OBJECTIVE: the academic and scientific community has reacted at pace to gather evidence to help and inform about COVID-19. Concerns have been raised about the quality of this evidence. The aim of this review was to map the nature, scope and quality of evidence syntheses on COVID-19 and to explore the relationship between review quality and the extent of researcher, policy and media interest. DESIGN AND SETTING: a meta-research: systematic review of reviews. INFORMATION SOURCES: PubMed, Epistemonikos COVID-19 evidence, the Cochrane Library of Systematic Reviews, the Cochrane COVID-19 Study Register, EMBASE, CINAHL, Web of Science Core Collection and the WHO COVID-19 database, searched between 10 June 2020 and 15 June 2020. ELIGIBILITY CRITERIA: Any peer-reviewed article reported as a systematic review, rapid review, overview, meta-analysis or qualitative evidence synthesis in the title or abstract addressing a research question relating to COVID-19. Articles described as meta-analyses but not undertaken as part of a systematic or rapid review were excluded. STUDY SELECTION AND DATA EXTRACTION: Abstract and full text screening were undertaken by two independent reviewers. Descriptive information on review type, purpose, population, size, citation and attention metrics were extracted along with whether the review met the definition of a systematic review according to six key methodological criteria. For those meeting all criteria, additional data on methods and publication metrics were extracted. RISK OF BIAS: for articles meeting all six criteria required to meet the definition of a systematic review, AMSTAR-2 ((A MeaSurement Tool to Assess systematic Reviews, version 2.0) was used to assess the quality of the reported methods. RESULTS: 2334 articles were screened, resulting in 280 reviews being included: 232 systematic reviews, 46 rapid reviews and 2 overviews. Less than half reported undertaking critical appraisal and a third had no reproducible search strategy. There was considerable overlap in topics, with discordant findings. Eighty-eight of the 280 reviews met all six systematic review criteria. of these, just 3 were rated as of moderate or high quality on AMSTAR-2, with the majority having critical flaws: only a third reported registering a protocol, and less than one in five searched named COVID-19 databases. Review conduct and publication were rapid, with 52 of the 88 systematic reviews reported as being conducted within 3 weeks, and a half published within 3 weeks of submission. Researcher and media interest, as measured by altmetrics and citations, was high, and was not correlated with quality. DISCUSSION: This meta-research of early published COVID-19 evidence syntheses found low-quality reviews being published at pace, often with short publication turnarounds. Despite being of low quality and many lacking robust methods, the reviews received substantial attention across both academic and public platforms, and the attention was not related to the quality of review methods. INTERPRETATION: Flaws in systematic review methods limit the validity of a review and the generalisability of its findings. Yet, by being reported as 'systematic reviews', many readers may well regard them as high-quality evidence, irrespective of the actual methods undertaken. The challenge especially in times such as this pandemic is to provide indications of trustworthiness in evidence that is available in 'real time'. PROSPERO REGISTRATION NUMBER: CRD42020188822.

Abstract
. Approximately two-thirds of hospital admissions are older adults and almost half of these are likely to have some form of dementia. People with dementia are not only at an increased risk of adverse outcomes once admitted, but the unfamiliar environment and routinised practices of the wards and acute care can be particularly challenging for them, heightening their confusion, agitation and distress further impacting the ability to optimise their care. It is well established that a person-centred care approach helps alleviate some of the unfamiliar stress but how to embed this in the acute-care setting remains a challenge. In this article, we highlight the challenges that have been recognised in this area and put forward a set of evidence-based ‘pointers for service change’ to help organisations in the delivery of person-centred care. The DEMENTIA CARE pointers cover areas of: dementia awareness and understanding, education and training, modelling of person-centred care by clinical leaders, adapting the environment, teamwork (not being alone), taking the time to ‘get to know’, information sharing, access to necessary resources, communication, involving family (ask family), raising the profile of dementia care, and engaging volunteers. The pointers extend previous guidance, by recognising the importance of ward cultures that prioritise dementia care and institutional support that actively seeks to raise the profile of dementia care. The pointers provide a range of simple to more complex actions or areas for hospitals to help implement person-centred care approaches; however, embedding them within the organisational cultures of hospitals is the next challenge.

IntroductionPatient experience of nursing care is correlated with safety, clinical effectiveness, care quality, treatment outcomes and service use. Effective nursing care includes actions to develop nurse–patient relationships and deliver physical and psychosocial care to patients. The high risk of transmission of the SARS-CoV-2 virus compromises nursing care. No evidence-based nursing guidelines exist for patients infected with SARS-CoV-2, leading to potential variations in patient experience, outcomes, quality and costs.Methods and analysiswe aim to recruit 840 in-patient participants treated for infection with the SARS-CoV-2 virus from 14 UK hospitals, to a cluster randomised controlled trial, with embedded process and economic evaluations, of care as usual and a fundamental nursing care protocol addressing specific areas of physical, relational and psychosocial nursing care where potential variation may occur, compared with care as usual. Our coprimary outcomes are patient-reported experience (Quality from the Patients’ Perspective; Relational Aspects of Care Questionnaire); secondary outcomes include care quality (pressure injuries, falls, medication errors); functional ability (Barthell Index); treatment outcomes (WHO Clinical Progression Scale); depression Patient Health Questionnaire-2 (PHQ-2), anxiety General Anxiety Disorder-2 (GAD-2), health utility (EQ5D) and nurse-reported outcomes (Measure of Moral Distress for Health Care Professionals). For our primary analysis, we will use a standard generalised linear mixed-effect model adjusting for ethnicity of the patient sample and research intensity at cluster level. We will also undertake a planned subgroup analysis to compare the impact of patient-level ethnicity on our primary and secondary outcomes and will undertake process and economic evaluations.Ethics and disseminationResearch governance and ethical approvals are from the UK National Health Service Health Research Authority Research Ethics Service. Dissemination will be open access through peer-reviewed scientific journals, study website, press and online media, including free online training materials on the Open University’s FutureLearn web platform.Trial registration numberISRCTN13177364; Pre-results.

Objectives: Few studies have captured the experiences of family carers who manage the nutritional needs of family members living with dementia at home. The identification and management of symptoms that may affect nutritional status is often reliant upon the family carer. This interpretative phenomenological study aimed to explore the experiences and perceptions of the nutritional care of people living with dementia at home from the perspectives of the family members who support them. Method: Semi-structured interviews were conducted between October 2017 and February 2018. Participants were also asked to keep a diary of experiences for two weeks before the interview. An Interpretative Phenomenological Analysis approach was used throughout. Findings: Eight participants, with a mean age of 69.6 years residing in South West England were recruited and represented a range of familial roles. Following analysis, three superordinate themes were identified: ‘becoming carer and cook’, ‘changing role and relationships’ and ‘emotional eating’. Conclusion: Family carers make food and drink decisions daily, and feel a duty to take on the responsibility for food shopping and cooking. They are conscious about ‘doing the right thing’ when it comes to providing nutritional care, and some feel uncertain about the food choices they are making, particularly regarding a reliance on convenience foods. Changes in appetite, food preferences and mealtime habits related to dementia can lead to disruption affecting the dyad. It is important that family carers and people living at home with dementia are provided with adequate support regarding identifying nutritional risks, making appropriate food and drink choices and preventing the risk of malnutrition in the dyad.

BACKGROUND: Guidance on provision of care for people with dementia states that occupation people find meaningful is essential for well-being; however, definitions of 'meaningful occupation' are often broad, with intrinsic meaning coming from within the person rather than the activity, leading to an inconsistent understanding of its purpose. OBJECTIVES: This study aimed to create a conceptual framework depicting the types of meaning that are seen as stemming from occupation. METHOD: Six electronic databases were searched (CINAHL, PubMed Central, PsycINFO, Embase, AMED, ASSIA) using a pre-specified search strategy to identify qualitative studies relating to meaningful occupation for people living with dementia. From 114 eligible full-text articles, six qualitative studies were identified as sufficiently rich, topically relevant and explicit in their definition of meaningful activity. A further 14 were purposefully sampled for their ability to refute or advance the emerging conceptual framework. The synthesis is based on meta-ethnography and is reported following eMERGe guidance. RESULTS: We found the fundamental purpose of occupation is to support the person living with dementia to feel they are living a meaningful and fulfilling life. Three overlapping concepts were identified: (i) catalytic environment, (ii) meaningful life and (iii) occupation as a tool. CONCLUSION: the framework proposes how occupation could support meaning in multiple ways and considers how these forms of meaning were influenced by the worldviews and values of the individual, and context in which they were experienced. IMPLICATIONS FOR PRACTICE: the conceptual framework offers a consistent theoretical grounding with which to measure effectiveness of meaningful occupation for people living with dementia.

BACKGROUND: Systematic reviews are comprehensive, robust, inclusive, transparent, and reproducible when bringing together the evidence to answer a research question. Various guidelines provide recommendations on the expertise required to conduct a systematic review, where and how to search for literature, and what should be reported in the published review. However, the finer details of the search results are not typically reported to allow the search methods or search efficiency to be evaluated. CASE PRESENTATION: This case study presents a search summary table, containing the details of which databases were searched, which supplementary search methods were used, and where the included articles were found. It was developed and published alongside a recent systematic review. This simple format can be used in future systematic reviews to improve search results reporting. CONCLUSIONS: Publishing a search summary table in all systematic reviews would add to the growing evidence base about information retrieval, which would help in determining which databases to search for which type of review (in terms of either topic or scope), what supplementary search methods are most effective, what type of literature is being included, and where it is found. It would also provide evidence for future searching and search methods research.

BACKGROUND: an increasingly high number of patients admitted to hospital have dementia. Hospital environments can be particularly confusing and challenging for people living with dementia (Plwd) impacting their wellbeing and the ability to optimize their care. Improving the experience of care in hospital has been recognized as a priority, and non-pharmacological interventions including activity interventions have been associated with improved wellbeing and behavioral outcomes for Plwd in other settings. This systematic review aimed at evaluating the effectiveness of activity interventions to improve experience of care for Plwd in hospital. METHODS: Systematic searches were conducted in 16 electronic databases up to October 2019. Reference lists of included studies and forward citation searching were also conducted. Quantitative studies reporting comparative data for activity interventions delivered to Plwd aiming to improve their experience of care in hospital were included. Screening for inclusion, data extraction and quality appraisal were performed independently by two reviewers with discrepancies resolved by discussion with a third where necessary. Standardized mean differences (SMDs) were calculated where possible to support narrative statements and aid interpretation. RESULTS: Six studies met the inclusion criteria (one randomized and five non-randomized uncontrolled studies) including 216 Plwd. Activity interventions evaluated music, art, social, psychotherapeutic, and combinations of tailored activities in relation to wellbeing outcomes. Although studies were generally underpowered, findings indicated beneficial effects of activity interventions with improved mood and engagement of Plwd while in hospital, and reduced levels of responsive behaviors. Calculated SMDs ranged from very small to large but were mostly statistically non-significant. CONCLUSIONS: the small number of identified studies indicate that activity-based interventions implemented in hospitals may be effective in improving aspects of the care experience for Plwd. Larger well-conducted studies are needed to fully evaluate the potential of this type of non-pharmacological intervention to improve experience of care in hospital settings, and whether any benefits extend to staff wellbeing and the wider ward environment.

BACKGROUND: Medication mismanagement is a major cause of both hospital admission and nursing home placement of frail older adults. Medication reviews by community pharmacists aim to maximise therapeutic benefit but also minimise harm. Pharmacist-led medication reviews have been the focus of several systematic reviews, but none have focussed on the home setting. REVIEW METHODS: to determine the effectiveness of pharmacist home visits for individuals at risk of medication-related problems we undertook a systematic review and meta-analysis of randomised controlled trials (RCTs). Thirteen databases were searched from inception to December 2018. Forward and backward citation of included studies was also performed. Articles were screened for inclusion independently by two reviewers. Randomised controlled studies of home visits by pharmacists for individuals at risk of medication-related problems were eligible for inclusion. Data extraction and quality appraisal were performed by one reviewer and checked by a second. Random-effects meta-analyses were performed where sufficient data allowed and narrative synthesis summarised all remaining data. RESULTS: Twelve RCTs (reported in 15 articles), involving 3410 participants, were included in the review. The frequency, content and purpose of the home visit varied considerably. The data from eight trials were suitable for meta-analysis of the effects on hospital admissions and mortality, and from three trials for the effects on quality of life. Overall there was no evidence of reduction in hospital admissions (risk ratio (RR) of 1.01 (95%CI 0.86 to 1.20, I2 = 69.0%, p = 0.89; 8 studies, 2314 participants)), or mortality (RR of 1.01 (95%CI 0.81 to 1.26, I2 = 0%, p = 0.94; 8 studies, 2314 participants)). There was no consistent evidence of an effect on quality of life, medication adherence or knowledge. CONCLUSION: a systematic review of twelve RCTs assessing the impact of pharmacist home visits for individuals at risk of medication related problems found no evidence of effect on hospital admission or mortality rates, and limited evidence of effect on quality of life. Future studies should focus on using more robust methods to assess relevant outcomes.

BACKGROUND: Missed hospital outpatient appointments is a commonly reported problem in healthcare services around the world; for example, they cost the National Health Service (NHS) in the UK millions of pounds every year and can cause operation and scheduling difficulties worldwide. In 2002, the World Health Organization (WHO) published a report highlighting the need for a model of care that more readily meets the needs of people with chronic conditions. Patient-initiated appointment systems may be able to meet this need at the same time as improving the efficiency of hospital appointments. OBJECTIVES: to assess the effects of patient-initiated appointment systems compared with consultant-led appointment systems for people with chronic or recurrent conditions managed in secondary care. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and six other databases. We contacted authors of identified studies and conducted backwards and forwards citation searching. We searched for current/ongoing research in two trial registers. Searches were run on 13 March 2019. SELECTION CRITERIA: We included randomised trials, published and unpublished in any language that compared the use of patient-initiated appointment systems to consultant-led appointment systems for adults with chronic or recurrent conditions managed in secondary care if they reported one or more of the following outcomes: physical measures of health status or disease activity (including harms), quality of life, service utilisation or cost, adverse effects, patient or clinician satisfaction, or failures of the 'system'. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all references at title/abstract stage and full-text stage using prespecified inclusion criteria. We resolved disagreements though discussion. Two review authors independently completed data extraction for all included studies. We discussed and resolved discrepancies with a third review author. Where needed, we contacted authors of included papers to provide more information. Two review authors independently assessed the risk of bias using the Cochrane Effective Practice and Organisation of Care 'Risk of bias' tool, resolving any discrepancies with a third review author. Two review authors independently assessed the certainty of the evidence using GRADE. MAIN RESULTS: the 17 included randomised trials (3854 participants; mean age 41 to 76 years; follow-up 12 to 72 months) covered six broad health conditions: cancer, rheumatoid arthritis, asthma, chronic obstructive pulmonary disease, psoriasis and inflammatory bowel disease. The certainty of the evidence using GRADE ratings was mainly low to very low. The results suggest that patient-initiated clinics may make little or no difference to anxiety (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.68 to 1.12; 5 studies, 1019 participants; low-certainty evidence) or depression (OR 0.79 95% CI 0.51 to 1.23; 6 studies, 1835 participants; low-certainty evidence) compared to the consultant-led appointment system. The results also suggest that patient-initiated clinics may make little or no difference to quality of life (standardised mean difference (SMD) 0.12, 95% CI 0.00 to 0.25; 7 studies, 1486 participants; low-certainty evidence) compared to the consultant-led appointment system. Results for service utilisation (contacts) suggest there may be little or no difference in service utilisation in terms of contacts between the patient-initiated and consultant-led appointment groups; however, the effect is not certain as the rate ratio ranged from 0.68 to 3.83 across the studies (median rate ratio 1.11, interquartile (IQR) 0.93 to 1.37; 15 studies, 3348 participants; low-certainty evidence). It is uncertain if service utilisation (costs) are reduced in the patient-initiated compared to the consultant-led appointment groups (8 studies, 2235 participants; very low-certainty evidence). The results suggest that adverse events such as relapses in some conditions (inflammatory bowel disease and cancer) may have little or no reduction in the patient-initiated appointment group in comparison with the consultant-led appointment group (MD -0.20, 95% CI -0.54 to 0.14; 3 studies, 888 participants; low-certainty evidence). The results are unclear about any differences the intervention may make to patient satisfaction (SMD 0.05, 95% CI -0.41 to 0.52; 2 studies, 375 participants) because the certainty of the evidence is low, as each study used different questions to collect their data at different time points and across different health conditions. Some areas of risk of bias across all the included studies was consistently high (i.e. for blinding of participants and personnel and blinding of outcome assessment, other areas were largely of low risk of bias or were affected by poor reporting making the assessment unclear). AUTHORS' CONCLUSIONS: Patient-initiated appointment systems may have little or no effect on patient anxiety, depression and quality of life compared to consultant-led appointment systems. Other aspects of disease status and experience also appear to show little or no difference between patient-initiated and consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on service utilisation in terms of service contact and there is uncertainty about costs compared to consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on adverse events such as relapse or patient satisfaction compared to consultant-led appointment systems.

