The impact of interventions to promote healthier ready-to-eat meals (to eat in, to take away or to be delivered) sold by specific food outlets open to the general public: a systematic review.

INTRODUCTION: Ready-to-eat meals sold by food outlets that are accessible to the general public are an important target for public health intervention. We conducted a systematic review to assess the impact of such interventions. METHODS: Studies of any design and duration that included any consumer-level or food-outlet-level before-and-after data were included. RESULTS: Thirty studies describing 34 interventions were categorized by type and coded against the Nuffield intervention ladder: restrict choice = trans fat law (n = 1), changing pre-packed children's meal content (n = 1) and food outlet award schemes (n = 2); guide choice = price increases for unhealthier choices (n = 1), incentive (contingent reward) (n = 1) and price decreases for healthier choices (n = 2); enable choice = signposting (highlighting healthier/unhealthier options) (n = 10) and telemarketing (offering support for the provision of healthier options to businesses via telephone) (n = 2); and provide information = calorie labelling law (n = 12), voluntary nutrient labelling (n = 1) and personalized receipts (n = 1). Most interventions were aimed at adults in US fast food chains and assessed customer-level outcomes. More 'intrusive' interventions that restricted or guided choice generally showed a positive impact on food-outlet-level and customer-level outcomes. However, interventions that simply provided information or enabled choice had a negligible impact. CONCLUSION: Interventions to promote healthier ready-to-eat meals sold by food outlets should restrict choice or guide choice through incentives/disincentives. Public health policies and practice that simply involve providing information are unlikely to be effective.

A systematic review of the effectiveness of individual, community and societal-level interventions at reducing socio-economic inequalities in obesity among adults.

BACKGROUND: Socioeconomic inequalities in obesity are well established in high-income countries. There is a lack of evidence of the types of intervention that are effective in reducing these inequalities among adults. OBJECTIVES: To systematically review studies of the effectiveness of individual, community and societal interventions in reducing socio-economic inequalities in obesity among adults. METHODS: Nine electronic databases were searched from start date to October 2012 along with website and grey literature searches. The review examined the best available international evidence (both experimental and observational) of interventions at an individual, community and societal level that might reduce inequalities in obesity among adults (aged 18 years or over) in any setting and country. Studies were included if they reported a body fatness-related outcome and if they included a measure of socio-economic status. Data extraction and quality appraisal were conducted using established mechanisms and narrative synthesis was conducted. RESULTS: The 'best available' international evidence was provided by 20 studies. At the individual level, there was evidence of the effectiveness of primary care delivered tailored weight loss programmes among deprived groups. Community based behavioural weight loss interventions and community diet clubs (including workplace ones) also had some evidence of effectiveness-at least in the short term. Societal level evaluations were few, low quality and inconclusive. Further, there was little evidence of long term effectiveness, and few studies of men or outside the USA. However, there was no evidence to suggest that interventions increase inequalities. CONCLUSIONS: The best available international evidence suggests that some individual and community-based interventions may be effective in reducing socio-economic inequalities in obesity among adults in the short term. Further research is required particularly of more complex, multi-faceted and societal-level interventions.

Technology-based dietary assessment: development of the Synchronised Nutrition and Activity Program (SNAP).

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.

Characterizing the EPODE logic model: unravelling the past and informing the future.

EPODE ('Ensemble Prévenons l'Obésité De Enfants' or 'Together let's Prevent Childhood Obesity') is a large-scale, centrally coordinated, capacity-building approach for communities to implement effective and sustainable strategies to prevent childhood obesity. Since 2004, EPODE has been implemented in over 500 communities in six countries. Although based on emergent practice and scientific knowledge, EPODE, as many community programs, lacks a logic model depicting key elements of the approach. The objective of this study is to gain insight in the dynamics and key elements of EPODE and to represent these in a schematic logic model. EPODE's process manuals and documents were collected and interviews were held with professionals involved in the planning and delivery of EPODE. Retrieved data were coded, themed and placed in a four-level logic model. With input from international experts, this model was scaled down to a concise logic model covering four critical components: political commitment, public and private partnerships, social marketing and evaluation. The EPODE logic model presented here can be used as a reference for future and follow-up research; to support future implementation of EPODE in communities; as a tool in the engagement of stakeholders; and to guide the construction of a locally tailored evaluation plan.

