A randomised controlled trial of an intervention to increase the implementation of a healthy canteen policy in Australian primary schools: study protocol

Background: The implementation of healthy school canteen policies has been recommended as a strategy to help prevent unhealthy eating and excessive weight gain. Internationally, research suggests that schools often fail to implement practices consistent with healthy school canteen policies. Without a population wide implementation, the potential benefits of these policies will not be realised. The aim of this trial is to assess the effectiveness of an implementation intervention in increasing school canteen practices consistent with a healthy canteen policy of the New South Wales (NSW), Australia, government known as the 'Fresh Tastes @ School NSW Healthy School Canteen Strategy'.Methods/design: The parallel randomised trial will be conducted in 70 primary schools located in the Hunter region of New South Wales, Australia. Schools will be eligible to participate if they are not currently meeting key components of the healthy canteen policy. Schools will be randomly allocated after baseline data collection in a 1:1 ratio to either an intervention or control group using a computerised random number function in Microsoft Excel. Thirty-five schools will be selected to receive a multi-component intervention including implementation support from research staff, staff training, resources, recognition and incentives, consensus and leadership strategies, follow-up support and implementation feedback. The 35 schools allocated to the control group will not receive any intervention support as part of the research trial. The primary outcome measures will be i) the proportion of schools with a canteen menu that does not contain foods or beverages restricted from regular sale ('red' and 'banned' items) and ii) the proportion of schools where healthy canteen items ('green' items) represent the majority (>50%) of products listed on the menu. Outcome data will be collected via a comprehensive menu audit, conducted by dietitians blind to group allocation. Intervention effectiveness will be assessed using logistic regression models adjusting for baseline values.Discussion: The proposed trial will represent a novel contribution to the literature, being the first randomised trial internationally to examine the effectiveness of an intervention to facilitate implementation of a healthy canteen policy.

The Healthy Migrant Families Initiative: Development of a culturally competent obesity prevention intervention for African migrants Disease epidemiology - Chronic

Background: Although obesity among immigrants remains an important area of study given the increasing migrant population in Australia and other developed countries, research on factors amenable to intervention is sparse. The aim of the study was to develop a culturally-competent obesity prevention program for sub-Saharan African (SSA) families with children aged 12-17 years using a community-partnered participatory approach. Methods: A community-partnered participatory approach that allowed the intervention to be developed in collaborative partnership with communities was used. Three pilot studies were carried out in 2008 and 2009 which included focus groups, interviews, and workshops with SSA parents, teenagers and health professionals, and emerging themes were used to inform the intervention content. A cultural competence framework containing 10 strategies was developed to inform the development of the program. Using findings from our scoping research, together with community consultations through the African Review Panel, a draft program outline (skeleton) was developed and presented in two separate community forums with SSA community members and health professionals working with SSA communities in Melbourne. Results: The 'Healthy Migrant Families Initiative (HMFI): Challenges and Choices' program was developed and designed to assist African families in their transition to life in a new country. The program consists of nine sessions, each approximately 1 1/2 hours in length, which are divided into two modules based on the topic. The first module 'Healthy lifestyles in a new culture' (5 sessions) focuses on healthy eating, active living and healthy body weight. The second module 'Healthy families in a new culture' (4 sessions) focuses on parenting, communication and problem solving. The sessions are designed for a group setting (6-12 people per group), as many of the program activities are discussion-based, supported by session materials and program resources. Conclusion: Strong partnerships and participation by SSA migrant communities enabled the design of a culturally competent and evidence-based intervention that addresses obesity prevention through a focus on healthy lifestyles and healthy families. Program implementation and evaluation will further inform obesity prevention interventions for ethnic minorities and disadvantaged communities.

A parent-based intervention to promote healthy eating and active behaviours in pre-school children: evaluation of the MEND 2-4 randomized controlled trial.

