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The CO-CREATE project focuses on the need for research on obesity prevention in adolescents to move away from studies of single interventions, toward the investigation of systems-based research incorporating youth involvement. This paper provides an overview of the project, presenting the objectives, design, and novel methodologies applied, as well as findings to date and anticipated outcomes. Adolescents (16–18 years old) in five European countries participated. Methods applied in the project include monitoring and benchmarking of policies, systematic literature reviews, epidemiological surveillance, linking observed overweight and obesity trends to observed policy landscapes, group model building to identify perceived drivers of obesity, alliance building with adolescents, dialog with stakeholders, and system dynamics modelling to explore the potential impact of policy options. Outcomes include tools for developing policy ideas and investigation of prevention strategies with adolescents, including policy databases, system maps of drivers of obesity, protocols for organizing youth alliances, an intergenerational policy dialog tool, and system dynamic models exploring the impacts of cocreated policy ideas. These outcomes make an important contribution to building a pan-European infrastructure for designing and evaluating policies and for providing youth with the opportunity to make their voices heard in the development and implementation of obesity prevention measures. publishedVersion

Background Global research shows a strong link between physical activity and risk of developing non-communicable diseases. To increase physical activity levels, governments must design and implement a comprehensive set of policy actions across a range of areas. To aid governments in this process, the MOVING benchmarking tool was developed to assess the strength of policies across three domains that make up a comprehensive approach to physical activity policy. Methods The MOVING benchmarking tool, which was developed using a consultative process that reviewed evidence on physical activity policy design and existing benchmarking tools, built on the policy areas of the MOVING framework. It values the strength of policy design, based on evidence-informed and aspirational attributes of effective policy-making that impacts health-related behaviours, with a focus on adolescents. The tool was applied to a set of physical activity policies from five countries: Netherlands, Norway, Poland, Portugal and UK. These countries were selected based on their participation in the EU-funded CO-CREATE project, which focuses on prevention of overweight and obesity among adolescents. Relevant physical activity policies in each participating country were identified based on a comprehensive scan, with a set methodology. Results The MOVING benchmarks assessed the strengths and weaknesses in the design of policies across the policy areas of the MOVING policy framework. They produced an overall assessment of policy environments for physical activity across the five countries, as well as an assessment of each individual policy area within the framework, such as walking and cycling infrastructure and active transport. Further, by allowing a fast assessment of many physical activity policies, the benchmarking tool enabled an analysis of the interplay of single policies and drawing conclusions about the overall policy environment in the five countries. Conclusion The MOVING benchmarking tools can identify gaps and assess the strength of actions taken by national governments to promote physical activity, and can be used by policymakers, researchers and civil society to inform advocacy for and design of policies. The scores generated by the benchmarking tool will be amalgamated into an overall policy index for 27 European countries.

Background Global research shows a strong link between physical activity and risk of developing non-communicable diseases. To increase physical activity levels, governments must design and implement a comprehensive set of policy actions across a range of areas. To aid governments in this process, the MOVING benchmarking tool was developed to assess the design and strength of countries' policies in promoting physical activity, as well as gaps in policy action. Methods The MOVING benchmarking tool was developed using a consultative process that reviewed evidence on physical activity policy design, existing benchmarking tools and built on the policy areas of the MOVING framework. The tool values the strength of policy design based on policy attributes that are evidence-based and aspirational - regardless of whether any countries have implemented them. The tool was applied to a set of physical activity policies from five countries participating in? CO-CREATE?, a European Commission-funded project: Netherlands, Norway, Poland, Portugal and UK. Physical activity policies that are currently implemented in these countries were identified based on a comprehensive country scan, with a set methodology. A set of policies from each country corresponding to benchmarks on access to quality public open space and green spaces and community and mass participation initiatives were analysed. The policies were assessed by applying the benchmark corresponding to the relevant policy area Results The benchmarking tools easily identified the strengths and weaknesses in the design of each policy. Thus, the benchmarking tool identified where there was scope for improvement in specific policy area for each country, such as walking and cycling infrastructure and active transport. It also allowed comparisons between countries for specific policy areas. Further, by allowing a fast assessment of many physical activity policies, the benchmarking tool enabled an analysis of the interplay of single policies and draw conclusions about the overall policy environment in the selected countries. Conclusion The MOVING benchmarking tool can inform the development and implementation of policies which promote physical activity. It can be used by government policy-makers, researchers and civil society organisations to identify areas of physical activity policy that require government action. The scores generated by the benchmarking tool will be amalgamated into an overall policy index for 27 European countries.

