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The HealthGap study aimed to understand cardiovascular risk among Indigenous Australians in Victoria using linked administrative data. A key challenge was differing spatial coverages of sources: state-level data for risk factors but cardiovascular outcomes for three hospitals. Catchments were defined based on hospital postcodes to estimate denominator populations for risk modelling: first- and second-order neighbours, and spatial distribution of outcomes ('spatial event distribution'). Catchment coverage was assessed through proportions of patients presenting to study hospitals from catchment postcodes. The spatial event distribution performed best, capturing 82% events overall (first-order:40%; second-order:64%) and 65% Indigenous (27% and 45%). No approach excluded proximal non-study hospitals. Spatial event distributions could help define denominator populations when geographic information on outcome data is available but may not avoid potential misclassification.

Research focusing on timely diagnosis and treatment of colorectal cancer is necessary to improve outcomes for people with cancer. Previous attempts to consolidate research on time to diagnosis and treatment have noted varied methodological approaches and quality, limiting the comparability of findings. This systematic review was conducted to comprehensively assess the scope of methodological issues in this field and provide recommendations for future research. Eligible articles had to assess the role of any interval up to treatment, on any outcome in colorectal cancer, in English, with no limits on publication time. Four databases were searched (Ovid Medline, EMBASE, EMCARE and PsycInfo). Papers were screened by two independent reviewers using a two-stage process of title and abstract followed by full text review. In total, 130 papers were included and had data extracted on specific methodological and statistical features. Several methodological problems were identified across the evidence base. Common issues included arbitrary categorisation of intervals (n = 107, 83%), no adjustment for potential confounders (n = 65, 50%), and lack of justification for included covariates where there was adjustment (n = 40 of 65 papers that performed an adjusted analysis, 62%). Many articles introduced epidemiological biases such as immortal time bias (n = 37 of 80 papers that used survival as an outcome, 46%) and confounding by indication (n = 73, 56%), as well as other biases arising from inclusion of factors outside of their temporal sequence. However, determination of the full extent of these problems was hampered by insufficient reporting. Recommendations include avoiding artificial categorisation of intervals, ensuring bias has not been introduced due to out-of-sequence use of key events and increased use of theoretical frameworks to detect and reduce bias. The development of reporting guidelines and domain-specific risk of bias tools may aid in ensuring future research can

OBJECTIVE: Compare the effects of osteoarthritis information, with or without pathoanatomical content, on people's beliefs about managing osteoarthritis. DESIGN: Online randomized controlled trial involving 556 participants. METHODS: Participants considered a hypothetical scenario where their doctor informed them that they had knee osteoarthritis. Participants were randomized to a control condition, where they received currently available osteoarthritis information with pathoanatomical content or an experimental condition, where they received the same osteoarthritis information but without pathoanatomical content. Primary outcomes were participants' beliefs about the need for x-ray to confirm diagnosis and joint replacement surgery in the future. RESULTS: There were no between-group differences in primary outcomes for x-ray (mean difference [MD], -0.3; 95% confidence interval [CI]: -0.9, 0.4) and surgery (MD, -0.2; 95% CI: -0.7, 0.2), each rated on an 11-point numeric rating scale. Participants in the experimental group had lower perceptions that exercise would damage the knee (MD, -0.4; 95% CI: -0.8, 0.0; rated on an 11-point numeric rating scale) and better osteoarthritis knowledge (MD, 0.9; 95% CI: 0.0, 1.9; rated on a scale ranging from 11 to 55). Among those without tertiary education, participants in the experimental group had lower perceptions that x-ray was necessary than control (MD, -0.8; 95% CI: -1.5, -0.1). Among those who had never sought care for knee pain, participants in the experimental group had lower perceptions about the need for surgery (MD, -0.7; 95% CI: -1.2, -0.2). CONCLUSIONS: Removing pathoanatomical content may not change beliefs about imaging and surgery but may lead to lower perceptions that exercise is damaging and may improve osteoarthritis knowledge. However, effects were small and of unclear clinical relevance. Tertiary education or a history of care seeking for knee pain may moderate effects on primary outcomes. J Orthop Sports Phys

OBJECTIVE: To explore the mediators of effects of two 6-month telehealth-delivered exercise programs, including exercise with and without weight-loss diet, on pain and function improvements in knee osteoarthritis (OA). METHODS: Secondary analysis of 345 participants from a 3-arm randomized controlled trial of exercise (Exercise program) and exercise plus diet (Diet + Exercise program) versus information (Control program) was conducted. Outcomes were changes in pain (11-point numeric rating scale) and function (Western Ontario and McMaster Universities Osteoarthritis Index [score range 0-68]) at 12 months. Potential mediators were change at 6 months in attitudes toward self-management, fear of movement, arthritis self-efficacy, weight, physical activity, and willingness for knee surgery. For the Diet + Exercise program versus the Exercise program, only change in weight was evaluated. RESULTS: Possible mediators of the Exercise program versus the Control program included reduced fear of movement (accounting for -1.11 units [95% confidence interval (95% CI) -2.15, -0.07] improvement in function) and increased arthritis self-efficacy (-0.40 units [95% CI -0.75, -0.06] reduction in pain, -1.66 units [95% CI -3.04, -0.28] improvement in function). The Diet + Exercise program versus the Control program mediators included reduced fear of movement (-1.13 units [95% CI -2.17, -0.08] improvement in function), increased arthritis self-efficacy (-0.77 units [95% CI -1.26, -0.28] reduction in pain, -5.15 units [95% CI -7.34, -2.96] improvement in function), and weight loss (-1.20 units [95% CI -1.73, -0.68] reduction in pain, -5.79 units [95% CI -7.96, -3.63] improvement in function). Weight loss mediated the Diet + Exercise program versus the Exercise program (-0.89 units [95% CI -1.31, -0.47] reduction in pain, -4.02 units [95% CI -5.77, -2.26] improvement in function). CONCLUSION: Increased arthritis self-efficacy, reduced fear of movement, and weight loss may partially mediat

OBJECTIVES: To assess the use of NHMRC Indigenous research guidelines by Australian researchers and the degree of Aboriginal and Torres Strait Islander governance and participation in Indigenous health research. DESIGN, SETTING, PARTICIPANTS: Cross-sectional survey of people engaged in Indigenous health research in Australia, comprising respondents to an open invitation (social media posts in general and Indigenous health research networks) and authors of primary Indigenous health research publications (2015-2019) directly invited by email. MAIN OUTCOME MEASURES: Reported use of NHMRC guidelines for Indigenous research; reported Indigenous governance and participation in Indigenous health research. RESULTS: Of 329 people who commenced the survey, 247 people (75%) provided responses to all questions, including 61 Indigenous researchers (25%) and 195 women (79%). The NHMRC guidelines were used "all the time" by 206 respondents (83%). Most respondents (205 of 247, 83%) reported that their research teams included Indigenous people, 139 reported dedicated Indigenous advisory boards (56%), 91 reported designated seats for Indigenous representatives on ethics committees (37%), and 43 reported Indigenous health research ethics committees (17%); each proportion was larger for respondents working in Indigenous community-controlled organisations than for those working elsewhere. More than half the respondents reported meaningful Indigenous participation during five of six research phases; the exception was data analysis (reported as apparent "none" or "some of the time" by 143 participants, 58%). CONCLUSIONS: Indigenous health research in Australia is largely informed by non-Indigenous world views, led by non-Indigenous people, and undertaken in non-Indigenous organisations. Re-orientation and investment are needed to give control of the framing, design, and conduct of Indigenous health research to Indigenous people.

BACKGROUND: Most people with dementia live in the community, not in residential care. Therefore, quality informal care for them is critical for managing behavioural and psychological symptoms of dementia (BPSD). Music therapy has been shown to reduce BPSD. However, no randomised controlled trial has examined the effects of music interventions delivered by caregivers in home settings. The HOME-based caregiver-delivered music intervention for people living with dementia (HOMESIDE) trial aims to evaluate the effectiveness of a 12-week music intervention in addition to standard care for BPSD. This article describes the statistical analysis plan. METHODS AND ANALYSIS: HOMESIDE is a large, pragmatic international three-arm parallel-group randomised controlled trial. Dyads (persons with dementia and caregiver) in Australia, Germany, the UK, Poland and Norway were randomised to receive music and standard care, reading and standard care or standard care alone. The primary outcome is BPSD (proxy) of the person living with dementia, measured using the Neuropsychiatric Inventory-Questionnaire (NPI-Q) at 90 and 180 days post-randomisation. Longitudinal analysis will compare NPI-Q severity between music and standard care versus standard care alone. Secondary outcomes include quality of life and depression (both person with dementia and caregiver), cognition (person with dementia only), distress, resilience, competence and caregiver-patient relationship (caregiver only). Treatment effects will be obtained at 90 and 180 days post-randomisation, where applicable. Safety outcomes (adverse events, hospitalisations, deaths) will be summarised. DISCUSSION: This statistical analysis plan provides a detailed methodology for the analysis of HOMESIDE and will improve the validity of the study and reduce the potential for bias. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001799246. Registered on November 05, 2018. CLINICALTRIALS: gov NCT03907748. Registered

