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1.  Efficacy of Standard Versus Enhanced Features in a Web-Based Commercial Weight-Loss Program for Obese Adults, Part 2: Randomized Controlled Trial 
Commercial Web-based weight-loss programs are becoming more popular and increasingly refined through the addition of enhanced features, yet few randomized controlled trials (RCTs) have independently and rigorously evaluated the efficacy of these commercial programs or additional features.
To determine whether overweight and obese adults randomized to an online weight-loss program with additional support features (enhanced) experienced a greater reduction in body mass index (BMI) and increased usage of program features after 12 and 24 weeks compared to those randomized to a standard online version (basic).
An assessor-blinded RCT comparing 301 adults (male: n=125, 41.5%; mean age: 41.9 years, SD 10.2; mean BMI: 32.2 kg/m2, SD 3.9) who were recruited and enrolled offline, and randomly allocated to basic or enhanced versions of a commercially available Web-based weight-loss program for 24 weeks.
Retention at 24 weeks was greater in the enhanced group versus the basic group (basic 68.5%, enhanced 81.0%; P=.01). In the intention-to-treat analysis of covariance with imputation using last observation carried forward, after 24 weeks both intervention groups had reductions in key outcomes with no difference between groups: BMI (basic mean –1.1 kg/m2, SD 1.5; enhanced mean –1.3 kg/m2, SD 2.0; P=.29), weight (basic mean –3.3 kg, SD 4.7; enhanced mean –4.0 kg, SD 6.2; P=.27), waist circumference (basic mean –3.1 cm, SD 4.6; enhanced mean –4.0 cm, SD 6.2; P=.15), and waist-to-height ratio (basic mean –0.02, SD 0.03; enhanced mean –0.02, SD 0.04, P=.21). The enhanced group logged in more often at both 12 and 24 weeks, respectively (enhanced 12-week mean 34.1, SD 28.1 and 24-week mean 43.1, SD 34.0 vs basic 12-week mean 24.6, SD 25.5 and 24-week mean 31.8, SD 33.9; P=.002).
The addition of personalized e-feedback in the enhanced program provided limited additional benefits compared to a standard commercial Web-based weight-loss program. However, it does support greater retention in the program and greater usage, which was related to weight loss. Further research is required to develop and examine Web-based features that may enhance engagement and outcomes and identify optimal usage patterns to enhance weight loss using Web-based programs.
Trial Registration
Australian New Zealand Clinical Trials Registry (ANZCTR) trial number: ACTRN12610000197033; (Archived by WebCite at
PMCID: PMC3786000  PMID: 23876832
intervention studies; weight loss; Internet; randomized controlled trial; reducing diet; telemedicine
3.  How Accurate is Web-Based Self-Reported Height, Weight, and Body Mass Index in Young Adults? 
Web-based approaches are an effective and convenient medium to deliver eHealth interventions. However, few studies have attempted to evaluate the accuracy of online self-reported weight, and only one has assessed the accuracy of online self-reported height and body mass index (BMI).
This study aimed to validate online self-reported height, weight, and calculated BMI against objectively measured data in young Australian adults.
Participants aged 18-35 years were recruited via advertisements on social media sites and reported their current height and weight as part of an online survey. They then subsequently had the same measures objectively assessed by a trained researcher.
Self-reported height was significantly overestimated by a mean of 1.36 cm (SD 1.93; P<.001), while self-reported weight was significantly underestimated by –0.55 kg (SD 2.03; P<.001). Calculated BMI was also underestimated by –0.56 kg/m2 (SD 0.08; P<.001). The discrepancy in reporting resulted in the misclassification of the BMI category of three participants. Measured and self-reported data were strongly positively correlated (height: r=.98, weight: r=.99, BMI: r=.99; P<.001). When accuracy was evaluated by BMI category and gender, weight remained significantly underreported by females (P=.002) and overweight/obese participants (P=.02).
There was moderate to high agreement between self-reported and measured anthropometric data. Findings suggest that online self-reported height and weight can be a valid method of collecting anthropometric data.
PMCID: PMC3906650  PMID: 24398335
Internet; height; weight; body mass index; self-report
4.  Diet Quality, Measured by Fruit and Vegetable Intake, Predicts Weight Change in Young Women 
Journal of Obesity  2013;2013:525161.
This study investigates the relationship between diet quality and weight gain in young women. Young women (n = 4,287, with 1,356 women identified as plausible subsample aged 27.6 ± 1.5 years at baseline) sampled from the Australian Longitudinal Study on Women's Health study completed food frequency questionnaires in 2003, which were used to evaluate diet quality using three indices: Australian Recommended Food Score (ARFS), Australian Diet Quality Index (Aus-DQI), and Fruit and Vegetable Index (FAVI). Weight was self-reported in 2003 and 2009. Multivariate linear regression was used to examine the association between tertiles of each diet quality index and weight change from 2003 to 2009. The ARFS and FAVI were significant predictors of 6-year weight change in this group of young women, while Aus-DQI did not predict weight change (P > 0.05). In the fully adjusted model, those who were in the top tertile of the ARFS significantly gained lower weight gain compared with the lower tertile for the plausible TEI sub-sample (β = −1.6 kg (95% CI: −2.67 to −0.56), P = 0.003). In the fully adjustment model, young women were classified in the highest FAVI tertile and gained significantly less weight than those in the lowest tertile for the plausible TEI (β = −1.6 kg (95% CI: −2.4 to −0.3) P = 0.01). In conclusion, overall diet quality measured by the ARFS and the frequency and variety of fruit and vegetable consumption may predict long-term weight gain in young women. Therefore, health promotion programs encouraging frequent consumption of a wide variety of fruits and vegetables are warranted.
