Healthy Communities Publications

Early environmental risks and the developmental dynamics of internalizing and externalizing problems from birth to adolescence

Wu K,   Zecchinato F, Guan C, Sun H

Internalizing and externalizing problems often co-exist throughout an individual’s development, shaped by a shared set of early environmental risks. However, most existing studies focused on discrete developmental periods, limiting understanding of how the negative impact of early-life adversity on mental health varies with age. Using data from 7,377 participants across seven waves of the UK Millennium Cohort Study (MCS), the current study investigated the bidirectional associations between internalizing and externalizing problems from ages 5 to 17, as well as the long-term impact of early environmental risks (i.e., prenatal influences, neonatal factors, maternal mental health, harsh parenting, and socioeconomic status) on the two symptom domains across time.

 Analyses indicated that individuals with higher internalizing symptoms tended to report higher externalizing symptoms, with both symptom domains showing high stability over time. A significant positive bidirectional relationship between internalizing and externalizing problems was found from childhood to early adolescence. However, this pattern diverged in late adolescence: internalizing problems at age 14 no longer predict externalizing problems at age 17, whereas externalizing problems negatively predict subsequent internalizing symptoms. Early environmental risk factors significantly predicted both internalizing and externalizing problems from ages 5 to 14, with the effects generally decreasing with age, except for an increase at age 11. Gender differences were also observed in both the bidirectional relationships between the symptom domains and the long-term impact of early environmental risks. 

Findings underscore the enduring impact of early adversity on adolescent mental health and highlight the complex, evolving interaction between internalizing and externalizing problems. The study offers critical insights for early, sustained interventions that address multiple risks and adapt to adolescents’ changing mental health needs over time.

https://doi.org/10.1007/s00787-025-02887-3

November 2025

 "It will sort of drive us to rethink our approach to high fat salt sugar products"- a qualitative analysis of businesses' reactions to the landmark Food (Promotion and Placement) Regulations in England

Dhuria P, Muir S, Shaw S, Lawrence W, Roe E, Baird J, Vogel C

Retail food environments have largely become settings which promote less healthy foods to their customers. In an effort to prompt healthier choices, the UK Government introduced regulations in October 2022 restricting most retailers in England from promoting products high in fat, sugar, or salt (HFSS) at store entrances, aisle-ends, and checkouts, and their online equivalents. Evidence is needed on how businesses approach compliance and adapt to these regulations. This study used in-depth interviews to examine business responses and generate insights to support effective implementation.

https://doi.org/10.1186/s12916-025-04384-5

October 2025

Process evaluation of a randomised controlled trial aimed at improving health behaviours and vitamin D status during pregnancy: Implementation of the SPRING trial

Proebstl S, Vogel C, Lawrence W, Strömmer S, Inskip H, Hammond J, Hart K, McGill K, Harvey NC, Barker M, Baird J

The Southampton PRegnancy Intervention for the Next Generation (SPRING) aimed to assess the efficacy of vitamin D supplementation and the behaviour change intervention 'Healthy Conversation Skills' (HCS) in improving the nutritional status of pregnant women. This paper describes the implementation of these interventions. Efficacy of HCS in improving diet quality and physical activity was evaluated in subgroups of women who discussed ways to improve these behaviours.

https://doi.org/10.1371/journal.pone.0319224

September 2025

The association between adolescents' independent food purchasing and dietary quality differs by socioeconomic status: Findings from a pilot study.

Shaw S, Crozier S, Cooper C, Smith D, Barker M, Vogel C

During adolescence, many young people start to make more independent food purchases. Subsequently, these independent food choices will increasingly contribute to their overall diet quality; little is known, however, about this relationship. This pilot study aimed to examine the role adolescents' independent food purchases play in their diet quality and assess if these relationships vary according to socio-economic status. A convenience sample of adolescents aged 11-18 years and attending secondary school or college in Hampshire, England, were recruited to participate in a one-week cross-sectional observational study

https://doi.org/10.1371/journal.pone.0312903

September 2025

Accountability for tackling childhood obesity: insights from local councillors in England

Taheem R, Woods-Townsend K, Lawrence W, Baird J, Godfrey KM, Hanson MA

Tackling the complex drivers of childhood obesity requires action across sectors and at all levels of government. Elected officials in local government can influence policies targeting communities to prevent childhood obesity, but little is known about their views on local government accountability for tackling the issue. Accountability is the obligation to justify actions on a topic and it could strengthen policy implementation. 

