Changing behaviour

Individual change in behaviour has the potential to decrease the burden of chronic disease due to smoking, diet and low physical activity. Smoking quit rates can be increased by simple advice from a physician or trained counsellor, overall and in people at high risk of smoking related disease, with low intensity advice as effective as high intensity advice. Advice from a nurse, telephone counselling, individualised self help materials and taking exercise may also be beneficial. Training health professionals increases the frequency of offering antismoking interventions but may not increase their effectiveness. Nicotine replacement therapy, bupropion and nortriptyline may improve short term quit rates as part of smoking cessation strategies. Moclobemide, selective serotonin reuptake inhibitors, anxiolytics and acupuncture have not been shown to be beneficial. Smoking cessation programmes increase quit rates in pregnant women, but nicotine patches may not be beneficial compared with placebo. Physical activity in sedentary people may be increased by counselling, with input from exercise specialists possibly being more effective than physicians, in women over 80 years and in younger adults. Advice on eating a low cholesterol diet leads to a mean 0.2 to 0.3 mmol/L decrease in blood cholesterol concentration in the long term, but no consistent effect of this on morbidity or mortality has been shown. Intensive interventions to reduce sodium intake lead to small decreases in blood pressure, but may not reduce morbidity or mortality. Advice to lose weight leads to greater weight loss than no advice, and cognitive behavioural therapy may be more effective than dietary advice

Parental response to a letter reporting child overweight measured as part of a routine national programme in England: results from interviews with parents

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

A secondary analysis of the childhood obesity prevention Cochrane Review through a wider determinants of health lens: implications for research funders, researchers, policymakers and practitioners

Background Randomised controlled trials (RCTs) are often regarded as the gold standard of evidence, and subsequently go on to inform policymaking. Cochrane Reviews synthesise this type of evidence to create recommendations for practice, policy, and future research. Here, we critically appraise the RCTs included in the childhood obesity prevention Cochrane Review to understand the focus of these interventions when examined through a wider determinants of health (WDoH) lens. Methods We conducted a secondary analysis of the interventions included in the Cochrane Review on “Interventions for Preventing Obesity in Children”, published since 1993. All 153 RCTs were independently coded by two authors against the WDoH model using an adaptive framework synthesis approach. We used aspects of the Action Mapping Tool from Public Health England to facilitate our coding and to visualise our findings against the 226 perceived causes of obesity. Results The proportion of interventions which targeted downstream (e.g. individual and family behaviours) as opposed to upstream (e.g. infrastructure, environmental, policy) determinants has not changed over time (from 1993 to 2015), with most intervention efforts (57.9%) aiming to change individual lifestyle factors via education-based approaches. Almost half of the interventions (45%) targeted two or more levels of the WDoH. Where interventions targeted some of the wider determinants, this was often achieved via upskilling teachers to deliver educational content to children. No notable difference in design or implementation was observed between interventions targeting children of varying ages (0–5 years, 6–12 years, 13–18 years). Conclusions This study highlights that interventions, evaluated via RCTs, have persisted to focus on downstream, individualistic determinants of obesity over the last 25 years, despite the step change in our understanding of its complex aetiology. We hope that the findings from our analysis will challenge research funders, researchers, policymakers and practitioners to reflect upon, and critique, the evidence-based paradigm in which we operate, and call for a shift in focus of new evidence which better accounts for the complexity of obesity

Could parental rules play a role in the association between short sleep and obesity in young children?

Short sleep duration is associated with obesity in young children. This study develops the hypothesis that parental rules play a role in this association. Participants were 3-year-old children and their parents, recruited at nursery schools in socioeconomically deprived and non-deprived areas of a North-East England town. Parents were interviewed to assess their use of sleep, television-viewing and dietary rules, and given diaries to document their child's sleep for 4 days/5 nights. Children were measured for height, weight, waist circumference and triceps and subscapular skinfold thicknesses. One-hundred and eight families participated (84 with complete sleep data and 96 with complete body composition data). Parental rules were significantly associated together, were associated with longer night-time sleep and were more prevalent in the non-deprived-area compared with the deprived-area group. Television-viewing and dietary rules were associated with leaner body composition. Parental rules may in part confound the association between night-time sleep duration and obesity in young children, as rules cluster together across behavioural domains and are associated with both sleep duration and body composition. This hypothesis should be tested rigorously in large representative samples

Correlates of English local government use of the planning system to regulate hot food takeaway outlets: a cross-sectional analysis

Background: Greater neighbourhood takeaway food outlet access has been associated with increased takeaway food consumption and higher body weight. National planning guidelines in England suggest that urban planning could promote healthier food environments through takeaway food outlet regulation, for example by restricting the proliferation of outlets near schools. It is unknown how geographically widespread this approach is, or local characteristics associated with its use. We aimed to address these knowledge gaps. Methods: We used data from a complete review of planning policy documents adopted by local government areas in England (n = 325), which contained policies for the purpose of takeaway food outlet regulation. This review classified local government area planning policies as having a health (diet or obesity) or non-health focus. We explored geographical clustering of similar planning policies using spatial statistics. We used multinomial logistic regression models to investigate whether the odds of planning policy adoption varied according to local characteristics, for example the proportion of children with excess weight or the current number of takeaway food outlets. Results: We observed clusters of local government areas with similar adopted planning policies in the North East, North West, and Greater London regions of England. In unadjusted logistic regression models, compared to local government areas with the lowest, those with highest proportion of 10–11 year olds with excess weight (OR: 25.31; 95% CI: 6.74, 94.96), and takeaway food outlet number (OR: 54.00; 95% CI: 6.17, 472.41), were more likely to have a health-focused planning policy, than none. In models adjusted for deprivation, relationships for excess weight metrics were attenuated. Compared to local government areas with the lowest, those with the highest takeaway food outlet number remained more likely to have a health-focused planning policy, than none (OR: 16.98; 95% CI: 1.44, 199.04). When local government areas were under Labour political control, predominantly urban, and when they had more geographically proximal and statistically similar areas in the same planning policy status category, they were also more likely to have health-focused planning policies. Conclusions: Planning policies for the purpose of takeaway food outlet regulation with a health focus were more likely in areas with greater numbers of takeaway food outlets and higher proportions of children with excess weight. Other characteristics including Labour political control, greater deprivation and urbanisation, were associated with planning policy adoption, as were the actions of similar and nearby local government areas. Further research should engage with local policymakers to explore the drivers underpinning use of this approach

