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Background: The increasing prevalence of type 2 diabetes poses a major public health challenge. Population-based screening and early treatment for type 2 diabetes could reduce this growing burden. However, the benefits of such a strategy remain uncertain.Methods and Design: The ADDITION-Cambridge study aims to evaluate the effectiveness and cost-effectiveness of (i) a stepwise screening strategy for type 2 diabetes; and (ii) intensive multifactorial treatment for people with screen-detected diabetes in primary care. 63 practices in the East Anglia region participated. Three undertook the pilot study, 33 were allocated to three groups: no screening (control), screening followed by intensive treatment (IT) and screening plus routine care (RC) in an unbalanced (1:3:3) randomisation. The remaining 27 practices were randomly allocated to IT and RC. A risk score incorporating routine practice data was used to identify people aged 40-69 years at high-risk of undiagnosed diabetes. In the screening practices, high-risk individuals were invited to take part in a stepwise screening programme. In the IT group, diabetes treatment is optimised through guidelines, target-led multifactorial treatment, audit, feedback, and academic detailing for practice teams, alongside provision of educational materials for newly diagnosed participants. Primary endpoints are modelled cardiovascular risk at one year, and cardiovascular mortality and morbidity at five years after diagnosis of diabetes. Secondary endpoints include all-cause mortality, development of renal and visual impairment, peripheral neuropathy, health service costs, self-reported quality of life, functional status and health utility. Impact of the screening programme at the population level is also assessed through measures of mortality, cardiovascular morbidity, health status and health service use among high-risk individuals.Discussion: ADDITION-Cambridge is conducted in a defined high-risk group accessible through primary care. It addresses the feasibility of population-based screening for diabetes, as well as the benefits and costs of screening and intensive multifactorial treatment early in the disease trajectory. The intensive treatment algorithm is based on evidence from studies including individuals with clinically diagnosed diabetes and the education materials are informed by psychological theory. ADDITION-Cambridge will provide timely evidence concerning the benefits of early intensive treatment and will inform policy decisions concerning screening for type 2 diabetes.Trial Registration: Current Controlled trials ISRCTN86769081. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although some interventions have been shown to improve adherence to medication for diabetes, results are not consistent. We have developed a theory-based intervention which we will evaluate in a well characterised population to test efficacy and guide future intervention development and trial design. METHODS AND DESIGN: The SAMS (Supported Adherence to Medication Study) trial is a primary care based multi-centre randomised controlled trial among 200 patients with type 2 diabetes and an HbA1c of 7.5% or above. It is designed to evaluate the efficacy of a two-component motivational intervention based on the Theory of Planned Behaviour and volitional action planning to support medication adherence compared with standard care. The intervention is delivered by practice nurses. Nurses were trained using a workshop approach with role play and supervised using assessment of tape-recorded consultations. The trial has a two parallel groups design with an unbalanced three-to-two individual randomisation eight weeks after recruitment with twelve week follow-up. The primary outcome is medication adherence measured using an electronic medication monitor over 12 weeks and expressed as the difference between intervention and control in mean percentage of days on which the correct number of medication doses is taken. Subgroup analyses will explore impact of number of medications taken, age, HbA1c, and self-reported adherence at baseline on outcomes. The study also measures the effect of dispensing medication to trial participants packaged in the electronic medication-monitoring device compared with conventional medication packaging. This will be achieved through one-to-one randomisation at recruitment to these conditions with assessment of the difference between groups in self-report of medication adherence and change in mean HbA1c from baseline to eight weeks. Anonymised demographic data are collected on non-respondents. Central randomisation is carried out independently of trial co-ordination and practices using minimisation to adjust for selected confounders. DISCUSSION: The SAMS intervention and trial design address weaknesses of previous research by recruitment from a well-characterised population, definition of a feasible theory based intervention to support medication taking and careful measurement to estimate and interpret efficacy. The results will inform practice and the design of a cost-effectiveness trial [ISRCTN30522359]. [ABSTRACT FROM AUTHOR]

Background: The SPEEDY study was set up to quantify levels of physical activity (PA) and dietary habits and the association with potential correlates in 9-10 year old British school children. We present here the analyses of the PA, dietary and anthropometry data.Methods: In a cross-sectional study of 2064 children (926 boys, 1138 girls) in Norfolk, England, we collected anthropometry data at school using standardised procedures. Body mass index (BMI) was used to define obesity status. PA was assessed with the Actigraph accelerometer over 7 days. A cut-off of > or = 2000 activity counts was used to define minutes of moderate-to-vigorous PA (MVPA). Dietary habits were assessed using the Health Behaviour in School Children food questionnaire. Weight status was defined using published international cut-offs (Cole, 2000). Differences between groups were assessed using independent t-tests for continuous data and chi-squared tests for categorical data.Results: Valid PA data (>500 minutes per day on > or = 3 days) was available for 1888 children. Mean (+/- SD) activity counts per minute among boys and girls were 716.5 +/- 220.2 and 635.6 +/- 210.6, respectively (p < 0.001). Boys spent an average of 84.1 +/- 25.9 minutes in MVPA per day compared to 66.1 +/- 20.8 among girls (p < 0.001), with an average of 69.1% of children accumulating 60 minutes each day. The proportion of children classified as overweight and obese was 15.0% and 4.1% for boys and 19.3% and 6.6% for girls, respectively (p = 0.001). Daily consumption of at least one portion of fruit and of vegetables was 56.8% and 49.9% respectively, with higher daily consumption in girls than boys and in children from higher socioeconomic backgrounds.Conclusion: Results indicate that almost 70% of children meet national PA guidelines, indicating that a prevention of decline, rather than increasing physical activity levels, might be an appropriate intervention target. Promotion of daily fruit and vegetable intake in this age group is also warranted, possibly focussing on children from lower socioeconomic backgrounds. [ABSTRACT FROM AUTHOR]

Background: The longitudinal associations between physical behaviours and lean muscle mass indices need to be better understood to aid healthy ageing intervention development., Methods: We assessed physical behaviours (total physical activity, moderate-to-vigorous physical activity (MVPA), light physical activity, total sedentary time and prolonged sedentary bout time) for 7 days using hip-worn accelerometers. We also assessed domain-specific physical behaviours (walking, cycling, gardening and housework time) with self-report questionnaires at baseline (2006-2011) and follow-up (2012-2016) in the European Prospective Investigation into Cancer (EPIC)-Norfolk study. We assessed body composition using dual-energy X-ray absorptiometry (DEXA) at follow-up in 1535 participants (≥ 60 years at baseline). From this, we derived appendicular lean muscle mass (ALM) indices (% relative ALM = (ALM/total body weight)*100), body mass index (BMI)-scaled ALM (ALM/BMI, kg/kg/m 2 ) and height-scaled ALM (ALM/height 2 , kg/m 2 )). We evaluated the prospective associations of both baseline and change in physical behaviours with follow-up muscle mass indices using multivariable linear regression., Results: Over 5.5 years (SD 14.8) follow-up, higher baseline accelerometer-measured physical activity and lower sedentary time were associated with higher subsequent relative ALM and BMI-scaled ALM, but not height-scaled ALM (e.g. 0.02% higher subsequent relative ALM per minute/day of baseline MVPA for men). Greater increases in physical activity and greater declines in sedentary time variables were associated with higher subsequent relative ALM and BMI-scaled ALM, but not height-scaled ALM (e.g. 0.001 kg/kg/m 2 subsequent BMI-scaled ALM and 0.04% subsequent relative ALM per min/day/year increases in LPA over follow-up; 0.001 kg/kg/m 2 subsequent BMI-scaled ALM and -0.03% subsequent relative ALM per min/day/year less of total sedentary time over follow-up). Greater increases in women's cycling and gardening over follow-up were associated with greater subsequent relative ALM (cycling 0.9% per hour/week/year; gardening 0.2% per hour/week/year) and BMI-scaled ALM (cycling 0.03 kg/kg/m 2 per hour/week/year; gardening 0.004 kg/kg/m 2 per hour/week/year)., Conclusion: Physical behaviours across all intensities, and in women more specifically cycling and gardening, may help prevent age-related declines in muscle mass., (© 2024. The Author(s).)

