Background:Childhood overweight and obesity is a public health priority. We have previously reported the efficacy of a parent-oriented mobile health (mHealth) app-based intervention (MINISTOP 1.0) which showed improvements in healthy lifestyle behaviors. However, the effectiveness of the MINISTOP app in real-world conditions needs to be established. Objective:To evaluate the real-world effectiveness of a 6-month mHealth intervention (MINISTOP 2.0 app) on childrens intake of fruits, vegetables, sweet and savory treats, sweet drinks, moderate-to-vigorous physical activity, and screen time (primary outcomes), and on parental self-efficacy (PSE) for promoting healthy lifestyle behaviors, and childrens body mass index (BMI) (secondary outcomes). Methods:A hybrid type 1 effectiveness-implementation design was utilized. For the effectiveness outcomes, a two-arm, individually randomized controlled trial was conducted. Parents (n = 552) of 2.5-to-3-year-old children were recruited from 19 child health care centers across Sweden, and, randomized to either a control (standard care) or intervention group (MINISTOP 2.0 app). The 2.0 version was adapted and translated into English, Somali and Arabic to increase reach. All recruitment and data collection were conducted by the nurses. Outcomes were assessed at baseline and after six months, using standardized measures (BMI) and a questionnaire (health behaviors, PSE). Results:Among the participating parents (n = 552, age: 34.1 +/- 5.0 years), 79% were mothers and 62% had a university degree. Twenty-four percent (n = 132) of children had two foreign-born parents. At follow-up, parents in the intervention group reported lower intakes of sweet and savory treats (-6.97 g/day; p = 0.001), sweet drinks (-31.52 g/day; p < 0.001), and screen time (-7.00 min/day; p = 0.012) in their children compared to the control group. The intervention group reported higher total PSE (0.91; p = 0.006), PSE for promoting healthy diet (0.34; p = 0.008) and PSE for promoting physical activity behaviors (0.31; p = 0.009) compared to controls. No statistically significant effect was observed for childrens BMI z-score. Overall, parents reported high satisfaction with the app, and 54% reported using the app at least once a week. Conclusion:Children in the intervention group had lower intakes of sweet and savory treats, sweet drinks, less screen time (primary outcomes) and their parents reported higher PSE for promoting healthy lifestyle behaviors. Our results from this real-world effectiveness trial support the implementation of the MINISTOP 2.0 app within Swedish child health care.

Early efforts for prevention of childhood overweight and obesity are needed. In order to adapt an app promoting healthy diet and physical activity behaviors in children (MINISTOP 1.0) for multi-ethnic communities, we explored: (1) needs and concerns among Somali-, Arabic-, and Swedish-speaking parents in terms of supporting healthy diet and activity behaviors in their children; (2) nurses perceptions of parental needs and concerns in relation to diet and physical activity behaviors; and (3) how the features and content of the MINISTOP 1.0 app could be refined to better support health behaviors in children, among both parents and nurses. Focus groups with Somali-, Arabic-, and Swedish-speaking parents (n = 15), and individual interviews with nurses (n = 15) were conducted. Parents expressed several challenges in supporting childrens health behaviors, the need for a tailored app, and alternative ways of accessing the content (audio/video). Nurses emphasized the need of supporting parents early, and the value of a shared platform in different languages, to facilitate communication. This study contributes valuable insights about parental needs and relevant adaptations to a parental support app, such as addition of audio/video files for increased accessibility. This adapted app version-MINISTOP 2.0, can be useful for childhood obesity prevention in multi-ethnic communities.

BackgroundPreventive and scalable interventions, accessible to all, to counteract childhood obesity are urgently needed. We have recently developed a novel, digital parental intervention (MINISTOP 2.0 app) available in Swedish, Somali, Arabic and English. We have previously reported its positive effects on childrens health behaviors and on parental self-efficacy. However, before introducing the app at scale in primary child healthcare, implementation aspects also need to be explored.AimThis study aims to explore and describe user experiences as well as acceptability and feasibility of the MINISTOP 2.0 app-based intervention in a diverse group of parents (end-users) and Swedish child healthcare nurses (implementers).MethodsIndividual interviews were conducted with Swedish- (n = 9), Somali- (n = 9), Arabic- (n = 5) and English-speaking (n = 1) parents as well as Swedish primary child healthcare nurses (n = 15). Data was analyzed using content analysis with an inductive latent approach.ResultsParents described how the app facilitated behavior change through increased awareness regarding current diet and physical activity behaviors. Furthermore, the evidence-based app content further facilitated trust and behavior change. Both parents and nurses acknowledged the apps preventive potential and the potential for reaching parents with diverse backgrounds or in need of extra support.ConclusionThe MINISTOP 2.0 app was perceived as a useful tool for health promotion both by parents and healthcare professionals, especially since it was adapted to several languages. These findings coupled with the previously shown beneficial effects on health behaviors support the large-scale implementation of the app in primary child healthcare.

Background: Heart failure (HF) is a common chronic condition that affects over 26 million people worldwide. It is a progressive and debilitating disease with a broad symptom profile, intermittently marked by periods of acute decompensation. People with HF generally do not self-manage their condition well (eg, monitoring symptoms, taking medications regularly, physical activity, etc). A better understanding of self-care activities and what factors may indicate deterioration is warranted.Objective: The aim of this study was to determine the feasibility and acceptability of using wearable cameras to assess self-care activities in people with HF. The study objectives were to (1) explore whether changes in self-care activities could be identified prior to hospitalization and (2) determine the acceptability of wearable cameras to people with HF.Methods: A total of 30 people recently diagnosed with HF wore a camera for a maximum of 30 days; the camera took a photo every 30 seconds in the forward-facing direction. At the end of the study, all 30 participants were presented with 8 statements of acceptability, scored on a 5-point Likert scale. To determine whether camera images could identify changes in self-care activities and lifestyle risk factors before hospitalization, we analyzed images from participants (n=8) who were hospitalized during the 30-day study period. Images from the period immediately prior to hospitalization and a comparison were selected for each participant. Images were manually coded according to 9 different event categories relating to self-care and lifestyle risk factors, and events were compared between the 2 periods.Results: The participants reported high acceptability for wearing the cameras, as most strongly agreed or agreed that they were comfortable to wear (28/30, 93%) and easy to use (30/30, 100%). The results of the camera image analysis showed that participants undertook fewer activities of daily living (P=.008) and were more sedentary (P=.02) prior to being hospitalized, compared to a period nonadjacent to hospitalization.Conclusions: Adults with HF were accepting of using a wearable camera for periods within a 30-day time frame. Wearable cameras were a feasible approach for providing data on selected self-care activities and lifestyle risk factors for HF and offer the potential to be a valuable tool for improving our understanding of self-care.

Background: Accumulating sufficient moderate to vigorous physical activity is recognized as a key determinant of physical, physiological, developmental, mental, cognitive, and social health among children and youth (aged 5-17 y). The Global Matrix 3.0 of Report Card grades on physical activity was developed to achieve a better understanding of the global variation in child and youth physical activity and associated supports. Methods: Work groups from 49 countries followed harmonized procedures to develop their Report Cards by grading 10 common indicators using the best available data. The participating countries were divided into 3 categories using the United Nations human development index (HDI) classification (low or medium, high, and very high HDI). Results: A total of 490 grades, including 369 letter grades and 121 incomplete grades, were assigned by the 49 work groups. Overall, an average grade of "C-," "D+," and "C-" was obtained for the low and medium HDI countries, high HDI countries, and very high HDI countries, respectively. Conclusions: The present study provides rich new evidence showing that the situation regarding the physical activity of children and youth is a concern worldwide. Strategic public investments to implement effective interventions to increase physical activity opportunities are needed.

Background: To better understand the childhood physical inactivity crisis, Report Cards on physical activity of children and youth were prepared concurrently in 30 very high Human Development Index countries. The aim of this article was to present, describe, and compare the findings from these Report Cards. Methods: The Report Cards were developed using a harmonized process for data gathering, assessing, and assigning grades to 10 common physical activity indicators. Descriptive statistics were calculated after converting letter grades to interval variables, and correlational analyses between the 10 common indicators were performed using Spearmans rank correlation coefficients. Results: A matrix of 300 grades was obtained with substantial variations within and between countries. Low grades were observed for behavioral indicators, and higher grades were observed for sources of influence indicators, indicating a disconnect between supports and desired behaviors. Conclusion: This analysis summarizes the level and context of the physical activity of children and youth among very high Human Development Index countries, and provides additional evidence that the situation regarding physical activity in children and youth is very concerning. Unless a major shift to a more active lifestyle happens soon, a high rate of noncommunicable diseases can be anticipated when this generation of children reaches adulthood.

