Publications by authors named "Andrea Sherriff"

36 Publications

Selective Caries Removal in Permanent Teeth (SCRiPT) for the treatment of deep carious lesions: a randomised controlled clinical trial in primary care.

BMC Oral Health 2021 Jul 9;21(1):336. Epub 2021 Jul 9.

Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, 9th Floor, Park Place, Dundee, DD1 4HN, UK.

Background: Dental caries is one of the most prevalent non-communicable disease globally and can have serious health sequelae impacting negatively on quality of life. In the UK most adults experience dental caries during their lifetime and the 2009 Adult Dental Health Survey reported that 85% of adults have at least one dental restoration. Conservative removal of tooth tissue for both primary and secondary caries reduces the risk of failure due to tooth-restoration, complex fracture as well as remaining tooth surfaces being less vulnerable to further caries. However, despite its prevalence there is no consensus on how much caries to remove prior to placing a restoration to achieve optimal outcomes. Evidence for selective compared to complete or near-complete caries removal suggests there may be benefits for selective removal in sustaining tooth vitality, therefore avoiding abscess formation and pain, so eliminating the need for more complex and costly treatment or eventual tooth loss. However, the evidence is of low scientific quality and mainly gleaned from studies in primary teeth.

Method: This is a pragmatic, multi-centre, two-arm patient randomised controlled clinical trial including an internal pilot set in primary dental care in Scotland and England. Dental health professionals will recruit 623 participants over 12-years of age with deep carious lesions in their permanent posterior teeth. Participants will have a single tooth randomised to either the selective caries removal or complete caries removal treatment arm. Baseline measures and outcome data (during the 3-year follow-up period) will be assessed through clinical examination, patient questionnaires and NHS databases. A mixed-method process evaluation will complement the clinical and economic outcome evaluation and examine implementation, mechanisms of impact and context. The primary outcome at three years is sustained tooth vitality. The primary economic outcome is net benefit modelled over a lifetime horizon. Clinical secondary outcomes include pulp exposure, progession of caries, restoration failure; as well as patient-centred and economic outcomes.

Discussion: SCRiPT will provide evidence for the most clinically effective and cost-beneficial approach to managing deep carious lesions in permanent posterior teeth in primary care. This will support general dental practitioners, patients and policy makers in decision making. Trial Registration Trial registry: ISRCTN.

Trial Registration Number: ISRCTN76503940. Date of Registration: 30.10.2019. URL of trial registry record: .
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July 2021

Improving the oral health of older people in care homes (TOPIC): a protocol for a feasibility study.

Pilot Feasibility Stud 2021 Jul 2;7(1):138. Epub 2021 Jul 2.

Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.

Background: Evidence for interventions promoting oral health amongst care home residents is weak. The National Institute for Health and Care Excellence (NICE) guideline NG48 aims to maintain and improve the oral health of care home residents. A co-design process that worked with residents and care home staff to understand how the NG48 guideline could be best implemented in practice has been undertaken to refine a complex intervention. The aim of this study is to assess the feasibility of the intervention to inform a future larger scale definitive trial.

Methods: This is a protocol for a pragmatic cluster randomised controlled trial with a 12-month follow-up that will be undertaken in 12 care homes across two sites (six in London, six in Northern Ireland). Care homes randomised to the intervention arm (n = 6) will receive the complex intervention based on the NG48 guideline, whilst care homes randomised to the control arm (n = 6) will continue with routine practice. The intervention will include a training package for care home staff to promote knowledge and skills in oral health promotion, the use of the Oral Health Assessment Tool on residents by trained care home staff, and a 'support worker assisted' daily tooth-brushing regime with toothpaste containing 1500 ppm fluoride. An average of ten residents, aged 65 years or over who have at least one natural tooth, will be recruited in each care home resulting in a recruited sample of 120 participants. Assessments will be undertaken at baseline, 6 months and 12 months, and will include a dental examination and questionnaires on general health and oral health administered by a research assistant. A parallel process evaluation involving semi-structured interviews will be undertaken to explore how the intervention could be embedded in standard practice. Rates of recruitment and retention, and intervention fidelity will also be recorded. A cost-consequence model will determine the relevance of different outcome measures in the decision-making context.

Discussion: The study will provide valuable information for trialists, policymakers, clinicians and care home staff on the feasibility and associated costs of oral health promotion in UK care homes.

Trial Registration: ISRCTN10276613. Registered on 17th April 2020. .
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July 2021

Trends in socioeconomic inequalities in underweight and obesity in 5-year-old children, 2011-2018: a population-based, repeated cross-sectional study.

BMJ Open 2021 03 19;11(3):e042023. Epub 2021 Mar 19.

School of Dentistry, Medicine and Nursing, College of MVLS, University of Glasgow, Glasgow, UK.

Objective: To explore trends in prevalence and socioeconomic inequalities in underweight and obesity in 5-year-old schoolchildren in Scotland between 2011/2012 and 2017/2018.

Design: A population-based, repeated cross-sectional study.

Setting: Local authority primary schools in Scotland.

Participants: 373 189 5-year-old schoolchildren in Scotland between 2011/2012 and 2017/2018.

Methodology: Trends in prevalence and inequalities in underweight and obesity were examined across seven school years (2011/2012-2017/2018) for 373 189 5-year-old schoolchildren in Scotland. Body mass index SD scores were calculated, and epidemiological cut-offs relative to the UK 1990 references categorised underweight and obesity. Slope/relative indices of inequality (SII/RII) were calculated for underweight and obesity by school year using the area-based Scottish Index of Multiple Deprivation.

Results: The prevalence of obesity rose slightly overall during the study period (9.8% in 2011/2012; 10.1% in 2017/2018). However, this masked a widening of inequalities, with children from the most deprived areas experiencing a greater risk of obesity in 2017/2018 than in 2011/2012 (risk ratio=1.14, 95% CI 1.04 to 1.25) compared with an unchanged risk in children from the least deprived areas (risk ratio=0.95, 95% CI 0.82 to 1.11). SII and RII indicate widening inequalities for obesity, with RII rising from 1.95 (95% CI 1.71 to 2.22) in 2011/2012 to 2.22 (95% CI 1.93 to 2.56) in 2017/2018. The prevalence of underweight was consistently low (compared with the UK 1990 references) and remained unchanged over the study period (1.2% in 2011/2012; 1.1% in 2017/2018), with no consistent evidence of social patterning over time.

Conclusions: Inequalities in obesity in schoolchildren in Scotland are large and have widened from 2011, despite only a slight rise in overall prevalence. In contrast there has been little change in underweight prevalence or inequalities during the study period. Extra resources for policy implementation and measures which do not widen inequalities and focus on reaching the most deprived children are required to tackle the high prevalence and growing inequalities in childhood obesity in Scotland.
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March 2021

Evaluation of a national complex oral health improvement programme: a population data linkage cohort study in Scotland.

