Developments in the design and delivery of selfmanagement support for children and young people with diabetes: A narrative synthesis of systematic reviews. Diabetic Medicine, e15035.

Capturing meal images using mobile phone cameras is a promising alternative to traditional dietary assessment methods. Acquiring photos is reasonably simple but nutritional content analysis of images is a major challenge. Automated food identification and portion size assessment is computationally and participant intensive; relying on participant feedback for accuracy (1) . Dietitian analysis of photos is accurate but time-consuming and expensive (2) . Crowdsourcing could offer a rapid low-cost alternative by utilising the life-long experience that all humans have in food identification. Previous crowdsourcing methods include the Eatery app, which produces a simple 11-point 'healthiness' scale for each meal (3) and the PlateMate system, which creates a list of all individual foods with portion sizes, energy and macronutrient content (4) . While the Eatery produces limited and subjective data on meal content, PlateMate represents a complex integrated system of multiple tasks requiring on average 25 workers, costing £2·75 and taking 90 min per image. For feasible data-capture in a large-scale longitudinal studies, crowdsourcing data from meal photos needs to be cheaper and quicker. We aimed to develop a simpler task and tested it's feasibility for crowdsourcing dietary data.FoodFinder, a single task for identifying food groups and portion sizes, developed using Qualtrics (www.qualtrics.com/), and linked to the Prolific Academic (https://prolific.ac/) crowdsourcing platform for recruitment and reimbursement of a UK crowd. Thirty meal photos with measured total meal weight (grams) were analysed by a dietitian and crowds ranging in size from 5 to 50 people. The difference between actual meal weight (the gold-standard) and total meal weight estimated by different sized crowds and ratings by a dietician were compared to each other. To establish group consensus crowd estimates were weighted by majority agreement (5) . Bland-Altman analysis assessed agreement with actual meal weight.A crowd of 5 people underestimated true meal weight by 63 g, equating to 15 % of actual meal weight with limits of agreement (LOA) from −299 to 174 g. In comparison experts overestimated by 28 g equating to 9 % of actual meal weight with LOA −158, 214 g. With a crowd of 5 people, crowdsourcing cost £3·35 and took a mean 2 mins 55 sec (SD 2 min 6 sec) per image. A crowd of 50 had similar accuracy and limits of agreement (−65 g LOA −278, 149 g) but was more expensive. Further development of FoodFinder is required to make rapid low-cost analysis of meal photos via crowdsourcing a feasible method for assessing diet.

Background Non-alcoholic fatty liver disease (NAFLD) is the commonest liver condition in the western world and is directly linked to obesity and the metabolic syndrome. Elevated body mass index is regarded as a major risk factor of NAFL (steatosis) and NAFLD fibrosis. Using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), we sought to investigate whether other variables from adolescence could improve prediction of future NAFL and NAFLD fibrosis risk at 24 years, above BMI and sex. Methods Aged 24 years, 4018 ALSPAC participants had transient elastography (TE) and controlled attenuation parameter (CAP) measurement using Echosens 502 Touch. 513 participants with harmful alcohol consumption were excluded. Logistic regression models examined which variables measured at 17 years were predictive of NAFL and NAFLD fibrosis in young adults. Predictors included sex, BMI, central adiposity, lipid profile, blood pressure, liver function tests, homeostatic model assessment for insulin resistance (HOMA-IR), and ultrasound defined NAFL at 17 years (when examining fibrosis outcomes). A model including all these variables was termed “routine clinical measures”. Models were compared using area under the receiver operator curve (AUROC) and Bayesian Information Criterion (BIC), analysis, which penalises model complexity. Models were tested in all participants and those with overweight or obese standardised BMIs (BMI SDS) centiles at the 17-year time point. A decision curve analysis (DCA) was performed to evaluate the clinical utility of models in overweight and obese adolescents predicting NAFLD fibrosis at a threshold probability of 0.1. Results The “routine clinical measures” model had the highest AUROC for predicting NAFL in all adolescent participants (AUROC 0.79 [SD 0.00]) and those with an overweight/obese BMI SDS centile (AUROC 0.77 [SD 0.01]). According to BIC analysis, insulin resistance was the best predictor of NAFL in all adolescents, whilst central adiposity was the best predictor in those with an overweight/obese BMI SDS centile. The “routine clinical measures” model also had the highest AUROC for predicting NAFLD fibrosis in all adolescent participants (AUROC 0.78 [SD 0.02]) and participants with an overweight/obese BMI SDS centile (AUROC 0.84 [SD 0.03]). However, following BIC analysis, BMI was the best predictor of NAFLD fibrosis in all adolescents including those with an overweight/obese BMI SDS centile. A decision curve analysis examining overweight/obese adolescent participants showed the model that had the greatest net benefit for increased NAFLD fibrosis detection, above a treat all overweight and obese adolescents’ assumption, was the “routine clinical measures” model. However, the net benefit was marginal (0.0054 [0.0034–0.0075]). Conclusion In adolescents, routine clinical measures were not superior to central adiposity and BMI at predicting NAFL and NAFLD fibrosis respectively in young adulthood. Additional routine clinical measurements do provide incremental benefit in detecting true positive fibrosis cases, but the benefit is small. Thus, to reduce morbidity and mortality associated with NASH cirrhosis in adults, the ultimate end point of NAFLD, the focus must be on obesity management at a population level.