Background: Population-based cancer screening programmes are shifting away from age and/or sex-based screening criteria towards a risk-stratified approach. Any such changes must be acceptable to the public and communicated effectively. We aimed to explore the social and ethical considerations of implementing risk stratification at three different stages of the bowel cancer screening programme and to understand public requirements for communication., Methods: We conducted two pairs of community juries, addressing risk stratification for screening eligibility or thresholds for referral to colonoscopy and screening interval. Using screening test results (where applicable), and lifestyle and genetic risk scores were suggested as potential stratification strategies. After being informed about the topic through a series of presentations and discussions including screening principles, ethical considerations and how risk stratification could be incorporated, participants deliberated over the research questions. They then reported their final verdicts on the acceptability of risk-stratified screening and what information should be shared about their preferred screening strategy. Transcripts were analysed using codebook thematic analysis., Results: Risk stratification of bowel cancer screening was acceptable to the informed public. Using data within the current system (age, sex and screening results) was considered an obvious next step and collecting additional data for lifestyle and/or genetic risk assessment was also preferable to age-based screening. Participants acknowledged benefits to individuals and health services, as well as articulating concerns for people with low cancer risk, potential public misconceptions and additional complexity for the system. The need for clear and effective communication about changes to the screening programme and individual risk feedback was highlighted, including making a distinction between information that should be shared with everyone by default and additional details that are available elsewhere., Conclusions: From the perspective of public acceptability, risk stratification using current data could be implemented immediately, ahead of more complex strategies. Collecting additional data for lifestyle and/or genetic risk assessment was also considered acceptable but the practicalities of collecting such data and how the programme would be communicated require careful consideration., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Heterogeneous studies have demonstrated ethnic inequalities in the risk of SARS-CoV-2 infection and adverse COVID-19 outcomes. This study evaluates the association between ethnicity and COVID-19 outcomes in two large population-based cohorts from England and Canada and investigates potential explanatory factors for ethnic patterning of severe outcomes., Methods: We identified adults aged 18 to 99 years in the QResearch primary care (England) and Ontario (Canada) healthcare administrative population-based datasets (start of follow-up: 24th and 25th Jan 2020 in England and Canada, respectively; end of follow-up: 31st Oct and 30th Sept 2020, respectively). We harmonised the definitions and the design of two cohorts to investigate associations between ethnicity and COVID-19-related death, hospitalisation, and intensive care (ICU) admission, adjusted for confounders, and combined the estimates obtained from survival analyses. We calculated the 'percentage of excess risk mediated' by these risk factors in the QResearch cohort., Results: There were 9.83 million adults in the QResearch cohort (11,597 deaths; 21,917 hospitalisations; 2932 ICU admissions) and 10.27 million adults in the Ontario cohort (951 deaths; 5132 hospitalisations; 1191 ICU admissions). Compared to the general population, pooled random-effects estimates showed that South Asian ethnicity was associated with an increased risk of COVID-19 death (hazard ratio: 1.63, 95% CI: 1.09-2.44), hospitalisation (1.53; 1.32-1.76), and ICU admission (1.67; 1.23-2.28). Associations with ethnic groups were consistent across levels of deprivation. In QResearch, sociodemographic, lifestyle, and clinical factors accounted for 42.9% (South Asian) and 39.4% (Black) of the excess risk of COVID-19 death., Conclusion: International population-level analyses demonstrate clear ethnic inequalities in COVID-19 risks. Policymakers should be cognisant of the increased risks in some ethnic populations and design equitable health policy as the pandemic continues., (© 2023. The Author(s).)

Background: Low attendance and engagement in behavioural weight management trials are common. Mental health may play an important role, however previous research exploring this association is limited with inconsistent findings. We aimed to investigate whether mental health was associated with attendance and engagement in a trial of behavioural weight management programmes., Methods: This is a secondary data analysis of the Weight loss referrals for adults in primary care (WRAP) trial, which randomised 1267 adults with overweight or obesity to brief intervention, WW (formerly Weight Watchers) for 12-weeks, or WW for 52-weeks. We used regression analyses to assess the association of baseline mental health (depression and anxiety (by Hospital Anxiety and Depression Scale), quality of life (by EQ5D), satisfaction with life (by Satisfaction with Life Questionnaire)) with programme attendance and engagement in WW groups, and trial attendance in all randomised groups., Results: Every one unit of baseline depression score was associated with a 1% relative reduction in rate of WW session attendance in the first 12 weeks (Incidence rate ratio [IRR] 0.99; 95% CI 0.98, 0.999). Higher baseline anxiety was associated with 4% lower odds to report high engagement with WW digital tools (Odds ratio [OR] 0.96; 95% CI 0.94, 0.99). Every one unit of global quality of life was associated with 69% lower odds of reporting high engagement with the WW mobile app (OR 0.31; 95% CI 0.15, 0.64). Greater symptoms of depression and anxiety and lower satisfaction with life at baseline were consistently associated with lower odds of attending study visits at 3-, 12-, 24-, and 60-months., Conclusions: Participants were less likely to attend programme sessions, engage with resources, and attend study assessments when reporting poorer baseline mental health. Differences in attendance and engagement were small, however changes may still have a meaningful effect on programme effectiveness and trial completion. Future research should investigate strategies to maximise attendance and engagement in those reporting poorer mental health., Trial Registration: The original trial ( ISRCTN82857232 ) and five year follow up ( ISRCTN64986150 ) were prospectively registered with Current Controlled Trials on 15/10/2012 and 01/02/2018., (© 2021. The Author(s).)

Background: Approximately 40% of cancers could be prevented if people lived healthier lifestyles. We have developed a theory-based brief intervention to share personalised cancer risk information and promote behaviour change within primary care. This study aimed to assess the feasibility and acceptability of incorporating this intervention into primary care consultations., Method: Patients eligible for an NHS Health Check or annual chronic disease review at five general practices were invited to participate in a non-randomised pilot study. In addition to the NHS Health Check or chronic disease review, those receiving the intervention were provided with their estimated risk of developing the most common preventable cancers alongside tailored behaviour change advice. Patients completed online questionnaires at baseline, immediately post-consultation and at 3-month follow-up. Consultations were audio/video recorded. Patients (n = 12) and healthcare professionals (HCPs) (n = 7) participated in post-intervention qualitative interviews that were analysed using thematic analysis., Results: 62 patients took part. Thirty-four attended for an NHS Health Check plus the intervention; 7 for a standard NHS Health Check; 16 for a chronic disease review plus the intervention; and 5 for a standard chronic disease review. The mean time for delivery of the intervention was 9.6 min (SD 3) within NHS Health Checks and 9 min (SD 4) within chronic disease reviews. Fidelity of delivery of the intervention was high. Data from the questionnaires demonstrates potential improvements in health-related behaviours following the intervention. Patients receiving the intervention found the cancer risk information and lifestyle advice understandable, useful and motivating. HCPs felt that the intervention fitted well within NHS Health Checks and facilitated conversations around behaviour change. Integrating the intervention within chronic disease reviews was more challenging., Conclusions: Incorporating a risk-based intervention to promote behaviour change for cancer prevention into primary care consultations is feasible and acceptable to both patients and HCPs. A randomised trial is now needed to assess the effect on health behaviours. When designing that trial, and other prevention activities within primary care, it is necessary to consider challenges around patient recruitment, the HCP contact time needed for delivery of interventions, and how best to integrate discussions about disease risk within routine care.

Background: Kidney cancer is often asymptomatic, leading to proposals for a screening programme. The views of the public towards introducing a new screening programme for kidney cancer are unknown. The aim of this study was to explore attitudes towards kidney cancer screening and factors influencing intention to attend a future screening programme., Methods: We conducted an online population-based survey of 1021 adults aged 45-77 years. The main outcome measure was intention to attend four possible screening tests (urine, blood, ultrasound scan, low-dose CT) as well as extended low-dose CT scans within lung cancer screening programmes. We used multivariable regression to examine the association between intention and each screening test., Results: Most participants stated that they would be 'very likely' or 'likely' to undergo each of the screening tests [urine test: n = 961 (94.1%); blood test: n = 922 (90.3%); ultrasound: n = 914 (89.5%); low-dose CT: n = 804 (78.8%); lung CT: n = 962 (95.2%)]. Greater intention to attend was associated with higher general cancer worry and less perceived burden/inconvenience about the screening tests. Less worry about the screening test was also associated with higher intention to attend, but only in those with low general cancer worry (cancer worry scale ≤ 5). Compared with intention to take up screening with a urine test, participants were half as likely to report that they intended to undergo blood [OR 0.56 (0.43-0.73)] or ultrasound [OR 0.50 (0.38-0.67)] testing, and half as likely again to report that they intended to take part in a screening programme featuring a low dose CT scan for kidney cancer screening alone [OR 0.19 (0.14-0.27)]., Conclusion: Participants in this study expressed high levels of intention to accept an invitation to screening for kidney cancer, both within a kidney cancer specific screening programme and in conjunction with lung cancer screening. The choice of screening test is likely to influence uptake. Together these findings support on-going research into kidney cancer screening tests and the potential for combining kidney cancer screening with existing or new screening programmes.

Background: Systematic reviews are vital to the pursuit of evidence-based medicine within healthcare. Screening titles and abstracts (T&Ab) for inclusion in a systematic review is an intensive, and often collaborative, step. The use of appropriate tools is therefore important. In this study, we identified and evaluated the usability of software tools that support T&Ab screening for systematic reviews within healthcare research., Methods: We identified software tools using three search methods: a web-based search; a search of the online "systematic review toolbox"; and screening of references in existing literature. We included tools that were accessible and available for testing at the time of the study (December 2018), do not require specific computing infrastructure and provide basic screening functionality for systematic reviews. Key properties of each software tool were identified using a feature analysis adapted for this purpose. This analysis included a weighting developed by a group of medical researchers, therefore prioritising the most relevant features. The highest scoring tools from the feature analysis were then included in a user survey, in which we further investigated the suitability of the tools for supporting T&Ab screening amongst systematic reviewers working in medical research., Results: Fifteen tools met our inclusion criteria. They vary significantly in relation to cost, scope and intended user community. Six of the identified tools (Abstrackr, Colandr, Covidence, DRAGON, EPPI-Reviewer and Rayyan) scored higher than 75% in the feature analysis and were included in the user survey. Of these, Covidence and Rayyan were the most popular with the survey respondents. Their usability scored highly across a range of metrics, with all surveyed researchers (n = 6) stating that they would be likely (or very likely) to use these tools in the future., Conclusions: Based on this study, we would recommend Covidence and Rayyan to systematic reviewers looking for suitable and easy to use tools to support T&Ab screening within healthcare research. These two tools consistently demonstrated good alignment with user requirements. We acknowledge, however, the role of some of the other tools we considered in providing more specialist features that may be of great importance to many researchers.

