Appendix 2: Summary tables of the studies included in evidence reviews Table 1a: Studies used to inform the evidence statement for whānau support of breastfeeding Reference (author, yr) Study type1 Intervention/ comparator2 Participants/ Popn3 N Results/Outcome4 Effect on risk5 Notes on quality Negin, 2016 SR of RCT, PCS, CS Level-I To quantify the impact of the grandmother on influencing a mother's BF practice USA n=2 Brazil n=3 Europe n=2 Asia n=5 Kuwait n=1 Age of grandmother not reported Range from 66 to 3822 8 CS, 1 RCT, 4 PCS Impact the grandmother had on BF rates and duration due to her attitude/experience with BF (n=8), 5/8 studies found sig. Positive impact on BF with grandmother's who had BF experience or were positively inclined towards BF (1.6-12.4 times more likely to exclusively BF or refrained from introducing solid food). impact on BF rates and duration when the grandmother was the main caretaker (n=2), mother up to 4.3 times more likely not to EBF impact of grandmother's education on BF rates and duration (n=1) - mothers were sig. Less likely to EBF if grandmothers were educated (Chinese study). 1RCT with intervention aimed at grandmother and adolescents saw reduced chance of exclusive BF among women who cohabitated with grandmother than those who lived apart Protect: have capacity to influence exclusive BF Difficult to accurately compared studies due to the heterogeneity of the effect measures used Cross cultural generalisability of these findings 2013 SR of RCT Level-I Impact of BF interventions on BF initiation, exclusivity, and continuation USA n=2 Italy n=1 Brazil n=1 Range from 57 to 601 10 studies found in literature, only 4 had been rigorously tested and were included in the SR 4 RCT (2 RCT and 2 quasi-experimental design): 3 hospital based and 1 clinic based interventions. One study restricted participants to those that had already initiated BF, the other 3 studies tracked BF initiation. Higher initiation was seen in mother's whose partner's had attended BF Protect Despite the recognition that male partners play an important role in supporting BF initiation and continuation, only 4 rigorously tested
classes/intervention. Greater exclusivity was seen in those receiving the intervention compared to control in n=3 studies. Varying results seen when analysing BF continuation in intervention vs. control groups educational programmes aimed to strengthen male partner support for BF were found Small samples Inoue, 2012 SR of QES, PCS and CS Level-III To summarise the factors that have influenced the duration of BF in Japan to provide information relevant to BF promotion programmes Japan Age of population not recorded Range from 264 to 45,569 Total n=12 (10 CS , 1 PCS, 1 QES) 3 CS looked at support from husbands/partners 1 CS looked at association with maternal grandmothers Women were more likely to continue 'full BF' to 3 months post partum if their husbands attended antenatal classes before delivery and for BF duration Mothers who were satisfied with the involvement of the father in childcare tended to continue 'full BF' at 3 months A negative association was seen with maternal grandparents towards BF duration. Not living with maternal grandparents was positively associated with BF status at 6 months compared with those that lived with the maternal grandparents Father = Protect Maternal grandparent = Increase Definition of EBF differs in Japan compared to WHO definitions Most reported Japanese BF studies are cross-sectional in design, have small sample sizes, and have unclear definitions of BF Meedya, 2010 SR of PCS, RCT, CS, QUAL Level-I To provide a firm evidence base for designing an educational intervention that can be offered to women and their families Aus n= 1 UK n=3 USA n=2 Canada n=1 Jamaica n=1 Range from 59 to 1249 3PCS, 1 QUAL, 1 CS, 2 RCT Women's feeding attitudes and practices are influenced by specific people in their social networks, including the baby's father, maternal grandmother, close friends and health care professionals. The attitude of the woman's partner to BF is crucial to the woman's attitude and her BF practices. Support of infant's father and society are important in BF success Father's involvement enhances the wellbeing of the mother and the child, as professional help cannot replace the day-to-day support that couples provide for each other. Protect Interventions discussing partner or grandparent based support are scare in the literature Small sample sizes
