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1.  Traditional and Emerging Lifestyle Risk Behaviors and All-Cause Mortality in Middle-Aged and Older Adults: Evidence from a Large Population-Based Australian Cohort 
PLoS Medicine  2015;12(12):e1001917.
Background
Lifestyle risk behaviors are responsible for a large proportion of disease burden worldwide. Behavioral risk factors, such as smoking, poor diet, and physical inactivity, tend to cluster within populations and may have synergistic effects on health. As evidence continues to accumulate on emerging lifestyle risk factors, such as prolonged sitting and unhealthy sleep patterns, incorporating these new risk factors will provide clinically relevant information on combinations of lifestyle risk factors.
Methods and Findings
Using data from a large Australian cohort of middle-aged and older adults, this is the first study to our knowledge to examine a lifestyle risk index incorporating sedentary behavior and sleep in relation to all-cause mortality. Baseline data (February 2006– April 2009) were linked to mortality registration data until June 15, 2014. Smoking, high alcohol intake, poor diet, physical inactivity, prolonged sitting, and unhealthy (short/long) sleep duration were measured by questionnaires and summed into an index score. Cox proportional hazards analysis was used with the index score and each unique risk combination as exposure variables, adjusted for socio-demographic characteristics.
During 6 y of follow-up of 231,048 participants for 1,409,591 person-years, 15,635 deaths were registered. Of all participants, 31.2%, 36.9%, 21.4%, and 10.6% reported 0, 1, 2, and 3+ risk factors, respectively. There was a strong relationship between the lifestyle risk index score and all-cause mortality. The index score had good predictive validity (c index = 0.763), and the partial population attributable risk was 31.3%. Out of all 96 possible risk combinations, the 30 most commonly occurring combinations accounted for more than 90% of the participants. Among those, combinations involving physical inactivity, prolonged sitting, and/or long sleep duration and combinations involving smoking and high alcohol intake had the strongest associations with all-cause mortality. Limitations of the study include self-reported and under-specified measures, dichotomized risk scores, lack of long-term patterns of lifestyle behaviors, and lack of cause-specific mortality data.
Conclusions
Adherence to healthy lifestyle behaviors could reduce the risk for death from all causes. Specific combinations of lifestyle risk behaviors may be more harmful than others, suggesting synergistic relationships among risk factors.
Analysis of large population cohort reveals short and long sleep duration and extended sitting for sedentary workers as lifestyle risks that can be added to other known mortality risk factors.
Editors' Summary
Background
For the first time in human history, noncommunicable diseases (NCDs) are killing more people than infectious diseases. Every year, about 38 million people die from a NCD—more than two-thirds of the world’s annual deaths. The most common NCDs are cardiovascular diseases (conditions that affect the heart and the circulation), cancers, diabetes, and chronic respiratory diseases (long-term diseases that affect the lungs and airways). These NCDs can be largely attributed to modifiable lifestyle risk factors such as smoking, harmful use of alcohol, physical inactivity, and having an unhealthy diet (one with low fruit and vegetable intake and high saturated fat and salt intake). More recently, a sedentary lifestyle (sitting for more than seven hours during a typical 24-hour day—separate from whether a person is physically active, i.e., undertaking more than 150 minutes of moderate-to-vigorous physical activity every week) and having an unhealthy sleep pattern (less than seven hours or more than nine hours of sleep per day) have also been identified as modifiable risk factors for NCDs.
Why Was This Study Done?
It should be possible to reduce the burden of NCDs by encouraging people to adopt a healthier lifestyle. Modifiable lifestyle risk factors tend to be associated with multiple disease outcomes (for example, physical inactivity is associated with an increased risk of cardiovascular disease, diabetes, and some cancers), and the common risk factors for NCDs tend to cluster within populations. Thus, the combined effects of modifiable risk factors need to be understood before effective public health programs to prevent NCDs can be designed. Here, using data from a large group of middle-aged and elderly Australians (the 45 and Up Study cohort), the researchers develop a lifestyle risk index (score) and examine the association between this score and all-cause mortality (death from any cause). They also identify the most commonly occurring combinations of health risk behaviors and quantify the risk for all-cause mortality for each combination of risk behaviors.
What Did the Researchers Do and Find?
The researchers used mortality registration data to ascertain all-cause mortality during six years of follow-up among 231,048 Australians aged 45 years or older who had completed a lifestyle questionnaire at baseline. They scored six health behaviors reported in the questionnaires (smoking, alcohol use, dietary behavior, physical activity, sedentary behavior, and sleep) for each participant and summed these scores to provide a lifestyle risk index. About a third of the participants reported exposure to no risk factors; about a third, a fifth, and a tenth reported exposure to one, two, and three or more risk factors, respectively. Statistical analysis indicated that exposure to multiple lifestyle risk factors was associated with increased all-cause mortality, that the index score was a good predictor of all-cause mortality, and that the population attributable risk was 31.3%. That is, a third of the person-years lost due to death could have been avoided if all the study participants had had a risk score of zero, provided all six risk factors are causal (responsible for illness and death). More than 90% of the participants had one of the 30 most commonly occurring combinations of risk factors (out of 96 possible combinations). Notably, combinations involving physical inactivity, sedentary behavior, and/or long sleep duration and combinations involving smoking and high alcohol consumption were most strongly associated with all-cause mortality.
What Do These Findings Mean?
Several aspects of the study design (for example, the reliance on self-reported exposure to risk factors and the lack of data on long-term patterns of lifestyle behaviors) may limit the accuracy of these findings. Confounding (people who reported exposure to a specific risk factor may have shared another characteristic that was actually responsible for their illness or death) and reverse causation (a reported behavior may have been caused by an underlying illness, rather than the behavior causing that illness) may also affect the findings’ accuracy. Nevertheless, this study reaffirms the importance of middle-aged and elderly people adopting healthy lifestyles and establishes prolonged sitting and unhealthy sleep duration as two additional risk factors for all-cause mortality that should be included in scores designed to quantify health risk. Finally, the finding that some combinations of health risk behaviors may be more harmful than others suggests that some risk factors have interactive (synergistic) effects on health outcomes. This information may help to guide the design of effective programs for the prevention of NCDs.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001917.
The US Centers for Disease Control and Prevention (CDC) provides information on all aspects of healthy living, on chronic disease prevention and health promotion, and on noncommunicable diseases around the world; web pages provided by CDC’s Division of Nutrition, Physical Activity, and Obesity include information on staying healthy by exercising and eating a healthy diet, instructional videos, and personal success stories (some information in English and Spanish)
The World Health Organization provides information about noncommunicable diseases and stories about noncommunicable disease prevention around the world (in several languages); its Global Recommendations on Physical Activity for Health is available in several languages; its Global Noncommunicable Disease Network (NCDnet) provides information about the four most common NCDs and about four modifiable risk factors for these diseases; the WHO webpage Face to Face with Chronic Disease is a selection of personal stories from around the world about dealing with NCDs
More information about the 45 and Up Study is available
doi:10.1371/journal.pmed.1001917
PMCID: PMC4672919  PMID: 26645683
2.  Changes in Intake of Fruits and Vegetables and Weight Change in United States Men and Women Followed for Up to 24 Years: Analysis from Three Prospective Cohort Studies 
PLoS Medicine  2015;12(9):e1001878.
Background
Current dietary guidelines recommend eating a variety of fruits and vegetables. However, based on nutrient composition, some particular fruits and vegetables may be more or less beneficial for maintaining or achieving a healthy weight. We hypothesized that greater consumption of fruits and vegetables with a higher fiber content or lower glycemic load would be more strongly associated with a healthy weight.
Methods and Findings
We examined the association between change in intake of specific fruits and vegetables and change in weight in three large, prospective cohorts of 133,468 United States men and women. From 1986 to 2010, these associations were examined within multiple 4-y time intervals, adjusting for simultaneous changes in other lifestyle factors, including other aspects of diet, smoking status, and physical activity. Results were combined using a random effects meta-analysis. Increased intake of fruits was inversely associated with 4-y weight change: total fruits -0.53 lb per daily serving (95% CI -0.61, -0.44), berries -1.11 lb (95% CI -1.45, -0.78), and apples/pears -1.24 lb (95% CI -1.62, -0.86). Increased intake of several vegetables was also inversely associated with weight change: total vegetables -0.25 lb per daily serving (95% CI -0.35, -0.14), tofu/soy -2.47 lb (95% CI, -3.09 to -1.85 lb) and cauliflower -1.37 lb (95% CI -2.27, -0.47). On the other hand, increased intake of starchy vegetables, including corn, peas, and potatoes, was associated with weight gain. Vegetables having both higher fiber and lower glycemic load were more strongly inversely associated with weight change compared with lower-fiber, higher-glycemic-load vegetables (p < 0.0001). Despite the measurement of key confounders in our analyses, the potential for residual confounding cannot be ruled out, and although our food frequency questionnaire specified portion size, the assessment of diet using any method will have measurement error.
Conclusions
Increased consumption of fruits and non-starchy vegetables is inversely associated with weight change, with important differences by type suggesting that other characteristics of these foods influence the magnitude of their association with weight change.
Using longitudinal data from health practitioners, Bertoia and colleagues explore associations between specific food choices and weight change.
Editors' Summary
Background
Obesity—having an unhealthy amount of body fat—is increasing worldwide. In the United States, for example, more than a third of adults are obese and another third are overweight. Obesity is defined as having a body mass index (BMI; an indicator of body fat calculated by dividing a person’s weight in kilograms by their height in meters squared) of more than 30 kg/m2; overweight individuals have a BMI of 25.0–29.9 kg/m2. Compared to people with a healthy weight, overweight and obese individuals have an increased risk of developing diabetes and cardiovascular diseases (conditions that affect the heart and/or the blood vessels), and tend to die younger. People gain too much fat by consuming food and drink that contains more energy (calories) than they need for their daily activities. So, people can avoid becoming obese or reduce their BMI by eating a healthy diet that contains fewer calories and by exercising more.
Why Was This Study Done?
The 2010 Dietary Guidelines for Americans recommend that adults and children should eat a variety of fruits and vegetables to help them achieve and maintain a healthy weight. But are all fruits and vegetables equally good at controlling weight? Fruits and vegetables differ in their dietary fiber content and their glycemic load. High fiber foods increase satiety (feeling full after eating), which can reduce total energy intake. Foods with a low glycemic load produce smaller and fewer blood sugar spikes after they are consumed, which may reduce hunger later on. In this study, the researchers investigate whether consumption of fruits and vegetable with a higher fiber content or lower glycemic load is more strongly associated with a healthy weight than consumption of fruits and vegetables with a lower fiber content or higher glycemic load by analyzing data on weight and diet changes among US men and women enrolled in three large prospective cohort studies set up to examine risk factors for major chronic diseases.