Background: Large changes in health behaviors achieved through intensive lifestyle intervention programs improve cardiovascular disease (CVD) risk factors among adults with type 2 diabetes. However, such interventions are not widely available, and there is limited evidence as to whether changes in behaviors affect risk of CVD events., Methods: Among 852 adults with screen-detected type 2 diabetes in the ADDITION-Cambridge study, we assessed changes in diet, physical activity, and alcohol use in the year following diabetes diagnosis. Participants were recruited from 49 general practices in Eastern England from 2002 to 2006, and were followed through 2014 for incidence of CVD events (n = 116) and all-cause mortality (n = 127). We used Cox proportional hazards regression to estimate hazard ratios (HR) for the associations of changes in behaviors with CVD and all-cause mortality. We estimated associations with CVD risk factors using linear regression. We considered changes in individual behaviors and overall number of healthy changes. Models adjusted for demographic factors, bodyweight, smoking, baseline value of the health behavior, and cardio-protective medication use., Results: Decreasing alcohol intake by ≥ 2 units/week was associated with lower hazard of CVD vs maintenance [HR: 0.56, 95% CI 0.36, 0.87]. Decreasing daily calorie intake by ≥ 300 kcal was associated with lower hazard of all-cause mortality vs maintenance [HR: 0.56, 95% CI 0.34, 0.92]. Achieving ≥ 2 healthy behavior changes was associated with lower hazard of CVD vs no healthy changes [HR: 0.39, 95% CI 0.18, 0.82]., Conclusions: In the year following diabetes diagnosis, small reductions in alcohol use were associated with lower hazard of CVD and small reductions in calorie intake were associated with lower hazard of all-cause mortality in a population-based sample. Where insufficient resources exist for specialist-led interventions, achievement of moderate behavior change targets is possible outside of treatment programs and may reduce long-term risk of CVD complications. Trial registration This trial is registered as ISRCTN86769081. Retrospectively registered 15 December 2006.

Background and Aims: The risk of hepatic steatosis may be reduced through changes to dietary intakes, but evidence is sparse, especially for dietary patterns including the Mediterranean diet. We investigated the association between adherence to the Mediterranean diet and prevalence of hepatic steatosis., Methods: Cross-sectional analysis of data from two population-based adult cohorts: the Fenland Study (England, n = 9645, 2005-2015) and CoLaus Study (Switzerland, n = 3957, 2009-2013). Habitual diet was assessed using cohort-specific food frequency questionnaires. Mediterranean diet scores (MDSs) were calculated in three ways based on adherence to the Mediterranean dietary pyramid, dietary cut-points derived from a published review, and cohort-specific tertiles of dietary consumption. Hepatic steatosis was assessed by abdominal ultrasound and fatty liver index (FLI) in Fenland and by FLI and non-alcoholic fatty liver disease (NAFLD) score in CoLaus. FLI includes body mass index (BMI), waist circumference, gamma-glutamyl transferase, and triglyceride; NAFLD includes diabetes, fasting insulin level, fasting aspartate-aminotransferase (AST), and AST/alanine transaminase ratio. Associations were assessed using Poisson regression., Results: In Fenland, the prevalence of hepatic steatosis was 23.9% and 27.1% based on ultrasound and FLI, respectively, and in CoLaus, 25.3% and 25.7% based on FLI and NAFLD score, respectively. In Fenland, higher adherence to pyramid-based MDS was associated with lower prevalence of hepatic steatosis assessed by ultrasound (prevalence ratio (95% confidence interval), 0.86 (0.81, 0.90) per one standard deviation of MDS). This association was attenuated [0.95 (0.90, 1.00)] after adjustment for body mass index (BMI). Associations of similar magnitude were found for hepatic steatosis assessed by FLI in Fenland [0.82 (0.78, 0.86)] and in CoLaus [0.85 (0.80, 0.91)], and these were also attenuated after adjustment for BMI. Findings were similar when the other two MDS definitions were used., Conclusions: Greater adherence to the Mediterranean diet was associated with lower prevalence of hepatic steatosis, largely explained by adiposity. These findings suggest that an intervention promoting a Mediterranean diet may reduce the risk of hepatic steatosis.

Background: Sedentary time increases and total physical activity decreases with age. The magnitude and correlates of changes in sedentary time, light-intensity physical activity (LPA), moderate-to-vigorous intensity physical activity (MVPA), and overall physical activity remain unclear. We quantified these changes and identified their individual and sociodemographic correlates., Methods: We used data from 1259 adults (67.8 ± 6.9 years; 41.9% women) who participated in the EPIC-Norfolk Study. Activity was assessed at baseline (2004-2011) and follow-up (2012-2016) for 7 days using accelerometers. Potential correlates of change were specified a priori. We used unadjusted and adjusted sex-stratified linear regressions to identify correlates of change., Results: Only 3.7% of adults met the current MVPA recommendations. Sedentary time increased by 3.0 min/day/year (SD = 12.3). LPA, MVPA, and overall PA decreased by 1.7 min/day/year (SD = 5.4), 3.0 min/day/year (SD = 6.0), and 8.8 cpm/year (SD = 18.8), respectively. Correlates of greater rates of increase in sedentary time included older age and higher BMI in men, and older age, higher BMI, smoking, and urban dwelling in women. Correlates of greater rates of decrease in physical activity included older age, higher BMI, living alone, depression, car use, and/or fair/poor self-rated health in men, and older age, higher BMI, depression, smoking, and/or urban dwelling in women (e.g. depressed women had a 1.0 min/day/year greater rate of decline in MVPA than non-depressed women, 95% CI -1.8, - 0.2)., Conclusions: Most (> 95%) adults are insufficiently active. Sedentary time increases and LPA, MVPA and overall physical activity decreases over time, with more pronounced rates of change observed in specific sub-groups (e.g. among older and depressed adults). To promote active living, the correlates of these changes should be considered in future interventions.

Background: Cancer is a leading cause of mortality and morbidity worldwide. Prevention is recognised by many, including the World Health Organization, to offer the most cost-effective long-term strategy for the control of cancer. One approach that focuses on individuals is the provision of personalised risk information. However, whether such information motivates behaviour change and whether the effect is different with varying formats of risk presentation is unclear. We aim to assess the short-term effect of providing information about personalised risk of cancer in three different formats alongside lifestyle advice on health-related behaviours, risk perception and risk conviction., Methods: In a parallel group, randomised controlled trial 1000 participants will be recruited through the online platform Prolific. Participants will be allocated to either a control group receiving cancer-specific lifestyle advice alone or one of three intervention groups receiving the same lifestyle advice alongside their estimated 10-year risk of developing one of the five most common preventable cancers, calculated from self-reported modifiable behavioural risk factors, in one of three different formats (bar chart, pictograph or qualitative scale). The primary outcome is change from baseline in computed risk relative to an individual with a recommended lifestyle at three months. Secondary outcomes include: perceived risk of cancer; anxiety; cancer-related worry; intention to change behaviour; and awareness of cancer risk factors., Discussion: This study will provide evidence on the short-term effect of providing online information about personalised risk of cancer alongside lifestyle advice on risk perception and health-related behaviours and inform the development of interventions., Trial Registration: ISRCTN17450583. Registered 30 January 2018.

Background: Physical activity (PA) and fruit and vegetable intake (FVI) are two key modifiable risk factors for cardiovascular disease (CVD). Achieving change in these behaviours is challenging and affected by many variables including psychosocial factors. We aimed to investigate the association between social support, stress and mood, and change in PA and FVI following provision of CVD risk information and web-based lifestyle advice., Methods: Seven hundred sixteen blood donors (56% male; mean age 57 years) from the intervention arms of the Information and Risk Modification (INFORM) trial, a randomised controlled trial to assess the impact of providing CVD risk and web-based lifestyle information, were analysed as a prospective cohort. We used linear and logistic regression analyses to quantify the association between social support, stress and mood at baseline and behaviour change following the intervention. We modelled objective (average acceleration measured by Axivity AX3 wrist-worn accelerometers and plasma carotenoid levels) and subjective (self-reported recreational PA and FVI) outcomes as change between baseline and 12 weeks follow-up., Results: There was no clear association between social support and change in objective or subjective PA. Higher levels of stress and, to a lesser extent, depression symptoms were associated with smaller improvement in self-reported PA (β -1.53 h/week vigorous PA, 95% confidence interval (CI) -2.30 to -0.75, p < 0.001 for stress; β -1.64 h/week, 95% CI -3.50 to 0.21, p = 0.082 for little interest). Higher social support was associated with greater odds and higher stress was associated with lower odds of increasing self-reported FVI to five portions per day (odds ratio (OR) 1.33, 95% CI 1.05 to 1.69, p = 0.020 for social support; OR 0.57, 95% CI 0.43 to 0.76, p < 0.001 for stress). The associations between psychosocial factors and objective FVI were not statistically significant., Conclusions: High stress and low mood may reduce the likelihood and extent of reported change in PA and FVI following CVD risk information and advice. Greater social support may be associated with increased FVI. The role of psychosocial factors should be considered when developing, tailoring and evaluating future interventions., Trial Registration: Current Controlled Trials ISRCTN17721237 . Registered 12 January 2015.

Neighbourhood environments have important implications for human health. In this piece, we reflect on the environments and health literature and argue that precise use of language is critical for acknowledging the complex and multifaceted influence that neighbourhood environments may have on physical activity and physical activity-related outcomes. Specifically, we argue that the term "neighbourhood walkability", commonly used in the neighbourhoods and health literature, constrains recognition of the breadth of influence that neighbourhood environments might have on a variety of physical activity behaviours. The term draws attention to a single type of physical activity and implies that a universal association exists when in fact the literature is quite mixed. To maintain neutrality in this area of research, we suggest that researchers adopt the term "neighbourhood physical activity environments" for collective measures of neighbourhood attributes that they wish to study in relation to physical activity behaviours or physical activity-related health outcomes.