eating and physical activity behaviours Hispanic children children when using non-food rewards, encouraged to ‘try one bite’ and allow self-selection. 2 QES found increased intake of healthy snacks when allowed to self-serve, and increased vegetable intake when given immediate positive verbal reinforcement and non-food rewards. positively influence eating behaviours reported ethnicity – both important as lower SES and certain ethnicities have been linked to poorer quality diets. Lack of consideration to demographic differences Did not report on whether the nutrition related data collection tools were valid Wolfenden, 2011 SR of RCT Level-I Increase in fruit and vegetable consumption following intervention with repeated exposure and tangible reward (non-food, social based) North America Western Europe <5 years of age Range from 156 to 1658 children 2 RCT targeting child feeding practices revealed no intervention effect of repeated food exposure alone compared to no treatment at 3 most post intervention. Of these, 1 RCT found higher vegetable consumption in children receiving repeated exposure + tangible reward (non-food/social based). 2 home based RCT showed no sig increase in fruit consumption, with 1 RCT finding a significant positive intervention effect in healthy weight (compared to overweight) children for combined fruit and vegetable consumption. 2pre-school based RCT’s found a sig increase in fruit consumption, but no differences between groups for vegetable consumption. Paired food exposure with tangible non-food reward can be effective Unclear regarding repeated food exposure alone Doesn’t measure long term effects of interventions (>12 months) Barends, 2013 RCT Level-II Whether infants who started weaning with vegetables continued eating more vegetables at 12 and 23 months than Netherlands 12 and 23 months 12 months n=86 23 months n=81 Using 3 day food diaries, reported daily intakes of vegetables at 12 months was 38% higher (p=0.02) in the vegetable group (75 ±43 g) than in the fruit group (54 ± 29 g) At 23 months, reported daily intakes of vegetables was similar to fruits (49 ± 43, 57 ± 35 g). This result was not significant. Increased vegetable at 12 months. Further research required into maintenance of intake
Table 2c: Studies used to inform the evidence statement for general parenting and feeding style Reference (author, yr) Study type1 Intervention/comparator2 Participants/Popn3 N Results/Outcome4 Effect on risk5 Notes on quality Mech, 2016 SR of CS, PCS and mixed method Level-I factors mediating SES and childhood overweight and obesity association Children 0-8 years in high income countries, North America (14), Europe (10), Australia (4) and Asia (1) N=176 to 17,136 30 studies: 15 CS, 12 PCS, 3 14 of which included parent system factors. Inconclusive evidence for feeding style mediating the weight relationship. Four studies investigated the interaction bewteen parenting style, SES and child weight: odds of children being obese increased over threefold with increasing permissive style in high SES families. High income predicted a greater likelihood of permissive parenting style, and permissive parenting style (and long maternal working hours) predicted early and sustained childhood overweight. In low SES other factors (parent’s obesity, high stress, maternal depression) were strong risk factors for child obesity Unclear, suggests permissive parenting in high income families increases risk. There are only a few studies looking at differences by SES, different measurements of SES Shloim, 2015 SR of PCS, CS and RCT Level-I Parenting styles, feeding styles, feeding practices and BMI, obesity or change in weight Children aged 4-12 years in Australia, USA, Netherlands n=69 (USA) to n=2596 (Australia) Parenting style: 3 PCS and 3 CS. Longitudinal studies all showed parenting style significantly associated with child weight. CS mixed findings (possibly due to small sample size unable to detect diff.) Indulgent and uninvolved (rejecting or neglectful) styles increased child BMI over time, compared with authoritative and authoritarian. Feeding style: 5 CS, indulgent feeding style associated with higher weight or BMI z-score. When parenting style and feeding style measured in same study, Indulgent and uninvolved (rejecting or neglectful) =Increase Four different parenting style instruments used