BACKGROUND: Osteoarthritis (OA) is a prevalent, chronic joint condition that commonly affects the knee and hip causing pain, impaired function, and reduced quality of life. As there is no cure, the main goal of treatment is to alleviate symptoms via ongoing self-management predominantly consisting of exercise and weight loss (if indicated). However, many people with OA do not feel adequately informed about their condition and management options to self-manage effectively. Patient education is recommended by all OA Clinical Practice Guidelines to support appropriate self-management, but little is known about the optimal delivery method and content. Massive Open Online Courses (MOOCs) are free, interactive, e-learning courses. They have been used to deliver patient education in other chronic health conditions but have not been used in OA. METHODS: A two-arm parallel-design, assessor- and participant-blinded superiority randomised controlled trial. People with persistent knee/hip pain consistent with a clinical diagnosis of knee/hip OA (n = 120) are being recruited from the Australia-wide community. Participants are randomly allocated into one of two groups i) electronic information pamphlet (control group) or ii) MOOC (experimental group). Those allocated to the control group receive access to an electronic pamphlet about OA and its recommended management, currently available from a reputable consumer organisation. Those allocated to the MOOC receive access to a 4-week 4-module interactive consumer-facing e-Learning course about OA and its recommended management. Course design was informed by behaviour theory and learning science, and consumer preferences. The two primary outcomes are OA knowledge and pain self-efficacy with a primary endpoint of 5 weeks and a secondary endpoint of 13 weeks. Secondary outcomes include measures of fear of movement, exercise self-efficacy, illness perceptions, OA management and health professional care seeking intentions, physical activ

Limited research has explored associations between blue spaces and mental health, specifically in children. This study assessed links between coastal proximity and depression and anxiety among children in Australia and tested whether duration of residency at current address moderated associations. It also explored associations between within-individual changes in coastal proximity and changes in depression and anxiety. Data were from 2400 children aged 11–12 years in Wave 5 (2012) and aged 14–15 years in Wave 6 (2014) of the national Longitudinal Study of Australian Children. Outcomes were children’s self-reported symptoms of depression and anxiety. Exposure was coastal proximity (<2, 2–<5, 5–<10, 10–<20, 20–<50, and ≥50 km). Linear models were fitted to examine cross-sectional associations and fixed effects models for within-individual associations. After adjustment for potential confounders, findings suggested that those living close to the coast (<2 km) had lower levels of depression than those living the furthest from the coast (≥50 km) during childhood (Wave 5) but not adolescence (Wave 6). No associations were observed with anxiety. There was weak evidence to suggest residency duration moderated associations. No associations were observed for within-individual changes. Further research is needed to understand whether and what characteristics of coastal environments may benefit children’s mental health.

Objective: To evaluate effects of general osteoarthritis (OA) information in addition to a treatment option grid and general practitioner (GP) recommendation to exercise on treatment beliefs and intentions. Methods: An online randomized trial of 735 people 45 years old or older without OA who were recruited from a consumer survey network. Participants read a hypothetical scenario about visiting their GP for knee problems and were randomized to the following: i) ‘general information', ii) ‘option grid' (general information plus option grid), or iii) ‘option grid plus recommendation' (general information plus option grid plus GP exercise recommendation). The primary outcome was an agreement that exercise is the best management option (0-10 numeric rating scale; higher scores indicating higher agreement that exercise is best). The secondary outcomes were beliefs about other management options and management intentions. Linear regression models estimated the mean (95% confidence interval [CI]) between-group difference in postintervention scores, adjusted for baseline. Results: Option grid plus recommendation led to higher agreement that exercise is the best management by a mean of 0.4 units (95% CI: 0.1-0.6) compared with general information. There were no other between-group differences for the primary outcome. Option grid led to higher agreement that surgery was best, and x-rays were necessary, compared with general information (mean between-group differences: 0.7 [CI: 0.2-1.1] and 0.5 [CI: 0.1-1.0], respectively) and option grid plus recommendation (0.5 [CI: 0.1-0.9] and 0.9 [CI: 0.4-1.3]). Conclusion: Addition of an option grid and GP exercise recommendation to general OA information led to more favorable views that exercise was best for the hypothetical knee problem. However, differences were small and of unclear clinical importance.

Abstract Background Recent rapid growth in urban areas and the desire to create liveable neighbourhoods has brought about a renewed interest in planning for compact cities, with concepts like the 20-minute neighbourhood (20MN) becoming more popular. A 20MN broadly reflects a neighbourhood that allows residents to meet their daily (non-work) needs within a short, non-motorised, trip from home. The 20MN concept underpins the key planning strategy of Australia’s second largest city, Melbourne, however the 20MN definition has not been operationalised. This study aimed to develop and operationalise a practical definition of the 20MN and apply this to two Australian state capital cities: Melbourne (Victoria) and Adelaide (South Australia). Methods Using the metropolitan boundaries for Melbourne and Adelaide, data were sourced for several layers related to five domains: 1) healthy food; 2) recreational resources; 3) community resources; 4) public open space; and 5) public transport. The number of layers and the access measures required for each domain differed. For example, the recreational resources domain only required a sport and fitness centre (gym) within a 1.5-km network path distance, whereas the public open space domain required a public open space within a 400-m distance along a pedestrian network and 8 ha of public open space area within a 1-km radius. Locations that met the access requirements for each of the five domains were defined as 20MNs. Results In Melbourne 5.5% and in Adelaide 7.6% of the population were considered to reside in a 20MN. Within areas classified as residential, the median number of people per square kilometre with a 20MN in Melbourne was 6429 and the median number of dwellings per square kilometre was 3211. In Adelaide&rsquo

BACKGROUND: Hip osteoarthritis (OA) is a leading cause of musculoskeletal pain. Exercise is a core recommended treatment. Most evidence is based on muscle-strengthening exercise, but aerobic physical activity has potential to enhance clinical benefits. The primary aim of this study is to test the hypothesis that adding aerobic physical activity to a muscle strengthening exercise leads to significantly greater reduction in hip pain and improvements in physical function, compared to a lower-limb muscle strengthening exercise program alone at 3 months. METHODS: This is a superiority, 2-group, parallel randomised controlled trial including 196 people with symptomatic hip OA from the community. Following baseline assessment, participants are randomly allocated to receive either i) aerobic physical activity and muscle strengthening exercise or; ii) muscle strengthening exercise only. Participants in both groups receive 9 consultations with a physiotherapist over 3 months. Both groups receive a progressive muscle strengthening exercise program in addition to advice about OA management. The aerobic physical activity plan includes a prescription of moderate intensity aerobic physical activity with a goal of attaining 150 min per week. Primary outcomes are self-reported hip pain assessed on an 11-point numeric rating scale (0 = 'no pain' and 10 = 'worst pain possible') and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index physical function subscale) at 3 months. Secondary outcomes include other measures of self-reported pain (assessed at 0, 3, 9 months), self-reported physical function (assessed at 0, 3, 9 months), performance-based physical function (assessed at 0, 3 months), joint stiffness (assessed at 0, 3, 9 months), quality of life (assessed at 0, 3, 9 months), muscle strength (assessed at 0, 3 months), and cardiorespiratory fitness (assessed at 0, 3 months). Other measures include adverse events, co-interventions, and adher

BACKGROUND: Through improved service provision and accessibility, 20-min neighbourhoods (20MNs) aim to enable people to meet most of their daily (non-work) needs within 20 min from home. Associations between 20MNs and food practices remain unknown. This study examines links with the frequency and location of eating out behaviours as well as the frequency of home food delivery. METHODS: This cross-sectional study used data from 769 adults from the Places and Locations for Activity and Nutrition study (ProjectPLAN) conducted in Melbourne and Adelaide, Australia, between 2018 and 2019. Outcomes were 1) visit frequency to i) cafés, ii) restaurants, bars or bistros, iii) major chain fast food outlets and iv) takeaway outlets to purchase food; 2) total number of different types of out-of-home food outlets visited; 3) use frequency of home food delivery services; 4) distance from home to the most frequented out-of-home food outlets. Exposure was whether participants had a 20MN (areas with high service/amenity provision) or a non-20MN (areas with low service/amenity provision). Ordinal regression models were fitted for the frequency outcomes. Poisson regression models were fitted for the number of different outlet types. Linear and spatial regression models were fitted for the distance outcomes. RESULTS: Results suggested no differences in frequency of visitations to out-of-home food outlets and use of food delivery services between those with a 20MN and those with a non-20MN. Yet, those with a 20MN were more likely to use a greater number of different types of outlets on a weekly basis. Where a regular eating out location was reported, it was nearer to home for those with a 20MN. CONCLUSIONS: This study provides evidence supportive of 20MNs potentially facilitating more localised food practices, however, 20MNs may also encourage greater cumulative frequency of meals out across a variety of out-of-home food providers.