Background: Promoting positive changes in lifestyle behavior in the whole population may be a feasible and effective approach to reducing type 2 diabetes burden, but the impact of population shifts of modifiable risk factors remains unclear. Currently most of the evidence on modifiable lifestyle behavior and type 2 diabetes risk on a population level comes from studies of between-individual differences. The objective of the study was to investigate the association and potential impact on disease burden for within-individual change in lifestyle behavior and diabetes risk., Methods: Population-based prospective cohort study of 35,680 participants aged 30-50 at baseline in 1990-2003 in Västerbotten County, Sweden (follow-up until 2013). Five self-reported modifiable lifestyle behaviors (tobacco use, physical activity, alcohol intake, dietary fiber intake and dietary fat intake) were measured at baseline and 10 year follow-up. Lifestyle behaviors were studied separately, and combined in a score. Incident diabetes was detected by oral glucose tolerance tests. Multivariate logistic regression models and population attributable fractions (PAF) were used to analyze the association between change in lifestyle behavior between baseline and 10 year follow-up, and risk of incident diabetes., Results: Incident diabetes was detected in 1,184 (3.3%) participants at 10 year follow-up. There was a reduced diabetes risk associated with increase in dietary fiber intake, odds ratio (OR) 0.79 (95% confidence interval (CI) 0.66, 0.96) for increase of at least one unit standard deviation (3.0 g/1,000 kcal) of the baseline distribution, PAF 16.0% (95% CI 4.2, 26.4%). Increase in the lifestyle behavior score was associated with reduced diabetes risk, OR 0.92 (95% CI 0.85, 0.99) per unit increase of the score., Conclusions: These results support a causal link between lifestyle behavior and type 2 diabetes incidence. A small shift in lifestyle behaviors, in particular intake of dietary fiber, has the potential to reduce diabetes burden in the population and might be a suitable target for public health intervention.

Background: Weight loss in individuals at high risk of diabetes is an effective prevention method and a major component of the currently prevailing diabetes prevention strategies. The aim of the present study was to investigate the public health potential for diabetes prevention of weight maintenance or moderate weight loss on a population level in an observational cohort with repeated measurements of weight and diabetes status., Methods: Height, weight and diabetes status were objectively measured at baseline and 10 year follow-up in a population-based cohort of 33,184 participants aged 30-60 years between 1990 and 2013 in Västerbotten County, Sweden. The association between risk of incident diabetes and change in BMI or relative weight was modelled using multivariate logistic regression. Population attributable fractions (PAF) were used to assess population impact of shift in weight., Results: Mean (SD) BMI at baseline was 25.0 (3.6) kg/m 2 . Increase in relative weight between baseline and follow-up was linearly associated with incident diabetes risk, odds ratio (OR) 1.05 (95% confidence interval (CI) 1.04-1.06) per 1% change in weight. Compared to weight maintenance (±1.0 kg/m 2 ), weight gain of > +1.0 kg/m 2 was associated with an increased risk of incident diabetes, OR 1.52 (95% CI 1.32, 1.74), representing a PAF of 21.9% (95% CI 15.8, 27.6%). For moderate weight loss (-1.0 to -2.0 kg/m 2 ) the OR was 0.72 (95% CI 0.52, 0.99)., Conclusions: Weight maintenance in adulthood is strongly associated with reduced incident diabetes risk and there is considerable potential for diabetes prevention in promoting this as a whole population strategy.

Background: Prolonged sitting, an independent risk factor for disease development and premature mortality, is increasing in prevalence in high- and middle-income countries, with no signs of abating. Adults in such countries spend the largest proportion of their day in sedentary behaviour, most of which is accumulated at work. One promising method for reducing workplace sitting is the use of sit-stand desks. However, key uncertainties remain about this intervention, related to the quality of existing studies and a lack of focus on key outcomes, including energy expenditure. We are planning a randomised controlled trial to assess the impact of sit-stand desks at work on energy expenditure and sitting time in the short and longer term. To reduce the uncertainties related to the design of this trial, we propose a preliminary study to assess the feasibility and acceptability of the recruitment, allocation, measurement, retention and intervention procedures., Methods: Five hundred office-based employees from two companies in Cambridge, UK, will complete a survey to assess their interest in participating in a trial on the use of sit-stand desks at work. The workspaces of 100 of those interested in participating will be assessed for sit-stand desk installation suitability, and 20 participants will be randomised to either the use of sit-stand desks at work for 3 months or a waiting list control group. Energy expenditure and sitting time, measured via Actiheart and activPAL monitors, respectively, as well as cardio-metabolic and anthropometric outcomes and other outcomes relating to health and work performance, will be assessed in 10 randomly selected participants. All participants will also be interviewed about their experience of using the desks and participating in the study., Discussion: The findings are expected to inform the design of a trial assessing the impact of sit-stand desks at work on short and longer term workplace sitting, taking into account their impact on energy expenditure and the extent to which their use has compensation effects outside the workplace. The findings from such a trial are expected to inform discussions regarding the potential of sit-stand desks at work to alleviate the harm to cardio-metabolic health arising from prolonged sitting., Trial Registration: ISRCTN44827407.

Background: Colorectal cancer (CRC) is the fourth leading cause of cancer-related death in Europe and the United States. Detecting the disease at an early stage improves outcomes. Risk prediction models which combine multiple risk factors and symptoms have the potential to improve timely diagnosis. The aim of this review is to systematically identify and compare the performance of models that predict the risk of primary CRC among symptomatic individuals., Methods: We searched Medline and EMBASE to identify primary research studies reporting, validating or assessing the impact of models. For inclusion, models needed to assess a combination of risk factors that included symptoms, present data on model performance, and be applicable to the general population. Screening of studies for inclusion and data extraction were completed independently by at least two researchers., Results: Twelve thousand eight hundred eight papers were identified from the literature search and three through citation searching. 18 papers describing 15 risk models were included. Nine were developed in primary care populations and six in secondary care. Four had good discrimination (AUROC > 0.8) in external validation studies, and sensitivity and specificity ranged from 0.25 and 0.99 to 0.99 and 0.46 depending on the cut-off chosen., Conclusions: Models with good discrimination have been developed in both primary and secondary care populations. Most contain variables that are easily obtainable in a single consultation, but further research is needed to assess clinical utility before they are incorporated into practice.

Background: Objectively measured physical activity between older individuals and between populations has been poorly described. We aimed to describe and compare the variation in accelerometry data in older UK (EPIC-Norfolk) and American (NHANES) adults., Methods: Physical activity was measured by uniaxial accelerometry in 4,052 UK (49-91 years) and 3459 US older adults (49-85 years). We summarized physical activity as volume (average counts/minute), its underlying intensity distribution, and as time spent <100counts/minute, ≥809counts/minute and ≥2020counts/minute both for total activity and that undertaken in ≥10-min bouts., Results: In EPIC-Norfolk 65% of wear-time was spent at <100 counts/minute and 20% spent in the range 100-500 counts/minute. Only 4.1% of this cohort accumulated more than 30 min/day of activity above 2020 counts/minute in 10-min bouts. If a cut-point of >809 counts/minute is used 18.7% of people reached the 30 min/day threshold. By comparison, 2.5% and 9.5% of American older adults accumulated activity at these levels, respectively., Conclusion: As assessed by objectively measured physical activity, the majority of older adults in this UK study did not meet current activity guidelines. Older adults in the UK were more active overall, but also spent more time being sedentary than US adults.

Background: Young children are thought to be inactive in childcare, but little is known about location-specific activity levels. This observational study sought to describe the in-care and out-of-care activity patterns of preschool-aged children and explore differences in physical activity level by childcare attendance., Methods: Three to four-year-old children were recruited from 30 preschool and nursery 'settings' in Cambridgeshire, UK. Average minutes per hour (min/h) spent sedentary (SED), in light physical activity (LPA) and in moderate-to-vigorous PA (MVPA) were measured by accelerometry for up to 7 days (mean: 6.7 ± 1.1). Weekly childcare attendance patterns were reported by parents. The within-child association between childcare attendance and outcomes was assessed using two- and three-level hierarchical regression; sex by care (in/out) interactions were considered., Results: Two hundred and two children (51% female) had valid activity data for ≥2 days. Children, and particularly boys, were less sedentary and more active when in care compared to at home (SED: Boys: β (SE): -6.4 (0.5) min/h, Girls: -4.8 (0.5); LPA: Boys: 0.6 (0.4), Girls: 1.8 (0.4); MVPA: Boys: 5.7 (0.5); Girls: 3.0 (0.4)). Differences between in-care and at-home activity were largest in the (early) mornings and early evenings for boys; no compensation in at-home activity occurred later in the day. On days when children were in care part-time (1-5 h) or full-time (>5 h), they were significantly less sedentary and more active compared with non-care days., Conclusions: Young children, and particularly boys, accumulate more MVPA in care compared to at home. Future research should identify factors accounting for this difference and consider targeting non-care time in intervention efforts to increase higher-intensity activity and decrease sedentary time in preschoolers.

Background: Web-based interventions for physical activity offer several advantages over face-to-face, print-and telephone-based interventions and are scalable and potentially cost-effective. Recent reviews of web-based interventions in adults show that they have positive but small effects on physical activity but identify a number of limitations including a reliance on self-report measures of outcome. This trial used an objective measure of physical activity to assess the effectiveness of three minimal contact interventions: 1) A multi-component web-based intervention incorporating objective monitoring and graphical feedback of physical activity; 2) A version of the first intervention that consisted only of objective monitoring plus web-based graphical feedback; and 3) Self-monitoring of physical activity using a paper diary., Methods/design: Get Moving is an individually randomised controlled trial with allocation of 488 participants to one of three interventions or to a no-intervention control group. Participants are physically inactive working adults aged 18-65 years. They attended a baseline assessment session at which anthropometric, biological and questionnaire measures were taken and they completed a treadmill exercise test. They then wore a combined movement and heart rate monitor for six days and nights before being randomised to one of the four trial arms. The baseline measures were repeated at the follow-up assessment which took place approximately 12 weeks post-randomisation, conducted by staff blind to group allocation. Participants wore the movement and heart rate monitor for six days and nights before this. The co-primary outcomes are: physical activity energy expenditure measured using individually calibrated combined heart-rate and movement data; and cardiorespiratory fitness measured using a sub-maximal treadmill exercise test., Discussion: Strengths of the trial include the use of an objective measure of physical activity, a measure of cardiorespiratory fitness, relatively large sample size and the use of robust methods of randomisation, allocation concealment and blinding to outcome assessment. Get Moving will contribute to the evidence base on minimal contact interventions for increasing physical activity. The interventions could be implemented in other settings such as primary care., Trial Registration: ISRCTN31844443. Registered 18 June 2010.