BMJ Open 2020 11 24;10(11):e038116. Epub 2020 Nov 24.

School of Medicine, Dentistry, and Nursing, University of Glasgow, Glasgow, UK

Objectives: Child dental caries is a global public health challenge with high prevalence and wide inequalities. A complex public health programme (Childsmile) was established. We aimed to evaluate the reach of the programme and its impact on child oral health.

Setting: Education, health and community settings, Scotland-wide.

Interventions: Childsmile (national oral health improvement programme) interventions: nursery-based fluoride varnish applications (FVAs) and supervised daily toothbrushing, community-based Dental Health Support Worker (DHSW) contacts and primary care dental practice visits-delivered to the population via a proportionate universal approach.

Participants: 50 379 children (mean age=5.5 years, SD=0.3) attending local authority schools (2014/2015).

Design: Population-based individual child-level data on four Childsmile interventions linked to dental inspection survey data to form a longitudinal cohort. Logistic regression assessed intervention reach and the independent impact of each intervention on caries experience, adjusting for age, sex and area-based Scottish Index of Multiple Deprivation (SIMD).

Outcome Measures: Reach of the programme is defined as the percentage of children receiving each intervention at least once by SIMD fifth. Obvious dental caries experience (presence/absence) is defined as the presence of decay (into dentine), missing (extracted) due to decay or filled deciduous teeth.

Results: 15 032 (29.8%) children had caries experience. The universal interventions had high population reach: nursery toothbrushing (89.1%), dental practice visits (70.5%). The targeted interventions strongly favoured children from the most deprived areas: DHSW contacts (SIMD 1: 29.5% vs SIMD 5: 7.7%), nursery FVAs (SIMD 1: 75.2% vs SIMD 5: 23.2%). Odds of caries experience were markedly lower among children participating in nursery toothbrushing (>3 years, adjusted OR (aOR)=0.60; 95% CI 0.55 to 0.66) and attending dental practice (≥6 visits, aOR=0.55; 95% CI 0.50 to 0.61). The findings were less clear for DHSW contacts. Nursery FVAs were not independently associated with caries experience.

Conclusions: The universal interventions, nursery toothbrushing and regular dental practice visits were independently and most strongly associated with reduced odds of caries experience in the cohort, with nursery toothbrushing having the greatest impact among children in areas of high deprivation.
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November 2020

The systemic inflammatory response following hand instrumentation versus ultrasonic instrumentation-A randomized controlled trial.

J Clin Periodontol 2020 09 27;47(9):1087-1097. Epub 2020 Jul 27.

Oral Sciences, Glasgow Dental Hospital and School, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.

Objective: This study sought to investigate whether the immediate systemic inflammatory response following full-mouth debridement differs following use of hand compared with ultrasonic instruments.

Methods: Thirty-nine periodontitis patients were randomized to treatment with full-mouth debridement using either hand or ultrasonic instrumentation completed within 24 hr. Serum and periodontal clinical parameters were collected at baseline, day 1, day 7 and day 90 post-treatment. Differences in systemic inflammatory markers were assessed using general linear models at each timepoint, corrected for age, gender, smoking status, body mass index and baseline levels of each marker.

Results: Across all patients, serum C-reactive protein increased at day 1, with no differences between hand and ultrasonic groups (p(adjusted) = .22). There was no difference between groups in interleukin-6 (p(adjusted) = .29) or tumour necrosis factor α (p(adjusted) = .53) at day 1. Inflammatory markers returned to baseline levels by day 7. Treatment resulted in equal and marked improvements in clinical parameters in both groups; however, total treatment time was on average shorter for ultrasonic instruments (p(adjusted) = .002).

Conclusions: Ultrasonic instrumentation resulted in shorter treatment time with comparable clinical outcomes. Levels of serum C-reactive protein at day 1 were similar following debridement with hand or ultrasonic instruments.
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September 2020

Development of a core outcome set for oral health services research involving dependent older adults (DECADE): a study protocol.

Trials 2020 Jul 1;21(1):599. Epub 2020 Jul 1.

Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.

Background: Oral healthcare service provision for dependent older adults is often poor. For dental services to provide more responsive and equitable care, evidence-based approaches are needed. To facilitate future research, the development and application of a core outcome set would be beneficial. The aim of this study is to develop a core outcome set for oral health services research involving dependent older adults.

Methods: A multi-step process involving consensus methods and including key stakeholders will be undertaken. This will involve identifying potentially relevant outcomes through a systematic review of previous studies examining the effectiveness of strategies to prevent oral disease in dependent older adults, combined with semi-structured interviews with key stakeholders. Stakeholders will include dependent older adults, family members, carers, care-home managers, health professionals, researchers, dental commissioners and policymakers. To condense and prioritise the long list of outcomes generated by the systematic review and semi-structured interviews, a Delphi survey consisting of several rounds with key stakeholders, as mentioned above, will be undertaken. The 9-point Likert scale proposed by the GRADE Working Group will facilitate this consensus process. Following the Delphi survey, a face-to-face consensus meeting with key stakeholders will be conducted where the stakeholders will anonymously vote and decide on what outcomes should be included in the finalised core outcome set.

Discussion: Developing a core set of outcomes that are clinically and patient-centred will help improve the design, conduct and reporting of oral health services research involving dependent older adults, and ultimately strengthen the evidence base for high-quality oral health care for dependent older adults.

Trial Registration: The study was registered with the COMET initiative on 9 January 2018 .
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July 2020

The effectiveness of Dental Health Support Workers at linking families with primary care dental practices: a population-wide data linkage cohort study.

BMC Oral Health 2018 11 21;18(1):191. Epub 2018 Nov 21.

Glasgow Dental School, School of Medicine, Dentistry and Nursing, College of MVLS, University of Glasgow, 378 Sauchiehall Street, Glasgow, UK.

Background: Link workers (lay health workers, health support workers) based in the community provide additional support to individuals and families to facilitate engagement with primary care and other services and resources. This additional support aims to tackle the wider socio-economic determinants of health that lead to inequalities. To date, there is no clear evidence of the effectiveness of these programmes. This study evaluates the effectiveness of Dental Health Support Workers (DHSW) at linking targeted families with young children to primary care dental practices. The DHSW role is one component of Childsmile, the national oral health improvement programme in Scotland.

Methods: A quasi-experimental approach captured the natural variation in the rollout of the DHSW intervention across Scotland in a cohort of children born between 2010 and 2013. Survival analysis explored "time to attendance" at primary care dental practice. Cox's regression models compared attendance rates and time until first attendance between those families who received support from the DHSW and those who did not.