BACKGROUND: There is a paucity of studies evaluating targeted obesity prevention interventions in pre-school children. OBJECTIVES: We conducted a randomized controlled trial to evaluate the efficacy of a parent-based obesity prevention intervention for pre-schoolers - MEND (Mind, Exercise, Nutrition … Do It!) 2-4 on child diet, eating habits, physical activity/sedentary behaviours, and body mass index (BMI). METHODS: Parent-child dyads attended 10 weekly 90-min workshops relating to nutrition, physical activity and behaviours, including guided active play and healthy snack time. Assessments were conducted at baseline, immediately post-intervention, and 6 and 12 months post-intervention; child intake of vegetables, fruit, beverages, processed snack foods, fussiness, satiety responsiveness, physical activity, sedentary behaviour and neophobia were assessed via parent proxy report. Parent and child height and weight were measured. RESULTS: Two hundred one parent-child dyads were randomized to intervention (n = 104) and control (n = 97). Baseline mean child age was 2.7 (standard deviation [SD] 0.6) years, and child BMI-for-age z-score (World Health Organization) was 0.66 (SD 0.88). We found significant positive group effects for vegetable (P = 0.01) and snack food (P = 0.03) intake, and satiety responsiveness (P = 0.047) immediately post-intervention. At 12 months follow-up, intervention children exhibited less neophobia (P = 0.03) than controls. CONCLUSION: Future research should focus on additional strategies to support parents to continue positive behaviour change. ACTRN12610000200088.

Understanding gestational weight gain: the role of weight-related expectations and knowledge

BACKGROUND: Health behaviour theories acknowledge that beliefs, attitudes and knowledge contribute to health behaviours, yet the role of these cognitions in predicting weight gain during pregnancy has not been widely researched. AIMS: To explore and compare the predictive nature of gestational weight gain (GWG) expectations and knowledge on weight gain during pregnancy. MATERIALS AND METHODS: One hundred and sixty-six women were tracked during pregnancy. Participants provided information on prepregnancy weight, height, GWG expectations and knowledge at 16-18 weeks' gestation (Time 1). To calculate gestational weight gain, prepregnancy weight was subtracted from weight at 36 weeks' gestation (collected at Time 2). Gestational weight gain above the Institute of Medicine's GWG recommendations was classified as excessive. A hierarchical regression examined the predictive nature of GWG expectations for actual GWG. Chi-square significance tests determined whether the accuracy of GWG knowledge differed depending on GWG status and prepregnancy BMI category. RESULTS: GWG expectations were a significant predictor of weight gain during pregnancy. Women who experienced excessive GWG were more likely to overestimate the minimum amount of weight that they needed to gain to have a healthy baby. CONCLUSIONS: GWG expectations are predictive of actual GWG, and GWG knowledge among women is generally poor. In particular, overestimating of the minimum amount of weight to gain during pregnancy is associated with excessive GWG. As such, it may be beneficial to design interventions to prevent excessive GWG that targets these cognitions.

Influence of price discounts and skill-building strategies on purchase and consumption of healthy food and beverages: outcomes of the Supermarket Healthy Eating for Life randomized controlled trial

BACKGROUND: Fiscal strategies are increasingly considered upstream nutrition promotion measures. However, few trials have investigated the effectiveness or cost effectiveness of pricing manipulations on diet in real-world settings. OBJECTIVE: We assessed the effects on fruit, vegetable, and beverage purchasing and consumption of a 20% price-reduction intervention, a tailored skills-based behavior-change intervention, and a combined intervention compared with a control condition. DESIGN: The Supermarket Healthy Eating for Life trial was a randomized controlled trial conducted over 3 mo [baseline (time 1) to postintervention (time 2) with a 6-mo follow-up (time 3)]. Female primary household shoppers in Melbourne, Australia, were randomly assigned to a 1) skill-building (n = 160), 2) price-reduction (n = 161), 3) combined skill-building and price-reduction (n = 160), or 4) control (n = 161) group. Supermarket transaction data and surveys were used to measure the following study outcomes: fruit, vegetable, and beverage purchases and self-reported fruit and vegetable consumption at each time point. RESULTS: At 3 mo (time 2), price reduction-alone participants purchased more total vegetables and frozen vegetables than did controls. Price reduction-alone and price reduction-plus-skill-building participants purchased more fruit than did controls. Relative to controls, in the price-reduction group, total vegetable consumption increased by 233 g/wk (3.1 servings or 15% more than at baseline), and fruit purchases increased by 364 g/wk (2.4 servings; 35% more than at baseline). Increases were not maintained 6 mo postintervention (time 3). Price reduction-alone participants showed a tendency for a slight increase in fruit consumption at time 2 (P = 0.09) that was maintained at time 3 (P = 0.014). No intervention improved purchases of bottled water or low-calorie beverages. CONCLUSIONS: A 20% price reduction in fruit and vegetables resulted in increased purchasing per household of 35% for fruit and 15% for vegetables over the price-reduction period. These findings show that price modifications can directly increase produce purchases. The Supermarket Healthy Eating for Life trial was registered at Current Controlled Trials Registration as ISRCTN39432901.