A narrative review of psychological and educational strategies applied to young children's eating behaviours aimed at reducing obesity risk.

Strategies to reduce risk of obesity by influencing preschool children's eating behaviour are reviewed. The studies are placed in the context of relevant psychological processes, including inherited and acquired preferences, and behavioural traits, such as food neophobia, 'enjoyment of food' and 'satiety responsiveness'. These are important influences on how children respond to feeding practices, as well as predictors of obesity risk. Nevertheless, in young children, food environment and experience are especially important for establishing eating habits and food preferences. Providing information to parents, or to children, on healthy feeding is insufficient. Acceptance of healthy foods can be encouraged by five to ten repeated tastes. Recent evidence suggests rewarding healthy eating can be successful, even for verbal praise alone, but that palatable foods should not be used as rewards for eating. Intake of healthier foods can be promoted by increasing portion size, especially in the beginning of the meal. Parental strategies of pressuring to eat and restriction do not appear to be causally linked to obesity, but are instead primarily responses to children's eating tendencies and weight. Moderate rather than frequent restriction may improve healthy eating in children. Actively positive social modelling by adults and peers can be effective in encouraging healthier eating.

Critical narrative review to identify educational strategies promoting physical activity in preschool.

The aim of this narrative review is critically to evaluate educational strategies promoting physical activity that are used in the preschool setting in the context of obesity prevention programmes. Literature search was conducted between April and August 2010 in English and German databases (PubMED, PsychINFO, PSYNDEX, ERIC, FIS Bildung). Outcomes considered were time and intensity of physical activity, motor skills or measures of body composition. A total of 19 studies were included. Ten studies added physical activity lessons into their curriculum, one study provided more time for free play, eight studies focused on the social and play environment. Studies reporting positive outcomes implemented physical activity sessions that lasted at least 30 min d(-1). Several studies showed that children are most active in the first 10-15 min. The existence or installation of playground markings or fixed play equipment had no effect, whereas the presence or addition of portable play equipment was positively correlated with moderate-to-vigorous physical activity. Teacher training may be a key element for successful interventions. To overcome time constraints, a suggested solution is to integrate physical activity into daily routines and other areas of the preschool curriculum.

Identifying effective behavioural models and behaviour change strategies underpinning preschool- and school-based obesity prevention interventions aimed at 4-6-year-olds: a systematic review.

The aim of this comprehensive systematic review was to identify the most effective behavioural models and behaviour change strategies, underpinning preschool- and school-based interventions aimed at preventing obesity in 4-6-year-olds. Searching was conducted from April 1995 to April 2010 using MEDLINE, EMBASE, CINAHL, PsycINFO and The Cochrane Library. Epidemiological studies relevant to the research question with controlled assignment of participants were included in the review, if they had follow-up periods of 6 months or longer. Outcomes included markers of weight gain; markers of body composition; physical activity behaviour changes and dietary behaviour changes. Twelve studies were included in the review. The most commonly used model was social cognitive theory (SCT)/social learning theory (SLT) either as a single model or in combination with other behavioural models. Studies that used SCT/SLT in the development of the intervention had significant favourable changes in one, or more, outcome measures. In addition, interventions that (i) combined high levels of parental involvement and interactive school-based learning; (ii) targeted physical activity and dietary change; and (iii) included long-term follow-up, appeared most effective. It is suggested that interventions should also be focused on developing children's (and parents') perceived competence at making dietary and physical changes.

Evidence-based recommendations for the development of obesity prevention programs targeted at preschool children.