What Did the Researchers Do and Find?
The researchers examined associations between changes in the intake of specific fruits and vegetables recorded in dietary questionnaires completed every 4 y and self-reported weight changes in 133,468 US men and women followed for up to 24 y. After adjusting for self-reported changes in other lifestyle factors likely to affect weight, such as smoking status and physical activity, an increased intake of fruits and of several vegetables was inversely associated with 4-y weight change. Thus, an increase in total fruit intake was associated with a change in weight over a 4-y interval of -0.53 lb (a weight loss of 0.24 kg) for each extra daily serving, and an increase in total vegetable intake was associated with a weight change of -0.25 lb (-0.11 kg) for each extra daily serving. However, increased intake of starchy vegetables such as corn, peas, and potatoes was associated with weight gain. Notably, higher-fiber, lower-glycemic load vegetables (for example, broccoli and Brussels sprouts) were more strongly inversely associated with weight change than lower-fiber, higher-glycemic load vegetables (for example, carrots and cabbage).
What Do These Findings Mean?
These findings suggest that increased consumption of fruits and non-starchy vegetables is inversely associated with weight change and that different fruits and vegetables have different effects on weight. The benefits of increased consumption were greater for fruits than for vegetables and strongest for berries, apples/pears, tofu/soy, cauliflower, and cruciferous and green leafy vegetables. Increased satiety with fewer calories could be partly responsible for the beneficial effects of increasing fruit and vegetable intake. These findings may not be generalizable—nearly all the participants were well-educated white adults. Moreover, the use of dietary questionnaires and self-reported weight measurement may have introduced measurement errors into this study and, although the researchers accounted for some key lifestyle factors that are likely to affect weight, individuals who increased their fruit and vegetable intake and lost weight may have shared other unknown characteristics that were actually responsible for their weight loss. Overall, however, these findings provide new food-specific guidance for the prevention of obesity, a primary risk factor for many life-shortening health conditions.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001878. The World Health Organization provides information on obesity (in several languages)The Global Burden of Disease websitey provides the latest details about global obesity trends; the International Obesity Taskforce also provides information about the global obesity epidemicThe United Kingdom National Health Service Choices website provides information about obesity, cardiovascular disease, and diabetes (including some personal stories), and about healthy eatingThe American Heart Association provides information on cardiovascular disease and diabetes and on keeping healthy, including nutritional informationThe US Centers for Disease Control and Prevention has information on all aspects of overweight and obesityChooseMyPlate.gov is a resource provided by the US Department of Agriculture that provides individuals and healthcare professionals with user-friendly nutritional information; the 2010 Dietary Guidelines for Americans are availableMedlinePlus provides links to other sources of information on obesity, heart disease, vascular disease, and diabetes (in English and Spanish)More information about the three cohort studies that provided data for this analysis (Nurses' Health Study and Nurses' Health Study II and Health Professionals Follow-up Study) is available
doi:10.1371/journal.pmed.1001878
PMCID: PMC4578962  PMID: 26394033
3.  Behavioral Self-Regulation and Weight-Related Behaviors in Inner-City Adolescents: A Model of Direct and Indirect Effects 
Childhood obesity (Print)  2011;7(4):306-315.
Background
This study examined the association of two distinct self-regulation constructs, effortful control and dysregulation, with weight-related behaviors in adolescents and tested whether these effects were mediated by self-efficacy variables.
Methods
A school-based survey was conducted with 1771 adolescents from 11 public schools in the Bronx, New York. Self-regulation was assessed by multiple indicators and defined as two latent constructs. Dependent variables included fruit/vegetable intake, intake of snack/junk food, frequency of physical activity, and time spent in sedentary behaviors. Structural equation modeling examined the relation of effortful control and dysregulation to lifestyle behaviors, with self-efficacy variables as possible mediators.
Results
Study results showed that effortful control had a positive indirect effect on fruit and vegetable intake, mediated by self-efficacy, as well as a direct effect. Effortful control also had a positive indirect effect on physical activity, mediated by self-efficacy. Dysregulation had direct effects on intake of junk food/snacks and time spent in sedentary behaviors.
Conclusions
These findings indicate that self-regulation characteristics are related to diet and physical activity and that some of these effects are mediated by self-efficacy. Different effects were noted for the two domains of self-regulation. Prevention researchers should consider including self-regulation processes in programs to improve health behaviors in adolescents.
PMCID: PMC3522174  PMID: 23243551
4.  Diet, Psychosocial Factors Related to Diet and Exercise, and Cardiometabolic Conditions in Southern Californian Native Hawaiians 
Hawaii Medical Journal  2010;69(5 suppl 2):16-20.
Objective
Native Hawaiians are at higher risk for cardiometabolic disease, including diabetes and cardiovascular disease compared with other ethnic groups. Diet, body mass index (BMI) and psychosocial, as well as cultural issues may influence risk for cardiometabolic disease. Our team conducted a community-based participatory research study and examined diet, height/weight, psychosocial factors, and community health concerns in Native Hawaiians living in Southern California.
Design and Methods
Cross-section of 55 participants, ≥ 18 years old. Dietary data were collected via three 24-hr dietary recalls, anthropometrics were measured, and psychosocial factors and cardiometabolic conditions were self-reported. Talk story related to diet and health was completed in a sub-sample. Means and frequencies were calculated on dietary intakes, cardiometabolic disease and BMI. Independent t-test and chi square analyses, as appropriate, were performed to assess differences in dietary intakes, obesity and psychosocial factors between those with and without a pre-existing cardiometabolic condition.
Results
Of those with pre-existing health conditions (n = 28), 72% reported being diagnosed with a cardiometabolic condition. For those with pre-existing cardiometabolic conditions, the daily vegetable consumption was 2.57 servings (± 1.66) and the mean fruit consumption was 1.43 servings (± 0.1.99). The mean fiber intake was 16.24 grams (± 6.92), the mean percentage energy from fat was 34.82% (± 6.40) and the mean % energy from carbohydrate was 47.15 (± 6.77). The psychosocial data showed significantly (p ≤ 0.05) lower social support, social interaction, self-monitoring and cognitive-behavioral strategies related to exercise for those with cardiometabolic disease compared with those without disease. All the talk story discussion groups expressed concern over diabetes and weight management, both as an individual and community issue.
Conclusions
The dietary data indicate that Native Hawaiians residing in Southern California should aim to increase their vegetable, fiber, and reduce % energy from fat and saturated fat. Additionally, the psychosocial data suggests that implementing physical activity programs based on socio-cultural values such as ohana, community gatherings, as well as individual self-monitoring and cognitive-behavioral strategies may improve cardiometabolic outcomes. In efforts to reduce cardiometabolic disease disparity, these data suggest that Native Hawaiians in Southern California are aware and concerned about cardiometabolic disease in the community, and that implementation of an effective energetic (diet plus physical activity) intervention that is socially, and culturally specific for Native Hawaiians in Southern California is critical.
PMCID: PMC3158438  PMID: 20544604
5.  Diet and Physical Activity for the Prevention of Noncommunicable Diseases in Low- and Middle-Income Countries: A Systematic Policy Review 
PLoS Medicine  2013;10(6):e1001465.
Carl Lachat and colleagues evaluate policies in low- and middle-income countries addressing salt and fat consumption, fruit and vegetable intake, and physical activity, key risk factors for non-communicable diseases.
Please see later in the article for the Editors' Summary
Background
Diet-related noncommunicable diseases (NCDs) are increasing rapidly in low- and middle-income countries (LMICs) and constitute a leading cause of mortality. Although a call for global action has been resonating for years, the progress in national policy development in LMICs has not been assessed. This review of strategies to prevent NCDs in LMICs provides a benchmark against which policy response can be tracked over time.
Methods and Findings
We reviewed how government policies in LMICs outline actions that address salt consumption, fat consumption, fruit and vegetable intake, or physical activity. A structured content analysis of national nutrition, NCDs, and health policies published between 1 January 2004 and 1 January 2013 by 140 LMIC members of the World Health Organization (WHO) was carried out. We assessed availability of policies in 83% (116/140) of the countries. NCD strategies were found in 47% (54/116) of LMICs reviewed, but only a minority proposed actions to promote healthier diets and physical activity. The coverage of policies that specifically targeted at least one of the risk factors reviewed was lower in Africa, Europe, the Americas, and the Eastern Mediterranean compared to the other two World Health Organization regions, South-East Asia and Western Pacific. Of the countries reviewed, only 12% (14/116) proposed a policy that addressed all four risk factors, and 25% (29/116) addressed only one of the risk factors reviewed. Strategies targeting the private sector were less frequently encountered than strategies targeting the general public or policy makers.
Conclusions
This review indicates the disconnection between the burden of NCDs and national policy responses in LMICs. Policy makers urgently need to develop comprehensive and multi-stakeholder policies to improve dietary quality and physical activity.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Noncommunicable diseases (NCDs)—chronic medical conditions including cardiovascular diseases (heart disease and stroke), diabetes, cancer, and chronic respiratory diseases (chronic obstructive pulmonary disease and asthma)—are responsible for two-thirds of the world's deaths. Nearly 80% of NCD deaths, close to 30 million per year, occur in low- and middle-income countries (LMICs), where they are also rising most rapidly. Diet and lifestyle (including smoking, lack of exercise, and harmful alcohol consumption) influence a person's risk of developing an NCD and of dying from it. Because they can be modified, these risk factors have been at the center of strategies to combat NCDs. In 2004, the World Health Organization (WHO) adopted the Global Strategy on Diet, Physical Activity and Health. For diet, it recommended that individuals achieve energy balance and a healthy weight; limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids; increase consumption of fruits, vegetables, legumes, whole grains, and nuts; limit the intake of free sugars; and limit salt consumption from all sources and ensure that salt is iodized. For physical activity, it recommended at least 30 minutes of regular, moderate-intensity physical activity on most days throughout a person's life.
Why Was This Study Done?
By signing onto the Global Strategy in 2004, WHO member countries agreed to implement it with high priority. A first step of implementation is usually the development of local policies. Consequently, one of the four objectives of the WHO Global Strategy is “to encourage the development, strengthening and implementation of global, regional, national and community policies and action plans to improve diets and increase physical activity.” Along the same lines, in 2011 the United Nations held a high-level meeting in which the need to accelerate the policy response to the NCD epidemic was emphasized. This study was done to assess the existing national policies on NCD prevention in LMICs. Specifically, the researchers examined how well those policies matched the WHO recommendations for intake of salt, fat, and fruits and vegetables, as well as the recommendations for physical activity.
