Poor quality of external validity reporting limits generalizability of overweight and/or obesity lifestyle prevention interventions in young adults: a systematic review

Accounting for diversity in the treatment of suicide and self-injury: A systematic review of the past 50 years of randomized controlled trials

PURPOSE

Patients receiving treatment for self-injurious thoughts and behaviors (SITBs) have diverse backgrounds, yet it remains unclear exactly who is represented in the current SITB treatment literature.

METHODS

We conducted a systematic review of the past 50 years of randomized controlled trials (RCTs) testing SITB treatments to evaluate sampling practices and reporting of sample characteristics, as well as inclusion of global populations across the included 525 papers. We also assessed changes over the past five decades in these three domains.

RESULTS

SITB RCTs frequently reported age and sex (98.6%-95.1%), less frequently reported race (83.4%-38.6%), socioeconomic status (48.1%-46.1%) and ethnicity (41.9%-8.1%), and rarely reported LGBTQ+ status (3.7%-1.6%). U.S.-based RCTs featured predominantly White, non-Hispanic, and non-LGBTQ+ samples. Most RCTs were conducted in high-income North American or European countries. Sample reporting practices, sample representativeness, and inclusion of global populations modestly and inconsistently improved over time.

CONCLUSIONS

There has not been substantial improvement in reporting practices, sample representativeness, or inclusion of global populations in SITB RCTs over the past 50 years. Acknowledging who is being studied and representing diverse populations in SITB treatment research is key to connecting research advances with those who may need it most.

A rapid review of the scalability of interventions targeting obesity prevention in infants

ISSUE ADDRESSED

Obesity in children is one of the most significant public health issues globally. Given the high prevalence of overweight and obesity in children, there is a need to identify effective obesity prevention efforts that can be delivered at scale to improve child health. We aimed to (i) identify obesity prevention interventions targeted at children aged 0-2 that have been scaled-up, and their relative efficacy compared to their pre-scale trial, (ii) describe adaptations made, and the extent to which factors related to scalability have been reported.

METHODS

We conducted a rapid review of pre-scale randomised controlled trials targeting nutrition, physical activity and obesity prevention in infants, and calculated the relative effect size for relevant outcomes in the corresponding scaled up trial. We documented adaptations made to the pre-scale trial for scale up, and explored how different components of scalability had been reported according to the Intervention Scalability Assessment Tool.

RESULTS

Of the 14 identified pre-scale trials, only one formal evaluation of the scale-up trial was identified. For body mass index, <10% of the effect was retained, however for nutrition and behavioural outcomes, the proportion of effect retained varied from -11.1% to 144%. Significant adaptations to modality were made in the scaled up trial primarily to reduce cost and increase reach of the intervention. Reporting of scalability components varied across the 14 trials, with only one trial reporting information for all assessed components.

CONCLUSIONS

The majority of effective interventions targeting obesity prevention in infants have not been evaluated in a scaled up form. The magnitude of effect retained for the single trial that was scaled up was variable. In general, reporting of components of scalability was sub-optimal. SO WHAT?: The findings suggest that there is substantial need for the development and rigorous evaluation of obesity prevention interventions in children aged 0-2 which are amenable for scale.

The CENTS program: promoting healthy eating by addressing perceived barriers

OBJECTIVE

Nutrition interventions addressing barriers to healthy eating can mitigate concerns regarding poor diet and obesity among college students. Aimed at reducing healthy eating perceived barriers, this investigation employed two mindset change intervention studies.

DESIGN

First, a nutrition improvement program called CENTS (Cost of Eating Nutritiously during Time as a Student) that disseminated specific information and utilized experiential activities for mindset change was developed and pilot tested using a pre/post study design. Second, using a similar pre/post method, the CENTS program was evaluated in a quasi-experimental design.

MAIN OUTCOME MEASURES

We examined perceived barriers to healthy eating (e.g. too costly, too much time), fruit and vegetable consumption, and other variables related to healthy eating (e.g. cost estimates, diet attitudes, self-efficacy, sugary foods consumption).

RESULTS

Results demonstrated some improvement in many outcomes between the two studies. Most noteworthy, the two major perceived barriers of healthy eating (i.e. too expensive, too much time to prepare) dramatically reduced and cost appraisal accuracy improved. Moreover, some attitudes to eat healthy improved and some unhealthy dietary behaviors reduced.

CONCLUSION

Using mindset change techniques to address perceived barriers to healthy eating, interventions can promote healthy eating and discourage unhealthy dietary habits among college students.

Objective understanding of front of pack warning labels among Mexican children of public elementary schools. A randomized experiment

Background

Warning Labels (WL) highlight excessive amounts of critical nutrients in order to discourage consumption of unhealthful packaged food products. This study aimed to evaluate among Mexican school children, the objective understanding of traditional and numeric WL (aimed at small products) considered by the Mexican regulation, and whether cartoon characters influenced the understanding of WL. We also tested some communication strategies to facilitate the correct use of the WL.

Methods

We carried out a randomized experiment in July 2019 in public elementary schools from Morelos, Mexico. Participants aged 6–13 years, were randomly assigned to one of four groups: 1) Nutrient Facts Panel (NF) (n = 120), 2) Nutrient Facts Panel with cartoon characters (NF + C) (n = 83), considered the control groups, 3) Warning Labels (WL) (n = 109), and 4) Warning Labels with cartoon characters (WL + C) (n = 96). After allocation, children assigned to both WL groups (WL or WL + C), were randomly required to watch two posters simultaneously or a video explaining how to correctly interpret WLs. Logistic regression models adjusted by sex, age and cluster (school) were fitted.

Results

The percentage of children correctly choosing the healthiest or the unhealthiest option was higher for WL groups (56.8, 95%CI; 40.8–72.8) compared to NF groups (24.3, 95%CI; 20.4–28.3, p < 0.05). The understanding of traditional WL was higher (28.7, 95%CI: 22.8–35.4) than the numeric WL (19, 95%CI: 14.2–25.0, p < 0.05). But, correct answers for identifying healthy and unhealthy products were higher for numeric WL than for NF groups. Cartoon characters reduced the percentage of correct answers for choosing unhealthiest products (WL + C: 48.9, 95%CI: 25.6–72.4 vs WL: 58.7, 95%CI: 36.4–81.1, p < 0.05). The video was 2.23 times more helpful than the posters to the correct interpretation of the WL (p < 0.05).

Conclusions

In scholar Mexican children, traditional and numeric WL were useful to identify healthier and unhealthier packaged products in comparison to NF, suggesting that both WL formats may effectively communicate the excessive content of nutrients of concern among children. Cartoon characters may reduce the objective understanding of the WL, underscoring the need to regulate advertising directed to children along with the implementation of front-of-pack labeling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-022-00791-z.

Participatory design application in obesity prevention targeting young adults and adolescents: a mixed-methods systematic scoping review protocol

BACKGROUND

Prevention of obesity is economically and sociologically preferable to treatment, with early intervention key to preventing excess weight gain and obesity. The transition from adolescence to young adulthood is a critical intervention period. An expert-led, top-down model has dominated obesity prevention research and practice with limited success. Participatory design (PD) offers potential in transforming obesity prevention research and practice by delivering bottom-up solutions that young people value and may therefore voluntarily engage with over time. An evidence synthesis of PD application in obesity prevention targeting adolescents and young adults is currently lacking.

OBJECTIVES

Report the protocol for a mixed-methods systematic scoping review which aims to integrate and synthesise available evidence on PD application in obesity prevention targeting adolescents and young adults. Specifically, the review will address three research questions: RQ1: How is PD defined in obesity prevention interventions targeting adolescents and young adults? RQ2: To what extent is PD applied in obesity preventions interventions targeting adolescents and young adults? RQ3a: How is the utility of PD evaluated in obesity preventions interventions targeting adolescents and young adults? RQ3b: What is the utility of PD application in obesity prevention interventions targeting adolescents and young adults?

METHODS

This mixed-methods systematic scoping review protocol adheres to the PRISMA-P guidelines and is informed by the PRISMA extension for scoping reviews (PRISMA-ScR). The search strategy and eligibility criteria are informed by the sample, phenomenon of interest, design, evaluation, and research type tool. Eligible studies will be peer-reviewed literature published in English, reporting on PD application in obesity prevention interventions (including intervention development, implementation, and/or evaluation) targeting adolescents and young adults (aged 10-35 years). Study designs will include qualitative, quantitative, and mixed methods. The review will comprise a systematic literature search, eligibility screening, data extraction, quality assessment using the Mixed-Methods Appraisal Tool (MMAT), and data analysis using an iterative narrative evidence synthesis approach. Evidence on PD application will be thematically integrated in terms of who was involved, when they were involved, and how and why they were involved. Further thematic analyses will be conducted according to the MATE taxonomy and the United Kingdom Medical Research Council (UK MRC's) key functions of process evaluations. The MATE taxonomy classifies PD application in terms of methodology, agent of change, training, and engagement. The MRC describes three functions of process evaluations: implementation, mechanisms of impact, and context. Applying both in the evidence synthesis is intended to provide a more complete picture of PD application. Exploratory analyses will be conducted to assess any potential associations between PD application and effectiveness across key outcomes (weight, physical activity, sedentary time, nutrition and dietary habit, mental health, and sleep) reported within intervention evaluations.

CONCLUSIONS

Elucidating PD application is a prerequisite to establishing its utility. Through the location and synthesis of available evidence on PD application in obesity prevention targeting adolescents and young adults, this review will categorise and describe different methods of PD application and explore the utility of PD application including whether any differences may be observed between PD method applied and the effectiveness of obesity prevention interventions. Implications will be delineated from the narrative evidence synthesis to inform future research and advance practice in this context.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021268240.

PEGASO e-Diary: User Engagement and Dietary Behavior Change of a Mobile Food Record for Adolescents

Background

Obesity amongst children and adolescents is becoming a major health problem globally and mobile food records can play a crucial role in promoting healthy dietary habits.