Background: Interventions to promote physical activity have had limited success. One reason may be that inactive adults are unaware that their level of physical activity is inadequate and do not perceive a need to change their behaviour. We aimed to assess awareness of physical activity, defined as the agreement between self-rated and objective physical activity, and to investigate associations with sociodemographic, biological, behavioural, and psychological factors., Methods: We conducted an exploratory, cross-sectional analysis of awareness of physical activity using baseline data collected from 453 participants of the Feedback, Awareness and Behaviour study (Cambridgeshire, UK). Self-rated physical activity was measured dichotomously by asking participants if they believed they were achieving the recommended level of physical activity. Responses were compared to objective physical activity, measured using a combined accelerometer and heart rate monitor (Actiheart®). Four awareness groups were created: overestimators, realistic inactives, underestimators, and realistic actives. Logistic regression was used to assess associations between awareness group and potential correlates., Results: The mean (standard deviation) age of participants was 47.0 (6.9) years, 44.4% were male, and 65.1% were overweight (body mass index ≥ 25). Of the 258 (57.0%) who were objectively classified as inactive, 130 (50.4%) misperceived their physical activity by incorrectly stating that they were meeting the guidelines (overestimators). In a multivariable logistic regression model adjusted for age and sex, those with a lower body mass index (Odds Ratio (OR) = 0.95, 95% Confidence Interval (CI) = 0.90 to 1.00), higher physical activity energy expenditure (OR = 1.03, 95% CI = 1.00 to 1.06) and self-reported physical activity (OR = 1.13, 95% CI = 1.07 to 1.19), and lower intention to increase physical activity (OR = 0.69, 95% CI = 0.48 to 0.99) and response efficacy (OR = 0.53, 95% CI = 0.31 to 0.91) were more likely to overestimate their physical activity., Conclusions: Overestimators have more favourable health characteristics than those who are realistic about their inactivity, and their psychological characteristics suggest that they are less likely to change their behaviour. Personalised feedback about physical activity may be an important first step to behaviour change.

Background: There is a well-established association between type 2 diabetes and non-alcoholic fatty liver disease (NAFLD) secondary to excess accumulation of intrahepatic lipid (IHL), but the mechanistic basis for this association is unclear. Emerging evidence suggests that in addition to being associated with insulin resistance, NAFLD may be associated with relative beta-cell dysfunction. We sought to determine the influence of liver fat on hepatic insulin extraction and indices of beta-cell function in a cohort of apparently healthy older white adults., Methods: We performed a cross-sectional analysis of 70 healthy participants in the Hertfordshire Physical Activity Trial (39 males, age 71.3 ± 2.4 years) who underwent oral glucose tolerance testing with glucose, insulin and C-Peptide levels measured every 30 minutes over two hours. The areas under the concentration curve for glucose, insulin and C-Peptide were used to quantify hepatic insulin extraction (HIE), the insulinogenic index (IGI), the C-Peptide increment (CGI), the Disposition Index (DI) and Adaptation Index (AI). Visceral fat was quantified with magnetic resonance (MR) imaging and IHL with MR spectroscopy. Insulin sensitivity was measured with the Oral Glucose Insulin Sensitivity (OGIS) model., Results: 29 of 70 participants (41%) exceeded our arbitrary threshold for NAFLD, i.e. IHL >5.5%. Compared to those with normal IHL, those with NAFLD had higher weight, BMI, waist and MR visceral fat, with lower insulin sensitivity and hepatic insulin extraction. Alcohol consumption, age, HbA1c and alanine aminotransferase (ALT) levels were similar in both groups. Insulin and C-Peptide excursions after oral glucose loading were higher in the NAFLD group, but the CGI and AI were significantly lower, indicating a relative defect in beta-cell function that is only apparent when C-Peptide is measured and when dynamic changes in glucose levels and also insulin sensitivity are taken into account. There was no difference in IGI or DI between the groups., Conclusions: Although increased IHL was associated with greater insulin secretion, modelled parameters suggested relative beta-cell dysfunction with NAFLD in apparently healthy older adults, which may be obscured by reduced hepatic insulin extraction. Further studies quantifying pancreatic fat content directly and its influence on beta cell function are warranted., Trial Registration: ISRCTN60986572.

Background: The global prevalence of type 2 diabetes is increasing. Effective strategies to address this public health challenge are currently lacking. A number of epidemiological studies have reported associations between low concentrations of 25-hydroxy vitamin D and the incidence of diabetes, but a causal link has not been established. We investigate the effect of vitamin D supplementation on the metabolic status of individuals at increased risk of developing type 2 diabetes., Methods/design: In a randomised double-blind placebo-controlled trial individuals identified as having a high risk of type 2 diabetes (non-diabetic hyperglycaemia or positive diabetes risk score) are randomised into one of three groups and given 4 doses of either placebo, or 100,000 IU Vitamin D₂ (ergocalciferol) or 100,000 IU Vitamin D₃ (cholecalciferol) at monthly intervals. The primary outcome measure is the change in glycated haemoglobin level between baseline and 4 months. Secondary outcome measures include blood pressure, lipid levels, apolipoproteins, highly sensitive C-reactive protein, parathyroid hormone (PTH) and safety of supplementation. and C-reactive protein. The trial is being conducted at two sites (London and Cambridge, U.K.) and a total of 342 participants are being recruited., Discussion: Trial data examining whether supplementation of vitamin D improves glycaemic status and other metabolic parameters in people at risk of developing type 2 diabetes are sparse. This trial will evaluate the causal role of vitamin D in hyperglycaemia and risk of type 2 diabetes. Specific features of this trial include recruitment of participants from different ethnic groups, investigation of the relative effectiveness and safety of vitamin D₂ and D₃ and an evidence based approach to determination of the dose of supplementation., Trial Registration: EudraCT2009-011264-11; ISRCTN86515510.

Background: There is limited evidence about predictors of health behaviour change in people with type 2 diabetes. The aim of this study was to assess change in health behaviours over one year and to identify predictors of behaviour change among adults with screen-detected and recently clinically diagnosed diabetes., Methods: ADDITION-Plus was a randomised controlled trial of a behaviour change intervention among 478 patients (40-69 years). Physical activity and diet were measured objectively (physical activity at 1 year) and by self-report at baseline and one year. Associations between baseline predictors and behaviour change were quantified using multivariable linear regression., Results: Participants increased their plasma vitamin C and fruit intake, reduced energy and fat intake from baseline to follow-up. Younger age, male sex, a smaller waist circumference, and a lower systolic blood pressure at baseline were associated with higher levels of objectively measured physical activity at one year. Greater increases in plasma vitamin C were observed in women (beta-coefficient [95% CI]: beta = -5.52 [-9.81, -1.22]) and in those with screen-detected diabetes (beta = 6.09 [1.74, 10.43]). Younger age predicted a greater reduction in fat (beta = -0.43 [-0.72, -0.13]) and energy intake (beta = -6.62 [-13.2, -0.05]). Patients with screen-detected diabetes (beta = 74.2 [27.92, 120.41]) reported a greater increase in fruit intake. There were no significant predictors of change in self-reported physical activity. Beliefs about behaviour change and diabetes did not predict behaviour change., Conclusions: Older patients, men and those with a longer duration of diabetes may need more intensive support for dietary change. We recommend that future studies use objective measurement of health behaviours and that researchers add predictors beyond the individual level. Our results support a focus on establishing healthy lifestyle changes early in the diabetes disease trajectory.

Background: Factors associated with parental awareness of children's physical activity (PA) levels have not been explored in preschool-aged children. This paper investigates maternal awareness of preschool-aged children's PA levels and determined correlates associated with maternal overestimation of PA., Methods: Data from the Southampton Women's Survey, a UK population-based study, were collected March 2006 through June 2009. Daily minutes of moderate-to-vigorous PA (MVPA) were derived using accelerometry in 478 4-year-old children. Mothers who were realistic or overestimated their child's PA were identified. Log-binomial regression was used to analyse correlates of maternal overestimation of PA levels in children whose mothers perceived them to be active (n = 438)., Results: 40.8% of children were classified as inactive: 89.7% of these were perceived to be active by their mothers (over-estimators). These mothers were more likely to think their child sometimes lacked skills required to be physically active (RR (95% CI) = 1.29(1.03-1.63)) and their child was more likely to attend nursery full-time (RR = 1.53(1.14-2.04)). They were less likely to have older children at home (RR = 0.71(0.56-0.90))., Conclusions: Almost 90% of mothers of inactive preschool-aged children perceive their child to be active. Nursery-school attendance and having older siblings at home may be important to consider when designing behavioural interventions to increase PA in preschool children.