Health coaching to prevent excessive gestational weight gain: a randomized-controlled trial

OBJECTIVES: The objectives of this study were to evaluate the efficacy of a health coaching (HC) intervention designed to prevent excessive gestational weight gain (GWG), and promote positive psychosocial and motivational outcomes in comparison with an Education Alone (EA) group. DESIGN: Randomized-controlled trial. METHODS: Two hundred and sixty-one women who were <18 weeks pregnant consented to take part. Those allocated to the HC group received a tailored HC intervention delivered by a Health Coach, whilst those in the EA group attended two education sessions. Women completed measures, including motivation, psychosocial variables, sleep quality, and knowledge, beliefs and expectations concerning GWG, at 15 weeks of gestation (Time 1) and 33 weeks of gestation (Time 2). Post-birth data were also collected at 2 months post-partum (Time 3). RESULTS: There was no intervention effect in relation to weight gained during pregnancy, rate of excessive GWG or birth outcomes. The only differences between HC and EA women were higher readiness (b = 0.29, 95% CIs = 0.03-0.55, p < .05) and the importance to achieve a healthy GWG (b = 0.27, 95% CIs = 0.02-0.52, p < .05), improved sleep quality (b = -0.22, 95% CIs = -0.44 to -0.03, p < .05), and increased knowledge for an appropriate amount of GWG that would be best for their baby's health (b = -1.75, 95% CI = -3.26 to -0.24, p < .05) reported by the HC at Time 2. CONCLUSIONS: Whilst the HC intervention was not successful in preventing excessive GWG, several implications for the design of future GWG interventions were identified, including the burden of the intervention commitment and the use of weight monitoring. Statement of contribution What is already known on the subject? Designing interventions to address gestational weight gain (GWG) continues to be a challenge. To date, health behaviour change factors have not been the focus of GWG interventions. What does this study add? Our health coaching (HC) intervention did not reduce GWG more so than education alone (EA). There was an intervention effect on readiness and importance to achieve healthy GWG. Yet there were no group differences regarding confidence to achieve healthy GWG post-intervention.

Gestational weight gain information: seeking and sources among pregnant women

BACKGROUND: Promoting healthy gestational weight gain (GWG) is important for preventing obstetric and perinatal morbidity, along with obesity in both mother and child. Provision of GWG guidelines by health professionals predicts women meeting GWG guidelines. Research concerning women's GWG information sources is limited. This study assessed pregnant women's sources of GWG information and how, where and which women seek GWG information. METHODS: Consecutive women (n = 1032) received a mailed questionnaire after their first antenatal visit to a public maternity hospital in Melbourne, Australia. Recalled provision of GWG guidelines by doctors and midwives, recalled provided GWG goals, and the obtaining of GWG information and information sources were assessed. RESULTS: Participants (n = 368; 35.7 % response) averaged 32.5 years of age and 20.8 weeks gestation, with 33.7 % speaking a language other than English. One in ten women recalled receiving GWG guidelines from doctors or midwives, of which half were consistent with Institute of Medicine guidelines. More than half the women (55.4 %) had actively sought GWG information. Nulliparous (OR 7.07, 95 % CI = 3.91-12.81) and obese (OR 1.96, 95 % CI = 1.05-3.65) women were more likely to seek information. Underweight (OR 0.29, 95 % CI = 0.09-0.97) women and those working part time (OR 0.52, 95 % CI = 0.28-0.97) were less likely to seek information. Most frequently reported GWG sources included the internet (82.7 %), books (55.4 %) and friends (51.5 %). The single most important sources were identified as the internet (32.8 %), general practitioners (16.9 %) and books (14.9 %). CONCLUSION: More than half of women were seeking GWG guidance and were more likely to consult non-clinician sources. The small numbers given GWG targets, and the dominance of non-clinical information sources, reinforces that an important opportunity to provide evidence based advice and guidance in the antenatal care setting is currently being missed.

