Pilot study of a ketogenic diet in bipolar disorder.

BACKGROUND: Recent evidence from case reports suggests that a ketogenic diet may be effective for bipolar disorder. However, no clinical trials have been conducted to date. AIMS: To assess the recruitment and feasibility of a ketogenic diet intervention in bipolar disorder. METHOD: Euthymic individuals with bipolar disorder were recruited to a 6-8 week trial of a modified ketogenic diet, and a range of clinical, economic and functional outcome measures were assessed. Study registration number: ISRCTN61613198. RESULTS: Of 27 recruited participants, 26 commenced and 20 completed the modified ketogenic diet for 6-8 weeks. The outcomes data-set was 95% complete for daily ketone measures, 95% complete for daily glucose measures and 95% complete for daily ecological momentary assessment of symptoms during the intervention period. Mean daily blood ketone readings were 1.3 mmol/L (s.d. = 0.77, median = 1.1) during the intervention period, and 91% of all readings indicated ketosis, suggesting a high degree of adherence to the diet. Over 91% of daily blood glucose readings were within normal range, with 9% indicating mild hypoglycaemia. Eleven minor adverse events were recorded, including fatigue, constipation, drowsiness and hunger. One serious adverse event was reported (euglycemic ketoacidosis in a participant taking SGLT2-inhibitor medication). CONCLUSIONS: The recruitment and retention of euthymic individuals with bipolar disorder to a 6-8 week ketogenic diet intervention was feasible, with high completion rates for outcome measures. The majority of participants reached and maintained ketosis, and adverse events were generally mild and modifiable. A future randomised controlled trial is now warranted.

Environmental and practice factors associated with children's device-measured physical activity and sedentary time in early childhood education and care centres: a systematic review.

BACKGROUND: Early childhood education and care (ECEC) settings offer a potentially cost-effective and sustainable solution for ensuring children have opportunities to meet physical activity (PA) and sedentary time (ST) guidelines. This paper systematically reviewed the association between childcare environment and practice and children's PA and ST. METHODS: Three electronic databases were searched, and citation tracking of eligible studies performed between June-July 2020 (updated March 2022). Studies were eligible when (i) participants attended ECEC settings, (ii) they reported the association between use of outdoor space, including factors of time, availability, play, size and equipment, and children's device-measured PA and ST, and (iii) where applicable, they compared the exposure to use of indoor space. Risk of bias was assessed using the Critical Appraisal Skills Program (CASP) tools. A synthesis was performed using effect direct plots and charts to visualise effect sizes. RESULTS: Of 1617 reports screened, 29 studies met the inclusion criteria. Studies provided data on outdoor versus indoor time (n = 9; 960 children), outdoor versus indoor play (n = 3; 1104 children), outdoor play space (n = 19; 9596 children), outdoor space use external to ECEC (n = 2; 1148 children), and portable (n = 7; 2408 children) and fixed (n = 7; 2451 children) outdoor equipment. Time spent outdoors versus indoors was associated with increased moderate-to-vigorous PA (MVPA), light PA (LPA) and total PA, while the association with ST was inconclusive. The mean (standard deviation) levels of outdoor MVPA (4.0 ± 3.2 to 18.6 ± 5.6 min/h) and LPA (9.9 ± 2.6 to 30.8 ± 11.8 min/h) were low, and ST high (30.0 ± 6.5 to 46.1 ± 4.3 min/h). MVPA levels doubled when children played outdoors versus indoors. Outdoor play space, and outdoor portable equipment, were associated with increased MVPA. A dose-response relationship for outdoor play area size was observed, demonstrating increased MVPA with areas ≥505m2 (5436 ft2), but no further increases when areas were > 900m2 (9688 ft2). No studies reported on injuries in outdoor settings. CONCLUSIONS: ECEC policies and practices should promote not only outdoor time but also the availability of resources such as portable play equipment and sufficient size of outdoor play areas that enable children to be physically active for sustained periods while outdoors. SYSTEMATIC REVIEW REGISTRATION: International prospective register of systematic reviews (PROSPERO) Registration Number: CRD42020189886.

The understanding, application and influence of complexity in national physical activity policy-making.

