Nurture Early for Optimal Nutrition (NEON) participatory learning and action women's groups to improve infant feeding and practices in South Asian infants: pilot randomised trial study protocol.

INTRODUCTION: Feeding practices developed in early life can impact a child's nutrition, growth, dental health, cognitive development and lifetime risk of chronic diseases. Substantial evidence suggests ethnic health inequalities, and non-recommended complementary infant feeding practices among UK's South Asian (SA) population. Nurture Early for Optimal Nutrition aims to use women's group participatory learning and action (PLA) cycles to optimise infant feeding, care and dental hygiene practices in SA infants <2 years in East London. METHODS AND ANALYSIS: A three-arm pilot feasibility cluster randomised controlled trial will assess feasibility, acceptability, costs and explore preliminary effectiveness for proposed primary outcome (ie, reporting on body mass index (BMI) z-score). Multilingual SA community facilitators will deliver the intervention, group PLA Cycle, to mothers/carers in respective ethnic/language groups. 12 wards are randomised to face-to-face PLA, online PLA and usual care arms in 1:1:1 ratio. Primary outcomes are feasibility and process measures (ie, BMI z-score, study records, feedback questionnaires, direct observation of intervention and sustainability) for assessment against Go/Stop criteria. Secondary outcomes are cluster-level and economic outcomes (ie, eating behaviour, parental feeding practices, network diffusion, children development performance, level of dental caries, general practitioner utilisation, costs, staff time). Outcomes are measured at baseline, every 2 weeks during intervention, 14 weeks and at 6 months by blinded outcome assessors where possible. This study will use concurrent mixed-methods evaluation. Quantitative analyses include descriptive summary with 95% CI and sample size calculation for the definitive trial. The intervention effect with CI will be estimated for child BMI z-score. Implementation will be evaluated qualitatively using thematic framework analysis. ETHICS AND DISSEMINATION: Ethics approval was obtained from University College London (UCL), National Health Service (Health Research Authority (HRA) and Health and Care Research Wales (HRCW)). Results will be published in peer-reviewed journals, presented at scientific conferences/workshops with commissioners, partners and participating communities. Plain language summaries will be disseminated through community groups, websites and social media. TRIAL REGISTRATION NUMBER: IRAS-ID-296259 (ISRCTN10234623).

Developing a community facilitator-led participatory learning and action women's group intervention to improve infant feeding, care and dental hygiene practices in South Asian infants: NEON programme.

INTRODUCTION: The Nurture Early for Optimal Nutrition (NEON) study is a multiphase project that aims to optimize feeding, care and dental hygiene practices in South Asian children <2 years in East London, United Kingdom. The multiphase project uses a participatory learning and action (PLA) approach facilitated by a multilingual community facilitator. In this paper, we elaborate on the process and results of the Intervention Development Phase in the context of the wider NEON programme. METHODS: Qualitative community-based participatory intervention codevelopment and adaptation. SETTING: Community centres in East London and online (Zoom) meetings and workshops. PARTICIPANTS: In total, 32 participants registered to participate in the Intervention Development Phase. Four Intervention Development workshops were held, attended by 25, 17, 20 and 20 participants, respectively. RESULTS: Collaboratively, a culturally sensitive NEON intervention package was developed consisting of (1) PLA group facilitator manual, (2) picture cards detailing recommended and nonrecommended feeding, care and dental hygiene practices with facilitators/barriers to uptake as well as solutions to address these, (3) healthy infant cultural recipes, (4) participatory Community Asset Maps and (5) list of resources and services supporting infant feeding, care and dental hygiene practices. CONCLUSION: The Intervention Development Phase of the NEON programme demonstrates the value of a collaborative approach between researchers, community facilitators and the target population when developing public health interventions. We recommend that interventions to promote infant feeding, care and dental hygiene practices should be codeveloped with communities. Recognizing and taking into account both social and cultural norms may be of particular value for infants from ethnically diverse communities to develop interventions that are both effective in and accepted by these communities. PATIENT AND PUBLIC INVOLVEMENT AND ENGAGEMENT: Considerable efforts were placed on Patient/Participant and Public Involvement and Engagement. Five community facilitators were identified, each of which represented one ethnic/language group: (i) Bangladeshi/Bengali and Sylheti, (ii) Pakistani/Urdu, (iii) Indian/Gujrati, (iv) Indian/Punjabi and (v) Sri Lankan/Tamil. The community facilitators were engaged in every step of the study, from the initial drafting of the protocol and study design to the Intervention Development and refinement of the NEON toolkit, as well as the publication and dissemination of the study findings. More specifically, their role in the Intervention Development Phase of the NEON programme was to: 1. Support the development of the study protocol, information sheets and ethics application. 2. Ensure any documents intended for community members are clear, appropriate and sensitively worded. 3. Develop strategies to troubleshoot any logistical challenges of project delivery, for example, recruitment shortfalls. 4. Contribute to the writing of academic papers, in particular reviewing and revising drafts. 5. Develop plain language summaries and assist in dissemination activities, for example, updates on relevant websites. 6. Contribute to the development of the NEON intervention toolkit and recruitment of the community members. 7. Attend and contribute to Intervention Development workshops, ensuring the participant's voices were the focus of the discussion and workshop outcomes.