. Background
. Being in hospital can be particularly confusing and challenging not only for people living with dementia, but also for their carers and the staff who care for them. Improving the experience of care for people living with dementia in hospital has been recognised as a priority.
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. Objectives
. To understand the experience of care in hospital for people living with dementia, their carers and the staff who care for them and to assess what we know about improving the experience of care.
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. Review methods
. We undertook three systematic reviews: (1) the experience of care in hospital, (2) the experience of interventions to improve care in hospital and (3) the effectiveness and cost-effectiveness of interventions to improve the experience of care. Reviews 1 and 2 sought primary qualitative studies and were analysed using meta-ethnography. Review 3 sought comparative studies and economic evaluations of interventions to improve experience of care. An interweaving approach to overarching synthesis was used to integrate the findings across the reviews.
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. Data sources
. Sixteen electronic databases were searched. Forwards and backwards citation chasing, author contact and grey literature searches were undertaken. Screening of title and abstracts and full texts was performed by two reviewers independently. A quality appraisal of all included studies was undertaken.
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. Results
. Sixty-three studies (reported in 82 papers) were included in review 1, 14 studies (reported in 16 papers) were included in review 2, and 25 studies (reported in 26 papers) were included in review 3. A synthesis of review 1 studies found that when staff were delivering more person-centred care, people living with dementia, carers and staff all experienced this as better care. The line of argument, which represents the conceptual findings as a whole, was that ‘a change of hospital culture is needed before person-centred care can become routine’. From reviews 2 and 3, there was some evidence of improvements in experience of care from activities, staff training, added capacity and inclusion of carers. In consultation with internal and external stakeholders, the findings from the three reviews and overarching synthesis were developed into 12 DEMENTIA CARE pointers for service change: key institutional and environmental practices and processes that could help improve experience of care for people living with dementia in hospital.
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. Limitations
. Few of the studies explored experience from the perspectives of people living with dementia. The measurement of experience of care across the studies was not consistent. Methodological variability and the small number of intervention studies limited the ability to draw conclusions on effectiveness.
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. Conclusions
. The evidence suggests that, to improve the experience of care in hospital for people living with dementia, a transformation of organisational and ward cultures is needed that supports person-centred care and values the status of dementia care. Changes need to cut across hierarchies and training systems to facilitate working patterns and interactions that enable both physical and emotional care of people living with dementia in hospital. Future research needs to identify how such changes can be implemented, and how they can be maintained in the long term. To do this, well-designed controlled studies with improved reporting of methods and intervention details to elevate the quality of available evidence and facilitate comparisons across different interventions are required.
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. Study registration
. This study is registered as PROSPERO CRD42018086013.
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. Funding
. This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 43. See the NIHR Journals Library website for further project information. Additional funding was provided by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.
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Background: People living with dementia at home are a group who are at increased risk of malnutrition. Health care professionals and home care workers, are ideally placed to support nutritional care in this vulnerable group. Yet, few, if any studies, have captured the experiences of these workers in respect of treating and managing nutritional issues. This interpretative phenomenological study aimed to explore the experiences and perceptions of the nutritional care of people living with dementia at home from the perspectives of health care professionals and home care workers. Methods: Semi-structured interviews were conducted between December 2017 and March 2018, and supplemented with the use of a vignette outlining a scenario of a husband caring for his wife with dementia. Health care professionals and home care workers were purposively recruited from local care providers in the south west of England, who had experience of working with people with dementia. An Interpretative Phenomenological Analysis (IPA) approach was used throughout. Results: Seven participants took part including two home care workers, a general practitioner, dietitian, occupational therapist, nurse and social worker. The time in their professions ranged from 3 to 15 years (mean = 8.9 years). Following analysis, four superordinate themes were identified: 'responsibility to care', 'practice restrained by policy', 'in it together', and 'improving nutritional care'. This group of health care professionals and home care workers recognised the importance of improving nutritional care for people living with dementia at home, and felt a responsibility for it. However they felt that they were restricted by time and/or knowledge. The importance of supporting the family carer and working collaboratively was highlighted. Conclusions: Health care professionals and home care workers require further training to better equip them to provide nutritional care for people living with dementia at home. Models of care may also need to be adapted to enable a more flexible and tailored approach to incorporate nutritional care. Future work in this area should focus on how health care professionals and home care workers can be better equipped to screen for malnutrition, and support changes to nutritional intake to mitigate malnutrition risk.

BACKGROUND: Robopets are small animal-like robots which have the appearance and behavioural characteristics of pets. OBJECTIVE: to bring together the evidence of the experiences of staff, residents and family members of interacting with robopets and the effects of robopets on the health and well-being of older people living in care homes. DESIGN: Systematic review of qualitative and quantitative research. DATA SOURCES: We searched 13 electronic databases from inception to July 2018 and undertook forward and backward citation chasing. METHODS: Eligible studies reported the views and experiences of robopets from residents, family members and staff (qualitative studies using recognised methods of qualitative data collection and analysis) and the effects of robopets on the health and well-being of care home residents (randomised controlled trials, randomised crossover trials and cluster randomised trials). Study selection was undertaken independently by two reviewers. We used the Wallace criteria and the Cochrane Risk of Bias tool to assess the quality of the evidence. We developed a logic model with stakeholders and used this as a framework to guide data extraction and synthesis. Where appropriate, we used meta-analysis to combine effect estimates from quantitative studies. RESULTS: Nineteen studies (10 qualitative, 2 mixed methods and 7 randomised trials) met the inclusion criteria. Interactions with robopets were described as having a positive impact on aspects of well-being including loneliness, depression and quality of life by residents and staff, although there was no corresponding statistically significant evidence from meta-analysis for these outcomes. Meta-analysis showed evidence of a reduction in agitation with the robopet "Paro" compared to control (-0.32 [95% CI -0.61 to -0.04, p = 0.03]). Not everyone had a positive experience of robopets. CONCLUSIONS: Engagement with robopets appears to have beneficial effects on the health and well-being of older adults living in care homes, but not all chose to engage. Whether the benefits can be sustained are yet to be investigated. IMPLICATIONS FOR PRACTICE: Robopets have the potential to benefit people living in care homes, through increasing engagement and interaction. With the robopet acting as a catalyst, this engagement and interaction may afford comfort and help reduce agitation and loneliness.

CLINICAL QUESTION: Do dietary interventions, such as probiotics, improve pain in children with recurrent abdominal pain? CLINICAL APPLICATION: Compared with placebo, children who were treated with probiotic preparations were more likely to experience improvement in pain in the short term (odds ratio, 1.63; 95% CI, 1.07-2.47), suggesting that clinicians could consider probiotics as part of a holistic management strategy in recurrent abdominal pain.

The aim of this systematic review was to explore the effects and experiences of parent-to-parent support in neonatal intensive care from the perspectives of those giving, receiving, or implementing support. Electronic database searches (14 databases; February 2018) were supplemented with forward and backward citation chasing. Study selection, data extraction and quality appraisal were performed independently by two reviewers. Fourteen studies (6 quantitative and 8 qualitative) met our inclusion criteria. Four major themes were identified in the qualitative literature: ‘trust’, ‘hope’, ‘information’, and ‘connecting’. Quantitative studies showed parent-to-parent support increased perceptions of support, reduced maternal stress, and increased mothers' confidence in the ability to care for their baby. Whilst the rich qualitative evidence suggested mostly positive experiences of parent-to-parent support from all perspectives, robust trial evidence was lacking. Furthermore, differences in models for implementing parent-to-parent support provided limited opportunities to develop recommendations to guide best practice. The protocol for this study was registered on PROSPERO, registration number CRD42018090569.

BACKGROUND: Qualitative research in dementia improves understanding of the experience of people affected by dementia. Searching databases for qualitative studies is problematic. Qualitative-specific search strategies might help with locating studies. OBJECTIVE: to examine the effectiveness (sensitivity and precision) of 5 qualitative strategies on locating qualitative research studies in dementia in 4 major databases (MEDLINE, EMBASE, PsycINFO, and CINAHL). METHODS: Qualitative dementia studies were checked for inclusion on MEDLINE, EMBASE, PsycINFO, and CINAHL. Five qualitative search strategies (subject headings, simple free-text terms, complex free-text terms, and 2 broad-based strategies) were tested for study retrieval. Specificity, precision and number needed to read were calculated. RESULTS: Two hundred fourteen qualitative studies in dementia were included. PsycINFO and CINAHL held the most qualitative studies out the 4 databases studied (N = 171 and 166, respectively) and both held unique records (N = 14 and 7, respectively). The controlled vocabulary strategy in CINAHL returned 96% (N = 192) of studies held; by contrast, controlled vocabulary in PsycINFO returned 7% (N = 13) of studies held. The broad-based strategies returned more studies (93-99%) than the other free-text strategies (22-82%). Precision ranged from 0.061 to 0.004 resulting in a number needed to read to obtain 1 relevant study ranging from 16 (simple free-text search in CINAHL) to 239 (broad-based search in EMBASE). CONCLUSION: Qualitative search strategies using 3 broad terms were more sensitive than long complex searches. The controlled vocabulary for qualitative research in CINAHL was particularly effective. Furthermore, results indicate that MEDLINE and EMBASE offer little benefit for locating qualitative dementia research if CINAHL and PSYCINFO are also searched.

BACKGROUND: Parents of babies admitted to neonatal units experience an arduous emotional journey. Feelings of helplessness, fear, sadness, guilt, grief and anger are common. These feelings can lead to anxiety, depression and post-traumatic stress which may persist long after discharge from the unit. Support from a parent with first-hand experience able to empathise with problems and challenges may help. This systematic review will identify quantitative and qualitative evidence to address the role of parent-to-parent support interventions for families of babies cared for in neonatal units, and combine the findings in an integrated synthesis. METHODS: We are working in collaboration with a study-specific Parent Advisory Group (PAG) of parents who have relevant and varied lived experience of having a baby in neonatal care and those who have been involved in providing peer support. With the PAG, we will carry out a systematic review bringing together all existing research on parent-to-parent support for parents of babies cared for in neonatal units. This will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The protocol has been produced in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol extension (PRISMA-P). We have co-produced a plain language protocol summary with the PAG which details the different stages of the project, and this is available via our website ( http://clahrc-peninsula.nihr.ac.uk/research/parent-to-parent-support ) for anyone interested in learning more about the detail of the project. DISCUSSION: all outputs will be available on the NIHR CLAHRC South West Peninsula (PenCLAHRC) website and promoted via PenCLAHRC networks as well as organisations that have been contacted throughout the project. PAG members will be involved in writing and reviewing the academic paper and final report and in co-producing dissemination products such as plain language summaries. The PAG will influence the main conclusions of the systematic review, aid interpretation and help to communicate results in the most appropriate ways. We will hold an impact conference with representatives from neonatal units, national neonatal networks, commissioners of services and parents to discuss what the findings mean for clinical practice and service provision. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018090569.

OBJECTIVES: Between 4% and 25% of school-aged children complain of recurrent abdominal pain (RAP) severe enough to interfere with their daily activities. METHODS: We carried out a systematic review of randomised controlled trials (RCTs) in eleven databases and 2 trials registries from inception to June 2016. An update search was run in November 2017. All screening was performed by 2 independent reviewers. Included studies were appraised using the Cochrane risk of bias tool and the evidence assessed using GRADE. We included any dietary, pharmacological or psychosocial intervention for RAP, defined by Apley or an abdominal pain-related functional gastrointestinal disorder, as defined by the Rome III criteria, in children and adolescents. RESULTS: We included 55 RCTs, involving 3572 children with RAP (21 dietary, 15 pharmacological, 19 psychosocial, and 1 multiarm). We found probiotic diets, cognitive-behavioural therapy (CBT) and hypnotherapy were reported to reduce pain in the short-term and there is some evidence of medium term effectiveness. There was insufficient evidence of effectiveness for all other dietary interventions and psychosocial therapies. There was no robust evidence of effectiveness for pharmacological interventions. CONCLUSIONS: Overall the evidence base for treatment decisions is poor. These data suggest that probiotics, CBT, and hypnotherapy could be considered as part of holistic management of children with RAP. The evidence regarding relative effectiveness of different strains of probiotics is currently insufficient to guide clinical practice. The lack of evidence of effectiveness for any drug suggests that there is little justification for their use outside of well-conducted clinical trials. There is an urgent need for high-quality RCTs to provide evidence to guide management of this common condition.

There are an increasing number of people with dementia living in their own home for longer, often supported by a family member. The symptoms of dementia can affect an individual's nutritional status, which can lead to a reduced quality of life for the person with dementia and their family members. A scoping review was conducted from July 2016 until September 2016, using a recognised framework, to explore what is currently known, and identify any gaps in the research regarding the nutritional care of people living with dementia at home. This included any interventions that may have been trialled or implemented, and the views of those living with dementia, carers and clinicians. Six electronic databases were searched from inception to July 2016. A review team was involved in screening and data extraction for selected articles. Published qualitative and quantitative studies were included that explored the nutritional care of people living with dementia at home. Methods included data extraction and conventional content analysis. Stakeholders were involved in the development of final categories. Following screening, 61 studies reported in 63 articles were included. Most studies were cross-sectional (n = 24), cohort (n = 15) or qualitative (n = 9). Only three were randomised controlled trials. Three overarching categories represented the results: Timely identification of nutritional risk and subsequent regular monitoring of nutritional status, multi-component tailored interventions and the influence of the care-giving dyad on nutritional status. Many studies identify people living at home with dementia as a vulnerable group prone to malnutrition; however, a lack of interventions exists to address the increased risk. There is a lack of research exploring the role of home care providers and healthcare professionals in the provision of nutritional care. Further research is required to explore how the emotional aspect of the care-giving dyad influences nutritional care.

Addressing problems associated with malnutrition in care home residents has been prioritized by researchers and decision-makers. This review aimed to better understand factors that may contribute to malnutrition by examining the attitudes, perceptions and experiences of mealtimes among care home residents and staff. Five databases were searched from inception to November 2015: Medline, Embase, PsychINFO, AMED, and the Cochrane Database. Forward and backward citation checking of included articles was conducted. Titles, abstracts, and full texts were screened independently by two reviewers and quality was assessed using the Wallace criteria. Thematic analysis of extracted data was undertaken. Fifteen studies were included in the review, encompassing the views and opinions of a total of 580 participants set in nine different countries. Four main themes were identified: (1) organizational and staff support, (2) resident agency, (3) mealtime culture, and (4) meal quality and enjoyment. Organizational and staff support was an over-arching theme, impacting all aspects of the mealtime experience. Mealtimes are a pivotal part of care home life, providing structure to the day and generating opportunities for conversation and companionship. Enhancing the mealtime experience for care home residents needs to take account of the complex needs of residents while also creating an environment in which individual care can be provided in a communal setting. PROSPERO Registration: CRD42015025890.

