Evaluation of the Children's Eating Habits Questionnaire used in the IDEFICS study by relating urinary calcium and potassium to milk consumption frequencies among European children

Identification and replication of urine metabolites associated with short-term and habitual intake of sweet and fatty snacks in European children and adolescents

BACKGROUND

Intake of sweet and fatty snacks may partly contribute to the occurrence of obesity and other health conditions in childhood. Traditional dietary assessment methods may be limited in accurately assessing the intake of sweet and fatty snacks in children. Metabolite biomarkers may aid the objective assessment of children's food intake and support establishing diet-disease relationships.

OBJECTIVE

The present study aimed to identify biomarkers of sweet and fatty snack intake in two independent cohorts of European children.

METHODS

We used data from the IDEFICS/I.Family cohort from baseline (2007/2008) and two follow-up examination waves (2009/2010 and 2013/2014). In total, n=1788 urine samples from 599 children were analysed for untargeted metabolomics using high-resolution liquid chromatography-mass spectrometry. Short-term dietary intake was assessed by 24-hour dietary recalls, and habitual dietary intake was calculated with the National Cancer Institute method. Data from the DONALD cohort of 24-hour urine samples (n=567) and 3-day weighted dietary records were used for external replication of results. Multivariate modelling with Unbiased Variable selection in R (MUVR) algorithms and linear mixed models were used to identify novel biomarkers. Metabolite features significantly associated with dietary intake were then annotated.

RESULTS

In total, 66 metabolites were discovered and found to be statistically significant for "chocolate candy", "cakes, puddings & cookies", "candy & sweets", "ice cream", and "crisps". Most of the features (n=62) could not be annotated. Short-term and habitual chocolate intake were positively associated with theobromine, xanthosine, and cyclo(L-prolyl-L-valyl). These results were replicated in the DONALD cohort. Short-term "candy & sweets" intake was negatively associated with octenoylcarnitine.

CONCLUSION

We identified potential metabolite biomarkers of sweet and fatty snacks in children, of which three biomarkers of chocolate intake, namely theobromine, xanthosine, and cyclo(L-prolyl-L-valyl) were externally replicated. However, these potential biomarkers require further validation in children.

Exploring the impact of lifestyle and environmental exposures on appetite hormone levels in children and adolescents: An observational study

BACKGROUND

Appetite hormones are considered a promising target in fighting obesity as impaired appetite hormone levels have already been associated with obesity. However, further insights in the drivers of appetite hormone levels are needed.

OBJECTIVES

In this study, we investigated the associations of fasting appetite hormone levels with lifestyle and environmental exposures in children and adolescents.

METHODS

A total of 534 fasting blood samples were collected from children and adolescents (4-16y,50% boys) and appetite hormone levels (glucagon-like peptide-1 (GLP-1), peptide YY (PYY), pancreatic polypeptide (PP), leptin and ghrelin) were measured. Exposures included dietary quality (fiber-rich food intake, sugar propensity, fat propensity), psychosocial stress (happiness, negative emotions, negative life events and emotional problems), sleep duration, physical activity and environmental quality (long term black carbon (BC), particulate matter <2.5 μM (PM2.5), nitrogen dioxide (NO2) exposure, and green space in a 100 m and 2000 m radius around the residence). A multi-exposure score was calculated to combine all the exposures at study in one measure. Associations of individual exposures and multi-exposure score with appetite hormone levels were evaluated using linear mixed regression models adjusting for sex, age, socioeconomic status, waist-to-height ratio and multiple testing.

RESULTS

GLP-1 was associated with air pollution exposure (NO2 β* = -0.13, BC β* = -0.15, PM2.5 β* = -0.16, all p < 0.001). Leptin was associated with green space in a 100 m radius around the residence (β* = -0.11; p = 0.002). Ghrelin was associated with negative emotions (active ghrelin β* = -0.16; p = 0.04, total ghrelin β* = -0.23; p = 0.0051) and happiness (active ghrelin β* = 0.25; p < 0.001, total ghrelin β* = 0.26; p < 0.001). Furthermore, total ghrelin levels were associated with the multi-exposure score, reflecting unhealthy exposures and lifestyle (β* = -0.22; p = 0.036).

DISCUSSION

Our findings provide new insights into the associations of exposures with appetite hormone levels, which are of high interest for preventive obesity research. Further research is crucial to reveal the underlying mechanisms of the observed associations.

A longitudinal causal graph analysis investigating modifiable risk factors and obesity in a European cohort of children and adolescents

Childhood obesity is a complex disorder that appears to be influenced by an interacting system of many factors. Taking this complexity into account, we aim to investigate the causal structure underlying childhood obesity. Our focus is on identifying potential early, direct or indirect, causes of obesity which may be promising targets for prevention strategies. Using a causal discovery algorithm, we estimate a cohort causal graph (CCG) over the life course from childhood to adolescence. We adapt a popular method, the so-called PC-algorithm, to deal with missing values by multiple imputation, with mixed discrete and continuous variables, and that takes background knowledge such as the time-structure of cohort data into account. The algorithm is then applied to learn the causal structure among 51 variables including obesity, early life factors, diet, lifestyle, insulin resistance, puberty stage and cultural background of 5112 children from the European IDEFICS/I.Family cohort across three waves (2007-2014). The robustness of the learned causal structure is addressed in a series of alternative and sensitivity analyses; in particular, we use bootstrap resamples to assess the stability of aspects of the learned CCG. Our results suggest some but only indirect possible causal paths from early modifiable risk factors, such as audio-visual media consumption and physical activity, to obesity (measured by age- and sex-adjusted BMI z-scores) 6 years later.

The role of psychosocial well-being and emotion-driven impulsiveness in food choices of European adolescents

BACKGROUND

It is unclear whether a hypothetical intervention targeting either psychosocial well-being or emotion-driven impulsiveness is more effective in reducing unhealthy food choices. Therefore, we aimed to compare the (separate) causal effects of psychosocial well-being and emotion-driven impulsiveness on European adolescents' sweet and fat propensity.

METHODS

We included 2,065 participants of the IDEFICS/I.Family cohort (mean age: 13.4) providing self-reported data on sweet propensity (score range: 0 to 68.4), fat propensity (range: 0 to 72.6), emotion-driven impulsiveness using the UPPS-P negative urgency subscale, and psychosocial well-being using the KINDLR Questionnaire. We estimated, separately, the average causal effects of psychosocial well-being and emotion-driven impulsiveness on sweet and fat propensity applying a semi-parametric doubly robust method (targeted maximum likelihood estimation). Further, we investigated a potential indirect effect of psychosocial well-being on sweet and fat propensity mediated via emotion-driven impulsiveness using a causal mediation analysis.

RESULTS

If all adolescents, hypothetically, had high levels of psychosocial well-being, compared to low levels, we estimated a decrease in average sweet propensity by 1.43 [95%-confidence interval: 0.25 to 2.61]. A smaller effect was estimated for fat propensity. Similarly, if all adolescents had high levels of emotion-driven impulsiveness, compared to low levels, average sweet propensity would be decreased by 2.07 [0.87 to 3.26] and average fat propensity by 1.85 [0.81 to 2.88]. The indirect effect of psychosocial well-being via emotion-driven impulsiveness was 0.61 [0.24 to 1.09] for average sweet propensity and 0.55 [0.13 to 0.86] for average fat propensity.

CONCLUSIONS

An intervention targeting emotion-driven impulsiveness, compared to psychosocial well-being, would be marginally more effective in reducing sweet and fat propensity in adolescents.

Rationale and design of integrating a parents first obesity intervention with a pediatric weight management intervention for rural families - Evaluating the ripple effect

Rural families are disproportionately affected by obesity. Obesity often runs in families and is impacted by hereditary components, the shared home environment, and parent modeling/child observational learning. Moreover, parent changes in weight predict child changes in weight. Thus, targeting the family unit has the potential to enhance outcomes for adults and children simultaneously. Additionally, engaging rural nurses in medical clinics and schools may be important in determining whether rural telehealth programs are successfully implemented and sustained. This paper describes the rationale and design of a randomized control trial (RCT) evaluating the effectiveness of an integrated adult- and child-focused obesity treatment tailored for rural participants. Outcomes of this study include participant weight loss from baseline to 9-months, device-measured physical activity, and dietary intake. This project will additionally compare reach between clinic and school settings and evaluate the impact of nurse engagement. This study will include 240 participants from eight rural communities who will be randomized to either a Parent +Family-based group or a Newsletter +Family-based group. Parents in the Parent +Family-based group will receive a 3-month adult obesity treatment designed for adult behavior change as a first step. Then, parents and children together will enter the family-based program (iAmHealthy), allowing for potential enhancement of a theorized ripple effect. Parents in the Newsletter +Family-based group will receive 3 monthly newsletters and then participate in the 6-month family-based intervention designed for child behavior change. This study is the first RCT to examine the effectiveness of an integrated adult- and child-focused obesity treatment program. Registered with ClinicalTrials.gov NCT ID NCT05612971.