BACKGROUND: Hip osteoarthritis (OA) is a leading cause of musculoskeletal pain. Exercise is a core recommended treatment. Despite some clinical guidelines also recommending weight loss for hip OA, there is no evidence from randomised controlled trials (RCT) to substantiate these recommendations. This superiority, 2-group, parallel RCT will compare a combined diet and exercise program to an exercise only program, over 6 months. METHODS: One hundred people with symptomatic and radiographic hip OA will be recruited from the community. Following baseline assessment, participants will be randomly allocated to either, i) diet and exercise or; ii) exercise only. Participants in the diet and exercise group will have six consultations with a dietitian and five consultations with a physiotherapist via videoconferencing over 6 months. The exercise only group will have five consultations with a physiotherapist via videoconferencing over 6 months. The exercise program for both groups will include prescription of strengthening exercise and a physical activity plan, advice about OA management and additional educational resources. The diet intervention includes prescription of a ketogenic very low-calorie diet with meal replacements and educational resources to support weight loss and healthy eating. Primary outcome is self-reported hip pain via an 11-point numeric rating scale (0 = 'no pain' and 10 = 'worst pain possible') at 6 months. Secondary outcomes include self-reported body weight (at 0, 6 and 12 months) and body mass index (at 0, 6 and 12 months), visceral fat (measured using dual energy x-ray absorptiometry at 0 and 6 months), pain, physical function, quality of life (all measured using subscales of the Hip Osteoarthritis Outcome Scale at 0, 6 and 12 months), and change in pain and physical activity (measured using 7-point global rating of change Likert scale at 6 and 12 months). Additional measures include adherence, adverse events and cost-effectiveness. DISCUSSION: Thi

INTRODUCTION: Exercise is important in the postoperative management of lung cancer, yet no strong evidence exists for delivery of home-based programmes. Our feasibility (phase I) study established feasibility of a home-based exercise and self-management programme (the programme) delivered postoperatively. This efficacy (phase II) study aims to determine whether the programme, compared with usual care, is effective in improving physical function (primary outcome) in patients after lung cancer surgery. METHODS AND ANALYSIS: This will be a prospective, multisite, two-arm parallel 1:1, randomised controlled superiority trial with assessors blinded to group allocation. 112 participants scheduled for surgery for lung cancer will be recruited and randomised to usual care (no exercise programme) or, usual care plus the 12-week programme. The primary outcome is physical function measured with the EORTC QLQ c30 questionnaire. Secondary outcomes include health-related quality of life (HRQoL); exercise capacity; muscle strength; physical activity levels and patient reported outcomes. HRQoL and patient-reported outcomes will be measured to 12 months, and survival to 5 years. In a substudy, patient experience interviews will be conducted in a subgroup of intervention participants. ETHICS AND DISSEMINATION: Ethics approval was gained from all sites. Results will be submitted for publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12617001283369.

BACKGROUND: Recent rapid growth in urban areas and the desire to create liveable neighbourhoods has brought about a renewed interest in planning for compact cities, with concepts like the 20-minute neighbourhood (20MN) becoming more popular. A 20MN broadly reflects a neighbourhood that allows residents to meet their daily (non-work) needs within a short, non-motorised, trip from home. The 20MN concept underpins the key planning strategy of Australia's second largest city, Melbourne, however the 20MN definition has not been operationalised. This study aimed to develop and operationalise a practical definition of the 20MN and apply this to two Australian state capital cities: Melbourne (Victoria) and Adelaide (South Australia). METHODS: Using the metropolitan boundaries for Melbourne and Adelaide, data were sourced for several layers related to five domains: 1) healthy food; 2) recreational resources; 3) community resources; 4) public open space; and 5) public transport. The number of layers and the access measures required for each domain differed. For example, the recreational resources domain only required a sport and fitness centre (gym) within a 1.5-km network path distance, whereas the public open space domain required a public open space within a 400-m distance along a pedestrian network and 8 ha of public open space area within a 1-km radius. Locations that met the access requirements for each of the five domains were defined as 20MNs. RESULTS: In Melbourne 5.5% and in Adelaide 7.6% of the population were considered to reside in a 20MN. Within areas classified as residential, the median number of people per square kilometre with a 20MN in Melbourne was 6429 and the median number of dwellings per square kilometre was 3211. In Adelaide's 20MNs, both population density (3062) and dwelling density (1440) were lower than in Melbourne. CONCLUSIONS: The challenge of operationalising a practical definition of the 20MN has been addressed by this study and applied to tw

BACKGROUND: Obesity is associated with knee osteoarthritis (OA). Weight loss, alongside exercise, is a recommended treatment for individuals with knee OA and overweight/obesity. However, many patients cannot access weight loss specialists such as dietitians. Innovative care models expanding roles of other clinicians may increase access to weight loss support for people with knee OA. Physiotherapists may be well placed to deliver such support. This two-group parallel, superiority randomized controlled trial aims to compare a physiotherapist-delivered diet and exercise program to an exercise program alone, over 6 months. The primary hypothesis is that the physiotherapist-delivered diet plus exercise program will lead to greater weight loss than the exercise program. METHODS: 88 participants with painful knee OA and body mass index (BMI) > 27 kg/m2 will be recruited from the community. Following baseline assessment, participants will be randomised to either exercise alone or diet plus exercise groups. Participants in the exercise group will have 6 consultations (20-30 min) via videoconference with a physiotherapist over 6 months for a strengthening exercise program, physical activity plan and educational/exercise resources. Participants in the diet plus exercise group will have 6 consultations (50-75 min) via videoconference with a physiotherapist prescribing a ketogenic very low-calorie diet with meal replacements and educational resources to support weight loss and healthy eating, plus the intervention of the exercise only group. Outcomes are measured at baseline and 6 months. The primary outcome is percentage change in body weight measured by a blinded assessor. Secondary outcomes include self-reported knee pain, physical function, global change in knee problems, quality of life, physical activity levels, and internalised weight stigma, as well as BMI, waist circumference, waist-to-hip ratio, physical performance measures and quadriceps strength, measured by a blind

BACKGROUND: In people with knee osteoarthritis (OA), ongoing exercise participation, particularly with strengthening exercises, is central to management. Patient adherence to prescribed exercise typically declines once consultations with a clinician have ceased. Mobile applications (apps) can incorporate behaviour change techniques that may assist adherence, potentially optimising clinical outcomes. METHODS: This is a two-arm, pragmatic, superiority randomised trial. One hundred and eighty two Australians with chronic knee pain (clinical knee OA) and who have at least a mild level of physical dysfunction are being recruited. Participants are randomly allocated i) exercise (physiotherapist-prescribed exercise) or; ii) exercise plus app (physiotherapist-prescribed exercise plus access to the 'My Exercise Messages' mobile app). Exercise care comprises two videoconferencing consultations with a physiotherapist over two weeks (30 min each) for a strengthening exercise program, which is then conducted independently at home for 24 weeks without any further physiotherapist consultations. Participants are also provided with exercise resources to facilitate home-based exercise. Those randomised to exercise plus app will download the app after completing the two weeks of physiotherapy consultations and will be instructed by research staff to use the app for the 24 weeks of unsupervised home-based exercises. The app works by tracking completion of weekly exercise sessions, providing regular messages to facilitate weekly exercise and providing personalised messages to help overcome individual barriers to exercise participation. The two primary outcomes are i) self-reported physical function; and ii) number of days strengthening exercises were performed (previous fortnight), with a primary endpoint of 26 weeks and a secondary endpoint of 14 weeks. Secondary outcomes include knee pain severity; knee-related quality of life; global change; exercise program satisfaction; exercise se

OBJECTIVES: To determine if motion control walking shoes are superior to neutral walking shoes in reducing knee pain on walking in people with lateral knee osteoarthritis (OA). DESIGN: Participant-blinded and assessor-blinded, comparative effectiveness, superiority randomised controlled trial. SETTING: Melbourne, Australia. PARTICIPANTS: People with symptomatic radiographic lateral tibiofemoral OA from the community and our volunteer database. INTERVENTION: Participants were randomised to receive either motion control or neutral shoes and advised to wear them >6 hours/day over 6 months. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was change in average knee pain on walking over the previous week (11-point Numeric Rating Scale (NRS), 0-10) at 6 months. The secondary outcomes included other measures of knee pain, physical function, quality of life, participant-perceived change in pain and function, and physical activity. RESULTS: We planned to recruit 110 participants (55 per arm) but ceased recruitment at 40 (n=18 motion control shoes, n=22 neutral shoes) due to COVID-19-related impacts. All 40 participants completed 6-month outcomes. There was no evidence that motion control shoes were superior to neutral shoes for the primary outcome of pain (mean between-group difference 0.4 NRS units, 95% CI -1.0 to 1.7) nor for any secondary outcome. The number of participants experiencing any adverse events was similar between groups (motion control shoes: n=5, 28%; neutral shoes: n=4, 18.2%) and were minor. CONCLUSIONS: Motion control shoes were not superior to neutral shoes in improving knee pain on walking in symptomatic radiographic lateral tibiofemoral joint OA. Further research is needed to identify effective treatments in this important but under-researched knee OA subgroup. TRIAL REGISTRATION NUMBER: ACTRN12618001864213.