Objective

To describe the methodology for the implementation of the e-Diary mobile food record, to assess its capability in promoting healthy eating habits, to evaluate the factors associated with its usage and engagement.

Methods

This is a descriptive study that compared the characteristics of participants engaged in the e-Diary, which was part of the PEGASO project in which an app to provide proactive health promotion was given to 365 students at 4 European sites enrolled during October to December 2016: England (UK), Scotland (UK), Lombardy (Italy), and Catalonia (Spain). The e-Diary tracked the users' dietary habits in terms of food groups, dietary indexes, and 6 dietary target behaviors relating to consumption of: fruit; vegetable; breakfast; sugar-sweetened beverages; fast-food; and snacks. The e-Diary provided also personalized suggestions for the next meal and gamification.

Results

The e-Diary was used for 6 months by 357 adolescents (53.8% females). The study showed that females used the e-Diary much more than males (aOR 3.8, 95% CI 1.6-8.8). Participants aged 14 years were more engaged in the e-Diary than older age groups (aOR 5.1, 95% CI 1.4-18.8) as were those with a very good/excellent self-perceived health status compared to their peers with fair/poor health perception (aOR 4.2, 95% CI 1.3-13.3). Compared to the intervention sites, those living in Catalonia (aOR 13.2 95% CI 2.5-68.8) were more engaged. In terms of behavior change, a significant positive correlation between fruit (p < 0.0001) and vegetables (p = 0.0087) intake was observed in association with increased engagement in the e-Diary. Similarly, adolescents who used the app for more than 2 weeks had significantly higher odds of not skipping breakfast over the study period (aOR 2.5, 95% CI 1.0-6.3).

Conclusions

The users highly engaged with the e-Diary were associated with improved dietary behaviors: increased consumption of fruit and vegetables and reduced skipping of breakfast. Although the overall usage of the e-Diary was high during the first weeks, it declined thereafter. Future applications should foster user engagement, particularly targeting adolescents at high risk.

Clinical Trial Registration

https://www.clinicaltrials.gov/, identifier: NCT02930148.

Preventing weight gain in adults: A systematic review and meta-analysis of randomized controlled trials

Weight gain prevention is a global public health priority to address escalating adiposity in adults. This review evaluates the efficacy of weight gain prevention trials targeting adults aged 18-50 years and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Trials of any duration from inception to May 2020 that evaluated a weight gain prevention intervention (using either prescriptive diet, prescriptive physical activity, prescriptive diet, and/or physical activity or non-prescriptive lifestyle) and included weight or body mass index (weight [kg]/height [m² ]) were eligible. Twenty-nine trials across 34 publications (participants n = 37,407) were included. Intervention resulted in less weight gain compared with controls (-1.15 kg [95% CI -1.50, -0.80 kg] p < 0.001). Subgroup analysis demonstrated greater effectiveness with prescriptive (-1.60 kg [95% CI -2.00, -1.19] p < 0.001) compared with non-prescriptive (-0.81 kg [95% CI 1.10, -0.53] p < 0.001) intervention types. Interventions had greatest impact in healthy weight (18.5-24.9 kg/m² ) (-0.82 kg [95% CI -1.5, -0.50] p < 0.001) or overweight (25.0-29.9 kg/m² ) (-1.48 kg [95% CI -1.85, -1.12] p < 0.001) compared with obese populations (≥30.0 kg/m² ) (-0.56 kg [95% CI -1.40, 0.27] p = 0.19). These findings demonstrate that lifestyle intervention prevents cumulative weight gain in non-obese adults, with future research required to inform cost-effectiveness and implementation feasibility.

The Relationship of Diet and Physical Activity with Weight Gain and Weight Gain Prevention in Women of Reproductive Age

Reproductive-age women often see increased weight gain, which carries an increased risk of long-term overweight and obesity and adverse maternal and child health outcomes. Supporting women to achieve optimal weight through lifestyle modification (diet and physical activity) is of critical importance to reduce weight gain across key reproductive life-stages (preconception, pregnancy and postpartum). This review comprehensively summarizes the current state of knowledge on the contribution of diet and physical activity to weight gain and weight gain prevention in reproductive-aged women. Suboptimal diets including a higher proportion of discretionary choices or energy intake from fats, added sugars, sweets or processed foods are associated with higher weight gain, whereas increased consumption of core foods including fruits, vegetables and whole grains and engaging in regular physical activity are associated with reduced weight gain in reproductive age women. Diet and physical activity contributing to excessive gestational weight gain are well documented. However, there is limited research assessing diet and physical activity components associated with weight gain during the preconception and postpartum period. This review highlights the need for further research to identify key dietary and physical activity components targeting the critical windows of reproductive life-stages in women to best guide interventions to prevent weight gain.

Automated Behavioral Workplace Intervention to Prevent Weight Gain and Improve Diet: The ChooseWell 365 Randomized Clinical Trial

IMPORTANCE

Personalized interventions that leverage workplace data and environments could improve effectiveness, sustainability, and scalability of employee wellness programs.

OBJECTIVE

To test an automated behavioral intervention to prevent weight gain and improve diet using employee cafeteria purchasing data.

DESIGN, SETTING, AND PARTICIPANTS

This individual-level randomized clinical trial of a 12-month intervention with 12 months of follow-up was conducted among employees of a hospital in Boston, Massachusetts, who purchased food at on-site cafeterias that used traffic-light labels (ie, green indicates healthy; yellow, less healthy; red, unhealthy). Participants were enrolled September 2016 to February 2018. Data were analyzed from May to September 2020.

INTERVENTIONS

For 12 months, participants in the intervention group received 2 emails per week with feedback on previous cafeteria purchases and personalized health and lifestyle tips and 1 letter per month with peer comparisons and financial incentives for healthier purchases. Emails and letters were automatically generated using survey, health, and cafeteria data. Control group participants received 1 letter per month with general healthy lifestyle information.

MAIN OUTCOMES AND MEASURES

The main outcome was change in weight from baseline to 12 months and 24 months of follow-up. Secondary outcomes included changes in cafeteria purchases, including proportion of green- and red-labeled purchases and calories purchased per day, from baseline (12 months preintervention) to the intervention (months 1-12) and follow-up (months 13-24) periods. Baseline Healthy Eating Index-15 (HEI-15) scores were compared to HEI-15 scores at 6, 12, and 24 months.

RESULTS

Among 602 employees enrolled (mean [SD] age, 43.6 [12.2] years; 478 [79.4%] women), 299 were randomized to the intervention group and 303 were randomized to the control group. Baseline mean (SD) body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) was 28.3 (6.6) and HEI-15 score was 60.4 (12.4). There were no between-group differences in weight change at 12 (0.2 [95% CI, -0.6 to 1.0] kg) or 24 (0.6 [95% CI, -0.3 to 1.4] kg) months. Compared with baseline, the intervention group increased green-labeled purchases by 7.3% (95% CI, 5.4% to 9.3%) and decreased red-labeled purchases by 3.9% (95% CI, -5.0% to -2.7%) and calories purchased per day by 49.5 (95% CI, -75.2 to -23.9) kcal more than the control group during the intervention period. In the intervention group, differences in changes in green (4.8% [95% CI, 2.9% to 6.8%]) and red purchases (-3.1% [95% CI, -4.3% to -2.0%]) were sustained at the 24-month follow-up. Differences in changes in HEI-15 scores were not significantly different in the intervention compared with the control group at 6 (2.2 [95% CI, 0 to 4.4]), 12 (1.8 [95% CI, -0.6 to 4.1]), and 24 (1.6, 95% CI, -0.7 to 3.8]) months.

CONCLUSIONS AND RELEVANCE

The findings of this randomized clinical trial suggest that an automated behavioral intervention using workplace cafeteria data improved employees' food choices but did not prevent weight gain over 2 years.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02660086.

Capability, opportunity, and motivation: an across contexts empirical examination of the COM-B model

BACKGROUND

There is limited evidence for successful weight gain prevention interventions targeting young adults. Developing effective interventions necessitates a theoretical model that can identify barriers and enablers for healthy eating and physical activity among young adults to support weight management. This study empirically examines the utility of the COM-B model as a framework for intervention planning across two behavioural contexts: eating and physical activity.

METHODS

A cross-sectional survey research design was employed to empirically test the COM-B model in the contexts of young adult's eating and physical activity behaviours. Informed by the Theoretical Domains Framework, pre-validated measures appropriate for capturing the latency of the COM (Capability, Opportunity, and Motivation) constructs were sourced. Both surveys (eating and physical activity) were administered online to two independent samples of young adults aged 18-35 years. Models were specified and tested using structural equation modelling.

RESULTS

A total of 582 (mean age = 22.8 years; 80.3% female) and 455 (mean age = 24.9 years; 80.8% female) participants were included in the physical activity and eating analyses, respectively. The COM-B model explained 31% of variance in physical activity behaviour and 23% of variance in eating behaviour. In the physical activity model (N = 582), capability and opportunity were found to be associated with behaviour through the mediating effect of motivation. In the eating model (N = 455), capability was found to be associated with behaviour through the mediating effect of motivation. Capability was also found to mediate the association between opportunity and motivation. Consistencies and variations were observed across both models in terms of COM indicators.

CONCLUSIONS

Findings support the COM-B model's explanatory potential in the context of young adult's physical activity and eating behaviours. Barriers and enablers underlying young adult's physical activity and eating behaviours were identified that represent potential targets for future intervention design. Further research is needed to validate present study findings across different populations and settings.

Recruiting and retaining young adults: what can we learn from behavioural interventions targeting nutrition, physical activity and/or obesity? A systematic review of the literature

OBJECTIVE

To describe strategies used to recruit and retain young adults in nutrition, physical activity and/or obesity intervention studies, and quantify the success and efficiency of these strategies.