Results: The cohort consisted of 35236 children. Thirty-three percent of the cohort (n = 11495) were considered to require additional support from a DHSW. Of these, 44% (5087) received that support. These families were more likely to attend a dental practice (Hazard Ratio [95% Confidence Interval] =1.87 [1.8 to 1.9]) and, on average, did so 9 months earlier (median time until first attendance: 8.8 months versus 17.8 months), compared to families not receiving additional support.

Conclusions: Link workers (DHSW) within the Childsmile programme are effective at linking targeted children to primary care dental services and, most notably, at a younger age for prevention. This is the first study of its kind to evaluate the effectiveness of link-worker programmes using a robust quasi-experimental design on three, population-wide, linked datasets. These results will inform future health programmes which aim to improve health and reduce inequalities by reaching and supporting families from more disadvantaged backgrounds.
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November 2018

The effect of introducing a financial incentive to promote application of fluoride varnish in dental practice in Scotland: a natural experiment.

Implement Sci 2018 07 11;13(1):95. Epub 2018 Jul 11.

Community Oral Health Section, School of Medicine, Dentistry and Nursing, College of Medicine, Veterinary and Life Sciences (MVLS), University of Glasgow, 378 Sauchiehall Street, Glasgow, G2 3JZ, UK.

Background: Financial incentives are often used to influence professional practice, yet the factors which influence their effectiveness and their behavioural mechanisms are not fully understood. In keeping with clinical guidelines, Childsmile (Scotland's oral health improvement programme) advocates twice yearly fluoride varnish application (FVA) for children in dental practice. To support implementation Childsmile offered dental practitioners a fee-per-item payment for varnishing 2-5-year-olds' teeth through a pilot. In October 2011 payment was extended to all dental practitioners. This paper compares FVA pre- and post-roll-out and explores the financial incentive's behavioural mechanisms.

Methods: A natural experimental approach using a longitudinal cohort of dental practitioners (n = 1090) compared FVA pre- (time 1) and post- (time 2) financial incentive. Responses from practitioners who did not work in a Childsmile pilot practice when considering their 2-5-year-old patients (novel incentive group) were compared with all other responses (continuous incentive group). The Theoretical Domains Framework (TDF) was used to measure change in behavioural mechanisms associated with the incentive. Analysis of covariance was used to investigate FVA rates and associated behavioural mechanisms in the two groups.

Results: At time 2, 709 74%, of eligible responders, were followed up. In general, FVA rates increased over time for both groups; however, the novel incentive group experienced a greater increase (β [95% CI] = 0.82 [0.72 to 0.92]) than the continuous incentive group. Despite this, only 33% of practitioners reported 'always' varnishing increased risk 2-5-year-olds' teeth following introduction of the financial incentive, 19% for standard risk children. Domain scores at time 2 (adjusting for time 1) increased more for the novel incentive group (compared to the continuous incentive group) for five domains: knowledge, social/professional role and identity, beliefs about consequences, social influences and emotion.

Conclusions: In this large, prospective, population-wide study, a financial incentive moderately increased FVA in dental practice. Novel longitudinal use of a validated theoretical framework to understand behavioural mechanisms suggested that financial incentives operate through complex inter-linked belief systems. While financial incentives are useful in narrowing the gap between clinical guidelines and FVA, multiple intervention approaches are required.
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July 2018

A systems approach using the functional resonance analysis method to support fluoride varnish application for children attending general dental practice.

Appl Ergon 2018 Apr 26;68:294-303. Epub 2017 Dec 26.

Glasgow Dental School, School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, 378 Sauchiehall Street, Glasgow, G2 3JZ, UK. Electronic address:

Background: All children attending General Dental Practice in Scotland are recommended to receive twice-yearly applications of sodium fluoride varnish to prevent childhood caries, yet application is variable. Development of complex interventions requires theorizing and modelling to understand context. This study applies the Functional Resonance Analysis Method (FRAM) to produce a sociotechnical systems model and identify opportunities for intervention to support application.

Methods: The FRAM was used to synthesise data which were: routine monitoring of fluoride varnish application in 2015/16; a longitudinal survey with practitioners (n = 1090); in-depth practitioner and key informant interviews (n = 43); and a 'world café' workshop (n = 56).

Results: We describe a detailed model of functions linked to application, and use this to make recommendations for system-wide intervention.

Conclusions: Rigorous research is required to produce accessible models of complex systems in healthcare. This novel paper shows how careful articulation of the functions associated with fluoride varnish application can support future improvement efforts.
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April 2018

How lay health workers tailor in effective health behaviour change interventions: a protocol for a systematic review.

Syst Rev 2016 06 16;5(1):102. Epub 2016 Jun 16.

University of Glasgow Library, Glasgow, UK.

Background: Lay health workers (LHWs) are utilised as a channel of delivery in many health interventions. While they have no formal professional training related to their role, they utilise their connections with the target group or community in order to reach individuals who would not normally readily engage with health services. Lay health worker programmes are often based on psychological theories of behaviour change that point to 'tailoring to individuals' needs or characteristics' as key to success. Although lay health workers have been shown to be effective in many contexts, there is, as yet, little clarity when it comes to how LHWs assess individuals' needs in order to tailor their interventions. This study aims to develop a better understanding of the effective implementation of tailoring in lay health worker interventions by appraising evidence and synthesising studies that report evaluations of tailored interventions.

Method: Health and psychology electronic databases (EMBASE, CINAHL, MEDLINE and PsycINFO) will be searched. Reference lists of included studies will also be searched. For articles that are deemed to be potentially relevant, we will employ a 'cluster searching' technique in order to identify all published papers related to a relevant intervention. Cluster searching will be undertaken in an effort to maximise the breadth and depth of description of the intervention. Quantitative studies will be assessed using the Quality Assessment Tool for Quantitative Studies, developed by the Effective Public Health Practice Project, ON, Canada. Qualitative studies will be assessed using the Critical Appraisal Skills Programme (CASP) checklist for qualitative research. Sythesising the data will enable the development of a taxonomy of strategies for the criteria used for individual assessment of recipients' needs and the ways in which messages or actions are tailored to these individual criteria by LHWs.

Discussion: This systematic review focuses specifically on how health promotion and support is individually tailored in effective programmes by LHWs. This study will be of value to those involved in the design and implementation of interventions that utilise a LHW.

Systematic Review Registration: PROSPERO CRD42015030071.
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June 2016

Assessment of adult body composition using bioelectrical impedance: comparison of researcher calculated to machine outputted values.

BMJ Open 2016 Jan 7;6(1):e008922. Epub 2016 Jan 7.

Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.

Objectives: To explore the usefulness of Bioelectrical Impedance Analysis (BIA) for general use by identifying best-evidenced formulae to calculate lean and fat mass, comparing these to historical gold standard data and comparing these results with machine-generated output. In addition, we explored how to best to adjust lean and fat estimates for height and how these overlapped with body mass index (BMI).

