Building a Systems Map: Applying Systems Thinking to Unhealthy Commodity Industry Influence on Public Health Policy.

BACKGROUND: Unhealthy commodity industries (UCIs) engage in political practices to influence public health policy, which poses barriers to protecting and promoting public health. Such influence exhibits characteristics of a complex system. Systems thinking would therefore appear to be a useful lens through which to study this phenomenon, potentially deepening our understanding of how UCI influence are interconnected with one another through their underlying political, economic and social structures. As such this study developed a qualitative systems map to depict the complex pathways through which UCIs influence public health policy and how they are interconnected with underlying structures. METHODS: Online participatory systems mapping workshops were conducted between November 2021 and February 2022. As a starting point for the workshops, a preliminary systems map was developed based on recent research. Twenty-three online workshops were conducted with 52 geographically diverse stakeholders representing academia, civil society, public office and global governance organisations. Analysis of workshop data in NVivo and feedback from participants resulted in a final systems map. RESULTS: The preliminary systems map consisted of 40 elements across six interdependent themes. The final systems map consisted of 64 elements across five interdependent themes, representing key pathways through which UCIs impact health policymaking: 1) direct access to public sector decision-makers; 2) creation of confusion and doubt about policy decisions; 3) corporate prioritisation of commercial profits and growth; 4) industry leveraging the legal and dispute settlement processes; and 5) industry leveraging policymaking, norms, rules, and processes. CONCLUSION: UCI influence on public health policy is highly complex, involves interlinked practices, and is not reducible to a single point within the system. Instead, pathways to UCI influence emerge from the complex interactions between disparate national and global political, economic and social structures. These pathways provide numerous avenues for UCIs to influence public health policy, which poses challenges to formulating a singular intervention or limited set of interventions capable of effectively countering such influence. Using participatory methods, we made transparent the interconnections that could help identify interventions future work.

Complex Interventions for a Complex System? Using Systems Thinking to Explore Ways to Address Unhealthy Commodity Industry Influence on Public Health Policy.

BACKGROUND: Interventions are needed to prevent and mitigate unhealthy commodity industry (UCI) influence on public health policy. Whilst literature on interventions is emerging, current conceptualisations remain incomplete as they lack considerations of the wider systemic complexities surrounding UCI influence, which may limit intervention effectiveness. This study applies systems thinking as a theoretical lens to help identify and explore how possible interventions relate to one another in the systems in which they are embedded. Related challenges to addressing UCI influence on policy, and actions to support interventions, were also explored. METHODS: Online participatory workshops were conducted with stakeholders with expertise in UCIs. A systems map, depicting five pathways to UCI influence, and the Action Scales Model were used to help participants identify interventions and guide discussions. Codebook thematic analysis was used to analyse the data. RESULTS: Fifty-two stakeholders participated in 23 workshops. Participants identified 27 diverse, interconnected and interdependent interventions corresponding to the systems map's pathways that reduce the ability of UCIs to influence policy, e.g., reform policy financing; regulate public-private partnerships; reform science governance and funding; frame and reframe the narrative, challenge neoliberalism and GDP growth; leverage human rights; change practices on multistakeholder governance; and reform policy consultation and deliberation processes. Participants also identified four potential key challenges to interventions (i.e., difficult to implement or achieve; partially formulated; exploited or misused; requires tailoring for context), and four key actions to help support intervention delivery (i.e., coordinate and cooperate with stakeholders; invest in civil society; create a social movement; nurture leadership). CONCLUSION: A systems thinking lens revealed the theoretical interdependence between disparate and heterogenous interventions. This suggests that to be effective, interventions need to align, work collectively, and be applied to different parts of the system synchronously. Importantly, these interventions need to be supported by intermediary actions to be achieved. Urgent action is now required to strengthen healthy alliances and implement interventions.

Co-designing adult weight management services: a qualitative study exploring barriers, facilitators, and considerations for future commissioning.

