Gilly A. Hendrie

Interventions that involve parents to improve children's weight-related nutrition intake and activity patterns - what nutrition and activity targets and behaviour change techniques are associated with intervention effectiveness?

Parent involvement is an important component of obesity prevention interventions. However, the best way to support parents remains unclear. This review identifies interventions targeting parents to improve childrens weight status, dietary and/or activity patterns, examines whether intervention content and behaviour change techniques employed are associated with effectiveness. Seventeen studies, in English, 1998–2008, were included. Studies were evaluated by two reviewers for study quality, nutrition/activity content and behaviour change techniques using a validated quality assessment tool and behaviour change technique taxonomy. Study findings favoured intervention effectiveness in 11 of 17 studies. Interventions that were considered effective had similar features: better study quality, parents responsible for participation and implementation, greater parental involvement and inclusion of prompt barrier identification, restructure the home environment, prompt self‐monitoring, prompt specific goal setting behaviour change techniques. Energy intake/density and food choices were more likely to be targeted in effective interventions. The number of lifestyle behaviours targeted did not appear to be associated with effectiveness. Intervention effectiveness was favoured when behaviour change techniques spanned the spectrum of behaviour change process. The review provides guidance for researchers to make informed decisions on how best to utilize resources in interventions to support and engage parents, and highlights a need for improvement in intervention content reporting practices.

Scores on the Dietary Guideline Index for Children and Adolescents Are Associated with Nutrient Intake and Socio-Economic Position but Not Adiposity

Diet quality indices reflect overall dietary patterns better than single nutrients or food groups. The study aims were to develop a measure of adherence with dietary guidelines applicable to child and adolescent populations in Australia and determine the association between index scores and food and nutrient intake, socio-demographic characteristics, and measures of adiposity. Data were analyzed from 4- to 16-y-old participants of the 2007 Australian Childrens Nutrition and Physical Activity Survey (n = 3416). The Dietary Guideline Index for Children and Adolescents (DGI-CA) comprises 11 components: 5 core food groups, wholegrain bread, reduced-fat dairy foods, extra foods (nutrient poor and high in fat, salt, and added sugar), healthy fats/oils, water, and diet variety (possible score of 100). The index criteria were age specific. The mean DGI-CA score was low (53.6 ± 0.4), similar between boys and girls, and differed by age; the youngest children scored higher than the oldest children (P < 0.0001). Higher DGI-CA scores were associated with lower energy intake, energy density, total and saturated fat, and sugar intake; higher protein, carbohydrate, fiber, calcium, iron, vitamin C, vitamin A, folate, phosphorous, magnesium, zinc, and iodine intakes; and a higher polyunsaturated:saturated fat ratio (P < 0.0001). DGI-CA scores were associated with socio-economic characteristics and measures of family circumstance. Weak positive associations were observed between DGI-CA score and BMI or waist circumference Z-scores in the 4- to 10-y and 12- to 16-y age groups only. This index is the first validated index in Australia and one of the few international indices to describe the diet quality of children and adolescents.

Combined Home and School Obesity Prevention Interventions for Children What Behavior Change Strategies and Intervention Characteristics Are Associated With Effectiveness

This review identifies studies describing interventions delivered across both the home and school/community setting, which target obesity and weight-related nutrition and physical activity behaviors in children. Fifteen studies, published between 1998 and 2010, were included and evaluated for effectiveness, study quality, nutrition/activity content, behavior change techniques, and theoretical basis, using validated assessment tools/taxonomies. Seven studies were rated as effective. Behavior change techniques used to engage families, and techniques associated with intervention effectiveness were coded. Effective studies used about 10 behavior change techniques, compared with 6.5 in ineffective studies. Effective interventions used techniques including providing general information on behavior–health links, prompting practice of behavior, and planning for social support/social changes. Different behavior change techniques were applied in the home and school setting. The findings of this review provide novel insights into the techniques associated with intervention effectiveness that can inform the development of public health obesity prevention strategies.

