Dr Duncan Radley

Purpose: This study explored Public Health employees experiences of participating in a commercial weight management programme funded through their employers over a 12 week period. Design/methodology/approach: Semi-structured interviews were conducted with 28 employees who had participated in the programme (group-based or online). Findings: The main motivators for enquiring about and attending the programme were: the offer to attend the programme free of charge, the opportunity to kick start their weight loss efforts, to take part in an academic research study, and the opportunity for ‘shared experience’s’ with their colleagues. Practical Implications: Employers should facilitate their employees efforts to lead a healthier lifestyle in the long-term creating employer health and safety policies that actively encourage healthy living and weight management. Improving employee health can contribute to increasing productivity, reducing stress and absenteeism. Originality/value: This paper presents a novel approach to facilitating employees weight management. Employees perceived their employer supported participation in a commercial weight management programme outside of their work setting as a positive experience that assisted their weight management efforts suggesting the acceptability and feasibility of this approach to addressing weight in the workplace. Keywords: Weight management, workplace, qualitative inquiry, employee health promotion

Background: In the current study, we report outcomes 2.4 years from baseline in a random subsample of overweight and obese children who attended MEND 7-13 programs delivered in UK community settings under service level conditions. Methods: The study employed an uncontrolled pre-follow-up design. A total of 165 children were measured. Outcomes included anthropometry, parental perception of emotional distress, body esteem, and self-esteem. Results: Overall, there were significant improvements in all outcomes apart from BMI z-score. In boys, BMI z-score, waist circumference z-score, and psychometrics all improved. In girls, there were no statistically significant differences at 2.4 years, except for body esteem. Conclusions: In real-world settings, the MEND intervention, when delivered by nonspecialists, may result in modest, yet positive, long-term outcomes. Subsequent research should focus on improving the outcome effect size, providing effective behavior change maintenance strategies, and further investigating the reasons behind the observed gender differences.

Objective: To assess the extent to which university students are following UK Government advice regarding appropriate consumption of alcohol, and to investigate if students can be placed into distinct clusters based on their drinking behaviour.

Design: A descriptive questionnaire study.

Setting: One hundred and nineteen undergraduate students from Leeds Metropolitan University, UK.

Method: An online survey, which included a diary to record daily alcohol consumption over the previous week, was completed during the winter of 2007/08. Cluster analysis was used to classify students into subgroups based on comparable alcohol-drinking characteristics. National recommended sensible drinking behaviour guidelines in terms of total weekly alcohol intake, maximum daily alcohol intake, number of alcohol-free days and estimated blood alcohol levels were used to compare drinking behaviour the previous week by age, sex and cluster group.

Results: Consuming weekly alcohol levels considered hazardous was common (58%) with nearly 70% of responders binge drinking at least once over that period; most students (80%) were, however, following the government’s recommendation for two consecutive alcohol-free days per week. No significant differences in drinking behaviour by sex were found, but binge drinkers tended to be younger. Four distinct alcohol-drinking behaviour clusters were identified based on alcohol consumption frequency and quantity. Only students in the non or light drinkers group all remained within national recommended guidelines for weekly intake and alcohol-free days.

Conclusion: Students who consume alcohol are commonly drinking daily and weekly alcohol levels in excess of national sensible drinking guidelines; most students, however, abstain from alcohol on at least two consecutive days. The four distinct drinking clusters suggest that students would benefit from targeted interventions. In particular, personalization of interventions to reflect the distinct patterns of drinking behaviour could increase intervention effectiveness.

Objective The aim of this study was to report outcomes of the UK service level delivery of MEND (Mind,Exercise,Nutrition...Do it!) 5-7, a multicomponent, community-based, healthy lifestyle intervention designed for overweight and obese children aged 5–7 years and their families. Design Repeated measures. Setting Community venues at 37 locations across the UK. Participants 440 overweight or obese children (42% boys; mean age 6.1 years; body mass index (BMI) z-score 2.86) and their parents/carers participated in the intervention. Intervention MEND 5-7 is a 10-week, family-based, child weight-management intervention consisting of weekly group sessions. It includes positive parenting, active play, nutrition education and behaviour change strategies. The intervention is designed to be scalable and delivered by a range of health and social care professionals. Primary and secondary outcome measures The primary outcome was BMI z-score. Secondary outcome measures included BMI, waist circumference, waist circumference z-score, children's psychological symptoms, parenting self-efficacy, physical activity and sedentary behaviours and the proportion of parents and children eating five or more portions of fruit and vegetables. Results 274 (62%) children were measured preintervention and post-intervention (baseline; 10-weeks). Post-intervention, mean BMI and waist circumference decreased by 0.5 kg/m2 and 0.9 cm, while z-scores decreased by 0.20 and 0.20, respectively (p<0.0001). Improvements were found in children's psychological symptoms (−1.6 units, p<0.0001), parent self-efficacy (p<0.0001), physical activity (+2.9 h/week, p<0.01), sedentary activities (−4.1 h/week, p<0.0001) and the proportion of parents and children eating five or more portions of fruit and vegetables per day (both p<0.0001). Attendance at the 10 sessions was 73% with a 70% retention rate. Conclusions Participation in the MEND 5-7 programme was associated with beneficial changes in physical, behavioural and psychological outcomes for children with complete sets of measurement data, when implemented in UK community settings under service level conditions. Further investigation is warranted to establish if these findings are replicable under controlled conditions.

BACKGROUND: BMI is often used to evaluate the effectiveness of childhood obesity interventions, but such interventions may have additional benefits independent of effects on adiposity. We investigated whether benefits to health outcomes following the Mind, Exercise, Nutrition…Do It! (MEND) childhood obesity intervention were independent of or associated with changes in zBMI. METHODS: A total of 79 obese children were measured at baseline; 71 and 42 participants were followed-up at 6 and 12 months respectively, and split into four groups depending on magnitude of change in zBMI. Differences between groups for waist circumference, cardiovascular fitness, physical and sedentary activities, and self-esteem were investigated. RESULTS: Apart from waist circumference and its z-score, there were no differences or trends across zBMI subgroups for any outcome. Independent of the degree of zBMI change, benefits in several parameters were observed in children participating in this obesity intervention. CONCLUSION: We concluded that isolating a single parameter like zBMI change and neglecting other important outcomes is restrictive and may undermine the evaluation of childhood obesity intervention effectiveness.

There has been growing interest in the potential of ‘big data’ to enhance our understanding in medicine and public health. Although there is no agreed definition of big data, accepted critical components include greater volume, complexity, coverage and speed of availability. Much of these data are ‘found’ (as opposed to ‘made’), in that they have been collected for non-research purposes but could include valuable information for research. The aim of this paper is to review the contribution of ‘found’ data to obesity research to date, and describe the benefits and challenges encountered. A narrative review was conducted to identify and collate peer-reviewed research studies. Database searches conducted up to September 2017 found original studies using a variety of data types and sources. These included: retail sales, transport, geospatial, commercial weight management data, social media, and smartphones and wearable technologies. The narrative review highlights the variety of data uses in the literature: describing the built environment, exploring social networks, estimating nutrient purchases or assessing the impact of interventions. The examples demonstrate four significant ways in which ‘found’ data can complement conventional ‘made’ data: firstly, in moving beyond constraints in scope (coverage, size, and temporality); secondly, in providing objective, quantitative measures; thirdly, in reaching hard-to-access population groups; and lastly in the potential for evaluating real-world interventions. Alongside these opportunities, ‘found’ data come with distinct challenges, such as: ethical and legal questions around access and ownership; commercial sensitivities; costs; lack of control over data acquisition; validity; representativeness; finding appropriate comparators; and complexities of data processing, management and linkage. Despite widespread recognition of the opportunities, the impact of ‘found’ data on academic obesity research has been limited. The merit of such data lies not in their novelty, but in the benefits they could add over and above, or in combination with, conventionally collected data.

Objectives: Implementation of a large-scale, child weight management program in underserved communities provided an important opportunity to evaluate its effectiveness under service level conditions. Methods: MEND 7–13 is a community-based, multicomponent, childhood obesity intervention designed to improve dietary, physical activity and sedentary behaviors. It comprises twice weekly sessions for 10 consecutive weeks (total of 35 contact hours) and is delivered to groups of children and their accompanying parents/caregivers. The current evaluation used an uncontrolled, repeated measures design. 4,324 children attended 415 MEND 7–13 programs in seven USA states, of which 2,738 (63%) had complete data for change in zBMI. The intervention targeted underserved families (70% with an income <$40,000 per year; 85.6% Hispanic or African American). Changes in anthropometric, fitness and psychological outcomes were evaluated. A longitudinal multivariate imputation model was used to impute missing data. Peer effects analysis was conducted using the instrumental variables approach and group fixed effects. Results: Mean changes in BMI, and zBMI at 10 weeks were -0.42 kg/m2 (95%CI: -0.49, -0.35) and -0.06 (95%CI: -0.08, -0.04) respectively. Benefits were observed for all other study outcomes. Mean peer reduction in zBMI was associated with a reduction in participant zBMI in the instrumental variables model (B=0.78, p=0.04, 95%CI: 0.03, 1.53). Mean program attendance and retention were 70.8% and 84.7% respectively. Conclusion: Similar to recently published efficacy trial results, implementing MEND 7–13 under service level conditions was associated with short-term improvements in anthropometric, fitness and psychological indices in a large sample of underserved overweight and obese children. A peer effect was quantified showing that benefits for an individual child were enhanced if peers in the same group also performed well. To our knowledge, this is the first study to show positive peer effects associated with participation in a childhood obesity intervention.

OBJECTIVES: To assess how outcomes associated with participation in a family-based weight management intervention (MEND 7-13, Mind, Exercise, Nutrition..Do it!) for childhood overweight or obesity implemented at scale in the community vary by child, family, neighbourhood and MEND programme characteristics. METHODS/SUBJECTS: Intervention evaluation using prospective service level data. Families (N=21,132) with overweight children are referred, or self-refer, to MEND. Families (participating child and one parent/carer) attend two sessions/week for 10 weeks (N=13,998; N=9563 with complete data from 1788 programmes across England). Sessions address diet and physical activity through education, skills training and motivational enhancement. MEND was shown to be effective in obese children in a randomised controlled trial (RCT). Outcomes were mean change in body mass index (BMI), age- and sex-standardised BMI (zBMI), self-esteem (Rosenberg scale) and psychological distress (Strengths and Difficulties Questionnaire) after the 10-week programme. Relationships between the outcome and covariates were tested in multilevel models adjusted for the outcome at baseline. RESULTS: After adjustment for covariates, BMI reduced by mean 0.76 kg m(-2) (s.e.=0.021, P<0.0001), zBMI reduced by mean 0.18 (s.e.=0.0038, P<0.0001), self-esteem score increased by 3.53 U  (s.e.=0.13, P<0.0001) and psychological distress score decreased by 2.65 U (s.e.=0.31, P<0.0001). Change in outcomes varied by participant, family, neighbourhood and programme factors. Generally, outcomes improved less among children from less advantaged backgrounds and in Asian compared with white children. BMI reduction under service conditions was slightly but not statistically significantly less than in the earlier RCT. CONCLUSIONS: The MEND intervention, when delivered at scale, is associated with improved BMI and psychosocial outcomes on average, but may work less well for some groups of children, and so has the potential to widen inequalities in these outcomes. Such public health interventions should be implemented to achieve sustained impact for all groups.

Abstract

Background: When implemented at scale, the impact on health and health inequalities of public health interventions depends on who receives them in addition to intervention effectiveness. Methods: The MEND 7–13 (Mind, Exercise, Nutrition…Do it!) programme is a family-based weight management intervention for childhood overweight and obesity implemented at scale in the community. We compare the characteristics of children referred to the MEND programme (N=18 289 referred to 1940 programmes) with those of the population eligible for the intervention, and assess what predicts completion of the intervention. Results: Compared to the MEND-eligible population, proportionally more children who started MEND were: obese rather than overweight excluding obese; girls; Asian; from families with a lone parent; living in less favourable socioeconomic circumstances; and living in urban rather than rural or suburban areas. Having started the programme, children were relatively less likely to complete it if they: reported ‘abnormal’ compared to ‘normal’ levels of psychological distress; were boys; were from lone parent families; lived in less favourable socioeconomic circumstances; and had participated in a relatively large MEND programme group; or where managers had run more programmes. Conclusions: The provision and/or uptake of MEND did not appear to compromise and, if anything, promoted participation of those from disadvantaged circumstances and ethnic minority groups. However, this tendency was diminished because programme completion was less likely for those living in less favourable socioeconomic circumstances. Further research should explore how completion rates of this intervention could be improved for particular groups.