DESIGN

A systematic review was conducted. The search included six electronic databases to identify randomised controlled trials (RCT) published up to 6 December 2019 that evaluated nutrition, physical activity and/or obesity interventions in young adults (17-35 years). Recruitment was considered successful if the pre-determined sample size goal was met. Retention was considered acceptable if ≥80 % retained for ≤6-month follow-up or ≥70 % for >6-month follow-up.

RESULTS

From 21 582 manuscripts identified, 107 RCT were included. Universities were the most common recruitment setting used in eighty-four studies (79 %). Less than half (46 %) of the studies provided sufficient information to evaluate whether individual recruitment strategies met sample size goals, with 77 % successfully achieving recruitment targets. Reporting for retention was slightly better with 69 % of studies providing sufficient information to determine whether individual retention strategies achieved adequate retention rates. Of these, 65 % had adequate retention.

CONCLUSIONS

This review highlights poor reporting of recruitment and retention information across trials. Findings may not be applicable outside a university setting. Guidance on how to improve reporting practices to optimise recruitment and retention strategies within young adults could assist researchers in improving outcomes.

Applying RE-AIM to Evaluate the External Validity of Weight Gain Prevention Interventions in Young Adults: A Systematic Review

OBJECTIVES

The purpose of this review was to use RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) to assess the extent to which weight gain prevention studies targeting young adults reported on elements of external validity.

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

Articles of interest included a lifestyle/behavioral intervention targeting weight gain prevention. Eligibility criteria included the following: study design of randomized controlled trials, quasi-randomized control trials, or natural experiments; average participant age between 18 and 35 years; study duration of at least 12 months; and published in English between January 2008 and May 2018. Studies had to report weight or body mass index as a measured outcome and were excluded if they were paired with smoking cessation programs, were conducted in specific groups (ie, pregnant women, breast cancer survivors), or were follow-ups to weight loss studies.

STUDY SELECTION

After removing duplicates, the search yielded 11426 articles. Titles and abstracts were screened by 1 reviewer; 144 articles were assessed in a full-text review by 2 reviewers. Discrepancies were resolved by consensus. Nine studies (13 articles) were included in the review.

MAIN OUTCOMES MEASURES

Reported elements of the RE-AIM framework.

RESULTS

A total of 9 studies met the selection criteria. All studies lacked full reporting on external validity elements. Of the total of 60 RE-AIM reporting criteria, 8 were reported by all 9 studies, 26 criteria were reported by fewer than 4 studies, and 22 criteria were not reported by any of the studies.

DISCUSSION

There remains inadequate reporting of elements of external validity and generalizability in weight gain prevention studies. This is a significant scientific constraint that limits the information required to disseminate and implement prevention of weight gain interventions for population impact. Standardized reporting may be needed to ensure results that demonstrate not only internal validity but also external validity and generalizability are needed to promote public health impact.

Effectiveness of gender-targeted versus gender-neutral interventions aimed at improving dietary intake, physical activity and/or overweight/obesity in young adults (aged 17-35 years): a systematic review and meta-analysis

BACKGROUND

Young adulthood has become synonymous with the development of poor lifestyle behaviours associated with an increased risk of preventable chronic disease in later years. Interventions aiming to improve health behaviours may be more engaging and effective if they are targeted to males or females than interventions with a gender-neutral approach. This review will examine the outcome effectiveness of gender-targeted and gender-neutral interventions targeting nutrition, physical activity or overweight/obesity in young adults (17-35 years).

METHODS

Six electronic databases were searched for randomised controlled trials (RCTs) published up to December 2019 that evaluated nutrition, physical activity and/or overweight/obesity interventions in young adults (17-35 years). An effective intervention was one where the change in one or more primary outcome was positive and statistically significantly different from baseline, compared with control, or if no control comparator, compared with another active intervention. Effectiveness of outcomes was compared between gender-targeted and gender-neutral studies.

RESULTS

In total 21,582 manuscripts were identified and 107 RCTs were included; 30 gender-targeted studies (28%) and 77 gender-neutral (72%). Most gender-targeted studies were female targeted (n = 22, 73%). Primary outcome/s were adiposity (n = 36, 34%), nutrition (n = 29, 27%), physical activity (n = 28, 26%), or a combination of (n = 14, 14%). A greater proportion of gender-targeted than gender-neutral studies were effective in improving nutrition (n = 6, 100% and n = 17, 74% of studies respectively) and physical activity outcomes (n = 6, 86% and n = 14, 67% respectively), where as a greater proportion of gender-neutral studies were effective in improving adiposity outcomes (n = 13, 59% and n = 5, 36% respectively). None of these differences were statistically significant. Meta-analyses for weight found no significant differences between gender-targeted and gender-neutral studies for weight loss or weight gain prevention studies. Meta-analysis for fruit and vegetable intake demonstrated a significantly greater increase in intervention participants in gender-targeted studies of +158 g/day for > 3 months.

CONCLUSIONS

Although differences in outcome effectiveness were identified between gender-targeted and gender-neutral studies, these were not significantly different. This is likely due to an insufficient number of studies to detect a difference. The meta-analysis for fruit and vegetable intake findings should be interpreted with caution due to including only two gender-targeted studies. The findings collectively are suggestive of a potential difference requiring further investigation. To truly determine the effectiveness of gender-targeted interventions, well-designed RCTs comparing gender-targeted interventions with gender-neutral and control are needed.

REGISTRATION

This systematic review is a secondary analysis of studies included in a systematic review examining the effectiveness of interventions targeting nutrition, physical activity, or overweight/obesity in young adults, for which a predefined protocol was registered with PROSPERO (CRD42017075795).

Which behaviour change techniques within interventions to prevent weight gain and/or initiate weight loss improve adiposity outcomes in young adults? A systematic review and meta-analysis of randomized controlled trials

Young adulthood is associated with the highest rate of weight gain compared with any other adult age group. This review evaluates the effectiveness of interventions with adiposity outcomes among young adults and identifies which behaviour change techniques (BCTs) are most effective. BCT utilization was assessed using Michie's 93-item BCT Taxonomy v1. Six electronic databases were searched for randomized controlled trials assessing change in adiposity in young adults (17-35 years) until December 2019; identifying 21,582 articles. Fifty-one studies were included. Meta-analyses for weight (n=19 studies), body mass index (BMI) (n=20 studies), and waist circumference (n=10 studies) demonstrated no significant between-group differences at ≤3 or >3 months. There were no differences between interventions focusing on weight loss or weight-gain prevention. Narrative synthesis showed significant between-group differences in weight change, favouring the intervention in 14/43 (33%) studies. In studies assessing BMI and waist circumference, this was 31% (11/36) and 25% (4/16). Two BCTs had a percentage effectiveness ratio >50% in weight loss interventions; social support (unspecified) and self-monitoring behaviour, and one in weight-gain prevention interventions; and goal-setting (outcome). Findings demonstrate initial potential for these types of BCTs and can help build cumulative evidence towards delivering effective, cost-efficient, and replicable interventions.

The efficacy of electronic health interventions targeting improved sleep for achieving prevention of weight gain in adolescents and young to middle-aged adults: A systematic review

Sleep is emerging as a modifiable risk factor in counteracting harmful weight gain. Electronic and mobile devices offer a channel for wide-reaching intervention delivery. This systematic review aimed to determine the efficacy of interventions that included sleep behaviour as part of health promotion for preventing weight gain. Seven databases were searched from 1 January 2000 until 28 June 2019. Eligible studies were controlled trials of weight gain prevention programs that addressed sleep in healthy participants aged 13 to 44 years of age. The primary outcome was change in measured or self-reported weight. From 824 publications located, only six eligible trials with a total of 3,277 participants were identified and all addressed multiple behaviours. One study demonstrated a decrease in weight for the intervention group, and two other studies showed a decreased prevalence of overweight and obesity. Only one trial showed improved sleep duration but failed to show differences in weight. No definitive conclusions concerning the efficacy of electronic weight gain prevention interventions that include sleep can be made, but future trials should provide more detail about intervention techniques used, employ objective sleep and physical activity measures and undertake mediation analysis to judge the contributions of changes in sleep to study outcomes. PROSPERO REGISTRATION: CRD42019121879.

Why young women gain weight: A narrative review of influencing factors and possible solutions

Significant weight gain occurs in women during young adulthood, which increases risk of diseases such as diabetes, cardiovascular disease, and many cancers. This review aims to inform future individually targeted weight gain prevention programmes and summarizes possible targets: key life events, mediators that influence energy intake and physical activity levels, and moderators that could identify groups of women at greatest risk. Life events affecting weight include pregnancy and motherhood, smoking cessation, marriage and cohabiting, attending university, and possibly bereavement. Research has identified successful methods for preventing weight gain associated with pregnancy and motherhood, which could now be used in practice, but evidence is inconclusive for preventing weight gain around other life events. Weight gain is mediated by lack of knowledge and skills around food and nutrition, depression, anxiety, stress, satiety, neural responses, and possibly sleep patterns and premenstrual cravings. A paucity of research exists into altering these to limit weight gain. Moderators include socioeconomic status, genetics, personality traits, and eating styles. More research is required to identify at-risk females and engage them in weight gain prevention. There is a need to address evidence gaps highlighted and implement what is currently known to develop effective strategies to limit weight gain in young women.

Effects of Intervention Characteristics on Willingness to Initiate a Weight Gain Prevention Program

PURPOSE

To determine characteristics of weight gain prevention programs that facilitate engagement.

DESIGN

Randomized factorial experiment (5 × 2).

SETTING

Recruited nationally online.

PARTICIPANTS

Adults aged 18 to 75 with body mass index ≥25 who decline a behavioral weight loss intervention (n = 498).