A qualitative study was conducted involving semi-structured interviews with sixteen Southampton City Council local government councillors. Factors limiting accountability included low citizen engagement, the lack of a national mandate to support local action and unachievable targets. Factors that improved accountability included setting a local mandate, public health officers proactively keeping the issue on the agenda and oversight from other system leaders. The findings from this study inform how public health officers and other stakeholders can work within the local system to progress childhood obesity prevention policies.

https://doi.org/10.1057/s41271-025-00573-x

July 2025

Maternal Dietary Inflammatory Status and Serum Neopterin During Pregnancy: Influence on Infantile Atopic Eczema in the Offspring

El-Heis S, Crozier SR, Loo EX, Tham EH, Harvey NC, Inskip HM; Southampton Women's Survey Study Group; Godfrey KM

Atopic eczema is a common inflammatory skin condition, globally affecting 1 in 5 children. It often runs a chronic relapsing and remitting course and can have a significant impact on sleep, growth and development. It can also have a bearing on the families of affected infants as well as the healthcare system.

There is increasing evidence for the importance of early life influences on infantile atopic eczema. Maternal diet before and during pregnancy and specific micronutrient status have been previously examined for their potential to modify the developing immune system risk of offspring atopic eczema. Reports of this have been largely inconsistent but evidence for healthy eating in pregnancy for allergy prevention has been well documented.

A lower risk of allergic conditions has been reported in infants whose mothers had higher serum levels of the pro-inflammatory Th1 markers MCP-1 and neopterin (produced through stimulation of M1 macrophages and monocytes by interferon-gamma) during pregnancy. It has therefore been hypothesized that a Th1 pro-inflammatory intrauterine environment may lower the risk of offspring atopic eczema by diminishing offspring Th2 responses, but supportive evidence is sparse.

Dietary inflammatory indices have been used to characterize the inflammatory potential of dietary patterns and can provide insights beyond those from individual nutrients. The Dietary Inflammatory Index (DII) is derived based on 45 dietary parameters linked to circulating levels of 6 inflammatory markers (IL-1b, IL-4, IL-6, IL-10, TNF-a, C-reactive protein).  The energy-adjusted DII (E-DII) was subsequently designed. It additionally accounts for potential impacts of energy intake on inflammatory potential and has been shown to correlate with DII. The E-DII allows more precise comparison of inflammatory potential of diets that vary in caloric intake.

Within a mother-offspring cohort, we aimed to examine the roles of an inflammatory maternal dietary pattern and serum neopterin in modifying the infant's risk of atopic eczema.

https://doi.org/10.1002/clt2.70080

July 2025

Systematic review of fruit and vegetable voucher interventions for pregnant women and families with young children

Grove G, Ziauddeen N, Malone M, Smith D, Alwan N

Health, poverty and poor diet quality are inextricably linked. Poor diet quality is linked with  many adverse health outcomes, both for children: obesity, gastrointestinal issues and  constipation , dental caries, hypertension, diabetes and growth stunting , and for pregnant  women: gestational diabetes, gestational hypertension and excessive weight gain.  

Looking at the impacts from a societal perspective, poor health can result in time away from  school or work, increased healthcare costs and losses to the economy. Food insecurity has  been associated with increased healthcare costs and poor health outcomes. Poverty has  been linked with childhood obesity, with children from the most deprived decile being  twice as likely to be obese as children from the least deprived decile . Maintaining a good quality diet is particularly challenging for those on low incomes.  Children from deprived backgrounds are more likely to have poorer diet quality than children  from more affluent backgrounds. 

