Table 1 Literature, local population evidence, desired outcomes and performance objectives for the BIB intervention

Maternal and paternal BMI are two of the strongest predictors of childhood overweight/obesity [12]. Children of overweight and obese mothers are at particular risk of childhood obesity. Parental obesity more than doubles the risk of adult obesity among both obese and non-obese children under 10 years of age [45–48].

PA is a key component of weight control [49].

National UK guidance recommends at least 30 minutes of moderate intensity PA throughout pregnancy for most women [50–52].

Evidence from BIB 1000 cohort study indicated that 25.6% and 18.2% of the sample overweight (BMI 25-29.9) or obese (BMI ≥30) respectively. Over 7% of BiB1000 women had a BMI greater than 35 [36].

Mothers who were overweight or obese had infants with higher BMI z-scores at age 3 compared to women who were underweight or normal weight [42].

Infants of mothers who were overweight or obese at 26-28 weeks gestation were more likely to be overweight at age 3 [42].

86.4% of pregnant women were inactive or moderately inactive at 26-28 weeks gestation, 62.4% were sedentary or insufficiently active at 6 months postnatally, and 63.9% were sedentary or insufficiently active at 12 months postnatally [43].

a) Mothers make antenatal healthy food choices and maintain a healthy diet postnatally

1 = Mother makes healthy food choices for herself

2 = Mother makes healthy food choices for her unborn baby

3 = Mother increases consumption of fruit and vegetables for herself

4 = Mother reduces the consumption of high-calorie, energy-dense foods and drinks for herself

5 = Mother copes with problems faced with eating a healthy diet

b) Mother increases PA during pregnancy and meets guidelines (150mins mod intensity/wk) within 12 months of giving birth

1 = Mother meets the recommended guidelines of 150 minutes moderate PA/wk (can be done in 10 minute bouts) during and after pregnancy

2 = Mother performs physical activities that are safe during pregnancy

3 = Mother tries new physical activities during and after pregnancy

4 = Mother resists pressure from family/friends not to do PA during or after pregnancy

5 = Mother copes with problems faced with doing PA during or after pregnancy

Systematic review: initial breastfeeding protective against obesity in later life [53].

Meta-analysis concluded that the duration of breastfeeding was inversely and linearly associated with the risk of overweight. The risk was reduced by 4 per cent per month of breastfeeding. The effect lasted up to duration of breastfeeding for 9 months [54].

Current recommendations are that babies are exclusively breastfed for 6 months and that 6 months is the optimum age for the introduction of solid food for both breastfed and formula fed infants [55]. If parents choose to wean earlier than this, 4 months (17 weeks) should be regarded as the earliest age at which solids should be introduce [56].

The overall mean duration of breastfeeding was 1.7 months (range 0.03 – 8 mths), indicating that although a high percentage of mothers initiate breastfeeding, the duration is well below the national recommendation to exclusively breastfeed for 6 months duration and the ranges suggest some mothers gave up in the first few days [44].

In a sample of 1365 mothers, although 75.5% initiated breastfeeding, only 11% of babies were exclusively breastfed until 4 months of age, and by 4 months of age, only 28% of babies were receiving any breast milk [44].

c) Breast feeding is encouraged until at least six months

1 = Mother initiates breastfeeding at birth

2 = Mother exclusively breast feeds (or offers expressed milk) for 6 months

3 = Mother continues to breast feed once solids are introduced

4 = Mother introduces solids at about 6 months

5 = Mother/other guardian(s) uses bottle feed appropriately if this is the preferred feeding choice

6 = Mother copes with problems faced which are associated with breastfeeding

Inappropriate early dietary patterns that are established during weaning may persist into the second year of life and beyond [57].

The introduction of a variety of foods, tastes and textures during weaning and in early childhood is likely to contribute to a more varied and balanced diet in later life [58].

Overall 93% of mothers had introduced savoury solids by 6 months [44].

71% of all mothers had offered sweet solids by 6 month. The mean age when sweet solids were introduced by all mothers was 4.9 months [44].

The overall mean age at which sweetened drinks were introduced was 4.8 months. Sweetened drinks are associated with the risk of development of obesity and the data indicate that all infants were offered these with some Pakistani infants being offered sweetened drinks as early as 5 weeks of age [44].

d) Infant develops healthy food preferences and dietary intake

1 = Mother/other guardian(s) is responsive to infant cues for hunger and fullness

2 = Mother/other guardian(s) adopts an authoritative parental feeding style (high control, high warmth)

3 = Mother/other guardian(s) does not use high energy foods as a reward

4 = Mother/other guardian(s) gives correct portion size for age of child.

5 = Mother/other guardian(s) does not feed baby in front of television.

6 = Mother/other guardian(s) encourages consumption of fruit and vegetables for child.

7 = Mother/other guardian(s) discourages inappropriate consumption of high-calorie, energy-dense foods and drinks for child.

8 = Mother/other guardian(s) copes with problems associated with ensuring infant has healthy dietary intake.

NB: The interventions in this section also combat performance objectives 1 and 2 from 'infant feeding’, and performance objectives 1 and 2 from 'infant diet’.

Engaging in more sedentary activities (including television viewing) has been linked to the development of childhood obesity [59].

40% of 3 month olds watching TV [60].

Expert groups recommend exposing infants to prone play or 'tummy time’ to help facilitate motor milstone development [61].

Many parents do not encourage prone play in their infants because of their infant resistance, or misperceptions around positioning during sleep and awake [62].

50.2% of infants had up to 1 hour of screen time per day, and 22.9% had > 1hour per day; these figures were similar for infants at 12 months. However, at 24 months, 37.7% of infants had up to 1 hour of screen time per day, and 54.7% were receiving > 1 hour [43].

e) PA for infant is facilitated and sedentary time is limited

1 = Mother/other guardian(s) ensures that infant has daily PA interactions in several bouts of both structured and unstructured play across the day.

2 = Mother/other guardian(s) provides a safe, clean floor space large enough for playing, rolling, crawling and other large muscle activities.

3 = Mother/other guardian(s) provide age appropriate equipment which promotes motor skill acquisition.

4 = Mother learns about the importance of PA for motor skill development and consequences for later life health.

5 = Mother/other guardian(s) encourages and motivates the infant’s PA participation.

6 = Mother/other guardian(s) ensures infant is not restrained in highchair/buggy/cot whilst awake for >1hr or watches TV for > 1hr.

7 = Mother/other guardian(s) copes with problems faced with ensuring infant has daily PA interactions.