Unpacking the behavioural components and delivery features of early childhood obesity prevention interventions in the TOPCHILD Collaboration: a systematic review and intervention coding protocol.

INTRODUCTION: Little is known about how early (eg, commencing antenatally or in the first 12 months after birth) obesity prevention interventions seek to change behaviour and which components are or are not effective. This study aims to (1) characterise early obesity prevention interventions in terms of target behaviours, delivery features and behaviour change techniques (BCTs), (2) explore similarities and differences in BCTs used to target behaviours and (3) explore effectiveness of intervention components in preventing childhood obesity. METHODS AND ANALYSIS: Annual comprehensive systematic searches will be performed in Epub Ahead of Print/MEDLINE, Embase, Cochrane (CENTRAL), CINAHL, PsycINFO, as well as clinical trial registries. Eligible randomised controlled trials of behavioural interventions to prevent childhood obesity commencing antenatally or in the first year after birth will be invited to join the Transforming Obesity in CHILDren Collaboration. Standard ontologies will be used to code target behaviours, delivery features and BCTs in both published and unpublished intervention materials provided by trialists. Narrative syntheses will be performed to summarise intervention components and compare applied BCTs by types of target behaviours. Exploratory analyses will be undertaken to assess effectiveness of intervention components. ETHICS AND DISSEMINATION: The study has been approved by The University of Sydney Human Research Ethics Committee (project no. 2020/273) and Flinders University Social and Behavioural Research Ethics Committee (project no. HREC CIA2133-1). The study's findings will be disseminated through peer-reviewed publications, conference presentations and targeted communication with key stakeholders. PROSPERO REGISTRATION NUMBER: CRD42020177408.

Transforming Obesity Prevention for CHILDren (TOPCHILD) Collaboration: protocol for a systematic review with individual participant data meta-analysis of behavioural interventions for the prevention of early childhood obesity.

INTRODUCTION: Behavioural interventions in early life appear to show some effect in reducing childhood overweight and obesity. However, uncertainty remains regarding their overall effectiveness, and whether effectiveness differs among key subgroups. These evidence gaps have prompted an increase in very early childhood obesity prevention trials worldwide. Combining the individual participant data (IPD) from these trials will enhance statistical power to determine overall effectiveness and enable examination of individual and trial-level subgroups. We present a protocol for a systematic review with IPD meta-analysis to evaluate the effectiveness of obesity prevention interventions commencing antenatally or in the first year after birth, and to explore whether there are differential effects among key subgroups. METHODS AND ANALYSIS: Systematic searches of Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo and trial registries for all ongoing and completed randomised controlled trials evaluating behavioural interventions for the prevention of early childhood obesity have been completed up to March 2021 and will be updated annually to include additional trials. Eligible trialists will be asked to share their IPD; if unavailable, aggregate data will be used where possible. An IPD meta-analysis and a nested prospective meta-analysis will be performed using methodologies recommended by the Cochrane Collaboration. The primary outcome will be body mass index z-score at age 24±6 months using WHO Growth Standards, and effect differences will be explored among prespecified individual and trial-level subgroups. Secondary outcomes include other child weight-related measures, infant feeding, dietary intake, physical activity, sedentary behaviours, sleep, parenting measures and adverse events. ETHICS AND DISSEMINATION: Approved by The University of Sydney Human Research Ethics Committee (2020/273) and Flinders University Social and Behavioural Research Ethics Committee (HREC CIA2133-1). Results will be relevant to clinicians, child health services, researchers, policy-makers and families, and will be disseminated via publications, presentations and media releases. PROSPERO REGISTRATION NUMBER: CRD42020177408.