The ToyBox intervention was developed using an evidence-based approach, using the findings of four reviews. These reviews included three critical and narrative reviews of educational strategies and psychological approaches explaining young children's acquisition and formation of energy-balance related behaviours, and the management of these behaviours, and also a systematic review of behavioural models underpinning school-based interventions in preschool and school settings for the prevention of obesity in children aged 4-6 years. This paper summarises and translates the findings from these reviews into practical evidence based recommendations for researchers and policy-makers to consider when developing and implementing interventions for the prevention of overweight and obesity in young (aged 4-6 years) children. The recommendations focus on two behaviours, physical activity and sedentary behaviour, and healthy eating, and include general recommendations, intervention approaches, interventions content, and simple messages. The review also briefly examines the role that the commercial sector plays in hindering or facilitating attempts to create healthy food environments for children. This paper also recognises that childhood obesity is not an issue for the education sector alone; it needs to be tackled at a multi sectoral level, recognizing the particularly important role of local governments, nongovernment organizations and the media.

Maternal body mass index and congenital anomaly risk: a cohort study.

OBJECTIVE: To investigate the association between maternal body mass index (BMI) and major, structural congenital anomalies. DESIGN: Cohort study using prospectively collected data. METHODS: Data on all singleton pregnancies booked at five maternity units in the north of England between 01 January 2003 and 31 December 2005 and data on congenital anomalies notified to the Northern Congenital Abnormality Survey were linked using key variables. Maternal pre-gestational diabetic status was derived from the Northern Diabetes in Pregnancy Survey. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated by maximum-likelihood logistic regression models, with missing values modelled as explicit categories. RESULTS: There was a total of 41,013 singleton pregnancies during the study period, of which 682 were affected by a structural congenital anomaly, a total prevalence of 166 (95% CI: 154, 179) per 10,000 registered births. Overall, the risk of a congenital anomaly was significantly increased among the maternal underweight (BMI

A nationally representative study of maternal obesity in England, UK: trends in incidence and demographic inequalities in 619 323 births, 1989-2007.

BACKGROUND: There is an absence of national statistics for maternal obesity in the UK. This study is the first to describe a nationally representative maternal obesity research data set in England. DESIGN: Retrospective epidemiological study of first trimester obesity. METHODS: Data from 34 maternity units were analysed, including 619 323 births between 1989 and 2007. Data analysis included trends in first trimester maternal body bass index status over time, and geographical distribution of maternal obesity. Population demographics including maternal age, parity, ethnic group, deprivation and employment were analysed to identify any maternal obesity-associated health inequalities. All demographics were tested for multicollinearity. Logistic regression analyses were adjusted for all demographics as confounders. RESULTS: First trimester maternal obesity is significantly increasing over time, having more than doubled from 7.6% to 15.6% over 19 years (P<0.001), and shows geographic variation in incidence. There are also demographic health inequalities associated with maternal obesity, including increased odds of being obese with increasing age, parity, Black ethnic group and deprivation. There is also an association between morbid obesity and increased levels of unemployment. CONCLUSIONS: The increase in maternal obesity has serious implications for the health of mothers, infants and service providers, yielding an additional 47 500 women per year requiring high dependency care in England. The demography of women most at risk of first trimester obesity highlights health inequalities associated with maternal obesity, which urgently needs to be addressed.

Objectively measured habitual physical activity in a highly obesogenic environment.

