The social and healthcare professional support drawn upon by women antenatally during the COVID-19 pandemic: A recurrent, cross-sectional, thematic analysis

OBJECTIVE

To explore antenatal experiences of social and healthcare professional support during different phases of social distancing restriction implementation in the UK.

DESIGN

Semi-structured interviews were conducted via telephone or video-conferencing software between 13 July 2020 - 2 September 2020. Interviews were transcribed and a recurrent, cross-sectional, thematic analysis was conducted.

PARTICIPANTS

Twelve antenatal women were interviewed during UK social distancing restrictions (Timepoint 1; T1) and a separate sample of twelve women were interviewed in the initial easing of these restrictions (Timepoint 2; T2).

FINDINGS

T1 themes were: 'Maternity care as non-essential' and 'Pregnancy is cancelled'. T2 themes were: 'Technology is a polarised tool' and 'Clinically vulnerable, or not clinically vulnerable? That is the question'.

KEY CONCLUSIONS

At T1, anxieties were ascribed to the exclusion of partners from routine care, and to perceived insensitivity and aggression from the public. For T2, insufficient Governmental transparency led to disillusionment, confusion, and anger. Covert workplace discrimination also caused distress at T2. Across timepoints: deteriorated mental wellbeing was attributed to depleted opportunities to interact socially and scaled back maternity care.

IMPLICATIONS FOR PRACTICE

Recommendations are made to: protect maternal autonomy; improve quality of mental health and routine care signposting; prioritise parental community support in the re-opening of 'non-essential' services; prioritise the option for face-to-face appointments when safe and legal; and protecting the rights of working mothers.

Acute and two-week effects of neotame, stevia rebaudioside M and sucrose-sweetened biscuits on postprandial appetite and endocrine response in adults with overweight/obesity-a randomised crossover trial from the SWEET consortium

BACKGROUND

Sweeteners and sweetness enhancers (S&SE) are used to replace energy yielding sugars and maintain sweet taste in a wide range of products, but controversy exists about their effects on appetite and endocrine responses in reduced or no added sugar solid foods. The aim of the current study was to evaluate the acute (1 day) and repeated (two-week daily) ingestive effects of 2 S&SE vs. sucrose formulations of biscuit with fruit filling on appetite and endocrine responses in adults with overweight and obesity.

METHODS

In a randomised crossover trial, 53 healthy adults (33 female, 20 male) with overweight/obesity in England and France consumed biscuits with fruit filling containing 1) sucrose, or reformulated with either 2) Stevia Rebaudioside M (StRebM) or 3) Neotame daily during three, two-week intervention periods with a two-week washout. The primary outcome was composite appetite score defined as [desire to eat + hunger + (100 - fullness) + prospective consumption]/4.

FINDINGS

Each formulation elicited a similar reduction in appetite sensations (3-h postprandial net iAUC). Postprandial insulin (2-h iAUC) was lower after Neotame (95% CI (0.093, 0.166); p < 0.001; d = -0.71) and StRebM (95% CI (0.133, 0.205); p < 0.001; d = -1.01) compared to sucrose, and glucose was lower after StRebM (95% CI (0.023, 0.171); p < 0.05; d = -0.39) but not after Neotame (95% CI (-0.007, 0.145); p = 0.074; d = -0.25) compared to sucrose. There were no differences between S&SE or sucrose formulations on ghrelin, glucagon-like peptide 1 or pancreatic polypeptide iAUCs. No clinically meaningful differences between acute vs. two-weeks of daily consumption were found.

INTERPRETATION

In conclusion, biscuits reformulated to replace sugar using StRebM or Neotame showed no differences in appetite or endocrine responses, acutely or after a two-week exposure, but can reduce postprandial insulin and glucose response in adults with overweight or obesity.

FUNDING

The present study was funded by the Horizon 2020 program: Sweeteners and sweetness enhancers: Impact on health, obesity, safety and sustainability (acronym: SWEET, grant no: 774293).

An interpretive phenomenological analysis of the experiences of mothers who continue to breastfeed despite facing difficulties

BACKGROUND

Breastfeeding offers many health benefits to mother and infant.

PROBLEM

Breastfeeding difficulties are common and are linked with postnatal distress.

AIM

To explore the lived experiences of breastfeeding continuation despite facing difficulties.

METHODS

Qualitative semi-structured interviews were conducted with eight women who had experienced breastfeeding difficulties yet continued breastfeeding. Interviews were analysed using Interpretative Phenomenological Analysis (IPA).

FINDINGS

The first superordinate theme, 'Radical acceptance of the imperfect' included sub-themes of: 'Taking it day-by-day', 'Breastfeeding takes a community', and, 'Finding what works for you'. The second superordinate theme, 'Determination and persistence' included sub-themes of: 'Adopting a headstrong attitude' and 'Transient challenges versus lifelong achievement'.

DISCUSSION

Participants found radical acceptance of breastfeeding as an imperfect, variable process which enabled them to sustain breastfeeding despite challenges. Participants proactively drew on social and personal resources to navigate guidance and to find solutions which worked for their individual circumstances. Finally, open-mindedness, optimism, self-compassion, and being headstrong and determined were all personal qualities which facilitated breastfeeding during exceptionally difficult moments on their breastfeeding journey.

CONCLUSION

Recommendations are made for healthcare professionals: to provide emotional counselling during routine care (with an aim to instil breastfeeding self-efficacy) and to encourage breastfeeding advocacy among fathers and the maternal social support network (with an aim to further scaffold successful breastfeeding). Recommendations are also made for mothers: to develop and refine maternal confidence, patience, flexibility, self-compassion, and trust.

A consensus statement on perinatal mental health during the COVID-19 pandemic and recommendations for post-pandemic recovery and re-build

Introduction

The COVID-19 pandemic posed a significant lifecourse rupture, not least to those who had specific physical vulnerabilities to the virus, but also to those who were suffering with mental ill health. Women and birthing people who were pregnant, experienced a perinatal bereavement, or were in the first post-partum year (i.e., perinatal) were exposed to a number of risk factors for mental ill health, including alterations to the way in which their perinatal care was delivered.

Methods

A consensus statement was derived from a cross-disciplinary collaboration of experts, whereby evidence from collaborative work on perinatal mental health during the COVID-19 pandemic was synthesised, and priorities were established as recommendations for research, healthcare practice, and policy.

Results

The synthesis of research focused on the effect of the COVID-19 pandemic on perinatal health outcomes and care practices led to three immediate recommendations: what to retain, what to reinstate, and what to remove from perinatal mental healthcare provision. Longer-term recommendations for action were also made, categorised as follows: Equity and Relational Healthcare; Parity of Esteem in Mental and Physical Healthcare with an Emphasis on Specialist Perinatal Services; and Horizon Scanning for Perinatal Mental Health Research, Policy, & Practice.

Discussion

The evidence base on the effect of the pandemic on perinatal mental health is growing. This consensus statement synthesises said evidence and makes recommendations for a post-pandemic recovery and re-build of perinatal mental health services and care provision.

Relative validity of habitual sugar and low/no-calorie sweetener consumption assessed by food frequency questionnaire, multiple 24-h dietary recalls and urinary biomarkers: an observational study within the SWEET project

BACKGROUND

Studies investigating associations between sweeteners and health yield inconsistent results, possibly due to subjective self-report dietary assessment methods.

OBJECTIVES

We compared the performance of a food frequency questionnaire (FFQ), multiple 24-h dietary recalls (24hRs), and urinary biomarkers to estimate intake of sugars and low/no-calorie sweeteners (LNCSs).

METHODS

Participants (n = 848, age 54 ± 12 y) from a 2-y observational study completed 1 semiquantitative FFQ and ≥ 3 nonconsecutive 24hRs. Both methods assessed intake of sugars (mono- and disaccharides, sucrose, fructose, free and added sugars) and sweetened foods and beverages (sugary foods, fruit juice, and sugar or LNCS-containing beverages [sugar-sweetened beverages and low/no-calorie sweetened beverages (LNCSBs)]); 24hRs also included LNCS-containing foods and tabletop sweeteners (low/no-calorie sweetened foods [LNCSFs]). Urinary excretion of sugars (fructose+sucrose) and LNCSs (acesulfame K+sucralose+steviol glucuronide+cyclamate+saccharin) were simultaneously assessed using ultrapressure liquid chromatography coupled to tandem mass spectrometry in 288 participants with 3 annual 24-h urine samples. Methods were compared using, amongst others, validity coefficients (correlations corrected for measurement error).

RESULTS

Median (interquartile range) FFQ intakes ranged from 0 (0-7) g/d for LNCSBs to 94 (73-117) g/d for mono- and disaccharides. LNCSB use was reported by 32% of participants. Median LNCSB+LNCSF intake using 24hRs was 1 (0-50) g/d and reported by 58%. Total sugar excretions were detected in 100% of samples [56 (37-85) mg/d] and LNCSs in 99% of urine samples [3 (1-10) mg/d]. Comparing FFQ against 24hRs showed VCs ranging from 0.38 (fruit juice) to 0.74 (LNCSB). VCs for comparing FFQ with urinary excretions were 0.25 to 0.29 for sugars and 0.39 for LNCSBs; for 24hR they amounted to 0.31-0.38 for sugars, 0.37 for LNCSBs, and 0.45 for LNCSFs.