In the UK, healthy diets are comparatively more  expensive, with Fruits & Vegetables (F&Vs) costing significantly more per 1,000 kcal energy provided (£11.79)  than foods and drinks high in fat and sugar (£5.82/1,000kcal). This makes it increasingly  difficult for families under financial strain to maintain healthy diets. F&V vouchers aim to improve dietary quality by safeguarding or increasing spend on F&Vs  in low-income families. They are intended to ensure that families can access F&Vs that may  be out of reach otherwise. Critics may argue that F&V vouchers could be used to offset  current spending, and could paradoxically decrease diet quality by freeing up money to be  spent on unhealthy foods. Evidence to support interventions such as F&V vouchers can  be challenging to gather and we are not aware of any previous mixed methods reviews that  have considered the impact of F&V voucher interventions on the diet and health of pregnant  women and families with young children. 

This review aimed to systematically synthesize  published studies (peer reviewed and grey literature) to assess the impact of F&V vouchers  on the diets and health of recipients (pregnant women and families with children under the  age of 5). The review also aimed to explore recipients’ experiences of F&V vouchers, where  F&V voucher schemes face challenges, and what might be done to mitigate these issues.

https://doi.org/10.1017/s1368980025100657

July 2025

Understanding food insecurity in England: a systems-based approach

Bijlani C, Ndlovu D, Smith D, Thompson C, Garcia L, Junghans C, Vamos EP, Seferidi P

Food insecurity is a significant public health issue in England. National and local policies have not been able to adequately address its complex drivers, in part due to unintended consequences that arise from the way these policies interact with the system. 

Through an integrative review and group model building workshops with 17 subject matter experts, we developed four causal loop diagrams (CLDs) to map the interactions between food insecurity drivers and major policies such as Universal Credit, Healthy Start, and School Meal programs. The CLDs reveal that while these policies and interventions are intended to reduce food insecurity, specific implementation issues can unintentionally perpetuate food insecurity. These unintended consequences result in a shift in responsibility between governments and communities, with a subsequent erosion of public trust in governments and policies. 

This study highlights the need for redistributing responsibility back to governments, rebuilding trust and mitigating unintended consequences of current policies. By addressing the feedback mechanisms driving food insecurity, this research provides actionable insights and policy recommendations for creating equitable and effective policies.

https://doi.org/10.1080/25741292.2025.2523114

June 2025

 Maternal smoking before and during pregnancy and offspring bone mineral density in early childhood: findings from the Southampton Women's Survey

Harish S, Moon RJ, Harvey NC, Inskip HM, Godfrey KM, Crozier SR, Baird J

Bone mineral accrual during childhood and adolescence is an important determinant of later life osteoporosis risk. Mathematical modelling has suggested that increasing peak bone mass is likely to delay the onset of osteoporosis and thus could reduce the high economic and health care burden of fragility fracture. A number of factors are associated with childhood bone mineral density (BMD), including sex, age, maternal health, lifestyle and dietary characteristics during pregnancy such as gestational vitamin D status and postnatal factors such as physical activity, diet and anthropometry.

Maternal smoking is a prevalent modifiable risk factor for many adverse pregnancy and fetal outcomes, including miscarriage, intrauterine death, intrauterine growth restriction and low infant birth weight. Maternal smoking during pregnancy increases infant mortality by 40% and increases the risk of sudden infant death.

The association between pregnancy smoking and BMD in childhood has previously been explored. However, the direction of the association is not consistent across all reported research. This inconsistency may reflect the varying gestations at which maternal smoking status was determined and the age at assessment of offspring BMD, in addition to the covariates considered. However, maternal smoking is associated with reduced placental function and impaired maternal dietary calcium absorption both of which might impact negatively on intrauterine skeletal development.