Comparison of Childhood Caries Levels between Children of Pediatric Dentists and Children of General Dentists: A Cross-Sectional Study

Caries development in children is a prevalent childhood disease. Factors affecting chronic teeth lesions include nutrition, parental involvement, and executing proper dental health attitude. Professional dentists are perceived as role models for the oral health and hygiene of their families. The purposes of the research were 1. To compare caries rates in the children of pediatric dentists and children of general dentists. 2. To compare children’s nutrition habits between pediatric dentists and general dentists. 3. To compare children’s oral health and hygiene between pediatric dentists and general dentists. 4. To compare children’s usage of fluoride-containing products between pediatric dentists and general dentists. A cross-sectional study was conducted by distributing self-reporting questionnaires to pediatric dentists and general dentists via the social media “snowball” platform. The following themes were surveyed: nutrition habits and oral hygiene of the children. The sample consisted of 176 participants. Children of pediatric dentists were found to have fewer cases of caries than children of general dentists (p = 0.018). Nutrition habits did not differ between the two groups. In addition, pediatric dentists reported that their children use more fluoridated toothpaste in comparison with general dentists. Professional training of pediatric dentists contributed to shaping the oral hygiene attitude of their children.

Dietary intake and meal patterns among young adults with high caries activity: a cross-sectional study

Background

Dental caries is a multifactorial disease that is highly dependent on diet, where a lower consumption and intake frequency of sugar would be favorable. The aims were (i) to examine dietary intake and meal patterns, more specifically sugar intake and foods high in sugar, among young adults with high caries activity, and (ii) to investigate the association between dietary and meal patterns consumption, and level of caries activity.

Methods

This study presents baseline data from an ongoing randomized controlled trial. A total of 50 young adults (aged 23.0 ± 3.0 years) with ≥ 2 decayed tooth surfaces were included. Dietary intake was captured with a 59-item food frequency questionnaire (FFQ) and a three-day food diary. Adherence to dietary guidelines was analyzed by comparing the dietary intake to the Nordic Nutritional Recommendations (NNR) 2012 and by using the Healthy Dietary Adherence score (HDAS). Participants were categorized into two groups: (i) the Caries group with 2–4 decayed surfaces, and (ii) the High caries group with ≥ 5 decayed surfaces.

Results

The High caries group reported a statistically significantly higher snack and total meal intake compared to the Caries group, as well as a sugar intake exceeding the Nordic nutritional recommendations. The majority of the participants reported a high intake frequency (> 2.5/day) of sweet foods and drinks and less than one intake of fruit and vegetables, respectively, per day. Similar results were found when analyzing adherence by using the HDAS, where the lowest adherence according to dietary guidelines was shown for the food groups of sugar, whole meal products, and fruit and vegetables.

Conclusion

The results indicated a high intake of sugar and low intake of fruit, vegetables, and fiber in high caries-active individuals.

The effects of a web-based computer-tailored diet and physical activity intervention based on self-determination theory and motivational interviewing: A randomized controlled trial

BACKGROUND

According to self-determination theory (SDT), autonomous forms of motivation are more likely to result in sustained behavioral changes than controlled forms. Principles of motivational interviewing (MI) can be applied to facilitate more autonomous forms of motivation. This study investigated whether a combined diet and physical activity (PA) web-based computer-tailored intervention based on SDT and MI, called MyLifestyleCoach, was effective in promoting dietary and PA behaviors.

METHODS

A two-arm randomized controlled trial with 1142 Dutch adults was conducted. The intervention and control group completed questionnaires at baseline, 6, and 12 months from baseline. Only participants in the intervention condition had access to MyLifestyleCoach. The waiting list control condition had access to the intervention after completing the 12-month follow-up questionnaire. A modified food frequency questionnaire was used to measure dietary behaviors (fruit, vegetables, fish, and unhealthy snacks). The Dutch Short Questionnaire to ASsess Health was used to measure the weekly minutes of moderate-to-vigorous PA (MVPA). Usage data, which is operationalized as completed sessions in this study, was objectively assessed by log data. We conducted two-step linear mixed effect models. In the first step, a model consisting of condition, time, potentially confounding variables and a random intercept for participants was tested. In the second step, an interaction term was added to investigate the intervention's (time × condition) and usage (time × opening session and time × completed sessions) effects over time for the dietary and PA outcomes.

RESULTS

The findings showed no differences between the groups for all four dietary behaviors and the weekly minutes of MVPA at any of the time points. In-depth analyses showed that participants who followed the opening session of the intervention, in which they received personalized feedback on their behaviors, had a stronger increase in fruit consumption at 6 months and 12 months than participants who did not follow the interventions' opening session. Lastly, participants who followed more sessions in the diet module had a stronger increase in fruit and vegetable consumption at 6 months, and a stronger decrease in the consumption frequency of unhealthy snacks at 12 months post-baseline.

CONCLUSION

Overall, the intervention was not effective in changing dietary and PA behavior. However, moderation analyses suggest that the intervention is effective in changing dietary behavior for those participants who used the intervention more intensively. Further research should focus on improving intervention use.

Clustering of motivational constructs based on self-determination theory for diet and physical activity and their associations with behaviour: a cross-sectional study

The present study explored whether motivational constructs for diet and physical activity (PA) cluster and how these motivational constructs relate to dietary and PA behaviour. Data of 1142 participants were used from a randomised controlled trial examining the effects of a web-based diet and PA promotion intervention based on self-determination theory and motivational interviewing. Motivation was assessed using the Treatment Self-Regulation Questionnaire and Behavioural Regulation in Exercise Questionnaire. The dietary outcomes were measured using an adapted Food Frequency Questionnaire. PA was assessed using the Short QUestionnaire to ASsess Health. Spearman rank-order correlations showed large correlation coefficients (r_s ≥ 0⋅63) between similar motivational constructs between the two lifestyle domains, except for intrinsic motivation where a medium correlation coefficient was found (r_s = 0⋅41). Furthermore, the exploratory factor analysis illustrated that more self-determined forms of motivation seem to be more domain-specific. In contrast, non-self-determined forms of motivation seem to be domain-independent. Last, regression analyses demonstrated that intrinsic motivation towards PA was the only motivational construct significantly positively associated with all PA sub-behaviours (standardised regression coefficients ranging from 0⋅17 to 0⋅28, all P < 0⋅0125). Intrinsic motivation to eat healthily was significantly positively associated with fruits, vegetables and fish intake (standardised regression coefficients ranging from 0⋅11 to 0⋅16, all P < 0⋅0125), but not with unhealthy snacks. Insight of this exploratory study is useful for understanding the interrelationships of motivational induced behaviours, the development of interventions targeting multiple behaviours, and the construction of questionnaires.

Use and Appreciation of a Web-Based, Computer-Tailored Diet and Physical Activity Intervention Based on the Self-determination Theory: Evaluation Study of Process and Predictors

Background

eHealth is a promising tool for promoting lifestyle behaviors such as a healthy diet and physical activity (PA). However, making people use interventions is a crucial and challenging problem in eHealth. More insight into use patterns and predicting factors is needed to improve future interventions.

Objective

This study aims to examine the use, predictors of use, and appreciation of a web-based, computer-tailored, dietary and PA promotion intervention, MyLifestyleCoach, which is based on the self-determination theory. First, we depict the participants’ flow in the intervention and identify moments when they are likely to discontinue use. Second, we investigate whether demographic, motivational, and program-related characteristics predict the use of several intervention elements. Finally, we report the appreciation scores for the intervention and the participant and program characteristics associated with these scores.

Methods

This study was based on data from web-based self-report questionnaires. Here, objectively assessed intervention use data were analyzed from participants randomized to the intervention condition. Multiple stepwise (logistic) regression analyses were conducted to examine the predictors of intervention use and evaluation scores.

Results

Our findings indicate a low full completion rate for the intervention among those who chose and completed the diet module (49/146, 33.6%), the PA module (2/12, 17%), and both modules (58/273, 21.2%). Several points in the intervention where participants were likely to stop using the intervention were identified. Autonomous and intrinsic motivation toward diet were related to the completion of the initial sessions of the intervention (ie, the opening session in which participants could choose which module to follow and the first session of the diet module). In contrast, controlled motivation was linked to the completion of both modules (initial and follow-up sessions). Appreciation scores were somewhat positive. Appreciation was predicted by several motivational constructs, such as amotivation and basic psychological needs (eg, competence) and program-related features (eg, number of completed sessions).

Conclusions

This study adds meaningful information on the use and appreciation of a web-based, computer-tailored dietary and PA intervention, MyLifestyleCoach. The results indicate that different types of motivations, such as extrinsic and intrinsic motivation, are at play at the points when people are likely to stop using the intervention. The intervention was appreciated fairly well, and several motivational constructs and fulfillment of basic psychological needs were associated with appreciation. Practical implications of these findings have been provided in this study.

Changes in Dietary Patterns through a Nutritional Intervention with a Traditional Atlantic Diet: The Galiat Randomized Controlled Trial

Unhealthy dietary patterns (DPs) can lead to cardiovascular and other chronic diseases. We assessed the effects of a community-focused intervention with a traditional Atlantic diet on changes in DPs in families and the associations of these changes with weight loss. The Galiat study is a randomized, controlled trial conducted in 250 families (720 adults and children) and performed at a primary care setting with the cooperation of multiple society sectors. Over 6 months, families randomized to the intervention group received educational sessions, cooking classes, written supporting material, and foods that form part of the Atlantic diet, whereas those randomized to the control group followed their habitual lifestyle. At baseline, five DPs that explained 30.1% of variance were identified: “Caloric”, “Frieds”, “Fruits, vegetables, and dairy products”, “Alcohol”, and “Fish and boiled meals.” Compared to the controls, the intervention group showed significant improvements in “Fruits, vegetables, and dairy products” and “Fish and boiled meals” and reductions in the “Caloric” and “Frieds”. Changes in bodyweight per unit increment of “Frieds” and “Fruits, vegetables, and dairy products” scores were 0.240 kg (95% CI, 0.050–0.429) and −0.184 kg (95% CI, −0.379–0.012), respectively. We found that a culturally appropriate diet improved DPs associated with weight loss.