CONCLUSIONS

The validity of the FFQ against 24hRs for the assessment of sugars and LNCSBs ranged from moderate to good. Comparing self-reports and urine excretions showed moderate agreement but highlighted an important underestimation of LNCS exposure using self-reports.

Psychosocial predictors of post-natal anxiety and depression: Using Structural Equation Modelling to investigate the relationship between pressure to breastfeed, health care professional support, post-natal guilt and shame, and post-natal anxiety and depression within an infant feeding context

High perceived pressure to breastfeed and poor perceived quality of health care professional support have been associated with early breastfeeding cessation, guilt, and shame. This is problematic because guilt and shame significantly predict post-natal anxiety and depression. No previous attempts have been made to provide quantitative evidence for relationships mapped between the post-natal social context, infant feeding method and post-natal emotional well-being. The current study aimed to empirically investigate aforementioned pathways. Structural equation modelling was applied to survey data provided online by 876 mothers. Guilt and shame both significantly predicted anxiety and depression. Poor health care professional support and high pressure to breastfeed increased anxiety and depression, and these effects were explained by indirect pathways through increases in guilt and shame. Formula feeding exclusivity was negatively correlated with post-natal anxiety symptoms. This finding may be explained by feelings of relief associated with observed infant weight gain and being able to share infant feeding responsibilities others e.g., with one's partner. This relationship was counterbalanced by an indirect pathway where greater formula feeding exclusivity positively predicted guilt, which increased post-natal anxiety score. While guilt acted as mediator of infant feeding method to increase post-natal depression and anxiety, shame acted independently of infant feeding method. These identified differences provide empirical support for the transferability of general definitions of guilt (i.e., as remorse for having committed a moral transgression) and shame (i.e., internalisation of transgressive remorse to the self), to an infant feeding context. Recommendations for health care practitioners and the maternal social support network are discussed.

Non-nutritive sweetened beverages versus water after a 52-week weight management programme: a randomised controlled trial

BACKGROUND/OBJECTIVE

Sugar-sweetened beverages are a substantial source of dietary sugar that can contribute to weight gain and the risk of type 2 diabetes. Dietary guidelines recommend non-nutritive sweetened (NNS) beverages to reduce sugar consumption, however, there is a need for long-term randomised controlled trials on their use. We aimed to compare the effects of NNS beverages and water on body weight during weight loss and maintenance in a behavioural weight management programme.

METHODS

In this parallel-group, open-label, controlled equivalence trial, adults with a BMI of 27-35 kg/m2 who regularly consumed cold beverages were randomised 1:1 to water or NNS beverages. Participants underwent a group behavioural weight management programme comprising weekly (during the 12-week weight-loss phase) then monthly (during the 40-week weight-maintenance phase) meetings. The primary endpoint was weight change at week 52 (equivalence: two-sided P > 0.05). Secondary endpoints included changes in anthropometrics, cardiometabolic risk factors, appetite and activity levels.

RESULTS

Of 493 participants randomised (water: n = 246; NNS beverages: n = 247), 24.1% were NNS-naïve. At week 52, water and NNS beverages were non-equivalent, with significantly greater weight loss in the NNS beverages group. Participants consuming water maintained a weight loss of 6.1 kg over 52 weeks versus 7.5 kg with NNS beverages (difference [90% CI]: 1.4 kg [-2.6, -0.2]; p < 0.05).

CONCLUSIONS

During a 52-week behavioural weight management programme, water and NNS beverages were non-equivalent, with weight loss maintained to a statistically greater extent with NNS beverages compared with water. However, this difference was not clinically significant.

CLINICAL TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov: NCT02591134.

Sugar and low/no-calorie-sweetened beverage consumption and associations with body weight and waist circumference changes in five European cohort studies: the SWEET project

PURPOSE

Results of prospective studies investigating associations between low/no-calorie sweeteners (LNCS) and body weight-related outcomes are inconclusive. We conducted dose-response and theoretical replacement individual patient data meta-analyses using harmonised prospective data to evaluate associations between sugar-sweetened beverage (SSB) consumption, low/no-calorie sweetened beverage (LNCB) consumption, and changes in body weight and waist circumference.

METHODS

Individual participant data were obtained from five European studies, i.e., Lifelines Cohort Study, NQplus study, Alpha Omega Cohort, Predimed-Plus study, and Feel4diabetes study, including 82,719 adults aged 18-89 with follow-up between 1 and 9 years. Consumption of SSB and LNCB was assessed using food-frequency questionnaires. Multiple regression analyses adjusting for major confounders and including substitution models were conducted to quantify associations in individual cohorts; random-effects meta-analyses were performed to pool individual estimates.

RESULTS

Overall, pooled results showed weak adverse associations between SSB consumption and changes in body weight (+ 0.02 kg/y, 95%CI 0.00; 0.04) and waist circumference (+ 0.03 cm/y, 95%CI 0.01; 0.05). LNCB consumption was associated with higher weight gain (+ 0.06 kg/y, 95%CI 0.04; 0.08) but not with waist circumference. No clear associations were observed for any theoretical replacements, i.e., LNCB or water for SSB or water for LNCB.

CONCLUSION

In conclusion, this analysis of five European studies found a weak positive association between SSB consumption and weight and waist change, whilst LNCB consumption was associated with weight change only. Theoretical substitutions did not show any clear association. Thus, the benefit of LNCBs as an alternative to SSBs remains unclear.

Effects of non-nutritive sweetened beverages versus water after a 12-week weight-loss program: A randomized controlled trial

OBJECTIVE

The aim of this study was to compare non-nutritive sweetened (NNS) beverages versus water for weight loss after a 12-week behavioral weight-management program.

METHODS

This is an ongoing, 2-year, parallel-group, open-label, controlled equivalence trial; week-12 data are reported. Adults with BMI of 27 to 35 kg/m2 who regularly drank cold beverages were randomized 1:1 to intention-to-treat water or NNS beverages while undergoing a weekly 12-week group behavioral weight-management program. Weight change to week 12 was the primary end point (equivalence: two-sided p > 0.05); changes in waist and hip circumference, blood pressure, glycemic control markers, fasting lipid profiles, liver function tests, hunger (visual analog scale), sugar and sweetener consumption, and activity levels were secondary end points.

RESULTS

Overall, 493 participants were randomized (water: n = 246; NNS beverages: n = 247); 24.1% were NNS beverage naïve. Weight change was equivalent with water versus NNS beverages (-5.6 vs. -5.8 kg; difference [90% CI]: -0.2 kg [-0.7 to 0.4]). There were no significant differences between groups for secondary end points except reductions in waist circumference (greater with NNS beverages vs. water), glycated hemoglobin, and consumption of any type of sweetener (both greater with water vs. NNS beverages).

CONCLUSIONS

Weight loss was equivalent with NNS beverages and water following a 12-week behavioral weight-management program.

The effect of weight loss on whole-body and tissue-specific insulin sensitivity and hepatic lipid content and composition: SWEET substudy

OBJECTIVE

This study (1) investigated the effect of weight loss on whole-body and tissue-specific insulin sensitivity and on intrahepatic lipid (IHL) content and composition and (2) investigated the association between weight-loss-induced changes in insulin sensitivity and IHL content in individuals with overweight or obesity.

METHODS

In this secondary analysis of the European SWEET project, 50 adults (age 18-65 years) with overweight or obesity (BMI ≥ 25 kg/m² ) followed a low-energy diet (LED) for 2 months. At baseline and after the LED, body composition (dual-energy x-ray absorptiometry), IHL content and composition (proton magnetic resonance spectroscopy), whole-body insulin sensitivity (Matsuda index), muscle insulin sensitivity index (MISI), and hepatic insulin resistance index (HIRI) were determined (7-point oral glucose tolerance test).

RESULTS

The LED reduced body weight (p < 0.001). This was accompanied by increased Matsuda index and reduced HIRI (both p < 0.001) but no change in MISI (p = 0.260). Weight loss decreased IHL content (mean [SEM], 3.9% [0.7%] vs. 1.6% [0.5%], p < 0.001) and the hepatic saturated fatty acid fraction (41.0% [1.5%] vs. 36.6% [1.9%], p = 0.039). The reduced IHL content was associated with an improvement in HIRI (r = 0.402, p = 0.025).

CONCLUSIONS

Weight loss decreased IHL content and the hepatic saturated fatty acid fraction. The decrease in IHL content was associated with weight-loss-induced improvement in hepatic insulin sensitivity in individuals with overweight or obesity.

The antenatal psychological experiences of women during two phases of the COVID-19 pandemic: A recurrent, cross-sectional, thematic analysis

Initial COVID-19-related social distancing restrictions, imposed in the UK in March 2020, and the subsequent lifting of restrictions in May 2020 caused antenatal disruption and stress which exceeded expected vulnerabilities associated with this lifecourse transition. The current study aimed to explore the antenatal psychological experiences of women during different phases of pandemic-related lockdown restrictions in the UK. Semi-structured interviews were held with 24 women about their antenatal experiences: twelve were interviewed after the initial lockdown restrictions (Timepoint 1; T1), and a separate twelve women were interviewed after the subsequent lifting of those restrictions (Timepoint 2; T2). Interviews were transcribed and a recurrent, cross-sectional thematic analysis was conducted. Two themes were identified for each timepoint, and each theme contained sub-themes. T1 themes were: 'A Mindful Pregnancy' and 'It's a Grieving Process', and T2 themes were: 'Coping with Lockdown Restrictions' and 'Robbed of Our Pregnancy'. COVID-19 related social distancing restrictions had an adverse effect on women's mental health during the antenatal period. Feeling trapped, anxious, and abandoned were common at both timepoints. Actively encouraging conversations about mental wellbeing during routine care and adopting a prevention opposed to cure attitude toward implementing additional support provisions may serve to improve antenatal psychological wellbeing during health crises.

