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Objective: The study objective was to assess participant weight change for the English National Health Service (NHS) Digital Weight Management Programme, the first such digital intervention to achieve population coverage. Methods: A service evaluation was used to assess intervention effectiveness for adults with obesity and a diagnosis of hypertension and/or diabetes, between April 2021 and March 2022, using prospectively collected, national service–level data in England. Results: Of the 63,937 referrals made from general practices, within the time period, 31,861 (50%) chose to take up the 12‐week Programme. There were 31,718 participants who had time to finish the Programme; of those, 14,268 completed the Programme (defined as attending ≥60%), a 45% completion rate. The mean weight change for those who had time to finish the Programme was −2.2 kg (95% CI: −2.25 to −2.16), for those who completed it was −3.9 kg (95% CI: −3.99 to −3.84), and for those who had time to finish the Programme but did not complete it was −0.74 kg (95% CI: −0.79 to −0.70). Conclusions: The NHS Digital Weight Management Programme is effective at achieving clinically meaningful weight loss. The outcomes compare favorably to web‐based weight management interventions tested in randomized trials and those delivered as face‐to‐face interventions, and results suggest that the approach may, with increased participation, bring population‐level benefits. [ABSTRACT FROM AUTHOR]

Aims: To assess weight change in the Healthier You: NHS Diabetes Prevention Programme (NHS DPP) delivered via video conferencing (remote) sessions or delivered via specific digital interventions through apps or websites, during the COVID‐19 pandemic compared to group‐based face‐to‐face interventions, pre‐pandemic. Methods: Prospectively collected national service‐level data relating to individuals with non‐diabetic hyperglycaemia (HbA1c 42–47 mmol/mol (6.0%–6.4%) or fasting plasma glucose 5.5–6.9 mmol/L) referred to the NHS DPP from June 2016 to March 2022. Results: Between March 2020 and March 2022, 335,961 people were referred to the programme and were offered a choice of remote or digital intervention. This was preceded by 556,793 people referred to the face‐to‐face programme between June 2016 and February 2022. Uptakes to intervention sessions were 47% for those offered a choice and 39% for face‐to‐face. Remote and digital participants were significantly younger (60 and 56 vs. 65 years) and heavier (86.1 kg and 91.0 kg vs. 84.1 kg) compared to face‐to‐face. Weight change was assessed for 42,407 remote, 7699 digital and 97,205 face‐to‐face participants with sufficient time to have finished the programme and no missing data. Mean weight losses for participants attending at least one intervention session were: 2.40 (2.36–2.44) kg, 2.59 (2.49–2.68) kg and 2.01 (1.98–2.04) kg for remote, digital and face‐to‐face participants respectively. Corresponding mean weight losses for those who completed the programme were: 3.24 (3.19–3.30) kg, 4.76 (4.60–4.92) kg and 3.04 (3.00–3.07) kg. There were no significant differences in weight change between interventions by ethnicity and deprivation. Conclusions: Weight losses achieved through remote and digital interventions were greater than those previously achieved through face‐to‐face interventions, without evidence of exacerbation of health inequalities. [ABSTRACT FROM AUTHOR]

Background: Guidelines recommend that GPs give patients lifestyle advice to manage hypertension and diabetes. Increasing evidence shows that this is an effective and practical treatment for these conditions, but it is unclear whether GPs offer this support.Aim: To investigate trends in the percentage of patients with hypertension/diabetes receiving lifestyle advice versus medication.Design and Setting: This was a trend analysis of self-reported data from the annual Health Survey for England (HSE) (2003-2017) and GP-recorded data from the QResearch database (2002-2016).Method: The percentage of patients with hypertension or diabetes who received lifestyle advice or medication was calculated in each year. Associations between likelihood of receiving lifestyle advice and characteristics were assessed using multivariable logistic regression.Results: The percentage of patients receiving lifestyle advice was consistently lower than those receiving medication in both self-reported and medical records. There was consistent evidence of increasing trends in the percentage of patients with hypertension receiving lifestyle advice (HSE 13.8% to 20.1%; Ptrend <0.001; QResearch 11.0% to 22.7%; Ptrend <0.001). For diabetes, there was a non-significant decline in self-reported receipt of lifestyle advice (45.0% to 27.9%; Ptrend = 0.111) and a significant increase in medically recorded delivery of this advice (20.7% to 40.5%; Ptrend <0.001). Patients with hypertension who were overweight or obese were more likely to receive lifestyle advice than those of a healthy weight, whereas the opposite was true for diabetes.Conclusion: Only a minority of patients with diabetes or hypertension report receiving lifestyle advice or have this recorded in their medical records. Interventions beyond guidelines are needed to increase the delivery of behavioural interventions to treat these conditions. [ABSTRACT FROM AUTHOR]