The temporal relationship between parental concern of overeating and childhood obesity considering genetic susceptibility: longitudinal results from the IDEFICS/I.Family study

BACKGROUND

Many genes and molecular pathways are associated with obesity, but the mechanisms from genes to obesity are less well known. Eating behaviors represent a plausible pathway, but because the relationships of eating behaviors and obesity may be bi-directional, it remains challenging to resolve the underlying pathways. A longitudinal approach is needed to assess the contribution of genetic risk during the development of obesity in childhood. In this study we aim to examine the relationships between the polygenic risk score for body mass index (PRS-BMI), parental concern of overeating and obesity indices during childhood.

METHODS

The IDEFICS/I.Family study is a school-based multicenter pan-European cohort of children observed for 6 years (mean ± SD follow-up 5.8 ± 0.4). Children examined in 2007/2008 (wave 1) (mean ± SD age: 4.4 ± 1.1, range: 2-9 years), in 2009/2010 (wave 2) and in 2013/2014 (wave 3) were included. A total of 5112 children (49% girls) participated at waves 1, 2 and 3. For 2656 children with genome-wide data we constructed a PRS based on 2.1 million single nucleotide polymorphisms. Z-score BMI and z-score waist circumference (WC) were assessed and eating behaviors and relevant confounders were reported by parents via questionnaires. Parental concern of overeating was derived from principal component analyses from an eating behavior questionnaire.

RESULTS

In cross-lagged models, the prospective associations between z-score obesity indices and parental concern of overeating were bi-directional. In mediation models, the association between the PRS-BMI and parental concern of overeating at wave 3 was mediated by baseline z-BMI (β = 0.16, 95% CI: 0.10, 0.21) and baseline z-WC (β = 0.17, 95% CI: 0.11, 0.23). To a lesser extent, baseline parental concern of overeating also mediated the association between the PRS-BMI and z-BMI at wave 3 (β = 0.10, 95% CI: 0.07, 0.13) and z-WC at wave 3 (β = 0.09, 95% CI: 0.07, 0.12).

CONCLUSIONS

The findings suggest that the prospective associations between obesity indices and parental concern of overeating are likely bi-directional, but obesity indices have a stronger association with future parental concern of overeating than vice versa. The findings suggest parental concern of overeating as a possible mediator in the genetic susceptibility to obesity and further highlight that other pathways are also involved. A better understanding of the genetic pathways that lead to childhood obesity can help to prevent weight gain.

TRIAL REGISTRATION

Registry number: ISRCTN62310987 Retrospectively registered 17 September 2018.

Cross-sectional associations between objectively measured sleep characteristics and body mass index in European children and adolescents

BACKGROUND

Short sleep duration has been found to be associated with a higher risk for overweight and obesity. However, previous studies have mainly relied on subjective measures of sleep duration and other sleep characteristics (eg quality, timing) have often been neglected. Therefore, we aimed to investigate associations between several, mainly objectively measured sleep characteristics and body mass index (BMI). Further, we aimed to identify distinct sleep subtypes based on these sleep characteristics and to study their association with BMI.

METHODS

Children aged 9-16 years participating in the European I.Family study (N = 559, 51.2% girls, 32.9% overweight/obese) wore an accelerometer for one week on their wrist and recorded their daily wake-up and lights-off times in a sleep diary. Information on sleep duration, sleep efficiency and sleep latency was derived. To identify sleep subtypes, we conducted a latent class analysis using all five sleep variables. Associations between single sleep variables, sleep subtype and age- and sex-specific BMI z-score were investigated using linear mixed-effects regression models to accommodate clustering among siblings.

RESULTS

No statistically significant associations were observed between the single sleep variables (sleep duration, sleep efficiency, sleep latency, wake-up and lights-off times) and BMI z-score. Four sleep subtypes were identified and children were assigned to one of the groups based on their highest probability for latent group membership: "early birds" (17.5% of the sample), "short sleep duration" (14.7%), "optimal sleep" (47.6%) and "poor sleep quality" (20.2%). Sleep subtype was not associated with BMI z-score.

CONCLUSIONS

Using objective sleep data, we did not find convincing evidence for associations between the sleep variables under investigation and BMI.

Weight Status and BMI-Related Traits in Adolescent Friendship Groups and Role of Sociodemographic Factors: The European IDEFICS/I.Family Cohort

BACKGROUND

During adolescence, health behaviors and weight status are increasingly influenced by friendship and peer networks. This paper examines resemblances in weight-related characteristics and how they differ by sociodemographic factors.

METHODS

Over 3,000 friendships were reported by 1,603 adolescents, aged 11-16 years, who participated in the school-based I.Family study in 6 European countries. Each "source child" named 1-10 friends for whom standardized weight-related traits were available in the same survey. The mean value of the friends' traits weighted by time spent together was calculated, and related to the source child's trait. Country, age and sex of the source child, parental education, and immigrant background were considered for confounding and moderation.

RESULTS

Source children's z-scores of body fat percent and BMI were positively associated with their friends' characteristics, in particular if they had highly educated parents. Positive associations were also found regarding the frequency of fast-food consumption, impulsivity, screen time, preference for sugar-sweetened foods, and hours spent in sports clubs, in increasing order of effect size. Additionally, correlations were observed between friends' cognitive and school functioning and being bullied. No associations were seen for a preference for high-fat foods, weight concerns, and health-related quality of life. Finally, parental education and immigrant background were associated between friends in all countries except Sweden, where no associations were observed.

CONCLUSION

Adolescent friends shared a number of weight-related characteristics. For weight measures per se, positive associations with friends' characteristics were only observed in adolescents with high parental education. Associations regarding energy-balance behaviors and indicators of school-related well-being did not differ by parental education. Parental education and immigrant background correlated positively in friends in most countries showing that social aggregation is already occurring in adolescence. The wide spectrum of friendship associations in weight-related traits and behaviors suggests that health promotion initiatives in adolescents should be directed towards peer groups in both school-related and leisure-time environments. ISRCTN Registry: Pan-European IDEFICS/I.Family children cohort (ID ISRCTN62310987; https://doi.org/10.1186/ISRCTN62310987).

[Effects of Program to Promote Obesity Prevention Behaviors on Pre-Schoolers: Focused on Kindergartener in Korea]

PURPOSE

This study aimed to develop a program to promote obesity prevention behaviors for pre-schoolers and to confirm the effectiveness of the program in Korea.

METHODS

The program comprised 8 sessions for 4 weeks including combined classroom lectures and physical activities. A non-equivalent control group pre-post test study design was used, and seventy two children, aged 5 to 6 years (experimental group: 33, control group: 39) and their parents participated in the study. To examine the effectiveness of the program, children's knowledge, intake of sugar-added beverages and fruits & vegetables, time of outdoor play and screen time, and parental self-efficacy were measured. Data were analyzed with SPSS/WIN ver. 22.0 and R 4.0.2, using descriptive analysis, chi-square test, Fisher's exact test, the independent t-test, and Analysis of covariance (ANCOVA).

RESULTS

The results showed that the experimental group reported significantly increased knowledge (p < .001) and longer time of outdoor play on weekends (p = .033). However, there were no significant differences in the intake of sugar-added beverages and fruits & vegetables, screen time, and parental self-efficacy in the two groups.

CONCLUSION

This study confirms the applicability of an obesity prevention intervention at kindergartens in Korea. The results can be used as basic data for the study of childhood obesity prevention in Korea.

Cross-Sectional and Longitudinal Associations Between Psychosocial Well-Being and Cardiometabolic Markers in European Children and Adolescents

OBJECTIVE

Research examining aspects of positive mental health as potential predictors of cardiometabolic health in young populations is scarce. We investigated the associations between psychosocial well-being and waist circumference (WAIST), blood pressure (BP), the homeostasis model assessment for insulin resistance, triglycerides, and high-density lipoprotein cholesterol considering life-style factors as mediators.

METHODS

Data of European children and adolescents participating in the baseline (2007/2008), first follow-up (FU1; 2009/2010) and second follow-up (FU2; 2013/2014) examinations of the IDEFICS/I.Family study were used (ncross-sectional = 6519; nlongitudinal = 1393). A psychosocial well-being score was calculated from 16 items on emotional well-being, self-esteem, and social relationships (0-48 points). Cardiometabolic markers were transformed to age- and sex-specific and, in case of BP, also height-specific z scores. Life-style factors included diet, physical activity, sleep, and electronic media use. Applying path analysis, we obtained unstandardized estimates of direct and indirect effects of well-being on cardiometabolic markers.

RESULTS

Cross-sectionally, well-being score showed a negative direct and a negative indirect effect through life-style factors on WAIST z score (estimate per 4-point increase, -0.051 [p = .001] and -0.014 [p < .001], respectively). Longitudinally, positive changes in well-being score between baseline and FU1 and between FU1 and FU2, respectively, demonstrated negative indirect effects through life-style factorsFU2 on WAIST z scoreFU2. Both cross-sectionally and longitudinally, higher levels of well-being showed lowering indirect effects on homeostasis model assessment, BP, and triglyceride z scores and an increasing indirect effect on high-density lipoprotein cholesterol z score through both life-style factors and WAIST z score.

CONCLUSIONS

These results supported our hypothesis that a healthier life-style may be one mechanism through which higher well-being is linked with lower abdominal obesity and fewer other cardiometabolic disorders in young populations.

