Professor Louisa Ells

We have based parts of the Methods, as well as Appendix 1, Appendix 2 and Appendix 3 of this Cochrane Protocol on a standard template established by the CMED Group. Editorial note This protocol will not be progressed to a review because the topic is no longer considered a priority. See https://doi.org/10.1002/14651858.cd012651, https://doi.org/10.1002/14651858.cd012691.

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of psychological interventions delivered as a single component intervention on the management of overweight or obesity in children and adolescents aged 6 to 17 years.

In the United Kingdom, the National Institute for Health and Care Excellence make recommendations to guide the local-level selection and implementation of adult behavioural weight management interventions (BWMIs) which lack specificity. The reporting of BWMIs is generally poorly detailed, resulting in difficulties when comparing effectiveness, quality and appropriateness for participants. This non-standardized reporting makes meta-analysis of intervention data impossible, resulting in vague guidance based on weak evidence, reinforcing the urgent need for consistency and detail within BWMI description. STAR-LITE - a 4-section, 119-item standardized adult BWMI reporting template - was developed and tested using a two-phase process. After initial design, the template was piloted using adult behavioural weight management RCTs and currently implemented UK BWMI mapping information to further refine the template and examine current reporting and variance. Overall, reporting quality of weight management RCTs was poor, and large variance across different components of real-world BWMIs was observed. Non-specific guidance and wide variation in adult BWMIs are likely linked to inadequate RCT reporting quality and the inability to perform reliable comparisons of data. Future use of STAR-LITE would facilitate the consistent, detailed reporting of adult BWMIs, supporting their evaluation and comparison, to ultimately inform effective policy and improve weight management practice.

Understanding the social and environmental influencers of eating behaviours has the potential to improve health outcomes for young people. This review aims to explore the effectiveness of school nutrition interventions and the perceptions of young people experiencing a nutrition focused intervention or change in school food policy. A comprehensive systematic search identified studies published between 1 December 2007 to 20 February 2020. Twenty‐seven studies were included: 22 quantitative studies of nutrition related outcomes and five qualitative studies reporting views and perceptions of young people (combined sample of 22,138 participants, mean ages 12–18 years). The primary outcome was nutrition knowledge/dietary behaviours, with secondary outcomes exploring body mass index (BMI) and wellbeing. Due to the heterogeneity of studies, a narrative results description is presented. The findings demonstrate that school nutrition programmes can be effective in reducing sugar, sugar sweetened beverages (SSB) and saturated fat and increasing fruit and vegetable (FV) intake. The lived experiences of young people in a school context provide valuable insights that should be considered in the development of effective school food policy and interventions. This review affirms the significant role that schools can play in supporting good nutrition in all young people and provides opportunities to inform the school food agenda.

© 2017 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity This systematic review synthesized the available evidence on the effect of short-term periods of intermittent energy restriction (weekly intermittent energy restriction; ≥7-d energy restriction) in comparison with usual care (daily continuous energy restriction), in the treatment of overweight and obesity in adults. Six electronic databases were searched from inception to October 2016. Only randomized controlled trials of interventions (≥12 weeks) in adults with overweight and obesity were included. Five studies were included in this review. Weekly intermittent energy restriction periods ranged from an energy intake between 1757 and 6276 kJ/d−1. The mean duration of the interventions was 26 (range 14 to 48) weeks. Meta-analysis demonstrated no significant difference in weight loss between weekly intermittent energy restriction and continuous energy restriction post-intervention (weighted mean difference: −1.36 [−3.23, 0.51], p = 0.15) and at follow-up (weighted mean difference: −0.82 [−3.76, 2.11], p = 0.58). Both interventions achieved comparable weight loss of >5 kg and therefore were associated with clinical benefits to health. The findings support the use of weekly intermittent energy restriction as an alternative option for the treatment of obesity. Currently, there is insufficient evidence to support the long-term sustainable effects of weekly intermittent energy restriction on weight management.

The aim of the present review was to perform a systematic in-depth review of the best evidence from controlled trial studies that have investigated the effects of nutrition, diet and dietary change on learning, education and performance in school-aged children (4-18 years) from the UK and other developed countries. The twenty-nine studies identified for the review examined the effects of breakfast consumption, sugar intake, fish oil and vitamin supplementation and ’good diets’. In summary, the studies included in the present review suggest there is insufficient evidence to identify any effect of nutrition, diet and dietary change on learning, education or performance of school-aged children from the developed world. However, there is emerging evidence for the effects of certain fatty acids which appear to be a function of dose and time. Further research is required in settings of relevance to the UK and must be of high quality, representative of all populations, undertaken for longer durations and use universal validated measures of educational attainment. However, challenges in terms of interpreting the results of such studies within the context of factors such as family and community context, poverty, disease and the rate of individual maturation and neurodevelopment will remain. Whilst the importance of diet in educational attainment remains under investigation, the evidence for promotion of lower-fat, -salt and -sugar diets, high in fruits, vegetables and complex carbohydrates, as well as promotion of physical activity remains unequivocal in terms of health outcomes for all schoolchildren.

Background Child overweight and obesity has increased globally, and can be associated with short‐ and long‐term health consequences. Objectives To assess the effects of diet, physical activity, and behavioural interventions for the treatment of overweight or obesity in preschool children up to the age of 6 years. Search methods We performed a systematic literature search in the databases Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, and LILACS, as well as in the trial registers ClinicalTrials.gov and ICTRP Search Portal. We also checked references of identified trials and systematic reviews. We applied no language restrictions. The date of the last search was March 2015 for all databases. Selection criteria We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions for treating overweight or obesity in preschool children aged 0 to 6 years. Data collection and analysis Two review authors independently assessed risk of bias, evaluated the overall quality of the evidence using the GRADE instrument, and extracted data following the Cochrane Handbook for Systematic Reviews of Interventions. We contacted trial authors for additional information. Main results We included 7 RCTs with a total of 923 participants: 529 randomised to an intervention and 394 to a comparator. The number of participants per trial ranged from 18 to 475. Six trials were parallel RCTs, and one was a cluster RCT. Two trials were three‐arm trials, each comparing two interventions with a control group. The interventions and comparators in the trials varied. We categorised the comparisons into two groups: multicomponent interventions and dietary interventions. The overall quality of the evidence was low or very low, and six trials had a high risk of bias on individual ’Risk of bias’ criteria. The children in the included trials were followed up for between six months and three years. In trials comparing a multicomponent intervention with usual care, enhanced usual care, or information control, we found a greater reduction in body mass index (BMI) z score in the intervention groups at the end of the intervention (6 to 12 months): mean difference (MD) ‐0.3 units (95% confidence interval (CI) ‐0.4 to ‐0.2); P < 0.00001; 210 participants; 4 trials; low‐quality evidence, at 12 to 18 months’ follow‐up: MD ‐0.4 units (95% CI ‐0.6 to ‐0.2); P = 0.0001; 202 participants; 4 trials; low‐quality evidence, and at 2 years’ follow‐up: MD ‐0.3 units (95% CI ‐0.4 to ‐0.1); 96 participants; 1 trial; low‐quality evidence. One trial stated that no adverse events were reported; the other trials did not report on adverse events. Three trials reported health‐related quality of life and found improvements in some, but not all, aspects. Other outcomes, such as behaviour change and parent‐child relationship, were inconsistently measured. One three‐arm trial of very low‐quality evidence comparing two types of diet with control found that both the dairy‐rich diet (BMI z score change MD ‐0.1 units (95% CI ‐0.11 to ‐0.09); P < 0.0001; 59 participants) and energy‐restricted diet (BMI z score change MD ‐0.1 units (95% CI ‐0.11 to ‐0.09); P < 0.0001; 57 participants) resulted in greater reduction in BMI than the comparator at the end of the intervention period, but only the dairy‐rich diet maintained this at 36 months’ follow‐up (BMI z score change in MD ‐0.7 units (95% CI ‐0.71 to ‐0.69); P < 0.0001; 52 participants). The energy‐restricted diet had a worse BMI outcome than control at this follow‐up (BMI z score change MD 0.1 units (95% CI 0.09 to 0.11); P < 0.0001; 47 participants). There was no substantial difference in mean daily energy expenditure between groups. Health‐related quality of life, adverse effects, participant views, and parenting were not measured. No trial reported on all‐cause mortality, morbidity, or socioeconomic effects. All results should be interpreted cautiously due to their low quality and heterogeneous interventions and comparators. Authors’ conclusions Muticomponent interventions appear to be an effective treatment option for overweight or obese preschool children up to the age of 6 years. However, the current evidence is limited, and most trials had a high risk of bias. Most trials did not measure adverse events. We have identified four ongoing trials that we will include in future updates of this review. The role of dietary interventions is more equivocal, with one trial suggesting that dairy interventions may be effective in the longer term, but not energy‐restricted diets. This trial also had a high risk of bias.

© 2016 World Obesity. Intervention studies have been undertaken to reduce sedentary behaviour (SB) and thereby potentially ameliorate unhealthy weight gain in children and adolescents. We synthesised evidence and quantified the effects of SB interventions (single or multiple components) on body mass index (BMI) or BMI z-score in this population. Publications up to March 2015 were located through electronic searches. Inclusion criteria were interventions targeting SB in children that had a control group and objective measures of weight and height. Mean change in BMI or BMI z-score from baseline to post-intervention were quantified for intervention and control groups and meta-analyzed using a random effects model. The pooled mean reduction in BMI and BMI z-score was significant but very small (standardized mean difference=-0.060, 95% confidence interval: -0.098 to -0.022). However, the pooled estimate was substantially greater for an overweight or obese population (standardized mean difference=-0.255, 95% confidence interval: -0.400 to -0.109). Multicomponent interventions (SB and other behaviours) delivered to children from 5 to 12years old in a non-educational setting appear to favour BMI reduction. In summary, SB interventions are associated with very small improvement in BMI in mixed-weight populations. However, SB interventions should be part of multicomponent interventions for treating obese children.

Review question Do drug (medicine) interventions reduce weight in obese children and adolescents and are they safe? Background Across the world more children and adolescents are becoming overweight and obese. These children and adolescents are more likely to have health problems, both while as children or adolescents and in later life. More information is needed about what works best for treating this problem recognising that so-called lifestyle changes (diet, exercise and counselling) have limited efficacy. Study characteristics We found 21 randomised controlled studies (clinical studies where people are randomly put into one of two or more treatment groups) comparing various drugs plus a behaviour changing intervention such as diet, exercise or both (= intervention groups) usually with placebo (a pretend drug) plus a behaviour changing intervention (= control groups). We also identified eight ongoing studies (studies which are currently running but not completed yet). A total of 2484 children and adolescents took part in the included studies. The length of the intervention period ranged from 12 weeks to 48 weeks, and the length of follow-up ranged from six months to 100 weeks. Key results The included studies investigated metformin (10 studies), sibutramine (six studies), orlistat (four studies) and one study group evaluated the combination of metformin and fluoxetine. The ongoing studies are investigating metformin (four studies), topiramate (two studies) and exenatide (two studies). Most studies reported on body mass index (BMI) and bodyweight: BMI is a measure of body fat and is calculated from weight and height measurements (kg/m2). In children, BMI is often measured in a way that takes into account sex, weight and height as children grow older (BMI z score). The average change in BMI across control groups was between a 1.8 kg/m2 reduction to a 0.9 kg/m2 increase, while across all intervention groups the average reduction was more pronounced (1.3 kg/m2 reduction). The same effect was observed for weight change: on average, children and adolescents in the intervention groups lost 3.9 kg more weight than the children and adolescents in the control groups. Study authors reported an average of serious side effects in 24 per 1000 participants in the intervention groups compared with an average of 17 per 1000 participants in the control groups. The numbers of participants dropping out of the study because of side effects were 40 per 1000 in the intervention groups and 27 per 1000 in the control groups. The most common side effects in the orlistat and metformin studies were gut (such as diarrhoea and mild tummy pain). Common side effects in the sibutramine trials included increased heart rate (tachycardia), constipation and high blood pressure. The fluoxetine study reported dry mouth and loose stools. One study reported health-related quality of life (a measure of physical, mental, emotional and social functioning) and found no marked differences between intervention and control. No study reported the participants’ views of the intervention or socioeconomic effects. Only one study reported on morbidity (how often a disease occurs in a specific area) associated with the intervention, where there were more gallstones after the orlistat treatment. Study authors reported one suicide in the orlistat intervention group. However, studies were not long enough to reliably investigate death from any cause. No study investigated drug treatment for children who were only overweight (obese children have a much higher weight, BMI or BMI z score than children being overweight). This evidence is up to date to March 2016. Quality of the evidence The overall certainty of the evidence was low or very low, mainly because there were only a few studies per outcome measurement, the number of included children or adolescents was small, and due to variation in the results of the studies. In addition, many children or ad

© 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Background: Adolescent overweight and obesity has increased globally, and can be associated with short- and long-term health consequences. Modifying known dietary and behavioural risk factors through behaviour changing interventions (BCI) may help to reduce childhood overweight and obesity. This is an update of a review published in 2009. Objectives: To assess the effects of diet, physical activity and behavioural interventions for the treatment of overweight or obese adolescents aged 12 to 17 years. Search methods: We performed a systematic literature search in: CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, and the trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of identified studies and systematic reviews. There were no language restrictions. The date of the last search was July 2016 for all databases. Selection criteria: We selected randomised controlled trials (RCTs) of diet, physical activity and behavioural interventions for treating overweight or obesity in adolescents aged 12 to 17 years. Data collection and analysis: Two review authors independently assessed risk of bias, evaluated the overall quality of the evidence using the GRADE instrument and extracted data following the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. We contacted trial authors for additional information. Main results: We included 44 completed RCTs (4781 participants) and 50 ongoing studies. The number of participants in each trial varied (10 to 521) as did the length of follow-up (6 to 24 months). Participants ages ranged from 12 to 17.5 years in all trials that reported mean age at baseline. Most of the trials used a multidisciplinary intervention with a combination of diet, physical activity and behavioural components. The content and duration of the intervention, its delivery and the comparators varied across trials. The studies contributing most information to outcomes of weight and body mass index (BMI) were from studies at a low risk of bias, but studies with a high risk of bias provided data on adverse events and quality of life. The mean difference (MD) of the change in BMI at the longest follow-up period in favour of BCI was -1.18 kg/m2 (95% confidence interval (CI) -1.67 to -0.69); 2774 participants; 28 trials; low quality evidence. BCI lowered the change in BMI z score by -0.13 units (95% CI -0.21 to -0.05); 2399 participants; 20 trials; low quality evidence. BCI lowered body weight by -3.67 kg (95% CI -5.21 to -2.13); 1993 participants; 20 trials; moderate quality evidence. The effect on weight measures persisted in trials with 18 to 24 months' follow-up for both BMI (MD -1.49 kg/m2 (95% CI -2.56 to -0.41); 760 participants; 6 trials and BMI z score MD -0.34 (95% CI -0.66 to -0.02); 602 participants; 5 trials). There were subgroup differences showing larger effects for both BMI and BMI z score in studies comparing interventions with no intervention/wait list control or usual care, compared with those testing concomitant interventions delivered to both the intervention and control group. There were no subgroup differences between interventions with and without parental involvement or by intervention type or setting (health care, community, school) or mode of delivery (individual versus group). The rate of adverse events in intervention and control groups was unclear with only five trials reporting harms, and of these, details were provided in only one (low quality evidence). None of the included studies reported on all-cause mortality, morbidity or socioeconomic effects. BCIs at the longest follow-up moderately improved adolescent's health-related quality of life (standardised mean difference 0.44 ((95% CI 0.09 to 0.79); P = 0.01; 972 participants; 7 trials; 8 comparisons; low quality of evidence) but not self-esteem. Trials were inconsistent in how they measured dietary intake, dietary behaviours, physical activity and behaviour. Authors' conclusions: We found low quality evidence that multidisciplinary interventions involving a combination of diet, physical activity and behavioural components reduce measures of BMI and moderate quality evidence that they reduce weight in overweight or obese adolescents, mainly when compared with no treatment or waiting list controls. Inconsistent results, risk of bias or indirectness of outcome measures used mean that the evidence should be interpreted with caution. We have identified a large number of ongoing trials (50) which we will include in future updates of this review.

OBJECTIVE: To examine the effectiveness of intermittent energy restriction in the treatment for overweight and obesity in adults, when compared to usual care treatment or no treatment. INTRODUCTION: Intermittent energy restriction encompasses dietary approaches including intermittent fasting, alternate day fasting, and fasting for two days per week. Despite the recent popularity of intermittent energy restriction and associated weight loss claims, the supporting evidence base is limited. INCLUSION CRITERIA: This review included overweight or obese (BMI ≥25 kg/m) adults (≥18 years). Intermittent energy restriction was defined as consumption of ≤800 kcal on at least one day, but no more than six days per week. Intermittent energy restriction interventions were compared to no treatment (ad libitum diet) or usual care (continuous energy restriction ∼25% of recommended energy intake). Included interventions had a minimum duration of 12 weeks from baseline to post outcome measurements. The types of studies included were randomized and pseudo-randomized controlled trials. The primary outcome of this review was change in body weight. Secondary outcomes included: i) anthropometric outcomes (change in BMI, waist circumference, fat mass, fat free mass); ii) cardio-metabolic outcomes (change in blood glucose and insulin, lipoprotein profiles and blood pressure); and iii) lifestyle outcomes: diet, physical activity, quality of life and adverse events. METHODS: A systematic search was conducted from database inception to November 2015. The following electronic databases were searched: MEDLINE, Embase, CINAHL, Cochrane Library, ClinicalTrials.gov, ISRCTN registry, and anzctr.org.au for English language published studies, protocols and trials. Two independent reviewers evaluated the methodological quality of included studies using the standardized critical appraisal instruments from the Joanna Briggs Institute. Data were extracted from papers included in the review by two independent reviewers using the standardized data extraction tool from the Joanna Briggs Institute. Effect sizes were expressed as weighted mean differences and their 95% confidence intervals were calculated for meta-analyses. RESULTS: Six studies were included in this review. The intermittent energy restriction regimens varied across studies and included alternate day fasting, fasting for two days, and up to four days per week. The duration of studies ranged from three to 12 months. Four studies included continuous energy restriction as a comparator intervention and two studies included a no treatment control intervention. Meta-analyses showed that intermittent energy restriction was more effective than no treatment for weight loss (-4.14 kg; 95% CI -6.30 kg to -1.99 kg; p ≤ 0.001). Although both treatment interventions achieved similar changes in body weight (approximately 7 kg), the pooled estimate for studies that investigated the effect of intermittent energy restriction in comparison to continuous energy restriction revealed no significant difference in weight loss (-1.03 kg; 95% CI -2.46 kg to 0.40 kg; p = 0.156). CONCLUSIONS: Intermittent energy restriction may be an effective strategy for the treatment of overweight and obesity. Intermittent energy restriction was comparable to continuous energy restriction for short term weight loss in overweight and obese adults. Intermittent energy restriction was shown to be more effective than no treatment, however, this should be interpreted cautiously due to the small number of studies and future research is warranted to confirm the findings of this review.

Background: Child and adolescent overweight and obesity have increased globally, and are associated with significant short and long term health consequences. Objectives: To assess the effects of surgical interventions for treating obesity in childhood and adolescence. Search methods: We searched the Cochrane Library,MEDLINE, PubMed, EMBASE as well as LILACS, ICTRP Search Portal and ClinicalTrials.gov (all from database inception to March 2015). References of identified studies and systematic reviews were checked.No language restrictions were applied. Selection criteria: We selected randomised controlled trials (RCTs) of surgical interventions for treating obesity in children and adolescents (age < 18 years) with a minimum of six months follow-up. Interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity were excluded. Pregnant females were also excluded. Data collection and analysis: Two review authors independently assessed risk of bias and extracted data. Where necessary authors were contacted for additional information. Main results: We included one RCT (a total of 50 participants, 25 in both the intervention and comparator group). The intervention focused on laparoscopic adjustable gastric banding surgery, which was compared to a control group receiving a multi component lifestyle programme. The participating population consisted of Australian adolescents (a higher proportion of girls than boys) aged 14 to 18 years, with a mean age of 16.5 and 16.6 years in the gastric banding and lifestyle group, respectively which was conducted in a private hospital, receiving funding from the gastric banding manufacturer. The study authors were unable to blind participants, personnel and outcome assessors which may have resulted in a high risk of performance and detection bias. Attrition bias was noted as well. The study authors reported a mean reduction in weight of 34.6 kg (95% confidence interval (CI) 30.2 to 39.0) at two years, representing a change in body mass index (BMI) of 12.7 (95% CI 11.3 to 14.2) for the surgery intervention; and a mean reduction in weight of 3.0kg (95% CI 2.1 to 8.1) representing a change in BMI of 1.3 (95% CI 0.4 to 2.9) for the lifestyle intervention. The differences between groups were statistically significant for all weight measures at 24 months (P < 0.001). The overall quality of the evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was low. Adverse events were reported in 12/25 (48%) participants in the intervention group compared to 11/25 (44%) in the control group (low quality evidence). A total of 28% of the adolescents undergoing gastric banding required revisional surgery. No data were reported for all-cause mortality, behaviour change, participants views of the intervention and socioeconomic effects. At two years, the gastric banding group performed better than the lifestyle group in two of eight health-related quality of life concepts (very low quality evidence) as measured by the Child Health Questionnaire (physical functioning score (94 versus 78, community norm 95) and change in health score (4.4 versus 3.6, community norm 3.5)). Authors’ conclusions: Laparoscopic gastric banding led to greater body weight loss compared to a multi component lifestyle program in one small study with 50 patients. These results do not provide enough data to assess efficacy across populations from different countries, socioeconomic and ethnic backgrounds, whomay respond differently. This systematic review highlights the lack of RCTs in this field. Future studies should assess the impact of the surgical procedure and post operative care to minimise adverse events, including the need for post operative adjustments and revisional surgery. Long-term follow-up is also critical to comprehensively assess the impact of surgery as participants enter adulthood.