Background: Physical activity is important for children's health, but successful physical activity promotion is challenging. Whether performing many different types of activities (Variety) is associated with higher physical activity independent of the number of activity sessions (Frequency) is unknown, but this information could inform physical activity promotion and public health strategies in children., Methods: In the SPEEDY study we measured moderate-to-vigorous intensity physical activity (MVPA; ≥2000 counts/minute) over 7 days using GT1M Actigraph accelerometers in 1700 children from Norfolk, UK (56% girls, Mean ± SD 10.3 ± 0.3 years-old). Children reported participation in 28 leisure-time activities over the previous 7 days. Sex differences in activity participation were assessed using multilevel logistic regression, clustered by school. Associations of log-transformed MVPA with z-score-Variety (number of different activities/week) and z-score-Frequency (sum of all activity sessions/week) were examined using multilevel linear regression, adjusted for age, sex, parental education and age-standardised BMI., Results: Children's activity participation often reflected gender stereotypes. Mean ± SD Variety was 10.8 ± 5.0 activities/week, and Frequency was 24.2±15.0 sessions/week. In separate models lnMVPA had similar strength, positive associations with z-score-Variety and z-score-Frequency (Exp β(95% CI); Variety 1.04(1.02-1.06), Frequency 1.04(1.02-1.06)). lnMVPA was not associated with z-score-Variety independent of z-score-Frequency (Variety 1.01(0.98-1.04), Frequency 1.03(1.00-1.06))., Conclusions: Future physical activity interventions and public health strategies could allow for gender specific activity preferences and could target both Variety and Frequency of activities participated in by children.

Background: Physical activity (PA) levels in type 2 diabetes mellitus (T2DM) patients are generally low. Poor PA perception may impede healthy behaviour change in this high risk group. We describe (i) objective PA levels, (ii) the difference between objective and self-reported PA ('PA disparity') and the correlates of (iii) PA disparity and (iv) overestimation in recently diagnosed T2DM patients., Methods: Cross-sectional analysis of 425 recently diagnosed T2DM patients aged 42 to 71, participating in the ADDITION-Plus study in Eastern England, UK. We define 'PA disparity' as the non-negative value of the difference (in mathematical terms the absolute difference) between objective and self-reported physical activity energy expenditure (PAEE in kJ · kg-1 · day-1). 'Overestimators' comprised those whose self-reported- exceeded objective-PAEE by 4.91 kJ · kg-1 · day-1(the equivalent of 30 minutes moderate activity per day). Multivariable linear regression examined the association between PA disparity (continuous) and socio-demographic, clinical, health behaviour, quality of life and psychological characteristics. Logistic regression examined the association between PA overestimation and individual characteristics., Results: Mean objective and self-reported PAEE levels ± SD were 34.4 ± 17.0 and 22.6 ± 19.4 kJ · kg-1·day-1, respectively (difference in means =11.8; 95% CI=9.7 to 13.9 kJ · kg-1 · day-1). Higher PA disparity was associated with male sex, younger age, lower socio-economic status and lower BMI. PA overestimators comprised 19% (n=80), with those in routine/manual occupations more likely to be overestimators than those in managerial/professional occupations., Conclusions: T2DM patients with poor physical activity perception are more likely to be male, younger, from a lower socio-economic class and to have a lower BMI. PA overestimators were more likely to be in lower socio-economic categories. Self-monitoring and targeted feedback, particularly to those in lower socio-economic categories, may improve PA perceptions and optimise interventions in T2DM patients. Our findings suggest that strategies for enabling realistic assessment of physical activity levels, through self-monitoring or feedback, warrant further investigation and may help refine and improve physical activity interventions.

Background: Active commuting is prospectively associated with physical activity in children. Few longitudinal studies have assessed predictors of change in commuting mode., Purpose: To investigate the individual, socio-cultural and environmental predictors of uptake and maintenance of active commuting in 10-year-old children., Methods: Children were recruited in 2007 and followed-up 12 months later. Children self-reported usual travel mode to school. 31 child, parent, socio-cultural and physical environment characteristics were assessed via self-reported and objective methods. Associations with uptake and maintenance of active travel were studied using multi-level multiple logistic regression models in 2012., Results: Of the 912 children (59.1% girls, mean ± SD baseline age 10.2 ± 0.3 yrs) with complete data, 15% changed their travel mode. Those children who lived less than 1 km from school were more likely to take up (OR: 4.73, 95% CI: 1.97, 11.32, p = 0.001) and maintain active commuting (OR: 2.80 95% CI: 0.98, 7.96, p = 0.02). Children whose parents reported it was inconvenient to use the car for school travel were also more likely to take up (OR: 2.04, 95% CI: 1.08, 3.85, p = 0.027) and maintain their active commuting (OR: 5.43 95% CI: 1.95, 15.13, p = 0.001). Lower socio-economic status and higher road safety were also associated with uptake., Conclusions: Findings from this longitudinal study suggest that reducing the convenience of the car and improving the convenience of active modes as well as improving the safety of routes to school may promote uptake and maintenance of active commuting and the effectiveness of these interventions should be evaluated.

Background: Predictors of physical activity (PA) change are rarely investigated separately for different PA intensities and for weekdays/weekends. We investigated whether individual-level predictors of one-year change in objectively-measured physical activity differ for moderate PA (MPA) and vigorous PA (VPA) and for weekends and weekdays., Methods: Accelerometer-assessed PA (mins) was obtained at baseline and +1 year (n = 875, 41.5% male, Mean ± SD baseline age: 9.8 ± 0.4 years-old). Potential predictors (n = 38) were assessed at baseline from psychological (e.g., self-efficacy), socio-cultural (e.g., parent support) and environmental domains (e.g., land use). Associations between predictors and change in MPA (2000-3999 counts/minute (cpm)) and VPA (≥4000 cpm) separately for weekdays and weekends were studied using multi-level linear regression. Analyses were adjusted for school clustering, sex and baseline PA., Results: Weekend PA declined (MPA decline 4.6 ± 21.8 mins/day; VPA decline: 2.1 ± 20.1 mins/day; both p < 0.001) whereas weekday PA did not significantly change. Higher baseline PA and being a girl were associated with greater PA declines in all four outcomes; remaining predictors differed for MPA and VPA and/or weekdays and weekends. Family logistic support was associated with less of a decline in weekend MPA (CI 95%) 0.15 (0.05, 0.25) and VPA 0.19 (0.09, 0.29), and peer support with less of a decline in weekday MPA 0.18 (0.02, 0.34) and VPA 0.22 (0.06, 0.38)., Conclusions: Results highlight the relevance of investigating predictors of PA change separately for different PA intensities and for weekdays/weekends. In addition to continued focus on school PA promotion, more effort to target interventions during weekends, such as in the family and community appears important. Encouraging peer support to increase weekday PA and targeting parent support for weekend PA may be health promotion priorities.

Background: Activity levels are known to decline with age and there is growing evidence of associations between the school environment and physical activity. In this study we investigated how objectively measured one-year changes in physical activity may be associated with school-related factors in 9- to 10-year-old British children., Methods: Data were analysed from 839 children attending 89 schools in the SPEEDY (Sport, Physical Activity, and Eating behaviours: Environmental Determinants in Young People) study. Outcomes variables were one year changes in objectively measured sedentary, moderate, and vigorous physical activity, with baseline measures taken when the children were 9-10 years old. School characteristics hypothesised to be associated with change in physical activity were identified from questionnaires, grounds audits, and computer mapping. Associations were examined using simple and multivariable multilevel regression models for both school (9 am - 3 pm) and travel (8-9 am and 3-4 pm) time., Results: Significant associations during school time included the length of the morning break which was found to be supportive of moderate (β coefficient: 0.68 [p: 0.003]) and vigorous (β coefficient: 0.52 [p: 0.002]) activities and helps to prevent adverse changes in sedentary time (β coefficient: -2.52 [p: 0.001]). During travel time, positive associations were found between the presence of safe places to cross roads around the school and changes in moderate (β coefficient: 0.83 [p:0.022]) and vigorous (β coefficient: 0.56 [p:0.001]) activity, as well as sedentary time (β coefficient: -1.61 [p:0.005])., Conclusion: This study suggests that having longer morning school breaks and providing road safety features such as cycling infrastructure, a crossing guard, and safe places for children to cross the road may have a role to play in supporting the maintenance of moderate and vigorous activity behaviours, and preventing the development of sedentary behaviours in children.

Background: Children who use active modes of travel (walking or cycling) to school are more physically active than those who use passive (motorised) modes. However, less is known on whether a change in mode of travel to school is associated with a change in children's physical activity levels. The purpose of this analysis was to investigate the association between change in mode of travel to school and change in overall physical activity levels in children., Methods: Data from 812 9-10 year old British children (59% girls) who participated in the SPEEDY study were analysed. During the summer terms of 2007 and 2008 participants completed a questionnaire and wore an accelerometer for at least three days. Two-level multiple linear regression models were used to explore the association between change in usual mode of travel to school and change in objectively measured time spent in MVPA., Results: Compared to children whose reported mode of travel did not change, a change from a passive to an active mode of travel was associated with an increase in daily minutes spent in MVPA (boys: beta 11.59, 95% CI 0.94 to 22.24; girls: beta 11.92, 95% CI 5.00 to 18.84). This increase represented 12% of boys' and 13% of girls' total daily time spent in MVPA at follow-up., Conclusion: This analysis provides further evidence that promoting active travel to school may have a role in contributing to increasing physical activity levels in children.