BACKGROUND: Weight management services have not always benefitted everyone equally. People who live in more deprived areas, racially minoritised communities, those with complex additional needs (e.g., a physical or mental disability), and men are less likely to take part in weight management services. This can subsequently widen health inequalities. One way to counter this is to co-design services with under-served groups to better meet their needs. Using a case study approach, we explored how co-designed adult weight management services were developed, the barriers and facilitators to co-design, and the implications for future commissioning. METHODS: We selected four case studies of adult weight management services in Southwest England where co-design had been planned, representing a range of populations and settings. In each case, we recruited commissioners and providers of the services, and where possible, community members involved in co-design activities. Interviews were conducted online, audio-recorded, transcribed verbatim, and analysed using thematic analysis. RESULTS: We interviewed 18 participants (8 female; 10 male): seven commissioners, eight providers, and three community members involved in co-designing the services. The case studies used a range of co-design activities (planned and actualised), from light-touch to more in-depth approaches. In two case studies, co-design activities were planned but were not fully implemented due to organisational time or funding constraints. Co-design was viewed positively by participants as a way of creating more appropriate services and better engagement, thus potentially leading to reduced inequalities. Building relationships- with communities, individual community members, and with partner organisations- was critical for successful co-design and took time and effort. Short-term and unpredictable funding often hindered co-design efforts and could damage relationships with communities. Some commissioners raised concerns over the limited evidence for co-design, while others described having to embrace "a different way of thinking" when commissioning for co-design. CONCLUSIONS: Co-design is an increasingly popular approach to designing health in services but can be difficult to achieve within traditional funding and commissioning practices. Drawing on our case studies, we present key considerations for those wanting to co-design health services, noting the importance of building strong relationships, creating supportive organisational cultures, and developing the evidence base.

Views, perceptions, and experiences of type 2 diabetes or weight management programs among minoritized ethnic groups living in high-income countries: A systematic review of qualitative evidence.

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.

How Do You Move? Everyday stories of physical activity.

Stories can be a powerful method of exploring complexity, and the factors affecting everyday physical activity within a modern urban setting are nothing if not complex. The first part of our How Do You Move? study focused on the communication of physical activity guidelines to under-served communities. A key finding was that adults especially wanted physical activity messages to come from 'everyday people, people like us'. This finding also reflects a wider move to use more relatable imagery in health promotion campaigns. Using a portrait vignette approach to create monologues, we set out to explore the experiences of people from diverse backgrounds living in Bristol, all of whom took part in varied leisure time physical activities but would also be considered to lead 'normal' lives. We aim to demonstrate that stories of such 'experts by experience' can contribute to how physical activity is perceived and elucidate the complex interplay of barriers and enablers in everyday experiences of physical activity.

The UK government has guidelines about how much physical activity people should do to stay healthy. However, many people don't manage to do as much physical activity as the government recommends. There are many reasons why people don't do enough physical activity. Reasons include where people live, what work they do or how much spare time they have. In the How Do You Move? project, we explored the messaging about physical activity guidelines. Many people told us that they wanted to hear physical activity advice from 'people like me'. We set out to find people who managed to stay active, despite how difficult that can sometimes be in modern life. We interviewed them about their physical activity. We then worked with them to write their experiences as personal stories. These stories are presented in this paper.

Advertisement of unhealthy commodities in Bristol and South Gloucestershire and rationale for a new advertisement policy.

BACKGROUND: Bristol City Council introduced a new advertisement policy in 2021/2022 which included prohibiting the advertising of unhealthy food and drink (HFSS), alcohol, gambling and payday loans across council-owned advertising spaces. This mixed methods study is part of the BEAR study, and aimed to explore the rationale and the barriers and facilitators to implementing the policy, and describe the perceived advertising environment prior to implementation. METHODS: Semi-structured interviews were carried out with seven stakeholders involved in the design and implementation of the advertising policy. A stakeholder topic guide was developed before interviews took place to help standardise the lines of inquiry between interviewees. A resident survey was developed to collect socio-demographic data and, for the purpose of this study, information regarding observations of advertising for HFSS products, alcohol and gambling. RESULTS: Fifty-eight percent of respondents residing in Bristol and South Gloucestershire reported seeing advertisements for unhealthy commodities in the week prior to completing the survey. This was highest for HFSS products (40%). 16% of residents reported seeing HFSS product advertisements specifically appealing to children. For HFSS products in particular, younger people were more likely to report seeing adverts than older people, as were those who were from more deprived areas. An advertisement policy that restricts the advertisement of such unhealthy commodities, and in particular for HFSS products, has the potential to reduce health inequalities. This rationale directly influenced the development of the advertisement policy in Bristol. Implementation of the policy benefitted from an existing supportive environment following the 'health in all policies' initiative and a focus on reducing health inequalities across the city. CONCLUSIONS: Unhealthy product advertisements, particularly for unhealthy food and drinks, were observed more by younger people and those living in more deprived areas. Policies that specifically restrict such advertisements, therefore, have the potential to reduce health inequalities, as was the hope when this policy was developed. Future evaluation of the policy will provide evidence of any public health impact.