MEASURES

Participants were randomly presented with one of 10 possible descriptions of hypothetical, free weight gain prevention programs that were all low dose and technology-based but differed in regard to 5 behavior change targets (self-weighing only; diet only; physical activity only; combined diet, physical activity, and self-weighing; or choice between diet, physical activity, and self-weighing targets) crossed with 2 financial incentive conditions (presence or absence of incentives for self-monitoring). Participants reported willingness to join the programs, perceived program effectiveness, and reasons for declining enrollment.

ANALYSIS

Logistic regression and linear regression to test effects of program characteristics offered on willingness to initiate programs and programs' perceived effectiveness, respectively. Content analyses for open-ended text responses.

RESULTS

Participants offered the self-weighing-only programs were more willing to initiate than those offered the programs targeting all 3 behaviors combined (50% vs 36%; odds ratio [OR] = 1.79; 95% confidence interval [CI], 1.01-3.13). Participants offered the programs with financial incentives were more willing to initiate (50% vs 33%; OR = 2.08; 95% CI, 1.44-2.99) and anticipated greater intervention effectiveness (β = .34, P = .02) than those offered no financial incentives. Reasons for declining to initiate included specific program features, behavior targets, social aspects, and benefits.

CONCLUSION

Targeting self-weighing and providing financial incentives for self-monitoring may result in greater uptake of weight gain prevention programs.

STUDY PREREGISTRATION

https://osf.io/b9zfh, June 19, 2018.

Incidence of depression in people with newly diagnosed tuberculosis in Ethiopia: a cohort study

BACKGROUND

Cross-sectional studies show that the prevalence of comorbid depression in people with tuberculosis (TB) is high. The hypothesis that TB may lead to depression has not been well studied. Our objectives were to determine the incidence and predictors of probable depression in a prospective cohort of people with TB in primary care settings in Ethiopia.

METHODS

We assessed 648 people with newly diagnosed TB for probable depression using Patient Health Questionnaire, nine-item (PHQ-9) at the time of starting their anti-TB medication. We defined PHQ-9 scores 10 and above as probable depression. Participants without baseline probable depression were assessed at 2 and 6 months to measure incidence of depression. Incidence rates per 1000-person months were calculated. Predictors of incident depression were identified using Poisson regression.

RESULTS

Two hundred and ninety-nine (46.1%) of the participants did not have probable depression at baseline. Twenty-two (7.4%) and 26 (8.7%) developed depression at 2 and 6 months of follow up. The incidence rate of depression between baseline and 2 months was 73.6 (95% CI 42.8-104.3) and between baseline and 6 months was 24.2 (95% CI 14.9-33.5) per 1000 person-months respectively. Female sex (adjusted β = 0.22; 95% CI 0.16-0.27) was a risk factor and perceived social support (adjusted β = -0.14; 95% CI -0.24 to -0.03) was a protective factor for depression onset.

CONCLUSION

There was high incidence of probable depression in people undergoing treatment for newly diagnosed TB. The persistence and incidence of depression beyond 6 months need to be studied. TB treatment guidelines should have mental health component.

Weight Gain Over 6 Years in Young Adults: The Study of Novel Approaches to Weight Gain Prevention Randomized Trial

OBJECTIVE

The study objective was to determine whether two self-regulation interventions that reduced 3-year weight gain in young adults remain effective at 6 years.

METHODS

A randomized trial was conducted in two academic settings in 599 young adults, aged 18 to 35 years, with normal weight or overweight; 504 (84%) reconsented for a 6-year extension (Study of Novel Approaches to Weight Gain Prevention-Extended [SNAP-E]) with ongoing intervention and assessments. Weight gain over 6 years was compared for all assigned to Control, Large Changes (LC; lose 5-10 pounds initially), and Small Changes (SC; make small daily changes in intake and activity).

RESULTS

Weight change from baseline to 6 years did not differ significantly among the three groups (Control = 3.9 kg, SC = 4.1 kg, and LC = 2.8 kg). However, there was a significant age-by-treatment interaction (P = 0.002). Among those < 25 years old, weight gain from baseline to 6 years averaged 7.3 kg in the Control group and was reduced by almost 50% in LC and SC. LC also significantly reduced mean weight gain (area under the curve) over 6 years compared with Control or SC.

CONCLUSIONS

Although the interventions did not reduce weight gain at 6 years for the full cohort, they were effective in those < 25 years old. Future efforts should focus on young adults aged 18 to 24.9 and test more intensive interventions with more diverse participants.

Reported theory use in electronic health weight management interventions targeting young adults: a systematic review

This review assesses the extent of reported theory use in electronic health weight management interventions targeting young adults aged 18-35 years. Twenty-four eligible studies were identified. Two independent reviewers extracted data and coded for theory use using the Theory Coding Scheme. Overall, the mean total use of theory score was 6/23 (SD = 5; Min. = 0, Max. = 17); 17 studies were classified as having weak application of theory, five as moderate, and two as strong. The majority (N = 18) of studies mentioned theory, however, most (N = 14) did not report how intervention techniques related to theoretical base. No study used theory to select intervention recipients and only four used theory to tailor intervention techniques to recipients. Limited studies reported theory testing (N = 6) and no study used intervention results to build and/or refine theory. Results indicate that weight-related outcomes may be enhanced when at least one or more theoretical constructs are explicitly linked to an intervention technique and when theoretical constructs are included in evaluations. Increases in theory application and reporting are needed to assist the scientific research community in systematically identifying which theories work, for whom, how, why, and when; thereby delivering an advanced understanding of how best to apply theory to enhance intervention outcomes.

Effectiveness of Interventions and Behaviour Change Techniques for Improving Dietary Intake in Young Adults: A Systematic Review and Meta-Analysis of RCTs

Poor eating habits are common during young adulthood and influence chronic disease morbidity. This systematic review evaluates the effectiveness of interventions aiming to improve dietary intake among young adults and, identifies which behaviour change techniques (BCTs) are most effective. Six electronic databases were searched for RCTs published until October 2018, and evaluating behavioural interventions assessing change in dietary intake in young adults (17–35 years). Of the 18,779 articles identified, 54 were included. Forty studies focused on fruit and/or vegetable intake, of which 63% showed a significant between-group difference in favour of the intervention group. Meta-analysis (n = 17) demonstrated a significant increase in fruit and vegetable intake of +68.6 g/day after three months of intervention and +65.8 g/day for interventions >3 months when compared to control. A meta-analysis (n = 5) on total energy intake found no significant differences between groups. The BCTs with the highest effectiveness ratio were habit formation (100%), salience of consequences (83%) and adding objects to the environment (70%). The review highlights the potential of behavioural interventions to improve young adults’ fruit and vegetable intake but was less convincing for other dietary outcomes. Due to the lack of studies including each BCT, the BCTs imperative to success could not be identified.

A Brief Web-Based Nutrition Intervention for Young Adult University Students: Development and Evaluation Protocol Using the PRECEDE-PROCEED Model

Background

Young adults are a priority population for nutrition interventions because of the high prevalence of unhealthy eating behaviors, high risk of weight gain, and the importance of this life stage for developing lifelong eating behaviors. Innovative intervention strategies are needed to reach and engage young adults, whereas more detailed reporting of intervention development and testing would facilitate progress in this challenging research area.

Objective

This paper describes the development of the EATS (Eating Advice To Students) intervention, a targeted, brief Web-based nutrition intervention for young adult (17 to 35 years) university students, and describes the pilot randomized controlled trial (RCT) to assess intervention feasibility.

Methods

EATS was developed using the PRECEDE-PROCEED model. The development involved a cross-sectional survey of university students’ eating behaviors and determinants, a systematic review of brief nutrition interventions, and consultation with a project steering committee. EATS was developed as a website with 4 components: (1) brief screening quiz with personalized feedback, (2) provision of information, tips, and strategies for each target eating behavior (consumption of vegetables, fruit, discretionary foods, and breakfast) and 2 guided exercises to facilitate behavior change, (3) goal setting, and (4) creating strategies. A pilot RCT with students from the University of Newcastle, Australia, was conducted from February to July 2018. The students were randomized to EATS or a brief Web-based alcohol intervention (attention control). The process evaluation included intervention acceptability (Web-based survey postintervention completion) and objective usage data (collected in real time). Efficacy data (Web-based survey at baseline and 3 months) included diet quality, consumption of target food groups (eg, fruits and vegetables), alcohol intake, self-efficacy to perform target eating behaviors, and well-being.

Results

Collection of the 3-month follow-up data was completed in July 2018.

Conclusions

EATS presents an innovative solution to many of the difficulties faced in targeting young adults to improve their eating behaviors. Given the strong methodological approach undertaken, this study provides a significant contribution to advance this research area.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000118202; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374365&isReview=true (Archived by WebCite at http://www.webcitation.org/765o5fVwa)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11992

Weight Management in Young Adults: Systematic Review of Electronic Health Intervention Components and Outcomes

Background

Young adulthood is a vulnerable period for unhealthy lifestyle adoption and excess weight gain. Scant attention has been focused on developing and evaluating effective weight gain prevention strategies for this age group. Electronic health (eHealth) offers potential as a cost-effective means of delivering convenient, individually-tailored, and contextually-meaningful interventions at scale.

Objective

The primary aim of this systematic review was to locate and synthesize the evidence on eHealth weight management interventions targeting young adults, with a particular focus on (eHealth) intervention components and outcomes.

Methods

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search strategy was executed across the following electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, EBSCO, EMBASE, Emerald, Education Resources Information Center, Medical Literature Analysis and Retrieval System Online, Ovid, ProQuest, PsycINFO, PubMed, Science Direct, Scopus, and Web of Science. Furthermore, 2 reviewers independently assessed records for eligibility: peer-reviewed, published in English, and report evaluations of eHealth weight management interventions targeting healthy young adults (aged 18-35 years). Data were then extracted from studies that met the criteria for inclusion. The methodological quality of studies was independently assessed by 2 reviewers using the Effective Public Health Practice Project’s (EPHPP) quality assessment tool. A comprehensive narrative evidence synthesis was then completed.

