Background: Unmet need for family planning in Pakistan is high, with 17% of all married women wanting to avoid or delay pregnancy. However, they cannot owing to a lack of access to modern contraception and sociocultural hindrances. With the modern contraceptive prevalence rate stagnant at approximately 25% over the last 5 years, it is important to explore barriers and enablers to modern contraception uptake to reduce maternal and child mortality and improve reproductive health outcomes for young girls and women.Objective: A formative research approach was taken to explore community member and health care provider perspectives on access to and use of family planning methods in 2 rural districts of Sindh, Pakistan. The broader goal of this study was to provide evidence to design and implement a socioculturally appropriate family planning intervention within the existing service delivery platforms to increase modern contraceptive uptake in the context of rural Sindh.Methods: A qualitative exploratory design was used. Between October 2020 and December 2020, 11 focus group discussions and 11 in-depth interviews were conducted. Focus group discussions were held with men and women from the community, including adolescents, to build an understanding of community beliefs and concepts regarding modern contraceptive methods. In-depth interviews were conducted with health care workers and explored intersections between family planning and reproductive health service delivery at the facility and outreach levels.Results: The findings revealed that limited financial autonomy, restricted women’s mobility, discriminatory gender norms, and cultural practices left women with little opportunity for independent decision-making on the use of modern contraceptive methods. Furthermore, facility-level and supply-side barriers, including frequent stock-outs of modern contraceptives combined with a lack of capacity of health workers to provide quality family planning services and counseling, played an important role in demotivating women from seeking services. In addition, a lack of integration of family planning with maternal and child health service delivery at the health system level was emphasized as a major missed opportunity for contraceptive uptake. Several demand-side barriers to family planning uptake were also highlighted. These included husbands’ or in-laws’ disapproval, social stigma, and perceived fear of side effects regarding modern family planning method use. More importantly, a lack of adolescent-friendly reproductive health services and spaces for counseling was identified as a critical intervention area.Conclusions: This study provides qualitative evidence on issues related to the effectiveness of family planning interventions, specifically in the context of rural Sindh. The findings emphasize the need to design socioculturally appropriate and health system–relevant family planning interventions—the effectiveness of which can be improved through their integration with maternal and child health service delivery mechanisms, consistent service provision, and opportunities for the capacity building of the health care workforce.International Registered Report Identifier (IRRID): RR2-10.2196/35291

Visual cues such as plate size, amount of food served and packaging are known to influence the effects of portion size on food intake. Unit bias is a well characterised heuristic and helps to determine consumption norms. In an obesogenic environment where large portions are common place, the unit or segmentation bias may be overridden promoting overconsumption of both amorphous or unit foods. The aim of this review was to investigate the impact of offering unit or amorphous food on the portion size effect (PSE) in children aged 2-12 years. A systematic search for literature was conducted in Medline, PsycInfo and Web of Science in February 2018. A total of 1197 papers were retrieved following the searches. Twenty-one papers were included in the systematic review, of which 15 provided requisite statistical information for inclusion in a random effects meta-analysis. Increasing children's food portion size by 51-100% led to a significant increase in intake (SMD = 0.47, 95% CI: 0.39-0.55). There was no evidence to suggest that increases in consumption were related to food type (p = 0.33), child age (p = 0.47) or initial portion size served (p=0.14). Residual heterogeneity was not significant (p=0.24). The PSE was demonstrated in children aged 2-12 years when offered both unit and amorphous food items. The effect was not restricted by food type, child age or influenced by initial portion size served. Of the studies included in the meta-analysis between study heterogeneity was low suggesting minimal variation in treatment effects between studies, however, more research is required to understand the mechanisms of the PSE in preschool children. Future research should determine feasible methods to downsize portion sizes served to children.

Summary: Grandparents are frequently relied upon to care for their preschool‐aged grandchildren. These early years are a crucial age in the development of dietary habits and preferences. This review aims to determine grandparental dietary provision, feeding practices and feeding styles when caring for their preschool‐aged grandchildren. Medline, PsycInfo and Web of Science were searched in January 2020. A systematic mixed methods approach was used to synthesize the qualitative (n= 13) and quantitative (n= 7) articles describing grandparents' feeding styles (n= 9), feeding practices (n= 14) and dietary provision (n= 18). Grandparents are serving large portion sizes and encouraging their grandchildren to eat frequently. Results are mixed for the types of foods provided; grandparents provide discretionary foods high in sugar and fat, and some also choose more expensive core foods as treats (e.g., berries). Grandparents engage in feeding practices that promote healthy eating (e.g., creating a healthy feeding environment) and promote autonomy and independence (e.g., considering their grandchild's preferences). However, they also use some coercive feeding practices (e.g., using food as a reward) and may be using indulgent feeding styles, which can be conducive to obesogenic dietary intakes. Interventions targeting grandparents could be an effective way to improve dietary‐related health outcomes in young children.

The aim of this study was to qualitatively examine weight stigma in individuals who exercise frequently. In total, six focus groups, comprising 30 participants aged 18–25 years, were conducted using convenience sampling. All participants were frequent exercisers. Five themes emerged in the data with participants discussing bullying, the consequences of obesity, causes of obesity, lack of willpower and interventions to reduce obesity. This study is the first qualitative examination of weight stigmatisation in frequent exercisers, where the beliefs reported by focus group participants suggest that frequent exercisers stigmatise, discriminate and dehumanise obese people. Future research to examine the impact of weight stigma on exercise motivation and behaviour of obese people appears warranted.

Large portions of high energy dense (HED) snacks are offered to children from a young age and are pervasive in our food environment. This study aimed to explore the feasibility, acceptability, and preliminary efficacy of two strategies of snack portion control: reduction and replacement. Forty-six mother-child dyads aged 22–56 months (36.6 ± 9.5 m, 48% female) completed a three-week intervention. In week 1 (baseline) no changes were made to the child’s diet; week 2 (acclimation) children received a standardised selection of HED snacks, and in week 3 (intervention) participants were randomly assigned to snack replacement (n = 24) or snack reduction (n = 22). Snack replacement involved swapping HED snacks for fruits and vegetables, whilst snack reduction involved reducing the size of HED snacks by 50%. Food and energy intake were measured using a weighed food diary for four consecutive days. Snack replacement resulted in more positive changes to children’s diets; vegetable intake increased (p < 0.01), and total daily energy intake decreased when compared to snack reduction (p < 0.05). Mothers expressed a more favourable attitude to snack replacement, although snack reduction was also well received by mothers. Despite increased preliminary efficacy of snack replacement on dietary intake, both strategies were feasible and acceptable. The current pilot study provides the necessary information to inform the design of future interventions.