Introduction: Obesity is a major and challenging public health problem. The aim of this substudy is to evaluate the effect of calcium supplementation on body weight in women recruited in the Calcium and Preeclampsia trial. Methods: Women were recruited before pregnancy and randomized to receive a calcium supplement containing 500 mg of elemental calcium or placebo until 20 weeks’ gestation; all women received 1.5 g from 20 weeks until delivery. Results: A total of 630 women conceived during the study, 322 allocated to calcium and 308 to placebo. Among these, 230 allocated to calcium and 227 allocated to placebo had information on body weight at baseline and at 8 weeks' gestation. During the study period, women allocated to calcium had a mean weight increase of 1.1 (SD ±5.5) kg, whereas those allocated to placebo had a mean increase of 1.5 (SD ±6.1) kg, a mean difference of 0.4 kg (95% −0.4 (−1.4 to 0.6); P =.408). Women classified as obese at the start of the trial had a lower body weight gain at 8 weeks’ gestation (1.0 kg; 95% CI: −3.2 to 1.2; P =.330) and at 32 weeks’ gestation (2.1 kg; 95% CI: 5.6-1.3; P =.225) if they received calcium as compared to placebo. However, none of these differences were statistically significant. Conclusion: The smaller increase in body weight found in women supplemented with 500 mg elemental calcium daily is quantitatively consistent with previous studies. However, in this study, the difference was not statistically significant. Fil: Cormick, Gabriela. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina. Universidad Nacional de La Matanza; Argentina. University of Cape Town; Sudáfrica Fil: Betrán, Ana Pilar. Organizacion Mundial de la Salud; Argentina Fil: Harbron, Janetta. University of Cape Town; Sudáfrica Fil: Seuc, Armando. Instituto Nacional de Higiene; Cuba Fil: White, Cintia. Universidad Nacional de La Matanza; Argentina Fil: Roberts, James M.. University of Pittsburgh; Estados Unidos Fil: Belizan, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Hofmeyr, G. Justus. University of the Witwatersrand; Sudáfrica

Overweight and obesity increase the risk of a range of poor physiological and psychosocial health outcomes. Previous work with well-defined cohorts has explored the determinants of obesity and employed various methods and measures; however, less is known on the broader societal drivers, beyond individual-level influences, using a systems framework with adolescents. The aim of this study was to explore the drivers of obesity from adolescents’ perspectives using a systems approach through group model building in four South African schools. Group model building was used to generate 4 causal loop diagrams with 62 adolescents aged 16–18 years. These maps were merged into one final map, and the main themes were identified: (i) physical activity and social media use; (ii) physical activity, health-related morbidity, and socio-economic status; (iii) accessibility of unhealthy food and energy intake/body weight; (iv) psychological distress, body weight, and weight-related bullying; and (v) parental involvement and unhealthy food intake. Our study identified meaningful policy-relevant insights into the drivers of adolescent obesity, as described by the young people themselves in a South African context. This approach, both the process of construction and the final visualization, provides a basis for taking a novel approach to prevention and intervention recommendations for adolescent obesity.