Impact of acute consumption of beverages containing plant-based or alternative sweetener blends on postprandial appetite, food intake, metabolism, and gastro-intestinal symptoms: Results of the SWEET beverages trial

Project SWEET examined the barriers and facilitators to the use of non-nutritive sweeteners and sweetness enhancers (hereafter "S&SE") alongside potential risks/benefits for health and sustainability. The Beverages trial was a double-blind multi-centre, randomised crossover trial within SWEET evaluating the acute impact of three S&SE blends (plant-based and alternatives) vs. a sucrose control on glycaemic response, food intake, appetite sensations and safety after a carbohydrate-rich breakfast meal. The blends were: mogroside V and stevia RebM; stevia RebA and thaumatin; and sucralose and acesulfame-potassium (ace-K). At each 4 h visit, 60 healthy volunteers (53% male; all with overweight/obesity) consumed a 330 mL beverage with either an S&SE blend (0 kJ) or 8% sucrose (26 g, 442 kJ), shortly followed by a standardised breakfast (∼2600 or 1800 kJ with 77 or 51 g carbohydrates, depending on sex). All blends reduced the 2-h incremental area-under-the-curve (iAUC) for blood insulin (p < 0.001 in mixed-effects models), while the stevia RebA and sucralose blends reduced the glucose iAUC (p < 0.05) compared with sucrose. Post-prandial levels of triglycerides plus hepatic transaminases did not differ across conditions (p > 0.05 for all). Compared with sucrose, there was a 3% increase in LDL-cholesterol after stevia RebA-thaumatin (p < 0.001 in adjusted models); and a 2% decrease in HDL-cholesterol after sucralose-ace-K (p < 0.01). There was an impact of blend on fullness and desire to eat ratings (both p < 0.05) and sucralose-acesulfame K induced higher prospective intake vs sucrose (p < 0.001 in adjusted models), but changes were of a small magnitude and did not translate into energy intake differences over the next 24 h. Gastro-intestinal symptoms for all beverages were mostly mild. In general, responses to a carbohydrate-rich meal following consumption of S&SE blends with stevia or sucralose were similar to sucrose.

Sugar-sweetened beverages, low/no-calorie beverages, fruit juice and non-alcoholic fatty liver disease defined by fatty liver index: the SWEET project

BACKGROUND

Sweetened beverage intake may play a role in non-alcoholic fatty liver disease (NAFLD) development, but scientific evidence on their role is limited. This study examined associations between sugar-sweetened beverages (SSB), low/no-calorie beverages (LNCB) and fruit juice (FJ) intakes and NAFLD in four European studies.

METHODS

Data for 42,024 participants of Lifelines Cohort, NQPlus, PREDIMED-Plus and Alpha Omega Cohort were cross-sectionally analysed. NAFLD was assessed using Fatty Liver Index (FLI) (≥60). Restricted cubic spline analyses were used to visualize dose-response associations in Lifelines Cohort. Cox proportional hazard regression analyses with robust variance were performed for associations in individual cohorts; data were pooled using random effects meta-analysis. Models were adjusted for demographic, lifestyle, and other dietary factors.

RESULTS

Each additional serving of SSB per day was associated with a 7% higher FLI-defined NAFLD prevalence (95%CI 1.03-1.11). For LNCB, restricted cubic spline analysis showed a nonlinear association with FLI-defined NAFLD, with the association getting stronger when consuming ≤1 serving/day and levelling off at higher intake levels. Pooled Cox analysis showed that intake of >2 LNCB servings/week was positively associated with FLI-defined NAFLD (PR 1.38, 95% CI 1.15-1.61; reference: non-consumers). An inverse association was observed for FJ intake of ≤2 servings/week (PR 0.92, 95% CI: 0.88-0.97; reference: non-consumers), but not at higher intake levels. Theoretical replacement of SSB with FJ showed no significant association with FLI-defined NAFLD prevalence (PR 0.97, 95% CI 0.95-1.00), whereas an adverse association was observed when SSB was replaced with LNCB (PR 1.12, 95% CI 1.03-1.21).

CONCLUSIONS

Pooling results of this study showed that SSB and LNCB were positively associated with FLI-defined NAFLD prevalence. Theoretical replacement of SSB with LNCB was associated with higher FLI-defined NAFLD prevalence. An inverse association was observed between moderate intake of FJ and FLI-defined NAFLD. Our results should be interpreted with caution as reverse causality cannot be ruled out.

Exploring the reasons why mothers do not breastfeed, to inform and enable better support

Introduction

Infant and maternal breastfeeding benefits are well documented, globally. Despite efforts to increase global breastfeeding rates, the majority of high-income settings fall short of recommended targets. Breastfeeding rates in the UK are especially poor, and physiological difficulties (e.g., inverted nipples), fail to account for the observed breastfeeding intention-behaviour gap.

Method

The current online study sought to investigate the infant feeding experiences of 624 UK formula feeding mothers, through open text survey responses.

Results

A content analysis identified the following clusters of reasons for formula feeding: Feeding Attitudes, Feeding Problems, Mental Health, and Sharing the Load.

Discussion

Feeding Attitudes explained a large percentage of reasons given for formula feeding. Recommendations are made to improve antenatal breastfeeding education and to develop an intervention with an aim to improve maternal breastfeeding attitudes and subsequent practice. Feeding Problems also explained a large portion of combination feeding and started but stopped infant feeding accounts. The current paper calls for more comprehensive and tailored antenatal breastfeeding education to refine practical breastfeeding skills necessary for successful breastfeeding establishment and maintenance. Mental Health explained relatively small coverage. Suggestions are therefore made to train mental health practitioners on infant feeding with an aim to provide more extensive support, which may serve to disrupt the bidirectional relationship between poor mental health and poor breastfeeding outcomes. Finally, Sharing the Load explained moderate coverage across never breastfed, combination fed, and started but stopped feeding groups. Recommendations are made, in light of these findings, to tighten workplace legislation to protect breastfeeding women.

Acute and repeated impact of sweeteners and sweetness enhancers in solid and semi-solid foods on appetite: protocol for a multicentre, cross-over, RCT in people with overweight/obesity - the SWEET Project

INTRODUCTION

Intake of free sugars in European countries is high and attempts to reduce sugar intake have been mostly ineffective. Non-nutritive sweeteners and sweetness enhancers (S&SEs) can maintain sweet taste in the absence of energy, but little is known about the impact of acute and repeated consumption of S&SE in foods on appetite. This study aims to evaluate the effect of acute and repeated consumption of two individual S&SEs and two S&SE blends in semisolid and solid foods on appetite and related behavioural, metabolic and health outcomes.

METHODS AND ANALYSIS

A work package of the SWEET Project; this study consists of five double-blind randomised cross-over trials which will be carried out at five sites across four European countries, aiming to have n=213. Five food matrices will be tested across three formulations (sucrose-sweetened control vs two reformulated products with S&SE blends and no added sugar). Participants (body mass index 25-35 kg/m²; aged 18-60 years) will consume each formulation for 14 days. The primary endpoint is composite appetite score (hunger, inverse of fullness, desire to eat and prospective food consumption) over a 3-hour postprandial incremental area under the curve during clinical investigation days on days 1 and 14.

ETHICS AND DISSEMINATION

The trial has been approved by national ethical committees and will be conducted in accordance with the Declaration of Helsinki. Results will be published in international peer-reviewed open-access scientific journals. Research data from the trial will be deposited in an open-access online research data archive.

TRIAL REGISTRATION NUMBER

NCT04633681.

Protocol for a multicentre, parallel, randomised, controlled trial on the effect of sweeteners and sweetness enhancers on health, obesity and safety in overweight adults and children: the SWEET project

INTRODUCTION

The aim of this randomised controlled trial (RCT) is to investigate whether prolonged consumption of sweeteners and sweetness enhancers (S&SEs) within a healthy diet will improve weight loss maintenance and obesity-related risk factors and affect safety markers compared with sugar.

METHODS AND ANALYSIS

SWEET (S&SEs: prolonged effects on health, obesity and safety) is a 1-year multicentre RCT including at least 330 adults with overweight (18-65 years, body mass index (BMI) >25 kg/m²) and 40 children (6-12 years, BMI-for-age >85th percentile). In an initial 2-month period, adults will consume a low-energy diet with the aim to achieve ≥5% weight loss. Children are advised to consume a generally healthy diet to maintain body weight, thus reducing their BMI-for-age z-score. In the following 10 months, participants will be randomised to follow a healthy ad libitum diet with or without S&SE products. Clinical investigations are scheduled at baseline, after 2, 6 and 12 months. The primary outcomes are body weight for efficacy and gut microbiota composition (in relation to metabolic health) for safety, both in adults. Secondary outcomes include anthropometry, risk markers for type-2 diabetes and cardiovascular diseases, questionnaires including, for example, food preferences, craving and appetite and tests for allergenicity.