PMCID: PMC3770048  PMID: 24062946
5.  An 8-Week Web-Based Weight Loss Challenge With Celebrity Endorsement and Enhanced Social Support: Observational Study 
Initial engagement and weight loss within Web-based weight loss programs may predict long-term success. The integration of persuasive Web-based features may boost engagement and therefore weight loss.
To determine whether an 8-week challenge within a commercial Web-based weight loss program influenced weight loss, website use, and attrition in the short term, when compared to the standard program.
De-identified data for participants (mean age 36.7±10.3 years; 86% female) who enrolled in the Biggest Loser Club (BLC) (n=952) and the BLC’s Shannan Ponton Fast Track Challenge (SC) for 8 weeks (n=381) were compared. The BLC program used standard evidence-based website features, with individualized calorie and exercise targets to facilitate a weight loss of 0.5-1 kg per week (–500kcal/day less than estimated energy expenditure). SC used the same website features but in addition promoted greater initial weight loss using a 1200 kcal/day energy intake target and physical activity energy expenditure of 600 kcal/day. SC used persuasive features to facilitate greater user engagement, including offering additional opportunities for social support (eg, webinar meetings with a celebrity personal trainer and social networking) endorsed by a celebrity personal trainer. Self-reported weekly weight records were used to determine weight change after 8 weeks. A primary analysis was undertaken using a generalized linear mixed model (GLMM) with all available weight records for all participants included. Dropout (participants who cancelled their subscription) and nonusage (participants who stopped using the Web-based features) attrition rates at 8 weeks were calculated. The number of participants who accessed each website feature and the total number of days each feature was used were calculated. The difference between attrition rates and website use for the two programs were tested using chi-square and Wilcoxon Rank Sum tests, respectively.
Using GLMM, including weight data for all participants, there was significantly greater (P=.03) 8-week weight loss in SC (–5.1 kg [–5.5 to –4.6 kg] or –6.0%) compared to BLC participants (–4.5 kg [–4.8, –4.2] or –5.0%). Dropout rates were low and consistent across groups (BLC: 17 (1.8%) vs SC: 2 (0.5%), P=.08) and 48.7% (456/936) of BLC and 51.2% (184/379) of SC participants accessed the website at 8 weeks, with no difference between programs (P=.48). SC participants accessed the discussion forums, menu plans, exercise plans, and educational materials significantly more than BLC participants (P<.05).
Using a short-term challenge with persuasive features, including online social support with endorsement by a celebrity personal trainer, as well as a greater energy balance deficit, within a commercial Web-based weight loss program may facilitate greater initial weight loss and engagement with some program components. The results support the need for a more rigorous and prospective evaluation of Web-based weight loss programs that incorporate additional strategies to enhance initial weight loss and engagement, such as a short-term challenge.
PMCID: PMC3713892  PMID: 23827796
weight loss; Internet; commercial sector; user engagement; retention
6.  A 12-Week Commercial Web-Based Weight-Loss Program for Overweight and Obese Adults: Randomized Controlled Trial Comparing Basic Versus Enhanced Features 
The development and use of Web-based programs for weight loss is increasing rapidly, yet they have rarely been evaluated using randomized controlled trials (RCTs). Interestingly, most people who attempt weight loss use commercially available programs, yet it is very uncommon for commercial programs to be evaluated independently or rigorously.
To compare the efficacy of a standard commercial Web-based weight-loss program (basic) versus an enhanced version of this Web program that provided additional personalized e-feedback and contact from the provider (enhanced) versus a wait-list control group (control) on weight outcomes in overweight and obese adults.
This purely Web-based trial using a closed online user group was an assessor-blinded RCT with participants randomly allocated to the basic or enhanced 12-week Web-based program, based on social cognitive theory, or the control, with body mass index (BMI) as the primary outcome.
We enrolled 309 adults (129/309, 41.8% male, BMI mean 32.3, SD 4 kg/m2) with 84.1% (260/309) retention at 12 weeks. Intention-to-treat analysis showed that both intervention groups reduced their BMI compared with the controls (basic: –0.72, SD 1.1 kg/m2, enhanced: –1.0, SD 1.4, control: 0.15, SD 0.82; P < .001) and lost significant weight (basic: –2.1, SD 3.3 kg, enhanced: –3.0, SD 4.1, control: 0.4, SD 2.3; P < .001) with changes in waist circumference (basic: –2.0, SD 3.5 cm, enhanced: –3.2, SD 4.7, control: 0.5, SD 3.0; P < .001) and waist-to-height ratio (basic: –0.01, SD 0.02, enhanced: –0.02, SD 0.03, control: 0.0, SD 0.02; P < .001), but no differences were observed between the basic and enhanced groups. The addition of personalized e-feedback and contact provided limited additional benefits compared with the basic program.
A commercial Web-based weight-loss program can be efficacious across a range of weight-related outcomes and lifestyle behaviors and achieve clinically important weight loss. Although the provision of additional personalized feedback did not facilitate greater weight loss after 12 weeks, the impact of superior participant retention on longer-term outcomes requires further study. Further research is required to determine the optimal mix of program features that lead to the biggest treatment impact over time.
Trial Registration
Australian New Zealand Clinical Trials Registry (ANZCTR): 12610000197033; (Archived by WebCite at
PMCID: PMC3376507  PMID: 22555246
Intervention; weight loss; Web-based intervention; randomized controlled trial; reducing diet; eHealth
7.  Weight Change in a Commercial Web-Based Weight Loss Program and its Association With Website Use: Cohort Study 
There is a paucity of information in the scientific literature on the effectiveness of commercial weight loss programs, including Web-based programs. The potential of Web-based weight loss programs has been acknowledged, but their ability to achieve significant weight loss has not been proven.
The objectives were to evaluate the weight change achieved within a large cohort of individuals enrolled in a commercial Web-based weight loss program for 12 or 52 weeks and to describe participants’ program use in relation to weight change.