Outbreak of SARS-CoV-2 in a Children's Nursery in the United Kingdom.

BACKGROUND: Early Years' Settings (EYSs) provide childcare and education for children 0-5 years old. They remained fully open in England during the third National lockdown when other educational settings were only open for selected children. EYSs are generally considered to be low-risk settings for transmission of severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). METHODS: An observational study describing a large outbreak of SARS CoV-2 within an EYS in Cambridgeshire, United Kingdom. RESULTS: Overall 45 cases of SARS-CoV-2 were identified; 24 adults (71% of staff members) and 21 children (25% of nursery attendees). One case was identified as the alpha variant (B.1.1.7 [VOC-20-DEC-01]). One staff member became critically unwell. CONCLUSIONS: Transmission of SARS-CoV-2 occurred quickly, with a high attack rate; likely a consequence of a variant with enhanced transmissibility and an inability of the setting to adhere to infection control measures.

Association of puberty timing with type 2 diabetes: A systematic review and meta-analysis.

BACKGROUND: Emerging studies have investigated the association between puberty timing, particularly age at menarche (AAM), and type 2 diabetes. However, whether this association is independent of adiposity is unclear. We aimed to systematically review published evidence on the association between puberty timing and type 2 diabetes (T2D) or impaired glucose tolerance (IGT), with and without adjustment for adiposity, and to estimate the potential contribution of puberty timing to the burden of T2D in the United Kingdom (UK). METHODS AND FINDINGS: We searched PubMed, Medline, and Embase databases for publications until February 2019 on the timing of any secondary sexual characteristic in boys or girls in relation to T2D/IGT. Inverse-variance-weighted random-effects meta-analysis was used to pool reported estimates, and meta-regression was used to explore sources of heterogeneity. Twenty-eight observational studies were identified. All assessed AAM in women (combined N = 1,228,306); only 1 study additionally included men. In models without adjustment for adult adiposity, T2D/IGT risk was lower per year later AAM (relative risk [RR] = 0.91, 95% CI 0.89-0.93, p < 0.001, 11 estimates, n = 833,529, I2 = 85.4%) and higher for early versus later menarche (RR = 1.39, 95% CI 1.25-1.55, p < 0.001, 23 estimates, n = 1,185,444, I2 = 87.8%). Associations were weaker but still evident in models adjusted for adiposity (AAM: RR = 0.97 per year, 95% CI 0.95-0.98, p < 0.001, 12 estimates, n = 852,268, I2 = 51.8%; early menarche: RR = 1.19, 95% CI 1.11-1.28, p < 0.001, 21 estimates, n = 890,583, I2 = 68.1%). Associations were stronger among white than Asian women, and in populations with earlier average AAM. The estimated population attributable risk of T2D in white UK women due to early menarche unadjusted and adjusted for adiposity was 12.6% (95% CI 11.0-14.3) and 5.1% (95% CI 3.6-6.7), respectively. Findings in this study are limited by residual and unmeasured confounding, and self-reported AAM. CONCLUSIONS: Earlier AAM is consistently associated with higher T2D/IGT risk, independent of adiposity. More importantly, this research has identified that a substantial proportion of T2D in women is related to early menarche, which would be expected to increase in light of global secular trends towards earlier puberty timing. These findings highlight the need to identify the underlying mechanisms linking early menarche to T2D/IGT risk.

