Perceived healthiness of food items and the traffic light front of pack nutrition labelling: choice-based conjoint analysis and cross-sectional survey

BACKGROUND

Although traffic light labelling (TLL) is designed to aid the selection of healthier choices, consumers often have to make trade-offs between (un)desirable attributes. With the current emphasis of public health on sugar reduction, the present study aimed to investigate the relative influence of sugar on the perceived healthiness of products.

METHODS

A choice-based conjoint analysis (CBC) survey was designed to assess the relative importance of the macronutrients commonly used in TLL, as well as the rescaled utilities of three attribute levels (red, amber and green), which involved 858 participants aged ≥18 years, who were recruited from the general population of Nottingham. An additional cross-sectional online survey was completed by another 901 participants to assess public knowledge about the intake recommendations underpinning the TLL.

RESULTS

Usable data for CBC analysis showed that, when deciding upon the healthiness of items, sugar was significantly the most important macronutrient (mean 0.34, 95% confidence interval = 0.32-0.35) among the 641 participants. Red labelling was significantly more influential than green across macronutrients. In the substudy, 13.3% of participants correctly identify the maximum recommended intake of free sugars. Moreover, 42.8% of the total sample could not identify whether the sugar information on TLL refers to the total or free sugar content.

CONCLUSIONS

Despite a lack of knowledge about the recommendations underpinning the TLL criteria, decisions made by participants concerning the healthfulness of food products were significantly influenced by sugar content. TLL appears to guide consumer beliefs in the absence of deep knowledge. The dominance of sugar in decision making is unsurprising in the current public health climate.

"Fat is really a four-letter word": Exploring weight-related communication best practices in children with and without disabilities and their caregivers

BACKGROUND

Health care professionals play a critical role in preventing and managing childhood obesity, but the American Academy of Pediatrics recently stressed the importance of using sensitive and nonstigmatizing language when discussing weight with children and families. Although barriers to weight-related discussions are well known, there are few evidence-based recommendations around communication best practices. Disability populations in particular have previously been excluded from work in this area. The objectives were to present the findings of a recent scoping review to children with and without disabilities and their caregivers for their reactions; and to explore the experiences and perceptions of the children and their caregivers regarding weight-related communication best practices.

METHODS

Focus group and individual interviews were conducted with 7-18-year olds with and without disabilities and their caregivers. The interview guide was created using findings from a recent scoping review of weight-related communication best practices. Inductive thematic analysis was employed.

RESULTS

Eighteen children (9 boys; 7 children with disabilities) and 21 caregivers (17 mothers, 1 step-father, 3 other caregivers) participated in 8 focus group and 7 individual interviews. Preferred communication strategies were similar across those with and without disabilities, although caregivers of children with autism spectrum disorder endorsed more concrete approaches. Discussions emphasizing growth and health were preferred over weight and size. Strengths-based, solution-focused approaches for weight conversations were endorsed, although had not been widely experienced.

CONCLUSION

Perceptions of weight-related communication were similar across stakeholder groups, regardless of children's disability or weight status. Participants generally agreed with the scoping review recommendations, suggesting that they apply broadly across different settings and populations; however, tailoring them to specific circumstances is critical. Empirical evaluations are still required to examine the influence of weight-related communication on clinically important outcomes, including behaviour change and family engagement in care.

Birthweight, HIV exposure and infant feeding as predictors of malnutrition in Botswanan infants

BACKGROUND

A better understanding of the nutritional status of infants who are HIV-Exposed-Uninfected (HEU) and HIV-Unexposed-Uninfected (HUU) during their first 1000 days is key to improving population health, particularly in sub-Saharan Africa.

METHODS

A cross-sectional study compared the nutritional status, feeding practices and determinants of nutritional status of HEU and HUU infants residing in representative selected districts in Botswana during their first 1000 days of life. Four hundred and thirteen infants (37.3% HIV-exposed), aged 6-24 months, attending routine child health clinics, were recruited. Anthropometric, 24-h dietary intake and socio-demographic data was collected. Anthropometric Z-scores were calculated using 2006 World Health Organization growth standards. Modelling of the determinants of malnutrition was undertaken using logistic regression.

RESULTS

Overall, the prevalences of stunting, wasting and being underweight were 10.4%, 11.9% and 10.2%, respectively. HEU infants were more likely to be underweight (15.6% versus 6.9%), (P < 0.01) and stunted (15.6% versus 7.3%), (P < 0.05) but not wasted (P = 0.14) than HUU infants. HEU infants tended to be formula fed (82.5%), whereas HUU infants tended to breastfeed (94%) for the first 6 months (P < 0.001). Significant predictors of nutritional status were HIV exposure, birthweight, birth length, APGAR (appearance, pulse, grimace, activity and respiration) score and mother/caregiver's education with little influence of socio-economic status.