Adoption and maintenance of gym-based strength training in the community setting in adults with excess weight or type 2 diabetes: a randomized controlled trial

BACKGROUND: Participant adoption and maintenance is a major challenge in strength training (ST) programs in the community-setting. In adults who were overweight or with type 2 diabetes (T2DM), the aim of this study was to compare the effectiveness of a standard ST program (SST) to an enhanced program (EST) on the adoption and maintenance of ST and cardio-metabolic risk factors and muscle strength. METHODS: A 12-month cluster-randomized controlled trial consisting of a 6-month adoption phase followed by a 6-month maintenance phase. In 2008-2009, men and women aged 40-75 years (n = 318) with T2DM (n = 117) or a BMI >25 (n = 201) who had not participated in ST previously were randomized into either a SST or an EST program (which included additional motivationally-tailored behavioral counselling). Adoption and maintenance were defined as undertaking ≥ 3 weekly gym-based exercise sessions during the first 6-months and from 6-12 months respectively and were assessed using a modified version of the CHAMPS (Community Healthy Activity Models Program for Seniors) instrument. RESULTS: Relative to the SST group, the adjusted odds ratio (OR) of adopting ST for all participants in the EST group was 3.3 (95 % CI 1.2 to 9.4). In stratified analyses including only those with T2DM, relative to the SST group, the adjusted OR of adopting ST in the EST group was 8.2 (95 % CI 1.5-45.5). No significant between-group differences were observed for maintenance of ST in either pooled or stratified analyses. In those with T2DM, there was a significant reduction in HbA1c in the EST compared to SST group during the adoption phase (net difference, -0.13 % [-0.26 to -0.01]), which persisted after 12-months (-0.17 % [-0.3 to -0.05]). CONCLUSIONS: A behaviorally-focused community-based EST intervention was more effective than a SST program for the adoption of ST in adults with excess weight or T2DM and led to greater improvements in glycemic control in those with T2DM. TRIAL REGISTRATION: Registered at ACTRN12611000695909 (Date registered 7/7/2011).

Altered response of the anterolateral abdominal muscles to simulated weight-bearing in subjects with low back pain

An important aspect of neuromuscular control at the lumbo-pelvic region is stabilization. Subjects with low back pain (LBP) have been shown to exhibit impairments in motor control of key muscles which contribute to stabilization of the lumbo-pelvic region. However, a test of automatic recruitment that relates to function has been lacking. A previous study used ultrasound imaging to show that healthy subjects automatically recruited the transversus abdominis (TrA) and internal oblique (IO) muscles in response to a simulated weight-bearing task. This task has not been investigated in subjects with LBP. The aim of this study was to compare the automatic recruitment of the abdominal muscles among subjects with and without LBP in response to the simulated weight-bearing task. Twenty subjects with and without LBP were tested. Real-time ultrasound imaging was used to assess changes in thickness of the TrA and internal oblique IO muscles as well as lateral movement ("slide") of the anterior fascial insertion of the TrA muscle. Results showed that subjects with LBP showed significantly less shortening of the TrA muscle (P < 0.0001) and greater increases in thickness of the IO muscle (P = 0.002) with the simulated weight-bearing task. There was no significant difference between groups for changes in TrA muscle thickness (P = 0.055). This study provides evidence of changes in motor control of the abdominal muscles in subjects with LBP. This test may provide a functionally relevant and non-invasive method to investigate the automatic recruitment of the abdominal muscles in people with and without LBP.