Randomised controlled trial of a theory-based behavioural intervention to reduce formula milk intake.

OBJECTIVE: To assess the efficacy of a theory-based behavioural intervention to prevent rapid weight gain in formula milk-fed infants. DESIGN: In this single (assessor) blind, randomised controlled trial, 669 healthy full-term infants receiving formula milk within 14 weeks of birth were individually randomised to intervention (n=340) or attention-matched control (n=329) groups. The intervention aimed to reduce formula milk intakes, and promote responsive feeding and growth monitoring to prevent rapid weight gain (≥+0.67 SD scores (SDS)). It was delivered to mothers by trained facilitators up to infant age 6 months through three face-to-face contacts, two telephone contacts and written materials. RESULTS: Retention was 93% (622) at 6 months, 88% (586) at 12 months and 94% attended ≥4/5 sessions. The intervention strengthened maternal attitudes to following infant feeding recommendations, reduced reported milk intakes at ages 3 (-14%; intervention vs control infants), 4 (-12%), 5 (-9%) and 6 (-7%) months, slowed initial infant weight gain from baseline to 6 months (mean change 0.32 vs 0.42 SDS, baseline-adjusted difference (intervention vs control) -0.08 (95% CI -0.17 to -0.004) SDS), but had no effect on the primary outcome of weight gain to 12 months (baseline-adjusted difference -0.04 (-0.17, 0.10) SDS). By 12 months, 40.3% of infants in the intervention group and 45.9% in the control group showed rapid weight gain (OR 0.84, 95% CI 0.59 to 1.17). CONCLUSIONS: Despite reducing milk intakes and initial weight gain, the intervention did not alter the high prevalence of rapid weight gain to age 12 months suggesting the need for sustained intervention. TRIAL REGISTRATION NUMBER: ISRCTN20814693.

Toward Understanding How Social Factors Shaped a Behavioral Intervention on Healthier Infant Formula-Feeding.

As part of a process evaluation, we explored in semi-structured interviews the experiences of 19 mothers who had taken part in a trial to reduce infant formula-milk intake and promote healthy weight gain, and reflections of three facilitators who delivered the intervention and control group protocols. Mothers appreciated the nonjudgmental support provided during the trial, after experiencing stigma and receiving limited advice on how, how much, and how often formula-milk should be given. The information mothers had previously found, printed on formula-milk tins, or provided by family, friends, and health professionals was often perceived as contradictory; the trial guidance also conflicted with social norms relating infant health positively with weight gain. For those recruited into the trial with older infants, who had already exceeded the recommendations, reducing formula-milk amounts was difficult. The findings highlight the difficulties of addressing a highly stigmatized, complex social practice with an individual, behavioral intervention approach.

Improving public health evaluation: a qualitative investigation of practitioners' needs.

BACKGROUND: In 2011, the House of Lords published a report on Behaviour Change, in which they report that "a lot more could, and should, be done to improve the evaluation of interventions." This study aimed to undertake a needs assessment of what kind of evaluation training and materials would be of most use to UK public health practitioners by conducting interviews with practitioners about everyday evaluation practice and needed guidance and materials. METHODS: Semi-structured interviews were conducted with 32 public health practitioners in two UK regions, Cambridgeshire and the South West. Participants included directors of public health, consultants in public health, health improvement advisors, public health intelligence, and public health research officers. A topic guide included questions designed to explore participants existing evaluation practice and their needs for further training and guidance. Data were analysed using thematic analyses. RESULTS: Practitioners highlighted the need for evaluation to defend the effectiveness of existing programs and protect funding provisions. However, practitioners often lacked training in evaluation, and felt unqualified to perform such a task. The majority of practitioners did not use, or were not aware of many existing evaluation guidance documents. They wanted quality-assured, practical guidance that relate to the real world settings in which they operate. Practitioners also mentioned the need for better links and support from academics in public health. CONCLUSION: Whilst numerous guidance documents supporting public health evaluation exist, these documents are currently underused by practitioners - either because they are not considered useful, or because practitioners are not aware of them. Integrating existing guides into a catalogue of guidance documents, and developing a new-quality assured, practical and useful document may support the evaluation of public health programs. This in turn has the potential to identify those programs that are effective; thus improving public health and reducing financial waste.