Participants enrolled in an Australian commercial Web-based weight loss program from August 15, 2007, through May 31, 2008. Self-reported weekly weight records were used to determine weight change after 12- and 52-week subscriptions. The primary analysis estimated weight change using generalized linear mixed models (GLMMs) for all participants who subscribed for 12 weeks and also for those who subscribed for 52 weeks. A sensitivity analysis was conducted using the last observation carried forward (LOCF) method. Website use (ie, the number of days participants logged on, made food or exercise entries to the Web-based diary, or posted to the discussion forum) was described from program enrollment to 12 and 52 weeks, and differences in website use by percentage weight change category were tested using Kruskal-Wallis test for equality of populations.
Participants (n = 9599) had a mean (standard deviation [SD]) age of 35.7 (9.5) years and were predominantly female (86% or 8279/9599) and obese (61% or 5866/9599). Results from the primary GLMM analysis including all enrollees found the mean percentage weight change was −6.2% among 12-week subscribers (n = 6943) and −6.9% among 52-week subscribers (n = 2656). Sensitivity analysis using LOCF revealed an average weight change of −3.0% and −3.5% after 12 and 52 weeks respectively. The use of all website features increased significantly (P < .01) as percentage weight change improved.
The weight loss achieved by 12- and 52-week subscribers of a commercial Web-based weight loss program is likely to be in the range of the primary and sensitivity analysis results. While this suggests that, on average, clinically important weight loss may be achieved, further research is required to evaluate the efficacy of this commercial Web-based weight loss program prospectively using objective measures. The potential association between greater website use and increased weight loss also requires further evaluation, as strategies to improve participants’ use of Web-based program features may be required.
PMCID: PMC3222206  PMID: 21993231
Weight loss; obesity; intervention; Internet; commercial
8.  Dropout, Nonusage Attrition, and Pretreatment Predictors of Nonusage Attrition in a Commercial Web-Based Weight Loss Program 
An understanding of the factors that predict retention and website use are critical to the development of effective Web-based weight loss interventions. However, poor retention (dropout attrition) and website utilization (nonusage attrition) are major inhibitors to the effectiveness of Web-based programs.
The study aimed to (1) describe the prevalence of dropout and nonusage attrition and (2) examine pretreatment predictors of nonusage attrition in a cohort of commercial Web-based weight loss program participants.
Participants enrolled in the online program, The Biggest Loser Club, Australia, from August 15, 2007, to May 31, 2008. Only those who subscribed for 12 or 52 weeks were included in this study. All data were collected by the program proprietors, SP Health Co Pty Ltd (Sydney, Australia), and provided in “deidentified” form. Data collected included responses to a pretreatment survey (sociodemographic and behavioral characteristics), subscription history (date of enrollment and subscription end), and website use (log-ins, food and exercise diary entries, weigh-ins, and forum posts). Participants were classified as a member of the program at 12 or 52 weeks if they held an active subscription plan at that point in time. Participants were classified as nonusers at 12 or 52 weeks if they had stopped using all of the website features and had not returned. Predictors of nonusage attrition were explored using Cox proportional hazards regression analysis.
Of the 9599 eligible participants, 6943 (72%) subscribed to the program for 12 weeks, and 2656 (28%) subscribed for 52 weeks. Of all participants, 31% (2975/9599) were classified as overweight, 61% (5866/9599) were classified as obese, 86% (8279/9599) were female, and participants’ mean (SD) age was 35.7 (9.5) years. The 12 week and 52 week subscribers’ retention rates were 97% and 77% respectively. Of 12 week subscribers, 35% were classified as program “users” after 12 weeks, and 30% of 52 week subscribers were classified as “users” after 52 weeks. Significant predictors of nonusage attrition among 12 week subscribers included age (hazard ratio for 45 to 55 years of age = 0.83, 95% confidence interval [CI] 0.73 - 0.93, P = .001; hazard ratio for 55 to 65 years of age = 0.80, 95% CI 0.66 - 0.99, P = .04), exercise level (hazard ratio = 0.76, 95% CI 0.72 - 0.81, P < .001), emotional eating (hazard ratio = 1.11, 95% CI 1.04 - 1.18, P = .001), eating breakfast (hazard ratio = 0.88, 95% CI 0.82 - 0.95, P = .001), and skipping meals (hazard ratio = 1.12, 95% CI 1.04 -1.19, P = .001). For 52 week subscribers, eating breakfast (hazard ratio = 0.88, 95% CI 0.79 - 0.99, P = .04) and not drinking tea or coffee with sugar (hazard ratio = 1.23, 95% CI 1.11 - 1.37, P < .001) were the pretreatment characteristics that significantly decreased risk of nonusage attrition.
The findings demonstrate a high prevalence of nonusage attrition among a cohort of commercial Web-based weight loss program participants. Several sociodemographic and behavioral factors were shown to independently predict nonusage attrition.
PMCID: PMC3056525  PMID: 21156470
Weight loss; Internet; commercial sector; retention
9.  The Prevalence of Food Addiction as Assessed by the Yale Food Addiction Scale: A Systematic Review 
Nutrients  2014;6(10):4552-4590.
Obesity is a global issue and it has been suggested that an addiction to certain foods could be a factor contributing to overeating and subsequent obesity. Only one tool, the Yale Food Addiction Scale (YFAS) has been developed to specifically assess food addiction. This review aimed to determine the prevalence of food addiction diagnosis and symptom scores, as assessed by the YFAS. Published studies to July 2014 were included if they reported the YFAS diagnosis or symptom score and were published in the English language. Twenty-five studies were identified including a total of 196,211 predominantly female, overweight/obese participants (60%). Using meta-analysis, the weighted mean prevalence of YFAS food addiction diagnosis was 19.9%. Food addiction (FA) diagnosis was found to be higher in adults aged >35 years, females, and overweight/obese participants. Additionally, YFAS diagnosis and symptom score was higher in clinical samples compared to non-clinical counterparts. YFAS outcomes were related to a range of other eating behavior measures and anthropometrics. Further research is required to explore YFAS outcomes across a broader spectrum of ages, other types of eating disorders and in conjunction with weight loss interventions to confirm the efficacy of the tool to assess for the presence of FA.