This study aimed to test the hypothesis that offspring bone density between age 8 and 9 years differs among offspring of mothers who smoke compared to mothers who do not smoke. Furthermore, we explored whether the effect of maternal smoking on offspring bone was similar for pre-conception, early pregnancy and late pregnancy smoking at multiple timepoints during early childhood and the dependence of associations on child weight.

https://doi.org/10.1007/s00198-025-07581-3

July 2025

How lived experiences of illness trajectories, burdens of treatment, and social inequalities shape service user and caregiver participation in health and social care: a theory-informed qualitative evidence synthesis

May CR, Gravenhorst KC, Hillis A, Arber M, Chew-Graham CA, Gallacher KI, Mair FS, Nolte E, Richardson A

When we become ill or need to look after others, we may have to do a lot of work. We may need to check, manage and record our symptoms: do different diets or physical activities; obtain and use different drugs, dressings and medical devices. We may also need to learn new skills to look after ourselves and others. Sometimes, we have to work out how we are going to pay for care. Doing this work may be affected by the inequalities and differences that we start out with when we are ill, for example, our incomes, ethnicity, housing, education, gender and age. The kinds of illnesses we have, and how these change over time as symptoms progress, can make this work harder, and we may find it difficult to look after ourselves or others.

To understand these challenges, and how they affect people’s experiences of health and illness, we looked at 279 studies by other researchers. They told us about people’s everyday experiences of living with six health problems. These were long-term conditions (Parkinson’s disease and schizophrenia); diseases that change over time (bipolar disorder and inflammatory bowel disease); and rapidly progressing diseases (brain cancer and young-onset dementia). These studies explored the ways in which people – and their caregivers – described their experiences of illness in their own words.

The 279 studies we looked at did not say much about the advantages and disadvantages that people start out with, but they did tell us about what is lost when people become sick. They lose ‘social capital’: this is their income, access to transport, and access to employment and networks of friends. They lose their ‘personal capacity’; this happens when people find it difficult to access care, find their diagnosis shocking and become fearful about the future. Symptoms can make it difficult to manage and may also make people think differently about them. Finally, they may need to take responsibility for their care, as diagnoses and symptoms become more difficult over time. This study has identified key ‘pressure points’ that are opportunities for supporting people as they travel through pathways of illness and care. Interventions that fit these pressure points are likely to effectively solve problems around their ability to influence the organisation and delivery of their care

https://doi.org/10.3310/hgtq8159

June 2025

The role of intersectionality in shaping participant engagement with health research through digital methods: findings from a qualitative study

Boxall C, Bishop FL, Alwan NA, Treweek S, Griffiths G, Ekeke N, McGavin J, Thorp J, Bradbury K

Digital research methods were rapidly adopted into clinical trials and health research during the COVID pandemic in 2020. Current UK policy aims to make digital research methods a norm, but their influence on recruitment, retention, and representation in health research remains largely unknown. Whilst efforts have been made to improve engagement with digital health interventions, less attention has been given to digital research methods-such as informed consent, data collection, and research communications-despite their potential to influence study participation and participant experience.

This qualitative study aims to understand the factors influencing the initial uptake and ongoing engagement with digital research methods across diverse populations, capturing experiences and perspectives to inform diverse and efficient health research conduct.

10.1186/s13063-025-08929-0

June 2025

Development of two short food frequency questionnaires to assess diet quality in UK pre-school and primary school-aged children based on National Diet and Nutrition Survey data

Mason M, Shaw SC, Baird J, Barrett M, Lovelock D, Woods-Townsend K, Godfrey KM, Vogel CA, Crozier SR

Assessing children’s diets is currently challenging and burdensome. Abbreviated food frequency questionnaires (FFQ) have potential to assess dietary patterns in a rapid and standardised manner. Using nationally representative UK dietary intake and biomarker data, we developed abbreviated FFQs to calculate dietary quality scores for pre-school and primary school-aged children. 

UK National Diet and Nutrition Survey (2008-2016) weekly consumption frequencies of 129 food groups from four-day diaries were cross-sectionally analysed using principal component analysis. A 129-item score was derived, alongside a 12-item score based on foods with the six highest and six lowest coefficients. Participants included 1,069 pre-schoolers and 2,565 primary school children. 

https://doi.org/10.1017/s0007114525103449

May 2025