Background: The proportion of energy from free sugars and saturated fat currently exceeds the UK-recommended intake across all age groups. Recognising the limits of reformulation programmes, the government in England has announced their intention to introduce legislation to restrict the promotion of foods high in free sugars, salt, and saturated fats in prominent store locations. Here, we evaluated a grocery store intervention to remove seasonal confectionery from prominent locations within a major UK supermarket. Methods and findings: A nonrandomised controlled intervention study with interrupted time series (ITS) analysis was used. Data were analysed from 34 intervention stores located in 2 London boroughs and 151 matched control stores located elsewhere in the UK owned by the same retailer. Stores were matched based on store size and overall sales during the previous year. Between 15 February 2019 and 3 April 2019 (before Easter), stores removed free-standing promotional display units of seasonal confectionery from prominent areas, although these products were available for purchase elsewhere in the store. Store-level weekly sales (units, weight (g), and value (£)) of seasonal chocolate confectionery products were used in primary analyses, with data from 1 January 2018 to 24 November 2019. Secondary outcomes included total energy, fat, saturated fat, and sugars from all in-store purchases. Multivariable hierarchical models were used to investigate pre/post differences in weekly sales of confectionery in intervention versus control stores. ITS analyses were used to evaluate differences in level and trends after intervention implementation. Over a preintervention baseline period (15 February 2018 to 3 April 2018), there were no significant differences in sales (units, weight, and value) of all chocolate confectionery between intervention versus control stores. After intervention implementation, there was an attenuation in the seasonal increase of confectionery sales (units) in intervention stores compared to control (+5% versus +18%; P < 0.001), with similar effects on weight (g) (+12% versus +31%; P < 0.001) and value (£) (−3% versus +10%; P < 0.001). ITS analyses generally showed statistically significant differences in the level at the point of intervention (P ranges 0.010 to 0.067) but also in the trend afterwards (P ranges 0.024 to 0.053), indicating that the initial difference between intervention and control stores reduced over time. There was a significant difference in level change in total energy sold, adjusted for the total weight of food and drink (kcal/g, P = 0.002), and total fat (fat/g) (P = 0.023), but no significant changes in saturated fat or sugars from total sales in ITS models. There was no evidence that the main results varied across store deprivation index. The limitations of this study include the lack of randomisation, residual confounding from unmeasured variables, absolute differences in trends and sales between intervention versus control stores, and no independent measures of intervention fidelity. Conclusions: Removal of chocolate confectionery from prominent locations was associated with reduced purchases of these products, of sufficient magnitude to observe a reduction in the energy content of total food purchases. These results from a "real-world" intervention provide promising evidence that the proposed legislation in England to restrict promotions of less healthy items in prominent locations may help reduce overconsumption. Trial registration: https://osf.io/br96f/. Carmen Piernas and team evaluate purchasing behaviour associated with a grocery store intervention to remove seasonal confectionery from prominent locations within a major UK supermarket. Author summary: Why was the study done?: The prevalence of obesity in the UK is continuing to increase especially in the most deprived areas. The proportion of energy from free sugars and saturated fat currently exceeds the UK-recommended intake across all age groups. Despite ambitious sugar reduction targets set by Public Health England, there has been little change in the confectionery category. Recognising the limits of reformulation programmes, the Government in England has announced their intention to introduce legislation to restrict the promotion of foods high in free sugars, salt, and saturated fats in prominent locations in grocery stores. What did the researchers find?: We partnered with a large UK food retailer to evaluate an intervention to remove seasonal chocolate confectionery from prominent areas of the store, specifically end-of-aisles and entrance areas, over 7 weeks before the Easter period. The intervention showed a significant attenuation of the seasonal increase in confectionery sales in intervention stores compared to control stores, with an absolute difference of approximately 127 units (approximately 21 kg) of confectionery per store per week. During the intervention period, there were significant reductions in total energy and fat from all food-related purchases in the stores implementing the intervention, but no significant changes in saturated fat or total sugars. There was no evidence that the main results varied according to the store deprivation index. What do these findings mean?: The Government in England has recently signalled its intention to bring forward legislation to restrict promotions of less healthy items in prominent locations in grocery stores, to help reduce overconsumption. This study provides new evidence that the government proposals to restrict foods high in fat, sugar, and salt from prominent locations in stores could lead to measurable reductions in total energy (calories) from purchases. [ABSTRACT FROM AUTHOR]

Background: A brief intervention whereby GPs opportunistically facilitate an NHS-funded referral to a weight loss programme is clinically and cost-effective.Aim: To test the acceptability of a brief intervention and attendance at a weight loss programme when GPs facilitate a referral that requires patients to pay for the service.Design and Setting: An observational study of the effect of a GP encouraging attendance at a weight loss programme requiring self-payment in the West Midlands from 16 October 2018 to 30 November 2018, to compare with a previous trial in England in which the service was NHS-funded.Method: Sixty patients with obesity who consecutively attended primary care appointments received an opportunistic brief intervention by a GP to endorse and offer a referral to a weight loss programme at the patient's own expense. Participants were randomised to GPs who either stated the weekly monetary cost of the programme (basic cost) or who compared the weekly cost to an everyday discretionary item (cost comparison). Participants were subsequently asked to report whether they had attended a weight loss programme.Results: Overall, 47% of participants (n = 28) accepted the referral; 50% (n = 15) in the basic cost group and 43% (n = 13) in the cost comparison group. This was significantly less than in a previous study when the programme was NHS-funded (77%, n = 722/940; P<0.0001). Most participants reported the intervention to be helpful/very helpful and appropriate/very appropriate (78%, n = 46/59 and 85%, n = 50/59, respectively) but scores were significantly lower than when the programme was NHS-funded (92% n = 851/922 and 88% n = 813/922, respectively; P = 0.004). One person (2%) attended the weight loss programme, which is significantly lower than the 40% of participants who attended when the programme was NHS-funded (P<0.0001).Conclusion: GP referral to a weight loss programme that requires patients to pay rather than offering an NHS-funded programme is acceptable; however, it results in almost no attendance. [ABSTRACT FROM AUTHOR]

Background: Consumption of sugars-sweetened beverages (SSB) increases energy intake and the risk of obesity. Large packages increase consumption of food, implying that smaller bottle sizes may help curb SSB consumption, but there is a lack of relevant evidence relating to these products. This study explores the feasibility and acceptability of conducting a randomised controlled trial to assess the impact of different bottle sizes on SSB consumption at home.Methods: Households in Cambridge, England, which purchased at least 2 l of regular cola drinks per week, received a set amount of cola each week for four weeks, in bottles of one of four sizes (1500 ml, 1000 ml, 500 ml, or 250 ml) in random order. The total volume received consisted of a modest excess of households' typical weekly purchasing, but was further increased for half the study households to avoid ceiling effects. Consumption was measured by recording the number of empty bottles at the end of each week. Eligible households were invited to complete a run-in period to assess levels of active participation.Results: Thirty-seven of 111 eligible households with an interest in the study completed the run-in period. The study procedures proved feasible. The target for recruitment (n = 16 households) was exceeded. Measuring consumption was feasible: over three quarters (n = 30/37) of households returned all bottles on the majority (n = 88/101) of the study weeks completed across households. The validity of this measure was compromised by guests from outside the household who drank the study cola (n = 18/37 households on 48/101 study weeks) and consumption of the study cola outside the home. Supplying enhanced volumes of cola to nine households was associated with higher consumption (11,592 ml vs 7869 ml). The intervention and study procedures were considered acceptable. Thirteen households correctly identified the study aims.Conclusion: The findings support the feasibility and acceptability of running a randomised controlled trial to assess the impact of presenting a fixed volume of SSB in different bottle sizes on in-home consumption. However, methods that avoid consumption being influenced by the amount of cola supplied weekly by the study and that capture out of home consumption are needed before conducting a randomised controlled trial.Trial Registration: ISRCTN14964130 ; Registered on 18th May, 2015. [ABSTRACT FROM AUTHOR]

Summary: Background: The prevalence of obesity in childhood is of high concern, especially in deprived populations. We explored trends in obesity following the introduction of a citywide strategy focused on preschool children. Methods: Analysis of obesity prevalence using the National Child Measurement Programme 2009 to 2017 for primary‐school children in Leeds using 5‐year aggregated data for Leeds, comparable cities, and England as a whole. Results: Prevalence of obesity in Leeds for school entry children fell significantly (9.4% to 8.8%), whilst comparable cities (CC) and England as a whole showed no change (comparison of trends: P < 0.001 and P < 0.001). The reduction in Leeds was primarily in the most deprived (11.5% to 10.5%; trend comparison CC: P < 0.001, Eng: P < 0.001), but also amongst the affluent (6.8% to 6.0%; trend comparison CC: P = 0.087, Eng: P = 0.012). Prevalence in older children in Leeds was unchanged whilst it increased for comparable cities and England (trend comparison CC: P < 0.001, Eng: P < 0.001). In the deprived, obesity increased: Leeds by 1.4%; CC 1.3%, England 1% (trend comparison Eng: P = 0.004). In the affluent, obesity prevalence reduced more in Leeds than elsewhere: 2% in Leeds, 0.8% in CC, and 0.7% in England (trend comparison CC: P < 0.001, Eng: P ≤ 0.001). Conclusions: There has been a notable decrease in the prevalence of obesity especially amongst the most disadvantaged children at entry to primary school in Leeds. How this was achieved merits in‐depth consideration. [ABSTRACT FROM AUTHOR]