TRIAL REGISTRATION

Pan-European IDEFICS/I.Family children cohort, ISRCTN registry number: ISRCTN62310987 (http://www.isrctn.com/ISRCTN62310987).

Relative validity of FFQ to assess food items, energy, macronutrient and micronutrient intake in children and adolescents: a systematic review with meta-analysis

FFQ are one of the most widely used tools of research into nutritional epidemiology, and many studies have been conducted in several countries using this dietary assessment method. The present study aimed to evaluate the relative validity of FFQ, in comparison with other methods, in assessing dietary intake of children and adolescents, through a systematic review. Four electronic databases (Embase, PubMed, Scopus and Web of Science) found sixty-seven articles, which met the inclusion criteria (healthy children and adolescents from 3 to 18 years of age; journal articles written in English, Spanish and Portuguese between 1988 and March 2019; results showing the comparison between the FFQ with other methods of assessment of dietary intake). The articles were analysed by two independent reviewers. A meta-analysis was conducted using correlation coefficients as estimate effects between the FFQ and the reference standard method. Subgroup analysis and meta-regression were performed to identify the probable source of heterogeneity. In fifty-five of the sixty-seven studies, a single dietary assessment method was used to evaluate the FFQ; nine combined the two methods and three used three reference methods. The most widely used reference method was the 24-h recall, followed by the food record. The overall relative validity of the FFQ to estimate energy, macronutrient, certain micronutrient and certain food item intakes in children and adolescents may be considered weak. The study protocol was registered in PROSPERO under number CRD42016038706.

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper: Plant-based Milks

Parents and caretakers are increasingly feeding infants and young children plant-based "milk" (PBM) alternatives to cow milk (CM). The US Food and Drug Administration currently defines "milk" and related milk products by the product source and the inherent nutrients provided by bovine milk. Substitution of a milk that does not provide a similar nutritional profile to CM can be deleterious to a child's nutritional status, growth, and development. Milk's contribution to the protein intake of young children is especially important. For almond or rice milk, an 8 oz serving provides only about 2% or 8%, respectively, of the protein equivalent found in a serving of CM. Adverse effects from the misuse of certain plant-based beverages have been well-documented and include failure to gain weight, decreased stature, kwashiorkor, electrolyte disorders, kidney stones, and severe nutrient deficiencies including iron deficiency anemia, rickets, and scurvy. Such adverse nutritional outcomes are largely preventable. It is the position of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) Nutrition Committee, on behalf of the society, that only appropriate commercial infant formulas be used as alternatives to human milk in the first year of life. In young children beyond the first year of life requiring a dairy-free diet, commercial formula may be a preferable alternative to cow's milk, when such formula constitutes a substantial source of otherwise absent or reduced nutrients (eg, protein, calcium, vitamin D) in the child's restricted diet. Consumer education is required to clarify that PBMs do not represent an equivalent source of such nutrients. In this position paper, we provide specific recommendations for clinical care, labelling, and needed research relative to PBMs.

Predictors of Self-Determined Module Choice in a Web-Based Computer-Tailored Diet and Physical Activity Intervention: Secondary Analysis of Data From a Randomized Controlled Trial

Background

Tailoring an online intervention to participant preferences (eg, by giving participants a choice which modules to follow) may increase engagement in the intervention, motivation for behavioral change, and possibly intervention effects. So far, little is known about what characteristics predict these module choices. Filling this knowledge gap is useful for optimizing program engagement.

Objective

We investigated participant choice for a dietary and/or physical activity (PA) promotion module in our web-based computer-tailored intervention based on self-determination theory (SDT) and motivational interviewing (MI). Furthermore, we investigated which demographic characteristics, current behavior, psychosocial constructs and constructs from SDT and MI, and program-related variables such as advice on which module to follow were associated with these choices.

Methods

Observational data were used from the randomized controlled trial MyLifestyleCoach of participants who were randomized into the intervention condition, completed the baseline questionnaire, and made a module choice in the opening session of the intervention. Here, they received advice on their own dietary and PA behavior. At the session’s end, they chose which lifestyle modules they would like to follow (both, diet, PA, or no module). Measurements included demographic information; self-reported diet and PA; and several psychosocial, SDT, and MI constructs. In total, data from 619 Dutch adults (59.6% women; mean age was 51.9 [SD 13.5] years) were analyzed. A stepwise multinomial logistic regression analysis was conducted to investigate which characteristics are related to module choice; the diet module served as reference category as almost everyone was advised to follow this module.

Results

Of this sample, 54.8% (339/619) chose to do both the diet and PA module, 25.4% (157/619) chose to follow the diet module, 17.8% (110/619) preferred to follow no module, and 2.1% (13/619) chose to do the PA module only. Furthermore, it was found that older people, those who consumed more fruit, and those who scored lower on importance to change their current diet were more likely to choose no module compared to the diet module. People who had more motivation to change their current PA and those who received strong advice compared with slight advice to follow the diet module were more likely to choose both modules compared with the diet module only.

Conclusions

The results show that more than half of the sample was interested in following both the diet and PA module in this online lifestyle intervention. Several characteristics were found to be related to module choice. A future challenge is to examine how this knowledge can be used to improve future interventions, such as tailoring (messages or content) on specific groups or examining where and how MI could be used to motivate people to make a certain module choice.

Trial Registration

Netherlands Trial Register NL7333; https://www.trialregister.nl/trial/7333

Development and Testing of a Personalized Web-Based Diet and Physical Activity Intervention Based on Motivational Interviewing and the Self-Determination Theory: Protocol for the MyLifestyleCoach Randomized Controlled Trial

Background

Unhealthy dietary patterns and insufficient physical activity (PA) are associated with negative health outcomes, such as cardiovascular diseases, type 2 diabetes, cancer, overweight, and obesity. This makes the promotion of healthy dietary and PA behaviors a public health priority.

Objective

This paper describes the development, design, and evaluation protocol of a Web-based computer-tailored (CT) dietary and PA promotion intervention, MyLifestyleCoach. A Web-based format was chosen for its accessibility and large-scale reach and low-cost potential. To achieve effective and persistent behavioral change, this innovative intervention is tailored to individual characteristics and is based on the self-determination theory and motivational interviewing (MI).

Methods

The 6 steps of the intervention mapping protocol were used to systematically develop MyLifestyleCoach based on the existing effective CT PA promotion intervention I Move. The MyLifestyleCoach intervention consists of 2 modules: I Move, which is aimed at promoting PA, and I Eat, which is aimed at promoting healthy eating. Development of the I Eat module was informed by the previously developed I Move. Both modules were integrated to form the comprehensive MyLifestyleCoach program. Furthermore, I Move was slightly adapted, for example, the new Dutch PA guidelines were implemented. A randomized controlled trial consisting of an intervention condition and waiting list control group will be used to evaluate the effectiveness of the intervention on diet and PA.

Results

Self-reported measures take place at baseline, 6 months, and 12 months after baseline. Enrollment started in October 2018 and will be completed in June 2020. Data analysis is currently under way, and the first results are expected to be submitted for publication in 2020.

Conclusions

MyLifestyleCoach is one of the first interventions to translate and apply self-determination theory and techniques from MI in Web-based computer tailoring for an intervention targeting PA and dietary behavior. Intervention mapping served as a blueprint for the development of this intervention. We will evaluate whether this approach is also successful in promoting eating healthier and increasing PA using an randomized controlled trial by comparing the intervention to a waiting list control condition. The results will provide an insight into the short- and long-term efficacy and will result in recommendations for the implementation and promotion of healthy eating and PA among adults in the Netherlands.

Trial Registration

Dutch Trial Register NL7333; https://www.trialregister.nl/trial/7333

International Registered Report Identifier (IRRID)

DERR1-10.2196/14491

Relative Validity of a Food and Beverage Preference Questionnaire to Characterize Taste Phenotypes in Children Adolescents and Adults

To assess the relative validity of our food and beverage preference questionnaire we investigated the association between sweet and fatty taste preference scores (assessed using a food and beverage preference questionnaire) and sweet and fatty food propensity scores (derived from a food frequency questionnaire). In I.Family, a large European multi-country cohort study, 12,207 participants from Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden, including 5291 adults, 3082 adolescents, and 3834 children, completed a food and beverage preference questionnaire with 63 items. Cumulative preference scores for sweet and fatty taste were calculated from the single item ranking ranging from 1 to 5. The relative consumption frequency of foods classified as sweet and fatty was used to calculate the corresponding consumption propensities, a continuous variable ranging from 0 to 100. We conducted regression analyses to investigate the association between sweet and fatty taste preference scores and sweet and fatty food propensity scores, respectively, separately for adults, adolescents ≥12 years, and for children <12 years. The overall sweet taste preference score was positively associated with the sweet food consumption propensity score (β = 2.4, 95% CI: 2.1;2.7) and the fatty taste preference score was positively associated with the fatty food consumption propensity score (β = 2.0, 95% CI: 1.8;2.2). After stratification for age (children <12 years, adolescents ≥12 years, and adults), the effect remained significant in all age groups and was strongest in adolescents and adults. We conclude that our food and beverage preference questionnaire is a useful instrument for epidemiological studies on sensory perception and health outcomes and for the characterization of sensory taste phenotypes.