Assessing exposure to outdoor advertisement for products high in fat, salt and sugar (HFSS); is self-reported exposure a useful exposure metric?

BACKGROUND: Exposure to advertising of unhealthy commodities such as fast-food and gambling is recognised as a risk factor for developing non-communicable diseases. Assessment of the impact of such advertisement and the evaluation of the impact of any policies to restrict such advertisements on public health are reliant on the quality of the exposure assessment. A straightforward method for assessing exposure is to ask people whether they noticed any such advertisements in their neighbourhoods. However, the validity of this method is unclear. We assessed the associations between measured exposure to outdoor advertising, self-reported exposure, and self-reported consumption. METHODS: We collected exposure information in January-March 2022 using two methods: (i) through a resident survey investigating advertising and consumption of unhealthy products, distributed across Bristol and neighbouring South Gloucestershire, and (ii) through in-person auditing. Self-reported exposure was obtained from the resident survey (N = 2,560) and measured exposure from photos obtained for all Council owned advertisement sites (N = 973 bus stops). Both data sources were geographically linked at lower-super-output-area level. Reporting ratios (RRs), 95% confidence intervals (CIs), and Cohen's kappas, are presented. RESULTS: 24% of advertisements displayed food and/or drink advertising. Bristol respondents in neighbourhoods displaying food/drink adverts were more likely to also report seeing these adverts compared to those in neighbourhoods without food/drink adverts (59% vs. 51%, RR = 1.15, 95%CI 1.01-1.31). There was no such association in South Gloucestershire (26% vs. 32%, RR = 0.82, 95%CI 0.58-1.14). Respondents in both Bristol and South Gloucestershire who recalled seeing advertising for unhealthy food and drink products were more likely to consume them (e.g. for fast-food: 22% vs. 11%, RR = 2.01, 95%CI 1.68-2.42). There was no such association between measured food and drink adverts in respondents' local areas and self-reported consumption of HFSS product (90.1% vs. 90.7%, RR = 0.99, 95%CI 0.96-1.03). CONCLUSIONS: Self-reported outdoor advertisement exposure is correlated with measured exposure, making this a useful methodology for population studies. It has the added advantage that it correlates with consumption. However, given that measurement error can be significant and self-reported exposure is known to be susceptible to various biases, inferences from studies using this exposure metric should be made with caution.

Navigating the river(s) of systems change: a multi-methods, qualitative evaluation exploring the implementation of a systems approach to physical activity in Gloucestershire, England.

OBJECTIVES: Systems approaches aim to change the environments in which people live, through cross-sectoral working, by harnessing the complexity of the problem. This paper sought to identify: (1) the strategies which support the implementation of We Can Move (WCM), (2) the barriers to implementation, (3) key contextual factors that influence implementation and (4) impacts associated with WCM. DESIGN: A multi-methods evaluation of WCM was completed between April 2019 and April 2021. Ripple Effects Mapping (REM) and semi-structured interviewers were used. Framework and content analysis were systematically applied to the dataset. SETTING: WCM-a physical activity orientated systems approach being implemented in Gloucestershire, England. PARTICIPANTS: 31 stakeholder interviews and 25 stakeholders involved in 15 REM workshops. RESULTS: A white-water rafting analogy was developed to present the main findings. The successful implementation of WCM required a facilitative, well-connected and knowledgeable guide (ie, the lead organisation), a crew (ie, wider stakeholders) who's vision and agenda aligned with WCM's purpose, and a flexible delivery approach that could respond to ever-changing nature of the river (ie, local and national circumstances). The context surrounding WCM further strengthened and hampered its implementation. Barriers included evaluative difficulties, a difference in stakeholder and organisational perspectives, misaligned expectations and understandings of WCM, and COVID-19 implications (COVID-19 also presented as a facilitative factor). WCM was said to strengthen cohesion and collaboration between partners, benefit other agendas and policies (eg, mental health, town planning, inequality), and improve physical activity opportunities and environments. CONCLUSIONS: This paper is one of the first to evaluate a systems approach to increasing physical activity. We highlight key strategies and contextual factors that influenced the implementation of WCM and demonstrate some of the wider benefits from such approaches. Further research and methodologies are required to build the evidence base surrounding systems approaches in Public Health.