Non-toxic food hypersensitivity is categorized as reactions that are either immune-mediated (food allergy; FA) or nonimmune-mediated (food intolerances). The prevalence of FA and intolerances has substantially increased over the past two decades and are a growing public health concern worldwide. Diagnosis of FA consists of clinical history and examination combined with diagnostic testing (through skin prick testing or serum-specific immunoglobulin E [IgE] testing) or oral food challenge (OFC). Nutritional management of FA involves avoidance of exposure to the allergen and establishing through OFC whether baked forms of the allergen are tolerated. Food intolerance is diagnosed with a clinical history, elimination diet, symptom improvement, and OFC, while breath tests can be performed to guide the elimination diet. Nutritional management of food intolerance does not usually require complete avoidance of the offending food(s), but determining tolerable amounts. Referral to a dietitian is necessary to help educate patients and plan nutritionally balanced and individualized elimination diets.

Precise identification of drinking and smoking patterns during pregnancy is crucial to better understand the risk to the fetus. The purpose of this manuscript is to describe the methodological approach used to define prenatal drinking and smoking trajectories from a large prospective pregnancy cohort, and to describe maternal characteristics associated with different exposure patterns. In the Safe Passage Study, detailed information regarding quantity, frequency, and timing of exposure was self-reported up to four times during pregnancy and at 1 month post-delivery. Exposure trajectories were developed using data from 11,692 pregnancies (9,912 women) where pregnancy outcome was known. Women were from three diverse populations: white (23%) and American Indian (17%) in the Northern Plains, US, and mixed ancestry (59%) in South Africa (other/not specified [1%]). Group-based trajectory modeling was used to identify 5 unique drinking trajectories (1 none/minimal, 2 quitting groups, 2 continuous groups) and 7 smoking trajectories (1 none/minimal, 2 quitting groups, 4 continuous groups). Women with pregnancies assigned to the low- or high-continuous drinking groups were less likely to have completed high school and were more likely to have enrolled in the study in the third trimester, be of mixed ancestry, or be depressed than those assigned to the none/minimal or quit-drinking groups. Results were similar when comparing continuous smokers to none/minimal and quit-smoking groups. Further, women classified as high- or low-continuous drinkers were more likely to smoke at moderate-, high-, and very high-continuous levels, as compared to women classified as non-drinkers and quitters. This is the first study of this size to utilize group-based trajectory modeling to identify unique prenatal drinking and smoking trajectories. These trajectories will be used in future analyses to determine which specific exposure patterns subsequently manifest as poor peri- and postnatal outcomes.

The objective of this study was to determine the prevalence and socio-demographic predictors of malnutrition in two urbanized economically active provinces (Gauteng N = 733, Western Cape N = 593) in South Africa. A multistage stratified cluster random sampling design was applied. Fieldworkers visited homes, measured children aged 1-&lt, 10-years old (N = 1326) and administered a questionnaire (mother/primary caregiver). In under-five year old children (N = 674) 21.6% were stunted [height-for-age z-score &lt, &minus, 2 SD], 5.6 % underweight [weight-for-age z-score &lt, 2 SD], 10.3% overweight (body mass index-for-age z-score) (BAZ)&gt, +2 SD &le, +3 SD] and 7.0% obese (BAZ &gt, +3 SD). In 5&ndash, &lt, 10-year olds (N = 626) 6.7% were stunted, 6.8% underweight, 13.4% overweight and 6.8% obese. Stunting and overweight in the same child was present in 5.7% under-five year olds and 1.7% in 5&ndash, 10-year olds. Multiple logistic regression analyses identified having a mother with a post-grade 12 qualification (OR = 0.34) and having an obese mother (OR 0.46) as protectors and being in the under-five age group (OR = 3.73) as a risk factor for stunting. Being in the under-five age group was also a risk factor for a BAZ &gt, 1 (OR 2.39), while being in the third wealth quintile was protective (OR = 0.62). Results indicate that stunting and overweight/obesity are still present at concerning levels, especially in the under-five age group.