Background: Clustering of multiple lifestyle risk behaviors has been associated with a greater risk of noncommunicable diseases and mortality than one lifestyle risk behavior or no lifestyle risk behaviors. The National Board of Health and Welfare in Sweden reported in 2018 that it is important to provide additional support to individuals with multiple lifestyle risk behaviors, as risks from these behaviors are multiplicative rather than additive. However, the same report emphasized that there is a lack of knowledge regarding interventions that support changes to unhealthy lifestyle behaviors.

Objective: The MoBILE (Mobile health Multiple lifestyle Behavior Interventions across the LifEspan) research program has brought together two Swedish research groups supported by international collaborators. Through this collaboration, we aim to design and evaluate a number of novel and tailored mobile health (mHealth) multiple lifestyle behavior interventions across the life span of different health care populations. In addition, the MoBILE research program will extend ongoing research to include mHealth interventions for migrant pregnant women and children.

Methods: Each project within the MoBILE program will focus on a specific group: pregnant women, preschool children, high school and university students, and adults in primary and clinical care. All the projects will follow the same 4 phases: requirements, development, evaluation, and implementation. During the requirements phase, implementers and end users will aid the design of content and functionality of the interventions. In the development phase, findings from the first phase will be synthesized with expert domain knowledge and theoretical constructs to create interventions tailored to the target groups. The third phase, evaluation, will comprise randomized controlled trials conducted to estimate the effects of the interventions on multiple lifestyle risk behaviors (eg, alcohol, nutrition, physical activity, and smoking). The final phase will investigate how the interventions, if found effective, can be disseminated into different health care contexts.

Results: The research program commenced in 2019, and the first results will be available in 2020. Projects involving pregnant women, preschool children, and high school and university students will be completed in the first 3 years, with the remaining projects being planned for the program’s final 3 years.

Conclusions:The development of evidence-based digital tools is complex, as they should be guided by theoretical frameworks, and requires large interdisciplinary teams with competence in technology, behavioral science, and lifestyle-specific areas. Individual researchers or smaller research groups developing their own tools is not the way forward, as it means reinventing the wheel over and over again. The MoBILE research program therefore aims to join forces and learn from the past 10 years of mHealth research to maximize scientific outcomes, as well as the use of financial resources to expand the growing body of evidence for mHealth lifestyle behavior interventions.

BackgroundNational surveys in Sweden demonstrate that the majority of young people do not engage in health promoting behaviours at levels recommended by the Public Health Agency of Sweden. The objective of this study is to estimate the effectiveness of a novel mHealth intervention named LIFE4YOUth, which targets multiple lifestyle behaviours (alcohol, diet, physical activity, and smoking) among high school students in Sweden.MethodsA 2-arm parallel groups single blind randomised controlled trial (1:1) will be employed to estimate the effectiveness of the novel mHealth intervention. Students will be recruited at high schools throughout Sweden, and will be included if they fulfil one of six criteria relating to unhealthy behaviours with respect to alcohol, diet, physical activity and smoking. Eligible participants will be randomised to either receive the novel intervention immediately, or to be placed on a waiting list for 4 months. The intervention consists of a combination of recurring screening, text messages, and an interactive platform which is adaptable to individual preferences. Outcome measures with respect to alcohol, diet, physical activity and smoking will be assessed through questionnaires at 2 and 4 months post randomisation.DiscussionThe findings of this trial could be generalised to a diverse high-school student population as our recruitment encompass a large proportion of schools throughout Sweden with various educational profiles. Furthermore, if effective, the mHealth intervention has good potential to be able to be scaled up and disseminated at high schools nationally.Trial registrationRegistered prospectively on 2020-05-20 in ISRCTN (ISRCTN34468623).

Background: Physical activity is associated with reduced risks of many chronic diseases. Data collected on physical activity in large epidemiological studies is often based on paper questionnaires. The validity of these questionnaires is debated, and more effective methods are needed. Objective: This study evaluates repeated measures of physical activity level (PAL) and the feasibility of using a Java-based questionnaire downloaded onto cell phones for collection of such data. The data obtained were compared with reference estimates based on the doubly labeled water method and indirect calorimetry (PAL(ref)). Method: Using a Java-based cell phone application, 22 women reported their physical activity based on two short questions answered daily over a 14-day period (PAL(cell)). Results were compared with reference data obtained from the doubly labeled water method and indirect calorimetry (PAL(ref)). Results were also compared against physical activity levels assessed by two regular paper questionnaires completed by women at the end of the 14-day period (PAL(quest1) and PAL(quest2)). PAL(cell), PAL(quest1), and PAL(quest2) were compared with PAL(ref) using the Bland and Altman procedure. Results: The mean difference between PAL(cell), and PAL(ref) was small (0.014) with narrow limits of agreement (2SD = 0.30) Compared with PAL(ref) the mean difference was also small for PAL(quest1) and PAL(quest2) (0.004 and 0.07, respectively); however, the limits of agreement were wider (PAL(quest), 2SD = 0.50 and PAL(quest2), 2SD = 0.90). The test for trend was statistically significant for PAL(quest1) (slope of regression line = 0.79, P = .04) as well as for PAL(quest2) (slope of regression line = 1.58, P andlt; .001) when compared with PAL(ref). Conclusion: A Java-based physical activity questionnaire administered daily using cell phones produced PAL estimates that agreed well with PAL reference values. Furthermore, the limits of agreement between PAL obtained using cell phones, and reference values were narrower than for corresponding estimates obtained using paper questionnaires. Java-based questionnaires downloaded onto cell phones may be a feasible and cost-effective method of data collection for large-scale prospective studies of physical activity.

Background: Physical activity promotes health and longevity. Further elaboration of the role of physical activity for human health in epidemiological studies on large samples requires accurate methods that are easy to use, cheap, and possible to repeat. The use of telecommunication technologies such as cell phones is highly interesting in this respect. In an earlier report, we showed that physical activity level (PAL) assessed using a cell phone procedure agreed well with corresponding estimates obtained using the doubly labeled water method. However, our earlier study indicated high within-subject variation in relation to between-subject variations in PAL using cell phones, but we could not assess if this was a true variation of PAL or an artifact of the cell phone technique. less thanbrgreater than less thanbrgreater thanObjective: Our objective was to compare within-and between-subject variations in PAL by means of cell phones with corresponding estimates using an accelerometer. In addition, we compared the agreement of daily PAL values obtained using the cell phone questionnaire with corresponding data obtained using an accelerometer. less thanbrgreater than less thanbrgreater thanMethods: PAL was measured both with the cell phone questionnaire and with a triaxial accelerometer daily during a 2-week study period in 21 healthy Swedish women (20 to 45 years of age and BMI from 17.7 kg/m(2) to 33.6 kg/m(2)). The results were evaluated by fitting linear mixed effect models and descriptive statistics and graphs. less thanbrgreater than less thanbrgreater thanResults: With the accelerometer, 57% (95% confidence interval [CI] 40%-66%) of the variation was within subjects, while with the cell phone, within-subject variation was 76% (95% CI 59%-83%). The day-to-day variations in PAL observed using the cell phone questions agreed well with the corresponding accelerometer results. less thanbrgreater than less thanbrgreater thanConclusions: Both the cell phone questionnaire and the accelerometer showed high within-subject variations. Furthermore, day-to-day variations in PAL within subjects assessed using the cell phone agreed well with corresponding accelerometer values. Consequently, our cell phone questionnaire is a promising tool for assessing levels of physical activity. The tool may be useful for large-scale prospective studies.

BackgroundMobile health, mHealth is recognized as a strategy to improve lifestyle behaviors. Research targeting specific lifestyle behaviors has shown that interventions using smartphones can be effective. However, few studies have evaluated solutions with multicomponent interventions, tailoring the intervention to the specific needs of the participant using a combination of mHealth and conventional treatment. To accomplish this, we developed Health Integrator, an mHealth platform with services and offers in the areas of diet, physical activity, sleeping habits, stress, alcohol and tobacco use. In the system, the user selects an area of intervention together with a health coach and set weekly goals. This study protocol presents the design and methodology of the Health Integrator Study, a randomized controlled trial to promote improved lifestyle behaviors.MethodsA three-arm parallel randomized controlled trial (1:1:1) is conducted in the Stockholm County, Sweden. In total, 209 employees at a four different companies representing both white and blue collar workers, have been recruited.Participants are randomized to either a control group or to one of two intervention groups receiving a 3-month lifestyle behavior change program including either 1) use of Health Integrator and monthly health coaching sessions or 2) only Health Integrator.At baseline and follow-up after 3- and 6-months, all participants answer questionnaires assessing lifestyle behaviors and quality of life. At baseline and the 3-month follow-up (end of intervention period), weight, height, waist circumference and blood pressure are measured, and all participants wear an Actigraph accelerometer for 7days to assess physical activity. Blood lipid profile and HbA1c are measured among all participants at baseline. If baseline measures fall outside the normal range, a second measurement is done after 3months.DiscussionThe Health Integrator Intervention Study will evaluate if a personalized intervention combining mHealth and conventional programs for lifestyle change, with or without additional health coach sessions, can improve lifestyle behaviors and quality of life. Based on the results from this trial, Health Integrator can easily be implemented within a broad public.Trial registrationClinicalTrials.gov Identifier: NCT03579342. Retrospectively registered, first submitted May 8, 2018.