Background: Child and adolescent overweight and obesity have increased globally, and are associated with short- and long-term health consequences.Objectives: To assess the efficacy of diet, physical activity and behavioural interventions delivered to parents only for the treatment of overweight and obesity in children aged 5 to 11 years.Search methods: We performed a systematic literature search of databases including the Cochrane Library,MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS as well trial registers.We checked references of identified trials and systematic reviews.We applied no language restrictions. The date of the last search was March 2015 for all databases.Selection criteria: We selected randomised controlled trials (RCTs) of diet, physical activity and behavioural interventions delivered to parents only for treating overweight or obesity in children aged 5 to 11 years.Data collection and analysis: Two review authors independently assessed trials for risk of bias and evaluated overall study quality using the GRADE instrument. Where necessary, we contacted authors for additional information.Main results: We included 20 RCTs, including 3057 participants. The number of participants ranged per trial between 15 and 645. Follow-up ranged between 24 weeks and two years. Eighteen trials were parallel RCTs and two were cluster RCTs. Twelve RCTs had two comparisons and eight RCTs had three comparisons. The interventions varied widely; the duration, content, delivery and follow-up of the interventions were heterogeneous. The comparators also differed. This review categorised the comparisons into four groups: parent-only versus parent-child, parent-only versus waiting list controls, parent-only versus minimal contact interventions and parent-only versus other parent-only interventions. Trial quality was generally low with a large proportion of trials rated as high risk of bias on individual risk of bias criteria. In trials comparing a parent-only intervention with a parent-child intervention, the body mass index (BMI) z score change showed a mean difference (MD) at the longest follow-up period (10 to 24 months) of -0.04 (95% confidence interval (CI) -0.15 to 0.08); P = 0.56; 267 participants; 3 trials; low quality evidence. In trials comparing a parent-only intervention with a waiting list control, the BMI z score change in favour of the parent-only intervention at the longest follow-up period (10-12 months) had an MD of -0.10 (95% CI -0.19 to -0.01); P = 0.04; 136 participants; 2 trials; low quality evidence. BMI z score change of parent-only interventions when compared with minimal contact control interventions at the longest follow-up period (9 to 12 months) showed an MD of 0.01 (95% CI -0.07 to 0.09); P = 0.81; 165 participants; 1 trial; low quality evidence. There were few similarities between interventions and comparators across the included trials in the parent-only intervention versus other parent-only interventions and we did not pool these data. Generally, these trials did not show substantial differences between their respective parent-only groups on BMI outcomes. Other outcomes such as behavioural measures, parent-child relationships and health-related quality of life were reported inconsistently. Adverse effects of the interventions were generally not reported, two trials stated that there were no serious adverse effects. No trials reported on all-cause mortality, morbidity or socioeconomic effects. All results need to be interpreted cautiously because of their low quality, the heterogeneous interventions and comparators, and the high rates of non-completion.Authors’ conclusions: Parent-only interventions may be an effective treatment option for overweight or obese children aged 5 to 11 years when compared with waiting list controls. Parent-only interventions had similar effects compared with parent-child interventions and compared with those with minimal contact controls. However, the evidence is at present limited; some of the trials had a high risk of bias with loss to follow-up being a particular issue and there was a lack of evidence for several important outcomes. The systematic review has identified 10 ongoing trials that have a parent-only arm, which will contribute to future updates. These trials will improve the robustness of the analyses by type of comparator, and may permit subgroup analysis by intervention component and the setting. Trial reports should provide adequate details about the interventions to be replicated by others. There is a need to conduct and report cost effectiveness analyses in future trials in order to establish whether parent-only interventions are more cost-effective than parent-child interventions.

The objective of the present study was to investigate the postprandial metabolism of two starches with contrasting rates of hydrolysis in vitro. Characterized using the Englyst method of in vitro starch classification, C*Set 06 598 contained predominantly rapidly digestible starch and C*Gel 04 201 contained predominantly slowly digestible starch. Each test starch, naturally enriched with 13C, was fed to ten healthy female volunteers as part of a moderate fat test meal (containing 75 g test starch and 21 g fat), in a double-blind randomized crossover design. The metabolic response to each starch was measured after an overnight fast, in an acute 6 h study, before and after 14 d of daily consumption of 75 g test starch. During each acute study, blood samples were taken at 15 min intervals for the first 2 h and at 30 min intervals for the remaining 4 h. Breath 13CO2 enrichment was measured at the same time points and indirect calorimetry was performed for 20 min every 40 min immediately before and throughout the study. Significantly more rapid, greater changes in postprandial plasma glucose, NEFA and serum insulin concentrations were observed after consumption of the rapidly digestible starch. Breath 13CO2 output over the first 3-4 h rose rapidly then began to decline following consumption of the rapidly digestible starch, but plateaued for the slowly digestible starch. The 14 d adaptation period did not affect any of the glycaemic or lipaemic variables but there was a reduction in postprandial plasminogen activator inhibitor-1 concentrations. These data confirm that starches characterized as predominantly rapidly digestible versus slowly digestible by the Englyst procedure provoke distinctly different patterns of metabolism postprandially.

The aim of this systematic review and meta-analysis was to examine the effectiveness of e health interventions for the treatment of children and adolescents with overweight or obesity. Databases were searched up to November 2020. Studies were randomised controlled trials where interventions were delivered via e-health (e.g. computers, tablets, smartphones, but not phone calls). Studies should target the treatment of overweight or obesity in children or their agent of changes and report BMI or BMI-z score. A meta-analysis using a random-effects model was conducted. Nineteen studies met the inclusion criteria, and 60% were of high quality. The narrative review revealed variation in behaviour change strategies and modes of delivery. The pooled mean reduction in BMI or BMI z-score showed evidence for a non-zero effect (standardised mean difference = -0.31, 95% confidence interval -0.49 to -0.13), with moderately high heterogeneity between studies (I2 = 74%, p<0.001). Subgroup analysis revealed high heterogeneity in studies with a high or unclear risk of bias. E-health interventions can be effective in treating children and adolescents with overweight and obesity and should be considered by practitioners and policymakers. However, an understanding of the most effective and acceptable intervention components, long-term benefits and sustainability should be further studied.

Parents typically do not recognise their child’s weight status accurately according to clinical criteria, and thus may not take appropriate action if their child is overweight. We developed a novel visual intervention designed to improve parental perceptions of child weight status according to clinical criteria for children aged 4–5 and 10–11 years. The Map Me intervention comprises age- and sex-specific body image scales of known body mass index and supporting information about the health risks of childhood overweight.

The prevalence of both obesity and disability is increasing globally and there is now growing evidence to suggest that these two health priorities may be linked. This paper explores the evidence linking obesity to muscular-skeletal conditions, mental health disorders and learning disabilities in both adult and child populations. The impact of obesity on the four most prevalent disabling conditions in the UK (arthritis, mental health disorders, learning disabilities and back ailments) has been examined through novel data analysis of the 2001 Health Survey for England and UK Back Exercise And Manipulation trial data. Together these analyses strongly suggest that whether the cause or result of disability, obesity is undeniably implicated, thus presenting a serious public health priority. Future research efforts are required to strengthen the evidence base examining obesity in back disorders, mental health and learning disabilities, in order to improve current clinical management.

© 2016 by the American College of Sports Medicine. Purpose Isotemporal substitution analysis offers new insights for public health but has only recently been applied to sedentary behavior research. We aimed to quantify associations between the substitution of 10 min of sedentary behavior with 10 min of light physical activity (LPA) or moderate-to-vigorous physical activity (MVPA) and the prevalence of cardiovascular disease (CVD). Age was also explored as a potential effect modifier. Methods We completed a secondary analysis of data from 1477 adults from the Health Survey for England (2008). Sedentary time, LPA, and MVPA were measured using accelerometry. We applied isotemporal models to quantify the relationship with CVD prevalence of replacing 10 min of sedentary time with equivalent amounts of LPA or MVPA. Prevalence risk ratios (RR) with 95% confidence intervals (CI) are presented, adjusted for covariates. The role of age as an effect modifier was explored via age-MVPA and age-LPA interactions. CVD was defined as per the International Classification of Diseases. Results The prevalence of CVD was 24%. The RR was 0.97 (95% CI, 0.96-0.99) for LPA and 0.88 (0.81-0.96) for MVPA. Substitution of approximately 50 min of LPA would be required for an association equivalent to 10 min of MVPA. The beneficial association of MVPA was attenuated with age, with a decrease in the relative risk reduction of approximately 7% per decade. Conclusions Isotemporal substitution of sedentary time with LPA was associated with a trivial relative risk reduction for CVD, whereas the equivalent replacement with MVPA had a small beneficial relationship. With respect to CVD prevalence, MVPA might become decreasingly important in older individuals. Prospective studies are needed to investigate causality.

Objectives Parental underdetection of child underweight and overweight/obesity may negatively affect children's longer‐term health. We examined psychological/behavioural mechanisms of a very low‐intensity intervention to improve acknowledgement and understanding of child weight after feedback from a school‐based weight monitoring programme. Design This sub‐study was nested within a larger 3‐arm cluster‐RCT (1:1:1; N = 57,300). Parents in all groups received written postal feedback on their child's weight classification. Intervention participants received an enhanced feedback letter with computer‐generated photorealistic images depicting children of different weight classifications, and access to a website about supporting healthy weight, once (intervention one) or twice (intervention two; repeated 6 months after first ‘dose’). Methods A quantitative process and outcome evaluation using baseline and 12‐month BMI z‐scores of an opt‐in sub‐sample of 502 children aged 4–5 and 10–11. Children completed dietary reports, used accelerometers (MVPA), and self‐reported self‐esteem; 10–11‐year‐olds also self‐reported quality of life and dietary restraint. Parents reported perceptions of child's weight classification, and their intentions, self‐efficacy, action planning and coping planning for child physical activity, dietary intake; parents of 4–5‐year‐olds reported their child's quality of life. Results Neither intervention differentially improved parental acknowledgement or understanding of weight classification at follow‐up, although parents in all groups reported better acknowledgement after receiving feedback. The interventions did not affect behavioural/psychological determinants, weight outcomes, children's self‐esteem, dietary restraint or quality of life. Conclusions The interventions neither improved parental acknowledgement of child weight, child BMI z‐scores and their psychological/behavioural determinants, nor worsened psycho‐social sequelae.

Background: Randomised controlled trials have shown that total diet replacement (TDR) can lead to remission of type 2 diabetes. In 2019, the English National Health Service (NHS) committed to establishing a TDR-based interventional programme delivered at scale within real-world environments; development followed of the NHS Type 2 Diabetes Path to Remission (T2DR) programme, a 12-month behavioural intervention to support weight loss involving an initial 3-month period of TDR. We assessed remission of type 2 diabetes for programme participants. Methods: In this national prospective service evaluation of programme implementation, people in England aged 18–65 years and diagnosed with type 2 diabetes in the last 6 years were referred to the programme between programme launch on Sept 1, 2020, and Dec 31, 2022. Programme data were linked to the National Diabetes Audit to ascertain HbA1c measurements and glucose-lowering medication prescriptions. The primary outcome was remission of type 2 diabetes at 1 year, defined as two HbA1c measurements of less than 48 mmol/mol recorded at least 3 months apart with no glucose-lowering medications prescribed from 3 months before the first HbA1c measurement, and the second HbA1c measurement recorded 11–15 months after the programme start date. Outcomes were assessed in two ways: for all participants who started TDR on the 12-month programme before January, 2022, for whom there were no missing data; and for all participants who started TDR on the 12-month programme before January, 2022, and had completed the programme (ie, had a valid weight recorded at month 12) by Dec 31, 2022, for whom there were no missing data. Findings: Between Sept 1, 2020, and Dec 31, 2022, 7540 people were referred to the programme; of those, 1740 started TDR before January, 2022, and therefore had a full 12-month opportunity to undertake the programme by the time of data extraction at the end of December, 2022. Of those who started TDR before January, 2022, 960 (55%) completed the programme (defined as having a weight recorded at 12 months). The mean weight loss for the 1710 participants who started the programme before January, 2022 and had no missing data was 8·3% (95% CI 7·9–8·6) or 9·4 kg (8·9–9·8), and the mean weight loss for the 945 participants who completed the programme and had no missing data was 9·3% (8·8–9·8) or 10·3 kg (9·7–10·9). For the subgroup of 710 (42%) of 1710 participants who started the programme before January, 2022, and also had two HbA1c measurements recorded, 190 (27%) had remission, with mean weight loss of 13·4% (12·3–14·5) or 14·8 kg (13·4–16·3). Of the 945 participants who completed the programme, 450 (48%) had two HbA1c measurements recorded; of these, 145 (32%) had remission, with mean weight loss of 14·4% (13·2–15·5) or 15·9 kg (14·3–17·4). Interpretation: Findings from the NHS T2DR programme show that remission of type 2 diabetes is possible outside of research settings, through at-scale service delivery. However, the rate of remission achieved is lower and the ascertainment of data is more limited with implementation in the real world than in randomised controlled trial settings. Funding: None.

Background Migration-related changes in dietary patterns and other structural and individual factors affect weight-related health practices of individuals migrating from low-and-middle-income to high-income countries. Thus, individuals of ethnically diverse backgrounds may be disproportionately affected by poorer health outcomes, including weight-related health issues. Understanding how this community could be supported to adopt weight-related healthy practices such as optimum dietary and exercise behaviour is an important issue for public health research. Against this backdrop, we explored structural and individual factors that facilitate and constrain the uptake of weight management services among members of minority ethnic communities in Medway, England. Methods Data were collected from audio-recorded interviews with 12 adult community members from minoritised ethnic communities using a semi-structured interview guide. Participants were recruited through a purposive and convenient sampling technique. Generated data were transcribed, coded into NVivo and analysed using the reflexive thematic analytical technique. Results Results showed that social support and health benefits of weight management were the main motivating factors for weight management among the study participants. Conversely, systemic barriers, family commitment and caring responsibilities, changes in dietary patterns post-migration and cultural norms were major factors constraining participants from adopting weight management behaviours. Conclusion The results of this study indicate that structural and person-level factors serve as both facilitators and barriers to weight management among ethnically diverse communities in Medway, England. While our study is exploratory and opens doors for more studies among the population, we conclude that these minoritised communities could benefit from more equitable, tailored weight management programmes to support them in adopting weight-related practices.

Overweight and obesity is usually determined by Body Mass Index (BMI). Twelve BAME adults participated in the interviews: six were female, ten were first-generation migrants, three were retirees, none lived with a disability, and all were concerned about their excess weight. There were four themes from the data and eight subthemes obtained. To improve the uptake of the weight management service provided in Medway, the participants recommended the use of strategies such as indigenous food labelling, BAME-led clinics, the use of translated leaflets, the recruitment of local weight management champions, better coordination of services, appropriate communication strategies, and further research. This study investigated a small sample of English-speaking participants, which may not represent all people from BAME backgrounds in Medway and across the United Kingdom (UK). This study investigated the perspectives of residents who are overweight or obese, as well as weight management concerns among ethnically diverse adults. It also investigated how to increase the use of weight management services in Medway, England. In Medway, 69.2% of adults are living with overweight or obesity, which is considerably higher than the national average of 62%. Indigenous food labelling, BAME-led clinics, the use of translated leaflets, the recruitment of local weight management champions, better coordination of services, appropriate communication strategies, and further research are essential ingredients that can be used to improve access to and uptake of weight management programmes in BAME communities.

Background Lifestyle modification interventions for adults with intellectual disabilities have had, to date, mixed effectiveness. This study aimed to understand how lifestyle modification interventions for adults with intellectual disabilities work, for whom they work and in what circumstances. Methods A realist evidence synthesis was conducted that incorporated input from adults with intellectual disabilities and expert researchers. Following the development of an initial programme theory based on key literature and input from people with lived experience and academics working in this field, five major databases (MEDLINE, EMBASE, CINAHL, PsycINFO and ASSIA) and clinical trial repositories were systematically searched. Data from 79 studies were synthesised to develop context, mechanism and outcome configurations (CMOCs). Results The contexts and mechanisms identified related to the ability of adults with intellectual disabilities to actively take part in the intervention, which in turn contributes to what works, for whom and in what circumstances. The included CMOCs related to support involvement, negotiating the balance between autonomy and behaviour change, fostering social connectedness and fun, accessibility and suitability of intervention strategies and delivery and broader behavioural pathways to lifestyle change. It is also essential to work with people with lived experiences when developing and evaluating interventions. Conclusions Future lifestyle interventions research should be participatory in nature, and accessible data collection methods should also be explored as a way of including people with severe and profound intellectual disabilities in research. More emphasis should be given to the broader benefits of lifestyle change, such as opportunities for social interaction and connectedness.

Background: Adults with intellectual disabilities (ID) are susceptible to multiple health risk behaviours such as alcohol consumption, smoking, low physical activity, sedentary behaviour, and poor diet. Lifestyle modification interventions can prevent or reduce negative health consequences caused by these behaviours. We aim to determine the effectiveness of lifestyle modification interventions and their components in targeting health risk behaviours in adults with IDs. Methods: A systematic review and meta-analysis were conducted. Electronic databases, clinical trial registries, grey literature, and citations of systematic reviews and included studies were searched in January 2021 (updated February 2022). Randomised controlled trials and non-randomised controlled trials targeting alcohol consumption, smoking, low physical activity, sedentary behaviours, and poor diet in adults (aged≥18 years) with ID were included. Meta-analysis was conducted at the intervention-level (pairwise and network meta-analysis) and the component-level (component network meta-analysis). Studies were coded using Michie’s 19-item theory coding scheme and 94-item behaviour change taxonomies. Risk of bias was assessed using the Cochrane Collaboration's Risk of Bias Assessment Tool (RoB Version 2) for RCTs and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tool for non-RCTs. The study involved a Patient and Public Involvement (PPI) group, including people with lived experience, who contributed extensively by shaping the methodology, providing valuable insights in interpreting results, and organising of dissemination events. Results: Our literature search identified 12,180 articles, of which 80 studies with 4,805 participants were included in the review. The complexity of lifestyle modification intervention was dismantled by identifying six core components that influenced outcomes. Interventions targeting single or multiple health risk behaviours could have a single or combination of multiple core-components. Interventions (2 RCTS; 4 non-RCTs; 228 participants) targeting alcohol consumption and smoking behaviour were effective but based on limited evidence. Similarly, interventions targeting low physical activity only (16 RCTs; 17 non-RCTs; 1413 participants) or multiple behaviours (low physical activity only, sedentary behaviours, and poor diet) (17 RCTs; 24 non-RCTs; 3164 participants) yielded mixed effectiveness in outcomes. Most interventions targeting low physical activity only and multiple behaviours generated positive effects on various outcomes, while some interventions led to no change or worsened outcomes which could be attributed to the presence of a single core component or a combination of similar core components in interventions. The intervention-level meta-analysis for weight management outcomes showed that none of the interventions were associated with a statistically significant change in outcomes when compared to treatment-as-usual. Interventions with core-components combination of energy deficit diet, aerobic exercise and behaviour change techniques showed the highest weight loss (MD=-3.61,95% CrI -9.68 – 1.95) and those with core-components combination dietary advice and aerobic exercise showed a weight gain (MD 0.94, 95% CrI -3.93 to 4.91). Similar findings were found with the components network meta-analysis for which additional components were identified. Studies had a high and moderate risk of bias. Various theories and behaviour change techniques were used in intervention development and adaptation. Conclusion: Our systematic review is the first to comprehensively explore lifestyle modification interventions targeting a range of single and multiple health risk behaviours in adults with ID, co-produced with people with lived experience. It has practical implications for future research as it highlights the importance of mixed-methods research in understanding lifestyle modification interventions and the need for population-specific improvements in the field (e.g., tailored interventions, development of evaluation instruments or tools, use of rigorous research methodologies, and comprehensive reporting frameworks). Wide dissemination of related knowledge and the involvement of PPI groups, including people with lived experience, will help future researchers design interventions that consider the unique needs, desires, and abilities of people with ID.