Ripple effects mapping: capturing the wider impacts of systems change efforts in public health.

BACKGROUND: Systems approaches are currently being advocated and implemented to address complex challenges in Public Health. These approaches work by bringing multi-sectoral stakeholders together to develop a collective understanding of the system, and then to identify places where they can leverage change across the system. Systems approaches are unpredictable, where cause-and-effect cannot always be disentangled, and unintended consequences - positive and negative - frequently arise. Evaluating such approaches is difficult and new methods are warranted. METHODS: Ripple Effects Mapping (REM) is a qualitative method which can capture the wider impacts, and adaptive nature, of a systems approach. Using a case study example from the evaluation of a physical activity-orientated systems approach in Gloucestershire, we: a) introduce the adapted REM method; b) describe how REM was applied in the example; c) explain how REM outputs were analysed; d) provide examples of how REM outputs were used; and e) describe the strengths, limitations, and future uses of REM based on our reflections. RESULTS: Ripple Effects Mapping is a participatory method that requires the active input of programme stakeholders in data gathering workshops. It produces visual outputs (i.e., maps) of the programme activities and impacts, which are mapped along a timeline to understand the temporal dimension of systems change efforts. The REM outputs from our example were created over several iterations, with data collected every 3-4 months, to build a picture of activities and impacts that have continued or ceased. Workshops took place both in person and online. An inductive content analysis was undertaken to describe and quantify the patterns within the REM outputs. Detailed guidance related to the preparation, delivery, and analysis of REM are included in this paper. CONCLUSION: REM may help to advance our understanding and evaluation of complex systems approaches, especially within the field of Public Health. We therefore invite other researchers, practitioners and policymakers to use REM and continuously evolve the method to enhance its application and practical utility.

Physiologic Insulin Resensitization as a Treatment Modality for Insulin Resistance Pathophysiology.

Prevalence of type 2 diabetes increased from 2.5% of the US population in 1990 to 10.5% in 2018. This creates a major public health problem, due to increases in long-term complications of diabetes, including neuropathy, retinopathy, nephropathy, skin ulcers, amputations, and atherosclerotic cardiovascular disease. In this review, we evaluated the scientific basis that supports the use of physiologic insulin resensitization. Insulin resistance is the primary cause of type 2 diabetes. Insulin resistance leads to increasing insulin secretion, leading to beta-cell exhaustion or burnout. This triggers a cascade leading to islet cell destruction and the long-term complications of type 2 diabetes. Concurrent with insulin resistance, the regular bursts of insulin from the pancreas become irregular. This has been treated by the precise administration of insulin more physiologically. There is consistent evidence that this treatment modality can reverse the diabetes-associated complications of neuropathy, diabetic ulcers, nephropathy, and retinopathy, and that it lowers HbA1c. In conclusion, physiologic insulin resensitization has a persuasive scientific basis, significant treatment potential, and likely cost benefits.

The Action Scales Model: A conceptual tool to identify key points for action within complex adaptive systems.

BACKGROUND: Systems thinking is integral to working effectively within complex systems, such as those which drive the current population levels of overweight and obesity. It is increasingly recognised that a systems approach - which corrals public, private, voluntary and community sector organisations to make their actions and efforts coherent - is necessary to address the complex drivers of obesity. Identifying, implementing and evaluating actions within complex adaptive systems is challenging, and may differ from previous approaches used in public health. METHODS: Within this conceptual article, we present the Action Scales Model (ASM). The ASM is a simple tool to help policymakers, practitioners and evaluators to conceptualise, identify and appraise actions within complex adaptive systems. We developed this model using our collective expertise and experience in working with local government authority stakeholders on the Public Health England Whole Systems Obesity programme. It aligns with, and expands upon, previous models such as the Intervention Level Framework, the Iceberg Model and Donella Meadows' 12 places to intervene within a system. RESULTS: The ASM describes four levels (synonymous with leverage points) to intervene within a system, with deeper levels providing greater potential for changing how the system functions. Levels include events, structures, goals and beliefs. We also present how the ASM can be used to support practice and policy, and finish by highlighting its utility as an evaluative aid. DISCUSSION: This practical tool was designed to support those working at the front line of systems change efforts, and while we use the population prevalence of obesity as an outcome of a complex adaptive system, the ASM and the associated principles can be applied to other issues. We hope that the ASM encourages people to think differently about the systems that they work within and to identify new and potentially more impactful opportunities to leverage change.