Digital technology to facilitate Proactive Assessment of Obesity Risk during Infancy (ProAsk): a feasibility study.

OBJECTIVE: To assess the feasibility and acceptability of using digital technology for Proactive Assessment of Obesity Risk during Infancy (ProAsk) with the UK health visitors (HVs) and parents. DESIGN: Multicentre, pre- and post-intervention feasibility study with process evaluation. SETTING: Rural and urban deprived settings, UK community care. PARTICIPANTS: 66 parents of infants and 22 HVs. INTERVENTION: ProAsk was delivered on a tablet device. It comprises a validated risk prediction tool to quantify overweight risk status and a therapeutic wheel detailing motivational strategies for preventive parental behaviour. Parents were encouraged to agree goals for behaviour change with HVs who received motivational interviewing training. OUTCOME MEASURES: We assessed recruitment, response and attrition rates. Demographic details were collected, and overweight risk status. The proposed primary outcome measure was weight-for-age z-score. The proposed secondary outcomes were parenting self-efficacy, maternal feeding style, infant diet and exposure to physical activity/sedentary behaviour. Qualitative interviews ascertained the acceptability of study processes and intervention fidelity. RESULTS: HVs screened 324/589 infants for inclusion in the study and 66/226 (29%) eligible infants were recruited. Assessment of overweight risk was completed on 53 infants and 40% of these were identified as above population risk. Weight-for-age z-score (SD) between the infants at population risk and those above population risk differed significantly at baseline (-0.67 SD vs 0.32 SD). HVs were able to collect data and calculate overweight risk for the infants. Protocol adherence and intervention fidelity was a challenge. HVs and parents found the information provided in the therapeutic wheel appropriate and acceptable. CONCLUSION: Study recruitment and protocol adherence were problematic. ProAsk was acceptable to most parents and HVs, but intervention fidelity was low. There was limited evidence to support the feasibility of implementing ProAsk without significant additional resources. A future study could evaluate ProAsk as a HV-supported, parent-led intervention. TRIAL REGISTRATION NUMBER: NCT02314494 (Feasibility Study Results).

Determinants of Change in Physical Activity in Children 0-6 years of Age: A Systematic Review of Quantitative Literature.

BACKGROUND: Understanding the determinants of children's health behaviours is important to develop successful behaviour-change interventions. OBJECTIVE: We aimed to synthesise the evidence around determinants ('preceding predictors') of change in physical activity (PA) in young children (0-6 years of age). METHODS: As part of a suite of reviews, prospective quantitative studies investigating change in physical activity in children aged 0-6 years were identified from eight databases (to October 2015): MEDLINE, Embase, CINAHL, PsycINFO, Web of Knowledge, British Nursing Index, Applied Social Sciences Index and Abstracts, and Sociological Abstracts. Determinants and direction of association were extracted, described and synthesised according to the socio-ecological model (individual, interpersonal, organisational, community, policy). RESULTS: Forty-four determinants, predominantly in the interpersonal and organisational domains, were reported across 44 papers (six prospective cohort, 38 interventional); 14 determinants were assessed in four or more papers. Parental monitoring showed a consistent positive association with change in PA; provider training was positively associated with change in children's moderate-to-vigorous PA only. Five (sex, parental goal setting, social support, motor skill training and increased time for PA) showed no clear association. A further seven (child knowledge, parental knowledge, parental motivation, parenting skills, parental self-efficacy, curriculum materials and portable equipment) were consistently not associated with change in children's PA. Maternal role-modelling was positively associated with change in PA in all three studies in which it was examined. CONCLUSIONS: A range of studied determinants of change in young children's PA were identified, but only parental monitoring was found to be consistently positively associated. More evidence dealing with community and policy domains from low-/middle-income countries and about lesser-explored modifiable family- and childcare-related determinants is required. INTERNATIONAL PROSPECTIVE REGISTER FOR SYSTEMATIC REVIEWS (PROSPERO) REGISTRATION NUMBER: CRD42012002881.