CONCLUSIONS

HEU infants aged 6-24 months had worse nutritional status compared to HUU infants. Low birthweight was the main predictor of undernutrition in this population. Optimisation of infant nutritional status should focus on improving birthweight. In addition, specific interventions should target HEU infants aiming to eliminate growth disparity between HEU and HUU infants.

Communicating with children and families about obesity and weight-related topics: a scoping review of best practices

BACKGROUND

Healthcare professionals have called for direction on how best to communicate about weight-related topics with children and families. Established scoping review methodology was used to answer the question: 'How can healthcare professionals best communicate with children and their families about obesity and weight-related topics?'

METHODS

We searched four scientific databases, two grey literature repositories and 14 key journals (2005-2016). Inclusion criteria were (i) children up to and including 18 years of age and/or their parents; (ii) communication about healthy weight, overweight, obesity or healthy/active living; and (iii) healthcare setting.

RESULTS

Thirty-two articles were included. Evidence-based best practices were largely absent from the literature, although the following guiding principles were identified: (i) include all stakeholders in discussions; (ii) raise the topic of weight and health early and regularly; (iii) use strengths-based language emphasizing health over weight; (iv) use collaborative goal-setting to engage children and parents and (v) augment discussions with appropriate tools and resources. Guidance on how to implement these principles and how to negotiate relevant contextual factors (e.g. age, culture and disability) is still needed.

CONCLUSION

Despite agreement on a number of guiding principles, evidence-based weight-related communication best practices are lacking. Rigorous, empirical evaluations of communication approaches are urgently required, especially those that include children's perspectives.

Setting targets leads to greater long-term weight losses and 'unrealistic' targets increase the effect in a large community-based commercial weight management group

Background

Setting personal targets is an important behavioural component in weight management programmes. Normal practice is to encourage ‘realistic’ weight loss, although the underlying evidence base for this is limited and controversial. The present study investigates the effect of number and size of weight‐loss targets on long‐term weight loss in a large community sample of adults.

Methods

Weight change, attendance and target weight data for all new UK members, joining from January to March 2012, were extracted from a commercial slimming organisation's electronic database.

Results

Of the 35 380 members who had weight data available at 12 months after joining, 69.1% (n = 24 447) had a starting body mass index (BMI) ≥30 kg m^–2. Their mean (SD) weight loss was 12.9% (7.8%) and, for both sexes, weight loss at 12 months was greater for those who set targets (P < 0.001). Those that set ≥4 targets achieved the greatest loss (P < 0.001). The odds ratio for weight loss ≥10% at 12 months was 10.3 (95% confidence interval = 9.7–11.1, P < 0.001) where targets had been set compared to none. At the highest quintile of target size, the size of the first target explained 47.2% (P < 0.001) of the variance in weight loss achieved at 12 months. The mean (SD) BMI reduction in those with a target >25% was 7.6 (4.0) kg m^–2. A higher percentage of obese members did not set targets (P < 0.001) compared to those with a BMI <30 kg m^–2.

Conclusions

Much of the variance in weight loss achieved in this population was explained by the number of targets set and the size of the first target. Although obese people were less likely to set targets, doing so increased the likelihood of achieving clinically significant weight loss and, for some ‘unrealistic’ targets, improved the results.

Qualitative research in nutrition and dietetics: getting started

Qualitative research is well placed to answer complex questions about food-related behaviour because it investigates how and why individuals act in certain ways. The field of qualitative health research is undoubtedly gaining momentum and, increasingly, there is a recognition that it should be a vital part of the decision-making processes that direct the development of health policy and practice. Much of the guidance available, however, is difficult to navigate for those new to 'qualitative research', and there is little discussion of qualitative research issues specifically in relation to nutrition and dietetics. This review, the first in a series, outlines the field of qualitative enquiry, its potential usefulness in nutrition and dietetics, and how to embark upon this type of research. Furthermore, it describes a process to guide high-quality qualitative research in this area that proceeds from the research question(s) and considers the key philosophical assumptions about ontology, epistemology and methodology that underpin the overall design of a study. Other reviews in this series provide an overview of the principal techniques of data collection and sampling, data analysis, and quality assessment of qualitative work, and provide some practical advice relevant to nutrition and dietetics, along with glossaries of key terms.