Results

Out of the 1301 studies assessed for eligibility, 24 met the criteria for inclusion. According to the EPHPP quality assessment tool, overall, 19 studies were as rated weak, 5 as moderate, and none as strong. The narrative synthesis of intervention outcomes found 8 studies reported positive weight-related outcomes, 4 reported mixed outcomes, and 12 did not report any significant changes in weight-related outcomes. The narrative synthesis of (eHealth) intervention components led to 3 levels of classification. A total of 14 studies were classified as Web-based, 3 as mobile-based, and 7 as multicomponent interventions. Following the narrative synthesis, 5 key strategies were thematically identified: self-regulation (goal setting and self-monitoring), tailored or personalized feedback, contact with an interventionist, social support, and behavioral prompts (nudges and reminders) and booster messages.

Conclusions

Findings highlight the limited evidence base for eHealth weight management interventions targeting young adults. The complex nature of weight management presents an ongoing challenge for interventionists to identify what works, for whom, how, and when. The quality of the evidence in this review was generally assessed as weak; however, assessment tools such as the EPHPP are principally concerned with what should be and this is seldom equivalent to what works. Thus, while sampling, study design and retention rates will remain key determining factors of reliability and validity, further research attention directed toward the development of guiding tools for community trials is warranted.

Dietary outcomes within the study of novel approaches to weight gain prevention (SNAP) randomized controlled trial

BACKGROUND

Young adults (YA) are at high-risk for unhealthy dietary behaviors and weight gain. The Study of Novel Approaches to Weight Gain Prevention (SNAP) Trial demonstrated that two self-regulation approaches were effective in reducing weight gain over 2 years compared with control. The goal of this analysis was to examine effects of intervention on dietary outcomes and the association of diet changes with weight change.

METHODS

Participants were 599 YA, age 18-35 years, BMI 21.0-30.0 kg/m² (27.4 ± 4.4 years; 25.4 ± 2.6 kg/m²; 22% men; 73% non-Hispanic White), who were recruited in Providence, RI and Chapel Hill, NC and randomized to self-regulation with Small Changes (SC), self-regulation with Large Changes (LC) or Control (C). SC and LC emphasized frequent self-weighing to cue behavior changes (small daily changes vs. periodic large changes) and targeted high-risk dietary behaviors. Diet and weight were assessed at baseline, 4 months and 2 years.

RESULTS

LC and SC had greater decreases in energy intake than C at 4 months but not 2 years. LC had the greatest changes in percent calories from fat at 4 months, but differences were attenuated at 2 years. No differences in diet quality were observed. Across conditions, increased total energy consumption, fast food, meals away from home, and binge drinking, and decreased dietary quality and breakfast consumption were all associated with weight gain at 2 years.

CONCLUSIONS

This study suggests the need to strengthen interventions to produce longer term changes in dietary intake and helps to identify specific behaviors associated with weight gain over time in young adults.

TRIAL REGISTRATION

Clinicaltrials.gov # NCT01183689 , registered August 18, 2010.

Recruiting young women to weight management programs: Barriers and enablers

AIM

Recruiting young women to weight management research programs is difficult. The purpose of this study was to gain insights into the barriers and motivators that influence participation and to explore effective methods of recruitment from the perspective of young women with obesity living in both urban and regional areas.

METHODS

Semi-structured interviews were used to elicit information from focus groups. The interviews were transcribed, coded and analysed qualitatively. Eight focus groups, which included a total of 27 women, were conducted. Participants had a mean age of 29.1 (±5.1) years and a mean body mass index of 35.8 (±2.9) kg/m² .

RESULTS

The barriers to participation were multifaceted and largely similar across urban and regional participants. Fear of judgement and uncertainty about the process were major psychosocial barriers. A lack of tailoring of program content was an important program-related barrier. Physical barriers such as time commitment, cost and access were discussed extensively, particularly in urban groups. The provision of incentives and the use of positive language that focusses on the benefits of the intervention were viewed positively. Physical and virtual methods of recruitment were identified as potentially effective provided they were presented in media that this group is likely to use and can access in a private location.

CONCLUSIONS

The results of this study provide a greater understanding of the challenges faced by young women in relation to participation in weight management programs and some of the potential methods that could be utilised to facilitate participation.

Feasibility and impact study of a reward-based mobile application to improve adolescents' snacking habits

OBJECTIVE

Adolescents' snacking habits are driven by both explicit reflective and implicit hedonic processes. Hedonic pathways and differences in sensitivity to food rewards in addition to reflective determinants should be considered. The present study evaluated the feasibility and impact of a mobile phone-delivered intervention, incorporating explicit reflective and implicit rewarding strategies, on adolescents' snack intake.

DESIGN

Adolescents (n 988; mean age 14·9 (sd 0·70) years, 59·4 % boys) completed a non-randomized clustered controlled trial. Adolescents (n 416) in the intervention schools (n 3) were provided with the intervention application for four weeks, while adolescents (n 572) in the control schools (n 3) followed the regular curriculum. Outcomes were differences in healthy snacking ratio and key determinants (awareness, intention, attitude, self-efficacy, habits and knowledge). Process evaluation data were collected via questionnaires and through log data of the app.

RESULTS

No significant positive intervention effects on the healthy snack ratio (b=-3·52 (se 1·82), P>0·05) or targeted determinants were observed. Only 268 adolescents started using the app, of whom only fifty-five (20·5 %) still logged in after four weeks. Within the group of users, higher exposure to the app was not significantly associated with positive intervention effects. App satisfaction ratings were low in both high and low user groups. Moderation analyses revealed small positive intervention effects on the healthy snack ratio in high compared with low reward-sensitive boys (b=1·38 (se 0·59), P<0·05).

CONCLUSIONS

The intervention was not able to improve adolescents' snack choices, due to low reach and exposure. Future interventions should consider multicomponent interventions, teacher engagement, exhaustive participatory app content development and tailoring.

"If I Can Afford Steak, Why Worry About Buying Beans": African American Men's Perceptions of Their Food Environment

Due to the high level of food-related chronic diseases for African American men, the purpose of this qualitative study was to induce (n = 83) urban American men’s perspective of their food environment considering different ethnic subgroups, built environment, and the temporal context using a phenomenological method and snowball sampling. Focus group interviews were audio-recorded, transcribed, and entered into ATLAS.ti to aid in establishing themes. African American men perceived that fast-food chains are their food choices and that they do not have any other healthy alternatives near their residential community. Their perspective of their current environment was primarily influenced by their formative years, the availability of current food environments, marketing and advertising of food on television, and the cost of eating healthy as compared to the cost of eating what is convenient to their residence. A central theme of the findings of this study is that the availability and accessibility of restaurants and food options are harmful to health over time. The finding suggests that future interventions should consider and incorporate how people develop and understand their current food practices and environment through the lens of time, not just their adult context.

Effectiveness of lifestyle interventions for preventing harmful weight gain among young adults from lower socioeconomic status and ethnically diverse backgrounds: a systematic review

The incidence of overweight and obesity are increasing with each successive generation of young adults. Associated co-morbidities will emerge at an earlier age unless weight gain is prevented. Evidence has demonstrated young adults (aged 18-35 years) from low socioeconomic and ethnically diverse backgrounds are at greater risk of overweight or obesity, yet it is unclear how to effectively intervene in this population. This systematic review aimed to assess the effectiveness of lifestyle interventions conducted in this population. Thirty studies reporting on lifestyle interventions for prevention of weight gain were identified from eight electronic databases searched. Six interventions included subgroup analyses to determine if ethnicity moderated weight change, and two included subgroup analyses to determine if socioeconomic status had an effect on change in weight. Five of these six studies were effective in preventing weight gain, and subgroup analyses showed no differences in effect by ethnicity. Of these five studies, two included a subgroup analysis that showed socioeconomic status to have no effect on weight outcome. Despite the promising results from these five lifestyle interventions utilizing online and mobile components to effectively reach and prevent weight gain in this priority population, the evidence base of high quality trials is limited.

Assessing the efficacy and external validity of interventions promoting calcium or dairy intake in young adults: A systematic review with meta-analysis

Calcium and dairy products have a role in the prevention of chronic diseases and attainment of peak bone mass, during adolescence to young adulthood. However, intakes are often suboptimal and interventions to improve consumption of food sources are needed. This systematic review aimed to investigate the efficacy and external validity of interventions promoting calcium or dairy foods among young adults. Eight databases were searched from inception to identify relevant studies. Inclusion criteria included those aged 18 to 35 years in an intervention promoting calcium or dairy food intake. The mean age of the participants was 19.9 ± 1.4 years. Of the 16 studies that met the selection criteria, five studies were included in the meta-analyses for calcium (pooled effect size 0.35, 95% CI 0.04 to 0.67) and three studies for dairy (pooled effect size 0.31, 95% CI 0.11 to 0.50). The quality of the body of evidence was determined using the GRADE system, and was of overall low quality with high risk of bias. Our review suggests young adults respond favorably to interventions but the effect size is small.

Geographic Information Systems to Assess External Validity in Randomized Trials

INTRODUCTION

To support claims that RCTs can reduce health disparities (i.e., are translational), it is imperative that methodologies exist to evaluate the tenability of external validity in RCTs when probabilistic sampling of participants is not employed. Typically, attempts at establishing post hoc external validity are limited to a few comparisons across convenience variables, which must be available in both sample and population. A Type 2 diabetes RCT was used as an example of a method that uses a geographic information system to assess external validity in the absence of a priori probabilistic community-wide diabetes risk sampling strategy.