BACKGROUND: This is an update of the original Cochrane review, last published in 2009 (Huertas-Ceballos 2009). Recurrent abdominal pain (RAP), including children with irritable bowel syndrome, is a common problem affecting between 4% and 25% of school-aged children. For the majority of such children, no organic cause for their pain can be found on physical examination or investigation. Many dietary inventions have been suggested to improve the symptoms of RAP. These may involve either excluding ingredients from the diet or adding supplements such as fibre or probiotics. OBJECTIVES: to examine the effectiveness of dietary interventions in improving pain in children of school age with RAP. SEARCH METHODS: We searched CENTRAL, Ovid MEDLINE, Embase, eight other databases, and two trials registers, together with reference checking, citation searching and contact with study authors, in June 2016. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing dietary interventions with placebo or no treatment in children aged five to 18 years with RAP or an abdominal pain-related, functional gastrointestinal disorder, as defined by the Rome III criteria (Rasquin 2006). DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We grouped dietary interventions together by category for analysis. We contacted study authors to ask for missing information and clarification, when needed. We assessed the quality of the evidence for each outcome using the GRADE approach. MAIN RESULTS: We included 19 RCTs, reported in 27 papers with a total of 1453 participants. Fifteen of these studies were not included in the previous review. All 19 RCTs had follow-up ranging from one to five months. Participants were aged between four and 18 years from eight different countries and were recruited largely from paediatric gastroenterology clinics. The mean age at recruitment ranged from 6.3 years to 13.1 years. Girls outnumbered boys in most trials. Fourteen trials recruited children with a diagnosis under the broad umbrella of RAP or functional gastrointestinal disorders; five trials specifically recruited only children with irritable bowel syndrome. The studies fell into four categories: trials of probiotic-based interventions (13 studies), trials of fibre-based interventions (four studies), trials of low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diets (one study), and trials of fructose-restricted diets (one study).We found that children treated with probiotics reported a greater reduction in pain frequency at zero to three months postintervention than those given placebo (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.98 to -0.12; 6 trials; 523 children). There was also a decrease in pain intensity in the intervention group at the same time point (SMD -0.50, 95% CI -0.85 to -0.15; 7 studies; 575 children). However, we judged the evidence for these outcomes to be of low quality using GRADE due to an unclear risk of bias from incomplete outcome data and significant heterogeneity.We found that children treated with probiotics were more likely to experience improvement in pain at zero to three months postintervention than those given placebo (odds ratio (OR) 1.63, 95% CI 1.07 to 2.47; 7 studies; 722 children). The estimated number needed to treat for an additional beneficial outcome (NNTB) was eight, meaning that eight children would need to receive probiotics for one to experience improvement in pain in this timescale. We judged the evidence for this outcome to be of moderate quality due to significant heterogeneity.Children with a symptom profile defined as irritable bowel syndrome treated with probiotics were more likely to experience improvement in pain at zero to three months postintervention than those given placebo (OR 3.01, 95% CI 1.77 to 5.13; 4 studies; 344 children). Children treated with probiotics were more likely to experience improvement in pain at three to six months postintervention compared to those receiving placebo (OR 1.94, 95% CI 1.10 to 3.43; 2 studies; 224 children). We judged the evidence for these two outcomes to be of moderate quality due to small numbers of participants included in the studies.We found that children treated with fibre-based interventions were not more likely to experience an improvement in pain at zero to three months postintervention than children given placebo (OR 1.83, 95% CI 0.92 to 3.65; 2 studies; 136 children). There was also no reduction in pain intensity compared to placebo at the same time point (SMD -1.24, 95% CI -3.41 to 0.94; 2 studies; 135 children). We judged the evidence for these outcomes to be of low quality due to an unclear risk of bias, imprecision, and significant heterogeneity.We found only one study of low FODMAP diets and only one trial of fructose-restricted diets, meaning no pooled analyses were possible.We were unable to perform any meta-analyses for the secondary outcomes of school performance, social or psychological functioning, or quality of daily life, as not enough studies included these outcomes or used comparable measures to assess them.With the exception of one study, all studies reported monitoring children for adverse events; no major adverse events were reported. AUTHORS' CONCLUSIONS: Overall, we found moderate- to low-quality evidence suggesting that probiotics may be effective in improving pain in children with RAP. Clinicians may therefore consider probiotic interventions as part of a holistic management strategy. However, further trials are needed to examine longer-term outcomes and to improve confidence in estimating the size of the effect, as well as to determine the optimal strain and dosage. Future research should also explore the effectiveness of probiotics in children with different symptom profiles, such as those with irritable bowel syndrome.We found only a small number of trials of fibre-based interventions, with overall low-quality evidence for the outcomes. There was therefore no convincing evidence that fibre-based interventions improve pain in children with RAP. Further high-quality RCTs of fibre supplements involving larger numbers of participants are required. Future trials of low FODMAP diets and other dietary interventions are also required to facilitate evidence-based recommendations.

BACKGROUND: the need to better understand implementing evidence-informed dementia care has been recognised in multiple priority-setting partnerships. The aim of this scoping review was to give an overview of the state of the evidence on implementation and dissemination of dementia care, and create a systematic evidence map. METHODS: We sought studies that addressed dissemination and implementation strategies or described barriers and facilitators to implementation across dementia stages and care settings. Twelve databases were searched from inception to October 2015 followed by forward citation and grey literature searches. Quantitative studies with a comparative research design and qualitative studies with recognised methods of data collection were included. Titles, abstracts and full texts were screened independently by two reviewers with discrepancies resolved by a third where necessary. Data extraction was performed by one reviewer and checked by a second. Strategies were mapped according to the ERIC compilation. RESULTS: Eighty-eight studies were included (30 quantitative, 34 qualitative and 24 mixed-methods studies). Approximately 60% of studies reported implementation strategies to improve practice: training and education of professionals (94%), promotion of stakeholder interrelationships (69%) and evaluative strategies (46%) were common; financial strategies were rare (15%). Nearly 70% of studies reported barriers or facilitators of care practices primarily within residential care settings. Organisational factors, including time constraints and increased workload, were recurrent barriers, whereas leadership and managerial support were often reported to promote implementation. Less is known about implementation activities in primary care and hospital settings, or the views and experiences of people with dementia and their family caregivers. CONCLUSION: This scoping review and mapping of the evidence reveals a paucity of robust evidence to inform the successful dissemination and implementation of evidence-based dementia care. Further exploration of the most appropriate methods to evaluate and report initiatives to bring about change and of the effectiveness of implementation strategies is necessary if we are to make changes in practice that improve dementia care.

BACKGROUND: Many interventions aim to alleviate well-documented problems of malnutrition in residential care homes and improve residents' health and wellbeing. Despite some positive findings, little is known about how and why mealtime interventions might be effective, and in particular, what effects residents' experiences of mealtimes have on health outcomes. The aim of this study was to gain an insight into these experiences and explore some of the issues that may impact on residents' enjoyment of meals, and resulting health and wellbeing. METHODS: Semi-structured interviews were conducted with eleven residents from four care homes in the South West UK. Thematic analysis was used to derive content and meaning from transcribed interviews. Interviews were supplemented by researcher observations of mealtimes. RESULTS: the dining experience was a focal point for participants' broader experiences of residing in a care home. Three themes pertaining to residents' experiences were identified: (1) Emotional and psychological connections with other residents; (2) managing competing interests with limited resources; and (3) familiarity and routine. CONCLUSION: Mealtimes are a mainstay of life in a care home through which residents' experiences are characterised, exemplified and magnified. Understanding how residents interact with one another, accommodating their preferences and encouraging autonomy may enhance their mealtime experiences. It may also help to ease the transition from independent-living to life in care, which can be particularly stressful for some residents, and improve health and wellbeing over the long-term.

BACKGROUND: Heart rate variability (HRV) is considered to explain improvements in cardiovascular health accrued by physical activity (PA) and cardiorespiratory fitness (CRF) over and above traditional cardiovascular risk factors. OBJECTIVE: to systematically address associations between HRV, PA and CRF in children and adolescents. DATA SOURCES: Medline, EMBASE, SportDISCUS and CINAHL Plus were searched on 5th September 2015 and updated on 4th August 2016. ELIGIBILITY CRITERIA: Observational studies comparing HRV in different groups of PA and CRF, and/or studies investigating associations between PA, CRF and HRV. Sports practices and PA intensities were also included. The square root of the mean of the sum of the squares of differences between adjacent RR intervals (RMSSD), the spectral density in the high (HF) and low (LF) frequency, and the LF/HF ratio were included. Risk of bias was assessed using the adapted Newcastle-Ottawa Scale (NOS). RESULTS: Heterogeneity exists in the assessment of the exposures and outcomes, and sample characteristics. Risk of bias (NOS) was observed in most of the studies. Studies with low risk of bias showed positive associations between moderate-to-vigorous PA and RMSSD. The evidence for the associations between PA and frequency indices is weak. Similarly, the evidence for the association between CRF and HRV is weak. CONCLUSIONS: Despite the heterogeneity in the studies, moderate-to-vigorous PA is positively associated with RMSSD, but less clear are the associations between CRF and HRV, as well as other PA intensities. Further research is needed to clarify the role of PA and CRF on HRV in children and adolescents.

Background: Between 4% and 25% of school-aged children at some stage complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with their daily lives. When no clear organic cause is found, the children are managed with reassurance and simple measures; a large range of pharmacological interventions have been recommended for use in these children. Objectives: to determine the effectiveness of pharmacological interventions for RAP in children of school age. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase, and eight other electronic databases up to June 2016. We also searched two trials registers and contacted researchers of published studies. Selection criteria: Randomised controlled trials involving children aged five to 18 years old with RAP or an abdominal pain-related functional gastrointestinal disorder, as defined by the Rome III criteria (Rasquin 2006). The interventions were any pharmacological intervention compared to placebo, no treatment, waiting list, or standard care. The primary outcome measures were pain intensity, pain duration or pain frequency, and improvement in pain. The secondary outcome measures were school performance, social or psychological functioning, and quality of daily life. Data collection and analysis: Two review authors independently screened titles, abstracts, and potentially relevant full-text reports for eligible studies. Two review authors extracted data and performed a 'Risk of bias' assessment. We used the GRADE approach to rate the overall quality of the evidence. We deemed a meta-analysis to be not appropriate as the studies were significantly heterogeneous. We have consequently provided a narrative summary of the results. Main results: This review included 16 studies with a total of 1024 participants aged between five and 18 years, all of whom were recruited from paediatric outpatient clinics. Studies were conducted in seven countries: seven in the USA, four in Iran, and one each in the UK, Switzerland, Turkey, Sri Lanka, and India. Follow-up ranged from two weeks to four months. The studies examined the following interventions to treat RAP: tricyclic antidepressants, antibiotics, 5-HT4 receptor agonists, antispasmodics, antihistamines, H2 receptor antagonists, serotonin antagonists, selective serotonin re-uptake inhibitors, a dopamine receptor antagonist, and a hormone. Although some single studies reported that treatments were effective, all of these studies were either small or had key methodological weaknesses with a substantial risk of bias. None of these 'positive' results have been reproduced in subsequent studies. We judged the evidence of effectiveness to be of low quality. No adverse effects were reported in these studies. Authors' conclusions: There is currently no convincing evidence to support the use of drugs to treat RAP in children. Well-conducted clinical trials are needed to evaluate any possible benefits and risks of pharmacological interventions. In practice, if a clinician chooses to use a drug as a 'therapeutic trial', they and the patient need to be aware that RAP is a fluctuating condition and any 'response' may reflect the natural history of the condition or a placebo effect, rather than drug efficacy.

BACKGROUND: This review supersedes the original Cochrane review first published in 2008 (Huertas-Ceballos 2008).Between 4% and 25% of school-aged children complain of recurrent abdominal pain (RAP) severe enough to interfere with their daily activities. No organic cause for this pain can be found on physical examination or investigation for the majority of such children. Although many children are managed by reassurance and simple measures, a large range of psychosocial interventions involving cognitive and behavioural components have been recommended. OBJECTIVES: to determine the effectiveness of psychosocial interventions for reducing pain in school-aged children with RAP. SEARCH METHODS: in June 2016 we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the references of identified studies and relevant reviews. SELECTION CRITERIA: Randomised controlled trials comparing psychosocial therapies with usual care, active control, or wait-list control for children and adolescents (aged 5 to 18 years) with RAP or an abdominal pain-related functional gastrointestinal disorder defined by the Rome III criteria were eligible for inclusion. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Five review authors independently selected studies, assessed them for risk of bias, and extracted relevant data. We also assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: This review includes 18 randomised controlled trials (14 new to this version), reported in 26 papers, involving 928 children and adolescents with RAP between the ages of 6 and 18 years. The interventions were classified into four types of psychosocial therapy: cognitive behavioural therapy (CBT), hypnotherapy (including guided imagery), yoga, and written self-disclosure. The studies were carried out in the USA, Australia, Canada, the Netherlands, Germany, and Brazil. The majority of the studies were small and short term; only two studies included more than 100 participants, and only five studies had follow-up assessments beyond six months. Small sample sizes and the degree of assessed risk of performance and detection bias in many studies led to the overall quality of the evidence being rated as low to very low for all outcomes.For CBT compared to control, we found evidence of treatment success postintervention (odds ratio (OR) 5.67, 95% confidence interval (CI) 1.18 to 27.32; Z = 2.16; P = 0.03; 4 studies; 175 children; very low-quality evidence), but no evidence of treatment success at medium-term follow-up (OR 3.08, 95% CI 0.93 to 10.16; Z = 1.85; P = 0.06; 3 studies; 139 children; low-quality evidence) or long-term follow-up (OR 1.29, 95% CI 0.50 to 3.33; Z = 0.53; P = 0.60; 2 studies; 120 children; low-quality evidence). We found no evidence of effects of intervention on pain intensity scores measured postintervention (standardised mean difference (SMD) -0.33, 95% CI -0.74 to 0.08; 7 studies; 405 children; low-quality evidence), or at medium-term follow-up (SMD -0.32, 95% CI -0.85 to 0.20; 4 studies; 301 children; low-quality evidence).For hypnotherapy (including studies of guided imagery) compared to control, we found evidence of greater treatment success postintervention (OR 6.78, 95% CI 2.41 to 19.07; Z = 3.63; P = 0.0003; 4 studies; 146 children; low-quality evidence) as well as reductions in pain intensity (SMD -1.01, 95% CI -1.41 to -0.61; Z = 4.97; P < 0.00001; 4 studies; 146 children; low-quality evidence) and pain frequency (SMD -1.28, 95% CI -1.84 to -0.72; Z = 4.48; P < 0.00001; 4 studies; 146 children; low-quality evidence). The only study of long-term effect reported continued benefit of hypnotherapy compared to usual care after five years, with 68% reporting treatment success compared to 20% of controls (P = 0.005).For yoga therapy compared to control, we found no evidence of effectiveness on pain intensity reduction postintervention (SMD -0.31, 95% CI -0.67 to 0.05; Z = 1.69; P = 0.09; 3 studies; 122 children; low-quality evidence).The single study of written self-disclosure therapy reported no benefit for pain.There was no evidence of effect from the pooled analyses for any type of intervention on the secondary outcomes of school performance, social or psychological functioning, and quality of daily life.There were no adverse effects for any of the interventions reported. AUTHORS' CONCLUSIONS: the data from trials to date provide some evidence for beneficial effects of CBT and hypnotherapy in reducing pain in the short term in children and adolescents presenting with RAP. There was no evidence for the effectiveness of yoga therapy or written self-disclosure therapy. There were insufficient data to explore effects of treatment by RAP subtype.Higher-quality, longer-duration trials are needed to fully investigate the effectiveness of psychosocial interventions. Identifying the active components of the interventions and establishing whether benefits are sustained in the long term are areas of priority. Future research studies would benefit from employing active control groups to help minimise potential bias from wait-list control designs and to help account for therapist and intervention time.

BACKGROUND: Active video games (AVGs) have been identified as a novel strategy to improve motor skill and physical activity in clinical populations. A recent cross-over randomized trial found AVGs to be ineffective at improving motor skill and physical activity in the home-environment for children with or at-risk for developmental coordination disorder (DCD). AIMS: the study purpose was to better understand why the intervention had been ineffective by examining the quantity and quality of AVG play during an AVG intervention for children with or at-risk for DCD. METHODS AND PROCEDURES: Participants (n=21, ages 9-12) completed the 16 week AVG intervention. Detailed quantitative and qualitative data were systematically triangulated to obtain the quantity of exposure (AVG exposure over time, patterns of exposure) and quality of use (game selection, facilitators and barriers to play). OUTCOMES AND RESULTS: the median AVG dose (range 30-35min/day) remained relatively stable across the intervention and met the prescribed dose. Play quality was impacted by game selection, difficulty playing games, lack of time, illness, technical difficulties and boredom. CONCLUSIONS AND IMPLICATIONS: the ineffectiveness of a home-based AVG intervention may be due to quality of play. Strategies to improve the quality of game play may help realize the potential benefits of AVGs as a clinical tool for children with DCD.