The role of parity in gestational weight gain and postpartum weight retention

OBJECTIVES: Parity, excessive gestational weight gain (GWG), and postpartum weight retention (PPWR) have been identified as risk factors for maternal obesity. The aim of this study was to explore whether GWG and PPWR at 6 and 12 months after birth differed for primiparous and multiparous Australian women. METHODS: One hundred thirty-eight Australian women provided weight measures in early to mid pregnancy (M = 16.7 weeks, SD = 2.3), late pregnancy (M = 37.7 weeks, SD = 2.4), 6 months postpartum (M = 6.1 months, SD = 1.4), and 12 months postpartum (M = 12.6 months, SD = 0.7). Height, parity, and demographic information were also collected. Prepregnancy body mass index (BMI), total GWG, incidence of excessive GWG, as well as change in BMI and BMI category from prepregnancy to 6 and 12 months postpartum were computed. Differences between primiparous and multiparous women were compared using analysis of covariance (controlling for age, prepregnancy BMI, and GWG) and χ(2) test of independence. RESULTS: Seventy women (50.7%) were primiparous and 68 women (49.3%) were multiparous. Primiparous women were more likely to retain weight at 12 months postpartum than multiparous women (p = .021; Cohen's d = .24). This difference was not reflected when analyzing change in BMI categories from prepregnancy to the postpartum. CONCLUSIONS: Evidence for the role of parity in PPWR is inconclusive. Future research should consider the temporal development of PPWR in primiparous and multiparous women, leading to tailored care in the postpartum period to help women return to a healthy prepregnancy weight.

Psychosocial factors and excessive gestational weight gain: the effect of parity in an Australian cohort

OBJECTIVES: psychosocial variables can be protective or risk factors for excessive gestational weight gain (GWG). Parity has also been associated with GWG; however, its effect on psychosocial risk factors for GWG is yet to be determined. The aim of this study was to investigate if, and how, psychosocial factors vary in their impact on the GWG of primiparous and multiparous women. DESIGN/PARTICIPANTS: pregnant women were recruited in 2011 via study advertisements placed in hospitals, online, in parenting magazines, and at baby and children's markets, resulting in a sample of 256 women (113 primiparous, 143 multiparous). Participants completed questionnaires at 16-18 weeks' gestation and their pregravid BMI was recorded. Final weight before delivery was measured and used to calculate GWG. FINDINGS: the findings revealed that primiparous women had significantly higher feelings of attractiveness (a facet of body attitude; p=0.01) than multiparous women. Hierarchical regressions revealed that in the overall sample, increased GWG was associated significantly with lower pre-pregnancy BMI (standardised coefficient β=-0.39, p<0.001), higher anxiety symptoms (β=0.25, p=0.004), and reduced self-efficacy to eat a healthy diet (β=-0.20, p=0.02). Although higher GWG was predicted significantly by decreased feelings of strength and fitness for primiparous women (β=-0.25, p=0.04) and higher anxiety was related significantly to greater GWG for multiparous women (β=0.43, p<0.001), statistical comparison of the model across the two groups suggested the magnitude of these effects did not differ across groups (p>0.05). CONCLUSIONS/IMPLICATIONS FOR PRACTICE: the findings suggest that psychosocial screening and interventions by healthcare professionals may help to identify women who are at risk of excessive GWG, and there may be specific psychosocial factors that are more relevant for each parity group.