Background Adults with learning disabilities face increased risks of unhealthy lifestyle behaviours, including alcohol consumption, smoking, low physical activity, sedentary behaviour and poor diet. Lifestyle modification interventions that target health-risk behaviours can prevent or reduce their negative effects. The goal of this project was to investigate the effectiveness and underlying mechanisms of lifestyle modification interventions in adults with learning disabilities. Methods A systematic review and meta-analysis were conducted to determine the effectiveness of lifestyle modification interventions and their components in targeting health risk behaviours in adults with learning disabilities. Major electronic databases, clinical trial registries, grey literature, and citations of systematic reviews and included studies were searched in January 2021 (updated in February 2022). We included randomised and non-randomised controlled trials targeting alcohol consumption, smoking, low physical activity only, sedentary behaviour and poor diet in adults (aged ≥ 18 years) with learning disabilities. Studies were also coded based on the extent of use of theories and behaviour change techniques in interventions. Risk of bias in studies was assessed using appropriate tools. A realist synthesis of qualitative, quantitative and mixed-methods literature was conducted to complement the systematic review findings by identifying key intervention mechanisms that are likely to improve the health of adults with learning disabilities. Data were synthesised in the form of a programme theory regarding complex causal mechanisms and how these interact with social context to produce outcomes. All findings were integrated into a logic model. A patient and public involvement group provided input and insights throughout the project. Results A total of 80 studies with 4805 participants were included in the systematic review. The complexity of lifestyle modification interventions was dismantled by identifying six core components that influenced outcomes. These components could be present in interventions targeting single or multiple health risk behaviors, either as individual elements or in various combinations. Interventions on alcohol and smoking behaviours were found to be effective, but this was based on limited evidence. The effectiveness of interventions targeting low physical activity only or multiple behaviours (low physical activity only, sedentary behaviours and poor diet) was mixed. All interventions had a varying level of statistical significance. The intervention-level network meta-analysis for weight management outcomes showed none of the interventions was associated with a statistically significant change in outcomes when compared to treatment as usual and each other. Similar findings were observed in the component network meta-analysis. A variety of theories and behaviour change techniques were employed in the development and adaptation of interventions. Most studies had a high and moderate risk of bias. A total of 79 studies, reporting the experiences of more than 3604 adults with intellectual disabilities and over 490 caregivers, were included in the realist synthesis. The resulting programme theory highlighted the contexts and mechanisms relating to support involvement, negotiating the balance between autonomy and behaviour change, fostering social connectedness and fun, the accessibility and suitability of intervention strategies and delivery, along with the broader behavioural pathways to lifestyle change. It also brought out the importance of working with people with lived experiences when developing and evaluating interventions. Our logic model, bringing together the findings of both syntheses, provides guidance on the design of future interventions. Discussion This study was the first comprehensive mixed-methods evidence synthesis to explore lifestyle modification interventions targeting multiple unhealthy lifestyle behaviours in adults with learning disabilities. We conclude that future research could benefit from codeveloping interventions and population-specific assessment frameworks with people with lived experiences. There is a need for more high-quality research with appropriate outcomes and a focus on qualitative and mixed-methods research to better understand what works for whom and why. Trial registration This trial is registered as PROSPERO CRD 42020223290. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128755) and is published in full in Health Technology Assessment; Vol. 29, No. 4. See the NIHR Funding and Awards website for further award information.

Background Minority ethnic groups are a fast-growing population in many high-income countries, partly due to the increasing population of immigrants and second-generation migrants. The dietary practices of some of these minority ethnic groups might make them to be disproportionately affected by obesity and increase their risks of developing non-communicable diseases. Population-specific interventions and strategies are vital to addressing poor nutritional practices among this population. Thus, this study systematically reviewed the perceptions of dietary intake amongst Black, Asian and other minority ethnic groups in high-income countries. Methods This systematic review was conducted in line with the guidelines of the Joanna Briggs Institute (JBI) methodology for systematic reviews, using a meta-aggregative design. This systematic review identified and synthesised qualitative literature on the perceptions of dietary intake amongst BlackAsian and other minority ethnic groups in high-income countries. An extensive and comprehensive database search was conducted between January 2000 – May 2022 and included twenty (20) studies that met the eligibility criteria from six countries. The included studies were assessed for quality using the JBI qualitative assessment and review instrument. The JBI data extraction tools were used to retrieve relevant data from included articles, and the data were thematically analysed. Results We identified eight major themes across this database: (1) “Social and Cultural Factors,” (2) “Availability and Accessibility,” (3) “Family and Community Influences,” (4) “Food Preferences”, (5) “Home Country Food Versus Host Country Food” (6) “Dietary Acculturation” (7) “Health and Healthy Eating” (8) “Perception of Nutritional Information.” Conclusion Overall, Black, Asian, and other minority ethnic groups individuals were found to be aware of the effects of unhealthy eating on their health, and some of them have nutritional knowledge, but social and cultural factors, including structural factors, were deterrents to their healthy eating behaviours. An important finding from this review is that some participants believed that nutritional information, based on bio-medical science, was intended for only White population groups and that it was antagonistic to their cultural and community well-being.

BACKGROUND: Communities with diverse ethnicity in high-income countries are disproportionately affected by poor diet-related health outcomes. In England, the United Kingdom's government's healthy eating dietary resources are not well accepted and are underutilised among this population. Thus, this study explored perceptions, beliefs, knowledge, and practices around dietary intake among communities with African and South Asian ethnicity residing in Medway, England. METHODS: This qualitative study generated data from 18 adults aged 18 and above using a semi-structured interview guide. These participants were sampled using purposive and convenience sampling strategies. All the interviews were conducted in English over the telephone, and responses were thematically analysed. RESULTS: Six overarching themes were generated from the interview transcripts: eating patterns, social and cultural factors, food preferences and routines, accessibility and availability, health and healthy eating, and perceptions about the United Kingdom government's healthy eating resources. CONCLUSION: The results of this study indicate that strategies to improve access to healthy foods are required to improve healthy dietary practices among the study population. Such strategies could help address this group's structural and individual barriers to healthy dietary practices. In addition, developing a culturally responsive eating guide could also enhance the acceptability and utilisation of such resources among communities with ethnic diversity in England.

Background: The high prevalence of childhood obesity is a concern for public health policy and practitioners, leading to a focus on early prevention. UK health visitors (HVs) are well-positioned to prevent excessive weight gain trends in pre-school children but experience barriers to implementing guideline recommended practices. This research engaged with HVs to design an intervention to strengthen their role in prevention of early childhood obesity. Methods: We describe the processes we used to develop a behaviour change intervention and measures to test its feasibility. We conducted a systematic review to identify factors associated with implementation of practices recommended for prevention of early childhood obesity. We carried out interactive workshops with HVs who deliver health visiting services in County Durham, England. Workshop format was informed by the behaviour change wheel framework for developing theory-based interventions and incorporated systematic review evidence. As intended recipients of the intervention, HVs provided their views of what is important and acceptable in the local context. The findings of the workshops were combined in an iterative process to inform the four steps of the Implementation Intervention development framework that was adapted as a practical guide for the development process. Results: Theoretical analysis of the workshop findings revealed HVs' capabilities, opportunities and motivations related to prevention of excess weight in 0-2 year olds. Intervention strategies deemed most likely to support implementation (enablement, education, training, modelling, persuasion) were combined to design an interactive training intervention. Measures to test acceptability, feasibility, and fidelity of delivery of the proposed intervention were identified. Conclusions: An interactive training intervention has been designed, informed by theory, evidence, and expert knowledge of HVs, in an area of health promotion that is currently evolving. This research addresses an important evidence-practice gap in prevention of childhood obesity. The use of a systematic approach to the development process, identification of intervention contents and their hypothesised mechanisms of action provides an opportunity for this research to contribute to the body of literature on designing of implementation interventions using a collaborative approach. Future research should be directed to evaluate the acceptability and feasibility of the intervention.

Aim To evaluate web search engines' informational content regarding community water fluoridation (CWF) when accessed from the UK. Methods The search engine result pages (SERPs) regarding CWF from Google were identified, the content was analysed for themes and sentiments, and Google Trends information on CWF was examined. Results The SERPs were predominantly in favour of CWF. Anti-fluoridation themes were observed in SERPs that presented the arguments supporting and opposing CWF with equanimity, irrespective of the quality of scientific evidence. Hence, a web search for CWF yields conflicting information. Correlation is observed between current affairs and public interest in CWF. Conclusion UK residents seeking online CWF advice may experience confusion due to the prevalent conflicting information, which may influence their decision-making. Dental health professionals, public health practitioners and policymakers should strive to improve the information provision on CWF online.

Primary care providers (PCPs) have an important role in prevention of excess weight gain in pre-school children. Guidelines exist to support PCPs' practices. This systematic review of PCPs' practice behaviors and their perceptions of barriers to and facilitators of implementation of guidelines was the first step toward the development of an intervention aimed at supporting PCPs. Five databases were searched to identify qualitative, quantitative, and mixed methods studies which examined PCPs' practice patterns and factors influencing implementation of recommended practices. The convergent integrated approach of the Joanna Briggs Institute (JBI) methodology for mixed methods reviews was used for data synthesis. Following analyses, the resultant factors were mapped onto the Capability, Opportunity, and Motivation model of Behaviour (COM-B). Fifty studies met the eligibility criteria. PCPs inconsistently implement recommended practices. Barriers and facilitators were identified at the provider (e.g., lack of knowledge), parent (e.g., lack motivation), and organization level (e.g., inadequate training). Factors were mapped to all three components of the COM-B model: psychological capability (e.g., lack of skills), reflective motivation (e.g., beliefs about guidelines), automatic motivation (e.g., discomfort), physical opportunity (e.g., time constraints), and social opportunity (e.g., stigma). These findings reflect the complexity of implementation of childhood obesity prevention practices.

BACKGROUND: Adults with learning disabilities have an increased disposition to unhealthy lifestyle behaviours which often occur simultaneously. Existing studies focus on complex interventions targeting unhealthy diet, physical inactivity, sedentary behaviour, smoking, and alcohol use to reduce health risks experienced. It is essential to understand how well these interventions work, what works, for whom, in what context and why. This study aims to investigate the effectiveness and underlying mechanisms of lifestyle modification interventions for adults with learning disabilities. METHODS: This is a mixed-methods systematic review consisting of a network meta-analysis (NMA) and realist synthesis. Electronic databases (ASSIA, CINAHL, EMBASE, MEDLINE, and PsycINFO) will be searched from inception to 14 January 2021 with no language restriction. Additionally, trial registries, grey literature databases and references lists will be searched. Studies related to lifestyle modification interventions on the adult population (>18 years) with learning disabilities will be eligible for inclusion. Two independent researchers will screen studies, extract data and assess its quality and risk of bias using the Cochrane Collaboration's Risk of Bias Assessment Tool (RoB Version 2) and ROBINS-I. The strength of the body of evidence will be assessed based on the GRADE approach. The NMA will incorporate results from RCTs and quasi-experimental studies to estimate the effectiveness of various lifestyle interventions. Where appropriate, a component NMA (CNMA) will be used to estimate effectiveness. The realist synthesis will complement and explain the findings of NMA and CNMA by including additional qualitative and mixed-methods studies. Studies will be included based on their relevance to the programme theory and the rigour of their methods, as determined by quality appraisal tools appropriate to the study design. Results from both syntheses will be incorporated into a logic model. DISCUSSION: The paucity of population-specific lifestyle interventions contributes to the challenges of behaviour change in adults with learning disabilities. This study will provide an evidence-base from which various stakeholders can develop effective interventions for adults with learning disabilities. The evidence will also help prioritise and inform research recommendations for future primary research so that people with learning disabilities live happier, healthier and longer lives. TRIAL REGISTRATION: PROSPERO CRD 42020223290.

Background The impact of obesity interventions on dietary intake in children and adolescents with overweight or obesity is unclear. This systematic review aimed to investigate the impact of the dietary component of weight management interventions on the change in diet in children and adolescents with overweight or obesity. Methods Eligible RCTs published between 1975 and 2020 were identified by a systematic search following PRISMA guidelines. Meta-analyses of eligible study outcomes was performed using R statistical software. A multi-level random effects model was used with three significant random effects fitted using Restricted Maximum Likelihood estimation. Results This review identified 109 RCTs, including 95 that reported at least one statistically significant dietary outcome change, and 14 reporting no significant dietary change. Results from the meta-analyses (n= 29 studies) indicated that compared to control groups, intervention groups achieved significantly greater reductions in mean total energy intake at ≤6 months (-194kcal/day, 95%CI -275.80 to -112.90kcal/day, p<0.001) and up to 12 months (-112k cal/ day 95% CI -218.92 to -5.83kcal/ day)p=0.038), increases in fruit and/or vegetable intakes over 2-12 months (n=34, range +0.6 to +1.5 servings/day) and reductions in consumption of sugar-sweetened beverages (n=28, range -0.25 to -1.5 servings/day) at 4-24 months follow-up. Conclusions Obesity interventions with a dietary component have a modest, but sustained impact on reducing total energy intake and improving intakes of specific food groups in children and adolescents with overweight or obesity. High quality RCTs that are powered to detect change in diet as a primary outcome are warranted.

The proposals that cancer might be preventable, and that food, nutrition, physical activity and body composition might affect the risk of cancer, were first made before science emerged in its modern form in the 19th and 20th centuries. Throughout recorded history, wise choices of food and drink, and of habitual behaviour, have been recommended to protect against cancer, as well as other diseases, and to improve well-being. Reports such as this, which incorporate systemtic examination of all relevant types of research, differ from ancient, historical, and even relatively recent accounts, and descriptive studies of the type detailed in Chapter 1, not only in the quantity and quality of evidence, but also in the reliability of the judgements and recommendations that derive from it.

This report describes research on the National Child Measurement Programme (NCMP), a national surveillance programme for measuring children’s body mass index (BMI), as part of broader UK public health initiatives to halt the current rise in childhood obesity. The programme was implemented in response to the 2004 Public Service Agreement (PSA) target to halt the year on year rise in obesity amongst children under 11 in England by 2010. All Primary Care Trusts (PCT) in England are now required to measure the height and weight of reception children (aged 4-5) and year 6 children (aged 10-11) in order to inform local planning and targeting of resources and interventions and to enable tracking of local progress against the PSA target (Department of Health 2006).The research, based in North East England, was carried out in two phases. The first phase involved audit of all independent and special needs schools within the North East Strategic Health Authority. Telephone interviews with these schools in February/March 2007 established rates of compliance with and experiences of the programme. Phase two involved a qualitative study in two schools from one PCT. Interviews, discussion groups and observation were used to explore the experiences of teachers, parents and children involved in the programme.Findings from the audit show minimal participation by special or independent schools. Special schools present a number of reasons for being wary of inclusion in the measurement scheme, from small cohort sizes leading to fears that children will be singled out or labelled, to concerns about children’s mental stability. The case for non inclusion of independent schools seems to rest on the fact that PCTs do not usually have existing relationships with them. Independent schools would agree to be included if resources were provided to carry out the exercise but are unlikely to do so unless participation is made compulsory. Qualitative findings from the project highlight issues such as multiple misunderstandings of the programme by different individuals, the difficulties children had with interpreting metric measures of height and weight, children sharing measurements with each other and understandings of body size. The school is also examined as a setting for BMI measurement. with a discussion of the ways in which responsibility for children’s health is placed with different individuals, the role of children’s competence and right to consent to measurement and the role of schools as sites for health promotion, screening and surveillance.The report concludes with a number of recommendations for future rounds of the programme, such as the inclusion of independent schools in the programme, the continued exemption of special needs schools, the provision of clearer information for teachers, parents and children concerning the purpose of the measurement programme, and the need to incorporate the programme into wider health initiatives in school in order to facilitate children’s participation and prevent distress regarding measurement of body size and weight.

The results of this follow up study have identified that there has been some significant development in maternal obesity services since the previous study conducted in 2005/2006. There are routine referrals for consultant led care and anaesthetics for obese women, and also to dietetics services in a number of maternity units. Maternity units are also in various stages of developing and implementing guidelines across the region. Overall Health Care Professionals (HCP) felt that the benefits of maternal obesity services were in safeguarding the health of the mother and her baby, and the majority of maternity units had the necessary equipment to manage the care of the obese pregnant woman safely. HCPs also felt that implementing obesity services during pregnancy meant that women were a captive audience, and may be more motivated to address obesity during pregnancy. However there is more scope for the development of services relating to maternal weight management, and addressing the psychosocial issues of maternal obesity. The needs of service users must be considered when developing services, and research is required to identify how to engage obese pregnant women with services to ensure that: * Service development meets the needs of obese pregnant women. * To ensure that resources are not wasted implementing interventions that wont be utilised by service users. * To ensure that women dont feel stigmatised during pregnancy. * To ensure that women dont disengage from maternity services altogether through feeling stigmatised. It was acknowledged that maternity services could not address this issue alone, and that additional expertise was required. In particular, the lack of communication between maternity services and public health services was identified as a barrier in establishing the necessary support pathways to effectively utilise existing expertise. HCPs felt that addressing obesity in pregnancy was bigger than us, and that it needed to be on the wider agenda to be addressed effectively, and that a national and strategic drive was required. The need for long term solutions to address maternal obesity were discussed, and how results would not necessarily be seen straight away as there was a need for services to break the cycle of obesity for the next generation. HCPs felt that there was also a need for the public health messages relating to obesity to include the impact on pregnancy, and how they needed to be more engaging of the obese population. HCPs identified areas of training that would be required in order to provide effective services for obesity. It was stressed that flexibility was required to ensure all HCPs that required training could attend, that midwives could potentially learn from dietitians, and there may be training needs for dietitians relating to the maternal and foetal needs of obese women during pregnancy. The specific training needs identified included: * How to broach the subject of maternal obesity with women. * A need to address the language barrier between HCPs and women. * How midwives didnt have the necessary expertise on obesity. Recommendations: Overall this study has shown that maternity services to address maternal obesity have developed significantly over the last two to three years in terms of the obstetric requirements of obese women, and there are improved multidisciplinary relations throughout maternity units in the majority of the region, especially in relation to anaesthetics services, and to a lesser extent, dietetics services. However, there is still a substantial amount of work to be done in terms of having a more holistic and strategic service that looks at the wellness of obese pregnant women rather than just health and safety aspects. HCPs have identified that to address maternal obesity effectively, services need to: * Consider the transition of care between the pregnancy and postnatal period to maximise engagement with services. * Address the identified training needs of HCPs who care for obese pregnant women. * Focus on improving communication between hospital maternity services and public health services. * Ensure the issue of maternal obesity is on the wider obesity agenda to facilitate the strategic and national support that is likely to be required to effectively address maternal obesity. * Be involved in further research to identify how to engage pregnant women with services to address their obesity.

The nutritional requirements of adolescence and the reported poor UK eating behaviours of young people are a significant public health concern. Schools are recognised as an effective 'place' setting to enable improvement to nutrition outcomes. The COVID-19 pandemic resulted in UK school closures from March 2020. In re-opening in September 2020, schools were required to meet guidelines to ensure the minimised impact of COVID-19 on the population (DfE 2020). We aimed to evaluate the impact of COVID-19 school guidelines on secondary and post-16 (16-18 years) food provision. An online survey was posted on 8th October to 1st December 2020, targeted at young people, parents and staff of secondary/post-16 education establishments in the UK. Two hundred and fifty-two responses were received, of which 91% reported a change in their school food provision, 77% reported time for lunch was shortened and 44% indicated the provision was perceived as less healthy during September 2020 (post-lockdown school return) compared with March 2020 (pre-lockdown). Analyses demonstrated that time, limited choice and healthiness impacted negatively upon young people's school food experience. The COVID-19 pandemic has presented a huge challenge to the delivery of healthy school food to young people. Therefore, schools require more support in following national food standards and incorporating nutrition education and behaviour change strategies within current guidelines.

Research suggests parental ability to recognise when their child has overweight is limited. It is hypothesised that recognition of child overweight/obesity is fundamental to its prevention, acting as a potential barrier to parental action to improve their child’s health-related behaviours and/or help seeking. The purpose of this study was to investigate the efficacy of an intervention (MapMe) to improve parental ability to correctly categorise their child as having overweight one-month post-intervention, and reduce child body mass index (BMI) z-score 12 months post-intervention. MapMe consists of body image scales of known child BMI and information on the consequences of childhood overweight, associated health-related behaviours and sources of support. We conducted a three-arm (paper-based MapMe, web-based MapMe and control) randomised control trial in fifteen English local authority areas with parents/guardians of 4–5- and 10–11-year-old children. Parental categorisation of child weight status was assessed using the question ‘How would you describe your child’s weight at the moment?’ Response options were: underweight, healthy weight, overweight, and very overweight. Child weight status and BMI z-scores were calculated using objectively measured height and weight data and UK90 clinical thresholds. There was no difference in the percentage of parents correctly categorising their child as having overweight/very overweight (n = 264: 41% control, 48% web-based, and 43% paper-based, p = 0.646). BMI z-scores were significantly reduced for the intervention group at 12 months post-intervention compared to controls (n = 338, mean difference in BMI z-score change −0.11 (95% CI −0.202 to −0.020, p = 0.017). MapMe was associated with a decrease in BMI z-score 12 months post-intervention, although there was no direct evidence of improved parental ability to correctly categorise child overweight status. Further work is needed to replicate these findings in a larger sample of children, investigate mechanisms of action, and determine the use of MapMe as a public health initiative.

© 2016 The Author(s). Background: Rising rates of childhood obesity have become a pressing issue in public health, threatening both the mental and physical well-being of children. Attempts to address this problem are multifaceted, and in England include the National Child Measurement Programme (NCMP) which assesses weight status in English primary school children in reception class (aged 4-5) and in year 6 (aged 10-11), with results being sent out to parents. However the effectiveness and impact of this routine parental feedback has yet to be fully understood. This paper reports one component of a mixed methods study undertaken in North East England, examining the impact of the feedback letters on parents' understanding and feelings about their child's weight status and whether or not this seemed likely to lead to behaviour change. Methods: One-to-one semi-structured interviews (n = 16) were conducted with a sample of parents/guardians after they had received their child's weight results letter. Eight parents/guardians were sub-sampled from the group whose child had been indicated to be overweight or obese and eight were from the group whose child had been indicated to be of ideal weight status. Interviews were conducted until data saturation was reached for both groups. Results: The reactions of parents/guardians whose children were identified as being overweight followed a sequence of behaviours ranging from shock, disgust with the programme, through denial and self-blame to acceptance, worry and intention to seek help. On the other hand, the reaction of parents/guardians whose children were identified as being ideal weight ranged from relief, pleasure and happiness through affirmation and self-congratulation to 'othering'. Conclusions: Whilst overweight and obesity is often portrayed as a medical condition, parents/guardians see it as deeply rooted in their social lives and not in health terms. Parents believe that the causes of overeating and lack of exercise relate closely to the obesogenic environment, particularly the complex social and cultural milieu and time pressures within which this sample of people live. Associating this problem in feedback letters with dangerous diseases like cancer, and advising parents to visit GPs to resolve child weight issues was perceived as inappropriate by the parents, and caused controversy and anger. Given the likelihood that the NCMP will continue as a monitoring device, it is evident that the management of the process needs to be reviewed, with particular attention being paid to the feedback process. Local health authorities will need to manage parental expectations and ensure linkage with appropriately commissioned remedial weight management interventions.