What Did the Researchers Do and Find?
The researchers searched the Internet (including websites of relevant ministries and departments) for all publicly available national policies related to diet, nutrition, NCDs, and health from all 140 WHO member countries classified as LMICs by the World Bank in 2011. For countries for which the search did not turn up policies, the researchers sent e-mail requests to the relevant national authorities, to the regional WHO offices, and to personal contacts. All documents dated from 1 January 2004 to 1 January 2013 that included national objectives and guidelines for action regarding diet, physical exercise, NCD prevention, or a combination of the three, were analyzed in detail.
Most of the policies obtained were not easy to find and access. For 24 countries, particularly in the Eastern Mediterranean, the researchers eventually gave up, unable to establish whether relevant national policies existed. Of the remaining 116 countries, 29 countries had no relevant policies, and another 30 had policies that failed to mention specifically any of the diet-related risk factors included in the analysis. Fifty-four of the 116 countries had NCD policies that addressed at least one of the risk factors. Thirty-six national policy documents contained strategies to increase fruit and vegetable intake, 20 addressed dietary fat consumption, 23 aimed to limit salt intake, and 35 had specific actions to promote physical activity. Only 14 countries, including Jamaica, the Philippines, Iran, and Mongolia, had policies that addressed all four risk factors. The policies of 27 countries mentioned only one of the four risk factors.
Policies primarily targeted consumers and government agencies and failed to address the roles of the business community or civil society. Consistent with this, most were missing plans, mechanisms, and incentives to drive collaborations between the different stakeholders.
What Do These Findings Mean?
More than eight years after the WHO Global Strategy was agreed upon, only a minority of the LMICs included in this analysis have comprehensive policies in place. Developing policies and making them widely accessible is a likely early step toward specific implementation and actions to prevent NCDs. These results therefore suggest that not enough emphasis is placed on NCD prevention in these countries through actions that have been proven to reduce known risk factors. That said, the more important question is what countries are actually doing to combat NCDs, something not directly addressed by this analysis.
In richer countries, NCDs have for decades been the leading cause of sickness and death, and the fact that public health strategies need to emphasize NCD prevention is now widely recognized. LMICs not only have more limited resources, they also continue to carry a large burden from infectious diseases. It is therefore not surprising that shifting resources towards NCD prevention is a difficult process, even if the human cost of these diseases is massive and increasing. That only about 3% of global health aid is aimed at NCD prevention does not help the situation.
The authors argue that one step toward improving the situation is better sharing of best practices and what works and what doesn't in policy development. They suggest that an open-access repository like one that exists for Europe could improve the situation. They offer to organize, host, and curate such a resource under the auspices of WHO, starting with the policies retrieved for this study, and they invite submission of additional policies and updates.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001465.
This study is further discussed in a PLOS Medicine Perspective by Stuckler and Basu
The WHO website on diet and physical activity contains links to various documents, including a diet and physical activity implementation toolbox that contains links to the 2004 Global Strategy document and a Framework to Monitor and Evaluate Implementation
There is a 2011 WHO primer on NCDs entitled Prioritizing a Preventable Epidemic
A recent PLOS Medicine editorial and call for papers addressing the global disparities in the burden from NCDs
A PLOS Blogs post entitled Politics and Global HealthAre We Missing the Obvious? and associated comments discuss the state of the fight against NCDs in early 2013
The NCD Alliance was founded by the Union for International Cancer Control, the International Diabetes Federation, the World Heart Federation, and the International Union Against Tuberculosis and Lung Disease; its mission is to combat the NCD epidemic by putting health at the center of all policies
The WHO European Database on Nutrition, Obesity and Physical Activity (NOPA) contains national and subnational surveillance data, policy documents, actions to implement policy, and examples of good practice in programs and interventions for the WHO European member states
doi:10.1371/journal.pmed.1001465
PMCID: PMC3679005  PMID: 23776415
6.  Tailored, iterative, printed dietary feedback is as effective as group education in improving dietary behaviours: results from a randomised control trial in middle-aged adults with cardiovascular risk factors 
Background
Tailored nutrition interventions have been shown to be more effective than non-tailored materials in changing dietary behaviours, particularly fat intake and fruit and vegetable intake. But further research examining efficacy of tailored nutrition education in comparison to other nutrition education methods and across a wider range of dietary behaviours is needed. The Stages to Healthy Eating Patterns Study (STEPs) was an intervention study, in middle-aged adults with cardiovascular risk factors, to examine the effectiveness of printed, tailored, iterative dietary feedback delivered by mail in improving short-term dietary behaviour in the areas of saturated fat, fruit, vegetable and grain and cereal intake.
Methods
STEPs was a 3-month randomised controlled trial with a pre and post-test design. There were three experimental conditions: 1) tailored, iterative, printed dietary feedback (TF) with three instalments mail-delivered over a 3-month period that were re-tailored to most recent assessment of dietary intake, intention to change and assessment of self-adequacy of dietary intake. Tailoring for dietary intake was performed on data from a validated 63-item combination FFQ designed for the purpose 2) small group nutrition education sessions (GE): consisting of two 90-minute dietitian-led small group nutrition education sessions and 3) and a wait-listed control (C) group who completed the dietary measures and socio-demographic questionnaires at baseline and 3-months later. Dietary outcome measures in the areas of saturated fat intake (g), and the intake of fruit (serves), vegetables (serves), grain and cereals as total and wholegrain (serves) were collected using 7-day estimated dietary records. Descriptive statistics, paired t-tests and general linear models adjusted for baseline dietary intake, age and gender were used to examine the effectiveness of different nutrition interventions.
Results
The TF group reported a significantly greater increase in fruit intake (0.3 serves/d P = 0.031) in comparison to GE and the C group. All three intervention groups showed a reduction in total saturated fat intake. GE also had a within-group increase in mean vegetable intake after 3 months, but this increase was not different from changes in the other groups.
Conclusions
In this study, printed, tailored, iterative dietary feedback was more effective than small group nutrition education in improving the short-term fruit intake behaviour, and as effective in improving saturated fat intake of middle-aged adults with cardiovascular risk factors. This showed that a low-level dietary intervention could achieve modest dietary behaviour changes that are of public health significance.
doi:10.1186/1479-5868-8-43
PMCID: PMC3117757  PMID: 21595978
7.  New Moves—Preventing Weight-Related Problems in Adolescent Girls 
Background
Weight-related problems are prevalent in adolescent girls.
Purpose
To evaluate New Moves, a school-based program aimed at preventing weight-related problems in adolescent girls.
Design
School-based group-randomized controlled design.
Setting/participants
356 girls (mean age=15.8± 1.2 years) from six intervention and six control high schools. Over 75% of the girls were racial/ethnic minorities and 46% were overweight or obese. Data were collected in 2007–2009 and analyzed in 2009–2010.
Intervention
An all-girls physical education class, supplemented with nutrition and self-empowerment components, individual sessions using motivational interviewing, lunch meetings, and parent outreach.
Main outcome measures
Percent body fat, BMI, physical activity, sedentary activity, dietary intake, eating patterns, unhealthy weight control behaviors, and body/self-image.
Results
New Moves did not lead to significant changes in the girls’ percent body fat or BMI but improvements were seen for sedentary activity, eating patterns, unhealthy weight control behaviors, and body/self-image. For example, in comparison to control girls, at 9-month follow-up, intervention girls decreased their sedentary behaviors by approximately one 30-minute block a day (p=.050); girls increased their portion control behaviors (p=.014); the percentage of girls using unhealthy weight control behaviors decreased by 13.7% (p=.021), and improvements were seen in body image (p=.045) and self-worth (p=.031). Additionally, intervention girls reported more support by friends, teachers, and families for healthy eating and physical activity.
Conclusions
New Moves provides a model for addressing the broad spectrum of weight-related problems among adolescent girls. Further work is needed to enhance the effectiveness of interventions to improve weight status of youth.
doi:10.1016/j.amepre.2010.07.017
PMCID: PMC2978965  PMID: 20965379
8.  The association of emotion regulation with lifestyle behaviors in inner-city adolescents 
Eating behaviors  2013;14(4):10.1016/j.eatbeh.2013.07.009.
Purpose
Recent research suggests a role of cognitive self-regulation skills on obesity and lifestyle behaviors. However, very little is known about the role of emotion regulation. This study examined the association of emotion regulation with lifestyle behaviors and examined a mediational model testing effects of emotion regulation through self-efficacy and depressive symptoms.
Methods
A cross-sectional study was conducted with 602 adolescents (mean age 12.7 years) from 4 public schools in the Bronx, NY. The sample was 58% female, predominantly Hispanic (74%) and US born (81%). Emotion regulation was assessed by 3 indicators and defined as a latent variable. Dependent variables included fruit/vegetable intake, snack/junk food intake, frequency of physical activity, and time spent in sedentary behaviors. Structural equation modeling examined the association of emotion regulation with lifestyle behaviors, with self-efficacy and depressive symptoms defined as potential mediators.
Results
The analyses showed that there was a positive association of emotion regulation with higher intake of fruits/vegetable and greater physical activity, which was mediated by self-efficacy. Emotion regulation was related to snack/junk food intake and sedentary behavior, and the structural equation model indicated pathways through an inverse relation to depressive symptoms, but these pathways were only observed in adolescent girls and not boys.
Conclusions
These findings indicate that the ability to regulate emotions among adolescents has a role in weight-related behaviors. Future studies may need to explore the relation of other dimensions of emotion to positive health behaviors and study aspects of emotion regulation that may be more relevant for boys.
doi:10.1016/j.eatbeh.2013.07.009
PMCID: PMC3817414  PMID: 24183148
Adolescents; Lifestyle behaviors; Emotion regulation; Depressive Symptoms; Self-efficacy
9.  Nutrition and Lifestyle in European Adolescents: The HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) Study123 
Advances in Nutrition  2014;5(5):615S-623S.