Greenhouse Gas Emissions and the Australian Diet—Comparing Dietary Recommendations with Average Intakes

Nutrition guidelines now consider the environmental impact of food choices as well as maintaining health. In Australia there is insufficient data quantifying the environmental impact of diets, limiting our ability to make evidence-based recommendations. This paper used an environmentally extended input-output model of the economy to estimate greenhouse gas emissions (GHGe) for different food sectors. These data were augmented with food intake estimates from the 1995 Australian National Nutrition Survey. The GHGe of the average Australian diet was 14.5 kg carbon dioxide equivalents (CO2e) per person per day. The recommended dietary patterns in the Australian Dietary Guidelines are nutrient rich and have the lowest GHGe (~25% lower than the average diet). Food groups that made the greatest contribution to diet-related GHGe were red meat (8.0 kg CO2e per person per day) and energy-dense, nutrient poor “non-core” foods (3.9 kg CO2e). Non-core foods accounted for 27% of the diet-related emissions. A reduction in non-core foods and consuming the recommended serves of core foods are strategies which may achieve benefits for population health and the environment. These data will enable comparisons between changes in dietary intake and GHGe over time, and provide a reference point for diets which meet population nutrient requirements and have the lowest GHGe.

Dairy food intake of Australian children and adolescents 2–16 years of age: 2007 Australian National Children's Nutrition and Physical Activity Survey

OBJECTIVE Dairy food consumption is important for Australian children as it contributes key nutrients such as protein and Ca. The aim of the present paper is to describe dietary intake from dairy foods for Australian children aged 2-16 years in 2007. DESIGN Secondary analysis of a quota-sampled survey using population-weighted, 1 d (24 h) dietary recall data. SETTING Australian national survey conducted from February to August 2007. SUBJECTS Children (n 4487) aged 2-16 years. RESULTS Most Australian children consumed dairy foods (84-98 %), with the proportion consuming tending to decrease with age and males consuming significantly more than females from the age of 4 years. Milk was the most commonly consumed dairy food (58-88 %) and consumed in the greatest amount (243-384 g/d). Most children consumed regular-fat dairy products. The contribution of dairy foods to total energy intake decreased with age; from 22 % of total energy at age 2-3 years to 11 % at age 14-16 years. This trend was similar for all nutrients analysed. Dairy food intake peaked between 06.00 and 10.00 hours (typical breakfast hours) corresponding with the peak in dairy Ca intake. Australian children (older than 4 years) did not reach recommendations for dairy food intake, consuming ≤2 servings/d. CONCLUSIONS The under-consumption of dairy foods by Australian children has important implications for intake of key nutrients and should be addressed by multiple strategies.

Change in the family food environment is associated with positive dietary change in children

BackgroundThe family food environment is an important influence in the development of children’s dietary habits. Research suggests that influences of current dietary behaviour and behaviour change may differ. The aims of this paper were to: (1) investigate the association between the food environment at baseline and change in children’s saturated fat intake; and (2) to explore whether a change in the food environment was associated with a change in children’s saturated fat intake.MethodSecondary analysis of a 12 week cluster randomised controlled trial in 133 4-13 year old children. Families were randomly allocated to parental education regarding changing to reduced-fat dairy foods or a comparison non-dietary behaviour. The interventions were family focused. Parents received education from a dietitian in 3x30minute sessions to facilitate behaviour change. Parents completed a comprehensive questionnaire capturing three domains of the food environment – Parent knowledge and attitudes; shaping practices; and behaviours and role modelling. Children’s dietary intake was assessed via multiple 24-hour recalls at baseline and week 12. Changes in the family food environment and primary outcome (saturated fat) were calculated. Hierarchical linear regression models were performed to explore the association between baseline and change in food environment constructs and change in saturated fat intake. Standardised Beta are presented (p<0.05).ResultsAfter adjustments for child and family demographics, higher levels of perceived food availability (β=-0.2) at baseline was associated with greater reduction in saturated fat intake, where as higher perceived responsibility (β=0.2), restriction (β=0.3) and pressure to eat (β=0.3) were associated with lesser change in saturated fat. An increase in nutrition knowledge (β=-0.2), perceived responsibility (β=-0.3) and restriction (β=-0.3) from baseline to week 12 were associated with greater reduction in saturated fat intake.ConclusionsThe present study was one of the first to quantify changes in the family food environment, and identify a number of factors which were associated with a positive dietary change. Because interventions focus on behaviour change, the findings may provide specific targets for intervention strategies in the future.Trial registrationAustralia New Zealand Clinical Trials Registry ACTRN12609000453280.