Association of Infant Feeding Patterns with Taste Preferences in European Children and Adolescents: A Retrospective Latent Profile Analysis

The aim was to investigate associations between the duration of infant feeding practices (FP) and taste preferences (TP) in European children and adolescents. A total of 5526 children (6-16 years old) of the I.Family study completed a Food and Beverage Preference Questionnaire to measure their preferences for sweet, fatty and bitter tastes. Mothers retrospectively reported the FPs duration in months: exclusive breastfeeding (EBF), exclusive formula milk feeding (EFMF), combined breastfeeding (BF&FMF) and the age at the introduction of complementary foods (CF). Using logistic regression analyses and latent class analysis (latent profiles of FP and CF were identified), we explored associations between profiles and TP, adjusting for various covariates, including the Healthy Diet Adherence Score (HDAS). A total of 48% of children had short durations of EBF (≤4 months) and BF&FMF (≤6 months) and were introduced to CF early (<6 months). No significant relationship was observed between the single FPs and TP, even when considering common profiles of FP. HDAS was inversely associated with sweet and fatty TP, but positively with bitter TP. Contrary to our hypotheses, we did not observe associations between FP and children's TP later in life. Further studies with higher FP variation and longitudinal design are needed to investigate the causal associations between infant FP and taste preferences later in life.

Pre-obese children's dysbiotic gut microbiome and unhealthy diets may predict the development of obesity

It is widely accepted that the intestinal microbiome is connected to obesity, as key mediator of the diet impact on the host metabolic and immunological status. To investigate whether the individual gut microbiome has a potential in predicting the onset and progression of diseases, here we characterized the faecal microbiota of 70 children in a two-time point prospective study, within a four-year window. All children had normal weight at the beginning of this study, but 36 of them gained excessive weight at the subsequent check-up. Microbiome data were analysed together with the hosts' diet information, physical activity, and inflammatory parameters. We find that the gut microbiota structures were stratified into a discrete number of groups, characterized by different biodiversity that correlates with inflammatory markers and dietary habits, regardless of age, gender, and body weight. Collectively, our data underscore the importance of the microbiome-host-diet configuration as a possible predictor of obesity.

Dietary Patterns in Primary School are of Prospective Relevance for the Development of Body Composition in Two German Pediatric Populations

This study performed comparative analyses in two pediatric cohorts to identify dietary patterns during primary school years and examined their relevance to body composition development. Nutritional and anthropometric data at the beginning of primary school and two or four years later were available from 298 and 372 participants of IDEFICS-Germany (Identification and prevention of Dietary-induced and lifestyle-induced health Effects In Children and infants Study) and the KOPS (Kiel Obesity Prevention Study) cohort, respectively. Principal component analyses (PCA) and reduced rank regression (RRR) were used to identify dietary patterns at baseline and patterns of change in food group intake during primary school years. RRR extracted patterns explaining variations in changes in body mass index (BMI), fat mass index (FMI), and waist-to-height-ratio (WtHR). Associations between pattern adherence and excess gain in BMI, FMI, or WtHR (>75th percentile) during primary school years were examined using logistic regression. Among PCA patterns, only a change towards a more Mediterranean food choice during primary school years were associated with a favorable body composition development in IDEFICS-Germany (p < 0.05). In KOPS, RRR patterns characterized by a frequent consumption of fast foods or starchy carbohydrate foods were consistently associated with an excess gain in BMI and WtHR (all p < 0.005). In IDEFICS-Germany, excess gain in BMI, FMI, and WtHR were predicted by a frequent consumption of nuts, meat, and pizza at baseline and a decrease in the consumption frequency of protein sources and snack carbohydrates during primary school years (all p < 0.01). The study confirms an adverse impact of fast food consumption on body composition during primary school years. Combinations of protein and carbohydrate sources deserve further investigation.

The Impact of Adding Sugars to Milk and Fruit on Adiposity and Diet Quality in Children: A Cross-Sectional and Longitudinal Analysis of the Identification and Prevention of Dietary- and Lifestyle-Induced Health Effects in Children and Infants (IDEFICS) Study

Sugar, particularly as free sugars or sugar-sweetened beverages, significantly contributes to total energy intake, and, possibly, to increased body weight. Excessive consumption may be considered as a proxy of poor diet quality. However, no previous studies evaluated the association between the habit of adding sugars to "healthy" foods, such as plain milk and fresh fruit, and indicators of adiposity and/or dietary quality in children. To answer to these research questions, we Panalysed the European cohort of children participating in the IDEFICS study. Anthropometric variables, frequency of consumption of sugars added to milk and fruit (SAMF), and scores of adherence to healthy dietary pattern (HDAS) were assessed at baseline in 9829 children stratified according to age and sex. From this cohort, 6929 children were investigated again after two years follow-up. At baseline, a direct association between SAMF categories and adiposity indexes was observed only in children aged 6⁻<10 years, while the lower frequency of SAMF consumption was significantly associated with a higher HDAS. At the two year follow-up, children with higher baseline SAMF consumption showed significantly higher increases in all the anthropometric variables measured, with the exception of girls 6⁻<10 years old. The inverse association between SAMF categories and HDAS was still present at the two years follow-up in all age and sex groups. Our results suggest that the habit to adding sugars to foods that are commonly perceived as healthy may impact the adherence to healthy dietary guidelines and increase in adiposity risk as well.

Children's propensity to consume sugar and fat predicts regular alcohol consumption in adolescence

Objective

The present study investigated the association between sugar and fat intake in childhood in relation to alcohol use in adolescence. We hypothesized that early exposure to diets high in fat and sugar may affect ingestive behaviours later in life, including alcohol use.

Design/Setting/Subjects

Children from the European IDEFICS/I.Family cohort study were examined at ages 5–9 years and followed up at ages 11–16 years. FFQ were completed by parents on behalf of children, and later by adolescents themselves. Complete data were available in 2263 participants. Children’s propensities to consume foods high in fat and sugar were calculated and dichotomized at median values. Adolescents’ use of alcohol was classified as at least weekly v. less frequent use. Log-binomial regression linked sugar and fat consumption in childhood to risk of alcohol use in adolescence, adjusted for relevant covariates.

Results

Five per cent of adolescents reported weekly alcohol consumption. Children with high propensity to consume sugar and fat were at greater risk of later alcohol use, compared with children with low fat and low sugar propensity (relative risk=2·46; 95 % CI 1·47, 4·12), independent of age, sex and survey country. The association was not explained by parental income and education, strict parenting style or child's health-related quality of life and was only partly mediated by sustained consumption of sugar and fat into adolescence.

Conclusions

Frequent consumption of foods high in fat and sugar in childhood predicted regular use of alcohol in adolescence.

Prospective associations between socioeconomically disadvantaged groups and metabolic syndrome risk in European children. Results from the IDEFICS study

OBJECTIVE

Socioeconomic disadvantages during childhood are hypothesised to have negative implications for health. We aimed to investigate the association between socioeconomic disadvantages and children's total metabolic syndrome (MetS) score at baseline and follow-up and the extent to which socioeconomic disadvantages over time and the accumulation of these socioeconomic disadvantages can affect children's MetS risk.

METHODS

The two-year longitudinal IDEFICS study included 2401 European children (aged 2.0-9.9) with complete information of the 16,229 participating at baseline. Sociodemographic variables, psychosocial factors and lifestyle were proxy-reported via questionnaires. Socioeconomically disadvantaged groups included children from families with low income, low education, migrant origin, unemployed parents, parents who lacked a social network, and from non-traditional families. MetS risk score was calculated as the sum of z-scores of waist circumference, blood pressure, lipids and insulin resistance. Linear mixed-effects models were used to study the association between social disadvantages and MetS risk. Models were adjusted for sex, age, well-being and lifestyle (fruit and vegetables consumption, physical activity, screen time).

RESULTS

At both time points, children from low-income families (0.20 [0.03-0.37]); (β estimate and 99% confidence interval), children from non-traditional families (0.14 [0.02-0.26]), children whose parents were unemployed (0.31 [0.05-0.57]) and children who accumulated >3 disadvantages (0.21 [0.04-0.37]) showed a higher MetS score compared to non-socioeconomically disadvantaged groups.

CONCLUSION

Children from socioeconomically disadvantaged families are at high metabolic risk independently of diet, physical activity, sedentary behaviours and well-being. Interventions focusing on these socioeconomically disadvantaged groups should be developed to tackle health disparities.

Food and beverage intakes according to physical activity levels in European children: the IDEFICS (Identification and prevention of Dietary and lifestyle induced health EFfects In Children and infantS) study

OBJECTIVE

Physical activity (PA) levels and dietary habits are considered some of the most important factors associated with obesity. The present study aimed to examine the association between PA level and food and beverage consumption in European children (2-10 years old).Design/Setting/SubjectsA sample of 7229 children (49·0 % girls) from eight European countries participating in the IDEFICS (Identification and prevention of Dietary and lifestyle induced health EFfects In Children and infantS) study was included. Moderate-to-vigorous PA (MVPA) was assessed objectively with accelerometers. FFQ was used to register dietary habits. ANCOVA and binary logistic regression were applied.

RESULTS

Boys who spent less time in MVPA reported lower consumption of vegetables, fruits, cereals, yoghurt, milk, bread, pasta, candies and sugar-sweetened beverages (SSB) than boys who spent more time in MVPA (P<0·05). Moreover, boys who spent less time in MVPA were more likely to consume fast foods and water than those in the highest MVPA tertile (P<0·05). Girls who spent less time in MVPA reported lower consumption frequencies of vegetables, pasta, bread, yoghurt, candies, jam/honey and SSB than girls in the highest MVPA tertile (P<0·05). Also, girls in the lowest MVPA tertile were more likely to consume fast foods and water than those with high levels of MVPA (P<0·05).

CONCLUSIONS

Food intake among European children varied with different levels of daily MVPA. Low time spent in MVPA was associated with lowest consumption of both high- and low-energy-dense foods and high fast-food consumption.