Preventing obesity in infants: the growing healthy feasibility trial protocol

INTRODUCTION: Early childhood is an important period for establishing behaviours that will affect weight gain and health across the life course. Early feeding choices, including breast and/or formula, timing of introduction of solids, physical activity and electronic media use among infants and young children are considered likely determinants of childhood obesity. Parents play a primary role in shaping these behaviours through parental modelling, feeding styles, and the food and physical activity environments provided. Children from low socio-economic backgrounds have higher rates of obesity, making early intervention particularly important. However, such families are often more difficult to reach and may be less likely to participate in traditional programs that support healthy behaviours. Parents across all socio-demographic groups frequently access primary health care (PHC) services, including nurses in community health services and general medical practices, providing unparalleled opportunity for engagement to influence family behaviours. One emerging and promising area that might maximise engagement at a low cost is the provision of support for healthy parenting through electronic media such as the Internet or smart phones. The Growing healthy study explores the feasibility of delivering such support via primary health care services.

METHODS: This paper describes the Growing healthy study, a non-randomised quasi experimental study examining the feasibility of an intervention delivered via a smartphone app (or website) for parents living in socioeconomically disadvantaged areas, for promoting infant feeding and parenting behaviours that promote healthy rather than excessive weight gain. Participants will be recruited via their primary health care practitioner and followed until their infant is 9 months old. Data will be collected via web-based questionnaires and the data collected inherently by the app itself.

ETHICS AND DISSEMINATION: This study received approval from the University of Technology Sydney Ethics committee and will be disseminated via peer-reviewed publications and conference presentations.

Healthy together Victoria and childhood obesity-a methodology for measuring changes in childhood obesity in response to a community-based, whole of system cluster randomized control trial

BACKGROUND: Healthy Together Victoria (HTV) - a complex 'whole of system' intervention, including an embedded cluster randomized control trial, to reduce chronic disease by addressing risk factors (physical inactivity, poor diet quality, smoking and harmful alcohol use) among children and adults in selected communities in Victoria, Australia (Healthy Together Communities).

OBJECTIVES: To describe the methodology for: 1) assessing changes in the prevalence of measured childhood obesity and associated risks between primary and secondary school students in HTV communities, compared with comparison communities; and 2) assessing community-level system changes that influence childhood obesity in HTC and comparison communities.

METHODS: Twenty-four geographically bounded areas were randomized to either prevention or comparison (2012). A repeat cross-sectional study utilising opt-out consent will collect objectively measured height, weight, waist and self-reported behavioral data among primary [Grade 4 (aged 9-10y) and Grade 6 (aged 11-12y)] and secondary [Grade 8 (aged 13-14y) and Grade 10 (aged 15-16y)] school students (2014 to 2018). Relationships between measured childhood obesity and system causes, as defined in the Foresight obesity systems map, will be assessed using a range of routine and customised data.

CONCLUSION: This research methodology describes the beginnings of a state-wide childhood obesity monitoring system that can evolve to regularly inform progress on reducing obesity, and situate these changes in the context of broader community-level system change.

Effects of weight loss on the cardiac parameters of obese dogs

A obesidade é uma das doenças nutricionais mais frequentemente observada em cães e pode provocar sérios problemas de saúde, como os distúrbios cardiovasculares. Realizou-se este estudo visando avaliar algumas das possíveis alterações estruturais e funcionais cardíacas decorrentes da correção da obesidade canina. Para isso foram utilizados 18 cães obesos divididos pelo peso corporal em Grupo I (até 15kg), Grupo II (entre 15,1 e 30 kg) e Grupo III (acima de 30 kg). Os animais foram submetidos à restrição calórica de forma a perderem 15% do peso vivo. Foram realizados os exames ecocardiográfico em modo-M, eletrocardiográfico e mensuração da pressão arterial dos animais antes do início do tratamento da obesidade e após atingirem o peso meta. Os resultados revelaram que após a redução de peso ocorreram diminuições significativas da espessura da parede livre do ventrículo esquerdo durante a sístole e diástole no Grupo III, diminuição da pressão arterial sistólica no Grupo III e também da pressão arterial média no Grupo II. Assim, concluiu-se que a perda de peso pode reverter as alterações estruturais cardíacas, como a hipertrofia excêntrica do ventrículo esquerdo em cães obesos acima de 30 kg, como também reduzir a pressão arterial sistêmica em cães obesos submetidos à restrição calórica mediante administração de dieta hipocalórica.