BACKGROUND: Yoga is a mind-body exercise typically done in groups in person, but this delivery method can be inconvenient, inaccessible, and costly. Effective online programs may increase access to exercise for knee osteoarthritis. OBJECTIVE: To evaluate the effectiveness of an unsupervised 12-week online yoga program. DESIGN: Two-group superiority randomized trial. (Australian New Zealand Clinical Trials Registry: ACTRN12620000012976). SETTING: Community. PARTICIPANTS: 212 adults with symptomatic knee osteoarthritis. INTERVENTION: Both groups received online osteoarthritis information (control). The yoga group also received access to an unsupervised online yoga program delivered via prerecorded videos over 12 weeks (1 video per week, with each session to be performed 3 times per week), with optional continuation thereafter. MEASUREMENTS: Primary outcomes were changes in knee pain during walking (0 to 10 on a numerical rating scale) and physical function (0 to 68 on the Western Ontario and McMaster Universities Osteoarthritis Index) at 12 weeks (primary time point) and 24 weeks, analyzed using mixed-effects linear regression models. Secondary outcomes were self-reported overall knee pain, stiffness, depression, anxiety, stress, global change, quality of life, self-efficacy, fear of movement, and balance confidence. Adverse events were also collected. RESULTS: A total of 195 (92%) and 189 (89%) participants provided 12- and 24-week primary outcomes, respectively. Compared with control at 12 weeks, yoga improved function (between-group mean difference in change, -4.0 [95% CI, -6.8 to -1.3]) but not knee pain during walking (between-group mean difference in change, -0.6 [CI, -1.2 to 0.1]), with more yoga participants than control participants achieving the minimal clinically important difference (MCID) for both outcomes. At 12 weeks, knee stiffness, quality of life, and arthritis self-efficacy improved more with yoga than the control intervention. Benefits were not mai

BACKGROUND: Problem anger is common after experiencing a traumatic event. Current evidence-driven treatment options are limited, and problem anger negatively affects an individual's capacity to engage with traditional psychological treatments. Smartphone interventions hold significant potential in mental health because of their ability to deliver low-intensity, precision support for individuals at the time and place they need it most. While wearable technology has the capacity to augment smartphone-delivered interventions, there is a dearth of evidence relating to several key areas, including feasibility of compliance in mental health populations; validity of in vivo anger assessment; ability to predict future mood states; and delivery of timely and appropriate interventions. METHODS: This protocol describes a cohort study that leverages 10 days of ambulatory assessment in the form of ecological momentary assessment and a wearable. Approximately 100 adults with problem anger will complete four-hourly in vivo mobile application-delivered micro-surveys on anger intensity, frequency, and verbal and physical aggression, as well as other self-reported mental health and wellbeing measures. Concurrently, a commercial wearable device will continuously record indicators of physiological arousal. The aims are to test the feasibility and acceptability of ambulatory assessment in a trauma-affected population, and determine whether a continuously measured physiological indicator of stress predicts self-reported anger intensity. DISCUSSION: This study will contribute new data around the ability of physiological indicators to predict mood state in individuals with psychopathology. This will have important implications for the design of smartphone-delivered interventions for trauma-affected individuals, as well as for the digital mental health field more broadly.

OBJECTIVE: To compare change in self-efficacy for managing knee osteoarthritis (OA) pain and kinesiophobia after watching an educational video based on an empowerment and participatory discourse with a video based on a disease and impairment discourse. DESIGN: Two-arm randomised controlled trial with participants aged ≥45 years with knee pain (n = 589). Participants completed both baseline and follow-up outcomes and watched one randomly-allocated video (12-minute duration) during one 30-45-minute session within a single online survey. The experimental video presented evidence-based knee OA information using design and language that aimed to empower people and focus on activity participation to manage OA, while the control video presented similar information but with a disease and impairment focus. Primary outcome measures were Arthritis Self-Efficacy Scale pain subscale (range 0-10) and Brief Fear of Movement Scale for OA (range 6-24). Secondary outcomes were expectations about prognosis and physical activity benefits, perceived importance and motivation to be physically active, knee OA knowledge, hopefulness for the future, level of concern and perceived need for surgery. RESULTS: Compared to control (n = 293), the experimental group (n = 296) showed improved self-efficacy for managing OA pain (mean difference 0.4 [95%CI 0.2, 0.6] units) and reduced kinesiophobia (1.6 [1.1, 2.0] units). The experimental group also demonstrated greater improvements in all secondary outcomes apart from hopefulness, which was high in both groups. CONCLUSION: An educational video based on an empowerment and participatory discourse improved pain self-efficacy and reduced kinesiophobia in people with knee OA more than a video based on a disease and impairment discourse. CLINICALTRIALS: gov registration NCT05156216, Universal trial number U1111-1269-6143.

BACKGROUND: Our understanding of meal choices is limited by methodologies that do not account for the complexity of food choice behaviors. Discrete choice experiments (DCEs) rank choices in a decision-making context. OBJECTIVES: This study aimed to rank the relative importance of influences on meal choices in young adults and examine interactions by subgroups. METHODS: Adults (18-30 y) living in Australia were recruited via social media to complete an Internet-based DCE and survey. Participants were presented with 12 choice sets about a typical weekday meal, consisting of 5 attributes (taste, preparation time, nutrition content, cost, and quality). Diet quality (Dietary Guideline Index) was calculated from brief dietary questions. Conditional logit models ranked meal attributes, including interactions by sex, education, area-level disadvantage, diet quality, and weight status. RESULTS: In total, 577 adults (46% female, mean ± SD age 23.8 ± 3.8 y) completed the DCE and survey. Nutrition content was the most important influence on meal choice (B: 1.48; 95% CI: 1.31, 1.64), followed by cost (B: -0.75; 95% CI: -0.87, -0.63), quality (B: 0.58; 95% CI: 0.49, 0.67), taste (B: 0.55; 95% CI: 0.45, 0.65), and preparation time (B: -0.42; 95% CI: -0.52, -0.31). Females, those with higher diet quality, and those with a BMI (in kg/m2) <25 had higher preferences for better nutrition content. Females had higher preferences for better taste and lower preferences for higher-cost meals. Participants with higher education had higher preferences for better nutrition content. Participants living in higher area-level disadvantage areas had higher preferences for longer preparation time. CONCLUSIONS: Nutrition content was the most important influence on young adults' meal choices. Preferences differed by sex, socioeconomic position, diet quality, and weight status. Findings show the suitability of DCEs for understanding food choice behaviors in young adults and support the need for meal-ba

BACKGROUND: A 24-week self-directed digitally delivered intervention was found to improve pain and function in people with knee osteoarthritis (OA). However, it is possible that this intervention may be better suited to certain subgroups of people with knee OA compared to others. OBJECTIVE: The aim of this study was to explore whether certain individual baseline characteristics moderate the effects of a self-directed digitally delivered intervention on changes in pain and function over 24 weeks in people with knee OA. METHODS: An exploratory analysis was conducted on data from a randomized controlled trial involving 206 people with a clinical diagnosis of knee OA. This trial compared a self-directed digitally delivered intervention comprising of web-based education, exercise, and physical activity program supported by automated exercise behavior change mobile phone text messages to web-based education alone (control). The primary outcomes were changes in overall knee pain (assessed on an 11-point numerical rating scale) and physical function (assessed using the Western Ontario and McMaster Universities Osteoarthritis Index function subscale [WOMAC]) at 24 weeks. Five baseline patient characteristics were selected as the potential moderators: (1) number of comorbidities, (2) number of other painful joints, (3) pain self-efficacy, (4) exercise self-efficacy, and (5) self-perceived importance of exercise. Separate linear regression models for each primary outcome and each potential moderator were fit, including treatment group, moderator, and interaction between treatment group and moderator, adjusting for the outcome at baseline. RESULTS: There was evidence that pain self-efficacy moderated the effect of the intervention on physical function compared to the control at 24 weeks (interaction P=.02). Posthoc assessment of the mean change in WOMAC function by treatment arm showed that each 1-unit increase in baseline pain self-efficacy was associated with a 1.52 (95% CI 0