ETHICS AND DISSEMINATION

The trial protocol has been approved by the following national ethical committees; The research ethics committees of the capital region (Denmark), approval code: H-19040679, The medical ethics committee of the University Hospital Maastricht and Maastricht University (the Netherlands), approval code: NL70977.068.19/METC19-056s, Research Ethics Committee of the University of Navarra (Spain), approval code: 2019.146 mod1, Research Ethics Committee of Harokopio University (Greece), approval code: 1810/18-06-2019. The trial will be conducted in accordance with the Declaration of Helsinki. Results will be published in international peer-reviewed scientific journals regardless of whether the findings are positive, negative or inconclusive.

TRIAL REGISTRATION NUMBER

NCT04226911 (Clinicaltrials.gov).

Dose-Response and Substitution Analyzes of Sweet Beverage Consumption and Body Weight in Dutch Adults: The Lifelines Cohort Study

Background/Methods

Prospective studies investigating sweet beverages and body weight associations show inconsistent results. Within the SWEET project, we examined prospective dose-response associations of sugar-sweetened beverages (SSB), low/no-calorie beverages (LNCB), and fruit juice with body weight-related outcomes among 78,286 Dutch adults followed for ~4 years. Baseline intakes were assessed using a validated food-frequency questionnaire (FFQ) with 150 ml representing a standard serving. Outcome variables were body weight change, waist circumference change, overweight/obesity, and abdominal obesity. Associations were investigated by using linear and non-linear dose-response analysis, as well as substitution models while adjusting for multiple socio-demographic, lifestyle, health, and dietary variables.

Results

Participants were 46 ± 13 (mean ± SD) years old and 60% were women. Adjusted dose-response analyzes indicated an association between SSB and LNCB, and both body weight (+0.02 kg/year; SE 0.01 and +0.06 kg/year; SE 0.01) and waist circumference changes (+0.04 cm/year; SE: 0.01 and +0.11 cm/year; SE: 0.01). Associations for overweight/obesity and abdominal obesity incidence were +3% (95%CI: 1.00–1.06) and +2% (95%CI: 0.99–1.06) for SSB and +8% (95%CI: 1.06–1.11) and +5% (95%CI: 1.03–1.07) for LNCB, respectively. Substitution of SSB with LNCB was associated with higher weight change (+0.04 kg/year), waist circumference change (+0.09 cm/year), overweight/obesity incidence (+6%), but not abdominal obesity incidence. For fruit juice, we observed beneficial associations for intake levels below ~1 serving/day with weight, waist circumference change, and overweight/obesity incidence, and no association with abdominal obesity. Subsequent substitution analyzes indicated a small beneficial association for the replacement of SSB with fruit juice on weight (−0.04 kg/year) and waist circumference (−0.04 cm/year), but not with other outcomes.

Conclusions

Overall, our results suggest that habitual consumption of both SSB and LNCB may adversely affect weight-related outcomes. In contrast, fruit juice consumption <150 ml may be beneficial with respect to weight and waist circumference.

Association of Sugar-Sweetened Beverages, Low/No-Calorie Beverages and Fruit Juice Intakes with Non-alcoholic Fatty Liver Disease: The SWEET Project

Objectives

Examine associations between the intake of sugar-sweetened beverages (SSB), low/no-calorie beverages (LNCB), and fruit juice (FJ) and non-alcoholic fatty liver (NAFLD) in 4 population-based studies included in the SWEET project.

Methods

Data of 42,024 participants from the Lifelines Cohort Study (LCS), NQPlus, PREDIMED-Plus and the Alpha Omega Cohort (AOC) were cross-sectionally analyzed. Dietary intake was assessed using food frequency questionnaires. NAFLD was assessed using the Fatty Liver Index (≥60). Restricted cubic spline analyses were used to visualize dose-response associations in LCS. Multivariate Cox proportional hazard regression analyses with robust variance were performed for the associations with NAFLD (prevalence ratio [PR]) in all cohorts and linear regression analyses were conducted for the associations with its markers (triglycerides, gamma-glutamyl transferase, aspartate aminotransferase and alanine aminotransferase). Models were adjusted for demographic, lifestyle, and dietary factors. Results of different cohorts were pooled using random-effects meta-analysis.

Results

NAFLD prevalence was 22% in LCS and NQplus, 60% in AOC and 78% in PREDIMED-Plus. Each additional serving/day of SSB was associated with a 7% higher NAFLD prevalence (PR 1.07, 95%CI 1.03–1.10). For LNCB, dose-response analyses showed evidence for a nonlinear association with NAFLD i.e., a sharp increase at intake ≤ 1 serving/day and more gradual at higher intake levels. The intake of >2 LNCB servings/week was positively associated with NAFLD (PR 1.38, 95%CI 1.15–1.60, ref: non-consumers), which disappeared after adjustment for BMI (PR 1.04, 95%CI 0.94–1.14). A J-shaped association was observed between FJ and NAFLD with an inverse association for intakes of >0–2 servings/week (PR 0.92, 95%CI: 0.88–0.96), but not for higher intakes, compared to no intake. Modest positive associations were observed between all beverages and most NAFLD clinical markers.

Conclusions

Pooling results across 4 studies showed that SSB and LNCB were associated with higher NAFLD prevalence and the majority of its markers. A J-shaped association was observed between FJ and NAFLD, suggesting lower prevalence at medium intakes.

Funding Sources

The SWEET project has received funding from the European Union's Horizon 2020 research and innovation program.

Long‐term low dose nitisinone therapy in adults with alkaptonuria shows no cognitive decline or increased severity of depression

Little is documented on whether nitisinone‐induced hypertyrosinaemia alters cognitive functioning or leads to worsening depression in alkaptonuria (AKU). Wechsler Adult Intelligence Scale‐IV (WAIS‐IV) and Beck Depression Inventory‐II (BDI‐II) assessments were performed before and annually following treatment with nitisinone 2 mg daily to assess the impact on cognitive functioning and severity of depression. Serum tyrosine concentrations were also measured annually. WAIS‐IV: 63 patients (27 females/36 males: mean age[years] [±standard deviation, range] 55.7[13.7, 26–79]; 60.3[9.6, 19–75]) were included at baseline for assessment of: verbal comprehension (VC), perceptual reasoning (PR), working memory (WM), and processing speed (PS) using separate indices. Over the 6‐year period studied 43, 39, 36, 29, 26 and 15 patients had annual assessments. Using a longitudinal model (age and sex adjusted) no significant differences were observed in any of the indices over this period, apart from VC which showed a significant increase after adjustment for sex (p < 0.05). BDI‐II: 74 patients (32 females/42 males: mean age[years] [±standard deviation, range] 56.1[13.2, 26–79]; 42 males, 51.5[16.3, 19–70]) were included at baseline. Over the 7‐year period studied 48, 47, 38, 34, 32, 24 and 12 patients had annual assessments. No significant differences in BDI‐II scores were observed when compared to baseline. Hypertyrosinaemia was observed in all patients following treatment with nitisinone (p < 0.001, at all annual visits). Serum tyrosine was not correlated with WAIS‐IV sub‐test indices or BDI‐II scores pre‐ or post‐nitisinone therapy. These findings suggest that treatment with nitisinone does not affect cognitive functioning and or lead to increased severity of depression.

The Postpartum Specific Anxiety Scale: Confirmatory factor analyses and relationships with birth experience

The Postpartum Specific Anxiety Scale [PSAS] was developed and validated as a research tool with a four-factor structure; with predictive validity corroborated in studies examining infant-feeding and maternal bonding outcomes. The PSAS has not been examined in relation to birth experiences. We aimed to confirm the PSAS four-factor structure and examine these domains of anxiety in relation to subjective and objective birth experiences. Postpartum mothers (≤ 12-months; N = 500) completed the PSAS alongside measures of subjective birth satisfaction and objective obstetric interventions/complications. Confirmatory factor analyses [CFA] tested eight models, theoretically derived from the preceding exploratory work. Structural equation modelling [SEM] tested associations between each PSAS factor and birth experience variables in the best-fitting model. An identical 51-item four-factor model fits the data well. SEM analyses revealed associations between lower perceptions of quality of intrapartum care and increased maternal competence and attachment anxieties, practical infant care anxieties, and infant safety and welfare anxieties. High subjective stress and negative emotional response to labour were associated with increased psychosocial adjustment to motherhood anxieties. Specific associations were found between neonatal care unit admission and practical infant care anxieties; and infant asphyxia and infant safety and welfare anxieties. Findings confirm construct and convergent validity of the four-factor PSAS and its use in measuring postpartum anxiety. Unique associations were also identified, indicating specific subjective and objective experiences occurring during birth may elicit a differential anxiety response, in that they are related to specific forms of postpartum anxiety which occur during the first postpartum year.

Postpartum women's psychological experiences during the COVID-19 pandemic: a modified recurrent cross-sectional thematic analysis

BACKGROUND

COVID-19 has placed additional stressors on mothers during an already vulnerable lifecourse transition. Initial social distancing restrictions (Timepoint 1; T1) and initial changes to those social distancing restrictions (Timepoint 2; T2) have disrupted postpartum access to practical and emotional support. This qualitative study explores the postpartum psychological experiences of UK women during different phases of the COVID-19 pandemic and associated 'lockdowns'.