Co-design and content validity of the movement measurement in the early years (MoveMEY) tool for assessing movement behaviour of pre-school aged children

Abstract Background Movement behaviours (physical activity, sedentary behaviour, and sleep) are important for pre-school children’s health and development. Currently, no tools with appropriate content validity exist that concurrently capture these movement behaviours in young children. The aim of this study was to co-design and assess the content validity of a novel tool to concurrently measure movement behaviours in pre-school aged children (aged 3–4 years). Methods We followed four distinct steps to develop and assess the content validity of Movement Measurement in the Early Years (MoveMEY): (1) We conducted an extensive literature search, to identify pre-existing proxy measurement tools (questionnaires and diaries) to inform the design of a novel tool, which aimed to effectively capture movement behaviour guidelines of pre-school aged children. (2) We facilitated focus group discussions with parents and carers of pre-school aged children (n = 11) and (3) a qualitative survey with free text responses was completed by topic relevant researchers (n = 6), to co-design the measurement tool. (4) We assessed the content validity of the developed tool, MoveMEY, through interviews with parents of pre-school aged children (n = 12) following piloting of the tool. Results We developed an initial version of MoveMEY based on the format of an existing questionnaire and by mapping the content of questions to the guidelines. Co-design of MoveMEY resulted in changes to the format (e.g. short questionnaire to a seven-day diary) and content (e.g. inclusion of ‘general information’ questions on illness, disabilities and sleep disturbances; question on screen time before bed). Content validity assessment demonstrated that the items of MoveMEY were relevant and comprehensive for the assessment of children’s movement behaviours. MoveMEY was felt to be comprehensible, however, parental suggestions were implemented to finalise and improve MoveMEY (e.g. adding examples to questions aiming to detect moderate to vigorous physical activity). Conclusion MoveMEY is the first co-designed measurement tool that has relevance for assessing the movement behaviour guidelines of pre-school aged children. Parent/carer and topic relevant researcher involvement throughout the development process resulted in a seven-day daily reported activity diary that is comprehensive of children’s movement behaviours and comprehensible to parents and carers

Lived experiences of routine antenatal dietetic services among women with obesity: A qualitative phenomenological study

Objective: To understand the lived experiences and views of being referred to an antenatal dietetic service from the perspective of pregnant women with obesity.Design: A qualitative, interpretive approach using one-to-one in-depth interviews to explore the lived experience of pregnant women with obesity following referral to an antenatal dietetics service. Thematic content analysis was carried out by two researchers independently to develop data-driven themes.Setting: One NHS Trust maternity and dietetic services, North East England, UKParticipantsFifteen pregnant women with a booking body mass index ≥30 kg/m2 attending an obesity-specific antenatal dietetic service. All women were White, parity between 0–2, and BMI range 30–51 kg/m2.Findings: Four themes were identified within this concept. 1) Women's overall experience of the service: experiences were predominately positive with only two negative cases identified. 2) Process of referral: women placed importance on informative and in-person communication about the service, with health professionals, at the point of referral. 3) Delivery of the service: dietitians were considered to be the experts and women wanted more frequent contact. 4) Content of the service: tailored advice enabled behaviour change, and women desired increased physical activity support and weight monitoring.Key conclusions: Women reported an overall positive experience and thought that dietitians were the expert health professionals to support them. Women in this study felt that tailoring advice specific to their personal circumstances helped them implement changes, and had a strong interest in the nutritional benefits for fetal development. Women considered weight monitoring to be a positive element of the service; however, further research is required given the limited and conflicting evidence-base.Implications for practice: It is important to incorporate women's experiences in the development and delivery of antenatal weight management services to facilitate person-centred care. Communication by health professionals at the point of referral is particularly important to provide accurate expectations of services and to reduce anxieties. Dietitians are considered to be appropriate experts to deliver these services, although they may need additional support to address women's physical activity needs in pregnancy

Children's experiences of care on walking and cycling journeys between home and school in Healthy New Towns: Reframing active school travel

The Healthy New Town programme in England set out to ‘put health into place’ by supporting the design and construction of healthy places to live, including by creating safe environments for active travel. To explore the impact of this approach, this study examined how children and their families experienced school journeys in two contrasting Healthy New Towns in England, one an affluent new town in the early stages of construction and the other more economically deprived and established. We undertook photo-elicitation and go-along interviews with 24 children aged 7-12 years and semi-structured interviews with 17 caregivers. We found that experiences of care were important for children's school travel. In the ‘deprived’ town, opportunities for children to care and to be cared for were enjoyed, facilitated by routes with limited traffic, pockets of ‘nature’, and possibilities to encounter meaningful others. For families living in a town under construction, the need to negotiate unfinished travel infrastructure, and a sense of being ‘in limbo’, was experienced as an absence of care by planners and developers. Interventions to promote children's active travel should consider the role of care-full planning in facilitating walking and cycling journeys

Exploring the evidence base for Tier 3 specialist weight management interventions for children aged 2–18 years in the UK: a rapid systematic review

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