Purpose of review: Air-displacement plethysmography holds promise as an alternative to more traditional body composition techniques, although our understanding of air-displacement plethysmography is less than complete, Specifically, factors that influence its validity and application in certain populations, for example children, the obese, and athletes, must be better understood. This review will summarize recent findings on the validity and precision of air-displacement plethysmography and will focus primarily on papers published since 2004, with particular attention on its use in infants. Recent findings: The most significant recent findings in the air-displacement plethysmography literature are mechanistic in nature specifically dealing with measurement issues such as heat, moisture, clothing, and recently, inter-device variability. Summary: It is important to recognize that air-displacement plethysmography can be a practical instrument in the evaluation of body composition in a wide range of populations. Therefore, based on the body of literature that has emerged, air-displacement plethysmography appears to be a suitable and reliable instrument in the assessment of body composition. Of particular interest is its use in pediatric and obese individuals, areas requiring further study. Research is also needed to help us better understand sources of measurement error. © 2005 Lippincott Williams & Wilkins.

Palliative and End of Life Care (PEoLC) is considered internationally as an essential health service for all people with chronic progressive conditions, and it is a key part of the required global systemwide response to realign health and social care to the needs of our aging populations. Leeds Palliative Care Network (LPCN) has been leading a project to improve PEoLC in the Community in Leeds. The focus of the project is PEoLC within the community in Leeds, including interface with hospital-based care. This report provides detail of the work undertaken by Leeds Beckett University to support Phase 1 of the project.

Background: The prevalence of obesity in English adults and children has reached critical levels. Obesity is determined by a wide range of factors including the environment and actions to reduce obesity prevalence requires a whole systems approach. The spatial planning system empowers local authorities to manage land use and development decisions to tackle obesogenic environments. Methods: This research aimed to better understand what and how planning powers are being utilised by local authorities to help tackle population obesity. It reviewed literature on the six planning healthy weight environments themes. It identified what powers exist within the planning system to address these themes. It collated professionals’ perspectives on the barriers and opportunities through focus groups within local authorities and semi-structured interviews with national stakeholders. Results: The research complements current research on the association between the environment and obesity outcomes, though methods employed by researchers in the literature were inconsistent. It identified three categories of planning powers available to both require and encourage those with responsibilities for and involvement in planning healthy weight environments. Through direct engagement with practitioners, it highlighted challenges in promoting healthy weight environments, including wider systems barriers such as conflicting policy priorities, lack of policy prescription and alignment at local levels, and impact from reduced professional and institutional capacity in local government. Conclusions: The conclusions support a small but increasing body of research which suggests that policy makers need to ensure barriers are removed before planning powers can be effectively used to promote healthy weight environments as part of a whole systems approach. The research is timely with continuing policy and guidance focus on tackling obesity prevalence from national government departments and their agencies. This research was conducted as part of a Master of Research at Leeds Beckett University associated with a national whole-systems to obesity programme.

Background: The prevalence of obesity in English adults and children has reached critical levels. Obesity is determined by a wide range of factors including the environment and actions to reduce obesity prevalence requires a whole systems approach. The spatial planning system empowers local authorities to manage land use and development decisions to tackle obesogenic environments. Methods: This research aimed to better understand what and how planning powers are being utilised by local authorities to help tackle population obesity. It reviewed literature on the six planning healthy weight environments themes. It identified what powers exist within the planning system to address these themes. It collated professionals’ perspectives on the barriers and opportunities through focus groups within local authorities and semi-structured interviews with national stakeholders. Results: The research complements current research on the association between the environment and obesity outcomes, though methods employed by researchers in the literature were inconsistent. It identified three categories of planning powers available to both require and encourage those with responsibilities for and involvement in planning healthy weight environments. Through direct engagement with practitioners, it highlighted challenges in promoting healthy weight environments, including wider systems barriers such as conflicting policy priorities, lack of policy prescription and alignment at local levels, and impact from reduced professional and institutional capacity in local government. Conclusions: The conclusions support a small but increasing body of research which suggests that policy makers need to ensure barriers are removed before planning powers can be effectively used to promote healthy weight environments as part of a whole systems approach. The research is timely with continuing policy and guidance focus on tackling obesity prevalence from national government departments and their agencies. This research was conducted as part of a Master of Research at Leeds Beckett University associated with a national whole-systems to obesity programme.

Obesity is a complex problem with multiple causes and significant implications for health and beyond. With the majority of adults in England overweight or obese, and a substantial number of children on the same trajectory, particularly those in the most deprived areas, national and local action is needed now. We know that there is no one single solution. Tackling such an ingrained problem requires a long-term, system-wide approach that makes obesity everybody’s business, is tailored to local needs and works across the life course.

Purpose: This report provides the final phase of feedback, capturing insights into the implementation of Project HE:RO across the four intervention schools. These insights can be used to increase the programme effectiveness for year two. Method: Interviews were conducted with Evolve health mentors (n=4), teachers (n=12) and senior leaders (n=5). Focus groups and interviews were transcribed and analysed thematically to highlight critical areas of the intervention, considering what is working well and what are the current challenges. Results: During the analysis, seven overarching themes were identified with 26 sub-themes. The overarching themes were: (i) teachers beliefs about Project HE:RO, (ii) relationships between health mentors and school staff, (iii) implementing project HE:RO, (iv) implementing the mentoring sessions (v) perceived pupil engagement and relationship with health mentors (vi) behavioural management and (vii) health mentors competencies and future personal development. Conclusion: Overall the evaluation on Project HE: RO’s pilot study has identified a myriad of benefits. All schools reported improved trust for teachers in the relevance of the programme for their children’s health. Senior leaders, teachers and health mentors all expressed perceived engagement levels form the children; often describing the children as happy and healthy pupils enjoying the programme. Throughout the year, health mentors have demonstrated improved competence and confidence levels. Drawn from the themes, three considerations for future investment were discussed to improve the provision and implementation of Project HE:RO: (i) tackling school staff’s lack of ownership, (ii) project personalisation to increase the alignment to the school’s ethos and existing provision and (iii) health mentor’s personal development. Our recommendation for Evolve would be to continue actioning the best practices of the project in combination with a discussion around the action points and considerations to improve the success of project HE:RO for the second year the implementation.

Aims: This study presents data gathered as part of the Re:Mission evaluation of the NHS low-calorie diet programme pilot for Type 2 Diabetes, to address two research questions: 1) What is the presence and severity of emotional and binge eating within this population? 2) Are demographic and health factors associated with the presence of binge eating or the severity of emotional eating? Methods: An online survey gathered data from n = 580 individuals who were enrolled on the programme but had not yet begun total diet replacement. The survey assessed emotional eating (TFEQ-R21), potential Binge Eating Disorder diagnosis (BEDS-7), wellbeing (Short Warwick-Edinburgh Mental Wellbeing Scale), quality of life (EQ-5D-5L), frequency of weight cycling and demographic factors (collected via NHS England programme monitoring). Descriptive statistics and regression analyses were used to address the research questions. Results: The mean emotional eating score from the TFEQ-R21 was 2.58 (0.96), and the presence of potential Binge Eating Disorder diagnosis was demonstrated in 26.0% of the sample. Regression analyses suggested that being female and engaging in more frequent weight cycling was associated with higher emotional eating and greater likelihood of binge eating. Lower wellbeing and lower quality of life were associated with emotional and binge eating, respectively. Conclusions: Rates of emotional and binge eating in the NHS low-calorie diet pilot sample are higher than in the general public, and in other similar samples. Consideration should be given to screening for emotional and disordered eating, and for additional tailored support and monitoring for such individuals.

This feature article is written by some of the Editorial Board at Perspectives in Public Health. It introduces the use of Plain Language Summaries, how to write one and the benefits of including them in your article.

Objective. The aim of the study was to evaluate air-displacement plethysmography (ADP) thoracic gas volume (TGV) prediction equations in children representing a wide range of body mass index (BMI). Methods. 254 children (5 to 17 years) were recruited from two centres (England and the United States). Subjects were stratified into three BMI categories according to the International Obesity TaskForce (IOTF) criteria: lean (48 male, 42 female), overweight (15 male, 29 female), and obese (52 male, 68 female). As part of the normal ADP procedure, TGV was measured (TGVMeas), predicted using child specific equations developed by Fields (TGVFields) and adult derived equations by Crapo (TGVCrapo) with percentage body fat (PF) estimates subsequently calculated (PFMeas, PFFields, PFCrapo). Results. Compared with the mean TGVMeas, the TGVFields estimates were within ±0.2 L in all groups, except obese males (+0.5 L), while the mean TGVCrapo estimates were greater than ±0.3 L in all groups except lean males (+0.1 L). When converted to PF, the mean PFFields estimates were within ±1% of the measured value in all groups, except obese males (+1.1%), while the mean PFCrapo estimates were greater than ±1% in all groups, except lean males (+0.5%). Using either prediction equation, Bland-Altman analysis revealed that the greatest PF±95% limits of agreement were in the lean and overweight groups and lowest in the obese groups. Conclusion. The Fields child-specific TGV prediction equations provide accurate mean PF estimates and appear better than using the Crapo equations if a measured TGV cannot be achieved in children of a wide range of BMI. However, individual predictions may result in large PF errors especially in lean children.

Purpose: Psychosocial Interventions (PSI) are commonly utilised in mental health management, and to our knowledge, have not been explicitly used in weight management. PSI are characterised by three distinct phases: 1) an initial in-depth assessment; 2) an intensive group intervention to stabilise the condition (in this instance weight gain); and 3) an intensive group maintenance programme. PSI focus on the psychosocial elements of obesity, including: stress management, body dysmorphia and self-esteem. As such, the PSI approach is more holistic than traditional weight management approaches. This paper evaluated the outcomes of a PSI when delivered under service level conditions. Methods: SHINE (Self-Help, Independence, Nutrition, and Exercise) is a community-based weight management programme that implements a PSI approach. The programme is located in Sheffield, UK. Adolescents (n = 393) with severe obesity signed onto the programme between 2011 and 2013. The programme spans 12-15 months and participants attend three phases of the PSI. Phase One is undertaken before the programme, Phase Two is a 12-week intervention and Phase Three is split into three 12-week maintenance interventions. Anthropometric measurements (BMI and WC) were collected at baseline, 3-, 6-, 9- and 12-months. Psychosocial measures (self-esteem, anxiety and depression) were collected at baseline and 3-months. Participant retention was also assessed. Results: 304 participants started the programme and 289 were retained at 3 months. At 3 months BMI z-score reduced by 0.21 (95% CI: 0.19, 0.24) and WC by 7.8cm (95% CI: 7.2, 8.5). Almost 25% of participants reduced their BMI classification (e.g. severely obese to obese). Anxiety and self-esteem improved by 63% and 50% respectively. 89 participants continued to attend the programme after 12 months, obtaining a BMI z-score reduction of 0.46 (95% CI: 0.35, 0.58) and a WC reduction of 10.5cm (95% CI: 7.8, 13.1). Conclusions: Obesity is a highly complex condition to manage and requires intensive and prolonged support to produce meaningful and lasting behavioural and anthropometric changes. The SHINE PSI approach has shown promise and demonstrated encouraging results - suggesting that it may be beneficial for interventions to consider wider determinants of health and wellbeing beyond simply diet and physical activity.