Background: To optimize postoperative outcomes after bariatric surgery, lifestyle changes including increased physical activity are needed. Micronutrient deficiency after surgery is also common and daily supplementation is recommended. Objective: The aim of the PromMera study is to evaluate the effects of a 12-week smartphone app intervention on promotion of physical activity (primary outcome) and adherence to postsurgery vitamin and mineral supplementation, as well as on other lifestyle factors and overall health in patients undergoing bariatric surgery. Methods: The PromMera study is a two-arm, randomized controlled trial comprising patients undergoing bariatric surgery. Participants are randomized postsurgery 1:1 to either the intervention group (ie, use of the PromMera app for 12 weeks) or the control group receiving only standard care. Clinical and lifestyle variables are assessed pre- and postsurgery after 18 weeks (postintervention assessment), 6 months, 1 year, and 2 years. Assessments include body composition using Tanita or BOD POD analyzers, muscle function using handgrip, biomarkers in blood, and an extensive questionnaire on lifestyle factors. Physical activity is objectively measured using the ActiGraph wGT3X-BT triaxial accelerometer. Results: A total of 154 participants have been enrolled in the study. The last study participant was recruited in May 2019. Data collection will be complete in May 2021. Conclusions: Implementing lifestyle changes are crucial after bariatric surgery and new ways to reach patients and support such changes are needed. An app-based intervention is easily delivered at any time and can be a key factor in the adoption of healthier behavioral patterns in this rapidly growing group of patients.

Purpose Ways to motivate and support patients in being physically active after bariatric surgery are needed. This trial was aimed at evaluating the effect of using a smartphone application targeting physical activity during 12 weeks on moderate-to-vigorous physical activity (MVPA, primary outcome) and secondary outcomes of inactivity, light physical activity (LPA), body mass index (BMI), and percent total weight loss (%TWL) after bariatric surgery.Materials and Methods Data from a randomized controlled trial comprising 146 patients (79.5% women) undergoing bariatric surgery was analyzed. Mean age and BMI pre-surgery were 40.9 years and 40.5 kg/m(2), respectively. Participants were randomized 1:1 to an intervention or a control group. Physical activity and body weight were objectively measured at baseline pre-surgery and post-surgery follow-ups after 6 weeks (weight only), 18 weeks, 6 months, and 1 year. Linear mixed models were fitted to assess longitudinal differences in outcomes between the groups.Results A significant effect of the intervention (group-by-time interaction 16.2, 95% CI 3.5 to 28.9) was seen for MVPA at 18 weeks; the intervention group had increased their MVPA since baseline, while the control group had decreased their MVPA. The control group had lowered their BMI approximately 1 kg/m(2) more than the intervention group at follow-up after 18 weeks and 12 months, yet, mean BMI did not differ between the groups. No intervention effect was seen on inactivity, LPA, or %TWL.ConclusionOur results indicate that use of a smartphone application targeting physical activity may have the potential to promote short-term MVPA post bariatric surgery.

OBJECTIVES: Reference values are necessary for classifying children, for health screening, and for early prevention as many non-communicable diseases aggravate during growth and development. While physical fitness reference standards are available in children aged 6 and older, such information is lacking in preschool children. Therefore, the purposes of this study were (1) to provide sex-and age-specific physical fitness reference standards for Spanish preschool children; and (2) to study sex differences across this age period and to characterise fitness performance throughout the preschool period.

DESIGN: Cross-sectional.

METHODS: A total of 3179 preschool children (1678 boys) aged 2.8-6.4 years old from Spain were included in the present study. Physical fitness was measured using the PREFIT battery.

RESULTS: Age- and sex-specific percentiles for the physical fitness components are provided. Boys performed better than girls in the cardiorespiratory fitness, muscular strength, and speed-agility tests over the whole preschool period studied and for the different percentiles. In contrast, girls performed slightly better than boys in the balance test. Older children had better performance in all fitness tests than their younger counterparts.

CONCLUSIONS: Our study provides age- and sex-specific physical fitness reference standards in preschool children allowing interpretation of fitness assessment. Sexual dimorphism in fitness tests exists already at preschool age, and these differences become larger with age. These findings will help health, sport, and school professionals to identify preschool children with a high/very low fitness level, to examine changes in fitness over time, and to analyse those changes obtained due to intervention effects.

The aim of this study was to examine the associations of fitness and physical activity with academic achievement in children with overweight/obesity. A total of 106 (10.0 +/- 1.1y, 61 boys) children participated. The fitness components were assessed by field and laboratory-based tests. Physical activity was measured via accelerometry. The academic achievement was assessed by a standardised test and school-grades. Field-based cardiorespiratory fitness was associated with language skills (ss-standardised- ranging from 0.281 to 0.365, p amp;lt; 0.01). The field-based muscular strength was associated with grade point average, natural and social sciences, and foreign language (ss = 0.280-0.326, all p amp;lt;= 0.01). Speed-agility was associated with some language-related skills (ss = 0.325-0.393, all p amp;lt;= 0.01). The laboratory-based muscular strength also showed an association with mathematics skills (ss = 0.251-0.306, all p amp;lt;= 0.01). Physical activity did not show significant association with academic achievement (p amp;gt; 0.01). Overall, the significant associations observed for muscular strength and speed/agility were attenuated and disappeared in many cases after additional adjustments for body mass index and cardiorespiratory fitness, indicating that these associations are inter-dependent. Our study contributes by indicating that other fitness components apart from cardiorespiratory fitness, such as muscular strength and speed-agility, are positively associated with academic achievement. However, these associations appear to be dependent on body mass index and cardiorespiratory fitness.

BackgroundMental health problems among children and adolescents are a growing public health concern. Self-report questionnaires are pivotal for screening and early detection of mental health issues. We evaluate the psychometric properties and provide norm data of the 25-item child and 25-item parent-report versions of the Revised Child Anxiety and Depression Scale (RCADS).MethodsA random probability sample of 29,000 children and adolescents (ages 4-17) from the Swedish population registry was invited. Data collection occurred from September 2021 to January 2022, accompanied by one postal and four SMS reminders.ResultsParticipants (N = 7045, 48.98% girls) demonstrate that the RCADS-25 possesses relatively sound psychometric properties, albeit that the child-report version assessed with children and adolescents aged 8 to 17 years rendered relatively better psychometric properties (e.g., omega = 0.87-0.92, CFI = 0.89) compared with the parent-report version and the children 4 to 7 years old (e.g., omega = 0.72-0.82, CFI = 0.84).ConclusionThe RCADS-25 instruments may be used as an effective instrument for the initial assessment of anxiety and depression in children and adolescents in Sweden.

BackgroundAs unhealthy lifestyle habits have been found to be established early in life and often track into adulthood, early preventive initiatives are important. 'Saga Stories in health talks' is a newly developed material that is intended to be used as a support for nurses at child health care (CHC) centers in their health talks with children and parents in Sweden. The aim of this study is to explore how CHC nurses experience the usability of the 'Saga Stories in health talks' material.MethodsThis study used a qualitative design. The material 'Saga Stories in health talks' was tested by 33 CHC nurses working in 11 CHC centers in three regions in Sweden. All CHC nurses were invited to participate in the interviews and 17 agreed. The interviews were transcribed and analysed using content analysis.ResultsThree categories and eight sub-categories emerged. The categories were: (1) An appreciated tool suitable for health talks, (2) Illustrations to capture children's interest in the conversation with families, and (3) Barriers and facilitators. Saga Stories in health talks' was experienced by the CHC nurses as an appreciated tool with content highly relevant to what should be discussed during the health talks. The CHC nurses described the material as well-designed with illustrations that helped them capture the child's interest and increase their participation, while still involving the parents. Support from colleagues, the researchers, and managers were seen as important facilitators. Challenges included structural factors such as how and when to best use the material, especially concerning that the 4-year visit contained many other mandatory parts.ConclusionsThis pilot study show that the material 'Saga Stories in health talks' was highly appreciated by CHC nurses and facilitated their health talks with families in CHC. Important aspects with the material were the relevant content and the focus on healthy living habits, as well as the child friendly illustrations. These findings can be used when similar material is developed to facilitate health talks with families in other contexts. Our results also highlight the importance to adjust the implementation of a new material with already established practice and routines.

Background

A Mediterranean diet has a recognized beneficial effect on health and longevity, with a protective influence on several cancers. However, its association with breast cancer risk remains unclear.

Objective

We aimed to investigate whether adherence to a Mediterranean dietary pattern influences breast cancer risk.