Achieving a sustained energy deficit is essential for weight loss, but the cognitive and behavioral strategies that support this goal are unclear. The goal of this study was to investigate the number and type of cognitive and behavioral strategies used by participants who were enrolled in a 1-year weight loss trial and to explore associations between strategies and magnitude of weight loss at 3 months and 1 year. The study is a secondary post-hoc exploratory analysis of data collected as part of the Doctor Referral of Overweight People to Low-Energy total diet replacement Treatment (DROPLET), a randomized controlled trial conducted in general practices in England, United Kingdom, between January 2016 and August 2017. This study involved 164 participants from both intervention and control groups of the DROPLET trial who completed the Oxford Food and Behaviours (OxFAB) questionnaire to assess the use of 115 strategies grouped into 21 domains used to manage their weight. Participants were randomized to either a behavioral weight loss program involving 8 weeks total diet replacement (TDR) and 4 weeks of food reintroduction or a program delivered by a medical practice nurse over a 3-month period (usual care [UC]). Weight was objectively measured at baseline, 3 months, and 1 year. Cognitive and behavioral strategies used to support weight loss were assessed using the OxFAB questionnaire at 3 months. Exploratory factor analysis was used to generate data-driven patterns of strategy use, and a linear mixed-effects model was used to examine associations between use of these patterns and weight change. No evidence was found of a difference in the number of strategies (mean difference, 2.41; 95% confidence interval [CI], −0.83, 5.65) or the number of domains used (mean difference, −0.23; 95% CI, −0.69, 0.23) between the TDR group and the UC group. The number of strategies was not associated with weight loss at either 3 months (−0.02 kg; 95% CI, −0.11, 0.06) or 1 year (−0.05 kg; 95% CI, −0.14, 0.02). Similarly, the number of domains used was not associated with weight loss at 3 months (−0.02 kg; 95% CI, −0.53, 0.49) or 1 year (−0.07 kg; 95% CI, −0.60, 0.46). Factor analysis identified four coherent patterns of strategy use, identified as Physical Activity, Motivation, Planned Eating, and Food Purchasing patterns. Greater use of strategies in the Food Purchasing (−2.6 kg; 95% CI, −4.42, −0.71) and Planned Eating patterns (−3.20 kg; 95% CI, −4.94, −1.46) was associated with greater weight loss at 1 year. The number of cognitive and behavioral strategies or domains used does not appear to influence weight loss, but the types of strategy appear of greater importance. Supporting people to adopt strategies linked to planned eating and food purchasing may aid long-term weight loss. [ABSTRACT FROM AUTHOR]

Clinical trials have shown that providing advice and support for people with excess weight can lead to meaningful weight loss. Despite this evidence and guidelines endorsing this approach, provision in real-world clinical settings remains low. We used Strong Structuration Theory (SST) to understand why people are often not offered weight management advice in primary care in England. Data from policy, clinical practice and focus groups were analysed using SST to consider how the interplay between weight stigma and structures of professional responsibilities influenced clinicians to raise (or not) the issue of excess weight with patients. We found that general practitioners (GPs) often accounted for their actions by referring to obesity as a health problem, consistent with policy documents and clinical guidelines. However, they were also aware of weight stigma as a social process that can be internalised by their patients. GPs identified addressing obesity as a priority in their work, but described wanting to care for their patients by avoiding unnecessary suffering, which they were concerned could be caused by talking about weight. We observed tensions between knowledge of clinical guidelines and understanding of the lived experience of their patients. We interpreted that the practice of 'caring by not offering care' produced the outcome of an absence of weight management advice in consultations. There is a risk that this outcome reinforces the external structure of weight stigma as a delicate topic to be avoided, while at the same time denying patients the offer of support to manage their weight. • Guidelines recommend weight management be offered routinely in primary care. • Despite evidence of effectiveness, many patients are not offered weight management. • Strong structuration theory enables interactional analysis of weight stigma and clinical practice. • Avoiding the topic of weight, and the associated stigma, can be understood as a form of caring. • In attempting to avoid causing distress, healthcare professionals fail to offer support. [ABSTRACT FROM AUTHOR]

Overconsumption of foods high in fat, sugars, and salt (HFSS) poses a significant risk to health. The government in England has passed legislation that would limit some price promotions of HFSS foods within supermarkets, but evidence regarding likely impacts of these policies, especially in online settings, is limited. This study aimed to determine whether there were any differences in the energy and nutrient content of shopping baskets after removing promotions on HFSS foods in an online experimental supermarket. UK adults (n = 511) were asked to select food from four categories with a £10 budget in an online experimental supermarket: confectionery; biscuits and crackers; crisps, nuts and snacking fruit; cakes and tarts. They were randomly allocated to one of two trial arms: (1) promotions present (matched to promotion frequency seen in a major UK retailer) (n = 257), or (2) all promotions removed from all products within the target food categories (n = 254). The primary outcome analysis used linear regression to compare total energy (kcal) of items placed in shopping baskets when promotions were present vs. absent, while secondary analyses investigated differences in nutrients and energy purchased from individual food categories. Mean energy in food selected without promotions was 5156 kcal per basket (SD 1620), compared to 5536 kcal (SD 1819) with promotions, a difference of −552kcal (95%CIs: −866, −238), equivalent to 10%. There were no significant differences in energy purchased for any individual category between groups. No evidence was found of other changes in nutritional composition of baskets or of significant interactions between the impact of promotions and participant characteristics (gender, age, ethnicity) on energy purchased. Removing promotions on HFSS foods resulted in significantly less total energy selected in an online experimental supermarket study. [ABSTRACT FROM AUTHOR]