Researching Effective Strategies to Improve Insulin Sensitivity in Children and Teenagers - RESIST. A randomised control trial investigating the effects of two different diets on insulin sensitivity in young people with insulin resistance and/or pre-diabetes.

BackgroundConcomitant with the rise in childhood obesity there has been a significant increase in the number of adolescents with clinical features of insulin resistance and prediabetes. Clinical insulin resistance and prediabetes are likely to progress to type 2 diabetes and early atherosclerosis if not targeted for early intervention. There are no efficacy trials of lifestyle intervention in this group to inform clinical practice. The primary aim of this randomised control trial (RCT) is to determine the efficacy and effectiveness of two different structured lifestyle interventions differing in diet composition on insulin sensitivity, in adolescents with clinical insulin resistance and/or prediabetes treated with metformin.Methods/designThis study protocol describes the design of an ongoing RCT. We are recruiting 108 (54 each treatment arm) 10 to 17 year olds with clinical features of insulin resistance and/or prediabetes, through physician referral, into a multi-centred RCT. All participants are prescribed metformin and participate in a diet and exercise program. The lifestyle program is the same for all participants except for diet composition. The diets are a high carbohydrate, low fat diet and a moderate carbohydrate, increased protein diet.The program commences with an intensive 3 month dietary intervention, implemented by trained dietitians, followed by a 3 month intensive gym and home based exercise program, supervised by certified physical trainers. To measure the longer term effectiveness, after the intensive intervention trial participants are managed by either their usual physician or study physician and followed up by the study dietitians for an additional 6 months. The primary outcome measure, change in insulin sensitivity, is measured at 3, 6 and 12 months.DiscussionClinical insulin resistance and prediabetes in the paediatric population are rapidly emerging clinical problems with serious health outcomes. With appropriate management these conditions are potentially reversible or at least their progression can be delayed. This research study is the first trial designed to provide much needed data on the effective dietary management for this cohort. This study will inform clinical practice guidelines for adolescents with clinical insulin resistance and may assist in preventing metabolic complications, type 2 diabetes and early cardiovascular disease.Trial registrationAustralian and New Zealand Clinical Trials Registration Number ACTRN12608000416392

Improving children's dairy food and calcium intake: can intervention work? A systematic review of the literature

OBJECTIVE Strategies are needed to address the shortfall in childrens dairy food and Ca intakes. The present review identified interventions targeting an increase in childrens dairy food or Ca intakes, and determined characteristics associated with successful intervention. DESIGN A systematic literature search identified fourteen intervention studies, published in English, between 1990 and 2010. Studies were evaluated for study population, setting and mode of delivery, dietary targets and outcome measures, measures of intervention intensity, intervention description, the use of behaviour change techniques and intervention effectiveness. SETTING Interventions targeting an increase in dairy food or Ca intake. SUBJECTS Children aged 5-12 years. RESULTS Ten of the fourteen studies were considered to be effective. Studies focusing on encouraging intake of dairy foods or Ca alone were all effective, compared with 55 % of studies promoting dairy within the context of a healthy diet. Effective interventions tended to be higher in intensity, provide dairy foods and were delivered across a variety of settings to a range of primary targets. The number of behaviour change techniques used did not differentiate effective and ineffective interventions, but the use of taste exposure and prompting practice appeared to be important for effective intervention. CONCLUSIONS Interventions that target an increase in childrens dairy food or Ca intake could potentially increase childrens dairy food intake by about one serving daily. Research conducted outside the USA is needed. The review has identified some promising strategies likely to be part of effective interventions for improving dairy and Ca intakes in countries where childrens intake is insufficient.