BACKGROUND: Complexity theory and systems-thinking are increasingly popular in physical activity (PA) research and policy discourse. The impact of this perspective shift, across many sectors, may be underwhelming. We explore why, by focusing on how these concepts are understood and applied by PA policy-makers. This is of particular interest given the challenges of multisectoral interest and poorly defined stakeholder boundaries that are associated with PA promotion. In this study, we critique key elements of complexity theory and consider how it is understood and put into practice in PA policy-making. METHODS: We adopted a complex realist position. Ten semi-structured interviews were conducted with national-level policy-makers from United Kingdom government settings (five civil servants, three politicians, two policy advisors). An inductive thematic analysis was conducted, and managed with NVivo 10 software. RESULTS: Three overarching themes were constructed to reflect policy-makers' uncertainty about complexity and the application of such perspectives to this policy space, their sense that PA was an unexceptionable yet unclaimed policy issue, and their desire for influence and change. Participants discussed complexity in contrasting ways. Its meaning was context-dependent and dynamic, which generated uncertainty about applying the concept. Participants also perceived an increasingly diverse but ill-defined PA policy system that spans the domains of expertise and responsibility. Collaborative practices may contribute to a previously unobserved sense of detachment from the systems' complexity. Nevertheless, participants suggested potentially effective ways to stimulate system change, which require passionate and enterprising leadership, and included varied evidence use, a focus on localised implementation and different ways to connect people. CONCLUSIONS: This research highlighted the importance of extending complexity theory and systems-thinking. While emphasizing the prevalence of these ideas across the PA sector, there is uncertainty as to their meaning and implications. This may prevent their use in ways that enhance PA policies and programmes. Participants conceptualised PA as a tool, which was imposed on the system. While this may support participative decision-making and localised implementation, further research is needed to understand how local systems foster leadership, the practical application of complexity and systems-thinking, and how to support system-wide change in the development and implementation of PA policies.

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.

Effectiveness of Digital Interventions for Reducing Behavioral Risks of Cardiovascular Disease in Nonclinical Adult Populations: Systematic Review of Reviews.

BACKGROUND: Digital health interventions are increasingly being used as a supplement or replacement for face-to-face services as a part of predictive prevention. They may be offered to those who are at high risk of cardiovascular disease and need to improve their diet, increase physical activity, stop smoking, or reduce alcohol consumption. Despite the popularity of these interventions, there is no overall summary and comparison of the effectiveness of different modes of delivery of a digital intervention to inform policy. OBJECTIVE: This review aims to summarize the effectiveness of digital interventions in improving behavioral and health outcomes related to physical activity, smoking, alcohol consumption, or diet in nonclinical adult populations and to identify the effectiveness of different modes of delivery of digital interventions. METHODS: We reviewed articles published in the English language between January 1, 2009, and February 25, 2019, that presented a systematic review with a narrative synthesis or meta-analysis of any study design examining digital intervention effectiveness; data related to adults (≥18 years) in high-income countries; and data on behavioral or health outcomes related to diet, physical activity, smoking, or alcohol, alone or in any combination. Any time frame or comparator was considered eligible. We searched MEDLINE, Embase, PsycINFO, Cochrane Reviews, and gray literature. The AMSTAR-2 tool was used to assess review confidence ratings. RESULTS: We found 92 reviews from the academic literature (47 with meta-analyses) and 2 gray literature items (1 with a meta-analysis). Digital interventions were typically more effective than no intervention, but the effect sizes were small. Evidence on the effectiveness of digital interventions compared with face-to-face interventions was mixed. Most trials reported that intent-to-treat analysis and attrition rates were often high. Studies with long follow-up periods were scarce. However, we found that digital interventions may be effective for up to 6 months after the end of the intervention but that the effects dissipated by 12 months. There were small positive effects of digital interventions on smoking cessation and alcohol reduction; possible effectiveness in combined diet and physical activity interventions; no effectiveness for interventions targeting physical activity alone, except for when interventions were delivered by mobile phone, which had medium-sized effects; and no effectiveness observed for interventions targeting diet alone. Mobile interventions were particularly effective. Internet-based interventions were generally effective. CONCLUSIONS: Digital interventions have small positive effects on smoking, alcohol consumption, and in interventions that target a combination of diet and physical activity. Small effects may have been due to the low efficacy of treatment or due to nonadherence. In addition, our ability to make inferences from the literature we reviewed was limited as those interventions were heterogeneous, many reviews had critically low AMSTAR-2 ratings, analysis was typically intent-to-treat, and follow-up times were relatively short. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42019126074; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=126074.