Maternal obesity increases the risk of a number of serious child and maternal complications. Currently 60% of women in England have excess weight, leading to more women entering pregnancy with excess weight: with around 50% of women being overweight when they become pregnant, and 1 in 5 women presenting with obesity at their 12 week booking appointment. Obesity (having a BMI over 30kg/m2) both during and before/after pregnancy is also associated with health inequalities, with a higher prevalence among older women, those residing in the most deprived areas, or of Black or Asian ethnicity. In 2018 Public Health England (PHE) commissioned a mapping of healthy weight services in England before, during and after pregnancy, which demonstrated a lack of services specifically targeting women of child bearing age with a higher BMI. This research highlighted the need for an increased focus on practitioner level action, and appropriate guidance to support professionals to take action to address maternal and child obesity. Concurrently, the PHE guidance: ‘Promoting a healthier weight for children, young people and families: consistent messaging’ was developed. This study evaluates the local implementation of this resource

REVIEW QUESTION/OBJECTIVE: Are intermittent fasting interventions an effective treatment for overweight and obesity in adults, when compared to usual care treatment (continuous daily energy restriction - reduced calorie diet) or no treatment (ad libitum diet)? BACKGROUND: Overweight and obesity (classified as Body Mass Index [BMI] of greater than or equal to 25 and 30 respectively) is a global public health concern, with more than 1.9 billion adults worldwide being overweight in 2014 (over 600 million of whom are obese), and resulting in more deaths than underweight. A raised BMI in adulthood is associated with an increased risk of developing a number of chronic diseases which include diabetes, cardiovascular disease, muscular skeletal disorders and some cancers. In addition to this substantial impact on individual health and well being, there are also significant wider costs, for example, in England the annual direct cost to the national health service for treating overweight, obesity and associated morbidity is estimated at over £5 billion pounds, with costs to the wider economy estimated at £27 billion. Therefore effective weight management is essential.As overweight and obesity results from an accumulation of excess body fat arising from an energy imbalance - consuming more energy (kcal) than is expended - the majority of weight management approaches center around behaviors to address this imbalance, i.e. reducing energy intake through caloric restriction and increasing energy expenditure through physical activity. However, the aetiology of overweight and obesity is highly complex, involving an interplay of biological, psychological, societal and environmental drivers. Consequently, effective weight management is challenging, and whilst there exists a plethora of available weight loss programs, not all are comprehensively evaluated and compared, and many weight loss attempts result in weight regain and poor long term results. It is therefore vitally important to review the effectiveness of all new approaches to support an evidence-based approach to weight management.Intermittent fasting (IF), also known as alternate day fasting (ADF), periodic fasting or intermittent energy restriction (IER) is a relatively new dietary approach to weight management that involves interspersing normal daily caloric intake with a short period of severe calorie restriction/fasting. In terms of the possible underlying biological benefits of intermittent fasting, there is some evidence, predominantly from animal studies, to demonstrate beneficial effects on weight loss and cardio-metabolic risk factors. Whilst the underpinning mechanistic evidence is limited, there is some evidence to suggest that the benefits may be explained mechanistically through fat utilization and nutritional stress. However current National Institute for Health and Care Excellence (NICE) guidance on the treatment of adult obesity does not recommend the routine use of very low calorie diets (VLCD) (defined as a hypocaloric diet of 800 or less kcal/day) for the treatment of adult obesity. The National Institute for Health and Care Excellence states that this approach should only be recommended if there is a clinical rationale for rapid weight loss and must be nutritionally complete, part of a multi-component weight management strategy, including ongoing support, and should be undertaken for a maximum of 12 weeks (followed continuously or intermittently). Furthermore, the British Dietetic Association raises concerns that rapid weight loss associated with fasting may largely be due to loss of water and glycogen rather than fat, and may result in fatigue, dizziness and low energy levels. Essentially IF involves the intermittent use of a VLCD, and there remain questions about the side effects of this approach, whether there is an optimal fasting pattern or calorie limit, and how sustainable it is for long term weight management.Intermittent fasting has recently gained much popularity following significant media attention. In the UK this dietary approach reached mainstream after a BBC Horizon documentary aired in August 2012, featured an IF approach called the 5:2 diet, which involves five days of regular eating patterns interchanged with two days of fasting (max 500kcal for women and 600kcal for men). However other IF patterns are used such as alternate day fasting. Despite the recent popularity of intermittent fasting and associated weight loss claims, the supporting evidence base in humans remains small and there is only one published systematic review examining the health benefits of this approach. However the aim of this review was to examine the impact of this intervention on wider health benefits (not specifically as a treatment approach for overweight and obesity), and did not provide a comprehensive methodology or meta-analysis of RCT data. This proposed review will hence address these gaps in the evidence base.

Tackling obesity requires multi-level action across all sectors, and part of this action should include local authorities and clinical commissioning groups co-commissioning weight management services across the obesity pathway. This guide brings together the evidence to support the local commissioning and delivery of effective tier 2 weight management services for overweight and obese children and their families. This guide is most appropriate for designing and commissioning services for children aged 4-12 years old and is not aimed at supporting the design, delivery and commissioning of adolescent weight management services.

Agent-based computational models are gaining traction as a means for modelling the complexities of designing and implementing health interventions in our rapidly-changing society. When such models are integrated with an interactive virtual environment they o er a way to investigate complex conditions including social and environmental de- terminants, while also facilitating participation and interaction from re- search users and policy-makers. Here we present a prototype Agent-Based Virtual Environment which features an early-stage model of obesity in- tended to support planners and local authority members in the develop- ment of environments that encourage healthy diets and higher physical exertion. We illustrate the construction of the model and its intended role in raising awareness of the role of the built environment in prevent- ing obesity. We also describe future extensions and ways to extend this framework to other areas of concern in public health.

Background: Maternal obesity, excessive gestational weight gain (GWG) and post-partum weight retention (PPWR) constitute new public health challenges, due to the association with negative short- and long-term maternal and neonatal outcomes. The aim of this evidence review was to identify effective lifestyle interventions to manage weight and improve maternal and infant outcomes during pregnancy and postpartum.Methods: A review of systematic reviews and meta-analyses investigating the effects of lifestyle interventions on GWG or PPWR was conducted (Jan.2009-Jan.2018) via electronic searches in the databases Medline, Pubmed, Web of Science and Cochrane Library using all keywords related to obesity/weight gain/loss, pregnancy or postpartum and lifestyle interventions;15 relevant reviews were selected.Results: In healthy women from all BMI classes, diet and physical activity interventions can decrease: GWG (mean difference -1.8 to -0.7 kg, high to moderate-quality evidence); the risks of GWG above the IOM guidelines (risk ratio [RR] 0.72 to 0.80, high to low-quality evidence); pregnancy-induced hypertension (RR 0.30 to 0.66, low to very low-quality evidence); caesarean section (RR 0.91 to 0.95; high to moderate-quality evidence) and neonatal respiratory distress syndrome (RR 0.56, high-quality evidence); without any maternal/foetal/neonatal adverse effects. In women with overweight/obesity, multi-component interventions can decrease: GWG (-0.91 to -0.63 kg, moderate to very low-quality evidence); pregnancy-induced hypertension (RR 0.30 to 0.66, low-quality evidence); macrosomia (RR 0.85, 0.73 to 1.0, moderate-quality evidence) and neonatal respiratory distress syndrome (RR 0.47, 0.26 to 0.85, moderate-quality evidence). Diet is associated with greater reduction of the risks of GDM, pregnancy-induced hypertension and preterm birth, compared with any other intervention. After delivery, combined diet and physical activity interventions reduce PPWR in women of any BMI (-2.57 to -2.3 kg, very low quality evidence) or with overweight/obesity (-3.6 to -1.22, moderate to very low-quality-evidence), but no other effects were reported.Conclusions: Multi-component approaches including a balanced diet with low glycaemic load and light to moderate intensity physical activity, 30-60 minutes per day 3-5 days per week, should be recommended from the first trimester of pregnancy and maintained during the postpartum period. This evidence review should help inform recommendations for health care professionals and women of child-bearing age.

School food provision is an important lever to shape the eating behaviours and dietary intake of school-aged children and young people, and may help to address issues of children with obesity, inadequate nutrient intakes and the widening gap of health inequalities. The regulation of school meals has been an issue since 1940, with the challenges of developing a school food policy that supports health and wellbeing and can be effectively translated in practice remaining to the present day. This paper examines changes in school food policy with regards to school food provision in England since the 1940s, in relation to the political structure and decisions made by each respective government. It considers the lessons learned from the development of school food provision regulations over this period and possible ways to improve the standards of school food in the future.

Parents are central to the development of their child’s health-related behaviours and play an important role in childhood obesity prevention. However, evidence shows that parents typically do not recognise when their child is overweight; they tend to use how their children look compared with others to identify weight status, relying on extreme cases as a reference point. Addressing parents’ misperceptions of child weight status is important because without recognition of overweight in their child they are unlikely to take appropriate action. The aim of this study was to develop a visual tool to improve parents’ ability to assess their child’s weight status. Height and weight measurements were taken from children age matched to both National Child Measurement Programme age groups (4–5 and 10–11 years) and in all the UK90 weight categories. 3D body scans were also taken using 3D surface body scanning technology. Data from 388 children (n = 211 4–5 years, n = 177 10–11 years), together with qualitative work with a parent panel (n = 39) and health professionals working in childhood obesity (n = 5), were used to develop age- and gender-specific body image scales (BIS) of known body mass index (BMI). To our knowledge, this study developed the first BIS of known BMI for children aged 4–5 and 10–11 years based on UK90 criteria and they are being used in a large cluster randomised trial to test their effectiveness in improving parental recognition of childhood overweight. This work is funded by the National Prevention Research Initiative

© 2018 World Obesity Federation. Adult obesity in the UK remains a public health priority. Current guidance recommends local areas provide multicomponent interventions to treat adults with overweight and obesity; however, there is currently a dearth of published evidence on the evaluation of these programmes. This study reports on a mixed method evaluation of seven tier 2 weight management programmes funded by a local authority in the North of England through their public health grant (a lifestyle multicomponent weight management programme for the treatment of adults with overweight and obesity, but not severe obesity, or obesity with severe co-morbidities). Data collected from over 2000 participants demonstrated that the proportion of participants achieving 5% initial body weight loss was comparable to that reported in recent UK weight management trials. Two services exceeded national criteria of 30% of participants achieving 5% initial body weight loss at 12 weeks, although long term data was limited. Greater weight loss was also observed in participants aged 35-44 and those without co-morbidities. This study provides important learning points for improvements in real world weight management services, these include: standardised data collection and management tools; staff training and communication requirements; the importance of programmes that are joined up to wider support services; and the importance of providing ongoing peer and provider support, continuous monitoring and feedback, and physical activities tailored to user needs.

© 2017 The Author(s). Background: Excess body weight and risky alcohol consumption are two of the greatest contributors to global disease. Health behaviours cluster in adolescence and track to adulthood. Very little is known about similar and contrasting influences on young people's eating behaviours and alcohol use. Whilst there are bodies of literature which explore the influences on young people's eating behaviour and alcohol consumption respectively, no qualitative studies have been identified with an explicit and concurrent focus on adolescent eating behaviours and alcohol consumption. This review will identify and synthesise qualitative research evidence to provide insight into common underlying factors which influence alcohol use and unhealthy eating behaviours amongst young people aged 10-17. This will involve bringing together two separate bodies of literature to enable analysis and comparison across two associated fields of study. Methods: We will conduct searches in MEDLINE, Scopus, PsycINFO, Sociological Abstracts (via ProQuest social science premium collection), CINAHL, ERIC, IBSS (via ProQuest social science premium collection), ASSIA (via ProQuest social science premium collection), and Web of Science Core Collection. Studies reporting primary data of any qualitative design, for example, ethnographic studies, studies that used a phenomenological or grounded theory approach, or participatory action research will be included in the review. Database searches will be supplemented with searches of Google Scholar, hand searches of key journals, and backward and forward citation searches of reference lists of identified papers. Search records will be independently screened by two researchers, with full text copies of potentially relevant papers retrieved for in-depth review against the inclusion criteria. Reporting of identified studies will be assessed using the Critical Appraisal Skills Programme (CASP) Qualitative Research Checklist. GRADE-CERQual will also be used to assess confidence in the findings arising from our review. Qualitative synthesis will involve three core phases: line-by-line coding of findings; development of descriptive themes; and development of analytical themes. Findings from papers will be examined for overlaps, similarities and differences. Discussion: This synthesis will interpret individual studies by identification of second-order constructs (interpretations offered by the original researchers) and third-order constructs (development of new interpretations beyond those offered in individual studies) by way of the development of a 'model structure' of shared influences upon both unhealthy eating behaviours and alcohol use. It is anticipated that this 'model structure' will aid subsequent co-design and piloting of a future intervention to help reduce health risk and social inequalities due to excess weight gain and alcohol consumption. Systematic review registration:CRD42017060624.

Genetic predisposition to obesity is no barrier to successful weight management Globally, the prevalence of obesity has tripled since 1975, with 671 million adults and 124 million young people (5-19 years) estimated to be affected in 2016.1 Given the serious associated health and economic consequences of obesity,234 finding effective weight management strategies is both a national and a global priority.56 Although behavioural interventions that improve dietary intake and increase physical activity can be effective in reducing body weight in adults, long term efficacy is often limited,78 and it can be tempting to attribute failure to a genetic predisposition. Such discussions risk promoting a perception that policies and interventions to tackle obesity are futile, leading to loss of commitment and associated resources. Family, twin, and adoption studies show a moderate to high heritability for obesity,9 but monogenic causes of obesity are rare. Genetic predisposition in most people is polygenic. Important analyses of environment-gene interactions clearly show the detrimental effect of our obesogenic environment.910 The linked …

© 2017 The Author(s). To aim of the review was to examine the most recent (2010 onwards) research evidence on the health and behavioural impacts, in adults and children, of fiscal strategies that target high sugar foods and sugar-sweetened drinks (SSDs). A pragmatic rapid review was undertaken using a systematic search strategy. The review was part of a programme of work to support policy development in relation to high sugar food and SSDs. A total of 11 primary research publications were included, describing evidence from France (n = 1), the Netherlands (n = 3), and the United States of America (n = 7), assessed through a variety of study designs, with the majority in adult populations (n = 10). The evidence reviewed focused on consumer behaviour outcomes and suggested that fiscal strategies can influence purchases of high sugar products. Although the majority of studies (n = 10), including three field studies, demonstrated that an increase in the price of high sugar foods and SSDs resulted in a decrease in purchases, eight studies were conducted in a laboratory or virtual setting which may not reflect real-life situations. Findings from this review support evidence from the broader literature that suggests that fiscal measures can be effective in influencing the purchasing of high sugar foods and SSDs.

© 2017 John Wiley & Sons Ltd Aims and objectives: To gain insight into the lived experience of adults with overweight/obesity and chronic musculoskeletal pain. Knowledge gained will inform healthcare professionals about the complexity of the weight–pain relationship and enable more effective engagement with this population. Background: Quantitative studies show links between weight and pain. Adults with overweight/obesity are more likely to experience comorbidity; however, qualitative research describing the complexities of the relationship is limited. Methods: A purposive sample of adults with overweight/obesity and chronic musculoskeletal pain participated in face-to-face interviews. Interviews were audio-recorded, transcribed verbatim and analysed using interpretive phenomenological analysis. Results: Eighteen adults (16 female) aged 29–71, body mass index ≥25–46, participated in this study. Three superordinate themes emerged: “pain as a motivator and barrier to weight loss”; “fear of weight causing more damage”; and “activity is positive.” Pain motivates some individuals to lose weight while simultaneously inhibiting weight loss efforts. Participants' perception that extra pressure caused by their weight further damaged joints contributed to fear and catastrophising. Fear is often exacerbated by healthcare professionals' descriptions of musculoskeletal damage, or participants' perception of healthcare professionals' attitude towards people with overweight/obesity. Conversely, individuals acknowledged the benefits of increased activity. Conclusion: Adults with overweight/obesity and chronic musculoskeletal pain in this study identified a bidirectional relationship between their weight and pain that challenged their weight loss efforts. Overweight/obesity contributed to fear and catastrophising, which resulted in avoidance of exercise that would have assisted their weight loss. Relevance to clinical practice: Healthcare professionals need to understand the complex relationship between weight and pain, and their patients' understanding of that relationship. Healthcare professionals should use therapeutic communication to reduce the fear of weight causing damage, and thus promote physical activities that will contribute to weight loss. It is also important to ensure that the language used with this patient group does not stigmatise individuals, or cause or exacerbate fear of normal movement.

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of commercial weight loss products and services for overweight or obese people.

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of commercial weight loss products and services for overweight or obese people.

REVIEW OBJECTIVE/QUESTION: The objective of this umbrella review is to examine the effectiveness of different types of weight management, smoking cessation and alcohol reduction interventions in producing explicitly measured behavior change or proxy measures of behavior change in pregnant women.Specifically the review question is: are weight management, smoking cessation and alcohol reduction interventions effective in producing behavior change in pregnant women?

© The Author 2017. Background Parents tend to visually assess children to determine their weight status and typically underestimate child body size. A visual tool may aid parents to more accurately assess child weight status and so support strategies to reduce childhood overweight. Body image scales (BIS) are visual images of people ranging from underweight to overweight but none exist for children based on UK criteria. Our aim was to develop sex- and age-specific BIS for children, based on British growth reference (UK90) criteria. Methods BIS were developed using 3D surface body scans of children, their associated weight status using UK90 criteria from height and weight measurements, and qualitative work with parents and health professionals. Results Height, weight and 3D body scans were collected (211: 4-5 years; 177: 10-11 years). Overall, 12 qualitative sessions were held with 37 participants. Four BIS (4-5-year-old girls and boys, 10-11-year-old girls and boys) were developed. Conclusions This study has created the first sex- and age-specific BIS, based on UK90 criteria. The BIS have potential for use in child overweight prevention and management strategies, and in future research. This study also provides a protocol for the development of further BIS appropriate to other age groups and ethnicities.

© 2018 THE JOANNA BRIGGS INSTITUTE. Review question/objective: To update an existing systematic review series1,2 of randomized controlled trials (RCT) that include a dietary intervention for the management of overweight or obesity in children or adolescents. Specifically, the review questions are: In randomized controlled trials of interventions which include a dietary intervention for the management of overweight or obesity in children or adolescents: • What impact do these interventions have on participants' adiposity and dietary outcomes? • What are the characteristics or intervention components that predict adiposity reduction or improvements in dietary outcomes?

REVIEW QUESTION/OBJECTIVE: The overall aim of this mixed methods systematic review is to explore the effectiveness and experience of early intervention programs using volunteers, peer supporters and community champions with the aim of improving one or more of the following outcomes of children from conception to two years:Specifically the review questions are.

© 2019 This single-blind, pragmatic, cluster randomised controlled trial aims to investigate uptake of children's weight management services in response to enhanced National Child Measurement Programme (NCMP) letters providing weight status feedback to parents in three English counties in 2015. Parents of 2642 overweight or very overweight (obese) children aged 10–11 years received an intervention or control letter informing them of their child's weight status. Intervention letters included (i) a visual tool to help weight status recognition, (ii) a social norms statement, and for very overweight children, (iii) a prepopulated booking form for weight management services. The primary outcome was weight management service enrolment. Additional outcome measures included attendance at and contact made with weight management services, and a number of self-report variables. A small effect was observed, with intervention parents being significantly more likely to enrol their children in weight management services (4.33% of Intervention group) than control parents (2.19% of Control group) in both unadjusted (OR = 2.08, p = .008) and adjusted analyses (AOR = 2.48, p = .001). A similar picture emerged for contact with services (4.80% Intervention vs. 2.41% Control; OR = 2.10, p = .003; AOR = 2.46, p < .001) and attendance at services, although group differences in the latter measure were not significant after corrections for multiple comparisons (1.89% Intervention vs. 1.02% Control; AOR = 2.11, p = .047). No effects were found on self-report variables. Theoretically informed weight status feedback letters appear to be an effective strategy to improve enrolment in paediatric weight management services.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. INTRODUCTION: Weight management interventions in research studies and in clinical practice differ in length, advice, frequency of meetings, staff and cost. Very few real-world programmes have published patient-related outcomes, and those that have published used different ways of reporting the information, making it impossible to compare interventions and further develop the evidence base. Developing a core outcome set for behavioural weight management programmes (BWMPs) for adults with overweight and obesity will allow different BWMPs to be compared and reveal which interventions work best for which members of the population. METHODS AND ANALYSIS: An expert group, comprised of 40 people who work in, refer to, or attend BWMPs for adults with overweight and obesity, will be asked to decide which outcomes services should report. An online Delphi process will be employed to help the group reach consensus as to which outcomes should be measured and reported, and which definitions/instruments should be used in order to do so. The first stage of the Delphi process (three rounds of questionnaires) will focus on outcomes while the second stage (three additional rounds of questionnaires) will focus on definition/instrument selection. ETHICS AND DISSEMINATION: Ethical approval for this study has been received from the University of Glasgow College of Medical, Veterinary and Life Sciences Ethics Committee. With regard to disseminating results, a report will be submitted to our funding body, the Chief Scientist Office of the Scottish Government Health Department. In addition, early findings will be shared with Public Health England and Health Scotland, and results communicated via conference presentations, peer review publication and our institutions' social media platforms.