Design: Cross-sectional observational study within population representative cohort study.

Setting: Urban community, North East England

Participants: Sample of 506 mothers of children aged 7-8 years, mean age 36.3 years.

Methods: Participants were measured at a home visit using a portable height measure and leg-to-leg BIA machine (Tanita TBF-300MA).

Measures: Height, weight, bioelectrical impedance (BIA).

Outcome Measures: Lean and fat mass calculated using best-evidenced published formulae as well as machine-calculated lean and fat mass data.

Results: Estimates of lean mass were similar to historical results using gold standard methods. When compared with the machine-generated values, there were wide limits of agreement for fat mass and a large relative bias for lean that varied with size. Lean and fat residuals adjusted for height differed little from indices of lean (or fat)/height(2). Of 112 women with BMI >30 kg/m(2), 100 (91%) also had high fat, but of the 16 with low BMI (<19 kg/m(2)) only 5 (31%) also had low fat.

Conclusions: Lean and fat mass calculated from BIA using published formulae produces plausible values and demonstrate good concordance between high BMI and high fat, but these differ substantially from the machine-generated values. Bioelectrical impedance can supply a robust and useful field measure of body composition, so long as the machine-generated output is not used.
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January 2016

The Oral Microbiome of Denture Wearers Is Influenced by Levels of Natural Dentition.

PLoS One 2015 14;10(9):e0137717. Epub 2015 Sep 14.

Glasgow Dental School, School of Medicine, College of Medicine, Veterinary and Life Sciences, University of Glasgow, 378 Sauchiehall Street, Glasgow, G2 3JZ, United Kingdom.

Objectives: The composition of dental plaque has been well defined, whereas currently there is limited understanding of the composition of denture plaque and how it directly influences denture related stomatitis (DS). The aims of this study were to compare the microbiomes of denture wearers, and to understand the implications of these towards inter-kingdom and host-pathogen interactions within the oral cavity.

Methods: Swab samples were obtained from 123 participants wearing either a complete or partial denture; the bacterial composition of each sample was determined using bar-coded illumina MiSeq sequencing of the bacterial hypervariable V4 region of 16S rDNA. Sequencing data processing was undertaken using QIIME, clustered in Operational Taxonomic Units (OTUs) and assigned to taxonomy. The dentures were sonicated to remove the microbial flora residing on the prosthesis, sonicate was then cultured using diagnostic colorex Candida media. Samples of unstimulated saliva were obtained and antimicrobial peptides (AMP) levels were measured by ELISA.

Results: We have shown that dental and denture plaques are significantly distinct both in composition and diversity and that the oral microbiome composition of a denture wearer is variable and is influenced by the location within the mouth. Dentures and mucosa were predominantly made up of Bacilli and Actinobacteria. Moreover, the presence of natural teeth has a significant impact on the overall microbial composition, when compared to the fully edentulous. Furthermore, increasing levels of Candida spp. positively correlate with Lactobacillus spp. AMPs were quantified, though showed no specific correlations.

Conclusions: This is the first study to provide a detailed understanding of the oral microbiome of denture wearers and has provided evidence that DS development is more complex than simply a candidal infection. Both fungal and bacterial kingdoms clearly play a role in defining the progression of DS, though we were unable to show a defined role for AMPs.
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June 2016

Trends in socio-economic inequalities in the Scottish diet: 2001-2009.

Public Health Nutr 2015 Nov 16;18(16):2970-80. Epub 2015 Mar 16.

1Centre for Public Health Nutrition Research,University of Dundee,Ninewells Hospital and Medical School,Dundee DD1 9SY,UK.

Objective: To explore the association between diet and socio-economic position for 2007-2009 and investigate trends in socio-economic inequalities in the Scottish diet between 2001 and 2009.

Design: UK food purchase data (collected annually from 2001 to 2009) were used to estimate household-level consumption data. Population mean food consumption, nutrient intakes and energy density were estimated by quintiles of an area-based index of multiple deprivation. Food and nutrient intakes estimated were those targeted for change in Scotland and others indicative of diet quality. The slope and relative indices of inequality were used to assess trends in inequalities in consumption over time.

Setting: Scotland.

Subjects: Scottish households (n 5020).

Results: Daily consumption of fruit and vegetables (200 g, 348 g), brown/wholemeal bread (17 g, 26·5 g), breakfast cereals (16 g, 27 g) and oil-rich (21 g, 40 g) and white fish (77 g, 112 g) were lowest, and that of total bread highest (105 g, 91·5 g) in the most deprived compared with the least deprived households, respectively, for the period 2007-2009. With regard to nutrients, there was no association between deprivation and the percentage of food energy from total fat and saturated fat; however, non-milk extrinsic sugar intakes (15·5%, 14·3%) and energy density (741 kJ/100 g, 701 kJ/100 g) were significantly higher in the most deprived households. The slope and relative indices of inequality showed that inequalities in intakes between 2001 and 2009 have changed very little.

Conclusions: There was no evidence to suggest that the difference in targeted food and nutrient intakes between the least and most deprived has decreased compared with previous years.
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November 2015

Use of the theoretical domains framework to further understanding of what influences application of fluoride varnish to children's teeth: a national survey of general dental practitioners in Scotland.

Community Dent Oral Epidemiol 2015 Jun 6;43(3):272-81. Epub 2015 Feb 6.

Community Oral Health Section, Faculty of Medicine, Glasgow Dental School, University of Glasgow, Glasgow, UK.

Objectives: Despite recent improvements in the oral health of Scotland's population, the persistence of childhood dental caries underscores a need to reduce the disease burden experienced by children living in Scotland. Application of fluoride varnish (FV) to children's teeth provides an evidence-based approach to achieving this goal. Despite policy, health service targets and professional recommendations supporting application, not all children receive FV in line with guidance. The objective of this study was to use the theoretical domains framework (TDF) to further an understanding of what may influence fluoride varnish application (FVA) in General Dental Practice in Scotland.

Methods: A postal questionnaire assessing current behaviour (frequency of FVA) and theoretical domains (TDs) was sent to all General Dental Practitioners (GDPs) in Scotland. Correlations and linear regression models were used to examine the association between FVA and the TDs.

Results: One thousand and ninety (53.6%) eligible GDPs responded. Respondents reported applying FV more frequently to increased risk and younger children (aged 2-5 years). Higher scores in eight TDs (Knowledge, Social/professional role and identity, Beliefs about consequences, Motivation and goals, Environmental context and resources, Social influences, Emotion and Behavioural regulation) were associated with greater frequency of FVA. Four beliefs in particular appear to be driving GDPs' decision to apply FV (recognizing that FVA is a guideline recommended behaviour (Knowledge), that FVA is perceived as an important part of the GDPs' professional role (Professional role/identity), that FV is something parents want for their children (Social influences) and that FV is something GDPs really wanted to do (Emotion).