A whole system approach to increasing children's physical activity in a multi-ethnic UK city: a process evaluation protocol.

BACKGROUND: Engaging in regular physical activity requires continued complex decision-making in varied and dynamic individual, social and structural contexts. Widespread shortfalls of physical activity interventions suggests the complex underlying mechanisms of change are not yet fully understood. More insightful process evaluations are needed to design and implement more effective approaches. This paper describes the protocol for a process evaluation of the JU:MP programme, a whole systems approach to increasing physical activity in children and young people aged 5-14 years in North Bradford, UK. METHODS: This process evaluation, underpinned by realist philosophy, aims to understand the development and implementation of the JU:MP programme and the mechanisms by which JU:MP influences physical activity in children and young people. It also aims to explore behaviour change across wider policy, strategy and neighbourhood systems. A mixed method data collection approach will include semi-structured interview, observation, documentary analysis, surveys, and participatory evaluation methods including reflections and ripple effect mapping. DISCUSSION: This protocol offers an innovative approach on the use of process evaluation feeding into an iterative programme intended to generate evidence-based practice and deliver practice-based evidence. This paper advances knowledge regarding the development of process evaluations for evaluating systems interventions, and emphasises the importance of process evaluation.

The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC): International consensus statement and user guide.

Effective physical activity messaging plays an important role in the pathway towards changing physical activity behaviour at a population level. The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC) are outputs from a recent modified Delphi study. This sought consensus from an international expert panel on how to aid the creation and evaluation of physical activity messages. In this paper, we (1) present an overview of the various concepts within the PAMF and PAMC, (2) discuss in detail how the PAMF and PAMC can be used to create physical activity messages, plan evaluation of messages, and aid understanding and categorisation of existing messages, and (3) highlight areas for future development and research. If adopted, we propose that the PAMF and PAMC could improve physical activity messaging practice by encouraging evidence-based and target population-focused messages with clearly stated aims and consideration of potential working pathways. They could also enhance the physical activity messaging research base by harmonising key messaging terminologies, improving quality of reporting, and aiding collation and synthesis of the evidence.

Preventing Childhood Obesity in Primary Schools: A Realist Review from UK Perspective.

Childhood obesity is a global public health concern. While evidence from a recent comprehensive Cochrane review indicates school-based interventions can prevent obesity, we still do not know how or for whom these work best. We aimed to identify the contextual and mechanistic factors associated with obesity prevention interventions implementable in primary schools. A realist synthesis following the Realist And Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES) guidance was with eligible studies from the 2019 Cochrane review on interventions in primary schools. The initial programme theory was developed through expert consensus and stakeholder input and refined with data from included studies to produce a final programme theory including all of the context-mechanism-outcome configurations. We included 24 studies (71 documents) in our synthesis. We found that baseline standardised body mass index (BMIz) affects intervention mechanisms variably as a contextual factor. Girls, older children and those with higher parental education consistently benefitted more from school-based interventions. The key mechanisms associated with beneficial effect were sufficient intervention dose, environmental modification and the intervention components working together as a whole. Education alone was not associated with favourable outcomes. Future interventions should go beyond education and incorporate a sufficient dose to trigger change in BMIz. Contextual factors deserve consideration when commissioning interventions to avoid widening health inequalities.

Eight Investments That Work for Physical Activity.

BACKGROUND: The International Society for Physical Activity and Health (ISPAH) is a leading global organization working to advance research, policy, and practice to promote physical activity. Given the expanding evidence base on interventions to promote physical activity, it was timely to review and update a major ISPAH advocacy document-Investments that Work for Physical Activity (2011). METHODS: Eight investment areas were agreed upon through consensus. Literature reviews were conducted to identify key evidence relevant to policymakers in each sector or setting. RESULTS: The 8 investment areas were as follows: whole-of-school programs; active transport; active urban design; health care; public education; sport and recreation; workplaces; and community-wide programs. Evidence suggests that the largest population health benefit will be achieved by combining these investments and implementing a systems-based approach. CONCLUSIONS: Establishing consensus on 'what works' to change physical activity behavior is a cornerstone of successful advocacy, as is having appropriate resources to communicate key messages to a wide range of stakeholders. ISPAH has created a range of resources related to the new investments described in this paper. These resources are available in the 'advocacy toolkit' on the ISPAH website (www.ispah.org/resources).