METHODS

A geographic information system, 2009-2013 county death certificate records, and 2013-2014 electronic medical records were used to identify community-wide diabetes prevalence. Color-coded diabetes density maps provided visual representation of these densities. Chi-square goodness of fit statistic/analysis tested the degree to which distribution of RCT participants varied across density classes compared to what would be expected, given simple random sampling of the county population. Analyses were conducted in 2016.

RESULTS

Diabetes prevalence areas as represented by death certificate and electronic medical records were distributed similarly. The simple random sample model was not a good fit for death certificate record (chi-square, 17.63; p=0.0001) and electronic medical record data (chi-square, 28.92; p<0.0001). Generally, RCT participants were oversampled in high-diabetes density areas.

CONCLUSIONS

Location is a highly reliable "principal variable" associated with health disparities. It serves as a directly measurable proxy for high-risk underserved communities, thus offering an effective and practical approach for examining external validity of RCTs.

A systematic review of eHealth behavioral interventions targeting smoking, nutrition, alcohol, physical activity and/or obesity for young adults

A systematic review of randomized control trials (RCT) was undertaken to evaluate the effectiveness of eHealth behavioral interventions aiming to improve smoking rates, nutrition behaviors, alcohol intake, physical activity levels and/or obesity (SNAPO) in young adults. Seven electronic databases were searched for RCTs published in English from 2000 to April 2015 and evaluating eHealth interventions aiming to change one or multiple SNAPO outcomes, and including young adult (18-35years) participants. Of 2,159 articles identified, 45 studies met the inclusion criteria. Most interventions targeted alcohol (n=26), followed by smoking (n=7), physical activity (n=4), obesity (n=4) and nutrition (n=1). Three interventions targeted multiple behaviors. The eHealth interventions were most often delivered via websites (79.5%). Most studies (n=32) compared eHealth interventions to a control group (e.g. waiting list control, minimal intervention), with the majority (n=23) showing a positive effect on a SNAPO outcome at follow-up. Meta-analysis demonstrated a significantly lower mean number of drinks consumed/week in brief web or computer-based interventions compared to controls (Mean Difference -2.43 [-3.54, -1.32], P<0.0001, n=10). Sixteen studies compared eHealth delivery modes, with inconsistent results across target behaviors and technology types. Nine studies compared eHealth to other modes of delivery (e.g. in person) with all finding no difference in SNAPO outcomes between groups at follow-up. This review provides some evidence for the efficacy of eHealth SNAPO interventions for young adults, particularly in the short-term and for alcohol interventions. But there is insufficient evidence for their efficacy in the longer-term, as well as which mode of delivery is most effective.

Health Promotion for Young Adults With Serious Mental Illness

OBJECTIVE

Young adulthood represents a critical time to address elevated obesity rates and the risk of early mortality, particularly among people with serious mental illness. Few studies have assessed the benefits of lifestyle interventions targeting weight loss among these young adults. This study examined the impact of the 12-month In SHAPE lifestyle intervention on weight loss and fitness among overweight and obese young adults with serious mental illness (ages 21-30) compared with participants over age 30.

METHODS

Data were combined from three trials of the 12-month In SHAPE program delivered through community mental health centers. In SHAPE includes weekly fitness trainer meetings, a gym membership, and nutrition education. Primary outcomes were weight loss and change in fitness at 12 months.

RESULTS

Participants (N=194) had a schizophrenia spectrum disorder (53%) or a mood disorder (47%). The overall sample achieved significant weight loss and improved fitness; differences between young adults (N=29) and participants over age 30 (N=165) were not significant. An important finding was that 42% of young adults achieved clinically significant reductions in cardiovascular risk, defined as ≥5% weight loss or improved fitness (>50-m increase on the 6-Minute Walk Test), compared with 54% of adults over age 30 (a nonsignificant difference between age groups).

CONCLUSIONS

Among persons enrolled in a lifestyle intervention, overweight and obese young adults experienced benefits comparable with those of adults over age 30. Young adults with serious mental illness face high risk of gaining weight, but a meaningful proportion of these individuals can achieve clinically significant cardiovascular risk reduction, thus highlighting the need to promote lifestyle intervention participation in this group.

Weight-Gain Reduction Among 2-Year College Students: The CHOICES RCT

INTRODUCTION

The young adult years have been recognized as an influential period for excess weight gain. Non-traditional students and those attending 2-year community colleges are at particularly high risk for a range of adverse weight-related outcomes.

DESIGN

Choosing Healthy Options in College Environments and Settings was an RCT with students randomly assigned into a control or intervention condition after baseline assessment. The study was designed to evaluate if a 24-month weight-gain prevention intervention reduces the expected increase in BMI and overweight prevalence in young adults attending 2-year colleges. Two cohorts were recruited, corresponding to the fall and spring semesters. Data collection occurred at four time points for each cohort, with baseline occurring in fall 2011 for Cohort 1 and spring 2012 for Cohort 2. The 24-month follow-up occurred in fall 2013 for Cohort 1 and spring 2014 for Cohort 2. Data analysis occurred in 2015-2016.

SETTING/PARTICIPANTS

This research was conducted with 441 students from three community colleges in Minnesota.

INTERVENTION

The 24-month intervention began with a 1-credit college course on healthy weight behaviors. A social networking and social support website was introduced as part of the course and participation encouraged for the duration of the trial.

MAIN OUTCOME MEASURES

Changes in BMI, weight, body fat percentage, waist circumference, and weight status were assessed.

RESULTS

Retention of the cohorts at 24 months was 83.4%. There was not a statistically significant difference in BMI between conditions at the end of the trial. However, there was a statically significant difference in the prevalence of overweight/obesity between treatment conditions at 24 months. Also, participants randomized to the intervention who were overweight or obese at baseline were more than three times as likely to transition to a healthy weight by the end of the trial as compared with control students.

CONCLUSIONS

The intervention was not successful in achieving BMI differences between treatment groups. However, an 8% reduction in the prevalence of overweight and obesity over time may have population-level significance.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01134783.

Evaluation of a large healthy lifestyle program: informing program implementation and scale-up in the prevention of obesity

BACKGROUND

The Healthy Lifestyle Program for women (HeLP-her) is a low-intensity, self-management program which has demonstrated efficacy in preventing excess weight gain in women. However, little is known about the implementation, reach, and sustainability of low-intensity prevention programs in rural settings, where risk for obesity in women is higher than urban settings. We aimed to evaluate a low-intensity healthy lifestyle program delivered to women in a rural setting to inform development of effective community prevention programs.

METHODS

A mixed method hybrid implementation and evaluation study, guided by the RE-AIM framework (addressing the Reach, Effectiveness, Adoption, Implementation, and Maintenance), was undertaken. Data collection tools included anthropometric measures, program checklists, questionnaires, and semi-structured interviews with participants and local stakeholders. The RE-AIM self-audit tool was applied to assess evaluation rigor.

RESULTS

Six hundred and forty-nine women from 41 relatively socio-economic disadvantaged communities in Australia participated: mean age 39.6 years (±SD 6.7) and body mass index of 28.8 kg/m2 (±SD 6.9). A between-group weight difference of -0.92 kg (95% CI -1.67 to -0.16) showed program effectiveness. Reach was broad across 41 towns with 62% of participants reporting influencing some of the health behaviors of their families. Strong implementation fidelity was achieved with good retention rates at 1 year (76%) and high participant satisfaction (82% of participants willing to recommend this program). Over 300 multi-level community partnerships were established supporting high adoption. Stakeholders reported potential capacity to implement and sustain the prevention program in resource poor rural settings, due to the low-intensity design and minimal resources required.

CONCLUSIONS

Our comprehensive RE-AIM evaluation demonstrates that an evidence-based obesity prevention program can be successfully implemented in real-world settings. The program achieved broad reach, effectiveness, and satisfaction at the community and stakeholder level, revealing potential for program sustainability. The evaluation addressed implementation knowledge gaps to support future obesity prevention program scale-up.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry ACTRN 12612000115831 [ http://www.anzctr.org.au/ ].

Improved confidence in performing nutrition and physical activity behaviours mediates behavioural change in young adults: Mediation results of a randomised controlled mHealth intervention

BACKGROUND

The burden of weight gain disproportionally affects young adults. Understanding the underlying behavioural mechanisms of change in mHealth nutrition and physical activity interventions designed for young adults is important for enhancing and translating effective interventions.

PURPOSE

First, we hypothesised that knowledge, self-efficacy and stage-of-change for nutrition and physical activity behaviours would improve, and second, that self-efficacy changes in nutrition and physical activity behaviours mediate the behaviour changes observed in an mHealth RCT for prevention of weight gain.

METHODS

Young adults, aged 18-35 years at risk of weight gain (n = 250) were randomly assigned to an mHealth-program, TXT2BFiT, consisting of a three-month intensive phase and six-month maintenance phase or to a control group. Self-reported online surveys at baseline, three- and nine-months assessed nutrition and physical activity behaviours, knowledge, self-efficacy and stage-of-change. The mediating effect of self-efficacy was assessed in multiple PROCESS macro-models for three- and nine-month nutrition and physical activity behaviour change.

RESULTS

Young adults randomised to the intervention increased and maintained knowledge of fruit requirements (P = 0.029) compared to controls. Intervention participants' fruit and takeaway behaviours improved to meet recommendations at nine months, with a greater proportion progressing to action or maintenance stage-of-change (P < 0.001 and P = 0.012 respectively) compared to controls. Intervention participants' vegetable and physical activity behaviours did not meet recommendations, thereby halting progress to action or maintenance stage-of-change. Indirect effects of improved nutrition and physical activity behaviours at three- and nine-months in the intervention group were explained by changes in self-efficacy, accounting for 8%-37% of the total effect.

CONCLUSIONS

This provides insights into how the mHealth intervention achieved part of its effects and the importance of improving self-efficacy to facilitate improved eating and physical activity behaviours in young adults.