Adolescence is a critical period, because major physical and psychologic changes occur during a very short period of time. Changes in dietary habits may induce different types of nutritional disorders and are likely to track into adulthood. The aim of this review is to describe the key findings related to nutritional status in European adolescents participating in the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) study. We performed a cross-sectional study in 3528 (1845 females) adolescents aged 12.5–17.5 y. Birth weight was negatively associated with abdominal fat mass in adolescents and serum leptin concentrations (in female adolescents), providing additional evidence for a programming effect of birth weight on energy homeostasis control. Breakfast consumption was associated with lower body fat content and healthier cardiovascular profile. Adolescents eat half of the recommended amount of fruit and vegetables and less than two-thirds of the recommended amount of milk and milk products but consume more meat and meat products, fats, and sweets than recommended. For beverage consumption, sugar-sweetened beverages, sweetened milk, low-fat milk, and fruit juice provided the highest amount of energy. Although the intakes of saturated fatty acids (FAs) and salt were high, the intake of polyunsaturated FAs was low. Adolescents spent, on average, 9 h/d of their waking time (66–71% and 70–73% of the registered time in boys and girls, respectively) in sedentary activities. Factors associated with adolescents’ sedentary behavior included the following: 1) age; 2) media availability in the bedroom; 3) sleeping time; 4) breakfast consumption; and 5) season. Sedentary time was also associated with cardiovascular risk factors and bone mineral content. In European adolescents, deficient concentrations were identified for plasma folate (15%), vitamin D (15%), pyridoxal 5′-phosphate (5%), β-carotene (25%), and vitamin E (5%). Scientists and public health authorities should raise awareness of the importance of a healthy and sustainable lifestyle as a foundation of the health of the European population, now and in the future.
doi:10.3945/an.113.005678
PMCID: PMC4188245  PMID: 25469407
10.  Make Better Choices (MBC): Study design of a randomized controlled trial testing optimal technology-supported change in multiple diet and physical activity risk behaviors 
BMC Public Health  2010;10:586.
Background
Suboptimal diet and physical inactivity are prevalent, co-occurring chronic disease risk factors, yet little is known about how to maximize multiple risk behavior change. Make Better Choices, a randomized controlled trial, tests competing hypotheses about the optimal way to promote healthy change in four bundled risk behaviors: high saturated fat intake, low fruit and vegetable intake, low physical activity, and high sedentary leisure screen time. The study aim is to determine which combination of two behavior change goals - one dietary, one activity - yields greatest overall healthy lifestyle change.
Methods/Design
Adults (n = 200) with poor quality diet and sedentary lifestyle will be recruited and screened for study eligibility. Participants will be trained to record their diet and activities onto a personal data assistant, and use it to complete two weeks of baseline. Those who continue to show all four risk behaviors after baseline recording will be randomized to one of four behavior change prescriptions: 1) increase fruits and vegetables and increase physical activity, 2) decrease saturated fat and increase physical activity, 3) increase fruits and vegetable and decrease saturated fat, or 4) decrease saturated fat and decrease sedentary activity. They will use decision support feedback on the personal digital assistant and receive counseling from a coach to alter their diet and activity during a 3-week prescription period when payment is contingent upon meeting behavior change goals. They will continue recording on an intermittent schedule during a 4.5-month maintenance period when payment is not contingent upon goal attainment. The primary outcome is overall healthy lifestyle change, aggregated across all four risk behaviors.
Discussion
The Make Better Choices trial tests a disseminable lifestyle intervention supported by handheld technology. Findings will fill a gap in knowledge about optimal goal prescription to facilitate simultaneous diet and activity change. Results will shed light on which goal prescription maximizes healthful lifestyle change.
Trial Registration
Clinical Trials Gov. Identifier NCT00113672
doi:10.1186/1471-2458-10-586
PMCID: PMC2955698  PMID: 20920275
11.  Familial correlates of adolescent girls' physical activity, television use, dietary intake, weight, and body composition 
Background
The family environment offers several opportunities through which to improve adolescents' weight and weight-related behaviors. This study aims to examine the cross-sectional relationships between multiple factors in the family environment and physical activity (PA), television use (TV), soft drink intake, fruit and vegetable (FV) intake, body mass index (BMI), and body composition among a sample of sociodemographically-diverse adolescent girls.
Methods
Subjects included girls (mean age = 15.7), 71% of whom identified as a racial/ethnic minority, and one of their parents (dyad n = 253). Parents completed surveys assessing factors in the family environment including familial support for adolescents' PA, healthful dietary intake, and limiting TV use; parental modeling of behavior; and resources in the home such as availability of healthful food. Girls' PA and TV use were measured by 3-Day Physical Activity Recall (3DPAR) and dietary intake by survey measures. BMI was measured by study staff, and body fat by dual-energy X-ray absorptiometry (DXA). Hierarchical linear regression models tested individual and mutually-adjusted relationships between family environment factors and girls' outcomes.
Results
In the individual models, positive associations were observed between family support for PA and girls' total PA (p = .011) and moderate-to-vigorous PA (p=.016), home food availability and girls' soft drink (p < .001) and FV (p < .001) intake, and family meal frequency and girls' FV intake (p = .023). Across the individual and mutually-adjusted models, parental modeling of PA, TV, and soft drink and FV intake was consistently associated with girls' behavior.
Conclusions
Helping parents improve their physical activity and dietary intake, as well as reduce time watching television, may be an effective way to promote healthful behaviors and weight among adolescent girls.
doi:10.1186/1479-5868-8-25
PMCID: PMC3078831  PMID: 21453516
12.  The effects of a controlled worksite environmental intervention on determinants of dietary behavior and self-reported fruit, vegetable and fat intake 
BMC Public Health  2006;6:253.
Background
Eating patterns in Western industrialized countries are characterized by a high energy intake and an overconsumption of (saturated) fat, cholesterol, sugar and salt. Many chronic diseases are associated with unhealthy eating patterns. On the other hand, a healthy diet (low saturated fat intake and high fruit and vegetable intake) has been found important in the prevention of health problems, such as cancer and cardio-vascular disease (CVD). The worksite seems an ideal intervention setting to influence dietary behavior. The purpose of this study is to present the effects of a worksite environmental intervention on fruit, vegetable and fat intake and determinants of behavior.
Methods
A controlled trial that included two different governmental companies (n = 515): one intervention and one control company. Outcome measurements (short-fat list and fruit and vegetable questionnaire) took place at baseline and 3 and 12 months after baseline. The relatively modest environmental intervention consisted of product information to facilitate healthier food choices (i.e., the caloric (kcal) value of foods in groups of products was translated into the number of minutes to perform a certain (occupational) activity to burn these calories).
Results
Significant changes in psychosocial determinants of dietary behavior were found; subjects at the intervention worksite perceived more social support from their colleagues in eating less fat. But also counter intuitive effects were found: at 12 months the attitude and self-efficacy towards eating less fat became less positive in the intervention group. No effects were found on self-reported fat, fruit and vegetable intake.
Conclusion
This environmental intervention was modestly effective in changing behavioral determinant towards eating less fat (social support, self-efficacy and attitude), but ineffective in positively changing actual fat, fruit and vegetable intake of office workers.
doi:10.1186/1471-2458-6-253
PMCID: PMC1626462  PMID: 17044935
13.  Covariation of Adolescent Physical Activity and Dietary Behaviors over 12-Months 
Purpose
This study examined covariation among changes in dietary, physical activity, and sedentary behaviors over 12 months among adolescents participating in a health behavior intervention. Evidence of covariation among behaviors would suggest multi-behavior interventions could have synergistic effects.
Methods
Prospective analyses were conducted with baseline and 12 month assessments from a randomized controlled trial to promote improved diet, physical activity and sedentary behaviors (experimental condition) or SUN protection behaviors (comparison condition). Participants were adolescent girls and boys (N = 878) aged 11 to 15 years on entry. The main outcomes were: diet, based on multiple 24-hour recalls (total fat, grams of fiber, servings of fruit and vegetables, total calories); average daily energy expenditure (kcals/kg) based on 7-Day physical activity recall interviews; daily minutes of moderate-vigorous physical activity minutes from accelerometery; and self-reported daily hours of sedentary behavior.
Results
Covariation was found between fat and calories (r = .16), fiber and calories (r = .53), fiber and fruit/vegetables (r = .53), calories and fruit/vegetables (r = .34), and fruit and vegetables and sedentary behavior (r = -.12) for the total sample (all p < .01). The pattern of findings was similar for most subgroups defined by sex and study condition.
Conclusions
The strongest covariation was observed for diet variables that are inherently related (calories and fat, fiber, and fruit/vegetables). Little covariation was detected within or between other diet, physical activity and sedentary behavior domains suggesting that interventions to improve these behaviors in adolescents need to include specific program components for each target behavior of interest.
doi:10.1016/j.jadohealth.2007.05.018
PMCID: PMC2121661  PMID: 17950167
14.  Explaining the effects of a 1-year intervention promoting a low fat diet in adolescent girls: a mediation analysis 
Background
Although it is important to investigate how interventions work, no formal mediation analyses have been conducted to explain behavioral outcomes in school-based fat intake interventions in adolescents. The aim of the present study was to examine mediation effects of changes in psychosocial determinants of dietary fat intake (attitude, social support, self-efficacy, perceived benefits and barriers) on changes in fat intake in adolescent girls.
Methods
Data from a 1-year prospective intervention study were used. A random sample of 804 adolescent girls was included in the study. Girls in the intervention group (n = 415) were exposed to a multi-component school-based intervention program, combining environmental changes with a computer tailored fat intake intervention and parental support. Fat intake and psychosocial determinants of fat intake were measured with validated self-administered questionnaires. To assess mediating effects, a product-of-coefficient test, appropriate for cluster randomized controlled trials, was used.
Results
None of the examined psychosocial factors showed a reliable mediating effect on changes in fat intake. The single-mediator model revealed a statistically significant suppression effect of perceived barriers on changes in fat intake (p = 0.011). In the multiple-mediator model, this effect was no longer significant, which was most likely due to changes in perceived barriers being moderately related to changes in self-efficacy (-0.30) and attitude (-0.25). The overall mediated-suppressed effect of the examined psychosocial factors was virtually zero (total mediated effect = 0.001; SE = 7.22; p = 0.992).