Design

The Swedish Women’s Lifestyle and Health cohort study includes 49,258 women aged 30 to 49 years at recruitment in 1991–1992. Consumption of foods and beverages was measured at enrollment using a food frequency questionnaire. A Mediterranean diet score was constructed based on the consumption of alcohol, vegetables, fruits, legumes, cereals, fish, the ratio of unsaturated to saturated fat, and dairy and meat products. Relative risks (RR) for breast cancer and specific tumor characteristics (invasiveness, histological type, estrogen/progesterone receptor status, malignancy grade and stage) associated with this score were estimated using Cox regression controlling for potential confounders.

Results

1,278 incident breast cancers were diagnosed. Adherence to a Mediterranean dietary pattern was not statistically significantly associated with reduced risk of breast cancer overall, or with specific breast tumor characteristics. A RR (95% confidence interval) for breast cancer associated with a two-point increment in the Mediterranean diet score was 1.08 (1.00–1.15) in all women, and 1.10 (1.01–1.21) and 1.02 (0.91–1.15) in premenopausal and postmenopausal women, respectively. When alcohol was excluded from the Mediterranean diet score, results became not statistically significant.

Conclusions

Adherence to a Mediterranean dietary pattern did not decrease breast cancer risk in this cohort of relatively young women.

Background: Childhood obesity is an increasing health problem globally. Overweight and obesity may be established as early as 2-5 years of age, highlighting the need for evidence-based effective prevention and treatment programs early in life. In adults, mobile phone based interventions for weight management (mHealth) have demonstrated positive effects on body mass, however, their use in child populations has yet to be examined. The aim of this paper is to report the study design and methodology of the MINSTOP (Mobile-based Intervention Intended to Stop Obesity in Preschoolers) trial. Methods/Design: A two-arm, parallel design randomized controlled trial in 300 healthy Swedish 4-year-olds is conducted. After baseline measures, parents are allocated to either an intervention-or control group. The 6-month mHealth intervention consists of a web-based application (the MINSTOP app) to help parents promote healthy eating and physical activity in children. MINISTOP is based on the Social Cognitive Theory and involves the delivery of a comprehensive, personalized program of information and text messages based on existing guidelines for a healthy diet and active lifestyle in pre-school children. Parents also register physical activity and intakes of candy, soft drinks, vegetables as well as fruits of their child and receive feedback through the application. Primary outcomes include body fatness and energy intake, while secondary outcomes are time spent in sedentary, moderate, and vigorous physical activity, physical fitness and intakes of fruits and vegetables, snacks, soft drinks and candy. Food and energy intake (Tool for Energy balance in Children, TECH), body fatness (pediatric option for BodPod), physical activity (Actigraph wGT3x-BT) and physical fitness (the PREFIT battery of five fitness tests) are measured at baseline, after the intervention (six months after baseline) and at follow-up (12 months after baseline). Discussion: This novel study will evaluate the effectiveness of a mHealth program for mitigating gain in body fatness among 4-year-old children. If the intervention proves effective it has great potential to be implemented in child-health care to counteract childhood overweight and obesity.

Very few early childhood interventions have observed sustained effects regarding television viewing and none have examined the mechanisms behind sustained intervention effects at long-term follow-ups. Thus, the aim of this study was to investigate potential mechanisms relating to the maintained intervention effect on television viewing at two long-term follow-ups in the Melbourne Infant Feeding Activity and Nutrition Trial (INFANT). INFANT was a cluster-randomised controlled trial. At the 2- and 3.5-year follow-ups, a total of 262 infant/mother pairs had complete information. Television viewing was assessed via a questionnaire at both follow-ups and six potential mediators were measured post-intervention (i.e. 15 months after baseline). Causal mediation analysis was conducted. At the 2- and 3.5-year follow-ups, the positive impacts of INFANT on maternal television viewing knowledge were maintained (B = 0.34 units; 95% confidence interval (CI95): 0.21, 0.48). An indirect effect of the intervention on reducing childrens television viewing time was observed at the 2- and 3.5-year follow-ups (B = -11.73 min/day; CI95: -22.26, -3.28 and B = -4.78 min/day; CI95: -9.48, -0.99, respectively) via improved maternal television viewing knowledge. Conclusion: The positive impacts of INFANT on maternal television viewing knowledge were maintained at both follow-ups, with better maternal knowledge associated with less television viewing time in their children. These results have implications for paediatricians and healthcare professionals as educating new parents early on regarding screen time may lead to the development of healthier screen time habits that are sustained through to the pre-school years.

The International Study of Movement Behaviors in the Early Years (SUNRISE) was initiated in response to the 2019 WHO guidelines for physical activity, sedentary behavior, and sleep in children aged 0-5 years. This Swedish pilot study aimed to: (i) assess the proportion of preschoolers meeting the guidelines, (ii) evaluate the feasibility of the methods for the SUNRISE study, and (iii) assess how movement behaviors have been affected in preschoolers during the COVID-19 pandemic. Physical activity and sleep (waist-worn ActiGraph); screen time and movement behaviors (parental questionnaire); motor skills (Ages and Stages Questionnaire); and executive functions (3 iPad games) were assessed in 100 Swedish preschoolers (n = 58 boys). There were 19.4% of preschoolers (n = 14) who met the WHO guidelines. The motor skill and executive function assessments were feasible; however, 20% refused to wear the ActiGraph overnight. Additionally, during the pandemic Swedish childrens physical activity, time spent outside on weekdays and weekend days, and screen time significantly increased (+53; +124; +68; +30min/day, respectively, all p-values <= 0.001). Methods for the SUNRISE study were feasible in a Swedish context; however, considerations to switch to a wrist-worn accelerometer should be made. Furthermore, childrens physical activity increased during the pandemic, which is likely due to how the rules/restrictions were implemented in Sweden.

Mobile phones are becoming important instruments for assessing diet and energy intake. We developed the Tool for Energy Balance in Children (TECH), which uses a mobile phone to assess energy and food intake in pre-school children. The aims of this study were: (a) to compare energy intake (EI) using TECH with total energy expenditure (TEE) measured via doubly labelled water (DLW); and (b) to compare intakes of fruits, vegetables, fruit juice, sweetened beverages, candy, ice cream, and bakery products using TECH with intakes acquired by 24 h dietary recalls. Participants were 39 healthy, Swedish children (5.5 +/- 0.5 years) within the ongoing Mobile-based Intervention Intended to Stop Obesity in Preschoolers (MINISTOP) obesity prevention trial. Energy and food intakes were assessed during four days using TECH and 24 h telephone dietary recalls. Mean EI (TECH) was not statistically different from TEE (DLW) (5820 +/- 820 kJ/24 h and 6040 +/- 680kJ/24 h, respectively). No significant differences in the average food intakes using TECH and 24 h dietary recalls were found. All food intakes were correlated between TECH and the 24 h dietary recalls (r = 0.665-0.896, p < 0.001). In conclusion, TECH accurately estimated the average intakes of energy and selected foods and thus has the potential to be a useful tool for dietary studies in pre-school children, for example obesity prevention trials.

Quick, easy-to-use, and valid body composition measurement options for young children are needed. Therefore, we evaluated the ability of the bioelectrical impedance (BIA) device, Tanita SC-240, to measure fat mass (FM), fat free mass (FFM) and body fatness (BF%) in 40 healthy, Swedish 5.5 years old children against the three component model (3C model). Average BF%, FM, and FFM for BIA were: 19.4% +/- 3.9%, 4.1 +/- 1.9 kg, and 16.4 +/- 2.4 kg and were all significantly different (p amp;lt; 0.001) from corresponding values for the 3C model (25.1% +/- 5.5%, 5.3 +/- 2.5 kg, and 15.2 +/- 2.0 kg). Bland and Altman plots had wide limits of agreement for all body composition variables. Significant correlations ranging from 0.81 to 0.96 (p amp;lt; 0.001) were found for BF%, FM, and FFM between BIA and the 3C model. When dividing the children into tertiles for BF%, 60% of children were classified correctly by means of BIA. In conclusion, the Tanita SC-240 underestimated BF% in comparison to the 3C model and had wide limits of agreement. Further work is needed in order to find accurate and easy-to-use methods for assessing body composition in pre-school children.