PMCID: PMC4210934  PMID: 25338274
food addiction; Yale Food Addiction Scale; YFAS; obesity; eating disorders; substance dependence; addiction
10.  A scoping review of risk behaviour interventions in young men 
BMC Public Health  2014;14(1):957.
Young adult males commonly engage in risky behaviours placing them at risk of acute and chronic health conditions. The purpose of this scoping review was to provide an overview of existing literature, describing the interventions targeting risk behaviours in young adult males.
A search of seven electronic databases, grey literature and relevant journals reported in English language until May 2013 was conducted. All interventions that promoted healthy behaviours or reductions in risky behaviours to treat or prevent an associated health issue(s) in young adult males (17-35 years) in upper-middle and high-income countries were included. For inclusion the appropriate age range had to be reported and the sample had to be young adult male participants only or the outcomes reported with stratification by age and/or sex to include young adult males. Risk behaviours included: physical inactivity, poor diet, alcohol use, tobacco smoking, recreational drug use, unsafe sexual behaviours, tanning/sun exposure, violence, unsafe vehicle driving, gambling and self-harm.
The search strategy identified 16,739 unique citations and the full-text of 1149 studies were retrieved and screened with 100 included studies focussed on: physical inactivity (27%), alcohol use (25%), unsafe sexual behaviour (21%), poor diet (5%), unsafe vehicle driving (5%), tobacco smoking (4%), recreational drug use (2%), and tanning/sun exposure (1%) with no relevant studies targeting violence, gambling or self-harm. Also 10% of the studies targeted multiple risk behaviours. The most common study design was randomized controlled trials (62%). Face-to-face was the most common form of intervention delivery (71%) and the majority were conducted in university/college settings (46%). There were 46 studies (46%) that included young adult male participants only, the remaining studies reported outcomes stratified by age and/or sex.
Risk behaviours in young men have been targeted to some extent, but the amount of research varies across risk behaviours. There is a need for more targeted and tailored interventions that seek to promote healthy behaviours or decrease risky behaviours in young men.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-957) contains supplementary material, which is available to authorized users.
PMCID: PMC4177699  PMID: 25224717
Scoping review; Young men; Risk behaviours; Health behaviour; Risk reduction behaviour; Intervention
11.  Validity of the Australian Recommended Food Score as a diet quality index for Pre-schoolers 
Nutrition Journal  2014;13(1):87.
Diet quality tools provide researchers with brief methods to assess the nutrient adequacy of usual dietary intake. This study describes the development and validation of a pediatric diet quality index, the Australian Recommended Food Scores for Pre-schoolers (ARFS-P), for use with children aged two to five years.
The ARFS-P was derived from a 120-item food frequency questionnaire, with eight sub-scales, and was scored from zero to 73. Linear regressions were used to estimate the relationship between diet quality score and nutrient intakes, in 142 children (mean age 4 years) in rural localities in New South Wales, Australia.
Total ARFS-P and component scores were highly related to dietary intake of the majority of macronutrients and micronutrients including protein, β-carotene, vitamin C, vitamin A. Total ARFS-P was also positively related to total consumption of nutrient dense foods, such as fruits and vegetables, and negatively related to total consumption of discretionary choices, such as sugar sweetened drinks and packaged snacks.
ARFS-P is a valid measure that can be used to characterise nutrient intakes for children aged two to five years. Further research could assess the utility of the ARFS-P for monitoring of usual dietary intake over time or as part of clinical management.
PMCID: PMC4162955  PMID: 25178263
Diet quality index; Food frequency questionnaire; Pre-schoolers; Nutritional adequacy
12.  Participants in an online weight loss program can improve diet quality during weight loss: a randomized controlled trial 
Nutrition Journal  2014;13(1):82.
Better diet quality has been associated with less weight gain over time. However, few studies have examined the role of diet quality during weight loss. This study aimed to compare changes in diet quality in overweight/obese adults during a weight loss intervention, and determine whether an association between diet quality score and weight loss exists.
Overweight or obese (BMI 25-40 kg/m2) adults, aged 18–60 years, were recruited from the Hunter Region of NSW, Australia and randomized to one of three groups: a standard online weight loss program (n = 94); an enhanced version of this online program that provided additional personalized feedback and reminders (n = 98); or a wait-list control group (n = 97). Diet quality was calculated using the Australian Recommended Food Score (ARFS) with dietary data from the Australian Eating Survey (AES) Food Frequency Questionnaire at baseline and 12-weeks.
The basic and enhanced groups lost significantly more weight than the control group after 12 weeks (basic -2.2 ± 3.4 kg, enhanced -3.0 ± 4.0 kg, control 0.4 ± 2.4 kg, P < 0.001) with no difference between the basic and enhanced groups. The mean change in ARFS in the enhanced group (2.2 ± 5.7) was significantly higher (P = 0.03) than the control group. There were no significant differences in change in ARFS between the enhanced and basic, or basic and control groups. The ARFS and the fruit, meat, wholegrain, dairy and water sub-scale scores at 12 weeks were significantly associated with greater weight loss (P < 0.05).
Diet quality improved significantly in the enhanced group compared to controls following 12-weeks intervention. Furthermore, higher diet quality was associated with greater weight loss.