A systematic review of methods to assess intake of saturated fat (SF) among healthy European adults and children: a DEDIPAC (Determinants of Diet and Physical Activity) study

BACKGROUND

Dietary fat is an essential macronutrient. However, saturated fact has been associated with negative health outcomes including cardiovascular disease. Shifting consumption from saturated fat to unsaturated fats and limiting the level of saturated fat in the diet has been recommended. Currently, there is no standard method to measure saturated fat intake in etiologic studies. Therefore, it is difficult to obtain a reliable picture of saturated fat intake in Europe. To inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods, we aimed to identify the assessment methods and specific instruments which have been used to assess saturated fat intake among children or adults in pan-European studies.

METHODS

Three electronic databases were searched for English language studies of any design which assessed intake of saturated fat. Reference lists were hand-searched. Studies were included if they were conducted in two or more European countries, and involved healthy, free-living children and adults.

RESULTS

The review identified 20 pan-European studies which assessed saturated fat intake. Food Frequency Questionnaires (n = 8) and diet records (n = 7) were most common, followed by 24-h recalls (n = 5). Methods differed in portion size estimation and the composition data which was used to calculate nutrient intake. Of the instruments used in more than two European countries, five Food Frequency Questionnaires had been specifically tested for validity to assess saturated fat intake; four among adults (Food4me, PURE, IMMIDIET, Health, Alcohol and Psychosocial factors in Eastern Europe (HAPIEE)) and one among children (used by Piqueras et al.).

CONCLUSIONS

A standardised approach to portion size estimation and a common source of food composition data are required to measure saturated fat intake across Europe effectively. Only five instruments had been used in more than two European countries and specifically tested for validity to assess saturated fat intake. These instruments may be most appropriate to evaluate intake of saturated fat in future pan-European studies. However, only two instruments had been tested for validity in more than one European country. Future work is needed to assess the validity of the identified instruments across European countries.

Urinary sucrose and fructose to validate self-reported sugar intake in children and adolescents: results from the I.Family study

PURPOSE

Excessive consumption of free sugar increases the risk for non-communicable diseases where a proper assessment of this intake is necessary to correctly estimate its association with certain diseases. Urinary sugars have been suggested as objective biomarkers for total and free sugar intake in adults but less is known about this marker in children and adolescents. Therefore, the aim of this exploratory study is to evaluate the relative validity of self-reported intake using urinary sugars in children and adolescents.

METHODS

The study was conducted in a convenience subsample of 228 participants aged 5-18 years of the I.Family study that investigates the determinants of food choices, lifestyle and health in European families. Total, free and intrinsic sugar intake (g/day) and sugar density (g/1000 kcal) were assessed using 24-h dietary recalls (24HDRs). Urinary sucrose (USUC) and urinary fructose (UFRU) were measured in morning urine samples and corrected for creatinine excretion (USUC/Cr, UFRU/Cr). Correlation coefficients, the method of triads and linear regression models were used to investigate the relationship between intake of different types of sugar and urinary sugars.

RESULTS

The correlation between usual sugar density calculated from multiple 24HDRs and the sum of USUC/Cr and UFRU/Cr (USUC/Cr + UFRU/Cr) was 0.38 (p < 0.001). The method of triads revealed validity coefficients for the 24HDR from 0.64 to 0.87. Linear regression models showed statistically significant positive associations between USUC/Cr + UFRU/Cr and the intake of total and free sugar.

CONCLUSIONS

These findings support the relative validity of total and free sugar intake assessed by self-reported 24HDRs in children and adolescents.

Prospective associations between dietary patterns and body composition changes in European children: the IDEFICS study

OBJECTIVE

To describe dietary patterns by applying cluster analysis and to describe the cluster memberships of European children over time and their association with body composition changes.

DESIGN

The analyses included k-means clustering based on the similarities between the relative frequencies of consumption of forty-three food items and regression models were fitted to assess the association between dietary patterns and body composition changes.

SETTING

Primary schools and pre-schools of selected regions in Italy, Estonia, Cyprus, Belgium, Sweden, Hungary, Germany and Spain.

SUBJECTS

Participants (n 8341) in the baseline (2-9 years old) and follow-up (4-11 years old) surveys of the IDEFICS (Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS) study.

RESULTS

Three persistent clusters were obtained at baseline and follow-up. Children consistently allocated to the 'processed' cluster presented increased BMI (β=0·050; 95 % CI 0·006, 0·093), increased waist circumference (β=0·071; 95 % CI 0·001, 0·141) and increased fat mass gain (β=0·052; 95 % CI 0·014, 0·090) over time v. children allocated to the 'healthy' cluster. Being in the 'processed'-'sweet' cluster combination was also linked to increased BMI (β=0·079; 95 % CI 0·015, 0·143), increased waist circumference (β=0·172; 95 % CI 0·069, 0·275) and increased fat mass gain (β=0·076; 95 % CI 0·019, 0·133) over time v. the 'healthy' cluster.

CONCLUSIONS

Children consistently showing a processed dietary pattern or changing from a processed pattern to a sweet pattern presented the most unfavourable changes in fat mass and abdominal fat. These findings support the need to promote overall healthy dietary habits in obesity prevention and health promotion programmes targeting children.

Associations between social vulnerabilities and psychosocial problems in European children. Results from the IDEFICS study

The effect of socioeconomic inequalities on children's mental health remains unclear. This study aims to explore the cross-sectional and longitudinal associations between social vulnerabilities and psychosocial problems, and the association between accumulation of vulnerabilities and psychosocial problems. 5987 children aged 2-9 years from eight European countries were assessed at baseline and 2-year follow-up. Two different instruments were employed to assess children's psychosocial problems: the KINDL (Questionnaire for Measuring Health-Related Quality of Life in Children and Adolescents) was used to evaluate children's well-being and the Strengths and Difficulties Questionnaire (SDQ) was used to evaluate children's internalising problems. Vulnerable groups were defined as follows: children whose parents had minimal social networks, children from non-traditional families, children of migrant origin or children with unemployed parents. Logistic mixed-effects models were used to assess the associations between social vulnerabilities and psychosocial problems. After adjusting for classical socioeconomic and lifestyle indicators, children whose parents had minimal social networks were at greater risk of presenting internalising problems at baseline and follow-up (OR 1.53, 99% CI 1.11-2.11). The highest risk for psychosocial problems was found in children whose status changed from traditional families at T0 to non-traditional families at T1 (OR 1.60, 99% CI 1.07-2.39) and whose parents had minimal social networks at both time points (OR 1.97, 99% CI 1.26-3.08). Children with one or more vulnerabilities accumulated were at a higher risk of developing psychosocial problems at baseline and follow-up. Therefore, policy makers should implement measures to strengthen the social support for parents with a minimal social network.

Palatable food consumption in children: interplay between (food) reward motivation and the home food environment

To understand the importance of the home food environment on unhealthy food consumption in children high in reward sensitivity, this study tested the hypothesis that the home availability of unhealthy food moderates the effect of reward sensitivity on children's fast-food consumption frequency, exerted via food cue responsiveness. Children between 7.5 and 14 years (n = 174, 50.6% boys) reported on reward sensitivity and food cue responsiveness (by means of the subscale 'external eating'). Their height and weight were measured. Parents reported on their children's fast-food consumption frequency, food cue responsiveness (by means of the subscale 'food responsiveness'), and on the home availability of unhealthy foods. Two moderated mediation models were conducted, one with the parent- and one with the child-reported food cue responsiveness as mediator. Findings suggested that with a high home availability of unhealthy foods, (a) a higher fast-food consumption frequency was found in children high in reward sensitivity and (b) the relation between reward sensitivity and the fast-food consumption frequency was mediated by external eating.

CONCLUSIONS

The findings point at the importance of the home food environment in children high in reward sensitivity. They suggest to limit the home availability of unhealthy foods. What is Known: • Reward sensitivity (RS) is positively associated with children's palatable food consumption • In adolescents, this effect is mediated by food cue responsiveness, which determines the strength of an individual's motivation to obtain food when perceiving food cues What is New: • Children high in RS may be more vulnerable to palatable food cues in their everyday food environment because of a higher food cue responsiveness • The home food environment may be an important determining factor of the palatable food consumption of these children.

Prospective associations between dietary patterns and high sensitivity C-reactive protein in European children: the IDEFICS study

PURPOSE

This prospective study explores high sensitivity C-reactive protein (hs-CRP) levels in relation to dietary patterns at two time points in European children.

METHODS

Out of the baseline sample of the IDEFICS study (n = 16,228), 4020 children, aged 2-9 years at baseline, with available hs-CRP levels and valid data from a food frequency questionnaire (FFQ) at baseline (T0) and 2 years later (T1) were included. K-means clustering algorithm based on the similarities between relative food consumption frequencies of the FFQ was applied. hs-CRP was dichotomized according to sex-specific cutoff points. Multilevel logistic regression was performed to assess the relationship between dietary patterns and hs-CRP adjusting for covariates.

RESULTS

Three consistent dietary patterns were found at T0 and T1: 'animal protein and refined carbohydrate', 'sweet and processed' and 'healthy'. Children allocated to the 'protein' and 'sweet and processed' clusters at both time points had significantly higher odds of being in the highest category of hs-CRP (OR 1.47; 95% CI 1.03-2.09 for 'animal protein and refined carbohydrate' and OR 1.44; 95% CI 1.08-1.92 for 'sweet and processed') compared to the 'healthy' cluster. The odds remained significantly higher for the 'sweet and processed' pattern (OR 1.39; 95% CI 1.05-1.84) when covariates were included.

