Towards a new model of evidence for public health

BackgroundWe are faced with a growing crisis of non-communicable diseases driven by factors such as unhealthy diets, physical inactivity, tobacco use, and alcohol consumption, compounded by major inequalities in health. Over recent decades, biomedical research methods have helped to answer many important questions about treatment and prevention, but the kinds of tools that can tell us which intervention to choose over another are not invariably the most appropriate to address complex challenges such as designing healthier cities, or creating healthier, more sustainable food systems. The aim of this project was to identify the main obstacles to obtaining valid and appropriate evidence to guide public health decision making, and propose a set of solutions to address these problems

An obesogenic island in the Mediterranean: mapping potential drivers of obesity in Malta.

OBJECTIVE: The prevalence of childhood and adult obesity in Malta is among the highest in the world. Although increasingly recognised as a public health problem with substantial future economic implications for the national health and social care systems, understanding the context underlying the burden of obesity is necessary for the development of appropriate counter-strategies. DESIGN: We conducted a contextual analysis to explore factors that may have potentially contributed to the establishment of an obesogenic environment in Malta. A search of the literature published between 1990 and 2013 was conducted in MEDLINE and EMBASE. Twenty-two full-text articles were retrieved. Additional publications were identified following recommendations by Maltese public health experts; a review of relevant websites; and thorough hand searching of back issues of the Malta Medical Journal since 1990. SETTING: Malta. SUBJECTS: Whole population, with a focus on children. RESULTS: Results are organised and presented using the ANalysis Grid for Elements Linked to Obesity (ANGELO) framework. Physical, economic, policy and socio-cultural dimensions of the Maltese obesogenic environment are explored. CONCLUSIONS: Malta's obesity rates may be the result of an obesogenic environment characterised by limited infrastructure for active living combined with an energy-dense food supply. Further research is required to identify and quantify the strength of interactions between these potential environmental drivers of obesity in order to enable appropriate countermeasures to be developed

Using flawed, uncertain, proximate and sparse (FUPS) data in the context of complexity: learning from the case of child mental health.

The use of routinely collected data that are flawed and limited to inform service development in healthcare systems needs to be considered, both theoretically and practically, given the reality in many areas of healthcare that only poor-quality data are available for use in complex adaptive systems. Data may be compromised in a range of ways. They may be flawed, due to missing or erroneously recorded entries; uncertain, due to differences in how data items are rated or conceptualised; proximate, in that data items are a proxy for key issues of concern; and sparse, in that a low volume of cases within key subgroups may limit the possibility of statistical inference. The term 'FUPS' is proposed to describe these flawed, uncertain, proximate and sparse datasets. Many of the systems that seek to use FUPS data may be characterised as dynamic and complex, involving a wide range of agents whose actions impact on each other in reverberating ways, leading to feedback and adaptation. The literature on the use of routinely collected data in healthcare is often implicitly premised on the availability of high-quality data to be used in complicated but not necessarily complex systems. This paper presents an example of the use of a FUPS dataset in the complex system of child mental healthcare. The dataset comprised routinely collected data from services that were part of a national service transformation initiative in child mental health from 2011 to 2015. The paper explores the use of this FUPS dataset to support meaningful dialogue between key stakeholders, including service providers, funders and users, in relation to outcomes of services. There is a particular focus on the potential for service improvement and learning. The issues raised and principles for practice suggested have relevance for other health communities that similarly face the dilemma of how to address the gap between the ideal of comprehensive clear data used in complicated, but not complex, contexts, and the reality of FUPS data in the context of complexity

Economic impact of reduced mortality due to increased cycling.

Increasing regular physical activity is a key public health goal. One strategy is to change the physical environment to encourage walking and cycling, requiring partnerships with the transport and urban planning sectors. Economic evaluation is an important factor in the decision to fund any new transport scheme, but techniques for assessing the economic value of the health benefits of cycling and walking have tended to be less sophisticated than the approaches used for assessing other benefits. This study aimed to produce a practical tool for estimating the economic impact of reduced mortality due to increased cycling. The tool was intended to be transparent, easy to use, reliable, and based on conservative assumptions and default values, which can be used in the absence of local data. It addressed the question: For a given volume of cycling within a defined population, what is the economic value of the health benefits? The authors used published estimates of relative risk of all-cause mortality among regular cyclists and applied these to levels of cycling defined by the user to produce an estimate of the number of deaths potentially averted because of regular cycling. The tool then calculates the economic value of the deaths averted using the "value of a statistical life." The outputs of the tool support decision making on cycle infrastructure or policies, or can be used as part of an integrated economic appraisal. The tool's unique contribution is that it takes a public health approach to a transport problem, addresses it in epidemiologic terms, and places the results back into the transport context. Examples of its use include its adoption by the English and Swedish departments of transport as the recommended methodologic approach for estimating the health impact of walking and cycling

Characteristics and use of urban health indicator tools by municipal built environment policy and decision-makers: a systematic review protocol.