Results of a 2-year randomized, controlled obesity prevention trial: Effects on diet, activity and sleep behaviors in an at-risk young adult population

Excess weight gain tends to occur in young adulthood. However, research examining effective weight-related interventions for this age group has been limited. As one of seven trials in the EARLY Trials consortium (Early Adult Reduction of weight through LifestYle intervention), the CHOICES Study (Choosing Healthy Options in College Environments and Settings) tested effects of a technology-integrated, young adult weight gain prevention intervention. It was a randomized controlled trial with assessments at baseline (2011) and 4-, 12- and 24-months post-intervention initiation and included 441 participants (ages 18-35) who were students at three Minnesota community colleges. The 24-month intervention included a 1-credit academic course and social networking and support online intervention. This analysis examined effects on 12 secondary behavioral outcomes across three domains: diet (fast food, sugary beverages, breakfast, at-home meal preparation), physical activity/screen time (minutes and energy expenditure in leisure time physical activity, television viewing, leisure time computer use) and sleep (hours of sleep, time required to fall asleep, days not getting enough rest, difficulty staying awake). The intervention resulted in significant reductions in fast food (p=0.007) but increases in difficulty staying awake (p=0.015). There was limited evidence of other behavior changes at 4months (0.05<p<0.1) in the expected direction but differences by treatment condition dissipated over time. Analyses examining summary treatment effects (i.e., modeling effects on all behavioral outcomes simultaneously) indicated significant overall effects (p=0.014), largely driven by 4-month results (p=0.005). Additional research is needed to understand effective obesity prevention among young adults, particularly when addressing multiple weight-related outcomes.

A Mobile Health Lifestyle Program for Prevention of Weight Gain in Young Adults (TXT2BFiT): Nine-Month Outcomes of a Randomized Controlled Trial

Background

The unprecedented rise in obesity among young adults, who have limited interaction with health services, has not been successfully abated.

Objective

The objective of this study was to assess the maintenance outcomes of a 12-week mHealth intervention on prevention of weight gain in young adults and lifestyle behaviors at 9 months from baseline.

Methods

A two-arm, parallel, randomized controlled trial (RCT) with subjects allocated to intervention or control 1:1 was conducted in a community setting in Greater Sydney, Australia. From November 2012 to July 2014, 18- to 35-year-old overweight individuals with a body mass index (BMI) of 25-31.99 kg/m2 and those with a BMI ≥ 23 kg/m2 and a self-reported weight gain of ≥ 2 kg in the past 12 months were recruited. A 12-week mHealth program “TXT2BFiT” was administered to the intervention arm. This included 5 coaching calls, 96 text messages, 12 emails, apps, and downloadable resources from the study website. Lifestyle behaviors addressed were intake of fruits, vegetables, sugar-sweetened beverages (SSBs), take-out meals, and physical activity. The control group received 1 phone call to introduce them to study procedures and 4 text messages over 12 weeks. After 12 weeks, the intervention arm received 2 further coaching calls, 6 text messages, and 6 emails with continued access to the study website during 6-month follow-up. Control arm received no further contact. The primary outcome was weight change (kg) with weight measured at baseline and at 12 weeks and self-report at baseline, 12 weeks, and 9 months. Secondary outcomes were change in physical activity (metabolic equivalent of task, MET-mins) and categories of intake for fruits, vegetables, SSBs, and take-out meals. These were assessed via Web-based surveys.

Results

Two hundred and fifty young adults enrolled in the RCT. Intervention participants weighed less at 12 weeks compared with controls (model β=−3.7, 95% CI −6.1 to −1.3) and after 9 months (model β=− 4.3, 95% CI − 6.9 to − 1.8). No differences in physical activity were found but all diet behaviors showed that the intervention group, compared with controls at 9 months, had greater odds of meeting recommendations for fruits (OR 3.83, 95% CI 2.10-6.99); for vegetables (OR 2.42, 95% CI 1.32-4.44); for SSB (OR 3.11, 95% CI 1.47-6.59); and for take-out meals (OR 1.88, 95% CI 1.07-3.30).

Conclusions

Delivery of an mHealth intervention for prevention of weight gain resulted in modest weight loss at 12 weeks with further loss at 9 months in 18- to 35-year-olds. Although there was no evidence of change in physical activity, improvements in dietary behaviors occurred, and were maintained at 9 months. Owing to its scalable potential for widespread adoption, replication trials should be conducted in diverse populations of overweight young adults.

Trial Registration

Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000924853; (Archived by WebCite at http://www.webcitation.org/6i6iRag55)

Efficacy and External Validity of Electronic and Mobile Phone-Based Interventions Promoting Vegetable Intake in Young Adults: Systematic Review and Meta-Analysis

Background

Young adults (18–35 years) remain among the lowest vegetable consumers in many western countries. The digital era offers opportunities to engage this age group in interventions in new and appealing ways.

Objective

This systematic review evaluated the efficacy and external validity of electronic (eHealth) and mobile phone (mHealth) -based interventions that promote vegetable intake in young adults.

Methods

We searched several electronic databases for studies published between 1990 and 2015, and 2 independent authors reviewed the quality and risk of bias of the eligible papers and extracted data for analyses. The primary outcome of interest was the change in vegetable intake postintervention. Where possible, we calculated effect sizes (Cohen d and 95% CIs) for comparison. A random effects model was applied to the data for meta-analysis. Reach and representativeness of participants, intervention implementation, and program maintenance were assessed to establish external validity. Published validation studies were consulted to determine the validity of tools used to measure intake. We applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the overall quality of the body of evidence.

Results

Of the 14 studies that met the selection criteria, we included 12 in the meta-analysis. In the meta-analysis, 7 studies found positive effects postintervention for fruit and vegetable intake, Cohen d 0.14–0.56 (pooled effect size 0.22, 95% CI 0.11–0.33, I²=68.5%, P=.002), and 4 recorded positive effects on vegetable intake alone, Cohen d 0.11–0.40 (pooled effect size 0.15, 95% CI 0.04–0.28, I²=31.4%, P=.2). These findings should be interpreted with caution due to variability in intervention design and outcome measures. With the majority of outcomes documented as a change in combined fruit and vegetable intake, it was difficult to determine intervention effects on vegetable consumption specifically. Measurement of intake was most commonly by self-report, with 5 studies using nonvalidated tools. Longer-term follow-up was lacking from most studies (n=12). Risk of bias was high among the included studies, and the overall body of evidence was rated as low quality. The applicability of interventions to the broader young adult community was unclear due to poor description of external validity components.

Conclusions

Preliminary evidence suggests that eHealth and mHealth strategies may be effective in improving vegetable intake in young adults; whether these small effects have clinical or nutritional significance remains questionable. With studies predominantly reporting outcomes as fruit and vegetable intake combined, we suggest that interventions report vegetables separately. Furthermore, to confidently establish the efficacy of these strategies, better-quality interventions are needed for young adults, using valid measures of intake, with improved reporting on costs, sustainability and long-term effects of programs.

Trial registration

PROSPERO International Prospective Register of Systematic Reviews: CRD42015017763; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015017763 (Archived by WebCite at http://www.webcitation.org/6fLhMgUP4)

Improved eating behaviours mediate weight gain prevention of young adults: moderation and mediation results of a randomised controlled trial of TXT2BFiT, mHealth program

BACKGROUND

Explanatory evaluation of interventions for prevention of weight gain is required beyond changes in weight, to determine for whom the intervention works and the underlying mechanisms of change. It was hypothesised that participant characteristics moderate intervention effect on weight change and improved eating and physical activity behaviours during the 3-month program mediate the relationship between intervention and weight.

METHODS

In our randomised controlled trial, young adults at risk of weight gain (n = 250) were assigned either to an intervention group that received a 3-month mHealth (TXT2BFiT) program with 6-month maintenance or to a control group. Data were collected via online self-report surveys. Hypothesised moderators and mediators of the intervention effect on weight were independently assessed in PROCESS macro models for 3 and 9-month weight change.

RESULTS

Males (P = 0.01), mid-20s age group (P = 0.04), and higher income earners (P = 0.02) moderated intervention effects on weight change at 3-months and males only at 9-months (P = 0.02). Weight change at 3 (-1.12 kg) and 9-months (-1.38 kg) remained significant when 3-month nutrition and physical activity behaviours were specified as mediators (P <0.01 and P = 0.01 respectively). Indirect paths explained 39% (0.72/1.85 kg) and 40 % (0.92/2.3 kg) of total effect on weight change at 3 and 9-months respectively. Increased vegetable intake by intervention group at 3-months accounted for 19 and 17% and decreased sugar-sweetened beverages accounted for 8 and 13% of indirect weight change effects at 3 and 9-months respectively.

CONCLUSIONS

TXT2BFiT was effective for both young men and women. Small sustained behavioural changes, including increased vegetable intake and decreased sugar-sweetened beverages consumption significantly mediated the intervention's effects on weight change. Improved eating behaviours and increased physical activity accounted for approximately 40% of the weight change.

TRIAL REGISTRATION

The trial is registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12612000924853 ).

Bridging the Science-Practice Gap in Obesity Treatment

The number of putative causes of obesity continues to increase at a rapid rate. As science identifies novel causes of obesity, innovations in the treatment of obesity also evolve. These innovations have important implications for clinical practice; however, a gap exists between research and the clinical application of research. Practical considerations about how to address this gap between research and practice are discussed.