This study aims to determine the prevalence of risk of malnutrition on admission and discharge in African hospitals, and to identify the association with selected indicators. In this multi-center prospective cohort study, adult patients from hospitals in South Africa, Kenya, and Ghana were screened on admission and discharge and contacted 3 months post-discharge. Relevant morbidity and mortality outcomes were assessed. At risk of malnutrition was indicated if NRS-2002 score &ge, 3. Adult patients (n = 2126, 43.11 years, IQR: 31.95&ndash, 55.60, 52.2% female) were screened on admission and 61% were identified as at risk of malnutrition. The proportion of at-risk patients for the three hospitals in Kenya and Ghana (66.2%) were significantly higher than that of the three South African hospitals (53.7%) (Chi2 = 31.0, p &lt, 0.001). Discharge risk of malnutrition was 71.2% (n = 394). Mean length of stay (LOS) was 6.46 &plusmn, 5.63 days. During hospitalization, 20.6% lost &ge, 5% body weight, 18.8% were referred for nutrition support, and discharge BMI (23.87 &plusmn, 7.38 kg/m2) was significantly lower than admission BMI (24.3 &plusmn, 7.3 kg/m2) (p &lt, 0.001). Admission nutrition risk was associated with lower admission and discharge BMI (p &lt, 0.001), longer LOS (p &lt, 0.001), increased 3-month re-admission rates (Chi2 = 1.35, p = 0.245) and increased mortality (Chi2 = 21.68, 0.001). Nearly two-thirds of patients were at risk of malnutrition on admission. This was associated with longer LOS and greater hospital mortality. The nutritional status of patients deteriorated during hospitalization. Routine screening practices with appropriate nutrition support action should be implemented as a matter of urgency.

OBJECTIVES: Background: Overweight/obesity is a problem in Nigeria and roll out of treatment programmes at secondary health care level is a priority. Objective: This research aimed to compile a profile of behaviours and moderating factors for the development of a weight loss intervention. METHODS: Two groups of patients were recruited from outpatient clinics at secondary health care facilities. Group 1 (n = 328) completed a questionnaire on socio-demographics, medical history, body image, food choices and physical activity. Group 2 (n = 18) completed an in-depth interview on weight loss concepts/body image. Height and weight of both groups were measured. Six health care personnel were involved in key informant interviews. Quantitative data (QtD) were analysed with SPSS and in-depth interviews (qualitative = QID) with Nvivo. RESULTS: About 40% of survey respondents were overweight and 60% obese; 44.4% of in-depth interview respondents were overweight and 55.6% obese. Physical inactivity (55.8% inactive), low fruit/vegetable intake (consumed ≤ 2 times/day), high fat meat intake (consumed > 1 time/day) and large carbohydrate staple portions (consumed 2 times/day) were identified as key target behaviours (QtD). Moderating factors include underestimation of weight (QtD, QlD), satisfaction with current size although overweight/obese (QlD), co-morbidities and not obesity per se identified as problematic (QID), lack of insight in the role of physical inactivity (QlD), poor knowledge of healthy eating (QtD), too comfortable and relaxed, resulting in over-eating (QlD) and no control over body size (genes, God's will) (QlD). From the health personnel perspective (three physicians, two matrons and one nutritionist) (QlD), only few recognised obesity as a disease. Obesity was not routinely screened for except it is obvious, partly due to lack of tools/skills. Lifestyle modification was mentioned as treatment but only the context of treatment of hypertension and type 2 diabetes mellitus. CONCLUSIONS: Considerations for intervention development are poor food choices, physical inactivity, satisfaction with a large body size and not recognising obesity as such and lack of understanding of causes of obesity. FUNDING SOURCES: Postgraduate Academic Mobility for African Physician Scientists (PAMAPS), EU-PhD sponsorship.