OBJECTIVES: to evaluate the effectiveness of behaviour changing interventions targeting ordering of thyroid function tests. DESIGN: Systematic review. DATA SOURCES: MEDLINE, EMBASE and the Cochrane Database up to May 2015. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included studies evaluating the effectiveness of behaviour change interventions aiming to reduce ordering of thyroid function tests. Randomised controlled trials (RCTs), non-randomised controlled studies and before and after studies were included. There were no language restrictions. STUDY APPRAISAL AND SYNTHESIS METHODS: 2 reviewers independently screened all records identified by the electronic searches and reviewed the full text of any deemed potentially relevant. Study details were extracted from the included papers and their methodological quality assessed independently using a validated tool. Disagreements were resolved through discussion and arbitration by a third reviewer. Meta-analysis was not used. RESULTS: 27 studies (28 papers) were included. They evaluated a range of interventions including guidelines/protocols, changes to funding policy, education, decision aids, reminders and audit/feedback; often intervention types were combined. The most common outcome measured was the rate of test ordering, but the effect on appropriateness, test ordering patterns and cost were also measured. 4 studies were RCTs. The majority of the studies were of poor or moderate methodological quality. The interventions were variable and poorly reported. Only 4 studies reported unsuccessful interventions but there was no clear pattern to link effect and intervention type or other characteristics. CONCLUSIONS: the results suggest that behaviour change interventions are effective particularly in reducing the volume of thyroid function tests. However, due to the poor methodological quality and reporting of the studies, the likely presence of publication bias and the questionable relevance of some interventions to current day practice, we are unable to draw strong conclusions or recommend the implementation of specific intervention types. Further research is thus justified. TRIAL REGISTRATION NUMBER: CRD42014006192.

REVIEW QUESTION/OBJECTIVE: This qualitative review aims to gain an increased understanding of the factors that support (facilitators) and challenge (barriers) people who have dementia and live alone in being able to remain living in their own homes. The review will contribute to the development of a complex intervention, inform clinical practice and influence policy development for this population.Overarching review question: what are the barriers to, and facilitators for, people with a dementia who live alone being able to remain in their own homes? SUB-QUESTIONS: 1. What are the factors that support and/or challenge a person with dementia who lives alone?2. What are the barriers to, and facilitators for, people with a dementia who live alone being able to remain in their own homes from the perspective of people who have dementia and live alone?3. What are the barriers to, and facilitators for, people with dementia who live alone being able to remain in their own homes from the perspective of people who interact closely with this population, including family, and health and social care workers?

Fitness is an important component of health, and obese adolescents regularly have poor fitness. Unfortunately, few have assessed the impact of community-based lifestyle interventions on multiple components of fitness. The purpose of this study was to assess the impact of participation in a community-based intervention involving adolescents and parents on multiple components of fitness of obese adolescents. In a within-subject, waitlist controlled clinical trial with 12 months follow-up in Western Australia, participants (n = 56) completed multiple fitness measures at baseline, immediately prior to beginning an 8-week intervention and at 3, 6 and 12 months during a maintenance period. Performance on the shuttle walk was improved immediately post-intervention (increase of 42.8 m, 95% CI: 7.5, 78.2) and at 12 months post-intervention (increase of 44.6 m, 95% CI: 1.3, 87.8) compared with pre-intervention. Muscle performance of quadriceps and deltoids were improved post-intervention (increase of 1.1 (95% CI: 0.1, 2.1) kg · F and 1.0 (0.02, 2.1) kg · F, respectively) and all muscle performance measures were improved at 12 months following the intervention. There were no changes in waist circumference. A community-based lifestyle programme such as Curtin University’s Activity, Food and Attitudes Program (CAFAP) may be a viable strategy for improving fitness in overweight adolescents.

BACKGROUND: to provide a detailed description of young adults' sedentary time and physical activity. METHODS: 384 young women and 389 young men aged 22.1 ± 0.6 years, all participants in the 22 year old follow-up of the Raine Study pregnancy cohort, wore Actigraph GT3X+ monitors on the hip for 24 h/day over a one-week period for at least one 'valid' day (≥10 h of waking wear time). Each minute epoch was classified as sedentary, light, moderate or vigorous intensity using 100 count and Freedson cut-points. Mixed models assessed hourly and daily variation; t-tests assessed gender differences. RESULTS: the average (mean ± SD) waking wear time was 15.0 ± 1.6 h/day, of which 61.4 ± 10.1% was spent sedentary, 34.6 ± 9.1% in light-, 3.7 ± 5.3% in moderate- and, 0.3 ± 0.6% in vigorous-intensity activity. Average time spent in moderate to vigorous activity (MVPA) was 36.2 ± 27.5 min/day. Relative to men, women had higher sedentary time, but also higher vigorous activity time. The 'usual' bout duration of sedentary time was 11.8 ± 4.5 min in women and 11.7 ± 5.2 min in men. By contrast, other activities were accumulated in shorter bout durations. There was large variation by hour of the day and by day of the week in both sedentary time and MVPA. Evenings and Sundays through Wednesdays tended to be particularly sedentary and/or inactive. CONCLUSION: for these young adults, much of the waking day was spent sedentary and many participants were physically inactive (low levels of MVPA). We provide novel evidence on the time for which activities were performed and on the time periods when young adults were more sedentary and/or less active. With high sedentary time and low MVPA, young adults may be at risk for the life-course sequelae of these behaviours.

BACKGROUND: the detailed patterns of physical activity and sedentary behaviors of overweight and obese adolescents are unknown, but may be important for health outcomes and targeted intervention design. METHODS: Participants completed Curtin University's Activity, Food and Attitudes Program (CAFAP), an 8-week intervention with 12 months of maintenance intervention. Physical activity and sedentary time were assessed at 6 time periods with accelerometers and were analyzed by 1) time and type of day, 2) intensity bout patterns using exposure variation analysis, and 3) individual case analysis. RESULTS: Participants (n = 56) spent a lower percentage of time at baseline in light activity during school days compared with weekend days (24.4% vs 29.0%, P =. 004). The majority of time was in long uninterrupted sedentary bouts of greater than 30 minutes (26.7% of total time, 36.8% of sedentary time at baseline). Moderate activity was accumulated in short bouts of less than 5 minutes (3.1% of total time, 76.0% moderate time). Changes varied by individuals. CONCLUSIONS: Exposure variation analysis revealed specific changes in activity patterns in overweight and obese adolescents who participated in a lifestyle intervention. A better understanding of these patterns can help to design interventions that meaningfully affect specific behaviors, with unique health consequences.

Background: Young adulthood is a critical life period for health and health behaviours. Related measurements collected before and after birth, and during childhood and adolescence can provide a life-course analysis of important factors that contribute to health and behaviour in young adulthood. The Western Australian Pregnancy Cohort (Raine) Study has collected a large number of such measurements during the fetal, perinatal, infancy, childhood and adolescence periods and plans to relate them to common health issues and behaviours in young adults, including spinal pain, asthma, sleep disorders, physical activity and sedentary behaviour and, work absenteeism and presenteeism. The aim of this paper is to describe the rationale, design and methods of the 22 year follow-up of the Raine Study cohort. Methods/Design: the Raine Study is a prospective cohort study. Participants still active in the cohort (n = 2,086) were contacted around the time of their 22nd birthday and invited to participate in the 22 year follow-up. Each was asked to complete a questionnaire, attend a research facility for physical assessment and an overnight sleep study, wear activity monitors for a week, and to maintain a sleep and activity diary over this week. The questionnaire was broad and included questions related to sociodemographics, medical history, quality of life, psychological factors, lifestyle factors, spinal pain, respiratory, sleep, activity and work factors. Physical assessments included anthropometry, blood pressure, back muscle endurance, tissue sensitivity, lung function, airway reactivity, allergic status, 3D facial photographs, cognitive function, and overnight polysomnography. Discussion: Describing the prevalence of these health issues and behaviours in young adulthood will enable better recognition of the issues and planning of health care resources. Providing a detailed description of the phenotype of these issues will provide valuable information to help educate health professionals of the needs of young adults. Understanding the life-course risk factors of health issues and behaviours in young adulthood will have important health planning implications, supporting the development of targeted interventions to improve current health status and reduce the onset and development of further ill-health across adulthood.

Objective: Depression is more common among individuals with chronic physical illness than in the general population New treatments for severe and chronic inflammatory conditions which inhibit tumour necrosis factor alpha (TNF-α), a pro-inflammatory cytokine, may be able to shed some light on the role of inflammatory mediators in depression This systematic review and meta-analysis of randomised controlled trials determined the effects of TNF-α inhibitor therapy on depression and anxiety in people with chronic physical illness. Methods: Seven databases were searched from inception to January 2014: AMED, Central, Cochrane Database of Systematic Reviews, CINAHL, Embase, MEDLINE, and PsycINFO. Articles were screened for inclusion independently by two reviewers. Data extraction and appraisal were conducted by one reviewer and checked by a second. Random-effects meta-analyses were performed. Results: Six randomised controlled trials (reported in seven articles) met eligibility criteria and were included in the final review. In total 2540 participants were enrolled across the trials, with participants presenting with rheumatoid arthritis (n = 3 trials), psoriasis (n = 2) or ankylosing spondylitis (n = 1). Meta-analyses, using standardised mean differences, showed evidence of small reductions in depression (- 0.24; 95% CI - 0.33 to - 0.14; p < 0.001), and anxiety (- 0.17; 95% CI - 0.31 to - 0.02; p = 0.02). Conclusion: TNF-α inhibitor therapy reduces depression in people with chronic disease though the effects are small. Whilst this is consistent with inflammation contributing to the development of depression, further studies investigating a more detailed timeline of changes in depression, inflammatory biomarkers and disease activity status are required.

BACKGROUND: Capturing the complex time pattern of physical activity (PA) and sedentary behavior (SB) using accelerometry remains a challenge. Research from occupational health suggests exposure variation analysis (EVA) could provide a meaningful tool. This paper (1) explains the application of EVA to accelerometer data, (2) demonstrates how EVA thresholds and derivatives could be chosen and used to examine adherence to PA and SB guidelines, and (3) explores the validity of EVA outputs. METHODS: EVA outputs are compared with accelerometer data from 4 individuals (Study 1a and 1b) and 3 occupational groups (Study 2): seated workstation office workers (n = 8), standing workstation office workers (n = 8), and teachers (n = 8). RESULTS: Line graphs and related EVA graphs highlight the use of EVA derivatives for examining compliance with guidelines. EVA derivatives of occupational groups confirm no difference in bouts of activity but clear differences as expected in extended bouts of SB and brief bursts of activity, thus providing evidence of construct validity. CONCLUSIONS: EVA offers a unique and comprehensive generic method that is able, for the first time, to capture the time pattern (both frequency and intensity) of PA and SB, which can be tailored for both occupational and public health research.

This is the protocol for a review and there is no abstract. The objectives are as follows: to examine the effectiveness of dietary interventions for RAP in children of school age.

OBJECTIVE: Elderly residents with dementia commonly exhibit increased agitation at mealtimes. This interferes with eating and can be distressing for both the individual and fellow residents. This review examines the effectiveness of mealtime interventions aimed at improving behavioral symptoms in elderly people living with dementia in residential care. DESIGN: Systematic review. DATA SOURCES: Medline, PsycINFO, Embase, HMIC, AMED (OvidSP); CDSR, CENTRAL, DARE (Cochrane Library, Wiley); CINAHL (EBSCOhost); British Nursing Index (NHS Evidence); ASSIA (ProQuest); Social Science Citation Index (Web of Knowledge); EThOS (British Library); Social Care Online and OpenGrey from inception to November 2012. Forward and backward citation chases, hand searches of other review articles identified in the search, and key journals. TYPES OF STUDY: all comparative studies were included. Articles were screened for inclusion independently by 2 reviewers. Data extraction and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Data were not suitable for meta-analysis so narrative synthesis was carried out. RESULTS: a total of 6118 articles were identified in the original search. Eleven articles were finally included. Mealtime interventions were categorized into 4 types: music, changes to food service, dining environment alteration, and group conversation. Study quality was poor, making it difficult to reach firm conclusions. Although all studies showed a trend in favor of the intervention, only 6 reported a statistically significant improvement in behavioral symptoms. Four studies suggest cumulative or lingering effects of music on agitated and aggressive behaviors. CONCLUSION: There is some evidence to suggest that mealtime interventions improve behavioral symptoms in elderly people with dementia living in residential care, although weak study designs limit the generalizability of the findings. Well designed, controlled trials are needed to further understand the utility of mealtime interventions in this setting.

Objective: to determine the effectiveness of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) on psychological and physical outcomes for people with vascular disease. Design: Systematic review and meta-analysis of randomised controlled trials. Data sources: AMED, CINAHL, EMBASE, British Nursing Index, Medline, Web of Science, PsycINFO, Cochrane Database of Systematic Reviews, Central, Social Sciences Citation Index, Social Policy and Practice, and HMIC from inception to January 2013. Review methods: Articles were screened for inclusion independently by two reviewers. Data extraction and quality appraisal were performed by one reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Random-effects meta-analyses were performed. Results: Nine articles (from eight original randomised controlled trials) met eligibility criteria and were included in the final review. In total, 578 participants were enrolled across the trials, with participants presenting with prehypertension/hypertension (n. = 3 trials), type 1 or 2 diabetes (n. = 2), heart disease (n. = 2) and stroke (n. = 1). Meta-analyses, using standardised mean differences, showed evidence of reductions in stress (- 0.36; 95% CI - 0.67 to - 0.09; p. = 0.01), depression (- 0.35; 95% CI - 0.53 to - 0.16; p. = 0.003) and anxiety (- 0.50; 95% CI - 0.70 to - 0.29; p. < 0.001). Effects on physical outcomes (blood pressure, albuminuria, stress hormones) were mixed. Conclusion: Whilst populations with vascular disease appear to derive a range of psychological benefits from MBSR/MBCT intervention, the effects on physical parameters of disease are not yet established. More robust studies, with longer term follow-up, are required to ascertain full effectiveness of such intervention. © 2014.

Electronic games (e-games) are widely used by children, often for substantial durations, yet to date there are no evidence-based guidelines regarding their use. The aim of this paper is to present guidelines for the wise use of e-games by children based on a narrative review of the research. This paper proposes a model of factors that influence child-e-games interaction. It summarises the evidence on positive and negative effects of use of e-games on physical activity and sedentary behaviour, cardio-metabolic health, musculoskeletal health, motor coordination, vision, cognitive development and psychosocial health. Available guidelines and the role of guidelines are discussed. Finally, this information is compiled into a clear set of evidence-based guidelines, about wise use of e-games by children, targeting children, parents, professionals and the e-game industry. These guidelines provide an accessible synthesis of available knowledge and pragmatic guidelines based on e-game specific evidence and related research. Practitioner Summary: E-games are an important part of life for many children. Evidence suggests they impact on many aspects of children's behaviour, health and development, though many issues lack convincing evidence. These evidence-based guidelines provide an accessible synthesis of available knowledge and pragmatic guidelines based on e-game specific evidence and related research. © 2014 © 2014 Taylor & Francis.

Electronic games (e-games) are widely used by children, often for substantial durations, yet to date there are no evidence-based guidelines regarding their use. The aim of this paper is to present guidelines for the wise use of e-games by children based on a narrative review of the research. This paper proposes a model of factors that influence child-e-games interaction. It summarises the evidence on positive and negative effects of use of e-games on physical activity and sedentary behaviour, cardio-metabolic health, musculoskeletal health, motor coordination, vision, cognitive development and psychosocial health. Available guidelines and the role of guidelines are discussed. Finally, this information is compiled into a clear set of evidence-based guidelines, about wise use of e-games by children, targeting children, parents, professionals and the e-game industry. These guidelines provide an accessible synthesis of available knowledge and pragmatic guidelines based on e-game specific evidence and related research.