Strategies for successful recruitment of young adults to healthy lifestyle programmes for the prevention of weight gain: a systematic review

Recruiting healthy young adults, aged 18-35, to lifestyle programmes for prevention of weight gain is challenging but important given their increasing rates of obesity. This review aimed to examine the success of different recruitment strategies. A systematic literature search identified 26 separate studies using 10 electronic databases. Participant characteristics and efficacy of interventions were well reported in all studies, but reporting of recruitment procedures, costs, times and effectiveness was minimal. Of those reporting recruitment, both active (e.g. face-to-face) and passive (e.g. print-media and mass-mailings) approaches were identified with the latter most frequently employed. Novel strategies such as social media and marketing approaches were identified. Television and radio have potentially high reach but low efficiency with high cost compared with mass-mailings which yield high numbers of participants. Marketing campaigns appeared to be a promising approach. Incentives demonstrated enhanced recruitment. The use of formative research to guide recruitment strategies for interventions is recommended. Reporting of success, cost and timelines for recruitment should be included in reporting of future trials. This first synthesis of recruitment information can be used to inform recruitment frameworks for lifestyle programmes seeking to attract young adults.

Process evaluation of TXT2BFiT: a multi-component mHealth randomised controlled trial to prevent weight gain in young adults

Background

TXT2BFiT was one of the first few innovative mHealth programs designed for young adults (18–35 years) with demonstrated efficacy in weight management. However, research is lacking to understand intervention effectiveness, especially in complex, multi-component mHealth programs. This paper investigates participant perceptions of and engagement with the mHealth program components in the TXT2BFiT to understand program effects.

Methods

Process evaluation data were collected continuously for the study duration. The TXT2BFiT program was a multi-component lifestyle program delivered intensively for 3-month followed by a 6-month maintenance phase. Program components included personalised coaching calls, text messages, emails, smartphone apps and website access. Process evaluation measures included frequency of use of components and frequency for number of components used (online survey data); dose delivered and engagement with program components (researcher logs and web platform reports); frequency, timing and difficulties experienced with program components (online survey data) and overall perceptions of program components (online survey data and semi-structured telephone interviews). Qualitative data analysis was performed using NVivo10.

Results

Over 80 % of participants completed post-intervention (3-months, intervention, n = 110, control n = 104) and follow-up surveys (9-months, intervention, n = 96, control n = 104). Thirty intervention participants completed semi-structured telephone interviews. Participants reported high use of coaching calls, text messages and emails and no issues in content delivery from these components. These components were described as helping them to achieve their goals. Website and app use and engagement was low for the duration of the program. Participants would prefer incorporation of the self-monitoring apps and website resources into one smartphone application that can be individualised by entry of their personal data.

Conclusions

Our process evaluation has allowed a comprehensive understanding of use and preference for different program components. The high value placed on the coaching calls is consistent with a desire for personalisation of the mHealth program and even further tailoring of text messages and emails. The findings of this study will be used to revise TXT2BFiT for future users.

Trial registration

The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000924853).

The IDEFICS intervention: what can we learn for public policy?

INTRODUCTION

As considered in the rest of this volume, the effects of the IDEFICS intervention on obesity rates were not encouraging. This paper considers how far findings from the IDEFICS study and similar intervention studies are relevant to the policy process and political decision-making.

METHODS

The paper offers theoretical and policy-level arguments concerning the evaluation of evidence and its implications for policymaking. The paper is divided into three parts. The first considers problems in the nature and applicability of evidence gained from school- and community-level obesity interventions. The second part considers whether such interventions present a model that policymakers could implement. The third part considers how we should think about policy measures given the limited evidence we can obtain and the many different goals that public policy must take account of.

RESULTS

The paper argues that (1) there are clear reasons why we are not obtaining good evidence for effective school- and community-level interventions; (2) public policy is not in a good position to mandate larger-scale, long-term versions of these interventions; and (3) there are serious problems in obtaining 'evidence' for most public policy options, but this should not deter us from pursuing options that tackle systemic problems and have a good likelihood of delivering benefits on several dimensions.

CONCLUSIONS

Research on school- and community-level obesity interventions has not produced much evidence that is directly relevant to policymaking. Instead, it shows how difficult it is to affect obesity rates without changing wider social and economic factors. Public policy should focus on these.

Discordant identification of pediatric severe sepsis by research and clinical definitions in the SPROUT international point prevalence study

INTRODUCTION

Consensus criteria for pediatric severe sepsis have standardized enrollment for research studies. However, the extent to which critically ill children identified by consensus criteria reflect physician diagnosis of severe sepsis, which underlies external validity for pediatric sepsis research, is not known. We sought to determine the agreement between physician diagnosis and consensus criteria to identify pediatric patients with severe sepsis across a network of international pediatric intensive care units (PICUs).

METHODS

We conducted a point prevalence study involving 128 PICUs in 26 countries across 6 continents. Over the course of 5 study days, 6925 PICU patients <18 years of age were screened, and 706 with severe sepsis defined either by physician diagnosis or on the basis of 2005 International Pediatric Sepsis Consensus Conference consensus criteria were enrolled. The primary endpoint was agreement of pediatric severe sepsis between physician diagnosis and consensus criteria as measured using Cohen's κ. Secondary endpoints included characteristics and clinical outcomes for patients identified using physician diagnosis versus consensus criteria.

RESULTS

Of the 706 patients, 301 (42.6%) met both definitions. The inter-rater agreement (κ ± SE) between physician diagnosis and consensus criteria was 0.57 ± 0.02. Of the 438 patients with a physician's diagnosis of severe sepsis, only 69% (301 of 438) would have been eligible to participate in a clinical trial of pediatric severe sepsis that enrolled patients based on consensus criteria. Patients with physician-diagnosed severe sepsis who did not meet consensus criteria were younger and had lower severity of illness and lower PICU mortality than those meeting consensus criteria or both definitions. After controlling for age, severity of illness, number of comorbid conditions, and treatment in developed versus resource-limited regions, patients identified with severe sepsis by physician diagnosis alone or by consensus criteria alone did not have PICU mortality significantly different from that of patients identified by both physician diagnosis and consensus criteria.

CONCLUSIONS

Physician diagnosis of pediatric severe sepsis achieved only moderate agreement with consensus criteria, with physicians diagnosing severe sepsis more broadly. Consequently, the results of a research study based on consensus criteria may have limited generalizability to nearly one-third of PICU patients diagnosed with severe sepsis.

Recruiting and retaining young adults in a weight gain prevention trial: Lessons learned from the CHOICES study

BACKGROUND/AIMS

Young adults are at risk of weight gain, but little is known about designing effective weight control trials for young adults or how to recruit and retain participants in these programs. The Choosing Healthy Options in College Environments and Settings (CHOICES) study evaluated the effectiveness of a weight gain prevention intervention for 2-year college students. We describe the methods used to recruit and retain the colleges and their students, describe the sample and discuss recommendations for future studies.

METHODS

Students were recruited into a 24-month trial of a weight control intervention with assessment periods at baseline, 4-, 12- and 24-month follow-up.

RESULTS

We successfully recruited 441 students through partnerships with three 2-year colleges through a variety of campus-based methods. Ultimately, 83.4% of the randomized cohort participated in the 24-month assessment period. Those retained more often were White (p = 0.03) compared to those who dropped out or were lost to follow-up; no other socio-demographic factor (e.g. gender, ethnicity and education), body mass index, body fat, waist circumference or weight status was observed to differ between randomly assigned groups.

CONCLUSION

Two-year colleges and their students are interested in participating in weight-related trials and partnering with universities for research. Researchers must work closely with administrators to identify benefits to their institutions and to resolve student-level barriers to recruitment and retention. Our experiences from the Choosing Healthy Options in College Environments and Settings study should be useful in identifying effective recruitment and retention methods for weight gain prevention trials among young adults.

Nutrition Promotion to Prevent Obesity in Young Adults

Young adulthood is a vulnerable period for weight gain and the health consequences of becoming obese during this life-stage of serious concern. Some unhealthy dietary habits are typical of young adults in many developed nations encountering the obesity epidemic. These include high sugar-sweetened beverage consumption, lower vegetable intake and greater consumption of foods prepared outside the home including fast foods. Each of these dietary behaviours may place young adults at increased risk for overweight and obesity. Evidence suggests many young adults with unhealthy nutrition behaviours are not considering nor preparing to make changes. To improve their nutrition and health as they progress through the lifecycle requires approaches specifically targeted to this age group. Strategies and programs should include both individual level and population approaches. The evidence base for prevention of weight gain and halting overweight and obesity in young adulthood is currently small with few studies of high quality. Studies modifying food environments in colleges and universities are also of limited quality, but sufficiently promising to conduct further research employing better, more sophisticated, study designs and additionally to include health outcome measures. More research into programs tailored to the needs of young adults is warranted with several studies already underway.

Optimizing Implementation of Obesity Prevention Programs: A Qualitative Investigation Within a Large-Scale Randomized Controlled Trial

PURPOSE

The prevalence of obesity in rural and remote areas is elevated in comparison to urban populations, highlighting the need for interventions targeting obesity prevention in these settings. Implementing evidence-based obesity prevention programs is challenging. This study aimed to investigate factors influencing the implementation of obesity prevention programs, including adoption, program delivery, community uptake, and continuation, specifically within rural settings.

METHODS

Nested within a large-scale randomized controlled trial, a qualitative exploratory approach was adopted, with purposive sampling techniques utilized, to recruit stakeholders from 41 small rural towns in Australia. In-depth semistructured interviews were conducted with clinical health professionals, health service managers, and local government employees. Open coding was completed independently by 2 investigators and thematic analysis undertaken.

FINDINGS

In-depth interviews revealed that obesity prevention programs were valued by the rural workforce. Program implementation is influenced by interrelated factors across: (1) contextual factors and (2) organizational capacity. Key recommendations to manage the challenges of implementing evidence-based programs focused on reducing program delivery costs, aided by the provision of a suite of implementation and evaluation resources. Informing the scale-up of future prevention programs, stakeholders highlighted the need to build local rural capacity through developing supportive university partnerships, generating local program ownership and promoting active feedback to all program partners.

CONCLUSION

We demonstrate that the rural workforce places a high value on obesity prevention programs. Our results inform the future scale-up of obesity prevention programs, providing an improved understanding of strategies to optimize implementation of evidence-based prevention programs.