Background: There has been considerable interest in the role of access to unhealthy food options as a determinant of weight status. There is conflict across the literature as to the existence of such an association, partly due to the dominance of cross-sectional study designs and inconsistent definitions of the food environment. The aim of our study is to use longitudinal data to examine if features of the food environment are associated to measures of adolescent weight status. Methods: Data were collected from secondary schools in Leeds (UK) and included measurements at school years 7 (ages 11/12), 9 (13/14), and 11 (15/16). Outcome variables, for weight status, were standardised body mass index and standardised waist circumference. Explanatory variables included the number of fast food outlets, supermarkets and ‘other retail outlets’ located within a 1 km radius of an individual’s home or school, and estimated travel route between these locations (with a 500 m buffer). Multi-level models were fit to analyse the association (adjusted for confounders) between the explanatory and outcome variables. We also examined changes in our outcome variables between each time period. Results: We found few associations between the food environment and measures of adolescent weight status. Where significant associations were detected, they mainly demonstrated a positive association between the number of amenities and weight status (although effect sizes were small). Examining changes in weight status between time periods produced mainly non-significant or inconsistent associations. Conclusions: Our study found little consistent evidence of an association between features of the food environment and adolescent weight status. It suggests that policy efforts focusing on the food environment may have a limited effect at tackling the high prevalence of obesity if not supported by additional strategies.

PURPOSE: Psychosocial interventions (PSIs) are characterized by three phases: (1) an initial in-depth assessment, (2) an intensive multifaceted intervention to stem a condition, and (3) an extensive maintenance program. PSIs are often used for treatment of mental health conditions; however, applicability in the treatment of adolescent obesity is unknown. This article sought to evaluate the service-level outcomes of a PSI for young people (aged 10-17) with severe obesity. METHODS: A retrospective evaluation of participants attending the Self Help, Independence, Nutrition and Exercise program between 2011 and 2016 (n = 435; age: 13.1 ± 2.1 years, male: 51%, white: 87.4%, body mass index [BMI]: 33.5 ± 7.5 kg/m(2), standardized BMI [BMI SDS]: 3.1 ± .5 units). Anthropometric measurements (BMI and waist circumference) were collected at baseline, 3, 6, 9, and 12 months. Psychosocial measures (anxiety, depression, and self-esteem) were collected at baseline and 3 months. Participant retention was also assessed. RESULTS: After 3 months, 95% of participants remained with a mean BMI SDS reduction of .19 units (95% confidence interval: .17, .21). Anxiety, depression, and self-esteem improved by 50%, 54%, and 38%, respectively. BMI SDS reductions of .29, .35, and .41 units were found at 6, 9, and 12 months. Fifty-four percent of participants chose to attend the final intervention phase. A higher baseline BMI SDS and a greater reduction in BMI SDS predicted final intervention phase attendance. CONCLUSIONS: The Self Help, Independence, Nutrition and Exercise PSI demonstrated positive mean reductions in all measurements across all time points. In contrast to other community-based weight management services, these results suggest the utility of, and further exploration of, PSIs in the treatment of severe adolescent obesity.

This report accompanies a guide and set of resources to support local authorities in implementing a whole-systems approach to addressing obesity and promoting healthy weight from Public Health England.

This pilot study explored the use of a novel behavioural artificial intelligence (AI) tool to examine whether personality is associated with the lived experience of the NHS England launched a low calorie diet (LCD). A cross-sectional survey was disseminated to service users to gather data on emotional wellbeing, physical activity, pain, motivation to manage diabetes, motivation to lose weight, rating of total diet replacement (TDR) products and frequency of using fibre supplements. The scaled insights behavioural AI tool was used to infer personality traits from service users' language construction, and in doing so, examine associations with the outcomes indicated above. Findings show that service users can be profiled by personality, and this can provide a method of understanding programme outcomes. Three clusters of personality traits were identified. Despite this, there was no association between personality features and emotional wellbeing, physical activity, pain, motivation to manage diabetes, motivation to lose weight, rating of TDR products and frequency of using fibre supplements. As the self-selected sample size was limited, future research should examine the use of behavioural AI tools and personality using larger and longitudinal samples.

Background: Systems thinking is integral to working effectively within complex systems, such as those which drive the current population levels of overweight and obesity. It is increasingly recognised that a systems approach – which corrals public, private, voluntary and community sector organisations to make their actions and efforts coherent – is necessary to address the complex drivers of obesity. Identifying, implementing and evaluating actions within complex adaptive systems is challenging, and may differ from previous approaches used in public health. Methods: Within this conceptual article, we present the Action Scales Model (ASM). The ASM is a simple tool to help policymakers, practitioners and evaluators to conceptualise, identify and appraise actions within complex adaptive systems. We developed this model using our collective expertise and experience in working with local government authority stakeholders on the Public Health England Whole Systems Obesity programme. It aligns with, and expands upon, previous models such as the Intervention Level Framework, the Iceberg Model and Donella Meadows’ 12 places to intervene within a system. Results: The ASM describes four levels (synonymous with leverage points) to intervene within a system, with deeper levels providing greater potential for changing how the system functions. Levels include events, structures, goals and beliefs. We also present how the ASM can be used to support practice and policy, and finish by highlighting its utility as an evaluative aid. Discussion: This practical tool was designed to support those working at the front line of systems change efforts, and while we use the population prevalence of obesity as an outcome of a complex adaptive system, the ASM and the associated principles can be applied to other issues. We hope that the ASM encourages people to think differently about the systems that they work within and to identify new and potentially more impactful opportunities to leverage change.

Abstract

This paper introduces the Qualitative Systems Exploration Model (QSEM), a new semi-quantitative framework for systematically interpreting and analysing Causal Loop Diagrams within participatory system dynamics. QSEM is applied at late-stage model conceptualisation and offers researchers and modelling practitioners a set of tools and techniques to improve transparency and reproducibility in model assessment, ensuring that component and feedback structure selections are traceable and well-justified. Throughout its three core phases: (i) System Factor Classification; (ii) Loops of Interest; and, (iii) Archetype Identification and Analysis, QSEM integrates with established Group Model Building scripts to facilitate structured participant engagement and collaborative sensemaking. Real-world application is demonstrated in a commissioned government project aimed at understanding factors influencing dietary choices and food systems, where the framework helped identify potential policy-relevant system drivers. Future directions involve applying QSEM in other projects, evaluating its robustness, consistency and scalability, refining archetype detection, enhancing data visualisation, and exploring dedicated software solutions to expand its utility in qualitative SD.

BACKGROUND: Health and wellbeing can be profoundly impacted by both obesity and type 2 diabetes, while the normalisation and equity of care for people living with these non-communicable diseases remain as challenges for local health systems. The National Health Service Low Calorie Diet programme in England, aims to support people to achieve type 2 diabetes remission, while also reducing health inequalities. We have explored the experiences of health care staff who have made a referral to the LCD programme, while identifying effective and equitable delivery of programme referrals, and their normalisation into routine care. METHODS: Nineteen individual semi-structured interviews were completed health care staff in the first year of the Low Calorie Diet programme. Interviewees were purposively sampled from the ten localities who undertook the Low Calorie Diet programme pilot. Each interview explored a number of topics of interest including communication and training, referrals, equity, and demands on primary care, before being subjected to a thematic analysis. RESULTS: From the data, five core themes were identified: Covid-19 and the demands on primary care, the expertise and knowledge of referrers, patient identification and the referral process, barriers to referrals and who gets referred to the NHS LCD programme. Our findings demonstrate the variation in the real world settings of a national diabetes programme. It highlights the challenge of COVID-19 for health care staff, whereby the increased workload of referrals occurred at a time when capacity was curtailed. We have also identified several barriers to referral and have shown that referrals had not yet been normalised into routine care at the point of data collection. We also raise issues of equity in the referral process, as not all eligible people are informed about the programme. CONCLUSIONS: Referral generation had not yet been consistently normalised into routine care, yet our findings suggest that the LCD programme runs the risk of normalising an inequitable referral process. Inequalities remain a significant challenge, and the adoption of an equitable referral process, normalised at a service delivery level, has the capacity to contribute to the improvement of health inequalities.

Background: Attrition remains a significant public health challenge as individuals who do not complete programmes are likely to have poorer programme outcomes. On calorie- restricted diets, including the NHS Low Calorie Diet (LCD) Programme pilot, approximately 50% of people are discharged prematurely, and thus do not complete the programme. Reducing attrition therefore has the potential to improve programme efficacy, impact and cost-effectiveness. Methods: Ten semi-structured interviews were conducted with purposively sampled individuals who did not complete the NHS LCD programme. Interviews explored service user experiences of the programme and experiences of being discharged. Interview data were analysed thematically. Results: Four core themes were identified: 1) the pre- programme struggles of service users and their route to LCD; 2) a positive and impactful programme; 3) life gets in the way; and 4) a perceived lack of support from the provider. These findings show that individuals had pre-programme struggles and a series of life events that constrained their good intentions, and whilst they were positive about the programme, they were critical of the support they received from providers to deal with their life circumstances. Conclusions: Policy makers and providers can act proportionately to ensure that programmes, such as the NHS LCD Programme pilot, recognise the circumstances and context of people’s lives, and take a more person-centred approach.

Background: The small Atlantic island of St Helena is a United Kingdom Overseas Territory (UKOT) with a high prevalence of childhood obesity (over a quarter of 4-5 and 10-11 year olds) and, anecdotally, adulthood obesity and its associated health detriments. St Helena have taken a whole systems approach to obesity (WSAO) to address the issue. A WSAO recognises the factors that impact obesity as a complex system and requires a ‘health in all policies’ approach. UK academic and public health technical support was provided to the local St Helena delivery team. This process evaluation sought to explore the early stages of the WSAO implementation and implications for the transferability of the approach to other small island developing states and UKOT. Methods: Data was collected via eight semi-structured interviews, paper based and online surveys, and document analysis. Thematic analysis was used to analyse the data. Results: The analysis identified three factors which aided the first phase of WSAO implementation: (1) senior leaders support for the approach; (2) the academic support provided to establish and develop the approach; and (3) effective adaptation of UK Government resources to suit the local context. Key challenges of early implementation included: maintaining and broadening stakeholder engagement; limited local workforce capacity and baseline knowledge related to obesity and systems thinking; and limited capacity for support from the UK-based academic team due to contract terms and COVID-19 restrictions. Conclusions: Early stages of implementation of a WSAO in a UKOT can be successful when using UK’s resources as a guide and adapting them to a small island context. All participants recommended other small islands adopt this approach. Continued senior support, dedicated leadership, and comprehensive community engagement is needed to progress implementation and provide the foundation for long-term impact. Small island developing states considering adopting a WSAO should consider political will, senior level buy-in and support, funding, and local workforce knowledge and capacity to enable the best chances of successful and sustainable implementation.

OBJECTIVES: To examine the validity of body composition estimates obtained using foot-to-foot bio-electrical impedance analysis (BIA) in overweight and obese children by comparison to a reference four-compartment model (4-CM). SUBJECTS/METHODS: 38 males: age (mean +/- sd) 13.6 +/- 1.3 years, body mass index 30.3 +/- 6.0 kg.m(-2) and 14 females: age 14.7 +/- 2.2 years, body mass index 32.4 +/- 5.7 kg.m(-2) participated in the study. Estimates of fat-free mass (FFM), fat mass (FM) and percentage body fat (PBF) obtained using a Tanita model TBF-310 and a 4-CM (derived from body mass, body volume, total body water and total body bone mineral measurements) were compared using bias and 95% limits of agreement (Tanita minus 4-CM estimates). RESULTS: Body composition estimates obtained with the Tanita TBF-310 were not significantly different from 4-CM assessments: for all subjects combined the bias was -0.7kg for FM, 0.7kg for FFM and -1.3% for PBF. However, the 95% limits of agreement were substantial for individual children: males, up to +/-9.3kg for FFM and FM and +/-11.0% for PBF; females, up to +/-5.5kg for FFM and FM and +/-6.5% for PBF. CONCLUSIONS: The Tanita TBF-310 foot-to-foot BIA body composition analyser with the manufacturer's prediction equations is not recommended for application to individual children who are overweight and obese although it may be of use for obtaining group mean values.