CONCLUSIONS

A dietary pattern characterized by frequent consumption of sugar and processed products and infrequent consumption of vegetables and fruits over time was independently related with inflammation in European children. Efforts to improve the quality of the diet in childhood may prevent future diseases related with chronic inflammation.

Dietary Patterns of European Children and Their Parents in Association with Family Food Environment: Results from the I.Family Study

The aim of this study was to determine whether an association exists between children's  and  parental  dietary  patterns  (DP),  and  whether  the  number  of  shared  meals  or  soft  drink  availability  during  meals  strengthens  this  association.  In  2013/2014  the  I.Family  study  cross-sectionally assessed the dietary intakes of families from eight European countries using 24-h  dietary recalls. Usual energy and food intakes from six- to 16-year-old children and their parents  were estimated based on the NCI Method. A total of 1662 child-mother and 789 child-father dyads  were included; DP were derived using cluster analysis. We investigated the association between  children's and parental DP and whether the number of shared meals or soft drink availability  moderated this association using mixed effects logistic regression models. Three DP comparable in  children and parents were obtained: Sweet &amp; Fat, Refined Cereals, and Animal Products. Children  were more likely to be allocated to the Sweet &amp; Fat DP when their fathers were allocated to the  Sweet &amp; Fat DP and when they shared at least one meal per day (OR 3.18; 95% CI 1.84; 5.47). Being  allocated to the Sweet &amp; Fat DP increased when the mother or the father was allocated to the Sweet  &amp; Fat DP and when soft drinks were available (OR 2.78; 95% CI 1.80; 4.28 or OR 4.26; 95% CI 2.16;  8.41, respectively). Availability of soft drinks and negative parental role modeling are important  predictors of children's dietary patterns.

A systematic review of methods to assess intake of sugar-sweetened beverages among healthy European adults and children: a DEDIPAC (DEterminants of DIet and Physical Activity) study

OBJECTIVE

Research indicates that intake of sugar-sweetened beverages (SSB) may be associated with negative health consequences. However, differences between assessment methods can affect the comparability of intake data across studies. The current review aimed to identify methods used to assess SSB intake among children and adults in pan-European studies and to inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods suitable for use in future European studies.

DESIGN

A literature search was conducted using three electronic databases and by hand-searching reference lists. English-language studies of any design which assessed SSB consumption were included in the review.

SETTING

Studies involving two or more European countries were included in the review.

SUBJECTS

Healthy, free-living children and adults.

RESULTS

The review identified twenty-three pan-European studies which assessed intake of SSB. The FFQ was the most commonly used (n 24), followed by the 24 h recall (n 6) and diet records (n 1). There were several differences between the identified FFQ, including the definition of SSB used. In total, seven instruments that were tested for validity were selected as potentially suitable to assess SSB intake among adults (n 1), adolescents (n 3) and children (n 3).

CONCLUSIONS

The current review highlights the need for instruments to use an agreed definition of SSB. Methods that were tested for validity and used in pan-European populations encompassing a range of countries were identified. These methods should be considered for use by future studies focused on evaluating consumption of SSB.

Associations between social vulnerabilities and dietary patterns in European children: the Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS (IDEFICS) study

Socio-economic inequalities in childhood can determine dietary patterns, and therefore future health. This study aimed to explore associations between social vulnerabilities and dietary patterns assessed at two time points, and to investigate the association between accumulation of vulnerabilities and dietary patterns. A total of 9301 children aged 2-9 years participated at baseline and 2-year follow-up examinations of the Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS study. In all, three dietary patterns were identified at baseline and follow-up by applying the K-means clustering algorithm based on a higher frequency of consumption of snacks and fast food (processed), sweet foods and drinks (sweet), and fruits and vegetables (healthy). Vulnerable groups were defined at baseline as follows: children whose parents lacked a social network, children from single-parent families, children of migrant origin and children with unemployed parents. Multinomial mixed models were used to assess the associations between social vulnerabilities and children's dietary patterns at baseline and follow-up. Children whose parents lacked a social network (OR 1·31; 99 % CI 1·01, 1·70) and migrants (OR 1·45; 99 % CI 1·15, 1·83) were more likely to be in the processed cluster at baseline and follow-up. Children whose parents were homemakers (OR 0·74; 99 % CI 0·60, 0·92) were less likely to be in the processed cluster at baseline. A higher number of vulnerabilities was associated with a higher probability of children being in the processed cluster (OR 1·78; 99 % CI 1·21, 2·62). Therefore, special attention should be paid to children of vulnerable groups as they present unhealthier dietary patterns.

A systematic review of methods to assess intake of fruits and vegetables among healthy European adults and children: a DEDIPAC (DEterminants of DIet and Physical Activity) study

Objective

Evidence suggests that health benefits are associated with consuming recommended amounts of fruits and vegetables (F&V), yet standardised assessment methods to measure F&V intake are lacking. The current review aims to identify methods to assess F&V intake among children and adults in pan-European studies and inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods suitable for use in future European studies.

Design

A literature search was conducted using three electronic databases and by hand-searching reference lists. English-language studies of any design which assessed F&V intake were included in the review.

Setting

Studies involving two or more European countries were included in the review.

Subjects

Healthy, free-living children or adults.

Results

The review identified fifty-one pan-European studies which assessed F&V intake. The FFQ was the most commonly used (n42), followed by 24 h recall (n11) and diet records/diet history (n7). Differences existed between the identified methods; for example, the number of F&V items on the FFQ and whether potatoes/legumes were classified as vegetables. In total, eight validated instruments were identified which assessed F&V intake among adults, adolescents or children.

Conclusions

The current review indicates that an agreed classification of F&V is needed in order to standardise intake data more effectively between European countries. Validated methods used in pan-European populations encompassing a range of European regions were identified. These methods should be considered for use by future studies focused on evaluating intake of F&V.

Urinary Mineral Concentrations in European Pre-Adolescent Children and Their Association with Calcaneal Bone Quantitative Ultrasound Measurements

This study investigates differences and associations between urinary mineral concentrations and calcaneal bone measures assessed by quantitative ultrasonography (QUS) in 4322 children (3.1–11.9 years, 50.6% boys) from seven European countries. Urinary mineral concentrations and calcaneal QUS parameters differed significantly across countries. Clustering revealed a lower stiffness index (SI) in children with low and medium urinary mineral concentrations, and a higher SI in children with high urinary mineral concentrations. Urinary sodium (uNa) was positively correlated with urinary calcium (uCa), and was positively associated with broadband ultrasound attenuation and SI after adjustment for age, sex and fat-free mass. Urinary potassium (uK) was negatively correlated with uCa but positively associated with speed of sound after adjustment. No association was found between uCa and QUS parameters after adjustment, but when additionally adjusting for uNa, uCa was negatively associated with SI. Our findings suggest that urinary mineral concentrations are associated with calcaneal QUS parameters and may therefore implicate bone properties. These findings should be confirmed in longitudinal studies that include the food intake and repeated measurement of urinary mineral concentrations to better estimate usual intake and minimize bias.

A comparison of heuristic and model-based clustering methods for dietary pattern analysis

OBJECTIVE

Cluster analysis is widely applied to identify dietary patterns. A new method based on Gaussian mixture models (GMM) seems to be more flexible compared with the commonly applied k-means and Ward's method. In the present paper, these clustering approaches are compared to find the most appropriate one for clustering dietary data.

DESIGN

The clustering methods were applied to simulated data sets with different cluster structures to compare their performance knowing the true cluster membership of observations. Furthermore, the three methods were applied to FFQ data assessed in 1791 children participating in the IDEFICS (Identification and Prevention of Dietary- and Lifestyle-Induced Health Effects in Children and Infants) Study to explore their performance in practice.

RESULTS

The GMM outperformed the other methods in the simulation study in 72 % up to 100 % of cases, depending on the simulated cluster structure. Comparing the computationally less complex k-means and Ward's methods, the performance of k-means was better in 64-100 % of cases. Applied to real data, all methods identified three similar dietary patterns which may be roughly characterized as a 'non-processed' cluster with a high consumption of fruits, vegetables and wholemeal bread, a 'balanced' cluster with only slight preferences of single foods and a 'junk food' cluster.

CONCLUSIONS

The simulation study suggests that clustering via GMM should be preferred due to its higher flexibility regarding cluster volume, shape and orientation. The k-means seems to be a good alternative, being easier to use while giving similar results when applied to real data.

Behavioural effects of a community-oriented setting-based intervention for prevention of childhood obesity in eight European countries. Main results from the IDEFICS study

OBJECTIVE

The objective of this paper is to evaluate the behavioural effects, as reported by the parents of the participating boys and girls, of the IDEFICS (Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS) intervention.

METHODS

The effectiveness of the IDEFICS intervention was evaluated through a cluster-controlled trial in eight European countries (control and intervention communities in each country) including more than 16,000 children. The 2- to 9.9-year-old children in the intervention group were exposed to a culturally adapted intervention that aimed to prevent childhood obesity through the community, schools/kindergartens and family. Parents completed questionnaires to measure water, soft drink and fruit juice intake; fruit and vegetable intake; daily TV viewing and other sedentary behaviours; daily physical activity levels and strengthening of the parent-child relationships at baseline and follow-up (2 years later). Mixed models with an additional random effect for country were used to account for the clustered study design, and results were stratified by sex.