Effectiveness of a behavioural intervention to prevent excessive weight gain during infancy (The Baby Milk Trial): study protocol for a randomised controlled trial.

BACKGROUND: Infancy is a period of rapid growth and habit formation and hence could be a critical period for obesity prevention. Excess weight gain during infancy is associated with later obesity and formula-fed babies are more likely to gain excess weight compared to breastfed babies. The primary trial outcome is a change in the weight standard deviation score from birth to 1 year. METHODS/DESIGN: We will recruit 650 to 700 parents who introduce formula-milk feeds within 14 weeks of their baby's birth to a single (assessor) blind, parallel group, individually randomised controlled trial. The focus of the intervention is the caregiver (usually the mother), and the focus of the primary outcome is the infant. The intervention group will receive the behavioural intervention, which aims to reduce formula-milk intake, promote responsive feeding and healthy weaning, and prevent excessive weight gain during infancy. The intervention is based on Social Cognitive Theory and action planning ('implementation intentions'). It consists of three components: (1) a motivational component to strengthen parents' motivation to follow the Baby Milk feeding guidelines, (2) an action planning component to help translate motivation into action, and (3) a coping planning component to help parents deal with difficult situations. It will be delivered by trained facilitators (research nurses) over 6 months through three face-to-face contacts, two telephone contacts and written materials. The control group will have the same number of contacts with facilitators, and general issues about feeding will be discussed. Anthropometric outcomes will be measured by trained research staff, blind to group allocation, at baseline, 6 months and 12 months following standard operating procedures. Validated questionnaires will assess milk intake, temperament, appetite, sleep, maternal quality of life and maternal psychological factors. A 4-day food diary will be completed at 8 months. DISCUSSION: The results of the trial will help to inform infant feeding guidelines and to understand the links between infant feeding, behaviour, appetite and growth. TRIAL REGISTRATION: ISRTCN20814693 . Registration date 13 January 2011.

Factors influencing obesogenic dietary intake in young children (0-6†years): systematic review of qualitative evidence.

BACKGROUND: Obesogenic dietary intake is prevalent in young children and is associated with obesity and other adverse health outcomes in childhood and later in life. OBJECTIVE: To describe the barriers to and facilitators of obesogenic dietary intake in early childhood, in order to inform interventions and public health policies to prevent obesity. DESIGN: Systematic review of qualitative literature on factors influencing obesogenic diets in children aged 0-6 years. DATA SOURCES: MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Knowledge, British Nursing Index, ASSIA and Sociological Abstracts. REVIEW METHODS: Qualitative studies meeting the inclusion criteria were synthesised. Data were analysed by creating a thematic framework, underpinned by the socioecological model, which included familiarisation of data across the studies, indexing, charting, mapping and interpretation. RESULTS: 20 studies from the USA (10), Europe (6) and Australia (4) included the views of 1067 participants (901 parents/caregivers, 37 children, 87 teachers, 15 dieticians and 27 nursery staff). Study designs included focus groups (n=16), individual interviews (n=6) and ethnography (n=1) with some studies using more than one design. Despite wide differences in the study context and focus, several consistent themes emerged. Parental factors increasing young children's obesogenic diets were: negative parent/family/peer modelling, lack of knowledge, time constraints, using food as reward, affordability and concerns about child's health. Child preferences also increased intake. Environmental factors increasing intake include: availability, advertising, societal, cultural and preschool/childcare influences. CONCLUSIONS: Future intervention strategies should aim to promote modelling of positive behaviours, create home and preschool environments that promote healthy diets, and simultaneously target factors at the family and preschool/childcare levels. TRIAL REGISTRATION NUMBER: This review is one of a series of systematic reviews on the determinants of obesogenic behaviours in young children, registered with the International Prospective Register for Systematic Reviews (PROSPERO), CRD42012002881.

Using the Medical Research Council framework for the development and evaluation of complex interventions in a theory-based infant feeding intervention to prevent childhood obesity: the baby milk intervention and trial.