Background: Type 2 diabetes (T2D) is associated with increased risk of morbidity and premature mortality. Among those at high risk, incidence can be halved through healthy changes in behaviour. Information about genetic and phenotypic risk of T2D is now widely available. Whether such information motivates behaviour change is unknown. We aim to assess the effects of communicating genetic and phenotypic risk of T2D on risk-reducing health behaviours, anxiety, and other cognitive and emotional theory-based antecedents of behaviour change., Methods: In a parallel group, open randomised controlled trial, approximately 580 adults born between 1950 and 1975 will be recruited from the on-going population-based, observational Fenland Study (Cambridgeshire, UK). Eligible participants will have undergone clinical, anthropometric, and psychosocial measurements, been genotyped for 23 single-nucleotide polymorphisms associated with T2D, and worn a combined heart rate monitor and accelerometer (Actiheart(®)) continuously for six days and nights to assess physical activity. Participants are randomised to receive either standard lifestyle advice alone (control group), or in combination with a genetic or a phenotypic risk estimate for T2D (intervention groups). The primary outcome is objectively measured physical activity. Secondary outcomes include self-reported diet, self-reported weight, intention to be physically active and to engage in a healthy diet, anxiety, diabetes-related worry, self-rated health, and other cognitive and emotional outcomes. Follow-up occurs eight weeks post-intervention. Values at follow-up, adjusted for baseline, will be compared between randomised groups., Discussion: This study will provide much needed evidence on the effects of providing information about the genetic and phenotypic risk of T2D. Importantly, it will be among the first to examine the impact of genetic risk information using a randomised controlled trial design, a population-based sample, and an objectively measured behavioural outcome. Results of this trial, along with recent evidence syntheses of similar studies, should inform policy concerning the availability and use of genetic risk information.

Introduction: Locked knee caused by inferior patellar dislocation is considered rare in elderly patients. It was originally thought that, in the osteoarthritic knee, osteophytes on the pole of the patella become entrapped in the inter-condylar notch, which is managed by performing closed reduction and immobilization in a knee splint for three to four weeks. We present an unusual case of a locked knee with an impaction fracture. To the best of our knowledge, there have been no previous reports of such impaction fractures managed with arthroscopy., Case Presentation: We present an unusual case of an 88-year-old Caucasian woman with moderate arthritis who had a locked knee caused by an impaction fracture of the patella into the lateral femoral condyle. In this case report, we describe the need for arthroscopic surgery to prevent relocking of the knee in these patients., Conclusions: This case report emphasizes the need for careful assessment of locked knees in elderly patients. Impaction fractures should be considered in all rare cases of patellar dislocation, and we advocate arthroscopic assessment of the articular cartilage in these patients. This is an important consideration, as the population demographics change and such impaction fractures may become more common in patients with degeneration in the knees.

Background: The weather may be a driver of seasonal patterns in children's physical activity (PA). A better understanding of the relationships between weather and PA may help increase children's PA. This study aims to examine the association between PA and rainfall in 9-10 year old children, and how it may be modified by school policies., Methods: 1794 participants in the SPEEDY study in Norfolk, UK recorded PA using ActiGraph accelerometers over up to six days in the summer term of 2007. Multilevel regression models were used to determine the day-by-day association between rainfall and minutes spent sedentary, in moderate-to-vigorous PA (MVPA), and average counts per minute (cpm) over the whole day (07:00-21:00) and the lunchtime period (12:00-14:00). School policies for break times in bad weather were fitted as interaction terms with rainfall., Results: Relative to days with no rain, children spent 9.4 minutes (95%CI 7.0 to 11.9) fewer in MVPA, were sedentary for 13.6 minutes (8.8 to 18.4) more, and accumulated 85.9 cpm (66.2 to 105.5) fewer over the whole day on the wettest days. Children allowed to play outside in wet weather showed the lowest lunchtime PA levels on the wettest days, undertaking 9.8 minutes (6.2 to 13.5) fewer MVPA, 16.1 minutes (10.3 to 21.9) more sedentary, and accumulating 408.0 cpm (250.9 to 565.1) fewer than those allowed to be active indoors., Conclusions: Rainfall is negatively associated with PA in primary school children, but providing indoor physical activities in wet weather may help children maintain physical activity levels irrespective of rainfall.

Background: There is increasing recognition that public health strategies to prevent childhood obesity need to start early in life. Any behavioural interventions need to target maternal attitudes and infant feeding practices, This paper describes the development and preliminary validation of a questionnaire to assess maternal attitudes towards infant growth and milk feeding practices., Methods: We designed a 57-item (19 questions), self-administered questionnaire to measure the following four domains- 1) type of milk feeding, decision making and sources of advice; 2) frequency and quantity of milk feeds; 3) attitudes to infant feeding and growth; and 4) theory-based beliefs about following infant feeding recommendations. Forty mothers completed the questionnaire on two occasions six days apart (to assess test-retest reliability) and then participated in a semi-structured, open-ended telephone interview covering the same domains (to assess criterion validity). Percentage agreement, Cohen's Kappas (for categorical variables) and Spearman's correlation coefficients (for continuous variables) were used to quantify reliability and validity. Internal consistency between theory-based constructs (self-efficacy, outcome expectancy and intention) was quantified by Chronbach's alpha., Results: Of the 57 questionnaire items 51 (89%) had percentage agreement above 70% indicating good test-retest reliability, and the remaining 6 items had moderate or substantial levels of agreement (kappa 0.41-0.68). Comparing questionnaire with interview coding (validity), percentage agreement was above 66% for 39/57 items (68%). Of the 16 items with percentage agreement below 66%, only five had kappa values below 0.20 (two items had insufficient interview responses). Internal consistency was 0.51, 0.79 and 0.90 for self-efficacy, outcome expectancy and intention respectively., Conclusions: This questionnaire could be a useful tool in understanding the determinants of infant feeding and the 'causal mechanism' of interventions that target infant feeding practices to prevent early obesity.

Background: The increasing prevalence of type 2 diabetes poses both clinical and public health challenges. Cost-effective approaches to prevent progression of the disease in primary care are needed. Evidence suggests that intensive multifactorial interventions including medication and behaviour change can significantly reduce cardiovascular morbidity and mortality among patients with established type 2 diabetes, and that patient education in self-management can improve short-term outcomes. However, existing studies cannot isolate the effects of behavioural interventions promoting self-care from other aspects of intensive primary care management. The ADDITION-Plus trial was designed to address these issues among recently diagnosed patients in primary care over one year., Methods/design: ADDITION-Plus is an explanatory randomised controlled trial of a facilitator-led, theory-based behaviour change intervention tailored to individuals with recently diagnosed type 2 diabetes. 34 practices in the East Anglia region participated. 478 patients with diabetes were individually randomised to receive (i) intensive treatment alone (n = 239), or (ii) intensive treatment plus the facilitator-led individual behaviour change intervention (n = 239). Facilitators taught patients key skills to facilitate change and maintenance of key behaviours (physical activity, dietary change, medication adherence and smoking), including goal setting, action planning, self-monitoring and building habits. The intervention was delivered over one year at the participant's surgery and included a one-hour introductory meeting followed by six 30-minute meetings and four brief telephone calls. Primary endpoints are physical activity energy expenditure (assessed by individually calibrated heart rate monitoring and movement sensing), change in objectively measured dietary intake (plasma vitamin C), medication adherence (plasma drug levels), and smoking status (plasma cotinine levels) at one year. We will undertake an intention-to-treat analysis of the effect of the intervention on these measures, an assessment of cost-effectiveness, and analyse predictors of behaviour change in the cohort., Discussion: The ADDITION-Plus trial will establish the medium-term effectiveness and cost-effectiveness of adding an externally facilitated intervention tailored to support change in multiple behaviours among intensively-treated individuals with recently diagnosed type 2 diabetes in primary care. Results will inform policy recommendations concerning the management of patients early in the course of diabetes. Findings will also improve understanding of the factors influencing change in multiple behaviours, and their association with health outcomes.

Background: The influence of the family and home environment on childhood physical activity (PA) and whether this differs between ethnic groups remains uncertain. This paper investigates associations between family and home factors and childhood PA in a multi-ethnic population and explores whether associations differ between ethnic groups., Methods: Cross-sectional study of 9-10 year-old schoolchildren, in which PA was objectively measured by Actigraph GT1 M accelerometers for ≤7 days to estimate average activity counts per minute (CPM). Information on 11 family and home environmental factors were collected from questionnaires. Associations between these factors and CPM were quantified using multi-level linear regression. Interactions with ethnicity were explored using likelihood ratio tests., Results: 2071 children (mean ± SD age: 9.95 ± 0.38 years; 47.8% male) participated, including 25% white European, 28% black African-Caribbean, 24% South Asian, and 24% other ethnic origin. Family PA support and having a pet were associated with higher average CPM (adjusted mean difference: 6 (95%CI:1,10) and 13 (95%CI:3,23), respectively) while car ownership and having internet access at home were associated with lower average CPM (adjusted mean difference: -19 (95%CI:-30,-8) and -10 (95%CI:-19,0), respectively). These associations did not differ by ethnicity. Although the number of siblings showed no overall association with PA, there was some evidence of interaction with ethnicity (p for ethnicity interaction=0.04, 0.05 in a fully-adjusted model); a positive significant association with number of siblings was observed in white Europeans (per sibling CPM difference 10.3 (95% CI 1.7, 18.9)) and a positive non-significant association was observed in black African-Caribbeans (per sibling CPM difference: 3.5 (-4.2, 11.2)) while a negative, non-significant association was observed in South Asians (per sibling CPM difference -6.0 (-15.5, 3.4))., Conclusions: Some family and home environmental factors have modest associations with childhood PA and these are mostly similar across different ethnic groups. This suggests that targeting these factors in an intervention to promote PA would be relevant for children in different ethnic groups., (© 2011 McMinn et al; licensee BioMed Central Ltd.)