Objective: For people with type 2 diabetes who are overweight, weight loss increases the likelihood of achieving diabetes remission. The aim here was to draw on the experiences of people living with type 2 diabetes and coaches who deliver type 2 diabetes prevention and remission programmes. This was done to develop a service that increases the proportion of people who achieve remission by identifying an effective weight management service., Research Design and Methods: A qualitative researcher and co-researcher with type 2 diabetes conducted 37 narrative interviews with adults with type 2 diabetes (October 2022-June 2023) and 16 semi-structured interviews with health coaches delivering type 2 diabetes programmes in England. Data were analysed using Reflexive Thematic Analysis. Participants were diverse in ethnicity, socioeconomic status, age, gender and years since diabetes diagnosis., Results: Four themes were generated relating to moments in a person's diabetes care: (1) coming to terms with diagnosis, (2) lightbulb moments, (3) sustaining change as normal and (4) becoming expert/building confidence. These four themes were united under a high-level interpretivist theme: 'Same journey, different experience', capturing the mismatch between a linear rigid care pathway described by coaches and the diversity of experience of people living with type 2 diabetes., Conclusions: Coaches and people with type 2 diabetes are aligned on their reports of key moments in adapting to diabetes. Participants' desire for flexibility in their care contrasted with coach reports of rigid service provision. These insights may enable more people with type 2 diabetes to engage and adhere to weight management services aimed at diabetes remission., (© 2024 The Author(s). Health Expectations published by John Wiley & Sons Ltd.)

Objectives: There is evidence that general practitioners (GPs) can increase the uptake of weight management programmes that enhance weight loss compared with self-directed efforts, but the rate at which they do so is unclear. This study examined the prevalence of weight control efforts and practices, the reported frequency and impact of receipt of GP advice on weight loss attempts and perceptions of the appropriateness of health professionals delivering weight loss advice., Design: A nationally representative cross-sectional survey., Setting: England., Participants: 1722 adults (≥16 years) surveyed in October 2018 (mean (SD) age=47.4 (19.2), 51.1% women)., Main Outcome Measures: Weight control efforts and practices, whether a GP gave advice or a specific referral/prescription medication, perception of the appropriateness of GP weight loss advice., Results: Two-thirds (64.7% (95% CI 58.1% to 71.3%)) of people with obesity reported trying to lose weight. Of people with obesity who visited their GP in the past year, 40% (95% CI 32.2% to 47.7%) recalled receiving any advice on weight loss: 30.8% (95% CI 23.5% to 38.2%) general advice and 9.2% (95% CI 4.6% to 13.7%) a referral to a weight loss service or prescription medication for weight loss. Having received weight loss advice from a GP was strongly associated with a greater likelihood of trying to lose weight (general advice: OR adj =4.49, 95% CI 2.52 to 8.00; referral/medication: OR adj =9.25, 95% CI 2.65 to 32.3). Views on whether health professionals should deliver weight loss advice were mixed, with a substantial minority (19.4% (95% CI 17.5% to 21.4%)) finding it unacceptable. People with a BMI outside of the healthy weight range (underweight/overweight/obesity), women and those from more disadvantaged social grades were less likely to find it acceptable., Conclusions: Most people with obesity reported trying to lose weight but less than half recalled receiving advice on weight loss from their GP in the past year and few were referred to community weight-loss programmes. Those who recalled receiving GP advice on weight loss were substantially more likely to report taking action to lose weight. One in five people thought GP advice on weight loss was inappropriate., Competing Interests: Competing interests: JB has received unrestricted research funding from Pfizer and J&J. LS has received honoraria for talks, unrestricted research grants and travel expenses to attend meetings and workshops from Pfizer and J&J and has acted as a paid reviewer for grant awarding bodies and as a paid consultant for health care companies. All other authors declare no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Randomised controlled trials have shown that total diet replacement (TDR) can lead to remission of type 2 diabetes. In 2019, the English National Health Service (NHS) committed to establishing a TDR-based interventional programme delivered at scale within real-world environments; development followed of the NHS Type 2 Diabetes Path to Remission (T2DR) programme, a 12-month behavioural intervention to support weight loss involving an initial 3-month period of TDR. We assessed remission of type 2 diabetes for programme participants., Methods: In this national prospective service evaluation of programme implementation, people in England aged 18-65 years and diagnosed with type 2 diabetes in the last 6 years were referred to the programme between programme launch on Sept 1, 2020, and Dec 31, 2022. Programme data were linked to the National Diabetes Audit to ascertain HbA 1c measurements and glucose-lowering medication prescriptions. The primary outcome was remission of type 2 diabetes at 1 year, defined as two HbA 1c measurements of less than 48 mmol/mol recorded at least 3 months apart with no glucose-lowering medications prescribed from 3 months before the first HbA 1c measurement, and the second HbA 1c measurement recorded 11-15 months after the programme start date. Outcomes were assessed in two ways: for all participants who started TDR on the 12-month programme before January, 2022, for whom there were no missing data; and for all participants who started TDR on the 12-month programme before January, 2022, and had completed the programme (ie, had a valid weight recorded at month 12) by Dec 31, 2022, for whom there were no missing data., Findings: Between Sept 1, 2020, and Dec 31, 2022, 7540 people were referred to the programme; of those, 1740 started TDR before January, 2022, and therefore had a full 12-month opportunity to undertake the programme by the time of data extraction at the end of December, 2022. Of those who started TDR before January, 2022, 960 (55%) completed the programme (defined as having a weight recorded at 12 months). The mean weight loss for the 1710 participants who started the programme before January, 2022 and had no missing data was 8·3% (95% CI 7·9-8·6) or 9·4 kg (8·9-9·8), and the mean weight loss for the 945 participants who completed the programme and had no missing data was 9·3% (8·8-9·8) or 10·3 kg (9·7-10·9). For the subgroup of 710 (42%) of 1710 participants who started the programme before January, 2022, and also had two HbA 1c measurements recorded, 190 (27%) had remission, with mean weight loss of 13·4% (12·3-14·5) or 14·8 kg (13·4-16·3). Of the 945 participants who completed the programme, 450 (48%) had two HbA 1c measurements recorded; of these, 145 (32%) had remission, with mean weight loss of 14·4% (13·2-15·5) or 15·9 kg (14·3-17·4)., Interpretation: Findings from the NHS T2DR programme show that remission of type 2 diabetes is possible outside of research settings, through at-scale service delivery. However, the rate of remission achieved is lower and the ascertainment of data is more limited with implementation in the real world than in randomised controlled trial settings., Funding: None., Competing Interests: Declaration of interests JV reports being the National Clinical Director for Diabetes and Obesity at NHS England from April, 2013, to September, 2023. EB and JV report funding from CW+, the official charity of Chelsea and Westminster Hospital NHS Foundation Trust. CB reports being an adviser to the NHS Diabetes Programme. RT reports funding for educational lectures by Novo Nordisk, Janssen, and Novartis; and being an advisor to Fast800. SJ and PA report donation of total diet replacement products by Nestlé to support NHS treatment in a separate trial of total diet replacement for treating non-alcoholic fatty disease. LE reports funding from NIHR and the UK Medical Research Council; and being part of the ACTION Teens authorship and HOT trial in Denmark. JW reports consultancy or advisory board work contracted via the University of Liverpool (no personal payment) for Altimmune, AstraZeneca, Boehringer Ingelheim, Cytoki, Lilly, Napp, Novo Nordisk, Menarini, Pfizer, Rhythm Pharmaceuticals, Sanofi, Saniona, Tern, Shionogi, and YSOPIA; research grants for clinical trials from AstraZeneca and Novo Nordisk; personal honoraria or lecture fees from AstraZeneca, Boehringer Ingelheim, Medscape, Napp, Novo Nordisk, and Rhythm Pharmaceuticals; being former president of the World Obesity Federation; membership of the Association for the Study of Obesity, Diabetes UK, the European Association for the Study of Diabetes, the American Diabetes Association, the Society for Endocrinology, and the Rank Prize Funds Nutrition Committee; and being national lead for the Metabolic and Endocrine Speciality Group of the UK NIHR Clinical Research Network. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.)