INTRODUCTION: We describe our experience of using the Medical Research Council framework on complex interventions to guide the development and evaluation of an intervention to prevent obesity by modifying infant feeding behaviours. METHODS: We reviewed the epidemiological evidence on early life risk factors for obesity and interventions to prevent obesity in this age group. The review suggested prevention of excess weight gain in bottle-fed babies and appropriate weaning as intervention targets; hence we undertook systematic reviews to further our understanding of these behaviours. We chose theory and behaviour change techniques that demonstrated evidence of effectiveness in altering dietary behaviours. We subsequently developed intervention materials and evaluation tools and conducted qualitative studies with mothers (intervention recipients) and healthcare professionals (intervention deliverers) to refine them. We developed a questionnaire to assess maternal attitudes and feeding practices to understand the mechanism of any intervention effects. CONCLUSIONS: In addition to informing development of our specific intervention and evaluation materials, use of the Medical Research Council framework has helped to build a generalisable evidence base for early life nutritional interventions. However, the process is resource intensive and prolonged, and this should be taken into account by public health research funders. This trial is registered with ISRTCN: 20814693 Baby Milk Trial.

Protocol for systematic reviews of determinants/correlates of obesity-related dietary and physical activity behaviors in young children (preschool 0 to 6 years): evidence mapping and syntheses.

BACKGROUND: The aim of these reviews is to inform the design and content of interventions to reduce obesity in young children. The behaviors that are associated with obesity/overweight have been studied extensively; however, the factors associated with these behaviors in young children (0 to 6 years) have not been systematically reviewed. Over the past few years the focus of obesity prevention has shifted to preschool children because of the high prevalence of obesity at school entry and recognition that habits formed in early life could track into adulthood. In order to develop effective interventions and change behavior, it is important to understand the factors that are associated with those behaviors. For example, we need to understand whether it would be more important to target the family, childcare settings or the wider environment and identify the most effective way of changing these energy balance related behaviors. METHODS/DESIGN: Quantitative (intervention and observational) and qualitative literature on determinants/correlates of fruit and vegetable intake, sugar sweetened beverage and other unhealthy diet intake, and physical activity and sedentary behaviors in young children will be systematically identified, mapped and reviewed. A common search strategy (no language or period restrictions) will be used to identify papers from eight electronic databases and this will be supplemented by hand-searching. Next, studies in developed countries that examine the factors associated with these behaviors in children aged 0 to 6 years (at baseline) will be screened and mapped descriptively followed by in-depth data extraction, quality assessment and synthesis. Data from quantitative studies will be summarized using either forest plots or harvest plots and narrative synthesis, and qualitative studies using thematic analysis. Qualitative evidence will be integrated with the quantitative evidence, using a parallel synthesis approach, to provide a deeper understanding of effective strategies to influence these energy balance related behaviors. DISCUSSION: In addition to updating and mapping current research, these reviews will be the first to comprehensively synthesize and integrate both the quantitative and qualitative evidence pertaining to determinants/correlates/barriers/facilitators of obesity related behaviors in this young age group (0 to 6 years) with the aim of informing future interventions. TRIAL REGISTRATION: International Prospective Register for Systematic Reviews (PROSPERO) Registration number: CRD42012002881.

Higher maternal education is associated with favourable growth of young children in different countries.