BACKGROUND: There is wide agreement that there is a lack of attention to health in municipal environmental policy-making, such as urban planning and regeneration. Explanations for this include differing professional norms between health and urban environment professionals, system complexity and limited evidence for causality between attributes of the built environment and health outcomes. Data from urban health indicator (UHI) tools are potentially a valuable form of evidence for local government policy and decision-makers. Although many UHI tools have been specifically developed to inform policy, there is poor understanding of how they are used. This study aims to identify the nature and characteristics of UHI tools and their use by municipal built environment policy and decision-makers. METHODS: Health and social sciences databases (ASSIA, Campbell Library, EMBASE, MEDLINE, Scopus, Social Policy and Practice and Web of Science Core Collection) will be searched for studies using UHI tools alongside hand-searching of key journals and citation searches of included studies. Advanced searches of practitioner websites and Google will also be used to find grey literature. Search results will be screened for UHI tools, and for studies which report on or evaluate the use of such tools. Data about UHI tools will be extracted to compile a census and taxonomy of existing tools based on their specific characteristics and purpose. In addition, qualitative and quantitative studies about the use of these tools will be appraised using quality appraisal tools produced by the UK National Institute for Health and Care Excellence (NICE) and synthesised in order to gain insight into the perceptions, value and use of UHI tools in the municipal built environment policy and decision-making process. This review is not registered with PROSPERO. DISCUSSION: This systematic review focuses specifically on UHI tools that assess the physical environment's impact on health (such as transport, housing, air quality and greenspace). This study will help indicator producers understand whether this form of evidence is of value to built environment policy and decision-makers and how such tools should be tailored for this audience. SYSTEMATIC REVIEW REGISTRATION: N/A

Successful behavior change in obesity interventions in adults: a systematic review of self-regulation mediators

International audienceBackground: Relapse is high in lifestyle obesity interventions involving behavior and weight change. Identifying mediators of successful outcomes in these interventions is critical to improve effectiveness and to guide approaches to obesity treatment, including resource allocation. This article reviews the most consistent self-regulation mediators of medium-and long-term weight control, physical activity, and dietary intake in clinical and community behavior change interventions targeting overweight/obese adults. Methods: A comprehensive search of peer-reviewed articles, published since 2000, was conducted on electronic databases (for example, MEDLINE) and journal reference lists. Experimental studies were eligible if they reported intervention effects on hypothesized mediators (self-regulatory and psychological mechanisms) and the association between these and the outcomes of interest (weight change, physical activity, and dietary intake). Quality and content of selected studies were analyzed and findings summarized. Studies with formal mediation analyses were reported separately. Results: Thirty-five studies were included testing 42 putative mediators. Ten studies used formal mediation analyses. Twenty-eight studies were randomized controlled trials, mainly aiming at weight loss or maintenance (n = 21). Targeted participants were obese (n = 26) or overweight individuals, aged between 25 to 44 years (n = 23), and 13 studies targeted women only. In terms of study quality, 13 trials were rated as " strong " , 15 as " moderate " , and 7 studies as " weak ". In addition, methodological quality of formal mediation analyses was " medium ". Identified mediators for medium-/long-term weight control were higher levels of autonomous motivation, self-efficacy/barriers, self-regulation skills (such as self-monitoring), flexible eating restraint, and positive body image. For physical activity, significant putative mediators were high autonomous motivation, self-efficacy, and use of self-regulation skills. For dietary intake, the evidence was much less clear, and no consistent mediators were identified. Conclusions: This is the first systematic review of mediational psychological mechanisms of successful outcomes in obesity-related lifestyle change interventions. Despite limited evidence, higher autonomous motivation, self-efficacy, and self-regulation skills emerged as the best predictors of beneficial weight and physical activity outcomes; for weight control, positive body image and flexible eating restraint may additionally improve outcomes. These variables represent possible targets for future lifestyle interventions in overweight/obese populations

Exploring the mediating role of energy balance-related behaviours in the association between sleep duration and obesity in European adults. The SPOTLIGHT project.

Sleep restriction is a risk factor for weight gain and obesity. Few studies have formally investigated the mediating role of energy balance-related behaviours in the sleep - obesity association. The aim of this study was to explore the mediating role of physical activity, sedentary behaviours and dietary habits in the association of sleep duration with obesity in adults in five European urban regions. Data on self-reported sleep duration, energy balance-related behaviours, height and weight and other covariates were collected between February and September 2014 from participants to the SPOTLIGHT survey (N=5900, mean age 52years). Participants were recruited from 60 urban neighbourhoods in Belgium, France, Hungary, the Netherlands and the United Kingdom. Multilevel logistic regression analyses were used to assess the associations of sleep duration, energy balance-related behaviours and obesity and mediating effects were calculated using MacKinnon's product-of-coefficients method. Results indicated that a 1h increase in sleeping time was associated with a 14% lower likelihood of being obese (OR=0.86, 95%CI=0.80; 0.93). Only work-related sedentary behaviour was identified as a statistically significant mediator in the association between sleep duration and obesity for the total sample, and youngest and oldest age group. We did not find evidence for a mediating role of dietary habits and physical activities

Reassessing Ethnic Differences in Mean BMI and Changes Between 2007 and 2013 in English Children.