METHODS

Semi-structured interviews were conducted with 12 women, approximately 30 days after initial social distancing guidelines were imposed in the UK (22 April 2020). A separate 12 women were interviewed approximately 30 days after the initial easing of social distancing restrictions (10 June 2020). Data were transcribed verbatim, uploaded into NVivo for management and analysis, which followed a recurrent cross-sectional approach to thematic analysis.

RESULTS

Two main themes were identified for T1: 'Motherhood is Much Like Lockdown' and 'A Self-Contained Family Unit'. Each main T1 theme contained two sub-themes. Two main themes were also identified for T2: 'Incongruously Held Views of COVID-19' and 'Mothering Amidst the Pandemic'. Each main T2 theme contained three sub-themes. Comparisons between data gathered at each timepoint identified increased emotional distress over time. Current findings call for the improvement of postpartum care by improving accessibility to social support, and prioritising the re-opening of schools, and face-to-face healthcare appointments and visitation.

CONCLUSION

Social distancing restrictions associated with COVID-19 have had a cumulative, negative effect on postpartum mental health. Recommendations such as: Allowing mothers to 'bubble' with a primary support provider even at their healthcare appointments; allowing one support partner to attend all necessary healthcare appointments; and providing tailored informational resources, may help to support postpartum emotional wellbeing during this, and similar health crises in the future.

Changes in Circulating Metabolites During Weight Loss are Associated with Adiposity Improvement, and Body Weight and Adiposity Regain During Weight Loss Maintenance: The SATIN Study

SCOPE

To examine the relationship between changes in circulating metabolites during diet-induced weight loss and changes of adiposity. This study also investigates changes in these metabolites in relation to body weight and adiposity regain during a weight loss maintenance period.

METHODS AND RESULTS

This cohort study is nested within the Satiety Innovation (SATIN) study. Participants (n = 162) achieving ≥8% weight loss during an initial 8-week low-calorie formula diet (LCD) are included in a 12-week weight loss maintenance period. A targeted metabolite profiling (123 metabolites) approach is applied using three different platforms (proton nuclear magnetic resonance, liquid chromatography mass spectrometry, gas chromatography mass spectrometry). Changes in several lipid species and citric acid are significantly associated with greater reduction of body weight, total fat, and abdominal adiposity distribution during the LCD. Decreases in the concentrations of lysophosphatidylcholines (LPCs) 14:0, LPC 20:3, phosphatidylcholine (PC) 32:2, PC 38:3, sphingomyelin (SM) 32:2, and increases in citric acid concentrations during the LCD are associated with adiposity regain and loss, respectively, during the weight loss maintenance period.

CONCLUSIONS

The results show that weight loss is associated with changes in lipid species and citric acid. These changes are related to subsequent weight and adiposity regain identifying the adipose lipid metabolism as an important factor for the maintenance of lost weight and adiposity.

A randomised, controlled, double blind study to assess mechanistic effects of combination therapy of dapagliflozin with exenatide QW versus dapagliflozin alone in obese patients with type 2 diabetes mellitus (RESILIENT): study protocol

INTRODUCTION

The newer glucose-lowering therapies for type 2 diabetes (T2D), the glucagon-like peptide-1 receptor agonists (GLP1-RAs) and the sodium-glucose co-transporter 2 inhibitors (SGLT2i), have additional clinical benefits beyond improving glycaemic control; promoting weight loss, addressing associated cardiovascular risk factors and reducing macrovascular and microvascular complications. Considering their independent mechanisms of actions, there is a potential for significant synergy with combination therapy, yet limited data exist. This 32-week randomised, double-blind, placebo-controlled trial will gain mechanistic insight into the effects of coadministration of exenatide QW, a weekly subcutaneous GLP1-RA, with dapagliflozin, a once daily oral SGLT2i, on the dynamic, adaptive changes in energy balance, total, regional and organ-specific fat mass and multiorgan insulin sensitivity.

METHODS AND ANALYSIS

110 obese patients with diagnosed T2D (glycated haemoglobin, HbA_1c ≥48 mmol/mol) will be treated for 32 weeks with dapagliflozin (10 mg once daily either alone or in combination with exenatide QW (2 mg once weekly); active treatments will be compared with a control group (placebo tablet and sham injection). The primary objective of the study is to compare the adjusted mean reduction in total body fat mass (determined by dual-energy X-ray absorptiometry, DEXA) from baseline following 32 weeks of treatment with exenatide QW and dapagliflozin versus dapagliflozin alone compared with control (placebo). Secondary outcome measures include changes in (1) energy balance (energy intake and energy expenditure measured by indirect calorimetry); (2) appetite (between and within meals) and satiety quotient; (3) body composition including visceral adipose tissue, subcutaneous adipose tissue, liver and pancreatic fat. Exploratory outcome measures include metabolic changes in hepatic and peripheral insulin sensitivity (using a two-stage hyperinsulinaemic, euglycaemic clamp), central nervous system responses to food images using blood oxygen level-dependent (BOLD) functional MRI (fMRI) and changes in cardiovascular function (using transthoracic echocardiography, cardiac MR and duplex ultrasonography).

ETHICS AND DISSEMINATION

This study has been approved by the North West Liverpool Central Research Ethics Committee (14/NW/1147) and is conducted in accordance with the Declaration of Helsinki and the Good Clinical Practice. Results from the study will be published in peer-reviewed scientific and open access journals and/or presented at scientific conferences and summarised for distribution to the participants.

TRIAL SPONSOR

University of Liverpool.

TRIAL REGISTRATION NUMBER

ISRCTN 52028580; EUDRACT number 2015-005242-60.

Short-Term Physical Inactivity Induces Endothelial Dysfunction

Objective

This study examined the effects of a short-term reduction in physical activity, and subsequent resumption, on metabolic profiles, body composition and cardiovascular (endothelial) function.

Design

Twenty-eight habitually active (≥10,000 steps/day) participants (18 female, 10 male; age 32 ± 11 years; BMI 24.3 ± 2.5 kg/m²) were assessed at baseline, following 14 days of step-reduction and 14 days after resuming habitual activity.

Methods

Physical activity was monitored throughout (SenseWear Armband). Endothelial function (flow mediated dilation; FMD), cardiorespiratory fitness ( V . ⁢ O 2 peak) and body composition including liver fat (dual-energy x-ray absorptiometry and magnetic resonance spectroscopy) were determined at each assessment. Statistical analysis was performed using one-way within subject's ANOVA; data presented as mean (95% CI).

Results

Participants decreased their step count from baseline by 10,111 steps/day (8949, 11,274; P < 0.001), increasing sedentary time by 103 min/day (29, 177; P < 0.001). Following 14 days of step-reduction, endothelial function was reduced by a 1.8% (0.4, 3.3; P = 0.01) decrease in FMD. Following resumption of habitual activity, FMD increased by 1.4%, comparable to the baseline level 0.4% (-1.8, 2.6; P = 1.00). Total body fat, waist circumference, liver fat, whole body insulin sensitivity and cardiorespiratory fitness were all adversely affected by 14 days step-reduction (P < 0.05) but returned to baseline levels following resumption of activity.

Conclusion

This data shows for the first time that whilst a decline in endothelial function is observed following short-term physical inactivity, this is reversed on resumption of habitual activity. The findings highlight the need for public health interventions that focus on minimizing time spent in sedentary behavior.

A validation of the Postpartum Specific Anxiety Scale 12-item research short-form for use during global crises with five translations

BACKGROUND

Global crises inevitably increase levels of anxiety in postpartum populations. Effective and efficient measurement is therefore essential. This study aimed to create a 12-item research short form of the 51-item Postpartum Specific Anxiety Scale [PSAS] and validate it for use in rapid response research at a time of global crises [PSAS-RSF-C]. We also present the same 12-items, in five other languages (Italian, French, Chinese, Spanish, Dutch) to increase global accessibility of a psychometric tool to assess maternal mental health.

METHODS

Twelve items from the PSAS were selected on the basis of a review of their factor loadings. An on-line sample of UK mothers (N = 710) of infants up to 12 weeks old completed the PSAS-RSF-C during COVID-19 'lockdown'.

RESULTS

Principal component analyses on a randomly split sample (n = 344) revealed four factors, identical in nature to the original PSAS, which in combination explained 75% of the total variance. Confirmatory factor analyses (n = 366) demonstrated the four-factor model fit the data well. Reliability of the overall scale and of the underlying factors in both samples proved excellent.

CONCLUSIONS

Findings suggest the PSAS-RSF-C may prove useful as a clinical screening tool and is the first postpartum-specific psychometric scale to be validated during the COVID-19 pandemic. This offers psychometrically sound assessment of postpartum anxiety. By increasing the accessibility of the PSAS, we aim to enable researchers the opportunity to measure maternal anxiety, rapidly, at times of global crisis.

