Diet, nutrition and the prevention of excess weight gain and obesity

Objective: To review the evidence on the diet and nutrition causes of obesity and to recommend strategies to reduce obesity prevalence.
Design: The evidence for potential aetiological factors and strategies to reduce obesity prevalence was reviewed, and recommendations for public health action, population nutrition goals and further research were made.
Results: Protective factors against obesity were considered to be: regular physical activity (convincing); a high intake of dietary non-starch polysaccharides (NSP)/fibre (convincing); supportive home and school environments for children (probable); and breastfeeding (probable). Risk factors for obesity were considered to be sedentary lifestyles (convincing); a high intake of energy-dense, micronutrient-poor foods (convincing); heavy marketing of energy-dense foods and fast food outlets (probable); sugar-sweetened soft drinks and fruit juices (probable); adverse social and economic conditions—developed countries, especially in women (probable).
A broad range of strategies were recommended to reduce obesity prevalence including: influencing the food supply to make healthy choices easier; reducing the marketing of energy dense foods and beverages to children; influencing urban environments and transport systems to promote physical activity; developing community-wide programmes in multiple settings; increased communications about healthy eating and physical activity; and improved health services to promote breastfeeding and manage currently overweight or obese people.
Conclusions: The increasing prevalence of obesity is a major health threat in both low- and high income countries. Comprehensive programmes will be needed to turn the epidemic around.

Population health and wellbeing: identifying priority areas for Victorian children

Background
Population health information, collected using soundly-designed methodologies, is essential to inform policy, research, and intervention programs. This study aimed to derive policy-oriented recommendations for the content of a health and wellbeing population survey of children 0–12 years living in Victoria, Australia.

Results
Qualitative interviews were conducted with 54 academic and policy stakeholders, selected to encompass a wide breadth of expertise in areas of public health and inter-sectoral organisations relevant to child health outcomes, including universities, government and non-government agencies across Victoria. These stakeholders were asked to provide advice on strategic priorities for child health information (data) using a structured interview technique. Their comments were summarised and the major themes were extracted. The priority areas of health and wellbeing recommended for regular collection include obesity and its determinants, pregnancy and breastfeeding, oral health, injury, social and emotional health and wellbeing, family environment, community, health service utilisation, illness, and socioeconomic position. Population policy questions for each area were identified.

Conclusion
In contrast to previous population survey programs nationally and internationally, this study sought to extract contemporary policy-oriented domains for inclusion in a strategic program of child health data collection, using a stakeholder consultation process to identify key domains and policy information needs. The outcomes are a rich and relevant set of recommendations which will now be taken forward into a regular statewide child health survey program.

In the shadow of the volcanoes: the impact of intervention on the nutrition and health status of Rwandan refugee children in Zaire two years from the exodus

Objective: To evaluate the public health and nutritional situation of refugee children in Katale camp, Eastern Zaire, after two years of nutritional and health intervention from 1994 to 1996.
Design: Cross-sectional survey using a two-stage cluster sampling method. Anthropometric data were collected from 28 May 1996 to 4 June 1996. Retrospective review of food basket monitoring data over the preceding six months and the United Nations High Commission for Refugees' weekly mortality data was conducted. Measles immunisation coverage data were surveyed simultaneously, using child health records.
Main outcome measures: Nutritional status measured by weight-for-height index (W/H), measles immunisation status, average daily energy content of the general food ration and crude mortality rate.
Setting: Katale refugee camp, Zaire, June 1996.
Analysis: Weight-for-height index and proportion of immunised children were computed using EPINUT, part of EPINFO computer package.
Results: Malnutrition was found to be most prevalent in children aged six to 29 months old (W/H < -2 Z-score and/or oedema: 6.2%; 95% CI: 3.4%, 10.6%), among whom the malnutrition rate was almost double the overall malnutrition prevalence (W/H < -2 Z-score and/or oedema: 3.5% (95% CI: 1.5%, 7.2%). The general food ration, although conforming to the World Food Program minimum standards of adequacy in terms of variety (being composed of cereals, oil, beans, blended cereal and legume mixes and salt), provided only 6240 kJ on average (95% CI: 5040, 7140 kJ) per person per day, thus meeting only 57% to 84% of the minimum energy requirements for an adult, and falling well below the needs for sub groups with higher nutritional requirements such as children, pregnant and breastfeeding women and the sick. Measles immunisation coverage in children nine to 59 months was 88.6%. The crude mortality rate was found to be 0.3 per 10 000 per day. Refugees received 15 litres of clean water per person per day.
Conclusion: Public health interventions in Katale camp 1994 to 1996 had reduced mortality and morbidity rates dramatically. This was not reflected in the malnutrition rates for children under five years, that remained stable after an initial fall despite two years of nutritional intervention. The factors contributed to this were related to an inadequate general food ration (due to food shortages), lack of ability to supplement the diet, (due to economic restrictions that were imposed in the camp) and inequities in the food distribution process (due to food being siphoned off by camp leaders for military purposes).