Background: The period between cancer diagnosis and surgery presents an opportunity for trials to assess the feasibility of behaviour change interventions. However, this can be a worrying time for patients and may hinder recruitment. We describe the perspectives of patients with excess weight awaiting colorectal cancer surgery about their recruitment into a randomised trial of a prehabilitation weight loss intervention., Methods: We interviewed the first 26 participants from the 8 recruitment sites across England in the 'CARE' feasibility trial. Participants were randomised into either usual care (n = 13) or a low-energy nutritionally-replete total diet replacement programme with weekly remote behavioural support by a dietitian (n = 13). The semi-structured interviews occurred shortly after recruitment and the questions focused on participants' recollections of being recruited into the trial. We analysed data rapidly and then used a mind-mapping technique to develop descriptive themes. Themes were agreed by all co-authors, including a person with lived-experience of colorectal surgery., Results: Participants had a mean body mass index (± SD) of 38 kg/m 2 (± 6), age of 50 years (± 12), and 42% were female. People who participated in the trial were motivated by the offer of structured weight loss support that could potentially help them improve their surgical outcomes. However, participants also had concerns around the potential unpalatability of the intervention diet and side effects. Positive attitudes of clinicians towards the trial facilitated recruitment but participants were disappointed when they were randomised to usual care due to clinical teams' overemphasis on the benefits of losing weight., Conclusions: Patients were motivated to take part by the prospect of improved surgical outcomes. However, the strong preference to be allocated to the intervention suggests that balanced communication of equipoise is crucial to minimise disappointment from randomisation to usual care and differential dropout from the trial., Clinical Trial Registration: ISRCTN39207707, Registration date 13/03/2023., (© 2024. The Author(s).)