Do low-calorie sweetened beverages help to control food cravings? Two experimental studies

Low-calorie sweetened (LCS) beverages may help consumers to satisfy hedonic food cravings without violating dieting goals, however this remains unexplored. The present research investigated the effect of priming hedonic eating motivations on ad libitum energy intake in frequent and non-consumers of LCS beverages. It was hypothesised that energy intake would be greater after the hedonic eating prime relative to a control prime in non-consumers, but that frequent LCS beverage consumers would be protected from this effect. In Study 1 (N = 120), frequent and non-consumers were exposed to either chocolate or neutral cues (craving vs. control condition) and then completed a beverage-related visual probe task with concurrent eye-tracking. Ad libitum energy intake from sweet and savoury snacks and beverages (including LCS) was then assessed. Study 2 followed a similar protocol, but included only frequent consumers (N = 172) and manipulated the availability of LCS beverages in the ad libitum eating context (available vs. unavailable). Measures of guilt and perceived behavioural control were also included. In Study 1, as hypothesised, non-consumers showed greater energy intake in the craving condition relative to the control condition, but frequent consumers had similar energy intake in both conditions. Frequent consumers (but not non-consumers) also demonstrated an attentional bias for LCS beverage stimuli compared to both sugar and water stimuli. In contrast, in Study 2 frequent consumers showed greater energy intake in the craving condition relative to the control condition; however, overall energy intake was significantly greater when LCS beverages were unavailable compared to when they were available. Ratings of guilt were higher and perceived control was lower in the LCS-unavailable condition relative to the LCS-available condition. Conclusions: LCS beverages did not consistently protect consumers from craving-induced increases in energy intake. However, frequent consumers consumed fewer calories overall when LCS beverages were available (relative to unavailable), as well as perceiving more control over their food intake and feeling less guilty.

Clinical and biochemical assessment of depressive symptoms in patients with Alkaptonuria before and after two years of treatment with nitisinone

OBJECTIVE

Concerns exist over hypertyrosinaemia that is observed following treatment with nitisinone. It has been suggested that tyrosine may compete with tryptophan for uptake into the central nervous system, and or inhibit tryptophan hydroxylase activity reducing serotonin production. At the National Alkaptonuria (AKU) Centre nitisinone is being used off-licence to treat AKU, and there is uncertainty over whether hypertyrosinaemia may alter mood. Herein results from clinical and biochemical assessments of depression in patients with AKU before and after treatment with nitisinone are presented.

PATIENTS AND METHODS

63 patients were included pre-nitisinone treatment, of these 39 and 32 patients were followed up 12 and 24 months after treatment. All patients had Becks Depression Inventory-II (BDI-II) assessments (scores can range from 0 to 63, the higher the score the more severe the category of depression), and where possible urinary monoamine neurotransmitter metabolites and serum aromatic amino acids were measured as biochemical markers of depression.

RESULTS

Mean (±standard deviation) BDI-II scores pre-nitisinone, and after 12 and 24 months were 10.1(9.6); 9.8(10.0) and 10.5(9.9) (p ≥ 0.05, all visits). Paired scores (n = 32), showed a significant increase at 24 months compared to baseline 10.5(9.9) vs. 8.6 (7.8) (p = 0.03). Serum tyrosine increased at least 6-fold following nitisinone (p ≤ 0.0001, all visits), and urinary 3-methoxytyramine (3-MT) increased at 12 and 24 months (p ≤ 0.0001), and 5-hydroxyindole acetic acid (5-HIAA) decreased at 12 months (p = 0.03).

CONCLUSIONS

BDI-II scores were significantly higher following 24 months of nitisinone therapy in patients that were followed up, however the majority of these patients remained in the minimal category of depression. Serum tyrosine and urinary 3-MT increased significantly following treatment with nitisinone. In contrast urinary 5-HIAA did not decrease consistently over the same period studied. Together these findings suggest nitisinone does not cause depression despite some observed effects on monoamine neurotransmitter metabolism.

The emotional and practical experiences of formula-feeding mothers

The majority of infant-feeding research is focused on identifying mother's reasons for the cessation of breastfeeding. The experience of mothers who choose to use formula is largely overlooked in quantitative designs. This study aimed to describe the emotional and practical experiences of mothers who formula feed in any quantity, and examine whether these experiences would vary among different cohorts of formula-feeding mothers according to prenatal feeding intention and postnatal feeding method. A total of 890 mothers of infants up to 26 weeks of age, who were currently formula feeding in any quantity, were recruited through relevant international social media sites via advertisements providing a link to an online survey. Predictors of emotional experiences included guilt, stigma, satisfaction, and defense as a result of their infant feeding choices. Practical predictor variables included support received from health professionals, respect displayed by their everyday environment, and main sources of infant feeding information. Descriptive findings from the overall sample highlighted a worryingly high percentage of mother's experienced negative emotions as a result of their decision to use formula. Multinomial logit models revealed that negative emotions such as guilt, dissatisfaction, and stigma were directly associated with feeding intention and method. The evidence suggests that the current approach to infant-feeding promotion and support may be paradoxically related to significant issues with emotional well-being. These findings support criticisms of how infant-feeding recommendations are framed by health care professionals and policy makers, and highlight a need to address formula feeding in a more balanced, woman-centered manner.

EffectS of non-nutritive sWeetened beverages on appetITe during aCtive weigHt loss (SWITCH): Protocol for a randomized, controlled trial assessing the effects of non-nutritive sweetened beverages compared to water during a 12-week weight loss period and a follow up weight maintenance period

BACKGROUND

Acute and medium-term intervention studies suggest that non-nutritive sweeteners (NNS) are beneficial for weight loss, however there is limited human data on the long-term effects of consuming NNS on weight loss, maintenance, and appetite. Further research is therefore required to elucidate the prolonged impact of NNS consumption on these outcome measures.

METHODS/DESIGN

A randomized parallel groups design will be used to assess whether regular NNS beverage intake is equivalent to a water control in promoting weight loss over 12-weeks (weekly weight loss sessions; Phase I), then supporting weight maintenance over 40-weeks (monthly sessions; Phase II) and subsequently independent weight maintenance over 52-weeks (Phase III) in 432 participants. A subset of these participants (n=116) will complete laboratory-based appetite probe days (15 sessions; 3 sessions each at baseline, at the start of phase I and the end of each phase). A separate subset (n=50) will complete body composition scans (DXA) at baseline and at the end of each phase. All participants will regularly be weighed and will complete questionnaires and cognitive tasks to assess changes in body weight and appetitive behaviours. Measures of physical activity and biochemical markers will also be taken.

DISCUSSION

The trial will assess the efficacy of NNS beverages compared to water during a behavioural weight loss and maintenance programme. We aim to understand whether the impact of NNS on weight, dietary adherence and well-being are beneficial or transient and effects on prolonged successful weight loss and weight maintenance through sustained changes in appetite and eating behaviour.

TRIAL REGISTRATION

Clinical Trials: NCT02591134; registered: 23.10.2015.

A Pilot Study of Obesogenic Eating Behaviors in Children With Migraine

We studied associations between migraine severity and obesogenic eating behaviors in children with a prospective cross-sectional, clinic-based study. Migraine severity was quantified using the PedMIDAS tool and attack frequency. Eating behaviors were assessed using the Dutch Eating Behaviour Questionnaire and the Child Eating Behaviour Questionnaire. Food intake was assessed using a Food Intake Questionnaire. Statistical tests of association between eating behavior, food intake, and adiposity with migraine severity were performed. Sixty children (mean age = 10.9 years, standard deviation = 3.1; 26 males) were recruited. There was a positive correlation between the Child Eating Behaviour Questionnaire desire to drink subscale and PedMIDAS scores (r = 0.41, P = .01). Attack frequency was associated with higher intake of high fat or sugar content food and drink (r = 0.27, P = .04). No association between migraine severity and adiposity was found. Suggestion that migraine severity in children is associated with certain obesogenic eating behaviors requires further large study investigation.

Coconut and sunflower oil ratios in ice cream influence subsequent food selection and intake

The effect of coconut oil (CO, containing mainly medium chain triglycerides - MCTs) and sunflower oil (SO, containing mainly long chain triglycerides - LCTs) used as fat source (10% fat ice cream) in different ratios (25% CO and 75% SO - 25CO:75SO, 50% CO and 50% SO - 50CO:50SO, 75% CO and 25% SO - 75CO:25SO) was investigated to assess differences in appetite and ad-libitum (evening and snack) food intake using a single blind design. 36 healthy female participants consumed a fixed portion (150g) of ice cream 45min before an ad-libitum dinner and snacks. Appetite sensations were tracked across the day. Participants ate significantly less fat after 75CO:25SO than 25CO:75SO (p=0.007) and there was also a trend for lower fat intake in this condition as compared to 50CO:50SO (p=0.068). High fat savoury snack intake significantly decreased after 75CO:25SO in comparison with both 25CO:75SO (p=0.038) and 50CO:50SO (p=0.008). Calorie intake from snacks was also found to be significantly lower after 25CO:75SO and 50CO:50SO than 75CO:25SO (p=0.021 and 0.030 respectively). There was no effect of condition on appetite or desire ratings over the day. Eating a standard portion of ice cream containing different ratios of MCTs and LCTs can modestly influence acute food selection and intake, with MCTs manifesting their effect earlier and LCTs later due to differences in the absorption and metabolism of these lipids. However, the differences evident in the present study were small, and require further research before firm conclusions can be drawn.