BACKGROUND: Childhood growth affects long-term health and could contribute to health inequalities that persist throughout life. METHODS: We compared growth data of 4-year-old to 6-year-old children born 1997-2002 in UK (n=15,168), Sweden (n=6749) and rural China (n=10,327). SD scores (SDS) were calculated against the WHO Growth Standard. Obesity and overweight were defined by the International Obesity Taskforce cut-offs, and stunting, underweight and thinness by height, weight or body mass index (BMI)<-2 SDS. Associations with maternal education were standardised by calculating the Slope Index of Inequality (SII). RESULTS: Mean SDS height, weight and BMI in the UK (-0.01, 0.42, 0.62, respectively) and Sweden (0.45, 0.59, 0.45) were higher than in China (-0.98, -0.82, -0.29). Higher maternal education was consistently associated with taller offspring height SDS (SII: UK 0.25; Sweden 0.17; China 1.06). Underweight and stunting were less common in the UK (prevalence: 0.6% and 2.2%, respectively) and Sweden (0.3% and 0.6%) than in China (9.5% and 16.4%), where these outcomes were inversely associated with maternal education (SII: -25.8% and -12.7%). Obesity prevalence in the UK, Sweden and China was 4.8%, 3.7% and 0.4%, respectively. Maternal education was inversely associated with offspring obesity in the UK (SII: -3.3%) and Sweden (-2.8%), but not in China (+0.3%). CONCLUSIONS: Higher maternal education was associated with more favourable growth in young children: lower obesity and overweight in the UK and Sweden, and lower stunting and underweight in rural China. Public health strategies to optimise growth in early childhood need to acknowledge socioeconomic factors, but possibly with a different emphasis in different settings.

Development of a questionnaire to assess maternal attitudes towards infant growth and milk feeding practices.

BACKGROUND: There is increasing recognition that public health strategies to prevent childhood obesity need to start early in life. Any behavioural interventions need to target maternal attitudes and infant feeding practices, This paper describes the development and preliminary validation of a questionnaire to assess maternal attitudes towards infant growth and milk feeding practices. METHODS: We designed a 57-item (19 questions), self-administered questionnaire to measure the following four domains- 1) type of milk feeding, decision making and sources of advice; 2) frequency and quantity of milk feeds; 3) attitudes to infant feeding and growth; and 4) theory-based beliefs about following infant feeding recommendations. Forty mothers completed the questionnaire on two occasions six days apart (to assess test-retest reliability) and then participated in a semi-structured, open-ended telephone interview covering the same domains (to assess criterion validity). Percentage agreement, Cohen's Kappas (for categorical variables) and Spearman's correlation coefficients (for continuous variables) were used to quantify reliability and validity. Internal consistency between theory-based constructs (self-efficacy, outcome expectancy and intention) was quantified by Chronbach's alpha. RESULTS: Of the 57 questionnaire items 51 (89%) had percentage agreement above 70% indicating good test-retest reliability, and the remaining 6 items had moderate or substantial levels of agreement (kappa 0.41-0.68). Comparing questionnaire with interview coding (validity), percentage agreement was above 66% for 39/57 items (68%). Of the 16 items with percentage agreement below 66%, only five had kappa values below 0.20 (two items had insufficient interview responses). Internal consistency was 0.51, 0.79 and 0.90 for self-efficacy, outcome expectancy and intention respectively. CONCLUSIONS: This questionnaire could be a useful tool in understanding the determinants of infant feeding and the 'causal mechanism' of interventions that target infant feeding practices to prevent early obesity.

Association between area-level socioeconomic deprivation and a cluster of behavioural risk factors: cross-sectional, population-based study.

BACKGROUND: The Commission on Social Determinants of Health has urged governments across the world to promote health equity by reducing the gap between the most and least deprived individuals in society. Some of this gap can be bridged by promoting healthy lifestyles through targeted Public Health policy and interventions. METHODS: Cross-sectional analyses of data on behavioural risk factors, individual socioeconomic factors and neighbourhood deprivation score collected from 26 290 adults aged over 16 years who participated in the 2008 East of England Lifestyle Survey. RESULTS: After adjustment for individual socioeconomic factors, across quintiles of increasing neighbourhood deprivation, participants were more likely to smoke and less likely to consume five portions of fruit and vegetables on five or more days of the week (least deprived versus most deprived quintile: odds ratios for not smoking 0.45 (0.41-0.50); and fruit and vegetable consumption 0.70 (0.64-0.76), P-trend <0.0001). Greater neighbourhood deprivation and lower occupational social class were independently associated with a lower summary healthy lifestyle score (both P-trend <0.0001). CONCLUSIONS: Public health interventions aimed at reducing health inequalities by targeting behavioural risk factors may focus in particular on reducing smoking and increasing fruit and vegetable consumption in more deprived communities.