Conclusion
Given the lack of intervention effects on attitudes, social support, self-efficacy and perceived benefits and barriers, it is suggested that future interventions should focus on the identification of effective strategies for changing these theoretical mediators in the desired direction. Alternatively, it could be argued that these constructs need not be targeted in interventions aimed at adolescents, as they may not be responsible for the intervention effects on fat intake. To draw any conclusions regarding mediators of fat-intake change in adolescent' girls and regarding optimal future intervention strategies, more systematic research on the mediating properties of psychosocial variables is needed.
doi:10.1186/1479-5868-4-55
PMCID: PMC2200660  PMID: 17996087
15.  Self-Reported Dietary Intake Following Endurance, Resistance and Concurrent Endurance and Resistance Training 
With regards to obesity-related disease the impact of exercise training on health depends on the ability of exercise to promote a negative energy balance. Exercise's effect on promoting a negative energy balance is more likely to occur if exercise can induce a favourable dietary intake such as a reduced relative fat content in the diet. As such, the aim of this study was to evaluate and compare the effectiveness of aerobic training, weight training and concurrent aerobic and weight training on self-reported dietary intake. The effects of 16 weeks of aerobic (n = 12), weight (n = 13) and concurrent aerobic and weight training (n = 13) on self-reported dietary intakes were compared in previously sedentary males using the computer-based Dietary Manager® software programme. Only the concurrent aerobic and weight training group showed significant (p ≤ 0.05) reductions in total kilocalories, carbohydrates, proteins and fats consumed while the aerobic training group showed significant reductions in fat intake at the completion of the experimental period (before: 91.0 ± 42.1g versus after: 77.1 ± 62.1g). However, no changes were observed in self-reported dietary intake in the weight training or non-exercising control groups. It is concluded that concurrent aerobic and weight training is the most effective mode of exercise at promoting a favourable improvement in self-reported dietary intake in the short term. This finding provides support for efforts to promote increases in overall physical activity in an attempt to modify the patterns of dietary intake.
Key pointsConcurrent aerobic and weight training can significantly reduce the amount of total kilocalories, carbohydrates, proteins and fats consumed.Aerobic training can significantly reduce fat intake.Weight training resulted in no changes in dietary intake.Concurrent aerobic and weight training is the most effective mode of exercise at promoting a favourable improvement in self-reported dietary intake.
PMCID: PMC3761454  PMID: 24149458
Kilocalories; carbohydrate; diet; exercise; fat; protein
16.  Family Functioning: Associations with Weight Status, Eating Behaviors, and Physical Activity in Adolescents 
Purpose
This paper examines the relationship between family functioning (e.g. communication, closeness, problem solving, behavioral control) and adolescent weight status and relevant eating and physical activity behaviors.
Methods
Data are from EAT 2010 (Eating and Activity in Teens), a population-based study that assessed eating and activity among socioeconomically and racially/ethnically diverse youth (n = 2,793). Adolescents (46.8% boys, 53.2% girls) completed anthropometric assessments and surveys at school in 2009–2010. Multiple linear regression was used to test the relationship between family functioning and adolescent weight, dietary intake, family meal patterns, and physical activity. Additional regression models were fit to test for interactions by race/ethnicity.
Results
For adolescent girls, higher family functioning was associated with lower body mass index z-score and percent overweight, less sedentary behavior, higher intake of fruits and vegetables, and more frequent family meals and breakfast consumption. For adolescent boys, higher family functioning was associated with more physical activity, less sedentary behavior, less fast food consumption, and more frequent family meals and breakfast consumption. There was one significant interaction by race/ethnicity for family meals; the association between higher family functioning and more frequent family meals was stronger for non-white boys compared to white boys. Overall, strengths of associations tended to be small with effect sizes ranging from - 0.07 to 0.31 for statistically significant associations.
Conclusions
Findings suggest that family functioning may be protective for adolescent weight and weight-related health behaviors across all race/ethnicities, although assumptions regarding family functioning in the homes of overweight children should be avoided given small effect sizes.
doi:10.1016/j.jadohealth.2012.07.006
PMCID: PMC3580029  PMID: 23299010
Family Functioning; Adolescent Obesity; Dietary Intake; Family Meals; Physical Activity
17.  Effect of Physical Inactivity on the Oxidation of Saturated and Monounsaturated Dietary Fatty Acids: Results of a Randomized Trial  
PLoS Clinical Trials  2006;1(5):e27.
Objectives:
Changes in the way dietary fat is metabolized can be considered causative in obesity. The role of sedentary behavior in this defect has not been determined. We hypothesized that physical inactivity partitions dietary fats toward storage and that a resistance exercise training program mitigates storage.
Design:
We used bed rest, with randomization to resistance training, as a model of physical inactivity.
Setting:
The trial took place at the Space Clinic (Toulouse, France).
Participants:
A total of 18 healthy male volunteers, of mean age ± standard deviation 32.6 ± 4.0 y and body mass index 23.6 ± 0.7 kg/m2, were enrolled.
Interventions:
An initial 15 d of baseline data collection were followed by 3 mo of strict bed-rest alone (control group, n = 9) or with the addition of supine resistance exercise training every 3 d (exercise group, n = 9).
Outcome measures:
Oxidation of labeled [d31]palmitate (the main saturated fatty acid of human diet) and [1-13C]oleate (the main monounsaturated fatty acid), body composition, net substrate use, and plasma hormones and metabolites were measured.
Results:
Between-group comparisons showed that exercise training did not affect oxidation of both oleate (mean difference 5.6%; 95% confidence interval [95% CI], −3.3% to 14.5%; p = 0.20) and palmitate (mean difference −0.2%; 95% CI, −4.1% to 3.6%; p = 0.89). Within-group comparisons, however, showed that inactivity changed oxidation of palmitate in the control group by −11.0% (95% CI, −19.0% to −2.9%; p = 0.01) and in the exercise group by −11.3% (95% CI, −18.4% to −4.2%; p = 0.008). In contrast, bed rest did not significantly affect oleate oxidation within groups. In the control group, the mean difference in oleate oxidation was 3.2% (95% CI, −4.2% to 10.5%; p = 0.34) and 6.8% (95% CI, −1.2% to 14.7%; p = 0.08) in the exercise group.
Conclusions:
Independent of changes in energy balance (intake and/or output), physical inactivity decreased the oxidation of saturated but not monounsaturated dietary fat. The effect is apparently not compensated by resistance exercise training. These results suggest that Mediterranean diets should be recommended in sedentary subjects and recumbent patients.
Editorial Commentary
Background: Obesity is an important contributor to the burden of chronic diseases, particularly type II diabetes, cardiovascular disease, hypertension, and stroke. Being inactive is a risk factor for all of these conditions. However, the physiological effects of inactivity are not well understood. In this trial, supported by the European Space Agency, a group of researchers aimed to further understand the effects of physical inactivity on the way that fat from the diet is metabolized (i.e., broken down to generate energy). 18 healthy male volunteers were randomized into two groups, both of whom underwent 90 days of bed rest, aiming to mimic sedentary behavior. One group also received an exercise training program during the 90 days' bed rest. The researchers examined to what extent two different types of fatty acids common in the diet were metabolized over the duration of the trial: oleate (monounsaturated fat) and palmitate (saturated fat). As secondary objectives of the study, body weight, water, fat, and energy expenditure were also examined in the participants.
What this trial shows: The researchers did not see any statistically significant changes between the groups—that is, participants receiving bed rest, and those receiving bed rest plus exercise training—for any of the primary or secondary outcomes, except for resting metabolic rate, which was higher in the exercise group. However, they did see physiologically relevant changes in fat metabolism of one of the fatty acids, palmitate, over the course of the trial within both groups studied. Although metabolism of oleate (monounsaturated fat) did not show significant changes over the course of the trial, metabolism of palmitate (saturated fat) dropped by nearly 10% in both groups (bed rest, and bed rest plus exercise).
Strengths and limitations: The study design was appropriate to the questions being posed, and the techniques for examining fat metabolism were relevant. Although the number of participants was very small, this problem is true of many such studies due to the cost and complexity of the interventions. The model for inactivity used in this trial—90 days' bed rest—is very extreme. Very few studies of this type have been performed, with most of the evidence relating to activity and fat handling coming from training studies in otherwise sedentary people.
Contribution to the evidence: It is already known that physical activity has numerous health benefits, including the prevention of obesity. This trial provides data showing that inactivity lowers the ability to metabolize fat, specifically saturated fat, from the diet, which would therefore be more likely to be stored in the body.
doi:10.1371/journal.pctr.0010027
PMCID: PMC1584255  PMID: 17016547
18.  Web-Based Guide to Health: Relationship of Theoretical Variables to Change in Physical Activity, Nutrition and Weight at 16-Months 
Background
Evaluation of online health interventions should investigate the function of theoretical mechanisms of behavior change in this new milieu.
Objectives
To expand our understanding of how Web-based interventions influence behavior, we examined how changes at 6 months in participants’ psychosocial characteristics contributed to improvements at 16 months in nutrition, physical activity (PA), and weight management as a result of the online, social cognitive theory (SCT)-based Guide to Health intervention (WB-GTH).
Methods
We conducted recruitment, enrollment, and assessments online with 272 of 655 (41.5%) participants enrolling in WB-GTH who also completed 6- and 16-month follow-up assessments. Participants’ mean age was 43.68 years, 86% were female, 92% were white, mean education was 17.45 years, median income was US $85,000, 84% were overweight or obese, and 73% were inactive. Participants received one of two equally effective versions of WB-GTH. Structural equation analysis of theoretical models evaluated whether psychosocial constructs targeted by WB-GTH contributed to observed health behavior changes.
Results
The longitudinal model provided good fit to the data (root mean square error of approximation <.05). Participants’ weight loss at 16 months was predicted by improvements in their PA (betatotal = -.34, P = .01), consumption of fruits and vegetables (F&V) (betatotal = -.20, P = .03) and calorie intake (betatotal = .15, P = .04). Improvements at 6 months in PA self-efficacy (betatotal = -.10, P = .03), PA self-regulation (betatotal = -.15, P = .01), nutrition social support (betatotal = -.08, P = .03), and nutrition outcome expectations (betatotal = .08, P = .03) also contributed to weight loss. WB-GTH users with increased social support (betatotal = .26, P = .04), self-efficacy (betatotal = .30, P = .01), and self-regulation (betatotal = .45, P = .004) also exhibited improved PA levels. Decreased fat and sugar consumption followed improved social support (betatotal = -.10, P = .02), outcome expectations (betatotal = .15, P = .007), and self-regulation (betatotal = -.14, P = .008). Decreased calorie intake followed increased social support (betatotal = -.30, P < .001). Increased F&V intake followed improved self-efficacy (betatotal = .20, P = .01), outcome expectations (betatotal = -.29, P = .002), and self-regulation (betatotal = .27, P = .009). Theorized indirect effects within SCT variables were also supported.