© 2019 by the authors. Licensee MDPI, Basel, Switzerland. Excess body weight and risky alcohol consumption are two of the greatest contributors to global disease. Alcohol use contributes directly and indirectly to weight gain. Health behaviours cluster in adolescence and track to adulthood. This review identified and synthesised qualitative research to provide insight into common underlying factors influencing alcohol use and unhealthy eating behaviours amongst young people aged 10–17. Sixty two studies met inclusion criteria. Twenty eight studies focused on alcohol; 34 focused on eating behaviours. Informed by principles of thematic analysis and meta-ethnography, analysis yielded five themes: (1) use of alcohol and unhealthy food to overcome personal problems; (2) unhealthy eating and alcohol use as fun experiences; (3) food, but not alcohol, choices are based on taste; (4) control and restraint; and (5) demonstrating identity through alcohol and food choices. Young people faced pressure, reinforced by industry, to eat and drink in very specific ways, with clear social consequences if their attitudes or behaviour were deemed unacceptable. No qualitative studies were identified with an explicit and concurrent focus on adolescent eating behaviours and alcohol consumption. Further exploratory work is needed to examine the links between food and alcohol in young people’s emotional, social and cultural lives.

Childhood obesity results in premature atherosclerosis and requires early intervention. Compare the effectiveness of 6-month lifestyle interventions (with choice of either individual or group therapy) with standard care on body mass index (BMI) z-score and cardiovascular disease (CVD) risks factors in children with obesity. This 6-month randomized controlled trial with a 6-month follow-up included 74 pre-pubertal children with obesity (7.5-11.9 years) assigned randomly (2:1) to intervention or control. Families in the intervention arm choose between an individually delivered treatment (3 hours paediatrician + 4 hours dietician) or group treatment (35 hours with a multidisciplinary team). Children participated also to a weekly physical activity programme. We measured BMI, BMI z-score; waist circumference (WC); total and abdominal fat; blood pressure; common carotid artery intima-media thickness and incremental elastic modulus (Einc); endothelium-dependent and independent dilation (nitroglycerin-mediated dilation [NTGMD]) of the brachial artery; fasting plasma glucose, insulin, lipids; and high-sensitivity C-reactive protein (hs-CRP). Compared to controls, at 6 months, abdominal fat and hs-CRP were reduced in both interventions. The group intervention was also effective in reducing BMI (-0.55 kg/m2 ; 95% confidence interval -1.16 to 0.06) and BMI z-score (-0.08; -0.15 to 0.00) at 6 months and BMI, BMI z-score, WC, NTGMD, total and abdominal fat at 12 months. Abdominal fat and low-grade inflammation were significantly decreased in both interventions. High-intensity group treatment improved early signs of atherosclerosis in children with obesity. These findings are important for the promotion of cardiometabolic health in this population.

© © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. Introduction Primary school-based physical activity interventions, such as The Daily Mile initiative, have the potential to increase children's physical activity levels over time, which is associated with a variety of health benefits. Comparing interventions or combining results of several studies of a single intervention is challenging because previous studies have examined different outcomes or used different measures that are not feasible or relevant for researchers in school settings. The development and implementation of a core outcome set (COS) for primary school-based physical activity interventions would ensure outcomes important to those involved in implementing and evaluating interventions are standardised. Methods and analysis Our aim is to develop a COS for studies of school-based physical activity interventions. We will achieve this by undertaking a four-stage process:(1) identify a list of outcomes assessed in studies through a systematic review of international literature; (2) establish domains from these outcomes to produce questionnaire items; (3) prioritise outcomes through a two-stage Delphi survey with four key stakeholder groups (researchers, public health professionals, educators and parents), where stakeholders rate the importance of each outcome on a 9-point Likert scale (consensus that the outcomes should be included in the COS will be determined as 70% or more of all stakeholders scoring the outcome 7%-9% and 15% or less scoring 1 to 3); (4) achieve consensus on a final COS in face-to-face meetings with a sample of stakeholders and primary school children. Ethics and dissemination We have received ethical approval from Imperial College London (ref: 19IC5428). The results of this study will be disseminated via conference presentations/public health meetings, peer-reviewed publications and through appropriate media channels. Trial registration number Core Outcome Measures in Effectiveness Trials Initiative (COMET) number: 1322.

Behavioural weight management interventions in research studies and clinical practice differ in length, advice, frequency of meetings, staff, and cost. Few real-world programmes have published patient outcomes and those that have used different ways of reporting information, making it impossible to compare interventions and develop the evidence base. To address this issue, we have developed a core outcome set for behavioural weight management intervention programmes for adults with overweight and obesity. Outcomes were identified via systematic review of the literature. A representative expert group was formed comprising people with experience of adult weight management services. An online Delphi process was employed to reach consensus as to which outcomes should be measured and reported and which definitions/instruments should be utilised. The expert group identified eight core outcomes and 12 core processes for reporting by weight management services. Eleven outcomes and five processes were identified as optional. The most appropriate definitions/instruments for measuring each outcome/process were also agreed. Our core outcome set will ensure consistency of reporting. This will allow behavioural weight management interventions to be compared, revealing which interventions work best for which members of the population and helping inform development of adult behavioural weight management interventions.

Self-report recall questionnaires used to measure physical activity and dietary intake in children can be labour intensive and monotonous and tend to focus on either dietary intake or physical activity. The web-based software, Synchronised Nutrition and Activity Program™ (SNAP™), was developed to produce a novel, simple, quick and engaging method of assessing energy balance-related behaviours at a population level, combining principles from new and existing 24 h recall methodologies, set within a user-friendly interface. Dietary intake was measured using counts for twenty-one food groups and physical activity levels were measured in min of moderate to vigorous physical activity (MVPA). A combination of the mean difference between methods, type II regression and non-parametric limits of agreement techniques were used to examine the accuracy and precision of SNAP™. Method comparison analyses demonstrated a good agreement for both dietary intake and physical activity behaviours. For dietary variables, accuracy of SNAP™ (mean difference) was within ± 1 count for the majority of food groups. The proportion of the sample with between-method agreement within ± 1 count ranged from 0.40 to 0.99. For min of MVPA, there was no substantial fixed or proportional bias, and a mean difference between methods (SNAP™ -accelerometry) of -9 min. SNAP™ provides a quick, accurate, low-burden, cost-effective and engaging method of assessing energy balance behaviours at a population level. Tools such as SNAP™, which exploit the popularity, privacy and engagement of the computer interface, and linkages with other datasets, could make a substantial contribution to future public health monitoring and research.

Objectives: This study was conducted to develop a better understanding of community-based initiatives relating to maternal obesity, and to gain community service providers’ views on maternal obesity services and their perceived role in the management and prevention of maternal obesity. Study design: An interpretive constructionist approach using semi-structured interviews and focus groups. Methods: Semi-structured interviews and focus groups were carried out with community service providers in the North East of England, UK. Data were analysed using thematic content analysis. Results: Five dominant themes emerged: community-based obesity services, understanding maternal obesity services, participation in maternal obesity services, challenges in the development of community maternal obesity services, and factors contributing to successful maternal obesity services. Community service providers identified their role in tackling maternal obesity alongside maternity services. Participants identified a lack of community maternal obesity services, distinct training requirements, and felt that a multi-agency approach was likely to be required. Conclusions: Increasing rates of maternal obesity and the relationship between maternal obesity and childhood obesity mean that the preconception, pregnancy and postnatal periods are important and timely stages in the life course for public health intervention. However, current public health and community service provision lacks structured maternal obesity objectives.

Background: Public health genomics is a new field that brings the findings of research in genetic and molecular technologies together with public health. The purpose of this paper is to examine the interface between this new emerging field and that of public health intelligence. We describe the possible areas of integration between genomics and public health, suggesting a future potential role for the Public Health Observatories. Methods: A small group comprising of a public health geneticist and representatives from Public Health Observatories met and discussed the ways in which the public health information and intelligence community might contribute to the developing agenda of public health genomics. Results: The results of the deliberations are presented in this paper, and a combination of short, medium and longer term possibilities are described. Also, necessary changes and additions to routinely collected data are proposed. Conclusions: The emerging field of public health genomics has implications for the collection, management and analysis of routine data. The benefits of this will accrue over time, but changes need to be made now in order to make the best use of these developments. A possible supporting action plan for the development of public health genomics within Public Health Observatories is proposed.

Background: The authors examined the uptake of obesity surgery across England. Methods: Data were analyzed from the Hospital Episode Statistics covering all 9 goverment office regions with a total population of 49.1 million. The data analyzed covered 9 years 1996/97 - 2004/05. Results: 1,465 records were identified with a primary diagnostic code for obesityand an operation code for obesity surgery. The surgery was performed mostly in women (male to female ratio of 1:5), who were predominantly mid-aged (average 40.4 years ± SD 9.00), the majority of whom reside in local authority districts ranked within the lowest two deprivation quintiles. The availability of obesity surgery varied considerably across the 9 different regions of England, although the number of operations increased nationally over time. Conclusions: Access to this intervention is highly variable and does not appear to reflect estimated regional differences in morbid obesity. This specialist service may benefit from more effective national organization, to ensure appropriate capacity and eliminate inequalities in service delivery.

Childhood obesity is a complex disease with different genetic, metabolic, environmental and behavioural components that are interrelated and potentially confounding, thus making causal pathways difficult to define. Given the tracking of obesity and the associated risk factors, childhood is an important period for prevention. To date, evidence would support preventative interventions that encourage physical activity and a healthy diet, restrict sedentary activities and offer behavioural support. However, these interventions should involve not only the child but the whole family, school and community. If the current global obesity epidemic is to be halted, further large-scale, well-designed prevention studies are required, particularly within settings outside of the USA, in order to expand the currently limited evidence base upon which clinical recommendations and public health approaches can be formulated. This must be accompanied by enhanced monitoring of paediatric obesity prevalence and continued support from all stakeholders at global, national, regional and local levels.

A systematic review of randomized controlled trials was conducted to evaluate the effectiveness of eHealth interventions for the prevention and treatment of overweight and obesity in adults. Eight databases were searched for studies published in English from 1995 to 17 September 2014. Eighty‐four studies were included, with 183 intervention arms, of which 76% (n = 139) included an eHealth component. Sixty‐one studies had the primary aim of weight loss, 10 weight loss maintenance, eight weight gain prevention, and five weight loss and maintenance. eHealth interventions were predominantly delivered using the Internet, but also email, text messages, monitoring devices, mobile applications, computer programs, podcasts and personal digital assistants. Forty percent (n = 55) of interventions used more than one type of technology, and 43.2% (n = 60) were delivered solely using eHealth technologies. Meta‐analyses demonstrated significantly greater weight loss (kg) in eHealth weight loss interventions compared with control (MD −2.70 [−3.33,−2.08], P < 0.001) or minimal interventions (MD −1.40 [−1.98,−0.82], P < 0.001), and in eHealth weight loss interventions with extra components or technologies (MD 1.46 [0.80, 2.13], P < 0.001) compared with standard eHealth programmes. The findings support the use of eHealth interventions as a treatment option for obesity, but there is insufficient evidence for the effectiveness of eHealth interventions for weight loss maintenance or weight gain prevention.

Background: International evidence shows that severe paediatric obesity results in an increased risk of ill health and may require specialised weight management strategies, yet there remains a lack of data on the extent of the problem. Objective: To examine the prevalence of severe obesity in children aged 4-5 and 10-11 years, attending English schools between 2006/2007 and 2012/2013. Design: A retrospective analysis of National Child Measurement Programme (NCMP) data. Setting: Maintained schools in England. Participants: All children aged 4-5 and 10-11 years included in the NCMP dataset. Main outcome measures: Prevalence of severe childhood obesity, defined using the 99.6th centile of the British 1990 (UK90) growth reference for body mass index (BMI), analysed by sex, geography, ethnic group and deprivation. Results: The key findings show that in 2012/2013, severe obesity (BMI ≥UK90 99.6th centile) was found in 1.9% of girls and 2.3% of boys aged 4-5 years, and 2.9% of girls and 3.9% of boys aged 10-11 years. Severe obesity prevalence varies geographically and is more prevalent in children from deprived areas, and among those from black ethnic groups. Conclusions: The findings from this study should help to raise awareness of the prevalence of severe obesity and support the provision of adequate treatment and prevention services both to support children who are already severely obese and reduce the prevalence of extreme weight in the future.

Background/objective: There are reports that childhood obesity tracks into later life. Nevertheless, some tracking statistics, e.g. correlations, do not quantify individual agreement, while others, e.g. diagnostic test statistics, can be difficult to translate into practice. We aimed to employ a novel analytic approach, based on ordinal logistic regression, to predict weight status of 11-year-old children from measurements at age 5.Subjects/methods: UK 1990 growth references were used to generate clinical weight status categories of 12 076 children enrolled in the Millennium Cohort Study. Using ordinal regression, we derived the predicted probability (percent chances) of an 11-year-old child becoming underweight, normal weight, overweight, obese and severely obese from their weight status category at age 5.Results: The chances of becoming obese (including severely obese) at age 11 were 5.7% (95% CI: 5.2% to 6.2%) for a normal weight 5-year-old and 32.3% (29.8% to 34.8%) for an overweight 5-year-old. An obese 5-year-old child had a 68.1% (63.8% to 72.5%) chance of remaining obese at 11 years. Severely obese 5-year-old children had a 50.3% (43.1% to 57.4%) c 50 hance of remaining severely obese. There were no substantial differences between sexes. Non-deprived obese 5- year-old boys had a lower probability of remaining obese than deprived obese boys: -21.8% (-40.4% to -3.2%). This association was not observed in obese 5-year-old girls, in whom the non-deprived group had a probability of remaining obese 7% higher (-15.2% to 29.2%). The sex difference in this interaction of deprivation and baseline weight status was therefore -28.8% (-59.3% to 1.6%).Conclusions: We have demonstrated that ordinal logistic regression can be an informative approach to predict the chances of a child changing to, or from, an unhealthy weight status. This approach is easy to interpret and could be applied to any longitudinal dataset with an ordinal outcome.

© Copyright 2017 Ryan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Objective: To quantify the influence of baseline pain levels on weight change at one-year follow-up in patients attending a National Health Service specialist weight management programme. Methods: We compared one-year follow-up weight (body mass) change between patient sub-groups of none-to-mild, moderate, and severe pain at baseline. A mean sub-group difference in weight change of ≥5kg was considered clinically relevant. Results: Of the 141 complete cases, n = 43 (30.5%) reported none-to-mild pain, n = 44 (31.2%) reported moderate pain, and n = 54 (38.3%) reported severe pain. Covariate-adjusted mean weight loss (95%CI) was similar for those with none-to-mild (8.1kg (4.2 to 12.0kg)) and moderate pain (8.3kg (4.9 to 11.7kg). The mean weight loss of 3.0kg (-0.4 to 6.4kg) for the severe pain group was 5.1kg (-0.6 to 10.7, p = 0.08) lower than the none-to-mild pain group and 5.3kg (0.4 to 10.2kg, p = 0.03) lower than the moderate pain group. Conclusions: Patients with severe pain upon entry to a specialist weight management service in England achieve a smaller mean weight loss at one-year follow-up than those with none-to-moderate pain. The magnitude of the difference in mean weight loss was clinically relevant, highlighting the importance of addressing severe persistent pain in obese patients undertaking weight management programmes.

Objective: to identify developments in maternal obesity services and health-care practitioners’ views on how maternity services need to be further developed to be more effective in the care of obese pregnant women. Design: follow-up qualitative study using purposive sampling, interviews and focus groups. Setting: 10 maternity units in the North East Government Office Region of England, UK. Participants: 30 maternity unit health-care practitioners with personal experience of maternal obesity services. Measurements and findings: semi-structured interviews and focus groups were carried out with health-care practitioners representing each National Health Service trust in the region that provides maternity services to identify views on the barriers, facilitators, advantages and disadvantages of developing maternal obesity services, and how maternity services can be more effective in managing maternal obesity. Transcripts were analysed using thematic content analysis. Three dominant themes emerged: questioning maternal obesity service development; psychosocial issues and maternal obesity service development; and the way forward. Key conclusions: there has been a substantial improvement in the management of the health and safety aspects of maternal obesity over the last three years. However, more work is needed around the psychosocial issues, weight management and public health aspects of maternal obesity. Implications for practice: to meet the needs of obese pregnant women, maternity services should consider the transition of care between pregnancy and the postnatal period, improve communication between hospital and public health services, and develop services that will engage pregnant women to address their obesity.

Correction to: International Journal of Obesity (2009) 33, S28–S34; doi:10.1038/ijo.2009.86 Since the publication of IJO (2009) Volume 33, Supplement 3, the authors have identified several errors in this paper: On pages S29–S31, the fifth paragraph of Section 5.3.4.1, Sugary drinks (not carbonated),the first paragraph of Section 5.

Correction to: International Journal of Obesity (2009) 33, S13–S27; doi:10.1038/ijo.2009.85 Since the publication of IJO (2009) Volume 33, Supplement 3, the authors have identified an error in this paper: On page S26, the second paragraph in the left-hand column should read (revised text in bold): ‘In a cohort of American (mainly white and low income) preschool children (n=1345 were participants from the original North Dakota WIC Program cohort), followed up over 8.

Objective: The aim of this study was to identify trends in maternal obesity incidence over time and to identify those women most at risk and potential-associated health inequalities. Design: Longitudinal database study. Setting: James Cook University Hospital maternity unit, Middlesbrough, UK. Sample: A total of 36 821 women from 1 January 1990 to 31 December 2004. Methods: Trends in maternal obesity incidence over time were analysed using chi-square test for trend. Demographic predictor variables were analysed using multivariate logistic regression, adjusting for confounding factors after testing for multicollinearity. National census data were used to place the regional data into the context of the general population. Main outcome measure: Trends in maternal obesity incidence. Demographic predictor variables included ethnic group, age, parity, marital status, employment and socio-economic disadvantage. Results: The proportion of obese women at the start of pregnancy has increased significantly over time from 9.9 to 16.0% (P < 0.01). This is best described by a quadratic model (P < 0.01) showing that the rate is accelerating; by 2010, the rate will have increased to 22% of this population if the trend continues. There is also a significant relationship with maternal obesity and mothers’ residing in areas of most deprivation (odds ratio [OR] = 2.44, 95% CI = 1.98, 3.02, P < 0.01), with increasing age (OR = 1.04, 95% CI = 1.04, 1.05, P < 0.01), and parity (OR = 1.17, 95% CI = 1.12, 1.21, P < 0.01). Conclusions: The incidence of maternal obesity at the start of pregnancy is increasing and accelerating. Predictors of maternal obesity are associated with health inequalities, particularly socio-economic disadvantage.

The UK Government has identified obesity as a priority area, as it is thought to present a serious public health problem. Although it is a highly complex multifactorial disease, it has been hypothesized that obesity, in particular morbid obesity, may decrease life by up to 9 years and significantly increase the risk of many other important diseases, e.g. diabetes, heart disease and some cancers. Furthermore, it has been estimated that if obesity continues to rise at the current rate, children could die earlier than their parents (1).A joint report from the Audit Commission, the Healthcare Commission and the National Audit Office estimated that the current cost of obesity to the National Health Service (NHS) in England stands at £1 billion, and that the cost to the UK economy is £2.3–2.6 billion in indirect costs. If this present trend continues, by 2010 the annual cost to the economy could be £3.6 billion a year (2).Obesity cannot be considered in isolation from other lifestyle factors, in particular, physical exercise. Strategies for reducing obesity must therefore consider both sides of the energy equation.

Objectives: While direct links between obesity and some illnesses are well-established, there is a relative paucity of research on associations between obesity and disabilities. The aim of this study was to test for significant associations between overweight and obesity and the presence of a wide range of disabling conditions in adults, controlling for sex, age, education, social class, income, cigarette smoking status and alcohol consumption. Study design: Data were extracted from the Health Survey for England (2001); a cross-sectional survey of the community-dwelling population. In total, 8613 adult participants were included in the analysis. Methods: Multivariate logistic regression was employed to test whether the odds of having a range of disabling conditions are higher in the overweight and obese populations compared with those in the ideal weight range. Results: The risk of nearly all disabling conditions tested was elevated in the obese and morbidly obese groups. Of great importance for public health, the risks of musculoskeletal illness, arthritis and rheumatism, and personal care disability were significantly elevated, even in those in the overweight category (currently about half of the adult population living in the UK). Conclusions: Obesity is independently associated with a range of disabling conditions in adults. The present study highlights the need for further research into the mechanisms by which these associations occur.

Background: Accurate, reliable and feasible methods of dietary intake and physical activity assessment are required to improve our understanding of the associations between energy balance-related behaviours and health. Methods: The Synchronised Nutrition and Activity Program (SNAP™) was developed to enhance recall in children by integrating new and established methods of dietary intake and physical activity recall. A list of commonly consumed foods (n = 40), drinks (n = 9) and physical activities (n = 29) was used in SNAP™. All foods and drinks were analysed by count (i.e. the number of times a particular food was selected), as a proxy indicator of dietary behaviours. All reported physical activities were assigned an intensity code [in metabolic equivalents (METs)] to determine minutes of moderate-vigorous activity (MVPA; ≥3 METs). Results: Most participants completed a whole day’s recall (both dietary intake and physical activities) in less than 25 min. SNAP™ was compared against 24-h multiple pass questionnaire and accelerometry in 121 children (aged 7-15 years old). For dietary variables, the accuracy of SNAP™ (mean difference) was within ±1 count for the majority of food groups. The proportion of the sample with a between-method agreement within ±1 count ranged from 0.40 to 0.99. For MVPA, there was no substantial fixed or proportional bias, with a mean difference between methods (SNAP™ - accelerometry) of -9 min of MVPA. Qualitatively, participants have indicated that they find SNAP™ easy and fun to use. Conclusions: SNAP™ was developed to be a simple, quick and engaging method of assessing energy balance-related behaviours at a group or population level and succeeded because it can collect a whole day’s recall (dietary intake and physical activities) in less than 25 min to a reasonable and acceptable degree of accuracy.