Conclusions: The findings of this study support the use of the TDF as a tool to understand GDPs application of FV and suggest that a multifaceted intervention, targeting dental professionals and families, and more specifically those domains and items associated with FVA may have the greatest likelihood of influencing the evidence-based behaviour.
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June 2015

Timing of adiposity rebound and adiposity in adolescence.

Pediatrics 2014 Nov 13;134(5):e1354-61. Epub 2014 Oct 13.

Physical Activity for Health, School of Psychological Sciences and Health, University of Strathclyde, Glasgow, United Kingdom;

Objectives: To investigate associations between timing of adiposity rebound (AR; the period in childhood where BMI begins to increase from its nadir) and adiposity (BMI, fat mass) at age 15 years in the Avon Longitudinal Study of Parents and Children (ALSPAC).

Methods: The sample consisted of 546 children with AR derived in childhood and BMI and fat mass index (FMI; fat mass measured by dual-energy radiograph absorptiometry/height in m(2)) measured at 15 years. Multivariable linear regression models were based on standardized residuals of log BMI and log FMI to allow comparison of regression coefficients across outcomes.

Results: There were strong dose-response associations between timing of AR and both adiposity outcomes at 15 years independent of confounders. BMI was markedly higher in adolescence for those with very early AR (by 3.5 years; β = 0.70; 95% confidence interval [CI]: 0.33-1.07; P ≤ .001) and was also higher for those with early AR (between 3.5 and 5 years; β = 0.34; 95% CI: 0.08-0.59; P = .009) compared with those with later AR (>5 years) after full adjustment for a range of potential confounders. Similar magnitudes of association were found for FMI after full adjustment for confounders (compared with later AR: very early AR β = 0.74; 95% CI: 0.34-1.15; P ≤ .001; early AR β = 0.35; 95% CI: 0.07-0.63; P = .02).

Conclusions: Early AR is strongly associated with increased BMI and FMI in adolescence. Preventive interventions should consider targeting modifiable factors in early childhood to delay timing of AR.
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November 2014

Energy density of the Scottish diet estimated from food purchase data: relationship with socio-economic position and dietary targets.

Br J Nutr 2014 Jul 7;112(1):80-8. Epub 2014 May 7.

Centre for Public Health Nutrition Research, Division of Cancer Research, Ninewells Hospital and Medical School, University of Dundee,Dundee DD1 9SY,Scotland,UK.

Frequent consumption of energy-dense foods has been strongly implicated in the global increase of obesity. The World Cancer Research Fund suggests a population-level energy density (ED) goal for diets of 523 kJ/100 g (125 kcal/100 g) as desirable for reducing weight gain and related co-morbidities. However, there is limited information about the ED of diets of contemporary populations. The aims of the present study were to (1) estimate the mean ED of the Scottish diet, (2) assess differences in ED over time by socio-economic position, by household (HH) composition and for HH meeting dietary targets for fat and fruit and vegetables, and (3) assess the relationship between ED and the consumption of foods and nutrients, which are indicative of diet quality. ED of the diet was estimated from food (including milk) from UK food purchase survey data. The average ED of the Scottish diet was estimated as 718 kJ/100 g with no change between the survey periods 2001 and 2009. Individuals living in the most deprived areas had a higher mean ED than those living in the least deprived areas (737 v. 696 kJ/100 g). Single-parent HH had the highest mean ED (765 kJ/100 g) of all the HH surveyed. The mean ED of HH achieving dietary targets for fat and fruit and vegetables was 576 kJ/100 g compared with 731 kJ/100 g for non-achievers. HH within the lowest quintile of ED were, on average, closest to meeting most dietary guidelines. Food purchase data can be used to monitor the quality of the diet in terms of dietary ED of the population and subgroups defined by an area-based measure of socio-economic status.
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July 2014

Effectiveness and reach of a directed-population approach to improving dental health and reducing inequalities: a cross sectional study.

BMC Public Health 2013 Aug 27;13:778. Epub 2013 Aug 27.

Glasgow Dental Hospital & School, 378 Sauchiehall Street, Glasgow G2 3JZ, Scotland.

Background: Childsmile School adopts a directed-population approach to target fluoride varnish applications to 20% of the primary one (P1) population in priority schools selected on the basis of the proportion of enrolled children considered to be at increased-risk of developing dental caries. The study sought to compare the effectiveness of four different methods for identifying individuals most in need when a directed-population approach is taken.

Methods: The 2008 Basic National Dental Inspection Programme (BNDIP) cross-sectional P1 Scottish epidemiological survey dataset was used to model four methods and test three definitions of increased-risk. Effectiveness was determined by the positive predictive value (PPV) and explored in relation to 1-sensitivity and 1-specificity.

Results: Complete data was available on 43,470 children (87% of the survey). At the Scotland level, at least half (50%) of the children targeted were at increased-risk irrespective of the method used to target or the definition of increased-risk. There was no one method across all definitions of increased-risk that maximised PPV. Instead, PPV was highest when the targeting method complimented the definition of increased-risk. There was a higher percentage of children at increased-risk who were not targeted (1-sensitivity) when caries experience (rather than deprivation) was used to define increased-risk, irrespective of the method used for targeting. Over all three definitions of increased-risk, there was no one method that minimised (1-sensitivity) although this was lowest when the method and definition of increased-risk were complimentary. The false positive rate (1-specificity) for all methods and all definitions of increased-risk was consistently low (<20%), again being lowest when the method and definition of increased-risk were complimentary.

Conclusion: Developing a method to reach all (or even the vast majority) of individuals at increased-risk defined by either caries experience or deprivation is difficult using a directed-population approach at a group level. There is a need for a wider debate between politicians and public health experts to decide how best to reach those most at need of intervention to improve health and reduce inequalities.
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August 2013

Measuring socio-economic inequalities in edentate Scottish adults--cross-sectional analyses using Scottish Health Surveys 1995-2008/09.

Community Dent Oral Epidemiol 2013 Dec 11;41(6):499-508. Epub 2013 Feb 11.

Clinical Dentistry, Glasgow Dental Hospital & School, University of Glasgow, Glasgow, UK.

Objectives: To investigate the appropriateness of different measures of socio-economic inequalities, in relation to adult oral health in Scotland, utilizing data from a series of large, representative population surveys.

Methods: The Scottish Health Surveys (SHeS) (1995; 1998; 2003; 2008/09) are cross-sectional national population-based surveys used to monitor health status in those living in private households. The age groups included in this study are as follows: 45-54; 55-64 years: all survey years; 65-74: 1998 onwards; 75+: 2003 onwards. Primary outcome was no natural teeth (edentulism). Three measures of socio-economic position: Occupational social class, Education, Carstairs deprivation score (2001) were used. Simple (absolute/relative differences) and complex measures (Slope Index, Relative Index, Concentration Index and c-index) of inequality were produced for each age group across all four surveys.