Objective. The evidence base for child obesity treatment is weak. Children's weight-loss camps, despite their popularity, have not been properly evaluated. This study evaluated the effectiveness of a residential weight-loss camp program for overweight and obese children. Methods. A total of 185 overweight children (mean age: 13.9 years) enrolled in 1 of 4 consecutive programs between 1999 and 2002 (intervention group) were compared with 94 children of similar ages who were not camp attendees, ie, 38 overweight children and 56 normal-weight children. The intervention group attended a 6-week (maximum) summer residential weight-loss camp. The program included a daily schedule of six 1-hour, skill-based, fun, physical activity sessions, moderate dietary restriction, and group-based educational sessions. All children were assessed for body weight, height, and other anthropometric measures, blood pressure, aerobic fitness, self-esteem, and selected sports skills. Results. Campers, who stayed for a mean of 29 days, lost 6.0 kg, reduced their BMI by 2.4 units, and reduced their BMI SD scores by 0.28. Fat mass decreased significantly (from 42.7 to 37.1 kg), whereas fat-free mass did not change. In contrast, both comparison groups gained weight during this period. Camp attendees also showed significant improvements in blood pressure, aerobic fitness, and self-esteem. Longer durations of stay were associated with greater improvements in outcomes. Conclusions. In the short term at least, this weight-loss program was effective across a range of health outcomes. Ongoing research is examining the maintenance of these improvements. Future research should investigate whether benefits can be generalized across weight-loss camps and how the intervention can be adapted to nonresidential, term-time settings.

Abstract

Objective: To compare percentage body fat (percentage fat) estimates from DXA and air displacement plethysmography (ADP) in overweight and obese children.

Research Methods and Procedures: Sixty‐nine children (49 boys and 20 girls) 14.0 ± 1.65 years of age, with a BMI of 31.3 ± 5.6 kg/m2 and a percentage fat (DXA) of 42.5 ± 8.4%, participated in the study. ADP body fat content was estimated from body density (Db) using equations devised by Siri (ADPSiri) and Lohman (ADPLoh).

Results: ADP estimates of percentage fat were highly correlated with those of DXA in both male and female subjects (r = 0.90 to 0.93, all p < 0.001; standard error of estimate = 2.50% to 3.39%). Compared with DXA estimates, ADPSiri and ADPLoh produced significantly (p < 0.01) lower estimates of mean body fat content in boys (−2.85% and −4.64%, respectively) and girls (−2.95% and −5.15%, respectively). Agreement between ADP and DXA methods was further examined using the total error and methods of Bland and Altman. Total error ranged from 4.46% to 6.38% in both male and female subjects. The 95% limits of agreement were relatively similar for all percentage fat estimates, ranging from ±6.73% to ±7.94%.

Discussion: In this study, conversion of Db using the Siri equation led to mean percentage fat estimates that agreed better with those determined by DXA compared with the Lohman equations. However, relatively high limits of agreement using either equation resulted in percentage fat estimates that were not interchangeable with percentage fat determined by DXA.

Objective: To evaluate the accuracy of percentage body fat (%fat) estimates from air displacement plethysmography (ADP) against an increasingly recognised criterion method, dual-energy X-ray absorptiometry (DXA), in young adolescents. Design: Cross-sectional evaluation. Setting: Leeds General Infirmary, Centre for Bone and Body Composition Research, Leeds, UK. Subjects: In all, 28 adolescents (12 males and 16 females), age (mean±s.d.) 14.9±0.5y, body mass index 21.2±2.9 kg/m

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The objective of the present study was to investigate the accuracy of percent body fat (%fat) estimates from dual-energy X-ray absorptiometry, air-displacement plethysmography (ADP), and total body water (TBW) against a criterion four-compartment (4C) model in overweight and obese children. A volunteer sample of 30 children (18 male and 12 female), age of (mean ± SD) 14.10 ± 1.83 yr, body mass index of 31.6 ± 5.5 kg/m, and %fat (4C model) of 41.2 ± 8.2%, was assessed. Body density measurements were converted to %fat estimates by using the general equation of Siri (ADPSiri) (Siri WE. Techniques for Measuring Body Composition. 1961) and the age- and gender-specific constants of Lohman (ADPLoh) (Lohman TG. Exercise and Sport Sciences Reviews. 1986). TBW measurements were converted to %fat estimates by assuming that water accounts for 73% of fat-free mass (TBW73) and by utilizing the age- and gender-specific water contents of Lohman (TBWLoh). All estimates of %fat were highly correlated with those of the 4C model ( r ≥ 0.95, P < 0.001; SE ≤ 2.14). For %fat, the total error and mean difference ± 95% limits of agreement compared with the 4C model were 2.50, 1.8 ± 3.5 (ADPSiri); 1.82, -0.04 ± 3.6 (ADPLoh); 2.86, -2.0 ± 4.1 (TBW73); 1.90, -0.3 ± 3.8 (TBWLoh); and 2.74, 1.9 ± 4.0 DXA (dual-energy X-ray absorptiometry), respectively. In conclusion, in overweight and obese children, ADPLoh and TBWLoh were the most accurate methods of measuring %fat compared with a 4C model. However, all methods under consideration produced similar limits of agreement.

Geographic Information Systems (GIS) are widely used to measure retail food environments. However the methods used are hetrogeneous, limiting collation and interpretation of evidence. This problem is amplified by unclear and incomplete reporting of methods. This discussion (i) identifies common dimensions of methodological diversity across GIS-based food environment research (data sources, data extraction methods, food outlet construct definitions, geocoding methods, and access metrics), (ii) reviews the impact of different methodological choices, and (iii) highlights areas where reporting is insufficient. On the basis of this discussion, the Geo-FERN reporting checklist is proposed to support methodological reporting and interpretation.

Background: Current UK policy in relation to the influence of the ‘food environment’ on childhood obesity appears to be driven largely on assumptions or speculations because empirical evidence is lacking and findings from studies are inconsistent. The aim of this study was to investigate the number of food outlets and the proximity of food outlets in the same sample of children, without solely focusing on fast food. Methods: Cross sectional study over 3 years (n = 13,291 data aggregated). Body mass index (BMI) was calculated for each participant, overweight and obesity were defined as having a BMI >85th (sBMI 1.04) and 95th (sBMI 1.64) percentiles respectively (UK90 growth charts). Home and school neighbourhoods were defined as circular buffers with a 2 km Euclidean radius, centred on these locations. Commuting routes were calculated using the shortest straight line distance, with a 2 km buffer to capture varying routes. Data on food outlet locations was sourced from Leeds City Council covering the study area and mapped against postcode. Food outlets were categorised into three groups, supermarkets, takeaway and retail. Proximity to the nearest food outlet in the home and school environmental domain was also investigated. Age, gender, ethnicity and deprivation (IDACI) were included as covariates in all models. Results: There is no evidence of an association between the number of food outlets and childhood obesity in any of these environments; Home Q4 vs. Q1 OR = 1.11 (95% CI = 0.95-1.30); School Q4 vs. Q1 OR = 1.00 (95% CI 0.87 – 1.16); commute Q4 vs. Q1 OR = 0.1.00 (95% CI 0.83 – 1.20). Similarly there is no evidence of an association between the proximity to the nearest food outlet and childhood obesity in the home (OR = 0.77 [95% CI = 0.61 – 0.98]) or the school (OR = 1.01 [95% CI 0.84 – 1.23]) environment. Conclusions: This study provides little support for the notion that exposure to food outlets in the home, school and commuting neighbourhoods increase the risk of obesity in children. It seems that the evidence is not well placed to support Governmental interventions/recommendations currently being proposed and that policy makers should approach policies designed to limit food outlets with caution.

Despite considerable research, evidence supporting associations between the ‘Retail Food Environment’ (RFE) and obesity remains mixed. Differences in the methods used to measure the RFE may explain this heterogeneity. Using data on a large (n = 10,111) sample of adults from the Yorkshire Health Study (UK), we modelled cross-sectional associations between the RFE and weight status using (i) multiple definitions of ‘Fast Food’, ‘Convenience’ and ‘Supermarkets’ and (ii) multiple RFE metrics, identified in a prior systematic review to be common in the literature. Both the choice of outlet definition and the choice of RFE metric substantively impacted observed associations with weight status. Findings differed in relation to statistical significance, effect sizes, and directions of association. This study provides novel evidence that the diversity of RFE measurement methods is contributing to heterogeneous study findings and conflicting policy messages. Greater attention is needed when selecting and communicating RFE measures in research.

Background: Secondary data containing the locations of food outlets is increasingly used in nutrition and obesity research and policy. However, evidence evaluating these data is limited. This study validates two sources of secondary food environment data: Ordnance Survey Points of Interest data (POI) and food hygiene data from the Food Standards Agency (FSA), against street audits in England and appraises the utility of these data. Methods: Audits were conducted across 52 Lower Super Output Areas in England. All streets within each Lower Super Output Area were covered to identify the name and street address of all food outlets therein. Audit-identified outlets were matched to outlets in the POI and FSA data to identify true positives (TP: outlets in both the audits and the POI/FSA data), false positives (FP: outlets in the POI/FSA data only) and false negatives (FN: outlets in the audits only). Agreement was assessed using positive predictive values (PPV: TP/(TP+FP)) and sensitivities (TP/(TP+FN)). Variations in sensitivities and PPVs across environment and outlet types were assessed using multi-level logistic regression. Proprietary classifications within the POI data were additionally used to classify outlets, and agreement between audit-derived and POI-derived classifications was assessed. Results: Street audits identified 1172 outlets, compared to 1100 and 1082 for POI and FSA respectively. PPVs were statistically significantly higher for FSA (0.91, CI: 0.89-0.93) than for POI (0.86, CI: 0.84-0.88). However, sensitivity values were not different between the two datasets. Sensitivity and PPVs varied across outlet types for both datasets. Without accounting for this, POI had statistically significantly better PPVs in rural and affluent areas. After accounting for variability across outlet types, FSA had statistically significantly better sensitivity in rural areas and worse sensitivity in rural middle affluence areas (relative to deprived). Audit-derived and POI-derived classifications exhibited substantial agreement (p < 0.001; Kappa = 0.66, CI: 0.63 - 0.70). Conclusions: POI and FSA data have good agreement with street audits; although both datasets had geographic biases which may need to be accounted for in analyses. Use of POI proprietary classifications is an accurate method for classifying outlets, providing time savings compared to manual classification of outlets.

Objective: To investigate the value of additional days of active commuting for meeting a criterion of 300+ minutes of moderate-to-vigorous physical activity (MVPA; 60+ mins/day x 5) during the school week.

Methods: Based on seven-day diaries supported by teachers, binary logistic regression analyses were used to predict achievement of MVPA criteria according to days of active commuting to and from school. MVPA was recorded across five time points: (a) before school, (b) walking/cycling to and from school, (c) during school, (d) in school-based clubs and (e) during leisure time. The study was conducted in Derby, UK, in June 2006.

Results: Active commuting was reported by 4218 (78 per cent of 5422) children for an average daily commuting time of 18.4 ± 16.4 minutes. Children who commuted on more days in the week were most likely to achieve the MVPA criterion. Every day of active commuting doubled the chances of meeting the MVPA criterion; in Year 10 girls this effect was stronger (odds ratio 6.45).

Conclusion: Results confirm the ubiquity of active commuting among young people. Even one additional day of active commuting helps to meet established criteria. In older girls active commuting is uniquely powerful in contributing to attainment of public health targets of MVPA.

Understanding the determinants of attendance at public health interventions is critical for effective policy development. Most research focuses on individual-level determinants of attendance, while less is known about environmental-level determinants. Data were obtained from the Leeds Let's Get Active public health intervention in Leeds, England. Longitudinal data (April 2015–March 2016) on attendance were obtained for n = 25,745 individuals (n = 185,245 total visits) with baseline data on sociodemographic determinants and lifestyle practices obtained for n = 3621 individuals. This resulted in a total of n = 744,468 days of attendance and non-attendance. Random forests were used to explore the relative importance of the determinants on attendance, while generalised linear models were applied to examine specific associations (n = 3621). The probability that a person will attend more than once, the number of return visits, and the probability that a person will attend on a particular day were investigated. When considering if a person returned to the same leisure centre after one visit, the most influential determinant was the distance from their home. When considering number of return visits overall however, age group was the most influential. While distance to a leisure centre was less important for predicting the number of return visits, the difference between estimates for 300 m and 15,000 m was 7–10 visits per year. Finally, calendar month was the most important determinant of daily attendance. This longitudinal study highlights the importance of both individual and environmental determinants in predicting various aspects of attendance. It has implications for strategies aiming to increase attendance at public health interventions.