Changing from regular-fat to low-fat dairy foods reduces saturated fat intake but not energy intake in 4–13-y-old children

BACKGROUND Dairy foods are nutrient rich but also a source of saturated fat in the diets of children. OBJECTIVE We assessed effects on dietary intakes and health outcomes of changing dairy foods consumed by children from regular- to reduced-fat varieties. DESIGN This study was a 24-wk cluster randomized controlled trial in 93 families with 4-13-y-olds who were randomly allocated to parental education regarding changing to reduced-fat dairy foods (n = 76 children) or reducing screen time (n = 69 children). Study outcomes, which were measured at weeks 0, 12 (end of the intervention), and 24, included saturated fat, energy, and nutrient intakes; pentadecanoic acid and blood lipid concentrations; body mass index z score; and waist circumference. Multilevel analyses were used with adjustment for child- and family-level covariates. RESULTS There were no group differences in overall dairy intakes (-45 g dairy; 95% CI: -141, 51 g dairy; P = 0.356). Saturated fat intakes were 3.3 percentage points lower (P < 0.0001) in the intervention group at week 24 than in the comparison group. Pentadecanoic acid concentrations were lower at week 12 (0.03%; P = 0.012) but not at week 24. LDL-cholesterol concentrations were not different at week 12, but LDL-cholesterol concentration was 0.15 mmol/L lower in the intervention group at week 24 than in the comparison group (P = 0.037). There were no significant group differences in total energy or adiposity measures. Regular-fat dairy foods decreased from 88% to 14% of dairy intake in the intervention group. Calcium, magnesium, and carbohydrate (percentage of energy) intakes were higher in the intervention group than in the comparison group; retinol intakes were lower in the intervention group than in the comparison group; and overall vitamin A intakes were similar between groups. CONCLUSION Advice to parents to change to reduced-fat products was effective in reducing childrens saturated fat intakes but did not alter energy intakes or measures of adiposity. This trial was registered in the Australia New Zealand Clinical Trials Registry as ACTRN12609000453280.

The reliability and relative validity of a diet index score for 4-11-year-old children derived from a parent-reported short food survey.

OBJECTIVE To assess the reliability and relative validity of a diet index score derived from a Short Food Survey (SFS). DESIGN The thirty-eight-item SFS was designed to assess recent dietary intake of 4-11-year-olds to enable calculation of the Dietary Guideline Index for Children and Adolescents. Reliability was assessed based on two online administrations of the SFS, one week apart. Relative validity was assessed by comparing intakes derived from the SFS with those from the mean of three 24 h recalls. Intra-class correlations, Bland-Altman plots and estimated biases were assessed. Cohens κ coefficients were used to determine the level of agreement between the two methods. SETTING Adelaide, Australia. SUBJECTS Sixty-three parents reported on their childrens intake (mean age 7·1 (sd 2·1) years). RESULTS The intra-class correlation for reliability ranged from 0·43 for dairy foods to 0·94 for beverages, and was 0·92 for total diet index score (all P < 0·01). The intra-class correlation for validity ranged from 0·04 for meat and alternatives to 0·41-0·44 for fruit, beverages and extra foods, and was 0·44 for the total diet index score. The SFS overestimated the mean diet index score by 16 %, and the bias was consistent across levels of compliance. The percentage agreement into tertiles of index scores was 84% between the administrations of the two SFS, but only 43 % when comparing the SFS with the mean of the recalls. CONCLUSIONS The SFS can provide a consistent estimate of overall compliance to dietary guidelines for children aged 4-11 years, but overestimated the total diet index score by 16 % across all levels of compliance.