BACKGROUND: While the prevalence of overweight and obesity among children continues to grow nationally, prevalence in the North-East of England is among the highest in the UK. The objective of this study was to investigate the habitual physical activity levels in a particularly obesogenic environment in the North-East of England. METHODS: Eight primary schools were selected using a stratified random sampling frame ranking average deprivation levels. Participating children (n = 246, mean age 10 years) wore an accelerometer (Actigraph, GT-256) over five consecutive days (weekend plus three weekdays). Total daily moderate-to-vigorous intensity physical activity was calculated using thresholds by Puyau and colleagues. RESULTS: Only 7% (17/246) of children were sufficiently active. Boys were more physically active than girls (766 +/- 268 vs. 641 +/- 202 counts/min, 95% CI for the difference 63-186 cpm.). Total physical activity was not influenced significantly by deprivation levels or weight status, and there were no significant differences in physical activity between school or weekend days. CONCLUSIONS: The North-East of England is a recognized 'hot spot' for paediatric obesity and the present study shows that low levels of habitual physical activity are typical. Choice of accelerometry threshold affects both the apparent amount of physical activity and the ability to detect groups with particularly low levels of physical activity.

The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis.

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.

Dietary advice for treatment of type 2 diabetes mellitus in adults.

BACKGROUND: While initial dietary management immediately after formal diagnosis is an 'accepted' cornerstone of treatment of type 2 diabetes mellitus, a formal and systematic overview of its efficacy and method of delivery is not currently available. OBJECTIVES: To assess the effects of type and frequency of different types of dietary advice for adults with type 2 diabetes. SEARCH STRATEGY: We carried out a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, bibliographies and contacted relevant experts. SELECTION CRITERIA: All randomised controlled trials, of six months or longer, in which dietary advice was the main intervention. DATA COLLECTION AND ANALYSIS: The lead investigator performed all data extraction and quality scoring with duplication being carried out by one of the other six investigators independently with discrepancies resolved by discussion and consensus. Authors were contacted for missing data. MAIN RESULTS: Thirty-six articles reporting a total of eighteen trials following 1467 participants were included. Dietary approaches assessed in this review were low-fat/high-carbohydrate diets, high-fat/low-carbohydrate diets, low-calorie (1000 kcal per day) and very-low-calorie (500 kcal per day) diets and modified fat diets. Two trials compared the American Diabetes Association exchange diet with a standard reduced fat diet and five studies assessed low-fat diets versus moderate fat or low-carbohydrate diets. Two studies assessed the effect of a very-low-calorie diet versus a low-calorie diet. Six studies compared dietary advice with dietary advice plus exercise and three other studies assessed dietary advice versus dietary advice plus behavioural approaches. The studies all measured weight and measures of glycaemic control although not all studies reported these in the articles published. Other outcomes which were measured in these studies included mortality, blood pressure, serum cholesterol (including LDL and HDL cholesterol), serum triglycerides, maximal exercise capacity and compliance. The results suggest that adoption of regular exercise is a good way to promote better glycaemic control in type 2 diabetic patients, however all of these studies were at high risk of bias. AUTHORS' CONCLUSIONS: There are no high quality data on the efficacy of the dietary treatment of type 2 diabetes, however the data available indicate that the adoption of exercise appears to improve glycated haemoglobin at six and twelve months in people with type 2 diabetes. There is an urgent need for well-designed studies which examine a range of interventions, at various points during follow-up, although there is a promising study currently underway.

Controlled clinical trial of two weight reducing diets in a NHS hospital dietetic outpatient clinic: a pilot study.

BACKGROUND: Outpatient dietary weight reduction for obesity is unsatisfactory. The objective of this study was to compare the efficacy of an energy prescription diet with usual care (a healthy eating diet) in adult overweight patients referred to a NHS hospital dietetic outpatient clinic, in terms of weight change over 12 weeks. METHODS: Controlled clinical trial (systematic allocation). RESULTS: Of the 53 patients who attended their first appointment, 27 completed the trial. Mean weight loss (kg) after 12 weeks was 4.2 (sd 3.8) on the energy prescription diet (n = 16) and 6.0 (sd 2.8) on the healthy eating diet (n = 11). CONCLUSIONS: Patients on a weight reducing diet based on energy prescription or healthy eating lost, on average, clinically significant amounts of body weight by 12 weeks. Mean weight loss was greater by about 50% in the healthy eating group and supports the development of a larger trial to estimate true effect.