Background: Participation in higher intensity activity (i.e. vigorous physical activity [VPA]) appears more consistently associated with lower adiposity, unfortunately little is known about the nature and patterns of VPA participation in children., Objective: To examine the volume and patterns of vigorous and sedentary activity during different segments of the week (weekend, school-based and out-of-school). We also investigated differences by sex, socioeconomic status (SES) and weight status., Design: A cross-sectional study including 1568 UK children aged 9-10 years., Outcome Measures: Sedentary activity (mins), total activity (counts/min) and VPA (mins) were measured by accelerometry. Using a series of 2 level mixed effects linear regression models we tested differences across the segmented week (school time [0900-1500] vs. out-of-school time [0700-0900 & 1500-2100]; and weekday vs. weekend); all models were adjusted for sex, weight status (gender- and age-specific body mass index [BMI] cut points), SES, age and accelerometer registered wear time., Results: Boys and girls accumulated higher VPA out-of-school compared to during school (boys mean ± SD 16.9 ± 9.6 vs 12.6 ± 5.8; girls, 13.1 ± 7.7 vs 8.2 ± 4.0, both p < 0.001); but there were no differences for weekday v weekend VPA (p > 0.05). Less time was spent sedentary on weekdays compared to weekends (p < 0.001). Although boys were more physically active and girls accumulated more sedentary time, the overall pattern in which their physical activity intensity varied across the various day segments was similar when stratified by weight status and SES; and large volumes of sedentary time were observed each hour across the day., Conclusions: The promotion of VPA during the weekend may hold the greatest promise for increasing VPA. Interventions aimed at increasing physical activity in 9-10 year old children should aim to target all children independent of sex, SES or weight status.

Background: Poor recognition of physical inactivity may be an important barrier to healthy behaviour change, but little is known about this phenomenon. We aimed to characterize a high-risk population according to the discrepancies between objective and self-rated physical activity (PA), defined as awareness., Methods: An exploratory cross-sectional analysis of PA awareness using baseline data collected from 365 ProActive participants between 2001 and 2003 in East Anglia, England. Self-rated PA was defined as 'active' or 'inactive' (assessed via questionnaire). Objective PA was defined according to achievement of guideline activity levels (≥30 minutes or <30 minutes spent at least moderate intensity PA, assessed by heart rate monitoring). Four awareness groups were created: 'Realistic Actives', 'Realistic Inactives', 'Overestimators' and 'Underestimators'. Logistic regression was used to assess associations between awareness group and 17 personal, social and biological correlates., Results: 63.3% of participants (N = 231) were inactive according to objective measurement. Of these, 45.9% rated themselves as active ('Overestimators'). In a multiple logistic regression model adjusted for age and smoking, males (OR = 2.11, 95% CI = 1.12, 3.98), those with lower BMI (OR = 0.89, 95% CI = 0.84, 0.95), younger age at completion of full-time education (OR = 0.83, 95% CI = 0.74, 0.93) and higher general health perception (OR = 1.02 CI = 1.00, 1.04) were more likely to overestimate their PA., Conclusions: Overestimation of PA is associated with favourable indicators of relative slimness and general health. Feedback about PA levels could help reverse misperceptions.

Background: The aim was to identify predictors of change in objectively measured physical activity over 12 months in the ProActive cohort to improve understanding of factors influencing change in physical activity., Methods: ProActive is a physical activity promotion trial that took place in Eastern England (1999-2004). 365 offspring of people with type 2 diabetes underwent measurement of physical activity energy expenditure (PAEE) using heart rate monitoring, fitness, and anthropometric and biochemical status at baseline and 1 year (n = 321). Linear regression was used to quantify the associations between baseline demographic, clinical, psychosocial and behavioural variables and change in PAEE over 12 months. This study is registered as ISRCTN61323766., Results: ProActive participants significantly increased their PAEE by 0.6 kj/min (SD 4.2, p = 0.006) over one year, the equivalent of around 20 minutes brisk walking/day. Male sex and higher fitness at baseline predicted increase in PAEE. No significant associations were found for any other variables. Very few baseline demographic, clinical, psychosocial and behavioural predictors were associated with change in objectively measured physical activity., Conclusions: Traditional baseline determinants of self-reported physical activity targeted by behavioural interventions may be relatively weak predictors of change in objectively measured physical activity. Further research is needed to improve our understanding of factors influencing change in physical activity to inform the development and targeting of interventions.

Background: While there are increasing data implicating poor recognition of physical inactivity as a potential barrier to healthy behaviour change, the efficacy of feedback to promote physical activity is uncertain. Using a randomised controlled trial nested within a population-based cohort study, we plan to test three variations of physical activity feedback against a control group. Our primary objective is to assess the efficacy of physical activity feedback in promoting physical activity behaviour change. Secondary objectives are to determine the influence of feedback on physical activity awareness and cognitions, and to compare behavioural effects by type of feedback., Methods/design: We aim to recruit 500 healthy participants aged 30 to 55 years from the ongoing Fenland Study (Cambridge, UK). Following careful phenotyping during baseline measurement (anthropometric, clinical, body composition and fitness measurements, as well as questionnaires assessing self-reported and self-rated physical activity, psychosocial correlates of physical activity behaviour, diet, lifestyle and general health), participants wear a combined heart rate and movement sensor (Actiheart(R)) for six continuous days and nights. After receipt of the physical activity data (around 2 weeks later), participants are randomly allocated to either a control group (no feedback) or one of three types of personalised physical activity feedback ('simple', 'visualised' or 'contextualised'), and complete repeat measures of self-rated physical activity and psychosocial correlates. Approximately five weeks after receiving feedback, all participants wear the Actiheart(R) for another six-day follow-up period and complete repeat questionnaires. Values at outcome, adjusted for baseline, will be compared between randomised groups., Discussion: Given the randomised trial design and use of objective measure of physical activity, this study is likely to provide valuable insights into the efficacy of a feedback intervention in changing physical activity behaviour, as well as the psychological mechanisms involved., Trial Registration: Current Controlled Trials: ISRCTN92551397.

Background: Earlier diagnosis followed by multi-factorial cardiovascular risk intervention may improve outcomes in type 2 diabetes mellitus (T2DM). Latent phase identification through screening requires structured, appropriately targeted population-based approaches. Providers responsible for implementing screening policy await evidence of clinical and cost effectiveness from randomised intervention trials in screen-detected T2DM cases. UK South Asians are at particularly high risk of abnormal glucose tolerance and T2DM. To be effective national screening programmes must achieve good coverage across the population by identifying barriers to the detection of disease and adapting to the delivery of earlier care. Here we describe the rationale and methods of a systematic community screening programme and randomised controlled trial of cardiovascular risk management within a UK multiethnic setting (ADDITION-Leicester)., Design: A single-blind cluster randomised, parallel group trial among people with screen-detected T2DM comparing a protocol driven intensive multi-factorial treatment with conventional care., Methods: ADDITION-Leicester consists of community-based screening and intervention phases within 20 general practices coordinated from a single academic research centre. Screening adopts a universal diagnostic approach via repeated 75g-oral glucose tolerance tests within an eligible non-diabetic population of 66,320 individuals aged 40-75 years (25-75 years South Asian). Volunteers also provide detailed medical and family histories; complete health questionnaires, undergo anthropometric measures, lipid profiling and a proteinuria assessment. Primary outcome is reduction in modelled Coronary Heart Disease (UKPDS CHD) risk at five years. Seven thousand (30% of South Asian ethnic origin) volunteers over three years will be recruited to identify a screen-detected T2DM cohort (n = 285) powered to detected a 6% relative difference (80% power, alpha 0.05) between treatment groups at one year. Randomisation will occur at practice-level with newly diagnosed T2DM cases receiving either conventional (according to current national guidelines) or intensive (algorithmic target-driven multi-factorial cardiovascular risk intervention) treatments., Discussion: ADDITION-Leicester is the largest multiethnic (targeting >30% South Asian recruitment) community T2DM and vascular risk screening programme in the UK. By assessing feasibility and efficacy of T2DM screening, it will inform national disease prevention policy and contribute significantly to our understanding of the health care needs of UK South Asians., Trial Registration: Clinicaltrial.gov (NCT00318032).

Background: Valid measures of physical activity correlates in preschool children are lacking. This study aimed to assess the validity, factor structure and internal consistency of a maternal questionnaire on potential correlates of four-year-old children's physical activity., Methods: The questionnaire was designed to measure the following constructs: child personal factors; parental support and self-efficacy for providing support; parental rules and restrictions; maternal attitudes and perceptions; maternal behaviour; barriers to physical activity; and the home and local environments. Two separate studies were conducted. Study I included 24 mothers of four-year-old children who completed the questionnaire then participated in a telephone interview covering similar items to the questionnaire. To assess validity, the agreement between interview and questionnaire responses was assessed using Cohen's kappa and percentage agreement. Study II involved 398 mothers of four-year-old children participating in the Southampton Women's Survey. In this study, principal components analysis was used to explore the factor structure of the questionnaire to aid future analyses with these data. The internal consistency of the factors identified was assessed using Cronbach's alpha., Results: Kappa scores showed 30% of items to have moderate agreement or above, 23% to have fair agreement and 47% to have slight or poor agreement. However, 89% of items had fair agreement as assessed by percentage agreement (>/= 66%). Limited variation in responses to variables is likely to have contributed to some of the low kappa values. Six questions had a low kappa and low percentage agreement (defined as poor validity); these included questions from the child personal factors, maternal self-efficacy, rules and restrictions, and local environment domains. The principal components analysis identified eleven factors and found several variables to stand alone. Eight of the composite factors identified had acceptable internal consistency (alpha >/= 0.60) and three fell just short of achieving this (0.60 > alpha > 0.50)., Conclusion: Overall, this maternal questionnaire had reasonable validity and internal consistency for assessing potential correlates of physical activity in young children. With minor revision, this could be a useful tool for future research in this area. This, in turn, will aid the development of interventions to promote physical activity in this age group.