory of Planned Behaviour.

Although physical activity guidelines recommend muscle-strengthening activities (MSA), public health initiatives tend to focus on increasing aerobic activity and fail to mention MSA. This study sought to identify the issues influencing pre-, peri- and post-menopausal women's intentions to perform MSA with a view to informing future interventions for these populations. Mixed methods guided by the Theory of Planned Behaviour (TPB) were used to explore factors that influence women's intentions to perform MSA. In stage one, 34 women participated in either a focus group or interview. Discussions were transcribed verbatim and analysed based on menopausal status using a deductive approach. In stage two, 186 women (M = 47 years, SD = 9) completed a questionnaire to assess participant demographics, levels of MSA, affective and instrumental attitudes, injunctive and descriptive norms, self-efficacy and perceived behavioural control. Quantitative data were analysed using descriptive statistics, bivariate correlations, regression analyses and analysis of variances. Behavioural beliefs were: improved muscular health; psychological benefits; improved body shape. Normative beliefs were: health professionals; family members; work colleagues. Control beliefs were: equipment; motivation; time constraints; knowledge; physical capability; fear of judgement. However, these beliefs were not well established. Self-efficacy was the strongest predictor of intentions (spc2 = 0.11) followed by affective attitudes (spc2 = 0.09), with no significant differences on TPB variables between groups. If rising rates of musculoskeletal conditions in women are to be prevented, there is an urgent need to increase women's knowledge of recommended levels of muscle strengthening, with a view to promoting positive attitudes and enhancing women's sense of self-efficacy across all menopausal phases.

Effects of a peer-led Walking In ScHools intervention (the WISH study) on physical activity levels of adolescent girls: a cluster randomised pilot study.

BACKGROUND: School-based interventions may be effective at increasing levels of physical activity (PA) among adolescents; however, there is a paucity of evidence on whether walking can be successfully promoted to increase PA in this age group. This pilot study aimed to assess the effects of a 12-week school-based peer-led brisk walking programme on levels of school-time PA post intervention. METHODS: Female participants, aged 11-13 years, were recruited from six post-primary schools in Northern Ireland. Participants were randomized by school (cluster) to participate in regular 10-15-min peer-led brisk walks throughout the school week (the WISH study) (n = 101, two schools) or to continue with their usual PA (n = 98, four schools). The primary outcome measure was school-time PA post intervention (week 12), assessed objectively using an Actigraph accelerometer. Secondary outcome measures included anthropometry, cardiorespiratory fitness and psychosocial measures. Changes in PA data between baseline (T0) and end of intervention (week 12) (T1) were analysed using a mixed between-within subjects analysis of variance with one between (group) and one within (time) subjects factor, with two levels. RESULTS: Of 199 participants recruited (mean age = 12.4 ± 0.6 years, 27% overweight/obese), 187 had valid accelerometer data for inclusion in subsequent analysis. A significant interaction effect was observed for changes in light intensity PA across the school day (p = 0.003), with those in the intervention increasing their light intensity PA by 8.27 mins/day compared with a decrease of 2.14 mins/day in the control group. No significant interactions were observed for the other PA measures across the intervention. Intervention effects on school-time PA were not sustained four months post intervention. CONCLUSIONS: The intervention increased daily light intensity PA behaviour in these adolescent girls but did not change moderate to vigorous physical activity (MVPA). These findings suggest that a school-based brisk walking intervention may be feasible and can change PA behaviour in the short term, but it is possible that the self-selected walking speeds determined by a peer-leader may not be sufficient to reach MVPA in this age group. Further research is needed to evaluate the potential of school-based brisk walking to contribute to MVPA in adolescent girls. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02871830 . Registered on 16 August 2016).