Satiety Innovations: Food Products to Assist Consumers with Weight Loss, Evidence on the Role of Satiety in Healthy Eating: Overview and In Vitro Approximation

The prevalence of overweight and obesity is increasing globally, driven by the availability of energy-dense palatable foods. Most dietary strategies fail because of hunger generated by calorie restriction, and interventions that specifically control hunger and/or promote fullness may aid success. Current consumers have a limited choice of satiety-enhancing products with proven health benefits, and innovative ways to produce new foods (as structural modification) to enhance satiety/satiation may provide new opportunities. However, this potential is hindered by the cost of product testing. Within the SATIN-SATiety INnovation project-an in vitro platform has been developed to offer a cost-effective means of assessing the potential satiation/satiety effect of novel foods. This combines in vitro technologies to assess changes in colonic bacteria metabolism, appetite hormone release and the stability and bioavailability of active compounds in the new products/ingredients. This article provides a brief review of nutrients for which an impact on short-term appetite regulation has been demonstrated, and a summary of the changes to food structure which can be used to produce a change in appetite expression. Furthermore, the SATIN in vitro platform is discussed as a means of assessing the impact of nutritional and structural manipulations on appetite.

Heightened eating drive and visual food stimuli attenuate central nociceptive processing

Hunger and pain are basic drives that compete for a behavioral response when experienced together. To investigate the cortical processes underlying hunger-pain interactions, we manipulated participants' hunger and presented photographs of appetizing food or inedible objects in combination with painful laser stimuli. Fourteen healthy participants completed two EEG sessions: one after an overnight fast, the other following a large breakfast. Spatio-temporal patterns of cortical activation underlying the hunger-pain competition were explored with 128-channel EEG recordings and source dipole analysis of laser-evoked potentials (LEPs). We found that initial pain ratings were temporarily reduced when participants were hungry compared with fed. Source activity in parahippocampal gyrus was weaker when participants were hungry, and activations of operculo-insular cortex, anterior cingulate cortex, parahippocampal gyrus, and cerebellum were smaller in the context of appetitive food photographs than in that of inedible object photographs. Cortical processing of noxious stimuli in pain-related brain structures is reduced and pain temporarily attenuated when people are hungry or passively viewing food photographs, suggesting a possible interaction between the opposing motivational forces of the eating drive and pain.

Will smaller plates lead to smaller waists? A systematic review and meta-analysis of the effect that experimental manipulation of dishware size has on energy consumption

It has been suggested that providing consumers with smaller dishware may prove an effective way of helping people eat less and preventing weight gain, but experimental evidence supporting this has been mixed. The objective of the present work was to examine the current evidence base for whether experimentally manipulated differences in dishware size influence food consumption. We systematically reviewed studies that experimentally manipulated the dishware size participants served themselves at a meal with and measured subsequent food intake. We used inverse variance meta-analysis, calculating the standardized mean difference (SMD) in food intake between smaller and larger dishware size conditions. Nine experiments from eight publications were eligible for inclusion. The majority of experiments found no significance difference in food intake when participants ate from smaller vs. larger dishware. With all available data included, analysis indicated a marginal effect of dishware size on food intake, with larger dishware size associated with greater intake. However, this effect was small and there was a large amount of heterogeneity across studies (SMD: -0.18, 95% confidence interval: -0.35, 0.00, I(2) = 77%). Evidence to date does not show that dishware size has a consistent effect on food intake, so recommendations surrounding the use of smaller plates/dishware to improve public health may be premature.

Stigmatisation of a formerly obese young female

BACKGROUND

Weight loss does not necessarily decrease the negative appraisal of a formerly overweight individual. Since past weight history tends to be disclosed in several contexts, this study aims to investigate whether negative appraisals are gender-specific and if they are modulated by the evaluators' own BMI.

METHODS

202 young adults (106 male and 96 female) viewed a picture of a young attractive female (target) accompanied by one of two statements about her past weight (overweight (OW) or always kept a normal weight (NW)), and then rated her using the Fat Phobia Scale (FPS).

RESULTS

Female evaluators rated the target with the OW statement more negatively than the target with the NW statement. In contrast, males exposed to the OW statement rated the target as having fewer emotional/psychological problems and being less stupid/uncreative. BMI only influenced ratings in males, where those with higher BMI ascribed more negative attributes to the target with the NW statement than the OW statement.

CONCLUSION

Information on weight history impacts upon the appraisal of peers. These effects are dependent on gender and BMI. Knowing that a young female was overweight triggered negative evaluations from females but did not appear to impact the judgment of males.

Food choice and overconsumption: effect of a premium sports celebrity endorser

OBJECTIVE

To determine whether exposure to celebrity endorsement in television (TV) food advertising and a nonfood context would affect ad libitum intake of the endorsed product and a perceived alternative brand.

STUDY DESIGN

A total of 181 children from the UK aged 8-11 years viewed 1 of the following embedded within a cartoon: (1) a commercial for Walker's Crisps (potato chips), featuring a long-standing celebrity endorser; (2) a commercial for a savory food; (3) TV footage of the same endorser in his well-known role as a TV presenter; or (4) a commercial for a nonfood item. Children's ad libitum intake of potato chips labeled "Walker's" and "supermarket brand" was measured using ANOVA.

RESULTS

Children who viewed the endorsed commercial or the TV footage of the endorser outside of a food context consumed significantly more of the Walker's chips compared with children in other groups. These children did not reduce their intake of the supermarket brand product to compensate; thus, the endorser effect contributed to overconsumption.

CONCLUSION

The influence of a celebrity endorser on food intake in children extends beyond his or her role in the specific endorsed food commercial, prompting increased consumption of the endorsed brand even when the endorser has been viewed in a nonfood context. Our data suggest that the ubiquitous nature of celebrity media presence may reinforce unhealthy eating practices in children, although research with other endorsers is needed.

Acute effects of a herb extract formulation and inulin fibre on appetite, energy intake and food choice

The impact of two commercially available products, a patented herb extract Yerbe Maté, Guarana and Damiana (YGD) formulation and an inulin-based soluble fermentable fibre (SFF), alone or in combination, on appetite and food intake were studied for the first time in a double blind, placebo-controlled, cross-over design. 58 normal to slightly overweight women consumed a fixed-load breakfast followed 4h later by an ad libitum lunch. They were administered YGD (3 tablets) and SFF (5g in 100ml water), YGD and water (100ml), SFF and placebo (3 tablets) or water and placebo 15min before meals. Appetite was assessed using visual analogue scales, and energy intake was measured at lunch. Significant reductions in food intake and energy intake were observed when YGD was present (59.5g, 16.3%; 112.4kcal, 17.3%) and when SFF was present (31.9g, 9.1%; 80kcal, 11.7%) compared with conditions were products were absent. The lowest intake (gram and kcal) was in the YGD+SFF condition. Significant reductions in AUC hunger and AUC desire to eat were also observed after YGD+SFF combination. The data demonstrate that YGD produces a robust short-term effect on caloric intake, an effect augmented by SFF. Caloric compensation for SFF indicates independent effects on appetite regulation.

Serotonergic anti-obesity agents: past experience and future prospects

The role of serotonin (5-hydroxytryptamine) in appetite control is long established. Serotonergic manipulations reduce food intake in rodents in a manner consistent with satiety. In humans, drugs such as fenfluramine, dexfenfluramine and sibutramine all reduce energy intake, suppress hunger and enhance satiety. Effects on eating behaviour and subjective sensations of appetite are associated with the weight loss-inducing effects of these treatments. Currently, no appetite-suppressing drugs are approved specifically for the treatment of obesity. However, a new generation of serotonergic drugs have progressed through clinical development. The serotonin 5-HT(2C)-receptor selective agonist lorcaserin, a drug specifically developed to target satiety without producing the side effect profiles of its predecessors, has been shown to significantly reduce energy intake and body weight. The weight loss produced by lorcaserin appears modest, and behavioural effects, particularly its supposed satiety-enhancing effects, have yet to be characterized. The monoaminergic re-uptake inhibitor tesofensine has also been shown to produce impressive weight loss in smaller-scale clinical studies. It remains unclear if this drug produces any effects on appetite mediated by serotonin, or whether weight loss is produced largely through enhanced energy expenditure. Evidence indicates that tesofensine strengthens satiety, but behavioural specificity and psychological side effects remain an issue. The serotonergic system remains a viable target for anti-obesity treatment. In this review, we examine the limited behavioural data available on these two new CNS-acting appetite suppressants.

5-HT(2C) receptor agonists and the control of appetite

The role of serotonin (5-HT) in appetite control is well recognised. 5-HT drugs reduce food intake in rodents in a manner consistent with an enhancement of satiety. In humans, they have been shown to reduce caloric intake, an effect associated with reduced hunger and increased satiety. These effects appear to be mediated, at least in part, by the 5-HT(2C) receptor subtype. 5-HT-acting drugs such as fenfluramine, d-fenfluramine, and sibutramine have provided effective anti-obesity treatments in the past. However, more selective agents are needed that produce the same changes in eating behaviour and induce weight loss without unacceptable side effects. Lorcaserin, a selective 5-HT(2C) receptor agonist, is a novel anti-obesity agent that reduces both energy intake and body weight. The effects of lorcaserin on eating behaviour remain to be characterised as does its behavioural specificity.