Qualitative research in nutrition and dietetics: data collection issues

The wide scope of qualitative enquiry presents the researcher with a number of choices regarding data collection and sampling. Selecting data collection and sampling techniques can therefore be somewhat daunting, particularly because, often, there is no single, universally accepted 'correct' option. Appropriate research methods are, however, crucial to ensure high-quality research. This review, the second in the series, provides an overview of the principal techniques of data collection and sampling that may be used for qualitative research in nutrition and dietetics. In addition, it describes a process for choosing appropriate data collection and sampling methods that considers the extent to which they provide data that answers the research question(s) and are compatible with the philosophical assumptions about ontology, epistemology and methodology that underpin the overall design of a study. Finally, it discusses the central role that the researcher plays in qualitative data collection and encourages researchers to acknowledge and reflect upon their impact on the data. Other reviews in this series provide a model for embarking on a qualitative research project in nutrition and dietetics, an overview of the principal techniques of data analysis and quality assessment of this kind of research, and some practical advice relevant to nutrition and dietetics, along with glossaries of key terms.

Qualitative research in nutrition and dietetics: assessing quality

In recent years, qualitative research has become much more widely used in healthcare settings and undoubtedly has much to offer nutrition and dietetics. Its value is, however, still sometimes called into question and, for those unfamiliar with qualitative approaches, it can be difficult to grasp what distinguishes 'good' qualitative research from that which has been less rigorously conceived and conducted. This review, the fourth in the series, aims to highlight some of the key scientific debates around the quality criteria that can be applied to qualitative research, and offers some flexible guidelines that may be used both in producing and assessing qualitative health research, including studies in nutrition and dietetics. Other reviews in this series provide a model for embarking on a qualitative research project in nutrition and dietetics, an overview of the principal techniques of data collection, sampling and analysis and some practical advice relevant to nutrition and dietetics, along with glossaries of key terms.

Trainee health care professionals' knowledge of the health risks associated with obesity

BACKGROUND

Trainee nurses, doctors and dietitians will direct the future of obesity treatment and prevention. To do so effectively, they must have sufficient knowledge regarding the health risks associated with obesity and feel that part of their professional role is to counsel obese patients regarding these risks.

METHODS

An online survey collected data on professional roles, training needs and the Obesity Risk Knowledge-10 (ORK-10) scale from 38 dietetic, 88 nursing (Diploma), 74 nursing (Masters) and 389 medical students.

RESULTS

Final-year dietetic students demonstrated higher ORK-10 scale scores than final-year nursing (Dip), nursing (MSc) and medical students (P < 0.001). The majority of students agreed that part of their profession's role was to counsel obese patients about the health risks associated with obesity. Dietetic students were more satisfied with the teaching they had received than each of the other student groups (P < 0.05).

CONCLUSION

Future health care professionals recognize their responsibility to communicate health risk information to obese patients. Dietetic students have a sound knowledge base to support them in this. Educators of trainee nurses and doctors may like to respond to their students' lower levels of knowledge and desire for more training.

Validation of a brief, reliable scale to measure knowledge about the health risks associated with obesity

BACKGROUND

Obesity represents a serious threat to health through its association with conditions such as type 2 diabetes mellitus, coronary heart disease and certain types of cancer. Knowledge regarding risk to health is an important determinant of behaviour and is the focus of many health education strategies. To the authors' knowledge, there is no valid and reliable measure of knowledge regarding the health risks associated with obesity.

AIM

To validate a short, reliable psychometric scale measuring knowledge regarding the effects of obesity on health, the Obesity Risk Knowledge (ORK-10) scale.

METHODS

The ORK-10 scale was administered to a sample of individuals with no specific obesity-related expertise (n=230) and a sample of experts (n=200). Univariate and multivariate statistical analyses were used to investigate the scale's criterion validity.

RESULTS

The ORK-10 scale has good internal consistency (Cronbach's alpha coefficient>0.7) and is acceptable for use in a UK adult population with an estimated reading age of 12-13 years. The scale demonstrated strong criterion validity, as those with educational or vocational expertise in the field of obesity achieved significantly higher scores than nonexperts (median 9.0 vs 4.0, Z=-17.364; P<0.001). This relationship was maintained after controlling for the potentially confounding factors of age and level of education. Nonexperts demonstrated low levels of knowledge regarding the health risks associated with obesity.

CONCLUSIONS

The ORK-10 scale meets standard psychometric criteria for reliability and validity. This scale could be used to assess the effectiveness of health education interventions, to target the provision of health information and to investigate the interaction between knowledge and obesity-related behaviour.