Background Physical activity guidelines for children encourage moderate-to-vigorous intensity activities (MVPA); however, some studies have found that only vigorous intensity activities (VPA) might promote health benefits in young children. Thus, the aim of this study is to investigate cross-sectional and 5-year longitudinal associations of VPA and MVPA with cardiovascular disease (CVD) risk factors in childhood using compositional data analysis.Results This study utilized data from the SPINACH study (n = 411). Physical activity was measured with accelerometers at 4- and 9-years of age. CVD risk factors were measured at 9-years of age, and included blood pressure (BP), lipid metabolism, and glucose metabolism biomarkers, as well as a continuous metabolic syndrome risk score (MetS). Cross-sectional and longitudinal linear regression models were built using compositional data analysis standards. Cross-sectionally, reallocating time to VPA from lower-intensity behaviours at 9-years was associated with lower waist circumference (B = - 3.219, P = 0.002), diastolic BP (B = - 1.836, P = 0.036), triglycerides (B = - 0.214, P < 0.001), glucose (B = - 0.189, P = 0.033), insulin (B = - 2.997, P < 0.001), and HOMA-IR (B = - 0.778, P < 0.001). Similarly, reallocating time to VPA at 4-years was associated with lower MetS (B = - 0.831, P = 0.049), waist circumference (B = - 4.211, P = 0.015), systolic BP (B = - 5.572, P = 0.015), diastolic BP (B = - 2.931, P = 0.044), triglycerides (B = - 0.229, P = 0.034), glucose (B = - 0.325, P = 0.032), insulin (B = - 5.114, P = 0.001), and HOMA-IR (B = - 0.673, P = 0.001) at 9-years. Reallocations of time to MVPA at 4- or 9-years were not associated with CVD risk factors at 9-years.Conclusions VPA was associated with CVD risk factors in children both cross-sectionally (9-years) and longitudinally (at 4- and 9-years). MVPA seemed not to be a stimulus of enough intensity to trigger these potential cardiometabolic benefits in healthy children. Thus, these findings suggest the importance of higher intensity activities, i.e., VPA already in early childhood for cardiometabolic health.

Air displacement plethysmography utilises a two-component model to assess body composition, which relies on assumptions regarding the density of fat-free mass (FFM). To date, there is no evidence as to whether Lohmans or Wells et al.s FFM density values are more accurate in young children. Therefore, the aims of this study were to compare total body fat percentage (TBF%) assessed using the BodPod with both Lohmans and Wells et al.s FFM density values with TBF% from the three-component (3C) model in forty healthy Swedish children aged 5.5 years. Average TBF% calculated using Lohmans FFM density values underestimated TBF% in comparison with the corresponding value assessed using the 3C model (22.2 (SD 5.7) and 25.1 (SD 5.5)%, respectively; P amp;lt;0.001). No statistically significant difference was observed between TBF% assessed using Wells et al.s FFM density values and the 3C model (24.9 (so 5.5) and 251 (so 5.5)%, respectively; P= 0.614). The Bland and Altman plots for TBF% using both Lohmans and Wells et al.s FFM density values did not show any bias across the range of body fatness (Lohman: r0.056, P= 0.733 and Wells el al.: r-0.006, P= 0.970). These results indicate that Wells Cl al.s FFM density values should be used when assessing body composition with the paediatric option for BodPod in 5-year-old children. However, future studies are needed to confirm these results in other populations, including a wider age range of children.

yyy Background: Active transportation (AT; ie, walking and cycling as a mode for transportation) has been associated with decreased morbidity and mortality; however, low-cost and scalable intervention programs are lacking. Objective: The goal of the research was to determine the effectiveness of a 3-month behavior change program delivered via a mobile phone app to promote AT (TravelVu Plus) on time spent in moderate-to-vigorous physical activity (MVPA). Methods: For this 2-arm parallel randomized controlled trial, we recruited a population-based sample of 254 adults from Stockholm County who were aged 20 to 65 years and had access to a smartphone. On completion of 1-week baseline measures, the 254 participants were randomized to either the control or intervention group (1:1 ratio). Both groups had access to the standard TravelVu app (Trivector AB) for monitoring their AT for 6 months. The intervention group also received a 3-month behavior change program to promote AT (TravelVu Plus app). Assessors of outcomes were blinded to group allocation. Outcomes were objectively measured MVPA at 3 (primary) and 6 months. Secondary outcomes were AT, attitudes toward AT, and health-related quality of life at 3 and 6 months. Results: No effect on MVPA was observed after 3 months (P=.29); however, at 6 months the intervention group had a greater improvement in MVPA than the controls (6.05 minutes per day [95% CI 0.36 to 11.74; P=.04]). A Bayesian analyses showed that there was a 98% probability that the intervention had any effect at 6 months, and a 63% probability that this effect was >5 minute MVPA per day. Conclusions: No effect on MVPA immediately after the intervention period (at 3 months) was observed; however, there was a delayed effect on MVPA (6 minutes per day) at 6 months, which corresponds to approximately 30% of the weekly MVPA recommendation. Our findings suggest that a behavior change program promoting AT delivered via an app may have a relevant effect on PA.

BackgroundChildhood overweight and obesity is a serious public health issue with an increase being observed in preschool-aged children. Treating childhood obesity is difficult and few countries use standardized treatments. Therefore, there is a need to find effective approaches that are feasible for both health care providers and families. Thus, the overall aim of this study is to assess the acceptance and effectiveness of a parent support program (the More and Less, ML) for the management of overweight and obesity followed by a mobile health (mHealth) program (the MINISTOP application) in a socially diverse population of families.Methods/designA two-arm, parallel design randomized controlled trial in 300 2-to 6-year-old children with overweight and obesity from Romania, Spain and Sweden (n=100 from each). Following baseline assessments children are randomized into the intervention or control group in a 1:1 ratio. The intervention, the ML program, consists of 10-weekly group sessions which focus on evidence-based parenting practices, followed by the previously validated MINISTOP application for 6-months to support healthy eating and physical activity behaviors. The primary outcome is change in body mass index (BMI) z-score after 9-months and secondary outcomes include: waist circumference, eating behavior (Child Eating Behavior Questionnaire), parenting behavior (Comprehensive Feeding Practices Questionnaire), physical activity (ActiGraph wGT3x-BT), dietary patterns (based onmetabolic markers from urine and 24h dietary recalls), epigenetic and gut hormones (fasting blood samples), and the overall acceptance of the overweight and obesity management in young children (semi-structured interviews). Outcomes are measured at baseline and after: 10-weeks (only BMI z-score, waist circumference), 9-months (all outcomes), 15- and 21-months (all outcomes except physical activity, dietary patterns, epigenetics and gut hormones) post-baseline.DiscussionThis study will evaluate a parent support program for weight management in young children in three European countries. To boost the effect of the ML program the families will be supported by an app for 6-months. If the program is found to be effective, it has the potential to be implemented into routine care to reduce overweight and obesity in young children and the app could prove to be a viable option for sustained effects of the care provided.Trial registrationClinicalTrials.gov NCT03800823; 11 Jan 2019.

Background: Physical activity (PA) is already beneficial at the preschool age. In many countries, young children spend most of their days in the preschool setting, making it a common arena for PA interventions. Mobile health tools are becoming increasingly popular to promote PA in different populations; however, little is known about the interest for and how the preschool setting could incorporate such a tool. Objective: This study aimed to examine how teachers and parents perceive PA in preschool-aged children in general and their perceptions of how a mobile phone app could be used to promote PA in the preschool setting. Methods: Semistructured interviews were conducted with 15 teachers (93%, [14/15] women, mean age 43.5 years, 47%, [7/15] with a university degree and 10 parents [91%, 9/10] women, mean age 38.9 years, all with a university degree) recruited from 2 urban preschools in central Sweden. The interviews were recorded, fully transcribed, coded, and analyzed using thematic analysis by means of an inductive approach. Results: The analysis revealed 4 themes: (1) children are physically active by nature, (2) the environment as a facilitator or a barrier, (3) prerequisites of the adult world, and (4) an app in the preschool setting-challenges and possibilities. Parents and teachers perceived preschoolers as being spontaneously physically active; however, high-intensity PA was perceived as low. The PA was specifically performed during the day in the preschool. Identified facilitators of PA were access to safe and engaging outdoor environments such as forests, spacious indoor areas, and adult involvement. Adult involvement was considered especially important for children preferring sedentary activities. Identified barriers for PA were restricted indoor and outdoor space, rules for indoor activities, and lack of adult involvement because of time constraints. The teachers perceived that they had limited skills and experiences using apps in general, although they also acknowledged the increasing role of technological tools in the curriculum. Thus, the teachers expressed an interest for an app designed as a support tool for them, especially for situations when PA was limited because of perceived barriers. They suggested the app to include accessible information regarding the health benefits of PA in children linked to a library of activities for different settings and seasons. Parents suggested interactive app features including problem-solving tasks and music and dance, but not video clips as they made children passive. Conclusions: Vigorous PA was perceived as low in preschool-aged children. Future tailoring of interventions in the preschool setting should work around barriers and support facilitators to PA, especially PA of high intensity. In such work, an app could serve as a source of inspiration for PA in different ages, settings, and seasons and thus reduce environmental and structural inequalities in the preschool setting.

BACKGROUND:

Physical activity (PA) is already beneficial at the preschool age. In many countries, young children spend most of their days in the preschool setting, making it a common arena for PA interventions. Mobile health tools are becoming increasingly popular to promote PA in different populations; however, little is known about the interest for and how the preschool setting could incorporate such a tool.

OBJECTIVE:

This study aimed to examine how teachers and parents perceive PA in preschool-aged children in general and their perceptions of how a mobile phone app could be used to promote PA in the preschool setting.