Strategies which aim to positively impact on weight, physical activity, diet and sedentary behaviours in children from zero to five years. A systematic review of the literature

Preventing the development of obesity in children is an international health priority. To assess the effectiveness of interventions designed to prevent obesity, promote healthy eating and/or physical activity and/or to reduce sedentary behaviours in 0–5-year-old children, a systematic review of the literature was performed. Literature searches were limited to articles published between January 1995 and June 2006, printed in English and sampling children aged 0–5-years. Searches excluded literature concerned with breastfeeding, eating disorders, and interventions which were school-based or concerned with obesity treatment. Two reviewers independently extracted data and assessed study strengths and weaknesses. Nine included studies were grouped based on the settings in which they were delivered. Most studies involved multi-approach interventions, were conducted in the USA and varied in study designs and quality. All showed some level of effectiveness on at least one obesity-behaviour in young children. These studies support, at a range of levels, the premise that parents are receptive to and capable of some behavioural changes that may promote healthy weight in their young children. The small quantity of research heralds the need, particularly given the potential for early intervention to have long-lasting impacts on individual and population health, to build in a substantial way upon this evidence base.

Painful nipples in nursing mothers: fungal or staphylococcal?

Painful nipples, or ‘breast thrush’, in nursing mothers is a well recognised condition. It is a clinical diagnosis characterised by intense nipple pain often radiating into the breast, especially during breastfeeding. Between feeds it may cause a burning sensation and tenderness; breastfeeding may be abandoned because of it.

Support needs of parents of sick and/or preterm infants admitted to a neonatal unit

Background: The sudden unexpected delivery of a preterm infant is a shock to parents with studies confirming the importance of providing them with nursing support. The purpose of this descriptive study was to identify the type and level of support that nurses provided to the parents of sick and/or preterm infants. It also investigated whether parents were satisfied with the support provided by nursing staff.
Method: A convenience sample of 112 parents in an Australian tertiary neonatal unit were invited to complete the ‘Nurse Parent Support Tool’ (NPST), which is a 21-item questionnaire. The NPST consists of four domains: emotional, informational, appraisal and instrumental support. A second tool was used to assess parents’ satisfaction with the nurse to parent support.
Results: Instrumental support had the highest mean score for both nurse to parent support at 4.51 (out of 5) and 4.36 (out of 5) for satisfaction. The mean score for nursing support was 4.21 followed by parental satisfaction with nurse to parent support which was 4.16. In contrast, emotional support had the lowest mean score for both nurse to parent support at 3.94 and 3.97 for satisfaction. Parents indicated that they needed further support with lactation, breastfeeding and assistance with parenting skills.
Conclusion: Overall, the results from the study indicated that parents’ perception of nursing support was positive and that parents were highly satisfied with the nursing support provided in the neonatal unit. However, some attention needs to be given to providing more support and information on breastfeeding and parenting skills.

Support needs of parents of sick and/or preterm infants admitted to a neonatal unit

The sudden unexpected delivery of a preterm infant elicits many emotional responses from parents, with studies confirming the importance of providing parents with nursing support. The purpose of this study was to measure parents' perception of the type and level of support that nurses provided in an Australian neonatal unit, and to determine the extent to which parents were satisfied with the support currently provided. A convenience sample of 112 parents in an Australian tertiary neonatal unit were invited to complete the nurse parent support tool (NPST), which is a 21-item questionnaire used to measure the level of nursing support. The NPST consists of four domains -emotional, informational, appraisal and instrumental support. A second tool was used to assess parent satisfaction with nurse-to-parent support. A total of 62 parents completed the NPST and satisfaction tool.