BACKGROUND: Diabetes mellitus represents a substantial global health challenge, with prevalence rising in low- and middle-income countries (LMICs). Although diabetes is known to follow a socioeconomic gradient, patterns in LMICs are unclear. This study examined associations between education and diabetes, and diabetes self-management behaviours, in six LMICs. METHODS: Cross-sectional data for 31,780 participants from China, Ghana, India, Mexico, Russia, and South Africa from the World Health Organization Study on Global AGEing and adult health (SAGE) study were used. Participants aged ≥50 years completed face-to-face interviews between 2007 and 2010. Participants self-reported diabetes diagnosis, physical activity, sedentary time, fruit and vegetable consumption, any special diet/program for diabetes, whether they were taking insulin for diabetes and number of years of education. Height, weight, waist, and hip circumference were measured. Country-specific survey-weighted log-binomial regression models were fitted to examine associations between the number of years of education and self-reported diabetes diagnosis (primary analysis). In secondary analyses, among those with a self-reported diabetes diagnosis, generalised linear regression models were fitted to examine associations between education and i) physical activity, ii) sedentary time, iii) fruit and vegetable consumption, iv) special diet for diabetes, v) taking insulin, vi) BMI, vii) waist circumference and viii) hip circumference. RESULTS: There was strong evidence of an association between years of education and diabetes diagnosis in Ghana (RR = 1.09, 95% CI: 1.06-1.13) and India (RR = 1.09, 95% CI: 1.07-1.12) only. In India, greater years of education was associated with higher leisure physical activity, fruit and vegetable intake, rates following a special diet or taking insulin, but also higher mean BMI, waist and hip circumference. Relationships between education and self-management behaviours were rar

OBJECTIVE: To explore differences in proportion of food budget and total food expenditure by dwelling type. DESIGN: A cross-sectional study using data from the Australian Bureau of Statistics 2015-2016 Household Expenditure Survey. Food expenditure was examined on multiple categories: fresh fruits, fresh vegetables, pre-prepared meals, meals in restaurants, hotels and clubs, and fast food and takeaway meals, using two-part models and zero-one inflated beta regression models. Dwelling types were categorised as separate house, semi-detached house, low-rise apartment and high-rise apartment. SETTING: Australia, 2015-2016. PARTICIPANTS: Seven thousand three hundred and fifty-eight households from greater capital city areas. RESULTS: Households living in high-rise apartments were estimated to allocate a greater proportion of their food budget to meals in restaurants, hotels and clubs, and to spend more (actual dollars) on that category, compared with other dwelling types. No substantial differences were estimated in the proportion of food budget allocated to the other food categories across dwelling types. CONCLUSIONS: The dwelling type households live in may play a role in their food budget. Households living in a high-rise apartment may potentially spend more on meals in restaurants, hotels and clubs than those living in other dwelling types. Given the growth in urban population and the changes in living arrangements, findings point to the critical need for a better understanding of the influence of dwelling types on food expenditure and call for research investigating the relationship between the two.

BACKGROUND/OBJECTIVES: In many high-income countries people living in regional (rural) areas have higher rates of chronic disease compared to people living in urban areas. Food purchasing behaviour provides a potential pathway linking residential location with dietary intake and health outcomes. This study examined the relationship between geographic location and food expenditure on a range of foods. SUBJECTS/METHODS: Data from the 2015-2016 Australian Household Expenditure Survey (number of households = 9827) were used to examine weekly household food expenditure and proportion of total food expenditure on 14 categories of food items. Foods were classified using the Australian Guide to Healthy Eating. Two-part models and zero-one inflated beta regression models were used to assess the association between geographic area and food expenditure. RESULTS: Average proportion of total food expenditure on fruit was estimated to be more for households located in major cities compared to households located in inner and outer regional areas. Households located in inner and outer regional areas allocated less to fresh fruit, fish and meals out compared to households in major cities. Households located in inner regional areas allocated a greater proportion of their food budget to sweet cakes, biscuits, puddings, desserts, chocolate and ice-cream compared to households in major cities and outer regional areas. CONCLUSIONS: The geographic patterns in food purchasing suggest those in regional areas may be at risk of diets less aligned with healthy guidelines. Given the findings of this study suggesting geographic differences in food purchasing, further research is warranted to enhance contextual understanding of food purchasing behaviours in regional areas.

Sedentary and physical activity patterns (bouts/breaks) may be important for cardiometabolic health in early life. This study aimed to examine cross-sectional associations of total daily volume and patterns across the activity spectrum with cardiometabolic risk factors in youth aged 7-13 years. Objectively measured accelerometer and cardiometabolic risk factor data were pooled from two studies (n = 1219; 69% valid accelerometry). Total daily volume of sedentary time and light-, moderate-, and vigorous-intensity physical activity was determined. Time in sustained bouts and median bout lengths of all intensities and breaks in sedentary time were also calculated. Outcomes included body mass index, waist circumference, blood pressure, blood lipids, and a cardiometabolic summary score. Regression models revealed beneficial associations between total daily volumes of moderate- and vigorous-intensity physical activity and cardiometabolic risk. Time spent in ≥1 min vigorous-intensity physical activity bouts was beneficially associated with cardiometabolic risk, yet this disappeared after adjusting for total vigorous-intensity physical activity and confounders. Time accumulated in light- (≥1 min; ≥5 min) and moderate-intensity (≥1 min) physical activity bouts was detrimentally associated with cardiometabolic risk. Total daily volume and activity patterns may have implications for cardiometabolic risk early in life. Sporadic physical activity may be more beneficial for health than sustained physical activity.

BACKGROUND: The food stores within residential environments are increasingly investigated as a possible mechanism driving food behaviours and health outcomes. Whilst increased emphasis is being placed on the type of study designs used and how we measure the outcomes, surprisingly little attention gets diverted to the measures of the food environment beyond calls for standardised approaches for food store coding and geographic scales of exposure. Food environments are a challenging concept to measure and model and the use of ratio and proportion measures are becoming more common in food environment research. Whilst these are seemingly an advance on single store type indicators, such as simply counting the number of supermarkets or fast food restaurants present, they have several limitations that do not appear to have been fully considered. MAIN BODY: In this article we report on five issues related to the use of ratio and proportion food environment measures: 1) binary categorisation of food stores; 2) whether they truly reflect a more or less healthy food environment; 3) issues with these measures not reflecting the quantity of food stores; 4) difficulties when no stores are present; and 5) complications in statistical treatment and interpretation of ratio and proportion measures. Each of these issues are underappreciated in the literature to date and highlight that ratio and proportion measures need to be treated with caution. CONCLUSION: Calls for the broader adoption of relative food environment measures may be misguided. Whilst we should continue to search for better ways to represent the complexity of food environments, ratio and proportion measures are unlikely to be the answer.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

BACKGROUND: The diet of young adults is poor, yet little is known about the relative importance of influences on healthy eating in a decision-making context. The aim of this exploratory study was to understand the relative ranking of influences on meal choices in young adults and to investigate interactions between meal preferences and demographic and health characteristics. METHODS: Adults aged 18-30 years (n = 92, mean age: 23.9 (SD 3.4) years) completed an online discrete choice experiment. Participants were presented with 12 choice sets reflecting a typical weekday meal and were asked to choose between four meal options. Each meal consisted of a combination of five meal attributes (preparation time, cost, taste, familiarity and nutrition content) that each had three attribute levels. Data were analysed using conditional logit models. Subgroup analyses were performed by sex, education, income, weight status and meeting fruit and vegetable recommendations. RESULTS: Comparing the highest and lowest attribute levels, meal preferences were higher for better taste (B = 0.38; 95% CI: 0.12, 0.63), familiarity (B = 0.37; 95% CI: 0.21, 0.54) and nutrition content (B = 1.11; 95% CI: 0.81, 1.41) and lower for increased preparation times (B = -0.33; 95% CI: - 0.53, - 0.12) and cost (B = -0.50; 95% CI: - 0.75, - 0.24). Nutrition content was the most important influence on meal choice. Cost was the second most important, followed by taste, familiarity and preparation time. Compared to males, females had a higher preference for better nutrition content, taste and familiarity and a lower preference for increased cost. Higher educated participants had a higher preference for better nutrition content, familiarity and taste compared to lower educated participants. Young adults who met recommendations for fruit and vegetable intake had a higher preference for better nutrition content compared to participants who did not meet recommendations. CONCLUSION: Nutrition content was the mos

BACKGROUND: Self-selection into residential neighbourhoods is a widely acknowledged, but under-studied problem in research investigating neighbourhood influences on physical activity and diet. Failure to handle neighbourhood self-selection can lead to biased estimates of the association between the neighbourhood environment and behaviour. This means that effects could be over- or under-estimated, both of which have implications for public health policies related to neighbourhood (re)design. Therefore, it is important that methods to deal with neighbourhood self-selection are identified and reviewed. The aim of this review was to assess how neighbourhood self-selection is conceived and accounted for in the literature. METHODS: Articles from a systematic search undertaken in 2017 were included if they examined associations between neighbourhood environment exposures and adult physical activity or dietary behaviour. Exposures could include any objective measurement of the built (e.g., supermarkets), natural (e.g., parks) or social (e.g., crime) environment. Articles had to explicitly state that a given method was used to account for neighbourhood self-selection. The systematic review was registered with the PROSPERO International Prospective Register of Systematic Reviews (number CRD42018083593) and was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: Of 31 eligible articles, almost all considered physical activity (30/31); few examined diet (2/31). Methods used to address neighbourhood self-selection varied. Most studies (23/31) accounted for items relating to participants' neighbourhood preferences or reasons for moving to the neighbourhood using multi-variable adjustment in regression models (20/23) or propensity scores (3/23). Of 11 longitudinal studies, three controlled for neighbourhood self-selection as an unmeasured confounder using fixed effects regression. CONCLUSIONS: Most studie