Background Modifying the environment is considered an effective population-level approach for increasing healthy behaviours, but associations remain ambiguous. This exploratory study aims to compare researcher-defined buffers and self-drawn neighbourhoods (SDN) to objectively measured availability of physical activity (PA) facilities and greenspaces in adolescents. Methods Seven consecutive days of GPS data were collected in an adolescent sample of 14–18 year olds (n = 69). Using Points of Interest and greenspace data, availability of PA opportunities within activity spaces were determined. We compared 30 different definitions of researcher-defined neighbourhoods and SDNs to objectively measured availability. Results :Findings showed low agreement for all researcher-defined buffers in measuring the availability of PA facilities in activity spaces. However, results were less clear for greenspace. SDNs also demonstrate low agreement for capturing availability to the PA environment. Conclusion This exploratory study highlights the inadequacy of researcher-defined buffers and SDNs to define availability to environmental features.

Background There is a persistent lack of understanding on the influence of the environment on behaviour and health. While the environment is considered an important modifiable determinant of health behaviour, past research assessing environments often relies on static, researcher-defined buffers of arbitrary distance. This likely leads to misrepresentation of true environmental exposures. This exploratory study aims to compare researcher-defined and self-drawn buffers in reflecting the spaces and time adolescents engage in physical activity (PA) and sedentary behaviour. It also investigates if adolescent’s access the PA facility and greenspace nearest their home or school for PA, as well as examine how much time adolescents spent in PA at any PA facilities and greenspaces. Methods Adolescents (aged 14–18 years; n = 34) were recruited from schools in West Yorkshire, England. Seven consecutive days of global positioning system (GPS) and accelerometer data were collected at 15 second intervals. Using ArcGIS, we compared 30 different researcher-defined buffers including: radial, network and ellipse buffers at 400m, 800m, 1000m, 1600m and 3000m and participant-defined self-drawn neighbourhoods to objectively measured PA and sedentary space and PA time. Location of PA was also compared to Points of Interest data to determine if adolescents use the nearest PA facility or greenspace to their home or school and to examine how much PA was undertaken within these locations. Results Our exploratory findings show the inadequacy of researcher-defined buffer size in assessing MVPA space or sedentary space. Furthermore, less than 35% of adolescents used the greenspaces or PA facilities nearest to their home or school. Approximately 50% of time spent in PA did not occur within the home, school, PA facility, or greenspace environments. Conclusion Our exploratory findings help to begin to quantify the inadequacy of researcher-defined, and self-drawn buffers in capturing adolescent MVPA and sedentary space, as well as time spent in PA. Adolescents often do not use PA facilities and greenspaces nearest their home and school and a large proportion of PA is achieved outside PA facilities and greenspaces. Further research with larger samples are needed to confirm the findings of this exploratory study.

Background: The Systems Evaluation Network (SEN) aims to build capability and capacity regarding the use of systems science in public health evaluation. The SEN was established in June 2021 and 3 years from its inception, we undertook a member survey to understand the engagement with, and impact of, the SEN. Methods: An 18-item cross-sectional survey captured quantitative and qualitative responses regarding SEN member perspectives, centring around their experience of the SEN, associated impacts, and future requirements. We analysed quantitative data descriptively and qualitative data through content analysis. Sub-group analyses explored differences between those working in academia vs practice/policy. Results: Seventy-three participants completed the survey, with 60% working in academia and 40% in practice/policy. Considering experiences of the SEN, participants felt the SEN has shared information about innovative methods and evaluation approaches (94.0% agreed), has provided the opportunity to share and learn with other members (86.0% agreed), and has improved knowledge of systems evaluation methods (86.2% agreed). Regarding impacts of the SEN, participants stated that the SEN has increased their capability to apply systems-oriented methods and evaluation of systems approaches (76% agreed) and has facilitated relationships with others (56.9% agreed). Participants shared future capability requirements for evaluation, which focused on methods (e.g. systems dynamics modelling and ripple effects mapping), approaches (e.g. developmental evaluation and embedded researchers), and other ways in which capability could be increased (e.g. by using case studies). Conclusion: This paper illustrates the experiences and impacts of the SEN, identifying its strengths such as the wide range of topics/content and the flexible and accessible delivery format, but contrast against the difficulties of fostering new relationships in an online setting. These findings can help inform the future direction of the SEN and provide insight to other online communities of practice.

Background: In 2020, NHS England commissioned independent commercial service providers to deliver a Low Calorie Diet Programme pilot, offering Total Diet Replacement alongside behavioural support. Methods: This paper presents participant experiences of the programme using both quantitative and qualitative data derived from four cross-sectional surveys, and examines differences by sociodemographics, delivery model and provider. Results: The majority of participants reported a positive experience with the referral process, with a small proportion feeling that insufficient information was provided and that they did not feel respected or listened to by their healthcare professional. Participants’ relationship with their coach was generally positive throughout each phase of the programme, and highlights the importance of coach-participant relationships. The relationship with the coach via digital delivery was less favourable compared to other delivery models, as was the perceived adequacy of support provided. Conclusions: The experience of the referral from general practice and the relationship with the coach are key elements of the participant experience. They demonstrate the importance of, and need for, person-centred care.

Background: There continues to be a lack of understanding as to the geographical area at which the environment exerts influence on behaviour and health. This exploratory study compares different potential methods of both researcher- and participant-defined definitions of neighbourhood reflect an adolescent's activity space. Methods: Seven consecutive days of global positioning system (GPS) tracking data were collected at 15 s intervals using a small exploratory adolescent sample of 14–18 year olds (n = 69) in West Yorkshire, England. A total of 304,581 GPS tracking points were collected and compared 30 different definitions of researcher-defined neighbourhoods including radial, network and ellipse buffers at 400 m, 800 m, 1000 m, 1600 m and 3000 m, as well as participant-defined self-drawn neighbourhoods. Results: This exploratory study supports emerging evidence cautioning against the use of static neighbourhood definitions for defining exposure. Traditional buffers (network and radial) capture at most 67% of activity space (home radial), and at worst they captured only 3.5% (school network) and range from capturing between 3 and 88% of total time. Similarly, self-drawn neighbourhoods captured only 10% of actual daily movement. Interestingly, 40% of an adolescent's self-drawn neighbourhood was not used. We also demonstrate that buffers capture a range of space (22–95%) where adolescents do not go, thus misclassifying the exposure. Conclusion: Our exploratory findings demonstrate that neither researcher- nor participant-defined definition of neighbourhood adequately captures adolescent activity space. Further research with larger samples are needed to confirm the findings of this exploratory study.

This article provides an account of the positive contribution of a patient and public involvement (PPI) team involved in research evaluating the National Health Service (NHS) in England’s low-calorie diet pilot aiming to reduce levels of type-2 diabetes. The article has been co-written by the PPI team and academics from the Re:Mission study. The PPI team members’ voice and experiences are included throughout the article and are reflected using terms ‘our’ and ‘we’.

Aims NHS England commissioned independent service providers to deliver the NHS Low‐Calorie Diet Programme pilot. Previous research has illustrated a drift in the fidelity of behaviour change techniques (BCTs) during the delivery of the programme provided through face‐to‐face group or one‐to‐one behavioural support. The aim of this study was to assess the delivery fidelity of the BCT content in the digital delivery of the programme. Methods Online, app chat and phone call support content was coded using The Behaviour Change Technique Taxonomy. BCTs delivered by each service provider (N = 2) were calculated and compared to the BCTs specified in the NHS service specification and those specified in the providers' programme plans. Results Between 78% and 83% of the BCTs identified in the NHS service specification were delivered by the service providers. The fidelity of BCT delivery to those specified in providers' programme plans was 60%–65% for provider A, and 82% for provider B. Conclusions The BCT content of the digital model used in the NHS‐LCD programme adhered well to the NHS service specification and providers' plans. It surpassed what has been previously observed in face‐to‐face services provided through group or one‐on‐one behavioural support models.

Introduction Although behavioural interventions have been found to help control type 2 diabetes (T2D), it is important to understand how the delivery context can influence implementation and outcomes. The NHS committed to testing a low-calorie diet (LCD) programme designed to support people living with excess weight and T2D to lose weight and improve diabetes outcomes. Understanding what influenced implementation during the programme pilot is important in optimising rollout. This study explored the transferability of the NHS LCD Programme prior to wider adoption. Methods Twenty-five interviews were undertaken with stakeholders involved in implementing the LCD programme in pilot sites (health service leads, referring health professionals and programme deliverers). Interviews with programme participants (people living with T2D) were undertaken within a larger programme of work, exploring what worked, for whom and why, which is reported separately. The conceptual Population–Intervention–Environment–Transfer Model of Transferability (PIET-T) guided study design and data collection. Constructs of the model were also used as a deductive coding frame during data analysis. Key themes were identified which informed recommendations to optimise programme transfer. Results Population: Referral strategies in some areas lacked consideration of population characteristics. Many believed that offering a choice of delivery model would promote acceptability and accessibility of the eligible population. Intervention: Overall, stakeholders had confidence in the LCD programme due to the robust evidence base along with anecdotal evidence, but some felt the complex referral process hindered engagement from GP practices. Environment: Stakeholders described barriers to accessing the programme, including language and learning difficulties. Transferability: Multidisciplinary working and effective communication supported successful implementation. Conclusion Referral strategies to reach underrepresented groups should be considered during programme transfer, along with timely data from service providers on access and programme benefits. A choice of delivery models may optimise uptake. Knowledge sharing between sites on good working practices is encouraged, including increasing engagement with key stakeholders.

Background: Obesity and type 2 diabetes can both profoundly impact health and wellbeing, and their prevalence largely follows a social gradient. The National Health Service Low Calorie Diet programme in England, aims to support people to achieve type 2 diabetes remission, while also reducing health inequalities. We aimed to explore the experiences of local health service leads and identify barriers and facilitators in relation to the equitable mobilisation of the Low Calorie Diet programme. Methods: Twenty semi-structured interviews were completed with 24 locality leads across the first two years of the Low Calorie Diet programme. Interviewees were purposively sampled from the ten localities who undertook the Low Calorie Diet programme pilot. Each interview explored a number of topics of interest including referrals, training, communication, incentivisation, governance and engagement, before being subjected to a thematic analysis. Results: From the data, seven core themes were identified: Covid-19 and primary care capacity and engagement, methods of communication, approaches to training, approaches to incentivisation, approaches to Referrals, barriers to referrals and the importance of collaboration. Covid-19 presented a specific challenge to the mobilisation and delivery of the Low Calorie Diet programme; however, our findings demonstrate the large variation and differences in the approaches taken when delivering the programme across ten geographically and demographically distinct pilot sites. We also identified a lack of a recognised approach or strategy to mobilisation and delivery support for the Low Calorie Diet programme, such as proportionate universalism, which is a social policy response to tackling health inequalities by ensuring service delivery is equitable. Conclusions: Health inequalities remain a significant challenge, and health service leads have the potential to adopt an equity perspective from the start of programme mobilisation. In doing so resources at their disposal can be managed equitably and can therefore contribute to efforts to reduce the potential occurrence of intervention generated inequalities.