Results: Simple and complex (absolute) measures of inequality have both demonstrated narrowing disparities in edentulism over time in the 45- to 64-year-old group, a levelling off in those aged 65 and above, and a rise in those aged 75+. Complex relative measures (RII, Concentration Index and c-index), however, show an increasing trend in inequalities over time for all age groups, suggesting that rates of improvement in edentulism rates are not uniform across all social groups.

Conclusions: Simple absolute inequality provides a quick and easy indication of the extent of disparities between extreme groups, whereas complex measures (absolute and relative) consider the gradient in health across all social groups. We have demonstrated that both are useful measures of inequality and should be considered complementary to one another. The appropriate choice of complex measure of inequality will depend on the audience to whom the results are to be communicated. This methodological approach is not confined to oral health but is applicable to other health outcomes that are socially patterned.
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December 2013

Slow pace of dietary change in Scotland: 2001-9.

Br J Nutr 2013 May 21;109(10):1892-902. Epub 2012 Sep 21.

School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen AB25 1HG, UK.

Monitoring changes in the food and nutrient intake of a nation is important for informing the design and evaluation of policy. Surveys of household food consumption have been carried out annually in the UK since 1940 and, despite some changes over the years 1940-2000, the method used for the Expenditure and Food Survey (Living Costs and Food Survey from 2008) has been fundamentally the same since 2001. Using these surveys an analytical procedure was devised to compare food consumption and nutrient intake in Scotland with the Scottish dietary targets, and monitor change. This method takes into account contributions to composite foods and losses due to food preparation, as well as inedible and edible waste. There were few consistent improvements in consumption of foods or nutrients targeted for change over the period 2001-9. A significant but small increase was seen in mean fruit and vegetable consumption (259 g/d in 2001, 279 g/d in 2009, equating to an increase of less than 3 g/person per year). There was also a significant decrease in the percentage of food energy from SFA (15·5 % in 2001, 15·1 % in 2009) and from non-milk extrinsic sugars (15·5 % in 2001, 14·8 % in 2009), concurrent with a reduction in whole milk consumption and soft drink consumption, respectively. These small changes are encouraging, but highlight the time taken for even modest changes in diet to occur. To achieve a significant impact on the health of the present Scottish population, the improvements in diet will need to be greater and more rapid.
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May 2013

Infant feeding in relation to eating patterns in the second year of life and weight status in the fourth year.

Public Health Nutr 2012 Sep 25;15(9):1705-14. Epub 2012 May 25.

Institute for Applied Health Research, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK.

Objective: To explore associations of early infant feeding with (i) eating patterns in the second year of life and (ii) weight status in the fourth year of life in a prospective cohort of children in Scotland.

Design: Growing Up in Scotland (GUS) longitudinal birth cohort study (2005-2008).

Setting: Scotland, UK.

Subjects: Children aged 9-12 months (n 5217) followed through to 45-48 months.

Results: Infant feeding was associated with eating patterns, defined by using SPSS two-step cluster analysis, in the second year of life. Children who were ever breast-fed compared with never breast-fed (adjusted OR = 1·48, 95 % CI 1·27, 1·73) were more likely to have a positive eating pattern (Cluster 2). Children who started complementary feeding at 4-5 months or 6-10 months compared with 0-3 months (adjusted OR = 1·32, 95 % CI 1·09, 1·59 or AOR = 1·50, 95 % CI 1·19, 1·89) were more likely to belong to Cluster 2. Breast-feeding was negatively associated with being overweight or obese in the fourth year of life compared with no breast-feeding (adjusted OR = 0·81, 95 % CI 0·81, 1·01). Introduction of complementary feeding at 4-5 months compared with 0-3 months was negatively associated with being overweight or obese (adjusted OR = 0·74, 95 % CI 0·57, 0·97).

Conclusions: Breast-feeding and introduction of complementary feeding after 4 months were associated with a positive eating pattern in the second year of life. Introduction of complementary feeding at 4-5 months compared with 0-3 months was negatively associated with being overweight or obese.
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September 2012

Periodontitis in non-smoking type 1 diabetic adults: a cross-sectional study.

J Clin Periodontol 2012 Jan 31;39(1):20-9. Epub 2011 Oct 31.

Infection and Immunity Research Group, School of Medicine, University of Glasgow Dental School.

Aim: To compare levels of periodontitis in non-smoking type 1 diabetic patients and controls.

Material And Methods: Type 1 diabetic patients, aged 20-55 years, were recruited from outpatient clinics at five hospitals in Glasgow, UK. Control subjects were recruited from physiotherapy clinics, using the buddy system and through an advertisement in a free newspaper. The primary outcome was severe periodontitis defined by clinical attachment level ≥6 mm on ≥1 tooth.

Results: There were 34 well controlled patients (HbA1c ≤ 7.5%), 169 poorly controlled patients and 112 non-diabetic subjects. Prevalence of severe periodontitis was higher in all type 1 diabetic patients [24.1% (95% CI: 18.4-30.6%)] and poorly controlled patients [27.2% (20.7-34.6%)] than in controls [20.5% (13.5-29.2%)]. The fully adjusted odds ratios (ORs) in never smokers comparing the whole diabetic group, and the poorly controlled group, with the control group were 1.35 [0.66-2.8] (p = 0.41) and 1.58 [0.75-3.33] (p = 0.23), respectively. Mean clinical attachment level was higher in all type 1 diabetic and poorly controlled patients than in controls (both p < 0.001).

Conclusions: These results indicate worse periodontal health in type 1 diabetic patients than in control subjects.

Trial Registration: This study was registered with the UKCRN, ID: 9314 and Scottish Diabetes Research Network registration number: 128.
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January 2012

To what extent do weight gain and eating avidity during infancy predict later adiposity?

Public Health Nutr 2012 Apr 18;15(4):656-62. Epub 2011 Oct 18.

Community Child Health, PEACH Unit, School of Medicine, MVLS, QMH Tower, Yorkhill Hospitals, Glasgow G3 8SJ, UK.

Objective: To determine the extent to which weight gain and eating behaviours in infancy predict later adiposity.

Design: Population-based, prospective, longitudinal birth cohort study. Weights collected in infancy were used to calculate Z-scores for weight gain to age 1 year conditional on birth weight (CWG). To avoid multiple significance tests, variables from the parent questionnaire completed at age 1 year describing eating avidity were combined using general linear modelling to create an infancy avidity score. Anthropometry, skinfold thicknesses and bioelectrical impedance data collected at age 7-8 years were combined using factor analysis, to create an adiposity index.