RESULTS

The pan-European analysis revealed no significant time by condition interaction effects, neither for boys nor girls, i.e. the analysis revealed no intervention effects on the behaviours of the IDEFICS children as reported by their parents (F = 0.0 to 3.3, all p > 0.05). Also very few significances were found in the country-specific analyses. Positive intervention effects were only found for sport club participation in Swedish boys, for screen time in weekends for Spanish boys and for TV viewing in Belgian girls.

CONCLUSION

Although no expected intervention effects as reported by the parents on diet, physical activity and sedentary behaviours could be shown for the overall IDEFICS cohort, a few favourable intervention effects were found on specific behaviours in some individual countries. More in-depth analyses of the process evaluation data are needed to obtain more insight into the relationship between the level of exposure to the intervention and its effect.

Food intake and inflammation in European children: the IDEFICS study

PURPOSE

This cross-sectional study assesses the relationship between consumption frequencies of food items and high-sensitivity C-reactive protein (hs-CRP) in European children.

METHODS

Out of the baseline sample (N = 16.228) of the IDEFICS study, 6.403 children (1.315 boys aged 2 to <6, 1.908 boys aged 6 to <10, 1.204 girls aged 2 to <6 and 1.976 girls aged 6 to <10 years) had hs-CRP measured and the Children's Eating Habits Questionnaire filled, including a food frequency questionnaire. Logistic regression adjusted for body mass index z-score, education of the mother, breast-feeding and self-reported hours of physical activity in a sport club per week was conducted.

RESULTS

Mean frequency intake of raw vegetable was lower in boys (p = 0.022 in young and p = 0.020 in old) and older girls (p = 0.026) with high hs-CRP concentration, while in younger girls (p = 0.008) the same occurred with the cooked vegetables. The probability of having higher hs-CRP concentration was significantly associated with having low consumption frequency of vegetables (p = 0.004 in older boys, raw vegetables; and p = 0.0032 in younger girls, cooked vegetables). Also, honey/jam intake decreased the probability of having higher concentration of hs-CRP, whereas soft drinks with sugar, mayonnaise and cereals milled increased this probability.

CONCLUSIONS

Out of all food items associated with hs-CRP, frequency intake of vegetables presented more associations across all the analysis. Findings suggest that a high-frequency intake of vegetables is inversely related to an inflammatory status in children. More studies are needed to assess the association between diet and inflammation.

Impact of physical activity, sedentary behaviour and muscle strength on bone stiffness in 2-10-year-old children-cross-sectional results from the IDEFICS study

Background

Physical activity (PA), weight-bearing exercises (WBE) and muscle strength contribute to skeletal development, while sedentary behaviour (SB) adversely affects bone health. Previous studies examined the isolated effect of PA, SB or muscle strength on bone health, which was usually assessed by x-ray methods, in children. Little is known about the combined effects of these factors on bone stiffness (SI) assessed by quantitative ultrasound. We investigated the joint association of PA, SB and muscle strength on SI in children.

Methods

In 1512 preschool (2- < 6 years) and 2953 school children (6–10 years), data on calcaneal SI as well as on accelerometer-based sedentary time (SED), light (LPA), moderate (MPA) and vigorous PA (VPA) were available. Parents reported sports (WBE versus no WBE), leisure time PA and screen time of their children. Jumping distance and handgrip strength served as indicators for muscle strength. The association of PA, SB and muscle strength with SI was estimated by multivariate linear regression, stratified by age group. Models were adjusted for age, sex, country, fat-free mass, daylight duration, consumption of dairy products and PA, or respectively SB.

Results

Mean SI was similar in preschool (79.5 ± 15.0) and school children (81.3 ± 12.1). In both age groups, an additional 10 min/day in MPA or VPA increased the SI on average by 1 or 2 %, respectively (p ≤ .05). The negative association of SED with SI decreased after controlling for MVPA. LPA was not associated with SI. Furthermore, participation in WBE led to a 3 and 2 % higher SI in preschool (p = 0.003) and school children (p < .001), respectively. Although muscle strength significantly contributed to SI, it did not affect the associations of PA with SI. In contrast to objectively assessed PA, reported leisure time PA and screen time showed no remarkable association with SI.

Conclusion

This study suggests that already an additional 10 min/day of MPA or VPA or the participation in WBE may result in a relevant increase in SI in children, taking muscle strength and SB into account. Our results support the importance of assessing accelerometer-based PA in large-scale studies. This may be important when deriving dose–response relationships between PA and bone health in children.

Association between bone stiffness and nutritional biomarkers combined with weight-bearing exercise, physical activity, and sedentary time in preadolescent children. A case-control study

Physical activity (PA) and micronutrients such as calcium (Ca), vitamin D (25OHD), and phosphate (PO) are important determinants of skeletal development. This case-control study examined the association of these nutritional biomarkers and different PA behaviours, such as habitual PA, weight-bearing exercise (WBE) and sedentary time (SED) with bone stiffness (SI) in 1819 2-9-year-old children from the IDEFICS study (2007-2008). SI was measured on the calcaneus using quantitative ultrasound. Serum and urine Ca and PO and serum 25OHD were determined. Children's sports activities were reported by parents using a standardised questionnaire. A subsample of 1089 children had accelerometer-based PA data (counts per minute, cpm). Moderate-to-vigorous PA (MVPA) and SED were estimated. Children with poor SI (below the 15th age-/sex-/height-specific percentile) were defined as cases (N=603). Randomly selected controls (N=1216) were matched by age, sex, and country. Odds ratios (OR) for poor SI were calculated by conditional logistic regression for all biomarkers and PA behaviour variables separately and combined (expressed as tertiles and dichotomised variables, respectively). ORs were adjusted for fat-free mass, dairy product consumption, and daylight duration. We observed increased ORs for no sports (OR=1.39, p<0.05), PA levels below 524 cpm (OR=1.85, p<0.05) and MVPA below 4.2% a day (OR=1.69, p<0.05) compared to WBE, high PA levels (<688 cpm) and high MVPA (6.7%), respectively. SED was not associated with SI. ORs were moderately elevated for low serum Ca and 25OHD. However, biomarkers were not statistically significantly associated with SI and did not modify the association between PA behaviours and SI. Although nutritional biomarkers appear to play a minor role compared to the osteogenic effect of PA and WBE, it is noteworthy that the highest risk for poor SI was observed for no sports or low MVPA combined with lower serum Ca (<2.5 mmol/l) or lower 25OHD (<43.0 nmol/l).

Systematic review to identify and appraise outcome measures used to evaluate childhood obesity treatment interventions (CoOR): evidence of purpose, application, validity, reliability and sensitivity

BACKGROUND

Lack of uniformity in outcome measures used in evaluations of childhood obesity treatment interventions can impede the ability to assess effectiveness and limits comparisons across trials.

OBJECTIVE

To identify and appraise outcome measures to produce a framework of recommended measures for use in evaluations of childhood obesity treatment interventions.

DATA SOURCES

Eleven electronic databases were searched between August and December 2011, including MEDLINE; MEDLINE In-Process and Other Non-Indexed Citations; EMBASE; PsycINFO; Health Management Information Consortium (HMIC); Allied and Complementary Medicine Database (AMED); Global Health, Maternity and Infant Care (all Ovid); Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); Science Citation Index (SCI) [Web of Science (WoS)]; and The Cochrane Library (Wiley) - from the date of inception, with no language restrictions. This was supported by review of relevant grey literature and trial databases.

REVIEW METHODS

Two searches were conducted to identify (1) outcome measures and corresponding citations used in published childhood obesity treatment evaluations and (2) manuscripts describing the development and/or evaluation of the outcome measures used in the childhood intervention obesity evaluations. Search 1 search strategy (review of trials) was modelled on elements of a review by Luttikhuis et al. (Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O'Malley C, Stolk RP, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev 2009;1:CD001872). Search 2 strategy (methodology papers) was built on Terwee et al.'s search filter (Terwee CB, Jansma EP, Riphagen II, de Vet HCW. Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments. Qual Life Res 2009;18:1115-23). Eligible papers were appraised for quality initially by the internal project team. This was followed by an external appraisal by expert collaborators in order to agree which outcome measures should be recommended for the Childhood obesity Outcomes Review (CoOR) outcome measures framework.

RESULTS

Three hundred and seventy-nine manuscripts describing 180 outcome measures met eligibility criteria. Appraisal of these resulted in the recommendation of 36 measures for the CoOR outcome measures framework. Recommended primary outcome measures were body mass index (BMI) and dual-energy X-ray absorptiometry (DXA). Experts did not advocate any self-reported measures where objective measurement was possible (e.g. physical activity). Physiological outcomes hold potential to be primary outcomes, as they are indicators of cardiovascular health, but without evidence of what constitutes a minimally importance difference they have remained as secondary outcomes (although the corresponding lack of evidence for BMI and DXA is acknowledged). No preference-based quality-of-life measures were identified that would enable economic evaluation via calculation of quality-adjusted life-years. Few measures reported evaluating responsiveness.

LIMITATIONS

Proposed recommended measures are fit for use as outcome measures within studies that evaluate childhood obesity treatment evaluations specifically. These may or may not be suitable for other study designs, and some excluded measures may be more suitable in other study designs.

CONCLUSIONS

The CoOR outcome measures framework provides clear guidance of recommended primary and secondary outcome measures. This will enhance comparability between treatment evaluations and ensure that appropriate measures are being used. Where possible, future work should focus on modification and evaluation of existing measures rather than development of tools de nova. In addition, it is recommended that a similar outcome measures framework is produced to support evaluation of adult obesity programmes.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.