BACKGROUND: Antipsychotic medications are commonly used to manage the behavioral and psychological symptoms of dementia. Several large studies have demonstrated an association between treatment with antipsychotics and increased morbidity and mortality in people with dementia. AIMS: to assess the effectiveness of interventions used to reduce inappropriate prescribing of antipsychotics to the elderly with dementia in residential care. METHOD: Systematic searches were conducted in 12 electronic databases. Reference lists of all included studies and forward citation searching using Web of Science were also conducted. All quantitative studies with a comparative research design and studies in which recognized methods of qualitative data collection were used were included. Articles were screened for inclusion independently by 2 reviewers. Data extraction and quality appraisal were performed by 1 reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. RESULTS: Twenty-two quantitative studies (reported in 23 articles) were included evaluating the effectiveness of educational programs (n = 11), in-reach services (n = 2), medication review (n = 4), and multicomponent interventions (n = 5). No qualitative studies meeting our inclusion criteria were identified. Eleven studies were randomized or controlled in design; the remainder were uncontrolled before and after studies. Beneficial effects were seen in 9 of the 11 studies with the most robust study design with reductions in antipsychotic prescribing levels of between 12% and 20%. Little empirical information was provided on the sustainability of interventions. CONCLUSION: Interventions to reduce inappropriate prescribing of antipsychotic medications to people with dementia resident in care homes may be effective in the short term, but longer more robust studies are needed. For prescribing levels to be reduced in the long term, the culture and nature of care settings and the availability and feasibility of nondrug alternatives needs to be addressed.

BACKGROUND: Limited attention has been paid in the literature to multiple component fall prevention interventions that comprise two or more fixed combinations of fall prevention interventions that are not individually tailored following a risk assessment. The study objective was to determine the effect of multiple component interventions on fall rates, number of fallers and fall-related injuries among older people and to establish effect sizes of particular intervention combinations. METHODS: Medline, EMBASE, CINAHL, PsychInfo, Cochrane, AMED, UK Clinical Research Network Study Portfolio, Current Controlled Trials register and Australian and New Zealand Clinical Trials register were systematically searched to August 2013 for randomised controlled trials targeting those aged 60 years and older with any medical condition or in any setting that compared multiple component interventions with no intervention, placebo or usual clinical care on the outcomes reported falls, number that fall or fall-related injuries. Included studies were appraised using the Cochrane risk of bias tool. Estimates of fall rate ratio and risk ratio were pooled across studies using random effects meta-analysis. Data synthesis took place in 2013. RESULTS: Eighteen papers reporting 17 trials were included (5034 participants). There was a reduction in the number of people that fell (pooled risk ratio = 0.85, 95% confidence interval (95% CI) 0.80 to 0.91) and the fall rate (pooled rate ratio = 0.80, 95% CI 0.72 to 0.89) in favour of multiple component interventions when compared with controls. There was a small amount of statistical heterogeneity (I(2) =20%) across studies for fall rate and no heterogeneity across studies examining number of people that fell. CONCLUSIONS: This systematic review and meta-analysis of randomised controlled trials found evidence that multiple component interventions that are not tailored to individually assessed risk factors are effective at reducing both the number of people that fall and the fall rate. This approach should be considered as a service delivery option.

This is the protocol for a review and there is no abstract. The objectives are as follows: to determine the effectiveness of pharmacological interventions for RAP in children of school age.

This is the protocol for a review and there is no abstract. The objectives are as follows: to determine the effectiveness of psychosocial interventions for RAP in children of school age.

BACKGROUND: to determine the effects of participation in Curtin University's Activity, Food and Attitudes Program (CAFAP), a community-based, family-centered behavioural intervention, on the physical activity, sedentary time, and healthy eating behaviours of overweight and obese adolescents. METHODS: in this waitlist controlled clinical trial in Western Australia, adolescents (n = 69, 71% female, mean age 14.1 (SD 1.6) years) and parents completed an 8-week intervention followed by 12 months of telephone and text message support. Assessments were completed at baseline, before beginning the intervention, immediately following the intervention, and at 3-, 6-, and 12- months follow-up. The primary outcomes were physical activity and sedentary time assessed by accelerometers and servings of fruit, vegetables and junk food assessed by 3-day food records. RESULTS: During the intensive 8-week intervention sedentary time decreased by -5.1 min/day/month (95% CI: -11.0, 0.8) which was significantly greater than the rate of change during the waitlist period (p = .014). Moderate physical activity increased by 1.8 min/day/month (95% CI: -0.04, 3.6) during the intervention period, which was significantly greater than the rate of change during the waitlist period (p = .041). Fruit consumption increased during the intervention period (monthly incidence rate ratio (IRR) 1.3, 95% CI: 1.10, 1.56) and junk food consumption decreased (monthly IRR 0.8, 95% CI: 0.74, 0.94) and these changes were different to those seen during the waitlist period (p = .004 and p = .020 respectively). CONCLUSIONS: Participating in CAFAP appeared to have a positive influence on the physical activity, sedentary and healthy eating behaviours of overweight and obese adolescents and many of these changes were maintained for one year following the intensive intervention. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry ACTRN12611001187932.

OBJECTIVE: to examine the impact of gardens and outdoor spaces on the mental and physical well-being of people with dementia who are resident in care homes and understand the views of people with dementia, their carers, and care home staff on the value of gardens and outdoor spaces. DESIGN: Systematic review. METHODS: Fourteen databases were searched from inception to February 2013. Forward and backward citation chasing of included articles was conducted; 38 relevant organizations were contacted to identify unpublished reports. Titles, abstracts, and full texts were screened independently by 2 reviewers in a 2-stage process and were discussed with a third reviewer where necessary. Results were synthesized narratively. RESULTS: Seventeen studies were included: 9 quantitative, 7 qualitative, and 1 mixed methods. The quantitative studies were of poor quality but suggested decreased levels of agitation were associated with garden use. The views and experiences of the garden are discussed in relation to themes of how the garden was used, nature of interactions, impact/effect of the gardens, mechanisms/how the garden was thought to have an effect, and negatives (such as perception of the garden as a hazard and the limited staff time). CONCLUSION: There are promising impacts on levels of agitation in care home residents with dementia who spend time in a garden. Future research would benefit from a focus on key outcomes measured in comparable ways with a separate focus on what lies behind limited accessibility to gardens within the residential care setting.

The need to improve the nutrition of the elderly living in long term care has long been recognised, but how this can best be achieved, and whether (and which) intervention is successful in reducing morbidity is less well understood. The aim of this systematic review was to determine the effectiveness of mealtime interventions for the elderly living in residential care. Mealtime interventions were considered as those that aimed to change/improve the mealtime routine, practice, experience or environment. Following comprehensive searches, review and appraisal, 37 articles were included. Inadequate reporting in over half of the articles limited data quality appraisal. Mealtime interventions were categorised into five types: changes to food service, food improvement, dining environment alteration, staff training and feeding assistance. Meta-analysis found inconsistent evidence of effects on body weight of changes to food service (0.5 kg; 95% CI: -1.1 to 2.2; p=0.51), food improvement interventions (0.4 kg; 95% CI: -0.8 to 1.7; p=0.50) or alterations to dining environment (1.5 kg; 95% CI: -0.7 to 2.8; p=0.23). Findings from observational studies within these intervention types were mixed, but generally positive. Observational studies also found positive effects on food/caloric intake across all intervention types, though meta-analyses of randomised studies showed little evidence of any effects on food/caloric intake in food improvement studies (-5 kcal; 95% CI: -36 to 26; p=0.74). There was some evidence of an effect on daily energy intakes within dining environment studies (181 kcal/day, 95% CI: -5 to 367, p=0.06). The need to improve the nutrition of the elderly living in residential long term care is well recognised. This review found some evidence that simple intervention around various aspects of mealtime practices and the mealtime environment can result in favourable nutritional outcomes. Further large scale pragmatic trials, however, are still required to establish full efficacy of such interventions.

This is the protocol for a review and there is no abstract. The objectives are as follows: to assess the effects of patient-initiated appointment systems compared with usual care in people with chronic or recurrent conditions managed in the secondary care setting. In particular, we are interested in whether these appointment systems can effectively manage disease without causing harm to patients and whether costs related to the provision of the service can be reduced compared with usual care.

OBJECTIVE: Sedentary behavior in children is positively associated with an increased risk of both obesity and insulin resistance. Children spend a considerable portion of their awake time in sedentary behavior; however, the pattern of accumulation is not known. Thus the objective of this study was to describe the patterning of sedentary behavior of children at and away from school. DESIGN AND METHODS: the patterns of sedentary time in a sample of 53 children (28 girls) aged 10-12 years during school-term time were examined. Children wore an accelerometer for 1 week. Total sedentary time, prolonged sequences (bouts) of sedentary time, and frequency of active interruptions to sedentary were examined on school days and weekends and within school time and non-school time on school days. RESULTS: the data did not support our hypothesis that children accumulated more sedentary time on school days when compared with weekend days (mean [SD]: 64.4% [5.3] vs. 64.9% [9.0], P = 0.686). However, when comparing school time with non-school time on school days, children accumulated more sedentary time at school (66.8% [7.3] vs. 62.4% [5.2], P < 0.001) and spent more time at school in sustained sedentary sequences, that is, uninterrupted sedentary time for 30 min or more (75.6 min [45.8] vs. 45.0 min [26.8], P < 0.002). The children also recorded less breaks per sedentary hour within school time when compared with non-school time (8.9 h(-1) vs. 10.2 h(-1) , P < 0.001). CONCLUSION: Reducing total sedentary time spent both in and out of school remains an important challenge. Interrupting sedentary time more often in the "working" (school) day could also reap important musculoskeletal and metabolic health rewards for children.

BACKGROUND: Screen-based media (SBM) occupy a considerable portion of young peoples' discretionary leisure time. The aim of this paper was to investigate whether distinct clusters of SBM use exist, and if so, to examine the relationship of any identified clusters with other activity/sedentary behaviours and physical and mental health indicators. METHODS: the data for this study come from 643 adolescents, aged 14 years, who were participating in the longitudinal Western Australian Pregnancy Cohort (Raine) Study through May 2003 to June 2006. Time spent on SBM, phone use and reading was assessed using the Multimedia Activity Recall for Children and Adults. Height, weight, muscle strength were measured at a clinic visit and the adolescents also completed questionnaires on their physical activity and psychosocial health. Latent class analysis (LCA) was used to analyse groupings of SBM use. RESULTS: Three clusters of SBM use were found; C1 'instrumental computer users' (high email use, general computer use), C2 'multi-modal e-gamers' (both high console and computer game use) and C3 'computer e-gamers' (high computer game use only). Television viewing was moderately high amongst all the clusters. C2 males took fewer steps than their male peers in C1 and C3 (-13,787/week, 95% CI: -4619 to -22957, p = 0.003 and -14,806, 95% CI: -5,306 to -24,305, p = 0.002) and recorded less MVPA than the C1 males (-3.5 h, 95% CI: -1.0 to -5.9, p = 0.005). There was no difference in activity levels between females in clusters C1 and C3. CONCLUSION: SBM use by adolescents did cluster and these clusters related differently to activity/sedentary behaviours and both physical and psychosocial health indicators. It is clear that SBM use is not a single construct and future research needs to take consideration of this if it intends to understand the impact SBM has on health.

Background Sedentary behaviour, light activity and moderate or vigorous physical activity are linked to major chronic diseases in adults. For adult workers, occupational activity contributes substantially to overall exposure. Despite considerable concern about the activity profiles of school children, there is limited data comparing their 'occupational' (school) and non-occupational (non-school) sedentary behaviour and activity. Aims the aim of this study was to compare sedentary behaviour, light activity, moderate and vigorous physical activity of school children during school time with non-school time on school days as well as to compare school days with weekend days. Methods a cross sectional observational design study was used to gather activity data on 53 children aged 10-12 years. Accelerometers were worn for a week. Intensity of activity was categorised based on accelerometer counts per minute thresholds. Results Children spent a greater proportion of school time in potentially health detrimental sedentary behaviours (school time 66% vs non-school time 62%) with less exposure to potentially health supporting light activity (25% vs 32%). Conversely children also spent a greater proportion of their school time in health supporting moderate (8% vs 5%) and vigorous (1.4% vs 0.7%) physical activity and a greater proportion of children met daily moderate and vigorous physical activity guidelines on school days (49% vs 17%). Conclusion 'Occupational' exposure for children contributes significantly to their overall activity profile and schools, parents and interested professionals should work towards school systems which promote health beneficial activity exposures for children.

OBJECTIVE: to evaluate the impact of (1) the removal of home access to traditional electronic games or (2) their replacement with active input electronic games, on daily physical activity and sedentary behaviour in children aged 10-12 years. DESIGN: Crossover randomised controlled trial, over 6 months. SETTING: Family homes in metropolitan Perth, Australia from 2007 to 2010. PARTICIPANTS: 10-year-old to 12-year-old children were recruited through school and community media. From 210 children who were eligible, 74 met inclusion criteria, 8 withdrew and 10 had insufficient primary outcome measures, leaving 56 children (29 female) for analysis. INTERVENTION: a counterbalanced randomised order of three conditions sustained for 8 weeks each: no home access to electronic games, home access to traditional electronic games and home access to active input electronic games. MAIN OUTCOME MEASURES: Primary outcome was accelerometer assessed moderate/vigorous physical activity (MVPA). Secondary outcomes included sedentary time and diary assessed physical activity and sedentary behaviours. RESULTS: Daily MVPA across the whole week was not significantly different between conditions. However, compared with home access to traditional electronic games, removal of all electronic games resulted in a significant increase in MVPA (mean 3.8 min/day, 95% CI 1.5 to 6.1) and a decrease in sedentary time (4.7 min/day, 0.0 to 9.5) in the after-school period. Similarly, replacing traditional games with active input games resulted in a significant increase in MVPA (3.2 min/day, 0.9 to 5.5) and a decrease in sedentary time (6.2 min/day, 1.4 to 11.4) in the after-school period. Diary reports supported an increase in physical activity and a decrease in screen-based sedentary behaviours with both interventions. CONCLUSIONS: Removal of sedentary electronic games from the child's home and replacing these with active electronic games both resulted in small, objectively measured improvements in after-school activity and sedentary time. Parents can be advised that replacing sedentary electronic games with active electronic games is likely to have the same effect as removing all electronic games. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry (ACTRN 12609000279224).

Being Aboriginal or Torres Strait Islander in contemporary Australia is often discursively constructed in health literature as equating with risks of many kinds. This article explores the ways in which a group of urban Australian Indigenous young people perceive, navigate and articulate the so-called 'risks' pertaining to issues surrounding their health and physical activity. Eight girls and six boys aged 11-13 years were recruited from an urban school in a major Australian city. Each young person was interviewed up to eight times, using multi-modal tools, over two and a half years, to explore the ways in which they engaged with discourses about health, risk and physical activity. Data were analysed both thematically and through a process of critical discourse analysis. The young people in this study did not perceive themselves as 'at-risk' of ill-health despite the recognition of 'unhealthy' choices or a family history of chronic illness. They appeared to negotiate risk based on both their knowledge of public health messages and their trust in themselves and those around them. The young people's narratives offer an alternate view to the pathologised, statistical 'stories' often representing Indigenous Australians in scientific and popular literature and the media. © 2012 Copyright Taylor and Francis Group, LLC.

In the context of rising chronic diseases amongst Indigenous peoples, there are calls for the adoption of more healthy "lifestyles." in this context, this paper explores thoughts about physical activity from 21 Indigenous families through the voices of women and girls living in remote rural communities in the Torres Strait and Northern Peninsula Area, Australia. Speaking back to physical activity as a lifestyle "choice," three consistent themes emerged: shame, gendered positioning, and welfarism. In conclusion, the perspectives of Torres Strait islanders and Northern Peninsula Area communities suggest that there are deeply embedded ways of thinking about the body, familial obligations, and the provision of and access to being active that are not consistent with Western health policies predicated upon individuals shouldering responsibility for "taking exercise.". © 2012 Taylor and Francis Group, LLC.

BACKGROUND: Current estimates place just under one quarter of adolescents in Australia as overweight or obese. Adolescence has been identified as a critical period for the development of obesity, yet despite this recognition, there is limited systematic research into or evaluation of interventions for overweight adolescents. Reviews have concluded that there is a substantive evidence gap for effective intervention, but physical activity, lifestyle change and family involvement have been identified as promising foci for treatment. METHODS: This paper reports on the development of a staggered-entry, waitlist controlled clinical trial to assess the impact of a multidisciplinary intervention aiming to change the poor health trajectory of overweight adolescents and help them avoid morbid obesity in adulthood-Curtin University's Activity, Food and Attitudes Program (CAFAP). 96 adolescents, aged 11-16 years, and parents, will attend twice weekly during an 8 week intensive multidisciplinary program with maintenance follow-up focussed on improving activity, food and attitude habits. Follow-up assessments will be conducted immediately after completing the intensive program, and at 3, 6 and 12 months post intensive program. Main outcomes will be objectively-measured physical activity, sedentary behaviour and activity behaviours; food intake (measured by 3 day diary) and food behaviours; body composition, fitness and physical function; mental and social well-being (quality of life, mood and attitudes), and family functioning. DISCUSSION: This trial will provide important information to understand whether a community based multidisciplinary intervention can have short and medium term effects on activity and food habits, attitudes, and physical and mental health status of overweight adolescents. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12611001187932.