Aim: Small dense LDL particles are associated with an increased risk of coronary heart disease and are prevalent in obesity related dyslipidaemia. This study evaluated the effect of weight loss in nine children (BMI 33.4 +/- 8.4 kg.m(-2) and age 15.1 +/- 2.9 years) on LDL peak particle size, and cholesterol concentrations within particular LDL sub-fractions. Methods: Each child undertook fan based physical activity, dietary restriction and modification and lifestyle education classes in a residential summer weight loss intervention. Blood was drawn before and after intervention and LDL heterogeneity measured by ultracentrifugation. Results: The mean change in body weight were -6.8 +/- 4.9 kg, BMI units -2.5 +/- 1.4 kg.m(-2), and waist circumference -6.3 +/- 6.3 cm (all p < 0.01). Absolute LDL-c concentration reduced from 106.2 mg/dL to 88.3 mg/dL (p < 0.01). The cholesterol contained within the small dense LDL sub-fraction (LDL-c M) reduced from 54.1 mg/dL to 40.4 mg/dL (p < 0.01). Peak particle density decreased from 1.041g/mL to 1.035g/mL (p < 0.01). At pre intervention 50.9% of absolute cholesterol was within LDL-c M particles, changing to 46.2%. Conclusion: Mean weight loss of -6.8 +/- 4.9 kg lowers absolute LDL-c and the cholesterol specifically within LDL-c III particles. LDL peak particle size increased and a degree of LDL particle remodelling occurred. These favourable adaptations, accrued in a matter of 4 weeks, maybe associated with a reduction in CHD risk.

This article explores the potential of using Global Positioning Systems (GPS) to capture valuable data in measuring food environments. Such data, when triangulated with more conventional methods of collection, for example daily 24-hour dietary recalls and food purchase receipts, allow researchers to gain a fuller picture of individual activity in dynamic food environments. This is vital to understanding both individual and environmental factors that influence individuals’ decision and behaviour patterns within food environments. However, the practicalities of triangulating data collection methods are challenging to both researchers and participants, and so a pilot study was undertaken to test different methods of measuring the food environment. Recruitment for the pilot study took place between August and September 2017 and of the 16 participants initially recruited, 13 took part and completed all data collection methods and provided valuable feedback about the experience. The participants’ perspectives on the process of triangulating methods, along with the findings, are discussed in the paper.

Background: In 2020, the National Health Service Low-Calorie Diet Programme (NHS-LCD) was launched, piloting a total diet (TDR) replacement intervention with behaviour change support for people living with Type 2 Diabetes (T2D) and excess weight. Four independent service providers were commissioned to design and deliver theoretically grounded programmes in localities across England. Aims: 1) to develop a logic model detailing how the NHS-LCD programme is expected to produce changes in health behaviour, and (2) to analyse and evaluate the use of behaviour change theory in providers’ NHS-LCD Programme designs. Methods: A documentary review was conducted. Information was extracted from the NHS-LCD service specification documents on how the programme expected to produce outcomes. The Theory Coding Scheme (TCS) was used to analyse theory use in providers’ programme design documents. Results: The NHS-LCD logic model included techniques aimed at enhancing positive outcome expectations of programme participation and beliefs about social approval of behaviour change, to facilitate programme uptake and behaviour change intentions. This was followed by techniques aimed at shaping knowledge and enhancing the ability of participants to self-regulate their health behaviours, alongside a supportive social environment and person-centred approach. Application and type of behaviour change theory within service providers’ programme designs varied. One provider explicitly linked theory to programme content; two providers linked 63% and 70% of intervention techniques to theory; and there was limited underpinning theory identified in the programme design documents for one of the providers. Conclusion: The nature and extent of theory use underpinning the NHS-LCD varied greatly amongst service providers, with some but not all intervention techniques explicitly linked to theory. How this relates to outcomes across providers should be evaluated. It is recommended that explicit theory use in programme design and evidence of its implementation becomes a requirement of future NHS commissioning processes.

Background Obesity remains one of the most challenging public health issues of our modern time. Despite the face validity of claims for influence, studies on the causes of obesity have reported the influence of the food environment to be inconsistent. This inconsistency has been attributed to the variability of measures used by researchers to represent the food environments—Researcher-Defined Food Environments (RDFE) like circular, street-network buffers, and others. This study (i.) determined an individual’s Activity Space (AS) (ii.) explored the accuracy of the RDFE in representing the AS, (iii.) investigated the accuracy of the RDFE in representing actual exposure, and (iv.) explored whether exposure to food outlet reflects the use of food outlets. Methods Data were collected between June and December 2018. A total of 65 participants collected Global Positioning System (GPS) data, kept receipt of all their food purchases, completed a questionnaire about their personal information and had their weight and height measured. A buffer was created around the GPS points and merged to form an AS (GPS-based AS). Results Statistical and geospatial analyses found that the AS size of participants working away from home was positively related to the Euclidean distance from home to workplace; the orientation (shape) of AS was also influenced by the direction of workplace from home and individual characteristics were not predictive of the size of AS. Consistent with some previous studies, all types and sizes of RDFE variably misrepresented individual exposure in the food environments. Importantly, the accuracy of the RDFE was significantly improved by including both the home and workplace domains. The study also found no correlation between exposure and use of food outlets. Conclusions Home and workplace are key activity nodes in modelling AS or food environments and the relationship between exposure and use is more complex than is currently suggested in both empirical and policy literature.

Abstract

Objective: To evaluate the effect of a high‐protein diet on anthropometry, body composition, subjective appetite, and mood sensations in overweight and obese children attending a residential weight‐loss camp.

Research Methods and Procedures: Children (120; BMI, 33.1 ± 5.5 kg/m2; age, 14.2 ± 1.9 years) were randomly assigned to either a standard or high‐protein diet group (15% vs. 22.5% protein, respectively). All children were assessed at baseline and at the end of the camp for anthropometry, body composition, blood pressure, biochemical variables (n = 27), and subjective appetite and mood sensations (n = 50).

Results: Attendance at the weight‐loss camp resulted in significant improvements in most measures. Campers lost 5.5 ± 2.9 kg in body weight (p < 0.001) and 3.8 ± 5.4 kg in fat mass (p < 0.001) and reduced their BMI standard deviation score by 0.27 ± 0.1 (p < 0.001) and their waist circumference by 6.6 ± 2.8 cm (p < 0.001). Subjective sensations of hunger increased significantly over the camp duration, but no other changes in appetite or mood were observed. There were no significant differences between the two diets on any physical or subjective measures.

Discussion: Weight‐loss camps are effective in assisting children to lose weight and improve on a range of health outcomes, independently of the protein content of the diet. The implications of an increase in hunger associated with weight loss needs to be considered. Further work is warranted to investigate whether higher levels of dietary protein are feasible or effective in longer‐term weight‐loss interventions of this type.

Summary Background There is limited evidence and clinical guidelines on the behavior change support required for low‐calorie diet programs. This systematic review aimed to establish the behavior change technique(s) (BCT) implemented in weight loss interventions (≤1200 kcal/d) and how these contribute to effectiveness. Methods Databases were searched from inception to April 2022. Screening, data extraction, BCT coding, and quality appraisal were conducted in duplicate using the Template for Intervention Description and Replication framework, Behavior Change Technique Taxonomy, and Cochrane Risk of Bias 2 tool. Data were analyzed via narrative synthesis and random effects multi‐level meta‐analyses. Results Thirty‐two papers reporting on 27 studies were included. Twenty‐four BCTs were identified across studies. Eight BCTs were significantly associated with a larger reduction in weight at the end‐of‐diet time‐point; one BCT was statistically significant at the end of weight maintenance. Physical activity, Type 2 Diabetes, and BMI category moderated intervention effects. Conclusions and implications This is the first meta‐analysis to examine how specific BCTs contribute to the effectiveness of low‐calorie diets. It is recommended that a) these findings are used to develop clinical guidelines specific to behavioral support in low‐calorie diet programs, and b) program commissioners stipulate the use of these BCTs in their service specifications.

Introduction: The National Health Service (NHS) Low Calorie Diet (LCD) pilot programme aimed to support people with type 2 diabetes (T2DM) to lose weight, reduce glycaemia and potentially achieve T2DM remission using total diet replacement alongside behaviour change support. The Re:Mission study seeks to provide an enhanced understanding of the long-term cost-effectiveness of the programme and its implementation, equity, transferability and normalisation across broad and diverse populations. This article presents an overview of the methods used in the Re:Mission study. Methods and analysis: A mixed method approach was used to draw together service user insights from across longitudinal and cross-sectional online surveys and semi-structured interviews supported by a modified photovoice technique. Insights were captured from active service users across the three phases of the programme (total diet replacement, food reintroduction and maintenance) in addition to those discharged prematurely. Survey data were analysed using descriptive statistics and qualitative data were thematically analysed and interpreted through a realist informed lens to understand which aspects of the service work and do not work, for whom, in what context and why. Results: Results from the study are presented elsewhere, with recommendations for policy practice and research.

This study aimed to evaluate the weight loss and hunger motivation effects of an energy-restricted high-protein (HP) diet in overweight and obese children. In total, 95 overweight and obese children attended an 8-week (maximum) program of physical activity, reduced-energy intake, and behavior change education. Children were randomly assigned to one of two isoenergetic diets (standard (SP): 15% protein; HP: 25% protein), based on individually estimated energy requirements. Anthropometry and body composition were assessed at the start and end of the program and appetite and mood ratings completed on the first 3 consecutive weekdays of each week children attended camp. The HP diet had no greater effect on weight loss, body composition, or changes in appetite or mood when compared to the SP diet. Overall, campers lost 5.2 3.0 kg in body weight and reduced their BMI standard deviation score (sds) by 0.25. Ratings of desire to eat increased significantly over the duration of the intervention, irrespective of diet. This is the third time we have reported an increase in hunger motivation in weight-loss campers and replicates our previous failure to block this with a higher protein diet. Further work is warranted into the management of hunger motivation as a result of negative energy balance.

Background: In 2004 the UK Government, within the Choosing Health White Paper, outlined a target ‘To halt, by 2010, the year on year increase in obesity among children under 11 in the context of a broader strategy to tackle obesity in the population as a whole’. In order to justify action there is a need to highlight the scale of the problem. In addition, further analysis comparing differences between schools is important to identify where appropriate resources/support should be provided. Methods: During 2005 BMI measurements were obtained in 2425 boys and 2267 girls, aged 11.6±0.3y, from 33 out of 40 schools in Leeds, UK. Standardized values were calculated using National Centile Charts and overweight and obesity prevalence defined at the 85th and 95th centiles, respectively. Results: Overall UK BMI centile charts identified 33.5% of children overweight and obese compared to the 27.7% prevalence reported in the Health Survey of England (2003) for children aged 9–11y. When the data were analysed by school the prevalence of overweight and obesity varied from 23.0% to 42.9%, with 3 schools less than 30% and 4 schools higher than 40%. Conclusion: These data should be of major concern given the increasing trend in an age group extremely close to that the government has prioritised. In addition, it is clear that there was large variability in the prevalence of overweight and obesity according to school. The upper prevalence values are particularly high and demonstrate the scale of the problem in children attending specific schools.

Background: UK levels of overweight and obesity in children are high and continue to increase (Health Survey of England 2004). Recently alternative methods to determine prevalence of overweight and obesity have gained recognition and been made available. Therefore this study was undertaken using three accepted methods for determining prevalence of overweight and obesity in a large sample of 11 year old children. Methods: 4711 children were assessed in 33 schools in Leeds, UK. All children were assessed for stature, body mass, waist circumference, % body fat and selected sports performance tests. Overweight and obesity was recognised using each of the three anthropometric measures (BMI, Waist circumference and % body fat) above the 85th percentile for age and gender. Results: Overweight and obesity prevalence was high with BMI, Waist circumference and % body fat mean prevalence being 34.4%, 47.9% and 25.2% respectively. Of concern was the high variability between schools, with the variation being 22.8% – 42.3% (BMI), 22.5% – 72.8% (waist circumference) and 16.4% - 36.9%% (Body fat). Conclusion: These data show that levels of childhood obesity are high in comparison to the 27.7% reported in the Health Survey of England (2004) and that there is high variation between schools in a large UK city. These findings provide strong evidence and information for targeted action in the form of both prevention and treatment for this population.