This study reviewed the use in primary care of national surveillance data for children to determine the data’s potential utility to inform policy and practice decisions on how to prevent and treat childhood obesity. We reviewed the 28 countries identified by the World Obesity Federation as having high-quality comparable body mass index data for children. Literature published from any period up to December 2013 was included. Peer review literature was searched using Web of Science (Core Collection, MEDLINE). Grey literature was searched using the Internet by country name, programme name and national health and government websites. We included studies that (i) use national surveillance obesity data in primary care, or (ii) explore practitioner or parent perspectives about the use of such data. The main uses of national surveillance data in primary care were to identify and recruit obese children and their parents to participate in school and general practice-based research and/or interventions, and to inform families of children’s measurements. Findings indicate a need for school staff and practitioners to receive additional training and support to sensitively communicate with families. Translation of these findings into policy and practice could help to improve current uses of national child obesity surveillance data in primary care.

The percentage flow-mediated dilation of the brachial artery (FMD%) is purported to be an early indicator of atherosclerosis and has been reported to be reduced in people with obstructive sleep apnoea. Nevertheless, FMD% scales poorly for, and is concomitantly dependent on, initial artery diameter, which may, itself, be higher in obstructive sleep apnoea patients. Therefore, for the first time, we aimed to quantify the differences in initial diameter and properly-scaled flow-mediated dilation between people with, and without, sleep apnoea. The prevalence of physician-diagnosed sleep apnoea, as well as initial and peak diameters of the brachial artery were recorded for 3354 participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Arterial data were analysed using FMD% and an allometric approach, which scales the flow-mediated response properly for initial diameter. In the sex, race and age-adjusted model, initial diameter was 0.19 mm larger in sleep apnoea patients (95%CI: 0.07 to 0.32 mm, P=0.003) and correlated negatively with FMD% (r= -0.43, 95%CI: -0.57 to -0.26, P<0.0005). Using this same adjusted model, FMD% was 3.8±2.7% for sleep apnoea patients (n=104) vs 4.4±2.7% for undiagnosed people (95%CI for difference: -1.12 to -0.07%, P=0.028). Allometric scaling halved this FMD%-indicated sample difference in flow-mediated dilation (95%CI: -0.7% to 0.1%, P=0.19). In conclusion, the initial diameter of the brachial artery is larger in MESA participants diagnosed with sleep apnoea compared with undiagnosed people. However, the difference in flow-mediated dilation between these two cohorts is trivial when the flow-mediated response is scaled properly for resting diameter.

Sleep-disordered breathing is an important comorbidity for several diseases, including stroke. Initial screening tools comprise simple yes/no questions about known risk factors for sleep-disordered breathing, e.g., obesity, sex. But walking speed has not been investigated in this context. We examined the cross-sectional association between walking pace and sleep-disordered breathing in the population-level Multi-Ethnic Study of Atherosclerosis. A sample of 2912 men and 3213 women (46-87 years) reported perceived walking pace outside their homes. A walking pace<0.89m/s was deemed slow, with ≥0.89m/s considered average/brisk according to validated thresholds. Sample prevalences were: sleep apnoea (3.5%), self-reported apnoeas (8.4%), loud snoring (20.5%), daytime tiredness (22.2%) and slow-walking pace (26.9%). The 95% CI risk differences (multivariable-adjusted) for slow vs. faster walking pace were; sleep apnoea (0.4-2.5%), self-reported apnoeas (0.1-3.8%), loud snoring (1.2-8.3%), and daytime tiredness (3.0-7.8%). Risk differences were similar between sexes. The multivariable-adjusted risk ratio indicated that slower walkers had 1.5 (95% CI: 1.0 to 2.1) times the risk of sleep apnoea vs. faster walkers. In conclusion, a slower walking speed was associated with a greater prevalence of sleep-disordered breathing, independently from other common screening factors. Therefore, a simple walking speed question may help consolidate screening for this disorder.

Background

Behavioural weight management interventions are the primary treatment for obesity in the United Kingdom. These interventions focus on diet, physical activity and behaviour change, and are typically delivered over a period of 12 weeks. Although National Institute for Health and Care Excellence guidance makes recommendations on the content of behavioural weight management interventions, there are substantial variations in practice. As a result, what constitutes the most effective composition of behavioural weight management interventions is unclear.

Abstract

This chapter examines the co-production endeavour from the academic researcher’s point of view. It considers the barriers and facilitators to effective co-production in academia, drawing on many years of practice experience. The chapter presents feature interviews with researchers in order to capture their opinions around the unique opportunities afforded by co-production work. A number of academics and practitioners who have been involved in long-running co-production projects centred on the evaluation of locally commissioned public health services, and providing national policy and practice support. Co-production projects can be tricky; as with any industry, stakeholders working together face a number of challenges. An additional pressure point concerns the practicalities of running a project, such as organising honorary contracts and administrative support. One of the fundamental reasons for undertaking co-production research is the ability to influence policy and practice. Not only can research provide academic benefits, such as an original contribution to the wider literature, but it can offer wider benefits to policy.

Abstract

Background

Behavioural weight management interventions are complex interventions having several coexisting components designed to facilitate weight loss. Existing evidence has shown behavioural weight management interventions to be effective; however, the magnitude of weight loss varies among programmes. There is value in understanding whether differences in the intervention components influence the overall effectiveness of the interventions. The current study is the first attempt to explore the effects of individual components of interventions using data from both randomised controlled trials and real-world services based in the United Kingdom.

Background

Behavioural weight management interventions are the main funded interventions for people living with obesity in the United Kingdom, but there is high intervention variability, including mode of delivery, dietary, physical activity and behavioural components.

RATIONALE: Childhood obesity is a global public health problem with multiple causes. First-line obesity interventions target changes in health-related behaviours (diet, physical activity, behaviour). However, the sustainability and long-term results of these interventions are uncertain. OBJECTIVES: To assess the effects of multimodal health behaviour-changing interventions for children under 10 years living with obesity and their parents. SEARCH METHODS: We used CENTRAL, MEDLINE, three other databases, and two trial registers, together with reference checking and contact with study authors, to identify studies included in the review. The latest search date was 28 February 2024. ELIGIBILITY CRITERIA: We included randomised controlled trials in children under 10 with obesity (and their parents) that tested multimodal health behaviour interventions (diet, physical activity, and/or behaviour change) versus control (no treatment, usual care, or waiting list), with at least one year of follow-up. OUTCOMES: Critical outcomes were physical well-being, mental well-being, physical activity, health-related quality of life (HRQoL), obesity-associated disability, adverse events, and anthropometry (body mass index (BMI) z-score). RISK OF BIAS: We used the original version of the Cochrane Collaboration's tool for assessing risk of bias (RoB 1). SYNTHESIS METHODS: We synthesised outcomes using random-effects meta-analysis where possible, otherwise narratively. For continuous outcomes on the same scale, we calculated mean differences (MDs) with 95% confidence intervals (CIs). We calculated standardised mean differences (SMDs) with 95% CIs when studies used different instruments for the same outcome or when applying a generic minimally important difference. We assessed certainty of evidence for critical outcomes with GRADE. INCLUDED STUDIES: We included 34 RCTs involving 6849 participants, aged four to nine, conducted in high-income countries. We identified 23 healthcare-based interventions implemented in primary care and hospitals, and 11 community-based interventions implemented in schools and community centres. The intervention components included sessions on dietary modification, physical activity, and behavioural change. Three studies targeted parents directly, and the remainder used family-based approaches, primarily through individual or group sessions. SYNTHESIS OF RESULTS: Healthcare-based multimodal interventions versus control Healthcare-based multimodal interventions likely result in little to no difference in physical well-being at 12 months of follow-up (Pediatric Quality of Life Inventory (PedsQL) physical score, final value: SMD 0.05, 95% CI -0.09 to 0.19; I² = 0%; 2 studies, 757 participants; moderate-certainty evidence). When measured on the PedsQL physical functioning or DUX-25 physical subscale as a change-from-baseline score, these interventions may improve physical well-being at 12 months, but the evidence is very uncertain (SMD 1.16, 95% CI -0.73 to 3.04; I² = 85%; 2 studies, 56 participants; very low-certainty evidence). They likely result in little to no difference in mental well-being at 12 months of follow-up (PedsQL emotional or psychosocial scores; SMD 0.02, 95% CI -0.12 to 0.16; I² = 0%; 2 studies, 757 participants; moderate-certainty evidence). These interventions may improve objectively-assessed physical activity at 12 months (SMD 0.23, 95% CI -0.16 to 0.63; I² = 60%; 3 studies, 278 participants; low-certainty evidence), but may result in little to no difference in subjectively-assessed physical activity at 12 months (SMD 0.01, 95% CI -0.20 to 0.22; I² = 47%; 5 studies, 776 participants; low-certainty evidence) and 24 months (SMD 0.15, 95% CI -0.47 to 0.77; I² = 82%; 2 studies, 275 participants; low-certainty evidence). They likely result in little to no difference in HRQoL at 12 months (MD 0.36, 95% CI -1.18 to 1.90; I² = 0%; 5 studies, 921 participants; moderate-certainty evidence). We are very uncertain about the effects of these interventions on adverse events (3 studies, 614 participants; very low-certainty evidence). The evidence is very uncertain about the effect of healthcare-based multimodal interventions on BMI z-score at 12 months (MD -0.15, 95% CI -0.23 to -0.06; I² = 68%; 16 studies, 2397 participants; very low-certainty evidence). They may result in little to no difference in BMI z-score at 24 months (MD -0.08, 95% CI -0.18 to 0.02; I² = 65%; 4 studies, 608 participants; low-certainty evidence). None of the studies reported obesity-associated disability. Community-based multimodal interventions versus control Community-based multimodal interventions may result in little to no difference in physical well-being (MD 2.92, 95% CI -3.63 to 9.47; I² not applicable; 1 study, 87 participants; low-certainty evidence) and likely result in little to no difference in mental well-being at 12 months of follow-up (SMD -0.04, 95% CI -0.23 to 0.16; I² = 0%; 2 studies, 428 participants; moderate-certainty evidence). These interventions may result in little to no difference in objectively-assessed physical activity at 12 months (SMD -0.02, 95% CI -0.27 to 0.23; I² = 39%; 4 studies, 481 participants; low-certainty evidence) and likely result in little to no difference at 24 months (SMD 0.06, 95% CI -0.15 to 0.26; I² = 0%; 2 studies, 362 participants; moderate-certainty evidence). These interventions may result in little to no difference in HRQoL (final score) at 12 months (MD 0.58, 95% CI -2.11 to 3.27; I² = 19%; 4 studies, 653 participants; low-certainty evidence), but may lead to a small benefit in HRQoL (change-from-baseline score) at 24 months (MD 4.30, 95% CI -0.76 to 9.36; I² not applicable; 1 study, 121 participants; low-certainty evidence). They likely result in little to no difference in BMI z-score at 12 months (MD 0.02, 95% CI -0.08 to 0.12; I² = 63%; 5 studies, 420 participants; moderate-certainty evidence) and 24 months (MD 0.01, 95% CI -0.11 to 0.12; I² = 0%; 2 studies, 190 participants; moderate-certainty evidence). None of the studies reported adverse events or obesity-associated disability. AUTHORS' CONCLUSIONS: Multimodal health behaviour-changing interventions may improve objectively-assessed physical activity at 12 months when delivered in healthcare settings and may slightly improve HRQoL at 24 months when delivered in the community, but they may have little to no effect on the other pre-defined critical outcomes, including physical and mental well-being, and anthropometry (BMI z-score). Future research should explore innovative approaches to the care of children living with obesity and ensure the inclusion of diverse populations, given the limited evidence from disadvantaged or culturally/ethnically diverse groups, and from low-resource settings. FUNDING: World Health Organization (WHO) REGISTRATION: Protocol (2024): PROSPERO CRD42023468867.

RATIONALE: Adolescent obesity is a global public health problem with multiple causes. The mainstay approach for managing obesity includes interventions targeting changes in health-related behaviours (diet, physical activity, and behaviour). However, previous research highlighted uncertainty about the sustainability and long-term results of these approaches. OBJECTIVES: To assess the effects of multimodal health behaviour-changing interventions for adolescents aged 10 to 19 living with obesity. SEARCH METHODS: We used CENTRAL, MEDLINE, three other databases, and two trial registers, together with reference checking and contact with study authors, to identify studies included in the review. The latest search date was 28 February 2024. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) in adolescents aged 10 to 19 living with obesity that compared interventions involving a minimum of two health-related behaviour components (modifications in diet, physical activity, or behavioural change) to control (including no treatment, usual care, or waiting-list control) with a minimum of one year of follow-up. OUTCOMES: Critical outcomes included physical well-being, mental well-being, physical activity, health-related quality of life (HRQoL), obesity-associated disability, adverse events, and anthropometry (body mass index (BMI) z-score). RISK OF BIAS: We used the original version of the Cochrane Collaboration's tool for assessing risk of bias (RoB 1). SYNTHESIS METHODS: We synthesised results for each outcome using meta-analysis, where possible, with a random-effects model. Where this was not possible, we described the results narratively. We used GRADE to assess the certainty of evidence for critical outcomes included in two key summary of findings tables. For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMD). INCLUDED STUDIES: We included 33 RCTs with 5949 participants aged 10 to 19, primarily from high-income countries. We included 13 community-based interventions in schools, churches, and community centres, and 20 healthcare-based interventions implemented in primary care and hospitals. Intervention components included sessions on dietary modification, physical activity, and behavioural change. Of the 33 included studies, one targeted parents only, one involved only adolescents, and the remainder used family-based approaches, primarily through individual or group sessions. SYNTHESIS OF RESULTS: Healthcare-based multimodal interventions versus control Healthcare-based multimodal interventions may result in little to no difference in physical well-being at 12 months of follow-up (multiple scales: SMD 0.13, 95% CI -0.13 to 0.39; I² = 67%; 4 studies, 1006 participants; low-certainty evidence). They may result in little to no difference in mental well-being at 12 to 18 months of follow-up (multiple scales: SMD 0.09, 95% CI -0.07 to 0.24; I² = 0%; 4 studies, 693 participants; low-certainty evidence). The evidence is very uncertain about the effect of these interventions on self-reported physical activity (final score) at 12 months (multiple scales: SMD 0.51, 95% CI -0.07 to 1.10; I² = 93%; 4 studies, 964 participants; very low-certainty evidence), and when measured as a change-from-baseline score, these interventions may result in little to no difference in self-reported physical activity (multiple scales: SMD 0.02, 95% CI -0.29 to 0.34; I² = 0%; 2 studies, 156 participants; low-certainty evidence). These interventions may slightly improve HRQoL at 12 months (multiple scales: SMD 0.13, 95% CI 0.02 to 0.24; I² = 4%; 7 studies, 1454 participants; low-certainty evidence). The evidence is very uncertain about the effect of healthcare-based multimodal interventions on adverse events (0 events; 1 study, 46 participants; very low-certainty evidence). These interventions may result in little to no difference in BMI z-score at 12 to 18 months (MD -0.11, 95% CI -0.19 to -0.02; I² = 78%; 17 studies, 2666 participants; low-certainty evidence) and 24 months (MD 0.50, 95% CI -0.35 to 1.35; I² not applicable; 1 study, 33 participants; low-certainty evidence). None of the included studies reported obesity-associated disability. Community-based multimodal interventions versus control Community-based multimodal interventions may improve physical well-being at 12 months of follow-up (Youth Quality of Life instrument - Weight module: MD 13.50, 95% CI 4.99 to 22.01; I² not applicable; 1 study, 136 participants; low-certainty evidence). These interventions may result in little to no difference in mental well-being at 12 months (Strengths and Difficulties Questionnaire: MD 1.20, 95% CI -0.46 to 2.86; I² not applicable; 1 study, 208 participants; low-certainty evidence). These interventions may result in little to no difference in self-reported physical activity at 24 months (Global Physical Activity Questionnaire: ß coefficient = -0.04, 95% CI -0.3 to 0.2; P = 0.76; low-certainty evidence). Community-based multimodal interventions likely result in little to no difference in HRQoL at 12 months (multiple scales: SMD 0.06, 95% CI -0.11 to 0.24; I² = 19%; 4 studies, 666 participants; moderate-certainty evidence) and may result in little to no difference in HRQoL at 24 months (Pediatric Quality of Life Inventory: SMD -0.03, 95% CI -0.33 to 0.27; I² not applicable; 1 study, 188 participants; low-certainty evidence). These interventions may result in little to no difference in BMI z-score at 12 months (MD -0.07, 95% CI -0.21 to 0.08; I² = 85%; 5 studies, 585 participants; low-certainty evidence), and may reduce BMI z-score slightly at 24 months of follow-up (MD -0.47, 95% CI -0.96 to 0.02; I² = 98%; 3 studies, 430 participants; low-certainty evidence). None of the included studies reported data on obesity-associated disability or adverse events. AUTHORS' CONCLUSIONS: Multimodal health behaviour-changing interventions may result in a small improvement in physical well-being at 12 months and BMI z-score at 12 months when delivered in the community, and in HRQoL at 12 months when delivered in healthcare settings. They may have little to no effect on other pre-defined critical outcomes, including mental well-being and physical activity. Future research should consider innovative approaches to the care of adolescents living with obesity and involve diverse populations, as we found limited research conducted in disadvantaged and culturally/ethnically diverse populations and other low-resource settings. FUNDING: World Health Organization (WHO) REGISTRATION: Protocol (2024): PROSPERO CRD42023468867.

Background The National Health Service Type 2 Diabetes Path to Remission programme in England (known as the NHS Low Calorie Diet programme when piloted) was established to support people living with excess weight and Type 2 Diabetes to lose weight and improve their glycaemic control. A mixed method evaluation was commissioned to provide an enhanced understanding of the long-term cost effectiveness of the pilot programme, its implementation, equity and transferability across broad and diverse populations. This study provided key insights on implementation and equity from the service providers’ perspective. Methods Thirteen focus groups were conducted with commercial providers of the programme, during the initial pilot rollout. Participants were purposively sampled across all provider organisations and staff roles involved in implementing and delivering the programme. Normalisation Process Theory (NPT) was used to design the topic schedule, with the addition of topics on equity and person-centredness. Data were thematically analysed using NPT constructs with additional inductively created codes. Codes were summarised, and analytical themes generated. Results The programme was found to fulfil the requirements for normalisation from the providers’ perspective. However, barriers were identified in engaging GP practices and receiving sufficient referrals, as well as supporting service users through challenges to remain compliant. There was variation in communication and training between provider sites. Areas for learning and improvement included adapting systems and processes and closing the gap where needs of service users are not fully met. Conclusions The evaluation of the pilot programme demonstrated that it was workable when supported by effective primary care engagement, comprehensive training, and effective internal and external communication. However, limitations were identified in relation to programme specifications e.g. eligibility criteria, service specification and local commissioning decisions e.g. pattern of roll out, incentivisation of general practice. A person-centred approach to care is fundamental and should include cultural adaptation(s), and the assessment and signposting to additional support and services where required.

The UK’s Health and Care Act (2022; paused until 2025) includes a globally novel ban on paid-for online advertising of food and beverage products high in saturated fat, salt and sugar (HFSS), to address growing concerns about the scale of digital marketing and its impact in particular on children’s food and beverage preferences, purchases and consumption. This study aimed to understand the potential impact of the novel ban (as proposed in 2020) on specified forms of online HFSS advertising, through the lens of interdisciplinary expertise. We conducted semi-structured interviews via videoconference with eight purposively selected UK and global digital marketing, food and privacy experts. We identified deductive and inductive themes addressing the policy’s scope, design, implementation, monitoring and enforcement through iterative, consensual thematic analyses. Experts felt this novel ‘breakthrough’ policy has potential to substantially impact global marketing by establishing the principle of no HFSS advertising online to consumers of all ages, but they also identified substantive limitations that could potentially render it ‘entirely ineffective’, for example, the exclusion of common forms of digital marketing, especially brand marketing and marketing integrated within entertainment content; virtual/augmented reality, and ‘advertainment’ as particularly likely spaces for rapid growth of digital food marketing; and technical digital media issues that raise significant barriers to effective monitoring and compliance. Experts recommended well-defined regulations with strong enforcement mechanisms. These findings contribute insights for effective design and implementation of global initiatives to limit online HFSS food marketing, including the need for government regulations in place of voluntary industry restrictions.

© 2017 World Obesity Federation. Specialist weight management services provide a treatment option for severe obesity. The objective of the study is to review the characteristics, impact and practice implications of specialist weight management services for adults in the UK. Systematic review: EMBASE, MEDLINE and PsycINFO were searched from January 2005 to March 2016 with supplementary searches. Adults with a body mass index of ≥40 kg m-2 , or ≥35 kg m-2 with comorbidity or ≥30 kg m-2 with type 2 diabetes and any study of multicomponent interventions, in any UK or Ireland setting, delivered by a specialist multidisciplinary team are the inclusion criteria. Fourteen studies in a variety of settings were included: 1 randomized controlled trial, 3 controlled and 10 observational studies. Mean baseline body mass index and age ranged from 40 to 54 kg m-2 and from 40 to 58 years. The studies were heterogeneous making comparisons of service characteristics difficult. Multidisciplinary team composition and eligibility criteria varied; dropout rates were high (43-62%). Statistically significant reduction in mean body mass index over time ranged from -1.4 to -3.1 kg m-2 and mean weight changes ranged from -2.2 to -12.4 kg. Completers achieving at least 5% reduction of initial body weight ranged from 32 to 51%. There was evidence for improved outcomes in diabetics. Specialist weight management services can demonstrate clinically significant weight loss and have an important role in supporting adults to manage severe and often complex forms of obesity. This review highlights important variations in provision and strongly indicates the need for further research into effective approaches to support severely obese adults.