This article presents the evaluation findings of an education policy initiative that involved the employment of facilitators to broker the policy and its implementation. An Australian state's education authority piloted the employment of physical activity facilitators to expedite the implementation of 'Smart Moves' in schools, a policy mandating daily physical activity for all state school students from pre-school to Year 10. The evaluation data was collected through facilitator diaries, semi-structured interviews, reflective writing, network mapping, and a school survey. The introduction of physical activity facilitators to accelerate the uptake of a health promotion policy in schools was highly instructive in terms of the conditions of policy uptake in schools. These facilitators were able to intervene in the value-laden, mandated state activity and shift the discourses to those that were palatable for schools and teachers. Significantly, in Bernsteinian terms, they were bridging the official and pedagogic recontextualizing fields thus acting as contributors to the recontextualization of official policy knowledge despite some school resistance. © the Author(s) 2011.

BACKGROUND/OBJECTIVES: Dietary assessment in humans is hampered by the phenomena of under and overreporting of energy intake, when food records are used to evaluate habitual dietary intake. Different methods to evaluate mis-reporting have been proposed using cut-offs derived from estimates of reported energy intake and basal metabolic rate, or, from predictions of total energy expenditure. This study compares the effect of using two different cut-off approaches to screen food records for validity, completed by a large cohort of Australian children (n=2460), from Grades 1, 5 and 10 (aged 5-17 years). SUBJECTS/METHODS: Energy intake was calculated from 24-h food and drink records for each child. These data were screened using the Goldberg and McCrory cut-offs. The effect of using these two cut-offs on the collected dataset was explored by considering the mean and standard deviation of energy intake in each year level before and after the cut-offs were applied. RESULTS: the use of the Goldberg cut-off resulted in 9% of the total cohort being classified as underreporters, with 60% of these subjects being in Grade 10. The McCrory cut-offs revealed that overall, 22% of the total cohort underreported EI. 33.3% of Grade 1 children were classified as overreporters with this value falling to about 20% of Grade 10 children, while 10-15% of Grade 1 children underreported, with this figure rising to about 30% in Grade 10. CONCLUSIONS: Both the Goldberg and McCrory approaches have their advantages and disadvantages, and we suggest that consideration should be given to the reason for screening data before a particular approach is used, with recognition that these methods do differ in their aims and outcomes. The McCrory method consistently classified a greater number of children as underreporters.

BACKGROUND: it is evident from previous research that the role of dietary composition in relation to the development of childhood obesity remains inconclusive. Several studies investigating the relationship between body mass index (BMI), waist circumference (WC) and/or skin fold measurements with energy intake have suggested that the macronutrient composition of the diet (protein, carbohydrate, fat) may play an important contributing role to obesity in childhood as it does in adults. This study investigated the possible relationship between BMI and WC with energy intake and percentage energy intake from macronutrients in Australian children and adolescents. METHODS: Height, weight and WC measurements, along with 24 h food and drink records (FDR) intake data were collected from 2460 boys and girls aged 5-17 years living in the state of Queensland, Australia. RESULTS: Statistically significant, yet weak correlations between BMI z-score and WC with total energy intake were observed in grades 1, 5 and 10, with only 55% of subjects having a physiologically plausible 24 hr FDR. Using Pearson correlations to examine the relationship between BMI and WC with energy intake and percentage macronutrient intake, no significant correlations were observed between BMI z-score or WC and percentage energy intake from protein, carbohydrate or fat. One way ANOVAs showed that although those with a higher BMI z-score or WC consumed significantly more energy than their lean counterparts. CONCLUSION: No evidence of an association between percentage macronutrient intake and BMI or WC was found. Evidently, more robust longitudinal studies are needed to elucidate the relationship linking obesity and dietary intake.

BACKGROUND: a healthy start to life requires adequate motor development and physical activity participation. Currently 5-15% of children have impaired motor development without any obvious disorder. These children are at greater risk of obesity, musculoskeletal disorders, low social confidence and poor mental health. Traditional electronic game use may impact on motor development and physical activity creating a vicious cycle. However new virtual reality (VR) game interfaces may provide motor experiences that enhance motor development and lead to an increase in motor coordination and better physical activity and mental health outcomes. VR games are beginning to be used for rehabilitation, however there is no reported trial of the impact of these games on motor coordination in children with developmental coordination disorder. METHODS: This cross-over randomised and controlled trial will examine whether motor coordination is enhanced by access to active electronic games and whether daily activity, attitudes to physical activity and mental health are also enhanced. Thirty children aged 10-12 years with poor motor coordination (≤ 15th percentile) will be recruited and randomised to a balanced ordering of 'no active electronic games' and 'active electronic games'. Each child will participate in both conditions for 16 weeks, and be assessed prior to participation and at the end of each condition. The primary outcome is motor coordination, assessed by kinematic and kinetic motion analysis laboratory measures. Physical activity and sedentary behaviour will be assessed by accelerometry, coordination in daily life by parent report questionnaire and attitudes to physical activity, self-confidence, anxiety and depressed mood will be assessed by self report questionnaire. A sample of 30 will provide a power of > 0.9 for detecting a 5 point difference in motor coordination on the MABC-2 TIS scale (mean 17, sd = 5). DISCUSSION: This is the first trial to examine the impact of new virtual reality games on motor coordination in children with developmental coordination disorder. The findings will provide critical information to understand whether these electronic games can be used to have a positive impact on the physical and mental health of these children. Given the importance of adequate motor coordination, physical activity and mental health in childhood, this project can inform interventions which could have a profound impact on the long term health of this group of children. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12611000400965.

BACKGROUND: the current decline in children's participation in physical activity has attracted the attention of those concerned with children's health and wellbeing. A sustainable approach to ensuring children engage in adequate amounts of physical activity is to support their involvement in incidental activity such as active travel (AT), which includes walking or riding a bicycle to or from local destinations, such as school or a park. Understanding how we can embed physical activity into children's everyday occupational roles is a way in which occupational therapists can contribute to this important health promotion agenda. AIMS: to present a simple, coherent and comprehensive framework as a means of examining factors influencing children's AT. METHODS: Based on current literature, this conceptual framework incorporates the observable environment, parents' perceptions and decisions regarding their children's AT, as well as children's own perceptions and decisions regarding AT within their family contexts across time. CONCLUSION: the Model of Children's Active Travel (M-CAT) highlights the complex and dynamic nature of factors impacting the decision-making process of parents and children in relation to children's AT. The M-CAT offers a way forward for researchers to examine variables influencing active travel in a systematic manner. Future testing of the M-CAT will consolidate understanding of the factors underlying the decision-making process which occurs within families in the context of their communities.

AIM: to explore weight status perception and its relation to actual weight status in a contemporary cohort of 5- to 17-year-old children and adolescents. METHODS: Body mass index (BMI), derived from height and weight measurements, and perception of weight status ('too thin', 'about right' and 'too fat') were evaluated in 3043 participants from the Healthy Kids Queensland Survey. In children less than 12 years of age, weight status perception was obtained from the parents, whereas the adolescents self-reported their perceived weight status. RESULTS: Compared with measured weight status by established BMI cut-offs, just over 20% of parents underestimated their child's weight status and only 1% overestimated. Adolescent boys were more likely to underestimate their weight status compared with girls (26.4% vs. 10.2%, P

This paper aims to present what is currently known about Indigenous Australians and their engagement in physical activity and to then challenge some of the 'taken-for-granted' ways of thinking about promoting or researching physical activity with Indigenous Australians. Major health, education and sport databases, as well as government websites were searched using the key terms of physical activity, sport, leisure, recreation, Indigenous and Aboriginal/Aborigine. A social-ecological model of health was adapted and used as an organizing framework to synthesize the literature. It is concluded that socioecological models can be valuable tools for understanding and promoting issues related to physical activity engagement for a range of populations but they may require complementary critical insights, including those from Indigenous perspectives. Productive theoretical spaces where Western and Indigenous knowledges come together can assist health educators to consider the complexity and diversity of Indigenous people's lived experiences when planning and implementing programs.

Epidemiological data on childhood obesity has prompted a significant response from both governments and academics seeking to recommend solutions to the reported 'crisis'. The 'Kinder Overweight Active Living Action' (KOALA) healthy lifestyle programme is a randomized obesity prevention and intervention study designed to provide an understanding of how school, family, and community can work in partnership to holistically address childhood obesity. Located within the KOALA project, this paper focuses on the children's and parents' experiences and perceptions of the KOALA intervention and its articulation with school health and physical education (HPE). Observations on the interactions that occur between home, school, and community as key sites of intervention in childhood obesity are also unpacked. The study employed a qualitative methodology to gauge perspectives regarding the multiple sites of obesity intervention. Perspectives of children, parents, and teachers regarding the KOALA experience would suggest that there is value in planning childhood obesity interventions that link families with community programs, such as scouts, girl guides, and club sport. While long-term outcomes are yet to be ascertained, KOALA has provided scope for new possibilities in holistic approaches to healthy body weight. © the Author(s) 2010.

The majority of children in affluent countries now play electronic games, and this has lead to concerns about the health impact of this activity. Traditional electronic games have used gamepad, keyboard, and mouse input, but newer game interfaces that require more movement are now available. However the movement and muscle activity demands of electronic games have not been described. This study compared the amount of movement and muscle activity while 20 children aged 9 to 12 years watched a DVD and played games using handheld computer, gamepad, keyboard, steering wheel and, active-input (Webcam motion analysis-Sony EyeToy®) devices. Movement of the head, sacrum, foot, shoulder, wrist, and thumb was measured along with activity in cervical erector spinae, lumbar erector spinae, rectus femoris, upper trapezius, anterior deltoid, and wrist extensor muscles. Use of the wheel resulted in some increase in upper limb movement and muscle activity, but the other traditional input devices were usually as sedentary as watching a DVD. In contrast, use of the active-input device (EyeToy) resulted in substantial movement and muscle activity in limbs and torso. These results suggest that playing traditional electronic games is indeed a sedentary activity but that new active-input technologies may be useful in encouraging more movement and muscle activity in children. © Taylor & Francis Group, LLC.

This systematic review investigated the environmental (physical, economic, socio-cultural and political) correlates of active transportation (AT) among young people aged 5-18 years to better inform the promotion of active living. Greater distance, increasing household income and increasing car ownership are consistently associated with lower rates of AT among children. Having a non-white ethnic background has a convincing positive association with AT. Having recreation facilities and walk or bike paths present are possibly associated with higher rates of AT. Further research requires longitudinal and intervention studies, utilizing multi-level design methodologies and objective measures of environmental attributes.

This paper explores rural young people's perceptions of their local environments in relation to their experiences with physical activities through the use of visual methodologies. The main findings from map, photo and interview data from 13 rural young Australians included the importance of friends, family, and gender structures which are discussed in relation to developing a sense of place and how this shapes their experience in physical activities. The findings highlight the importance of sociocultural issues and raises questions regarding measuring physical activity prompting further qualitative research to inform sustainable and equitable physical activity promotion initiatives for rural young people. © 2009 Taylor & Francis.

BACKGROUND: Many children are reported to have insufficient physical activity (PA) placing them at greater risk of poor health outcomes. Participating in sedentary activities such as playing electronic games is widely believed to contribute to less PA. However there is no experimental evidence that playing electronic games reduces PA. There is also no evidence regarding the effect of different types of electronic games (traditional sedentary electronic games versus new active input electronic games) on PA. Further, there is a poor understanding about how characteristics of children may moderate the impact of electronic game access on PA and about what leisure activities are displaced when children play electronic games. Given that many children play electronic games, a better understanding of the effect of electronic game use on PA is critical to inform child health policy and intervention. METHODS: This randomised and controlled trial will examine whether PA is decreased by access to electronic games and whether any effect is dependent on the type of game input or the child's characteristics. Children aged 10-12 years (N = 72, 36 females) will be recruited and randomised to a balanced ordering of 'no electronic games', 'traditional' electronic games and 'active' electronic games. Each child will participate in each condition for 8 weeks, and be assessed prior to participation and at the end of each condition. The primary outcome is PA, assessed by Actical accelerometers worn for 7 days on the wrist and hip. Energy expenditure will be assessed by the doubly labelled water technique and motor coordination, adiposity, self-confidence, attitudes to technology and PA and leisure activities will also be assessed. A sample of 72 will provide a power of > 0.9 for detecting a 15 mins difference in PA (sd = 30 mins). DISCUSSION: This is the first such trial and will provide critical information to understand whether access to electronic games affects children's PA. Given the vital importance of adequate PA to a healthy start to life and establishing patterns which may track into adulthood, this project can inform interventions which could have a profound impact on the long term health of children. TRIAL REGISTRATION: This trial is registered in the Australia and New Zealand Clinical Trials Registry (ACTRN 12609000279224).

Prevention and management of childhood overweight and obesity is a health priority for governments and communities throughout the developed world. A conceptual model, Research around Practice in Childhood Obesity (RAPICO), has been developed to guide capacity building in a coordinated 'bench to fieldwork' initiative to address this public health problem. Translation of research findings into sustainable responses with optimal fit requires consideration of context-specific relevance, cost-effectiveness, feasibility and levels of available support. The RAPICO model uses program theory to describe a framework for progressing practitionercommunityresearch partnerships to address low, medium and high levels of risk for childhood overweight and obesity within community settings. A case study describing the development of a logic model to inform risk-linked responses to childhood overweight and obesity is presented for the Ipswich community in south-east Queensland. © La Trobe University 2009.

'Taking exercise', whether it be recreational walking, participating in club sport, or joining in a physical education (PE) lesson, is a culturally loaded behaviour. We all see, do and talk about physical activity differently, yet, there has been relatively little research or theorising around difference in race, ethnicity, cultural diversity and physical activity from an educational perspective. This paper presents snapshots of data from three research projects with Indigenous and Muslim young people to illuminate how they and their families think about PE, physical activity and health. We will draw on 'post' discussions around biopolitics, colonisation, governmentality and citizenship to argue that PE needs to better account for 'others' and 'othering' in its research, planning and practices.

Objective measurement of daily steps was used to assess whether children (n = 2,076) in Years 1, 5 and 10 who reported walking to or from school were more active and more likely to reach recommended step targets than those who were driven or took public transport to school. Walking to school was associated with higher school-day steps in older children (16,238 vs 15,275 for Year 5 male p <. 05, 13,521 vs 12,502 for Year 5 female p <. 01, 12,109 vs 11,373 for Year 10 female p <. 05). The proportion of children who met recommended step thresholds was higher in those who walked to school compared with those who took motorized transport, and this was significant for Year 5 females (71.7% vs 54.5%, p <. 01). This study suggests that walking to school for older children has potential to contribute significantly to daily activity levels and increases the likelihood of attaining recommended step targets. These data should encourage public policy and those concerned with the built environment to provide and support opportunities for walking to school.

AIM: to assess the statistical validity of the waist-height ratio (WHtR) as an appropriate method of adjusting waist circumference (WC) for height in children and adolescents. INTRODUCTION: Recently, WHtR has been proposed to be of greater value than body mass index (BMI), in predicting obesity-related cardiovascular co-morbidities in children. This index, however, is yet to be extensively validated within the paediatric population. METHODS: Height and WC in centimetres, were measured in 3597 children from grades 1 (5-7 years), 5 (9-11 years) and 10 (15-17 years). Log regression analyses using WC and height were performed to determine appropriate powers (p) to raise height, to completely adjust the index for height, by sex and grade. Correlations between WHtR and height were assessed. RESULTS: Statistically, the WHtR is only valid for use among grade 1 boys and girls (p = 1.09 [95%CI 0.95-1.23] and p = 1.07 [95%CI 0.92-1.22], respectively) and grade 10 girls p = 0.85 (95%CI 0.62-1.08). However, the error (0.25%-1.85%), associated with the use of this index, in all ages and both sexes is clinically and biologically acceptable. CONCLUSION: the WHtR is a clinically and biologically valid index to use among Australian children and adolescents.