© 2019 Elsevier B.V. Local government organisations (LAs) have a major role in the prevention and treatment of obesity in England. This study aims to 1) understand what actions are being taken by LAs to address obesity, and 2) determine how actions counter the perceived causes of obesity when mapped against the Wider Determinants of Health (WDoH) model. Thirty-two LAs were invited to complete an Action Mapping Tool, 10 participated. The tool requires LAs to document actions being implemented locally to address obesity. This then enables LAs to map their actions against the perceived causes of obesity, using the WDoH model as an analytical lens. We collated data from the 10 LAs and used an adapted framework synthesis method for analysis. 280 actions were documented across the 10 LAs; almost 60% (n = 166) targeted Individual Lifestyle Factors (ILF), with 7.1% (n = 20), 16.8% (n = 47) and 16.4% (n = 46) targeting Social and Community Factors (SCF), Living and Working Conditions (LWC) and Wider Conditions (WC) respectively. Conversely, 60% of causes were spread across the LWC and WC, with 16.4% regarded as ILF. Physical activity-, weight management-, and health improvement- programmes were most frequently implemented by LAs. There is a stark mismatch between LA actions on obesity and its perceived causes. Given that LAs acknowledge the complex aetiology of obesity, an equally comprehensive approach should be implemented in the future.

Objective: The aim of the present study was to compare percentage body fat (PF) estimates using bioelectrical impedance analysis (BIA) with that determined by air displacement plethysmography in overweight and obese children. Methods: All participants had standardised BMI values >85th centile according to National Centile Charts. 302 males: age 13.9±1.7 y, BMI 32.8±6.6 kg.m-2, PF ADP 40.8±9.6 %, and 354 females: age 14.5±1.8 y, BMI 33.8±6.2 kg.m-2, PF ADP 44.2±7.2 %, were assessed. BIA PF estimates were obtained at 50 kHz using a foot-plate system device (Tanita TBF-310) and the inbuilt manufacturer prediction equations. ADP PF measurements were obtained using the child-specific thoracic gas volume prediction equations of Fields (2004) and the age and gender-specific body density conversion equations of Lohman (1989). Results: BIA estimates of PF were significantly correlated with those of ADP (males r=0.80, females r=0.68; both P<0.001). BIA significantly underestimated mean PF compared to ADP (males -3.6 %, females -1.7 %; both P<0.001). According to the methods of Bland and Altman, the ±95 % limits of agreement were slightly higher in males (±12.0 %) than females (±10.4 %). Further, correlation on the Bland and Altman plots revealed a significant bias as a function of increasing PF in females (r = - 0.45; P<0.001). Conclusion: On an individual basis there may be large discrepancies between BIA and ADP PF estimates. Results from devices are therefore not interchangeable in overweight and obese children.

Summary This umbrella review assessed the association between excess weight and COVID‐19 outcomes. MEDLINE, PsycINFO, and CINAHL were systematically searched for reviews that assessed the association between excess weight and COVID‐19 outcomes. A second‐order meta‐analysis was conducted on the available data for intensive care unit admission, invasive mechanical ventilation administration, disease severity, hospitalization, and mortality. The quality of included reviews was assessed using the AMSTAR‐2 appraisal tool. In total, 52 systematic reviews were included, 49 of which included meta‐analyses. The risk of severe outcomes (OR = 1.86; 95% CI: 1.70 to 2.05), intensive care unit admission (OR = 1.58; 95% CI: 1.45 to 1.72), invasive mechanical ventilation administration (OR = 1.70; 95% CI: 1.57 to 1.83), hospitalization (OR = 1.82; 95% CI: 1.61 to 2.05), and mortality (OR = 1.35; 95% CI: 1.24 to 1.48) following COVID‐19 infection was significantly higher in individuals living with excess weight compared with those with a healthy weight. There was limited evidence available in the included reviews regarding the influence of moderating factors such as ethnicity, and the majority of included reviews were of poor quality. Obesity appears to represent an important modifiable pre‐infection risk factor for severe COVID‐19 outcomes, including death.

Background: The food reintroduction phase of the NHS Low Calorie Diet (LCD) programme aims to support service users to reintroduce food gradually back into their diet. Understanding experiences of food reintroduction from a broad and diverse range of service users is critical in helping to improve service delivery and commissioning and equity in care. Methods: This was a co-produced qualitative study underpinned by a realist informed approach, using interviews and photovoice techniques. Service users (n=43) of the NHS LCD Programme were recruited from three delivery models across 21 pilot sites in England. Data were analysed using a thematic approach. Results: The food introduction phase required control and planning that challenged the behaviours of participants. Around a third of participants continued use of Total Diet Replacement products, or considered doing so, for convenience and to maintain calorie control. The coach–service user relationship was important to understanding of session content and translation into behaviour change. Physical activity increased during this phase, which contributed to positive health outcomes. Conclusions: The paper reports insights from the food reintroduction phase of the LCD programme. Key messages include the need for increased frequency of support and the need for tailored and culturally representative education.

Background: The National Health Service (NHS) Low Calorie Diet (LCD) programme in England aims to support people with type 2 diabetes (T2DM) to lose weight, improve glycaemic parameters and potentially achieve diabetes remission. The programme pilot launched in 2020 using three different delivery models: one-to-one, group and digital via an App. Service users begin the programme with 12 weeks of Total Diet Replacement (TDR). This study aims to understand the experience of this TDR phase from the service user perspective. Methods: This was a co-produced qualitative longitudinal and cross-sectional study, underpinned by a realist informed approach using semi-structured interviews and photovoice techniques. Service users (n=45) from the NHS LCD programme were recruited across the three delivery models and 21 pilot sites in England. Data were analysed using a thematic approach. Results: Participant demographics were representative of the overall LCD pilot population sample and included experiences from a mix of delivery models and providers. Three themes were presented chronologically. 1) life pre-LCD: the LCD programme was viewed as an opportunity to reset eating behaviours and improve quality of life; 2) experience of TDR: flexibility in allowing supplementary non-starchy vegetables and adapting the flavour and texture of TDR products supported adherence; 3) looking ahead to food reintroduction: at the end of the TDR phase, weight and glycaemia had reduced, while subjective energy levels and mobility improved. Some participants were concerned about progressing to the food reintroduction phase and the possibility of weight regain. Conclusions: The paper reports insight from the TDR phase of the LCD programme. The co-production of this work has resulted in several recommendations for policy and practice which have informed the national roll out of the programme.

Background: The weight maintenance phase of the NHS Low CalorieaDiet (LCD) programme focuses on embedding long- term dietary and physical activity changes. Understanding individual experiences of this phase is crucial to exploring long- term effectiveness and equity of the intervention approach. Methods: This was a coproduced qualitative study underpinned by a realist informed approach, using interviews and photovoice techniques. Service users (n=25) of the NHS LCD programme were recruited from three delivery models, across 21 sites in England. Data were analysed using a thematic approach. Results: The experiences reported were largely positive, with many participants reporting changes in their diet and physical activity. Some service users expressed a need for additional support and there appeared variation in their experiences of the service providers and the wider available support network. Fear of weight regain and its glycaemic consequences was expressed by many; various mitigations were employed, including participating in other weight loss services and continuing use of Total Diet Replacement products. Conclusions: The NHS LCD programme has been life-changing for some people. However, service user insights suggest that a stronger person-centred focus might further improve effectiveness and service user experience.

This systematic review quantifies methods used to measure the ‘retail food environment’ (RFE), appraises the quality of methodological reporting, and examines associations with obesity, accounting for differences in methods. Only spatial measures of the RFE, such as food outlet proximity were included. Across the 113 included studies, methods for measuring the RFE were extremely diverse, yet reporting of methods was poor (average reporting quality score: 58.6%). Null associations dominated across all measurement methods, comprising 76.0% of 1937 associations in total. Outcomes varied across measurement methods (e.g. narrow definitions of ‘supermarket’: 20.7% negative associations vs 1.7% positive; broad definitions of ‘supermarket’: 9.0% negative associations vs 10.4% positive). Researchers should report methods more clearly, and should articulate findings in the context of the measurement methods employed.

BACKGROUND: NHS England commissioned four independent service providers to pilot low-calorie diet programmes to drive weight loss, improve glycaemia and potentially achieve remission of Type 2 Diabetes across 10 localities. Intervention fidelity might contribute to programme success. Previous research has illustrated a drift in fidelity in the design and delivery of other national diabetes programmes. AIMS: (1) To describe and compare the programme designs across the four service providers; (2) To assess the fidelity of programme designs to the NHS England service specification. METHODS: The NHS England service specification documents and each provider's programme design documents were double-coded for key intervention content using the Template for Intervention Description and Replication Framework and the Behaviour Change Technique (BCT) Taxonomy. RESULTS: The four providers demonstrated fidelity to most but not all of the service parameters stipulated in the NHS England service specification. Providers included between 74% and 87% of the 23 BCTs identified in the NHS specification. Twelve of these BCTs were included by all four providers; two BCTs were consistently absent. An additional seven to 24 BCTs were included across providers. CONCLUSIONS: A loss of fidelity for some service parameters and BCTs was identified across the provider's designs; this may have important consequences for programme delivery and thus programme outcomes. Furthermore, there was a large degree of variation between providers in the presence and dosage of additional BCTs. How these findings relate to the fidelity of programme delivery and variation in programme outcomes and experiences across providers will be examined.

Background: Increasing awareness of the complexity of public health problems, including obesity, has led to growing interest in whole systems approaches (WSAs), defined as those that consider the multifactorial drivers of overweight and obesity, involve transformative co-ordinated action across a broad range of disciplines and stakeholders, operate across all levels of governance and throughout the life course. This paper reports a systematic review of WSAs targeting obesity and other complex public health and societal issues, such as healthy lifestyles for prevention of non-communicable disease. Methods: Seven electronic databases were searched from 1995 to 2018. Studies were included if there had been an effort to implement a WSA. Study selection was conducted by one reviewer with a random 20% double checked. Data extraction and validity assessment were undertaken by one reviewer and checked by a second reviewer. Narrative synthesis was undertaken. Results: 65 articles were included; 33 about obesity. Most examined multicomponent community approaches, and there was substantial clinical and methodological heterogeneity. Nevertheless, a range of positive health outcomes were reported, with some evidence of whole systems thinking. Positive effects were seen on health behaviours, body mass index (BMI), parental and community awareness, community capacity building, nutrition and physical activity environments, underage drinking behaviour and health, safety and wellbeing of community members, self-efficacy, smoking and tobacco-related disease outcomes. Features of successful approaches reported in process evaluations included: full engagement of relevant partners and community; time to build relationships, trust and capacity; good governance; embedding within a broader policy context; local evaluation; finance. Conclusions: Systems approaches to tackle obesity can have some benefit, but evidence of how to operationalise a WSA to address public health problems is still in its infancy. Future research should: (a) develop an agreed definition of a WSA in relation to obesity, (b) look across multiple sectors to ensure consistency of language and definition, (c) include detailed descriptions of the approaches, and (d) include process and economic evaluations.

Background Previous research has illustrated a drift in the fidelity of behaviour change techniques (BCTs) during the design of the pilot NHS England Low-Calorie Diet (NHS-LCD) Programme. This study evaluated a subsequent domain of fidelity, intervention delivery. Two research questions were addressed: 1) To what extent were BCTs delivered with fidelity to providers programme plans? 2) What were the observed barriers and facilitators to delivery? Methods A mixed-methods sequential explanatory design was employed. Remote delivery of one-to-one and group-based programmes were observed. A BCT checklist was developed using the BCT Taxonomy v1; BCTs were coded as present, partially delivered, or absent during live sessions. Relational content analysis of field notes identified observed barriers and facilitators to fidelity. Results Observations of 122 sessions across eight samples and two service providers were completed. Delivery of the complete NHS-LCD was observed for five samples. Fidelity ranged from 33%-70% across samples and was higher for group-based delivery models (64%) compared with one-to-one models (46%). Barriers and facilitators included alignment with the programme's target behaviours and outcomes, session content, time availability and management, group-based remote delivery, and deviation from the session plan. Conclusions Overall, BCTs were delivered with low-to-moderate fidelity. Findings indicate a dilution in fidelity during the delivery of the NHS-LCD and variation in the fidelity of programmes delivered across England. Staff training could provide opportunities to practice the delivery of BCTs. Programme-level changes such as structured activities supported by participant materials and with sufficient allocated time, might improve the delivery of BCTs targeting self-regulation.