Background: Excess weight is a major risk factor for severe disease after infection with SARS-CoV-2. However, the effect of BMI on COVID-19 hospital resource use has not been fully quantified. This study aimed to identify the association between BMI and hospital resource use for COVID-19 admissions with the intention of informing future national hospital resource allocation., Methods: In this community-based cohort study, we analysed patient-level data from 57 415 patients admitted to hospital in England with COVID-19 between April 1, 2020, and Dec 31, 2021. Patients who were aged 20-99 years, had been registered with a general practitioner (GP) surgery that contributed to the QResearch database for the whole preceding year (2019) with at least one BMI value measured before April 1, 2020, available in their GP record, and were admitted to hospital for COVID-19 were included. Outcomes of interest were duration of hospital stay, transfer to an intensive care unit (ICU), and duration of ICU stay. Costs of hospitalisation were estimated from these outcomes. Generalised linear and logit models were used to estimate associations between BMI and hospital resource use outcomes., Findings: Patients living with obesity (BMI >30·0 kg/m 2 ) had longer hospital stays relative to patients in the reference BMI group (18·5-25·0 kg/m 2 ; IRR 1·07, 95% CI 1·03-1·10); the reference group had a mean length of stay of 8·82 days (95% CI 8·62-9·01). Patients living with obesity were more likely to be admitted to ICU than the reference group (OR 2·02, 95% CI 1·86-2·19); the reference group had a mean probability of ICU admission of 5·9% (95% CI 5·5-6·3). No association was found between BMI and duration of ICU stay. The mean cost of COVID-19 hospitalisation was £19 877 (SD 17 918) in the reference BMI group. Hospital costs were estimated to be £2736 (95% CI 2224-3248) higher for patients living with obesity., Interpretation: Patients admitted to hospital with COVID-19 with a BMI above the healthy range had longer stays, were more likely to be admitted to ICU, and had higher health-care costs associated with hospital treatment of COVID-19 infection as a result. This information can inform national resource allocation to match hospital capacity to areas where BMI profiles indicate higher demand., Funding: National Institute for Health Research., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: A high BMI has been associated with a reduced immune response to vaccination against influenza. We aimed to investigate the association between BMI and COVID-19 vaccine uptake, vaccine effectiveness, and risk of severe COVID-19 outcomes after vaccination by using a large, representative population-based cohort from England., Methods: In this population-based cohort study, we used the QResearch database of general practice records and included patients aged 18 years or older who were registered at a practice that was part of the database in England between Dec 8, 2020 (date of the first vaccination in the UK), to Nov 17, 2021, with available data on BMI. Uptake was calculated as the proportion of people with zero, one, two, or three doses of the vaccine across BMI categories. Effectiveness was assessed through a nested matched case-control design to estimate odds ratios (OR) for severe COVID-19 outcomes (ie, admission to hospital or death) in people who had been vaccinated versus those who had not, considering vaccine dose and time periods since vaccination. Vaccine effectiveness against infection with SARS-CoV-2 was also investigated. Multivariable Cox proportional hazard models estimated the risk of severe COVID-19 outcomes associated with BMI (reference BMI 23 kg/m 2 ) after vaccination., Findings: Among 9 171 524 participants (mean age 52 [SD 19] years; BMI 26·7 [5·6] kg/m 2 ), 566 461 tested positive for SARS-CoV-2 during follow-up, of whom 32 808 were admitted to hospital and 14 389 died. Of the total study sample, 19·2% (1 758 689) were unvaccinated, 3·1% (287 246) had one vaccine dose, 52·6% (4 828 327) had two doses, and 25·0% (2 297 262) had three doses. In people aged 40 years and older, uptake of two or three vaccine doses was more than 80% among people with overweight or obesity, which was slightly lower in people with underweight (70-83%). Although significant heterogeneity was found across BMI groups, protection against severe COVID-19 disease (comparing people who were vaccinated vs those who were not) was high after 14 days or more from the second dose for hospital admission (underweight: OR 0·51 [95% CI 0·41-0·63]; healthy weight: 0·34 [0·32-0·36]; overweight: 0·32 [0·30-0·34]; and obesity: 0·32 [0·30-0·34]) and death (underweight: 0·60 [0·36-0·98]; healthy weight: 0·39 [0·33-0·47]; overweight: 0·30 [0·25-0·35]; and obesity: 0·26 [0·22-0·30]). In the vaccinated cohort, there were significant linear associations between BMI and COVID-19 hospitalisation and death after the first dose, and J-shaped associations after the second dose., Interpretation: Using BMI categories, there is evidence of protection against severe COVID-19 in people with overweight or obesity who have been vaccinated, which was of a similar magnitude to that of people of healthy weight. Vaccine effectiveness was slightly lower in people with underweight, in whom vaccine uptake was also the lowest for all ages. In the vaccinated cohort, there were increased risks of severe COVID-19 outcomes for people with underweight or obesity compared with the vaccinated population with a healthy weight. These results suggest the need for targeted efforts to increase uptake in people with low BMI (<18·5 kg/m 2 ), in whom uptake is lower and vaccine effectiveness seems to be reduced. Strategies to achieve and maintain a healthy weight should be prioritised at the population level, which could help reduce the burden of COVID-19 disease., Funding: UK Research and Innovation and National Institute for Health Research Oxford Biomedical Research Centre., Competing Interests: Declaration of interests QResearch is a registered trademark of Egton Medical Information Systems and the University of Nottingham. PA spoke at a symposium at the Royal College of General Practitioners annual conference on interventions for weight loss that was funded by Novo Nordisk but received no personal payments. JH-C received personal fees and other support from ClinRisk (until 2019) outside the submitted work and is an unpaid director of QResearch. MG, NMA, CP, MP, SD, MS-H, CC, and SAJ declare no competing interests. AS is a member of the Scottish Government COVID-19 Chief Medical Officers Advisory Group and its Standing Committee on Pandemics; a member of NERVTAG's Risk Stratification Subgroup; and a member of AstraZeneca's Thrombotic Thrombocytopenic Taskforce. KK is a member of Chair of the Ethnicity Subgroup of the UK Scientific Advisory Group for Emergencies (SAGE) and a member of SAGE., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Obesity is a major risk factor for adverse outcomes after infection with SARS-CoV-2. We aimed to examine this association, including interactions with demographic and behavioural characteristics, type 2 diabetes, and other health conditions., Methods: In this prospective, community-based, cohort study, we used de-identified patient-level data from the QResearch database of general practices in England, UK. We extracted data for patients aged 20 years and older who were registered at a practice eligible for inclusion in the QResearch database between Jan 24, 2020 (date of the first recorded infection in the UK) and April 30, 2020, and with available data on BMI. Data extracted included demographic, clinical, clinical values linked with Public Health England's database of positive SARS-CoV-2 test results, and death certificates from the Office of National Statistics. Outcomes, as a proxy measure of severe COVID-19, were admission to hospital, admission to an intensive care unit (ICU), and death due to COVID-19. We used Cox proportional hazard models to estimate the risk of severe COVID-19, sequentially adjusting for demographic characteristics, behavioural factors, and comorbidities., Findings: Among 6 910 695 eligible individuals (mean BMI 26·78 kg/m 2 [SD 5·59]), 13 503 (0·20%) were admitted to hospital, 1601 (0·02%) to an ICU, and 5479 (0·08%) died after a positive test for SARS-CoV-2. We found J-shaped associations between BMI and admission to hospital due to COVID-19 (adjusted hazard ratio [HR] per kg/m 2 from the nadir at BMI of 23 kg/m 2 of 1·05 [95% CI 1·05-1·05]) and death (1·04 [1·04-1·05]), and a linear association across the whole BMI range with ICU admission (1·10 [1·09-1·10]). We found a significant interaction between BMI and age and ethnicity, with higher HR per kg/m 2 above BMI 23 kg/m 2 for younger people (adjusted HR per kg/m 2 above BMI 23 kg/m 2 for hospital admission 1·09 [95% CI 1·08-1·10] in 20-39 years age group vs 80-100 years group 1·01 [1·00-1·02]) and Black people than White people (1·07 [1·06-1·08] vs 1·04 [1·04-1·05]). The risk of admission to hospital and ICU due to COVID-19 associated with unit increase in BMI was slightly lower in people with type 2 diabetes, hypertension, and cardiovascular disease than in those without these morbidities., Interpretation: At a BMI of more than 23 kg/m 2 , we found a linear increase in risk of severe COVID-19 leading to admission to hospital and death, and a linear increase in admission to an ICU across the whole BMI range, which is not attributable to excess risks of related diseases. The relative risk due to increasing BMI is particularly notable people younger than 40 years and of Black ethnicity., Funding: NIHR Oxford Biomedical Research Centre., Competing Interests: Declaration of interests NMA, PA, and SAJ were investigators on a trial of total diet replacement for weight loss funded by a grant from Cambridge Weight Plan UK to the University of Oxford (Oxford, UK) and received no personal payments from this. PA spoke at a symposium at the Royal College of General Practitioners annual conference on interventions for weight loss that was funded by Novo Nordisk and received no personal payments. JH-C reports grants from National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), John Fell Oxford University Press Research Fund, Cancer Research UK (C5255/A18085) through the Cancer Research UK Oxford Centre, and Oxford Wellcome Institutional Strategic Support Fund (204826/Z/16/Z) during the conduct of the study. JH-C received personal fees and other support from ClinRisk (until 2019) outside of the submitted work, and is an unpaid director of QResearch, a not-for-profit organisation that is a partnership between the University of Oxford and Egton Medical Information Systems (EMIS) Health who supply the QResearch database used for this work. All other authors declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Consumption of free sugars in the UK greatly exceeds dietary recommendations. Public Health England (PHE) has set voluntary targets for industry to reduce the sales-weighted mean sugar content of key food categories contributing to sugar intake by 5% by 2018 and 20% by 2020. The aim of this study was to assess changes in the sales-weighted mean sugar content and total volume sales of sugar in selected food categories among UK companies between 2015 and 2018., Methods and Findings: We used sales data from Euromonitor, which estimates total annual retail sales of packaged foods, for 5 categories-biscuits and cereal bars, breakfast cereals, chocolate confectionery, sugar confectionery, and yoghurts-for 4 consecutive years (2015-2018). This analysis includes 353 brands (groups of products with the same name) sold by 99 different companies. These data were linked with nutrient composition data collected online from supermarket websites over 2015-2018 by Edge by Ascential. The main outcome measures were sales volume, sales-weighted mean sugar content, and total volume of sugar sold by category and company. Our results show that between 2015 and 2018 the sales-weighted mean sugar content of all included foods fell by 5.2% (95% CI -9.4%, -1.4%), from 28.7 g/100 g (95% CI 27.2, 30.4) to 27.2 g/100 g (95% CI 25.8, 28.4). The greatest change seen was in yoghurts (-17.0% [95% CI -26.8%, -7.1%]) and breakfast cereals (-13.3% [95% CI -19.2%, -7.4%]), with only small reductions in sugar confectionery (-2.4% [95% CI -4.2%, -0.6%]) and chocolate confectionery (-1.0% [95% CI -3.1, 1.2]). Our results show that total volume of sugars sold per capita fell from 21.4 g/d (95% CI 20.3, 22.7) to 19.7 g/d (95% CI 18.8, 20.7), a reduction of 7.5% (95% CI -13.1%, -2.8%). Of the 50 companies representing the top 10 companies in each category, 24 met the 5% reduction target set by PHE for 2018. The key limitations of this study are that it does not encompass the whole food market and is limited by its use of brand-level sales data, rather than individual product sales data., Conclusions: Our findings show there has been a small reduction in total volume sales of sugar in the included categories, primarily due to reductions in the sugar content of yoghurts and breakfast cereals. Additional policy measures may be needed to accelerate progress in categories such as sugar confectionery and chocolate confectionery if the 2020 PHE voluntary sugar reduction targets are to be met., Competing Interests: The authors have declared that no competing interests exist.