Wholegrain cereals for coronary heart disease.

BACKGROUND: There is increasing evidence from observational studies that wholegrains can have a beneficial effect on risk factors for coronary heart disease (CHD). OBJECTIVES: The primary objective is to review the current evidence from randomised controlled trials (RCTs) that assess the relationship between the consumption of wholegrain foods and the effects on CHD mortality, morbidity and on risk factors for CHD, in participants previously diagnosed with CHD or with existing risk factors for CHD. SEARCH STRATEGY: We searched CENTRAL (Issue 4, 2005), MEDLINE (1966 to 2005), EMBASE (1980 to 2005), CINAHL (1982 to 2005), ProQuest Digital Dissertations (2004 to 2005). No language restrictions were applied. SELECTION CRITERIA: We selected randomised controlled trials that assessed the effects of wholegrain foods or diets containing wholegrains, over a minimum of 4 weeks, on CHD and risk factors. Participants included were adults with existing CHD or who had at least one risk factor for CHD, such as abnormal lipids, raised blood pressure or being overweight. DATA COLLECTION AND ANALYSIS: Two of our research team independently assessed trial quality and extracted data. Authors of the included studies were contacted for additional information where this was appropriate. MAIN RESULTS: Ten trials met the inclusion criteria. None of the studies found reported the effect of wholegrain diets on CHD mortality or CHD events or morbidity. All 10 included studies reported the effect of wholegrain foods or diets on risk factors for CHD. Studies ranged in duration from 4 to 8 weeks. In eight of the included studies, the wholegrain component was oats. Seven of the eight studies reported lower total and low density lipoproteins (LDL) cholesterol with oatmeal foods than control foods. When the studies were combined in a meta-analysis lower total cholesterol (-0.20 mmol/L, 95% confidence interval (CI) -0.31 to -0.10, P = 0.0001 ) and LDL cholesterol (0.18 mmol/L, 95% CI -0.28 to -0.09, P < 0.0001) were found with oatmeal foods. However, there is a lack of studies on other wholegrains or wholegrain diets. AUTHORS' CONCLUSIONS: Despite the consistency of effects seen in trials of wholegrain oats, the positive findings should be interpreted cautiously. Many of the trials identified were short term, of poor quality and had insufficient power. Most of the trials were funded by companies with commercial interests in wholegrains. There is a need for well-designed, adequately powered, longer term randomised controlled studies in this area. In particular there is a need for randomised controlled trials on wholegrain foods and diets other than oats.

Trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36,821 women over a 15-year period.

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.

Obesity in pregnancy: a study of the impact of maternal obesity on NHS maternity services.

OBJECTIVE: To gain a detailed understanding of healthcare professionals' perceptions of the impact that caring for obese pregnant women has on maternity services. DESIGN: Qualitative interview study using purposeful sampling and face-to-face interviews. SETTING: Sixteen maternity units in NHS Trusts in the North East Government Office Region of England, UK. SAMPLE: Thirty-three maternity and obstetric healthcare professionals with personal experience of managing the care of obese pregnant women. METHODS: Semi-structured interviews with healthcare professionals representing each maternity unit in the region. Transcripts were analysed using systematic content analysis. MAIN OUTCOME MEASURES: Views on the impact maternal obesity has on maternity services, the facilities required to care for obese mothers in pregnancy, and existing services directed towards maternal obesity. RESULTS: Five dominant themes relating to service delivery emerged; booking appointments, equipment, care requirements, complications and restrictions, and current and future management of care. Many of the issues identified were associated with managing the care of obese women in pregnancy safely, resources and cost issues to be able to do this, multidisciplinary care requirements because of coexisting morbidities when the mother is obese, and restricted care options and patient choice. CONCLUSIONS: Healthcare professionals in the North East of England feel that maternal obesity has a major impact on services and resource, on the health of both the mother and child, and on the psychological wellbeing of the mother.

Obesity and disability - a short review.

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.