An increasing number of studies in children are being published using accelerometry to determine the levels of moderate-to-vigorous physical activity (MVPA). Although accelerometry is regarded as an objective measure, a review of the literature reveals a large disparity in the proportions of children meeting current MVPA recommendations. Therefore, the aim of the present study was to evaluate the variability of MVPA estimates in children using published accelerometry threshold values. With institutional ethical approval, 46 (27 males) children, aged 11–12 years, participated in the study. Weekday physical activity was measured using an Actigraph GT1M accelerometer, set at 10-s epochs. Time spent in MVPA was calculated using five adjusted intensity thresholds based on previously published counts per minute (cpm) values: (i) 1130 (Freedson et al., 1997: Medicine and Science in Sports and Exercise, 29, S45), (ii) 2000 (Ekelund et al., 2004: American Journal of Clinical Nutrition, 80, 584–590), (iii) 3000 (Treuth et al., 2004: Medicine and Science in Sports and Exercise, 36, 1259–1266), (iv) 3200 (Puyau et al., 2002: Obesity Research, 10, 150–157) and (v) 3600 (Riddoch et al., 2007: Archives of Disease in Childhood, 92, 963–969). Additionally, using each threshold the percentage of children acquiring an average of 60 min MVPA per day was calculated. Using the five intensity thresholds, participants spent (in ascending order) (i) mean 100, s=32 min, (ii) mean 59, s=23 min, (iii) mean 32, s=15 min, (iv) mean 28, s=13 min and (v) mean 21, s=11 min per weekday in MVPA, respectively. All differences were statistically significant (P<0.001). Within each threshold, the percentage of children acquiring an average of 60 min MVPA was 93, 41, 9, 2 and 0%, respectively. Although based on only a small sample, these findings illustrate the variability of defining MVPA using different thresholds. Although accelerometry overcomes many of the reliability and validity problems associated with self-report, pedometer and heart-rate assessment, careful consideration is warranted when interpreting accelerometry data. Indeed, even though acceleroAn increasing number of studies in children are being published using accelerometry to determine the levels of moderate-to-vigorous physical activity (MVPA). Although accelerometry is regarded as an objective measure, a review of the literature reveals a large disparity in the proportions of children meeting current MVPA recommendations. Therefore, the aim of the present study was to evaluate the variability of MVPA estimates in children using published accelerometry threshold values. With institutional ethical approval, 46 (27 males) children, aged 11–12 years, participated in the study. Weekday physical activity was measured using an Actigraph GT1M accelerometer, set at 10-s epochs. Time spent in MVPA was calculated using five adjusted intensity thresholds based on previously published counts per minute (cpm) values: (i) 1130 (Freedson et al., 1997: Medicine and Science in Sports and Exercise, 29, S45), (ii) 2000 (Ekelund et al., 2004: American Journal of Clinical Nutrition, 80, 584–590), (iii) 3000 (Treuth et al., 2004: Medicine and Science in Sports and Exercise, 36, 1259–1266), (iv) 3200 (Puyau et al., 2002: Obesity Research, 10, 150–157) and (v) 3600 (Riddoch et al., 2007: Archives of Disease in Childhood, 92, 963–969). Additionally, using each threshold the percentage of children acquiring an average of 60 min MVPA per day was calculated. Using the five intensity thresholds, participants spent (in ascending order) (i) mean 100, s=32 min, (ii) mean 59, s=23 min, (iii) mean 32, s=15 min, (iv) mean 28, s=13 min and (v) mean 21, s=11 min per weekday in MVPA, respectively. All differences were statistically significant (P<0.001). Within each threshold, the percentage of children acquiring an average of 60 min MVPA was 93, 41, 9, 2 and 0%, respectively. Although based on only a small sample, these findings illustrate the variability of defining MVPA using different thresholds. Although accelerometry overcomes many of the reliability and validity problems associated with self-report, pedometer and heart-rate assessment, careful consideration is warranted when interpreting accelerometry data. Indeed, even though accelerometry counts may be regarded as an objective assessment of physical activity, analysis of the data still requires a subjective choice of MVPA threshold. Moreover, until a quantifiable evidencebased definition of MVPA is developed in association with appropriate accelerometry thresholds, any conclusion regarding the proportions of 11–12 year old school children meeting current government guidelines must be interpreted with caution.

Purpose: Disabled young people are at a substantially increased risk of obesity, together with an increased risk of developing serious health conditions. A lack of current provision, guidelines and data on effective weight management programmes serve to maintain this health inequality. The aim of this research was to explore and understand the weight management programme experiences of disabled young people and key stakeholders within a special school setting. This insight addresses a clear gap in the literature and provides a better understanding of how more suitable programmes can be developed.  Methods: Conducting a systematic review provided a transparent and reliable synthesis of existing weight management programmes and focused on disabled young people with obesity. Following the systematic review, the main primary research was undertaken and underpinned by a qualitative approach to data collection. This explored how a group of 11 disabled young people aged 10-12 years, their parents, school staff and service staff experienced a special school-based weight management programme in England. Innovative data collection techniques of repeat semi-structured interviews, scaffolding techniques and visual aids captured insights before, during and after the programme. Thematic analysis enabled the interpretation of participants’ experiences.  Findings: The findings of the systematic review demonstrated a clear need for further qualitative-orientated research focusing on weight management programmes for disabled young people. The review also demonstrated the need to consider additional outcomes independent of effects on adiposity or weight status. The qualitative research offered a unique contribution into how multiple stakeholders experienced a weight management programme. Specifically, findings revealed an increased awareness of healthy eating, more physical activity, dietary changes, social exposure and wider, longer-term effects in school. The findings from this research highlighted features that other providers could incorporate into the development and delivery of future weight management interventions for disabled young people. These features include programme adaptations that accommodate the ii specific needs of disabled young people and reframing the focus away from weight data in favour of other noteworthy outcomes. Similarly, valuing the individual personality and prior knowledge of practitioners, and recognising the need to involve parents and family life were highlighted as being fundamental to effective implementation and could be utilised in future delivery.  Conclusions: This research provides new insight and evidence that disabled young people and stakeholders working together can begin to address inequalities. The findings may have important implications for health services, practitioners and policy-makers in facilitating and developing more suitable and inclusive public health interventions, to better meet the needs of disabled young people.

Obesity is a major public health challenge which continues to increase and disproportionally affects vulnerable population groups, resulting in widening health inequalities. There is consequently an urgent need for innovative approaches to identify and implement evidence-based policy and practice to prevent and treat obesity which has been accelerated by the COVID-19 pandemic. The population levels of obesity are driven by numerous interacting political, economic, environmental, social, cultural, digital, behavioural, and biological determinants. However, causal links between determinants and how they vary between different groups of individuals are not well defined. The identification, implementation, and evaluation of effective responses to the prevention and treatment of obesity require a set of approaches that work within this complexity. The limited efforts to date reflect a misunderstanding of the nature of the chronic and complex nature of obesity, and importantly a limited understanding of how the multifaceted nature of the problem should influence how research, policy, and practice approach it. To date, the evidence underpinning the current approach does not reflect the complexity of the condition: Evidence is largely generated by tools and methods developed to answer questions about the effectiveness of isolated interventions, commonly grounded in linear models of cause and effect. This is the pathway between a cause, for example, exposure to fast food restaurants, and the outcome, obesity, is assumed to be linear, when it is far more complex than this. There is a focus on individual behaviour, yet social and structural determinants of health have a far greater influence on obesity and contribute more to health inequalities. It is acknowledged that we live in an obesogenic environment, yet most approaches to addressing obesity are focused on behaviour change to support individuals adopt healthy weight behaviours, with little (or no) consideration of the environment in which they live. Outcomes are largely measured in the short term and the effects of efforts to reduce population obesity will take many years to be realised. Effectiveness is primarily determined by a narrow focus on weight change, which fails to capture the underlying complexity. Instead of investigating whether a single intervention is (cost-)effective in terms of fixing the problem (i.e. obesity), we need to understand how actions drive positive changes within the system. A systems approach captures and responds to complexity through a dynamic way of working: bringing together academic, policy, practice, and community representatives to develop a ‘shared understanding of the challenge’ and to integrate action to bring about sustainable, long-term systems change. The benefit of a systems approach to addressing population levels of obesity has been outlined: in 2013, the EPODE logic model retrospectively provided insight into the system dynamics of the programme; the ‘Improving the Health of the Public by 2040’ report acknowledged that responses to major public health challenges require a wider set of approaches; in 2017, Rutter et al. called for ‘a complex systems model of evidence for public health’, which was echoed in 2019, as part of The Lancet commission on obesity. More recently, the logic model underpinning the Amsterdam Healthy Weight Approach (AHWA) was published. There are also examples of projects that have embraced system approaches in an applied setting, as well as toolkits, guidance documents, and operational frameworks. These resources demonstrate that the concept of a systems approach to obesity is not new, and importantly that systems methods do not have to replace traditional methods, but instead incorporate and enhance them. Despite this activity and rhetoric, systems approaches are rarely operationalised in ways that generate relevant evidence or effective policies.

Background National Health Service England piloted a low-calorie diet programme, delivered through total diet replacement and behaviour change support via 1 : 1, group or digital delivery, to improve type 2 diabetes in adults with excess weight. Aim To coproduce a qualitative and economic evaluation of the National Health Service low-calorie diet pilot, integrated with National Health Service data to provide an enhanced understanding of the long-term cost-effectiveness, implementation, equity and transferability across broad and diverse populations. Research questions What are the theoretical principles, behaviour change components, content and mode of delivery of the programme, and is it delivered with fidelity to National Health Service specifications? What are the service provider, user and National Health Service staff experiences of the programme? Do sociodemographics influence programme access, uptake, compliance and success? What aspects of the service work and what do not work, for whom, in what context and why? Can the programme be improved to enhance patient experience and address inequities? What are the programme delivery costs, and policy implications for wide-spread adoption? Methods A mixed-methods study underpinned by a realist-informed approach was delivered across five work packages, involving: semistructured interviews with service users (n = 67), National Health Service staff (n = 55), service providers (n = 9); 13 service provider focus groups; and service user surveys (n = 719). Findings were triangulated with clinical data from the National Health Service England’s first cohort analysis (n = 7540). Results Fifty-five per cent of service users who started total diet replacement completed the programme and lost an average of 10.3 kg; 32% of those with data available to measure remission achieved it. Examination of programme mobilisation identified barriers around referral equality and the impact of COVID-19, while effective cross-stakeholder working and communication were key facilitators. Service delivery and fidelity assessments identified a drift in implementation fidelity, alongside variation in the behaviour change content across providers. Perceived barriers to programme uptake and engagement aligned across service providers and users, resulting in key learning on: the importance of person-centred care, service user support needs, improvements to total diet replacement and the social and cultural impact of the programme. Early National Health Service quantitative analyses suggest some socioeconomic variation in programme uptake, completion and outcomes. Insights from the evaluation and National Health Service data were combined to develop the programme theory and underpinning context, mechanisms and outcomes. These were used to develop a list of recommendations to improve the cultural competency of programme delivery, total diet replacement delivery, peer support and address psychological support needs. Cost-effectiveness analyses using short-term follow-up data indicated there is potential for the programme to be cost-effective, but not cost saving. Conclusions The National Health Service low-calorie diet can provide a clinically effective and potentially cost-effective programme to support weight loss and glycaemic control in adults with type 2 diabetes. However, this evaluation identified areas for improvement in referral equity, uptake and completion, and fidelity of delivery, which have informed the development of the programme, which has now been rolled out nationally. Ongoing programme monitoring and long-term follow-up are now required. Future work and limitations The real-world setting limited some data collection and analysis. Future work will focus on the analysis of long-term clinical and cost-effectiveness, and addressing inequalities. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132075.

Member led symposium at UK Congress on Obesity 2022