Hypertelorism, ptosis, and myopia associated with drug-resistant epilepsy, mental delay, growth deficiency, ectodermal defects, and osteopenia

We report a 30-year-old woman with hypertelorism, ptosis, and myopia associated with drug-resistant epilepsy (DRE, Lennox-Gastaut syndrome), mental delay, growth deficiency, ectodermal defects, and osteopenia. To the best of our knowledge, this patient has an unusual combination of symptoms not previously described, associated with severe central nervous system dysfunction. The ectodermal defects were present in a very intriguing form, were difficult to diagnose, and did not conform to any classification or previous description.

Lamellar subcomponents of the cuticular cell membrane complex of mammalian keratin fibres show friction and hardness contrast by AFM

There is a substantial body of information indicating that 18-methyleicosanoic acid (18-MEA) is covalently linked to the outer surface of all mammalian keratin fibres and also forms the outer beta-layer of the cuticular cell membrane complex (CCMC) which separates the cuticle cells from each other. Low cohesive forces are expected between the lipid-containing outer beta-layer and the delta-layer of the CCMC, thus providing a weak point for cuticular delamination and presenting a fresh layer of 18-MEA to the newly exposed surface. We have used lateral force microscopy and force modulation atomic force microscopy (AFM) to examine human hair fibres in which the non-covalently linked fatty acids have been removed. Examination of the lateral force images of new cuticle surfaces revealed by the attrition of overlying cuticle layers showed three separate zones of clearly defined frictional contrast. These are thought to correspond with the delta-layer, the proteinaceous epicuticle and outer beta-layers of the CCMC. The delta-layer was found to have a thickness of 16 nm (SD = 1 nm, n = 25), comparable to the 18.0 nm thickness measured from transverse cross-sections of fibres with transmission electron microscopy. Force modulation AFM showed that the outer beta-layer was softer than the epicuticle and the delta-layer. The frictional contrast was removed following treatment with methanolic KOH (0.1 mol dm-3) at 25 degrees C for 30 min, suggesting the hydrolysis of the thioester linkage and removal of 18-MEA from the surface.

Microscopical investigations on the epicuticle of mammalian keratin fibres

The existence of a thin chemically resistant layer, the epicuticle, close to the surfaces of all undamaged mammalian keratin fibres has been known since 1916. The identification of such a specific structure within the fibre cuticle has remained elusive. Now, through transmission electron microscope investigations of stained transverse sections of hairs from various animal species, the epicuticle has been tentatively identified as a sharply defined and continuous layer approximately 13 nm thick covering the entire outwardly facing intracellular surface of every cuticle cell. The staining behaviour of the epicuticle leads one to suppose that it is rich in cystine and that thioester-bound lipids might be present within its bulk. With the atomic force microscope it was established that the undamaged outer surface of all mammalian keratin fibres, even including those from the monotremes, were longitudinally striated. The lateral spacing of the striations was always in the range 0.29-0.39 microm. Striations only occurred on the freely exposed outer surfaces of the original undamaged fibres; evidently arising by some, as yet undefined, interaction in the follicle with the cuticle of the inner root sheath. By stripping off fatty acids known to be covalently attached to the fibre's outer surface, the striations were shown to reflect a corresponding irregularity of the epicuticle's surface.

Metric engineering of soft molecular host frameworks

The self-assembly and solid-state structures of host-guest inclusion compounds with lamellar architectures based on a common building block, a resilient hydrogen-bonded sheet consisting of guanidinium ions and sulfonate moieties of organodisulfonate "pillars", are described. The pillars connect adjacent sheets to generate galleries with molecular-scale cavities occupied by guest molecules. The size, shape, and physicochemical character of the inclusion cavities can be systematically adjusted by interchanging framework components while maintaining the lamellar architecture, enabling prediction and control of crystal lattice metrics with a precision that is unusual for "crystal engineering". The reliability of the lamellar architecture is a direct consequence of conformational flexibility exhibited by these hosts that, unlike rigid systems, enables them to achieve optimal packing with guest molecules. The adaptability of these hosts is further reflected by an architectural isomerism that is driven by guest templating during assembly of the inclusion compounds. Host frameworks constructed with various pillars display metric interdependences among specific structural features that reveal a common mechanism by which these soft frameworks adapt to different guests. This unique feature facilitates structure prediction and provides guidance for the design of inclusion compounds based on these hosts.