Trial Registration
PMCID: PMC4266894  PMID: 25108506
Diet quality; Index; Score; Weight loss; Intervention
13.  Associations between program outcomes and adherence to Social Cognitive Theory tasks: process evaluation of the SHED-IT community weight loss trial for men 
Despite rising international rates of obesity, men remain reluctant to participate in weight loss research. There is a lack of evidence to guide the development of effective weight loss interventions that engage men. The objective of this study was to provide a comprehensive process evaluation of the SHED-IT (Self-Help, Exercise and Diet using Information Technology) weight loss program for men, as delivered in the SHED-IT community weight loss trial, and to identify key components associated with success.
In an assessor-blinded randomised controlled trial, 159 overweight and obese men (BMI 25.0-40.0 kg/m2) were randomised to one of two gender-tailored weight loss interventions with no face-to-face contact, or a control group. The interventions were informed by Bandura’s Social Cognitive Theory (SCT) with men encouraged to complete a Support Book containing SCT-based tasks including goal setting, reward setting, creation of social support strategies and self-monitoring of: i) weight, ii) physical activity, and iii) diet. At post-test, compliance with SCT tasks was examined and men also completed a process evaluation questionnaire.
Both SHED-IT intervention groups demonstrated greater weight loss during the intervention compared to the control, with no difference between intervention groups. Most men engaged with the SCT tasks although compliance declined over time and utilisation of social support networks and reward selection was poor. In a multiple regression model, the number of goals set (β [95% CI] = -0.3 [-0.6, -0.1], p = 0.01) and the number of weight records documented (β [95% CI] = -0.2 [-0.4, -0.0], p = 0.03) independently predicted weight loss. The process evaluation indicated that men found the programs to be supportive, enjoyable and beneficial.
This process evaluation provides valuable information to inform the development of obesity treatment strategies that engage men. Future studies with men should include a strong focus on self-monitoring and goal setting to enhance behaviour change and improve treatment effects.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12610000699066.
PMCID: PMC4105870  PMID: 25011421
Social cognitive theory; Men; Obesity; Online; Process evaluation; Weight loss
14.  A Study of the Effects of Latent Iron Deficiency on Measures of Cognition: A Pilot Randomised Controlled Trial of Iron Supplementation in Young Women  
Nutrients  2014;6(6):2419-2435.
Rates of iron deficiency are high amongst healthy young women. Cognitive impairment occurs secondary to iron deficiency in infants and children, but evaluation of the impact on cognition among young women is inconsistent. The aim was to determine the suitability of the IntegNeuro test battery for assessing cognitive function in iron-deficient and iron-sufficient young women. A pilot double-blinded, placebo-controlled intervention trial was conducted in iron-deficient (serum ferritin ≤ 20 μg/L and haemoglobin > 120 g/L) and iron-sufficient young women (18–35 years). Cognitive function and haematological markers of iron status were measured at baseline and follow-up. Iron-deficient participants (n = 24) were randomised to receive placebo, 60 mg or 80 mg elemental iron daily supplements for 16 weeks. A control group of iron-sufficient participants (n = 8) was allocated to placebo. Change scores for Impulsivity and Attention were significantly greater in plasma ferritin improvers than in non-improvers (p = 0.004, p = 0.026). IntegNeuro was easy to administer and acceptable to young women. Based on the differences in Memory and Attention scores between iron-deficient participants on iron treatment and those on placebo, it was decided that between 26 and 84 participants would be required in each iron treatment group for an adequately powered extension of this pilot RCT.
PMCID: PMC4073160  PMID: 24959952
iron; women; cognition; memory; attention; supplementation
15.  Food and beverage portion sizes in Australian children: a secondary analysis of 1995 and 2007 national data 
BMC Public Health  2014;14:517.
Portion size of foods is reported to contribute to the rise in obesity prevalence. However, evidence of changes in portion size for commonly consumed foods in Australia is lacking. The aim was to evaluate whether Australian child and adolescent portion sizes of selected foods changed from 1995 to 2007.
Time-series study, comparing dietary data from two national cross-sectional surveys in nationally representative population survey of Australian households. The dietary data was from children aged 2–16 years who participated in the 1995 National Nutrition Survey (n = 2198) and 2007 Australian National Children’s Nutrition and Physical Activity Survey (n = 4799).
Differences were found across survey years in median portion size of common foods and beverages assessed by 24-hour recalls for age and sex categories. Of the 61 foods items evaluated across the whole population sample, portion size increased in 18 items, decreased in 22, with no change in 20, although the magnitude of change varied by age and sex. Decreases in portion size were detected for most dairy products, breakfast cereal, some packaged snack foods and vegetables, p < 0.0001. Increases were detected for cooked chicken, mixed chicken dishes, bacon and ham (p < 0.0001), cooked meat (p < 0.05), fish (p < 0.01) and pizza (p < 0.0001). No significant changes were detected for many items including white and wholemeal bread, mincemeat, chocolate and soft drink.
Small changes in portion sizes were detected over 12 years in Australian children and adolescents with the degree of change varying by sex, age and food group. Knowledge of usual portion sizes could inform programs targeting appropriate serving sizes selection in children and adolescents.
PMCID: PMC4061520  PMID: 24886094
16.  Comparison of Two Doses of Elemental Iron in the Treatment of Latent Iron Deficiency: Efficacy, Side Effects and Blinding Capabilities 
Nutrients  2014;6(4):1394-1405.