OBJECTIVE: National body fatness (BF) data for English South Asian and Black children use BMI, which provides inaccurate ethnic comparisons. BF levels and time trends in the English National Child Measurement Programme (NCMP) between 2007 and 2013 were assessed by using ethnic-specific adjusted BMI (aBMI) for South Asian and Black children. METHODS: Analyses were based on 3,195,323 children aged 4 to 5 years and 2,962,673 children aged 10 to 11 years. aBMI values for South Asian and Black children (relating to BF as in White children) were derived independently. Mean aBMI levels and 5-year aBMI changes were obtained by using linear regression. RESULTS: In the 2007-2008 NCMP, mean aBMIs in 10- to 11-year-old children (boys, girls) were higher in South Asian children (20.1, 19.9 kg/m2 ) and Black girls, but not in Black boys (18.4, 19.2 kg/m2 ) when compared with White children (18.6, 19.0 kg/m2 ; all P < 0.001). Mean 5-year changes (boys, girls) were higher in South Asian children (0.16, 0.32 kg/m2 per 5 y; both P < 0.001) and Black boys but not girls (0.13, 0.15 kg/m2 per 5 y; P = 0.01, P = 0.41) compared with White children (0.02, 0.11 kg/m2 per 5 y). Ethnic differences at 4 to 5 years were similar. Unadjusted BMI showed similar 5-year changes but different mean BMI patterns. CONCLUSIONS: BF levels were higher in South Asian children than in other groups in 2007 and diverged from those in White children until 2013, a pattern not apparent from unadjusted BMI data

Obesity-related behaviours and BMI in five urban regions across Europe: sampling design and results from the SPOTLIGHT cross-sectional survey.

OBJECTIVES: To describe the design, methods and first results of a survey on obesity-related behaviours and body mass index (BMI) in adults living in neighbourhoods from five urban regions across Europe. DESIGN: A cross-sectional observational study in the framework of an European Union-funded project on obesogenic environments (SPOTLIGHT). SETTING: 60 urban neighbourhoods (12 per country) were randomly selected in large urban zones in Belgium, France, Hungary, the Netherlands and the UK, based on high or low values for median household income (socioeconomic status, SES) and residential area density. PARTICIPANTS: A total of 6037 adults (mean age 52 years, 56% female) participated in the online survey. OUTCOME MEASURES: Self-reported physical activity, sedentary behaviours, dietary habits and BMI. Other measures included general health; barriers and motivations for a healthy lifestyle, perceived social and physical environmental characteristics; the availability of transport modes and their use to specific destinations; self-defined neighbourhood boundaries and items related to residential selection. RESULTS: Across five countries, residents from low-SES neighbourhoods ate less fruit and vegetables, drank more sugary drinks and had a consistently higher BMI. SES differences in sedentary behaviours were observed in France, with residents from higher SES neighbourhoods reporting to sit more. Residents from low-density neighbourhoods were less physically active than those from high-density neighbourhoods; during leisure time and (most pronounced) for transport (except for Belgium). BMI differences by residential density were inconsistent across all countries. CONCLUSIONS: The SPOTLIGHT survey provides an original approach for investigating relations between environmental characteristics, obesity-related behaviours and obesity in Europe. First descriptive results indicate considerable differences in health behaviours and BMI between countries and neighbourhood types

Obesogenic environments: a systematic review of the association between the physical environment and adult weight status, the SPOTLIGHT project.

BACKGROUND: Understanding which physical environmental factors affect adult obesity, and how best to influence them, is important for public health and urban planning. Previous attempts to summarise the literature have not systematically assessed the methodological quality of included studies, or accounted for environmental differences between continents or the ways in which environmental characteristics were measured. METHODS: We have conducted an updated review of the scientific literature on associations of physical environmental factors with adult weight status, stratified by continent and mode of measurement, accompanied by a detailed risk-of-bias assessment. Five databases were systematically searched for studies published between 1995 and 2013. RESULTS: Two factors, urban sprawl and land use mix, were found consistently associated with weight status, although only in North America. CONCLUSIONS: With the exception of urban sprawl and land use mix in the US the results of the current review confirm that the available research does not allow robust identification of ways in which that physical environment influences adult weight status, even after taking into account methodological quality