After the RCT: who comes to a family-based intervention for childhood overweight or obesity when it is implemented at scale in the community?

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

Psychosocial Interventions in the Treatment of Severe Adolescent Obesity: The SHINE Programme

Purpose: Psychosocial Interventions (PSI) are characterised by three phases: 1) an initial in-depth assessment, 2) an intensive multifaceted intervention to stem a condition, and 3) an extensive maintenance programme. PSIs are often used for treatment of mental health conditions, however applicability in the treatment of adolescent obesity is unknown. This paper sought to evaluate the service-level outcomes of a PSI for young people (aged 10-17) with severe obesity. Methods: A retrospective evaluation of participants attending the SHINE programme between 2011-2016 (n = 435; Age: 13.1±2.1 years, Male: 51%, White: 87.4%, BMI: 33.5±7.5 kg/m2, BMI SDS: 3.1±0.5 units). Anthropometric measurements (BMI and WC) were collected at baseline, 3-, 6-, 9-, and 12-months. Psychosocial measures (anxiety, depression, and self-esteem) were collected at baseline and 3 months. Participant retention was also assessed. Results: After 3 months, 95% of participants remained with a mean BMI SDS reduction of 0.19 units (95% CI: 0.17, 0.21). Anxiety, depression, and self-esteem improved by 50%, 54% and 38% respectively. BMI SDS reductions of 0.29, 0.35 and 0.41 were found at 6-, 9-, and 12- months. Fifty-four percent of participants chose to attend the final intervention phase. A higher baseline BMI SDS and a greater reduction in BMI SDS predicted final intervention phase attendance. Conclusion: The SHINE PSI demonstrated positive mean reductions in all measurements across all time points. In contrast to other community-based weight management services, these results suggest the utility of, and further exploration of, PSIs in the treatment of severe adolescent obesity

Is adolescent body mass index and waist circumference associated with the food environments surrounding schools and homes? A longitudinal analysis

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

A cross sectional study investigating the association between exposure to food outlets and childhood obesity in Leeds, UK

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

A qualitative study of the experiences of individuals who did not complete the NHS Low Calorie Diet Programme Pilot

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

The Benefits of Plain Language Summaries in Public Health Publishing

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

Examining the validity and utility of two secondary sources of food environment data against street audits in England

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

Participant experiences during the NHS Low Calorie Diet Programme pilot. Findings from an online survey.

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

Normalisation and equity of referral to the NHS Low Calorie Diet programme pilot; a qualitative evaluation of the experiences of health care staff

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