Atomic force microscopy of human hair

The atomic force microscope (AFM) was used to investigate the surface architecture of the entire lengths of cleaned human head hairs. Many features previously seen with the scanning electron microscope (SEM) were identified. However, the AFM has provided much greater detail and, in particular, the hair's cuticular surfaces appear not to be as smooth as had been previously supposed. A consistent feature was of step discontinuities or "ghosts" on the scale surfaces. These delineated the original location of each overlying scale before its edge had been chipped away. There was a change in the longitudinal angular presentation of the surfaces about each ghost. This means the distal ends of each cuticle cell have been synthesised in the follicle to be thicker than where that same cuticle cell is bounded on both sides by other cuticle cells. The undamaged outer cuticular surfaces at the root end of each hair were covered everywhere by longitudinal ridges (striations). Where the hair surface was worn, the striations terminated at a scale edge ghost. The ridges were approximately 9 nm high and were in parallel array with a lateral repeat spacing of about 350 nm. The striations are evidently formed on the outer surface of each cuticle cell following earlier contact in the hair follicle with the inner root sheath. The study of stained transverse sections of hairs in the transmission electron microscope (TEM) is suggested as a means for throwing some light on the underlying structure and chemistry of the striations. Finally, our AFM studies have revealed that the surface of the freshly emergent hair gradually changes over a distance of about 20 mm and that the surface of the hair for most of its length is quite different from that near the root. This is likely to be of import to those engaged in the hair toiletries industry.

Stereoscopic display of atomic force microscope images using anaglyph techniques

This paper describes the use of a standard stereo-pair image display method for presenting the three-dimensional relief information found in atomic force microscope (AFM) images. The method makes use of commercially available image processing software packages. The techniques are illustrated on AFM images of the cuticle structure of a human hair fibre.

Morphology and histochemistry of human hair

This chapter is concerned with the structure of the mature human hair shaft and the chemical composition of its subcomponents as adduced from the examination of fibres mainly with the conventional transmission electron microscope (TEM). The broad outlines of the techniques used in the study of hair are reviewed, with particular attention being paid to the processes of chemical staining which enable one to define various aspects of the chemical composition of the hair's microscopic sub-components. Against this background the internal structure of normal undamaged hair is described.

Gas-Phase reactions of O 2 (-.) with alkyl and aryl esters of benzenedicarboxylic acids

The reactions of O 2 (-.) with alkyl and aryl esters of benzenedicarboxylic acids have been studied under negative-ion chemical ionization (NICI) conditions via a conventional chemical ionization source. Reaction mechanisms have been elucidated by using ion isolation techniques on a Fourier transform ion cyclotron resonance mass spectrometer. In addition, (18)O 2 (-.) has been used as the reagent and the products of competitive reactions that involve the mixed esters of benzenedicarboxylic acids have been studied. O 2 (-.) reactions with the alkyl esters of 1,2- and l,3-benzenedicarboxylic acids are attributed to SN2 displacement at the O-alkyl carbon. The spectra of mixed alkyl esters show that O 2 (-.) attack is reduced at sterically hindered alkyl groups. In contrast with the spectra of 1,2- and l,3-benzenedicarboxylic acids, the spectra of 1,4-benzenedicarboxylic acids are dominated by M(-.) production. Reactions of O 2 (-.) with phenyl benzoates and the aryl esters of benzenedicarboxylic acids proceed via addition-elimination pathways. Experiments with mixed alkyl-aryl benzenedicarboxylic acid esters show that the addition-elimination reaction pathway is preferred over O-alkyl SN2 displacement. The O2/ Ar-NICI mass spectra show features that can be used to distinguish 1,2-, 1,3-, and 1/4-benzenedicarboxylic acid esters. Molecular and fragment ions provide structural information complementary to that generated under electron ionization and chemical ionization conditions.

Monilethrix: an electron microscopic and electron histochemical study

We have carried our electron microscopic and electron histochemical investigations on affected hair follicles and hair shafts to elucidate further the structural abnormality in monilethrix. The structural abnormalities manifest in the cortex and cuticle of the hair shaft could be traced to the locality of the 'zone of keratinization' of the follicle. Abnormal orientation of the cortical cell proteins, folding of the cuticle cell membrane and varying amounts of endocuticular material were all observed in the region prior to full keratinization. We observed structural abnormalities within all the component layers of the inner root sheath adjacent to the faults within the hair shaft, indicating a possible asynchrony within the monilethrix follicle.

A technique for obtaining scanning electron micrographs in colour

A digital electronic unit is described which, by modifying the video signal of the scanning electron microscope (SEM), permits the selection of images in separate tonal or grey-scale levels. By the sequential exposure of these grey levels onto colour film with the intervention of colour filters, coloured scanning electron micrographs have been obtained. Full details of the procedure are given. The process is applicable to any normal image capable of being displayed at the scanning electron microscope.

A study of the small intestinal mucosa using the scanning electron microscope

In this paper we describe the features of small intestinal structure in normal control subjects using the scanning electron microscope.

Studies of small-intestinal mucosa with the scanning electron microscope

Preliminary observations indicate that scanning electron microscopy is a useful method for studying the surface of the small intestine.