BACKGROUND AND OBJECTIVE: As caesarean delivery and childhood allergy continue to rise, their inter-relationships may change. We examined whether caesarean delivery predicts allergic disease and impaired lung function in two contemporary harmonised population-based cohorts. METHODS: Parent-reported asthma and eczema data were drawn from two prospective Australian infant cohorts, HealthNuts (n=5276, born 2006-2010) and the Longitudinal Study of Australian Children (LSAC, n=5107, born 2003-2004) at age 6-7 years, and spirometric lung function from LSAC's Child Health CheckPoint (n=1756) at age 11-12 years. Logistic regression estimated associations between delivery mode and current asthma and eczema at 6-7 years, and linear regression examined lung function at 11-12 years. Models were adjusted for potential confounding factors. RESULTS: Complete case analysis included 3135 HealthNuts and 3654 LSAC children (32.2% and 30.9% born by caesarean, respectively). An association was evident between caesarean delivery and asthma at age 6-7 years in HealthNuts (adjusted OR (aOR) 1.25, 95% CI 1.00 to 1.57) but not in LSAC (aOR 1.05, 95% CI 0.86 to 1.28), while neither study showed clear associations with eczema (HealthNuts: aOR 1.09, 95% CI 0.88 to 1.35; LSAC: aOR 0.89, 95% CI 0.69 to 1.15). Spirometric lung function parameters at age 11-12 years were similar by delivery mode. Associations were not modified by duration of breast feeding, maternal history of asthma/eczema, childcare attendance, number of older siblings or pet exposure. CONCLUSIONS: In two unselected populations using harmonised protocols, the likely association of caesarean delivery with developing childhood allergy was small.

INTRODUCTION: This cross-sectional study aimed to i) identify and characterize youth according to distinct physical activity (PA) and sedentary (SED) accumulation patterns, and ii) investigate associations of these derived patterns with cardiometabolic risk factors. METHODS: ActiGraph accelerometer data from 7- to 13-yr-olds from two studies were pooled (n = 1219; 843 (69%) with valid accelerometry included in analysis). Time accumulated in ≥5- and ≥10-min SED bouts, ≥1- and ≥5-min bouts of light, and ≥1-min bouts of moderate and vigorous PA was calculated. Frequency of breaks in SED was also obtained. Latent profile analysis was used to identify groups of participants based on their distinct accumulation patterns. Linear and logistic regression models were used to test associations of group accumulation patterns with cardiometabolic risk factors, including adiposity indicators, blood pressure, and lipids. Total PA and SED time were also compared between groups. RESULTS: Three distinct groups were identified: "prolonged sitters" had the most time in sustained SED bouts and the least time in vigorous PA bouts; "breakers" had the highest frequency of SED breaks and lowest engagement in sustained bouts across most PA intensities; and "prolonged movers" had the least time accumulated in SED bouts and the most in PA bouts across most intensities. Although breakers engaged in less time in PA bouts compared with other groups, they had the healthiest adiposity indicators. No associations with the remaining cardiometabolic risk factors were found. CONCLUSION: Youth accumulate their daily activity in three distinct patterns (prolonged sitters, breakers, and prolonger movers), with those breaking up sitting and least time in prolonged PA bouts across the day having a lower adiposity risk. No relationships with other cardiometabolic risk factors were identified.

Numerous studies have shown associations between public open space and a variety of health outcomes. Yet the extent to which firm conclusions and planning policy recommendations can be drawn from this body of work depends on how public open space availability has been measured and reported. Other researchers have highlighted potential issues with the way that public open space has been measured but have not systematically assessed the extent of this problem. This paper provides a comprehensive critical review of studies of public open space and health conducted in Australia to identify and compare public open space measurement and data treatment. Our analysis showed wide variation in how public open space was measured, as well as a lack of consistency in reporting public open space exposure measures and under‐reporting of measurement methods. We find that such tendencies limit how much these studies can be compared and contrasted with each other. The corollary of that finding is that without more detailed reporting of exposure measures, it will be difficult to establish an evidence base that informs planning for healthy, liveable environments. In response, we develop and present a checklist for reporting public open space exposure to address this challenge.

Researchers investigating relationships between the neighbourhood environment and health first need to decide on the spatial extent of the neighbourhood they are interested in. This decision is an important and ongoing methodological challenge since different methods of defining and delineating neighbourhood boundaries can produce different results. This paper explores this issue in the context of a New Zealand-based study of the relationship between the built environment and multiple measures of physical activity. Geographic information systems were used to measure three built environment attributes-dwelling density, street connectivity, and neighbourhood destination accessibility-using seven different neighbourhood definitions (three administrative unit boundaries, and 500, 800, 1000- and 1500-m road network buffers). The associations between the three built environment measures and five measures of physical activity (mean accelerometer counts per hour, percentage time in moderate-vigorous physical activity, self-reported walking for transport, self-reported walking for recreation and self-reported walking for all purposes) were modelled for each neighbourhood definition. The combination of the choice of neighbourhood definition, built environment measure, and physical activity measure determined whether evidence of an association was detected or not. Results demonstrated that, while there was no single ideal neighbourhood definition, the built environment was most consistently associated with a range of physical activity measures when the 800-m and 1000-m road network buffers were used. For the street connectivity and destination accessibility measures, associations with physical activity were less likely to be detected at smaller scales (less than 800 m). In line with some previous research, this study demonstrated that the choice of neighbourhood definition can influence whether or not an association between the built environment and adults' physical activity i

BACKGROUND: Understanding changes in physical activity and sedentary time (SED) during early childhood may provide insights into how to effectively promote a healthy start to life. This study examined changes in total volume and bouts of SED, light- (LPA), and moderate- to vigorous-intensity physical activity (MVPA) across early childhood, and explored differences in change between boys and girls. METHODS: Data were drawn from 330 children participating in the Melbourne InFANT Program, collected between 2008 and 2013 and analysed in 2017. Children's physical activity and SED were assessed for at least 7 days at each timepoint using ActiGraph GT1M accelerometers at 19 months, 3.5 and 5 years of age. Total volume of SED (≤100 counts per minute [CPM]), LPA (101-1680 CPM) and MVPA (≥1681 CPM) were expressed as a percentage of wear time, and the frequency (number of bouts/day) and duration (mins/bout) of SED, LPA and MVPA bouts ≥1 min were calculated at each time point. Multilevel models with random intercepts and slopes were used to examine changes in total volume and bouts of SED, LPA and MVPA for boys and girls. RESULTS: Compared to aged 19 months, children's total volume of SED and LPA decreased at 3.5 and 5 years old, while MVPA increased. The frequency of SED bouts at 3.5 and 5 years was greater than at 19 months, but the duration was shorter. Additionally, the frequency and duration of LPA bouts was lower and MVPA bout frequency and duration was greater at 3.5 and 5 years. In general, there was no evidence of sex differences in trajectories of children's physical activity and SED. However, variations in trajectory were observed at the individual child level. CONCLUSIONS: Children's total volume and bouts of SED, LPA and MVPA change across early childhood, mostly in a favourable direction. Trajectories appear to be similar for boys and girls. Investigation of individual variation in trajectories is likely to provide greater insight into associations between physica

INTRODUCTION: Total volumes of physical activity and sedentary behaviour have been associated with cardio-metabolic risk profiles; however, little research has examined whether patterns of activity (e.g., prolonged bouts, frequency of breaks in sitting) impact cardio-metabolic risk. The aim of this review was to synthesise the evidence concerning associations between activity patterns and cardio-metabolic risk factors in children and adolescents aged 5-19 years. MATERIALS AND METHODS: A systematic search of seven databases was completed in October 2017. Included studies were required to report associations between objectively-measured activity patterns and cardio-metabolic risk factors in children and/or adolescents, and be published between 1980 and 2017. At least two researchers independently screened each study, extracted data, and undertook risk of bias assessments. RESULTS: From the 15,947 articles identified, 29 were included in this review. Twenty-four studies were observational (cross-sectional and/or longitudinal); five were experimental. Ten studies examined physical activity patterns, whilst 19 studies examined sedentary patterns. Only one study examined both physical activity and sedentary time patterns. Considerable variation in definitions of activity patterns made it impossible to identify which activity patterns were most beneficial to children's and adolescents' cardio-metabolic health. However, potential insights and current research gaps were identified. DISCUSSION AND CONCLUSION: A consensus on how to define activity patterns is needed in order to determine which activity patterns are associated with children's and adolescents' cardio-metabolic risk. This will inform future research on the impact of activity patterns on children's and adolescents' short- and longer-term health.