OBJECTIVE: the present study explored the practices of, and perceived barriers to, physical activity of young people living in remote communities in the Torres Strait and Northern Peninsula Area of Far North Queensland. DESIGN AND SETTING: a cross-sectional survey exploring physical activity practices of children attending primary and secondary schools in two communities in the Torres Strait, Far North Queensland. PARTICIPANTS: a total of 367 primary and secondary school-aged children (aged 9-16 years). MAIN OUTCOME MEASURES: Only 50% of the children reported being active for more than 30 min a day and approximately 25% of both primary and high school children surveyed were 'pretty much active only at week-ends'. The major barriers cited to being active were related to the climate, lack of equipment and child-specific activities and low self-perception of ability. CONCLUSIONS: a large proportion of school students in the Torres Strait and Northern Peninsula Area reported low levels of physical activity. The main barriers cited to being active suggest that structural and family-based strategies are required to help young people, especially girls, to engage in more physical activity. There is also a need for skills and confidence-building activities delivered in a non-competitive environment for those who feel that they lack the necessary skills to participate fully.

The majority of children in affluent communities now play electronic games. This has lead to concerns about increased inactivity and the poor health sequelae. Traditional electronic games using gamepad, keyboard and mouse input have been considered sedentary, but newer virtual game interfaces require active movement. The physical activity demands of these active-input games are unknown. This study compared the movement, muscle activity, energy expenditure and heart rate of 20 children aged 9-12 years playing electronic games with traditional input devices and with a webcam motion analysis (Sony Eye Toy®) device. Usingtraditional input devices children were usually as sedentary as watching a DVD. In contrast, using the active-input virtual gaming device resulted in substantial increases in all measures. These results suggest playing traditional electronic games is indeed a sedentary activity and may thus exacerbate current trends for obesity and other inactivity related disorders. In contrast the new active input virtual technologies offer the potential of allowing children to enjoy playing electronic games without becoming more sedentary.

This study compared the cardiovascular responses and energy costs of new and traditional screen based entertainments, as played by twenty 9- to 12-year-old children. Playing traditional electronic games resulted in little change to heart rate or energy expenditure compared with watching a DVD. In contrast, playing an active-input game resulted in a 59% increase in heart rate (p <. 001) and a 224% increase in energy expenditure (p <. 001) for boys and girls. The average heart rate of 130 bpm and energy expenditure of 0.13 kcal. min-1. kg-1 achieved during active-input game use equates with moderate intensity activities such as basketball and jogging. Active-input electronic games might provide children with opportunities to engage with technology and be physically active at the same time.

There is little research that reports children's perspectives on physical activity, bodies and health. This paper, drawn from a larger multi-method study on physical activity in the lives of seven- and eight-year-old Australian children, attempts to 'give a voice' to 13 children's views. Interviews focused on children's activity preferences and related decision making and motivations pertaining to these activities, as well as how they thought about the relationships between physical activity, health and their bodies. Data suggest some tensions surrounding the importance of fun for children alongside their awareness of 'healthist' discourses that require self-monitoring and improvement. © Taylor & Francis Group Ltd.

BACKGROUND: Body mass index (BMI) is used to diagnose obesity. However, its ability to predict the percentage fat mass (%FM) reliably is doubtful. Therefore validity of BMI as a diagnostic tool of obesity is questioned. AIM: This study is focused on determining the ability of BMI-based cut-off values in diagnosing obesity among Australian children of white Caucasian and Sri Lankan origin. SUBJECTS AND METHODS: Height and weight was measured and BMI (W/H2) calculated. Total body water was determined by deuterium dilution technique and fat free mass and hence fat mass derived using age- and gender-specific constants. A %FM of 30% for girls and 20% for boys was considered as the criterion cut-off level for obesity. BMI-based obesity cut-offs described by the International Obesity Task Force (IOTF), CDC/NCHS centile charts and BMI-Z were validated against the criterion method. RESULTS: There were 96 white Caucasian and 42 Sri Lankan children. of the white Caucasians, 19 (36%) girls and 29 (66%) boys, and of the Sri Lankans 7 (46%) girls and 16 (63%) boys, were obese based on %FM. The FM and BMI were closely associated in both Caucasians (r=0.81, P

Being able to compare the energy cost of physical activity across and between populations is important. However, energy expenditure is related to body size, so it is necessary to appropriately adjust for differences in body size when comparisons are made. This study examined the relationship between the daily energy cost of activity and body weight in 47 children aged 6-10 years. Log-log regression showed weight1.0 to be an inappropriate adjustment for activity energy expenditure in children, with a more valid adjustment being weight0.3. Clearly, both weight dependent and non-weight dependent activities are part of everyday living in children. This balance influences how energy expenditure is correctly adjusted for body size. Investigators interpreting data of energy expenditure in children from children of different body sizes need to take this into consideration.

BACKGROUND: Concerns of a decrease in physical activity levels (PALs) of children and a concurrent increase in childhood obesity exist worldwide. The exact relation between these two parameters however has as yet to be fully defined in children. OBJECTIVE: This study examined the relation in 47 children, aged 5-10.5 y (mean age 8.4+/-0.9 y) between habitual physical activity, minutes spent in moderate, vigorous and hard intensity activity and body composition parameters. DESIGN: Total energy expenditure (TEE) was calculated using the doubly labelled water technique and basal metabolic rate (BMR) was predicted from Schofield's equations. PAL was determined by PAL=TEE/BMR. Time spent in moderate, vigorous and hard intensity activity was determined by accelerometry, using the Tritrac-R3D. Body fatness and body mass index (BMI) were used as the two measures of body composition. RESULTS: Body fat and BMI were significantly inversely correlated with PAL (r=-0.43, P=0.002 and r=-0.45, P=0.001). Times spent in vigorous activity and hard activity were significantly correlated to percentage body fat (r=-0.44, P=0.004 and r=-0.39, P=0.014), but not BMI. Children who were in the top tertiles for both vigorous activity and hard activity had significantly lower body fat percentages than those in the middle and lowest tertiles. Moderate intensity activity was not correlated with measures of body composition. CONCLUSIONS: As well as showing a significant relation between PAL and body composition, these data intimate that there may be a threshold of intensity of physical activity that is influential on body fatness. In light of world trends showing increasing childhood obesity, this study supports the need to further investigate the importance of physical activity for children.

Objective. Many studies have shown that children born small for gestational age (SGA) are at a neurodevelopmental disadvantage. We have shown that nutrient enrichment of formula fed to term SGA infants improves their growth and hypothesized that it also would improve their neurodevelopmental outcome. Design. A randomized, controlled trial of standard term-infant (n = 147) or nutrient-enriched (n = 152) formula for the first 9 months. A reference group of 175 breastfed SGA infants was also recruited. Setting. Subjects were recruited in 5 maternity hospitals in Cambridge, Nottingham, and Leicester, all in the United Kingdom. Participants. Healthy, term infants (gestation: ≥37 weeks) with birth weight

OBJECTIVE: Many studies have shown that children born small for gestational age (SGA) are at a neurodevelopmental disadvantage. We have shown that nutrient enrichment of formula fed to term SGA infants improves their growth and hypothesized that it also would improve their neurodevelopmental outcome. DESIGN: a randomized, controlled trial of standard term-infant (n = 147) or nutrient-enriched (n = 152) formula for the first 9 months. A reference group of 175 breastfed SGA infants was also recruited. SETTING: Subjects were recruited in 5 maternity hospitals in Cambridge, Nottingham, and Leicester, all in the United Kingdom. PARTICIPANTS: Healthy, term infants (gestation: > or =37 weeks) with birth weight

Objective: to test the efficacy and safety of long-chain polyunsaturated fatty acid (LCPUFA) supplementation with gamma-linolenic acid, a precursor of arachidonic acid, and docosahexaenoic acid in preterm infants. Study design: Preterm (< 35 weeks, ≤2000 g birth weight) infants (n = 238) randomly assigned to unsupplemented or LCPUFA-supplemented formula to 9 months after term. The main outcome measure was the Bayley Mental and Psychomotor Indexes (MDI, PDI) at 18 months after term. Safety outcome measures were anthropometry (9 and 18 months), feed tolerance, infection, and clinical complications. Results: There were no significant differences in neurodevelopment between groups overall. In preplanned subgroup analyses, LCPUFA-supplemented boys had significantly higher Bayley MDI than did control boys (difference, 5.7 points; 95% CI, 0.3 to 11.1; P =. 04). LCPUFA-supplemented infants showed significantly greater weight gain (difference. 310 g; 95% CI, 30 to 590 g; P =. 03) and length gain (difference, 1.0 cm; 95% CI, 0.02 to 1.9; P =. 05) between birth and 9 months, with greater effect in boys (weight difference at 9 months, 510 g; 95% CI, 80 to 930 g; P =. 02; length difference at 18 months, 1.8 cm; 95% CI, 0.1 to 1.8; P =. 03). Conclusions: This trial, using the strategy of providing gamma-linolenic acid as a source of arachidonic acid, showed efficacy for growth and for neurodevelopment in boys, with no adverse effects. These data have important implications for LCPUFA-supplementation strategy in preterm infants.

Endothelial dysfunction is an early key event of atherogenesis. Both fitness level and exercise intervention have been shown to positively influence endothelial function. In a cross-sectional study of 47 children, the relationship between habitual physical activity and flow-mediated dilation (FMD) of the brachial artery was explored. Habitual physical activity levels (PALs) were assessed using a validated stable isotope technique, and FMD of the brachial artery was measured via high-resolution ultrasound. The results showed that habitual physical activity significantly correlated with FMD (r=0.39, P=0.007), and remained the most influential variable on dilation in multivariate analysis. Although both fitness level and exercise intervention have previously been shown to positively influence FMD, this is the first time that a relationship with normal PALs has been investigated, especially, at such a young age. These data support the concept that physical activity exerts its protective effect on cardiovascular health via the endothelium and add further emphasis to the importance of physical activity in childhood.

Objective. We tested the hypothesis that balanced addition of long-chain polyunsaturated fatty acid (LCPUFA) to preterm formula during the first weeks of life would confer long-term neurodevelopmental advantage in a double-blind, randomized, controlled trial of preterm formula with and without preformed LCPUFA. Methods. The participants were 195 formula-fed preterm infants (birth weight

OBJECTIVE: We tested the hypothesis that balanced addition of long-chain polyunsaturated fatty acid (LCPUFA) to preterm formula during the first weeks of life would confer long-term neurodevelopmental advantage in a double-blind, randomized, controlled trial of preterm formula with and without preformed LCPUFA. METHODS: the participants were 195 formula-fed preterm infants (birth weight

BACKGROUND: Simple anthropometric indices of body composition have particular appeal for use in children, and as such body mass index (BMI) has been used to predict percentage body fat in a number of studies. AIM: to evaluate the relationship between BMI and percentage body fat (%body fat) and a proposed, more appropriate relationship between BMI and fat mass/height(2) in a cohort of young children. SUBJECTS AND METHODS: Cross-sectional study of 109 children aged between 6 and 10 years residing in either Sydney or Brisbane, Australia. Weight and height were measured using standard methods. Body composition was measured using a stable isotope method to firstly determine total body water and subsequently fat free mass. RESULTS: the correlation between BMI and fat mass/height(2) was markedly greater than that between BMI and percentage body fat. In the entire group of children the R(2) (x100%) value for the relationship between BMI and fat mass/height(2) was 73.3% compared with 46.5% for the relationship between BMI and percentage body fat. CONCLUSIONS: We have shown that the use of BMI to predict fat mass/height(2), and consequently percentage body fat, is superior to the use of BMI to predict percentage body fat based directly upon the R(2) values of the above analysis.

BACKGROUND: Small-for-gestational-age (SGA) term infants are at risk of long-term growth deficits. OBJECTIVE: the objectives were to test the hypothesis that postnatal growth in SGA term infants can be altered by dietary intervention and to examine whether there is a critical window for nutritional programming of the growth trajectory during the first 9 mo postnatally. DESIGN: Healthy term (gestation > or =37 wk) infants with birth weights below the 10th centile were randomly assigned to receive standard term formula (TF; n = 147) or nutrient-enriched formula (EF; n = 152) for the first 9 mo; 175 breast-fed SGA term infants formed a reference group. The main outcome measures were weight, length, and occipitofrontal head circumference (OFC) at 9 and 18 mo. RESULTS: the infants fed the EF showed greater gains in length by 9 (1.1 cm; 95% CI: 0.38, 1.79) and 18 (1.0 cm; 0.25, 1.83) mo and in OFC by 9 (0.5 cm; 0.1, 0.9) and 18 (0.6 cm; 0.2, 1.1) mo than did infants fed the TF; the differences were larger in females. The dietary effects were independent of the pattern of growth retardation. Breast-fed infants showed greater gains in weight and OFC by 18 mo than did infants fed the TF; however, these differences disappeared after adjustment for age, parental size, and birth order. CONCLUSIONS: Linear growth and OFC gains in SGA term infants improve after nutritional intervention during the first 9 mo of life and the effects persist for > or =9 mo beyond the intervention period. Further information on whether catch-up growth is beneficial or detrimental to long-term outcomes is required before public health interventions can be recommended.

OBJECTIVES: Preterm infants are frequently discharged from the hospital growth retarded and show reduced growth throughout childhood. In a large efficacy and safety trial, we tested the hypothesis that nutritional intervention in the first 9 months postterm would reverse postdischarge growth deficits and improve neurodevelopment without adverse safety outcomes. PARTICIPANTS AND INTERVENTION: Two hundred eighty-four infants (mean gestation: 30.9 weeks) were studied; 229 were randomly assigned a protein, energy, mineral, and micronutrient-enriched postdischarge formula (PDF; N = 113) or standard term formula (TF; N = 116) from discharge (mean 36.5 weeks' postmenstrual age). A reference group (N = 65) was breastfed until at least 6 weeks' postterm. Outcome measures. Anthropometry was performed at 6 weeks and 3, 6, 9, and 18 months. Development was measured at 9 months (Knobloch, Passamanick, and Sherrard's developmental screening inventory) and 18 months (Bayley Scales of Infant Development II; primary outcome) postterm. RESULTS: at 9 months, compared with the TF group, those fed PDF were heavier (difference 370 g; 95% confidence interval [CI]: 84-660) and longer (difference 1.1 cm; 95% CI: 0.3-1.9); the difference in length persisted at 18 months (difference 0.82 cm; 95% CI: -0.04-1.7). There was no effect on head circumference. The effect of diet was greatest in males; at 9 months length deficit with TF was 1.5cm (95% CI: 0.3-2.7), and this remained at 18 months (1.5cm [95% CI: 0.3-2.7]). There was no significant difference in developmental scores at 9 or 18 months, although PDF infants had a 2.8 (-1.3-6.8) point advantage in Bayley motor score scales. At 6 weeks' postterm, exclusively breastfed infants were already 513 g (95% CI: 310-715) lighter and 1.6cm (95% CI: 0.8-2.3) shorter than the PDF group, and they remained smaller up to 9 months' postterm. CONCLUSIONS: 1) Improving postdischarge nutrition in the first 9 months may "reset" subsequent growth-at least until 18 months for body length. We intend to follow-up the children at older ages. The observed efficacy of PDF was not associated with adverse safety outcomes. 2) We cannot reject the hypothesis that postdischarge nutrition benefits motor development and this requires additional study. 3) Our data raise the possibility that breastfed postdischarge preterm infants may require nutritional supplementation, currently under investigation.