Results showed that instrumental support had the highest mean score for both nurse-to-parent support 4.51 (out of 5) and 4.36 for satisfaction. The mean score for nursing support was 4.21 followed by satisfaction with nurse-to-parent support at 4.16. In contrast, emotional support had the lowest mean score for both nurse-to-parent support at 3.94 and 3.97 for satisfaction. Parents indicated that they needed further support with lactation, breastfeeding and assistance with parenting skills. Overall, results indicated that parent perception of nursing support was positive and that parents were highly satisfied with the nursing support provided in the neonatal unit. However, some attention needs to be given to providing more support and information on breastfeeding and parenting skills.

Lactation in Australian women : the effect of oral contraceptives on the vitamin and trace element content of breast milk

The aim of this project was to investigate the effects of oral contraceptives on the nutrient composition of breast milk. The design of the study also allowed the effects of stage of lactation and maternal diet on milk composition to be observed. A prospective study was designed to measure maternal dietary intake and vitamin and trace element concentration in milk and plasma. Vitamin A, ascorbic acid and iron, copper, zinc, manganese, selenium, cobalt, chromium, rubidium and caesium were measured. Two groups of women participated, oral contraceptive users and controls. Fasting milk and blood samples and 24-hour food records were collected from the women once a week for 20 weeks commencing 3-8 weeks post-partum, and 1-2 weeks before they began to take oral contraceptives. Fifteen women participated in the study; 5 took progestogen-only oral contraceptives, 1 took an oestrogen-progestogen oral contraceptive and 9 acted as controls. Progestogen-only oral contraceptives did not affect the milk or plasma concentration of the vitamins and trace elements measured. As only 1 subject took an oestrogen-progestogen preparation no conclusion could be drawn as to its effect. The mean milk and plasma concentration of all nutrients studied did not change significantly with the progression of lactation, with the exception of iron and zinc. The mean milk iron concentration was significantly higher at 16 weeks post-partum than at 8 and 23 weeks post-partum. The mean milk zinc concentration was significantly lower at 23 weeks post-partum than at 8 and 16 weeks post-partum. The infants1 mean estimated daily intakes of ascorbic acid and vitamin A from breast milk were above the U.S. and British Recommended Dietary Allowance for those vitamins. However, their mean estimated intakes of iron, zinc, copper, manganese and selenium were well below the U.S. recommendations. Effects of the maternal dietary intake on milk and plasma composition were variable. Implications of these findings have been discussed.

Interventions to prevent obesity in 0-5 year olds : an updated systematic review of the literature

The small number and recency of the early childhood obesity-prevention literature identified in a previous review of interventions to prevent obesity, promote healthy eating, physical activity, and/or reduce sedentary behaviors in 0-5 year olds suggests this is a new and developing research area. The current review was conducted to provide an update of the rapidly emerging evidence in this area and to assess the quality of studies reported. Ten electronic databases were searched to identify literature published from January 1995 to August 2008. Inclusion criteria: interventions reporting child anthropometric, diet, physical activity, or sedentary behavior outcomes and focusing on children aged 0-5 years of age. Exclusion criteria: focusing on breastfeeding, eating disorders, obesity treatment, malnutrition, or school-based interventions. Two reviewers independently extracted data and assessed study quality. Twenty-three studies met all criteria. Most were conducted in preschool/childcare (n = 9) or home settings (n = 8). Approximately half targeted socioeconomically disadvantaged children (n = 12) and three quarters were published from 2003 onward (n = 17). The interventions varied widely although most were multifaceted in their approach. While study design and quality varied most studies reported their interventions were feasible and acceptable, although impact on behaviors that contribute to obesity were not achieved by all. Early childhood obesity-prevention interventions represent a rapidly growing research area. Current evidence suggests that behaviors that contribute to obesity can be positively impacted in a range of settings and provides important insights into the most effective strategies for promoting healthy weight from early childhood.