The contribution of rapid weight gain (RWG) during infancy to later adiposity has received considerable investigation. The present systematic review and meta-analysis aimed to update the literature on association between RWG and subsequent adiposity outcomes. Electronic searches were undertaken in EMBASE, MEDLINE, psycINFO, PubMed and ScienceDirect. Studies that examined the associations between RWG (a change in weight z-scores > 0.67) during infancy (from birth to age 2 years) and subsequent adiposity outcomes were included. Random effects meta-analysis was conducted to obtain the weighted-pooled estimates of the odds of overweight/obesity for those with RWG. Seventeen studies were eligible for inclusion with the majority of studies (15/17) being of high/acceptable quality and reporting positive associations between RWG during infancy and later adiposity outcomes. RWG in infancy was associated with overweight/obesity from childhood to adulthood (pooled odds ratio = 3.66, 95% confidence interval: 2.59-5.17, I2 > 75%). Subgroup analyses revealed that RWG during infancy was associated with higher odds of overweight/obesity in childhood than in adulthood, and RWG from birth to 1 year was associated with higher odds of overweight/obesity than RWG from birth to 2 years. The present study supports that RWG during infancy is a significant predictor of adiposity in later life.

BACKGROUND: This study examined associations between alcohol outlet access and alcohol intake, depressive symptoms score and risk of depression among women residing in disadvantaged neighbourhoods in Victoria, Australia. METHODS: Data on depressive symptoms, alcohol intake and socio-demographic characteristics were obtained from a sample of 995 adult women from Victoria, Australia who were surveyed as part of the Resilience in Eating and Activity Despite Inequality (READI) study. The location of all licensed alcohol outlets in Victoria was obtained from the Victorian Commission for Gambling and Liquor Regulation. Participant and alcohol outlet addresses were geocoded to calculate individual alcohol outlet access, defined as the number of outlets (all and by sub-type) within 0.4 km and 3 km of participants' homes. Separate regression models with clustered standard errors were fitted to examine associations between access and alcohol intake according to national recommended limits for short- and long-term harm, frequency of consumption above long-term harm guidelines, depressive symptoms score and risk of depression. RESULTS: Odds of consumption within short-term harm guidelines (≤4 drinks on any day) decreased with increasing access within 3 km, irrespective of outlet type. Typically, there was no evidence to support associations between access and consumption above long-term harm guidelines (>2 drinks on any day) unless considering frequency of consumption at this level where results showed decreased odds of 'don't drink' versus frequently drinking above long-term harm guidelines (i.e., >2 drinks at least once per week) with increasing access at either distance. Although there was no evidence of an association between any of the alcohol outlet access measures and depressive symptoms score, odds of being at risk of depression decreased with increasing access within 3 km. CONCLUSIONS: This study found some evidence to support an association between increasing alcohol

OBJECTIVES: The residential neighbourhood fast-food environment has the potential to lead to increased levels of obesity by providing opportunities for residents to consume energy-dense products. This longitudinal study aimed to examine whether change in body mass index (BMI) differed dependent on major chain fast-food outlet availability among women residing in disadvantaged neighbourhoods. SETTING: Eighty disadvantaged neighbourhoods in Victoria, Australia. PARTICIPANTS: Sample of 882 women aged 18-46 years at baseline (wave I: 2007/2008) who remained at the same residential location at all three waves (wave II: 2010/2011; wave III: 2012/2013) of the Resilience for Eating and Activity Despite Inequality study. PRIMARY OUTCOME: BMI based on self-reported height and weight at each wave. RESULTS: There was no evidence of an interaction between time and the number of major chain fast-food outlets within 2 (p=0.88), 3 (p=0.66) or 5 km (p=0.24) in the multilevel models of BMI. Furthermore, there was no evidence of an interaction between time and change in availability at any distance and BMI. CONCLUSIONS: Change in BMI was not found to differ by residential major chain fast-food outlet availability among Victorian women residing in disadvantaged neighbourhoods. It may be that exposure to fast-food outlets around other locations regularly visited influence change in BMI. Future research needs to consider what environments are the key sources for accessing and consuming fast food and how these relate to BMI and obesity risk.

OBJECTIVES: To investigate associations between maternal body mass index (BMI) at delivery (using pregnancy-specific BMI cut-off values 5 kg/m2 higher in each of the WHO groups) and clinical, theatre utilisation and health economic outcomes for women undergoing caesarean section (CS). DESIGN: A prospective multicentre observational study. SETTING: Seven secondary or tertiary referral obstetric hospitals. PARTICIPANTS: One thousand and four hundred and fifty-seven women undergoing all categories of CS. DATA COLLECTION: Height and weight were recorded at the initial antenatal visit and at delivery. We analysed the associations between delivery BMI (continuous and pregnancy-specific cut-off values) and total theatre time, surgical time, anaesthesia time, maternal and neonatal adverse outcomes, total hospital admission and theatre costs. RESULTS: Mean participant characteristics were: age 32 years, gestation at delivery 38.4 weeks and delivery BMI 32.2 kg/m2. Fifty-five per cent of participants were overweight, obese or super-obese using delivery pregnancy-specific BMI cut-off values. As BMI increased, total theatre time, surgical time and anaesthesia time increased. Super-obese participants had approximately 27% (17 min, p<0.001) longer total theatre time, 20% (9 min, p<0.001), longer surgical time and 40% (11 min, p<0.001) longer anaesthesia time when compared with normal BMI participants. Increased BMI at delivery was associated with increased risk of maternal intensive care unit admission (relative risk 1.07, p=0.045), but no increased risk of neonatal admission to higher acuity care. Total hospital admission costs were 15% higher in super-obese women compared with normal BMI women and theatre costs were 27% higher in super-obese women. CONCLUSIONS: Increased maternal BMI was associated with increased total theatre time, surgical and anaesthesia time, increased total hospital admission costs and theatre costs. Clinicians and health administrators should consider the

BACKGROUND: Studies exploring associations between food environments and food purchasing behaviours have been limited by the absence of data on where food purchases occur. Determining where food purchases occur relative to home and how these locations differ by individual, neighbourhood and trip characteristics is an important step to better understanding the association between food environments and food behaviours. METHODS: Conducted in Melbourne, Australia, this study recruited participants within sixteen neighbourhoods that were selected based on their socioeconomic characteristics and proximity to supermarkets. The survey material contained a short questionnaire on individual and household characteristics and a food purchasing diary. Participants were asked to record details related to all food purchases made over a 2-week period including food store address. Fifty-six participants recorded a total of 952 food purchases of which 893 were considered valid for analysis. Households and food purchase locations were geocoded and the network distance between these calculated. Linear mixed models were used to determine associations between individual, neighbourhood, and trip characteristics and distance to each food purchase location from home. Additional analysis was conducted limiting the outcome to: (a) purchase made when home was the prior origin (n. 484); and (b) purchases made within supermarkets (n. 317). RESULTS: Food purchases occurred a median distance of 3.6 km (IQR 1.8, 7.2) from participants' homes. This distance was similar when home was reported as the origin (median 3.4 km; IQR 1.6, 6.4) whilst it was shorter for purchases made within supermarkets (median 2.8 km; IQR 1.6, 5.6). For all purchases, the reported food purchase location was further from home amongst the youngest age group (compared to the oldest age group), when workplace was the origin of the food purchase trip (compared to home), and on weekends (compared to weekdays). Differences were al

OBJECTIVES: To investigate associations between maternal body mass index (BMI) at delivery (using pregnancy-specific BMI cut-off values 5 kg/m2 higher in each of the WHO groups) and clinical, theatre utilisation and health economic outcomes for women undergoing caesarean section (CS). DESIGN: A prospective multicentre observational study. SETTING: Seven secondary or tertiary referral obstetric hospitals. PARTICIPANTS: One thousand and four hundred and fifty-seven women undergoing all categories of CS. DATA COLLECTION: Height and weight were recorded at the initial antenatal visit and at delivery. We analysed the associations between delivery BMI (continuous and pregnancy-specific cut-off values) and total theatre time, surgical time, anaesthesia time, maternal and neonatal adverse outcomes, total hospital admission and theatre costs. RESULTS: Mean participant characteristics were: age 32 years, gestation at delivery 38.4 weeks and delivery BMI 32.2 kg/m2. Fifty-five per cent of participants were overweight, obese or super-obese using delivery pregnancy-specific BMI cut-off values. As BMI increased, total theatre time, surgical time and anaesthesia time increased. Super-obese participants had approximately 27% (17 min, p<0.001) longer total theatre time, 20% (9 min, p<0.001), longer surgical time and 40% (11 min, p<0.001) longer anaesthesia time when compared with normal BMI participants. Increased BMI at delivery was associated with increased risk of maternal intensive care unit admission (relative risk 1.07, p=0.045), but no increased risk of neonatal admission to higher acuity care. Total hospital admission costs were 15% higher in super-obese women compared with normal BMI women and theatre costs were 27% higher in super-obese women. CONCLUSIONS: Increased maternal BMI was associated with increased total theatre time, surgical and anaesthesia time, increased total hospital admission costs and theatre costs. Clinicians and health administrators should consider the