Background: the recent worldwide increase in the prevalence of childhood obesity may be due in part to a decrease in children's physical activity levels. Objective: the current study of children in the years just before puberty aimed to 1) measure total energy expenditure (TEE) by use of the doubly labeled water (DLW) method, 2) determine the proportion of TEE related to physical activity, 3) investigate the relations between measures of physical activity and body fatness, and 4) investigate possible sex differences in these relations. Design: the DLW technique was used to measure TEE over 10 d in 106 healthy children (52 boys) aged 7.8 ± 0.9 y (±SD). Fatfree mass, and hence fat mass, was derived from the 18O dilution space. Resting energy expenditure (REE) was calculated with use of the Schofield equations. Physical activity level was calculated as TEE/REE. Results: Mean TEE in both boys (7871 ± 1135 kJ/d) and girls (7512 ± 1195 kJ/d) was significantly different (P < 0.0001) from FAO/WHO/UNU recommendations (13% and 9% lower, respectively). There was no significant difference in physical activity level between boys (1.69 ± 0.22) and girls (1.71 ± 0.23). In boys but not girls, physical activity level was inversely correlated with BMI (r = -0.37, P < 0.01), fat mass (r = -0.46, P < 0.005), and percentage of body fat (r = -0.50, P < 0.0001). Conclusions: in boys but not girls, percentage of body fat is inversely associated with physical activity level. Physical activity is one factor contributing to body fatness in boys, but additional factors may influence the size of the fat stores in girls.

Low levels of vitamin a have a major impact on growth, development, and immunity. The aim of this study was to determine the relationship between cord concentrations of vitamin a and neonatal anthropometry in 711 babies born at term in Brazil. Gestational age of the babies was evaluated by the Capurro method. Vitamin a was measured by high performance liquid chromatography. Concentrations of vitamin a in cord blood correlated significantly (p < 0.001) with birthweight (r = 0.24), length (r = 0.20), chest circumference (r = 0.24), mid-upper arm circumference (r = 0.23), triceps skinfold thickness (r = 0.26), and head circumference (r = 0.12) of the babies. The anthropometric measurements of the babies were sorted by the vitamin a concentrations (means and standard deviations) and divided into quartiles. Differences between the quartiles were tested by analysis of variance. Babies in the bottom length, head circumference and triceps skinfold thickness quartiles had lower mean vitamin a concentrations than those of quartiles two, three and four. Babies in the bottom birthweight, chest and mid-upper arm circumferences quartiles had lower mean vitamin a concentrations than those of quartiles three and four (p < 0.003). These data shows that smaller/shorter babies had lower concentrations of vitamin a than heavier/longer babies, probably reflecting the important role of this micronutrient on growth.

BACKGROUND: Iron-fortified formulas are recommended throughout infancy and are frequently used beyond, yet safety aspects have been inadequately studied. Iron could theoretically increase pro-oxidant stress, with potential adverse effects, including infection risk, and some clinicians suspect that iron-fortified formulas induce gastrointestinal disturbance. OBJECTIVE: a planned component of a large intervention trial has been to test the hypothesis that infants receiving iron-fortified formula do not have a higher incidence of infections (primary outcome) or gastrointestinal problems (secondary outcome) than infants on low iron-formulas or cow's milk. Methods. Children (n = 493) 9 months old receiving cow's milk were recruited in 3 UK centers and randomized to: 1) cow's milk as before, 2) formula containing.9 mg/L of iron, or 3) an otherwise identical formula but containing 12 mg/L of iron. Children were followed at 3 monthly intervals and the episodes of infections, diarrhea and constipation, and general morbidity to 18 months old were recorded. Hematologic indices of iron status were determined at 18 months old. RESULTS: Serum ferritin concentrations were increased in infants receiving iron-fortified formula but there were no intergroup differences in incidence of infection, gastrointestinal problems, or in general morbidity or weight gain. CONCLUSIONS: We were unable to identify adverse health effects in older infants and toddlers consuming a high iron-containing formula (12 mg/L) even when used in populations with a low incidence of iron deficiency.

Background: the low sn-2 palmitate content of infant formulas results in formation of fatty acid calcium soaps in the stools and reduced calcium absorption. Objective: Our objective was to test the hypotheses that increasing the proportion of sn-2 palmitate in formula for term infants would result in greater skeletal mineral deposition and reduced stool hardness. Design: Healthy term neonates were randomly assigned to receive standard formula (n = 103) or formula containing 50% sn-2 palmitate (high-sn-2 formula; n = 100) for 12 wk. One hundred twenty breast-fed infants were also studied. The main outcome measures were 1) radial (single-photon absorptiometry) and whole-body (dual-energy X-ray absorptiometry) bone mineral content (WBBMC) at 12 wk and 2) stool frequency, volume, and consistency at 6 and 12 wk. Secondary outcome measures included stool fatty acid content. Results: Infants receiving high-sn-2 formula had higher WBBMC (128.1 ± 9.7 compared with 122.7 ± 10.1 g, adjusted for size and sex), softer stools at 6 and 12 wk, and a lower proportion of stool soap fatty acids than did infants receiving the control formula. Breast-fed infants had adjusted WBBMC values (128.3 ± 9.1 g) similar to those of infants fed high- sn-2 formula and significantly higher than those of infants fed the control formula. Conclusions: Changing the stereoisomeric structure of palmitate in infant formula resulted in higher WBBMC, reduced stool soap fatty acids, and softer stools more like those of breast-fed infants. The greater bone mass measured could be important if it persists beyond the trial period; this merits further investigation.

Background. We tested whether addition of n-3 and n-6 long-chain polyunsaturated fatty acids (LCPUFA) to infant-formula milk during the first 6 months promotes long-term cognitive and motor development, without adverse consequences. Methods. We did a double-blind, randomised, controlled, efficacy and safety trial of formula with and without LCPUFAs, with an additional breastfed reference group, in four hospitals in two cities in the UK. The participants were 447 healthy full-term babies. 309 were fed formula (155 without LCPUFAs) and 138 were breastfed for at least 6 weeks. The main outcome measures were: Bayley Mental and Psychomotor Development Indices (MDI, PDI) at 18 months (primary efficacy outcome) and Knobloch, Passamanick, and Sherrards test at 9 months (secondary outcome). Principal safety outcomes were: infection, atopy, growth, and gastrointestinal tolerance. Findings. Babies fed formula with and without LCPUFA did not differ in cognitive or motor development, growth, infection, atopy or tolerance. The mean (95% CI) MDI was 0.5 (-2.7 to 3.8) units and the PDI 0.6 (-1.8 to 3.0) units higher in the supplementation group. Formula-fed infants had similar developmental scores to the breastfed reference group after adjustment for higher social class and maternal education in the latter. Interpretation. There was no evidence of a beneficial or adverse effect on cognitive and motor development or growth up to 18 months. Although no significant differences in safety outcomes were observed, we suggest such data should be collected in future LCPUFA trials. Our trial does not provide support for addition of LCPUFA to standard infant formula but we are now doing further follow-up of this cohort.

Aims - Iron deficiency anaemia is associated, in observational studies, with developmental disadvantage. This study tested the hypothesis that feeding iron supplemented formula from 9 to 18 months of age would improve developmental performance. Subjects and methods - 493 healthy children aged 9 months being fed pasteurised cows' milk were recruited from three UK centres. They were randomised to: cows' milk as before, formula containing 0.9 mg/litre iron, or formula containing 1.2 mg/litre irons until 18 months of age. Bayley mental and psychomotor developmental indices were measured at 18 months, as were growth and haematological indices. Results - Children fed iron fortified formula had higher plasma ferritin concentrations, but there were no significant intergroup differences in development or growth. Conclusions - There are no developmental or growth advantages in children given iron supplemented formulas but a benefit for a minority who were anaemic, or the possibility that a benefit may emerge at a later age, cannot be excluded.

From a questionnaire completed by 195 mothers of infants aged 3-12 weeks we found that significantly more formula than breast-feeding mothers had concerns about stool hardness and had sought professional advice, resulting in both increased use of health care resources and more dietary interventions.

A case-control study of 712 Brazilian mother-baby pairs was performed to assess maternal nutritional factors, more specifically low or marginal concentrations of vitamin A, folate and iron, as risk factors for intrauterine growth retardation (IUGR). Newborns were classified as being IUGR according to the Lubchenco classification. The gestational age of the newborns was evaluated by the Capurro method. Vitamin A, folate, ferritin and haemoglobin were measured by high-performance liquid chromatography, radioimmunoassay, immunoenzymetric assay and by the cyanmethaemoglobin method respectively. The relationship between maternal nutritional status and IUGR was investigated using stratification and logistic regression. According to the final logistic regression model, the risk factors for IUGR were: maternal body weight, per capita income, cigarette smoking, maternal weight gain, prior history of low birthweight, high maternal ferritin, beer intake and coffee intake. Specific interventions likely to have the major short-term impact in this region are not directly related to nutritional. factors, but to efforts to reduce or eliminate toxic exposures. Over the long term, improvement in maternal nutritional status and socioeconomic conditions would be expected to produce important benefits.

Objectives: (i) to evaluate the relationship between the levels of vitamin A, folate and iron in maternal blood and cord blood from mother-baby pairs who had intrauterine growth retardation (IUGR) and appropriate birth weight (ABW) for gestational age. (ii) to assess low or marginal levels of vitamin A, folate and iron as risk factors for IUGR. Design: Retrospective unmatched case-control study. Setting: Maternidade de Campinas, Universidade Estadual de Campinas, Pontificia Universidade Catolica de Campinas, Hospital Albert Sabin. Subjects: 356 mother-baby pairs who had IUGR and 356 mother-baby pairs who had ABW for gestational age. Interventions: Newborns were classified as being IUGR according to the Lubchenco classification. Gestational age of the newborns was evaluated by the Capurro method. Vitamin A, folate, ferritin, and haemoglobin were measured respectively by high performance liquid chromatography (HPLC), radioimmunoassay, immunoenzymetric assay and by the cyanmethaemoglobin method. Results: the percentages of IUGR babies with abnormal levels of nutritional indices compared with ABW babies were 33.1 vs 14.6 for vitamin A, 25.7 vs 19.9 for red blood cell (RBC) folate, 37.0 vs 21.4 for haemoglobin, but similar for ferritin. The percentages of IUGR mothers with abnormal levels of nutritional indices compared to ABW mothers were similar (1.1 vs 1.4) for vitamin A, and 36.8 vs 32.1 for RBC folate. IUGR mothers were less often anaemic (43.2 vs 50.8), but tended to have higher levels of ferritin (37.6 vs 23.9) compared to ABW mothers. Conclusions: These results indicate marked differences in cord blood between IUGR and ABW with small differences in maternal levels. They suggest that micronutrient deficiency is the result of being born small rather than vice versa. The high levels of ferritin in IUGR mothers may reflect subclinical maternal infection contributing to IUGR. Maternal micronutrient deficiency is unlikely to be a causative factor for IUGR in this population. Sponsorship: ODA (Overseas Development Agency), United Kingdom; CNPq (Conselho Nacional de Desenvolvimento Cientifico e Tecnologico), Brazil. Descriptors: cord blood, folate, intra-uterine growth retardation (IUGR), iron, maternal blood, vitamin A.

OBJECTIVE: to investigate the association between vitamin a status and conjunctival epithelial function in young children in rural northern Ghana and to consider whether impaired epithelial function was associated with increased measures of systemic infection in these children. DESIGN: Children were selected from the Ghana Vitamin a Supplementation Trials' Child Health Study, a randomized, double-blind, placebo-controlled trial of the effect of vitamin a supplementation on morbidity. Treatment group and serum retinol concentrations were used as measures of vitamin a status, conjunctival impression cytology and tear IgA concentrations as measures of conjunctival epithelial integrity, and serum immunoglobulin and alpha 1-acid glycoprotein concentrations as indicators of chronic or acute systemic infection. SUBJECTS: Children 13-64 months old. INTERVENTION: 60 mg retinol as retinyl palmitate every 4 months for 1 year. RESULTS: Vitamin a status was not significantly associated with epithelial integrity nor with measures of systemic infection. Impaired conjunctival epithelial integrity was also not associated with increased systemic infection. CONCLUSIONS: There was no evidence for a major role of improved epithelial integrity and function on the biochemical indices of chronic or acute systemic infection after vitamin a supplementation. These data support the observations in the main study that vitamin a supplementation did not improve conjunctival impression cytology nor decrease the prevalence of most morbidity symptoms.

Serum retinol concentrations decrease during illness and thus may not accurately reflect the vitamin a status of populations with a high prevalence of illness. To quantify the contribution of illness to low serum retinol in a field study of children aged 6-59 mo in northern Ghana, serum retinol values were compared with two indicators of recent illness; symptoms reported by parents and acute-phase protein concentrations in serum. Serum retinol was not associated with symptoms of illness but showed a significant negative correlation with both alpha 1-acid glycoprotein (AGP) and serum amyloid a (SAA). Elevated AGP was associated with a 24% decrease in mean serum retinol. A large proportion of asymptomatic children had elevated AGP or SAA concentrations, suggesting that subclinical infections may have had important effects on serum retinol. A significant negative correlation between malaria parasite density and serum retinol indicated that malaria may have been one of the subclinical infections responsible. Measurement of AGP may improve interpretation of serum retinol data from populations with a high prevalence of morbidity.

This study set out to compare the long‐term palatability of three oral sip‐feed supplements. Sixty patients with various malignancies were randomized to receive one of three products—Build‐Up, Fortimel and Fortisip. Participants were encouraged to take as much of the supplements each day for as long as they could manage. At the initial tasting, palatability and acceptability of the products was recorded and this was repeated throughout the trial period. Patients' reasons for discontinuing the trial were noted. Build‐Up was found to be the best‐tolerated product of the three. It was taken for a significantly longer time than either Fortimel or Fortisip. There was an indication that Build‐Up was more acceptable at the initial tasting than Fortisip but not Fortimel. A smaller proportion of patients stopped taking Build‐Up due to flavour‐related reasons compared to Fortisip but there was no significant difference between Build‐Up and Fortimel. In all, 54% of the patients discontinued the trial for flavour‐related reasons. Thirty‐five per cent found that the sip‐feeds they had been allotted unpalatable at the initial tasting, while 19% stopped the trial due to ‘flavour fatigue’. Only 10% of the sample continued taking their allotted product for 90 days or more. Copyright © 1992, Wiley Blackwell. All rights reserved

The effect of non-insulin-dependent diabetes on the hepatic microsomal cytochrome P450-dependent mixed-function oxidase system and on cytosolic glutathione S-transferase activity was determined using the spontaneously obese-diabetic (ob/ob) mouse model. The activities of the xenobiotic-metabolizing cytochrome P450 proteins were monitored by the use of chemical probes. Non-insulin-dependent diabetes did not influence the hepatic metabolism of substrates associated with the P450 I, IIB, IIE, III and IV families of cytochromes. In contrast, cytosolic glutathione S-transferase activity was markedly reduced and glutathione levels were significantly lowered. These findings raise the possibility that patients suffering from this disease may be more susceptible to chemicals that rely on glutathione conjugation for their deactivation. © 1992.

Nutritional status was assessed in a group of patients with Parkinson's disease. Weight loss since the onset of disease occurred in 52% of the patients and 22% had lost more than 12.8 kg. Although 67% of patients experienced eating difficulties of some kind, dietary intakes of protein and energy were not significantly lower than recommended intakes. Plasma levels of albumin (44.2 g/l vs 45.7 g/l), vitamin a (2.61 vs 2.94 mumol/l), vitamin E (22.0 vs 32.0 mumol/l), iron (15.3 vs 18.3 mumol/l) and zinc (14.2 vs 18.7 mumol/l) were significantly lower (P < 0.05) in the patients than in healthy controls. Levels of ferritin, total iron-binding capacity and copper were similar between groups. The potential significance of low levels of vitamin E and zinc are discussed in relation to oxidative stress in the pathogenesis of this disease.

Reduced food intake is a common problem in patients with malignant disease. Oral supplements can be easily added to foods to increase their nutrient‐energy content. In a previous study (Parkinson et ah, 1987), Polycal was found to be the most acceptable energy supplement although it did not increase the energy content as much as had been hoped. Duocal, a relatively new product, was not then tested. It has a higher energy density, so might be expected to give a greater increase at the same level of palatability. This study was set up to compare the palatability and ability to increase energy of Polycal and Duocal, when incorporated into commonly used recipes. The first stage assessed the relative palatability of the two energy supplements, and found them to be equal. The second stage then set out to find the maximum acceptable amount of Duocal which could be added to a recipe. It was found that Duocal could make a larger contribution to increasing the energy content of the diet than Polycal. Copyright © 1990, Wiley Blackwell. All rights reserved

The acceptability of commercially available oral supplements has a great influence on their long‐term use by cancer patients with a poor nutritional status. This study compares short‐term and long‐term palatability of six oral supplements used widely in hospitals throughout the UK, and their effect on the nutritional intake of the patient. Copyright © 1990, Wiley Blackwell. All rights reserved