Setting: Gateshead, UK.

Subjects: Members of the Gateshead Millennium Study cohort with data at both time points (n 561).

Results: CWG in infancy significantly predicted adiposity at age 7 years, but related more strongly to length and lean mass. High adiposity (> 90th internal percentile) at age 7 years was significantly associated with high CWG (relative risk 2·76; 95% CI 1·5, 5·1) in infancy, but less so with raised (> 74th internal percentile) eating avidity in infancy (relative risk 1·87; 95% CI 0·9, 3·7). However, the majority of children with high weight gain (77·6%) or avidity (85·5%) in infancy did not go on to have high adiposity at age 7 years.

Conclusions: Rapid weight gain in infancy and the eating behaviours which relate to it do predict later adiposity, but are more strongly predictive of later stature and lean mass.
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April 2012

Incidence of obesity during childhood and adolescence in a large contemporary cohort.

Prev Med 2011 May 1;52(5):300-4. Epub 2011 Mar 1.

University of Stirling, Department of Sports Studies, Stirling, FK9 4LA, Scotland, UK.

Background And Aims: Timing of obesity development during childhood and adolescence is unclear, hindering preventive strategies. The primary aim of the present study was to quantify the incidence of overweight and obesity throughout childhood and adolescence in a large contemporary cohort of English children (the Avon Longitudinal Study of Parents and Children, ALSPAC; children born 1991-1992). A secondary aim was to examine the persistence of overweight and obesity.

Methods: Longitudinal data on weight and height were collected annually from age 7-15 years in the entire ALSPAC cohort (n=4283), and from 3 to 15 years in a randomly selected subsample of the cohort (n=549; 'Children in Focus' CiF). Incidence of overweight and obesity (BMI (Body mass index) at or above the 85th and 95th centiles relative to U.K. reference data) was calculated. Risk ratios (RR) for overweight and obesity at 15 years based on weight status at 3, 7, and 11 years were also calculated.

Results: In the entire cohort, four-year incidence of obesity was higher between ages 7 and 11 years than between 11 and 15 years (5.0% vs. 1.4% respectively). In the CiF sub-sample, four-year incidence of obesity was also highest during mid-childhood (age 7-11years, 6.7%), slightly lower during early childhood (3-7 years, 5.1%) and lowest during adolescence (11-15 years 1.6%). Overweight and obesity at all ages had a strong tendency to persist to age 15 years as indicated by risk ratios (95% CI (Confidence interval)) for overweight and obesity at 15 years from overweight and obesity (relative to healthy weight status) at 3 years (2.4, 1.8-3.1), 7 years (4.6, 3.6-5.8), and 11 years (9.3, 6.5-13.2).

Conclusion: Mid-late childhood (around age 7-11 years) may merit greater attention in future obesity prevention interventions.
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May 2011

Timing of excess weight gain in the Avon Longitudinal Study of Parents and Children (ALSPAC).

Pediatrics 2011 Mar 21;127(3):e730-6. Epub 2011 Feb 21.

Department of Sports Studies, University of Stirling, Stirling, Scotland.

Objectives: To test the hypothesis that most excess weight gain occurs by school entry in a large sample of English children, and to determine when the greatest gain in excess weight occurred between birth and 15 years.

Methods: Longitudinal data were collected annually from birth to 15 years in 625 children. Weight and BMI at each time point were expressed relative to UK 1990 growth reference as z scores. Excess weight gain was calculated as the group increase in weight and BMI z scores between specific time periods.

Results: Weight z score did not increase from birth to 5 years (mean difference: 0.04 [95% confidence interval (CI): -0.03-0.12] P = .30) but increased from 5 to 9 years (mean difference: 0.19 [95% CI: 0.14-0.23] P < .001). BMI z score increased from 7 to 9 years (mean difference: 0.22 [95% CI: 0.18-0.26] P < .001), with no evidence of a large increase before 7 years and after 9 years.

Conclusions: Our results do not support the hypothesis that most excess weight gain occurs in early childhood in contemporary English children. Excess weight gain was substantial in mid-childhood, with more gradual increases in early childhood and adolescence, which indicates that interventions to prevent excess weight should focus on school-aged children and adolescents as well as the preschool years.
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March 2011

Reconstructing past occupational exposures: how reliable are women's reports of their partner's occupation?

Occup Environ Med 2011 Jun 23;68(6):452-6. Epub 2010 Nov 23.

Child Health, Royal Aberdeen Children's Hospital, University of Aberdeen, Westburn Road, Aberdeen AB25 2ZP, UK.

Objectives: Most of the evidence on agreement between self- and proxy-reported occupational data comes from interview-based studies. The authors aimed to examine agreement between women's reports of their partner's occupation and their partner's own description using questionnaire-based data collected as a part of the prospective, population-based Avon Longitudinal Study of Parents and Children.

Methods: Information on present occupation was self-reported by women's partners and proxy-reported by women through questionnaires administered at 8 and 21 months after the birth of a child. Job titles were coded to the Standard Occupational Classification (SOC2000) using software developed by the University of Warwick (Computer-Assisted Structured Coding Tool). The accuracy of proxy-report was expressed as percentage agreement and kappa coefficients for four-, three- and two-digit SOC2000 codes obtained in automatic and semiautomatic (manually improved) coding modes. Data from 6016 couples at 8 months and 5232 couples at 21 months postnatally were included in the analyses.

Results: The agreement between men's self-reported occupation and women's report of their partner's occupation in fully automatic coding mode at four-, three- and two-digit code level was 65%, 71% and 77% at 8 months and 68%, 73% and 76% at 21 months. The accuracy of agreement was slightly improved by semiautomatic coding of occupations: 73%/73%, 78%/77% and 83%/80% at 8/21 months respectively. While this suggests that women's description of their partners' occupation can be used as a valuable tool in epidemiological research where data from partners are not available, this study revealed no agreement between these young women and their partners at the two-digit level of SOC2000 coding in approximately one in five cases.

Conclusion: Proxy reporting of occupation introduces a statistically significant degree of error in classification. The effects of occupational misclassification by proxy reporting in retrospective occupational epidemiological studies based on questionnaire data should be considered.
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June 2011

Progression from childhood overweight to adolescent obesity in a large contemporary cohort.

Int J Pediatr Obes 2011 Jun 30;6(2-2):e138-43. Epub 2010 Sep 30.

University of Glasgow, Glasgow, Scotland.

Context: The overweight - as distinct from obese - child is a potential target for obesity prevention interventions, on the assumption that overweight often progresses to obesity. However, there is limited empirical evidence on the probability that overweight progresses to obesity in contemporary children. Aim. To quantify progression from overweight to obesity in a large contemporary cohort of children.