Objective: To assess weight and HbA 1c changes in the Healthier You: National Health Service Diabetes Prevention Programme (NHS DPP), the largest DPP globally to achieve universal population coverage., Research Design and Methods: A service evaluation assessed intervention effectiveness for adults with nondiabetic hyperglycemia (HbA 1c 42-47 mmol/mol [6.0-6.4%] or fasting plasma glucose 5.5-6.9 mmol/L) between program launch in June 2016 and December 2018, using prospectively collected, national service-level data in England., Results: By December 2018, 324,699 people had been referred, 152,294 had attended the initial assessment, and 96,442 had attended at least 1 of 13 group-based intervention sessions. Allowing sufficient time to elapse, 53% attended an initial assessment, 36% attended at least one group-based session, and 19% completed the intervention (attended >60% of sessions). Of the 32,665 who attended at least one intervention session and had sufficient time to finish, 17,252 (53%) completed: intention-to-treat analyses demonstrated a mean weight loss of 2.3 kg (95% CI 2.2, 2.3) and an HbA 1c reduction of 1.26 mmol/mol (1.20, 1.31) (0.12% [0.11, 0.12]); completer analysis demonstrated a mean weight loss of 3.3 kg (3.2, 3.4) and an HbA 1c reduction of 2.04 mmol/mol (1.96, 2.12) (0.19% [0.18, 0.19]). Younger age, female sex, Asian and black ethnicity, lower socioeconomic status, and normal baseline BMI were associated with less weight loss. Older age, female sex, black ethnicity, lower socioeconomic status, and baseline overweight and obesity were associated with a smaller HbA 1c reduction., Conclusions: Reductions in weight and HbA 1c compare favorably with those reported in recent meta-analyses of pragmatic studies and suggest likely future reductions in participant type 2 diabetes incidence., (© 2019 by the American Diabetes Association.)

Background: High salt intake is a risk factor for hypertension and cardiovascular disease. Reducing salt intake has been shown to reduce blood pressure. Despite population-level interventions, including product reformulation and public awareness campaigns, adult salt consumption in the UK still exceeds recommendations; this is primarily due to salt consumed in processed and pre-packaged foods. Moderate or high-intensity dietary advice to encourage individuals to reduce their salt intake has been shown to be effective at reducing blood pressure, but evidence of the effectiveness of interventions that are suitable for delivery at scale in routine primary care is scarce. This feasibility trial investigates a complex behavioural change intervention to reduce dietary salt intake and blood pressure by encouraging individuals to purchase lower-salt foods when grocery shopping., Methods: This randomised controlled trial will test the feasibility of a novel intervention to reduce salt intake, and the trial procedures to assess its effectiveness. We will recruit participants through UK general practices and randomise 40 participants with high blood pressure, in a 2:1 allocation to receive either the Salt Swap intervention or a control information leaflet. The primary outcomes relate to the criteria for progression to a large-scale trial. These include follow-up rates at 6 weeks, fidelity of intervention delivery and use of the intervention mobile app. Secondary outcomes include the effect of the intervention on the salt content of purchased foods (grams per 100 g), urinary sodium excretion assessed through 24-hour urine samples and blood pressure. Trial process measures will be collected and qualitative assessment will provide insights into participant engagement with the intervention content and perceived barriers to and facilitators of salt reduction dietary behavioural change., Discussion: If the outcomes indicate the trial is feasible and there is evidence that behavioural change may result in salt reduction, we will proceed to a definitive trial to test the effectiveness of the intervention to lower blood pressure. If successful, this intervention approach could be applied not only to people with high blood pressure, but also to the wider population with normal blood pressure in whom dietary salt intake exceeds recommendations., Trial Registration: ISRCTN, 20910962 . Registered on 5 April 2017.