Adherence to iron supplementation can be compromised due to side effects, and these limit blinding in studies of iron deficiency. No studies have reported an efficacious iron dose that allows participants to remain blinded. This pilot study aimed to determine a ferrous sulfate dose that improves iron stores, while minimising side effects and enabling blinding. A double-blinded RCT was conducted in 32 women (18–35 years): 24 with latent iron deficiency (serum ferritin < 20 µg/L) and 8 iron sufficient controls. Participants with latent iron deficiency were randomised to 60 mg or 80 mg elemental iron or to placebo, for 16 weeks. The iron sufficient control group took placebo. Treatment groups (60 mg n = 7 and 80 mg n = 6) had significantly higher ferritin change scores than placebo groups (iron deficient n = 5 and iron sufficient n = 6), F(1, 23) = 8.46, p ≤ 0.01. Of the 24 who completed the trial, 10 participants (77%) on iron reported side effects, compared with 5 (45%) on placebo, but there were no differences in side effects (p = 0.29), or compliance (p = 0.60) between iron groups. Nine (69%) participants on iron, and 11 (56%) on placebo correctly guessed their treatment allocation. Both iron doses were equally effective in normalising ferritin levels. Although reported side-effects were similar for both groups, a majority of participants correctly guessed their treatment group.
PMCID: PMC4011041  PMID: 24714351
ferrous sulfate; side effects; women; serum ferritin
17.  Efficacy of interventions that include diet, aerobic and resistance training components for type 2 diabetes prevention: a systematic review with meta-analysis 
Current recommendations for the prevention of type 2 diabetes advise modification of diet and exercise behaviors including both aerobic and resistance training. However, the efficacy of multi-component interventions involving a combination of these three components has not been established. The aims of this review were to systematically review and meta-analyze the evidence on multi-component (diet + aerobic exercise + resistance training) lifestyle interventions for type 2 diabetes prevention. Eight electronic databases (Medline, Embase, SportDiscus, Web of Science, CINAHL, Informit health collection, Cochrane library and Scopus) were searched up to June 2013. Eligible studies 1) recruited prediabetic adults or individuals at risk of type 2 diabetes; 2) conducted diet and exercise [including both physical activity/aerobic and resistance training] programs; and 3) reported weight and plasma glucose outcomes. In total, 23 articles from eight studies were eligible including five randomized controlled trials, one quasi-experimental, one two-group comparison and one single-group pre-post study. Four studies had a low risk of bias (score ≥ 6/10). Median intervention length was 12 months (range 4–48 months) with a follow-up of 18 months (range 6.5 - 48 months). The diet and exercise interventions varied slightly in terms of their specific prescriptions. Meta-analysis favored interventions over controls for weight loss (-3.79 kg [-6.13, -1.46; 95% CI], Z = 3.19, P = 0.001) and fasting plasma glucose (-0.13 mmol.L-1 [-0.24, -0.02; 95% CI], Z = 2.42, P = 0.02). Diabetes incidence was only reported in two studies, with reductions of 58% and 56% versus control groups. In summary, multi-component lifestyle type 2 diabetes prevention interventions that include diet and both aerobic and resistance exercise training are modestly effective in inducing weight loss and improving impaired fasting glucose, glucose tolerance, dietary and exercise outcomes in at risk and prediabetic adult populations. These results support the current exercise guidelines for the inclusion of resistance training in type 2 diabetes prevention, however there remains a need for more rigorous studies, with long-term follow-up evaluating program efficacy, muscular fitness outcomes, diabetes incidence and risk reduction.
PMCID: PMC3898566  PMID: 24423095
Prediabetes; Diabetes; Obesity; Lifestyle; Weight loss; Diet; Exercise; Resistance training
18.  The 40-Something randomized controlled trial to prevent weight gain in mid-age women 
BMC Public Health  2013;13:1007.
Obesity prevention is a major public health priority. Despite the health risks associated with weight gain, there has been a distinct lack of research into effective interventions to prevent, rather than treat, obesity particularly at high risk life stages such as menopause in women. This paper describes the rationale for and design of a 2-year randomized controlled trial (RCT) (the 40-Something Study) aimed at testing the feasibility and efficacy of a relatively low intensity intervention designed to achieve weight control in non-obese women about to enter the menopause transition.
Methods and design
The study is a parallel-group RCT consisting of 12 months of intervention (Phase 1) and 12 months of monitoring (Phase 2). Non-obese pre-menopausal healthy females 44–50 years of age were screened, stratified according to Body Mass Index (BMI) category (18.5-24.9 and 25–29.9 kg/m2) and randomly assigned to one of two groups: motivational interviewing (MI) intervention (n = 28), or a self-directed intervention (SDI) (control) (n = 26). The MI intervention consisted of five consultations with health professionals (four with a Dietitian and one with an Exercise Physiologist) who applied components of MI counselling to consultations with the women over a 12 month period. The SDI was developed as a control and these participants received print materials only. Outcome measures were collected at baseline, three, 12, 18 and 24 months and included weight (primary outcome), waist circumference, body composition, blood pressure, plasma markers of metabolic syndrome risk, dietary intake, physical activity and quality of life. Analysis of covariance will be used to investigate outcomes according to intervention type and duration (comparing baseline, 12 and 24 months).
The 40-Something study is the first RCT aimed at preventing menopausal weight gain in Australian women. Importantly, this paper describes the methods used to evaluate whether a relatively low intensity, health professional led intervention will achieve better weight control in pre-menopausal women than a self-directed intervention. The results will add to the scant body of literature on obesity prevention methods at an under-researched high-risk life stage, and inform the development of population-based interventions.