Objectives Rapid-onset obesity with hypoventilation, hypothalamic dysfunction, autonomic dysregulation (ROHHAD) is a rare syndrome associated with high morbidity and mortality. Diagnosis is often challenging. We describe three cases of ROHHAD with heterogeneous presentations but some consistent clinical features, including hyperprolactinaemia at diagnosis. We highlight when the diagnosis of ROHHAD should be considered at an early stage. Case presentation All three patients presented between 4 and 6 years old with rapid-onset obesity. They all have central hypoventilation requiring nocturnal BiPAP, varying degrees of hypothalamic dysfunction with hyperprolactinaemia being a consistent feature, and autonomic dysfunction. One patient has a neuro-endocrine tumour (NET) and two have glucose dysregulation. Conclusions High prolactin was a consistent early feature. Central hypoventilation and NET may present later and therefore regular sleep studies and screening for NETs are required. A high suspicion of ROHHAD is warranted in patients with rapid, early-onset obesity and hyperprolactinaemia without structural pituitary abnormality.

Aim To assess cholesterol screening of children with Type 1 diabetes by diabetes professionals using a survey of current practice, given that National Institute of Health and Care Excellence guidelines on childhood Type 1 diabetes do not recommend cholesterol screening, yet the National Paediatric Diabetes Audit has an annual cholesterol measure (> 12 years) as a key outcome indicator.Methods An online survey was sent to 280 members of the Association of Children's Diabetes Clinicians to assess cholesterol screening practice in children.Results A total of 87 diabetes professionals (31%) responded. The results showed that 94% of respondents measured cholesterol, 33% did this annually on all children, and 7% measured fasting cholesterol. A total of 63% used no guidelines to decide treatment or further investigation. The definition of 'high' cholesterol varied from > 4.5 to > 8 mmol/l, with 40% giving no response or specific level. Only 14% of clinicians had started statin therapy in their diabetes clinic in the previous 5 years.Conclusion Whilst the majority of diabetes professionals measured cholesterol in children with Type 1 diabetes, there was marked variability in sampling, in children screened and in action taken if levels were considered abnormal. It is debatable whether cholesterol measures should be undertaken, certainly more than once, and whether cholesterol level should feature as a key outcome in the national audit in future. Diabet. Med. 34, 983-986 (2017)

Introduction: There is a growing understanding of the benefits of patient and public involvement (PPI), and its evaluation, in research. An online version of the CUBE PPI evaluation framework has been developed. We sought to use the CUBE to evaluate the value of early PPI with two small healthcare companies during product development.Methods: Contributors were recruited online and had lived experience of either type 1 diabetes or obesity. Two 1-h sessions were run with a company developing a smartphone application to manage diabetes (DEE-EM): one with young people (YP; n = 5) and one with parents (n = 7). Two 1-h sessions were run with a company developing a weight-loss product, both with adults (n = 7 in each session). Sessions were facilitated by an independent University researcher and attended by company representatives, who presented their product. One facilitator led the evaluation of the session by giving a demonstration of the CUBE and asking simple questions in the YP session.Results: A high proportion of contributors completed the CUBE (80.5% DEE-EM; 93% Oxford Medical Products). Responses were positive to all four CUBE dimensions (in italics). Contributors felt there were diverse ways to contribute to the sessions, and that they had a strong voice to add to the discussion. Balance was achieved regarding whose concerns (public or company) led the agenda, and contributors felt that both companies would make changes based on the discussion.The supportive attitude of both companies resulted in most contributors feeling comfortable participating in PPI sessions with the industry, while recognising the profit-making aspect of their work.Conclusions: PPI with small healthcare companies is both feasible and worthwhile.

Introduction: Craniopharyngiomas are rare brain tumours (incidence 1.1-1.7 cases/million/year). Although benign, craniopharyngioma causes major endocrine and visual morbidities including hypothalamic obesity, yet mechanisms leading to obesity are poorly understood. This study investigated the feasibility and acceptability of eating behaviour measures in patients with craniopharyngioma, to inform the design of future trials. Methods: Patients with childhood-onset craniopharyngioma and controls matched for sex, pubertal stage and age were recruited. After an overnight fast, participants received the following measures: body composition, resting metabolic rate, oral-glucose-tolerance-test including MRI (patients only), appetite ratings, eating behaviour and quality of life questionnaires, ad libitum lunch, and an acceptability questionnaire. Data are reported as median/IQR, with effect size measure (Cliffs delta) and Kendalls Tau for correlations, due to the small sample size. Results: Eleven patients (median age=14yrs; 5F/6M) and matched controls (median age=12yrs; 5F/6M) were recruited. All patients had received surgery and 9/11 also received radiotherapy. Hypothalamic damage post-surgery was graded (Paris grading): grade 2 n=6; grade 1 n=1; grade 0 n=2. The included measures were deemed highly tolerable by participants and their parent/carers. Preliminary data suggests a difference in hyperphagia between patients and controls (d=0.5), and a relationship between hyperphagia with body mass index (BMISDS) in patients (tau=0.46). Discussion: These findings demonstrate that eating behaviour research is feasible and acceptable to craniopharyngioma patients and there is an association between BMISDS and hyperphagia in patients. Thus, food approach and avoidance behaviours may be useful targets for interventions to manage obesity in this patient group.

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