Challenges, opportunities and solutions for local physical activity stakeholders: an implementation case study from a cross-sectoral physical activity network in Northeast England.

BACKGROUND: Increasingly, national policy initiatives and programmes have been developed to increase physical activity (PA). However, challenges in implementing and translating these policies into effective local-level programmes have persisted, and change in population PA levels has been small. This may be due to insufficient attention given to the implementation context, and the limited interactions between local policy-makers, practitioners and researchers. In this paper we use a case study of a cross-sectoral network in Northeast England, to identify the local-level challenges and opportunities for implementing PA policies and programmes, particularly the updated 2019 UK PA guidelines. METHODS: Five focus groups (n = 59) were conducted with practice partners, local policy-makers and researchers during an initial workshop in April 2018. Through facilitated discussion, participants considered regional priorities for research and practice, along with barriers to implementing this agenda and how these may be overcome. During a second workshop in December 2018, overarching findings from workshop one were fedback to a similar group of stakeholders, along with national policy-makers, to stimulate feedback from delegates on experiences that may support the implementation of the UK PA guidelines locally, focusing on specific considerations for research, evidence and knowledge exchange. RESULTS: In workshop one, three overarching themes were developed to capture local challenges and needs: (i) understanding complexity and context; (ii) addressing the knowledge and skills gap; and (iii) mismatched timescales and practices. In workshop two, participants' implementation plans encompassed: (i) exploring a systems approach to implementation; (ii) adapting policy to context; and (iii) local prioritising. CONCLUSIONS: Our findings suggest that academics, practitioners and policy-makers understand the complexities of implementing PA strategies, and the challenges of knowledge exchange. The updated UK PA guidelines policy presented an opportunity for multiple agencies to consider context-specific implementation and address enduring tensions between stakeholders. An organically derived implementation plan that prioritises PA, maps links to relevant local policies and supports a context-appropriate communication strategy, within local policy, practice and research networks, will help address these. We present 10 guiding principles to support transferable knowledge exchange activities within networks to facilitate implementation of national PA policy in local contexts.

Inequities and inequalities in outdoor walking groups: a scoping review.

BACKGROUND: Outdoor walking groups are widely-used programmes aimed at improving physical activity and health outcomes. Despite being promoted as accessible and inclusive, emerging work highlights participation biases based on gender, age and socioeconomic status, for example. To explicate the impact of outdoor walking groups on physical activity inequities, we conducted a scoping review of published outdoor walking group literatures. Specifically, we critically examined: (a) equity integration strategies; (b) intervention reach; (c) effectiveness; and (d) potential social determinants of engagement relating to the World Health Organization's conceptual framework. METHODS: Arksey and O'Malley's scoping review protocol was used to develop a comprehensive search strategy and identify relevant academic and grey literatures, which were screened using pre-defined inclusion and exclusion criteria. Data were organised by Cochrane PROGRESS-Plus equity characteristics and a narrative summary was presented for each thematic area. FINDINGS: Sixty-two publications were included. Key findings were: (a) some evidence of targeted intervention trials. Large-scale national programmes were tailored to regional activity and health needs, which may contribute toward addressing inequities. However, participant demographics seldom informed reported analyses; (b) participation was more likely among white, more socioeconomically advantaged, middle-to-older aged, female and able-bodied adults; (c) positive physical and psychological outcomes were unlikely to extend along social gradients; and (d) interventions primarily addressed intermediary determinants (e.g. psychosocial barriers; material resource). Social capital (e.g. friend-making) was identified as potentially important for addressing physical activity inequalities. CONCLUSIONS: The published literature on outdoor walking groups leaves unanswered questions regarding participation inequalities, with implications for future physical activity promotion. Currently, participation in outdoor walking groups is typically more prevalent among advantaged subpopulations. We make recommendations for research and practice to address these issues, as well as aid the translation of existing knowledge into practice. We advocate increased focus on the social determinants of engagement. A more consistent approach to collecting and analysing participant socio-demographic data is required. Our findings also support recommendations that appropriate tailoring of universal programmes to community needs and embedding strategies to increase social cohesion are important in developing equitable programmes.