The Early Prevention of Obesity in CHildren (EPOCH) collaboration : an individual patient data prospective meta-analysis

Background
Efforts to prevent the development of overweight and obesity have increasingly focused early in the life course as we recognise that both metabolic and behavioural patterns are often established within the first few years of life. Randomised controlled trials (RCTs) of interventions are even more powerful when, with forethought, they are synthesised into an individual patient data (IPD) prospective meta-analysis (PMA). An IPD PMA is a unique research design where several trials are identified for inclusion in an analysis before any of the individual trial results become known and the data are provided for each randomised patient. This methodology minimises the publication and selection bias often associated with a retrospective meta-analysis by allowing hypotheses, analysis methods and selection criteria to be specified a priori.

Methods/Design
The Early Prevention of Obesity in CHildren (EPOCH) Collaboration was formed in 2009. The main objective of the EPOCH Collaboration is to determine if early intervention for childhood obesity impacts on body mass index (BMI) z scores at age 18-24 months. Additional research questions will focus on whether early intervention has an impact on children's dietary quality, TV viewing time, duration of breastfeeding and parenting styles. This protocol includes the hypotheses, inclusion criteria and outcome measures to be used in the IPD PMA. The sample size of the combined dataset at final outcome assessment (approximately 1800 infants) will allow greater precision when exploring differences in the effect of early intervention with respect to pre-specified participant- and intervention-level characteristics.

Discussion
Finalisation of the data collection procedures and analysis plans will be complete by the end of 2010. Data collection and analysis will occur during 2011-2012 and results should be available by 2013.

An audit of local government planning tools for their potential use in addressing community food and nutrition issues

Issues addressed: This project aimed to identify how local government planning tools could be used to influence physical and policy environments to support healthy eating behaviours in communities.
Methods: An audit of Queensland's legislative and non-legislative local government planning tools was conducted by a public health nutritionist to assess their potential use in addressing strategies to achieve positive nutrition outcomes. Ten strategies were identified and covered the following themes: improving access to healthy foods and drinks; increasing access to breastfeeding facilities; decreasing fast food outlet density; and unhealthy food advertising. 
Results: The audit found that all of the 10 strategies to achieve positive nutrition outcomes could be considered through three or more of the planning tools.
Conclusion: Based on the findings of this audit, local government planning tools provide opportunities to address food and nutrition issues and contribute toward creating physical and policy environments that support healthy eating behaviours.

Age and exposure to arsenic alter base excision repair transcript levels in mice

Arsenic (As) induces DNA-damaging reactive oxygen species. Most oxidative DNA damage is countered by base excision repair (BER), the capacity for which may be reduced in older animals. We examined whether age and consumption of As in lactational milk or drinking water influences BER gene transcript levels in mice. Lactating mothers and 24-week-old mice were exposed (24 h or 2 weeks) to As (2 or 50 p.p.m.) in drinking water. Lung tissue was harvested from adults, neonates (initially 1 week old) feeding from lactating mothers and untreated animals 1– 26 weeks old. Transcripts encoding BER proteins were quantified. BER transcript levels decreased precipitously with age in untreated mice but increased in neonates whose mothers were exposed to 50 p.p.m. As for 24 h or 2 weeks. Treatment of 24-week-old mice with 2 or 50 p.p.m. As for 2 weeks decreased all transcript levels measured. Exposure to As attenuated the age-related transcript level decline for only one BER gene. We conclude that aging is associated with a rapid reduction of BER transcript levels in mice, which may contribute to decreased BER activity in older animals. Levels of As that can alter gene expression are transmitted to neonatal mice in lactational milk produced by mothers drinking water containing As, raising concerns about breastfeeding in countries having As-contaminated groundwater. Reduction of BER transcript levels in 24- week-old mice exposed to As for 2 weeks suggests As may potentiate sensitivity to itself in older animals.

The role of micro-organisms (staphylococcus aureus and Candida Albicans) in the pathogenesis of breast pain and infection in lactation women : study protocol

Background: The CASTLE (Candida and Staphylococcus Transmission: Longitudinal Evaluation) study will investigate the micro-organisms involved in the development of mastitis and “breast thrush” among breastfeeding women. To date, the organism(s) associated with the development of breast thrush have not been identified. The CASTLE study will also investigate the impact of physical health problems and breastfeeding problems on maternal psychological health in the early postpartum period.