Conclusions
The WB-GTH influenced behavior and weight loss in a manner largely consistent with SCT. Improving social support, self-efficacy, outcome expectations, and self-regulation, in varying combinations, led to healthier diet and exercise habits and concomitant weight loss. High initial levels of self-efficacy may be characteristic of Web-health users interested in online interventions and may alter the function of SCT in these programs. Researchers may find that, although increased self-efficacy enhances program outcomes, participants whose self-efficacy is tempered by online interventions may still benefit.
Trial Registration
Clinicaltrials.gov NCT00128570; http://clinicaltrials.gov/ct2/show/NCT00128570 (Archived by WebCite at http://www.webcitation.org/5vgcygBII)
doi:10.2196/jmir.1614
PMCID: PMC3221349  PMID: 21447470
Internet users; dietary habits; physical activity; psychosocial aspects; self-efficacy; social support; self-regulation
19.  Physical Activity Attenuates the Influence of FTO Variants on Obesity Risk: A Meta-Analysis of 218,166 Adults and 19,268 Children 
Kilpeläinen, Tuomas O. | Qi, Lu | Brage, Soren | Sharp, Stephen J. | Sonestedt, Emily | Demerath, Ellen | Ahmad, Tariq | Mora, Samia | Kaakinen, Marika | Sandholt, Camilla Helene | Holzapfel, Christina | Autenrieth, Christine S. | Hyppönen, Elina | Cauchi, Stéphane | He, Meian | Kutalik, Zoltan | Kumari, Meena | Stančáková, Alena | Meidtner, Karina | Balkau, Beverley | Tan, Jonathan T. | Mangino, Massimo | Timpson, Nicholas J. | Song, Yiqing | Zillikens, M. Carola | Jablonski, Kathleen A. | Garcia, Melissa E. | Johansson, Stefan | Bragg-Gresham, Jennifer L. | Wu, Ying | van Vliet-Ostaptchouk, Jana V. | Onland-Moret, N. Charlotte | Zimmermann, Esther | Rivera, Natalia V. | Tanaka, Toshiko | Stringham, Heather M. | Silbernagel, Günther | Kanoni, Stavroula | Feitosa, Mary F. | Snitker, Soren | Ruiz, Jonatan R. | Metter, Jeffery | Larrad, Maria Teresa Martinez | Atalay, Mustafa | Hakanen, Maarit | Amin, Najaf | Cavalcanti-Proença, Christine | Grøntved, Anders | Hallmans, Göran | Jansson, John-Olov | Kuusisto, Johanna | Kähönen, Mika | Lutsey, Pamela L. | Nolan, John J. | Palla, Luigi | Pedersen, Oluf | Pérusse, Louis | Renström, Frida | Scott, Robert A. | Shungin, Dmitry | Sovio, Ulla | Tammelin, Tuija H. | Rönnemaa, Tapani | Lakka, Timo A. | Uusitupa, Matti | Rios, Manuel Serrano | Ferrucci, Luigi | Bouchard, Claude | Meirhaeghe, Aline | Fu, Mao | Walker, Mark | Borecki, Ingrid B. | Dedoussis, George V. | Fritsche, Andreas | Ohlsson, Claes | Boehnke, Michael | Bandinelli, Stefania | van Duijn, Cornelia M. | Ebrahim, Shah | Lawlor, Debbie A. | Gudnason, Vilmundur | Harris, Tamara B. | Sørensen, Thorkild I. A. | Mohlke, Karen L. | Hofman, Albert | Uitterlinden, André G. | Tuomilehto, Jaakko | Lehtimäki, Terho | Raitakari, Olli | Isomaa, Bo | Njølstad, Pål R. | Florez, Jose C. | Liu, Simin | Ness, Andy | Spector, Timothy D. | Tai, E. Shyong | Froguel, Philippe | Boeing, Heiner | Laakso, Markku | Marmot, Michael | Bergmann, Sven | Power, Chris | Khaw, Kay-Tee | Chasman, Daniel | Ridker, Paul | Hansen, Torben | Monda, Keri L. | Illig, Thomas | Järvelin, Marjo-Riitta | Wareham, Nicholas J. | Hu, Frank B. | Groop, Leif C. | Orho-Melander, Marju | Ekelund, Ulf | Franks, Paul W. | Loos, Ruth J. F.
PLoS Medicine  2011;8(11):e1001116.
Ruth Loos and colleagues report findings from a meta-analysis of multiple studies examining the extent to which physical activity attenuates effects of a specific gene variant, FTO, on obesity in adults and children. They report a fairly substantial attenuation by physical activity on the effects of this genetic variant on the risk of obesity in adults.
Background
The FTO gene harbors the strongest known susceptibility locus for obesity. While many individual studies have suggested that physical activity (PA) may attenuate the effect of FTO on obesity risk, other studies have not been able to confirm this interaction. To confirm or refute unambiguously whether PA attenuates the association of FTO with obesity risk, we meta-analyzed data from 45 studies of adults (n = 218,166) and nine studies of children and adolescents (n = 19,268).
Methods and Findings
All studies identified to have data on the FTO rs9939609 variant (or any proxy [r2>0.8]) and PA were invited to participate, regardless of ethnicity or age of the participants. PA was standardized by categorizing it into a dichotomous variable (physically inactive versus active) in each study. Overall, 25% of adults and 13% of children were categorized as inactive. Interaction analyses were performed within each study by including the FTO×PA interaction term in an additive model, adjusting for age and sex. Subsequently, random effects meta-analysis was used to pool the interaction terms. In adults, the minor (A−) allele of rs9939609 increased the odds of obesity by 1.23-fold/allele (95% CI 1.20–1.26), but PA attenuated this effect (pinteraction  = 0.001). More specifically, the minor allele of rs9939609 increased the odds of obesity less in the physically active group (odds ratio  = 1.22/allele, 95% CI 1.19–1.25) than in the inactive group (odds ratio  = 1.30/allele, 95% CI 1.24–1.36). No such interaction was found in children and adolescents.
Conclusions
The association of the FTO risk allele with the odds of obesity is attenuated by 27% in physically active adults, highlighting the importance of PA in particular in those genetically predisposed to obesity.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
Two in three Americans are overweight, of whom half are obese, and the trend towards increasing obesity is now seen across developed and developing countries. There has long been interest in understanding the impact of genes and environment when it comes to apportioning responsibility for obesity. Carrying a change in the FTO gene is common (found in three-quarters of Europeans and North Americans) and is associated with a 20%–30% increased risk of obesity. Some overweight or obese individuals may feel that the dice are loaded and there is little point in fighting the fat; it has been reported that those made aware of their genetic susceptibility to obesity may still choose a poor diet. A similar fatalism may occur when overweight and obese people consider physical activity. But disentangling the influence of physical activity on those genetically susceptible to obesity from other factors that might impact weight is not straightforward, as it requires large sample sizes, could be subject to publication bias, and may rely on less than ideal self-reporting methods.
Why Was This Study Done?
The public health ramifications of understanding the interaction between genetic susceptibility to obesity and physical activity are considerable. Tackling the rising prevalence of obesity will inevitably include interventions principally aimed at changing dietary intake and/or increasing physical activity, but the evidence for these with regards to those genetically susceptible has been lacking to date. The authors of this paper set out to explore the interaction between the commonest genetic susceptibility trait and physical activity using a rigorous meta-analysis of a large number of studies.
What Did the Researchers Do and Find?
The authors were concerned that a meta-analysis of published studies would be limited both by the data available to them and by possible bias. Instead of this more widely used approach, they took the literature search as their starting point, identified other studies through their collaborators’ network, and then undertook a meta-analysis of all available studies using a new and standardized analysis plan. This entailed an extremely large number of authors mining their data afresh to extract the relevant data points to enable such a meta-analysis. Physical activity was identified in the original studies in many different ways, including by self-report or by using an external measure of activity or heart rate. In order to perform the meta-analysis, participants were labeled as physically active or inactive in each study. For studies that had used a continuous scale, the authors decided that the bottom 20% of the participants were inactive (10% for children and adolescents). Using data from over 218,000 adults, the authors found that carrying a copy of the susceptibility gene increased the odds of obesity by 1.23-fold. But the size of this influence was 27% less in the genetically susceptible adults who were physically active (1.22-fold) compared to those who were physically inactive (1.30-fold). In a smaller study of about 19,000 children, no such effect of physical activity was seen.
What Do these Findings Mean?
This study demonstrates that people who carry the susceptibility gene for obesity can benefit from physical activity. This should inform health care professionals and the wider public that the view of genetically determined obesity not being amenable to exercise is incorrect and should be challenged. Dissemination, implementation, and ensuring uptake of effective physical activity programs remains a challenge and deserves further consideration. That the researchers treated “physically active” as a yes/no category, and how they categorized individuals, could be criticized, but this was done for pragmatic reasons, as a variety of means of assessing physical activity were used across the studies. It is unlikely that the findings would have changed if the authors had used a different method of defining physically active. Most of the studies included in the meta-analysis looked at one time point only; information about the influence of physical activity on weight changes over time in genetically susceptible individuals is only beginning to emerge.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001116.
This study is further discussed in a PLoS Medicine Perspective by Lennert Veerman
The US Centers for Disease Control and Prevention provides obesity-related statistics, details of prevention programs, and an overview on public health strategy in the United States
A more worldwide view is given by the World Health Organization
The UK National Health Service website gives information on physical activity guidelines for different age groups, while similar information can also be found from US sources
doi:10.1371/journal.pmed.1001116
PMCID: PMC3206047  PMID: 22069379
20.  Food Pricing Strategies, Population Diets, and Non-Communicable Disease: A Systematic Review of Simulation Studies 
PLoS Medicine  2012;9(12):e1001353.
A systematic review of simulation studies conducted by Helen Eyles and colleagues examines the association between food pricing strategies and food consumption and health and disease outcomes.
Background
Food pricing strategies have been proposed to encourage healthy eating habits, which may in turn help stem global increases in non-communicable diseases. This systematic review of simulation studies investigates the estimated association between food pricing strategies and changes in food purchases or intakes (consumption) (objective 1); Health and disease outcomes (objective 2), and whether there are any differences in these outcomes by socio-economic group (objective 3).