Methods: Changes in weight status were studied longitudinally in 7-year-olds (n=5 175) participating in the Avon Longitudinal Study of Parents and Children (ALSPAC), over a 6-year period. Obesity was defined as BMI z-score ≥1.64 and overweight defined as BMI z-score ≥1.04 but <1.64.

Results: Adjusted odds ratio for progression to obesity at age 13 for overweight at age 7 was 18.1 (95% CI 12.8-25.6), and 34% of overweight children at age 7 became obese by age 13 years.

Conclusions: The present study could inform judgements as to the value of monitoring changes in weight status in overweight children, and the extent to which the overweight state might be a useful target of future obesity prevention interventions.
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June 2011

Comparison of waist circumference percentiles versus body mass index percentiles for diagnosis of obesity in a large cohort of children.

Int J Pediatr Obes 2010 Apr;5(2):151-6

University of Glasgow Medical Faculty, Division of Developmental Medicine, Yorkhill Hospitals, Glasgow, Scotland.

Context: Waist circumference may offer improved diagnosis of obesity in youth compared with body mass index (BMI), but empirical evidence is limited.

Objective: To compare the ability of BMI percentile using UK reference data and waist circumference percentile using UK reference data to diagnose high fat mass in English children.

Design And Methods: In 7,722 9-10-year-olds (3,809 boys, 3,913 girls) sensitivity and specificity were calculated and receiver operator characteristic (ROC) analyses undertaken to determine the diagnostic accuracy of BMI and waist circumference z-scores to define high fat mass measured by dual energy x-ray absorptiometry (DXA). High fat mass was defined as being in the top decile of fatness for each sex (359 boys and 367 girls).

Results: The area under the ROC curve was slightly higher for BMI percentile (0.92 in boys, 95% CI: 0.91 -0.93; 0.94 in girls, 95% CI: 0.93-0.95) than waist circumference percentile (0.89 in boys, 95% CI: 0.86-0.91; 0.81 in girls, 95% CI: 0.73-0.90). Specificity of BMI percentile was slightly but significantly higher than that of waist circumference percentile for both sexes (p<0.05 in each case).

Conclusions: The present study suggests that waist circumference percentile has no advantage over BMI percentile for the diagnosis of high fat mass in children.
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April 2010

Validation of dual-energy x-ray absorptiometry and foot-foot impedance against deuterium dilution measures of fatness in children.

Int J Pediatr Obes 2010 ;5(1):111-5

University of Glasgow Division of Developmental Medicine, Faculty of Medicine, Yorkhill Hospitals, Glasgow, Scotland.

Objective: To determine the validity of estimation of body fatness by dual-energy x-ray absorptiometry (DXA) and foot-foot bio-electrical impedance (BIA).

Methods: In 176, 11-12-year-olds (84 boys; 92 girls) body fatness was measured using total body water (TBW), derived from deuterium oxide dilution space. Body fatness was also estimated from DXA and BIA. Methods were compared by regression and by Bland-Altman analysis using TBW measures as the reference.

Results: In boys, mean fat mass from TBW was 9.8 kg (standard deviation, SD=6.1); bias by DXA estimated fat mass was +0.9 kg (limits of agreement -2.2 to +4.1) and bias for BIA was -5.2 kg (limits of agreement +0.5 to -10.8). In boys, regression analysis indicated significant differences in slope (p<0.001) for DXA, and both slope (p < 0.001) and intercept (p < 0.001) for BIA. In girls, mean fat mass from TBW was 12.1 kg (SD 7.7); bias for DXA was +1.2 kg (limits of agreement -1.9 to +5.1) and bias for BIA was -0.2 kg (limits of agreement -5.4 to +5.1). In girls, regression analysis indicated significant differences for slope and intercept (p<0.001 in all cases) for both DXA and BIA.

Conclusions: Errors in estimation of fat mass using BIA and DXA can be very large, and the direction of error can differ between the sexes.
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July 2010

Age- and sex-standardised lean and fat indices derived from bioelectrical impedance analysis for ages 7-11 years: functional associations with cardio-respiratory fitness and grip strength.

Br J Nutr 2009 Jun 24;101(12):1753-60. Epub 2008 Nov 24.

Division of Developmental Medicine, 9th Floor, University of Glasgow Dental School, 378 Sauchiehall Street, Glasgow G3 8SJ, UK.

Indices for lean and fat mass adjusted for height derived from bioelectrical impedance for children aged 7 years have been published previously and their usefulness in the clinical assessment of undernutrition has been demonstrated. However, there is a need for norms that cover a wider age range and to explore their functional significance. The aim of the present study is to derive lean and fat indices for children aged 7-11 years and investigate associations with objective measures of cardio-respiratory fitness and grip strength. Subjects were 9574 children participating in the Avon Longitudinal Study of Parents and Children (ALSPAC). Bioelectrical impedance analysis (BIA) data collected longitudinally between ages 7 and 11 were used to derive lean and fat indices using the method of standardised residuals. Cardio-respiratory fitness (CRF) (9 years) and grip strength (11 years) were also measured. Correlation coefficients and 95 % CI were calculated to assess the strength of association between lean index, fat index and CRF and grip strength. Equations for calculating lean and fat indices in children aged 7-11 years relative to the ALSPAC population are presented. Lean index was linearly associated with CRF (rboys 0.20 (95 % CI 0.15, 0.25), rgirls 0.26 (95 % CI 0.22, 0.30)) and grip strength (rboys 0.29 (95 % CI 0.26, 0.32), rgirls 0.26 (95 % CI 0.23, 0.29)). BMI showed slightly weaker associations, while fat index was unrelated to either CRF or grip strength. Lean indices relate to muscle function and fitness while fat index does not.
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June 2009

Epidemiological and physiological approaches to understanding the etiology of pediatric obesity: finding the needle in the haystack.

Pediatr Res 2007 Jun;61(6):646-52

Division of Developmental Medicine, University of Glasgow, Yorkhill Hospitals, Glasgow, Scotland, G3 8SJ, United Kingdom.

Recent increases in the prevalence of childhood obesity have created an urgent need for preventive strategies, but such strategies in turn depend on an improved understanding of the etiology of pediatric obesity. There is a dearth of evidence of the cause of pediatric obesity at present, with much of the literature of limited quality, inconclusive, and contradictory. The present review highlights the paradox of energy imbalance-its apparent simplicity but actual complexity-and the difficulties in etiologic research that arise from this complexity. The review identifies a number of emerging problems for etiologic studies. The review also makes a number of proposals that might improve future etiologic studies and provides a framework for integrating the diverse body of evidence of etiology that will become available in future. Gathering improved evidence of etiology, and then integrating and interpreting it, will take many years. In the meantime, an emphasis on developing more effective preventive interventions is necessary.
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June 2007