Trial registration
PMCID: PMC4016250  PMID: 24156558
Obesity prevention; Intervention; Menopause; Motivational interviewing
19.  Iron deficiency, cognition, mental health and fatigue in women of childbearing age: a systematic review 
It is known that Fe deficiency has a negative impact on cognitive function in children by altering brain energy metabolism and neurotransmitter function. It is unclear whether Fe deficiency has detrimental effects on cognition, mental health and fatigue in women of childbearing age. Our aim was to systematically review the literature to determine whether Fe deficiency in women of childbearing age affects cognition, mental health and fatigue, and whether a change in Fe status results in improvements in cognition, mental health and fatigue. Studies using Fe supplement interventions were reviewed to examine the effect of Fe deficiency in women of childbearing age (13–45 years) on their cognition, mental health and fatigue. English-language articles ranging from the earliest record to the year 2011 were sourced. The quality of retrieved articles was assessed and the Fe pathology, cognitive, mental health and fatigue data were extracted. Means and standard deviations from cognitive test data were included in meta-analyses of combined effects. Of the 1348 studies identified, ten were included in the review. Three studies showed poorer cognition and mental health scores and increased fatigue with Fe deficiency at baseline. Seven studies reported an improvement in cognitive test scores after Fe treatment. Results of three of these studies were included in meta-analyses of the effect of Fe supplement intervention on cognition. The results of the meta-analyses showed a significant improvement in Arithmetic scores after treatment (P < 0·01), but no effect on Digit Symbol, Digit Span or Block Design. While an improvement in cognition after Fe treatment was seen in seven out of ten studies, the evidence base is limited by poor study quality and heterogeneity across studies. Additional high-quality studies using consistent measures are warranted.
PMCID: PMC4153327  PMID: 25191562
Iron deficiency; Women of childbearing age; Cognition; Mental health; Fatigue; JBI, Joanna-Briggs Institute; RCT, randomised controlled trial; SF, serum ferritin; SMD, standardised mean difference
20.  The development and evaluation of the Australian child and adolescent recommended food score: a cross-sectional study 
Nutrition Journal  2012;11:96.
Diet quality tools have been developed to assess the adequacy of dietary patterns for predicting future morbidity and mortality. This study describes the development and evaluation of a brief food-based diet quality index for use with children at the individual or population level. The Australian Child and Adolescent Recommended Food Score (ACARFS) was developed to reflect adherence to the Dietary Guidelines for Children and Adolescents in Australia and modelled on the approach of the US Recommended Food Score.
The ACARFS has eight sub-scales and is scored from zero to 73. The diet quality score was evaluated by assessing correlation (Spearman’s correlations) and agreement (weighted κ statistics) between ACARFS scores and nutrient intakes, derived from a food frequency questionnaire in 691 children (mean age 11.0, SD 1.1) in New South Wales, Australia. Nutrient intakes for ACARFS quartiles were compared with the relevant Australian nutrient reference values.
ACARFS showed slight to substantial agreement (κ 0.13-0.64) with nutrient intakes, with statistically significant moderate to strong positive correlations with all vitamins, minerals and energy intake (r = 0.42-0.70). ACARFS was not related to BMI.Participants who scored less than the median ACARFS were more likely to have sub-optimal intakes of fibre, folic acid and calcium.
ACARFS demonstrated sufficient accuracy for use in future studies evaluating diet quality. Future research on its utility in targeting improvements in the nutritional quality of usual eating habits of children and adolescents is warranted.
PMCID: PMC3546018  PMID: 23164095
Diet quality; Diet variety; Index; Score; Pediatrics; Child; Australia
21.  Protocol for the Women And Their Children’s Health (WATCH) Study: A Cohort of Pregnancy and Beyond 
Journal of Epidemiology  2012;22(3):267-275.
The developmental origins of health and disease is a conceptual framework that helps explain the links between our early life exposures and later health outcomes, and is a burgeoning field of research. In this report, we describe the study protocol used in a prospective cohort of women recruited during pregnancy, with postnatal follow-up of the mothers and offspring.
The Women And Their Children’s Health (WATCH) cohort (n = 180 women) is being conducted at the John Hunter Hospital, Australia (from June 2006). Women attended study visits during pregnancy at 19, 24, 30, and 36 weeks’ gestation. Postnatal follow-up of the women and their offspring occurred at 3-month intervals during the first year after birth and annually thereafter, until age 4 years. Fetal ultrasound scans were performed at each pregnancy visit. Pregnancy and birth data were obtained from hospital records. Data collection has included maternal and child anthropometric, biochemical, dietary, physical activity, socioeconomic, medical, and other variables.
The 2 most novel components of our prospective cohort study are (1) the regular and systematic tracking of fetal and child growth and body composition, starting in the second trimester of pregnancy and continuing to age 4 years, and (2) the detailed maternal and child dietary data collection, including biochemical parameters. Detailed cohorts that collect data on the early nutritional, physiological, and social determinants of health are valuable. Despite its relatively small sample size, many hypotheses on developmental origins can be tested or piloted using data collected from the WATCH cohort.
PMCID: PMC3798629  PMID: 22374367
child; diet; growth; pregnancy; weight
22.  Mediators of weight loss in the 'Healthy Dads, Healthy Kids' pilot study for overweight fathers 
A poor understanding of the specific lifestyle behaviors that result in weight loss has hindered the development of effective interventions. The aim of this paper was to identify potential behavioral mediators of weight loss in the Healthy Dads, Healthy Kids (HDHK) intervention for overweight fathers.
The three-month intervention was evaluated in a randomized controlled trial and conducted in Newcastle, New South Wales, Australia. Baseline, three month (immediate post-intervention) and six month assessments were conducted. Recruitment and follow-up occurred between October 2008 and May 2009. The study sample included 53 overweight/obese men [mean ( SD) age=40.6( 97.1) years; body mass index (BMI)=33.2 (3.9) kgm-2] and their primary school-aged children [n=71, 54% boys; age=8.2 (2.0) years] who were randomized to HDHK program or a wait-list control group. Physical activity (PA) was assessed using pedometers and dietary behaviors were measured using a validated food frequency questionnaire. The intervention resulted in significant weight loss (5.131.27kg, P<0.0001) and increased PA among fathers (2769750 steps/day, P<0.001) and their children (1486521 steps/day, P<0.01). Fathers PA mediated weight loss in the intervention (AB=2.31, 95% CI=4.63 to 0.67) and was responsible for 47% of the intervention effect. Changes in dietary behaviors were not statistically significant.