OBJECTIVES: To investigate associations between maternal body mass index (BMI) at delivery (using pregnancy-specific BMI cut-off values 5 kg/m2 higher in each of the WHO groups) and clinical, theatre utilisation and health economic outcomes for women undergoing caesarean section (CS). DESIGN: A prospective multicentre observational study. SETTING: Seven secondary or tertiary referral obstetric hospitals. PARTICIPANTS: One thousand and four hundred and fifty-seven women undergoing all categories of CS. DATA COLLECTION: Height and weight were recorded at the initial antenatal visit and at delivery. We analysed the associations between delivery BMI (continuous and pregnancy-specific cut-off values) and total theatre time, surgical time, anaesthesia time, maternal and neonatal adverse outcomes, total hospital admission and theatre costs. RESULTS: Mean participant characteristics were: age 32 years, gestation at delivery 38.4 weeks and delivery BMI 32.2 kg/m2. Fifty-five per cent of participants were overweight, obese or super-obese using delivery pregnancy-specific BMI cut-off values. As BMI increased, total theatre time, surgical time and anaesthesia time increased. Super-obese participants had approximately 27% (17 min, p<0.001) longer total theatre time, 20% (9 min, p<0.001), longer surgical time and 40% (11 min, p<0.001) longer anaesthesia time when compared with normal BMI participants. Increased BMI at delivery was associated with increased risk of maternal intensive care unit admission (relative risk 1.07, p=0.045), but no increased risk of neonatal admission to higher acuity care. Total hospital admission costs were 15% higher in super-obese women compared with normal BMI women and theatre costs were 27% higher in super-obese women. CONCLUSIONS: Increased maternal BMI was associated with increased total theatre time, surgical and anaesthesia time, increased total hospital admission costs and theatre costs. Clinicians and health administrators should consider the

BACKGROUND: The aim of this country-wide study was to link individual health and behavioural data with area-level spatial data to examine whether the body mass index (BMI) of adults was associated with access to recreational physical activity (PA) facilities by different modes of transport (bus, car, walking, cycling) and the extent to which any associations were mediated by PA participation. METHODS: Data on individual objectively-measured BMI, PA (number of days of (a) ≥20 min of moderate-to-vigorous PA, and (b) ≥15 min of sport or exercise, in previous 4 weeks), and socio-demographic characteristics were obtained from a nationally representative sample of 6365 adults. The number of accessible PA facilities per 1,000 individuals in each small area (data zones) was obtained by mapping a representative list of all fixed PA facilities throughout mainland Scotland. A novel transport network was developed for the whole country, and routes on foot, by bike, by car and by bus from the weighted population centroid of each data zone to each facility were calculated. Separate multilevel models were fitted to examine associations between BMI and each of the 24 measures of accessibility of PA facilities and BMI, adjusting for age, gender, longstanding illness, car availability, social class, dietary quality and urban/rural classification. RESULTS: We found associations (p < 0.05) between BMI and 7 of the 24 accessibility measures, with mean BMI decreasing with increasing accessibility of facilities-for example, an estimated decrease of 0.015 BMI units per additional facility within a 20-min walk (p = 0.02). None of these accessibility measures were found to be associated with PA participation. CONCLUSIONS: Our national study has shown that some measures of the accessibility of PA facilities by different modes of transport (particularly by walking and cycling) were associated with BMI; but PA participation, as measured here, did not appear to play a part in this relationship.

Background: A randomized controlled trial in Fiji examined the immunogenicity and effect on nasopharyngeal carriage after 0, 1, 2, or 3 doses of 7-valent pneumococcal conjugate vaccine (PCV7; Prevnar) in infancy followed by 23-valent pneumococcal polysaccharide vaccine (23vPPV; Pneumovax) at 12 months of age. At 18 months of age, children given 23vPPV exhibited immune hyporesponsiveness to a micro-23vPPV (20%) challenge dose in terms of serotype-specific IgG and opsonophagocytosis, while 23vPPV had no effect on vaccine-type carriage. Objective: This follow-up study examined the long-term effect of the 12-month 23vPPV dose by evaluating the immune response to 13-valent pneumococcal conjugate vaccine (PCV13) administration 4 to 5 years later. Methods: Blood samples from 194 children (now 5-7 years old) were taken before and 28 days after PCV13 booster immunization. Nasopharyngeal swabs were taken before PCV13 immunization. We measured levels of serotype-specific IgG to all 13 vaccine serotypes, opsonophagocytosis for 8 vaccine serotypes, and memory B-cell responses for 18 serotypes before and after PCV13 immunization. Results: Paired samples were obtained from 185 children. There were no significant differences in the serotype-specific IgG, opsonophagocytosis, or memory B-cell response at either time point between children who did or did not receive 23vPPV at 12 months of age. Nasopharyngeal carriage of PCV7 and 23vPPV serotypes was similar among the groups. Priming with 1, 2, or 3 PCV7 doses during infancy did not affect serotype-specific immunity or carriage. Conclusion: Immune hyporesponsiveness induced by 23vPPV in toddlers does not appear to be sustained among preschool children in this context and does not affect the pneumococcal carriage rate in this age group.

BACKGROUND: Low fruit and vegetable consumption is a risk factor for poor health. Studies have shown consumption varies across neighbourhoods, with lower intakes in disadvantaged neighbourhoods. However, findings are inconsistent, suggesting that socio-spatial inequities in diet could be context-specific, highlighting a need for international comparisons across contexts. This study examined variations in fruit and vegetable consumption among adults from neighbourhoods of varying socioeconomic status (SES) across seven countries (Australia, Canada, Netherlands, New Zealand, Portugal, Scotland, US). METHODS: Data from seven existing studies, identified through literature searches and knowledge of co-authors, which collected measures of both neighbourhood-level SES and fruit and vegetable consumption were used. Logistic regression was used to examine associations between neighbourhood-level SES and binary fruit and vegetable consumption separately, adjusting for neighbourhood clustering and age, gender and education. As much as possible, variables were treated in a consistent manner in the analysis for each study to allow the identification of patterns of association within study and to examine differences in the associations across studies. RESULTS: Adjusted analyses showed evidence of an association between neighbourhood-level SES and fruit consumption in Canada, New Zealand and Scotland, with increased odds of greater fruit intake in higher SES neighbourhoods. In Australia, Canada, New Zealand and Portugal, those residing in higher SES neighbourhoods had increased odds of greater vegetable intake. The other studies showed no evidence of a difference by neighbourhood-level SES. CONCLUSIONS: Acknowledging discrepancies across studies in terms of sampling, measures, and definitions of neighbourhoods, this opportunistic study, which treated data in a consistent manner, suggests that associations between diet and neighbourhood-level socioeconomic status vary across count

BACKGROUND: Inequalities in eating behaviours are often linked to the types of food retailers accessible in neighbourhood environments. Numerous studies have aimed to identify if access to healthy and unhealthy food retailers is socioeconomically patterned across neighbourhoods, and thus a potential risk factor for dietary inequalities. Existing reviews have examined differences between methodologies, particularly focussing on neighbourhood and food outlet access measure definitions. However, no review has informatively discussed the suitability of the statistical methodologies employed; a key issue determining the validity of study findings. Our aim was to examine the suitability of statistical approaches adopted in these analyses. METHODS: Searches were conducted for articles published from 2000-2014. Eligible studies included objective measures of the neighbourhood food environment and neighbourhood-level socio-economic status, with a statistical analysis of the association between food outlet access and socio-economic status. RESULTS: Fifty-four papers were included. Outlet accessibility was typically defined as the distance to the nearest outlet from the neighbourhood centroid, or as the number of food outlets within a neighbourhood (or buffer). To assess if these measures were linked to neighbourhood disadvantage, common statistical methods included ANOVA, correlation, and Poisson or negative binomial regression. Although all studies involved spatial data, few considered spatial analysis techniques or spatial autocorrelation. CONCLUSIONS: With advances in GIS software, sophisticated measures of neighbourhood outlet accessibility can be considered. However, approaches to statistical analysis often appear less sophisticated. Care should be taken to consider assumptions underlying the analysis and the possibility of spatially correlated residuals which could affect the results.

BACKGROUND: In the analysis of the effect of built environment features on health, it is common for researchers to categorise built environment exposure variables based on arbitrary percentile cut-points, such as median or tertile splits. This arbitrary categorisation leads to a loss of information and a lack of comparability between studies since the choice of cut-point is based on the sample distribution. DISCUSSION: In this paper, we highlight the various drawbacks of adopting percentile categorisation of exposure variables. Using data from the SocioEconomic Status and Activity in Women (SESAW) study from Melbourne, Australia, we highlight alternative approaches which may be used instead of percentile categorisation in order to assess built environment effects on health. We discuss these approaches using an example which examines the association between the number of accessible supermarkets and body mass index. We show that alternative approaches to percentile categorisation, such as transformations of the exposure variable or factorial polynomials, can be implemented easily using standard statistical software packages. These procedures utilise all of the available information available in the data, avoiding a loss of power as experienced when categorisation is adopted.We argue that researchers should retain all available information by using the continuous exposure, adopting transformations where necessary.