Background: Literature and practice recommendations for lifestyle interventions to treat the increasing number of obese patients with non-communicable diseases (NCDs) or risk factors for NCDs attending resource-constrained public healthcare facilities in South Africa are scarce. Aim: To compare the impact of a facility-based therapeutic group (FBTG) intervention with usual care on weight in obese participants, with NCDs or risk factors for NCDs. Setting: Public healthcare facility providing primary healthcare services in Cape Town, South Africa. Methods: A quasi-experimental study design was used where participants chose to receive weight loss treatment with either the FBTG or usual care interventions. Both interventions involved a one-on-one medical and dietetic consultation, while FBTG participants had six additional group sessions. Follow-up assessments took place 6 months after baseline. Socio-demographic variables, blood pressure, smoking status, weight, height, waist circumference, dietary intake, physical activity and stage of change were measured. Results: Of the 193 obese adults enrolled, 96 selected the FBTG and 97 selected usual care. There were no significant differences at baseline between the two groups. Weight loss over 6 months was greater ( p < 0.001) in FBTG (median [IQR] of −2.9 [−5.1; −0.3] kg) than usual care (−0.9 [−0.9; 0.6] kg) participants. At 6 months, more FBTG completers reached the weekly target of 150 min ( p = 0.009), while both groups showed improvements in dietary intake. More FBTG (74%) than usual care (49%) participants were in the action stage of change by 6 months ( p = 0.010). Conclusions: The group-based intervention was more effective than usual care in weight reduction as well as improvements in physical activity and stage of change.

This study investigated the dietary intake of pregnant women with gestational diabetes mellitus (GDM) and their beliefs relating to the consumption of fruits and vegetables (F&amp, V) and sugary foods and drinks. A cross-sectional study was conducted on 239 pregnant women with GDM in Cape Town. Dietary intake was assessed using a quantified Food Frequency Questionnaire and beliefs relating to food choices were assessed using the Theory of Planned Behaviour (TPB). The mean energy intake was 7268 KJ, carbohydrate was 220 (±104.5) g, protein 60.3 (±27.5) g and fat 67.7 (±44.2) g. The macronutrient distribution was 55% carbohydrates, 14.5% protein and 30.5% fat of total energy. The majority of the sample had inadequate intakes of vitamin D (87.4%), folate (96.5%) and iron (91.3%). The median (IQR) amount of added table sugar and sugar sweetened beverages (SSBs) was 4.0 (0.00–12.5) g and 17.9 (0.0–132.8) mL per day, respectively. Only 31.4% met the recommendation (400 g per day) for F&amp, V. Beliefs that it was not easy to exclude sugary foods/drinks and that knowing how to control cravings for sugary foods/drinks are areas to target messages on the sugar content of SSBs. In conclusion, the dietary intake of these women was not optimal and fell short of several nutritional guidelines for pregnant women with hyperglycaemia. The strongly held beliefs regarding sugary foods/drinks may contribute to poor adherence to nutritional guidelines among pregnant women with GDM in South Africa.

The fat mass and obesity-associated (FTO) gene is currently recognized as the most robust predictor of polygenic obesity. We investigated associations between the FTO rs1421085 and rs17817449 polymorphisms and the FTO rs1421085–rs17817449 haplotype and dietary intake, eating behavior, physical activity, and psychological health, as well as the effect of these associations on BMI. N = 133 treatment seeking overweight/obese Caucasian adults participated in this study. Genotyping was performed from whole blood samples. Weight and height was measured and a non-quantified food frequency questionnaire was completed to assess food group intake. Validated questionnaires were completed to assess physical activity (Baecke questionnaire), psychological health (General Health questionnaire, Rosenburg self-esteem scale and Beck Depression Inventory), and eating behavior (Three Factor Eating questionnaire). The risk alleles of the FTO polymorphisms were associated with poorer eating behaviors (higher hunger, internal locus for hunger, and emotional disinhibition scores), a higher intake of high fat foods and refined starches and more depressive symptoms. The modeled results indicate that interactions between the FTO polymorphisms or haplotypes and eating behavior, psychological health, and physical activity levels may be associated with BMI. The clinical significance of these results for implementation as part of weight management interventions needs further investigation.