PA was an important mediator of weight loss in the HDHK intervention. Encouraging overweight fathers to be more active with their children appears to be a promising strategy for obesity treatment in men.
PMCID: PMC3418215  PMID: 22512861
Physical activity; Mediation; Diet; Nutrition; Weigh loss; Intervention
23.  The 'Healthy Dads, Healthy Kids' community effectiveness trial: study protocol of a community-based healthy lifestyle program for fathers and their children 
BMC Public Health  2011;11:876.
The 'Healthy Dads, Healthy Kids' program was designed to help overweight fathers lose weight and positively influence the health behaviors of their children. The aim of the current study was to evaluate the previously established program in a community setting, in a large effectiveness trial.
The Healthy Dads, Healthy Kids community trial consists of three stages: (i) Stage 1 - program refinement and resource development (ii) Stage 2 - community randomized controlled trial (iii) Stage 3 - community effectiveness trial. The program will be evaluated in five Local Government Areas in the Hunter Valley Region of NSW, Australia. For the community randomized controlled trial, 50 overweight/obese men (aged 18-65 years) from one Local Government Area with a child aged between 5-12 years of age will be recruited. Families will be randomized to either the program or a 6-month wait-list control group. Fathers and their children will be assessed at baseline, post-intervention (3-months) and 6-months. Inclusion criteria are: body mass index 25-40 kg/m2; no participation in other weight loss programs during the study; pass a health-screening questionnaire; and access to a computer with Internet facilities. In the community trial, the program will be evaluated using a non-randomized, prospective design in five Local Government Areas. The exclusion criteria is body mass index < 25 kg/m2 or lack of doctor's approval. Measures will be collected at baseline, 3-, 6- and 12-months. The program involves fathers attending seven face-to-face group sessions (three with children) over 3-months. Measures: The primary outcome is fathers' weight. Secondary outcomes for both fathers and children include: waist circumference, blood pressure, resting heart rate, physical activity, sedentary behaviors and dietary intake. Father-only measures include portion size, alcohol consumption, parenting for physical activity and nutrition and parental engagement. Process evaluation will determine the fidelity, dose (delivered and received), reach, recruitment and context of the program.
As a unique approach to reducing obesity prevalence in men and improving lifestyle behaviours in children, our findings will provide important evidence relating to the translation of Healthy Dads, Healthy Kids, which will enable it to be delivered on a larger scale.
Trial registration
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000608066
PMCID: PMC3260407  PMID: 22099889
24.  Disparities exist between National food group recommendations and the dietary intakes of women 
BMC Women's Health  2011;11:37.
Preconception and pregnancy dietary intakes can influence the health of future generations. In this study we compared the food intakes of reproductive-aged women by pregnancy status, to current Australian recommendations.
Data are from the Australian Longitudinal Study on Women's Health, younger cohort aged 25-30 years in 2003, with self-reported status as pregnant (n = 606), trying to conceive (n = 454), given birth in the last 12 months (n = 829) or other (n = 5597). Diet was assessed using a validated 74-item food frequency questionnaire. Food group servings and nutrient intakes were compared to the Australian Guide to Healthy Eating (AGHE) and Australian Nutrient Reference Values (NRVs).
No women met all AGHE food group recommendations. Highest adherence rates [mean (95% CI) servings/day] were for meat [85%, 1.9(1.8-1.9)], fruit [44%, 2.1(2.1-2.2)] and dairy [35%, 1.8(1.8-1.9)], with < 14% meeting remaining recommendations. Women who achieved NRVs (folate, iron, calcium, zinc, fibre) for pregnancy, breastfeeding and adult life stages were 1.5%, 3.3% and 13.7%, respectively. Compared to AGHE, women consumed more servings of fruit (4.9 vs 4.0;P = 0.034) and dairy (3.4 vs 2.0;P = 0.006) to achieve pregnancy NRVs; more dairy (2.9 vs 2.0;P = 0.001), less fruit (3.9 vs 5.0;P < .001) and vegetables (3.4 vs 7.0;P < .001) to achieve breastfeeding NRVs; more fruit (3.6 vs 3.0;P < .001), dairy (2.5 vs 2.0;P < .001), meat (1.8 vs 1.5;P = 0.015), less vegetables (3.6 vs 5.0;P < .001) to achieve adult NRVs.
The AGHE does not align with contemporary diets of Australian women or enable them to meet all NRVs. Current tools to guide food consumption by women during pregnancy require revision.
PMCID: PMC3170266  PMID: 21819627
25.  Higher Diet Quality Does Not Predict Lower Medicare Costs but Does Predict Number of Claims in Mid-Aged Australian Women 
Nutrients  2011;3(1):40-48.
Optimal dietary quality, indicated by higher diet quality index scores, reflects greater adherence to National dietary recommendations and is also associated with lower morbidity and mortality from chronic disease. Whether this is reflected in lower health care cost over time has rarely been examined. The aim of this study was to examine whether higher diet quality, as measured by the Australian Recommended Food Score (ARFS), was associated with lower health care costs within the mid-aged cohort of the Australian Longitudinal Study on Women’s Health. We found that there was a statistically significant association between five year cumulative costs and ARFS, but in the opposite direction to that predicted, with those in the highest quintiles of ARFS having higher health care costs. However the number of Medicare claims over the six year period (2002–2007) was lower for those in the highest compared with the lowest quintile, p = 0.002. There is a need to monitor both costs and claims over time to examine health care usage in the longer term in order to determine whether savings are eventually obtained for those with the dietary patterns that adhere more closely to National recommendations.
PMCID: PMC3257731  PMID: 22254075
diet quality; diet scores; diet index; nutrition surveys; Medicare; health costs

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