"We're just stuck in a daily routine": Implications of the temporal dimensions, demands and dispositions of mothering for leisure time physical activity.

The reduced physical activity of women when they become mothers is a public health priority. Existing studies show that mothers have little time for leisure, or time that is fragmented and requiring negotiation with others. However, the temporal features of mothering are undertheorised and qualitative studies tend to focus on how mothers can skilfully construct physically active identities and balance societal expectations about being a "good mother". In line with other research that focuses on the configuration of everyday practices that condition the "possibilities" for health-related practices like physical activity, we shift our focus away from the resisting capacities of mothers to the temporal features of mothering practices. We interrogate the lived experiences of 15 mothers of preschool children in deprived urban areas and illuminate the inherent temporal dimensions, demands and dispositions of mothering practices that condition the possibility of leisure time physical activity being undertaken. Together, these temporal features mean mothering practices can readily work against leisure time physical activity. The focus on the mothering practices rather than mothers brings a novel perspective for developing public health policy designed to support mothers into regular leisure time physical activity.

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.

Strategies to reduce attrition in managing paediatric obesity: A systematic review.

OBJECTIVE: To conduct a systematic review of the literature for strategies designed to reduce attrition in managing paediatric obesity. METHODS: We searched Ovid Medline (1946 to May 6, 2020), Ovid Embase (1974 to May 6, 2020), EBSCO CINAHL (inception to May 6, 2020), Elsevier Scopus (inception to April 14, 2020), and ProQuest Dissertations & Theses (inception to April 14, 2020). Reports were eligible if they included any obesity management intervention, included 2 to 18 year olds with overweight or obesity (or if the mean age of participants fell within this age range), were in English, included experimental study designs, and had attrition reduction as a main outcome. Two team members screened studies, abstracted data, and appraised study quality. RESULTS: Our search yielded 5,415 original reports; six met inclusion criteria. In three studies, orientation sessions (n = 2) and motivational interviewing (MI) (n = 1) were used as attrition-reduction strategies before treatment enrollment; in three others, text messaging (n = 2) and MI (n = 1) supplemented existing obesity management interventions. Attrition-reduction strategies led to decreased attrition in two studies, increased in one, and no difference in three. For the two strategies that reduced attrition, (a) pre-treatment orientation and (b) text messaging between children and intervention providers were beneficial. The quality of the six included studies varied (good [n = 4]; poor [n = 2]). CONCLUSION: Some evidence suggests that attrition can be reduced. The heterogeneity of approaches applied and small number of studies included highlight the need for well-designed, experimental research to test the efficacy and effectiveness of strategies to reduce attrition in managing paediatric obesity.

"Let's Talk about Physical Activity": Understanding the Preferences of Under-Served Communities when Messaging Physical Activity Guidelines to the Public.

Despite many countries having physical activity guidelines, there have been few concerted efforts to mobilize this information to the public. The aim of this study was to understand the preferences of under-served community groups about how the benefits of physical activity, and associated guidelines, can be better communicated to the public. Participatory workshops, co-developed between researchers, a local charity, and a community artist, were used to gather data from four groups in Bristol, UK: young people (n = 17); adults (n = 11); older adults (n = 5); and Somali women (n = 15). Workshop content was structured around the study aims. The community artist and/or the local charity delivered the workshops, with researchers gathering data via observation, photos, and audio-recordings, which were analysed using the framework method. All four groups noted that the benefits of physical activity should be included within any communications efforts, though not restricted to health-related benefits. Language used should be simple and jargon-free; terms such as "sedentary", "vigorous" and "intensity" were deemed inaccessible, however all groups liked the message "some is good, more is better". Views about preferred mechanisms, and messenger, for delivering physical activity messages varied both between, and within, groups. Recommendations for those working in physical activity communications, research, and policy are provided.