Methods and Findings
Electronic databases, Internet search engines, and bibliographies of included studies were searched for articles published in English between 1 January 1990 and 24 October 2011 for countries in the Organisation for Economic Co-operation and Development. Where ≥3 studies examined the same pricing strategy and consumption (purchases or intake) or health outcome, results were pooled, and a mean own-price elasticity (own-PE) estimated (the own-PE represents the change in demand with a 1% change in price of that good). Objective 1: pooled estimates were possible for the following: (1) taxes on carbonated soft drinks: own-PE (n = 4 studies), −0.93 (range, −0.06, −2.43), and a modelled −0.02% (−0.01%, −0.04%) reduction in energy (calorie) intake for each 1% price increase (n = 3 studies); (2) taxes on saturated fat: −0.02% (−0.01%, −0.04%) reduction in energy intake from saturated fat per 1% price increase (n = 5 studies); and (3) subsidies on fruits and vegetables: own-PE (n = 3 studies), −0.35 (−0.21, −0.77). Objectives 2 and 3: variability of food pricing strategies and outcomes prevented pooled analyses, although higher quality studies suggested unintended compensatory purchasing that could result in overall effects being counter to health. Eleven of 14 studies evaluating lower socio-economic groups estimated that food pricing strategies would be associated with pro-health outcomes. Food pricing strategies also have the potential to reduce disparities.
Conclusions
Based on modelling studies, taxes on carbonated drinks and saturated fat and subsidies on fruits and vegetables would be associated with beneficial dietary change, with the potential for improved health. Additional research into possible compensatory purchasing and population health outcomes is needed.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
For the first time in human history, non-communicable diseases (NCDs) are killing more people than infectious diseases. Every year, more than 35 million people die from NCDs—nearly two-thirds of the world's annual deaths. More than 80% of these deaths are in developing countries, where a third of NCD-related deaths occur in people younger than 60 years old. And NCDs are not just a growing global public health emergency. They are also financially costly because they reduce productivity and increase calls on health care systems worldwide. Cardiovascular diseases (conditions that affect the heart and circulation such as heart attacks and stroke), cancers, diabetes, and chronic respiratory diseases (long-term diseases that affect the lungs and airways) are responsible for most NCD-related illnesses and death. The main behavioral risk factors for all these diseases are tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diets (diets that have a low fruit and vegetable intake and high saturated fat and salt intakes).
Why Was This Study Done?
Improvements in population diets and reductions in salt intake are crucial for the control and prevention of NCDs, but how can these behavioral changes be encouraged? One potential but poorly studied strategy is food pricing—the introduction of taxes on unhealthy foods (for example, foods containing high levels of saturated fat) and subsidies on healthy foods (for example, foods high in fiber). However, although a tax on soft drinks, for example, might decrease purchases of these high-sugar drinks, it might also increase purchases of fruit juices, which contain just as much sugar and energy as soft drinks (“compensatory purchasing”), and thus undermine the intended health impact of the tax. Because randomized controlled trials of the effects of food pricing strategies are difficult to undertake, many researchers have turned to mathematical models (sets of equations that quantify relationships between interventions and outcomes) to provide the evidence needed to inform policy decisions on food taxes and subsidies. In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), Helen Eyles and colleagues investigate the association between food pricing strategies and food consumption and NCDs by analyzing the results of published mathematical modeling studies of food pricing interventions.
What Did the Researchers Do and Find?
The researchers identified 32 studies that met their predefined inclusion criteria, which included publication by researchers in a member country of the Organisation for Economic Co-operation and Development (a group of largely developed countries that promotes global development). Most of the studies were of low to moderate quality and provided uncertain and varying estimates of the impact of pricing on food consumption. Where three or more studies examined the same pricing strategy and consumption or health outcome, the researchers calculated the average change in demand for a food in response to changes in its price (“own-price elasticity”). For taxes on carbonated soft drinks, the average own-price elasticity was −0.93; that is, the models predicted that a 1% increase in the price of soft drinks would decrease consumption by 0.93%. The modeled reduction in the proportion of energy intake from saturated fat resulting from a 1% increase in the price of saturated fats was 0.02%. Finally, although the researchers' analysis suggested that for each 1% reduction in the price of fruits and vegetables, consumption would increase by 0.35%, they also found evidence that such a subsidy might result in compensatory purchasing, such as a reduction in fish purchases.
What Do These Findings Mean?
These findings suggest that pricing strategies have the potential to produce improvements in population diets, at least in developed countries, but also highlight the need for more research in this area. Notably, the researchers found insufficient data to allow them to quantify the effects of pricing strategies on health or to analyze whether the effect of pricing strategies is likely vary between socio-economic groups. Given their findings, the researchers suggest that future modeling studies should include better assessments of the unintended effects of compensatory purchasing and should examine the potential impact of food pricing strategies on long-term health and NCD-related deaths. Finally, they suggest that robust evaluations should be built into the implementation of food pricing policies to answer some of the outstanding questions about this potential strategy for reducing the global burden of NCDs.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001353.
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living, on chronic diseases and health promotion, and on non-communicable diseases around the world
The Global Noncommunicable Disease Network (NCDnet) aims to help low- and middle-income countries reduce NCD-related illnesses and death through implementation of the 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (also available in French); NCDnet's Face to face with chronic disease webpage is a selection of personal stories from around the world about dealing with NCDs
The American Heart Association and the American Cancer Society provide information on many important risk factors for non-communicable diseases and include some personal stories about keeping healthy
doi:10.1371/journal.pmed.1001353
PMCID: PMC3519906  PMID: 23239943
21.  Preventing Weight Gain in Women in Rural Communities: A Cluster Randomised Controlled Trial 
PLoS Medicine  2016;13(1):e1001941.
Background
Obesity is reaching epidemic proportions in both developed and developing countries. Even modest weight gain increases the risk for chronic illness, yet evidence-based interventions to prevent weight gain are rare. This trial will determine if a simple low-intensity intervention can prevent weight gain in women compared to general health information.
Methods and Findings
We conducted a 1-yr pragmatic, cluster randomised controlled trial in 41 Australian towns (clusters) randomised using a computer-generated randomisation list for intervention (n = 21) or control (n = 20). Women aged 18 to 50 yr were recruited from the general population to receive a 1-yr self-management lifestyle intervention (HeLP-her) consisting of one group session, monthly SMS text messages, one phone coaching session, and a program manual, or to a control group receiving one general women’s health education session. From October 2012 to April 2014 we studied 649 women, mean age 39.6 yr (+/− SD 6.7) and BMI of 28.8 kg/m2 (+/− SD 6.9) with the primary outcome weight change between groups at 1 yr. The mean change in the control was +0.44 kg (95% CI −0.09 to 0.97) and in the intervention group −0.48kg (95% CI −0.99 to 0.03) with an unadjusted between group difference of −0.92 kg (95% CI −1.67 to −0.16) or −0.87 kg (95% CI −1.62 to −0.13) adjusted for baseline values and clustering. Secondary outcomes included improved diet quality and greater self-management behaviours. The intervention appeared to be equally efficacious across all age, BMI, income, and education subgroups. Loss to follow-up included 23.8% in the intervention group and 21.8% in the control group and was within the anticipated range. Limitations include lack of sensitive tools to measure the small changes to energy intake and physical activity. Those who gained weight may have been less inclined to return for 1 yr weight measures.
Conclusions
A low intensity lifestyle program can prevent the persistent weight gain observed in women. Key features included community integration, nonprescriptive simple health messages, small changes to behaviour, low participant burden, self-weighing, and delivery including a mix of group, phone, and SMS text reminders. The findings support population strategies to halt the rise in obesity prevalence.
In a pragmatic, cluster-randomised controlled trial, Catherine Lombard and colleagues assess the value of a self-management lifestyle intervention to prevent weight gain among women living in rural Australia.
Editors' Summary
Background
Obesity—having an unhealthy amount of body fat—is a global public health problem. In the US, for example, more than one-third of adults are obese and another third are overweight. Obesity is defined as having a body mass index (BMI; an indicator of body fat calculated by dividing a person’s weight in kilograms by their height in meters squared) of equal to or more than 30 kg/m2; overweight individuals have a BMI of 25.0–29.9 kg/m2. Increased body fat is associated with an increased risk of developing diabetes, cancer, cardiovascular disease and other chronic diseases.. People gain body fat by consuming food and drink that contains more energy (calories) than they need for their daily activities. So excess body fat can be prevented and reversed by eating a diet that contains fewer calories and by being more active.
Why Was This Study Done?
BMI increases with age in most adults although in recent years young adults have been shown to be gaining body fat faster than older adults. However, the adult weight gain per year is generally less than 1 kg and could be prevented by encouraging people to eat just a little less and exercise just a little more. Prevention of weight gain is likely to be easier than reversal of established obesity, but few interventions designed to prevent weight gain have been rigorously tested. In this pragmatic randomized controlled trial, the researchers investigate whether a simple low-intensity intervention can prevent weight gain among 18–50-year-old women living in rural communities in Australia. Rates of obesity are generally higher among women than men and, in affluent countries, rural-dwelling women have higher rates of weight gain and obesity than urban-dwelling women—in Australia, young women living in rural and metropolitan areas gain an average of 700 g and 550 g per year, respectively. A pragmatic cluster randomized controlled trial randomly assigns groups of people (here, women living in different towns) to receive alternative interventions and compares outcomes in the differently treated “clusters” under real-life conditions.
What Did the Researchers Do and Find?
The researchers assigned 41 Australian towns to receive a 1 yr self-management lifestyle intervention (HeLP-her) or to act as controls. The intervention consisted of one group session during which facilitators delivered general health information and five simple health messages (for example, try to eat two servings of fruit and five servings of vegetables a day), a program manual to help participants develop a personalized weight gain prevention strategy, monthly text message to remind participants of key behaviors for weight gain prevention, and a 20-min personal phone coaching session delivered three months into the trial. Participants in the control clusters received a group education session on general women’s health topics at the start of the trial. In total, 649 women with an average baseline BMI of 28.2kg/m2 participated in the trial. After one year, the average weight change was +0.44 kg in the control arm of the trial and −0.48 kg in the intervention arm (a between group difference in weight change of −0.92 kg). The intervention also improved diet quality and self-management behavior and was equally efficacious across all age, BMI, income, and education subgroups.
What Do These Findings Mean?
These findings suggest that a low-intensity lifestyle program can prevent persistent weight gain among women. Specifically, the year-long HeLP-her intervention prevented a weight gain of nearly 1 kg on average among women living in rural Australia. Notably, a recent modeling study estimated that a 1 kg weight loss, if applied across the US population, could avoid 2 million cases of diabetes, 1.5 million cases of cardiovascular disease, and more than 73,000 cases of cancer. Although it is difficult to identify the successful elements of any intervention that targets multiple behaviors, key components of the HeLP-her intervention probably include the use of simple, non-prescriptive health messages, the focus on small behavioral changes, regular self-weighing, and the use of both personal and electronic means to deliver the intervention. Some aspects of this trial (for example, nearly a quarter of the participants did not complete the trial) may affect the accuracy of its findings and a longer follow-up is needed to determine the long-term effects of the intervention. Nevertheless, these findings provide new information on effective weight gain prevention strategies that align with current clinical guidelines and population strategies designed to halt the global rise in obesity.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001941.