Background: Child and adolescent overweight and obesity has increased globally, and can be associated with significant short- and longterm health consequences. This is an update of a Cochrane Review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages. Objectives: To assess the effects of diet, physical activity and behavioural interventions (behaviour-changing interventions) for the treatment of overweight or obese children aged 6 to 11 years. Search methods: We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and RsdI1401 Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases. Selection criteria: We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour-changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months’ follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity. Data collection and analysis: Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out metaanalyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. Main results: We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty-five trials compared a behaviour-changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour-changing intervention. Sixty-four trials were parallel RCTs, and four were cluster RCTs. Sixty-four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2. Primary analyses demonstrated that behaviour-changing interventions compared to no treatment/usual care control at longest follow-up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was -0.53 kg/m2 (95% confidence interval (CI) -0.82 to -0.24); P < 0.00001; 24 trials; 2785 participants; low-quality evidence. MD in BMI z score was -0.06 units (95% CI -0.10 to -0.02); P = 0.001; 37 trials; 4019 participants; low-quality evidence and MD in weight was -1.45 kg (95% CI -1.88 to -1.02); P < 0.00001; 17 trials; 1774 participants; low-quality evidence. Thirty-one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour-changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health-related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI -12.88 to -0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all-cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta-analysed.

Obesity is rising in the obstetric population, yet there is an absence of services and guidance for the management of maternal obesity. This systematic review aimed to investigate relationships between obesity and impact on obstetric care. Literature was systematically searched for cohort studies of pregnant women with anthropometric measurements recorded within 16-weeks gestation, followed up for the term of the pregnancy, with at least one obese and one comparison group. Two researchers independently data-extracted and quality-assessed each included study. Outcome measures were those that directly or indirectly impacted on maternity resources. Primary outcomes included instrumental delivery, caesarean delivery, duration of hospital stay, neonatal intensive care, neonatal trauma, haemorrhage, infection and 3rd/4th degree tears. Meta-analysis shows a significant relationship between obesity and increased odds of caesarean and instrumental deliveries, haemorrhage, infection, longer duration of hospital stay and increased neonatal intensive care requirement. Maternal obesity significantly contributes to a poorer prognosis for mother and baby during delivery and in the immediate post-partum period. National clinical guidelines for management of obese pregnant women, and public health interventions to help safeguard the health of mothers and their babies are urgently required.

Purpose of review To examine the evidence and continuing role of strategies for the primary prevention and treatment of obesity in the context of effective obesity pharmacotherapies, through a narrative review. Recent findings Global policies to improve nutritional labelling and reduce sugar-sweetened beverages consumption have been implemented worldwide (> 45 countries) with some success which varies by population and environment. Tailored behavioural interventions are effective and essential to reduce individual risk of progression from preclinical to clinical obesity. Pharmacotherapies are powerful treatment agents for clinical obesity but must consider nutritional and metabolic risks of use and discontinuation. The obesogenic environment continues to undermine individual agency to adopt healthier dietary and physical activity patterns. Population health informatics tools could inform tailored interventions based on real-time risk and contribute to obesity prevention and treatment. Summary Efforts to rebalance investment towards obesity prevention must continue to improve population health and reduce healthcare burden.

Background: Childhood obesity remains a significant public health concern. Sleep duration and quality among children and youth are suboptimal worldwide. Accumulating evidence suggests an association between inadequate sleep and obesity risk, yet it is unclear whether this relationship is causal. This systematic review examines the efficacy of sleep interventions alone or as a part of lifestyle interventions for the management of overweight or obesity among children and adolescents. Methods: A keyword/reference search was performed twice, in January 2021 and May 2022 in MEDLINE/PubMed, EMBASE/Ovid, PsycINFO/EBSCO, The Cochrane Library, Web of Science Core Collection/Web of Science, SciELO/Web of Science, and CINAHL/EBSCO. Study eligibility criteria included youth with overweight or obesity between 5 and 17, were RCTs or quasi-randomized, and focused on the treatment of overweight and obesity with a sleep behavior intervention component. Risk of bias was assessed using the Cochrane Risk of Bias assessment tool (RoB2). A Meta-analysis was conducted to estimate the effect of interventions with a sleep component on BMI. The study protocol was registered in PROSPERO (CRD42021233329). Results: A total of 8 studies (2 quasi-experiments, 6 RCTs) met inclusion criteria and accounted for 2,231 participants across 7 countries. Only one study design isolated the effect of sleep in the intervention and reported statistically significant decreases in weight and waist circumference compared to control, though we rated it at high risk of bias. Our meta-analysis showed no significant overall effect on children’s BMI as a result of participation in an intervention with a sleep component (Cohen’s d= 0.18, 95% CI= -0.04, 0.40, Z=1.56, P=0.11), though caution is warranted due to substantial heterogeneity observed across studies (Tau2 = 0.08; Chi2 = 23.05, df = 7; I2 = 83.73%). Conclusions: There were mixed results on the effect of sleep interventions across included studies on BMI, other weight-related outcomes, diet, physical activity, and sleep. Except for one study at low risk of bias, three were rated as ‘some concerns’ and four ‘high risk of bias’. Findings from this study highlight the need for additional RCTs isolating sleep as a component, focusing on children and adolescents living with overweight and obesity.

INTRODUCTION: Obesity affects nearly 1 in 4 European adults increasing their risk for mortality and physical and psychological morbidity. Obesity is a chronic relapsing disease characterized by abnormal or excessive adiposity with risks to health. Medical nutrition therapy based on the latest scientific evidence should be offered to all Europeans living with obesity as part of obesity treatment interventions. METHODS: A systematic review was conducted to identify the latest evidence published in the November 2018-March 2021 period and to synthesize them in the European guidelines for medical nutrition therapy in adult obesity. RESULTS: Medical nutrition therapy should be administered by trained dietitians as part of a multidisciplinary team and should aim to achieve positive health outcomes, not solely weight changes. A diverse range of nutrition interventions are shown to be effective in the treatment of obesity and its comorbidities, and dietitians should consider all options and deliver personalized interventions. Although caloric restriction-based interventions are effective in promoting weight reduction, long-term adherence to behavioural changes may be better supported via alternative interventions based on eating patterns, food quality, and mindfulness. The Mediterranean diet, vegetarian diets, the Dietary Approaches to Stop Hypertension, portfolio diet, Nordic, and low-carbohydrate diets have all been associated with improvement in metabolic health with or without changes in body weight. In the November 2018-March 2021 period, the latest evidence published focused around intermittent fasting and meal replacements as obesity treatment options. Although the role of meal replacements is further strengthened by the new evidence, for intermittent fasting no evidence of significant advantage over and above continuous energy restriction was found. Pulses, fruit and vegetables, nuts, whole grains, and dairy foods are also important elements in the medical nutrition therapy of adult obesity. DISCUSSION: Any nutrition intervention should be based on a detailed nutritional assessment including an assessment of personal values, preferences, and social determinants of eating habits. Dietitians are expected to design interventions that are flexible and person centred. Approaches that avoid caloric restriction or detailed eating plans (non-dieting approaches) are also recommended for improvement of quality of life and body image perceptions.

Introduction: This position statement on medical nutrition therapy (MNT) in the management of overweight or obesity in children and adolescents was prepared by an expert committee convened by the European Association for the Study of Obesity (EASO) and developed in collaboration with the European Federation of the Associations of Dietitians (EFAD). Methods: It is based on the best evidence available from systematic reviews of randomised controlled trials on child and adolescent overweight and obesity treatment and other relevant peer-reviewed literature. Results: Multi-component behavioural interventions are generally considered to be the gold standard treatment for children and adolescents living with obesity. The evidence presented in this position statement confirms that dietary interventions can effectively improve adiposity-related outcomes. Dietary strategies should focus on the reduction of total energy intake through promotion of food-based guidelines that target modification of usual eating patterns and behaviours. These should target increasing intakes of nutrient-rich foods with a lower energy density, specifically vegetables and fruits, and a reduction in intakes of energy dense nutrient-poor foods and beverages. In addition, higher intensity, longer duration treatments, delivered by interventionists with specialised dietetic-related skills and co- designed with families are associated with greater treatment effects. Discussion: Such interventions should be resourced adequately so that they can be implemented in a range of settings and in different formats, including digital or online delivery, to enhance accessibility.

Socio‐economic status and ethnic background are recognized as predictors of risk for the development of obesity in childhood. The present review assesses the effectiveness of treatment for children according to their socio‐economic and ethnic background. Sixty‐four systematic reviews were included, from which there was difficulty reaching general conclusions on the approaches to treatment suitable for different social subgroups. Eighty‐one primary studies cited in the systematic reviews met the inclusion criteria, of which five directly addressed differential effectiveness of treatment in relation to social disparities, with inconsistent conclusions. From a weak evidence base, it appears that treatment effectiveness may be affected by family‐level factors including attitudes to overweight, understanding of the causes of weight gain and motivation to make and maintain family‐level changes in health behaviours. Interventions should be culturally and socially sensitive, avoid stigma, encourage motivation, recognize barriers and reinforce opportunities and be achievable within the family's time and financial resources. However, the evidence base is remarkably limited, given the significance of social and economic disparities as risk factors. Research funding agencies need to ensure that a focus on social disparities in paediatric obesity treatment is a high priority for future research.

© 2018, Springer Nature Limited. Children and adolescents with overweight and obesity are a global health concern. This is an integrative overview of six Cochrane systematic reviews, providing an up-to-date synthesis of the evidence examining interventions for the treatment of children and adolescents with overweight or obesity. The data extraction and quality assessments for each review were conducted by one author and checked by a second. The six high quality reviews provide evidence on the effectiveness of behaviour changing interventions conducted in children <6 years (7 trials), 6–11 years (70 trials), adolescents 12–17 years (44 trials) and interventions that target only parents of children aged 5–11 years (20 trials); in addition to interventions examining surgery (1 trial) and drugs (21 trials). Most of the evidence was derived from high-income countries and published in the last two decades. Collectively, the evidence suggests that multi-component behaviour changing interventions may be beneficial in achieving small reductions in body weight status in children of all ages, with low adverse event occurrence were reported. More research is required to understand which specific intervention components are most effective and in whom, and how best to maintain intervention effects. Evidence from surgical and drug interventions was too limited to make inferences about use and safety, and adverse events were a serious consideration.

Clinical Question How effective are diet, physical activity, and behavioral interventions in treating children aged 6 to 11 years with overweight or obesity? Bottom Line Multicomponent behavior-changing interventions may be beneficial in achieving small, short-term reductions in body mass index (calculated as weight in kilograms divided by height in meters squared), body mass index z score, and weight in children aged 6 to 11 years. Adverse events, health-related quality of life, behavior change outcomes, and sociodemographics were poorly or inconsistently reported. Overall, the quality of the evidence was low or very low, with no evidence from lower-income countries.

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© The Author 2017. Background The impact of specialist weight management services (Tier 3) for children with severe and complex obesity in the UK is unclear. This review aims to examine the impact of child Tier 3 services in the UK, exploring service characteristics and implications for practice. Methods Rapid systematic review of any study examining specialist weight management interventions in any UK setting including children (2-18 years) with a body mass index >99.6th centile or >98th centile with comorbidity. Results Twelve studies (five RCTs and seven uncontrolled) were included in a variety of settings. Study quality was moderate or low and mean baseline body mass index z-score ranged from 2.7 to 3.6 units. Study samples were small and children were predominantly older (10-14 years), female and white. Multidisciplinary team composition and eligibility criteria varied; dropout ranged from 5 to 43%. Improvements in zBMI over 1-24 months ranged from -0.13 to -0.41 units. Conclusions Specialist weight management interventions for children with severe obesity demonstrated a reduction in zBMI, across a variety of UK settings. Studies were heterogeneous in content and thus conclusions on service design cannot be drawn. There is a paucity of evidence for Tier 3 services for children, and further research is required.

Pediatric obesity is a global public health concern. While in most countries the incidence keeps rising, the need for effective and long-term management for children and adolescents living with this chronic, relapsing disease is pressing. Health behavior and lifestyle treatment (HBLT) is recommended as first-line treatment. A new generation of recently approved anti-obesity medications (AOM) now has the potential to fill the gap between limited effects on body mass index (BMI) by HBLT alone and large effects by metabolic and bariatric surgery in adolescents with obesity aged 12 years and older. While, for semaglutide and phentermine/topiramate, effectiveness is substantial with relevant, but mostly mild to moderate adverse events, there is a gap in evidence regarding long-term effects and safety, effects on outcomes beyond BMI reduction and data for certain groups of patients, such as children <12 years and minority groups. When integrating AOM treatment into national health care systems it should be offered as part of a comprehensive patient-centered approach. This article summarizes recent AOM developments, integration into pediatric obesity management, and identifies research gaps.

Background: The ‘Type 2 Diabetes Path to Remission’ programme (T2DPR) of NHS England (NHSE) is a low-calorie diet intervention with behavioural support for adults with a recent type 2 diabetes mellitus (T2D) diagnosis and body mass index (BMI) > 25 kg/m

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BACKGROUND: A significantly higher proportion of UK Black ethnic adults live with overweight or obesity, compared to their White British counterparts. The role of obesity in excess infection rates and mortality from COVID-19 has increased the need to understand if weight management interventions are appropriate and effective for Black ethnic groups. There is a paucity of existing research on weight management services in Black populations, and whether anticipated or experienced institutional and interpersonal racism in the healthcare and more widely affects engagement in these services. Understanding the lived experience of target populations and views of service providers delivering programmes is essential for timely service improvement. METHODS: A qualitative study using semi-structured interviews was conducted in June-October 2021 among 18 Black African and Black Caribbean men and women interested in losing weight and 10 weight management service providers. RESULTS: The results highlighted a positive view of life in the United Kingdom (UK), whether born in the UK or born abroad, but one which was marred by racism. Weight gain was attributed by participants to unhealthy behaviours and the environment, with improving appearance and preventing ill health key motivators for weight loss. Participants relied on self-help to address their overweight, with the role of primary care in weight management contested as a source of support. Anticipated or previously experienced racism in the health care system and more widely, accounted for some of the lack of engagement with services. Participants and service providers agreed on the lack of relevance of existing services to Black populations, including limited culturally tailored resources. Community based, ethnically matched, and flexibly delivered weight management services were suggested as ideal, and could form the basis of a set of recommendations for research and practice. CONCLUSION: Cultural tailoring of existing services and new programmes, and cultural competency training are needed. These actions are required within systemic changes, such as interventions to address discrimination. Our qualitative insights form the basis for advancing further work and research to improve existing services to address the weight-related inequality faced by UK Black ethnic groups.

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.

Objectives The Awareness, Care and Treatment In Obesity maNagement (ACTION) Teens study explored attitudes, behaviours, perceptions and barriers regarding effective obesity care among adolescents living with obesity (ALwO), caregivers and healthcare professionals (HCPs). Design Cross-sectional online survey study. Setting Study across 10 countries; here, we report data from UK respondents. Participants Overall, 416 ALwO (aged 12 to <18 years; body mass index ≥95th percentile for age and sex (WHO charts)), 498 caregivers and 250 HCPs in the UK completed the survey (August–December 2021). Primary and secondary outcome measures Survey questions addressed key aspects of obesity management for ALwO. Results Overall, 46% of ALwO perceived their weight as normal or below normal and 86% believed their health was at least good; 56% and 93% of caregivers responded similarly for their ALwO. Despite this, most ALwO (57%) had attempted to lose weight in the past year and 34% felt highly motivated to lose weight. YouTube and social media were most often used by ALwO for information about weight management (41% and 39%); few ALwO and caregivers sought information from a doctor (13% and 22%). Among ALwO who had discussed weight with an HCP (n=122), 49% trusted their weight-management advice. Only 10% of ALwO and 8% of caregivers were told by a doctor that they/their child had obesity. For HCPs, obesity-related comorbidities were the most common reason for initiating weight conversations with ALwO (73%), while short appointment times were the most common barrier (46%). Overall, 30% of ALwO and 11% of caregivers did not feel comfortable bringing up weight with an HCP. Conclusions Improved education and communication are needed among ALwO, caregivers and HCPs in the UK to help improve awareness of obesity, its aetiology and its impact on health, and to support HCPs to proactively initiate weight-related conversations and build trust with ALwO and caregivers.

Background: Child and adolescent overweight and obesity have increased globally and are associated with significant short- and long-term health consequences. Objectives: To assess the effects of surgery for treating obesity in childhood and adolescence. Search methods: For this update, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Latin American and Caribbean Health Science Information database (LILACS), World Health Organization International Clinical Trials Registry Platform (ICTRP)and ClinicalTrials.gov on 20 August 2021 (date of the last search for all databases). We did not apply language restrictions. We checked references of identified studies and systematic reviews. Selection criteria: We selected randomised controlled trials (RCTs) of surgical interventions for treating obesity in children and adolescents (age < 18 years) with a minimum of six months of follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or which included participants with a secondary or syndromic cause of obesity, or who were pregnant. Data collection and analysis: We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias using the Cochrane Risk of Bias 2.0 tool. Where necessary, we contacted authors for additional information. Main results: With this update, we did not find any new RCTs. Therefore, this updated review still includes a single RCT (a total of 50 participants, 25 in both the intervention and comparator groups). The intervention focused on laparoscopic adjustable gastric banding surgery, which was compared to a control group receiving a multi-component lifestyle programme. The participating population consisted of Australian adolescents (a higher proportion of girls than boys) aged 14 to 18 years, with a mean age of 16.5 and 16.6 years in the gastric banding and lifestyle groups, respectively. The trial was conducted in a private hospital, receiving funding from the gastric banding manufacturer. For most of the outcomes, we identified a high risk of bias, mainly due to bias due to missing outcome data. Laparoscopic gastric banding surgery may reduce BMI by a mean difference (MD) of -11.40 kg/m

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Summary

Worldwide prevalence of adult overweight and obesity is a growing public health issue. Adults with overweight/obesity often have chronic musculoskeletal pain. Using a mixed‐methods review, we aimed to quantify the effectiveness and explore the appropriateness of weight loss interventions for this population. Electronic databases were searched for studies published between 01/01/90 and 01/07/16. The review included 14 randomized controlled trials that reported weight and pain outcomes and three qualitative studies that explored perceptions of adults with co‐existing overweight/obesity and chronic musculoskeletal pain. The random‐effects pooled mean weight loss was 4.9 kg (95%CI:2.9,6.8) greater for intervention vs control. The pooled mean reduction in pain was 7.3/100 units (95%CI:4.1,10.5) greater for intervention vs control. Study heterogeneity was substantial for weight loss (I2 = 95%, tau = ±3.5 kg) and pain change (I2 = 67%, tau = ±4.1%). Meta‐regression slopes for the predictors of study quality, mean age and baseline mean weight on mean study weight reduction were shallow and not statistically significant (P > 0.05). The meta‐regression slope between mean pain reduction and mean weight lost was shallow, and not statistically significant, −0.09 kg per unit pain score change (95%CI:−0.21,0.40, P = 0.54). Meta‐synthesis of qualitative findings resulted in two synthesized findings; the importance of healthcare professionals understanding the effects of pain on ability to control weight and developing management/education programmes that address comorbidity.

REVIEW QUESTION/OBJECTIVE: The objective of this mixed methods review is to develop an aggregated synthesis of qualitative and quantitative data on weight-loss interventions for overweight/obese adults with chronic musculoskeletal pain in an attempt to derive conclusions and recommendations useful for clinical practice and policy decision making.The objective of the quantitative component of this review is to quantify the effectiveness of weight-loss interventions on weight, pain and physical and/or psychosocial function in overweight/obese adults with chronic musculoskeletal pain.The objectives of the qualitative component of this review are to explore the perceptions and experiences of overweight/obese adults with chronic musculoskeletal pain of the link between their weight and pain, and the effectiveness and appropriateness of weight-loss interventions and sustainability of weight-loss efforts.

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.

Childhood obesity remains a major public health and social issue. Its’ prevalence has grown significantly over the last 30years and it is expected to rise further in future years. The physical, psychological, social, emotional, and economic consequences of obesity are significant on both the individual and society as a whole. There is a moderate evidence base for the treatment of childhood obesity, with many reviews suggesting that weight management (WM) programs can be both effective and cost effective. That said, data on longer term efficacy is currently limited, as is that for specialist weight management services and pharmacotherapy. This chapter sets out to discuss a range of WM programs and their component parts, how to ensure appropriate services are referred to, and distill the evidence base around effectiveness. We also place WM in the context of the wider political systems in the UK – those which fundamentally shape the offer available to families in need. In this Edition 3 update, we highlight recent advancements and contemporary issues in childhood WM provision.

Purpose of Review: This article discusses what person-centred care is; why it is critically important in providing effective care of a chronic, complex disease like obesity; and what can be learnt from international best practice to inform global implementation. Recent Findings: There are four key principles to providing person-centred obesity care: providing care that is coordinated, personalised, enabling and delivered with dignity, compassion and respect. The Canadian 5AsT framework provides a co-developed person-centred obesity care approach that addresses complexity and is being tested internationally. Summary: Embedding person-centred obesity care across the globe will require a complex system approach to provide a framework for healthcare system redesign, advances in people-driven discovery and advocacy for policy change. Additional training, tools and resources are required to support local implementation, delivery and evaluation. Delivering high-quality, effective person-centred care across the globe will be critical in addressing the current obesity epidemic.

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.