Background: Calorie labelling may help to reduce energy consumption, but few well-controlled experimental studies have been conducted in real world settings. In a previous randomised controlled pilot trial we did not observe an effect of calorie labelling on energy purchased in worksite cafeterias. In the present study we sought to enhance the effect by making the labels more prominent, and to address the operational challenges reported previously by worksites., Methods: Three worksite cafeterias were randomised in a stepped wedge design to start the intervention at one of three fortnightly periods between March and July 2018. The intervention comprised introducing prominent calorie labelling for all cafeteria products for which calorie information was available (on average 87% of products offered across the three sites were labelled). Calorie content was displayed in bold capitalised Verdana typeface with a minimum font size of 14 e.g.120 CALORIES. Feasibility and acceptability were assessed using post-intervention surveys with cafeteria patrons and semi-structured interviews with managers. Effectiveness was assessed using total daily energy (kcal) purchased from intervention items across the three sites, analysed using semi-parametric GAMLSS models., Results: Recruitment and retention of worksite cafeterias proved feasible: all three randomised sites successfully completed the study. Post-intervention feedback suggested high levels of intervention acceptability: 87% of responding patrons wanted calorie labelling to remain in place. No effect of the intervention on daily energy purchased was observed: -0.6% (95%CI -2.5 to 1.2, p = .487). By-site analyses showed similar null effects at each of the three sites, all ps > .110., Conclusions: There was no evidence that prominent calorie labelling changed daily energy purchased across three English-based worksite cafeterias. The intervention was feasible to implement and acceptable to patrons and managers., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: To assess the effectiveness of a brief behavioural intervention based on routine antenatal weighing to prevent excessive gestational weight gain (defined by US Institute of Medicine)., Design: Randomised controlled trial., Setting: Antenatal clinic in England., Participants: Women between 10 +0 and 14 +6 weeks gestation, not requiring specialist obstetric care., Interventions: Participants were randomised to usual antenatal care or usual care (UC) plus the intervention. The intervention involved community midwives weighing women at antenatal appointments, setting maximum weight gain limits between appointments and providing brief feedback. Women were encouraged to monitor and record their own weight weekly to assess their progress against the maximum limits set by their midwife. The comparator was usual maternity care., Primary and Secondary Outcome Measures: Excessive gestational weight gain, depression, anxiety and physical activity., Results: Six hundred and fifty-six women from four maternity centres were recruited: 329 women were randomised to the intervention group and 327 to UC. We found no evidence that the intervention decreased excessive gestational weight gain. At 38 weeks gestation, the proportions gaining excessive gestational weight were 27.6% (81/305) versus 28.9% (90/311) (adjusted OR 0.84, 95% CI: 0.53 to 1.33) in the intervention and UC group, respectively. There were no significant difference between the groups in anxiety or depression scores (anxiety: adjusted mean -0.58, 95% CI:-1.25 to -0.8; depression: adjusted mean -0.60, 95% CI:-1.24 to -0.05). There were no significant differences in physical activity scores between the groups., Conclusions: A behavioural intervention delivered by community midwives involving routine weighing throughout pregnancy, setting maximum weight gain targets and encouraging women to weigh themselves each week to check progress did not prevent excessive gestational weight gain. There was no evidence of psychological harm., Trial Registration Number: ISRCTN67427351., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Excess weight is associated with poor health and increased healthcare costs. There are no reliable data describing the association between BMI and the use and costs of primary care services in the United Kingdom., Methods: Among 69,440 participants in the Million Women Study with primary care records in the Clinical Practice Research Datalink between April 2006 (mean age 64 years) and March 2014, the annual rates and costs of their primary care consultations, prescription medications, and diagnostic and monitoring tests were estimated in relation to their self-reported body mass index (BMI) at recruitment in 1996-2001 (mean age 56 years). Associations of BMI with annual costs were projected to all women in England aged 55-79 years in 2013., Results: Over an average follow-up of 6.0 years, annual rates and mean costs were lowest for women with a BMI of 20 to <22.5 kg/m 2 for consultations (7.0 consultations, 99% CI 6.8-7.1; £288, £280-£295) and prescription medications (27.0 prescribed items, 26.0-27.9; £227, £216-£237). Above 20 kg/m 2 , a 2 kg/m 2 higher BMI (a 5 kg change in weight for a woman of average height) was associated with 5.2% (4.8-5.6) and 9.9% (9.2-10.6) higher mean annual consultation and prescription medication costs, respectively. Annual rates and mean costs of diagnostic and monitoring tests were similar for women with different BMIs. Among all women aged 55-79 years in England, excess weight accounted for an estimated 11% (£229 million/£2.2 billion) of all consultation costs and 20% (£384 million/£1.9 billion) of all prescription medication costs, of which 27% were for diabetes drugs, 19% for circulatory system drugs, and 13% for analgesics., Conclusions: Excess body weight is associated with higher use and costs of primary care services among women in England. Reducing the prevalence of excess weight could improve the health of women and reduce pressures on primary care.

Background: Regular breakfast consumption may protect against type 2 diabetes risk in adults but little is known about its influence on type 2 diabetes risk markers in children. We investigated the associations between breakfast consumption (frequency and content) and risk markers for type 2 diabetes (particularly insulin resistance and glycaemia) and cardiovascular disease in children., Methods and Findings: We conducted a cross-sectional study of 4,116 UK primary school children aged 9-10 years. Participants provided information on breakfast frequency, had measurements of body composition, and gave fasting blood samples for measurements of blood lipids, insulin, glucose, and glycated haemoglobin (HbA1c). A subgroup of 2,004 children also completed a 24-hour dietary recall. Among 4,116 children studied, 3,056 (74%) ate breakfast daily, 450 (11%) most days, 372 (9%) some days, and 238 (6%) not usually. Graded associations between breakfast frequency and risk markers were observed; children who reported not usually having breakfast had higher fasting insulin (percent difference 26.4%, 95% CI 16.6%-37.0%), insulin resistance (percent difference 26.7%, 95% CI 17.0%-37.2%), HbA1c (percent difference 1.2%, 95% CI 0.4%-2.0%), glucose (percent difference 1.0%, 95% CI 0.0%-2.0%), and urate (percent difference 6%, 95% CI 3%-10%) than those who reported having breakfast daily; these differences were little affected by adjustment for adiposity, socioeconomic status, and physical activity levels. When the higher levels of triglyceride, systolic blood pressure, and C-reactive protein for those who usually did not eat breakfast relative to those who ate breakfast daily were adjusted for adiposity, the differences were no longer significant. Children eating a high fibre cereal breakfast had lower insulin resistance than those eating other breakfast types (p for heterogeneity <0.01). Differences in nutrient intakes between breakfast frequency groups did not account for the differences in type 2 diabetes markers., Conclusions: Children who ate breakfast daily, particularly a high fibre cereal breakfast, had a more favourable type 2 diabetes risk profile. Trials are needed to quantify the protective effect of breakfast on emerging type 2 diabetes risk. Please see later in the article for the Editors' Summary.

Background: Obesity affects 25% of the UK adult population but modest weight loss can reduce the incidence of obesity-related chronic disease. Some effective weight loss treatments exist but there is no nationally available National Health Service (NHS) treatment service, and general practitioners (GPs) rarely discuss weight management with patients or support behavior change. Evidence shows that commercial weight management services, that most primary care trusts have 'on prescription', are more effective than primary care treatment., Methods/design: We propose a controlled trial where patients will be randomized to receive either the offer of help by referral to a weight management service and follow-up to assess progress, or advice to lose weight on medical grounds. The primary outcome will be weight change at 12-months. Other questions are: what actions do people take to manage their weight in response to the two GP intervention types? How do obese patients feel about GPs opportunistically discussing weight management and how does this vary by intervention type? How do GPs feel about raising the issue opportunistically and giving the two types of brief intervention? What is the cost per kg/m2 lost for each intervention? Research assistants visiting GP practices in England (n = 60) would objectively measure weight and height prior to GP consultations and randomize willing patients (body mass index 30+, excess body fat, 18+ years) using sealed envelopes. Full recruitment (n = 1824) is feasible in 46 weeks, requiring six sessions of advice-giving per GP. Participants will be contacted at 3 months (postintervention) via telephone to identify actions they have taken to manage their weight. We will book appointments for participants to be seen at their GP practice for a 12-month follow-up., Discussion: Trial results could make the case for brief interventions for obese people consulting their GP and introduce widespread simple treatments akin to the NHS Stop Smoking Service. Likewise, the intervention could be introduced in the Quality and Outcomes Framework and influence practice worldwide., Trial Registration: Current Controlled Trials ISRCTN26563137.