Methods/Design: The CASTLE study is a longitudinal descriptive study designed to investigate the role of Staphylococcus spp (species) and Candida spp in breast pain and infection among lactating women, and to describe the transmission dynamics of S. aureus and Candida spp between mother and infant. The relationship between breastfeeding and postpartum health problems as well as maternal psychological well-being is also being investigated. A prospective cohort of four hundred nulliparous women who are at least thirty six weeks gestation pregnant are being recruited from two hospitals in Melbourne, Australia (November 2009 to June 2011). At recruitment, nasal, nipple (both breasts) and vaginal swabs are taken and participants complete a questionnaire asking about previous known staphylococcal and candidal infections. Following the birth, participants are followed-up six times: in hospital and then at home weekly until four weeks postpartum. Participants complete a questionnaire at each time points to collect information about breastfeeding problems and postpartum health problems. Nasal and nipple swabs and breast milk samples are collected from the mother. Oral and nasal swabs are collected from the baby. A telephone interview is conducted at eight weeks postpartum to collect information about postpartum health problems and breastfeeding problems, such as mastitis and nipple and breast pain.

Discussion: This study is the first longitudinal study of the role of both staphylococcal and candidal colonisation in breast infections and will help to resolve the current controversy about which is the primary organism in the condition known as breast thrush. This study will also document transmission dynamics of S. aureus and Candida spp between mother and infant. In addition, CASTLE will investigate the impact of common maternal physical health symptoms and the effect of breastfeeding problems on maternal psychological well-being.

Prevention and treatment of infant and childhood vitamin D deficiency in Australia and New Zealand : a consensus statement

• Vitamin D deficiency has re-emerged as a significant paediatric health issue, with complications including hypocalcaemic seizures, rickets, limb pain and fracture.

• A major risk factor for infants is maternal vitamin D deficiency. For older infants and children, risk factors include dark skin colour, cultural practices, prolonged breastfeeding, restricted sun exposure and certain medical conditions.

• To prevent vitamin D deficiency in infants, pregnant women, especially those who are dark-skinned or veiled, should be screened and treated for vitamin D deficiency, and breastfed infants of dark-skinned or veiled women should be supplemented with vitamin D for the first 12 months of life.

• Regular sunlight exposure can prevent vitamin D deficiency, but the safe exposure time for children is unknown.

• To prevent vitamin D deficiency, at-risk children should receive 400 IU vitamin D daily; if compliance is poor, an annual dose of 150 000 IU may be considered.

• Treatment of vitamin D deficiency involves giving ergocalciferol or cholecalciferol for 3 months (1000 IU/day if < 1 month of age; 3000 IU/ day if 1-12 months of age; 5000 IU/day if > 12 months of age).

• High-dose bolus therapy (300 000-500 000 IU) should be considered for children over 12 months of age if compliance or absorption issues are suspected.

Associations between dietary patterns at 6 and 15 months of age and sociodemographic factors

BACKGROUND/OBJECTIVES: Data from the Avon Longitudinal Study of Parents and Children (ALSPAC) have previously shown that dietary patterns are observable by 3 years. However, it is not clear when dietary patterns emerge. We aimed to describe dietary patterns in early life and their associations with maternal and infant sociodemographic characteristics.

SUBJECTS/METHODS: Principal component analysis was applied to diet questionnaires of ALSPAC participants at 6 months (n=7052) and 15 months (n=5610) to extract dietary patterns. The sociodemographic factors associated with dietary patterns were investigated using regression analyses.

RESULTS: Four dietary patterns were extracted at both 6 and 15 months. A traditional-style pattern characterized by home-prepared meats, vegetables and desserts, a second pattern characterized by ready-prepared baby foods and a third pattern characterized by discretionary foods such as biscuits, sweets and crisps were identified at both ages. At 6 months, the fourth pattern was characterized predominantly by breastfeeding and at 15 months, by contemporary-style foods including herbs, legumes, nuts, raw fruit and vegetables. Higher maternal age and education, number of siblings and lower body mass index (BMI) was associated with higher scores on the breastfeeding or meat, vegetables and desserts patterns, whereas higher discretionary food pattern scores were associated with younger maternal age, lower education, higher BMI and more siblings. Associations between sociodemographic factors and the ready-prepared baby food pattern scores were inconsistent across ages.

CONCLUSIONS: Dietary patterns emerge from infancy and are associated with sociodemographic characteristics.