The World Health Organization provides information on obesity (in several languages)
The Global Burden of Disease website provides the latest details about global obesity trends; the International Obesity Taskforce also provides information about the global obesity epidemic
The UK National Health Service Choices website provides information about obesity (including some real stories), healthy eating, exercising
The US Centers for Disease Control and Prevention has information on all aspects of overweight and obesity
ChooseMyPlate.gov is a resource provided by the US Department of Agriculture that provides individuals and health care professionals with user-friendly information on nutritional and physical exercise
The US National Institute of Diabetes and Digestive and Kidney Diseases provides information on weight control and healthy living
MedlinePlus provides links to other sources of information on obesity (in English and Spanish)
More information about obesity in Australia, this trial, and the HeLP-her intervention is available
doi:10.1371/journal.pmed.1001941
PMCID: PMC4718637  PMID: 26785406
22.  Lifestyle Behaviors in Metabolically Healthy and Unhealthy Overweight and Obese Women: A Preliminary Study 
PLoS ONE  2015;10(9):e0138548.
Background
Few studies have examined dietary data or objective measures of physical activity (PA) and sedentary behavior among metabolically healthy overweight/obese (MHO) and metabolically unhealthy overweight/obese (MUO). Thus, the purpose is to determine whether PA, sedentary behavior and/or diet differ between MHO and MUO in a sample of young women.
Methods
Forty-six overweight/obese (BMI ≥25 kg/m2) African American and Caucasian women 19–35 years were classified by cardiometabolic risk factors, including elevated blood pressure, triglyceride, glucose and C-reactive protein, low high density lipoprotein, and insulin resistance (MUO ≥2; MHO, <2). Time (mins/day) in light, moderate, vigorous PA, and sedentary behavior were estimated using an accelerometer (≥3 days; ≥8 hrs wear time). Questionnaires were used to quantify sitting time, TV/computer use and usual daily activity. The Block Food Frequency Questionnaire assessed dietary food intake. Differences between MHO and MUO for lifestyle behaviors were tested with linear regression (continuous data) or logistic regression (categorical data) after adjusting for age, race, BMI, smoking and accelerometer wear and/or total kilocalories, as appropriate.
Results
Women were 26.7±4.7 years, with a mean BMI of 31.1±3.7 kg/m2, and 61% were African American. Compared to MUO (n = 9), MHO (n = 37; 80%) spent less mins/day in sedentary behavior (difference: -58.1±25.5, p = 0.02), more mins/day in light PA (difference: 38.2±16.1, p = 0.02), and had higher daily METs (difference: 0.21±0.09, p = 0.03). MHO had higher fiber intakes (g/day of total fiber, soluble fiber, fruit/vegetable fiber, bean fiber) and daily servings of vegetables; but lower daily dairy servings, saturated fat, monounsaturated fat and trans fats (g/day) compared to MUO.
Conclusion
Compared to MUO, MHO young women demonstrate healthier lifestyle habits with less sedentary behavior, more time in light PA, and healthier dietary quality for fat type and fiber. Future studies are needed to replicate findings with larger samples that include men and women of diverse race/ethnic groups.
doi:10.1371/journal.pone.0138548
PMCID: PMC4575188  PMID: 26383251
23.  Psychosocial correlates of eating behavior in children and adolescents: a review 
Background
Understanding the correlates of dietary intake is necessary in order to effectively promote healthy dietary behavior among children and adolescents. A literature review was conducted on the correlates of the following categories of dietary intake in children and adolescents: Fruit, Juice and Vegetable Consumption, Fat in Diet, Total Energy Intake, Sugar Snacking, Sweetened Beverage Consumption, Dietary Fiber, Other Healthy Dietary Consumption, and Other Less Healthy Dietary Consumption in children and adolescents.
Methods
Cross-sectional and prospective studies were identified from PubMed, PsycINFO and PsycArticles by using a combination of search terms. Quantitative research examining determinants of dietary intake among children and adolescents aged 3–18 years were included. The selection and review process yielded information on country, study design, population, instrument used for measuring intake, and quality of research study.
Results
Seventy-seven articles were included. Many potential correlates have been studied among children and adolescents. However, for many hypothesized correlates substantial evidence is lacking due to a dearth of research. The correlates best supported by the literature are: perceived modeling, dietary intentions, norms, liking and preferences. Perceived modeling and dietary intentions have the most consistent and positive associations with eating behavior. Norms, liking, and preferences were also consistently and positively related to eating behavior in children and adolescents. Availability, knowledge, outcome expectations, self-efficacy and social support did not show consistent relationships across dietary outcomes.
Conclusion
This review examined the correlates of various dietary intake; Fruit, Juice and Vegetable Consumption, Fat in Diet, Total Energy Intake, Sugar Snacking, Sweetened Beverage Consumption, Dietary Fiber, Other Healthy Dietary Consumption, and Other Less Healthy Dietary Consumption in cross-sectional and prospective studies for children and adolescents. The correlates most consistently supported by evidence were perceived modeling, dietary intentions, norms, liking and preferences. More prospective studies on the psychosocial determinants of eating behavior using broader theoretical perspectives should be examined in future research.
doi:10.1186/1479-5868-6-54
PMCID: PMC3224918  PMID: 19674467
24.  Perceived Environmental Church Support is Associated with Dietary Practices among African American Adults 
Background
A unique strength of the African American community is the importance of the church and faith. Interventions promoting health may want to build on these strengths by developing faith-based interventions that encourage churches to create an environment that supports behavior change.
Objective
To examine the relationship between perceived environmental church support for healthy eating and intake of fruit and vegetables and fat and fiber-related behaviors, and to examine if these relationships differ by gender.
Design
A cross-sectional study in which participants completed self-report dietary and perceived church support measures prior to the initiation of an intervention. Relationships between fruit and vegetable consumption, fat and fiber-related behaviors, and perceived church support (total, written informational, spoken informational, instrumental [fruit and vegetable consumption only]), along with Support x Gender interactions were examined.
Participants/Setting
Participants were 1136 African American church members from four geographically-defined districts in South Carolina.
Statistical Analyses
Multiple regression models controlling for gender, age, years of education, health rating, and body mass index using SAS PROC MIXED. A separate model was conducted for each measure of perceived church support and each type of healthy eating index.
Results
Perceived total church support and perceived written and spoken informational church support were related to significantly higher fruit and vegetable intake and more favorable fiber-related behaviors, whereas only perceived total and perceived written informational support were associated with more low-fat dietary behaviors. Perceived instrumental church support was not associated with fruit and vegetable consumption. No gender differences were found.
Conclusion
The social and physical church environment may be important factors influencing the dietary habits of its members. Future faith-based interventions should further explore the role of the church environment in improving the dietary practices of its members.
doi:10.1016/j.jada.2011.03.014
PMCID: PMC3103703  PMID: 21616203
Dietary Practices; Faith-based; African American Adults; Church Support
25.  Short- and Medium-Term Efficacy of a Web-Based Computer-Tailored Nutrition Education Intervention for Adults Including Cognitive and Environmental Feedback: Randomized Controlled Trial 
Background
Web-based, computer-tailored nutrition education interventions can be effective in modifying self-reported dietary behaviors. Traditional computer-tailored programs primarily targeted individual cognitions (knowledge, awareness, attitude, self-efficacy). Tailoring on additional variables such as self-regulation processes and environmental-level factors (the home food environment arrangement and perception of availability and prices of healthy food products in supermarkets) may improve efficacy and effect sizes (ES) of Web-based computer-tailored nutrition education interventions.
Objective
This study evaluated the short- and medium-term efficacy and educational differences in efficacy of a cognitive and environmental feedback version of a Web-based computer-tailored nutrition education intervention on self-reported fruit, vegetable, high-energy snack, and saturated fat intake compared to generic nutrition information in the total sample and among participants who did not comply with dietary guidelines (the risk groups).
Methods
A randomized controlled trial was conducted with a basic (tailored intervention targeting individual cognition and self-regulation processes; n=456), plus (basic intervention additionally targeting environmental-level factors; n=459), and control (generic nutrition information; n=434) group. Participants were recruited from the general population and randomly assigned to a study group. Self-reported fruit, vegetable, high-energy snack, and saturated fat intake were assessed at baseline and at 1- (T1) and 4-months (T2) postintervention using online questionnaires. Linear mixed model analyses examined group differences in change over time. Educational differences were examined with group×time×education interaction terms.
Results
In the total sample, the basic (T1: ES=–0.30; T2: ES=–0.18) and plus intervention groups (T1: ES=–0.29; T2: ES=–0.27) had larger decreases in high-energy snack intake than the control group. The basic version resulted in a larger decrease in saturated fat intake than the control intervention (T1: ES=–0.19; T2: ES=–0.17). In the risk groups, the basic version caused larger decreases in fat (T1: ES=–0.28; T2: ES=–0.28) and high-energy snack intake (T1: ES=–0.34; T2: ES=–0.20) than the control intervention. The plus version resulted in a larger increase in fruit (T1: ES=0.25; T2: ES=0.37) and a larger decrease in high-energy snack intake (T1: ES=–0.38; T2: ES=–0.32) than the control intervention. For high-energy snack intake, educational differences were found. Stratified analyses showed that the plus version was most effective for high-educated participants.
Conclusions
Both intervention versions were more effective in improving some of the self-reported dietary behaviors than generic nutrition information, especially in the risk groups, among both higher- and lower-educated participants. For fruit intake, only the plus version was more effective than providing generic nutrition information. Although feasible, incorporating environmental-level information is time-consuming. Therefore, the basic version may be more feasible for further implementation, although inclusion of feedback on the arrangement of the home food environment and on availability and prices may be considered for fruit and, for high-educated people, for high-energy snack intake.
Trial Registration
Netherlands Trial Registry NTR3396; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3396 (Archived by WebCite at http://www.webcitation.org/6VNZbdL6w).
doi:10.2196/jmir.3837
PMCID: PMC4319071  PMID: 25599828
cognitive feedback; environmental feedback; self-regulation; computer tailoring; nutrition education; fruit consumption; vegetable consumption; fat consumption; snack consumption

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