METHODS:

Semistructured interviews were conducted with 15 teachers (93%, [14/15] women, mean age 43.5 years, 47%, [7/15] with a university degree and 10 parents [91%, 9/10] women, mean age 38.9 years, all with a university degree) recruited from 2 urban preschools in central Sweden. The interviews were recorded, fully transcribed, coded, and analyzed using thematic analysis by means of an inductive approach.

RESULTS:

The analysis revealed 4 themes: (1) children are physically active by nature, (2) the environment as a facilitator or a barrier, (3) prerequisites of the adult world, and (4) an app in the preschool setting-challenges and possibilities. Parents and teachers perceived preschoolers as being spontaneously physically active; however, high-intensity PA was perceived as low. The PA was specifically performed during the day in the preschool. Identified facilitators of PA were access to safe and engaging outdoor environments such as forests, spacious indoor areas, and adult involvement. Adult involvement was considered especially important for children preferring sedentary activities. Identified barriers for PA were restricted indoor and outdoor space, rules for indoor activities, and lack of adult involvement because of time constraints. The teachers perceived that they had limited skills and experiences using apps in general, although they also acknowledged the increasing role of technological tools in the curriculum. Thus, the teachers expressed an interest for an app designed as a support tool for them, especially for situations when PA was limited because of perceived barriers. They suggested the app to include accessible information regarding the health benefits of PA in children linked to a library of activities for different settings and seasons. Parents suggested interactive app features including problem-solving tasks and music and dance, but not video clips as they made children passive.

CONCLUSIONS:

Vigorous PA was perceived as low in preschool-aged children. Future tailoring of interventions in the preschool setting should work around barriers and support facilitators to PA, especially PA of high intensity. In such work, an app could serve as a source of inspiration for PA in different ages, settings, and seasons and thus reduce environmental and structural inequalities in the preschool setting.

Background: The prevalence of childhood overweight and obesity has increased recently, but the mechanisms involved are incompletely known. Previous research has shown a correlation between the percentage of total body fat (TBF) and physical activity level (PAL). However, the PAL values used may involve a risk of spurious correlations because they are often based on predicted rather than measured estimates of resting energy metabolism. less thanbrgreater than less thanbrgreater thanObjectives: We studied the development of body composition during early childhood and the relation between the percentage of TBF and PAL on the basis of the measured resting energy metabolism. less thanbrgreater than less thanbrgreater thanDesign: Body composition was previously measured in 108 children when they were 1 and 12 wk old. When 44 of these children (21 girls and 23 boys) were 1.5 y old, their total energy expenditure and TBF were assessed by using the doubly labeled water method. Resting energy metabolism, which was assessed by using indirect calorimetry, was used to calculate PAL. less thanbrgreater than less thanbrgreater thanResults: Significant correlations were shown for TBF (r = 0.32, P = 0.035) and fat-free mass (r = 0.34, P = 0.025) between values (kg) assessed at 12 wk and 1.5 y of age. For TBF (kg) a significant interaction (P = 0.035) indicated a possible sex difference. PAL at 1.5 y was negatively correlated with the percentage of TBF (r = -0.40, P = 0.0076) and the increase in the percentage of TBF between 12 wk and 1.5 y (r = 0.38, P = 0.0105). less thanbrgreater than less thanbrgreater thanConclusions: The results indicate that body fatness and physical activity interact during early childhood and thereby influence obesity risk. Our results are based on a small sample, but nevertheless, they motivate additional studies in boys compared with girls regarding the development of body composition during early life.

Aim: To use Pea Pod, a device based on air displacement plethysmography, to study body composition of healthy, full-term infants born to well-nourished women with a western life-style. Methods: Body composition was assessed in 53 girls and 55 boys at 1 week (before 10 days of age) and at 12 weeks (between 77 and 91 days of age). Results: At 1 week girls contained 13.4 +/- 3.7% body fat and boys 12.5 +/- 4.0%. At 12 weeks, these figures were 26.3 +/- 4.2% (girls) and 26.4 +/- 5.1% (boys). Body fat (%) did not differ significantly between the genders. Body fat (%) at the two measurements was not correlated. At 1 week, the weight (r = 0.20, p = 0.044) and BMI (r = 0.26, p = 0.007) of the infants, but not their body fat (g, %) or fat free mass (g), correlated with BMI before pregnancy in their mothers. Conclusions: Pea Pod has potential for use in studies investigating the effect of external (i.e. nutritional status) and internal (i.e. age, gender, gestational age at birth) factors on infant body composition. This may be of value when studying relationships between the nutritional situation during early life and adult health.

Equipment (Pea Pod) for assessing infant body density accurately and conveniently has recently become available. This density can be converted to body composition using the “Fomon” or the “Butte” model. These models differ regarding the water content in fat-free mass (hydration factor, HF). We assessed HF and its biological variability in newborns and compared results calculated using the two models at one and 12 weeks. Body volume and body weight were measured in 12 infants less than 10 days old using Pea Pod. Their total body water was assessed using isotope dilution. Their HF was found to be 80.9% with low biological variability (0.81% of average HF). Further, Pea Pod was used to assess body density of 108 infants at one and 12 weeks of age. Values for body fat (%) calculated using the “Butte” model were significantly lower than when using the “Fomon” model at one week (p<0.05) and 12 weeks (p<0.01). The difference between the two models was particularly large at one week, probably due to their different HF-values. Our HF-value is in agreement with that in the “Fomon” model and our results support the conclusion that this model is preferable when calculating body composition in infants.

Healthy human pregnancy is associated with changes in food intake, body fatness, energy expenditure and insulin resistance. However, available knowledge is limited regarding the physiological basis of these changes. Published evidence suggests that so-called adipokines (i.e. leptin, adiponectin and resistin) have significant roles when such changes are established. We explored, throughout a complete pregnancy, relationships between total body fat (TBF), energy expenditure, insulin resistance (homeostasic model of insulin resistance, HOMA-IR) and serum concentrations of leptin, adiponectin and resistin. Such concentrations were assessed before pregnancy in gestational weeks 8, 14, 20, 32 and 35, and 2 weeks postpartum in twenty-three healthy women. TBF, BMR (n 23) and HOMA-IR (n 17) were assessed before pregnancy in gestational weeks 14 and 32 and 2 weeks postpartum. TBF (%) was correlated with HOMA-IR (r 0.68-0.79, P < 0.01) and with serum leptin (r 0.85-0.88, P < 0.001) before and during pregnancy. Serum leptin was correlated with HOMA-IR (r 0.53-0.70, P < 0.05) before and during pregnancy. Serum adiponectin was inversely correlated with HOMA-IR in gestational week 32 (r - 0.52, P < 0.05). When HOMA-IR was regressed on TBF (%), the slope of the regression line was 0.046 before pregnancy, which was significantly (P < 0.05) different from the corresponding value, 0.111, in gestational week 32. The results indicate that pregnancy has an enhancing effect on the relationship between body fatness and insulin resistance. This effect, possibly mediated by leptin, may represent a mechanism by which offspring size is regulated in response to the nutritional situation of the mother.

During recent decades the prevalence of overweight and obesity in childhood has increased and studies of the mechanisms involved are motivated. Previous research has shown a correlation between total body fat (TBF) (%) and physical activity level (PAL) but the assessment of PAL has often involved a risk for spurious correlations. Thus we compared PAL calculated using basal metabolic rate (BMR) predicted from equations, based on body weight (PALBMR) and associated with a risk for spurious correlations, with PAL calculated using sleeping metabolic rate (SMR) assessed using indirect calorimetry (PALSMR) in 20 healthy children aged 1.5 years. Total energy expenditure and body fatness were assessed using the doubly labelled water method. Body fatness of these children was also assessed at one week and three months of age. PALBMR was significantly (r=-0.48, p=0.03) correlated with TBF (%) while PALSMR was not. Furthermore, the increase in body fatness between three months and 1.5 years was significantly (r=-0.52, p=0.02) correlated with PALSMR at the age of 1.5 years. Our results indicate complex relationships between body fatness and physical activity in early life. When conducting studies in this area, resting energy metabolism should be measured rather than predicted using equations based on body weight.

Background

Ultra-processed food consumption is a risk factor for obesity and has a negative environmental impact. Food companies spend billions of dollars on advertisements each year to increase the consumption of ultra-processed food. In Australia, USA, and New Zealand, most food advertisements around schools and in train stations promote ultra-processed food, but no similar studies have been conducted in Sweden. The aim of this study was to explore the proportion of ultra-processed food advertisements in two districts of Stockholm, Sweden with low vs. high socioeconomic status (SES).

Methods

Two independent researchers (per area) mapped all advertisements, including storefronts, in two Stockholm districts. During consecutive days, all advertisements were photographed in Skärholmen (low SES district), and Östermalmstorg (high SES district), on the streets inside and outside the subway stations, as well as inside and outside of local shopping malls. Advertisements promoting food products were identified and a trained dietician categorized whether they promoted ultra-processed foods. Chi-Square test was conducted to test for differences in the proportion of ultra-processed food advertisements between the two study areas.