Zarnowiecki, 2014 SR of CS Level IV Whether dietary predictors vary for children of different socioeconomic positions Children aged 9-13 years Ranged from 896 to 2529 3 CS and 2 CS from longitudinal data 1 baseline data from longitudinal study Positive associations with SEP were identified for parent modelling in 7 of 10 samples. The association of parent modelling with education was indeterminate overall, but >50% of samples showed a positive association of modelling with education. Observation of mother’s food intake and modelling mediated associations of SEP with fruit, vegetable, snack food and fast food intake. Positive Pinard, 2011 SR [add level] Examine tools used to validly and reliably assess the home environment related to childhood obesity Children and adolescents USA, Europe, Australia Range from 184 to 3957 [add types of studies, RCT etc] Caregiver role modelling, support, rules, policies were all significant predictors of dietary intake and PA Caregiver role modelling is a consistent correlate of positive health behaviours in children, not necessarily within the same behaviour domain (i.e. diet or PA) Internal consistencies ranged from moderate to high and test-re-test reliability was high Protect The majority of included studies that validate home environment measures did not seek out specific populations that experience obesity at disproportionate rates Pearson, 2009 SR of CS and PCS Level IV Family correlates of children and adolescent’s breakfast consumption Children 6-11 years Adolescents 12-18 years European Children (range from (range from 23 CS, 1 PCS Children 6-11years (n=5) Unable to draw conclusion on parent modelling in children and breakfast consumption Adolescents 12-18 years (n=20) Parental breakfast eating was positively associated with adolescent breakfast consumption in 6/7 samples = Protect Children = Unclear Several studies were not powered to detect significant associations between family correlates and breakfast behaviours Ventura, 2008 SR of CS and PCS Influence of parenting on Children and adolescents CS range from 180 Longitudinal observations (n=8) supported CS evidence that modelling of intake and Protect Variability in defining parenting styles,
4. Include assessment of whether effect is real, rather than due to chance (using a level of significance expressed as a P-value and/or a confidence interval) 5. None, Increase or Protective Table 4c: Studies used to inform the evidence statement for responsive eating Reference (author, yr) Study type1 Intervention/comparator2 Participants/Popn3 N Results/Outcome4 Effect on risk5 Notes on quality Daubmenmier, 2016 RCT Level-II Effects of weight loss intervention in adults with obesity Intervention 5.5 months diet-exercise intervention with or without mindfulness component. Adults BMI between 30 and 45.9 (waist circumference >102 cm for men; >88cm for women) N= 194 Mindfulness in addition to a programme did not show a substantial weight loss benefit. None Schaefer, 2014 SR of RCT, QES and PCS Level-I Review of Interventions that promote eating by internal cues. Overweight or obese women and men Range from N=10 to N=357 9 RCTs, 2 QES and 9 PCS Eating intuitively helped participants abandon unhealthy weight control behaviours, improve metabolic fitness, increase body satisfaction and improve psychological distress. Protective Inconsistent definitions of non-diet approaches and use of different instruments for measuring outcomes Katterman, 2014 SR of RCTs Level-I Mindfulness meditation an intervention for binge eating, emotional eating and weight loss Overweight obese women and men Range from N=10 to N=108 14 RCTs Mindfulness meditation effectively decreases binge eating and emotional eating in populations engaging in this behaviour; evidence for its effect on weight is mixed. Protective Inconsistent definitions of non-diet approaches and use of different instruments for measuring outcomes Clifford, 2014 SR of RCT and QES Level-I Impact of Non-Diet approaches on attitudes, behaviours and health outcomes Non-Diet Approaches: Mindfulness Healthy eating at any size Eating competence Intuitive Eating Adult males and females Predominantly overweight and obese Range from N= 26 to N= 1,689 14 RCTs and 2 QES Non-diet interventions resulted in statistically significant improvements in disordered eating patterns, and depression. Protective Inconsistent definitions of non-diet approaches and use of different instruments for measuring outcomes.