Persuasive techniques used in television advertisements to market foods to UK children

The aim of this study was to quantify the nature and extent of use of persuasive marketing techniques in television advertisements (adverts) to promote foods to children. Popular UK commercial television channels broadcasting children's/family viewing were recorded for 2 days (6 am-10 pm) every month in 2008 and recordings were screened for adverts. Eighteen thousand eight hundred and eighty eight adverts were for food and these were coded for peak/non-peak children's viewing time and representation of core (healthy)/non-core (unhealthy)/miscellaneous foods. The analysis assessed use of persuasive appeals, premium offers, promotional characters (brand equity and licensed characters), celebrity endorsers and website promotion in food adverts. Promotional characters, celebrity endorsers and premium offers were used more frequently to promote non-core than core foods, even on dedicated children's channels. Brand equity characters featured on a greater proportion of food adverts than licensed characters. A food brand website was promoted in a third of food adverts (websites are not covered by the statutory regulation on food advertising). This extensive analysis of television adverts demonstrated that the use of persuasive marketing techniques to promote unhealthy foods was extensive in broadcasting popular with children despite regulations. Further studies should incorporate an analysis of the content of websites promoted during food adverts.

The extent of food advertising to children on UK television in 2008

OBJECTIVE

To provide the most comprehensive analysis to date of the extent of food advertising on UK television channels popular with young people following regulatory reform of this type of marketing activity.

METHODS

UK television was recorded 06:00-22:00 h for a weekday and a weekend day every month between January and December 2008 for 14 of the most popular commercial channels broadcasting children's/family viewing. Recordings were screened for advertisements, which were coded according to predefined categories including whether they were broadcast in peak/non-peak children's viewing time. Food advertisements were coded as core (healthy)/non-core (unhealthy)/miscellaneous foods.

RESULTS

Food and drinks were the third most heavily advertised product category, and there were a significantly greater proportion of advertisements for food/drinks during peak compared to non-peak children's viewing times. A significantly greater proportion of the advertisements broadcast around soap operas than around children's programmes were for food/drinks. Children's channels broadcast a significantly greater proportion of non-core food advertisements than the family channels. There were significant differences between recording months for the proportion of core/non-core/miscellaneous food advertisements.

CONCLUSIONS

Despite regulation, children in the UK are exposed to more TV advertising for unhealthy than healthy food items, even at peak children's viewing times. There remains scope to strengthen the rules regarding advertising of HFSS foods around programming popular with children and adults alike, where current regulations do not apply. Ongoing, systematic monitoring is essential for evaluation of the effectiveness of regulations designed to reduce children's exposure to HFSS food advertising on television in the UK.

Food commercials increase preference for energy-dense foods, particularly in children who watch more television

OBJECTIVE

Our aim was to determine if levels of television viewing (a proxy measure for habitual commercial exposure) affect children's food preference responses to television food commercials.

METHODS

A total of 281 children aged 6 to 13 years from northwest England viewed toy or food television commercials followed by a cartoon on 2 separate occasions; they then completed 3 food preference measures, a commercial recognition task, and a television viewing questionnaire.

RESULTS

After viewing the food commercials, all children selected more branded and nonbranded fat-rich and carbohydrate-rich items from food preference checklists compared with after viewing the toy commercials. The food preferences of children with higher habitual levels of television viewing were more affected by food commercial exposure than those of low television viewers. After viewing food commercials, high television viewing children selected a greater number of branded food items compared with after the toy commercials as well as compared with the low television viewers. Children correctly recognized more food commercials than toy commercials.

CONCLUSIONS

Exposure to television food commercials enhanced high television viewers' preferences for branded foods and increased reported preferences for all food items (branded and nonbranded) relative to the low television viewers. This is the first study to demonstrate that children with greater previous exposure to commercials (high television viewers) seemed to be more responsive to food promotion messages than children with lower previous advertising exposure.

Pharmacological management of appetite expression in obesity

For obese individuals, successful weight loss and maintenance are notoriously difficult. Traditional drug development fails to exploit knowledge of the psychological factors that crucially influence appetite, concentrating instead on restrictive criteria of intake and weight reduction, allied to a mechanistic view of energy regulation. Drugs are under development that may produce beneficial changes in appetite expression in the obese. These currently include glucagon-like peptide-1 analogs such as liraglutide, an amylin analog davalintide, the 5-HT(2C) receptor agonist lorcaserin, the monoamine re-uptake inhibitor tesofensine, and a number of combination therapies such as pramlintide and metreleptin, bupropion and naltrexone, phentermine and topiramate, and bupropion and zonisamide. However, the effects of these treatments on eating behavior remain poorly characterized. Obesity is typically a consequence of overconsumption driven by an individual's natural sensitivity to food stimuli and the pleasure derived from eating. Intuitively, these processes should be effective targets for pharmacotherapy, and behavioral analysis can identify drugs that selectively affect desire to eat, enjoyment of eating, satiation or postmeal satiety. Rational interventions designed specifically to modulate these processes could limit the normally aversive consequences of caloric restriction and maximize an individual's capacity to successfully gain control over their appetite.

Neuropharmacology of human appetite expression

The regulation of appetite relies on the integration of numerous episodic (meal) and tonic (energy storage) generated signals in energy regulatory centres within the central nervous system (CNS). These centers provide the pharmacological potential to modify human appetite (hunger and satiety) to increase or decrease caloric intake, or to normalize aberrant eating behavior. With regard to obesity, the satiety enhancing anti-obesity drug sibutramine has proved effective at reducing body weight. Additionally, the endocannabinoid CB(1) antagonist rimonabant has recently been approved for use in Europe (but not in the US). A 5-HT(2C) agonist lorcaserin is also currently undergoing large-scale clinical trials, but the effect of the drug on human appetite is unknown as yet. Appetite enhancing drugs such as magestrol acetate and dronabiol are currently used to promote weight gain. Finally, sibutramine, selective serotonergic reuptake inhibitors such as fluoxetine and some anti-epileptic drugs have all been used to normalise aberrant eating behaviour. All these drugs act by modifying the expression of human appetite. An assessment of a drug's effects on caloric intake and feelings of hunger and satiety is necessary before they can be considered for clinical use.

The effect of Korean pine nut oil (PinnoThin) on food intake, feeding behaviour and appetite: a double-blind placebo-controlled trial

Certain free fatty acids have been shown to have potent effects on food intake and self-reported changes in appetite; effects associated with increases in the release of endogenous cholecystokinin (CCK) and glucagon like peptide-1 (GLP-1). In the current study, the effects of a Korean pine nut oil product, PinnoThin, at doses 2 g, 4 g and 6 g triglyceride (TG) and 2 g free fatty acid (FFA), on food intake and appetite were examined in a cross-over double-blind placebo-controlled randomised counter-balanced design in 42 overweight female volunteers. 2 g FFA PinnoThin, given 30 minutes prior to an ad-libitum buffet test lunch, significantly reduced food intake (gram) by 9% (F(4,164) = 2.637, p = 0.036) compared to olive oil control. No significant effect of PinnoThin on macronutrient intake or ratings of appetite were observed. Given the recent data showing that the TG form of PinnoThin may also reduce appetite by increasing CCK release, the lack of any effect of the TG form found in this study could be attributed to the timing of the dosing regime. Collectively, these data suggest that PinnoThin may exert satiating effects consistent with its known action on CCK and GLP-1 release, and previously observed effects on self-reported appetite ratings.

Chronic clozapine treatment in female rats does not induce weight gain or metabolic abnormalities but enhances adiposity: implications for animal models of antipsychotic-induced weight gain

The ability of clozapine to induce weight gain in female rats was investigated in three studies with progressively lowered doses of clozapine. In an initial preliminary high dose study, clozapine at 6 and 12 mg/kg (i.p., b.i.d.) was found to induce weight loss. In a subsequent intermediate dose study, we obtained no evidence for clozapine-induced weight gain despite using identical procedures and doses of clozapine (1-4 mg/kg, i.p., b.i.d.) with which we have observed olanzapine-induced weight gain, hyperphagia, enhanced adiposity and metabolic changes [Cooper G, Pickavance L, Wilding J, Halford J, Goudie A (2005). A parametric analysis of olanzapine-induced weight gain in female rats. Psychopharmacology; 181: 80-89.]. Instead, clozapine induced weight loss without alteration in food intake and muscle mass or changes in levels of glucose, insulin, leptin and prolactin. However, these intermediate doses of clozapine enhanced visceral adiposity and elevated levels of adiponectin. In a final study, low doses of clozapine (0.25-0.5 mg/kg, i.p, b.i.d.) induced weight loss. These data demonstrate that clozapine-induced weight gain can be much more difficult to observe in female rats than olanzapine-induced weight gain. Moreover, these findings contrast with clinical findings with clozapine, which induces substantial weight gain in humans. Clozapine-induced enhanced adiposity appears to be easier to observe in rats than weight gain. These findings, along with other preclinical studies, suggest that enhanced adiposity can be observed in the absence of antipsychotic-induced weight gain and hyperphagia, possibly reflecting a direct drug effect on adipocyte function independent of drug-induced hyperphagia [e.g. Minet-Ringuet J, Even P, Valet P, Carpene C, Visentin V, Prevot D, Daviaud D, Quignard-Boulange A, Tome D, de Beaurepaire R (2007). Alterations of lipid metabolism and gene expression in rat adipocytes during chronic olanzapine treatment. Molecular Psychiatry; 12: 562-571.]. These and other findings which show that the results of studies of antipsychotic treatment in animals do not always mimic clinical findings have important implications for the use of animal models of antipsychotic-induced weight gain. With regard to weight gain the results obtained appear to depend critically on the experimental procedures used and the specific drugs studied. Thus such models are not without limitations. However, they do consistently demonstrate the ability of various antipsychotics to enhance adiposity.