Results

In total, 4092 advertisements were photographed in Skärholmen (n = 1935) and Östermalm (n = 2157). 32.8% of all advertisements promoted food, while 65.4% of food advertisements promoted ultra-processed foods. A significantly higher proportion of ultra-processed food advertisements out of total food advertisements was identified in the low SES area, irrespective of the researcher taking the pictures (74.6% vs. 61.8%, p < 0.001 and 70.4% vs. 54.8%, p = 0.001). There was no significant difference in the proportion of food advertisements out of total advertisements between the two areas.

Conclusions

This study provides initial evidence about the scale and the differences in exposure to food advertisements across areas in Stockholm. The observed high proportion of ultra-processed food advertisements is concerning and is in sharp contrast to the Swedish dietary guidelines that recommend reduced consumption of such foods. Based on our results, residents in low SES areas might be more exposed to ultra-processed food advertisements than those in high SES areas in Stockholm. If such findings are confirmed in additional areas, they should be considered during the deployment of food advertisement regulatory actions.

ObjectiveTo explore perceptions among nurses, managers, and policymakers regarding organizational readiness to implement mHealth for the promotion of healthy lifestyle behaviors in child and school healthcare. MethodsIndividual semi-structured interviews with nurses (n = 10), managers (n = 10), and policymakers (n = 8) within child and school healthcare in Sweden. Inductive content analysis was used for data analysis. ResultsData showed that various trust-building aspects in health care organizations may contribute to readiness to implement mHealth. Several aspects were perceived to contribute trusting conditions: (a) how health-related data could be stored and managed; (b) how mHealth aligned with current organizational ways of working; (c) how implementation of mHealth was governed; and (d) camaraderie within a healthcare team to facilitate use of mHealth in practice. Poor capability to manage health-related data, as well as lack of governance of mHealth implementation were described as dealbreakers for readiness to implement mHealth in healthcare organizations. ConclusionsHealthcare professionals and policymakers perceived that trusting conditions for mHealth implementation within organizations were central for readiness. Specifically, governance of mHealth implementation and the ability to manage health-data produced by mHealth were perceived critical for readiness.

Purpose The relation between diet and maternal mental health during pregnancy might be relevant to prevent adverse materno-foetal outcomes. This study examined the association of Mediterranean diet (MD) adherence and MD components with mental health during pregnancy. Methods This secondary analysis of the GESTAFIT trial included longitudinal data from 152 pregnant women. Dietary habits were assessed with a food frequency questionnaire, and MD adherence was derived from it using the Mediterranean Food pattern. Psychological ill-being (i.e., negative affect, anxiety, and depression) and well-being (i.e., emotional intelligence, resilience, positive affect) were assessed with the Spanish version of well-established self-reported questionnaires. Cross-sectional (16th gestational week [g.w.]) and longitudinal associations (34th g.w.) between MD and mental health were studied using linear regression models. Results A greater MD adherence was inversely associated with negative affect and anxiety; and positively associated with emotional regulation, resilience and positive affect at the 16th and 34th g.w. (|beta| ranging from 0.179 to 0.325, all p &lt; 0.05). Additionally, a higher intake of whole grain cereals, fruits, vegetables, fish, olive oil and nuts, and a lower intake of red meat and subproducts and sweets were associated with lower negative affect, anxiety, depression and higher emotional regulation, resilience and positive affect throughout gestation (|beta| ranging from 0.168 to 0.415, all p &lt; 0.05). Conclusion A higher intake of whole grain cereals, fruits, vegetables, fish, olive oil and nuts, together with a lower intake of red meat and sweets, resulted in a higher MD adherence, which was associated with a better mental health during pregnancy.

Aim Obesity may start early in life. We investigated relationships between size and body composition variables in infancy and at 4 years of age using valid estimates of body composition. The results were compared to those obtained when body mass index (BMI) was used to estimate body fatness at 4 years. Methods Using air displacement plethysmography, size, fat mass and fat-free mass were studied, between 2007 and 2015, in 253 full-term healthy Swedish children at 1 week, 12 weeks and 4 years of age. Results Positive associations between variables in infancy and at 4 years were found at 1 and 12 weeks for weight, height, BMI, fat-free mass and fat-free mass index (p amp;lt;= 0.002) and for fat mass, per cent body fat and fat mass index (p amp;lt;= 0.04) at 12 weeks. Fat mass gained during infancy correlated positively (p amp;lt;= 0.031) with per cent fat mass, fat mass index and BMI, all at 4 years. In girls, gains in fat-free mass during infancy correlated with BMI (p = 0.0005) at 4 years. Conclusion The results provide information regarding body composition trajectories during early life and demonstrate limitations of BMI as a proxy for body fatness when relating early weight gain to variables, relevant for later obesity risk.

Childhood overweight and obesity, a worldwide problem, is generally identified using BMI (body mass index). However, this application of BMI has been little investigated in children below 5 years of age due to a lack of appropriate methods to assess body composition. Therefore, we used air displacement plethysmography (ADP) to study 4.4-year old boys and girls since this method is accurate in young children if they accept the requirements of the measurement. The purpose was to analyze the relationship between BMI and body fat in these children. Body composition was assessed in 76 (43 boys, 33 girls) of the 84 children brought to the measurement session. Boys and girls contained 25.2 ± 4.7 and 26.8 ± 4.0% body fat, respectively. BMI-based cut-offs for overweight could not effectively identify children with a high body fat content. There was a significant (P < 0.001) but weak (r = 0.39) correlation between BMI and body fat (%). In conclusion, requirements associated with a successful assessment of body composition by means of ADP were accepted by most 4-year-olds. Furthermore, BMI-based cut-offs for overweight did not effectively identify children with a high body fatness and BMI explained only a small proportion of the variation in body fat (%) in this age group.

A possibility to assess body composition during pregnancy is often important. Estimating body density (D-B) and use the two-component model (2CM) to calculate total body fat (TBF) represents an option. However, this approach has been insufficiently evaluated during pregnancy. We evaluated the 2CM, and estimated fat-free mass (FFM) density and variability in 17 healthy women before pregnancy, in gestational weeks 14 and 32, and 2 weeks postpartum based on D-B (underwater weighing), total body water (deuterium dilution) and body weight, assessed on these four occasions. TBF, calculated using the 2CM and published FFM density (TBF2CM), was compared to reference estimates obtained using the three-component model (TBF3CM). TBF2CM minus TBF3CM (mean +/- 2SD) was -1.63 +/- 5.67 (p = 0.031), -1.39 +/- 7.75 (p = 0.16), -0.38 +/- 4.44 (p = 0.49) and -1.39 +/- 5.22 (p = 0.043) % before pregnancy, in gestational weeks 14 and 32 and 2 weeks postpartum, respectively. The effect of pregnancy on the variability of FFM density was larger in gestational week 14 than in gestational week 32. The 2CM, based on D-B and published FFM density, assessed body composition as accurately in gestational week 32 as in non-pregnant adults. Corresponding values in gestational week 14 were slightly less accurate than those obtained before pregnancy.

Background: Physical activity is associated with health in women. Published MET-values (MET: metabolic equivalent of task) may assess physical activity and energy expenditure but tend to be too low for subjects with a high total body fat (TBF) content and therefore inappropriate for many contemporary women. The MET-value for an activity is the energy expenditure of a subject performing this activity divided by his/her resting energy expenditure, often assumed to be 4.2 kJ/kg/h. Relationships between TBF and MET have been little studied although overweight and obesity is common in women. Available data indicate that MET-values decrease during pregnancy but more studies in pregnant contemporary women are needed. Subjects and methods: Using indirect calorimetry we measured energy expenditure and assessed MET-values in women, 22 non-pregnant (BMI: 18-34) and 22 in gestational week 32 (non-pregnant BMI: 18-32) when resting, sitting, cycling (30 and 60 watts), walking (3.2 and 5.6 km/h) and running (8 km/h). Relationships between TBF and MET-values were investigated and used to predict modified MET-values. The potential of such values to improve calculations of total energy expenditure of women was investigated. Results: The resting energy expenditure was below 4.2 kJ/kg/h in both groups of women. Women in gestational week 32 had a higher resting energy metabolism (p amp;lt; 0.001) and 7-15% lower MET-values (p amp;lt; 0.05) than non-pregnant women. MET-values of all activities were correlated with TBF (p amp;lt; 0.05) in non-pregnant women and modified MET-values improved estimates of total energy expenditure in such women. In pregnant women, correlations (p amp;lt;= 0.03) between TBF and MET were found for running (8 km/h) and for walking at 5.6 km/h. Conclusions: Our results are relevant when attempts are made to modify the MET-system in contemporary pregnant and non-pregnant women. MET-values were decreased in gestational week 32, mainly due to an increased resting energy metabolism and studies describing how body composition affects the one MET-value (i.e. the resting energy metabolism in kJ/kg/h) during pregnancy are warranted. Studies of how pregnancy and TBF affect MET-values of high intensity activities are also needed. Corrections based on TBF may have a potential to improve the MET-system in non-pregnant women.