of eating occasions per day suggest limited practical significance. of a single study of boxers (Iwao, 1996) Kant, 2014 SR of RCT, QES and PCS Level-I Eating frequency with weight management (change in BMI, weight gain) Healthy children, adolescents and adults, mostly USA PCS n=7147 adults, 20064 men, 101 girls and 2372 girls RCT range from 8 to 100 QES n=6 4 PCS: 1 in adults found no relationship over 10 year follow-up with adjustment for activity and total energy intake, 1 in men found incr risk of weight gain over >5kg over 10 yr adjusting for activity but not intake. Large PCS in girls found less than 6 eating occasions a day associated with increased BMI at 10 years of followup. 7 RCT and 2 QES (adults) found no independent relationship. None Kaisari, 2013 SR of CS with MA Level-IV Eating frequency with weight, BMI Children and adolescents (aged 2-19yrs) from US, Europe, Brazil 18,849 pooled 11 studies included in MA (21 datapoints) Children and adolescents with higher number of eating episodes per day had 22% lower probabilities of being overweight or obese (significant assoc. in boys, not girls) Protect Variability in definitions of EF and body size, and confounders used. Mesas, 2012 SR of PCS and CS Level-I (adults) and (children) Eating frequency (meals and snacks) with body size Children and adolescents, and adults Range from 226 to 5811 in children and adolescents, range from 239 to 19,478 in adults 8 PCS and 31 CS studies included 14 CS in children showed heterogeneous results, however the 5 of these with the best adjustment for confounders found protective effect. Three good quality PCS found eating at least 3 times/day predicted lower BMI. In adults, 7 of the 9 CS studies with good adjustment for confounders reported an inverse association. One of the 2 PCS found no association after 8 years follow up, the other an increased risk of gaining 5kg+ over 10 years with >4 eating occasions per day. Possibly protect in children, unclear in adults
preference, reduced sugar consumption, increased nutritional knowledge reporting statistically significant reduction in reducing food consumption/energy intake and increasing nutritional knowledge. Smaller but positive effect also on fruit and veg consumption and preference. Cross-curricula and enhanced curricula approaches were also helpful. Langellotto and Gupta 2012 SR and MA Level-III Gardening effect on nutrition knowledge, preferences for fruit and or vegetables, consumption of fruit and or vegetables. Children from Kindergarten to Grade 12 in USA Not reported 20 QES (most included control, but not randomised). Participating in nutrition education programmes lead to increase in nutritional knowledge. However, increased preference and consumption were primarily documented in the gardening programmes. Gardening increased vegetable consumption, whereas the impacts of nutrition education programmes were marginal or non-significant. Hypothesis to explain results: gardening increases access and decreases reluctance to try new foods. Protect Small effect sizes and low fail-safe numbers in the meta-analyses, indicating need for more studies to be confident in findings. 2009 SR of CT, QES and QUAL Level-III Garden-based nutrition education on fruit and/or vegetable intake, willingness to taste fruits and vegetables, preferences for fruits and vegetables, and other nutrition-related outcomes 5-15 year olds in USA 5 interventions were 3 and 3 community-based 11 studies: 5 CT (3 compared gardening with standard nutrition education alone), 5 QES, 1 QUAL Garden-based nutrition-education programmes may have the potential to lead to improvements in fruit and veg intake, willingness to taste fruit and veg and increased preferences for fruit and veg when these are low among youth. However, difficult to make conclusions based on limited evidence. Possibly protective Usually convenience samples with limited (6 months was longest) Notes: 1. type [systematic review (SR) may include meta-analysis (MA), randomised controlled trial or randomised cross-over trials (RCT), non-randomised and quasi-experimental studies (QES), prospective and retrospective cohort studies (PCS, RCS), case series, case reports, case-control and cross-sectional studies (CS), qualitative studies (QUAL)] with level of evidence. 2. include definitions and outcome of interest: diet*(intake, patterns, quality), fruit/veg intake, body size, BMI, weight, weight gain, weight maintenance, weight loss, overweight, obesity.