INTRODUCTION: A limited number of diet, physical activity and weight management programmes suitable for UK black and Asian populations have been evaluated. We aim to coproduce 'Health Connections'-an ambitious new intervention to support dietary and physical activity choices, and maintaining a healthier weight, tailored to the needs of black Caribbean, black African and South Asian adults. Our existing research and public engagement work suggests that the intervention should be designed to be embedded in communities and delivered by peer educators supported by health professionals. METHODS AND ANALYSIS: The project is underpinned by a systems perspective that posits collective efficacy within communities, behaviour change theory and coproduction. Project activities will be conducted in three stages. Stage 1: semistructured interviews will be conducted with adults from diverse South Asian ethnic groups to understand their experiences, perspectives and intervention needs, adding to our existing data from black ethnic groups. We will synthesise the data, literature, available intervention resources and local practice, and develop the theoretical framework to codevelop intervention goals, programme theory and a draft logic model of change. Stage 2: a theorised list of potential intervention components, session content and mode/s of delivery will be explored in a modified Delphi exercise and workshop to achieve consensus on the intervention format. We will also develop prototype materials and a formal implementation plan. Stage 3: a description of the intervention will be documented. ETHICS AND DISSEMINATION: The study has received ethical approval from the School of Health Research Ethics Committee, Leeds Beckett University. Information on the project aims and voluntary participation is provided in the study participation information sheet. Consent will be certified by the completion and signing of a consent form prior to data collection. Dissemination for a range of stakeholders and audiences will include publications, presentations, short films and an infographic.

Background The management of type 2 diabetes (T2D) within diverse ethnic populations requires a culturally tailored approach. However, little is known about the experiences of coaches delivering interventions for T2D, such as the National Health Service (NHS) Low Calorie Diet (LCD) programme, to people from diverse ethnic backgrounds. Objective To explore the experiences of coaches delivering an NHS programme using total diet replacement approaches to individuals from diverse ethnic backgrounds, to inform the effective tailoring and equitable delivery of future interventions. Design Qualitative study. Setting Individuals delivering the NHS LCD programme. Participants One-to-one semistructured interviews were conducted with seven health coaches delivering the NHS LCD programme. Inclusion criteria included participants delivering the NHS LCD programme either from a minoritised ethnic background or delivering the programme to those from ethnic minority and white British backgrounds. Main outcome measures Qualitative semistructured interviews conducted through different stages of the programme. Reflexive thematic analysis was used to analyse the transcripts. Results Key themes highlighted the following experiences of delivering the LCD programme: (1) training and support needs; (2) needing to understand culture and ethnicity; (3) the impact of language; (4) the use of resources in providing dietary advice and (5) experiences of cultural tailoring. The themes highlight the need to prioritise person-centred care, to integrate culturally tailored approaches and for provision of education and training to those delivering health programmes. Conclusion These findings describe the experiences of health coaches in tailoring delivery and emphasise the role of cultural competence in ensuring equitable and effective healthcare interventions for diverse populations. This learning can inform future programmes and policies aimed at promoting inclusive healthcare practices.

BACKGROUND: Existing literature examines barriers to the provision of ethnically diverse dietary advice, however, is not specific to total diet replacement (TDR). There is a lack of literature from the UK, limiting the potential applicability of existing findings and themes to the UK context. This study addresses this gap in research by interviewing participants of South Asian ethnicity who have undertaken the National Health Service (NHS) low-calorie diet programme (LCD) for people with type 2 diabetes living with overweight or obesity. This study explores factors that may affect the uptake and acceptability of its TDR, food reintroduction and weight maintenance stages. This aims to provide rich data that can inform effective tailoring of future programmes with South Asian participants. OBJECTIVE: To explore the perspectives of individuals of South Asian ethnicity on an NHS programme using TDR approaches for the management of type 2 diabetes (T2D). DESIGN: Qualitative study. SETTING: Individuals in the community undertaking the NHS LCD programme. PARTICIPANTS: Twelve one-to-one interviews were conducted with individuals from a South Asian ethnicity participating in the NHS LCD. MAIN OUTCOME MEASURES: Qualitative semistructured interviews conducted through different stages of the programme. Reflexive thematic analysis was used to analyse the transcripts. RESULTS: Key themes highlighted positive and negative experiences of the programme: (1) more work is needed in the programme for person centeredness; (2) it is not the same taste; (3) needing motivation to make changes and feel better; (4) a mixed relationship with the coach; (5) social experiences; (6) culture-related experiences. CONCLUSION: This study provides important experience-based evidence of the need for culturally tailored T2D programmes. Action to address these findings and improve the tailoring of the NHS LCD may improve experience, retention and outcomes on the programme for people of South Asian ethnicity and thereby reduce inequalities.

ABSTRACT

The Eatwell Guide depicts the UK Government’s healthy eating recommendations and is widely used in clinical practice and public health settings. There is limited evidence on whether adherence to the Eatwell Guide differs by socio-demographic characteristics. This study aimed to explore patterns of Eatwell Guide adherence across socio-demographic groups in the UK Biobank cohort. Eatwell Guide adherence scores were derived for 192,825 individuals from 24-hour dietary recall data (Oxford WebQ), and quantified using a graded, food-based scoring system. Eatwell Guide scores were compared between different age, sex, BMI, ethnicity, socioeconomic status and education groups. Data were analysed using independent sample t-tests, and one-way ANOVA with Tukey post-hoc tests. Eatwell Guide adherence was higher for older than younger, and female compared with male participants (both p <0.001). There was a main effect of BMI on total adherence ( p <0.001), with the highest scores achieved by those with a healthy BMI. Eatwell Guide adherence was higher in white vs non-white participants ( p <0.001), and differed significantly by education level ( p <0.001), with the highest score achieved by participants with a higher education level. Total adherence scores differed by socio-economic status (all p <0.001), with the highest score achieved by the least deprived participants and the lowest score achieved by the most deprived participants. These data demonstrate that Eatwell Guide adherence differs significantly between socio-demographic groups in the UK Biobank. Exploring the consistency of these findings in other cohorts and developing strategies to increase adherence to the Eatwell Guide in groups with low adherence, are future research priorities.

Abstract

Background Young adulthood is a critical period where there is an increased weight gain trajectory. Understanding the weight management support needs of young adults with excess weight is essential to enable the delivery of appropriate and tailored services and prevent the development of comorbidities. This study sought to determine the current health service usage, weight management practices and support needs, in young adults with excess weight. Methods A mixed-methods convergent parallel design was employed. A cohort of community-dwelling young adults (18–35 years), with excess weight (BMI ≥ 25), residing in the UK and Australia participated in an online, longitudinal survey. Cross-sectional data was analysed descriptively, including quantitative measures of health service usage and weight management practices. Responses to an open-ended question asking what support participants would find most helpful were analysed using Thematic Template Analysis. Convergence and divergence across sociodemographic characteristics were explored. Results The sample (n = 410) included 204 women, 201 men and five non-binary people with a mean age of 28.3 and BMI of 35.8. Most participants reported a white ethnicity (80%) and resided in the UK (83%). Half reported a below median gross household income (49%). Most (73%) reported currently trying to manage their weight and 63% were using commercial weight management products or self-directed diets. Only 12% of participants reported accessing healthcare services for weight management support or treatment, yet qualitative responses indicated a desire for support from a dietitian or psychologist. Five themes indicated a need for structured but tailored resources, simplicity, addressing internal and external barriers, access to holistic professional support, and access to networks vs a preference for self-reliance. Conclusions Young adults with excess weight are using commercial products and self-led diets but many desire specialist healthcare professionals to support their weight management. Young adults appear to prefer online resources and support that are simplistic, structured and individually tailored to their diverse cultural preferences, routines, environments, and comorbidities. Furthermore, findings indicate unmet psychological support needs amongst young adults with excess weight in the UK and Australia. Protocol Whatnall, M., Fozard, T., Kolokotroni, K.Z., Marwood, J., Evans, T., Ells, L.J. and Burrows, T., 2022. Understanding eating behaviours, mental health and weight change in young adults: protocol paper for an international longitudinal study. BMJ open, 12(9), p.e064963.

Abstract

Abstract

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.

Previous work has found adverse mental health symptomology in women living with obesity, compared with those of healthy weight, around the time of pregnancy. This meta-analysis aimed to explore the association between anxiety, depression, and weight status in women living with obesity before, during, and after pregnancy. Bibliographic databases were systematically searched, and 14 studies were included, which aimed to assess the association between excess weight and anxiety or depression outcomes in women before, during, or after pregnancy. Data were analyzed via narrative synthesis and random effects multi-level meta-analyses. Scores on mental health indices were significantly greater (indicative of worse anxiety/depression) in women with obesity compared to women of a healthy weight, around the time of pregnancy (SMD = 0.21 [95% CI: 0.11–0.31; 95% prediction intervals: 0.13–0.56], I2 = 73%, p < 0.01). Depressive symptoms were greater during and after pregnancy (SMD = 0.23 [95% CI: 0.13–0.34; 95% prediction intervals: −0.12 to 0.59], I2 = 75.0%, p < 0.01), and trait anxiety symptoms were greater during pregnancy (SMD = 0.24 [95% CI: 0.01–0.47; 95% prediction intervals: −0.25 to 0.72], I2 = 83.7%, p = 0.039) in women living with obesity, compared to those of healthy weight. Narrative evidence suggests that socioeconomic status and ethnicity may modify the relationship between obesity and mental health symptomology. The findings indicate that maternal obesity is associated with greater anxiety and depression symptoms. These findings may inform the design of maternal weight management interventions.

Importance: The effectiveness of anti-obesity medications for children and adolescents is unclear. Objective: To update the evidence on the benefits and harms of anti-obesity medication. Data sources: Cochrane CENTRAL, MEDLINE, ClinicalTrials.gov, WHO ICTRP (1/1/16-17/3/23). Study selection: Randomized controlled trials ≥6-months in people <19years living with obesity. Data extraction and Synthesis: Screening, data extraction, quality assessment conducted in duplicate, independently. Main Outcomes and Measures: Body Mass Index (BMI): 95th percentile BMI, adverse events, quality of life. Results: Thirty-five trials (N=4,331), follow-up: 6-24 months; age: 8.8-16.3 years; BMI: 26.2-41.7kg/m2. Moderate certainty evidence demonstrated a -1.71 (95% confidence interval [CI]: -2.27 to -1.14)-unit BMI reduction, ranging from -0.8 to -5.9 units between individual drugs with Semaglutide producing the largest reduction of -5.88 kg/m2 (95% CI: -6.99 to -4.77, N = 201). Drug type explained ~44% of heterogeneity. Low certainty evidence demonstrated reduction in 95th percentile BMI: -11.88 percentage points (95% CI: -18.43 to -5.30, N = 668). Serious adverse events and study discontinuation due to adverse events, did not differ between medications and comparators, but medication dose adjustments were higher compared to comparator (10.6% vs 1.7%; RR = 3.74 [95% CI: 1.51 to 9.26], I2 = 15%), regardless of approval status. There was a trend towards improved quality of life. Evidence gaps exist for children, psychosocial outcomes, comorbidities, and weight loss maintenance. Conclusions and Relevance: Anti-obesity medications in addition to behaviour-change, improves BMI but may require dose adjustment, with 1 in 100 adolescents experiencing a serious adverse event.

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’.

The marketing of unhealthy foods has been implicated in poor diet and rising levels of obesity. Rapid developments in the digital food marketing ecosystem and associated research mean that contemporary review of the evidence is warranted. This preregistered (CRD420212337091)1 systematic review and meta-analysis aimed to provide an updated synthesis of the evidence for behavioural and health impacts of food marketing on both children and adults, using the 4Ps framework (Promotion, Product, Price, Place). Ten databases were searched from 2014 to 2021 for primary data articles of quantitative or mixed design, reporting on one or more outcome of interest following food marketing exposure compared with a relevant control. Reviews, abstracts, letters/editorials and qualitative studies were excluded. Eighty-two studies were included in the narrative review and twenty-three in the meta-analyses. Study quality (RoB2/Newcastle–Ottawa scale) was mixed. Studies examined ‘promotion’ (n 55), ‘product’ (n 17), ‘price’ (n 15) and ‘place’ (n 2) (some > 1 category). There is evidence of impacts of food marketing in multiple media and settings on outcomes, including increased purchase intention, purchase requests, purchase, preference, choice, and consumption in children and adults. Meta-analysis demonstrated a significant impact of food marketing on increased choice of unhealthy foods (OR = 2·45 (95 % CI 1·41, 4·27), Z = 3·18, P = 0·002, I2 = 93·1 %) and increased food consumption (standardised mean difference = 0·311 (95 % CI 0·185, 0·437), Z = 4·83, P < 0·001, I2 = 53·0 %). Evidence gaps were identified for the impact of brand-only and outdoor streetscape food marketing, and for data on the extent to which food marketing may contribute to health inequalities which, if available, would support UK and international public health policy development.

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.

Summary Obesity and Type 2 Diabetes Mellitus (T2DM) are chronic conditions with significant personal, societal, and economic impacts. Expanding on existing trial evidence, the NHS piloted a 52‐week low‐calorie diet programme for T2DM, delivered by private providers using total diet replacement products and behaviour change support. This study aimed to determine the extent to which providers and coaches adhered to the service specification outlined by NHS England. An observational qualitative study was conducted to examine the delivery of both one‐to‐one and group‐based delivery of programme sessions. Observations of 122 sessions across eight programme delivery samples and two service providers were completed. Adherence to the service specification was stronger for those outcomes that were easily measurable, such as weight and blood glucose, while less tangible elements of the specification, such as empowering service users, and person‐centred delivery were less consistently observed. One‐to‐one sessions were more successful in their person‐centred delivery, and the skills of the coaches delivering the sessions had a strong impact on adherence to the specification. Overall, the results show that there was variability by provider and delivery mode in the extent to which sessions of the NHS Low‐Calorie Diet Programme reflected the intended service specification. In subsequent programmes it is recommended that one‐to‐one sessions are used, with accompanying peer support, and that providers improve standardised training and quality assurance to ensure specification adherence.

Background: Emotional eating (EE) is a barrier to long-term success of weight loss interventions. Psychological interventions targeting EE have been shown to reduce EE scores and weight (kg), though the mechanisms remain unclear. This review and meta-analysis aimed to identify the specific behaviour change techniques (BCTs) associated with improved outcomes. Methods: This is a review update and extension, with new studies extracted from searches of CINAHL, PsycINFO, MEDLINE, and EMBASE 01/01/22- 31/04/23. EE interventions for adults with BMI >25kg/m2, were considered for inclusion. Paper screening, extraction, BCT-coding and risk of bias were completed using the Template for Intervention Description and Replication (TIDieR) checklist, Behaviour Change Taxonomy v1 (BCTTv1) and Risk of Bias2 (RoB2)/ Risk of Bias In Non-randomised Studies (ROBINS-I) tool. Narrative syntheses and random effects multi-level meta-analyses were conducted. Results: 6,729 participants were included across 47 studies (13 identified in the update). Forty-two studies contributed to the pooled estimate for the impact of interventions on EE (SMD = -0.99 [95% CI: -0.73 to -1.25], p < .001). Thirty-two studies contributed to the pooled estimate for the impact of interventions on weight (-4.09 kg [95% CI: -2.76 to -5.43 kgs], p < .001). Five BCTs related to identity, values and self-regulation, were associated with notable improvements to both weight and EE (‘incompatible beliefs’, ‘goal setting outcome’. ‘review outcome goals’, ‘feedback on behaviour’ and ‘pros/ cons’). Conclusion: Implementation and evaluation of the highlighted BCTs are required. Weight management services should consider screening patients for EE to tailor interventions to individual need.

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.

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.

Summary Background Prevalence of both obesity and type 2 diabetes can be higher in patients from certain ethnic groups, yet uptake and adherence to current support within these groups is lower, leading to widening health inequalities in high‐income countries. Objectives The main objective of this study is to understand the views, perceptions, and experiences of and barriers and facilitators in relation to the uptake and adherence to weight management and type 2 diabetes programs in minoritized ethnic groups in high‐income countries. Methods CINAHL, MEDLINE, PsycINFO, Scopus, Academic Search Complete, and PubMed were searched for English language studies undertaken in community‐dwelling adults residing in high‐income countries, who are from a minoritized ethnic group within the country of study. Results Seventeen studies were synthesized using the JBI System for the Unified Management of the Assessment and Review of Information. From these studies, 115 findings were retrieved, and seven key themes were identified: (1) family health status and program education, (2) social support, (3) challenges, (4) cultural beliefs, (5) increased awareness and dietary changes, (6) impact of psychological evaluations, and (7) considerations for future. Conclusions Nutritional considerations for type 2 diabetes mellitus and weight management programs in high‐income countries should include social, habitual, economic, and conceptual components, which should include consideration of local ethnic and cultural norms and building community relationships while creating culturally tailored programs.

Background Accurate anthropometric measurement is important within epidemiological studies and clinical practice. Traditionally, self-reported weight is validated against in-person weight measurement. Objectives This study aimed to 1) determine the comparison of online self-reported weight against images of weight captured on scales in a young adult sample, 2) compare this across body mass index (BMI), gender, country, and age groups, and 3) explore demographics of those who did/did not provide a weight image. Methods Cross-sectional analysis of baseline data from a 12-mo longitudinal study of young adults in Australia and the UK was conducted. Data were collected by online survey via Prolific research recruitment platform. Self-reported weight and sociodemographics (for example, age, gender) were collected for the whole sample (n = 512), and images of weight for a subset (n = 311). Tests included Wilcoxon signed-rank test to evaluate differences between measures, Pearson correlation to explore the strength of the linear relationship, and Bland-Altman plots to evaluate agreement. Results Self-reported weight [median (interquartile range), 92.5 kg (76.7–112.0)] and image-captured weight [93.8 kg (78.8–112.8)] were significantly different (z = −6.76, P < 0.001), but strongly correlated (r = 0.983, P < 0.001). In the Bland-Altman plot [mean difference −0.99 kg (−10.83, 8.84)], most values were within limits of agreement (2 standard deviation). Correlations remained high across BMI, gender, country, and age groups (r > 0.870, P < 0.002). Participants with BMI in ranges 30–34.9 and 35–39.9 kg/m2 were less likely to provide an image. Conclusions This study demonstrates the method concordance of image-based collection methods with self-reported weight in online research.

Background: Depression and obesity are two of the most highly prevalent global public health concerns. Obesity and poor mental health are strongly associated, and it is likely that mental health needs are common in people seeking weight management services. Aims: To identify what psychological support is provided and required in tier 2 adult weight management services (T2 WMS). Methods: Online survey: quantitative data was summarised, and open-ended free-text questions were coded and thematically analysed. Results: Participants were current or recent service users with self-reported mental health needs (n = 27), commissioners (n = 9) or providers (n = 17). Over half of service users did not feel their mental health needs were met and 60% said they would like additional psychological support within T2 WMS. Findings highlight the lack of psychological and emotional support. Psychological support and behaviour change techniques are conflated, with a lack of clear understanding or definition of what psychological support is, either between or within service users, providers, and commissioners. Conclusions: Moving towards more person-centred care, better identification and triaging of those living with mental health issues, together with improved resources and training of providers, is crucial to improve outcomes for people living with obesity and poor mental health.

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.

Introduction Understanding the complexities of change in eating behaviours, mental health, well-being and weight is crucial to inform healthcare and service provision, particularly in light of the exacerbating effects of the COVID-19 pandemic. This study aims to address the need for more comprehensive cross-sectional and longitudinal evidence, by tracking eating behaviours, mental health, health related behaviours and weight over a 12-month period, in a sample of young adults (18–35 years) in the UK and Australia. Methods and analysis Online surveys administered via the Prolific online research platform will be used for data collection at baseline, 6 months and 12 months. The survey (approximately 45 min) measures demographics, the impact of COVID-19, body mass index (BMI), weight management and health service usage, eating behaviours, personality, mental health, and health-related behaviours. An optional substudy component at each time point aims to validate self-reported weight in the main survey through images. Study inclusion criteria are; aged 18–34 years at baseline, BMI ≥20 kg/m2, and residing in the UK or Australia. A target of 500 participants at baseline was set, recruited through Prolific, and with recruitment stratified by BMI, sex and country. The proposed analyses include creating static predictive models using baseline data (eg, using latent class analysis, factor analysis or similar), and mapping changes longitudinally (eg, using multivariate regressions). These analyses will enable changes in the study measures to be identified, as well as predictors and outcomes of change. Ethics and dissemination Ethical approval was granted by Leeds Beckett University, UK (reference number 86004) and the University of Newcastle, Australia (reference number H-2022–0110). Study findings will be disseminated through scientific journals, conferences, institute websites and social media, and briefings tailored to policy, practice and the public, with the intention to help inform the future development of health and well-being care and support for young adults across Australia and the UK.

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.

Allied Health Professionals (AHPs) have the capacity to promote healthy behaviours in young children through routine ‘contact points’, as well as structured weight management programmes. This scoping review aims to evaluate the impact of AHPs in the prevention of obesity in young children. Databases were searched for relevant evidence between 1st January 2000 and 17th January 2022. Eligibility criteria included primary evidence (including, but not limited to; randomized controlled trials, observational studies, service evaluations) evaluating the impact of AHPs on the primary and secondary prevention of obesity in young children (mean age under 5 years old). AHP-related interventions typically demonstrated improvements in outcomes such as nutritional behaviour (e.g. lower sweetened drink intake), with some reductions in screen time. However, changes in weight outcomes (e.g. body mass index (BMI) z-score, BMI) in response to an AHP intervention were inconsistent. There was insufficient data to determine moderating effects, however tentative evidence suggests that those with a lower socioeconomic status or living in an underprivileged area may be more likely to lose weight following an AHP intervention. There was no evidence identified evaluating how AHPs use routine ‘contact points’ in the prevention of obesity in young children. AHP interventions could be effective in optimizing weight and nutritional outcomes in young children. However, more research is required to determine how routine AHP contact points, across the range of professional groups may be used in the prevention of obesity in young children.

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.

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.

Member led symposium at UK Congress on Obesity 2022

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.

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.