This review summarizes information regarding how human energy metabolism is affected by pregnancy, and current estimates of energy requirements during pregnancy are presented. Such estimates can be calculated using either increases in basal metabolic rate (BMR) or increases in total energy expenditure (TEE). The two modes of calculation give similar results for a complete pregnancy but different distributions of energy requirements in the three trimesters. Recent information is presented regarding the effect of pregnancy on BMR, TEE, diet-induced thermogenesis, and physical activity. The validity of energy intake (EI) data recendy assessed in well-nourished pregnant women was evaluated using information regarding energy metabolism during pregnancy. The results show that underreporting of EI is common during pregnancy and indicate that additional longitudinal studies, taking the total energy budget during pregnancy into account, are needed to satisfactorily define energy requirements during the three trimesters of gestation. Copyright © 2007 by Annual Reviews. All rights reserved.

Infant birth weight has increased recently, representing an obstetric and potentially a public health problem since high birth weight involves a risk of obesity later in life. Maternal nutritional status is important for fetal growth and therefore relationships between maternal body weight and composition v. birth weight and infant subcutaneous adipose tissue were investigated in twenty-three healthy women and their newborn infants using multiple and simple linear regression analysis. Furthermore, using previously published data for nineteen infants, it was demonstrated that an anthropometric method could provide useful estimates of the amount of subcutaneous adipose tissue. Birth weight was correlated with the maternal content of total body fat (TBF) both before pregnancy and in gestational week 32 and, together with gestational age at birth, TBF (%) before pregnancy explained 45% of the variation in birth weight. This figure was not increased when gestational gains in weight or TBF were added to the model. Furthermore, in infants, birth weight correlated with the amount of their subcutaneous adipose tissue. Together maternal TBF (%) and amount of subcutaneous adipose tissue in infants explained 61–63% of the variation in birth weight while the amount of infant subcutaneous adipose tissue alone explained only 55%. The maternal TBF content is likely to be important for the recent increase in birth weight. This factor probably causes a general augmentation in fetal growth rather than a specific stimulation of adipose tissue growth.

Activity energy expenditure (AEE) during free-living conditions can be assessed using devices based on different principles. To make proper comparisons of different devices' capacities to assess AEE, they should be evaluated in the same population. Thus, in the present study we evaluated, in the same group of subjects, the ability of three devices to assess AEE in groups and individuals during free-living conditions. In twenty women, AEE was assessed using RT3 (three-axial accelerometry) (AEE_RT3), Actiheart (a combination of heart rate and accelerometry) (AEE_Acti) and IDEEA (a multi-accelerometer system) (AEE_IDEEA). Reference AEE (AEE_ref) was assessed using the doubly labelled water method and indirect calorimetry. Average AEE_Acti was 5760 kJ per 24 h and not significantly different from AEE_ref (5020 kJ per 24 h). On average, AEE_RT3 and AEE_IDEEA were 2010 and 1750 kJ per 24 h lower than AEE_ref, respectively (P < 0·001). The limits of agreement (± 2 sd) were 2940 (Actiheart), 1820 (RT3) and 2650 (IDEEA) kJ per 24 h. The variance for AEE_RT3 was lower than for AEE_Acti (P = 0·006). The RT3 classified 60 % of the women in the correct activity category while the corresponding value for IDEEA and Actiheart was 30 %. In conclusion, the Actiheart may be useful for groups and the RT3 for individuals while the IDEEA requires further development. The results are likely to be relevant for a large proportion of Western women of reproductive age and demonstrate that the procedure selected to assess physical activity can greatly influence the possibilities to uncover important aspects regarding interactions between physical activity, diet and health.

Purpose: Interpretation of physical activity as energy expenditure requires adjustment for body size. This is usually accomplished by means of the MET system, which assumes a basal metabolic rate (BMR) of 4.184 kJ·kg -1·h-1 and, when the standard calculation is used, that the energy costs of different activities are proportional to BMR. These relationships may be altered by increases in percent total body fat (% TBF), and this paper examines relationships between % TBF and total energy expenditure (TEE) obtained using the standard and a proposed calculation. Methods: Published data regarding body composition, physical activity (heart rate recording), and BMR in 11 American women (before and after weight gain) and in 15 Swedish women (before and during pregnancy) were used to calculate TEE. Reference estimates of TEE were obtained using doubly labeled water. Results: In Swedish women, reference TEE minus standard TEE (MJ·24 h-1) was 1.37 ± 1.29 (P < 0.01) before and 1.03 ± 1.13 (P < 0.05) during pregnancy. For proposed TEE these differences were 0.43 ± 1.63 (P > 0.05) and 0.31 ± 1.28 (P > 0.05) (MJ·24 h-1), respectively. In American women before and after weight gain, reference TEE minus standard TEE (MJ·24 h-1) were 0.38 ± 1.79 (P > 0.05) and 1.39 ± 2.36 (P > 0.05), respectively, whereas the corresponding differences for proposed TEE (MJ·24 h-1) were -0.52 ± 2.20 (P > 0.05) and 0.21 ± 2.36 (P > 0.05), respectively. In Swedish women before pregnancy and American women after weight gain (N = 26, BMI = 18-39), significant (P < 0.001) relationships were found for standard TEE/proposed TEE (y) versus % TBF, (x, r = -0.65) and versus BMI (x, r = -0.70). Conclusions: In individuals with a TBF content typical for contemporary Western women, standard TEE is lower than proposed TEE. This bias increases as the TBF content of subjects increases. The results indicate that proposed TEE is more accurate than standard TEE, but this requires confirmation. Copyright © 2006 by the American College of Sports Medicine.

Introduction: Obesity is a common comorbidity in fibromyalgia (FM). Both FM and obesity have been connected to low-grade inflammation, although it is possible that previously reported inflammatory alterations in FM primarily may be linked to increased body mass index (BMI). Objective: This study aimed to investigate whether the inflammatory plasma protein profile, muscle blood flow, and metabolism and pain characteristics (clinical parameters and patient-reported outcome measurements) differed between female patients with FM with and without obesity. Methods: Patients with FM underwent clinical examinations, physical tests, and answered questionnaires. They were dichotomized according to BMI (&lt;30 kg/m(2) [n = 14]; &gt;= 30 kg/m(2) [n = 13]). Blood samples were collected and analyzed using a panel of 71 inflammatory plasma proteins. Results: There were significant (P &lt; 0.05) differences in blood pressure, pulse, max VO2, pain intensity, physical capacity, and Fibromyalgia Impact Questionnaire between the groups; the obese group had higher blood pressure, pulse, pain intensity, and Fibromyalgia Impact Questionnaire. There were 14 proteins that contributed to the group belonging. The 4 most important proteins for the group discrimination were MIP1 beta, MCP4, IL1RA, and IL6, which showed higher concentrations in obese patients with FM. Significantly decreased blood flow and increased concentration of pyruvate were detected in obese patients compared with nonobese patients. There was significant correlation between inflammatory proteins and sedentary behavior and health status in obese patients with FM. Conclusions: These findings suggest that metabolism and inflammation interact in female patients with FM with obesity and might cause chronic low-grade inflammation. Screening for obesity and monitoring of BMI changes should be considered in the treatment of patients with FM.

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Background: Dietary intake of phytoestrogens has been inversely associated to hormone-dependent cancers, such as prostate and breast cancers. Few studies have investigated the association between ovarian cancer and intake of phytoestrogens. We evaluated the associations between intake of phytoestrogens (isoflavonoids/lignans/coumestrol) and fiber (vegetable/cereal) and risk of ovarian cancer. Methods: In 1991-1992 a prospective population-based cohort study among Swedish women was conducted, including 47,140 women with complete dietary questionnaire data. During follow-up until December 2007, 163 women developed invasive (n = 117) and borderline (n = 46) ovarian cancers. The median follow-up time was 16 years and total person year was 747,178. Cox proportional hazards models were conducted to estimate multivariate risk ratios, 95% CI for associations with risk of ovarian cancer. Results: We found no association between intake of phytoestrogens or fiber and overall ovarian cancer risk. In addition, we found no statistically significant association between intake of specific food items rich in phytoestrogens (berries, nuts, beans/soy, and crisp or whole-grain bread) and ovarian cancer risk overall. Fiber and coumestrol was inversely associated with borderline ovarian cancer, but not with invasive ovarian cancer. Conclusions: We found no association between intake of phytoestrogens or fiber and overall ovarian cancer risk. Impact: Phytoestrogens do not play a major etiologic role in ovarian cancer, at least among women in this Swedish cohort with low bean/soy intake. However, our results of a difference in the effect of fiber or coumestrol between invasive and borderline ovarian cancer need to be evaluated in larger studies.